Pediatric Gastroenterology Unit Research Articles

Fata junior gastro SIGENP: A first Italian survey on nonsteroidal anti-inflammatory drugs (NSAID) and upper gastrointestinal bleeding in children

s / Digestive and Liver Disease 46 (2014) e71–e84 e77 FATA JUNIOR GASTRO SIGENP: A FIRST ITALIAN SURVEY ON NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAID) AND UPPER GASTROINTESTINAL BLEEDING IN CHILDREN Sabrina Cardile1,∗, Arrigo Barabino2, Paolo Gandullia2, Salvatore Cucchiara3, Giovanni Di Nardo3, Luigi Dall’Oglio4, Francesca Rea4, Gian Luigi de’Angelis5, Barbara Bizzarri5, Graziella Guariso6, Enzo Masci7, Annamaria Staiano8, Erasmo Miele8, Massimo Martinelli 8, Antonio Tomaino9, Claudio Romano1 1 Sezione di Gastroenterologia ed Endoscopia Digestiva, Dipartimento di Pediatria, Universita di Messina, Messina, Italy 2 UOC di Gastroenterologia ed Endoscopia Digestiva, Istituto Giannina Gaslini di Genova, Genova, Italy 3 UOC di Gastroenterologia, Endoscopia ed Epatologia Pediatrica, Policlinico Universitario Umberto I, Sapienza Universita di Roma, Roma, Italy 4 UOC di Chirurgia ed Endoscopia Digestiva, Ospedale Pediatrico Bambino Gesu, Roma, Italy 5 UOC di Gastroenterologia ed Endoscopia Digestiva, AOU di Parma, Parma, Italy 6 Unita di Gastroenterologia, Endoscopia Digestiva, Epatologia e Cura del Bambino con Trapianto di Fegato, Universita degli Studi di Padova, Padova, Italy 7 Gastroenterologia ed Endoscopia Digestiva, Azienda Ospedaliera San Paolo, Polo Universitario, Universita di Milano, Milano, Italy 8 Dipartimento di Scienze Mediche Traslazionali, Sezione di Pediatria, Universita Federico II di Napoli, Napoli, Italy 9 Dipartimento di Scienze del Farmaco e dei Prodotti per la Salute, Universita di Messina, Messina, Italy Objective: A retrospective population-based survey was conducted to assess the potential contribution of NSAIDs-related in upper gastrointestinal bleeding (UGIB) in pediatric population. Methods: A national retrospective study from seven pediatric Gastroenterology Units (GU) and one adult GU was conducted. Patients aged between 2months and 16 yearswere recruited. UGIB was defined as esophageal and/or gastric and/or duodenal bleeding. The odds ratios for UGIB andNSAIDwas assessed by comparing exposure during the 7 days preceding the date of hospitalization. Results: A total of 51 children were included over 8 years. Hematemesis was present in most patients and melena was more frequent in group aged before 2 years. 88% of patients presented gastric lesions. The UGIB was associated with use of ibuprofen and paracetamol (adjusted OR 2.9, 95% CI 2.1 to 4.0). Paracetamol showed a lower risk compared to ibuprofen (OR 2.0 versus 3.7). Conclusions: This is the first Italian pediatric study to assess an extensive analysis about adverse effects NSAIDs. The UGIB is rare but may be avoided with use of correct doses in most patients. http://dx.doi.org/10.1016/j.dld.2014.07.033 NARROW BAND IMAGING (NBI) COMBINED TO WATER IMMERSION TECHNIQUE (WIT): ANY DIAGNOSTIC YIELD FOR CELIAC DISEASE? A PEDIATRIC PROSPECTIVE STUDY Francesco Valitutti 1,∗, Donatella Iorfida1, Salvatore Oliva1, Ilaria Celletti 1, Stefania Leoni1, Silvia Gatti 1, Chiara Maria Trovato1, Maria Barbato1, Monica Montuori1, Caterina Anania1, Antonio Tiberti 2, Giovanni Di Nardo1, Salvatore Cucchiara1 1 UOC di Gastroenterologia ed Epatologia Pediatrica, Sapienza-Universita di Roma, Roma, Italy 2 Dipartimento di Medicina Interna e Specialita Mediche, Sapienza-Universita di Roma, Roma, Italy Objective: The “multiple-biopsy” approach both in the duodenum and in the bulb is the best strategy to confirm the diagnosis of celiac disease (CD); however, this approach increases the invasiveness of the endoscopic procedure itself and is fairly timeconsuming. Our aim was to evaluate the diagnostic yield for CD of a single biopsy guided by narrow-band imaging combined with water immersion technique (NBI plus WIT) in pediatric patients. Methods: Prospective assessment of the diagnostic accuracy of the “NBI plus WIT”-driven biopsy approach versus the standard protocol in the suspicion of CD. Results: The experimental approach correctly diagnosed 35 out of 40 children with CD, with an overall diagnostic sensitivity of 87.5% (C.I. 95%: 77.3–97.7). An altered pattern at “NBI plus WIT” endoscopic visualization was significantly associated to villous atrophy at guided biopsy (Spearman Rho 0.637, p<0.001). Concordance of “NBI plus WIT” endoscopic assessments was fairly high between two different operators (K: 0.884). After the passage through the pylorus of the endoscope, mean NBI plus WIT procedure time was 53.6 s, whereas mean time for multiple biopsy sampling was 218.2 s (p≤0.0001). Conclusions: In presence of an altered “NBI plus WIT” pattern coupled to high anti-transglutaminase antibodies, a single guided biopsymight suffice to diagnose CD.When no alteredmucosal pattern is visible even at “NBI plusWIT”,multiple bulbar and duodenal biopsies must be obtained to confirm CD diagnosis. http://dx.doi.org/10.1016/j.dld.2014.07.034 AZATHIOPRINE PHARMACOKINETICS IN EARLY ONSET INFLAMMATORY BOWEL DISEASE Gabriele Stocco1, Stefano Martelossi2,∗, Sara De Iudicibus2, Diego Favretto2, Eva Cuzzoni1, Raffaella Franca2, Giuliana Decorti 1, Alessandro Ventura2 1 Dipartimento di Scienze della Vita, Universita di Trieste, Trieste, Italy 2 Clinica Pediatrica, Istituto Materno Infantile,

