Category Archives: Pediatric Gastroenterology Intestinal Disorder

Injection Flu Vaccine Safe for Patients with IBD

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A recent article from Pediatrics, published online May 6, 2013
(doi: 10.1542/peds.2012-3567), confirms that influenza vaccination (injection/inactivated vaccine) is safe in patients with inflammatory bowel disease:

“Safety and Utilization of Influenza Immunization in Children With Inflammatory Bowel Disease”  Eric I. Benchimol, Steven Hawken, Jeffrey C. Kwong, and Kumanan Wilson

Abstract:

OBJECTIVE: Influenza immunization is recommended for children with IBD, however safety concerns may limit uptake. This study assessed whether immunization was associated with adverse events in IBD patients using a population-based database of children with IBD.

METHODS: All children <19 years diagnosed with IBD in Ontario, Canada between 1999–2009 were identified using health administrative data, and matched to non-IBD controls. Self-controlled case series (SCCS) analyses determined health services event rates (outpatient visits, hospitalizations and emergency visits) in any 2-week risk period to 180 days post-immunization compared to a no-risk control period. Relative incidence (RI) was calculated for overall and IBD-related events and rates were compared between IBD cases and controls using relative incidence ratios (RIR).

RESULTS: 4916 IBD patients were matched to 21,686 controls. IBD patients were more likely to have received immunization than controls (25.3% vs. 13.2%, P < .001). No increased event rates existed in IBD cases during risk periods (pooled RI 0.95, 95% CI 0.84–1.07), including hospitalizations and emergency visits. There was a slightly higher event rate in IBD cases versus controls for days 3–14 (RIR 1.60, 95% CI 1.05–2.44, P = .03). IBD-related visit rates were lower in risk periods compared to control period (pooled RI 0.81, 95% CI 0.68–0.96).

CONCLUSIONS: There was no increase in health services use in the post-vaccine risk period in IBD patients, and there was evidence for a protective effect of influenza immunization against IBD-related health services use. Influenza immunization is safe in children with IBD and should be encouraged to improve poor coverage rates.

Gluten-free, Casein-free -No Improvement in Autism

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From Kipp Ellsworth’s twitter feed:

The gluten-free, casein-free diet and autism: limited return on family investment

From Journal of Early Intervention

goo.gl/uulzis  (link to entire article)

Excerpt:

Abstract

The gluten-free, casein-free (GFCF) diet is widely used by families of children with autism spectrum disorders (ASD). Despite its popularity, there is limited evidence in support of the diet. The purpose of this article was to identify and evaluate well-controlled studies of the GFCF diet that have been implemented with children with ASD. A review of the literature from 1999 to 2012 identified five studies meeting inclusion criteria. Research rigor was examined using an evaluative rubric and ranged fromAdequate to Strong. In three of the studies, no positive effects of the diet were reported on behavior or development, even after double-blind gluten and casein trials. Two studies found positive effects after 1 year but had research quality concerns. Reasons why families continue to expend effort on GFCF diets despite limited empirical evidence are discussed. Recommendations are that families should invest time and resources in more robustly supported interventions and limit GFCF diets to children diagnosed with celiac disease or food allergies.

Fundoplication in children with neurologic impairment

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A recent study questions the value of fundoplication in children with neurologic impairment who undergo gastrostomy tube placement (JAMA Pediatr doi:10.1001/jamapediatrics.2013.334).

This paper’s findings are limited by the study’s design as a retrospective, observational cohort study.  However, the study has several strengths as well.  First of all, this was a large study which identified 4163 neurologically-impaired infants who underwent either tube placement with (n=1404) or without fundoplication (n=2759).  This population was drawn from 42,796 infants admitted to neonatal intensive care units from 42 children’s hospitals.  Thus, a second advantage of this study was looking at a broad range of children from the same NICU population.

Findings:

  • Infants who underwent fundoplication did not have a reduced rate of reflux-related hospitalizations.  The authors tried to control for differences in the population with propensity score-matched analysis.
  • Only a small number had a significant preoperative GERD workup.  In total, 9.4% of infants had pH probes and 4.3% had endoscopies preoperatively.
  • Mean number of reflux-related admissions (Table 3 in study) within 1 year after discharge from NICU: overall: for gtube 0.92 compared with 1.02 for gtube/fundo, for pneumonia 0.18 (Gtube) compared with 0.23 (Gtube/fundo), aspiration pneumonia was 0.08 for both groups.

The authors note that two previous studies had shown a reduction in reflux-related hospitalizations for children who had admissions due to reflux-related conditions.  However, they note that in their study, these patients had fundoplication performed prophylactically based on clinical judgement.

But, “clinical symptoms, including dysfunctional swallowing and intolerance of gastric feedings, likely influence the decision to perform a concomitant fundoplication; however, these were unavailable in the database.”  As such, the authors propensity score model could have failed to account for factors that are essential in deciding whether a concomitant fundoplication is worthwhile.

Bottom-line: A fundoplication may not effectively prevent reflux-related hospitalizations in neurologically-impaired infants; its expected benefits may be overstated.  The only way to definitively determine how useful (or how ineffective) a fundoplication is would be a prospective study.

Related blog posts:

POEMs in Practice for Achalasia

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As noted in a previous blog  regarding NOTES (see link below), peroral endoscopic myotomy (POEM) has been investigated for treatment of achalasia.  Now, a prospective study of 70 patients from 5 centers reports excellent results (Gastroeenterol 2013; 145: 309-11, editorial 272-73).

 Results:

  • 3 months after POEM, 97% of patients were in symptom remission.
  • 12 months after POEM, 82% of patients were in symptom remission.

Potential benefits of POEM:

Early results suggest similar efficacy to surgery but with the recovery profile of an endoscopy Painless

For more widespread adoption, many questions need to addressed:

  • the appropriate length & thickness of myotomy
  • the optimal equipment
  • the best ‘surgeons’ for this technique
  • how do long-term outcomes compare to Heller myotomy or balloon dilatation

Related blog posts:

Probiotics for Crohn’s Disease –No Beneficial Effects Noted

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With all the buzz regarding how a patient’s microbiome seems to affect everything from metabolic syndrome and colic to autoimmune diseases and inflammatory bowel disease, more attention has been paid in attempts to alter the microbiome for therapeutic benefits.  In Crohn’s disease (CD), the fact that antibiotics have shown beneficial effects have led to a number of studies of probiotics.  A recent study, like previous ones, did not demostrate any benefit with Saccharomyces boulardii (Clin Gastroenterol Hepatol 2013; 11: 982-87).

In this prospective double-blind, placebo-controlled study of 165 patients who achieved remission after steroids or salicylates, subjects were randomly assigned to groups given S boulardii (1 gram per day) or placebo for 52 weeks.

Results:

  • CD relapse occurred in 80 patients: 38 (47.5%) in the probiotic group  and 42 (53.2%) in the placebo group
  • Time to relapse did not differ significantly: 40.7 weeks in probiotic group vs 39 weeks in placebo group
  • No differences were seen in disease activity scores or serum inflammatory markers
  • In post hoc analysis, nonsmokers given S boulardii were less likely to experience a relapse compared with nonsmoker control patients (34.5 % vs. 72%)

One important limitation of this study was not examining the effects of the probiotic on the microbiome of these patients.  Perhaps, other probiotics would be more effective in restoring a “healthy” flora.

Based on these results, and others, the accompanying editorial (pg 988-89), advocates use of probiotics only for prevention of antibiotic-associated diarrhea, prevention of recurrent Clostridium difficile, and treatment/prevention of pouchitis.

Bottom-line: Probiotics have not been demonstrated to be helpful for Crohn’s disease.

Related blog posts:

An Unexpected Twist for “Gluten Sensitivity”

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While the concept of gluten sensitivity without celiac disease has been recognized since 1980 (Gastroenterol 1980; 79: 801-06), a recent study indicates that gluten may not be the main culprit in inducing these symptoms (Gastroenterol 2013; 145: 320-28; editorial 276-79).

The authors of this double-blind crossover study were the same investigators who popularized the concept of nonceliac gluten sensitivity (NCGS) two years ago (Am J Gastroenterol 2011; 106: 508-14).  In this current study, they demonstrate that in NCGS patients consuming a low FODMAPs diet (see previous post links below) gluten reintroduction did not cause specific or reproducible symptoms.

Methods: In this study, they enrolled 37 subjects with NCGS who fulfilled Rome III criteria for IBS and improved on a gluten-free diet (GFD).  All participants continued their GFD and after a 1-week baseline, started on a low FODMAP diet for a 2-week run in period.  Subsequently, patients were randomly assigned to 3 study arms: high gluten (16 g gluten/day), low gluten (2 g gluten & 14 g whey per day) or control (16 g whey/day).  Each participant took this diet for 1 week, had a 2-week washout, then crossed over to each arm.  In addition, at least 8 months, 22 subjects underwent another brief crossover study (high-gluten, whey only, or control with no additional protein).  As part of the study, clinical, serological, and immunologic parameters were monitored during all aspects of the rechallenges.

Results: “Gastrointestinal symptoms consistently and significantly improved during reduced FODMAP intake, but significantly worsened to a similar degree when their diets included gluten or whey protein.” There were no changes in any serological or immunologic parameters between the dietary challenges.

There were several limitations to this study of this highly-selected cohort which are well-described in their discussion.

Bottom-line: Gluten might not be a specific trigger once dietary FODMAPs are reduced.

Related blog posts:

Don’t forget HLH

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A recent clinical challenge (Gastroenterol 2013; 145: 289, 489) regarding a a 78-year-old with a 12-year history of ulcerative colitis serves as a good reminder to remember hemophagocytic lymphohistiocytosis (HLH) in inflammatory bowel disease patients with high fever, even in the presence of recognized viral infections like cytomegalovirus and Epstein-Barr virus which can trigger HLH.  Patients receiving immunosuppressive medications are at risk.

Other clinical points:

  • Consider HLH when cytopenias are present in addition to fever
  • Ferritin values >10,000 mcg/L serves as a good screen

Take-home point: HLH has a significant mortality rate.  Quick recognition can improve outcome.

Related blog post:

Diagnosing hemophagocytic lymphohistiocytosis … – gutsandgrowth

NASPGHAN: Enteral Nutrition for Crohn’s Remission

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A new document from NASPGHAN highlights the potential for enteric formulas (oral and nasogastric) as an alternative 1st line therapy for Crohn’s disease remission.  The following is a link with specific case examples along with background information and practical advice:

http://goo.gl/p19o0z 

Related blog post:

Rest easy with enteral nutrition | gutsandgrowth

Extensive Workup Not Needed for IBS

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Another study has shown that an extensive workup is not needed for IBS (Clin Gastro Hepatol 2013; 11 956-62).

In this study from Denmark, the authors enrolled 302 patients aged 18-50 from a primary care setting with suspected IBS.  250 patients completed the entire study including a 1-year followup.  These patients fulfilled Rome III criteria and had no alarm signals which were the following:

  • Unexplained weight loss >3 kg
  • Rectal bleeding
  • Unexplained fever or anemia
  • Family history of inflammatory bowel disease (IBD) or colorectal cancer (CRC)
  • Abnormal physical exam

Patients were randomly assigned to either an extensive diagnostic group which included blood tests (including celiac screen & lactase gene test), stool exams, and sigmoidoscopy or to a “positive strategy” which involved testing only with a blood count (CBC/diff) and C-reactive protein.

The group which underwent a more extensive workup had no cases of serious disease, like IBD or CRC identified.  11 patients were identified with lactose intolerance, 1 patient had a rectal adenoma, 1 patient had a benign polyp, and 1 patient had giardiasis.

Overall, the authors and the accompanying editorial (pgs 963-964) conclude that the positive strategy was noninferior to the more extensive evaluation.  One limitation of this study was that patients had carried symptoms compatible with IBS for an average of 7 years before enrollment.

Take-home message: this study “adds to the growing body of evidence in favor of a relatively minimal symptom-based approach to diagnosing IBS.”

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Understanding IBD Therapy Risks -A Good Link

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This link was posted on the GI Bulletin Board.  It is a 6 minute internet video overview of the treatments for IBD -it would be a useful resource for most families:

http://www.youandibd.com/en/understanding-ibd/understanding-the-risks-and-benefits-of-ibd-therapies.html

Some related blog posts: