Predicting Intestinal Failure After Gastroschisis Repair

N Vinit et al. J Pediatr 2022; DOI:https://doi.org/10.1016/j.jpeds.2021.11.004 (Ahead of print) Predicting Factors of Protracted Intestinal Failure in Children with Gastroschisis

Methods: Retrospective study. Among 180 patients, 35 required long-term parenteral nutrition (SBS-IF group) and 145 acquired full oral feeding within 6 months (oral feeding group) over mean f/u of 7.9 years.

Key findings:

  • Both bowel matting (OR, 14.2, P = .039) and secondarily diagnosed atresia or stenosis (OR, 17.78, P = .001) were independent postnatal predictors of SBS-IF.
  • An initial residual small bowel length of more than 50 cm was the best predictive cut-off for nutritional autonomy, with a sensitivity of 67% and a specificity of 100%

My take: This study identifies bowel matting and atresia/stenosis as additional factors in predicting nutritional autonomy.

Related blog posts:

Vitamin K Shots Protect Newborns from Severe Bleeding: AAP Policy Statement

HealthyChildren.org: Why Your Newborn Needs a Vitamin K Shot

AAP Policy Statement (I Hand et al. Pediatrics (2022) 149 (3): e2021056036) Open Access: Vitamin K and the Newborn Infant

This policy is welcome as there has been an increase in parents refusing vitamin K administration and a resultant increase in the number of cases of late-onset VKDB (vitamin K deficiency bleeding); some of these cases result in devastating outcomes.

Summary and Recommendations

VKDB remains a significant concern in newborn and young infants. Parenteral vitamin K has been shown to be the most effective way to prevent VKDB of the newborn and young infant, and the AAP recommends the following:

  1. Vitamin K should be administered to all newborn infants weighing >1500 g as a single, intramuscular dose of 1 mg within 6 hours of birth.
  2. Preterm infants weighing ≤1500 g should receive a vitamin K dose of 0.3 mg/kg to 0.5 mg/kg as a single, intramuscular dose. A single intravenous dose of vitamin K for preterm infants is not recommended for prophylaxis.
  3. Pediatricians and other health care providers must be aware of the benefits of vitamin K administration as well as the risks of refusal and convey this information to the infant’s caregivers.
  4. VKDB should be considered when evaluating bleeding in the first 6 months of life, even in infants who received prophylaxis, and especially in exclusively breastfed infants.

Related blog posts: 

“Bigorexia” and Body Image Distortion in Males

NY times (3/5/22): What Is ‘Bigorexia’?

This article appeared in the print edition of the NT Times on 3/6/22 (in the Style Section). Some excerpts:

Many doctors and researchers say that the relentless online adulation of muscular male bodies can have a toxic effect on the self-esteem of young men, with the never-ending scroll of six packs and boy-band faces making them feel inadequate and anxious...

A 2019 survey published in the Californian Journal of Health Promotion examined body image in boys. Almost a third of the 149 boys surveyed, aged 11 to 18, were dissatisfied with their body shapes. Athletes were more likely to be dissatisfied than non-athletes and most wanted to “increase muscle,” especially in the chest, arms and abs.

The quest for perfect pecs is so strong that psychiatrists now sometimes refer to it as “bigorexia,” a form of muscle dysmorphia exhibited mostly by men and characterized by excessive weight lifting, a preoccupation with not feeling muscular enough and a strict adherence to eating foods that lower weight and build muscle…

A scroll through the most popular TikTok or YouTube accounts today reveals a landscape dominated by musclemen…no form of media has disrupted how young men view their bodies quite like the insatiable voyeurism and staged exhibitionism that fuels platforms like TikTok and Instagram...

A study published last year in The Journal of Adolescent Health looked at eating disorders among men throughout young adulthood. By age 16 to 25, one-quarter of the 4,489 male participants told researchers they were worried about not having enough muscles. Eleven percent reported using muscle-building products such as creatine or anabolic steroids…

The line between getting fit and fanatical is not always clear…

Bigorexia can lead to interpersonal problems too. Many young men who overexercise and follow rigid diets often skip meals with family and friends, and complain of feeling isolated and socially anxious...

