Tag Archives: ESPGHAN

Arsenic in Rice –New Recommendations

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Over the last two years, there has been increased concern about arsenic in rice.  This has been addressed by consumer reports, the American Academy of Pediatrics (AAP), and is being looked into by the FDA.

Due to the concerns about arsenic in rice, the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) committee on nutrition has published a consensus statement (JPGN 2015; 60: 142-145).  Pediatric gastroenterologists and pediatricians need to familiarize themselves with the report and their recommendations.

Key points:

  • Inorganic arsenic is a carcinogen.
  • “Arsenic content in raw rice varies from 0.1 to 0.4 mg of inorganic arsenic/kg of dry mass.  Rice has a much higher arsenic level than that in other grains.”
  • “Brown rice contains higher concentrations of arsenic.”
  • There is increased inorganic arsenic in products made from rice bran such as rice drinks is much higher due to the concentration of arsenic in the bran layers.
  • “Traditionally in European adults, an average of 9g of rice is consumed daily compared with 300g/day in Asian diets.”
  • “In the US population, mean childhood (1-6 years of age) dietary intake of inorganic arsenic is 3.2 mcg per day”
  • Currently, in the UK, the Food Standards Agency recommends against substitution of breastmilk, formula, or cow’s milk formula by rice drinks up to 4.5 years of age;  in contrast, in Sweden, recommendations advise no rice-based drinks for children <6 years.

Committee Conclusions/Recommendations:

  • “Inorganic arsenic intake during childhood is likely to affect long-term health”
  • “There is a lack of published data on the amount of arsenic in rice protein-based infant formula”
  • Inorganic arsenic in childhood should be as low as possible and the content in dietary products needs to be regulated
  • Rice drinks should not be used in infants and young children
  • Inorganic arsenic exposure can be reduced by including a variety of grains such as oat, barley, wheat, and maize.
  • Rice protein-based infant formulas remain an option in those with cow’s milk protein allergy,,.”the potential risks should be considered”

This is a link to the full length article (available via JPGNonline twitter feed): JGPN “Arsenic in Rice: A Cause for Concern”

This topic has been addressed by Nutrition4Kids website as well. Nutrition4Kids FDA Studying Arsenic

Bottomline: If there is an impact of arsenic in rice on long-term health, it is unclear; the amounts of these exposures are tiny in most cases.  Yet, given the availability of alternatives to rice and rice-based drinks, some changes in practice (ie. adhering to these guidelines) may be worthwhile.

 

 

Pediatric NAFLD Position Paper

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A previous blog post (NAFLD Guidelines 2012) described comprehensive, up-to-date NAFLD guidelines from AASLD, AGA, and ACG.   Another group of experts from ESPGHAN (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition) has also published a position paper on the diagnosis of NAFLD in children; coincidentally, these were published recently as well (JPGN 2012; 54: 700-13).

While there is some overlap in the information between the two guidelines, there are some notable differences.  The JPGN manuscript does include a nice differential diagnosis list  which can cause fatty liver disease (Table 2), including some rare entities like Dorfman-Chanarin syndrome, Cantu syndrome, Madelung lipomatosis, and numerous medications.  This review has more emphasis on etiology.

Table 3 lists a recommended workup in children with suspected NAFLD:

  • Standard liver function tests/blood counts/coagulation studies
  • Fasting glucose & insulin
  • Lipid profile
  • Glucose tolerance test & glycosylated hemoglobin
  • Calculation of HOMA-IR, markers of insulin resistance

AND Tests to exclude other liver diseases: 

  • Lactate, uric acid, iron, ferritin, pyruvate
  • Copper, ceruloplasmin, 24-hour urinary copper
  • Sweat test
  • Celiac serology (TTG IgA and serum IgA)
  • α-1-antitrypsin levels and phenotype when indicated
  • Amino and organic acids
  • Plasma free fatty acids and acyl carnitine profile
  • Urinary steroid metabolites
  • Other specific tests as suggested by evaluation (eg. viral hepatitis panel, serum immunoglobulins, liver autoantibodies)

When one looks at the recommended diagnostic algorithm (Figure 1) and tests outlined, these guidelines are not nearly as practical as the NAFLD guidelines from AASLD, AGA, and ACG and often contradictory between the tables/figures and the text.  How much would it cost for the recommended testing if/when extrapolated to the vast numbers of individuals with these disorders?  In addition, a much more limited diagnostic approach is suggested in the final section than outlined in Table 3 and Figure 1.

Imaging: these authors advocate LFTs and ultrasonography in all obese children (> 3 years) and adolescents.  If normal LFTS and sonography, the algorithm suggests the use of MRI if clinical signs of insulin resistance.  Later, the authors conclude “MRI is not cost-effective.”

Liver Biopsy: while the authors state that there is “no present consensus or evidence base to formulate guidelines” for liver biopsy, this is not well-reflected in their diagnostic algorithm in which arrows point to liver biopsy in almost everyone –either early liver biopsy or eventual biopsy in patients with persistent disease.  Accepted liver biopsy indications, according to the executive summary, include the following:

  • Exclude other treatable disease
  • Suspected advanced disease
  • Before pharmaceutical/surgical treatment
  • Research purposes

My conclusion about this position paper is it is less helpful than the AASLD/AGA/ACG guidelines.  In fact, when extensive diagnostic testing is recommended by experts, it is fortunate that other expert guidelines are available that support a more cost-effective approach.  In NAFLD cases that seem atypical and especially in the very young patient, this reference may still be helpful.