More is Not Better: Protein for Preterm Infants

FH Bloomfield et al. NEJM 2022; 387: 1661-1672. Early Amino Acids in Extremely Preterm Babies

My take: For preterm infants <1000 gram, this study showed that the usual dosing of amino acids 2.5 gram to 3.5 gram per day (the placebo group) appeared to have better secondary outcomes (though within confidence intervals) than those who received an additional 1 gram per day.

Slides from video summary:

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Docosahexaenoic Acid (DHA) for Preterm Infants and Intelligence

JF Gould et al. NEJM 2022; 387: 1579-1588. Neonatal Docosahexaenoic Acid in Preterm Infants and Intelligence at 5 Years

Background: “Because its accretion into the brain is greatest during the final trimester of pregnancy, infants born before 29 weeks’ gestation do not receive the normal supply of DHA.”

In this randomized placebo-controlled study of infants born prior to 29 weeks gestation, DHA supplementation 60 mg/kg/day was given to the study group and cognitive outcomes were measured at 5 yrs. 480 (73%) had an full-scale intelligence quotient (FSIQ) score available — 241 in the DHA group and 239 in the control group.

Key findings:  FSIQ scores were 95.4±17.3 in the DHA group and 91.9±19.1 in the control group. Adverse events were similar in the two groups.

Short take video: DHA in Premature Infants

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What’s in Your Gut and How to Change It

W Turpin et al. Gastroenterol 2022; 163: 685-698. Open access! Mediterranean-Like Dietary Pattern Associations With Gut Microbiome Composition and Subclinical Gastrointestinal Inflammation

As part of the Genetic, Environmental, Microbial (GEM) Project, the researchers recruited a cohort of 2289 healthy first-degree relatives of patients with Crohn’s disease. Diet was assessed with a food frequency questionnaire. Key finding: A Mediterranean-like dietary pattern is associated with microbiome (increased Ruminococcus, as well as taxa such as Faecalibacterium) and lower intestinal inflammation.

L Zhao et al. Gastroenterol 2022; 163: 699-711. Open Access! Uncovering 1058 Novel Human Enteric DNA Viruses Through Deep Long-Read Third-Generation Sequencing and Their Clinical Impact This study discovered 1058 novel human gut viruses, and these findings can contribute to current viral reference genome, future virome investigation, and colorectal cancer diagnosis. From the editorial: “Previous literature also identified virome signatures associated with certain diseases, such as colorectal cancer14 or inflammatory bowel disease,15 such that a better understanding of the viral dark matter may be used to develop biomarkers to identify individuals at risk or even to influence gut physiology.”

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What is the Best Ferritin Threshold and Why It Needs to Be Checked In 1-Year-Olds

E Mantadakis. J Pediatr 2022; 245: 12-14. (Editorial) Open access. Serum Ferritin Threshold for Iron Deficiency Screening in One-Year-Old Children nutrition.

N Mukhtarova et al. J Pediatr 2022; 245: 217-221. Serum Ferritin Threshold for Iron Deficiency Screening in One-Year-Old Children. This study included 3153 infants, with 698 included in the final analysis.

Key points:

  • 11.4% had iron deficiency, 3.5% had iron deficiency anemia, 8.2% had anemia, and 76.9% were normal.
  • “The authors showed that the hemoglobin threshold of 110 g/L that  is currently recommended for diagnosing anemia at 1-year-old well-child visit corresponds with a very low serum ferritin (4.42 mcg/L).”
  • In a previous study, TARGet Kids!, “a higher serum ferritin was associated with higher cognitive function, with a serum ferritin of 17 mcg/L corresponding with the maximum level of cognition.” That is, iron deficiency, even in the absence of anemia, can contribute to detrimental cognitive outcomes.
  • Thus, current hemoglobin levels and ferritin need to be revised.  Neither a hemoglobin of 11.0 g/dL nor a ferritin of 12 mcg/L is sensitive in detecting iron deficiency in toddlers.
  • In the U.S., only ~40% of anemia in toddlers is attributable to iron deficiency; thus, checking a ferritin can help determine if iron supplementation is worthwhile.

My take: Iron deficiency anemia is a late indicator of iron deficiency and relying on hemoglobin alone could have irreversible detrimental effects on cognitive outcomes. These articles make a strong argument for the following:

  1. Use a ferritin threshold of at least 18 mcg/L to determine if iron deficient
  2. Check a ferritin along with a hemoglobin at 1-year well-child check. 

Related blog post: Briefly Noted: Ferritin Levels and Cognitive Outcomes

Rock Garden, Calhoun Ga

Avoidant/Restrictive Food Intake Disorder (ARFID) with Irritable Bowel Syndrome and with Inflammatory Bowel Disease

Last week, this blog highlighted a study regarding the prevalence of ARFID in pediatric neurogastroenterology (Prevalence of Avoidant/Restrictive Food Intake Disorders in Pediatric Neurogastroenterology).

Today, this post reviews a study with 955 adult patients from 4 prospective studies who had completed the IBS Quality of Life Instrument (IBS-QOL). The 3 questions constituting the food domain were used to identify patients with reported severe food avoidance and restriction.

Key findings:

  • In total, 13.2 % of the patients reported severe food avoidance and restriction, and in these patients all aspects of quality of life were lower (P < .01) and psychological, GI, and somatic symptoms were more severe (P < .05). 

The associated editorial provides a lot of information on ARFID in this setting.

Key points:

  • “The sine qua non of ARFID is a reduction in food intake, in terms of volume and/or variety, not primarily motivated by body image disturbance”
  • “Motivations behind changes in eating in ARFID need to be 1 or more of 3 prototypical presentations: (1) fear of aversive consequences (eg, IBS symptoms), (2) a lack of interest in eating or low appetite, and (3) sensitivity to sensory characteristics of food (eg, taste, texture, smell)”
  • “Weight suppression has similar deleterious health effects as is seen in anorexia nervosa, including cardiac abnormalities and bone mineral density loss”
  • “Up to 90% of patients in IBS reporting avoidance of specific foods”
  • “To identify presence of problematic avoidant/restrictive eating, there are ARFID measures validated with cutoffs (eg, the 9-item ARFID Screen;22,23 the PARDI-ARFID questionnaire).24 Nevertheless, more research is needed on the utility of these screening measures in IBS populations”

My take: Patients with ARFID and IBS need much more careful dietary counseling. So, it is important to consider the possibility of ARFID in this patient population.

Related article: E Yelencich et al. Clin Gastroenterol Hepatol 2022; 20: 1282-1289. Open Access PDF: Avoidant Restrictive Food Intake Disorder Prevalent Among Patients With Inflammatory Bowel Disease In this cross-sectional study of adults with IBD, 28/161 (17%) had a positive ARFID risk score (>/=24). Most participants (92%) reported avoiding 1 or more foods while having active symptoms, and 74% continued to avoid 1 or more foods even in the absence of symptoms. Patients with a positive ARFID risk screen were significantly more likely to be at risk for malnutrition (60.7% vs 15.8%; P < .01)

Related blog post:

Afraid to Eat -Could be “Avoidant Restrictive Food Intake Disorder”

Prevalence of Avoidant/Restrictive Food Intake Disorders in Pediatric Neurogastroenterology

HB Murray et al. JPGN 2022; 74: 588-592. Prevalence and Characteristics of Avoidant/Restrictive Food Intake Disorder in Pediatric Neurogastroenterology Patients

Associated commentary by SB Oliveira, A Kaul: Invited Commentary Re: Prevalence and Characteristics of Avoidant/ Restrictive Food Intake Disorder in Pediatric Neurogastroenterology Patients

This was a retrospective study with 129 consecutive neurogastroenterology patients. Key findings:

  • Eleven cases (8%) met the full criteria for ARFID (DSM, 5th ed) and 19 cases (15%) had clinically significant avoidant/ restrictive eating behaviors with insufficient information for a definitive ARFID diagnosis
  • In a separate retrospective study, the same center published data on ARFID in a general pediatric population, showing 1.5% meeting the full criteria and 2.4% with some features (KT Eddy et al. Int J Eat Disord . 2015 Jul;48(5):464-70. Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network)

The discussion notes that while elimination diets (eg. low FODMAPs diets) are frequently used for disorders of brain-gut interaction, they may increase the risk of ARFID. “Some children may develop fear of what will happen when they try foods again.”

The insightful commentary makes several useful points:

  • A retrospective study is not the best way to determine prevalence of ARFID particularly as many practitioners have limited familiarity and documentation may be inadequate
  • Nutritional rehabilitation can improve GI function. It has been shown that patients with anorexia nervosa have delayed gastric emptying which improved with refeeding. More broadly, it is often challenging to definitively determine the cause and effect in patients with malnutrition and gut dysmotility. (This is why I rarely obtain gastric emptying studies in patients with poor nutritional status)

My take: ARFID can be difficult to manage and is important to consider in our patient population, and probably even more so in patients seen in neurogastroenterology programs. The exact prevalence of ARFID in these programs is uncertain and prospective studies are needed.

Related blog post:

Predicting Intestinal Failure After Gastroschisis Repair

N Vinit et al. J Pediatr 2022; DOI: (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.

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

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“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..

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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.”

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Chattahoochee River, Atlanta