Professor John Feehally

  • Professor of Renal Medicine
  • John Walls Renal Unit
  • Leicester General Hospital
  • Leicester

Mosquitoes develop that feed by filtering particulate matter from in a wide range of aquatic larval habitats and water; they must remain in contact with the in all climates from the arctic to the tropics weight loss pills jadera order alli online pills. The pupae weight loss unexplained causes buy alli with paypal, known as Adult mosquitoes are generally similar in "tumblers weight loss pills bee pollen discount 60mg alli visa," are comma-shaped and aquatic weight loss pills johnson city tn cheap alli 60mg amex. Males and females feed on nectars and sugars weight loss meds 60mg alli with amex, although females of most species also feed on blood weight loss pills 2x purchase alli 60mg overnight delivery. Consequently, a female may take a blood meal every 2-4 days and contact Figure 38. Anopheles stephensi, a malaria vector found in Asia, particularly India and Pakistan. Some species are exclusively zooSubfamily Anophelinae philic, some are anthropophilic, and others are nonspecific biters. Feeding habits also the genus Anopheles contains the species vary between species. Certain species readily responsible for the transmission of human enter houses and feed on sleeping individumalaria. The aquatic larvae attach tropics, these mosquitoes breed continually, to the surface and assume a horizontal posi- although their population levels may fluctution. The larval period may last 1-3 weeks, ate drastically in relation to rainfall and dry depending on temperature. Although some spe- as malaria vectors within any geographic area cies are capable of extended flight and disper- (e. Anopheles dirus, one of the major malaria vectors in Southeast Asia, performing "plasmapheresis". Populations vary within each species with respect to their competence as vectors and capacity for transmission. Intense study has led to the division of several well-established species of vectors into morphologically similar but genetically distinct groups or complexes of species. Similar revision of species has resulted in a clearer definition of the members of the European complex and the Southeast Asian group. It appears that reexamination of most of the anopheline species that occupy large or ecologically diverse geographic areas will lead to the description of closely related but genetically divergent species. To learn more about the ecology of anopheline mosquitoes and control programs that take advantage of their biology, see Subfamily Culicinae the subfamily Culicinae consists of more than 1500 species distributed among 20 genera, six of which (Aedes, Ochlerotatus, Culex, Mansonia, Psorophora, and Culiseta) are of major importance to human health. Culicine mosquitoes are primary vectors of a number of viruses and filariae and pose a serious problem as pest insects in many parts of the world. Several species formerly recognized as members of the genus Aedes, the largest of the Culicine genera, have been undergoing a major reorganization. In 2000, the genus was divided into two genera, Aedes and Ochlerotatus, on the basis of consistent primary characters of the female and male genitalia. A more dramatic renaming was suggested where common mosquitoes such as Aedes aegypti would be called Stegomyia aegypti and Aedes albopictus renamed Stegomyia albopicta. Mosquitoes of the genera Aedes and Ochlerotatus remain in the "tribe" Aedini, and are found in all habitats, ranging from the tropics to the Arctic. Its eggs are laid singly, without floats, on or near the surface of water or in areas likely to be flooded periodically. Unlike the eggs of anopheles or culex mosquitoes, which usually hatch within a few days of deposition, aedine eggs have the capacity for an extended period of dormancy. This dormancy allows the eggs to survive the winter or to delay hatching until conditions are ideal for development. Aedine mosquitoes occupy salt marsh habitats, flood plains, tree holes, Figure 38. They develop and feed while suspended from the surface of water by a breathing tube. Larvae develop by progressing through four stages over a period of 6-10 days, or longer at lower temperatures. Aedine pupae are typical of those of most mosquitoes; this stage usually lasts less than three days. Adults usually emerge from breeding sites synchronously, followed by mass migrations of females in search of blood. Aedine species may develop overwhelming populations in salt marshes, tundras, pastures, and floodwater, and they have a severe impact on wildlife, livestock, and humans. If left uncontrolled, the salt-marsh mosquitoes of the East Coast of the United States, Ochlerotatus. Populations of Arctic aedes become so great at times that humans and larger mammals do not venture into the tundra area. In some Arctic species, the first egg batch is produced without need of a blood meal, a physiological adaptation termed autogeny. In tropical regions, populations of aedine mosquitoes are usually much smaller than in the Arctic. The mosquito lays eggs above the waterline in these containers, and the eggs remain dormant there, often as long as six months, until the container becomes filled with water. Because this mosquito is closely associated with humans and is almost exclusively anthropophilic, it has most of the characteristics of a good vector. Both of these introduced species are proving to be serious biting pests, particularly in urban and suburban areas of the Eastern and Southeastern U. The genus Culex is the second largest group in the subfamily, best represented by