D. Turck

Epidemiology of inflammatory bowel diseases: New insights from a French population-based registry (EPIMAD)

Most data regarding the natural history of inflammatory bowel diseases and their therapeutic management are from tertiary referral-centres. However, the patients followed in these centres represent a selected sample and extrapolation of these data to the general population is disputable. The EPIMAD Registry covers a large area of Northern France with almost 6 million inhabitants representing 9.3% of the entire French population. From 1988 to 2008, 18,170 incident patients were recorded in the registry including 8071 incident Crohns disease, 5113 incident ulcerative colitis and 591 unclassified inflammatory bowel disease cases. The aim of this study was to review some of the most recent information obtained from this large population-based registry since its launch in 1988.

Vitamin D: Still a topical matter in children and adolescents. A position paper by the Committee on Nutrition of the French Society of Paediatrics

The aims of the present position paper by the Committee on Nutrition of the French Society of Paediatrics were to summarize the recently published data on vitamin D in infants, children and adolescents, i.e., on metabolism, physiological effects, and requirements and to make recommendations on supplementation after careful review of the evidence. Scientific evidence indicates that calcium and vitamin D play key roles in bone health. The current evidence, limited to observational studies, however, does not support other benefits for vitamin D. More targeted research should continue, especially interventional studies. In the absence of any underlying risk of vitamin D deficiency, the recommendations are as follows: pregnant women: a single dose of 80,000 to 100,000 IU at the beginning of the 7th month of pregnancy; breastfed infants: 1000 to 1200 IU/day; children less than 18 months of age, receiving milk supplemented with vitamin D: an additional daily dose of 600 to 800 IU; children less than 18 months of age receiving milk not supplemented with vitamin D: daily dose of 1000 to 1200 IU; children from 18 months to 5 years of age: 2 doses of 80,000 to 100,000 IU every winter (November and February). In the presence of an underlying risk of vitamin D deficiency (dark skin; lack of exposure of the skin to ultraviolet B [UVB] radiation from sunshine in summer; skin disease responsible for decreased exposure of the skin to UVB radiation from sunshine in summer; wearing skin-covering clothes in summer; intestinal malabsorption or maldigestion; cholestasis; renal insufficiency; nephrotic syndrome; drugs [rifampicin; antiepileptic treatment: phenobarbital, phenytoin]; obesity; vegan diet), it may be justified to start vitamin D supplementation in winter in children 5 to 10 years of age as well as to maintain supplementation of vitamin D every 3 months all year long in children 1 to 10 years of age and in adolescents. In some pathological conditions, doses of vitamin D can be increased. If necessary, the determination of 25(OH) vitamin D serum concentration will help determine the level of vitamin D supplementation.

ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis

BACKGROUND Malnutrition is both a frequent feature and a comorbidity of cystic fibrosis (CF), with nutritional status strongly associated with pulmonary function and survival. Nutritional management is therefore standard of care in CF patients. ESPEN, ESPGHAN and ECFS recommended guidelines to cover nutritional management of patients with CF. METHODS The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for determining grades of evidence and strength of recommendation. Statements were discussed, submitted to Delphi rounds, reviewed by ESPGHAN and ECFS and accepted in an online survey among ESPEN members. RESULTS The Working Group recommends that initiation of nutritional management should begin as early as possible after diagnosis, with subsequent regular follow up and patient/family education. Exclusive breast feeding is recommended but if not possible a regular formula is to be used. Energy intake should be adapted to achieve normal weight and height for age. When indicated, pancreatic enzyme and fat soluble vitamin treatment should be introduced early and monitored regularly. Pancreatic sufficient patients should have an annual assessment including fecal pancreatic elastase measurement. Sodium supplementation is recommended and a urinary sodium:creatinine ratio should be measured, corresponding to the fractional excretion of sodium. If iron deficiency is suspected, the underlying inflammation should be addressed. Glucose tolerance testing should be introduced at 10 years of age. Bone mineral density examination should be performed from age 8-10 years. Oral nutritional supplements followed by polymeric enteral tube feeding are recommended when growth or nutritional status is impaired. Zinc supplementation may be considered according to the clinical situation. Further studies are required before essential fatty acids, anti-osteoporotic agents, growth hormone, appetite stimulants and probiotics can be recommended. CONCLUSION Nutritional care and support should be an integral part of management of CF. Obtaining a normal growth pattern in children and maintaining an adequate nutritional status in adults are major goals of multidisciplinary cystic fibrosis centers.

