Category Archives: Pediatric Gastroenterology Intestinal Disorder

N2U -Part 4: Obesity and Micronutrients

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2015 N2U Syllabus & Presentations

Critically-ill Obese Patient (Syllabus 51-61) Ann Scheimann

Case: 14 year old with obesity –admitted to PICU with respiratory distress, BM1 51, recent hx/o 30 lb weight loss and declining school performance.

  • Nutritional assessment (syllabus pg 55) References: Port et al. Curr Opin Clin Nutr Metab Care. 2010;13:184-191.McClave et al. JPEN J Parenter Enteral Nutr . 2011: 35: 88s.
  • Components of nutritional support (syllabus pg 56) References: Hurt et al. JPEN J Parenter Enteral Nutr . 2011;35: 60S.
  • Presentation provides good summary of vitamin deficiencies and toxicities (syllabus 57-61), which are more common after bariatric procedures.

 

IMG_1681 Nutrient Location

 

B12 Slide From Syllabus

B12 Slide From Syllabus

Key points:

  • For obese/overweight, for calorie calculation, can use adjusted weight to estimate energy expenditure (but don’t give more than 2000 calories per day). For teens/adults, usually need at least 1200 calories per day.
  • Harris-Benedict Equation (HBE) is often used but often overestimates needs (compared with indirect calorimetry) by about 600 cal/day. Common Equations (see below)
  • Protein –provide about 2 gm/kg for weight-for-length at 75-90% for age
  • Formulas with relatively higher protein content (eg. Jevity or Promote) can be helpful to provide adequate protein/nutrients/fluid without excessive calories
  • BUN can help with monitoring adequate nitrogen balance (in the abscess of diuretics). Goal: BUN 7-12 range
  • Goal initially (first 2 weeks) is weight stability or no more than 2-3 lbs of weight loss per week

Bottomline:  N2U served as a good review on a broad range of nutrition topics.  While this talk discussed obesity in critically-ill patients, given the prevalence of obesity and impact on long-term outcomes, I would suggest more attention to this topic at future meetings.

 

Energy Calculations

Energy Calculations

 

Disclaimer: This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

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.

 

Downtown Chicago

Downtown Chicago

 

N2U -Part 3: EoE, IBD, and Cystic Fibrosis

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2015 N2U Syllabus & Presentations

EoE Dietary Pointers (Syllabus pg 83-94): Sally Schwartz, Valeria Cohran

  • Even with SFED, elemental supplements helpful
  • Drink elemental beverages from covered glass with straw (improves palatability)
  • Cross-contamination –big issue
  • Label reading critical

Related posts:

IBD EEN Pointers (Syllabus pg 95-102): Rebecca Pipkorn, Justine Turner

  • Polymeric formulas –most palatable and least expensive. Oral EEN is used costly/not covered
  • EEN particularly helpful with microperforation/flare-up presentation and with infections (eg. TB)
  • EEN induces mucosal healing and improved symptoms

References:

  • Levin et al. Inflamm Bowel Dis. 2014;20:278-285.
  • Johnson et al. Gut 2006;55:356-361.
  • Sigall-Boneh et al. Inflamm Bowel Dis. 2014;20:1353-1360.
  • Wilschanski et al. Gut 1996;38543–548.
  • Critich et al. J Pediatr Gastroenterol Nutr. 2012;54: 298–305. NASPGHAN Guidelines

Conclusions:

  • Enteral therapy offers an alternative to steroids in patients with CD
  • Has potential to improve growth and IBD symptoms
  • Avoids the side effects of steroids
  • Need further research:
  1. – Unclear of the mechanism
  2. – Unclear of the best protocol
  3. – No standard protocol for reintroduction of food

Related posts:

Cystic Fibrosis (Syllabus pg 34-50) Justine Turner

Case in point: 10 yo with CF and poor growth, hx/o DIOS, poor intake, and distention.  Family had refused tube feedings previously.

Key point: Long-term survival is linked to nutritional status

  • Zemel et al. J Pediatr. 2000; 137(3):374-380.
  • Stallings et al. J Am Diet Assoc. 2008; 108(5):832-839.
  • McPhail et al. J Pediatr. 2008; 153(6):752-757.
  • Sharma et al. Thorax 2001; 56:746-750.

