Les dernières recommandations du

Comité de Nutrition

Christophe Dupont (Paris)

12h15-12h45

L’origine précoce des maladies chroniques de l’adulte

[Early origins of adult disease]. Simeoni U, Bocquet A,

Briend A, Chouraqui JP, Darmaun D, Dupont C, Feillet F,

Frelut ML, Girardet JP, Goulet O, Hankard R, Rieu D, Rozé JC,

Turck D, Vidailhet M; Comité de nutrition de la Société

française de pédiatrie. Arch Pediatr. 2016 May;23(5):443-6.

Vitamin A in pediatrics: An update from the Nutrition

Committee of the French Society of Pediatrics. Vidailhet

M, Rieu D, Feillet F, Bocquet A, Chouraqui JP, Darmaun D,

Dupont C, Frelut ML, Girardet JP, Hankard R, Rozé JC,

Simeoni U, Turck D, Briend A. Arch Pediatr. 2017

Mar;24(3):288-297.

Impact of obesity on biomarkers of iron and

vitamin D status in children and adolescents:

the risk of misinterpretation.

Frelut ML, Girardet JP, Bocquet A, Briend A,

Chouraqui JP, Darmaun D, Dupont C, Feillet F,

Hankard R, Rozé JC, Simeoni U; Committee on

Nutrition of the French Society of Paediatrics.

Arch Pediatr. 2018 Jan;25(1):3-5.

Editorial

Reviewing the current evidence on

iron and vitamin D status in obese

children, and the interpretation of

the biomarkers in this population

Iron status in obese children

• … studies based on several iron-status

biomarkers showed a consistent increase

in the prevalence, risk, and severity of

iron deficiency in overweight and obese

children and adolescents in industrialized

and in some emerging countries,

especially in girls after menarche.

• Hutchinson C. A review of iron studies in overweight and obese children

and adolescents: a double burden in the young? Eur J Nutr 2016;55:2179–

97.

Iron status in obese children

• The iron status in obese children seems to be more

related to a deviation of iron metabolism to

reticuloendothelial system and to inflammation-

related ferritin oversynthesis ...

• Therefore, iron supplementation is poorly efficient

in treating the microcytic anemia observed in obese

children because iron is not well absorbed because of

chronic inflammation.

• Even if the response to oral supplementation may be

less effective in obese than in normal-weight

ch…ildren [1,9], obese children should be screened

for iron deficiency because of its deleterious effects.

Which markers for iron deficiency in

obese children?

• Serum ferritin, … the best indicator of iron stores

in the general population, is increased in obese

patients because of the associated chronic

inflammation.

• This may in turn lead to an underestimation of

iron deficiency [7].

• … the NHANES III study, using serum ferritin as

one of the diagnostic criteria of iron deficiency,

reports a lower prevalence rate in obese children

and adolescents, compared to other studies

[4,6,7].

Obesity and vitamin D status

• In overweight and obese children and

adolescents, plasma 25(OH)D concentrations

lower than in normal-weight children ...

• … based on 25(OH)D plasma concentrations, the

prevalence of vitamin D deficiency is 35% higher

… in obese children and adolescents, and 24%

higher in overweights …, compared to normal-

weight …, irrespective of age, latitude, and

25(OH)D cut-offs used to define deficiency [2].

Obesity and vitamin D status

• Low plasma 25(OH)D concentrations do not

necessarily reflect true deficiency.

• They may be due to increased storage in

adipose tissue, impaired vitamin D release

from adipose tissue, or a lower bioavailability

of vitamin D synthesized in the skin despite

adequate UV-B exposure through yet

unknown mechanisms, as reported in obese

adults [10,11].

Iron and vitamin D status are difficult

to interpret in obese children

• Mild inflammation and excessive storage in the adipose

tissue impair adequate evaluation of body stores.

• Iron supplementation should be cautiously used

…when the ferritin level is low.

• Nutritional and environmental risk factors of vitamin D

deficiency … sought in obese children and adolescents,

and vitamin D status assessed [if] significant risk of

deficiency or showing evidence of early cardiovascular

or metabolic complications. Prevention of vitamin D

deficiency should follow the … guidelines [of] the

general pediatric population, namely regular

supplementation with two doses of 80,000–100,000 IU

every winter [10].

Hypercholesterolemia in children:

Why and how to screen for it?

Girardet JP, Bocquet A, Chouraqui JP, Darmaun D,

Feillet F, Frelut F, Hankard R, Rozé JC, Simeoni U,

Briend A, Dupont C, Committee on Nutrition of the

French Society of Paediatrics

Arch Pediatr. 2018 Mar 13. pii: S0929-693X(18)30048-4

Hypercholesterolemia in children:

Why and how to screen for it?

• Atherosclerosis begins during childhood … closely

related to the … LDL cholesterol (LDL-C) [1].

• Clinical cardiovascular (CV) complications of

hypercholesterolemia (HC) occur later in adulthood.

• Screening and management of children with HC,

particularly in its most severe presentations, are

therefore part of the primary prevention of CV

diseases [2].

• HC screening strategies in children … evaluated by …

prospective studies and reviewed … in recent years [2–

7].

• This paper explains why plasma cholesterol should be

measured at least once in every child.

Hypercholesterolemia in children:

Why and how to screen for it?

• HC : … cholesterol above the 95

percentile in

the general pediatric population [2,3,6,7], 

5% of children are hypercholesterolemic.

• FH is severe: heterozygous subjects …

probability of coronary heart disease before

age 50 : 20% (women), 50% (men) [8]. The risk

of coronary mortality before age 40 … x125 in

women and x48 in men compared to the

general population [9].

Hypercholesterolemia in children:

Why and how to screen for it?

• Screening … 1.5- to 2-mL blood sample …

fasting plasma total cholesterol, HDL

cholesterol, and triglyceride levels, and

calculation of LDL-C [3].

• Committee of Nutrition of the French

Society of Pediatrics : … all children living

in France be screened between 3 and 9

years of age [3].

Nutritional management of cow’s

milk allergy in children: An update

Dupont C, Chouraqui JP, Linglart A, Bocquet A,

Darmaun D, Feillet F, Frelut ML, Girardet JP, Hankard R,

Rozé JC, Simeoni jU, Briend A. Committee on Nutrition

of the French Society of Pediatrics

Arch Pediatr. 2018 Mar 22 pii: S0929-693X(18)30050-2.

Nutritional management of cow’s milk

allergy in children: An update

• … CMA, … several types of digestive, cutaneous, and

respiratory symptoms, some appearing in the form of

syndromes, since risks and handling differ largely according to

syndromes.

• Early diagnosis and … timely elimination diet needed to avoid

growth retardation.

• …adapted formulas available in most industrialized countries

generally tolerated by a majority of infants with CMA, …efficacy

not always proven by a clinical trial

• In …2012, we regretted the absence of safety and nutritional

efficacy information for most of the products available.

Although this situation slightly improved, with more studies

focusing on allergic populations, still proper growth has not

been shown for many formulas. A formula with proven safety

and suitability in children with CMA should therefore be

privileged.

Nutritional management of cow’s milk

allergy in children: An update

• Once solid foods are introduced, parents should be

carefully and regularly advised on how to adequately

replace dairy products and be aware that diversification

should not be restricted except in cases of other proven

food allergies

• Likewise, parents still need dietary advice when CMA is

outgrown.

• Baked milk largely helps feeding children with long

lasting CMA, but the appropriateness and timing of its

introduction should be individually and carefully

assessed by physicians.

• An appropriate challenge under medical supervision is

needed to test the tolerance of baked milk in children

from one year of age.

Nutritional management of cow’s milk

allergy in children: An update

• All children with CMA should have an assessment of

their calcium and vitamin D intakes and receive

counselling to reach RDA for these nutrients.

• Counselling to caregivers and families should include

the importance of calcium intake, sources of dietary

calcium and the expected objectives and timeline.

• The assessment of bone metabolism (BMD and

metabolic bone profile) is advised only in a small subset

of CMA patients with suspected bone fragility. …

fracture(s), rickets, CMA associated with another

chronic disease or multiple FAs, association of low

calcium intake; low vitamin D intake; low energy intake,

period of rapid growth, persisting CMA such as during

EoE.

Parenteral Nutrition for Preterm

Infants: Issues and Strategy

Darmaun D, Lapillonne A, Simeoni U, Picaud JC,

Rozé JC, Saliba E, Bocquet A, Jean-Pierre

Chouraqui JP, Dupont C, Feillet F, Frelut ML,

Girardet JP, Turck D, Briend A, Committee on

Nutrition of the French Society of Pediatrics

(CNSFP), French Society of Neonatology (SFN)

Arch Pediatr, in press 2018

Parenteral Nutrition for Preterm

Infants: Issues and Strategy

• For the very preterm infant, … PN is the main

source of nutrient intake for the first 2 weeks of

life.

• …ultimate goal … rate of growth close to … fetus

during the third trimester of pregnancy …optimal

brain growth.

• … cumulative energy and protein deficit during

hospital stay can lead to extra-uterine growth

restriction (EUGR).

• … more optimal nutrition though both enteral and

intravenous routes may prevent EUGR

Parenteral Nutrition for Preterm

Infants: Issues and Strategy

• … association between growth rate in the

first few weeks and long term

neurodevelopment … in …retrospective,

observational studies.

• … subjected to multiple sources of bias,

… correlation does not necessarily imply

a causal relationship, and … paucity of of

prospective, randomized trials.

Parenteral Nutrition for Preterm

Infants: Issues and Strategy

• Amino acid supply … the driver of growth,

and should be started from the time of birth,

if possible at rates recommended. … room for

improvement in the composition of parenteral

amino acid mixtures.

• Non-protein energy supply should combine

glucose and fat from the time of birth, and

primarily aims at covering brain requirements

for energy (glucose), and building materials

(poly-unsaturated fatty acids).

Parenteral Nutrition for Preterm

Infants: Issues and Strategy

• In children born preterm, … whether the risk of

developing chronic disease at adulthood is linked

to catch-up growth occurring after extra-uterine

growth restriction, or to a ‘poor quality’ of

growth (suboptimal fat/lean body mass

accretion).

• Optimized, personalized—rather than

‘aggressive’—intravenous nutrition may help

prevent both EUGR and suboptimal lean/fat mass

accretion, and may, in turn, improved long term

health outcomes.

Parenteral Nutrition for Preterm

Infants: Issues and Strategy

• … it appears reasonable to propose a more

optimal initial PN, and to follow the

recommended intakes.

• Based on the current nutritional knowledge,

the prevention of the onset of EUGR can be

used as a surrogate and intermediate marker

of adequate nutrition.

• More randomized trials …

Futurs travaux

• Ecritures en cours…

• Participation aux travaux de l’ANSES

• Participation aux travaux du codex

alimentarius

• Sujets d’intérêt en commun avec le GFGHNP