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Heat processing is essential for the preservation of milk-based infant formulas. Heating, however, induces a number of chemical changes during which lysine in the milk proteins reacts with reducing sugars to form Maillard reaction products (MRPs) and also reacts with the dehydroalanine resulting from cystine degradation to form lysinoalanine (LAL). Both products have been reported to induce histological changes in the straight portion of the proximal tubule in the rat kidney. This pilot study was made to investigate the urinary excretion by healthy preterm babies of MRPs and LAL contained in infant formula and to determine their influence on kidney function. Twelve healthy male preterm babies were first fed for 10 days with pooled human milk and then for 5 days with each of two experimental premature infant formulas in a cross-over design. The infant formulas were sterilized either by ultra-high temperature (UHT) treatment or by a conventional retort process to give products with low and high levels of MRPs and LAL, respectively. In total, some 15.6% of the initial lysine had been modified in the in-can-sterilized product, compared to 6.2% in the UHT product. Urinary excretion of MRP lactulosyl-lysine ranged from 1.3 to 3.9% of the ingested amount, whereas that of LAL ranged from 6.2 to 9.3%. The higher level of MRPs and LAL in the formulas compared to breast milk had no influence on creatinine clearance or electrolyte excretion. There was no evidence of tubular damage as determined by the urinary excretion of four kidney-derived enzymes. Feeding of formula, however, did result in a general increase in urinary microprotein levels. This did not seem to be a reflection of tubular impairment and was probably due to a transient and normal adaptation to the higher protein content of the formulas, although an effect of MRPs and LAL could not be ruled out.

Comment on the composition of soy protein based infant and follow-up formulas. ESPGAN Committee on Nutrition.

Varicella is a highly contagious disease due to varicella-zoster virus (VZV) belonging to the herpesvirus family. Following infection, the virus remains latent in neural ganglia, and upon subsequent reactivation VZV may cause zoster. While mostly a mild disorder in childhood, varicella tends to be more severe in adults. Healthy individuals may develop complications such as bacterial superinfections, pneumonia or encephalitis. Varicella may be fatal, especially in neonates and in immunocompromised persons. Control of varicella can be achieved only by widespread vaccination. The purpose of this review is to summarize the impact and the concerns of an universal varicella vaccination. The vaccines are based on the attenuated Oka-strain. The positive results of extensive safety, efficacy and cost-effectiveness analyses have warranted the introduction of these vaccines in the USA in 1995 and, more recently, in Australia and in Canada. However, European countries have some concerns. At low levels of coverage, there is a possible shift of the disease in older children and adults. At high levels of coverage, without natural exposure to the wild virus, the duration of the protection against varicella in vaccinated children could wane and zoster in elderly could increase. Recent reports suggest that a booster dose or a two doses regimen would be better for adequate immunisation in childhood. Vaccines combining measles, mumps, rubella and varicella are currently under studies and would warrant a high coverage.

Meningococcemia is a severe Gram negative septicemia whose mortality may be as high as 30%. It occurs more frequently in children but the proportion of teenagers is increasing in Belgium. During the past decade, a slow but sustained rise in the incidence of this illness has been noted, with a predominance of the serogroup B. We describe the symptoms, which often are poor in the early stage, the different therapies, most of them being still under investigation, and the chemoprophylaxis. Without being alarmist, the diagnosis must be considered in any child with cutaneous rash, even atypical and tachycardia.

We report the case of a 5 1/2 month baby with an atypical pneumonia. The PCR revealed a Pneumocystis carinii pneumonia. The complementary approach failed to show any immunosuppression. We will discuss the aetiology, physiopathology and treatment of Pneumocystis carnii pneumonia, particularly in cases without immunosuppression. We will also recall the importance of this disease in AIDS.

Gestational diabetes, even if it seems to induce far less foetal complications than classical type 1 or type 2 diabetes mellitus, may be deleterious for the child. We will successively consider the complications that could affect the child during gestation, during the neonatal period and during adult life. These consequences for the offspring require optimal screening and management of gestational diabetes mellitus.

We report the case of a rapidly progressing respiratory failure of a three-month old infant, who shows a cardiomyopathy with left ventricule hypertrophy leading to a Pompe's disease diagnosis. This type 2 glycogenosis will be confirmed by the enzymatic study of the hepatocytes. It is a genetic pathology associated with a deficient activity of the acid maltase resulting in a intralysosomial accumulation of glycogen. The most generally responsible mutations are: delta 18 et delta 525. Prognosis is quite bad with a progressive deterioration of the heart, brain and muscular functions causing death at around 4 to 8 months. Type 2 glycogenosis may be diagnosed before birth through enzymatic study of a material collected through an amniocentesis or a biopsy on chorionic villi, and through DNA analysis. Curative treatment is still under study, but two main research orientations are being developed: genic therapy using viral vector and the correction of the enzymatic deficiency thanks to the synthesis of alpha glucosidase modified to specially get affixed to the heart and muscular cells. Both techniques have already show some encouraging results even though the clinical applications are not presently valid yet.

Evaluation of the results obtained in the management of congenital heart diseases in Liège.We evaluated the results, the mortality and the morbidity of diagnostic and interventional cardiac catheterization, and of the cardiac surgery in the 123 cardiac children who were referred to us during the three first years of operation of our medico-surgical team.89 children underwent a catheterization, including 12 therapeutic interventions, whereas 68 were operated. In the two domains, the results are completely comparable with those of the established centers.The widening of the activity of paediatric cardiology and the creation of an activity of pediatric cardiac surgery in Liège appeared important to us for the quality of management of the cardiac children. This goal could be reached only if our results were comparable with those of the literature. The bet seems to be held. The ultimate objective is to contribute by an adequate policy of management to the quality of life and the health of the cardiac children.

A novel measles-mumps-rubella vaccine (Priorix) has been marketed by SmithKline Beecham. It contains live attenuated virus with measles and mumps strains slightly different from those present in MMR VAX (Pasteur Merieux MSD). The indications and contraindications are similar for both vaccines. Immunogenicity is also equivalent as well as general reactogenicity. By contrast local symptoms were reported significantly less frequently after Priorix.

Cat-scratch disease is a subacute, regional lymphadenitis syndrome that occurs mainly in children. The causative agent is Bartonella henselae. After an incubation period ranging usually between 1 and 2 weeks, red papules develop at the site of cutaneous inoculation and persist until the development of lymphadenopathy with some malaise. Cases with complications have been observed including Parinaud oculoglandular syndrome, encephalopathy, a variety of exanthems and granumatous hepatitis. Diagnosis is based on serologic tests and, when necessary, antimicrobial treatment can be considered. Incision and drainage should not be done.

Growth parameters, biochemical indice of protein metabolism and plasma Amino acid (AA) concentrations were investigated during the first month of life in term infants (n = 61) fed various protein hydrolysate formulas (whey (WHF, n = 3), soy collagen (SCHF, n = 1) and whey-casein hydrolysate formulas (WCHF, n = 1)). In addition, metabolic balance studies were performed in 10 infants fed WHF and in 5 fed WCHF. Comparatively to breast fed infants, growth reduction and decrease in plasma protein concentrations were observed with the use of one of the WHF and in a lesser extent with the SCHF and the WCHF. Plasma amino acid pattern reflected the AA content of the formulas. Whey hydrolysate formulas induced mainly an increase in threonine and a decrease in tyrosine concentrations. Soy-collagen hydrolysate formula led to an increase of non-essential amino acids, such as glycine and hydroxyproline and a decrease in plasma lysine and cystine. Whey-casein hydrolysate formula induced a plasma amino acid pattern close to the profile observed in breast fed infant. Metabolic balance studies showed a relative reduction in nitrogen absorption and utilisation in the infants fed the WHF and the WCHF. In addition a drastic reduction in fat, calcium and phosphorus absorption was also observed with the use of the WCHF. In preterm infants (n = 19) fed whey predominant hydrolysed preterm formulas (n = 3), metabolic balance studies an plasma AA concentration were evaluated at the end of the first month of life at 34 weeks of gestation age. Comparatively to similar preterm infants fed conventional preterm formulas, a relative reduction in nitrogen absorption (83% vs 90%) and retention (64 vs 70%) as well as in phosphorus absorption (78 vs 89%) was observed. Calcium retention was similar (48 vs 45 mg/kg/d) but calcium intake was significantly higher in infants fed hydrolysate formulas 120 vs 91 mg/kg/d. Plasma amino acid concentrations were related to amino acid composition of the formulas. Compared with the standard preterm formulas, all three protein hydrolysate formulas led to a significant increase in plasma threonine and a decrease in tyrosine and phenylalanine concentrations. In addition, there was a reduction in plasma histidine, valine, leucine, cystine, methionine and/or tryptophane with some of the hydrolysate formulas used. In conclusion, these studies provide evidence that protein hydrolysed formulas are not equivalent to whole protein formulas in terms of nutritional efficiency for preterm and term infants. Therefore further extensive nutritional studies on growth, biochemical indices of protein metabolism and metabolic balance, including minerals and trace elements, appear to be necessary before maintaining and promoting the use of such formulas for teh potential benefits on atopic disease in preterm and in full-term newborn infants.

We assessed the growth, tolerance, and acceptability as well as fecal flora composition and stool pH of 20 healthy full-term infants fed with a fermented whey-adapted infant formula containing viable bifidobacteria (10(6)/g of powder) during the first 2 months of life. This fermented infant formula, first biologically acidified by Streptococcus thermophilus and Lactobacillus helveticus, was compared to a whey-adapted, nonacidified, low-phosphate infant formula in a double-blind, randomized controlled study. The results were compared to a control group (n = 14) of fully breast-fed infants. The fermented whey-adapted formula containing viable bifidobacteria induced a prevalence of colonization with bifidobacteria at 1 month of age similar to that of breast-fed infants (12/20 versus 8/14) but significantly higher than in the group fed the standard infant formula (4/20). The mean bacterial count of bifidobacteria was similar in all colonized infants; however, fecal pH was significantly lower in the breast-fed infants than in the nonacidified bottle-fed infants. This kind of infant formula was well tolerated and promoted a normal growth during the first 2 months.

High frequency ventilation (HFV) has been used by the authors for about 5 years in low-weight premature neonates with severe hyaline membrane disease. This retrospective study concerns principally three classes of results: 1) early results of HFV vs conventional ventilation; 2) middle term results, HFV having been used in most severe cases; 3) long term outcome: HFV might prevent efficiently delayed complications such as bronchotracheal dysplasia. Recent therapy developments (surfactant, new ventilators) require controlled prospective studies to assess the real benefits of HFV compared with conventional methods.

Inadequate low intake of phosphorus can induce a hypophosphatemic depletion syndrome resulting in hypercalcemia, hypercalciuria, hypophosphatemia, and rickets. Tubular reabsorption for phosphate per liter glomerular filtration rate (TP/GFR) has been proposed as a reliable index of renal phosphate handling for all age groups. In the present study, carried out in 12 healthy premature babies fed unmodified pooled human milk and then a preterm formula for two periods of 10 days, we demonstrated clearly that TP/GFR as well as calciuria can reflect the poor phosphorus intake and that the kidney of preterm babies is able to rapidly adapt itself to an increase in phosphorus diet content.

The anti-infectious role of human milk may be, at least partly, ascribed to its content in secretory IgA. As lectins are present in various infectious antigens, the binding of different types of IgA to three lectins (concanavalin A, peanut agglutinin, wheat germ agglutinin) was studied by Elisa. The specificity of those bindings was assessed by inhibitory experiments performed with the corresponding oligosaccharides. The following were found for the three lectins: (1) the lectin-binding capacity of colostrum secretory IgA was markedly greater than that of normal plasma IgAl (p < 0.001); (2) the lectin-binding capacity of polymeric IgAl was greater than that of monomeric IgAl (p < 0.001). This property of mucosal IgA may be responsible of a nonimmune opsonization able to prevent the early step of some infectious mucosal diseases, i.e. the attachment of bacteria to epithelial cells by lectin-like bonds and also the penetration into the body of some antigens able to favor the development of allergy. Milk mucosal IgA, present in significant amounts in human colostrum and mature milk – but not in infant formulas – may therefore play an important polyvalent protective role in newborns.

The objectives of this paper are (1) to describe the organization of neonatal care in Belgium; (2) to review evaluative studies aiming at assessing the availability, effectiveness and cost of care, and (3) to compare the situation in Belgium with that in other countries. In the future, basic neonatal care should be provided in each maternity unit. This means that many maternities need upgrading in staffing and equipment. For intensive care, there is only a need for 10–12 specialized centers in the country. A policy for rapid transfer of sick neonates to specialized centers should be implemented.

Senterre, J. and Salle, B. (Departments of Neonatology, University hospital, Liege, Belgium and Lyon, France). Calcium and phosphorus economy of the preterm infant and its interaction with vitamin D and its metabolites. Acta Paediatr Scand, Suppl. 296: 85, 1982.—One hundred and seventeen 3-day metabolic balance studies were carried out in 69 preterm infants. Matched groups of infants were fed either banked human milk, an infant formula or a low birthweight infant formula with medium-chain triglycerides. In addition groups were constituted according to the vitamin D intake or the administration of 1,25–dihydroxyvitamin D. In infants fed human milk, mean fat absorption was 77%. Calcium absorption was 49±11% with no vitamin D supplementation and it reached 70±11% with a daily oral dose of 30 g of vitamin D. However in this latter group urinary excretion of calcium was very high because of the low phosphorus intake. With infant formula, mean fat absorption was 73%. Calcium absorption was 20±11% with no vitamin D supplementation, 32±13% with 25 g of vitamin D per day and 49±10% with daily administration of 0.5 g of 1,25-dihydroxyvitamin D. With low birthweight infant formula, mean fat absorption was 90%. Calcium absorption was 32±15% with no vitamin D supplementation, 45±13% with 25 g of vitamin D, 59±10% with 50 g of vitamin D and 58±6% with 0.5 g of 1,25-dihydroxyvitamin D per day. However with this active metabolite of vitamin D, serum level and urinary excretion of calcium were significantly higher. Whatever the milk or the vitamin D intake, phosphorus absorption was about 90%. Phosphorus retention was related to nitrogen plus calcium retentions. This study indicates that vitamin D status is the major factor regulating intestinal absorption of calcium. Activation pathways of vitamin D and gut response to 1,25-dihydroxyvitamin D are operative in preterm infant. However in populations where relative vitamin D deficiency is common as in the present study, it seems necessary to give preterm infants a daily oral dose of 30 to 50 g (1200–2000 IU) of vitamin D for achieving maximal calcium absorption. Preferably, plasma 25-hydroxyvitamin D level should guide the clinician in estimating the sufficiency of vitamin D intake.

Dry blood spot immunoreactive trypsin was measured by radioimmunoassay in 84 preterm babies and in 65 full-term newborns studied daily from the first to the fifth day of life. In a control group of 3858 full-term newborns, trypsin concentrations at days 4-6 of life exhibited a log-normal pattern distribution, the geometric mean being 18 ng/ml serum. Immunoreactive trypsin concentrations did not change significantly between days 1, 2, 3, 4 and 5 after birth. Immunoreactive trypsin was found to be significantly lower (geometric mean 9 ng/ml, P less than 0.01) in preterm newborns before 32 weeks of gestation. In hypotrophic newborns of 34 weeks gestational age, immunoreactive trypsin values were higher than those observed at 31 weeks of gestation in eutrophic newborns, the mean birth weight not being different between both groups. These data suggest that trypsin production by the pancreas is dependent on maturity but does not seem related to intrauterine nutritional status. Immunoreactive trypsin concentrations do not change after 32 weeks gestational age and during the first postnatal week.

Serum threonine concentration was determined during the first month of life in 163 low birthweight infants fed on either human milk, various adapted formulae, or total parenteral nutrition. On the pooled data, a significant positive relationship was found between the serum threonine concentration and threonine intake. However, the increase of the serum threonine level is more marked in the infants with the lowest actual gestational age; with a high threonine intake, the most premature infants have serum threonine levels twice as high (58.1 vs 31.7 microM/dl) as term infants. Therefore, threonine metabolism seems to be impeded in preterm infants. Considering the cord blood concentration of threonine (26.8 +/- 5.1 microM/dl) and the possible hazardous effect of hyperthreoninemia, it is suggested that threonine intake should not exceed 1200 microM (143 mg)/kg bodyweight/day in premature infants and that the amino acid composition of the diet should probably be modified in order to satisfy their protein requirement.

A case of idiopathic aortic thrombosis in a term neonate is reported. Ultrasound examination led to diagnosis and an embolectomy was carried out. Literature data concerning etiology and treatment of neonatal aortic thrombosis are reviewed.

Senterre, J. (Department of Paediatrics, University Hospital, Liege, Belgium). Net absorption of starch in low birth weight infants. Ada Paediatr Scand, 69: 653, 1980. —Twelve 3-day metabolic balance studies were carried out in 12 low birth weight infants fed an infant formula providing 3.5 g of corn starch per kilogram body weight per day. The mean coefficients of net absorption were 88±6% for starch, 70±14% for fat and 90±4% for nitrogen. No relationship was found between starch absorption and nitrogen or fat absorption. There was no relationship between starch absorption and the duration of starch feeding. It is concluded that the ability of young infants to digest large quantities of starch is most likely limited resulting from low pancreatic alpha-amylase activity. Nevertheless, from a practical point of view, small amounts of starch in infant formulas can be considered not only as a thickener but also as a source of calories.

Wegen der schnellen Entwicklung der anabolen Vorgange und des Hirnwachstums braucht kein Patient dringender eine optimale Ernahrung als das Fruhgeborene mit sehr niedrigem Geburtsgewicht (SNGG). Der Nahrungsbedarf dieser Kinder wird jedoch nach wie vor diskutiert. Das Komitee fur Ernahrung der American Academy of Pediatrics’ hat festgelegt: „Die optimale Nahrung fur SNGG-Kinder kann als eine solche definiert werden, die eine dem letzten Drittel der intrauterinen Entwicklung entsprechende Wachstumsrate aufrechterhalt, ohne dabei belastend auf die noch in der Entwicklung befindlichen Stoffwechsel- und Ausscheidungssysteme zu wirken. “ Ziegler et al. haben im Foetus den Einbau der Nahrstoffe im Gewebe unter Berucksichtigung der Verluste durch Urin und Haut und dem Ausmas der Resorption ausgerechnet, um daraus den theoretischen Nahrstoffbedarf von Kindern unterschiedlichen Gestationsalters abzuleiten. Diese Berechnungen weisen darauf hin, das Frauenmilch und viele Formulanahrungen zu kleine Mengen an Protein und bestimmten Mineralien aufweisen, um Wachstumsraten aufrechtzuerhalten, die mit den intrauterinen vergleichbar sind. Hingegen haben Raiha, Gaull und Mitarbeiter,3,4 berichtet, das mit gepoolter Frauenmilch ernahrte Fruhgeborene weniger haufig eine metabolische Azidose, niedrigere Harnstoff-, Stickstoff- und Ammoniakwerte im Blut, sowie seltener Plasma-Aminosaure-Konzentrationsabweichungen aufweisen als solche, die mit Formulas ernahrt wurden, die mehr Protein enthalten. Mit diesem Referat wollen wir einige Richtlinien zum Nahrungsbedarf von SNGG aufstellen, die auf mehr als 200 Stoffwechselbilanzuntersuchungen bei Fruhgeborenen in den letzten zehn Jahren beruhen.

The etiopathogenesis and the clinical implications of fat malabsorption in preterm infants are reviewed. Low pancreatic lipase activity and impaired solubilization of lipids due to low intraluminal concentration of bile salts appear to be the main factors of the inadequate lipid absorption. The compensatory role of intragastric lipolysis could be important. Currently available informations suggest that, chylomicron formation and transport of lipids are not limiting steps, but the efficiency of these processes in neonates needs further investigations. Due to its bile-stimulated lipase activity, non-heat-treated human milk used at least in part, appears to be the most effective method to improve fat absorption in the preterm infant.