European Society For Paediatric Gastroenterology , Hepatology And Nutrition Research Articles

Tamamlayıcı Beslenme Uygulamalarında Bebeğin Tercihleri ve Bebek Liderliğinde Beslenme Modeli

Bebek Liderliğinde Beslenme (BLW) 2001-2002 yılında Gill Rapley tarafından normal gelişim gösteren bebekler için geleneksel tamamlayıcı beslenme modeline alternatif olarak geliştirilmiştir. BLW modelinde bebeğe sunulan yiyecekler bebeğin beslenmesiyle ilgilenen kişilere göre değişmektedir. Hangi bakıcılara kimler tarafından nasıl eğitim verileceği ve uygulamaların nasıl gerçekleşeceği konusunda standart bir eğitim ve uygulama kılavuzu bulunmamaktadır. BLW modeli bebeğin aktif katılımı ve tercihleri doğrultusunda ilerlediği için makro ve mikro besin ögesi yetersizlikleri, boğulma riski, besin tercihleri ve kalitesi, açlık tokluk mekanizması üzerindeki etkisi, ailenin tutumlarının bebek üzerine etkisi gibi birçok yönden tartışmaya konu olmuştur. Dünya Sağlık Örgütü tarafından BLW modelini öneren bir açıklama yapılmamıştır. Avrupa Pediatrik Gastroenteroloji, Hepatoloji ve Beslenme Derneği (ESPGHAN) de 2017 yılında yayınlandığı raporda BLW modeli konusunda çıkarımda bulunmak için yeterli kanıtın bulunmadığını belirtmiştir. Bu nedenle bu alanda geniş çaplı kontrollü çalışmalara gereksinim bulunmaktadır. Bu derlemede, son günlerde popüler olan BLW modeli güncel literatür ışığında incelenmiştir.

Clinical practice guidelines in Wilson disease.

Three guidelines in Wilson disease (WD) have been issued to date: by the American Association for the Study of Liver Diseases (AASLD) in 2003 with revision in 2008, by the European Association for the Study of the Liver (EASL) in 2012, and most recently by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) in 2018. The following review aims to compare and contrast the approach to diagnosis and management of WD outlined in each guidance. Diagnostic criteria for WD are variable, with the AASLD proposing a clinical/biochemical algorithmic approach, while EASL and ESPGHAN favor use of the Leipzig score. Screening of first-degree relatives differs in modality: clinical and genetic testing in AASLD and ESPGHAN, versus genetic testing alone in EASL. There is general consensus regarding treatment of WD, though ESPGHAN favors zinc over chelators in maintenance phase and for asymptomatic patients. Liver transplantation is indicated in cases of acute liver failure (ALF) due to WD, but not primarily for neuropsychiatric disease in all guidelines. EASL and ESPGHAN advocate for use of the revised King's score to guide transplant listing. There are limited recommendations on special circumstances including pregnancy, surgery, and malignancy risk in WD. Though current recommendations address the management of liver disease due to WD, future guidelines may include a more detailed discussion of neurological and psychiatric manifestations of WD.

Nutritional red flags in children with cerebral palsy

Children with cerebral palsy (CP) are at risk for under-nutrition. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines identified anthropometric nutritional red flags for neurologically impaired children: weight for age z-score (WFA)<-2, triceps skinfold (TSF) or arm muscle area (AMA)<10th centile and faltering weight. This study aimed to (1) evaluate the nutritional status of Flemish children and adolescents with CP using different anthropometric indicators; (2) assess the prevalence of nutritional red flags and (3) identify risk factors for low anthropometric parameters. This study was a prospective, longitudinal observational study recruiting children and adolescents with CP (2-20 years) in 9 specialized Flemish centres. Measurements were performed at baseline (t1, n=325), after 6 (t2, total n=268) and 12 months (t3, total n=191). WFA z-scores were based on Flemish growth charts; TSF, subscapular skinfolds (SSF) and AMA compared with US reference data. Weight faltering was defined as ≥0.5 decrease in weight SDS at t2 or t3. At t1 50 patients (15.4%) were classified as gross motor function classification system (GMFCS) 1, 95 (29.2%) as GMFCS 2, 49 (15.1%) as GMFCS 3, 54 (16.6%) as GMFCS 4, and 77 (23.7%) as GMFCS 5. The overall median (Q1; Q3) age was 11.7 (8.2; 15.9) years; 61.5% were boys and 22 (6.8%) had a gastrostomy (17 (22.1%) of GMFCS 5 group). The median (Q1; Q3) WFA z-score was-1.13 (-2.6; -0.1); 71.4% of the GMFCS 5 children had a WFA z-score<-2. The median (Q1; Q3) MUAC z-score was 0.17 (-0.7; 1.0); 16.9% of the GFMCS 5 children had MUAC z-score<-2. Median (Q1; Q3) TSF and SSF z-scores were respectively-0.01 (-0.8; 0.9) and 0.27 (-0.3; 0.9). All anthropometric indices tended to decrease with increasing GMFCS (p<0.001). At t1 42.1% had at least one nutritional red flag, at t2 40.3% and at t3 41.4%. Of those with at least one nutritional red flag at t1 or t2, respectively 14.7% and 18.8% suffered weight loss 6 months later. A GMFCS >2 and dysphagia were associated with a higher risk for lower scores of nearly all nutritional indices. Underweight was detected in almost three quarters of CP patients with GMFCS 5 classification, whereas deficits in subcutaneous fat and arm muscle reserve were observed in one fifth. Nutritional red flags, present in about 40% of the Flemish CP children, were apparently not successfully addressed in clinical practice, since up to one-fifth of CP patients with warning signs lost even further weight in the following 6 months. Beside a GMFCS >2, dysphagia was one of the most common conditions influencing the presence of low nutritional indices.

Management of Juvenile Polyposis Syndrome in Children and Adolescents: A Position Paper From the ESPGHAN Polyposis Working Group.

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Polyposis Working Group developed recommendations to assist clinicians and health care providers with appropriate management of patients with juvenile polyposis. This is the first juvenile polyposis Position Paper published by ESPGHAN with invited experts. Many of the published studies were descriptive and/or retrospective in nature, consequently after incorporating a modified version of the GRADE system many of the recommendations are based on expert opinion. This ESPGHAN Position Paper provides a guide for diagnosis, assessment, and management of juvenile polyposis syndrome in children and adolescents, and will be helpful in the appropriate management and timing of procedures in children and adolescents. The formation of international collaboration and consortia is proposed to monitor patients prospectively to advance our understanding of juvenile polyposis conditions.

Management of Familial Adenomatous Polyposis in Children and Adolescents: Position Paper From the ESPGHAN Polyposis Working Group.

Familial adenomatous polyposis (FAP) is a well-described inherited syndrome, characterized by the development of hundreds to thousands of adenomas in the colorectum, with implications in children and adolescents. Almost all adult patients will develop colorectal cancer if they are not identified and treated early enough. Identifying and screening for FAP commences in adolescence. The syndrome is inherited as an autosomal dominant trait and caused by mutations in the adenomatous polyposis (APC) gene. This European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) position paper provides a guide for diagnosis, assessment, and management of FAP in children and adolescents.This is the first position paper regarding FAP published by ESPGHAN. Literature from PubMed, Medline, and Embase was reviewed and in the absence of evidence, recommendations reflect the opinion of paediatric and adult experts involved in the care of polyposis syndromes. Because many of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, these of the recommendations are supported on expert opinion. This position paper will instruct on the appropriate management and timing of procedures in children and adolescents with FAP.

P102 LOW PROPORTION OF TOTAL ABDOMINAL COLECTOMIES IN PEDIATRIC ULCERATIVE COLITIS OCCUR AT HIGH VOLUME CENTERS IN THE U.S.

The volume-outcome relationship for surgical procedures is well established in the U.S. healthcare system. Studies of adult ulcerative colitis (UC) demonstrate that high volume centers consistently produce better surgical outcomes with fewer complications than low volume centers. Recently, published guidelines from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend that pediatric UC surgeries be completed at high volume centers performing ≥10 pediatric colorectal surgeries annually. We aimed to evaluate the annual pediatric UC colectomy volume in hospitals across the U.S. and explore volume trends over time in high volume centers. We performed a cross-sectional analysis of pediatric (≤18 years) UC hospitalizations using the Kids’ Inpatient Database (KID), a nationally representative pediatric database that allows for valid nationwide estimates of pediatric inpatient hospitalization data. The KID includes approximately 7 million unique hospitalizations from up to 4,200 U.S. hospitals annually. We identified pediatric hospitalizations with a primary UC (International Classification of Diseases, Ninth Revision (ICD-9): 556.X) diagnosis and procedural code for total abdominal colectomy (TAC) (ICD-9: 45.8X) on a triennial basis between 1997 and 2012. We identified unique hospitals on an annual basis using a hospital ID-year combination. We defined high volume centers as performing ≥10 pediatric UC colectomies annually in accordance with ESPGHAN guidelines. A total of 517 unique hospital-year combinations accounted for 945 colectomies from 1997 to 2012. Weighted, this accounted for an estimated 1,610 pediatric UC colectomies (mean 268 colectomies per year). For hospitals performing 1 or more colectomies per year, the median annual hospital colectomy volume was 2 (IQR = 1,4). Less than 20% of colectomies were performed at high volume centers while 26.5% of colectomies occurred at centers performing ≤2 colectomies per year. High volume centers were more likely to be located in the Northeast and Midwest as compared to the South or West (p<0.01). No other patient or hospital characteristics were associated with having surgery at a high or low volume center (Table 1). Over the 15-year study period, there was a trend towards fewer colectomies being performed at high volume centers, though this trend appears to be reversing in more recent years (Figure 1). An alarmingly low proportion of colectomies in children with UC are performed at high volume centers. Hence the surgical care delivered to the vast majority of pediatric UC patients in the U.S. is not consistent with current guidelines. National efforts to re-direct care to high volume centers of excellence may lead to improved outcomes for pediatric UC patients. aLow Volume: < 10 colectomies annually; High volume: ≥ 10 colectomies annually. bRaw data is taken from the actual database. National Estimate reflects KID weighting of raw data to produce a national estimate. cData missing from 2012. Figure 1: Annual percentage estimates and standard errors of colectomies at high volume centers in the 1997-2012 KID database. Smoothing line demonstrates a decreasing proportion of colectomies in pediatric UC hospitalizations occurring at high volume centers over the 15-year study period with a modest increase in recent years.

P102 LOW PROPORTION OF TOTAL ABDOMINAL COLECTOMIES IN PEDIATRIC ULCERATIVE COLITIS OCCUR AT HIGH VOLUME CENTERS IN THE U.S.

