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Functional gastrointestinal disorders (FGID), such as infant regurgitation, infant colic, and functional constipation, are common and typically physiological phenomena during the early months of an infant's life and account for frequent consultations with pediatricians. Various infant formulas are marketed for their management and are frequently given by parents to infants before a medical consultation. However, the evidence supporting their effectiveness is limited and some have altered nutritional compositions when compared to standard formulas. Thus, these products should only be used under medical supervision and upon medical advice. Marketing and over‐the‐counter sales do not ensure proper medical guidance and supervision. The aim of this position paper is to review the current evidence regarding the safety and efficacy of formulas specifically formulated for addressing regurgitation, colic, and constipation, recognized as FGID. The objective is to provide guidance for clinical management based on the highest quality of available evidence. A wide search using Pubmed, MEDLINE, EMBASE and Cochrane Database of Systematic Reviews was performed including the MESH terms infant formula, colic, constipation, regurgitation, reflux, palmitate, lactase, lactose, magnesium, hydrolyzed protein, prebiotics or probiotics. 752 papers were identified and screened. Finally, 72 papers were included in the paper. In the absence of evidence, recommendations reflect the authors' combined expert opinion. Final consensus was obtained by multiple e‐mail exchange and meetings of the Nutrition Committee. (1) For breastfed infants experiencing FGID such as regurgitation, colic, or constipation, transitioning from breastfeeding to commercial formulas is not recommended. (2) In general, whether an infant is breastfed or formula‐fed, it's crucial to reassure parents that FGIDs are normal and typically do not necessitate treatment or change to a special formula. (3) Thickened formulas, often termed anti‐reflux formulas, may be considered in specific cases of regurgitation. (4) The usage of specialized formulas for infants with colic is not advised due to a lack of clinical evidence. (5) In the case of constipation in infants, the use of formulas enriched with high β‐palmitate and increased magnesium content may be considered to soften the stool. Generally, there is limited evidence supporting the use of specialized formulas for FGID. Breastfeeding should never be discontinued in favor of formula feeding. Functional gastrointestinal disorders, such as infant regurgitation, infant colic, and functional constipation, are common and typically physiological phenomena during the early months of an infant's life.The infant food industry provides a wide range of formulas designed for managing these mild functional gastrointestinal disorders.Despite the widespread use of these formulas, their effectiveness in treating mild functional gastrointestinal disorders remains uncertain. Functional gastrointestinal disorders, such as infant regurgitation, infant colic, and functional constipation, are common and typically physiological phenomena during the early months of an infant's life. The infant food industry provides a wide range of formulas designed for managing these mild functional gastrointestinal disorders. Despite the widespread use of these formulas, their effectiveness in treating mild functional gastrointestinal disorders remains uncertain. Weaning from breastfeeding is not advised for infants experiencing any or several functional gastrointestinal disorders. In majority of formula‐fed infants, no specific formulas are indicated.In breastfed infants with regurgitation, breast milk can be expressed and supplemented with thickening agents and in formula fed infants, industrially thickened infant formulas often referred to as “anti‐reflux formulas,” or formulas with appropriately added thickeners can be considered in special cases under medical guidance.Special anti‐colic formulas do not usually benefit infants with colic.In cases of infant constipation, considering formulas with high β‐palmitate and an elevated magnesium content may be an option to soften stool consistency.It is generally not recommended to use formulas for combined functional gastrointestinal disorders. Weaning from breastfeeding is not advised for infants experiencing any or several functional gastrointestinal disorders. In majority of formula‐fed infants, no specific formulas are indicated. In breastfed infants with regurgitation, breast milk can be expressed and supplemented with thickening agents and in formula fed infants, industrially thickened infant formulas often referred to as “anti‐reflux formulas,” or formulas with appropriately added thickeners can be considered in special cases under medical guidance. Special anti‐colic formulas do not usually benefit infants with colic. In cases of infant constipation, considering formulas with high β‐palmitate and an elevated magnesium content may be an option to soften stool consistency. It is generally not recommended to use formulas for combined functional gastrointestinal disorders.

The recent World Health Organization (WHO) guideline aims to provide evidence‐based recommendations on complementary feeding (CF) of healthy term infants and young children 6−23 months living in low‐, middle‐, and high‐income countries, including both breastfed and non‐breastfed children. Like WHO, our organizations aim to promote optimal infant and young child nutrition and health, with a focus on promoting breastfeeding as well as appropriate and timely CF. In this paper, we share our concerns about aspects of the guideline, some of which may have the potential to cause unintended harm in infants and young children and suggest alternative or modified proposals.

Coeliac disease is a chronic, immune‐mediated disorder for which the only treatment consists of lifelong strict adherence to gluten‐free diet (GFD). However, there is a lack of evidence‐based guidelines on the GFD dietary management of coeliac disease. This position paper, led by the Special Interest Group in coeliac disease of the European Society of Pediatric, Gastroenterology Hepatology, and Nutrition, supported by the Nutrition Committee and the Allied Health Professionals Committee, aims to present evidence‐based recommendations on the GFD as well as how to support dietary adherence. A wide literature search was performed using the MeSH Terms: “diet, gluten free,” “gluten‐free diet,” “diets, gluten‐free,” “gluten free diet,” and “coeliac disease” in Pubmed until November 8th, 2022. The manuscript provides an overview of the definition of the GFD, regulations as basis to define the term “gluten‐free,” which foods are naturally gluten‐free and gluten‐containing. Moreover, it provides recommendations and educational tips and infographics on suitable food substitutes, the importance of reading food labels, risk of gluten cross‐contact at home and in public settings, nutritional considerations as well as factors associated to dietary adherence based on available evidence, or otherwise clinical expertise. This position paper provides guidance and recommendations to support children with coeliac disease to safely adhere to a GFD. How to guide pediatric patients with coeliac disease to correctly follow a gluten‐free diet? Coeliac disease is a chronic disorder for which the only treatment consists of lifelong adherence to a strict gluten‐free diet.There is a lack of evidence‐based recommendations and guidelines on the nutritional management of coeliac disease. Coeliac disease is a chronic disorder for which the only treatment consists of lifelong adherence to a strict gluten‐free diet. There is a lack of evidence‐based recommendations and guidelines on the nutritional management of coeliac disease. This position paper is the first ESPGHAN position paper to provide evidence‐based and experience‐based recommendations on gluten‐free diet in pediatric coeliac disease.Infographic material is provided for the given recommendations. This position paper is the first ESPGHAN position paper to provide evidence‐based and experience‐based recommendations on gluten‐free diet in pediatric coeliac disease. Infographic material is provided for the given recommendations.

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.

This joint position paper of the Committees of Allied Health Professionals (CAHP) and Nutrition (CON) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) provides a comprehensive guide for health professionals to manage blended diets in children via gastrostomy tubes. A systematic literature search was performed from 1992 to 2021 using Pubmed, MEDLINE, and Cochrane Database of Systematic Reviews and recent guidelines reviewed. In the absence of evidence, recommendations reflect the authors’ expert opinion. Final consensus was obtained by multiple e-mail exchange and virtual meetings of the CAHP and CON. Reported benefits of blended diets include reduced GERD and infections, improved defecation, level of alertness and attention span, skin conditions, and appearance of hair and nails. Families report a sense of greater normality. Small case series, cross-sectional surveys, questionnaire-based small case studies, reports of personal experience, and single-center pilot studies are available in the medical literature. A total of 20 recommendations for practice were made based on the results and consensus process. There is little evidence published to formally inform about the potential health benefits or risks of this practice and how to use it in the best way. This leaves health professionals caring for such patients in a relative vacuum regarding what to consider when providing a duty of care to patients and carers who wish to pursue this method of feeding. This article provides guidelines for safe and appropriate use of a BD, but more research is needed.

Background: Most body composition techniques assume constant properties of fat free mass (FFM) (hydration and density) regardless of nutritional status, which may lead to biased values. Aim: To evaluate the interactive associations of age and body mass index (BMI) with hydration and density of FFM. Methods: Data from subjects aged between 4 and 22 years old from several studies conducted in London, UK were assessed. Hydration (HFFM) and density (DFFM) of FFM obtained from the four-component model in 936 and 905 individuals, respectively, were assessed. BMI was converted in to z-scores, and categorised into five groups using z-score cut-offs (thin, normal weight, overweight, obese, and severely obese). Linear regression models for HFFMand DFFMwere developed using age, sex, and BMI group as predictors. Results: Nearly 30% of the variability in HFFMwas explained by models including age and BMI groups, showing increasing HFFMvalues in heavier BMI groups. On the other hand, ~40% of variability in DFFMwas explained by age, sex, and BMI groups, with DFFMvalues decreasing in association with higher BMI group. Conclusion: Nutritional status should be considered when assessing body composition using two-component methods, and reference data for HFFMand DFFMis needed for higher BMI groups to avoid bias. Further research is needed to explain intra-individual variability in FFM properties.

BackgroundIntestinal microbiota of breast-fed infants is plenty of beneficial bifidobacteria. We aimed to determine whether an infant formula supplemented with probiotic Bifidobacterium longum subsp. infantis CECT7210 (B. infantis IM1) is effective at reducing diarrhea incidence in healthy term infants.MethodsDouble‐blinded, randomized, multicenter, controlled clinical trial, where formula-fed infants (<3 months) received an infant formula supplemented (Probiotic) or not (Control) with 107cfu/g of B. infantis IM1 over 12 weeks. Diarrheas, growth, digestive symptoms, stool bifidobacteria, and microbiota were assessed.ResultsIn all, 97 (Control) and 93 (Probiotic) infants were randomized, and 78 (Control) and 73 (Probiotic) completed the 12 week-follow-up. In the overall study period, a median of 0.29±1.07 and 0.05±0.28 diarrhea events/infant was observed in the Control and Probiotic groups, respectively (P=0.059). This trend to less diarrhea episodes in the Probiotic group reached statistical significance at 8 weeks (0.12±0.47 vs. 0.0±0.0 events/infant, P=0.047). Constipation incidence was higher (odds ratio (OR) 2.67 (1.09–6.50)) and stool frequency lower (2.0±1.0 vs. 2.6±1.3 stools/day, P=0.038) in the Control group after 4 weeks. No differences were found at other time points nor in other digestive symptoms, growth, or formula intake.ConclusionA B. infantis IM1-supplemented infant formula may reduce diarrhea episodes, being safe, well tolerated, and associated with lower constipation prevalence.

Background:Protein intake may modulate cardiac structure and function in pathological conditions, but there is a lack of knowledge on potential effects in healthy infants.Methods:Secondary analysis of an ongoing randomized clinical trial comparing two groups of infants receiving a higher (HP) or lower (LP) protein content formula in the first year of life, and compared with an observational group of breastfed (BF) infants. Growth and dietary intake were assessed periodically from birth to 2 y. Insulin-like growth factor 1 (IGF-1) axis parameters were analyzed at 6 mo in a blood sample. At 2 y, cardiac mass and function were assessed by echocardiography.Results:HP infants (n = 50) showed a higher BMI z-score at 2 y compared with LP (n = 47) or BF (n = 44). Cardiac function parameters were increased in the HP group compared with the LP and were directly related to the protein intake during the first 6 mo of life. Moreover, there was an increase in free IGF-1 in the HP group at 6 mo.Conclusion:A moderate increase in protein supply during the first year of life is associated with higher cardiac function parameters at 2 y. IGF-1 axis modifications may, at least in part, underlie these effects.

Background:Animal models have shown that insulin-like growth factor I (IGF-I) may mediate protein-induced kidney growth. Our aim was to analyze the effect of IGF-I on protein-induced kidney growth in healthy infants.Methods:This is a secondary analysis of a randomized trial that compared growth of infants fed with a higher-protein (HP) (n = 169) vs. lower-protein (LP) (n = 182) formula (in the first year of life). Outcome measures were anthropometric parameters, kidney volume (cm3), and total and free IGF-I (ng/ml).Results:The highest levels of total and free IGF-I were found in the HP group. Both parameters correlated significantly with BMI z-score (r = 0.229, P < 0.001 and r = 0.223, P < 0.001, respectively), kidney volume (r = 0.115, P = 0.006 and r = 0.208, P < 0.001, respectively), and kidney volume/body length (r = 0.109, P = 0.010 and r = 0.194, P < 0.001, respectively) at 6 mo. Linear regression analyses showed a significant effect of free IGF-I on kidney volume in models, including significant effects of HP formula and anthropometry. The structural equation model revealed a significant direct effect of the HP formula on kidney volume and an indirect effect mediated by free IGF-I.Conclusion:This study suggests that IGF-I partly mediates protein-induced kidney growth in healthy infants. IGF-I could be involved in a pathway for the programming of the renal system.

The estimation of dietary intake remains a challenge in human nutritional studies. In infants, the use of food diaries (FDs) is a suitable method already validated; however, this method is not exempt from error. In formula-fed infants, dilution of powdered formulas may produce errors. Our aim was to develop and validate standard operating procedures (SOPs) for the assessment of dietary intake in formula-fed infants, attending potential sources of error.

The estimation of dietary intake remains a challenge in human nutritional studies. In infants, the use of food diaries (FDs) is a suitable method already validated; however, this method is not exempt from error. In formula-fed infants, dilution of powdered formulas may produce errors. Our aim was to develop and validate standard operating procedures (SOPs) for the assessment of dietary intake in formula-fed infants, attending potential sources of error. We analysed sources of error in a random subsample of 3-day FDs from 100 infants enrolled in the European Childhood Obesity Project. Calculations to estimate intakes were standardised and included in a software tool (SOPsystem). An evaluation of a simulated FD was performed by 9 trained nutritionists and 23 nutrition students (n = 225 and n = 575 bottle evaluations, respectively) to compare the results obtained when using or not the SOPsystem. Correct answers (%), coefficients of variation, and the time spent (minutes) to assess the simulated FD were analysed. Overall, 60% of the FDs contained reports of incorrect volumes, and 37% reported incorrect formula dilutions. When the SOPsystem was used, correct answers in the simulated FD were more frequent (P< 0.001) and the mean coefficient of variation and the time spent were lower (P< 0.005 and P< 0.01, respectively). The development and implementation of SOPs with a software tool that identifies specific sources of error in record-keeping achieved a harmonised and improved process for assessing dietary intakes in formula-fed infants, minimising errors in calculations and reducing the work time invested.

Little is known about the practice of introducing complementary feeding across Europe. We aim at describing times of solid introduction in healthy infants in 5 European countries.

Little is known about the practice of introducing complementary feeding across Europe. We aim at describing times of solid introduction in healthy infants in 5 European countries. Between October 2002 and June 2004, 1678 healthy term infants were either breast-fed (BF) for at least 4 months (n = 588) or study formula–fed (FF) (n = 1090) with different protein contents. Three-day-weighed food protocols were obtained at ages 1, 2, 3, 4, 5, 6, 7, 8, 9, and 12 completed months. Solids were introduced earlier in FF infants (median 19 weeks, interquartile range 17–21) than BF infants (median 21 weeks, interquartile range 19–24). Some 37.2% of FF infants and 17.2% of BF infants received solid foods at 4 completed months, which is earlier than recommended in Europe. Solids had been introduced at 7 completed months in 99.3% of FF infants and 97.7% of BF infants, respectively. Belgium had the highest percentage of solids feeding in FF infants at 3 (15.8%) and 4 (55.6%) completed months, and in BF infants at 4 (43%) and 5 (84.8%) completed months. Multiple regression showed low maternal age, low education level, and maternal smoking to predictors an early introduction of solids at 3 and 4 completed months. Complementary feeding is introduced earlier than recommended in a sizeable number of infants, particularly among FF infants. Country- and population-specific approaches to adequately inform parents should be explored.