What is the Connection between Psychological Stress and Ulcers?

Posted on April 26, 2015 by gutsandgrowth

Briefly noted: “Psychological Stress Increases Risk for Peptic Ulcer, Regardless of Helicobacter pylori Infection, or Use of Nonsteroidal Anti-Inflammatory Drugs” Clin Gastroeenterol Hepatol 2015; 498-506. From an initial sample of 3379 Danish adults with medical data/blood in 1982-83, 76 subjects developed ulcers in this prospective study. Life stress at baseline increased the risk of subsequent ulcer and was not fully explained by confounding variables, by socioeconomic status or by association with NSAIDs or smoking. Ulcer incidence wa 3.5% in the highest tertile of stress compared with 1.6% in the lowest tertile.

Bottomline: Since the discovery of Helicobacter pylori, the role, if any, of psychological stress in contributing to ulcers has been questioned. This study indicates that stress may play a role in ulcer development or at the very least is a marker of individuals at increased risk.

Hyperbilirubinemia and Central Apnea

Posted on April 25, 2015 by gutsandgrowth

Briefly noted: “Unbound Unconjugated Hyperbilirubinemia is Associated with Central Apnea in Premature Infants” J Pediatr 2015; 166: 571-5. This was a prospective observational study with 100 27-33 gestational infants. The group with central apnea had higher unconjugated hyperbilirubinemia (UB). The authors speculate that UB could cause neurotoxicity via central chemoreceptors and more aggressive treatment of UB with phototherapy could be needed.

Wheat Intolerance Syndrome?

Posted on April 24, 2015 by gutsandgrowth

Even though we’ve lived in our house for many years, some of our neighbors refer to our house as the ‘Walden’ house; the Waldens lived here for a long time before we did. Probably when we move, our neighbors will call our present home the “Hochman” house, regardless of who resides there.

I think nomenclature in medicine has a similar reluctance to adopt new terms. A recent medical progress report (Guandalini S, Polanco I. J Pediatr 2015; 166: 805-10) suggests dropping the term “Nonceliac gluten sensitivity” (NCGS) in favor of “Wheat Intolerance Syndrome.”

It’s probably a good idea and their arguments are sound. Two key points:

“There is no proof that gluten is causing NCGS.”
It is likely that the majority of patients considered NCGS have not even eliminated celiac disease before instituting a gluten-free diet.

With regard to the first point, the authors note that recent studies have suggested that a “FODMAP” (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet is likely the culprit in many cases of so-called NCGS. They review a pivotal double-blind study (see related blog post: An Unexpected Twist for “Gluten Sensitivity” | gutsandgrowth) there was no role for gluten “at least in these patients with IBS-like NCGS.” In addition, other studies have demonstrated a strong role for a placebo/nocebo effect of dietary elimination. “It is quite conceivable that a portion of patients with NCGS, and arguably a substantial one, fall in this category.”

With regard to the second point, it is not a good idea to initiate a gluten-free diet before excluding the diagnosis of celiac disease (hence the prior term: “nonceliac” gluten sensitivity). A related comment from the authors is that a “Grade 1 [Marsh] intestinal lesion has traditionally been considered of a very low specificity for celiac disease.” More testing in this circumstance can help determine if celiac disease is the reason, including checking the levels of ϒδ T-cell receptors in intraepithelial lymphocytes (very specific for celiac disease) and/or detection of IgA anti-tissue transglutaminase antibody deposits in intestinal mucosa.

Other pointers:

Genetic testing for HLA-DQ2 and/or HLA-DQ8 genotypes (which are nearly 100% in celiac disease) are present in about 40% of NCGS which does not differ from the general population
“Estimating the prevalence of NCGS is impossible.” Estimates have ranged from 0.6% of the U.S. population to as high as 50% according to some websites.

Bottomline: While “Wheat Intolerance Syndrome” works fine for me, I think the term nonceliac gluten sensitivity is going to be around for a while. Hopefully, more families and care providers will exclude celiac disease before contemplating this label and consider other foods as potential contributors to the symptomatology.

Related Reference: “Coeliac Disease and Noncoeliac Gluten Sensitivity” Meijer CR, Shamir R, Mearin ML. JPGN 2015; 60: 429-32. This reference covers much of the same territory. The Table 1 in this article nicely summarizes the relevant literature/studies from 2008-2014.

Related blog posts:

How Likely is Celiac Disease if My TTG Test Is Only a Little Bit
Closer followup for Celiac disease & pediatric guidelines …
Gluten-Related Disorders” (Part 1) | gutsandgrowth Antibody tests “become negative in 15% after 1 month on GFD and in 57% after 3 months…diagnosis of CD cannot be made while on GFD.”
Gluten-Related Disorders” (Part 2) | gutsandgrowth
Food choices, FODMAPs, and gluten haters | gutsandgrowth

Foreign Bodies in Children -Expert Guidance

Posted on April 23, 2015 by gutsandgrowth

The NASPGHAN Endoscopy Committee has published a very helpful “Management of Ingested Foreign Bodies” Report (Kramer RE et al. JPGN 2015; 60: 562-74). At the current time, one way to access a PDF of the report is the following CME link on the NASPGHAN website (no login required): Management of Ingested Foreign Bodies -Clinical Report

Some key definitiions from the report.

Emergent removal <2 hours from presentation regardless of NPO status
Urgent removal <24 hours from presentation following usual NPO guidelines

As a general rule, all symptomatic ingestions in the esophagus require emergent removal if feasible. Most gastric ingestions do not require emergent removal, exceptions include multiple magnets, sharp objects in stomach (possibly with surgery), and possibly absorptive objects (due to obstruction).

1. Button Batteries:

Even with “spent” batteries, there is enough residual charge to cause injury and all ingestions (even if asymptomatic) into the esophagus require emergent removal. If these batteries are in the stomach & asymptomatic, urgent removal is recommended if age < 5 years and BB ≥20 mm.

What is different in the proposed algorithm (Figure 1) compared with the Poison Center Guidelines (see:Button Battery Algorithm Link | gutsandgrowth) is more detail regarding concerns about aortoenteric fistula & what to do after endoscopy. Key points:

If active bleeding or unstable, endoscopic removal in OR with surgery/cardiovascular surgery is recommended.
If any esophageal injury, recommendations include admission, NPO, and IV antibiotics. Chest imaging (CT angiography &/or MRI of chest) can help decide length of stay. In those with injury close to aorta, continuation of NPO/antibiotics are recommended along with followup imaging every 5-7 days. In those with clinical deterioration (eg. hematemesis w/in 21 days of injury), ‘assume aortoenteric fistula and emergently prepare for cardiovascular surgery.’

2. Magnets. Figure 3 provides algorithm for single and multiple magnets (adapted from Hussain SZ et al. JPGN 2012; 55: 239-42).

For single magnets, emergent removal from esophagus is recommended (like all other foreign bodies) if difficulty managing secretions, otherwise urgent esophageal removal is suggested.
If there are multiple magnets within reach of endoscope, then if symptomatic, emergent removal is recommended, otherwise, urgent removal is suggested.
For asymptomatic magnets beyond the reach of an upper endoscopy, potential for colonoscopy, or enteroscopy for removal &/or serial x-rays to follow progression. If there is no progression on X-rays (every 8-12 hrs) &/or development of symptoms, then surgical removal/endoscopic removal is recommended.

3. Sharp objects. Figure 4 provides algorithm.

Emergent removal from esophagus/stomach is recommended (like all other foreign bodies) if difficulty managing secretions, otherwise urgent esophageal removal is suggested. For radiolucent objects, if the ingestion was witnessed, urgent removal is suggested; if not witnessed, then further imaging (CT, esophagram, MRI) could be considered.
With regard to sharp foreign bodies beyond the reach of an endoscope, “follow clinically with serial x-ray. Enteroscopy or surgical removal considered if symptoms develop or >3 days without passage.”
Despite the low risk of severe morbidity/mortality from sharp objects (beyond esophagus), report recommends urgent “removal of all of the sharp objects within the reach of the endoscope..if possible.”

4. Food impaction in esophagus. If symptomatic, emergent removal; if asymptomatic, then urgent removal. Biopsies of the esophagus are recommended with endoscopy (Figure 5).

