Briefly Noted: Ferritin Levels and Cognitive Outcomes

PC Parkin et al. J Pediatr 2020; 217:189-91.

In this study, the authors conducted a secondary analysis of data from the Optimizing Early Child Development Study (Toronto) with 745 healthy children.  The authors note that the setting is from a high resource area with high maternal education.

Key finding:

  • In pediatric patients, 1-3 years, higher serum ferritin values were associated with higher cognitive function as measured by the Mullen Scales of Early Learning
  • Ferritin of 17 mcg/L or higher corresponded to maximum level of cognition

Based on this study, the authors recommend obtaining a ferritin level at 12 months of age at same time when a hemoglobin is recommended.

My take: The implication of this study is that iron deficiency, even in the absence of socioeconomic status, can have a detrimental effect on cognitive outcomes.

Related blog post: Nutrition Week (Day 6) Iron Deficiency in Breastfed Infants


Giant Flag in San Juan, Puerto Rico

Briefly Noted: Celiac Serology Normalization, Inflammatory Markers in Crohn’s Disease, Nutrition in Neurologically-Impaired

  • DM Isaac et al. JPGN 2017; 65: 195-99.

This retrospective study of 487 pediatric patients shows that it takes a long time to normalize celiac serology/anti-tissue transglutaminase antibody (TTG). The median time was 407 days for the 80.5% of patients that normalized their serology in the study time frame.  The time was 364 days for those who were considered adherent to a gluten-free diet.  Patients with type 1 diabetes were less likely to normalize their TTG levels. Faster normalization occurred in those with lower titers at baseline.

Related blog posts:

  • A Alper et al. JPGN 2017; 65: e25-e27

In this chart review, among 135 children, normal ESR and CRP were observed in 28% of children with Crohn disease and 42% of children with ulcerative colitis.

Related blog post: Do you really need both a ESR and CRP?

  • C Romano et al. JPGN 2017; 65: 242-64

This guideline paper details 31 recommendations (some with multiple parts) for the evaluation and management of children with neurologic impairment.  The recommendations include detailed evaluations including knee heights, skinfold thickness measures, DXA scan, routine micronutrient bloodwork, along with a low threshold for oropharyngeal dysphagia assessment.  The paper has recommendations for evaluations of reflux, constipation, and dental problems.  The authors suggest “considering use of enteral feeding if total oral feeding time exceeds 3 hours per day.”

Related blog post: Surgery for reflux works best for those who need it the least

NASPGHAN Postgraduate Course 2014 -Nutriton Module

Thanks to those who attended yesterday’s talk (10/24/14) at the clinical practice session and to those who provided helpful feedback.

This blog entry has abbreviated/summarized the presentations. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.  If you make it to the bottom of this post, you will find some useful patient resources along with previous related blog entries.

Diet and the Microbiome –Robert Baldassano (CHOP) pg 140 in Syllabus

This was a very effective lecture; it brought together a lot of useful information.

Trying to sort out balance between health and disease and role of dysbiosis (altered microbiome)

  • Things that we ingest such as food (diet), antibiotics, and xenobiotics shape the composition of the gut microbiota and serve as substrates for the gut microbiota to produce metabolites
  • We are not the only organism consuming what we eat

Specific studies:

  • Wu G, et al. Science. 2011 Oct 7;334(6052):105-8  The Bacteroides enterotype was highly associated with animal protein and saturated fats, which equates to frequent meat consumption as in a Western diet. The Prevotella enterotype high values for carbohydrates and simple sugars, indicating association with a carbohydrate-based diet more typical of agrarian societies.
  • De Filippo C, et al. PNAS 2010: 14691-96: African children (compared with European) with more bacterial diversity & richness along with higher levels of short-chain fatty acids
  • Holmes et al. Cell Met 2012; 16: 559. Diet serves as a substrate for the microbiota to produce certain metabolites.

IBD and diet (Hou JK et al. American Journal of Gastro 2011;106:563-73)

  • High dietary intakes of total fats, PUFAs, omega-6 and meat were associated with an increased risk of CD and UC
  • High fiber and fruit intakes were associated with decreased CD risk
  • High vegetable intake was associated with decreased UC risk.
  • Consumption of meat, particularly red and processed meat increased the likelihood of relapse (Jowett et al Gut 2004)
  • Enteral diet for IBD can improve stool calprotectin within 1-2 weeks.

Take-home messages: Don’t tell your patients with non-stricturing IBD to eat a low fiber diet.  Reduced red meat and reduced oral iron may be helpful.  Vegetarian diet and Mediterranean diets may be helpful.