The volume-outcome relationship for surgical procedures is well established in the U.S. healthcare system. Studies of adult ulcerative colitis (UC) demonstrate that high volume centers consistently produce better surgical outcomes with fewer complications than low volume centers. Recently, published guidelines from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend that pediatric UC surgeries be completed at high volume centers performing ≥10 pediatric colorectal surgeries annually. We aimed to evaluate the annual pediatric UC colectomy volume in hospitals across the U.S. and explore volume trends over time in high volume centers. We performed a cross-sectional analysis of pediatric (≤18 years) UC hospitalizations using the Kids’ Inpatient Database (KID), a nationally representative pediatric database that allows for valid nationwide estimates of pediatric inpatient hospitalization data. The KID includes approximately 7 million unique hospitalizations from up to 4,200 U.S. hospitals annually. We identified pediatric hospitalizations with a primary UC (International Classification of Diseases, Ninth Revision (ICD-9): 556.X) diagnosis and procedural code for total abdominal colectomy (TAC) (ICD-9: 45.8X) on a triennial basis between 1997 and 2012. We identified unique hospitals on an annual basis using a hospital ID-year combination. We defined high volume centers as performing ≥10 pediatric UC colectomies annually in accordance with ESPGHAN guidelines. A total of 517 unique hospital-year combinations accounted for 945 colectomies from 1997 to 2012. Weighted, this accounted for an estimated 1,610 pediatric UC colectomies (mean 268 colectomies per year). For hospitals performing 1 or more colectomies per year, the median annual hospital colectomy volume was 2 (IQR = 1,4). Less than 20% of colectomies were performed at high volume centers while 26.5% of colectomies occurred at centers performing ≤2 colectomies per year. High volume centers were more likely to be located in the Northeast and Midwest as compared to the South or West (p<0.01). No other patient or hospital characteristics were associated with having surgery at a high or low volume center (Table 1). Over the 15-year study period, there was a trend towards fewer colectomies being performed at high volume centers, though this trend appears to be reversing in more recent years (Figure 1). An alarmingly low proportion of colectomies in children with UC are performed at high volume centers. Hence the surgical care delivered to the vast majority of pediatric UC patients in the U.S. is not consistent with current guidelines. National efforts to re-direct care to high volume centers of excellence may lead to improved outcomes for pediatric UC patients.

Influence of breastfeeding and timing of gluten introduction on the onset of celiac disease in infants

Introduction/Objective. The classic type of celiac disease (CD) is most common in children under two years of age. The aim of this study was to investigate whether breastfeeding, particularly breastfeeding during gluten introduction, and timing of gluten introduction, influence the onset of CD at this age. Methods. We retrospectively analyzed medical records of 93 children, 40 in the first and 53 in the second year, with a classic CD diagnosed at the University Children?s Hospital, Belgrade between 2000 and 2010. The diagnosis of CD was based on the criteria of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) from 1989. Results. Duration of breastfeeding reduced the onset of the CD in the first year p = 0.039 (OR = 1.43 95% CI 1.019?1.899). Also, breastfeeding at the time of gluten introduction significantly delayed the age at diagnosis (F = 1.671, t = 2.39, p = 0.029). The timing of gluten introduction did not affect the age of occurrence of CD in these group of children. Conclusion. Longer breastfeeding, and breastfeeding at the time of gluten introduction, postponed the onset of classic CD in patients up to two years. The association between the occurrence of CD and the time of introduction of gluten in this age group of patients has not been established.

Compliance with gluten-free diet in a selected group of celiac children in the Slovak Republic.

Celiac disease (CD) is a chronic long-term disease with autoimmune disorder connected to an allergic reaction to the molecule of gluten. CD is manifested in persons who are genetically predisposed. The only therapy for CD is a strong gluten-free (GF) diet. The aim of our study was to follow the adherence to the gluten-free diet in the selected group of parents and caregivers of children with CD, and to compare factors influencing the adherence to GF diet and therefore influencing also clinical symptoms of CD. We compared and examined important food-related activities as well, by using a personal questionnaire in the group of CD children's parents or caregivers. We designed a cross-sectional study; 325 parents or caregivers of children with CD were recruited in the sample. CD was confirmed by the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) criteria. The anonymous questionnaires were collected at summer camps within period data 2012-2016 and followed factors which might have an influence on compliance with GF diet, according to parents' opinions. Adherence to GF diet was statistically significantly higher among girls compared to boys. Parents' questionnaires confirmed that younger group of children and children with the family history of CD had statistically higher compliance with GF diet. Parents with higher education confirmed better adherence to GF diet, statistical analyses confirmed higher adherence in mother´s education compared to father's education. Duration of CD, socio-demographic factors of parents - age of parent, gender of parent, and residency were not statistically significant in terms of compliance with the diet. Our study confirmed important factors influencing adherence to the GF diet, which are connected to the symptoms and consequences of CD. The assessment of parents' opinions and burden on the families of children with celiac disease should be also reflected in the evaluation of patient's status. Important is also the role of parents in order to facilitate and support clinical interventions and prevention of CD.

Autoimmune Hepatitis in Children: The Current State of the Problem

Aim.To generalize the results of existing research studies carried out to investigate autoimmune hepatitis (AIH) in children, and the contemporary approaches to the diagnosis and therapy of the disease. Key points. According to the results of serological studies, two types of AIH can be distinguished in children. AIH of type 1 is diagnosed, when anti-smooth muscle autoantibodies (ASMA) and/or antinuclear autoantibodies (ANA) have been detected. AIH of type 2 AIH is diagnosed, when liver kidney microsomal autoantibodies (anti-LKM-1) and/ or anti-liver cytosolic autoantibodies (anti-LC-1) have been detected. Liver parenchymal inflammation responds well to a standard immunosuppressive therapy with prednisolone and azathioprine. Disease relapses are observed in about 40% of patients during treatment. It is expedient to treat children at least for 2–3 years before attempting to cancel the treatment, which decision should be considered only when the levels of transaminases have remained normal and IgG has been negative, or autoantibody titers have been low (1:20 using immunofluorescence method) for at least a year. Before attempting to cancel the therapy, liver biopsy and histological study should be repeated in order to exclude the possibility of residual inflammatory changes. For a small number of patients, who do not respond to standard treatment and those who suffer from frequent disease relapses, it is advisable to offer an alternative immunosuppressive treatment, the effectiveness of which is still ambiguous and poorly understood (including, in order of priority, mycophenolate mofetil, calcineurin inhibitors, rituximab, Inhibitor of tumor necrosis factor-alpha). In cases of refractoriness to therapy and the disease progression to liver cirrhosis and its decompensation, liver transplantation is justified. It is shown that AIH might relapse after liver transplantation. De novo AIH develops after liver transplantation as a result of non-autoimmune diseases; it is characterized by the presence of autoantibodies (ANA, ASMA and typical or atypical anti-LKM-1), and histologically characterized by a pattern similar to that of AIH. De novo AIH after liver transplantation responds well to a classical immunosuppressive therapy, but not to a standard antiretroviral therapy. In the review, we discuss issues associated with the clinical manifestations and diagnosis of AIH in children. Approaches to the treatment and long-term observation of such children are reviewed, including, i.e., those formulated by the main group of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) members.Conclusion. Autoimmune hepatitis (AIH) in children has a progressive course with the outcome to liver cirrhosis. The presented review has summarized approaches to the diagnosis and selection of AIH therapy in children.

Pediatric Celiac Disease: Earlier Diagnosis for Better Lifelong Health.

To the Editor: Pediatric celiac disease is common, affecting 1 in 100 children in the majority of European countries and in some countries, as many as 3 in 100. Most children, however, remain undiagnosed. On International Celiac Day, which took place on 16 May, the Public Affairs Committee of European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and the Association of European Celiac Societies (AOECS) called on the EU and its Member States to employ effective detection programmes to achieve earlier diagnosis of pediatric celiac disease. The societies produced a joint “Manifesto for Change," which included an overview of the disease, the high-risk groups, common symptoms, and 3 steps in promoting earlier diagnosis. The manifesto was shared directly on 13 national society and patient organization websites and translated into 11 different languages. Five Members of the European Parliament voiced their support for the manifesto through their communication channels during the awareness day. ESPGHAN and the AOECS also produced an infographic, which was translated into 8 different languages, and hosted an online “Twitter chat" reaching 267,000 Twitter users. Social media impressions were the highest in the ESPGHAN's Twitter account's history (excluding the Annual Meeting). Press activity was undertaken, generating coverage in key consumer and political publications that achieved 7 million opportunities to highlight the need for early diagnosis of celiac disease to healthcare professionals and members of the public. The Public Affairs Committee of ESPGHAN would like to thank the AEOCS for their collaboration on this project and conclude that the joint manifesto has been a successful method of raising awareness of pediatric celiac disease.

Microbiota and infection prevention: making space for probiotics in healthcare

The human microbiome plays a vital role in patients' susceptibility to infections. A change to the composition of the microbiome—be it a change in the presence or abundance of microbial species or the introduction of new pathogens—may result in dysbiosis, which has been identified in patients with acute gastroenteritis (AGE) and antibiotic-associated diarrhoea (AAD). Probiotics can ameliorate dysbiosis, and there is extensive research into their use in AGE and AAD. Recently, national and international bodies—inlcuding the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and the National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries (CKS)—have recommended the use of probiotics in the treatment of AGE and the prevention of AAD and Clostridium difficile infections (CDI). Also, there is emerging evidence suggesting that the perioperative use of probiotics in elective surgery can reduce rates of surgical infections (SI) and reduce the need for postoperative antibiotics. A growing body of evidence suggests that probiotics should be considered as an adjunct to standard protocols in AGE, AAD, CDI and SI, and this review summarises recent developments in probiotic research in these conditions.

Evaluation of a European-wide survey on paediatric endoscopy training

ObjectiveTo evaluate quality of paediatric endoscopy training of Young members of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN).MethodsAn online questionnaire designed by the Young ESPGHAN Committee was...

Evidence Supporting Serology-based Pathway for Diagnosing Celiac Disease in Asymptomatic Children From High-risk Groups.

The European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines for diagnosing celiac disease (CD) in children were modified in 2012. They recommend that in symptomatic children with anti-tissue transglutaminase antibody (anti-tTG) titer of >10 times upper limit of normal (>10× ULN) and who have positive anti-endomysial antibody and HLA-DQ2/DQ8 haplotype, the diagnosis of CD can be based on serology. The aim of this study is to establish whether serology-based pathway of the ESPGHAN guidelines could also be reliably applied to asymptomatic children from high-risk groups. From March 2007 to February 2017, prospective data on anti-tTG titer, age, sex, and reason for screening were collected at diagnostic endoscopy on all asymptomatic children being diagnosed as having CD. The relationship between modified Marsh-Oberhuber classification histological grading and contemporaneous anti-tTG titers was analyzed. A total of 157 asymptomatic children were diagnosed as having CD. Eighty-four of 157 (53.5%) had antitTG >10× ULN (normal <10 IU/mL) and 75 of 84 were from high-risk groups. All 75 had definitive histological evidence (Marsh-Oberhuber 3a-3c) of small bowel enteropathy. Fifty-three of 84 children had anti-tTG >200 IU/mL and total villous atrophy was present in 29 of 53 (55%). Main reasons for serological screening were: type-1 diabetes mellitus (n = 36) and first-degree relatives with CD (n = 24). Mean age at diagnosis was 8.8 years. Serology-based diagnosis is cost-beneficial by around £1275 per child in the United Kingdom. All 75 asymptomatic children from high-risk groups with anti-tTG >10× ULN had histology-proven CD. This study provides further evidence that the guidelines for diagnosing CD by the serology-based pathway should be extended to these children.