Parental Satisfaction Assessment After Paediatric Procedural Sedation: There Are Still Issues to Address

As paediatric sedation practices are becoming safer and more feasible everyday, they have been widely used for diagnostic and therapeutic procedures. This study intended to determine the relation between parental satisfaction and the branches applying procedures and demographic data of the patients and their families, physicians, nurses, and the healthcare personnel in the room. In total, 223 successive patients under 18 years of age and ASA I-II undergoing diagnostic or therapeutic procedures in paediatric pulmonary disease, gastroenterology, cardiology, and invasive radiology units were included in the study. The satisfaction level of the patients' parents was determined through a questionnaire of 22 questions. Average satisfaction scores for paediatric bronchoscopy and endoscopic interventions varied between 8.06 and 9.30, while the satisfaction scores of the interventions for the cardiovascular system, hepatic system, and renal system, as well as the invasive radiologic interventions, varied between 7.5 and 9.6. There was a statistically significant negative correlation between the age of parents and children and the necessity for a playground in the waiting area (p<0.05). A significant correlation was found between the age of children and the adequacy of the anaesthetist's behaviors (p<0.05). Satisfaction levels of the parents were high at the units where paediatric sedation was applied. However, the expectations of young patients and their parents were higher. When the physical conditions and communication with patients and their relatives are improved and the process schedules are followed more precisely, the clinical results will increase in a positive way.

PRESENT; PREScription of Enteral Nutrition in pediaTric Crohn's disease in Spain.

Exclusive enteral nutrition (EEN) is one of the therapeutic strategies used to induce remission in pediatric Crohn's disease (CD). Although its use is recommended in clinical practice guidelines and consensus documents, the frequency of this practice in Spain is unknown. A 70-item questionnaire ( PREScription of Enteral Nutrition in pediaTric Crohn's disease in Spain) was drafted and distributed through the SEGHNP (Spanish Society for Pediatric Gastroenterology, Hepatology and Nutrition) e-mail list. We received information from 51 Pediatric Gastroenterology Units. Of the 287 patients newly diagnosed with CD in 2011-2012 at these centres (139 in 2011, 148 in 2012), 182 (63%) received EEN (58% in 2011 and 68% in 2012). 26% of the patients who received EEN in the period studied (64/246) did so during relapses. All the physicians (100%) who responded to the questionnaire believe that EEN is effective in inducing clinical remission in mild to moderate CD. However, 24.5% of respondents never use EEN during relapses. The enteral formulas used most often used were polymeric formulas specific for CD (70.6%) and the preferred administration route was oral, with 60.8% using flavouring and 9.3% allowing a variable percentage of calories in the form of other foods. 65% use 5-ASA together with EEN, 69% use antibiotics and 95% immunomodulators (thiopurines). The duration of EEN tends to be 8 weeks (47.1%), and transition to regular diet was achieved sequentially over a variable period of time. Regarding barriers and limiting factors for the use of EEN, those most frequently reported include lack of acceptance by the patient and/or family (71%), lack of time and/or ancillary staff (69%) and difficulty in convincing the patient and/or family of the suitability of treatment (43%). EEN use rates are similar to those of other European questionnaires. Tools that facilitate acceptance by the patient and family are needed. Increasing the time dedicated to this therapeutic modality is likewise important. Given the disparity of criteria for indicating treatment with EEN, it would be useful to have widely accepted clinical practice guidelines or protocols that facilitate the decision to use it.

Abnormal gallbladder volume in pediatric patients with Sclerosing Cholangitis

Background and aims: Abnormal gallbladder volume has been described in adults with Sclerosing Cholangitis (SC) but, gallbladder hydrops has rarely been reported. The purpose of this retrospective study was to evaluate the sonographic features and characteristics of gallbladder in a cohort of patients with SC, followed at Pediatric Gastroenterology Unit of University of Pisa.

Colitis-associated sclerosing cholangitis in children: A single centre experience

ObjectiveSclerosing cholangitis (SC) is an important immune-mediated extra-intestinal manifestation of inflammatory bowel disease (IBD), primarily affecting patients with ulcerative colitis (UC). The reported prevalence of SC in adults and children with UC is low at between 2 and 7%. We present findings from a hepatological work-up in children with inflammatory colitis and elevated liver function tests (LFT) from a tertiary paediatric gastroenterology unit. DesignThis study is designed as a retrospective review of the medical records of 17 children and adolescents with inflammatory colitis and abnormal LFTs who presented to our IBD service between April 2004 and April 2012. ResultsOver the eight year period a total of 52 patients were diagnosed with inflammatory colitis (ulcerative colitis and unclassified colitis). Seventeen of the 52 patients had abnormal liver function tests and underwent liver biopsy and cholangiography. All 17 patients (32.6%) were diagnosed with hepato-biliary disease. ConclusionThis is one of the largest reported series of children with inflammatory colitis and associated hepato-biliary disease. The data from this patient group indicate that the prevalence of IBD-associated hepato-biliary disease in children with abnormal LFTs is much higher than previously reported. As the diagnosis of IBD-associated hepato-biliary disease affects patient management, we recommend liver biopsy and cholangiography in all children with inflammatory colitis and abnormal liver function tests.

Manifestations of food protein induced gastrointestinal allergies presenting to a single tertiary paediatric gastroenterology unit

Background Food protein induced gastrointestinal allergies are difficult to characterise due to the delayed nature of this allergy and absence of simple diagnostic tests. Diagnosis is based on an allergy focused history which can be challenging and often yields ambiguous results. We therefore set out to describe a group of children with this delayed type allergy, to provide an overview on typical profile, symptoms and management strategies.Methods This retrospective analysis was performed at Great Ormond Street Children’s Hospital. Medical notes were included from 2002 – 2009 where a documented medical diagnosis of food protein induced gastrointestinal allergies was confirmed by an elimination diet with resolution of symptoms, followed by reintroduction with reoccurrence of symptoms. Age of onset of symptoms, diagnosis, current elimination diets and food elimination at time of diagnosis and co-morbidities were collected and parents were phoned again at the time of data collection to ascertain current allergy status.Results Data from 437 children were analysis. The majority (67.7%) of children had an atopic family history and 41.5% had atopic dermatitis at an early age. The most common diagnosis included, non-IgE mediated gastrointestinal food allergy (n = 189) and allergic enterocolitis (n = 154) with symptoms of: vomiting (57.8%), back-arching and screaming (50%), constipation (44.6%), diarrhoea (81%), abdominal pain (89.9%), abdominal bloating (73.9%) and rectal bleeding (38.5%). The majority of patients were initially managed with a milk, soy, egg and wheat free diet (41.7%). At a median age of 8 years, 24.7% of children still required to eliminate some of the food allergens.Conclusions This large retrospective study on children with food induced gastrointestinal allergies highlights the variety of symptoms and treatment modalities used in these children. However, further prospective studies are required in this area of food allergy.