Related blog posts:

FODMAP: Navigating this Novel Diet –Bruno Chumpitazi, MD, MPH (Texas Children’s Hospital) -page 152 in Syllabus

  • Fermentable Oligosaccharides Disaccharides and Polyols (FODMAPs): Poorly absorbed, osmotically active, rapidly fermented (produce gas)
  • Higher FODMAPs increase breath hydrogen (Murray K et al. Am J Gastroenterol 2014;109:110-9)
  • Higher FODMAPs increase stool/ileostomy output (Barret JS et al. Aliment Pharmacol Ther 2010;31:874-882,Halmos EP J Gastroenterol Hepatol 2013;28(Suppl4):25-28)

Evidence for use of low FODMAPs diet is best in adult irritable bowel syndrome.

  • Shepherd SJ et al. Clin Gastroenterol Hepatol 2008;6:765-71
  • Staudacher HM et al J Nutr 2012;142:1510-18
  • Ong DK et al. J Gastroenterol Hepatol 2010;25:1366-1373
  • Halmos EP et al. Gastroenterology 2014;146:67-75

Limited studies in children.

  • Chumpitazi BP et al. NASPGHAN 2014 abstract n=33 pediatric IBS.  Favorable response noted to low FODMAP diet.

Dietary recommendations were reviewed along with the caveat that obtaining the assistance of a dietician/nutritionist is recommended.


Related blog posts:

Nutrition in the Child with Neurological Disabilities –Kathleen Motil (Baylor College of Medicine) pg 162 in Syllabus

  • Nutritional disorders are highly prevalent in children with neurological disabilities: 29-46% are underweight; 8-14% are overweight.
  • Improved nutrition improves behavior, activity level, improves growth, and reduces infections.
  • Cause of nutritional disorders mostly related to inappropriate dietary intake but other factors can play a role
  • Growth/anthropometric measures are key determinant of nutritional assessment
  • Key questions: Is child taking all day to eat? Is child choking with feedings?
  • Critical BMI <12 kg/m-squared
  • Goal for BMI ~25%

Reasons for gastrostomy:

  • Flat growth >6 months/weight below curve
  • Parental request
  • Medication administration
  • Aspiration

Resource:  This site contains a terrific PDF download which explains enteral tubes in an easy to understand style along with good graphics. “What You Need to Know Now, A Parent’s Introduction to Tube Feeding is the guide book that every parent wished they had when they were first introduced to feeding tubes.”

Related blog posts:





Fundoplication in children with neurologic impairment

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.


  • 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:

Chronic Care Mode: GJ tube Data

A lot has changed in the field of pediatric gastroenterology since I completed my training 16 years ago.  One technology that is used frequently now is the gastrojejunal (GJ) tube for feeding neurologically-impaired children.  Previously, GJ tubes were used as a temporary solution.  Part of the rational for short-term usage was that these tubes were often difficult to maintain; they could easily become dislodged or clogged.

A recent study documents the more frequent usage of GJ tubes and their indefinite usage to treat complex feeding issues (JPGN 2013; 56: 523-27).

This retrospective chart review encompassed a 10 year period (1999-2009) at a single academic center.  In total 33 patients were treated with GJ tubes with 160 placements.  The mean age at initial placement was 6 years and the mean weight 19.4 kg. 76% of the patients had cerebral palsy/neurologic disorder, 21% had congenital heart disease, and 9% had chronic lung disease.

Common indications for replacement: dislodgment, obstruction, coiling into stomach, and broken tubing.

Three techniques were used:

  1. Fluoroscopy with guide wire and subsequent GJ
  2. Gastroduodenscopy via gastrostomy site to place guidewire for GJ placement
  3. Tube placement during esophagogastroduodenoscopy

Most procedures (85%) did not require sedation.


  • 13 (39%) maintained on GJ throughout study period
  • 10 (30%) converted to gastric or oral feeds
  • 5 (15%) surgical intervention
  • 5 (15%) deceased
  • Duration of tube survival: mean 91 days for Mic-Key GJ (low profile) and 177 days for  coaxial PEG-PEJ (e.g. 16 French Corflo gastric tube with 6 French jejunal tube)

When reading the study, it is hard to ignore Figure 3 which shows more than 30 placements per year after 2007 whereas the number was about two per year before 2001. In the discussion, the authors do not focus on how this technology has been embraced so widely.  It is mostly a discussion on the indications, methods, and complications.  Indications included high aspiration risk, intractable vomiting, failed Nissen fundoplication, and gastroparesis.  “Our study showed that long-term jejunal feeding via GJ tubes is possible and safe.”

My preference is generally to avoid GJ feedings as a primary intervention for long-term feeding problems.  That is, when patients need gastrostomy tube feeds but are prone to vomiting, most often a fundoplication is worthwhile.  When a patient has had a fundoplication that is no longer effective, a GJ tube should be considered.

Related blog links: