What Infants and Toddlers Should and Should NOT Be Drinking

Posted on by

NY Times: What Should Young Children Drink? Mostly Milk and Water, Scientists Say

An excerpt:

A panel of scientists issued new nutritional guidelines for children on Wednesday, describing in detail what they should be allowed to drink in the first years of life. The recommendations, among the most comprehensive and restrictive to date, may startle some parents.

Babies should receive only breast milk or formula, the panel said. Water may be added to the diet at 6 months; infants receiving formula may be switched to cow’s milk at 12 months. For the first five years, children should drink mostly milk and water, according to the guidelines.

Children aged 5 and under should not be given any drink with sugar or other sweeteners, including low-calorie or artificially sweetened beverages, chocolate milk or other flavored milk, caffeinated drinks and toddler formulas.

Plant-based beverages, like almond, rice or oat milk, also should be avoided. (Soy milk is the preferred alternative for parents who want an alternative to cow’s milk.)…

Young children should drink less than a cup of 100 percent juice per day — and that none at all is a better choice…Children do not need juice and are better off eating fruit, the panel said. ..

With the exception of soy milk, plant-based milks are poor in protein. Though they are often fortified, scientists do not know whether people are able to absorb these nutrients as efficiently as those naturally present in other foods.

Formulas marketed for toddlers are usually unnecessary, since most toddlers eat solid food

My take: These recommendations provide good advice.

 

“Bystander Effect” –Not the Norm

Posted on by

A recent study has cast some “shade” on the concept of the “bystander effect.”

From Washington Post: Forget What You May Have Been Told. New Study Shows Strangers Help 90 Percent of the Time

An excerpt:

Bystanders will intervene 9 times out of 10 to assist the victim in a public fight, an international team of researchers found in a study called “Would I be helped?,” published in American Psychologist this summer. After reviewing surveillance footage of more than 200 violent altercations around the world, the researchers concluded that having more bystanders around makes it more likely that someone will intervene…

On average, at least three people chose to intervene — and every additional bystander present increased the odds that the victim would receive assistance by roughly 10 percent.

Related blog posts:

 

 

PPIs: Good News on Safety (Part 2)

Posted on by

Earlier this year, I noted that a recent publication provided reassurance on PPI safety. (related blog post: PPIs: Good News on Safety).  In the journal issue with the printed version, a detailed editorial provides useful context.

DA Corley. Full Text Link: “Safety and Complications of Long-Term Proton Pump Inhibitor Therapy: Getting Closer to the Truth” Gastroenterol 2019; 157: 604:-7.

The Table 1 contrasts the useful information from this large double-blind randomized study and prior data/data quality.

The new study found NO ASSOCIATION between PPI use and kidney disease, dementia, bone fractures, myocardial infarction, pneumonia, or gastrointestinal malignancies.

An excerpt:

Recent publications have summarized both the evidence and evidence-based approaches toward teasing out whether proton pump inhibitors cause certain diseases or are only associated with them through other pathways (e.g., confounding).  Helpful strategies include using the classic criteria for evaluating causation such as the:

  • strength of the association
  • consistency of the findings between studies
  • specificity when an outcome happens almost exclusively from a specific exposure
  • temporality such that the exposure comes before the outcome
  • biological gradient whereby higher exposure doses or longer durations increase risk of the outcome
  • biological plausibility for the proposed association
  • coherence such as between observed effects and known biology of disease
  • experiment such as randomized trials that decrease confounding; and
  • analogy to similar exposure–disease associations known to be causal…

This massive undertaking included >17,000 patients from 33 countries who were randomized to pantoprazole versus placebo, followed for a median of approximately 3 years, and evaluated prospectively for potential complications. The study found an increased risk of enteric infections among pantoprazole users, a result found in both the intention-to-treat and “as-treated” analyses, which excluded people who stopped their medications. This association makes sense—stomach acid markedly decreases bacterial load in food, so decreasing stomach acid may increase the risk of enteric bacterial infections. The authors found no increased risk for several of the most feared associations previously reported, such as cardiovascular disease, kidney disease (directly measured using estimated glomerular filtration rate), dementia, pneumonia, fracture, and all-cause mortality.

My take: (borrowed from editorial): The current study would indicate, from the strongest study design available,… that there is an increased risk of gastrointestinal infections and no detectable excess risk for several other potentially important clinical events…Given known problems with overprescribing and overuse, patients and clinicians should maintain appropriate vigilance in prescribing acid suppression only to persons with defined indications and at the lowest effective dose and duration.

