G. D. Withers

Dichotomy of food and inhalant allergen sensitization in eosinophilic esophagitis.

Background:  Eosinophilic esophagitis (EE) is an emerging condition where patients commonly present with symptoms of gastroesophageal reflux disease and fail to respond adequately to anti‐reflux therapy. Food allergy is currently recognized as the main immunological cause of EE; recent evidence suggests an etiological role for inhalant allergens. The presence of EE appears to be associated with other atopic illnesses.

Quality of life in children with Crohn disease.

Objectives: Quality of life (QOL) is reportedly poor in children with Crohn disease (CD) but improves with increasing disease duration. This article aims to detail QOL in a cohort of Australian children with CD in relation to disease duration, disease activity, and treatment. Materials and Methods: QOL, assessed using the IMPACT-III questionnaire, and disease activity measures, assessed using the Pediatric Crohns Disease Activity Index (PCDAI), were available in 41 children with CD. For this cohort, a total of 186 measurements of both parameters were available. Results: QOL was found to be significantly lower, and disease activity significantly higher (F = 31.1, P = 0.00), in patients within 6 months of their diagnosis compared with those up to 2.5 years, up to 5 years, and beyond 5 years since diagnosis. Higher disease activity was associated with poorer QOL (r = −0.51, P = 0.00). Total QOL was highest in children on nil medications and lowest in children on enteral nutrition. The PCDAI (t = −6.0, P = 0.00) was a significant predictor of QOL, with the clinical history (t = −6.9, P = 0.00) and examination (t = −2.9, P = 0.01) sections of the PCDAI significantly predicting QOL. Disease duration, age, or sex was neither related to nor significant predictors of QOL, but height z score and type of treatment approached significance. Conclusions: Children with CD within 6 months of their diagnosis have impaired QOL compared with those diagnosed beyond 6 months. These patients, along with those with growth impairment, ongoing elevated disease activity with abdominal pain, diarrhoea and/or perirectal and extraintestinal complications, may benefit from regular assessments of QOL as part of their clinical treatment.

Airway cellularity, lipid laden macrophages and microbiology of gastric juice and airways in children with reflux oesophagitis

BackgroundGastroesophageal reflux disease (GORD) can cause respiratory disease in children from recurrent aspiration of gastric contents. GORD can be defined in several ways and one of the most common method is presence of reflux oesophagitis. In children with GORD and respiratory disease, airway neutrophilia has been described. However, there are no prospective studies that have examined airway cellularity in children with GORD but without respiratory disease. The aims of the study were to compare (1) BAL cellularity and lipid laden macrophage index (LLMI) and, (2) microbiology of BAL and gastric juices of children with GORD (G+) to those without (G-).MethodsIn 150 children aged <14-years, gastric aspirates and bronchoscopic airway lavage (BAL) were obtained during elective flexible upper endoscopy. GORD was defined as presence of reflux oesophagitis on distal oesophageal biopsies.ResultsBAL neutrophil% in G- group (n = 63) was marginally but significantly higher than that in the G+ group (n = 77), (median of 7.5 and 5 respectively, p = 0.002). Lipid laden macrophage index (LLMI), BAL percentages of lymphocyte, eosinophil and macrophage were similar between groups. Viral studies were negative in all, bacterial cultures positive in 20.7% of BALs and in 5.3% of gastric aspirates. BAL cultures did not reflect gastric aspirate cultures in all but one child.ConclusionIn children without respiratory disease, GORD defined by presence of reflux oesophagitis, is not associated with BAL cellular profile or LLMI abnormality. Abnormal microbiology of the airways, when present, is not related to reflux oesophagitis and does not reflect that of gastric juices.

Bone Health in Children With Inflammatory Bowel Disease: Adjusting for Bone Age

Objectives: Clinical results of bone mineral density for children with inflammatory bowel disease are commonly reported using reference data for chronological age. It is known that these children, particularly those with Crohn disease, experience delayed growth and maturation. Therefore, it is more appropriate to compare clinical results with bone age rather than chronological age. Materials and Methods: Areal bone mineral density (aBMD) was measured using dual energy x-ray absorptiometry, and bone age was assessed using the Tanner-Whitehouse 3 method from a standard hand/wrist radiograph. Results were available for 44 children ages 7.99 to 16.89 years. Areal bone mineral density measurements were converted to z scores using both chronological and bone ages for each subject. Results: Areal bone mineral density z scores calculated using bone age, as opposed to chronological age, were significantly improved for both the total body and lumbar spine regions of interest. When subjects were grouped according to diagnosis, bone age generated z scores remained significantly improved for those with Crohn disease but not for those diagnosed with ulcerative colitis. Grouping of children with Crohn disease into younger and older ages produced significantly higher z scores using bone age compared with chronological for the older age group, but not the younger age group. Conclusions: Our findings, in accordance with those presented in the literature, suggest that aBMD results in children with Crohn disease should include the consideration of bone age, rather than merely chronological age. Bone size, although not as easily available, would also be an important consideration for interpreting results in paediatric populations.