Other Caveats:

  • Intervene early
  • Breast milk (often with supplements) is optimal for infants
  • Poor oral intake àcould need periactin and/or supplemental feeds
  • Discussion re: pros/cons of Gtubes (pg 47 in syllabus)
  • Psychology support

Nutrition Goals

  • – Normal growth and optimal nutritional status
  • – Ages 0-2 year: Weight for length >50th percentile
  • – Ages 2-20 year: BMI percentile at or above 50th percentile
  • – BMI for males:23
  • – BMI for females: 22

Nutritional assessment at every visit & review:

  • – Weight, length/height, weight for length, BMI, head circumference in infants
  • – Nutritional education & dietary counseling
  • – Review PERT
  • – Review need for micronutrient supplementation: fat soluble vitamins (A, D, E, K), Ca, Fe, Zn, Na (salt), essential fatty acids

PERT (Pancreatic enzyme replacement therapy):

  • Infants 2000-4000 U lipase with 120 mL breast milk or formula– Mouth care for infants (and breast feeding mother)
  • Children 500-2500 U lipase/kg per meal (≤10000 U/kg/day or ≤ 4000 U/g fat/day); half meal dose with snacks
  • Ideally taken with meals and orally
  • Microspheres preferred formulation
  • Acid blockade (used to optimize enzyme activity)
  • Gold standard to assess adequacy is 72h fecal fat collection

Cystic Fibrosis Related Diabetes

  • Rare before 10 years of age
  • Increases mortality risk 6-fold
  • Weight loss and pulmonary decline begin 2-4 years prior to
  • diagnosis of CFRD

Related posts:

 

Robie House (at Univ Chicago)

Robie House (at Univ Chicago)

 

 

N2U -Part 2: Poor Growth and Short Bowel Syndrome

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Chicago -from Lincoln Park

Chicago -from Lincoln Park

2015 N2U Syllabus & Presentations

Failure to Thrive –Praveen Goday

These sessions were case-based learning.

Case 1

2 mo birth weight 4.5 kg, taking 80 cal/kg/day –20 cal, formula-fed.  Taking 8 gm/day

What to do?

Point –If infant has a high birth weight (relative to height), there is a tendency to drop significant percentiles.  Often, careful observation is best approach. (Taal et al. Obesity. 2013;21:1261-8.)

Case 2: 14 mo birth weight 2.2 kg (at term), weight and length below the 3rd percentile but tracking. Weight-for-length is at the 25th percentile.

What to do?

For SGA babies, ensure adequate calories, avoid juice, ensure no GI symptoms, follow their growth

Case 3: Patient born at 36 weeks gestation, birth weight 3 lb. 14 oz. lbs., birth length 17 in.; Growth was a consistent problem throughout pregnancy; Dysmorphic; genetic workup – negative (Growth curves on pg 72-73 of syllabus).

More data: Taking 27 cal/oz, high-calorie baby foods, no GI symptoms, screening labs negative.  What are your options?  Make sure the length is accurate.  If the weight-for-length is really decreasing, then probably a trial of nasogastric feedings.  In Milwaukee, AMT bridle is often used to prevent dislodgement –youtube video (7:37 min), uses magnets.  Still, tubes need to be changed month.  The AMT bridle can work for tubes as small as 5 Fr.

Practical definition of Failure to Thrive:

  • Weight-for-length <2nd percentile (WHO growth chart for kids <2 yrs) or BMI ❤rd percentile. BMI more problematic in infants because of accuracy of length. If any inaccurate measurement, BMI value squares the length value; thus exponentially inflating any discrepancy.
  • Poor or no weight gain over a period of time that varies according to the age of the child
  • Significant downward trend in weight percentiles; however, 30% of full-term infants cross one percentile and 23% cross two percentiles between birth and 2 years of age
  • Keep in mind parental heights and correction for prematurity (where applicable).

Key points:

  • Large for gestational infants often have “catch-down” growth. Avoid overly aggressive nutritional intervention
  • In small infants who are growing steady and with good wt-for-ht, avoid overly aggressive nutritional intervention.
  • Older kids with poor growth –screening labs: TTG IgA, IgA, CBC, ESR, CMP, TSH, Urinalysis, and possibly fecal elastase.
  • Older kids with poor growth—1st steps: avoid juices, avoid grazing (no feeding outside mealtimes except water)/scheduled meals & snacks, and probably cyprohepatadine. Management: Have child sit at table for 20 minutes, feedings every 3 hours, and avoid force feeding.
  • In children with history of prematurity under 32 weeks gestation who do not catch up by ~6 months of age — usually never catch up.
  • In infants/children with highly selective diets, may be presentation of autism. Often, an approach in those with food selectivity is to start by offering only foods the child used to eat (for a day) and see if this will work (should be safe for at least one day).