5. Coin ingestions/Blunt objects. Figure 6. “>250,000 ingestions and 20 deaths reported in the United States during a 10-year period.”

For esophagus: If symptomatic, emergent removal; if asymptomatic, then urgent removal. Report recommends check X-ray immediately before sedation. While the report does not address this, a possible alternative to x-ray would be the use of a metal detector. “Consider glucagon if distal esophageal coin or if endoscopy not readily available.”
For stomach: No endoscopy needed. Repeat X-ray at 2 weeks. Remove if not passed w/in 2-4 weeks. Report recommends check X-ray immediately before sedation. While the report does not address this, a possible alternative to x-ray would be the use of a metal detector.
For small bowel: removal (enteroscopy/surgery) if symptomatic.
For objects >25 mm width or >6 cm in length –> should be removed from stomach urgently.

6. Superabsorbent objects. The authors describe ingestions from materials from toys and diapers with polymers that can retain ‘up to 100 times their weight in water.”

For esophagus: If symptomatic, emergent removal; if asymptomatic, then urgent removal.
Stomach/small intestine: urgent removal is recommended

The authors state these recommendations are based on consensus rather than strong evidence and are “no substitute for clinical judgement.”

Take-home message: These guidelines are a good starting point to improve the management of children with foreign bodies.

N2U Part 5 -Biliary Atresia and Kwashiokor

Posted on April 22, 2015 by gutsandgrowth

2015 N2U Syllabus & Presentations

Growth Failure, Macro- and Micronutrients, and Biliary Atresia James Heubi (Syllabus pg 62 –68)

Case in Point: AK is a 5-month-old Hispanic male with biliary atresia s/p hepatoportoenterostomy at age 6 weeks who was seen in clinic with a 2 month history of poor nutritional intake (full details on syllabus pg 62).

Initial Focus/Management:

Increasing caloric density 24 cal with MCT-containing formula, then up to 30 cal (avoid monotherapy with portagen due to EFA deficiency); if not effective, then nocturnal tube feedings (NG/NJ) are likely to be needed. Parenteral supplementation –not being used at Cincinnati in pretransplant patients.
Ascites, when present, limits fluid volume intakes. Aldactone (often at about 3 mg/kg/day) can be helpful; check to make sure urine sodium indicates some natriuresis.
Fat soluble vitamin supplementation/micronutrient supplementation (when needed). Check levels at about 3 months of age. If Vitamin D (25-OH) is greater than 20 (in pediatrics), this is probably reasonable in this population. With Alagille/hyperlipidemic patients, need to correct vitamin E for cholesterol (or total lipid) (Sokol RJ, Heubi JE, et al. NEJM 1984; 310: 1209-12).
For biliary atresia, direct bilirubin >2 indicates need for fat soluble monitoring; in other cholestatic conditions (eg. Alagille, PFIC), don’t rely on direct bilirubin as fat soluble deficiency can develop with lower direct bilirubins.
Vitamin D supplementation: 1000 units/kg/day Drisdol D3 (expensive). D3 preferred but D2 usually OK. Monitor levels and increase dosing if needed. Check monthly until adequate level. Alternatives: Bio-D-Mulsion Forte (D3) http://www.bioticsresearch.com/node/1570, Nature’s Blend Ultra Strength (D3). http://www.nationalvitamin.com
Vitamin E supplementation: Liqui-E (w TPGS) or Nutr-E-sol 15-25 IU/kg/day. Alternative: Aqua-E
Vitamin A supplementation/monitoring: AquaADEKs is reasonable supplement. Harder to monitor vitamin A levels.
If failed Kasai, likely headed to transplantation fairly quickly.

Kwashiokor –Rob Shulman (Syllabus pgs 21-33)

Case in point: 15 mo –Fed a diet of coconut and rice milks managed by pediatrician and chiropractor. (This can occur with BRAT diets as well.)

Key points:

Terminology: from language spoken in a region of Ghana. Term developed to describe the sickness a baby gets when the new baby comes. This is a result of child who gets displaced from breastfeeding as the result of a sibling being born. Willaims CD. Lancet 1935; 226: 1151-52. Original description
Etiology: protein deficiency, protein quality, infection (‘pushes them over the edge’)
Microbiome in Kwashiokor References: Tilg et al. Nature Rev. 2013;10:261-262. Smith et al. Science. 2013;339:548-554. Initial study showed discrepant microbiome in identical twins with and without Kwashiokor. Followup study by placing stool (from Kwashiokor and from healthy children) in mice. Stool from twin with Kwashiokor resulted in mice malnutrition (Garrett W. NEJM 2013; 368: 1746-47). (Related blogs:Gut microbiomes of Malawian twin pairs discordant for … and Microbiome and the risk of Kwashiokor | gutsandgrowth )

Feeding plan/ Prevention of Refeeding Syndrome:

Check labs –including protime, zinc, phosphorus, potassium, magnesium
Oral feedings with standard formulas/diet (usually). Limit feeding volumes initially for 1^st week Kwashiokor (page 37 in syllabus) –about ½ full caloric intake (consider ½ strength formula).
‘Advancing diet slowly is not needed with other forms of malnutrition.’
Give multivitamin. In 3^rd world, it is recommended to add additional vitamin A (200,000 units once).
Hold off on iron (even in multivitamin) until improved for a few weeks.
Albumin infusions are not recommended àassociated with worse outcomes
Refeeding syndrome is an iatrogenic disease! This is associated with Kwashiokor and not with other malnutrition diseases.
Add Kphos to feedings (eg Neutraphos, NeutraphosK). Usually drop in phosphorus drop most likely in first 48 hours –monitor carefully in first few days and again during increments in feeding.
In 3^rd World countries, addition of antibiotics (amoxicillin or cefdinir for 7 d) to therapeutic regimens for uncomplicated severe acute malnutrition associated with a significant improvement in recovery and mortality rates. In U.S. this translates to low threshold for using antibiotics but not required in every case.

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.

Subway Mosaic Art (Chicago)

N2U -Part 4: Obesity and Micronutrients

Posted on April 21, 2015 by gutsandgrowth

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.

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

Downtown Chicago

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

Posted on April 20, 2015 by gutsandgrowth

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:

– Unclear of the mechanism
– Unclear of the best protocol
– 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)

N2U -Part 2: Poor Growth and Short Bowel Syndrome

Posted on April 19, 2015 by gutsandgrowth

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 3^rd percentile but tracking. Weight-for-length is at the 25^th 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 <2^nd 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—1^st 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:

Nutrition University -Part 1

Posted on April 18, 2015 by gutsandgrowth

While issues with nutrition are ubiquitous, among the three areas of expertise for pediatric gastroenterologists (gastroenterology, hepatology, and nutrition), it does seem that nutrition expertise receives the least interest overall. One effort to work on this is Nutrition University (N2U) sponsored by NASPGHAN/NASPGHAN foundation.

This is the first year in which the program has been opened up to physicians who have been in practice for more than 10 years and I am looking forward to a great review. Prior to attending, the participants were asked to review previous N2U modules which are available at NASPGHAN website: 2012 N2U Course ( a good source for CME as well).

This year’s syllabus: 2015 N2U Syllabus & Presentations (posted with permission from course organizers).

Last night the meeting started off with some comments by Praveen Goday (Praveen’s training in Cincinnati overlapped with mine) who has spearheaded this effort; subsequently the faculty addressed previously submitted attendee questions.

Here’s a sampling:

Should we be recommending a low FODMAPs diet for IBS? Rob Shulman indicated that about ~70% of adults responded in one study and that a similar study in children at Baylor College of Medicine produced similar results. However, the diet is difficult and help from a dietician/nutritionist is needed. If there is not a response in 7-10 days, then it is likely to be ineffective.

What should be the first formula for Cow’s Milk allergy/intolerance in infancy? The recommendation for most infants (not the very sickest) was to start with a hydrolysate formula which should be effective in more than 90%. It was suggested that amino acid based formulas be reserved for hospitalized infants and those who do not respond to hydrolysates.

What about fish oil enterally or parenterally? James Heubi(*) noted that a lot more data is needed but fish oil either enterally or parenterally may be beneficial. Rob Shulman commented that recent work indicates that vitamin E may be an important reason why fish oil could be better than soy-based lipid emulsions.

