Deficiencies and missed opportunities to formulate clinical guidelines in Australia for withholding or withdrawing life-sustaining treatment in severely disabled and impaired infants

This paper examines the few, but important legal and coronial cases concerning withdrawing or withholding life-sustaining treatment from severely disabled or critically impaired infants in Australia. Although sparse in number, the judgements should influence common clinical practices based on assessment of “best interests” but these have not yet been adopted. In particular, although courts have discounted assessment of “quality of life” as a legitimate component of determination of “best interests,” this remains a prominent component of clinical guidelines. In addition, this paper highlights the lack of uniform clinical guidelines available to medical professionals and parents in Australia when making end-of-life decisions for severely ill infants. Thus, it is argued here that there is a need for an overarching prescriptive uniform framework or set of guidelines in end-of-life decision-making for impaired infants. This would encourage greater transparency, consistency, and some degree of objectivity in an area that often appears subjective.

Is iron and zinc nutrition a concern for vegetarian infants and young children in industrialized countries?

Well-planned vegetarian diets are considered adequate for all stages of the life cycle, despite limited data on the zinc status of vegetarians during early childhood. The bioavailability of iron and zinc in vegetarian diets is poor because of their higher content of absorption inhibitors such as phytate and polyphenols and the absence of flesh foods. Consequently, children as well as adult vegetarians often have lower serum ferritin concentrations than omnivores, which is indicative of reduced iron stores, despite comparable intakes of total iron; hemoglobin differences are small and rarely associated with anemia. However, data on serum zinc concentrations, the recommended biomarker for identifying population groups at elevated risk of zinc deficiency, are sparse and difficult to interpret because recommended collection and analytic procedures have not always been followed. Existing data indicate no differences in serum zinc or growth between young vegetarian and omnivorous children, although there is some evidence of low serum zinc concentrations in vegetarian adolescents. Some vegetarian immigrants from underprivileged households may be predisposed to iron and zinc deficiency because of nondietary factors such as chronic inflammation, parasitic infections, overweight, and genetic hemoglobin disorders. To reduce the risk of deficiency, the content and bioavailability of iron and zinc should be enhanced in vegetarian diets by consumption of fortified cereals and milk, by consumption of leavened whole grains, by soaking dried legumes before cooking and discarding the soaking water, and by replacing tea and coffee at meals with vitamin C-rich drinks, fruit, or vegetables. Additional recommended practices include using fermented soy foods and sprouting at least some of the legumes consumed. Fortified foods can reduce iron deficiency, but whether they can also reduce zinc deficiency is less certain. Supplements may be necessary for vegetarian children following very restricted vegan diets.

Observable essential fatty acid deficiency markers and autism spectrum disorder

Autism Spectrum Disorder (ASD) has been associated with essential fatty acid (EFA) deficiencies, with some researchers theorising that dysregulation of phospholipid metabolism may form part of the biological basis for ASD. This pilot study compared observable signs of fatty acid status of 19 children with an ASD diagnosis to 23 of their typically developing siblings. A pregnancy, birth and breastfeeding history was also obtained from their parents, which included a measure of infant intake of fatty acid rich colostrum immediately post-partum. When considered within their family group, those infants not breastfed (with colostrum) within the first hour of life and who had a history of fatty acid deficiency symptoms were more likely to have an ASD diagnosis. Other variables such as formula use, duration of breastfeeding, gestational age and Apgar scores were not associated with group membership. The results of this study are consistent with previous research showing a relationship between fatty acid metabolism, breastfeeding and ASD such that early infant feeding practices and the influence this has on the fatty acid metabolism of the child may be a risk factor for ASD.

Environmental and genetic determinants of vitamin D insufficiency in 12-month-old infants

We aimed to investigate the relationship between genetic and environmental exposure and vitamin D status at age one, stratified by ethnicity. This study included 563 12-month-old infants in the HealthNuts population-based study. DNA from participants' blood samples was genotyped using Sequenom MassARRAY MALDI-TOF system on 28 single nucleotide polymorphisms (SNPs) in six genes. Using logistic regression, we examined associations between environmental exposure and SNPs in vitamin D pathway and filaggrin genes and vitamin D insufficiency (VDI). VDI, defined as serum 25-hydroxyvitamin D3(25(OH)D3) level ≤50 nmol/L, was measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Infants were stratified by ethnicity determined by parent's country of birth. Infants formula fed at 12 months were associated with reduced odds of VDI compared to infants with no current formula use at 12 months. This association differed by ethnicity (P;bsubesub;= 0.01). The odds ratio (OR) of VDI was 0.29 for Caucasian infants (95% CI, 0.18-0.47) and 0.04 for Asian infants (95% CI, 0.006-0.23). Maternal vitamin D supplementation during pregnancy and/or breastfeeding were associated with increased odds of infants being VDI (OR, 2.39; 95% CI, 1.11-5.18 and OR, 2.5; 95% CI, 1.20-5.24 respectively). Presence of a minor allele for any GC SNP (rs17467825, rs1155563, rs2282679, rs3755967, rs4588, rs7041) was associated with increased odds of VDI. Caucasian infants homozygous (AA) for rs4588 had an OR of 2.49 of being associated with VDI (95% CI, 1.19-5.18). In a country without routine infant vitamin D supplementation or food chain fortification, formula use is strongly associated with a reduced risk of VDI regardless of ethnicity. There was borderline significance for an association between filaggrin mutations and VDI. However, polymorphisms in vitamin D pathway related genes were associated with increased likelihood of being VDI in infancy. © 2014 Elsevier B.V. All rights reserved.

Tube-weaning infants and children: a survey of Australian and international practice

The aim of this study was to describe paediatric feeding-tube weaning practice in Australian children's hospitals and to compare this with practice in tube weaning programmes internationally.

Prevalence and stability of active play, restricted movement and television viewing in infants

This study describes engagement in and stability of physical activity and sedentary behaviours in early life, and assesses associations with sex, maternal education and developmental stage. Maternal-report data at child age 4, 9 and 20 months were collected from 542 families in the Melbourne Infant Feeding Activity and Nutrition Trial Program. Parents estimated average time per day their child spent in active pursuits or pursuits that restricted movement. With increasing age, children generally spent more time in active pursuits and watching television, and less time in situations that restrict movement. Associations were found with age of developmental milestone attainment but not sex or maternal education. Stability over time was strongest for television viewing (β = 0.34–0.38) and time spent outdoors (β = 0.27–0.33). Contrary to guidelines, television viewing increased and showed stability, suggesting a need to target this behaviour very early in life to achieve optimal longer term outcomes.