Considerable advances have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, the mechanisms underlying these benefits, and in the clinical management of breastfeeding. This policy statement on breastfeeding replaces the 1997 policy statement of the American Academy of Pediatrics and reflects this newer knowledge and the supporting publications. The benefits of breastfeeding for the infant, the mother, and the community are summarized, and recommendations to guide the pediatrician and other health care professionals in assisting mothers in the initiation and maintenance of breastfeeding for healthy term infants and high-risk infants are presented. The policy statement delineates various ways in which pediatricians can promote, protect, and support breastfeeding not only in their individual practices but also in the hospital, medical school, community, and nation.

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Breastfeeding and the Use of Human Milk

Prospective Cohort Study

With the continued interest in the role of the gut microbiota in health, attention has now turned to how to harness the microbiota for the benefit of the host. This Consensus Statement outlines the definition and scope of the term 'prebiotic' as determined by an expert panel convened by the International Scientific Association for Probiotics and Prebiotics in December 2016. In December 2016, a panel of experts in microbiology, nutrition and clinical research was convened by the International Scientific Association for Probiotics and Prebiotics to review the definition and scope of prebiotics. Consistent with the original embodiment of prebiotics, but aware of the latest scientific and clinical developments, the panel updated the definition of a prebiotic: a substrate that is selectively utilized by host microorganisms conferring a health benefit. This definition expands the concept of prebiotics to possibly include non-carbohydrate substances, applications to body sites other than the gastrointestinal tract, and diverse categories other than food. The requirement for selective microbiota-mediated mechanisms was retained. Beneficial health effects must be documented for a substance to be considered a prebiotic. The consensus definition applies also to prebiotics for use by animals, in which microbiota-focused strategies to maintain health and prevent disease is as relevant as for humans. Ultimately, the goal of this Consensus Statement is to engender appropriate use of the term 'prebiotic' by relevant stakeholders so that consistency and clarity can be achieved in research reports, product marketing and regulatory oversight of the category. To this end, we have reviewed several aspects of prebiotic science including its development, health benefits and legislation.

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Expert consensus document: The International Scientific Association for Probiotics and Prebiotics (ISAPP) consensus statement on the definition and scope of prebiotics

Prebiotics are non-digestible (by the host) food ingredients that have a beneficial effect through their selective metabolism in the intestinal tract. Key to this is the specificity of microbial changes. The present paper reviews the concept in terms of three criteria: (a) resistance to gastric acidity, hydrolysis by mammalian enzymes and gastrointestinal absorption; (b) fermentation by intestinal microflora; (c) selective stimulation of the growth and/or activity of intestinal bacteria associated with health and wellbeing. The conclusion is that prebiotics that currently fulfil these three criteria are fructo-oligosaccharides, galacto-oligosaccharides and lactulose, although promise does exist with several other dietary carbohydrates. Given the range of food vehicles that may be fortified by prebiotics, their ability to confer positive microflora changes and the health aspects that may accrue, it is important that robust technologies to assay functionality are used. This would include a molecular-based approach to determine flora changes. The future use of prebiotics may allow species-level changes in the microbiota, an extrapolation into genera other than the bifidobacteria and lactobacilli, and allow preferential use in disease-prone areas of the body.

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Dietary modulation of the human colonic microbiota: updating the concept of prebiotics

The different compartments of the gastrointestinal tract are inhabited by populations of micro-organisms. By far the most important predominant populations are in the colon where a true symbiosis with the host exists that is a key for well-being and health. For such a microbiota, 'normobiosis' characterises a composition of the gut 'ecosystem' in which micro-organisms with potential health benefits predominate in number over potentially harmful ones, in contrast to 'dysbiosis', in which one or a few potentially harmful micro-organisms are dominant, thus creating a disease-prone situation. The present document has been written by a group of both academic and industry experts (in the ILSI Europe Prebiotic Expert Group and Prebiotic Task Force, respectively). It does not aim to propose a new definition of a prebiotic nor to identify which food products are classified as prebiotic but rather to validate and expand the original idea of the prebiotic concept (that can be translated in 'prebiotic effects'), defined as: 'The selective stimulation of growth and/or activity(ies) of one or a limited number of microbial genus(era)/species in the gut microbiota that confer(s) health benefits to the host.' Thanks to the methodological and fundamental research of microbiologists, immense progress has very recently been made in our understanding of the gut microbiota. A large number of human intervention studies have been performed that have demonstrated that dietary consumption of certain food products can result in statistically significant changes in the composition of the gut microbiota in line with the prebiotic concept. Thus the prebiotic effect is now a well-established scientific fact. The more data are accumulating, the more it will be recognised that such changes in the microbiota's composition, especially increase in bifidobacteria, can be regarded as a marker of intestinal health. The review is divided in chapters that cover the major areas of nutrition research where a prebiotic effect has tentatively been investigated for potential health benefits. The prebiotic effect has been shown to associate with modulation of biomarkers and activity(ies) of the immune system. Confirming the studies in adults, it has been demonstrated that, in infant nutrition, the prebiotic effect includes a significant change of gut microbiota composition, especially an increase of faecal concentrations of bifidobacteria. This concomitantly improves stool quality (pH, SCFA, frequency and consistency), reduces the risk of gastroenteritis and infections, improves general well-being and reduces the incidence of allergic symptoms such as atopic eczema. Changes in the gut microbiota composition are classically considered as one of the many factors involved in the pathogenesis of either inflammatory bowel disease or irritable bowel syndrome. The use of particular food products with a prebiotic effect has thus been tested in clinical trials with the objective to improve the clinical activity and well-being of patients with such disorders. Promising beneficial effects have been demonstrated in some preliminary studies, including changes in gut microbiota composition (especially increase in bifidobacteria concentration). Often associated with toxic load and/or miscellaneous risk factors, colon cancer is another pathology for which a possible role of gut microbiota composition has been hypothesised. Numerous experimental studies have reported reduction in incidence of tumours and cancers after feeding specific food products with a prebiotic effect. Some of these studies (including one human trial) have also reported that, in such conditions, gut microbiota composition was modified (especially due to increased concentration of bifidobacteria). Dietary intake of particular food products with a prebiotic effect has been shown, especially in adolescents, but also tentatively in postmenopausal women, to increase Ca absorption as well as bone Ca accretion and bone mineral density. Recent data, both from experimental models and from human studies, support the beneficial effects of particular food products with prebiotic properties on energy homaeostasis, satiety regulation and body weight gain. Together, with data in obese animals and patients, these studies support the hypothesis that gut microbiota composition (especially the number of bifidobacteria) may contribute to modulate metabolic processes associated with syndrome X, especially obesity and diabetes type 2. It is plausible, even though not exclusive, that these effects are linked to the microbiota-induced changes and it is feasible to conclude that their mechanisms fit into the prebiotic effect. However, the role of such changes in these health benefits remains to be definitively proven. As a result of the research activity that followed the publication of the prebiotic concept 15 years ago, it has become clear that products that cause a selective modification in the gut microbiota's composition and/or activity(ies) and thus strengthens normobiosis could either induce beneficial physiological effects in the colon and also in extra-intestinal compartments or contribute towards reducing the risk of dysbiosis and associated intestinal and systemic pathologies.

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Prebiotic effects: metabolic and health benefits.

We evaluated the effects of low calcium in the diets of young adolescent girls. We measured calcium absorption and excretion using stable isotopes. We found partial adaptation to low intakes but a persistent large deficit relative to recommended intakes. Low calcium intakes pose a substantial risk of inadequate calcium retention. Introduction: A substantial number of adolescent girls in the United States have habitual calcium intakes 500 mg/day (about 40% of the current recommended intake). The ability to adapt to these very low intakes by increasing calcium absorption and decreasing calcium excretion is not known. We sought to determine the effects of recommended (REC-Ca) versus very low (LO-Ca) calcium intakes on calcium absorption and excretion in white and black girls. Materials and Methods: Pubertal, but premenarcheal girls, were adapted to low or recommended calcium intakes for at least 2 weeks before each study. Calcium absorption (n 51) and endogenous fecal calcium excretion (n 36 of the 51) were determined by dual-tracer stable isotope studies. Subjects were then switched to the other diet for at least 6 weeks, and the study was repeated. Results: Calcium intake was 389 10 mg/day on LO-Ca and 1259 35 mg/day on REC-Ca diets. Fractional absorption increased from 44.9 1.9% on REC-Ca to 63.4 1.7% on LO-Ca (p 0.01), but the net calcium absorption remained less than one-half the value on LO-Ca as on REC-Ca. Despite decreases in both endogenous fecal calcium excretion and urinary calcium excretion, net calcium balance was much lower on LO-Ca compared with REC-Ca1 (131 14 versus 349 32 mg/day, respectively; p 0.001). We found significantly lower urinary calcium excretion but not calcium absorption in black girls compared with white girls. Conclusions: Very low calcium intakes are only partially adapted to by increased absorption and decreased excretion. Very low calcium intakes place both white and black pubertal girls at substantial risk for inadequate calcium retention. J Bone Miner Res 2004;19:759 -763. Published online on January 19, 2004; doi: 10.1359/JBMR.040122

Pubertal girls only partially adapt to low dietary calcium intakes.

