Nutrition University -Part 1

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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.

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.

 

Complex Medicine and Informed Consent

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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:

  1. 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?”
  2. Adoption of Complex Technologies, like genetic sequencing. “How should information be presented [with]..complex information, substantial uncertainty…incidental findings, and implications for blood relatives?”
  3. 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?”
  4. 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.

Related blog post: According to the study which you would never qualify for …

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:

Behavioral Economics and Insurance Exchanges

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A recent commentary (NEJM 2015; 372: 695-98) explains how information provided on healthcare exchanges influences choices on coverage and what types of modifications could help improve these decisions.

Current plans are categorized as Bronze, Silver and Gold based on monthly premiums and out-of-pocket expenses (Related link: Understanding Plans on Healthcare.gov).  Gold plans are characterized by higher monthly premiums and lower out-of-pocket expenses.  However, the authors sampled a group of people.  They found that plans that are labeled as “gold” were preferred by the majority whether the plans had higher monthly premiums and lower out-of-pocket expenses or the reverse (low monthly premiums and higher out-of-pocket expenses).  Rather than using “gold,'” “silver,” or “bronze,” their recommendation would be to provide more practical information by providing estimates of annual costs with best-case and worst-case scenarios.

On many exchanges, the plans are listed by order of lowest monthly premiums to highest monthly premiums.  “When people make choices, they often settle for options at the top of a menu…for example, all else being equal, politicians listed at the top of ballots receive more votes than those whose names appear lower on the list.” Also, using monthly premium differences rather than weekly premium differences also influences choices. Thus, even the innocuous design of a website, could adversely influence the selection of the best plan for a given participant.

Bottomline: If the affordable care act and health exchanges are not eliminated, improving the presentation of information could help many participants get the health coverage that actually meets their needs.

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.

Empathy vs. Sympathy

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A short animated video from Brene Brown/Katy Davis (thanks to Kayla Lewis for this link) helps explain the difference between empathy and sympthany.  Here’s the link: Short Video on Empathy (the animation is not that great but the message is important)

Key points:

  • Empathy brings people to together and sympathy often drives people apart.
  • Empathy never begins with “at least” …it wasn’t worse
  • Sometimes empathy means saying ‘I don’t know what to say but I’m glad you told me.’

Harrison Ford defines Sympathy in 42 – YouTube.  In the movie “42,” Harrison Ford’s character describes sympathy as being derived from the Greek word to suffer together.  In many cases, sympathy can be difficult to distinguish from pity; this is one reason why empathy can be much more helpful.

Unrelated (but interesting): Comic Version Graphic Points Need for Discussions DNR

Here’s one frame:

From Annal of Intern Medicine Twitter Feed

From Annal of Int Med Twitter Feed

Vaccine Proven Effective for Hepatitis E

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An important advance in Hepatology -more data showing efficacy of a Hepatitis E vaccine (N Engl J Med 2015; 372:914-922).

Here’s the abstract:

BACKGROUND

Hepatitis E virus (HEV) is a leading cause of acute hepatitis. The long-term efficacy of a hepatitis E vaccine needs to be determined. 

METHODS

In an initial efficacy study, we randomly assigned healthy adults 16 to 65 years of age to receive three doses of either a hepatitis E vaccine (vaccine group; 56,302 participants) or a hepatitis B vaccine (control group; 56,302 participants). The vaccines were administered at 0, 1, and 6 months, and the participants were followed for 19 months. In this extended follow-up study, the treatment assignments of all participants remained double-blinded, and follow-up assessments of efficacy, immunogenicity, and safety were continued for up to 4.5 years. 

RESULTS

During the 4.5-year study period, 60 cases of hepatitis E were identified; 7 cases were confirmed in the vaccine group (0.3 cases per 10,000 person-years), and 53 cases in the control group (2.1 cases per 10,000 person-years), representing a vaccine efficacy of 86.8% (95% confidence interval, 71 to 94) in the modified intention-to-treat analysis. Of the participants who were assessed for immunogenicity and were seronegative at baseline, 87% of those who received three doses of the hepatitis E vaccine maintained antibodies against HEV for at least 4.5 years; HEV antibody titers developed in 9% in the control group. The rate of adverse events was similar in the two groups.

CONCLUSIONS

Immunization with this hepatitis E vaccine induced antibodies against HEV and provided protection against hepatitis E for up to 4.5 years. (Funded by the Chinese Ministry of Science and Technology and others; ClinicalTrials.gov number, NCT01014845.)

Related blog post:

Briefly noted:

Experience with molecular adsorbent recirculating system (MARS). Lexmond WS, et al. Liver Transpl 2015; 21: 369-80. Editorial 277-78. n=20 over 10 years. From the editorial: “Although MARS therapy has been available for more than a decade, there have been no randomized controlled trials of its use in children…the time has come to get the data necessary to prove whether MARS has utility or not.” Related blog post: Living on MARS | gutsandgrowth

“Unrecognized Chronic Hepatitis C Virus Infection Among Baby Boomers in the Emergency Department.” Hepatology 2015; 61: 776-82. 102 of 1529 individuals were confirmed to have HCV infection. Interestingly, only 54% were successfully contacted by phone and of these only 21 had attended their initial visit with a liver specialist. Related blog post: Wiping out Hepatitis C | gutsandgrowth

From NY Times Twitter Feed (screenshot)

From NY Times Twitter Feed (screenshot)

Unrelated story/link (from NY Times): FDA Slow to Act on Diet Supplement Dangers

 

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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