Lava Cave -near Bend, OR

 

AGA Guidelines for Evaluation of Functional Diarrhea and IBS-D

Posted on by

W Smalley et al. Gastroenterol 2019; 157: 851-54. Full Text Link: AGA Clinical Practice Guidelines on the Laboratory Evaluation of Functional Diarrhea and Diarrhea-Predominant Irritable Bowel Syndrome in Adults (IBS-D)

Clinical support tool on pg 855, Patient Summary 856-57, and Technical Review 859-80.

These guidelines/recommendations (listed below) do NOT apply to patients with any of the following:

  • Alarm features such as gross blood, weight loss, anemia, and hypoalbuminemia
  • Family history of of IBD, colon cancer, or celiac disease
  • Travel to areas with high prevalence of infectious diarrhea
  • Immune suppression
  • Ingestion of medications or substances known to cause diarrhea

 

Table 3  Summary of Recommendations of the American Gastroenterological Association on the Laboratory Evaluation of Functional Diarrhea and Diarrhea-Predominant Irritable Bowel Syndrome in Adults
Statement Strength of recommendation Quality of evidence
Recommendation 1: In patients presenting with chronic diarrhea, the AGA suggests the use of either fecal calprotectin or fecal lactoferrin to screen for IBD. Conditional Low
Recommendation 2: In patients presenting with chronic diarrhea, the AGA suggests against the use of ESR or CRP to screen for IBD. Conditional Low
Recommendation 3: In patients presenting with chronic diarrhea, the AGA recommends testing for Giardia. Strong High
Recommendation 4: In patients presenting with chronic diarrhea with no travel history to or recent immigration from high-risk areas, the AGA suggests against testing stools for ova and parasites (other than Giardia). Conditional Low
Recommendation 5: In patients presenting with chronic diarrhea, the AGA recommends testing for celiac disease with IgA-tTG and a second test to detect celiac disease in the setting of IgA deficiency Strong Moderate
Recommendation 6: In patients presenting with chronic diarrhea, the AGA suggests testing for bile acid diarrhea. Conditional Low
Recommendation 7. In patients presenting with chronic diarrhea, the AGA makes no recommendation for the use of currently available serologic tests for diagnosis of IBS None Knowledge gap

For recommendation #6, the authors note that tests for bile acid mediated diarrhea in the U.S. include total bile acid in a 48-hour stool collection and serum fibroblalt growth factor 19.

Image available online:

IBD Shorts: September 2019

Posted on by

S Olivia et al (including Stanley Cohen from GI Care for Kids) Clin Gastroenterol Hepatol 2019; 17: 2060-7. “A Treat to Target Strategy Using Panenteric Capsule Endoscopy in Pediatric Patients with Crohn’s Disease”  In this prospective study with 48 children with Crohn’s disease, pan-enteric capsule endoscopy (PCE) detected inflammation in 34 (71%) at baseline, 22 (46%) at week 24, and 18 (39%) at week 52.  PCE results were used to manage treatment and resulted in change in therapy in 71% at baseline and 23% at week 24.  Furthermore, PCE increased the proportions of patients in deep remission, up to 58% at week 52.

M Wright, et al. J Pediatr 2019; 210: 220-5. This case report of a 4 year-old boy with a perianal abscess and granulomatous colitis identified a NCF4 mutation causing severe neutrophil dysfunction.  He developed osteomyelitis with anti-TNF therapy and did not respond to vedolizumab. He had an excellent outcome following a hematopoietic stem cell transplantation. This study reinforces the potential benefit of investigating VEO-IBD which could allow more targeted therapy. Related blog post:

P Zapater et al. Inflamm Bowel Dis 2019; 25: 1357-66. This study with 112 patients with Crohn’s disease showed that serum interleukin-10 levels were directly related to infliximab and adalimumab levels.  This suggests that serum anti-TNF levels are significantly influenced by immunological activation.

JE Axelrad et al. Clin Gastroenterol Hepatol 2019; 17: 1311-22.  This study, using the Swedish National Patient Register, showed that gastrointestinal infection increased the odds of developing IBD in a nationwide case-control study.  “Of the patients with IBD, 3105 (7%) had a record of previous gastroenteritis compared with 17,685 control subjects (4.1%). IBD cases had higher odds for an antecedent episode of gastrointestinal infection (aOR 1.64), bacterial gastrointestinal infection (aOR 2.02) and viral gastrointestinal infection (aOR 1.55)…a previous episode of gastroenteriitis remained associated with odds for IBD more than 10 years later (aOR 1.26).”  The authors note that they cannot formally exclude misclassification bias, but it appears that enteric infections contribute to the development of IBD in susceptible individuals.

Polyposis in Pediatric Patients -Review

Posted on by

A recent review article (SP MacFarland et al. JPGN 2019; 69: 273-80) provides clearcut guidelines on polyposis syndromes in pediatric patients.

Table 1 lists the syndrome, the mutated gene (s), and recommended screening (onset & interval). The article and table provide more nuance/guidance but the basic recommendations are noted as follows:

  • For Familial Adenomatous Polyposis (FAP), the authors recommend onset of colonoscopy at 10 years and with 1 year intervals.  “Colectomy recommended by 20 to 25 years.”  EGD is recommended at 18 to 20 years. Thyroid ultrasound is recommended at 18 years.  Alpha-fetoprotein levels to check for hepatoblastoma are recommneded every 3-6 months in infancy up to 5 years of age.
  • For Juvenile Polyposis Syndrome, EGD and Colonoscopy are recommended at 15 years with interval evaluations at 1-3 years.
  • For Peutz-Jeghers syndrome, EGD and Colonoscopy are recommended at 8 to 10 years (along with small bowel evaluation with either MRE or video capsule).  Interval followup is recommended every 2-3 years.

Table 2 provides suggestions for familial screening in pediatric polyposis syndromes.

Related blog posts:

Pittock Mansion, Portland OR

 

Preliminary Recommendations from NASPGHAN on Zantac/Ranitidine Warnings

Posted on by

Recently, there have been concerns about zantac (ranitidine).  NASPGHAN has made the following preliminary recommendations:

NASPGHAN has been in conversation with the FDA and would like to offer the following language for you/your office/your division and your patients/parents.

The U.S. Food and Drug Administration has learned that some ranitidine medicines, including some products commonly known as the brand-name drug Zantac, contain a nitrosamine impurity called N-nitrosodimethylamine (NDMA) at low levels. NDMA is classified as a probable human carcinogen (a substance that could cause cancer) based on results from laboratory tests. NDMA is a known environmental contaminant and found in water and foods, including meats, dairy products, and vegetables.
The FDA has been investigating NDMA and other nitrosamine impurities in blood pressure and heart failure medicines called Angiotensin II Receptor Blockers (ARBs) since last year, and when it discovered unacceptable levels of nitrosamines the ARBs have been recalled.

The FDA is evaluating whether the low levels of NDMA in ranitidine pose a risk to patients and will post that information when it is available.

It is important to note that although NDMA may cause harm in large amounts, the levels the FDA is finding in ranitidine from preliminary tests barely exceed amounts you might expect to find in common foods.

The agency is working with international regulators and industry partners to determine the source of this impurity in ranitidine. The agency is examining levels of NDMA in ranitidine and evaluating any possible risk to patients. The agency will provide more information as it becomes available.

The FDA is not calling for individuals to stop taking ranitidine at this time; however, patients taking prescription ranitidine who wish to discontinue use should talk to their health care professional about other treatment options. People taking OTC ranitidine could consider using other OTC medicines approved for their condition. There are multiple drugs on the market that are approved for the same or similar uses as ranitidine.

Are There Any Babies with a Normal GI Tract?

Posted on by

A recent study (S Salvatore et al. J Pediatr 2019; 212: 44-51) examines the role of neonatal antibiotics and prematurity on the development of functional gastrointestinal disorders in the first year of life.

What is most striking, though, in this study is how many of these infants have a GI disorder.

Background: Prospective cohort multicenter study with 934 infants who completed study; n=302 premature, n=320 antibiotic recipients

Key findings:

  • 718 (77%) had at least one functional GI disorder (FGID) based on Rome III criteria, including 47% with colic, 40% with regurgitation, 32% with dyschezia, 27% with constipation, and 4% with functional diarrhea
  • Preterm infants had FGID rate of 86% compared with 73% of full term infants (P=.0001)
  • Use of antibiotics was associated with FGIDs as well, with aRR of 1.16 (P=.001)
  • The prevalence of FGIDs was highest in the first three months of life and then improved markedly by 6 months of age; by 12 months of age, each of the FGIDs was well below 10%.

Limitation: This study relied on parental reports which could overestimate infant’s symptoms.

My take: More than 75% of infants had at least one FGID.

Related blog posts:

Good Food and Bad Food for Crohn’s Disease -No Agreement

Posted on by

As noted in a previous blog (IBD Briefs August 2019), there have been numerous diets proposed to help with Crohn’s disease.   The chart below illustrates the lack of any consensus.

Related blog posts: