Category Archives: Nutrition

What Happened to Skepticism re: Lipid Emulsion Position Paper

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A recent position paper (from ESPGHAN) (I Hojsak et al. JPGN 2016; 62: 776-92) made me wonder how different people can look at the same data and come to opposite conclusions.

In short, this article systemically reviews intravenous lipid emulsions and the risk of hepatotoxicity.  The review on the data is quite helpful.  The authors conclude that short-term use of the various emulsions currently in use do not result in a significant difference in neonates, infants and children.

The authors acknowledge that the data for long-term use of these emulsions is limited. They state that “there is evidence indicating that just tailoring and adjusting PN in children on long-term PN could improve liver disease, meaning that the focus should not only be on the type of ILE.”

“Although the quality of data are lacking there is some evidence that the use of multicomponent fish oil-containing ILE may contribute to a decrease” in liver toxicity.

What I don’t understand: The authors recommend: “it appears prudent to use multicomponent FO [fish oil]-containing ILE (GR C)” and literally the next sentence: “The present evidence base is inadequate to determine the optimal strategy for intravenous lipid supply.”

My take: I think we need to gather the data before having official position paper  recommendations.

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Why a Diet History Can Be Helpful

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A recent clinical problem-solving case report (D Hafez, et al. NEJM 2016; 374: 1369-74) highlights why a dietary history is important.  The initial paragraph indicated that a 2 year old with delayed speech and a picky eater presented with a 6 week history of progressive inability to bear weight.

The authors of this report explained the entire sequence of diagnosis which included extensive studies like bloodwork, radiographs, MRI, and bone marrow biopsy.  The last paragraph indicates that finally someone asked about the child’s diet: “approximately 1.4 liters of chocolate milk and ate two to four graham crackers per day. His mother acknowledged that these items were the mainstay of his diet.”

It turns out that the patient had vitamin C deficiency causing scurvy.  “Unfortunately, a comprehensive dietary review was performed only after an exhaustive and costly workup had been pursued.”  Personally, if I were involved in such a case, I would be embarrassed if it were published.

My take: While scurvy is interesting and rare in this country, the broader lesson of this report is to get a better dietary history before pursuing a huge workup.

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Gibbs Gardens

Gibbs Gardens

The “EAT” Study

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A recent study from MR Perkin et al (NEJM 2016; 374: 1733-43) examined whether early introduction (3 months) of allergenic foods in 1303 infants lowered the rate of allergies to these foods at 3 years of life compared to standard introduction (after 6 months).  The six foods: peanut, egg, cow’s milk, sesame, whitefish, and wheat.

This EAT study (“Enquiring about Tolerance”) required parents in the intervention group to give 3 rounded teaspoons of smooth peanut butter, one small egg, two portions (40-60 g) of cow’s milk yogurt, 3 teaspoons of sesame paste, 24 g of white fish, and two wheat-based cereal biscuits every week.

While the study did not reach a statistical significance, the absolute rate of allergies was modestly lower in those in the early introduction group (5.6% compared with 7.1%).  In a per-protocol analysis of those who strictly adhered to the assigned treatment regimen, there was an even lower rate of 2.4% (compared to 7.3% in the standard group).  The associated editorial (pg 1783-84) indicates that the demanding protocol limited those who adhered to the protocol and points out that those who were not adherent could have been due to reverse causation (eg. subtle avoidance to certain foods due to reactions).  The editorial conclusion: “evidence is building that early consumption rather than delayed introduction of foods is likely to be more beneficial as a strategy for the primary prevention of food allergy.”

My take: Early introduction of allergenic solids at ~3 months of age probably lowers the risk of developing allergies to these foods.

Here’s a link to <2 minute quick take summary: The EAT Study NEJM

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Reference on consensus for guidance on introducing peanuts:  J Allergy Clin Immunol 2015; 136: 258-61.

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Get Here If You Can: Improved Vitamin D Status

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“I don’t care how you get here
Just get here if you can”

–Oleta Adams, “Get Here”

A recent study (Kugathasan et al. JPGN 2016; 62: 252-8) reminded me of the aforementioned song lyrics. (Full lyrics: Get Here)

This randomized pilot study comparing two regimens for low Vitamin D levels (serum 25-OH Vit D <30 ng/mL). During a treatment period of 6 weeks, patients were randomized to treatment with Vitamin D3 (cholecalciferol) at 10,000 units or to 5,000 units per 10 kg per week.  The maximum weekly dose in the first group was 50,000 units (IU) and the maximum dose in the latter group was 25,000 IU.

Both treatments were associated with improvement; in the higher dose group the mean serum level reached 49.2 whereas it was 41.5 in the lower dose group.  Of note, this repletion effect was nearly lost by the 12-week followup.

Other points:

  • This study used Vitamin D3 (cholecalciferol) which has greater bioavailability than Vitamin D2 (ergocalciferol).
  • No serious adverse effects were noted.  The study monitored Calcium, and parathyroid hormone concentrations.
  • The authors did not report any correlation with CRP values.   This is important because other studies (Why Adding Vitamin D May Not Help IBD | gutsandgrowth)
    have shown improvement in Vitamin D levels without vitamin D supplementation when underlying inflammation has been treated.

My take: This study shows that supplementation with Vitamin D is associated with improved levels  –one can ‘get here’ with either regimen the authors studied.  In those with low levels (not due to inflammation), it is likely that maintenance Vitamin D supplementation will be needed.

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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.

Pediatric Nutritionist: Blenderized & Pureed Gtube Diets

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A recent Children’s Healthcare of Atlanta Nutrition Support Colloquium provided a terrific update on the use of blenderized and pureed diets via gastrostomy tube.

Here’s the link to the talk (including slides) and a summary on the Pediatric Nutritionist blog site: The Blenderized and Pureed by Gtube Diets

I’ve found these diets to be particularly useful in children with retching.  In addition, these diets can lower costs, reduce other symptoms like constipation, and appeal to parents who desire more typical foods in their child’s diet.

Related blog post: Nutrition University -Part 1 | gutsandgrowth

Gibbs Gardens

Gibbs Gardens

 

Fresh Fruit Study

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A study from China has shown benefits associated with increased fresh fruit intake (H Du et al. NEJM; 2016; 374: 1332-43). Abstract Link: Fresh Fruit Consumption and Major Cardiovascular Disease in China

Study methods: 512,891 adults recruited from 2004-2008.  Prospective cohort.

Results: 18% of participants consumed fresh fruit daily.  This group had lower systolic blood pressure (by 4 mm Hg), lower glucose (by 0.5 mmol/L) (both with P<0.001).  The adjusted hazard ratio for cardiovascular death was 0.6 (CI 0.54-0.67), 0.66 for major coronary event, 0.75 for ischemic stroke, and 0.64 for hemorrhagic stroke.

Limitation: Fruit consumption was correlated with socioeconomic status and this may have affected findings even after adjustment due to residual confounding.

My take: While fruit consumption has not been proven to cause better health, daily fruit consumption is associated with better outcomes.

Related blog post: Eat your veggies…if you don’t want to get sick | gutsandgrowth

Savings with veggies

 

Goldilocks and Gluten

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A recent study (CA Aronsson et al. Clin Gastroenterol Hepatol 2016; 14: 403-09, editorial 410-12) suggests that how much gluten is given may be another important factor rather than looking at the timing with regard to the development of celiac disease (CD).

In this 1-to-3 nested case-control study with 146 cases of CD and 436 controls, the authors indicate that a larger intake of gluten than controls increased the likelihood of celiac disease.  Specifically, children receiving large amounts of gluten (>5 g/day) during their first 24 months had a 2.6-fold increased risk of CD compared to those who consumed lower quantities.

The associated editorial notes that the total amount of gluten intake was only marginally increased in CD cases versus all control patients (OR 1.05) and that the association was decreased when individuals with first-degree relatives with CD were excluded.  In addition, this high consumption increased the risk after the first 2 years of life, rather than during this period of high consumption.

Does this make sense? Not to me.  These findings need to be replicated in other studies to determine if gluten exposure is like Goldilocks: too little, too much –>just right.

My take: For now, I think sticking with the timing of gluten exposure (recommended at 4-6 months) rather than the quantity is worthwhile.

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Plumbism in Flint

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A brief commentary (DC Berlinger NEJM 2016; 1101-3) provides a succinct summary of the medical story from Flint.

Historical:

  • Lead exposure has been known to be a hazard since the 1st century: Dioscorides “observed in his De Materia Medica that ‘lead makes the mind give way.'”
  • In 1723, an industrial hygiene act in the colonies prohibited the use of lead in the apparatus to distill rum due to being “unwholesom.”
  • “Water doesn’t receive as much attention as paint…but,…our word ‘plumbing’ derives from the Latin for lead, and lead poisoning is often called ‘plumbism.'”
  • The past 40 years, the U.S. has had dramatic reductions in blood lead levels.  This is “one of the cardinal public health success stories.”
  • Lead in water poses unique problems because “it rarely originates in the source water.  Rather, the problem usually lies near the point of consumption.”

“There is no safe level of lead, particularly for children”

Flint:

  • In 2014, “the city began taking its water from the Flint river rather than Lake Huron.”  This was expected to save ~$100 per day; now, the cost of repairing infrastructure is estimated to be as high as $1.5 billion.  Yet the Flint river water was “19 times as corrosive,” leading to more lead in the water.
  • The incidence of blood lead concentrations above the reference value of 5 mcg/dL rose from 2.4% to 4.9% from 2013 to 2015.  “The increase was greatest, from 4.0% to 10.6%, among children in neighborhoods with the highest lead concentrations.”
  • Disadvantaged children already are at increased risk due to houses more likely to be in poor repair.  In addition, they are at increased risk from higher levels of lead in solid/dust and lead paint.
  • “In coming years, parents will undoubtedly wonder, with anxiety and even guilt, whether their children’s every developmental stumble stems from this episode.”

My take (borrowed from author): “We have the knowledge required to redress this social crime…what we lack is the political will to do what should be done.”

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Which kids who aspirate need a gastrostomy tube?

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While some may think all children who aspirate should have a gastrostomy tube, a recent study (ME McSweeney et al. J Pediatr 2016; 170: 79-84) indicates a more selective approach is appropriate.

This retrospective review of 114 patients (2006-2013) compared patients fed by gastrostomy tube (g-tube) and those who were fed orally.  In their introduction, the authors note, “there has been a practice shift at many institutions away from g-tube placement and more toward continuing to feed children with aspiration orally.”  All patients in the study had aspiration and/or penetration with thin liquids and/or nectar thick liquids on a videofluoroscopic swallow study (VFSS).

There were 61 who aspirated only thin liquids and 53 who aspirated thin and nectar thick liquids.  All patients were divided into two groups: a g-tube group which did not have a preoperative trial of thickened feeds and an orally-fed group.  Patients who had a fundoplication or post-pyloric feeds were excluded from this study.

Key findings:

  • There were no significant differences in admissions among those who aspirated thins compared with those that aspirated thin & nectar thick liquids.
  • Patients fed by gastrostomy were hospitalized more frequently (median 2 times compared to once with orally-fed) and for longer duration (median 24 days compared with median 2 days for orally-fed)
  • No differences in total pulmonary admissions were noted between gastrostomy-fed and orally-fed group

The authors advocate a trial of oral feeding in all children cleared to take nectar or honey thick liquids prior to g-tube placement.

 

While the authors note that g-tube placement did not result in fewer pulmonary admissions, in their discussion, they also reviewed studies which showed that fundoplication (with g-tube) was not associated with a reduced risk of respiratory complications and in fact, had higher rehospitalizations.

This current study, and previous studies, are limited by their design.  Patients were not randomized and g-tube-fed patients may have had more comorbidities, biasing the results.  The authors note that there were 11 children who failed oral thickening trials and needed g-tube placement.  At the same time, there are substantial numbers of children whose swallow function improve.  Also, the authors note that thickening agents have not been shown to lead to dehydration risk.

My take: the widespread availability of swallow studies has likely led to some children undergoing g-tube placement who may have been fine with ongoing orally-thickened feeds.  Avoiding g-tube placement for children who can tolerate and thrive on thickened feeds is worthwhile.

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Walnut Street Bridge & Tennessee River

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