From the Pediatric Nutritionist blog –two lectures from Dr. Scott Pentiuk:
Two Lectures: Blenderized diets and Eosinophilic esophagitis
These lectures feature a lot of useful references and practical advice.
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Shem Creek, SC
Some interesting images from a 48 year old who developed bowel wall vasculitis (NEJM 2016; 374: 2159). He had a history of granulomatosis with polyangiitis.
A recent study (B Sahn et al. JPGN 2016; 63: 19-24) with 155 patients prospectively showed that a 1-day polyethylene glycol (PEG) 3350 prep was safe and fairly effective.
The prep: 4 g/kg PEG in children with weights 10-50 kg and (with 238 gm for those >50 kg along with a single dose of a stimulant: either bisacodyl 5 mg-15 mg orally (10 mg for 21-30 kg) or senna (17.6 mg for 20 kg, 26.4 mg for 21-30 kg, and 52.8 mg for >31 kg). The PEG was mixed typically with a sports drink to a max of 64 oz.
Key findings:
My take: This study validates the common approach of using 1-day PEG 3350 preps in children. Due to the low risk of hypoglycemia, particularly in young children, and the frequent mild hypokalemia, some children may benefit from starting intravenous fluids prior to induction of anesthesia.
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Disclaimer: 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.
Arthur Ravenel Jr Bridge
While yesterday’s post discussed quadruple therapy for H pylori/need for multiple antibiotics, today’s post will focus on one of the downsides of antibiotic usage. For several years, this blog has highlighted numerous studies which show a link between antibiotics and later obesity (see related blog posts below). Another study (FI Scott et al. Gastroenterol 2016; 151: 120-29), using a large database, quantifies this risk further.
This retrospective study used prospectively collected data from The Health Improvement Network (THIN), using a cohort of 21,714 children from the UK.
Key findings:
In the discussion the authors make a number of useful points:
The study is in agreement with data from agriculture. Numerous studies have highlighted how antibiotics can improve weight gain in industry. Here are some useful references:
My take: Farmers have understood that antibiotics fatten up young animals for 70 years. Yet, this basic information is NOT commonly understood by parents and many physicians. If this risk for obesity were widely known, it would help limit the use of antibiotics for well-recognized indications.
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Toronto consensus guidelines (C Fallone et al. Gastroenterol 2016l 151: 51-69) for H pylori treatment in adults emphasize use of 14 day therapy and use of quadruple regimens. Specific recommendations included the following:
Full text link: Toronto Consensus for the Treatment of H Pylori
Abstract:
Helicobacter pylori infection is increasingly difficult to treat. The purpose of these consensus statements is to provide a review of the literature and specific, updated recommendations for eradication therapy in adults.
A systematic literature search identified studies on H pylori treatment. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an online platform, finalized, and voted on by an international working group of specialists chosen by the Canadian Association of Gastroenterology.
Because of increasing failure of therapy, the consensus group strongly recommends that all H pylorieradication regimens now be given for 14 days. Recommended first-line strategies include concomitant nonbismuth quadruple therapy (proton pump inhibitor [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]). PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens. Recommended rescue therapies include PBMT and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin). Rifabutin regimens should be restricted to patients who have failed to respond to at least 3 prior options.
Optimal treatment of H pylori infection requires careful attention to local antibiotic resistance and eradication patterns. The quadruple therapies PAMC or PBMT should play a more prominent role in eradication of H pylori infection, and all treatments should be given for 14 days.
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Sullivan’s Island, Low Tide
A recent review (X Roblin et al. Inflamm Bowel Dis 2016; 22: 1496-1501) provided a useful review of thiopurine/biologic combination therapy. The part of this review that I found intriguing was their Figure 3: “Proposed algorithm that may guide drug discontinuation or de-escalation in patients with IBD who achieved sustained deep remission while on combination therapy.”
The authors acknowledge that this algorithm has not been studied and “needs to be investigated in prospective trials specifically addressing this issue.”
My take: Until more studies emerge, the best way to balance control of IBD and minimize drug toxicity remains uncertain.
Unrelated references:
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Arthur Ravenel Jr Bridge
A recent study (JM Shapiro et al. JPGN 2016; 62: 867-72) reviewed 98 pediatric patients treated with infliximab (2012-2014) with inflammatory bowel disease (IBD).
The authors divided their patients into three groups, mainly based on extent of colonic involvement. In those with limited colonic involvement, they were labelled “limited” disease (n=53). In those with patchy inflammation involving the entire colon, they were considered to have “moderate” disease (n=27). In contrast, those with continuous pancolitis were ascribed to have “extensive” disease (n=18). Overall, Crohn’s disease accounted for 85 patients (87%), ulcerative colitis for 11 patients (11%), IBDU for 2 patients (2%). Interestingly, the majority (9 of 11) of those patients without Crohn’s disease were considered to have extensive disease.
Key findings:
My take: This is a small study. Yet, the implication is that early optimal dosing of IFX is likely helpful, especially in the setting of extensive disease.
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Chattahoochee River
Perhaps the Dos Equis’ guy’s slogan “Stay Thirsty My Friends” is not such great advice.
According to a study, summarized by NPR, inadequate hydration was associated with increased odds of obesity. While an association does not prove causation, it adds another potential reason to drink plenty of water.
NPR Story: Thirsty? New Study Links Good Hydration with Slimmer Waistlines
Here’s an excerpt:
A new study published in the Annals of Family Medicineadds to the evidence that hydration may play a role in weight management.
“What we found was that people who were inadequately hydrated had increased odds of being obese,” says study author Tammy Chang of the Department of Family Medicine at the University of Michigan.
The study was based on data collected by a federal health survey, in which researchers had documented weight and height of participants. They also conducted urine tests to establish an objective measure of participants’ level of hydration.
Chang and her colleagues found the odds of being obese were 1.59 times higher for people who were not well-hydrated. And overall, they found that a lack of proper hydration was associated with higher body mass index.
On a neighborhood walk
From NEJM:
A 48-year-old woman scheduled to receive a laparoscopic cholecystectomy underwent a preoperative evaluation that disclosed conjugated hyperbilirubinemia…
A biopsy specimen revealed coarse, deep-brown, pigmented granules on periodic acid–Schiff staining (Panel B), primarily at the canalicular pole of the hepatocytes and especially in the pericentral zones, with otherwise well-preserved lobular architecture. Expression of the multidrug-resistance–associated protein 2 (MRP2) was absent on anti–MRP2 immunohistochemical analysis (Panel C; see also comparison with control specimen [inset]). A diagnosis of the Dubin–Johnson syndrome was confirmed. This syndrome is an autosomal recessive disorder that is caused by a mutation in MRP2 that results in deficient canalicular expression of MRP2 and impaired secretion of conjugated bilirubin into the bile. Such mutations cause an isolated increase in serum levels of conjugated bilirubin and the appearance of a black liver, without associated sequelae.
An entire supplement (J Pediatr 2016; 173: S1-S65) provides an in-depth review of the bioactive components of breastmilk. The two components reviewed most extensively were lactoferrin and milk fat globule membrane (MFGM).
Lactoferrin: this glycoprotein is present in high concentrations in human milk, compared to formulas and cow’s milk. It is highest in concentration in early lactation. Its importance lies in its direct antibacterial effects. It is likely to reduce the risk of necrotizing enterocolitis and sepsis in preterm infants, which has been shown as well with bovine lactoferrin.
MFGM: this triglyceride is derived from a triple phospholipid membrane is absent from infant formulas. It has a role in both gastrointestinal and immune development. It appears to convey benefits in “terms of cognitive, metabolic, and health outcomes.”
My take: this supplement provides data that lactoferrin and MFGM “isolated from bovine milk retain bioactivity and are safe and efficacious additions to infant formula”
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Arthur Ravenel Jr Bridge
gutsandgrowth 