From Children’s Hospital Colorado – What is celiac disease?: http://youtu.be/l2KKyUo8Ujs (thanks to Eric Benchimol for this link).
This video provides useful information regarding celiac disease, especially helpful for kids and those who need a basic introduction.
In a small study with 60 patients with irritable bowel syndrome (DDW abstract 374), the response rate to a Low-FODMAPs/Normal gluten diet was as effective as a Low-FODMAPs/Gluten-free diet. Both diets were more effective in reducing abdominal symptoms than a normal diet. A summary of this abstract from Gastroenterology & Endoscopy News: Nixing Gluten Offers No Added Benefit To Low-FODMAPs Diet for IBS
According to Lin Chang, MD: “The beneficial effect of low FODMAPs does not appear to be predominantly due to gluten avoidance.”
Related blog post: An Unexpected Twist for “Gluten Sensitivity” | gutsandgrowth
Initially, this blog was titled: “Even More Work for Our IBD Nutritionists?” If you get to the bottom of this post, you will know why.
A provocative study (Inflamm Bowel Dis 2014; 20: 1353-60) describes the use of partial enteral nutrition (PEN) as effective for induction of remission in children and young adults with Crohn’s disease (CD). I’m a little wary commenting on this study as many individuals may take a glimmer of information and subject themselves to empiric trials. In fact, a recent case report (N Engl J Med 2014; 371:668-675) described an adult who without medical advice used fecal transplant therapy (obtained from spouse and infant) to self-treat his ulcerative colitis. In the case report, this patient ultimately was diagnosed with a secondary cytomegalovirus (CMV) infection and the fecal transplant was not effective.
With regard to the PEN study, the authors treated 47 patients (34 children) with up to 50% of their diet as a polymeric formula (Modulen or Pediasure) along with dietary counseling/changes. The authors note that CD “may arise from a sequence of events involving changes in the microbiome, intestinal permeability leading to bacterial adherence or penetration of the epithelium, and subsequent stimulation of the adaptive immune response leading to tissue damage. We have termed this sequence the Bacterial Penetration Cycle Hypothesis.” Given the compelling improvements noted with exclusive enteral nutrition (EEN), the authors sought to modify the diet after an initial clinical response in two patients who could not adhere to EEN.
Design: Strict diet for 6 weeks with 50% of calories from formula, then less restricted diet for next 6 weeks (25% of calories from formula). Also, diet required exclusion of gluten, dairy, animal fat, processed meats, products containing emulsifiers, candies, chocolates, gum, packaged snacks, sauces, and canned goods. A more extensive listing of the foods is given in the appendix (page 1360). The authors measured the clinical response with PCDAI, Harvey Bradshaw index, and bloodwork (eg. CRP, ESR, albumin, and hemoglobin).
Key finding:
Take home message: A PEN diet needs more study. I would not advise someone to radically change their diet without the instruction of a qualified nutritionist, unless the individual wants to be another case report of something gone awry.
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A recent study (JPGN 2014; 59: 225-28) examined fat-soluble vitamin deficiencies in pediatric patients with newly diagonosed Celiac disease (CD).
Of the 83 patients analyzed between 1995-2012 at the Mayo clinic, the key findings:
A limitation of the study was a selection bias as not all children underwent vitamin level measurements.
Take-home message (from authors): “fat-soluble deficiencies are uncommon in children with a new diagnosis of CD. Routine measuring of fat-soluble vitamin levels may not be necessary.”
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While a recent study (JPGN 2014; 59: 177-81) discusses the results of several strategies for limiting CVL infections, I found one approach in particular of interest.
This single center study (2009-2013, n=48 children) from Birmingham, UK examined a multidisciplinary enhanced care pathway regarding CVL care. Implementation of this pathway lowered the risk of all-cause line infections from 1.98 per 1000 parenteral nutrition days to 0.45. The pathway included training care providers, careful discharge planning, having those with skin conditions see dermatologists, and monitoring compliance.
One important observation was that methicillin-sensitive Staphylococcus aureus (MSSA) infections were often preceded by local signs of infection for a short period prior to systemic infection. “We devised a pathway for exit site infections in which a swab is taken and empiric topical mupirocin commenced immediately. A decision on any further management is made after 24 to 48 hours.”
Take-home message: Implementing a CVL care pathway lowers CVL infections. Implementing topical therapy at the first signs of a localized infection can be an important part of this effort.
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Despite all of the accolades that vitamin D has received, the fact that low vitamin D is associated with worse outcomes, in a number of disease states, does not prove causality. A recent article indicates that vitamin D is likely more of a marker of disease activity than a mediator of disease activity in inflammatory bowel disease (IBD), and specifically Crohn’s disease (CD) (Inflamm Bowel Dis 2014; 20: 856-60).
Background: Binding sites for the vitamin D receptor (VDR) have been “identified in genes associated with CD, and vitamin D has been shown to enhance the production of interleukin-10 (IL-10) and induction of regulatory T-cells.”
Design:The authors prospectively collected samples of 37 CD patients; the mean age in those with active disease (n=20) was 34 years and it was 30 years in those with inactive disease. In 8 patients with active disease, vitamin D levels were measured at the time of active inflammation (day 0) and at 14 days after receiving infliximab (day 14).
Take-home point: There is an inverse relationship between vitamin D levels and disease activity. However, the early increases in vitamin D levels with clinical response to anti-TNF therapy suggests that a major mechanism of vitamin D deficiency is related to the burden of systemic inflammation. Hence, repeat testing when patients are in remission may obviate the need for vitamin D supplementation in many patients.
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A provocative article (J Pediatr 2014; 165: 274-9) examines supplementation of enteral fat/fish oil in premature infants as a mechanism to reduce parenteral nutrition associated cholestasis (PNAC). While the study’s limitations will prevent any dramatic conclusions, the article and associated editorial (pgs 226-27) do make several useful points.
Before discussing the limitations, the design of the study:
Infants were block randomized (block size of 8) into either a control group or treatment group. While both groups received conventional PN, the treatment group received supplemental enteral fat as microlipid and fish oil after tolerating enteral feeds at 20 mL/kg/d. Microlipid was started at 1 g/kg/d and advanced up to 2.5 g/kg/d; coinciding with microlipid increases, parenteral intralipid was decreased. Fish oil was started at 0.2 g every 12 hours and was advanced to a maximum of 0.5 g every 6 hours. The two fish oil products were Major Fish Oil 500 (Major Pharmaceuticals) and Rugby Sea Omega 50 (Rugby Laboratories).
The limitations include the following:
With these limitations in mind, there authors were able to show that supplemental fat (with fish oil) was associated with less parenteral intravenous lipid, and reduced conjugated bilirubin prior to anastomosis. However, there was no significant difference in PN duration. Growth parameters were similar prior to anastomosis, but improved in the treatment group after anastomosis.
In the editorial, it is noted that “enteral feeding with a high-fat diet has been demonstrated to enhance structural features of resection-associated adaptation, the underlying mechanisms for this phenomenon are still presently unknown.”
Take-home message: Enteral fat/fish oil supplementation helped decrease parenteral intravenous lipids in this study. More broadly, advancing enteral nutrition by accepting higher ostomy outputs is likely the best strategy to avoid PNAC and other PN-associated complications.
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From Kipp Ellsworth’s Twitter Feed:
The Time for a Confirmatory NEC Probiotic Prevention Trial in ELBW Infants is Now. Editorial in J Peds http://goo.gl/XZ2kUk (The Journal of Pediatrics
Volume 165, Issue 2 , Pages 389-394, August 2014)
This editorial reviews previous studies and recommends implementing a Probiotic Trial in North America. Here’s an excerpt:
“An adequately powered double-blinded placebo-controlled trial replicating a previous effective NEC prevention study in VLBW infants was published (the ProPrem trial)…the study revealed a significant reduction of NEC: from 4.4%-2.0% but no effect on mortality (4.9% vs 5.1%)…A closer look at the results of the ProPrem study, however, reveals that the probiotic supplementation did not have any effect on NEC in the ELBW (<1000 g) infants, which is consistent with two small previous studies reporting data on these infants separately.36, 42 Thus, there is currently no compelling evidence for recommending prophylactic probiotics to prevent NEC in infants with a birth weight <1000 g. Especially important is the lack of safety information in these most immature and highly vulnerable babies…Probiotics appear promising for use as prevention strategy for NEC, but there is still insufficient data for general recommendation of the use of probiotics in the ELBW infant. We argue, therefore, that now is the time to conduct in the North American setting, a high quality confirmative NEC prevention trial using probiotics in at-risk ELBW infants.”
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In a number of media outlets, there has been a push for a highly successful (and under appreciated) treatment: walking.
Advantages:
Here’s a link (Every Body Walk!) and here’s an excerpt:
Researchers have discovered a “wonder drug” for many of today’s most common medical problems, says Dr. Bob Sallis, a family practitioner at a Kaiser Permanente clinic in Fontana, California. It’s been proven to help treat or prevent diabetes, depression, breast and colon cancer, high blood pressure, cardiovascular disease, obesity, anxiety and osteoporosis, Sallis told leaders at the 2013 Walking Summit in Washington, D.C.
“The drug is called walking,” Sallis announced. “Its generic name is physical activity.”
Recommended dosage is 30 minutes a day, five days a week, but children should double that to 60 minutes a day, seven days a week. Side effects may include weight loss, improved mood, improved sleep and bowel habits, stronger muscles and bones as well as looking and feeling better.
Comment: If only “walking” was marketed better. Physicians know that successful treatments need to have an “x” or a “z” or both to really do well (“X and Z in favor”).
While a life-long gluten-free diet (GFD) is effective in most individuals with Celiac disease (CD), it is not effective in some. This could be related to cross contamination of food products, improper/inaccurate labeling and perhaps other factors as well. As a consequence, there is a rationale for the development of medical therapy. A recent study (Gastroenterol 2014; 146: 1649-58) has shown the ability of ALV003, a mixture of 2 recombinant gluten-specific proteases administered orally, to protect patients with celiac disease from gluten-induced mucosal injury in a phase 2 trial.
Methods: In a 6-week challenge study, adults with biopsy-proven celiac disease were divided into a treatment group with ALV003 (n=20) or a placebo group (n=21). The 2.0 g gluten dose (equivalent to 1/2 slice of bread) for the study was determined after an optimization study (using 1.5 g, 3.0 g or 6.0 g of gluten (bread crumbs) in three divided doses). Biopsies were taken before and after the gluten challenge.
Key finding:
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