Comparison of the TriTrac-R3D accelerometer and a self-report activity diary with heart-rate monitoring for the assessment of energy expenditure in children

Determining total energy expenditure (EE) in children under free-living conditions has become of increasingly clinical interest. The aim of this study was to compare three different methods to assess EE triaxial accelerometry (TriTrac-R3D; Professional Products, Division of Reining International, Madison, WI, USA), activity diary and heart-rate (HR) monitoring combined with indirect calorimetry (IC). Twenty non-obese children and adolescents, aged 5.5 to 16.0 years, participated in this study. Results from the three methods were collected simultaneously under free-living conditions during the same 24 h schoolday period. Neither activity diary (5904 (sd 1756) kJ) nor the TriTrac-R3D (6389 (sd 979) kJ) showed statistical differences in 24 h total EE compared with HR monitoring (5965 (sd 1911) kJ). When considering different physical activity (PA) periods, compared with HR monitoring, activity diary underestimates total EE during sedentary periods (P<0.001) and overestimates total EE and PA-EE during PA periods (P<0.001) because of the high energy cost equivalence of activity levels. The TriTrac-R3D, compared with HR monitoring, shows good agreement for assessing PA-EE during PA periods (mean difference +0.25 (sd 1.9) kJ/min; 95 % CI for the bias -0.08, 0.58), but underestimates PA-EE and it does not show good precision during sedentary periods (-0.87 (sd 1.4) kJ/min, P<0.001). Correlation between the vector magnitude generated by the TriTrac-R3D accelerometer and EE of activities derived from HR monitoring is high. When compared with the HR method, the TriTrac-R3D and activity diary are not systematically accurate and must be carefully used for the assessment of childrens EE depending on the purpose of each study.

Calibration of the RT3 accelerometer for various patterns of physical activity in children and adolescents

Abstract The aim of this study was to determine thresholds for various intensities of physical activity in children and adolescents using the RT3 accelerometer. Forty healthy participants aged 10–16 years were recruited to the study. To validate the RT3 accelerometer data, an independent sample of 20 children and adolescents aged 10–16 years performed the same activities. Accelerometer data, heart rate, and oxygen consumption were measured at nine levels of physical activity, which varied in intensity: sedentary, light, moderate, and vigorous. Age and sex did not affect thresholds. The activity categories and accelerometer counts were: sedentary activity, 0–40 counts · min−1; light activity, 41–950 counts · min−1; moderate activity, 951–3410 counts · min−1; and vigorous activity, >3410 counts · min−1, respectively. These thresholds were considered valid as the difference between threshold values obtained using two independent groups of children was not significant. This study has established threshold values for various physical activities and enables the RT3 accelerometer to be used to quantify the duration of various levels of activity in adolescents under free-living conditions.

Alimentation des premiers mois de vie et prévention de l’allergie

Allergy consists in the different manifestations resulting from immune reactions triggered by food or respiratory allergens. Both its frequency and severity are increasing. The easiest intervention process for allergy prevention is the reduction of the allergenic load which, for a major allergen such as peanuts, has to begin in utero. The primary prevention strategy relies first on the detection of at risk newborns, i.e. with allergic first degree relatives. In this targeted population, as well as for the general population, exclusive breastfeeding is recommended until the age of 6 months. The elimination from the mothers diet of major food allergens potentially transmitted via breast milk may be indicated on an individual basis, except for peanut, which is systematically retrieved. In the absence of breastfeeding, prevention consists in feeding at-risk newborns until the age of 6 months with a hypoallergenic formula, provided that its efficiency has been demonstrated by well-designed clinical trials. Soy based formulae are not recommended for allergy prevention. Complementary feeding should not be started before the age of 6 months. Introduction of egg and fish into the diet can be made after 6 months but the introduction of potent food allergens (kiwi, celery, crustaceans, seafood, nuts, especially tree nuts and peanuts) should be delayed after 1 year. This preventive policy seems partially efficacious on early manifestations of allergy but does not restrain the allergic march, especially in its respiratory manifestations. Probiotics, prebiotics as well as n-3 fatty polyunsaturated acids have not yet demonstrated any definitive protective effect.

[Breast feeding: health benefits for child and mother].

The prevalence of breastfeeding in France is one of the lowest in Europe: 65% of infants born in France in 2010 were breastfed when leaving the maternity ward. Exclusive breastfeeding allows normal growth until at least 6 months of age, and can be prolonged until the age of 2 years or more, provided that complementary feeding is started after 6 months. Breast milk contains hormones, growth factors, cytokines, immunocompetent cells, etc., and has many biological properties. The composition of breast milk is influenced by gestational and postnatal age, as well as by the moment of the feed. Breastfeeding is associated with slightly enhanced performance on tests of cognitive development. Exclusive breastfeeding for at least 3 months is associated with a lower incidence and severity of diarrhoea, otitis media and respiratory infection. Exclusive breastfeeding for at least 4 months is associated with a lower incidence of allergic disease (asthma, atopic dermatitis) during the first 2 to 3 years of life in at-risk infants (infants with at least one first-degree relative presenting with allergy). Breastfeeding is also associated with a lower incidence of obesity during childhood and adolescence, as well as with a lower blood pressure and cholesterolemia in adulthood. However, no beneficial effect of breastfeeding on cardiovascular morbidity and mortality has been shown. Maternal infection with hepatitis B and C virus is not a contraindication to breastfeeding, as opposed to HIV infection and galactosemia. A supplementation with vitamin D and K is necessary in the breastfed infant. Very few medications contraindicate breastfeeding. Premature babies can be breastfed and/or receive mothers milk and/or bank milk, provided they receive energy, protein and mineral supplements. Return to prepregnancy weight is earlier in breastfeeding mothers during the 6 months following delivery. Breastfeeding is also associated with a decreased risk of breast and ovarian cancer in the premenopausal period, and of osteoporosis in the postmenopausal period.

Long-term outcome of colon interposition after esophagectomy in children.

Background and Objectives: Tissues derived from the colon, stomach, and jejunum have been used to replace the esophagus in childhood to cure esophageal atresia or stricture secondary to gastroesophageal reflux or the ingestion of corrosive agents. The outcome in adulthood of colon interposition performed at an early age has yet to be satisfactorily assessed. The aim of this single-center retrospective study was to evaluate the long-term nutritional, digestive, and respiratory outcome of all patients (n = 32) who underwent colon interposition during childhood in our hospital (1970–2001). Patients and Methods: Medical records of these subjects were reviewed and their nutritional (weight, height, 24-hour food diary), digestive (questionnaire), and pulmonary function status evaluated. Results: Of the patients, 17 had esophageal atresia (7 males, median age at surgery 11 months, range 0.5–61) and 15 had ingested corrosive substances (10 males, median age at surgery 50 months, range 22–113). Complications occurred less than 1 year postoperatively in 53% and long-term complications (occurring >1 year after surgery) in 84%. Long-term complications were common: digestive symptoms were found in 85% (most frequently observed during the first 5 years of follow-up), abnormal lung function in 7 (58%) of those tested (n = 12), feeding difficulties in 50%, scoliosis in 35%, and nutritional complications in 25%. Conclusions: Our study showed a high rate of sequelae following esophageal replacement. This highlights the need for multidisciplinary long-term follow-up into adulthood, and research into alternatives to colon interposition as treatment for esophageal strictures.

Long-term outcome after first intestinal resection in pediatric-onset Crohn's disease: a population-based study.

Background:To describe long-term postoperative evolution of pediatric-onset Crohns disease (CD) and identify predictors of outcome we studied a population-based cohort (1988–2004) of 404 patients (0–17 years), of which 130 underwent surgery. Methods:Risks for a second resection and first need for immunosuppressors (IS) and/or biologics were estimated by survival analysis and Cox models used to determine predictors of outcome. Impact of time of first surgery on nutritional catch-up was studied using regression. Results:In all, 130 patients (70 females) with a median age at diagnosis of 14.2 years (interquartile range: 12–16) were followed for 13 years (9.4–16.6). Probability of a second resection was 8%, 17%, and 29% at 2, 5, and 10 years, respectively. In multivariate analysis, age <14, stenosing (B2) and penetrating (B3) behaviors and upper gastrointestinal location (L4) at diagnosis were associated with an increased risk of second resection. Probability of receiving IS or biologics was 18%, 34%, and 47% at 2, 5, and 10 years, respectively. In multivariate analysis, L4 was a risk factor for requiring IS or biologics, while surgery within 3 years after CD diagnosis was protective. Catch-up in height and weight was better in patients who underwent surgery within 3 years after CD diagnosis than those operated on later. Conclusions:In this pediatric-onset CD study, mostly performed in a prebiologic era, a first surgery performed within 3 years after CD diagnosis was associated with a reduced need for IS and biologics and a better catch-up in height and weight compared to later surgery.

Sténose anastomotique après traitement chirurgical de lˈatrésie de lˈœsophage : fréquence, facteurs de risque et efficacité des dilatations œsophagiennes

Resume La stenose anastomotique est la principale complication apres traitement de lˈatresie de lˈœsophage. Elle est habituellement traitee par dilatation mecanique par bougie ou par ballonnet. Buts de lˈetude. – Les buts de ce travail retrospectif etaient dˈetudier dans une population dˈenfants operes a la naissance dˈune atresie de lˈœsophage de type III ou IV : 1) la frequence et les facteurs associes a la survenue dˈune stenose anastomotique ; 2) lˈefficacite des dilatations œsophagiennes par bougie de Savary. Patients et methodes. – Les caracteristiques de 52 enfants operes sur une periode de cinq ans ont ete analysees. Le terme et le poids de naissance, la duree du maintien des drains mediastinaux et trans-anastomotiques, la tension lors de la realisation de lˈanastomose, la survenue de complications precoces (fistule et/ou mediastinite) et la presence d’un reflux gastro-œsophagien ont ete notes. Les parametres concernant le groupe dˈenfants ayant eu une stenose anastomotique ont ete compares a ceux du groupe dˈenfants indemnes de stenose. En cas de survenue dˈune stenose anastomotique, lˈâge de lˈenfant lors de la premiere dilatation, le nombre de seances de dilatation realisees et lˈefficacite des seances etaient notes. Resultats. – Vingt enfants (40 %) ont eu une stenose anastomotique. Le terme, le poids de naissance, la duree du maintien des drains trans-anastomotiques ou mediastinaux n’etaient pas associes a la survenue ulterieure dˈune stenose anastomotique. Lˈexistence dˈune tension lors de la realisation de lˈanastomose etait significativement liee a la survenue dˈune stenose ( p n = 1) ou severe ( n = 1). Conclusions. – La survenue dˈune stenose anastomotique apres traitement chirurgical de lˈatresie de l’œsophage est frequente, favorisee par la longueur du segment atresique conditionnant la tension lors de la suture. La realisation de dilatations œsophagiennes par bougie de Savary est une technique efficace, mais necessite habituellement plusieurs seances pour obtenir la disparition de la dysphagie.Anastomotic stricture is the most common complication following the surgical repair of esophageal atresia, and is usually treated by esophageal dilation. Objectives. – The aims of this study were to assess in an infant population operated on at birth for type III or IV esophageal atresia: 1) the frequency of esophageal stenosis following the repair of esophageal atresia, and associated factors; 2) the efficacy of esophageal dilation by the Savary-Gaillard bougie technique. Materials and methods. – The medical records of 52 children presenting with esophageal atresia over a 5-year period were retrospectively reviewed. Gestional age and birth weight, duration of mediastinal and transanastomotic drainage, and anastomotic complications including leakage, stricture, and the presence of gastroesophageal reflux were recorded and analysed. Patients presenting with anastomotic stricture were compared with a group of children without stricture. The number of esophageal dilations, their efficacy and the complication rate were analyzed. Results. – Anastomotic stricture developed in 20 (40%) of the 50 patients undergoing primary repair for esophageal atresia. The occurrence of anastomotic stricture was related to anastomotic tension during esophageal surgical repair (p < 0.03). Young children required esophageal dilation at a mean age of 142 days (24–930 days). Stricture resolution occurred after a mean of 3.2 dilations (1–15) over an average period of 7.9 months (range: 0–30 months). Dilation was successful in 90% of the 20 patients. Seven patients required only one dilation. Perforation of the esophagus occurred in one case, and this severe complication led to the death of the child. Esophageal dilation was unsuccessful in two patients, who presented prolonged severe dysphagia. Conclusion. – Anastomotic stricture following repair of esophageal atresia is connected with the length of the gap that has to be repaired, and tension during suture. Esophageal dilation by the Savary-Gaillard bougie technique is an effective method for treating esophageal stricture. Several dilations are usually needed before the disappearance of dysphagia.