Short Bowel Syndrome –Valeria Cohran (pages 9-20 in syllabus)

Case:  3 ½-year-old AAF who presents for a second option. She is a former 26-week infant who had NEC. She has approximately 45 cm of residual bowel anastomosed to the transverse colon.

  • TPN-dependent
  • Minimal oral intake
  • Diarrhea up to 60 ml/kg with Enfacare

 

GI Fluid losses –see page 15 of syllabus (Wessel et al Semin Perinat 2007; 31: 104-11).  Sodium losses ~140 mEq/L from stomach, 80-140 mEq/L from ileostomy –in comparison, normal stool with sodium of ~5 mEq/L.

Key points:

  • Normal intestinal length varies greatly by gestational age; so residual 45 cm length in a 26 week infant suggests much greater potential for improvement than 45 cm length in a full term infants (page 14 in syllabus).
  • Avoid probiotics in patients with central lines.
  • Sodium depletion (urine sodium <10) associated with poor growth. Probably urine sodium >20 is adequate. Though, if high urine potassium (more than double urine sodium), this could indicate that urine sodium is retained at the expense of spilling potassium (ie. May need more sodium) Related post: Don’t Forget to Check Urine Sodium | gutsandgrowth
  • Pectin (liquid) can be helpful: 1% of volume intake. Benefiber can be helpful –expensive. Related blog post: Green beans for short gut syndrome | gutsandgrowth
  • Bacterial overgrowth –treatment can help diarrhea. Try to minimize PPIs –6 months after resection (period of gastric hypersecretion). Cholestyramine is not a popular option due to trouble with usage. Related post: Rehabilitation for Short Bowel Syndrome | gutsandgrowth
  • Micronutrient/vitamin monitoring. Page 16 in syllabus lists the micronutrient concentration of parenteral products and RDAs of micronutrients. “Don’t take copper out of TPN” –unless high level. ‘Worry some about micronutrient deficiency while on TPN but perhaps worry even more when transitioning off.’ Ubesie et al J Pediatr 2013 162: 1692-96. 93% anemic in this study of transitioning off TPN (iron,copper, other causes –pg 18 in syllabus). Related blog posts:Missing ingredients in TPN -Case Report | gutsandgrowth and TPN Drug Shortages -A Useful Reference | gutsandgrowth
  • B12 deficiency. If high MMA (likely due to B12 deficiency), then B12 shots recommended. B12 important for cognition. Related posts: Are we missing Vitamin B12? | gutsandgrowth and What I Didn’t Know About Vitamin B12 and Crohn’s Disease …
  • Iron deficiency. Consider anastomotic ulcers/ulceration of STEP procedure.
  • Lipid minimization/fish oil lipid formulations
  • Follow kids even after coming off TPN –at least annually. These kids can develop problems many years later.

More related posts:

Disclaimer: This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

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.

 

 

 

 

 

 

 

 

 

Headlines and Shorts for IBD and IBS

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“Higher Levels of Knowledge Reduce Health Care Costs in Patients with Inflammatory Bowel Disease.” Inflamm Bowel Dis 2015; 21: 615-22.  This retrospective observational cohort study asked 91 patients to complete a questionnaire about their knowledge on the disease after 1 year of follow-up. The authors noted an association between higher levels of knowledge and lower health care costs. While their are many limitations to this study, it is hard to argue with the conclusion that better education is worthwhile; it may also improve outcome and costs.

“Surgery and Postoperative Recurrence in Children with Crohn Disease.” Hansen LF et al. JPGN 2015; 60: 347-51. In a retrospective study dating back to 1978, the authors noted a high recurrence of surgery in children (n=115) with Crohn disease (CD).  More than 1 bowel resection was needed in 39%. The use of biologics occurred late in the study and its potential effect on lowering recurrent resection is unclear in this study. Related post:  More Lessons in TNF Therapy (Part 1) | gutsandgrowth

“Risk of Drug-Induced Liver Injury from Tumor Necrosis Factor Antagonists.” Bjornsson ES, et al. Clin Gastroenterol Hepatol 2015; 13: 602-08.  9 cases of DILI associated with infliximab (1 in 120 patients), 1 case (of 270) with adalimumab, and 1 case (of 430) associated with etanercept. 8 of 11 patients who were tested for ANA were positive. DILI was treated with steroids in 5 patients. 8 patients went on to receive a different anti-TNF without recurrent liver dysfunction. Related blog posts:

“The Prevalence of Intestinal Parasites is Not Greater Among Individuals with Irritable Bowel Syndrome: A Population-based Case-control Study” Clin Gastroenterol Hepatol 2015; 13: 507-13. Related post: Does it make sense to look for parasites in RAP …

Gastritis –Not Due to Helicobacter pylori

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A gastroenterologist identifying gastritis or an ulcer due to Helicobacter pylori is akin to an emergency room doctor treating a nursemaid’s elbow.  In both cases, identifying the cause allows for effective treatment and families are typically quite grateful. But what about the cases of Helicobacter-negative gastritis.  This is less straightforward.

A recent study (Genta RM, Sonnenberg A. Aliment Pharmacol Ther 2015; 41: 218-26 thanks to Ben Gold for this reference) provides some helpful data.  From a pathology national database, the authors reviewed 895,323 patient records from individuals with gastric biopsies (2008-2014).

Key findings:

  • 10.6% had Hp-gastritis. The prevalence of Hp-gastritis declined mildly from 11.2% in 2008 to 9.9% in 2014.
  • 1.5% had Hp-negative gastritis.  The prevalence of Hp-negative gastritis declined from 2.1% in 2008 to 1.1% in 2014.
  • In patients with Hp-negative gastritis who underwent a repeat endoscopy, on average 18 months after index biopsy, 7.4% had detectable Helicobacter pylori.  Thus, a small number of Hp-negative gastritis may represent a missed infection.
  • The authors note that only 3.5% of Hp-negative gastritis was associated with inflammatory bowel disease (IBD).

It is well-recognized that there are many limitations with analyzing databases.

Take-home message: Given the limited amount of information about Hp-negative gastritis, this study is helpful by indicating that only a small fraction represent a missed case of H pylori and a smaller fraction have coexistent IBD.  With improvements in microbiology, perhaps more clarity will emerge to determine what Hp-negative gastritis is rather than what it isn’t.

Related blog posts:

No Effect of Proton Pump Inhibitors and Irritability on Crying in Infants

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While the title of this blog will come as no surprise to most pediatric gastroenterologists, many parents would be surprised that a systemic review of randomized controlled trials (RCTs) showed` that proton pump inhibitors (PPI) are ineffective for crying infants (J Pediatr 2015; 166: 767-70).

In this review, only five trials (with 430 infants) met the prespecified inclusion criteria.  While some trials showed a decrease in crying/irritability form baseline to the end of the intervention, a similar effect was evident in the control group.  The authors found that one trial reported a higher risk of lower respiratory tract infections in the PPI group and note that “administration of PPIs is not without risk.”

Take-home message: “the limited data available suggest that PPIs are not effective for the management of crying/irritability in infants.”

Another PPI citation: Rosen R et al. J Pediatr 2015; 166: 917-23.  In this study, the authors prospectively showed that PPI use was associated with differences in gastric, lung, and oropharyngeal microflora (n=116 children with 59 receiving PPIs)

Related blog posts:

An Apple a Day …

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According to research, published in JAMA Internal Medicine (April 1st edition –done for fun and “is very tongue in cheek”) an apple a day does not “keep the doctor away.”

Here’s an excerpt from USA Today summary:

At first glance, data on 8,728 U.S. adults looked like it might uphold the saying: The 9% who ate at least one small apple daily were less likely to visit doctors several times a year….They adjusted their statistics to account for ways other than apple-eating that “apple eaters might be very different from everyone else,” Davis says. For example, they found apple lovers were less likely to smoke, were more educated and were less likely to be white than the 91% of the population eating less than an apple a day.

After adjusting for those factors, they found daily apple-eaters were just as likely as otherwise similar individuals to go to doctors…Other studies have found numerous possible health benefits associated with apple consumption, including weight loss, reduced cancer risk and improved cardiovascular health.

UTI in Infancy–New Risk Factor for Chronic Abdominal Pain?

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A recent study (Rosen JM, et al. JPGN 2015; 60: 214-16) identifies a history of a urinary tract infection (UTI) in infancy as a risk factor for development of chronic abdominal pain.

The authors identified 57 patients with a history of UTI during the first year of life and compared them to 58 sibling controls.  Mean age of UTI was 4.8 months and mean time since UTI was 9.3 years.

Key finding:

  • Chronic abdominal pain was noted in 10 (17.5%) of patients with prior UTI compared with 2 (3.4%) of controls (P=0.02)

The authors state that this is the first study showing an infection outside the GI tract could increase the risk of chronic abdominal pain.  It is not clear to me if the UTI would truly be a sensitizing factor or whether other factors like the administration of antibiotics could play a role.