Editorial introductions

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS R. Mark GhobrialR. Mark GhobrialAfter receiving his bachelor of medicine and bachelor of surgery degrees from Cairo University Medical School, Egypt, Dr. Ghobrial completed several surgical residencies in the United Kingdom and the United States. While a surgery resident at University of Texas Health Science Center in Houston, Texas, he completed a PhD in Immunology at the UT Graduate School of Biomedical Sciences in 1994. After residency, he accepted a position as Clinical Instructor in the Department of Surgery at the David Geffen School of Medicine at University of California, Los Angeles (UCLA) and was awarded a dumont-UCLA transplant fellowship. He received his full professorship in 2005 and served as the Director of the Pancreas Transplant Program and Living Donor Liver Transplantation, and Service Director for Liver, Pancreas, and Small Bowel Transplantation. He was recruited to the Houston Methodist Hospital, Texas, USA in 2008. Florence LacailleFlorence LacailleIn her eyes, Dr Lacaille is a pediatrician who was trained in the most beautiful city in the world (Paris!) as a modest resident in Pr Alagille's unit among others. She travelled to Montreal, Canada, for a fellowship in paediatric gastroenterology, hepatology and nutrition. Back in Paris, she established the unit of pediatric hepatology and liver transplantation in Necker-Enfants malades in 1992. The first world intestinal transplantation had been performed in this institution in 1987, and after a difficult start, a transplantation program developed from 1994. From 2004, Dr Lacaille cared for children who had undergone combined liver-small bowel transplantation and those who endured isolated small bowel transplantation. Dr Lacaille was also the co-editor of a French textbook on paediatric hepatology, with a new edition currently in preparation. She and her colleagues of the Network for Intestinal failure and Transplantation in Europe (NITE) organized two European workshops on intestinal transplantation in children in 2012 and 2014. Dr Lacaille also organized the ESPGHAN Summer school of Hepatology in 2012 and sat on the Council of ESPGHAN (European Society for Paediatric Gastroenterology, Hepatology and Nutrition) and ITA (Intestinal Transplant Association). Dr Lacaille is currently Chairperson of the Young Investigator Forum (YIF) of ESPGHAN. Together with the President, George Mazariegos, and the Council of ITA, she is organizing the next ITA meeting in Paris in 2019. Norah A. TerraultNorah A. TerraultDr Norah A. Terrault is a Professor of Medicine and Surgery and Director of the Viral Hepatitis Center at the University of California, San Francisco, USA. She received her MD from the University of Alberta, USA, and completed fellowships at the University of Toronto, Canada, before joining the faculty at the University of California, San Francisco. Her research focuses on the natural history and treatment of viral hepatitis and non-alcoholic fatty liver disease, especially in patients with cirrhosis and liver transplant recipients. She has conducted multiple clinical trials related to preventing and treating chronic hepatitis C and B, and is site PI for the NIH-supported HBV Clinical Research Network (HBRN) and NASH Clinical Research Network. She has authored over 250 peer-reviewed manuscripts, editorials, invited reviews, and chapters and is an Associate Editor for Hepatology and past Deputy Editor for Liver Transplantation. She has served on the AASLD governing board and as Councilor on the IASL governing board.

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.

Young Child Formula

Young child formulae (YCF) are milk-based drinks or plant protein-based formulae intended to partially satisfy the nutritional requirements of young children ages 1 to 3 years. Although widely available on the market, their composition is, however, not strictly regulated and health effects have not been systematically studied. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition (CoN) performed a systematic review of the literature to review the composition of YCF and consider their role in the diet of young children. The review revealed limited data but identified that YCF have a highly variable composition, which is in some cases inappropriate with very high protein and carbohydrate content and even high amounts of added sugars. Based on the evidence, ESPGHAN CoN suggests that the nutrient composition of YCF should be similar to that of follow-on formulae with regards to energy and nutrients that may be deficient in the diets of European young children such as iron, vitamin D, and polyunsaturated fatty acids (n-3 PUFAs), whereas the protein content should aim toward the lower end of the permitted range of follow-on formulae if animal protein is used. There are data to show that YCF increase intakes of vitamin D, iron, and n-3 PUFAs. However, these nutrients can also be provided via regular and/or fortified foods or supplements. Therefore, ESPGHAN CoN suggests that based on available evidence there is no necessity for the routine use of YCF in children from 1 to 3 years of life, but they can be used as part of a strategy to increase the intake of iron, vitamin D, and n-3 PUFA and decrease the intake of protein compared with unfortified cow's milk. Follow-on formulae can be used for the same purpose. Other strategies for optimizing nutritional intake include promotion of a healthy varied diet, use of fortified foods, and use of supplements.

Ketogenic parenteral nutrition in 17 pediatric patients with epilepsy.

SummaryObjectiveKetogenic parenteral nutrition (kPN) is indicated when enteral intake is temporarily limited or impossible, but evidence‐based prescriptions are lacking. Objective was to evaluate the efficacy and safety of kPN in children with epileptic encephalopathies using a new computer‐based algorithm for accurate component calculating.MethodsChildren with epilepsy receiving kPN were included. A computer‐based algorithm was established on the basis of guidelines of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN): fat intake not exceeding 4 g/kg/day, age‐adequate supply of protein, electrolytes, vitamins, and trace elements, but reduced carbohydrates. Primary outcome was successfully reaching relevant ketosis, defined as beta‐hydroxybutyrate plasma level of ≥ 2 mmol/L. Efficacy was defined as seizure reduction ≥50% in de novo kPN and maintenance of response in children already on a ketogenic diet (KD). Safety was assessed by adverse effects, laboratory findings, and the appropriateness of nutritional intake.ResultsSeventeen children (median 1.84 years) were studied, of which 76% (13/17) were already on an oral ketogenic diet. Indications for kPN were surgery, status epilepticus, vomiting, food refusal, and introduction of enteral feeding in neonates. The parenteral fat/nonfat ratio was mean 0.9 (±0.3; range 0.6–1.5). Relevant ketosis was reached in 10 children (median 2.9 mmol/L), but not in 7 (median = 1.4 mmol/L). In de novo kPN, significant response was observed in 50% (2/4); in patients previously responding to the KD (77%, 10/13), response was maintained. A significant correlation between the degree of ketosis and seizure reduction (correlation coefficient = 0.691; p = .002) was observed. Only mild and transient adverse events occurred during kPN.Significance KPN with fat intake of 3.5–4.0 g/kg/day was safe and effective. KPN was tailored according to guidelines and individual nutritional needs. In nearly half of the patients, ketosis was lower than during oral KD. Despite this, seizures remained controlled.

European Society for Pediatric Gastroenterology Hepatology and Nutrition's Educational Offer and the Training Syllabus.

The basic knowledge necessary for a European pediatric gastroenterologist/hepatologist/nutritionist is set-out in the training syllabus (TS) of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). We retrospectively compared the topics covered in ESPGHAN's training events between 2013 and 2016 with the basic knowledge TS items. Thirty-six initiatives including e-learning were identified. Twelve (33%) courses focused on gastroenterology, 9 (25%) on hepatology, and 10 (28%) on nutrition. Five (14%) courses covered >1 field and were classified "General." The initiatives covered 12 of 57 (21%) TS items; 31 of 57 items (54%) were partially covered; and 14 of 57 (25%) not covered. Five of 9 e-learning courses covered gastroenterology topics, whereas none covered hepatology topics. ESPGHAN's 3-year educational offer partially met the training needs listed in the TS. A coordinated educational program covering all TS items would harmonize training within Europe and would provide trainees with a professional portfolio for employment purposes.

Is There a Causal Relationship between Intussusception and Food Allergy?

Although intussusception and food allergy are common health problems in childhood, the relation between these two diseases remain obscure. The aim of this study is to investigate the relationship between food allergy and intussusception, and the factors associated with both. Patients diagnosed with intussusception by the Brighton Collaboration Intussusception Working Group criteria were prospectively investigated for food allergy per the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Guideline. They were analyzed per demographic features, clinical, physical and laboratory findings. There were eight (38.1%) patients diagnosed with food allergy, while 13 (61.9%) patients were non-allergic. The mean number of days of presenting symptoms was 1.13 days in the allergy group and 7.85 days in the non-allergy group. The mean number of intussusception attacks was 1.63 in the allergy group while 1 in the non-allergy group (p < 0.05, relative risk (RR) = 2.6). In the allergy group, one (13%) patient was followed up, six (75%) patients were reduced with pneumatic and one (13%) patient reduced manually. In the non-allergy group, four (31%) patients were followed up, six (46%) patients were reduced with pneumotic, one (7%) patient was reduced manually, and resection anastomosis was performed in two (15%) patients. Food allergy is an unrecognized associated factor for intussusception patients, which increases the risk for recurrence. Due to the small patient population, these results should be interpreted with caution.