European Society For Paediatric Gastroenterology , Hepatology And Nutrition Research Articles

Reevaluating the FDA's warning against the use of probiotics in preterm neonates: A societal statement by ESPGHAN and EFCNI.

The recent advisory issued by the United States Food and Drug Administration, cautioning against the routine administration of probiotics in preterm neonates, has sparked a lively debate within the scientific community. This commentary presents a perspective from members of the Special Interest Group on Gut Microbiota and Modifications within the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and other authors who contributed to the ESPGHAN position paper on probiotics for preterm infants, as well as representatives from the European Foundation for the Care of Newborn Infants. We advocate for a more nuanced and supportive approach to the use of certain probiotics in this vulnerable population, balancing the demonstrated benefits and risks.

Current practices and challenges of registered dietitians in the nutritional management of children with cerebral palsy in South Africa

Background: Feeding difficulties and subsequent malnutrition are common in children with cerebral palsy (CP). Objectives: A study was undertaken to determine the current practices and challenges of South African registered dietitians (SA RD) regarding the nutritional management of children with CP, to compare these practices with international guidelines and to compare the practices of private- and public-sector dietitians. Design: This was a cross-sectional descriptive study with an analytical component. Subjects and outcome measures: The SA RDs completed an online questionnaire, which was developed according to the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines. Participant answers were scored to assess their management of children with CP. Results: Of the 87 SA RDs who participated, 78 had work experience in CP (40 public and 38 private sector). Over two-thirds (n = 62/87, 71.2%) received training on the management of CP at university, albeit inadequate (n = 42/62, 67.7%). Common challenges that affect RDs’ management are poor caregiver compliance (n = 72; 92.2%) and poor networking between healthcare professionals (HCPs) (n = 60; 77.0%). The SA RD (n = 78) management of children with CP was significantly different from the ESPGHAN guidelines (p < 0.001). When comparing the total practice score, no significant difference was found between private- and public-sector RDs. The SA RDs did not achieve many of the recommended practices, particularly those pertaining to anthropometry. Conclusions: Improved training of SA RDs in the assessment and management of children with CP, and addressing barriers such as poor caregiver compliance, would enhance SA RDs’ competence to improve the nutritional management of children with CP.

Clinical guideline highlight for the hospitalist: Childhood eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis.

Joint ESPGHAN/NASPGHAN Guidelines on Childhood Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis. July 4, 2023 (e-publication ahead of print). None. European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatrics Gastroenterology, Hepatology and Nutrition (NASPGHAN). ESPGHAN and NASPGHAN. Children with eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis.

A Retrospective Study Evaluating Guideline Adherence of Neonatal Parenteral Nutrition in a Belgian Neonatal Intensive Care Unit.

Introduction Clinical nutrition for preterm and critically ill neonates remains a challenge. Preterms are often hemodynamically and metabolically compromised, which limits infusion volumes of nutrients and hinders achieving recommended nutrient intakes. While guidelines provide recommended ranges for parenteral nutrition (PN) intakes, they generally recommend enteral nutrition as soon as possible. Thus, in clinical practice, gradually increasing EN intakes complicates assessments of PN guideline adherence. Via a pragmatic approach, we assessed adherence to PN recommendations for macronutrients and energy as stated in the 2018 guidelines of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Methods In this retrospective study, we assessed the nutrition of preterm and critically ill term neonates from the neonatal intensive care unit of the University Hospital Brussels. We analyzed intakes for the first week of life, in which critically ill neonates at our center usually receive the majority of nutrients via PN. The PN-based provision of macronutrients and energy was analyzed descriptively in relation to the ESPGHAN 2018 recommendations. Results Macronutrients and energy provision gradually increased until they reached recommended or targeted values. Compared to term neonates, energy and lipid provision for preterms increased faster, while amino acid provision exceeded the ESPGHAN 2018 recommendations. Conclusions This study adds clinical practice data to the severely understudied field of the ESPGHAN 2018 PN guideline compliance. Using a pragmatic assessment of our nutrition protocols, we found the need to reduce the amount of amino acids per kg body weight per day to meet guideline recommendations.

Infant feeding-a scoping review for Nordic Nutrition Recommendations 2023.

The 2012 edition of the Nordic Nutrition Recommendations (NNR) included recommendations on breastfeeding, based on the most recent guidelines and recommendations from major national food and health authorities and organizations, systematic reviews, and some original research. For NNR 2023, the scope has been expanded and also includes formula feeding and the introduction of solid food. The main focus in this scoping review is on infants aged 0-12 months but also considers parts both before and beyond the first year, as the concept of 'the first 1000 days' emphasizes the importance of factors during pregnancy and the first 2 years of life for immediate and later health: physical as well as emotional and mental health. Breastmilk is the natural and sustainable way to feed an infant during the first months of life. Numerous studies have indicated immediate as well as long-term beneficial effects of breastfeeding on health for both the infant and the breastfeeding mother, and from a public health perspective, it is therefore important to protect, support, and promote breastfeeding. For full-term, normal weight infants, breastmilk is sufficient as the only form of nutrition for the first 6 months, except for vitamin D that needs to be given as supplement. The World Health Organization (WHO) and several other authoritative bodies therefore recommend exclusive breastfeeding during the first 6 months. Starting solids at about 6 months is necessary for both nutritional and developmental reasons. According to the European Food Safety Authority (EFSA) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), solid foods are safe to give from 4 months although exclusive breastfeeding until 6 months is the desirable goal. Breastfeeding can continue together with complementary foods as long as it is mutually desired by the mother and child. If breastfeeding is not enough or for some reason discontinued before the infant is 4 months of age, the infant should be fed infant formula, and, when possible, breastfeeding should be continued alongside the formula feeding. If the infant is 4 months or older, starting with solids together with continued breastfeeding and/or formula feeding is an option. Infant formulas have been developed for infants who are not breastfed or do not get enough breastmilk. Home-made formula should not be given.

Diagnosis, Clinical Presentation and Management of Celiac Disease in Children and Adolescents in Poland

Celiac disease (CD) is a chronic immune-mediated disorder triggered by the ingestion of gluten in genetically predisposed individuals, affecting about 1% of the general population in the developed world. In 2012, the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommendations for CD diagnoses in children and adolescents were introduced, allowing the “no-biopsy” approach if certain criteria were met. This approach was also confirmed in the revised guidelines published in 2020. Thus, the aim of this study was to assess—over a one-year period—the clinical presentations and current status of the management of children and adolescents diagnosed with CD in Poland. Medical records of children and adolescents, newly diagnosed with CD in 2022/2023 in three medical centers in Poland, were involved. Gastroenterologists completed the specific anonymous web-based forms developed in the CD SKILLS project, including data routinely assessed at individual visits about the diagnostic approach and clinical presentation of the disease. Our study assessed 100 patients (56% girls) with an age range 1.6–18.0 years. We found that 98% of patients were serologically tested prior to a CD diagnosis and 58% of patients were diagnosed using the “no-biopsy” approach. In the analyzed group, 40% belonged to a known risk group, only 22% had annual screening before the CD diagnosis (the longest for 9 years), and 19% showed no symptoms at the time of the CD diagnosis. Our research confirmed the applicability of the “no-biopsy” approach for the diagnosis of CD in children and adolescents in Poland, and also showed changes in the clinical picture of CD. Moreover, we highlight the need to introduce broad CD serological screening in risk groups of the Polish population.

Presentation, characteristics and management of obstructive intestinal conditions in cystic fibrosis

ObjectiveConstipation and distal intestinal obstruction syndrome (DIOS) are common gastrointestinal manifestations of cystic fibrosis (CF). The primary aim was to describe the characteristics of constipation and DIOS hospitalisations in a...

Towards a Standardized Classification of the Hepatobiliary Manifestations in Cystic Fibrosis (CFHBI): A Joint ESPGHAN/NASPGHAN Position Paper.

The broad spectrum of hepatobiliary involvement in cystic fibrosis (CF) has been commonly referred to as cystic fibrosis liver disease (CFLD). However, differences in the definitions of CFLD have led to variations in reported prevalence, incidence rates, and standardized recommendations for diagnosis and therapies. Harmonizing the description of the spectrum of hepatobiliary involvement in all people with CF (pwCF) is deemed essential for providing a reliable account of the natural history, which in turn supports the development of meaningful clinical outcomes in patient care and research. Recognizing this necessity, The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) commissioned and tasked a committee to develop and propose a systematic classification of the CF hepatobiliary manifestations to increase uniformity, accuracy, and comparability for clinical, registry, and research purposes. This report describes the committee's combined expert position statement on hepatobiliary involvement in CF, which has been endorsed by NASPGHAN and ESPGHAN. We recommend using CFHBI (Cystic Fibrosis Hepato-Biliary Involvement) as the updated term to describe and classify all hepatobiliary manifestations in all pwCF. CFHBI encompasses the current extensive spectrum of phenotypical, clinical, or diagnostic expressions of liver involvement observed in pwCF. We present a schematic categorization of CFHBI, which may also be used to track and classify the changes and development of CFHBI in pwCF over time. The proposed classification for CFHBI is based on expert consensus and has not been validated for clinical practice and research purposes. Achieving validation should be an important aim for future research.

Аллергия к белкам коровьего молока у младенцев: новые тенденции в профилактике и лечении

This article presents a literature review on the dynamics of dietary approaches to the prevention and treatment of cow’s milk allergy (CMA): from elimination of food allergens to the need to develop food tolerance; controversial views on the efficacy of using partially hydrolyzed formulas for the prevention of CMA from the perspective of evidence-based medicine. Of particular interest are current data on the lower prevalence of CMA and the need for accurate prescription of extensively hydrolyzed formulas with specific organoleptic qualities, composition features and high price, which may affect nitrogen metabolism, increase the financial burden on families and health care systems, and be a risk factor for the development of eating disorders in children in later years. Opinions are presented on approaches to dietary therapy for CMA from two major expert groups, the Middle East and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Key words: cow’s milk allergy, prevention, diet therapy, children

Joint ESPGHAN/NASPGHAN Guidelines on Childhood Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis.

Eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis (non-EoE EGIDs) are rare chronic inflammatory disorders of the gastrointestinal (GI) tract. Diagnosis is based on clinical symptoms and histologic findings of eosinophilic inflammation after exclusion of a secondary cause or systemic disease. Currently, no guidelines exist for the evaluation of non-EoE EGIDs. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed a task force group to provide consensus guidelines for childhood non-EoE EGIDs. The working group was composed of pediatric gastroenterologists, adult gastroenterologists, allergists/immunologists, and pathologists. An extensive electronic literature search of the MEDLINE, EMBASE, and Cochrane databases was conducted up to February 2022. General methodology was used in the formulation of recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to meet current standards of evidence assessment. The guidelines provide information on the current concept of non-EoE EGIDs, disease pathogenesis, epidemiology, clinical manifestations, diagnostic and disease surveillance procedures, and current treatment options. Thirty-four statements based on available evidence and 41 recommendations based on expert opinion and best clinical practices were developed. Non-EoE EGIDs literature is limited in scope and depth, making clear recommendations difficult. These consensus-based clinical practice guidelines are intended to assist clinicians caring for children affected by non-EoE EGIDs and to facilitate high-quality randomized controlled trials of various treatment modalities using standardized, uniform disease definitions.

The Use of Standardized Solutions Instead of Individualized Prescriptions for Parenteral Nutrition on the Neonatal Intensive Care Unit in UZ Brussel: A Feasibility Study.

For parenteral nutrition (PN) of newborns, the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) 2018 guidelines recommend standardized solutions over individual PN (IPN) solutions for most patients. This retrospective study assessed if a shift from IPN to standardized PN was feasible at the UZ Brussel. Using prescription data of 145 neonates, we calculated the nutrient provision for IPN and for standardized PN of the same volumes. We compared the macronutrient intakes with ESPGHAN 2018 recommendations to assess the feasibility. For neonates of a gestational age (GA) <32 or >36 weeks, standardized PN reached recommendations as least as fast as IPN. For neonates with a GA of 32 to 36 weeks, the administration protocol requires further adjustments as amino acid provision was lacking compared to IPN. Overall, the results support the feasibility of a shift from IPN to standardized PN at the UZ Brussel.

Bilateral gonarthrosis as the onset of Crohn’s disease in children: a clinical presentation

Crohn’s disease is an immune-mediated disease characterized by nonspecific granulomatous transmural inflammation with segmental damage to any part of the gastrointestinal tract with the formation of extraintestinal and systemic complications. The disease is complex, multifactorial, which lasts throughout life and affects the physical and psychological development of the individual. According to modern ideas, the occurrence of Crohn’s disease is influenced by external environmental factors against the background of genetic predisposition. According to the literature, in most cases, patients with Crohn’s disease complain of abdominal pain, diarrhea, unexplained anemia, fever, weight loss, or growth retardation. The classic triad of abdominal pain, diarrhea and weight loss occurs in only 25 % cases. Extraintestinal manifestations such as skin lesions, vasculitis, joint syndrome, aphthous stomatitis or para-anal lesions (anal itching, macerations, fissures, paraproctitis, fistulas) may be the first symptoms in 6–23 % of cases. The diagnosis of Crohn’s disease in children is made on the basis of anamnestic and clinical data, the results of using special research methods, including endoscopic, radiological, ultrasound, histological, spiral computer tomography, magnetic resonance imaging, as well as immunological and genetic markers. Achieving and maintaining remission can minimize psychological problems and improve patients’ quality of life. A clinical case of Crohn’s disease is presented, which was diagnosed in a 14-year-old child who was treated for juvenile idiopathic oligoarthritis since the age of two and had frequent bacterial and inflammatory diseases. The difficulties of diagnostic search are reflected, which are caused by various symptoms and early onset. Treatment and clinical monitoring were carried out in accordance with the international recommendations of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 2021. The authors emphasize the need for dynamic clinical monitoring of the patient’s condition, as well as a personalized approach to treatment.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 1: From Intestinal Resection to Home Discharge.

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 2: Long-Term Follow-Up on Home Parenteral Nutrition.

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.

Mezinárodní zkušenosti s dietou pro Crohnovu chorobu založenou na vyloučení konkrétních potravin (CDED) s parciální enterální výživou (PEN)

The role of dietary intervention in the induction of remission of Crohn’s disease (CD) has been confirmed again by the recent ECCO (European Crohn’s and Colitis Organization) and ESPGHAN (European Society for Paediatric Gastroenterology, Hepatology and Nutrition) guidelines. Exclusive enteral nutrition (EEN) should be the method of choice in induction of remission of active luminal CD in children. Steroids should be reserved for situations when intolerance or infectivity of EEN is present. The main limitations of EEN consist of its monotony and palatability. In search for a safe and at least similarly effective diet, Crohn’s disease exclusion diet (CDED) was developed. The number of published data regarding its safety and efficacy has increased significantly since the publication of the first randomized controlled trial in 2019. CDED seems, to be safe and its efficacy is very promising. It seems that CDED could be used in three scenarios: as a monotherapy, as a part of complex treatment and as rescue therapy in cases of loss of response. The use of CDED is promising but further research for evaluation of its efficacy, including the necessity of using partial enteral nutrition, on larger patient cohorts is required. Keywords Crohn’s disease, exclusive enteral nutrition, steroids, Crohn’s Disease Exclusion Diet (CDED), adherence

Pediatric Magnet Ingestion, Diagnosis, Management, and Prevention: A European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) Position Paper.

Magnet ingestion is a special category of foreign body ingestion associated with high levels of morbidity and mortality worldwide, particularly if it is associated with staggered ingestion of multiple magnets or with simultaneous ingestion of other metallic foreign bodies, especially button batteries. A special category of magnet ingestion is the ingestion of earth magnets, which have higher levels of magnetism and therefore, potentially, carries a worse outcome. Legislative bodies, scientific Societies and community-led initiatives have been implemented worldwide with the aim of mitigating the effects of this growing, yet avoidable potential medical emergency. A scoping literature review summarized epidemiology, diagnosis, management, and prevention, including an algorithm for the diagnosis and management of magnet ingestion is presented and compared to previously published reviews and position papers (North American Society of Pediatric Gastroenterology, Hepatology and Nutrition, National Poison Center, Royal College of Emergency Medicine). The main emphasis of the algorithm is on identification of staggered/multiple magnet ingestion, and early joint gastroenterology and surgical consultation and management.

Ethical Considerations Within the ESPGHAN Community.

There are limited data on ethical issues related to the daily practice of members of the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN). The role of the ESPGHAN Ethics Committee (EC) is to provide advice on such matters to its members. The present survey aimed to evaluate the current function, and reasons that ESPGHAN members consulted the ECs. One hundred and five participants from 24 different countries answered the questionnaire. Thirty-five point seven percent of the participants used the ESGHAN EC to ask about clinical practice problems and patient-related issues whereas 21.4% ask about human research questions. An important additional finding was that 66.3% of respondents consulted their hospital's EC when they had ethical concerns and 17.4% consulted with other colleagues with expertise. This is the first survey in the ESPGHAN and Europe that analyses ethical issues that are important to members of the National Societies for Pediatric Gastroenterology Hepatology and Nutrition.

Updated European guidelines for coeliac disease in children.

In January 2020, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) updated its guidelines for the diagnosis of paediatric coeliac disease. The revised ESPGHAN guidelines offer a more streamlined approach to diagnostic pathways for the detection of this disease in children. This article provides an update for clinicians on how to diagnose and manage coeliac disease in children based on the revised guidelines and other available literature.

Probiotics for the Management of Pediatric Gastrointestinal Disorders: Position Paper of the ESPGHAN Special Interest Group on Gut Microbiota and Modifications.

Probiotics, defined as live microorganisms that, when administered in adequate amounts, confer a health benefit on the host, are widely used despite uncertainty regarding their efficacy and discordant recommendations about their use. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Special Interest Group on Gut Microbiota and Modifications provides updated recommendations for the use of probiotics for the management of selected pediatric gastrointestinal disorders. All systematic reviews and/or meta-analyses, as well as subsequently published randomized controlled trials (RCTs) (until December 2021), that compared the use of probiotics in all delivery vehicles and formulations, at any dose, with no probiotic (ie, placebo or no treatment), were eligible for inclusion. The recommendations were formulated only if at least 2 RCTs on a similar well-defined probiotic strain were available. The modified Delphi process was used to establish consensus on the recommendations. Recommendations for the use of specific probiotic strains were made for the management of acute gastroenteritis, prevention of antibiotic-associated diarrhea, nosocomial diarrhea and necrotizing enterocolitis, management of Helicobacter pylori infection, and management of functional abdominal pain disorders and infant colic. Despite evidence to support the use of specific probiotics in some clinical situations, further studies confirming the effect(s) and defining the type, dose, and timing of probiotics are still often required. The use of probiotics with no documented health benefits should be discouraged.

Australasian paediatric gastroenterologist practices of coeliac disease diagnosis before and during the COVID-19 pandemic.

To explore the perceptions and practices of Australasian paediatric gastroenterologists in diagnosing coeliac disease (CD) before and during the COVID-19 pandemic. Paediatric gastroenterologists in Australasia were invited via email to complete an anonymous online questionnaire over a 2-week period in 2021. The questionnaire was completed by 39 respondents: 33 from Australia and six from New Zealand (NZ) equating to a 66% response rate. Thirty-four (87%) of the 39 respondents reported they currently practised non-biopsy diagnosis of CD in eligible children, while the rest diagnosed CD using biopsy confirmation only. All NZ respondents practised non-biopsy CD diagnosis. A majority of responders (76%) who practised non-biopsy CD diagnosis followed the 2020 European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines. Twenty-two (56%) respondents reported that they started using a non-biopsy CD diagnosis protocol before the pandemic and did not change their practice during the pandemic, 10 (26%) started diagnosing non-biopsy CD during the pandemic, 5 (13%) stated their practices of CD were not impacted by the pandemic and 2 (5%) did not respond on whether the pandemic changed their practice. The majority of Australasian gastroenterologist respondents reported they routinely utilised the 2020 ESPGHAN diagnostic criteria in eligible children; half of them started prior to the pandemic and another quarter started this approach due to the pandemic. A minority of practitioners routinely rely only on biopsy confirmation to diagnose CD.