Do these antibiotics make me look fat?

There has been a lot of interest and conflicting reports about whether antibiotics contribute to obesity.  Another interesting study on this theme:

  • ET Rogawski et al. JPGN 2017; 65: 350-6. 

The authors followed 1954 children twice weekly from birth to 2 years of age as part of the MAL-ED study.  There were 8 study sites, including in Bangladesh, India, Brazil, Pakistan, Nepal, South Africa, Peru, and Tanzania. Key finding:

  • Antibiotic use before 6 months of age was associated with increased weight from 6 months to 2 years of age.
  • Antibiotic use after 6 months did not affect growth.

The authors speculate: “If treatment of infections were the main mechanism, we would expect antibiotic exposure after 6 months to also have an impact.” Thus, they conclude that effects on the microbiome are likely a more important explanation.

My take (borrowed from te authors):  “Antibiotic use in low-resource settings” can improve growth, though the long-term consequences are not known.  In high-income settings, weight gain secondary to antibiotic exposure is more likely to be detrimental.

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Patient T-shirt



Diet and Stress in Pediatric Eosinophilic Esophagitis

When it comes to eosinophilic esophagitis (EoE), I sometimes worry that some treatments are worse than the disease, depending on the severity of the EoE. A recent study (C Case et al. JPGN 2017; 65: 281-84) indicates that dietary therapy is often stressful for families.

This study examined children ages 2-18 during an annual American Partnership for Eosinophilic Diseases ( patient education conference. What I found most interesting was Table 3. “Stress associated with eosinophilc esophagitis.”

Some of the data:

  • In response to ‘how stressful do you find the following since your child’s diagnosis of EoE?’ Family structure at mealtimes: Not stressful 13.5%, somewhat stressful 21.6%, moderate stressful 16.2%, significant stressful 32.4%, and severe stressful 16.2%
  • In response to ‘how stressful do you find the following since your child’s diagnosis of EoE? Buying and cooking separate foods/meals for your child: Not stressful 2.6%, somewhat stressful 21.1%, moderate stressful 21.1%, significant stressful 31.6%, and severe stressful 23.7%
  • In response to ‘how stressful do you find the following since your child’s diagnosis of EoE? Financial strain due to cost of food: Not stressful 10.5%, somewhat stressful 21.1%, moderate stressful 18.4%, significant stressful 23.7%, and severe stressful 36.3%
  • What is your current stress level in response to your child’s EoE? Not stressful 2.6%, somewhat stressful 15.8%, moderate stressful 36.8%, significant stressful 42.1%, and severe stressful 2.6%
  • 62% of respondents indicated that child’s EoE has affected marital relationship.

In addition, the study documented that “half of youth were affected by worry, anger, and sadness related to specialized diets.”  As this study relied on participants at an APFED meeting, this could skew the EoE population to be more severely affected.

My take: This study shows the emotional burden that dietary treatment of EoE places on families.

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Berry College

WIC Formula Selection in Infants and Children

Over the past year, I have been working with the Georgia Chapter of the American Academy of Pediatrics alongside Stan Cohen, MD and Kylia Crane RDN, LD to develop an algorithm to improve formula selection for young children who use the WIC program.  This project was modeled after a similar project for infants.  Here are two of the slides and then the entire slideset is included below:

Link to slideset: AAPformulaAlgorithmsWIC

Obesity Epidemic: Graphic Depiction

From NY Times: How Big Business Got Brazil Hooked on Junk Food

Excerpt from article:

Across the world, more people are now obese than underweight. At the same time, scientists say, the growing availability of high-calorie, nutrient-poor foods is generating a new type of malnutrition, one in which a growing number of people are both overweight and undernourished…

For a growing number of nutritionists, the obesity epidemic is inextricably linked to the sales of packaged foods, which grew 25 percent worldwide from 2011 to 2016, compared with 10 percent in the United States, according to Euromonitor, a market research firm. An even starker shift took place with carbonated soft drinks; sales in Latin America have doubled since 2000, overtaking sales in North America in 2013, the World Health Organization reported

In many ways, Brazil is a microcosm of how growing incomes and government policies have led to longer, better lives and largely eradicated hunger. But now the country faces a stark new nutrition challenge: over the last decade, the country’s obesity rate has nearly doubled to 20 percent, and the portion of people who are overweight has nearly tripled to 58 percent. Each year, 300,000 people are diagnosed with Type II diabetes, a condition with strong links to obesity.

Programming for Fatty Liver Disease May Occur Prior to Birth

A recent study (KP Newton et al. J Pediatr 2017; 187: 141-6; associated editorial pg 13-15)) in a multicenter retrospective cross-sectional study of children (n=538) with biopsy-proven nonalcoholic fatty liver disease (NAFLD) showed that birth weight influenced the development of NAFLD.  The participants were enrolled in the Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN).

Key findings:

  • There was increased NAFLD among both low birth weight (LBW) and high birth weight (HBW).
  • LBW occurred more commonly in the NAFLD cohort 9.3% compared with the general population prevalence 6.1%.
  • HBW occurred more commonly in the NAFLD cohort 14.9% compared with the general population prevalence 10.5%

The authors speculate that the explanation/mechanisms for increase in both LBW and HBW are likely to differ. It has been recognized that LBW is associated with higher cardiovascular disease and type 2 diabetes.  HBW start bigger and often stay bigger; that is, there are increased risks of more severe obesity.

There are numerous limitations to this study -there is a lot of data that is not available, including gestational age, maternal weight, breastfeeding exposure, and antibiotic administration.

My take: These findings add to the literature that risks for NAFLD along with other metabolic problems may be present at birth.  Is there a way to modify this risk?

Related study: ET Jensen et al. J Pediatr 2017; 187: 50-7, editorial pg 10-12.  In this study of 535 ten-year-old children, enrolled in a prospective multicenter extremely low gestational age newborn cohort study, the authors found that maternal overnutrition and undernutrition affected the brain health of these children. The authors used neurocognitive assessment tools.

  • Children born to women with a pregravid BMI >30 scored “lower on measures of general cognitive ability, executive functioning, fine motor function, and academic achievement.”
  • Children born to women with inadequate maternal weight gain during pregnancy had “lower language and academic achievement.”

Hidden Falls, Highlands NC


What Happens to Picky Eaters

“Little belly-achers grow up to be big belly-achers and big belly-achers beget little belly-achers” –John Apley

John Apley’s monographThe Child with Abdominal Pains indicates that children with recurrent abdominal pain often grow up to be adults with abdominal pains.  A recent study indicates the same type of phenomenon with picky eaters.

A summary of this study in Research Digest: The first study to see if fussy-eating children grow into fussy-eating adults (Thanks to Bonney Reed-Knight for this link.)

An excerpt:

60 per cent of fussy eating children in the study were also fussy eaters at age 23, but fussy eating young adults were no more likely to report signs of eating disorder than their non-fussy peers.

The researchers led by Meredith Van Tine at Stanford University School of Medicine managed to catch up with 61 individuals, now aged 23, who’d participated as children in a long-running study in which their eating habits had been scored by their parents at ages 2, 7, 9.5 and 11, including any signs of fussy eating (being a “selective eater”, having strong likes and dislikes, and only eating a limited variety of foods etc). The participants were now asked to rate themselves on whether they were selective or fussy eaters, and they answered questions about whether they engaged in behaviours related to eating disorders.

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Hypophosphatemia with an Elemental Formula

A recent retrospective study (LF Gonzalez Ballesteros et al Bone 2017; 97: 287-92) of 17 centers in North America and Ireland (2014-2016) identified a frequent association between an elemental formula and idiopathic hypophosphatemia in infants and children.

Key findings:

  • “Fifty-one children were identified at 17 institutions with unexplaned hypophosphatemia.  Most children had complex illnesses and been solely fed Neocate® formula products for variable periods of time.”
  • “Hypophosphatemia was detected during evaluation of fractures or rickets.  Increased alkaline phosphatase activity”  was noted in nearly all cases.
  • “Most all improved with addition of supplemental phosphate or change to a different formula product.”
  • Median age was 3.0 years (range 0.2 years to 15.5 years).  Median duration of Neocate® was 1.3 years

Since the composition of the formula had adequate phosphate, the authors speculate that the “bioavailability of formula phosphorus may be impaired in certain clinical settings.” Interestingly, this report singles out Neocate® products, “although the possibility of hypophosphatemia may occur with other amino-acid based formulas cannot be excluded.” Neocate® infant has similar amounts of phosphorus as Elecare®: 82.2 mg of phosphorus per 100 kcal compared with 84.2 mg.

My take: In patients receiving exclusive amino-acid based formulas (especially Neocate®), it is probably worthwhile to periodically monitor phosphate, calcium, alkaline phosphatase and possibly other micronutrients.

College of Charleston