At first, he thought a muscular physique might be a way to make new friends, especially among the girls at school. But most of the attention has come from other boys on TikTok looking to get buff.

“Your only new friends are the weights,” he says in one video.

My take: Fortunately, this blog author’s appearance will not cause anyone to develop toxic self-esteem issues. On a more serious note, this growing problem should lead physicians to review protein supplements/dietary supplements with our teen population in addition to being sensitive to associated emotional struggles..

Related blog posts:

Good News for Fans of Gluten

EW Lopes et al. Clin Gastroenterol Hepatol 2022; 20: 303-313.Open Access: Dietary Gluten Intake Is Not Associated With Risk of Inflammatory Bowel Disease in US Adults Without Celiac Disease

Key finding: In 3 large adult US prospective cohorts (n=208,280), gluten intake was not associated with risk of CD or UC in 5,115,265 person-years of follow-up evaluation.

My take (from authors): These ” findings are reassuring at a time when consumption of gluten has been increasingly perceived as a trigger for chronic gastrointestinal diseases.”

Related blog posts:

Chattahoochee River, Atlanta

FDA Warns Consumers Not to Use Certain Powdered Infant Formula Produced in Abbott Nutrition’s Facility in Sturgis, Michigan

Here’s the link: FDA Warns Consumers Not to Use Certain Powdered Infant Formula Produced in Abbott Nutrition’s Facility in Sturgis, Michigan

2/17/22: Today, the U.S. Food and Drug Administration announced it is investigating consumer complaints of Cronobacter sakazakii and Salmonella Newport infections. All of the cases are reported to have consumed powdered infant formula produced from Abbott Nutrition’s Sturgis, Michigan facility ..The FDA is investigating complaints of four infant illnesses from three states.

The FDA is advising consumers not to use Similac, Alimentum, or EleCare powdered infant formulas if:

  • the first two digits of the code are 22 through 37; and 
  • the code on the container contains K8, SH or Z2; and 
  • the expiration date is 4-1-2022 (APR 2022) or later. 
  • Products that do not contain the information listed above are not impacted. The FDA advisory does not include liquid formula products or any metabolic deficiency nutrition formulas. Consumers should continue to use all products not covered by the advisory. 

AAP News: FDA issues warning for potentially contaminated infant formula

From USAToday: Baby formula recall 2022: FDA warns consumers not to use select Similac, Alimentum and EleCare: “More information is available at Similacrecall.com where you can type in the code on the bottom of the package. You can also call 1-800-986-8540 and follow the instructions provided.”

What is Driving the Vitamin D Epidemic? (More Testing)

AA Kerber et al. J Pediatr 2021; 239; 212-218. Stable Rates of Low Vitamin D Status Among Children Despite Increased Testing: A Population-Based Study

Methods: The Rochester Epidemiology Project (REP) was used to identify Olmsted County, Minnesota residents aged <19 years who had 25-hydroxyvitamin D [25(OH)D] levels measured between January 2, 2002 and December 31, 2017.  Using each patient’s first 25(OH)D measurement during this period, patients were categorized as vitamin D deficiency/insufficiency if Vit 25(OH)D level was <20 ng/mL.

To convert nmol/L to ng/mL= nmol/L x 0.401 OR nmol/L =ng/mL x 2.496

Key finding:

  • There was a 42-fold increase in the proportion of the county’s pediatric population tested each year, starting at 3.7 per 10,000 persons in 2002 and increasing to 156.1 per 10,000 persons in 2017
  • During the 16-year period, the incidence of vitamin D deficiency/insufficiency (per 10,000 persons) increased from 1.7 in 2002-2003 to 19.9 in 2016-2017, but the proportion that were tested and had vitamin D deficiency/insufficiency remained stable –rates of 21.9% in 2006-2007 and 18.5% in 2016-2017
  • There was a higher rate of Vit D deficiency/insufficiency in females (22.8%) vs males (16.9%) (P<.001)
  • There was a significant association with obesity and Vit D deficiency/insufficiency (32.7% with moderate and 32.9% with severe obesity). It is unclear whether this is a causal link or an association (perhaps associated with less outdoor activity)
  • Limitation: Study was performed in Olmstead county which is 90-95% white; this limits generalizability (though other reports have noted increased testing rates as well in other locations)

My take: Clearly more kids are being screened for vitamin D deficiency. More data is needed on whether this results in any meaningful improvements in outcomes and the associated costs. In addition, it is important to recognize that vitamin D levels can be inversely proportional to inflammatory conditions and can improve without supplementation by addressing these disorders.

Related blog posts:

Best of Allergy Articles 2021 -Cow’s Milk Allergy/Allergic proctocolitis (Part 4)

In Pediatrics, supplement 3 summarizes 76 articles: Synopsis Book: Best Articles Relevant to Pediatric Allergy, Asthma and Immunology

Some of the studies that are most relevant to pediatric GI doctors I am reviewing for this blog over the next/past few days.

A Lemoine et al. Clin Exp Allergy  2021:51(9):1242-1245.  doi:10.1111/cea.13896. Rectal bleeding and cow’s milk protein-induced allergic proctocolitis: A prospective study

In this prospective cohort of infants (in France) with food protein-induced allergic proctocolitis (FPIAP) (n=76), all infants had rectal bleeding (RB) which resolved with cow’s milk protein (CMP) elimination. After the initial oral food challenge (OFC) which took place 2 to 8 weeks after resolution of rectal bleeding, OFC was repeated every 2 months.

Key findings:

  • Only 31% failed the initial OFC
  • The median age of tolerance, for those with a confirmed FPIAP based on OFC, was 6.8 months, with >75% of the cohort tolerant by 10 months of age

My take:

  1. This study shows that the majority of infants with RB probably do not have FPIAP. In those that do have FPIAP, earlier challenge is reasonable in the majority.
  2. FPIAP is generally mild and self-limited. Diagnosis is hampered by lack of validated criteria.
From Siesta Key, FL

Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 3)

In Pediatrics, supplement 3 summarizes 76 articles: Synopsis Book: Best Articles Relevant to Pediatric Allergy, Asthma and Immunology

Some of the studies that are most relevant to pediatric GI doctors I am reviewing for this blog over the next/past few days.

VM Martin et al. Pediatrics 2020; 146: e20200202. Open Access: Increased IgE-Mediated Food Allergy with Food-Protein-Induced Allergic Proctocolitis.

In this study of 153 infants with food protein-induced allergic proctocolitis (FPIAP) with documented blood in the stool, more children with FPIAP developed IgE-Food Allergy (IgE-FA) (11%) compared with healthy children.

Key points (from commentary by MT Kraft and D Stukus):

  • “Although conventional teaching is to wait until 12 months of age to reintroduce dairy to infants with FPIAP, it can likely be introduced much earlier.”
  • The diagnosis of FPIAP was associated with with an increased risk of IgE-FA, “although diagnosis was not confirmed through oral food challenges”

My take: Children with FPIAP are more likely to receive a diagnosis of IgE-FA. Prolonged restriction of milk, when no longer required, could contribute to this; in addition, some children are mislabeled as food allergic without appropriate confirmation (based on faulty testing).

Fix the Feeding Pump, Don’t Call DFACs

J David et al. JPGN 2021; 73: 599-603. Unexpected Poor Growth in Pediatric Patients on Food-based Enteral Therapy: Case Series and Suggested Practice Changes

In this chart review with five patients, weight loss occurred when patients received only a fraction of their feeds due to feeding pump inaccuracy.

Related blog posts:

Nutritional Management of Intestinal Failure in Pediatrics

A recent terrific update from Kipp Ellsworth: Nutritional Management of Intestinal Failure Patients. Slides:

Some selected slides:

Related blog posts for Short Bowel Syndrome: