Category Archives: Nutrition

#NASPGHAN18 Highlights and Tweets (part 1)

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I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.

Here are a couple of highlights for me:

Slides from postgraduate course on CVS from Dr. Katja Kovacic

The slide from Dr. Lightdale (pg 22 in Syllabus) below suggests it is OK for scope if platelets >20K and OK for biopsies if platelets >50K. It is worth noting that some adult data indicate that even lower biospy thresholds are reasonable for biopsies (Post: Lower Endoscopic Thresholds for Thrombocytopenia). As always, one needs to consider carefully the risks compared with the benefits.

From Postgraduate Course

 

 

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Briefly noted: Selective Serotonin Reuptake Inhibitors (SSRIs) and Linear Growth

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CA Calarge et al. J Pediatr 2018; 201: 245-51. This study analyzed data from 4 separate trials with a total of 267 boys treated with risperidone.  In this cohort, 71% had taken an SSRI.

Key finding: The duration and cumulative dose of SSRI was inversely associated with height z score, especially during Tanner 3 and 4 stages.  The effect was approximately 1 cm for every year of treatment.

The authors speculate that SSRIs could “alter serotonin signaling, which is known to control GH secretion.”

My take:

  1. This study shows an association between SSRIs and linear growth but it remains unclear if this affects adult height (could postpone growth).
  2. This potential adverse effect needs to be considered in the clinical picture of the severe impairment and distress that can occur due to untreated depression and anxiety.

Related blog post: Brave New World: Psychotropic Manipulation and Pediatric Functional GI Disorders

Lake Louise, Banff

Why I Don’t Check Vitamin D Levels During IBD Flare-ups

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A recent study (C Striscuiglio et al. JPGN 2018; 67: 501-6) helps explain the role of inflammation on vitamin D levels in pediatric patients (n=51) with inflammatory bowel disease (IBD).

Key findings:

  • The free/total 25-OH D ratio was higher in patients with newly-diagnosed IBD compared to healthy controls (P< .001)
  • A significant direct correlation was found between free/total 25-O D ratio and the activity index of disease (P= .01)
  • While there was frequent deficiency in total vitamin D levels,  the free 25-OH D which is the active form of vitamin D was normal or elevated in patients with newly-diagnosed IBD; this, in turn, was due to a decrease in vitamin-D binding protein which is related to inflammation. The authors hypothesized that at the cellular level in the intestine, there may be peripheral resistance due to inflammation and even supratherapeutic levels of free vitamin D could be needed to produce the active form (1,25-OH D).

My take: This study shows that 25-OH D levels (total) have almost no value at the onset of IBD.  Even normal or elevated free levels of 25-OH D which were found in this study does not preclude the potential need to supplement with vitamin D according to the study authors. In addition, as noted in previous posts, Vitamin D levels can normalize without supplementation when the patient’s IBD responds to therapy.

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Dangerous animal –seen on our hike to the tea house, Banff

With Regard to Avoiding Excessive Weight Gain, Breastfeeding is Best

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A recent study (AR Goetz et al J Pediatr 2018; 201: 27-33) examines the impact of breastfeeding on the growth of infants with high birth weight (HBW).

Background: “Exclusive breastfeeding is protective against high weight and is recommended by” the AAP for the first 6 months.  In this study, the authors hypothesized that “HBW infants would receive a lower percentage of breast milk and consume more formula than NBW infants.”

Key findings:

  • HBW infants with high weights at 7-12 months of age demonstrated a rapid decline in the percentage of breast milk feedings compared with HBW infants with normal weights at 7-12 months of age.
  • Normal birth weight infants with high weights at 7-12 months of age received a lower percentage of breast milk and more formula intake that those with normal weights at 7-12 months of age.

Because HBW is associated with later risk of obesity/overweight, identifying strategies early in life is important.  Furthermore, as a recent study in NEJM has shown (M Geserick et al. NEJM 2018; 379: 1303-12), a lot of weight gain issues happen in the first years of life:

  • Almost 90% of children who were obese at 3 years of age were overweight or obese in adolescence
  • Among obese adolescents, the most rapid weight gain had occurred between 2 and 6 years of age

My take: This study further shows a strong association between consumption of breast milk and normal weights at 7-12 months of age, both in HBW and NBW.

Related blog posts:

Near Lake Louise, Banff

One Bad Apple Spoils the Bunch

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A recent NY Times article highlights the end of a renowned food-scientist Brian Wansink’s career at Cornell which “came to an unceremonious end. On Sept. 20. The university announced that a yearlong investigation had found that he committed “academic misconduct in his research and scholarship, including misreporting of research data,” and that he had tendered his resignation.”  This commentary highlights other problems with nutrition studies: More Evidence That Nutrition Studies Don’t Always Add Up

My take: Nutrition studies are difficult –having academic misconduct is going to further undermine the credibility of these studies.

Losing the Obesity Battle Early in Life

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A recent study (M Geserick et al. NEJM 2018; 379: 1303-12) performed a prospective and retrospective analysis of a population-based sample of 51,505 German children to examine BMI in early childhood and risk of sustained obesity.

Key findings:

  • Most normal weight adolescents had a normal weight throughout childhood
  • Half (53%) of the obese adolescents had been overweight or obese from 5 years of age onward
  • Almost 90% of children who were obese at 3 years of age were overweight or obese in adolescence
  • Among obese adolescents, the most rapid weight gain had occurred between 2 and 6 years of age

My take: We are losing the childhood obesity battle at very young ages.

Abstract and Link to 1:32 Quick Summary: Acceleration of BMI in Early Childhood

 

Gastric Residual Volumes in Premature Infants

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Briefly noted: B Singh et al. J Pediatr 2018; 200: 79-83.  In this study of 87 infants witth birth weights 1500-2000, avoiding routine assessment of gastric residual volumes before feeding advancement did not shorten the time to reach full feeds.  However, checking these residuals provided no clear advantages and have some potential disadvantages:

  • Time-consuming to check and may inaccurate depending on size/location of orogastric/nasogastric tube
  • Discarding gastric contents results in loss of gastric enzymes and acid

The authors note that prior studies have shown that gastric residuals are “unreliable predictors of feeding intolerance” studies have had discrepancies with regard to whether they are predictive of necrotizing enterocolitis.

Related blog post: When to Check Gastric Residuals in Preterm Infants

Does Gastrostomy Tube Prolong Life in Rett Syndrome?

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A recent study (K Wong et al. J Pediatr 2018; 200: 188-95) examined a longitudinal cohort of 323 females in the Australian Rett Syndrome Study.

Key findings:

  • 30.3% of the cohort underwent gastrostomy placement
  • BMI was greater in individuals with gastrostomy placement
  • Median age of gastrostomy placement was 9 years
  • The all-cause mortality rate was greater in those who had gastrostomy placement compared with those who had not (hazard ratio 4.07, CI 1.96-8.45)
  • Survival: 66.1% of the entire cohort was alive at 20 years of age (median survival was 33 years). The survival was 87.3% in those without a gastrostomy.
  • Placement of a gastrostomy tube was not associated with fewer hospitalizations or improvement in parental physical or mental health

While the mortality was higher in those who received a gastrostomy tube, the study’s nonrandomized design does not allow definitive assessment of whether a gastrostomy tube is detrimental to long-term survival.  Children who received gastrostomy tube may have had additional comorbidities.

My take: In adult medicine, it is generally accepted that Gtube placement does not prolong life (Clin Gastro & Hep 2007; 5: 1372).  This study indicates that a Gtube may not improve longevity in many pediatric disorders as well.

Related blog posts:

Exclusive Enteral Nutrition for Crohn’s Disease -Less Effective in Those with Isolated Colonic Disease

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A recent study (Y Xu. Clinical Nutrition 2018; https://doi.org/10.1016/j.clnu.2018.08.022) showed that exclusive enteral nutrition (EEN) is less effective in patient’s with Crohn’s disease with isolated colonic disease.

Abstract Link: Isolated Colonic Crohn’s Disease is Associated with a Reduced Response to Exclusive Enteral Nutrition Compared to Ileal or Ileocolonic Disease

This was a retrospective study of 241 adults: 52 patients in the cCD (isolated colonic disease) group and 189 patients in the non-cCD group.

Key findings:

  • “The rates of clinical remission differed between the two groups (cCD group: 51.9% versus non-cCD group: 68.3%, P = 0.029). Multivariate analyses indicated that isolated colonic involvement was associated with a reduced response to EEN (OR = 2.74; [CI] 95% = [1.2 –6.23], P = 0.016).”
  • “Further analysis showed that even in patients who achieved clinical remission after EEN, inflammatory serum markers declined more slowly in the cCD group than in the non-cCD group, and the time to remission was longer in the cCD group.”

Related blog posts: