A. R. Barclay

Clinical progress in the two years following a course of exclusive enteral nutrition in 109 paediatric patients with Crohn's disease

Exclusive enteral nutrition (EEN) is an effective first line treatment for active paediatric Crohns disease (CD).

The epidemiology of anemia in pediatric inflammatory bowel disease: prevalence and associated factors at diagnosis and follow-up and the impact of exclusive enteral nutrition.

Background:Anemia is poorly studied in pediatric inflammatory bowel disease. This study explored the epidemiology and associated factors of anemia at diagnosis, after 1 year, and during treatment with exclusive enteral nutrition (EEN). Methods:Three cohorts were included: (1) a representative population of newly diagnosed inflammatory bowel disease children (n = 184); (2) patients currently receiving care with data available at diagnosis (n = 179) and after 1 year (n = 139); and (3) 84 children treated with EEN. Results:At diagnosis, 72% were anemic. Abnormal inflammatory markers were more common in Crohn’s disease with severe anemia (severe versus no anemia [%]: raised C-reactive protein; 89% versus 48%; suboptimal albumin; 97% versus 29%; P < 0.002). Anemic children with Crohn’s disease had shorter diagnosis delay and lower BMI than nonanemic patients (severe versus mild versus no anemia, median [interquartile range]; diagnosis delay [months]: 3 [3.9] versus 6 [10] versus 8 [18], P < 0.001; BMI z score [SD]: −1.4 [1.4] versus −1.3 [1.5] versus −0.2 [1.4], P = 0.003). Extensive colitis was associated with severe anemia in ulcerative colitis. The proportion of severely anemic patients decreased from 34% to 9% and mild anemia doubled at 1 year. After EEN, severe anemia decreased (32% to 9%; P < 0.001) and the hemoglobin concentration increased by 0.75 g/dL. This was observed only after 8 weeks of treatment. Disease improvement and low hemoglobin at EEN initiation but not weight gain were associated with hemoglobin improvement. Conclusions:Anemia is high at diagnosis and follow-up and should receive more attention from the clinical team; however, the focus should remain suppression of inflammatory process in active disease.

Probiotics for Preterm Infants: Confounding Features Warrant Caution

We read with interest the recent controversial debate on probiotics for preterm infants sparked by the meta-analysis by Deshpande et al1 and associated commentaries by distinguished authors.2,3 Although we are supportive of the therapeutic potential of probiotics for exclusively formula-fed, very low birth weight neonates, none of the meta-analyses published to date have extracted data in relation to extremely preterm, extremely low birth weight infants or those exclusively fed breast milk. As such, we would be cautious about encouraging widespread use.nnWe offer the following evidence base regarding associated confounders.nn1. Feed regimen: Infants exclusively fed maternal or donor breast milk have a significantly lower incidence of necrotizing enterocolitis in comparison with those who are formula fed.4,5 However, published trials to date and the recent meta-analysis failed to provide sufficient information …

Detailed assessment of nutritional status and eating patterns in children with gastrointestinal diseases attending an outpatients clinic and contemporary healthy controls

Background/objectives:In the era of modern multidisciplinary clinical management, very little is known about the prevalence and presentation of malnutrition in children with gastrointestinal disorders (GastroD) particularly employing composite, global measures of nutritional status.Subjects/methods:Anthropometry, body composition, dietary intake, eating habits and grip strength were assessed with bedside methods in 168 patients from outpatient gastroenterology clinics (n, median (IQR) years; Crohn’s disease (CD): n=53, 14.2 (11.6:15.4); ulcerative colitis (UC): n=27, 12.2 (10.7:14.2); coeliac disease: n=31, 9.3 (7.5:13.6); other GastroD: n=57, 9.8 (7.2:13.8)) and compared with 62 contemporary healthy controls (n, median (IQR): 9.8 (6.9:13.8)) and the results of the recent UK, National Diet and Nutritional Survey (NDNS).Results:Children with CD had lower BMI z-scores than controls (median (IQR): −0.3 (−0.9:0.4) vs 0.3 (−0.6:1.4); P=0.02) but only 2% were classified as thin (BMI z-score <−2u2009s.d.). The prevalence of obesity in children with UC was 19%, 6% in CD, 11% in children with other GastroD and 15% in controls. No difference was found in grip strength measurement between groups. Except for CD children, the proportion of patients with suboptimal micronutrient intake was similar to that of controls and the cohort of children from the latest NDNS. A higher proportion of children with CD had suboptimal intake for riboflavin, vitamin B6 and calcium and consumed significantly more meat products, juices (including carbonated drinks), spreads/jams and crisps and savoury snacks and significantly fewer portions of dairy, fish, fruits and vegetables compared with healthy controls.Conclusions:GastroD affect children’s body composition, growth, strength, dietary intake and eating habits, particularly CD, but to a lesser extent than expected.

The continued rise of paediatric home parenteral nutrition use: Implications for service and the improvement of longitudinal data collection.

BACKGROUND & AIMSnRobust data from the United Kingdom (UK) regarding the current epidemiology of patients with types II and III intestinal failure (IF; ≥28 day parenteral nutrition; home parenteral nutrition) are limited. We aimed to analyse trends in type II and III IF in children in the UK using historical and novel data.nnnMETHODSnA point survey of the 32 nutrition support teams that register patients with the British Intestinal Failure Survey was carried out in November 2012. Basic demographics for patients on home parenteral nutrition and receiving parenteral nutrition for ≥28 days were collected. Data were anonymised, collated by the registry coordinator and compared to previous surveys by the British Paediatric Surveillance Unit in 1993 and data from 2010.nnnRESULTSnAll 32 participating centres responded giving complete UK ascertainment. There were 195 type III patients, representing a four-fold increase since 1993. The proportion of patients with short bowel syndrome had almost doubled from 1993 (27% vs. 50% pxa0=xa00.001). The ratio of type II to type III IF patients varied considerably between centres.nnnCONCLUSIONnThese data suggest that type III IF point prevalence has risen in the short term, coincident with individual centres reporting improved survival in IF. Refinement in the methodology for prospective data collection is needed to gather more accurate incidence, period prevalence and outcome data for UK type II and type III IF.

NICE recommendations for the formal assessment of babies with prolonged jaundice: too much for well infants?

Prolonged jaundice (PJ) is common, affecting 2–15% of all neonates and up to 40% of breastfed infants.1 It presents a challenge to health professionals, who must identify those infants with pathology while avoiding the unnecessary investigation of normal babies. National Institute for Health and Clinical Excellence (NICE) recently recommended, that in addition to a thorough examination, the formal assessment of PJ should include conjugated bilirubin, urine culture, glucose-6-phosphate dehydrogenase where ethnically appropriate, full blood count, blood group determination and Coombs test.2nnThe three studies referenced had methodological flaws, including all …

Letter: Epstein-Barr virus status may be especially important in paediatric IBD populations.

Remission in proton pump inhibitor-responsive esophageal eosinophilia correlates with down regulation of eotaxin-3 and TH2 cytokines, similarly to eosinophilic esophagitis after steroids. Gastroenterology 2013; 144(Suppl. 1): S-484. 7. Dranove JE, Horn DS, Davis MA, et al. Predictors of response to proton pump inhibitor therapy among children with significant esophageal eosinophilia. J Pediatr 2009; 154: 96–100. 8. Sayej WN, Patel R, Baker RD, et al. Treatment with high-dose proton pump inhibitors helps distinguish eosinophilic esophagitis from noneosinophilic esophagitis. J Pediatr Gastroenterol Nutr 2009; 49: 393–9. 9. Peterson KA, Thomas KL, Hilden K, et al. Comparison of esomeprazole to aerosolized, swallowed fluticasone for eosinophilic esophagitis. Dig Dis Sci 2010; 55: 1313–9. 10. Abe Y, Iijima K, Ohara S, et al. A Japanese case series of 12 patients with esophageal eosinophilia. J Gastroenterol 2011; 46: 25–30. 11. Francis DL, Foxx-Orenstein A, Arora AS, et al. Results of ambulatory pH monitoring do not reliably predict response to therapy in patients with eosinophilic oesophagitis. Aliment Pharmacol Ther 2012; 35: 300–7. 12. Schroeder S, Capocelli KE, Masterson JC, et al. Effect of proton pump inhibitor on esophageal eosinophilia. J Pediatr Gastroenterol Nutr 2013; 56: 166–72. 13. Fujiwara Y, Sugawa T, Tanaka F, et al. A multicenter study on the prevalence of eosinophilic esophagitis and PPI-responsive esophageal eosinophilic infiltration. Intern Med 2012; 51: 3235–9. 14. Moawad FJ, Schoepfer A, Ally MR, et al. Eosinophilic esophagitis and proton pump inhibitor responsive esophageal eosinophilia: are they one and the same? Gastroenterology 2013; 144(Suppl. 1): S489 (Su1845). 15. Mangla S, Singal G, Hornick JL, et al. Clinical predictors of response to proton pump inhibitors in patients with esophageal eosinophilia. Gastroenterology 2013; 144(Suppl. 1): S495–6 (Su1866). 16. Dellon ES, Speck O, Woodward K, et al. Clinical and endoscopic characteristics do not reliably differentiate PPIresponsive esophageal eosinophilia and eosinophilic esophagitis in patients undergoing upper endoscopy: a prospective cohort study. Am J Gastroenterol 2013; doi: 10.1038/ajg.2013.363 [Epub ahead of print].

Scottish outcomes for extra hepatic biliary atresia post-rationalisation of services

Aims To evaluate the outcome of Scottish children with extra hepatic biliary atresia (EHBA) since rationalisation of Kasai services to three English centres in 2002 (The ‘Group A’ centres). Methods All Scottish children with EHBA diagnosed between 2002 and 2009 were identified via the Scottish Society of Paediatric Gastroenterology, Hepatology and Nutrition (SSPGHAN) clinicians. A case-note review was conducted with demographics, presentation and outcome data recorded. These data were compared with historical Scottish data and data published previously by the supraregional liver units. Results 25 patients were identified, of whom 22 were referred for Kasai in the group A centres, and of whom 19 had a Kasai. 2u2005year transplant-free survival (TFS) was significantly lower in the SSPGHAN 2002–2009 group than the group A centres in (1) (6/18 (33%) vs 36/57 (63%), p=0.023). Conclusions These postrationalisation data are disappointing. The emphasis for care will now focus on improved communication between, primary care, general paediatricians and surgical centres through regional and national managed clinical networks, aiming to improve future outcomes for Scottish children with BA.

EWTD: incompatible with subspecialty training?

Subspecialty paediatric training in the UK is organised through a national grid, with trainees centrally appointed for their final 3 years of training. Historically, the Royal College of Paediatrics and Child Health (RCPCH) College Specialty Advisory Committee has recommended that a trainee in paediatric gastroenterology, hepatology and nutrition (PGHAN) should spend at least 70% of working hours in that subspecialty. As a result of changes due to the European Working Time Directive (EWTD), there has been an increasing perception from both trainees and trainers that there is insufficient time spent within their subspecialty.nnTo attempt to quantify the effects of the EWTD on subspecialty training in PGHAN, we surveyed current UK trainees. For comparison, 14 consultants …

PWE-137 The epidemiology and outcome of biliary atresia in scotland 2002–2013

Introduction Biliary atresia (BA) is a rare and poorly understood liver disease of infancy that is fatal if not treated through early biliary drainage via the Kasai procedure. BA surgery was rationalised to three UK centres in 2002 following data supporting improved outcomes in institutions performing greater than five Kasai procedures per year.1We have previously shown that outcomes in Scottish children were worse than expected in the years following initial rationalisation.2We aimed to expand the post-rationalisation cohort of BA cases in Scotland to examine epidemiology and outcomes. Method Outcomes of the previously published 2002–2009 incident cohort2was first expanded. New incident cases of BA, with a Scottish postcode at birth and born between 2010–2013, were obtained using data from specialist nurse/team knowledge in the three Scottish regional paediatric gastroenterology networks. New data collection focussed on demographics, details of Kasai and outcomes (particularly 2 year transplant-free survival [2YTFS]). Accurate regional and national population data was obtained from the General Register Office for Scotland and statistics performed in R with Poisson regression analysis for incidence trends. Results 48 infants were initially identified, of whom 5 were excluded from outcome analysis (three with Kasai procedures performed in Edinburgh, one with less than 1 yr follow up post-Kasai and one child born outside Scotland). Three infants required immediate liver transplantation; 43 infants underwent Kasai. Median age at Kasai in the full cohort was 56 days (IQR 47–65) and showed significant improvement from 61 days in 2002–2009 to 51 days in 2010–2013 (p = 0.014). Of those with available data, 61% cleared their jaundice (bilirubin <20 umol/l) six months post-Kasai; 2YTFS was 45%. BA incidence in Scotland was 1 in 14,745 live births and was relatively stable over time (1 in 15,151 in 2002–2009 and 1 in 14,084 in 2010–2013). However a cluster of cases was identified in Lanarkshire where the incidence was 1 in 7,936 live births, significantly higher than the rest of Scotland (1 in 16,949, p = 0.033). Conclusion BA atresia incidence appears relatively stable in Scotland but with an unexplained cluster of cases in the Lanarkshire region; examination of this cluster may provide epidemiological insight into disease pathogenesis There was a significant reduction in time to Kasai portoenterostomy, with the 2YTFS improving since 2002–2009 cohort but is still lower than the pre-rationalisation figure of 65%.2 Disclosure of interest None Declared. References McKiernan P, et al. Lancet. 2000;355(9197):25-29 Tayler R, et al. Arch Dis Child. 2013;98(5):381-383