Bottomline: While this is a small study and the incidence of chronic abdominal pain was fairly low in both groups, it suggests that a history of a UTI may be a risk factor for recurrent abdominal pain; a bigger study is needed to validate these findings.

Related blog posts:

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Trending on Twitter -CampWeeKanEatIt Shoutout

Mongerson -Phase II Data Available in NEJM

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Previously, this blog noted that a phase II study showed that Mongerson, an oral SMAD7 antisense oligonucleotide, had promising data for moderate-to-severe Crohn’s: An Oral Oligonucleotide in the Crohn’s Treatment Pipeline …

The study has now been been published: NEJM 2015; 372: 1104-13.  Among patients who received 40 mg and 160 mg of mongerson, remission (CDAI <150) at 15 days was achieved in 55% and 65% respectively compared to 12% for 10 mg dose and 10% for placebo group.

The associated editorial (pg 1166-67) notes that only 18% of the patients with elevated C-reactive protein and randomized to the 40 mg and 160 mg doses normalized these levels at the end of the treatment period.  Thus, further trials will need to look more closely at objective biomarkers.

Unrelated but interesting -from John Pohl & Bryan Vartabedian’s twitter feeds:  “Food Babe” Exposed as a Fraud

How Likely is Celiac Disease if My TTG Test Is Only a Little Bit Abnormal?

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A terrific celiac serology study (Gidrewicz D, et al.Am J Gastroenterol 2015; -advanced online publication doi: 10.1038/ajg.2015.87) helps answer questions about the utility of serology in making diagnostic decisions. (Thanks to corresponding author J Decker Butzner for sharing reference.)

Using consecutive samples in a laboratory database with 17,505 patients, the authors retrospectively examined the performance of the tissue transglutaminase (TTG), endomysial antibody (EMA) tests and the ESPGHAN celiac guidelines for nonbiopsy diagnosis of celiac disease.  Among this large cohort, 775 with positive TTG and 574 with a negative TTG were biopsied.

Key findings:

  • If the TTG >10-fold the upper limit of normal (ULN) along with a positive EMA and symptoms were present, 98.2% had biopsies consistent with celiac disease.
  • If the TTG was 3-10-fold-ULN along with positive EMA, then 75.7% had biopsies consistent with celiac disease.  The histology of celiac disease (CD) was present in only 40% of the TTG 3-10-fold ULN if EMA was negative.
  • If the TTG was 1-3-fold-ULN along with positive EMA, 52.2% had CD-positive histology, whereas CD-positive histology was evident in only 13.3% of TTG 1-3-ULN if EMA was negative.
  • IgA deficiency is common in CD (“1in 60 vs 1 in 700” in general population)

Implications & Take-home points:

  • The researchers note that the positive predictive value of TTG drops when the prevalence of CD in the testing population is lower.  Thus, in their population and most clinical practice where the prevalence is below 35-40%, the PPV of the TTG-based tests drops to <80%.
  • While TTG-based tests have high specificity, there are multiple medical conditions that can cause a false positive (additional reference below), including autoimmune diseases like diabetes mellitus, inflammatory bowel diseases as well as infections, and liver disorders.
  • Asymptomatic patients with low TTG titers and negative EMA may benefit from following celiac serology rather than proceeding immediately to intestinal biopsy.
  • Using ESPGHAN nonbiopsy criteria (symptomatic child, TTG ≥10 ULN, positive EMA, positive HLA typing), there were four patients whose initial biopsies were not consistent with CD.  Thus these criteria identified 98.2% accurately who did not need an intestinal biopsy.  One of these four developed CD subsequently.  To achieve 100% PPV for non biopsy, the authors note that one would need an EMA titer ≥1:80.
  • Study limitations: retrospective study, lack of standardization between TTG assays

Bottomline: EMA improves the PPV of TTG testing, especially when low titer elevations are noted.  TTG alone is a highly sensitive test “with a 99.4% negative predictive value” in this study.

Related study: “Serum Anti-Tissue Transglutaminase Antibodies Detected during Febrile Illness May Not be Produced by the Intestinal Mucosa” J Pediatr 2015; 166: 761-3.  This case report describes two children with abnormal TTG (one more than 20-fold ULN)) both were EMA-negative. No mucosal anti-TTG was identified using two immunoassays.

Related blog posts: