Latin American Consensus: Children Born Small for Gestational Age

Background: Children born small for gestational age (SGA) experience higher rates of morbidity and mortality than those born appropriate for gestational age. In Latin America, identification and optimal management of children born SGA is a critical issue. Leading experts in pediatric endocrinology throughout Latin America established working groups in order to discuss key challenges regarding the evaluation and management of children born SGA and ultimately develop a consensus statement. Discussion: SGA is defined as a birth weight and/or birth length greater than 2 standard deviations (SD) below the population reference mean for gestational age. SGA refers to body size and implies length-weight reference data in a geographical population whose ethnicity is known and specific to this group. Ideally, each country/region within Latin America should establish its own standards and make relevant updates. SGA children should be evaluated with standardized measures by trained personnel every 3 months during year 1 and every 6 months during year 2. Those without catch-up growth within the first 6 months of life need further evaluation, as do children whose weight is <= -2 SD at age 2 years. Growth hormone treatment can begin in SGA children > 2 years with short stature (< -2.0 SD) and a growth velocity < 25th percentile for their age, and should continue until final height (a growth velocity below 2 cm/year or a bone age of > 14 years for girls and > 16 years for boys) is reached. Blood glucose, thyroid function, HbA1c, and insulin-like growth factor-1 (IGF-1) should be monitored once a year. Monitoring insulin changes from baseline and surrogates of insulin sensitivity is essential. Reduced fetal growth followed by excessive postnatal catch-up in height, and particularly in weight, should be closely monitored. In both sexes, gonadal function should be monitored especially during puberty. Summary: Children born SGA should be carefully followed by a multidisciplinary group that includes perinatologists, pediatricians, nutritionists, and pediatric endocrinologists since 10% to 15% will continue to have weight and height deficiency through development and may benefit from growth hormone treatment. Standards/guidelines should be developed on a country/region basis throughout Latin America.

Prevalence, magnitude, and methods of rapid weight loss among judo competitors

ARTIOLI, G. G., B. GUALANO, E. FRANCHINI, F. B. SCAGLIUSI, M. TAKESIAN, M. FUCHS, and A. H. LANCHA. Prevalence, Magnitude, and Methods of Rapid Weight Loss among Judo Competitors. Med. Sci. Sports Exerc., Vol. 42, No. 3, pp. 436-442, 2010. Purpose: To identify the prevalence, magnitude, and methods of rapid weight loss among judo competitors. Methods: Athletes (607 males and 215 females; age = 19.3 +/- 5.3 yr, weight = 70 +/- 7.5 kg, height = 170.6 +/- 9.8 cm) completed a previously validated questionnaire developed to evaluate rapid weight loss in judo athletes, which provides a score. The higher the score obtained, the more aggressive the weight loss behaviors. Data were analyzed using descriptive statistics and frequency analyses. Mean scores obtained in the questionnaire were used to compare specific groups of athletes using, when appropriate, Mann-Whitney U-test or general linear model one-way ANOVA followed by Tamhane post hoc test. Results: Eighty-six percent of athletes reported that have already lost weight to compete. When heavyweights are excluded, this percentage rises to 89%. Most athletes reported reductions of up to 5% of body weight (mean +/- SD: 2.5 +/- 2.3%). The most weight ever lost was 2%-5%, whereas a great part of athletes reported reductions of 5%-10% (mean +/- SD: 6 +/- 4%). The number of reductions underwent in a season was 3 +/- 5. The reductions usually occurred within 7 +/- 7 d. Athletes began cutting weight at 12.6 +/- 6.1 yr. No significant differences were found in the score obtained by male versus female athletes as well as by athletes from different weight classes. Elite athletes scored significantly higher in the questionnaire than nonelite. Athletes who began cutting weight earlier also scored higher than those who began later. Conclusions: Rapid weight loss is highly prevalent in judo competitors. The level of aggressiveness in weight management behaviors seems to not be influenced by the gender or by the weight class, but it seems to be influenced by competitive level and by the age at which athletes began cutting weight.

Efetividade de programa de suplementação alimentar no ganho ponderal de crianças

OBJETIVO: Avaliar a efetividade de programa governamental de suplementação alimentar no ganho ponderal de crianças. MÉTODOS: Estudo de coorte com dados secundários de 25.433 crianças de baixa renda com idade entre seis e 24 meses que ingressaram em programa de distribuição de leite fortificado Projeto Vivaleite, realizado no Estado de São Paulo de 2003 a 2008. O ganho ponderal foi medido por meio dos valores de escores z de peso para idade, calculados pelo padrão da Organização Mundial da Saúde (2007), obtidos, na rotina do programa, ao ingressar e a cada quatro meses durante a permanência. As crianças foram divididas em três grupos de escore z ao entrar: sem comprometimento de peso (z > -1); risco de baixo peso (-2 < z < -1) e baixo peso (z < -2). Utilizou-se regressão linear multinível (modelo misto), permitindo a comparação, em cada idade, das médias ajustadas do escore z dos ingressantes e participantes há pelo menos quatro meses, ajustadas para correlação entre medidas repetidas. RESULTADOS: Verificou-se efeito positivo do programa no ganho de peso das crianças, variando em função do estado nutricional ao ingressar; para as que entraram sem comprometimento de peso, o ganho médio ajustado foi 0,183 escore z;entre as que entraram com risco de baixo peso, foi 0,566; e entre as ingressantes com baixo peso, foi 1,005 escore z. CONCLUSÕES: O programa é efetivo para o ganho ponderal de crianças menores de dois anos, com efeito mais pronunciado entre as crianças que entram no programa em condições menos favoráveis de peso.

Fetal cystoscopy for severe lower urinary tract obstruction-initial experience of a single center

Objective To report the experience with fetal cystoscopy and laser fulguration of posterior urethral values (PUV) for severe lower urinary tract obstruction (LUTO). Methods Between July 2006 and December 2008, fetal cystoscopy was offered to 23 patients whose fetuses presented with severe LUTO. favorable urinary analysis and gestational age <26 weeks. Fetal urinary biochemistry was evaluated before and after cystoscopy. All infants were followed 6-12 months after birth. Abnormal renal function was defined when serum creatinine higher than 50 mu mol/L (2 Standard Deviation) or the necessity of dialysis or renal transplantation. Autopsy was always performed whenever fetal or neonatal deaths occurred. Results Eleven patients decided to undergo fetal therapy and 12 elected to continue with expectant observation. There was no difference between both groups in gestation age at diagnosis and referral examinations. Urethral atresia was diagnosed in 4/11 (36.4%) fetuses by fetal cystoscopy. At 26 weeks, fetuses that were managed expectantly presented with worse urinary biochemistry results (p < 0.05). Survival rates and percentage of infants with normal renal function were significantly higher in the cystoscopic group than in the expectant group (P < 0.05). Conclusions Percutaneous fetal cystoscopy is feasible using a thinner special cannula for prenatal diagnosis and therapy of LUTO. Prenatal laser ablation of the PUV under cystoscopy may prevent renal function deterioration improving postnatal outcome. Copyright (C) 2009 John Wiley & Sons, Ltd.

Abuse liability of intra-nasal midazolam in inhaled-cocaine abusers

Intra-nasally instilled benzodiazepines have been proposed for acute anxiety episodes. However, routes with faster absorption may increase abuse liability. This study compared abuse liability of intra-nasal midazolam between subjects with a history of intra-nasal drug abuse and non-psychiatric subjects on a single-blind randomized controlled trial. Thirty-one inhaled-cocaine abusers and 34 normal volunteers received either 1 mg intra-nasal midazolam or active placebo. Visual analogue scales assessing desire to repeat the experience (ER) and Experience Liking (EL) assessed abuse liability. Profile analysis for repeated measures showed a significant effect of time over ER (F-[5,F-57]=3.311, p=0.011) and EL (F-[5,F-57]=3.947, p=0.004), diagnostic group (cocaine abusers scoring higher on both - F-[5,F-57]=5.229, p=0.026; F-[5,F-57]=4.946, p=0.030), regardless of the administered substance. It is concluded that the intra-nasal route does not seem to pose risks for non-psychiatric individuals, but it may represent a risk in itself for subjects with a history of drug abuse through this path. (C) 2008 Elsevier B.V. and ECNP. All rights reserved.

Laryngeal split and rib cartilage interpositional grafting: Treatment option for glottic/subglottic stenosis in adults

Objectives: Severe glottic/subglottic stenosis (complex laryngotracheal stenosis) is a rare but challenging complication of endotracheal intubation. Laryngotracheal reconstruction with cartilage graft and an intralaryngeal stent is a procedure described for complex laryngotracheal stenosis management in children; however, for adults, few options remain. Our aim was to analyze the results of laryngotracheal reconstruction as a treatment for complex laryngotracheal stenosis in adults, considering postoperative and long-term outcome. Methods: Laryngotracheal reconstruction (laryngeal split with anterior and posterior interposition of a rib cartilage graft) has been used in our institution to manage glottic/subglottic stenosis restricted to the larynx; laryngotracheal reconstruction associated with cricotracheal resection has been used to treat glottic/subglottic/upper tracheal stenosis (extending beyond the second tracheal ring). A retrospective study was conducted, including all patients with complex laryngotracheal stenosis treated surgically in our institution from January of 2002 until December of 2005. Results: Twenty patients (10 male and 10 female patients; average age, 36.13 years; age range, 18-54 years) were included. There were no deaths, and the postoperative complications were as follows: dysphonia, 25%; subcutaneous emphysema, 10%; tracheocutaneous fistula, 20%; wound infection, 15%; and bleeding, 5.0%. Eighty percent of the patients were completely decannulated after a mean of 23.4 months of follow-up (range, 4 -55 months). Conclusions: Laryngeal split with anterior and posterior cartilage graft interposition as an isolated procedure or associated with a cricotracheal resection is a feasible and low-morbidity alternative for complex laryngotracheal stenosis treatment.

Gastroesophageal Reflux in Severe Cases of Robin Sequence Treated With Nasopharyngeal Intubation

Objective: To study the prevalence of abnormal gastroesophageal reflux in infants with Robin sequence who had severe respiratory obstruction treated with nasopharyngeal intubation and to evaluate the efficacy of nonsurgical treatment. Design: Longitudinal prospective study. Setting: Hospital de Reabilitacao de Anomalias Craniofaciais, University of Sao Paulo, Brazil. Patients: Twenty infants with severe isolated Robin sequence treated with nasopharyngeal intubation. Interventions: We performed 24-hour esophageal pH monitoring on each child at 2, 4, and 6 months of age. Respiratory and feeding status were evaluated. We considered abnormal gastroesophageal reflux as reflux index values above the 95th percentile of the Vandenplas reference for normal children. Results: The prevalence of reflux index above the 95th percentile at the first exam was 6/20, a value significantly higher than the reference (5/103, p < .01). At the second and third exams, reflux index values were decreased. Ninety percent of the infants showed improvement of respiratory difficulty and developed oral feeding capacity. Conclusions: The prevalence of abnormal gastroesophageal reflux is higher in infants with severe cases of Robin sequence than in normal infants. Nonsurgical procedures improved respiratory and feeding difficulties of most of these infants.

Reactivity of Nellore steers in two feedlot housing systems and its relationship with plasmatic cortisol

To evaluate reactivity to assess the temperament of Nellore steers in two feedlot housing systems (group pen or individual pen) and its relationship with plasmatic cortisol, 36 experimental units were observed five times at 28-day intervals of weight management during a 112-day feedlot confinement. A reactivity score scale ranging from 1 to 5 was applied when an animal was in the chute system. To the calmest animal, a reactivity score of 1 was ascribed and to the most agitated, 5. Blood samples were collected for cortisol analysis. No differences were found in reactivity and feedlot system. There was a relationship noted between reactivity and feedlot time in both housing systems (P < 0.01). There was a relation between reactivity and cortisol levels for group animals (P = 0.0616) and for individual ones (P < 0.01). Cortisol levels varied among housing systems (P < 0.01). Feedlot time influenced the cortisol levels (P < 0.09 individual; P < 0.01 group) and when variable time was included, these levels changed, decreasing in the group pen and increasing in individual pens. The continuous handling reduces reactivity and plasmatic cortisol, and group pen system seems to be less stressfully than individual pens. (C) 2010 Elsevier B.V. All rights reserved.

Ratio of weight to height gain: a useful tool for identifying children at risk of becoming overweight or obese at preschool age

PURPOSE: To analyze the usefulness of the weight gain/height gain ratio from birth to two and three years of age as a predictive risk indicator of excess weight at preschool age. METHODS: The weight and height/length of 409 preschool children at daycare centers were measured according to internationally recommended rules. The weight values and body mass indices of the children were transformed into a z-score per the standard method described by the World Health Organization. The Pearson correlation coefficients (rP) and the linear regressions between the anthropometric parameters and the body mass index z-scores of preschool children were statistically analyzed (alpha = 0.05). RESULTS: The mean age of the study population was 3.2 years (± 0.3 years). The prevalence of excess weight was 28.8%, and the prevalence of overweight and obesity was 8.8%. The correlation coefficients between the body mass index z-scores of the preschool children and the birth weights or body mass indices at birth were low (0.09 and 0.10, respectively). There was a high correlation coefficient (rP = 0.79) between the mean monthly gain of weight and the body mass index z-score of preschool children. A higher coefficient (rP = 0.93) was observed between the ratio of the mean weight gain per height gain (g/cm) and the preschool children body mass index z-score. The coefficients and their differences were statistically significant. CONCLUSION: Regardless of weight or length at birth, the mean ratio between the weight gain per g/cm of height growth from birth presented a strong correlation with the body mass index of preschool children. These results suggest that this ratio may be a good indicator of the risk of excess weight and obesity in preschool-aged children.

Weight loss associated with exercise training restores ventilatory efficiency in obese children

The purpose of this study was to test the hypothesis that in obese children: 1) Ventilatory efficiency (VentE) is decreased during graded exercise; and 2) Weight loss through diet alone (D) improves VentE, and 3) diet associated with exercise training (DET) leads to greater improvement in VentE than by D. Thirty-eight obese children (10 +/- 0.2 years; BMI > 95(th) percentile) were randomly divided into two Study groups: D (n=17; BMI = 30 +/- 1 kg/m(2)) and DET (n = 21; 28 +/- 1 kg/m(2)). Ten lean children were included in a control group (10 +/- 0.3 years; 17 +/- 0.5 kg/m(2)). All children performed maximal treadmill testing with respiratory gas analysis (breath-by-breath) to determine the ventilatory anaerobic threshold (VAT) and peak oxygen consumption (VO(2) peak). VentE was determined by the VE/VCO(2) method at VAT. Obese children showed lower VO(2) peak and lower VentE than controls (p < 0.05). After interventions, all obese children reduced body weight (p < 0.05). D group did not improve in terms of VO(2) peak or VentE (p > 0.05). In contrast, the DET group showed increased VO(2) peak (p = 0.01) and improved VentE(Delta VE/VCO(2) = -6.1 +/- 0.9; p = 0.01). VentE is decreased in obese children, where weight loss by means of DET, but not D alone, improves VentE and cardiorespiratory fitness during graded exercise.

Effects of Perilipin (PLIN) Gene Variation on Metabolic Syndrome Risk and Weight Loss in Obese Children and Adolescents

Context: Genetic polymorphisms at the perilipin (PLIN) locus have been investigated for their potential utility as markers for obesity and metabolic syndrome (MS). We examined in obese children and adolescents (OCA) aged 7-14 yr the association of single-nucleotide polymorphisms (SNP) at the PLIN locus with anthropometric, metabolic traits, and weight loss after 20-wk multi-disciplinary behavioral and nutritional treatment without medication. Design: A total of 234 OCA [body mass index (BMI = 30.4 +/- 4.4 kg/m(2); BMI Z-score = 2.31 +/- 0.4) were evaluated at baseline and after intervention. We genotyped four SNPs (PLIN1 6209T -> C, PLIN4 11482G -> A, PLIN5 13041A -> G, and PLIN6 14995A -> T). Results: Allele frequencies were similar to other populations, PLIN1 and PLIN4 were in linkage disequilibrium (D` = 0.999; P < 0.001). At baseline, no anthropometric differences were observed, but minor allele A at PLIN4 was associated with higher triglycerides (111 +/- 49 vs. 94 +/- 42 mg/dl; P = 0.003), lower high-density lipoprotein cholesterol (40 +/- 9 vs. 44 +/- 10 mg/dl; P = 0.003) and higher homeostasis model assessment for insulin resistance (4.0 +/- 2.3 vs. 3.5 +/- 2.1; P +/- 0.015). Minor allele A at PLIN4 was associated with MS risk (age and sex adjusted) hazard ratio 2.4 (95% confidence interval = 1.1-4.9) for genotype GA and 3.5 (95% confidence interval = 1.2-9.9) for AA. After intervention, subjects carrying minor allele T at PLIN6 had increased weight loss (3.3 +/- 3.7 vs. 1.9 +/- 3.4 kg; P = 0.002) and increased loss of the BMI Z-score (0.23 +/- 0.18 vs. 0.18 +/- 0.15; P +/- 0.003). Due to group size, risk of by-chance findings cannot be excluded. Conclusion: The minor A allele at PLIN4 was associated with higher risk of MS at baseline, whereas the PLIN6 SNP was associated with better weight loss, suggesting that these polymorphisms may predict outcome strategies based on multidisciplinary treatment for OCA. (J Clin Endocrinol Metab 93: 4933-4940, 2008)

Long-Term Results of Percutaneous Bilioenteric Anastomotic Stricture Treatment in Liver-Transplanted Children

The purpose of this study was to evaluate the mid- and long-term results of percutaneous transhepatic cholangiography (PTC) and biliary drainage in children with isolated bilioenteric anastomotic stenosis (BAS) after pediatric liver transplantation. Sixty-four children underwent PTC from March 1993 to May 2008. Nineteen cholangiograms were normal; 10 showed intrahepatic biliary stenosis and BAS, and 35 showed isolated BAS. Cadaveric grafts were used in 19 and living donor grafts in 16 patients. Four patients received a whole liver, and 31 patients received a left lobe or left lateral segment. Roux-en-Y hepaticojejunostomy was performed in all patients. Indication for PTC was based on clinical, laboratory, and histopathologic findings. In patients with isolated BAS, dilation and biliary catheter placement, with changes every 2 months, were performed. Patients were separated into 4 groups according to number of treatment sessions required. The drainage catheter was removed if cholangiogram showed no significant residual stenosis and normal biliary emptying time after a minimum of 6 months. The relationship between risk factors (recipient`s weight < 10 kg, previous exposure to Cytomegalovirus, donor-recipient sex and weight relations, autoimmune disease as indication for transplantion, previous Kasai`s surgery, use of reduced liver grafts, chronic or acute rejection occurrence) and treatment was evaluated. Before PTC, fever was observed in 46%, biliary dilation in 23%, increased bilirubin in 57%, and increased gamma-glutamyltransferase (GGT) in 100% of patients. In the group with BAS, 24 of 35 (69%) patients had histopathologic findings of cholestasis as did 9 of 19 (47%) patients in the group with normal PTC. Of the 35 patients, 23 (65.7%) needed 1 (group I), 7 needed 2 (group II), 4 needed 3 (group III), and 1 needed 4 treatment sessions (group IV). The best results were observed after 1 treatment session, and the mean duration of catheter placement and replacement was 10 months. The primary patency rate was 61.2%, and the recurrence rate was 34.3% (group I). Seven patients (7 of 35; 20%) had their stricture treated with a second treatment session (group II). The average drainage time in group II was 24 months. During a period > 20 months, 4 patients (4 of 35; 11.4%) required 1 additional treatment session (group III), and 1 patient (1 of 35; 2.9%) had a catheter placed at the end of the study period (group IV). Drainage time in group I was significantly shorter than those in groups II, III, and IV (p < 0.05). There was no statistically significant relation between therapeutic response and the selected risk factors (p > 0.05). The majority of complications, such as catheter displacement and leakage, were classified as minor; however, 2 patients (5.7%) with hemobilia were noted. Complications increased according to the need for reintervention. In conclusion, balloon dilation and percutaneous drainage placement is safe and effective, and it has long-term patency for children with BAS after liver transplantation. Because of prolonged treatment time, reintervention may be necessary, thereby increasing the complication rate. Balloon dilation and percutaneous drainage placement should be considered as the first treatment option because of its minimally invasive nature.

Craniocervical posture and hyoid bone position in children with mild and moderate asthma and mouth breathing

Introduction The objective of the present study was to assess the craniocervical posture and the positioning of the hyoid bone in children with asthma who are mouth breathers compared to non-asthma controls. Methods The study was conducted on 56 children, 28 of them with mild (n = 15) and moderate (n = 13) asthma (14 girls aged 10 79 +/- 1 31 years and 14 boys aged 9 79 +/- 1.12 years), matched for sex, height, weight and age with 28 non-asthma children who are not mouth breathers The sample size was calculated considering a confidence interval of 95% and a prevalence of 4% of asthma in Latin America. Eighteen variables were analyzed in two radiographs (latero-lateral teleradiography and lateral cervical spine radiography), both obtained with the head in a natural position The independent t-test was used to compare means values and the chi-square test to compare percentage values (p < 0 05) Intraclass correlation coefficient (ICC) was used to verify reliability. Results. The Craniovertebral Angle (CVA) was found to be significantly smaller in asthma than in control children (106.38 +/- 766 vs. 111 21 +/- 7.40. p = 0 02) and the frequency of asthma children with an absent or inverted hyoid triangle was found to be significantly higher compared to non-asthma children (36% vs 7%, p = 0.0001). The values of the inclination angles of the superior cervical spine in relation to the horizontal plane were significantly higher in moderate than in mild asthma children (CVT/Hor 85 10 +/- 725 vs. 90 92 +/- 6.69, p = 0 04 and C1/Hor. 80 93 +/- 5.56 vs 85 00 +/- 4 20, p = 0 04) Conclusions These findings revealed that asthma children presented higher head extension and a higher frequency of changes in hyoid bone position compared to non-asthma children and that greater the asthma severity greater the extension of the upper cervical spine. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

The relationship between birth weight and insulin resistance in childhood

Chronic diseases that are typical of adulthood may originate in intra-uterine life through inadequate fetal development. The present epidemiological cohort study of 506 healthy children aged 5\20138 years evaluated the relationship between birth weight and insulin resistance in an age group that has been assessed in few similar studies. Insulin concentration was determined by chemiluminescence and insulin resistance by the homeostasis model assessment (HOMA). Blood glucose, total cholesterol and fractions (LDL cholesterol and HDL cholesterol) and TAG concentrations were determined by automated enzymatic methods. Linear regression analysis investigated the relationship between birth weight (assessed as a continuous variable and in three categories: small for gestational age, SGA; adequate for gestational age and large for gestational age) and the HOMA index, using backward stepwise selection and biological models to explain the causal pathway of the relationship. There were negativeassociations between birth weight (P < 0·001), SGA (P = 0·027) and the HOMA index, and a positive association between waist circumference (P < 0·001) and the HOMA index. Considering the significant associations between birth weight and waist circumference (P < 0·001) and waist circumference and insulin resistance (P < 0·001), we can probably suspect that lower birth weight is a common cause of higher waist circumference and insulin resistance. In summary, the results of the present study showed increased insulin resistance in apparently healthy, young children, who had lower weight at birth and higher measurements of waist circumference. There is a need to develop public health policies that adopt preventive measures to promote adequate maternal-fetal and child development and enable early diagnosis of metabolic abnormalities

A survey on clinical presentation and nutritional status of infants with suspected cow' milk allergy

Background: Cow's milk is the most common food allergen in infants and the diagnosis of cow's milk allergy is difficult, even with the use of several diagnostic tests. Therefore, elimination diets and challenge tests are essential for the diagnosis and treatment of this disorder. The aim of this study is to report the clinical presentation and nutritional status of children evaluated by pediatric gastroenterologists for the assessment of symptoms suggestive of cow's milk allergy. Methods: An observational cross-sectional study was performed among 9,478 patients evaluated by 30 pediatric gastroenterologists for 40 days in 5 different geographical regions in Brazil. Clinical data were collected from patients with symptoms suggestive of cow's milk allergy. The nutritional status of infants (age <= 24 months) seen for the first time was evaluated according to z-scores for weight-for-age, weight-for-height, and height-for-age. Epi-Info (CDC-NCHS, 2000) software was used to calculate z-scores. Results: The prevalence of suspected cow's milk allergy in the study population was 5.4% (513/9,478), and the incidence was 2.2% (211/9,478). Among 159 infants seen at first evaluation, 15.1% presented with a low weight-for-age z score (< -2.0 standard deviation - SD), 8.7% with a low weight-for-height z score (< -2.0 SD), and 23.9% with a low height-for-age z score (< -2.0 SD). Conclusion: The high prevalence of nutritional deficits among infants with symptoms suggestive of cow's milk allergy indicates that effective elimination diets should be prescribed to control allergy symptoms and to prevent or treat malnutrition.