How practical are blenderized diets for gastrostomy fed children? Catherine Karls noted that the general goal is to provide nutrients which mimic the commercial formulas but there are many important caveats for DIY (do-it-yourself formula).

An RD needs to supervise to assure all micronutrient needs are being met. Using computer programs, this facilitates calculating dietary reference intakes (DRIs).
Many parents prefer as homebrews are perceived as more natural or holistic
Some children have better tolerance (eg. volume-sensitive, patients with retching)
Drawbacks: time commitment, additional costs (though may be cheaper for some), and concerns regarding food safety
Homebrews are not recommended for jejunostomy feeds (gastrostomy only) or for those with small-caliber feeding tubes (needs to be at least 14 Fr)
Don’t use without the assistance of an RD!

Which is better for NAFLD -low carb or low fat? Ann Scheimann stated that this question is misleading –it is a lot more complicated. It depends on the carbs and it depends on the fat. Fructose clearly worsens NAFLD but so does a diet high in animal fat.

What are the nutritional management recommendations for acute pancreatitis? Justine Turner indicated that too many centers continue to rely on parenteral nutrition. Yet, guidelines recommend the use of enteral nutrition due to lower risk of poor outcomes (eg. infections when NPO and on parenteral nutrition). ‘Resting pancreas is not helpful.’ With acute pancreatitis, enzyme secretion is reduced. Her approach is to start nasogastric (NG) feedings at about 24 hours after presentation, as long as hemodynamically stable. She indicated that nasojejunal (NJ) feedings can be done if NG is not well-tolerated. NJ feedings are effective at reducing enzyme secretion. However, Praveen Goday stated that his practice was often starting with NJ feeds. “Sometimes there is only one shot” before the ICU team starts HAL. Both physicians indicated that polymeric formulas were probably acceptable; however, starting with semi-elemental or elemental feedings are often done, again as a practical matter to minimize the likelihood of reverting to parenteral nutrition.

What is the advice regarding children who need far less than typical calories for weight (eg. wheelchair-bound inactive child)? Generally all nutrients are being met if a child less than 10 years is receiving 4 cans of commercial formula. For children 10 and older, receiving 6 cans per day should ensure adequate nutrients. For those who fall below this threshold, several options:

Reduced calorie formula (eg. Pediasure Sidekicks, Compleat Reduced) are approximately 0.6 cal/mL but have all the other nutrients
Supplementation: multivitamin, calcium, phosphorus, protein
Need to meet at least 80% of typical fluid needs, thus not much rationale for 2 cal/mL formulas. As a practical matter, if the child is urinating well, they are receiving enough fluids.

*I was fortunate to have Jim as an attending during my fellowship at Cincinnati. In fact, even before then, Jim interviewed me when I was considering Cincinnati for my pediatric residency. He is a terrific person and amazing to work with.

Complex Medicine and Informed Consent

Posted on April 17, 2015 by gutsandgrowth

A recent review (Grady, C. NEJM 2015; 372: 855-62) stresses some of the emerging challenges of informed consent, particularly in the research setting.

Key points:

“Research participants have deficits in their understanding of study information, particularly of research methods such as randomization.”
“Reasonable people disagree about the adequacy of the information presented on the consent forms.”

Trends Which Challenge Current Informed Consent Process:

Learning Health Systems. “Should informed consent for these activities be more similar to research informed consent or clinical informed consent?” “Is it ethically acceptable for a patient or research participant to provide consent for an unspecified or broad range of activities?”
Adoption of Complex Technologies, like genetic sequencing. “How should information be presented [with]..complex information, substantial uncertainty…incidental findings, and implications for blood relatives?”
Consent for Future Use of Clinical Data or Biologic Specimens. “How specific does the information provided in the consent process need to be regarding future uses of data or specimens?”
Demographic Changes/Diminished Capacity in Elderly. “Older age, diminished mental capacity, and dementia per se do not indicate that a person is incapable of consenting…there is a need for respectful and efficient tools and processes for assessing capacity.”

Bottomline: In order to treat patients in a respectful manner, continued efforts at addressing these questions are needed to promote informed choices of patients while advancing medical science and clinical care.