Cx. Culex mosquitoes deposit their eggs in rafts, which usually contain 50-200 eggs cemented together. The four larval stages develop and feed on nutrients in the water, much like aedine mosquitoes. The siphons of larval culex mosquitoes are usually longer and more slender than those of aedines. The larval period lasts less than two weeks and the pupal stage less than two days. Many show a preference for avian blood, but most members also feed on humans or other mammals. Insects 461 adapted to development in polluted waters, breeding in or near population centers and readily biting humans. The genus Mansonia includes a number of species important as vectors of Brugian filariasis. This genus differs in its development from most other mosquitoes in that its larvae and pupae affix themselves below the surface of water to the stems and roots of aquatic plants and derive oxygen from these plants. Culiseta includes several species involved in the transmission of arboviruses to humans. Pathogenesis of the Mosquito Bite the mouthparts of the adult female mosquito are adapted for piercing flesh and sucking the blood needed by the female for the production of eggs. During the act of feeding, the female repeatedly injects saliva, which produces the reaction that follows the bite. Individuals with no previous exposure to mosquitoes show neither immediate nor delayed reactions. After sensitization, a bite is followed by a small, flat wheal surrounded by a red flare, which appears within a few minutes and lasts about 1 hour, and is mediated by antibodies. The delayed reaction consists of itching, swelling, and reddening of the wound region. Eventually loss of the delayed reaction and desensitization can develop after repeated exposures. Desensitization to one species does not necessarily extend to other members of the same genus and usually does not include protection against the bites of mosquitoes of other genera. The intense itching, primarily associated with the delayed reaction, encourages scratching and secondary infection of the wound site. Yellow fever and its primary vector, Aedes aegypti, established itself throughout the tropics with the earliest voyages of exploration and colonization. Aedes albopictus, the Asian tiger mosquito, is a common species in Japan and Korea. Mosquito eggs, carried in used automobile tires, first invaded Houston, Texas where it was detected in 1985. Both species have become serious biting pests in urban and suburban backyards in the eastern U. Yellow fever, caused by a flavivirus, has historically been one of the most serious and widespread of the arboviral infections. The virus causes a severe hemorrhagic disease, characterized by high fever, jaundice, and prostration. The yellow fever virus naturally infects monkeys and is maintained in a monkey-to-monkey sylvatic cycle by forestdwelling mosquitoes. When these individuals return to their villages and become viremic, the ubiquitous Ae. An effective vaccine for yellow fever is available, and is usually required for travelers to endemic areas. Dengue, another flavivirus, is an acute, usually non-fatal viral disease characterized by high fever, severe headache, backache, and arthralgia. There is no verified animal reservoir for dengue; several vaccine candidates, which are effective against all four serotypes of the virus, are being evaluated in clinical and field trials. Under certain conditions, normally ornithophilic mosquito species that had previously fed on viremic birds feed on humans or other mammals. Louis encephalitis may be transmitted by members of the Culex pipiens complex in urban areas, by Cx. In Australia and New Guinea, Murray Valley encephalitis is transmitted by various Culex spp. West Nile virus is a member of the flavivirus group responsible for regular epidemics in human populations in Europe and Africa. It is hypothesized that dry, hot spells of weather of more than two weeks favor such outbreaks in humans. West Nile Virus vaccines have been developed for horses and are commercially available in the United States. A West Nile Virus vaccine protective for humans is undergoing final clinical evaluation. It has yet to be determined if a human vaccine will ever be mass-produced for general use. Two serious arboviruses, both of African origin, invaded the Americas in the second decade of the 21st Century. Chikungunya, an alphavirus, had already been seen in Ravenna, Italy in 2007, but appeared in several islands of the Caribbean in 2013. In 2013, Zika virus, another of the flavivirus group was reported in French Polynesia and in 2015 appeared in Mexico and Brazil. Mosquito Control the most effective method of mosquito control is reduction at the source. Control may take the form of draining of impoundments, level control of large bodies of water, the clearing or filling of ditches, or the elimination of human-made containers. Methodology must be tailored to the specific breeding requirements of the species. The general use of chemical insecticides has obvious potential for deleterious side effects. Given the serious nature of many of the mosquito-borne diseases, insecticide use may be required where reduction at the source is inadequate. The most common and effective method of malaria control employs insecticides applied to the walls of houses. Anopheline malaria vectors tend to rest on walls after feeding; they then come in contact with the residual insecticide and die. Consequently, insecticides applied to the insides of walls affect only those mosquitoes that have fed on humans and are potentially infected. This scheme does little to reduce mosquito populations and usually has little environmental impact; it does, however, reduce the inci- dence of malaria by interrupting transmission of the disease. In addition to toxicity to resting mosquitoes, this insecticide produced a repellant effect that discouraged mosquitoes from entering treated houses. Bed nets, with or without insecticide impregnation, can provide significant protection from feeding mosquitoes. Disposal of used automobile tires and tin cans, clearing gutters of standing water, covering rain barrels, and generally denying water containers to mosquito breeding is an important first step. Control of Aedes aegypti, the primary vector of Zika Virus, has taken a significant leap forward with the demonstration that the release of genetically modified male mosquitos can significantly reduce populations of this species. Field trials of the strategy in Panama, Brazil, and the Cayman Islands have been particularly promising with vector population reductions of over 90%. Food and Drug Administration has approved a field trial to be conducted in a suburb of Key West, Florida. If successful, the use of genetically modified sterile male mosquitos could provide an environmentally friendly method for controlling this important vector without the use of insecticides. However, a coalition of environmental public interest groups has mounted a major campaign to block the field trials. Recent studies have shown that oral ivermectin given to humans and domestic animals will kill anopheline mosquitoes, notably the major African vector An gambiae, and could have a major effect on vector populations and malaria transmission. Tabanidae: Horse and Deer flies the Tabanidae are a large family of bloodsucking dipterans with a cosmopolitan distribution.

Soy protein formulae have no benefit for the prevention of allergy and food intolerance [12] weight loss pills lipofuze purchase alli 60 mg on line. Some of these formulations were shown to be effective for the long-term prevention of allergic manifestations weight loss pills visalia ca purchase alli us, in particular of atopic dermatitis [13] weight loss videos best purchase alli. Therefore weight loss supplements xenadrine cheap alli amex, it is recommended that powdered formula should be freshly prepared for each feed and be fed within a period of 2 h after preparation weight loss zumba purchase 60 mg alli amex. Hospitals weight loss herbs alli 60mg fast delivery, day care centres and other institutions should follow strict hygienic standards as well as written guidelines for the preparation and handling of formula. For neonatal wards, the use of ready-to-feed liquid formula is encouraged where feasible and affordable. Preparation, Storage and Handling of Infant Formula Follow-Up Formula for Infants Powdered formula is sterile and may contain pathogenic bacteria such as Cronobacter spp. Retinol contents shall be provided by preformed retinol, while any contents of carotenoids should not be included in the calculation and declaration of vitamin A activity. The concept of follow-up formula offers the potential to adapt the product composition to the changing needs with increasing age. The current Codex standard for follow-up formula was adopted in 1987 and does not reflect current scientific knowledge. Such products are not necessary to meet the nutritional needs of young children who receive a balanced, quality diet. Systematic review and practice recommendations from an Early Nutrition Academy workshop. Breastfeeding was almost universal in the 19th century until the first commercial breast milk substitutes came out [2]. Thereafter, substitute feeding became available as an alternative to breastfeeding. Soon, in various countries breastfeeding rates decreased significantly, and this had an impact in the form of increased mortality because of diarrhea and infections in developing countries. One main reason behind the drastic fall in breastfeeding to low rates in the late 19th century and in the 20th century was widespread advertising by formula companies. During the 1970s and 1980s, breastfeeding rates picked up again, especially with older and educated mothers in industrialized countries. Formula companies responded by vigorously seeking new markets in the developing world. Companies started giving gifts and other incentives to health workers for promoting formulae. The International Code On May 21, 1981, the 34th meeting of the World Health Assembly adopted the fourth draft of the International Code of Marketing of Breast-Milk Substitutes as a minimum requirement to protect and promote appropriate feeding of infants and young children [4]. It was developed to protect mothers and health workers from commercial pressure by manufacturers of breast milk substitutes. It forbids provision of free samples to mothers or health facilities (except for professional research), because of their negative impact on breastfeeding. It also forbids inducements to health workers, because recipients are more likely to promote a particular product and remain passive in promoting breastfeeding (table 1). By the 1996 World Health Assembly meeting, all 191 member states had affirmed their support for the code, its implementation and the implementation of relevant resolutions. The code also covers ethical considerations and regulations for the marketing of feeding bottles and teats. Even after 3 decades of implementation of the code there are continuing issues of implementation, monitoring and compliance, which predominantly reflect weak governance [5]. Monitoring the Code Violations of the Code Since 1981, when the code was formulated, numerous violations have been reported both from the developing and the developed world. In developing nations, multistage, random sampling of pregnant mothers and mothers of infants less than 6 months old was carried out in 4 cities (Dhaka, Durban, Bangkok and Warsaw) with disappointing results: 26% of mothers in Bangkok received free samples of breast milk substitutes from companies [6]. Many violations were reported in Uganda in a survey of mothers and health workers. In 2008, 70% of 427 health professionals in Pakistan were unaware of their own breastfeeding laws, and 80% unaware of the code; 12% had received sponsorship from pharmaceutical companies for training sessions or attendance at conferences [7]. In India, where advertising is strictly controlled by the Infant Milk Substitutes Act [8], breastfeeding rates are 46% at 5 months of age. In contrast, the Philippines, with much weaker regulations, have 3 times lower breastfeeding rates [9]. In the developed world, marketing tends to be more subtle than in developing countries [10]. The reports on violations demonstrate the need for transparent, independent and effective controls in the marketing of baby food and bottles. Governments should ensure a consistent strategy of monitoring, involving investigation, observation and recording of information. The basics of monitoring include: familiarization with the main points of the International Code and with national measures; obtaining information on the breast milk substitutes locally used; recording details about the company and brand names and the hospitals/clinics where infant formula is used; description of posters, displays, etc. It is now recognized that voluntary initiatives alone are inadequate for implementation of the International Code of Marketing of Breast-Milk Substitutes. Health professionals and breastfeeding organizations call for enforcement of stricter rules. Under the international code, information provided by the manufacturers should not imply or create a belief that bottle feeding is equivalent or superior to breastfeeding. Impact on Mortality and Morbidity In developing countries, numerous studies have reported an increased mortality and morbidity with the use of breast milk substitutes. In a Ghanaian study, neonatal mortality of babies fed after the first 24 h was more than twice that of those fed within the first hour. In the developed world, exclusive breastfeeding has no detectable effect on mortality, but significant reductions in both short-term and long-term morbidity were noted. Failure to breastfeed increases the risk of gastrointestinal disease, acute otitis media and acute lower respiratory tract infection in infancy. In older children, the likelihood of obesity, elevated cholesterol levels, hypertension as well as type 1 and type 2 diabetes is increased. In a recent meta-analysis, negative emotions such as guilt, anger, uncertainty and sense of failure were found more often in mothers of bottle-fed babies [12]. Term small-for-gestational-age babies are at risk of obesity and metabolic problems like hypertension and diabetes. Breastfeeding is protective by preventing accelerated growth in these subsets of babies [13]. This practice led to an increase in infant mortality in resource-poor countries where safe formula feeding was not feasible. Conclusions Situations in Which Breast Milk Substitutes Can Be Used Formula feeding is clearly essential in certain circumstances, such as when the mother is on cytotoxic drugs or is unwilling to breastfeed. Complementary foods are required during the second part of the first year of life for both nutritional and developmental reasons, and to enable the transition from milk feeding to family foods. From a nutritional point of view, the ability of breast milk to continue to meet macro- and micronutrient requirements becomes limited, whereas from a developmental perspective, infants develop the ability to chew and start to show an interest in foods other than milk. Content of the Diet Timing of Complementary Feeding Complementary feeding recommendations and practices are generally not evidence based and vary between countries. Gastrointestinal and renal functions are likely to be sufficiently mature by around 4 months of age to enable infants to process some complementary foods, whereas the age at which infants attain the necessary motor skills is likely to fall within the 4- to 6-month period. There is general consensus that complementary foods should not be given before 17 weeks of age as this may be associated with increased later fatness, respiratory symptoms and eczema. While there is agreement that exclusive breastfeeding for 6 months is desirable in situations where there is a lack of clean drinking water or of safe nutritious complementary foods, there is less consensus regarding infants in higher-income settings. A review by an expert panel of the European Food Safety Authority also concluded that the introduction of complementary Most current guidelines on the gradual introduction of different foods during complementary feeding are based on cultural factors and food availability rather than scientific evidence. In developing countries, the focus is still on providing adequate nutrients to support growth and development, whereas in more affluent environments, achieving a better balance of nutrients and avoiding excess may be more important. Recommendations are based on the concept that breast milk cannot meet the full requirements for energy, protein and micronutrients beyond about 6 months of age. The fat content of the diet is an important determinant