The Scintigraphic Findings of Gastroesophageal Reflux in Children is Related to Body Weight?

BackgroundGastroesophageal reflux disease (GERD) is the most common cause of children admissions to pediatric gastroenterology unit and affects about 30% of pediatric population. Body weight and height percentiles of children with GERD and their relationship between presence and the severity of reflux on scintigraphic images were studied.MethodsPatients who underwent reflux scintigraphy between 2005 - 2012 were retrospectively reviewed. Among 200 patients, 49 patients were involved that their ages were ranging from 0 to 18 years old and body weight and height percentiles were recorded. Accurately 37 MBq (1 mCi) 99mTc-MAA in 100 - 150 mL of milk was ingested by the patient. Presence, number, duration and level of reflux were evaluated on the dynamic images. Presences of reflux within last ten minute were also recorded. Region-of-interests were drawn on esophagus and stomach and reflux ratio (RR) was calculated.ResultsThe ratio of the presence of reflux which occurred within the last ten minutes was significantly higher in children with low body weight percentile. High-level reflux frequency was higher in these children than in normal’s. Presence of reflux which occurred within the last ten minutes was related with low body weight percentile.ConclusionsIf reflux is shown within the last ten minutes and there is high level of reflux, the clinician should be warned about possible low body weight percentile in the future and scintigraphic study should be a guide or a reference for the assessment of more effective treatment methods.

Understanding Infliximab in Crohn’s Disease: The Long-Term Outcomes

Only a few years elapsed from the first clinical trial of infliximab in Crohn’s disease (CD) in 1997 [1] to its widespread use in clinical practice [2]. This is a short interval given the novelty of the drug and its shockingly high cost. The rapid acceptance of the anti-TNF therapies despite the lack of long-term data could be easily understood in light of the striking unmet need for effective salvage therapies that was present prior to the anti-TNF era, when only one-third of patients had mild disease, judged longitudinally [3]. Indeed, anti-TNF medications brought rapid change to the management of IBD and improved the quality of life of countless patients. Accompanied by massive industry-driven aggressive marketing, more antiTNF drugs have been introduced including adalimumab, certolizumab pegol and golimumab, contributing further to the increasing use of biologics in IBD. Although clinical trials are essential for evaluating the effectiveness of emerging therapies, standard trial design cannot be considered sufficient in view of its inherent limitations. Only approximately one-third of potentially eligible patients are enrolled into trials, imposing a significant selection bias which is further enhanced by the typical conduct of clinical trials in large referral centers. The meticulous follow-up during the trial, not routinely employed in clinical practice, imposes measurement bias; furthermore, the length of follow-up does not usually exceed 1–1.5 years. Given these limitations, the postmarketing, real-life evaluation of drugs, as performed by Seminerio et al. in this issue [4] is of utmost importance. Seminerio et al. elegantly reported their long-term experience of patients treated with infliximab with a median follow-up of 6.4 years, the longest to date [4]. The medical records of 492 unselected patients (or 464 with outcome data, used here as the denominator to calculate rates) treated with infliximab at the Mayo Clinic (1998–2002) were systematically reviewed. The study showed an 86 % initial response rate (or 80 % calculated on an ITT basis), similar to the 82–89 % reported in most other publications such as the pediatric REACH trial [5], the Edmonton cohort [6], the large Leuven cohort [7], the Leeds cohort [8], and the Targan initial RCT [1] but higher than the short-term response rate achieved in the ACCENT trial (65 %) [2]. This figure (82–89 %) also includes those with partial response, variably defined in the different studies. In the current study, the complete response rate was 65 %, but it should be emphasized that the vast majority had only one or two induction doses rather than the current standard of a three-dose protocol. The long-term outcome of the current study is shown in Fig. 1, benchmarked by some other long-term real-life reports, most notably the Leuven cohort, which reviewed the outcome of 614 patients [7] and the safety of 734 patients [9]. Direct comparison between the studies is challenging in view of the different follow-up periods and definitions of response as well as the variable inclusion of patients with episodic treatment and fistulizing disease. Nonetheless, some overall conclusions can be extrapolated along with estimation of long-term outcomes. The longterm failure rate (i.e., the need to discontinue infliximab for low effectiveness or unbearable adverse events) is high at *40 %. The comparable rates between the cohorts despite the differing follow-up periods (2–6.4 years) could be D. Turner (&) R. Lev-Tzion Pediatric Gastroenterology and Nutrition Unit, Shaare Zedek Medical Center, P.O. Box 3235, 91031 Jerusalem, Israel e-mail: turnerd@szmc.org.il

Drug Development

Drug Development

Gastrointestinal Endoscopy and Mucosal Biopsy in the First Year of Life

Lower threshold and widening indications for paediatric gastrointestinal endoscopy have resulted in a significant increase in the numbers of endoscopic procedures performed in infants. Despite this, knowledge of gastrointestinal mucosal findings in this age group is limited and data on the clinical usefulness of endoscopy are lacking. All of the children younger than 1 year referred to a single tertiary paediatric gastroenterology unit during the period June 1987 to August 2007 who underwent gastrointestinal endoscopy were identified and the clinical indications and histological outcomes were reviewed. A total of 933 gastroesophageal duodenoscopies and 439 colonoscopies were performed in 1024 cases in a total of 823 infants. In order of frequency, clinical indications were diarrhoea (51%), failure to thrive (41.2%), symptoms of reflux (27.1%), and rectal bleeding (8.5%). Mucosal biopsies were insufficient for assessment in only 2.4% of cases. Mucosal histology was normal in 33.8%, whereas histological abnormalities were identified in 63.8%. Specific histological diagnoses included microvillous inclusion disease, autoimmune enteropathy, graft-versus-host disease post-bone marrow transplantation, tufting enteropathy, and disaccharidase deficiency. There was only 1 colonic perforation complicating endoscopy in a total of 889 cases for which relevant information was available (0.1%). In two-thirds of cases, histological abnormalities were detected that influenced management following endoscopic examination and mucosal biopsy in infants. Endoscopy with biopsies is a greatly informative test with low failure and complication rates in the first year of life.

Bronchial reactivity and fractional exhaled NO in Crohn’s disease in the era of immunomodulating treatment

Our aim was to determine bronchial hyper-responsiveness (BHR) and fractional exhaled NO (FeNO) in a cohort followed and treated for Crohn's disease (CD) in a Pediatric Gastroenterology Unit. Consecutive children with CD were referred to the Pediatric Pulmonary Unit. Each patient completed a questionnaire, followed by spirometry, methacholine challenge test (MCT) and determination of FeNO. The control group included patients evaluated for functional cough who had negative MCT. Twenty-three children and young adults (mean age, 17.39 ± 2.96 years) with CD were compared to 24 healthy controls. 20/23 patients received immunomodulating treatment. Forced expiratory volume in 1 sec (FEV1) was significantly lower prior to (93.74 ± 10.81%, p = 0.009) and at the end of (78.91 ± 18.39%, p = 0.001) the MCT in the CD group compared with the control group (102.2 ± 10.477% and 95.33 ± 11.075%, respectively). Bronchial hyper-responsiveness was observed in 30.4% of patients with CD. FeNO levels were 15.37 ± 24.17 in CD and 11.38 ± 5.42 in the control group (p = 0.21). Neither the response to MCT nor FeNO levels were affected by the disease duration or activity index. In our series, BHR is less frequent than previously described in children with CD. We hypothesize that our finding could result from immunomodulating treatments or lower disease activity.

Cutaneous vasculitis in ulcerative colitis mimicking Henoch–Schönlein purpura

To the best of our knowledge, no cases of ulcerative colitis (UC) mimicking Henoch–Schönlein purpura (HSP) have been reported so far. During a 28-year period 5635 patients were followed up at our Pediatric Rheumatology Unit and 357 had HSP according to the European League Against Rheumatism, the Paediatric Rheumatology International Trials Organisation and the Paediatric Rheumatology European Society validated classification criteria. At the same period, 148 patients with IBD according to the European Society for Paediatric Gastroenterology, Hepatology and Nutrition criteria were followed up at the Pediatric Gastroenterology Unit in our University Hospital. Only two of them had vasculitis, as an extra intestinal manifestation of UC mimicking HSP, and fulfilled both disease criteria. A 2-year old girl had bloody diarrhoea, severe abdominal pain, arthritis in ankles, petechiae and palpable purpura not related to thrombocytopenia in lower limbs. A 5-year old boy had bloody diarrhoea, palpable purpura in buttocks, lower limbs, penis and scrotum associated with arthritis in knees, orchitis in right testicle and periarticular swelling in hands and feet. Their ileocolonoscopy showed diffuse mucosal erythema, oedema, friability and multiple irregular ulcers, and histopathological examination of colonic specimen revealed diffuse chronic mucosal inflammation, crypt distortion and crypt abscesses suggesting ulcerative colitis. There were no signs of intestinal vasculitis in both cases. In conclusion, this is the first study in a paediatric population that evidenced palpable purpura associated with UC mimicking HSP.

Is faecal calprotectin useful in the screening of inflammatory bowel disease in children? - a three year review of practice

Aims Calprotectin is a neutrophil intracellular calcium and zinc binding protein that has been shown to be associated with intraluminal intestinal inflammation when detected in stool. Its use as a non-invasive marker of inflammatory bowel disease (IBD) is well validated in children and adults. Levels of faecal calprotectin (FC) >60 μg/g is considered abnormal, however a FC >100 μg/g has a sensitivity of 98% and specificity of 91% in detecting children with IBD. The authors carried out a study to evaluate the current use of FC as screening tool for IBD, in a tertiary paediatric gastroenterology unit. Methods All FC requests sent over a 3 year period between January 2008 and February 2011 in children aged 1 to 16 years of age (n=68) were reviewed. Additionally clinical notes were analysed for indication for testing, clinical impression on first consultation and subsequent change in management following FC result. Results Of the 68 FC requests, 47 were in children suspected to have inflammatory bowel disease, 7 were used to monitor known inflammatory bowel disease and 14 were for other indications. FC was >100 μg/g in 23 of 68 children (30%). Of the 47 children with suspected IBD at referral, 35 (74%) had normal FC and did not subsequently undergo an endoscopy. 4 children with FC 5 children with suspected IBD with a FC>100 μg/g had abnormal endoscopy. 1 child with a FC>100 μg/g, had no endoscopy as campylobacter was isolated through stool culture, and responded well to treatment. There were however 2 children with elevated FC, but with normal histology following endoscopy. Conclusion Review of our practice over the last 3 years has demonstrated that when FC was measured ie when IBD was possible but children seemed clinically well, IBD was only diagnosed in those with a raised FC. During the study period no child with symptoms consistent with IBD, with a normal FC was subsequently diagnosed with IBD. In well children a normal FC could reduce the need for diagnostic endoscopy. FC is a useful additional screening tool.

Comparison of Quick Point‐of‐Care Test for Small‐bowel Hypolactasia With Biochemical Lactase Assay in Children

The aim of the present study was to compare the Biohit Lactose Intolerance Quick Test (BLIQT) to the criterion standard biochemical duodenal lactase (DL) activity assay in the paediatric population using standard statistical comparative tests. Using standard Olympus endoscopes, 2 postbulbar duodenal biopsies were taken from 38 prospective children (0-16 years) from June 2008-May 2009 at a single tertiary paediatric gastroenterology unit. The biopsies were used for the BLIQT and for biochemical disaccharides assay. Thirty-eight children (19 boys) of median age 5.45 years (0.3-14.8 years) underwent the combined BLIQT and disaccharidase testing. We subdivided the group into those who had biopsies with a larger endoscope (XQ, n = 26) and those who had a smaller endoscope (XP, n = 12) and thus a smaller biopsy forcep. When using a larger endoscope, the BLIQT showed a sensitivity of 100%, specificity of 86%, and positive and negative predictive value of 57.1% and 100%, respectively, on comparing it with DL. With a smaller endoscope, the BLIQT had a sensitivity of 100%, specificity of 80%, positive predictive value of 50%, and a negative predictive value of 100%. As in adult studies, the sensitivity and negative predictive value of the BLIQT was 100%. The specificity too appears to be high but variable, probably because of smaller biopsies obtained, and may warrant the need for 2 biopsies. The high sensitivity, specificity, and negative predictive value of the BLIQT for indicating hypolactasia make it an effective point-of-care test for paediatric hypolactasia.