Ability of commonly used prediction equations to predict resting energy expenditure in children with inflammatory bowel disease

Background: Paediatric onset inflammatory bowel disease (IBD) may cause alterations in energy requirements and invalidate the use of standard prediction equations. Our aim was to evaluate four commonly used prediction equations for resting energy expenditure (REE) in children with IBD. Methods: Sixty‐three children had repeated measurements of REE as part of a longitudinal research study yielding a total of 243 measurements. These were compared with predicted REE from Schofield, Oxford, FAO/WHO/UNU, and Harris‐Benedict equations using the Bland‐Altman method. Results: Mean (±SD) age of the patients was 14.2 (2.4) years. Mean measured REE was 1566 (336) kcal per day compared with 1491 (236), 1441 (255), 1481 (232), and 1435 (212) kcal per day calculated from Schofield, Oxford, FAO/WHO/UNU, and Harris‐Benedict, respectively. While the Schofield equation demonstrated the least difference between measured and predicted REE, it, along with the other equations tested, did not perform uniformly across all subjects, indicating greater errors at either end of the spectrum of energy expenditure. Smaller differences were found for all prediction equations for Crohns disease compared with ulcerative colitis. Conclusions: Of the commonly used equations, the equation of Schofield should be used in pediatric patients with IBD when measured values are not able to be obtained. (Inflamm Bowel Dis 2010;)

Resting Energy Expenditure in Children With Inflammatory Bowel Disease

Objectives: There is controversy in the literature regarding the effect of inflammatory bowel disease (IBD) on resting energy expenditure (REE). In many cases this may have resulted from inappropriate adjustment of REE measurements to account for differences in body composition. This article considers how to appropriately adjust measurements of REE for differences in body composition between individuals with IBD. Patients and Methods: Body composition, assessed via total body potassium to yield a measure of body cell mass (BCM), and REE measurements were performed in 41 children with Crohn disease and ulcerative colitis in the Royal Childrens Hospital, Brisbane, Australia. Log-log regression was used to determine the power function to which BCM should be raised to appropriately adjust REE to account for differences in body composition between children. Results: The appropriate value to “adjust” BCM was found to be 0.49, with a standard error of 0.10. Conclusions: Clearly, there is a need to adjust for differences in body composition, or at the very least body weight, in metabolic studies in children with IBD. We suggest that raising BCM to the power of 0.5 is both a numerically convenient and a statistically valid way of achieving this aim. Under circumstances in which the measurement of BCM is not available, raising body weight to the power of 0.5 remains appropriate. The important issue of whether REE is changed in cases of IBD can then be appropriately addressed.

Paediatric capsule endoscopy: a single-centre experience

Small bowel capsule endoscopy is a useful technique for examining the small bowel mucosa. It has been extensively utilised in adult populations but there is minimal literature about its use in the paediatric population. Here we describe our unit experience in small bowel capsule endoscopy in patients aged < 17 years. Methods Children undergoing capsule endoscopy were entered prospectively into a patient database. Demographic details, indication for study and results of study were collated as well as any complications. Results A total of 13 paediatric patients (6 female) underwent capsule endoscopy in the period from May 2008 until May 2010. Ages ranged from 4 to 16 years. 4 patients had Peutz-Jeghers syndrome and 6 had iron defi ciency anaemia with occult GI blood loss. The remaining patients had suspected intestinal lymphangiectasia (1) or suspected small bowel Crohn’s disease without iron defi ciency (2). 6 capsules were endoscopically placed (3 in 4 year olds and 3 in older children who required endoscopy for collection of biopsies). All capsules were well tolerated. 3 capsules (23%) ceased recording prior to reaching the caecum, one of these due to premature battery failure at 4 hours. 6 studies (46%) recorded signifi cant results which led to altered management decisions. These included newly diagnosed small bowel Crohn’s disease in 1, location of small bowel polyps in 4. Summary Capsule endoscopy is a safe technique for the paediatric population. In our population, capsule studies established the diagnosis or added information which altered management in 46% of patients. Prolonged fasting is unnecessary in children undergoing capsule endoscopy LC EE, CO HALL, EC MCINTYRE Queensland Paediatric Gastroenterology, Hepatology & Nutrition Service, Royal Children’s Hospital, Brisbane, Children’s Nutrition Research Centre, The University of Queensland, Brisbane Capsule endoscopy is now an important diagnostic modality to view the small intestine. Patient preparation frequently involves bowel preparation prior to the procedure, an extended fasting period, and the use of prokinetics or laxatives to ensure optimal views of the small intestine. This regime however is potentially problematic in children who are at signifi cant risk of hypoglycemia and dehydration with prolonged fasting. We describe our experience of capsule endoscopy with limited fasting times and no bowel preparation nor prokinetic use. Methods All children were allowed a light meal the evening prior to the procedure. Thereafter, clear fl uids only were allowed until 0600 on the morning of the procedure. The capsule was either swallowed or placed endoscopically under general anaesthesia about 3 hours after their last drink at around 0900. Clear fl uids were again allowed 1–2 hours post capsule ingestion depending on size of the child. A light snack was allowed 3 hours post capsule ingestion. No laxatives or prokinetics were used prior to or during study. Review of all children undergoing capsule endoscopy was undertaken. The duration of time before the capsule left the stomach and the views obtained were recorded. Results 11 children with mean age of 10.6 years (range 4.08–16.5 years) had capsule endoscopy using our fasting protocol as described. Four chil-