of its energy density and should not be less than 25% of energy intake. However, in countries with high rates of childhood obesity, it may be advantageous to accustom children to low-fat products from a fairly early age. Iron and Zinc More than 90% of iron requirements during the complementary feeding period of a breastfed infant must be provided by complementary foods. Salt and Sugar High intakes of salt in infancy may be associated with later higher blood pressure [6]. Furthermore, infants may become accustomed to a salty taste, which could affect subsequent food preferences. Gluten In contrast to data from previous observational studies, the findings from two recent randomised trials have shown that the age at introduction of gluten does not influence the risk of developing coeliac disease. Both trials also concluded that the risk was not influenced by breastfeeding at the time of introduction of gluten [7, 8]. Vegetarian Diets If infants receive a vegetarian diet, it is important that the diet includes a sufficient amount of milk (about 500 ml/day) and dairy products. Vegan diets should be discouraged in infancy, particularly because of the risk of vitamin B12 deficiency, which can affect neurodevelopment. Allergy Certain foods, including egg, fish, nuts and seafood, are potentially allergenic. However, the evidence that delaying the introduction of such foods reduces the risk of developing food allergy is not convincing. Furthermore, the exclusion of fish and eggs from the diet could itself have undesirable nutritional consequences. Taste and Food Acceptance Children are predisposed to like high-energy foods, to prefer sweet and salty tastes and to reject new foods, but these predispositions may be modified by early dietary experience and feeding practices. Nutritional intervention aiming at a reduction in allergy risk should be started early in infancy, and potentially even with the maternal diet during the last weeks of pregnancy. Data on alimentary allergy prevention were obtained in observational cohort studies, which describe associations and can generate hypotheses, and in controlled intervention studies, which can demonstrate causal relationships. The available data do not support the conclusion that maternal elimination diets during pregnancy and lactation provide a benefit for allergy risk reduction in the infant. Maternal Diet and Avoidance of Allergenic Foods during Pregnancy and Lactation Maternal dietary allergen exclusion during pregnancy has been proposed as a potential strategy for reducing allergy risk in the offspring, but the available data do not support any beneficial effects [1]. Whether these low amounts of antigen in breast milk induce sensitization or tolerance is not clear. In a randomized controlled trial, no beneficial effect of avoidance of egg and milk consumption by lactating women was found with regard to the development of allergic disease in children up to 5 years of age [2]. In the absence of beneficial evidence, maternal exclusion diets during pregnancy and lactation for allergy prevention are not recommended. However, there is some evidence that consumption of oily fish by the mother during pregnancy and breastfeeding reduces the risk of allergic diseases in the offspring [3]. Mothers who breastfeed exclusively differ markedly from those who feed formula with regard to education, socioeconomic factors, smoking, keeping pets at home, introduction of other foods, and many other factors which may influence the incidence of allergy. However, evidence from a cluster randomized trial of the promotion of breastfeeding in the Republic of Belarus [4] and from a recent meta-analysis of the effect of breastfeeding on allergy in the offspring support that exclusive breastfeeding for 3 months or longer confers a protective effect against atopic dermatitis during infancy [5]. Feeding Hydrolyzed Infant Formulae Breastfeeding Breastfeeding is preferred for infants because of its nutritional, immunological and psychological benefits. All randomized trials published were performed on infants with an increased atopy risk, based on one parent or sibling affected by allergy, both parents affected, elevated cord blood IgE or other criteria. Some of the studies included additional cointerventions such as maternal dietary or environmental restrictions, or delayed introduction of complementary feeding. For this and other reasons, the Cochrane review has been criticized, and the conclusions were challenged by an international panel of allergy experts [7]. The German Infant Nutritional Intervention study is by far the largest double-blind, randomized, controlled intervention trial in this area, and the only trial sponsored by a governmental grant rather than by industry funds [8, 9]. Among different atopic manifestations (atopic dermatitis, asthma, gastrointestinal manifestations, allergic rhinitis and urticaria), only the risk of atopic dermatitis was reduced by the hydrolyzed formulae. In contrast, the risk reduction with the extensively hydrolyzed whey formula did not reach significance. The effect developed in the first year of live and persisted until the age of 10 years (fig. No significant effect was observed on asthma, allergic rhinitis or sensitization pattern. Cumulative incidence of parent-reported, physi- cian-diagnosed atopic dermatitis in 988 infants who were fed 1 of 4 study formulae during the first 4 months of life and were followed until 10 years of age (per-protocol analysis). A Cochrane review concluded that infant formulae based on soy protein do not reduce allergy risk, including food allergy [10].

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Here weight loss pills with no side effects buy alli pills in toronto, the response of the intestine to a bolus feed depends on the maturity of the gut weight loss pills guarana alli 60mg line. In small infants before 31 weeks of postconceptional age weight loss journey discount 60 mg alli with mastercard, who usually receive low volumes of continuous enteral feed weight loss 4 fat fighting ingredients buy alli 60mg without prescription, ordinary postprandial activity does not occur [9] weight loss pills khloe took buy alli 60mg lowest price. Between 31 and 35 weeks of postconceptional age weight loss pills quiz order 60mg alli amex, postprandial activity is induced in infants by giving them larger volumes of feed. However, the activity remains in a fasting pattern with superimposed, more random postprandial activity. Finally, in infants over 35 weeks of postconceptional age who receive large volumes of bolus feed, there is a disruption in cyclical fasting activity and replacement by continuous activity. Whether this motility pattern can be advanced by pharmacological measures such as the administration of cortisol remains to be seen [10, 11]. Conclusions Feeding of premature infants below 35 weeks of gestation requires knowledge of physiological functions at this time. Whereas digestive and absorptive functions are mostly developed from the 24th week of postconceptional age, gastrointestinal motility is still not very active. From the 31st postconceptional week onward, the quantity of enteral feeds becomes less of a problem. The digestion of fat increases quickly from the 26th week of gestation and can be enhanced by administration of milk lipase via breast milk. Stress and dietary habits during later pregnancy have a significant impact on the microbiota. Even in healthy pregnancy, the maternal microbiota changes considerably between the 1st and the 3rd trimester [3]. Such changes influence the quality and quantity of the initial colonizers of the newborn. Succession of Microbial Communities Establishment of the microbiota in the newborn occurs in a stepwise fashion. In the newborn, initial colonization with facultative anaerobes, enterobacteria, coliforms, proteobacteria, lactobacilli and streptococci is rapidly followed by colonization with anaerobic genera such as Bifidobacterium, Bacteroides, Clostridium and lactic acid bacteria. Although recent research indicates that the interhost differences are much less marked than previously thought, molecular analyses demonstrate differences between the microbiota of formula-fed and breastfed infants with respect to bifidobacterial numbers and species composition. Lactic acid bacteria composition in breastfed and formula-fed infants is similar (with some geographic differences), with Lactobacillus casei group microorganisms such as L. Differences in microbiota between breastfed and formula-fed infants have lessened with improved infant formulae. Breastfeeding also facilitates the exchange of microbes between mother and infant, since breast milk itself is a rich source of bacteria. Of note, the breast milk microbiota in mothers having a cesarian section differs from that of mothers having a vaginal delivery [6]. Microbes are also exchanged via skin contact and exposure to the microbiota in the immediate environment. Every individual has a unique, characteristic microbiota during later phases of breastfeeding that comprises a dynamic mixture of microbes typical to each individual. Weaning, introduction of solid foods, and antimicrobial drug treatment will break the constant supply of oligosaccharides and microbes from the mother, thus affecting intestinal microbiota development. Bifidobacterium and Ruminococcus species dominate the intestinal microbiota with highlevel, stable expression over time. A Canadian study on 4-month-old infants reported higher bifidobacterial levels and lower clostridial numbers in breastfed infants than in infants receiving formula [14]. The healthy intestinal microbiota in infancy is characterized by a large Gram-positive bacterial population which contains significant numbers of bifidobacteria, mainly B. Lactic acid bacteria may play a role in providing the right intestinal environment for bifidobacteria to dominate. A healthy microbiota during infancy is particularly important as this establishes the basis for healthy gut microbiota later in life. Gut Microbiota in Infants from Six Months Onward After the first 6 months of life, the microbiota becomes more diverse [1, 6, 9]. Relative changes in gut microbiota composition suggested by culture-dependent and culture-independent studies. The numbers of bifidobacteria can be influenced by diet, probiotics and prebiotics. Weaning is associated with changes including increased levels of Escherichia coli, enterococci, bacteroides and anaerobic gram-positive cocci and decreased enterobacteria. Early change of the microbiota to the adult type may be linked with development of eczema [9]. The intestinal microbiota is crucial for normal development of the gut-associated lymphoid tissue and has important effects on intestinal mucosal barrier function and other aspects of intestinal function. Immune Development Microbial colonization of the newborn intestine is required for normal immune development, which in turn is important for regulation of gut inflammatory responses and oral tolerance induction. The mucosal immune system of the gastrointestinal tract is constantly challenged by diverse antigens, such as microbial and food antigens. Such priming of the gut-associated lymphoid tissue is important for two opposing functions: mounting a response to pathogens and maintaining hyporesponsiveness to innocuous antigens. Mice raised in a germ-free environment fail to develop oral tolerance and have a persistent Th2dependent antibody response [11]. This immune deviation can be corrected by reconstitution of intestinal microbiota, but only if this occurs during the neonatal period [11]. Prenatal exposure to companion animals is linked with changes in microbiota and infantile pet exposure is negatively associated with wheezy bronchitis at 24 months of age [10]. The strains of healthy gut microbiota are likely to stimulate local and systemic immune responses via pattern recognition molecules such as Toll-like receptors, providing the host with an anti-inflammatory stimulus and directing the host-microbe interaction toward immune tolerance. The bifidobacteria-dominated environment in childhood in particular may provide more of an anti-inflammatory stimulus than bacteria from adults, which have been shown to be more proinflammatory. A complex microbial community is required to achieve a healthy microbiota that exhibits powerful antipathogenic and anti-inflammatory capabilities. Intestinal Function An absent or inadequate intestinal microbiota has been shown to cause defects in intestinal barrier function. Before weaning, formulafed infants have a greater ability to ferment complex carbohydrates than breastfed infants, probably due to the presence of a more complex microbiota. Breastfed infants have delayed establishment of mucin-degrading microbiota, but this increases in both groups between 6 and 9 months. Conversion of cholesterol to coprostanol commences after 6 months of age, and levels of ammonia, phenol, -glucosidase and -glucuronidase activity increase after weaning. Maintenance and Modulation of the Individually Optimized Healthy Microbiota the healthy gut microbiota created during early life must be maintained throughout life. Deviations in microbiota associated with disease can be redirected to a healthy balance by dietary means, for instance by using probiotics or prebiotics. Probiotics are defined as viable microbes which through oral administration produce health benefits to the host. Probiotics are members of the healthy gut microbiota that mimic the healthy microbiota of a healthy infant, and are generally regarded as safe [12]. Prebiotics are oligosaccharides that promote expansion of specific microbes with potential to maintain health. A prerequisite for the efficacy of prebiotics is that such strains are already present in the gut. Carefully designed combinations of probiotics and prebiotics may offer an optimal means of creating and maintaining a healthy microbiota as this would mimic the mother-infant relationship of offering both microbes and oligosaccharides to the newborn infant. It is important to recognize that individual probiotic bacterial strains can have distinct and specific effects. Therefore, the effects of one probiotic strain cannot be generalized to another, and the individual properties of a probiotic strain must be evaluated prior to clinical application. Furthermore, in addition to species/strain-specific effects of probiotics, the timing of probiotic administration may also be important. Metaanalysis of randomized controlled trials of probiotic interventions for allergic disease prevention show beneficial effects when probiotic supplementation is commenced during the prenatal period, and not when probiotics are solely administered to the infant postnatally [13]. This suggests that prenatal administration may be a requisite for efficacy in the prevention of allergic disease. These results highlight the different effects of specific probiotics, which are further supported by genomic studies. Similarly, prebiotic oligosaccharides have different microbiota-modifying properties. Although most prebiotic components have been shown to enhance the bifidobacterial microbiota, detailed investigation of specific effects is required. A wide variety of oligosaccharides (human milk oligosaccharides) is found in breast milk and has documented bifidogenic and healthpromoting effects on the infant gut. Some fructooligosaccharides have been reported to enhance levels of unknown microbes in the human gut, thus potentially facilitating untoward effects in infants. Therefore, when evaluating a probiotic or prebiotic for clinical use, the safety and clinical benefit of that