No Relation Between Disease Activity Measured by Multiple Methods and REE in Childhood Crohn Disease

Increased resting energy expenditure (REE) unmatched by dietary intake is implicated as a cause of poor nutrition in childhood inflammatory conditions. Adequate description of disease activity and correction of REE data for body composition are important to reach reliable conclusions about changes in REE associated with disease. The present study aimed to determine the effect of disease activity measured by clinical status, systemic and stool inflammatory markers on REE in children with Crohn disease using appropriate correction for confounding factors. Sixty children with Crohn disease were recruited from the regional paediatric gastroenterology unit and studied on 1 occasion. REE was measured by indirect calorimetry. Fat-free mass (FFM) was estimated by skinfold thickness. Disease activity was measured using systemic (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]) and faecal markers of inflammation (lactoferrin, calprotectin) and clinical scores (Paediatric Crohn Disease Activity Index). Using a multiple regression model, there was no significant change in REE from active or inactive disease (β = 0.03, P = 0.7) nor from CRP (β = -0.05, P = 0.52), ESR (β = -0.07, P = 0.43), faecal calprotectin (β = -0.07, P = 0.38), and faecal lactoferrin (β = 0.01, P = 0.88). REE/kg FFM was not associated with the Paediatric Crohn Disease Activity Index (r = 0.1, P = 0.44), CRP (r = -0.3, P = 0.84) or ESR (r = 0.12, P = 0.4), faecal calprotectin (r = 0.04, P = 0.97), or faecal lactoferrin (r = 0.02, P = 0.87). REE corrected for physiologically relevant confounders is not associated with degree of disease activity using clinical tools or systemic and local inflammatory markers, and therefore is an unlikely mechanism for poor nutritional state.

Inflammatory bowel disease in transition: challenges and solutions in adolescent care

The prevalence of inflammatory bowel disease (IBD) in childhood is increasing with a phenotype now established as one of complicated and extensive disease. Adolescent patients form a significant proportion of...

L’ingestion de corps étranger chez l’enfant : à propos de 105 cas

The ingestion of a foreign body (FB) is one of the most frequent childhood accidents requiring urgent care depending on the type and localization. Coins are the most frequent, and disk battery ingestion can lead to a significant risk of complications. FB stagnation in the esophagus entails a major risk of perforation. This article reports a retrospective study of 105cases of foreign body ingestion admitted to the pediatric gastroenterology unit between November 2002and June 2010. The average age of these patients was 4years with a 1.5sex ratio. Ten patients were followed for esophagus stenosis; the others had no considerable pathological histories. The fibroscopy performed on 104patients allowed us to visualize the foreign body in 96cases (91.4%). In the 8 remaining cases, the FB was not found (it had already migrated in the digestive tract). Coins were the most frequent (64.7%). Endoscopic extraction removed 83FBs (86.4%). In 11cases, it was pushed towards the stomach, split up in 1 case, and surgery was necessary in only 1 case. The progress of child digestive fibroscopy has decreased both the morbidity related to the ingestion of foreign bodies and the use of surgery. Prevention should be based on educating the parents by informing them about the risk of this kind of accident.

Misinterpretation of REE data in childhood

IntroductionInflammation is thought to place a metabolic burden on the body which can be detected by raised resting energy expenditure (REE). Increased REE unmatched by dietary intake is frequently implicated...

Change in disease activity and resting energy expenditure in children with Crohn's disease

IntroductionMany children with Crohn's disease have poor nutritional status. Inflammation is thought to place a metabolic burden on the body which can be detected by raised resting energy expenditure (REE)....

Resting energy expenditure is not associated with disease activity in children with Crohn's disease

IntroductionMany children with Crohn's disease have poor nutritional status. Increased resting energy expenditure (REE) unmatched by dietary intake is frequently implicated as a cause of weight loss, poor nutritional status...