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Cow's milk protein allergy (CMPA) is one of the most common food allergies in early childhood. Although a strict elimination diet effectively prevents allergic symptoms, it does not promote the development of tolerance to cow's milk proteins (CMPs). The milk ladder is a stepwise approach to the reintroduction of CMPs, starting with extensively heated forms and gradually progressing to unheated cow's milk, according to the individual tolerance levels. The rationale for this approach lies in the reduced allergenicity of heated forms, mainly due to the food matrix effect. The milk ladder was originally developed to gradually expand the diet in children with non-IgE-mediated CMPA. However, recent evidence suggests that it can also be applied in IgE-mediated CMPA to accelerate tolerance development. In children with high-risk IgE-mediated CMPA, this approach may be more challenging. Even minor recipe modifications, particularly those affecting composition or heating conditions, can alter the allergenicity of heated foods. Moreover, barriers to reintroducing food allergens, including parental anxiety or the child's food aversion, may be more pronounced in this group. Although for high-risk patients, reintroduction is usually performed in hospital settings, increasing evidence indicates that, in selected cases, it may also be safely conducted at home. Several emerging strategies, including early low-dose exposure and oral immunotherapy, show promise in further enhancing tolerance development. Despite these challenges, early reintroduction of CMPs appears to play a crucial role in modulating the immune response and promoting tolerance. This review provides the summary of evidence and practical insights into the implementation of the milk ladder in children with IgE-mediated CMPA.

Background/Objectives: This study aimed to evaluate diet diversity and feeding practices in toddlers with food allergy (FA) compared to healthy peers. Methods: This cross-sectional survey was conducted in Polish nurseries and included children aged 13–36 months with and without FA. Parents completed a questionnaire assessing feeding practices, anthropometric measurements, diet diversity using the Food Frequency Questionnaire, and feeding difficulties using the Montreal Children’s Hospital Feeding Scale. Results: Data from 388 children (predominantly from Warsaw and from families with high socioeconomic status) were analyzed. Among them, 61 (16%) had FA confirmed by a physician (however, an oral food challenge was performed only in one-third of cases). The proportion of underweight children (≤third percentile) was similar between the FA and non-FA groups (3.4 vs. 0.9%, respectively). Compared with the non-FA group, children with FA had significantly lower median overall diet diversity, food group diversity (≥nine food groups), food item diversity, and mean food allergen diversity. We found no difference in the proportion of children with feeding difficulties between the FA and non-FA groups (median = 18% vs. 13.5%). Although a lower proportion of children with FA had introduced cow’s milk, hen’s egg, tree nuts, nuts, and sesame compared with the non-FA group, only a minority had confirmed allergies to nuts, peanuts, and sesame. Most children with cow’s milk and hen’s egg allergy reintroduced baked milk (48.9%) and egg (40%). Conclusions: Children aged 13–36 months with FA are at risk of reduced overall diet diversity and over-restriction of potentially allergenic foods.

IntroductionIntroducing baked milk into the diet of children with cow’s milk protein allergy (CMPA) has been shown to potentially accelerate the development of tolerance to non-heated milk. However, there is no standardised milk ladder (ML) protocol, and different scientific societies across countries recommend varying versions. This study aims to assess the effectiveness and safety of the four-step ML (4-ML) compared with the six-step ML (6-ML) in children with IgE-mediated CMPA.Methods and analysisWe will perform an open-label randomised trial with two parallel arms in two departments of the same academic hospital. A total of 92 children with IgE-mediated CMPA will be allocated in a 1:1 ratio to introduce cow’s milk into their diet according to either 4-ML or 6-ML with a 4-week break period between subsequent steps. Oral food challenge (OFC) with tested products at each subsequent step of the ML will be conducted in hospital settings. The primary outcome will be the percentage of children with tolerance to non-heated cow’s milk proteins defined as no allergic reaction to raw cow’s milk (120–240 mL depending on the age of the patient) during the last OFC; measured at the end of the 12-week observation period for the 4-ML and 20-week observation period for the 6-ML. Secondary outcomes will include the percentage of children with a negative OFC to each ML step; the percentage of children with anaphylaxis (both those who were treated and those who were not treated with epinephrine); the percentage of children with exacerbation of atopic dermatitis; growth; compliance; and quality of life of the caregivers and parents’ anxiety about adverse events during their child’s OFC.Ethics and disseminationThe bioethics committee of the Medical University of Warsaw, Poland, approved this protocol (KB/107/2024). The findings will be published in a peer-reviewed journal and submitted to relevant conferences no later than 1 year after data collection.Trial registration numberNCT06664918.

IntroductionCurrent recommendations for early introduction of cow’s milk proteins in infants who cannot be breastfed vary and are inconsistent due to a lack of clear evidence. We aim to assess whether early supplementation with various nutritional interventions, including cow’s milk formula (CMF), amino acid formula (AAF), donor human milk (DHM) or high-pressure processed ‘pascalised’ DHM (DHM-P) is effective for the primary prevention of cow’s milk allergy (CMA) in breastfed neonates.Methods and analysisWe will perform an open-label randomised, controlled, head-to-head trial with four parallel arms in three Polish study centres (Warsaw). 1000 healthy full-term newborns of mothers eager to exclusively breastfeed will be allocated to receive early supplementation with one of four nutritional interventions: CMF, AAF, DHM or DHM-P. All children will receive 10 mL of each intervention per day for the first 3 days of life; exclusive breastfeeding will be recommended. However, if any supplementation in addition to the breastfeeding is needed, the assigned nutritional intervention will be provided until 4 months of age. The primary outcome is a cumulative incidence of CMA confirmed by open oral food challenge at 4–6 months and 12 months of age. Secondary outcomes include an incidence of sensitisation to cow’s milk protein; a total score in the Cow’s Milk Related Symptom Score; the percentage of children with acquired tolerance to cow’s milk, feeding difficulties and exclusively and predominantly breastfed; an incidence of atopic dermatitis, allergic rhinitis and wheezing; growth; compliance and adverse events. The level of immunomodulatory factors in maternal milk and its nutritional component analysis will also be performed.Ethics and disseminationThe ethics committee of the Medical University of Warsaw, Poland, approved this protocol (KB/61/2023). The results of this study will be submitted to a peer-reviewed journal no later than 1 year after data collection. The abstract will be presented at relevant national and international conferences.Trial registration numberNCT06652698.

Objective: This systematic review aimed to evaluate the efficacy and safety of preoperative nutrition-based interventions on pre-, intra-, and postoperative outcomes in children undergoing cardiac surgical procedures. Methods: CENTRAL, MEDLINE, and EMBASE were systematically searched for interventional and observational studies comparing any nutritional preoperative intervention with a control or alternative strategy in pediatric patients undergoing cardiac surgery, up to July 2025. The main outcome was the postoperative length of stay in the intensive care unit (ICU). The certainty of evidence was assessed using the GRADE approach. Results: Nineteen studies were included (8 randomized controlled trials [RCTs], 1 non-randomized trial, and 10 observational studies), evaluating heterogeneous interventions or exposures, including fatty acids, vitamin D supplementation, and structured preoperative nutritional protocols. Two RCTs demonstrated shorter ICU and hospital stays with extended preoperative nutritional support (2 weeks vs. 1 week; n = 40; and 1 month vs. no support; n = 80). Observational data indicated an association between preoperative nutritional support and reduced hospital length of stay (meta-analysis of four studies; n = 278), as well as fewer days to achieve full enteral feeding postoperatively (meta-analysis of three studies; n = 138). No significant difference in postoperative ICU stay was observed between groups (meta-analysis of two studies; n = 175). No intervention-related serious adverse events were reported. The overall certainty of evidence was very low. Conclusions: This systematic review provides very low-certainty evidence suggesting that preoperative nutrition-based interventions in children undergoing cardiac surgery are safe and may offer clinical benefits. Substantial heterogeneity across studies underscores the need for well-designed trials and standardized preoperative nutritional protocols. PROSPERO number: CRD420251085196.

Background Evidence from studies in adults documents that fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) may be triggers of symptoms in individuals with functional abdominal pain disorders (FAPDs). However, in children, the evidence is very limited. We aim to assess the effects of a low-FODMAP diet compared with a regular diet for the management of children with FAPDs. Methods We will perform a randomized, quadruple-blinded, controlled trial. Seventy-four children aged 8 to 18 years with a FAPD (Irritable Bowel Syndrome or Functional Abdominal Pain-Not Otherwise Specified), diagnosed according to the Rome IV criteria, will be randomly allocated to receive either a low-FODMAP diet or a regular diet for 4 weeks. The primary outcome will be the percentage of the responders, defined as the participants who have at least 30% improvement in abdominal pain intensity on a Visual Analogue Scale (VAS) during the last week of the trial compared with baseline, that is at least equal to the Reliable Change Index (≥ 25 mm change on VAS). Other outcomes will include changes in stool consistency, abdominal pain frequency, total scores on the Gastrointestinal Symptom Rating Scale, KIDSCREEN-10 Index and World Health Organization Five Well-Being Index, child’s school attendance and parents’ work absenteeism, and BMI-for-age z-score. Compliance, tolerability of the low-FODMAP diet, and adverse events also will be evaluated. Each FAPD subtype will be assessed separately. Discussion There is a need for high-quality evidence regarding the dietary management of children with FAPDs. This randomized controlled trial (RCT) of rigorous methodological design will help to establish the effectiveness, if any, of a low-FODMAP diet for the management of FAPDs in the pediatric population. The findings of this RCT will assist with the development of guidelines and influence the direction of further research. Trial registration NCT04528914 Data and protocol version identifier: 24/08/2020

Uncertainty remains in regard to when, how, and in what form gluten should be introduced into the diet, particularly of infants genetically predisposed to developing celiac disease (CD). MEDLINE (PubMed), EMBASE, and Cochrane Central Register of Controlled Trials databases will be searched from inception. Randomized controlled trials (RCTs) and observational studies (cohort, case-control, or cross-sectional studies) investigating the association between early feeding practices and the risk of CD and/or CD autoimmunity will be included. In prospective studies, participants will be infants regardless of the risk of developing CD. For retrospective studies, participants will be children or adults with CD or presenting with positive serology indicative of CD. Interventions will be gluten-containing products of any type. Exposures will be breastfeeding and/or the introduction of gluten-containing products of any type. In control groups, there will be no exposure, different degrees of exposure (partial vs. exclusive breastfeeding, different amounts of gluten, etc.), or a placebo. The primary outcome measure will be CD or CD autoimmunity (i.e., anti-transglutaminase or anti-endomysial antibodies). At least two reviewers will independently assess the risk of bias using a validated risk assessment tool depending on study design. Disagreements will be resolved by discussion to achieve a consensus with the involvement of one or more additional reviewers if required. If appropriate, data will be pooled. If not, a narrative synthesis will be performed. The findings will be submitted to a peer-reviewed journal.

This cross-sectional online survey performed in Poland aimed to improve understanding of how COVID-19 pandemic restrictions affected complementary feeding practices among parents of infants aged 4 to 12 months. Self-selected parents were recruited through the internet. The anonymous questionnaire was opened during two intervals during COVID-19 restrictions. The primary outcome was an assessment of sources of information and infant feeding practices in the context of COVID-19 restrictions. Data from 6934 responders (92.2% mothers) were analyzed. Most responders received information from multiple sources, with other parents, family members, or friends being the most frequently reported (48.6%), followed by webinars and experts’ recommendations (40.8%). COVID-19 restrictions largely did not impact the method of feeding, changes in feeding patterns, or complementary feeding introduction, although the latter was more likely to be impacted in families with average versus the best financial situations. Multivariate logistic regression analysis also most consistently showed that parents with a tertiary education and living in a city above 500 k were at higher odds of using webinars/experts’ recommendations, internet/apps, and professional expert guides and lower odds of claiming no need to deepen knowledge. This study clarifies major issues associated with complementary feeding practices during the implementation of COVID-19 restrictions in Poland.

Infant colic is a common functional gastrointestinal disorder that affects infants during their first months of life. The etiology of this condition remains unclear. However, some studies suggest lactase deficiency may be a contributing factor. Currently, the evidence on dietary treatment and lactase supplementation for management of infant colic is limited. We aim to systematically review evidence on the efficacy and safety of using a lactase supplementation for managing infant colic. The Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), MEDLINE, and EMBASE will be searched to identify randomized controlled trials comparing oral lactase supplementation with placebo or no intervention in infants aged less than 6‐month‐old with infant colic using any recognized definition. The risk of bias will be assessed using the second version of the Cochrane Collaboration's risk‐of‐bias tool. The main outcome will be the number of responders in each group after treatment, defined as infants who experienced a decrease in daily crying as reported by the study authors. Additional outcomes will include the duration and frequency of crying episodes, infant sleep duration, parental satisfaction, discomfort of infants, number of hospital admissions, family quality of life, and adverse events during the intervention. The study findings will be published in a peer‐reviewed journal and will be submitted to relevant conferences. What is Known Although infant colic is a common problem during first months of life, there is no well‐established treatment. Evidence on use of lactase supplementation in treatment of infant colic is limited. What is New This systematic review of rigorous methodological design will evaluate the evidence on the efficacy and safety of using lactase supplementation for the management of infant colic. Quality assessment of randomized controlled trials considering lactase supplementation in infant colic will be performed. Translational Impact The findings of this systematic review may guide further studies and the development of clinical practice guidelines.

Background Evidence from studies in adults documents that fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) may be triggers of symptoms in individuals with functional abdominal pain disorders (FAPDs). However, in children, the evidence is very limited. We aim to assess the effects of a low-FODMAP diet compared with a regular diet for the management of children with FAPDs. Methods We will perform a randomized, quadruple-blinded, controlled trial. Seventy-four children aged 8 to 18 years with a FAPD (Irritable Bowel Syndrome or Functional Abdominal Pain-Not Otherwise Specified), diagnosed according to the Rome IV criteria, will be randomly allocated to receive either a low-FODMAP diet or a regular diet for 4 weeks. The primary outcome will be the percentage of the responders, defined as the participants who have at least 30% improvement in abdominal pain intensity on a Visual Analogue Scale (VAS) during the last week of the trial compared with baseline, that is at least equal to the Reliable Change Index (≥ 25 mm change on VAS). Other outcomes will include changes in stool consistency, abdominal pain frequency, total scores on the Gastrointestinal Symptom Rating Scale, KIDSCREEN-10 Index and World Health Organization Five Well-Being Index, child’s school attendance and parents’ work absenteeism, and BMI-for-age z-score. Compliance, tolerability of the low-FODMAP diet, and adverse events also will be evaluated. Each FAPD subtype will be assessed separately. Discussion There is a need for high-quality evidence regarding the dietary management of children with FAPDs. This randomized controlled trial (RCT) of rigorous methodological design will help to establish the effectiveness, if any, of a low-FODMAP diet for the management of FAPDs in the pediatric population. The findings of this RCT will assist with the development of guidelines and influence the direction of further research. Trial registration: NCT04528914