While much research has focused on intake and eating behaviors of young adolescents, few studies have examined their knowledge of the Nutrition Facts label. The goals of this project were to assess the understanding of Nutrition Facts labels and the response of young adolescents to an educational program about Nutrition Facts labels. Thirty-four young adolescents participated by answering a short questionnaire and taking a pretest about Nutrition Facts labels and their food choices, which involved using actual Nutrition Facts labels from foods typically eaten by adolescents. Then the subjects participated in a short educational program on how to read the Nutrition Facts label. This was followed by a posttest. Initial knowledge of the basic use of the Nutrition Facts label was marginal, with only 6.65 (standard deviation=2.23) or ∼55% of pretest questions answered correctly. However, the subjects' scores improved significantly to 8.32 (standard deviation=2.01) or ∼70% correct on the posttest ( P

An educational program enhances food label understanding of young adolescents.

After 1 y of distributing a milk-based fortified weaning food provided by the Mexican social program PROGRESA positive effects on physical growth prevalence of anemia and several vitamin deficiencies were observed. There was no effect on iron status which we hypothesized was related to the poor bioavailability from different iron sources added as fortificants to the weaning food. Children (n=54) aged 2-4 y were randomly assigned to receive 44 g of the weaning food fortified with ferrous sulfate ferrous fumarate or reduced iron + Na2EDTA. Iron absorption was measured using an established double-tracer isotopic methodology. Iron absorption from ferrous sulfate (7.9 ± 9.8% was greater than from either ferrous fumarate (2.43 ± 2.3%) or reduced iron + Na2EDTA (1.4 ± 1.3%) (P < 0.01). The absorption of log-(58)Fe sulfate given with the iron source correlated with serum ferritin (s-ferritin) concentration (n = 13 r = 0.63 P = 0.01) and log-(57)Fe absorption (reference dose) (n = 14 r = -0.52 P = 0.02). Absorption from ferrous fumarate and reduced iron + Na2EDTA did not correlate with s-ferritin or absorption of (57)Fe. The recommended daily portion of the fortified complementary food provides an average of 0.256 0.096 0.046 mmol (1.44 0.54 and 0.26 mg) of absorbed iron if fortified with sulfate fumarate and reduced iron + Na2EDTA respectively. Ferrous sulfate was more bioavailable than either ferrous fumarate or reduced iron + Na2EDTA when added to the milk-based fortified food and more readily met the average daily iron requirements for children 2-3 y of age. (authors)

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Ferrous Sulfate Is More Bioavailable among Preschoolers than Other Forms of Iron in a Milk-Based Weaning Food Distributed by PROGRESA, a National Program in Mexico

Background: Iron and zinc deficiency remain substantial problems in small children in both developed and developing nations. Optimizing mineral absorption is an important strategy in minimizing this problem.Objectives: To assess the effects of beef and soy proteins on the bioavailability of non-heme iron and zinc in children.Methods: We measured iron (n = 26) and zinc (n = 36) absorption in 4–8 y old children from meals differing only in protein source (beef or a low-phytate soy protein concentrate). Iron and zinc absorption were measured using multi-tracer stable isotope techniques. Iron absorption was calculated from the red blood cell iron incorporation measured after 14 days and zinc absorption from the ratio of the oral and intravenous excretion of the zinc tracers 48 hours after dosing.Results: Iron absorption from the beef meal was significantly greater (geometric mean, 7.6%) than from the soy meal (3.5%, p = 0.0015). Zinc absorption from the beef meal was greater (mean ± SD, 13.7 ± 6.0%) than from...

Ian J. Griffin

Papers

Pubertal girls only partially adapt to low dietary calcium intakes.

An educational program enhances food label understanding of young adolescents.

Ferrous Sulfate Is More Bioavailable among Preschoolers than Other Forms of Iron in a Milk-Based Weaning Food Distributed by PROGRESA, a National Program in Mexico

Effect of beef and soy proteins on the absorption of non-heme iron and inorganic zinc in children

Calcium fortification of breakfast cereal enhances calcium absorption in children without affecting iron absorption