A. Coruzzo

Natural History of Potential Celiac Disease in Children

BACKGROUND & AIMS The presence of celiac disease-associated autoantibodies (antiendomysium and antitissue transglutaminase [anti-TG2]) with normal jejunal mucosa indicate potential celiac disease. We performed a prospective, 3-year cohort study to determine the natural history of potential celiac disease in children. METHODS The study included 106 children with potential celiac disease, based on serology analysis and normal duodenal architecture. All but 2 carried the HLA-DQ2 and/or DQ8 haplotype. In all children, every 6 months, growth, nutritional parameters, celiac disease serology, and autoimmunity were investigated. In biopsies, γδ intraepithelial-, CD3-, and lamina propria CD25-positive cells were counted; duodenal deposits of anti-TG2 immunoglobulin A were detected. Biopsy analysis was repeated after 2 years on patients with persistent positive serology and/or symptoms. RESULTS Celiac disease was detected primarily in first-degree relatives and patients with autoimmune disorders (40.6%). A gluten-free diet was prescribed to 20/106 patients because of symptoms, which were relieved in only 11. Eighty-nine of the 106 patients entered the follow-up study, with normal daily consumption of gluten. During the follow-up antibodies disappeared in 14.6% and fluctuated in 32.6%. Villous atrophy was observed in 12/39 patients (30.8%) who underwent a repeat biopsy. CONCLUSIONS Most children with potential celiac disease remain healthy. After 3 years, approximately 33% of patients develop villous atrophy. Intestinal deposits of anti-TG2 IgA identify children at risk for villous atrophy.

Celiac disease: predictors of compliance with a gluten-free diet in adolescents and young adults.

Aims: To identify risk as well as protective factors related to compliance with the gluten-free diet in a cohort of teenagers with celiac disease (CD). Patients and Methods: Two hundred four patients with CD (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition criteria) older than or equal to 13 years and residents of Campania (southern Italy) were enrolled in the study. Patients underwent clinical examination and blood sampling, and were interviewed about school performance, social relationships, family integration, smoking habit, and compliance with a gluten-free diet. Anti-tissue transglutaminase antibodies were assayed with an enzyme-linked immunosorbent assay. Results: One hundred fifty of 204 (73.5%) reported no dietary transgressions, and 54 of 204 (26.5%) reported occasional or frequent transgressions. During the previous month 29 of 54 (53.7%) poor compliers ate from 0.001 to 1 g of gluten per day, 14 (25.9%) from 1 to 5 g, and 11 (20.4%) more than 5 g. The daily intake of gluten was significantly related to anti-tissue transglutaminase antibodies (χ2 = 38.872, P = 0.000). Height was below the third percentile in 19 of 204 (9.3%), and weight was above the 97th percentile in 20 of 204 (9.8%). Diet compliance did not seem to influence the weight and height. One hundred eleven of 150 good compliers (74%) and 31of 54 (57.4%) poor compliers were asymptomatic. Most patients reported good family relationships (88.7%), social relationships (91.2%), and school integration (88.2%). Alternatively, 54% of patients reported some limitation in their social life. Compliance was good in patients who reported excellent school integration (83%) and social relationships (81%). Conclusion: Optimal school integration significantly contributes to the likelihood of good compliance. A better understanding within the school environment about CD-related issues could improve motivation to adhere to a gluten-free diet.

The Effects of Dietary Counseling on Children with Food Allergy: A Prospective, Multicenter Intervention Study

Although dietary counseling is generally recommended in children with food allergy (FA), its effect on the nutritional status of these patients has not yet been evaluated. Our nonrandomized multicenter prospective intervention study was undertaken to investigate the effects of dietary counseling on children with FA. Anthropometric data, dietary intakes, and laboratory biomarkers of nutritional status were evaluated in children with FA (aged 6 to 36 months) before and after dietary counseling, by multidisciplinary teams composed of pediatricians, dietitians, and nurses. Ninety-one children with FA (49 boys and 42 girls; mean age 18.9 months, 95% CI 16.5 to 21.3) were evaluated; 66 children without FA (41 boys and 25 girls; mean age 20.3 months, 95% CI 17.7 to 22.8) served as controls providing baseline values only. At enrollment, energy and protein intakes were lower in children with FA (91 kcal/kg/day, interquartile range [IQR]=15.1, minimum=55.2, maximum=130.6; and 2.2 g/kg/day, IQR=0.5, minimum=1.5, maximum=2.7, respectively) than in children without FA (96 kcal/kg/day, IQR=6.1, minimum=83.6, maximum=118.0; and 4.6 g/kg/day, IQR=1.2, minimum=2.0, maximum=6.1, respectively; P<0.001). A weight to length ratio <2 standard deviations was more frequent in children with FA than in children without FA (21% vs 3%; P<0.001). At 6 months following dietary counseling, the total energy intake of children with FA was similar to the baseline values of control children. Dietary counseling also resulted in a significant improvement of their anthropometric and laboratory biomarkers of nutritional status. The results of our study support the crucial role of dietary counseling in the clinical management of children with FA.