specific product must be documented before it can be recommended for clinical application. Bifidobacteria play a key role in this process the mother-infant contact has an important impact on initial microbiota development, providing the critical first inoculum already prior to birth, followed by another inoculum at delivery, and then progressing with breastfeeding the potential application of specific probiotics and/or prebiotics to influence microbiota development for the treatment and prevention of disease also warrants further evaluation 1 References 1 Rautava S, Luoto R, Salminen S, Isolauri E: Microbial contact during pregnancy, intestinal colonization and human disease. In industrialized countries, continued partial breastfeeding up to the age of 12 months or beyond is the general recommendation. In most populations, the duration of both exclusive breastfeeding and continued breastfeeding is considerably shorter, emphasizing the need to protect, promote and support breastfeeding via broad public health initiatives and support from the health care systems. It has been estimated that, globally, suboptimal breastfeeding may result in more than 800,000 deaths annually [5]. This is a reflection of the much slower growth velocity in infants than in calves, and thereby a lower requirement for growth nutrients. Human milk also contains many other substances apart from nutrients with specific important functions. These include hormones, growth factors, oligosaccharides, and immune-related compounds such as antibodies (sIgA), leukocytes (B and T lymphocytes, neutrophils and macrophages), nucleotides and cytokines. These nonnutritional substances are involved in many of the short- and long-term effects breastfeeding has on the infant. Positive Effects on the Infant and Mother Breastfeeding has significant positive effects on health and development during infancy, with some effects reaching into childhood and adulthood [1, 2, 6]. Most studies, however, are observational, and confounding can therefore be difficult to rule out; mothers who choose to breastfeed in industrialized countries, for example, are typically better educated and their children also have a lower risk of developing some diseases. The most evident effect of breastfeeding is protection against infectious diseases, especially diarrhea and respiratory tract infections [1]. This is the main reason that mortality in low-income countries is several times higher among those not being breastfed. In high-income countries, the risk of diarrhea in breastfed infants is only about one third of the risk in infants not breastfed [2]. There is also convincing evidence that breastfeeding has positive effects on long-term health and development [1, 2, 6]. The influence of breastfeeding on the development of the immune system could be the reason for the fact that some immune-related diseases. A consistent finding throughout many studies from both industrial and low-income countries is a small but significant advantage of breastfeeding to later cognitive function [6]. Breastfed infants gain weight faster during the first months of life and are leaner and slightly shorter than formula-fed infants at the age of 12 months [7; Chapter 1. It has been suggested that the difference in growth pattern could be one of the reasons why breastfed infants have a lower risk of some noncommunicable diseases, including obesity, later in life. From a global perspective, the most important byproduct is the inhibitory effect on ovulation, i. Breastfeeding induces utilization of maternal body fat stores and thus can help to decrease excessive body fat depots. Cumulative duration of breastfeeding for more than 12 months is in some studies associated with substantial reductions in the risk of breast and ovarian cancer, type 2 diabetes and rheumatoid arthritis [2]. In severe cases this can cause convulsions and brain damage, and in rare cases death [11]. This can be prevented by supervision and support during initiation of breastfeeding, monitoring weight loss and urine production, and provision of other fluids if there are signs of dehydration. However, it is difficult to disentangle intrauterine exposure from exposure through breast milk. There is general agreement that the positive effects of breastfeeding are far more important than the potential negative effects, but also that it is important to reduce the level of contaminants in the environment and in the diet of pregnant and lactating mothers. Maternal Medication Most drugs given to a breastfeeding mother are excreted in her milk. A mother should not breastfeed if she receives chemotherapy, ergotamines, amphetamines or statins [2].

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  • LyP (lymphomatoid papulosis)
  • Human ewingii ehrlichiosis
  • Exercise induced anaphylaxis
  • Persistent truncus arteriosus
  • Dyschondrosteosis nephritis
  • Oculocutaneous tyrosinemia
  • Epidermolysa bullosa simplex and limb girdle muscular dystrophy

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