Narrator

Introducing Doctor Rodrigo Vázquez Frías, a renowned pediatric gastroenterologist and nutritionist at the Department of Gastroenterology and Nutrition, Hospital Infantil de México, Federico Gomez. He is a professor of pediatrics at Universidad Nacional Autonoma de México, and holds several masters and a PhD degree, including a master's in microbiota, probiotics and prebiotics from Universidad Europea. Doctor Vázquez Fríasis actively involved in professional organizations, serving as the president of the Latin American Society of Pediatric Gastroenterology and Nutrition and the Mexican Society of Microbiota.

He also contributed significantly to academia with numerous scientific publications in national and international journals and book chapters, and is passionate about shaping the future of pediatric gastroenterology and nutrition through his mentorship of over 30 postgraduate and master's students. Please welcome Doctor Vázquez Frías.

Rodrigo Vázquez Frías:

Thank you very much to all of you to be here. Don't worry, I'm going to speak in Spanish. Muchisimas. Gracias. Thank you so much to all of you. Thank you so much Mead Johnson for the invitation to participate in this big event. They asked me to talk about one of the topics that perhaps, most recently has been very controversial because, all parties have been broken and many things all of us had learned that there weren't in tuned in our skin.

So I wanted to try to give you the best evidence we have got available until this moment. So it is important for us to remember that many of the activities or the recommendations in the field of nutrition that we traditionally shared or we gave to the children, to the parents of our patients, were based on issues that had to do more with the traditions and something we do not have to look down on or to reject.

But there was a little evidence based on issues of nutrition and to talk about this topic after having listened to Rosan Meyer. It's very difficult for me, really, and it is. This is really very bold on my side that I'm going to try to do my best. So in a very recent way, we have had several positions regarding and this probably you will read and you will see and you will have you must have seen some of these suggestions or recommendations.

But have been set up, depending on the different places where they have been published, but quite recently we have got their recommendations set up by the World Health Organization. And for many of us that are devoted to this discipline turn out to be some somehow shocking regarding certain recommendations. And that's the reason why, in a very early way, we, really started with the task of meeting and trying to set up a positioning regarding these things.

And I do tell you, and I do, suggest you to read this publication, it is really a publication that is reflected into the questions of the reasons why we from our different societies gather in several societies. We give the reasons why we believe that there are things that should be modified regarding this first position, regarding the document of the World Health Organization with a whole respect to this institution, but also saying expresses that we have to make better decisions based on the best available evidence.

We have started with complementary feeding, and this is the introduction of foods in a different way to the breastfeeding. So this is the definition of the WHO. However is other societies have established that in order to avoid difficulties, especially in those children that are not breastfed, that process that they find should be given complementary foods.

This shouldn't provoke problems, not for the professionals of the health care, although we are talking with each of the parents. So in such a way that we establish that this complementary feeding is the moment where we introduce different foods to their and, breastfeeding or to the human milk or what it corresponds to their child formula. And this is very important because it takes some aspects, not only from the nutritional point of view.

We are not just talking about nutritional issues, we are also talking about creating the best atmosphere so that this process of feeding can be as easy as possible, as suitable as possible. And they told us that they love, affection, the environment where we are feeding our children. Absolutely important. And this is something that we have to have to we have to recommend to all the parents.

So they have to favor this. And always taking into account the cultural aspects so we cannot make a guideline, a recipe of how this complementary feeding plan can be done in Peru and in Sri Lanka. Because both countries have different realities and we have to get adapted to those situations. And another very important point that we shouldn't forget has to do with issues of provision of textures, especially taking into account different approaches that have been launched and really trying to give preference to certain food that for the dishes are complete and so on.

So there have been certain trends that somehow this has been fashions that have been adapted, and they are not bad, however, probably everything separates us and the variety,the diversity of textures of food, everything, all these things are going to be much better than just, being focused on one of them. And this is something very important because this is issues of progression of textures, not to skip this progression of textures are important to for all the facial issues of favoring the appropriate chewing and even with certain connotations regarding language too, but it's also a very important period for the establishment of their preferences in food.

It was known that the earlier this process, the exposure to these food that are considered to be bitter, it is much easier that afterwards the people can be adapted to it. So the earlier you expose to children the more frequent way to vegetables, the bigger the possibilities that they are going to eat vegetables. Later in life. But it doesn't mean that the whole feeding has to be, vegetables.

Diversity must be there. But the new research that has also been mentioned in the previous, conference has to do that. This is a very important process in order to increase the diversity of the microbiota. And nowadays, as you know, there is a very strong association with many processes of health, that have been presented along the history of mankind but that in a very important way, represent this first exposure to the complementary foods.

And one of the big explosions, the quality somehow of increasing diversity. And, what does this mean? That probably the right selection of the complementary food could have an impact on processes of health and sickness in later stages of life? And nowadays, in this way to warranty. This is with the introduction of a diet that must be as varied as possible on all the groups of foods must be included there.

The typical question that to all of us when we are talking about complementary foods, pose is when? isn't it? So according to the document of positioning of this World Health Organization, they say, is that this complementary food must start at the six months. And this is something that is stuck to us because we have heard that every day, every year.

So this situation seems to be something common for us. However, it is very important that you can see the degree of evidence. The degree of evidence, although their recommendation is strong, is very low. And why? Because there are some researches that have proven that. Not necessarily, this breast feeding shouldn't last six months because it is much better from a nutritious point of view.

I know that many of these recommendations have the goal of protecting breast feeding, and this is something I don't altogether agree with it. But there are evidences where it is shown. It is clearly shown that in certain situations, in certain places, in certain regions, it's perhaps that this the breast feeding is not the best recommendation we can make.

So there are not as studies that say in an obvious way that this, milk in this, in that this breastfeeding in the first 6 months is going to improve the neurodevelopment or the nutrition, then the nutritious development is better. And sometimes, for instance, we can start with a complementary food when people are four months old.

So of course, we are not saying that starting with this complementary food when the babies are four months old doesn't mean that you have to stop with the breastfeeding. But taking into account the strong evidence that you could reduce the risk of certain allergies in populations where there is an increase of this risk of allergies, the fact of has started with this complementary food when the babies are four months old, could be beneficial.

So quite a lot of this positioning is not necessarily we should start or wait until the six months. But this is a decision you have to think over. Depending on the situation, on the reality in the place where you are living. Another question. I would like that all of you would support me, by answering with the app, if you can.

You can you see this in the app? So in addition to age, what other clinical parameter do you take to decide the start of the complementary food. So A the fact that the baby is ready to sit, B  gastrointestinal maturation, C renal maturation, D all the previous ones and E none of the above.

So I give you some seconds to answer.

Are you ready? Do we have the answer by now?

Okay.

So 30% of you have said that they must be ready to sit. They will have to take into account that a baby can sit in order to start with it. Say 12% say gastrointestinal maturation. Renal maturation is not important for you 0.57%. And the other ones 58% all of the above, and 14% of all of them that say that none of them is important for this decision of the start of this complementary food.

And this is the reality. This is the answer, really, with the best evidence we have got right now, the age is the only parameter in order to take into account. So if we wait until certain kind of factors that traditionally generation after generation have, people have said, no, this there is no scientific evidence for that at all.

So in fact, it has been set up even in a document of this from Europe, from the year 2019, they set up quite clearly. Could you put the presentation so that the can is here. So maturity, this gastro intestinal and renal maturity there's apparent factors for in favor of it have nothing to do in order to decide the start of the complementary effort.

And this is from the point of view of the development, is so that a baby can, can be ready to sit this range is much too big because apparently it can be as soon as four months, and it can be as late as nine months. So that was this would mean that I should wait until the baby, say 8 or 9 and the baby can sit.

So of course not. I would view, this a very important period of induction issues is about tolerance. So none of them is a parameter in order to decide on the complementary foods. And even less this issue of weight. This is something people told us we knew about this rule of six. So from the six months and until they waited six kilograms weight has nothing to do with the decision of is following complementary food either to postpone neither to postpone it, not to start sooner.

So with a baby has got a low weight and you you can decide. Well, I'm going to start with this complementary food or one that has, speed up gaining weight. So to this side, postpone or speed up this complementary food has nothing to do with this. So in what way can we give this complementary food, if I was to ask you, is should be the first food that we have to introduce in a boy very probably there can be many opinions.

And the most important answer is it doesn't matter which one, any of them, it's absolutely the same. They want. You can think of probably a baby that is breastfed. You know, an exclusive one will probably we could increase because it is not supplemented with iron. Perhaps those rich, foods in iron would be one of the best ideas.

So try to prefer food that are original source of iron or with an iron supplement. That should be the best thing. But a baby that is receiving a child formula probably, he won't or she won't require any kind of a supplement because it's already included in the child formula. Another thing that we had and one of the mistakes, well-known mistakes, but the things that have been we had been told to do that we had to wait three days to introduce a new, new piece of food.

So we should see where reactions from an allergic point of view. We can have some allergic manifestations that can happen almost immediately. So you could identify this from daily basis. But if we wait for three days, we are not going to see, slow reactions because these reactions can, can be presented to 2 or 3 weeks later.

So this shouldn't be the parameters. Even the American Pediatric Society says quite clearly that with every day you can start with a new kind of food, and it is a good idea to give a new kind of food every three days, probably in order to favor the ratio out of the number of exposure to these new foods. So both in the morning and the afternoon, in the evening you are giving this new piece of food and you are giving at least, nine, nine new exposures.

So we should try to increment it, but not from allergical point of view. You can start every day without any problem, and this should not have any implication in issues of development of allergy. However. Anyway, another of the things is that from the beginning of these complementary foods, you can establish the number of types of foods you want to the sugar rich as one, can be two, can be three.

And the suggestion when those are children that, they said with foods matrixes. So food that is really very full in energy to try to do it at least three times a day. There shouldn't be any contraindication for that to do one, 2 or 3. What is what is a good recommendation is that each new food is given whenever the child is hungry.

In order to minimize the rejection in the reaction, he or she can have. Two these new foods are going to start in the morning to start with this new food first of all, and then giving, then the food that this child previously has already acquired or has already tasted. It is very important to try to have a daily exposure with fruit and with vegetables.

I think this is something that we are doing less and less luckily, and it would be good also to confirm this, let's not do the practice of being just one month only with fruit, then another month just with vegetables, then another month with cereals or grains. Because this is not a good practice. We have to try to diversify food as much as possible to try that his plate or her plate it is as varied as possible in very early stages.

And another important point is best. Last, we have decided that they are going to start with a complementary feeding. We have to leave behind the old practices of delaying the introduction of those foods considered to be potentially allergenic. In fact, we must remove this connotation. We have to know that there are foods that are more allergenic because they are related to the highest number of food allergies, but it doesn't mean that we should be afraid of them.

Doctor Meyer told us about the researches we have got regarding the early introduction. So this means in a period between the four and six months, there would be a reduction, probably in the development of these allergies. So there are at least seven clinical trials. Most of them are addressed to the, peanut and to the egg, where we can see both in open populations and in populations of high risk.

When we can see that the introduction, in a way, in, in a convenient way, not an early one. So from the former in some was is not increasing the risk of allergy. Quite the contrary, it could even reduce at this type of allergies, such a way that nowadays we have got sufficient information to recommend quite clearly, that at least the egg or the peanuts should be introduced, since the children are 4 or 6 months old.

In another great way, in this complementary food, and probably the rest of the food is going to follow this same process too and this means to understand that at the moment when this  complementary food starts, we are favoring processes, we are fostering processes of induction, of oral tolerance. And we do know that the failure of this oral tolerance is what implies or what lead us to these issues of allergy.

So even and this is something really important. A boy that has got allergies had took this or even got a food allergy the way she or he has to follow complementary food for this child shouldn’t be different. The fact that a boy, I think a child has got allergy to be or another allergy doesn't mean that I have to modify the way of the intake of this food.

For instance, if he is allergic to this cow protein milk, I am not going to restrict the introduction of the of the egg or other allergens. It is very, very it's very relevant that we start destigmatize food allergies. I mean even let's not consider a stigma. Kids with allergy, those are not special kids. We don't have to be more careful than with any other child.

That is why even nutrition questions, we should start medicating them. It sounds really attractive trying to have medical evidence, but we have to try to be more organic. Having into account tradition, cultural factors in the way we give a nutrition thinks, even taking into account the parents, the realities of those children at the moment when they are explained how they should introduce these feeding.

Finally, one of the main, things that, this, WHO document says has to do with the timing where we should continue breastfeeding kids. Let's hope our problem, especially in Latin America, it is that moms want to breastfeed for much longer. That's a reality that if they get up to four months, we really are very happy.

But really that's not a problem. But in certain countries, prolonging breastfeeding beyond one year old or two years old is a reality that is being, in a more intense way. And the fact that we established that if a child is not breastfed after six months, it can be complemented this human milk with animal milk directly has a lot of, shocks with medical evidence.

I mean, we know that the reality of many countries, different regions are really different. But saying that since I have to have a public global policy, I can say that it doesn't matter if we recommend, formula versus cow milk or animal milk, putting them at the same level. It's a far less especially because we have information, two systemic, revisions from the WHO that state that kids that get formula do much better.

And he has a better impact in infection prevention and also better, nutrition factors. And the fact that maternal milk is prolonged beyond the year of life doesn't have benefits in prevention of malnutrition. I mean, it's something that we have to promote. We can offer, we can recommend. But, we didn't have to see tha. it's no good.

The mom or the health professional that don't breastfeed anymore. That's why our main recommendation is that we know in certain circumstances, it is much better for a child to be breastfed beyond the year of life. But also, if they cannot take, breast milk under conditions cultural, social, economical that are present, don't allow these child to have formula.

We could use then animal milk. But this would be like a last resort. We know for sure that even being exposed to this milk with high protein content increases the possibilities of overweight and obesity, and increases the possibilities of anemia in our patients. There is many other myths that we need to take down, but the truth is that, I have no more time.

Thank you so much.