Calcium and vitamin D intakes in children: a randomized controlled trial

BackgroundCalcium (Ca2+) and vitamin D (VitD) play an important role in child health. We evaluated the daily intake of Ca2+ and VitD in healthy children. Moreover, we demonstrate the efficacy of Ca2+ and VitD supplementation.MethodsDaily Ca2 + and VitD intake was evaluated in consecutive healthy children through a validated questionnaire. Subjects with <70% of dietary reference intakes (DRIs) of Ca2+ and VitD were invited to participate in a prospective randomized trial with 2 groups of nutritional intervention: Group 1, dietary counseling aiming to optimize daily Ca2+ and VitD intake plus administration of a commercially available Ca2 + and VitD supplementation product; Group 2, dietary counseling alone. At the enrollment (T0) and after 4 months (T1) serum 25(OH) Vitamin D levels were assessed.ResultsWe evaluated 150 healthy children (male 50%, mean age 10 years); at baseline a low VitD intake was observed in all subjects (median 0.79 μg/die, IQR 1.78; range 0.01-5.02); this condition was associated with Ca2+ intake <70% of the DRIs in 82 subjects (55%). At baseline serum 25(OH)D levels were low (<30 ng/ml) in all study subjects and after 4 months of nutritional intervention, a normalization of serum 25(OH)D levels (≥30 ng/ml) was observed in all children in Group 1 and in only one subject in Group 2 [Group 1: T1 33.8 ng/ml (IQR 2.5) vs Group 2: T1 24.5 ng/ml (IQR 5.2), p <0.001].ConclusionsAdequate Ca2+ and VitD intakes are difficult to obtain through dietary counseling alone in pediatric subjects. Oral supplementation with of Ca2+ and VitD is a reliable strategy to prevent this condition.Trial registrationThe study was registered in Clinical Trials Protocol Registration System (ID number: NCT01638494).

PP19 EFFECT OF LACTOBACILLUS GG ON TOLERANCE ACQUISITION IN CHILDREN WITH COW'S MILK ALLERGY

Results: The diagnosis was obtained with barium enema in 4 patients. The remaining child, operated for intestinal occlusion, at surgery presented a dolicosigma with tight mesenteric root. All patients underwent colic resection with intestinal anastomosis. The resection was performed as emergency procedure in three cases. In two cases, an attempt to resolve the volvulus after barium enema was successful, and the patients were operated electively after having performed anorectal manometry (normal findings in both). Surgical specimens were investigated for aganglionosis, resulting normal in all cases. No post-operative complications were reported. During the follow up (range 20 months – 31 years) one patient presented an episode of intestinal subocclusion, treated conservatively. Discussion: Sigmoid volvulus has to be considered in the differential diagnosis of intense recurrent abdominal pain associated to vomiting and distension. A high index of suspicion is essential in order to perform the diagnostic barium enema or CT scan. Colonic resection (with laparotomic or laparoscopic approach) represents the optimal therapeutic solution, possibly as elective surgery. Considering the risk of intestinal necrosis and peritonitis, a nonoperative approach (decompressive rectal probe, rigid or flexible colonoscopy) is not warranted as a routine. The variable clinical presentation and the possible spontaneous resolution of pain can determine diagnostic delay and errors, responsible for the high mortality reported in adulthood (up to 16% in surgical series and 36% in patients treated conservatively).

PA24 PECULIARITIES IN FATTY ACIDS PROFILE IN CHILDREN WITH FOOD ALLERGY

L. Cosenzaa , G. Terrin a, M. Di Costanzoa, R. Nocerino a , A. Coruzzoa , A. Celardoa, M. Velardoa, A. Passariello a , B. Malamisurab , V. Brunoa, R. Auricchio a,c , R. Tronconea,c , R. Berni Canani a,c aDepartment of Pediatrics, University of Naples “Federico II”; bPediatric Unit S. Maria dell’Olmo Hospital Cava dei Tirreni, Salerno; cEuropean Laboratory for the Investigation on Food Induced Diseases (ELFID), University of Naples “Federico II”

COMPARISON AMONG AUXOLOGIC INDEXES TO EVALUATE NUTRITIONAL STATUS OF PEDIATRIC CF PATIENTS AND CREATION OF CF GROWTH CHARTS: A MULTI-CENTRIC ITALIAN STUDY

Chronic airway obstruction may determine early hypoxaemia during exercise and sleep even in patients with normal diurnal blood gases. The aim of our study was to establish the occurrence of sleep-disordered breathing (SDB) in a cohort of patients with cystic fibrosis (CF), followed in our Cystic Fibrosis Unit. We therefore studied 55 patients (49% M; 36% children (mean age 4.3±3.9, SaO2 % awake 97.7±1.5); 64% adults (mean age 20.9±4.9, BMI 21.1±3.6, SaO2 % awake 97.1±1.1). All patients, in stable clinical conditions, underwent a nocturnal standard polysomnography (sleep monitoring system Compumedics S-Series) and respiratory functional evaluation during the day. Scoring of respiratory events was performed according to standard criteria. Polysomnographic monitoring revealed the occurrence of SDB, defined as an apnea-hypopnea index (AHI) >5, in 52% of adults and in 56% of children. In adults we found mean AHI 16.8±7.8, mean nocturnal SaO2 93.9%±2.3, mean SaO2 min 88.2%±2.2; in children we found mean AHI 12.5±5.8, mean nocturnal SaO2 93.7%±1.2, mean SaO2 min 89.2%±3.2. In both adults and children we found a similar prevalence of upper airways obstruction (sinusitis and rhinitis), a major cause of SDB, in groups with SDB and without SDB. In adults we found a lower mean FEV1% in the group with SDB as compared to the group without SDB (50% vs 64%, respectively). These data show a high prevalence of sleep-disordered breathing in patients with cystic fibrosis. In these patients SDB occurs in an early phase of life and in adulthood SDB seems to be associated to a lower respiratory function.