Ketil Størdal

Acid suppression does not change respiratory symptoms in children with asthma and gastro-oesophageal reflux disease.

Background: Epidemiological studies have shown an association between gastro-oesophageal reflux disease (GORD) and asthma, and oesophageal acid perfusion may cause bronchial constriction. However, no causative relation has been proven. Aim: To assess whether acid suppression would lead to reduced asthma symptoms in children with concomitant asthma and GORD. Methods: Thirty eight children (mean age 10.8 years, range 7.2–16.8; 29 males) with asthma and a reflux index ⩾5.0 assessed by 24 hour oesophageal pH monitoring were randomised to 12 weeks of treatment with omeprazole 20 mg daily or placebo. The groups were similar in age, gender, mean reflux index, and asthma severity. Primary endpoints were asthma symptoms (daytime wheeze, symptoms at night, in the morning, and during exercise) and quality of life (PAQLQ). Secondary endpoints were changes in lung function and the use of short acting bronchodilators. At the end of the study a repeated pH study was performed to confirm the efficacy of acid suppression. Results: The change in total symptom score did not differ significantly between the omeprazole and the placebo group, and decreased by 1.28 (95% CI −0.1 to 2.65) and 1.28 (95% CI −0.72 to 3.27) respectively. The PAQLQ score increased by 0.62 (95% CI 0.29 to 0.95) in the omeprazole group compared to 0.50 (95% CI 0.29 to 0.70) in the placebo group. Change in lung function and use of short acting bronchodilators were similar in the groups. The acid suppression was adequate (reflux index <5.0) under omeprazole treatment. Conclusion: Omeprazole treatment did not improve asthma symptoms or lung function in children with asthma and GORD.

Organic abnormalities in recurrent abdominal pain in children

Using an investigation protocol, the aim of this study was to determine the frequency of organic abnormalities in children with recurrent abdominal pain, as new diagnostic approaches may reveal a higher prevalence of organic disease in this group than has been found in most studies. Included in the study were 44 children (mean age 8.3 y; 2–15) with more than three bouts of abdominal pain severe enough to affect the daily activities of the child and lasting more than 3 mo. The investigation covered a detailed medical story, a physical examination, blood, urine and stool samples. The somatic investigation was completed by abdominal X‐ray and ultrasound, lactose‐breath‐hydrogen test and 24‐h pH monitoring in the lower oesophagus. A Child Behaviour Checklist was completed to assess psychosocial aspects of the illness. The blood, urine and stool samples were normal, and abdominal ultrasound did not give any results related to the symptoms. Constipation was diagnosed in 7 patients (16%); 9 patients (21%) had gastro‐oesophageal reflux and oesophagitis was found in another 3 children. One child had nodular antral gastritis with colonization by Helicobacter pylori, and three children had pathological lactose‐breath‐hydrogen tests. Twenty‐four children (55%) did not have any signs of organic disease. The total score for the CBCL was in the normal range in 89%.

Early Feeding and Risk of Celiac Disease in a Prospective Birth Cohort

OBJECTIVES: Timing of gluten introduction has been associated with the risk of celiac disease (CD) in children, but the optimal time window is unknown. We aimed to study the effect of age of gluten introduction on the risk of CD, adjusting for continued breastfeeding. METHODS: In The Norwegian Mother and Child Cohort Study, a prospective birth cohort including 107 000 children, CD was identified by questionnaires and by linkage to the Norwegian Patient Register. Gluten introduction was reported monthly from 0 to 6 months of age, and breastfeeding from 0 to 18 months. RESULTS: After exclusion of cases with insufficient information, 324 children with CD in a cohort of 82 167 were used in the analyses. Gluten was introduced before or at 4 months in 8.0%, 5 to 6 months in 45.3%, and after 6 months in 46.6%, whereas continued breastfeeding was stable at ∼78% at 6 months age. CD was diagnosed in 3.68/1000 of the infants with gluten introduction at 5 to 6 months compared with 4.15/1000 with late and 4.24/1000 with early gluten introduction. After adjustment for the child’s age and gender, breastfeeding, and maternal CD, delayed gluten introduction was associated with an increased risk of CD (adjusted odds ratio, 1.27 [95% confidence interval, 1.01–1.65], P = .045). Breastfeeding >12 months was also associated with increased risk (adjusted odds ratio, 1.49 [95% confidence interval, 1.01–2.21], P = .046). CONCLUSIONS: We found an increased risk of CD in children introduced to gluten after 6 months and a higher risk in children breastfed after 12 months age.

Recurrent abdominal pain: A five-year follow-up study

To explore the long‐term prognosis for children referred for recurrent abdominal pain (RAP), 44 children investigated for RAP 5 y ago were compared to a group of controls (n=88). The former RAP patients reported RAP, headache and school absence more frequently than controls.

Pediatric Inflammatory Bowel Disease in Southeastern Norway: A Five-Year Follow-Up Study

Objectives: Few prospective population-based studies have been carried out on the incidence of inflammatory bowel disease (IBD). In a population-based study of pediatric IBD in southeastern Norway, patients <16 years at the time of diagnosis were followed up prospectively. The study reports on changes in diagnosis and clinical outcome 5 years after diagnosis. Methods: From 1990 to 1993 new cases of IBD were registered in a population of 174,482 children aged less than 16 years. The patients’ diagnoses were systematically evaluated 1 year after diagnosis and the patients were followed up clinically for up to 5 years after diagnosis. Results: Sixteen cases of Crohn’s disease (CD), 14 cases of ulcerative colitis (UC) and 3 cases of indeterminate colitis (IND) were initially registered. After 1 year IND were reclassified as UC (n = 2) or CD (n = 1). Altogether, 18% (6/33) had their diagnosis changed during the 5 years of follow-up, which yielded a mean annual incidence of 2.7/100,000 for CD and 2.0/100,000 for UC. Of the children with CD, more than 80% had relapses during the 5-year period, and 6 of 18 had surgery. Two-thirds of the children with UC had relapses during the 5-year period, and 3 patients underwent colectomy. Conclusions: An incidence of 4.7/100,000 is comparable to that found in most other studies made in Europe. The relationship between UC and CD in children was found to differ from that in the adult population. One of 5 patients had their diagnosis changed during the follow-up period. Pediatric UC seems to have a more serious course of disease than in the adult IBD population, which may be explained by the higher risk of pancolitis at diagnosis.

Asthma and overweight are associated with symptoms of gastro‐oesophageal reflux

Aim: To explore the prevalence of symptoms suggestive of gastro‐oesophageal reflux disease (GERD) in asthmatics and controls, and to control for the possible effect of overweight. Methods: The prevalence of GERD symptoms was assessed using a questionnaire about reflux symptoms in children with asthma (n=872, mean age 10.4 y, 65% males) compared to non‐asthmatic controls (n=264, mean age 10.8 y, 48% males), and a symptom score was calculated. The association between GERD symptoms and overweight (age‐adjusted BMI>25) was assessed independently. Results: A positive reflux symptom score was found in 19.7% of the asthmatics compared to 8.5% of the non‐asthmatic control group (odds ratio (OR) 2.6, 95% CI 1.7–4.2). Overweight children reported GERD symptoms more frequently than children with normal weight (OR 1.8, 95% CI 1.2–2.6). Asthma and obesity remained significant predictors when analysed simultaneously by logistic regression analysis. One hundred and fifty‐two children with asthma consented to an oesophageal pH study, and an abnormal pH study result (reflux index > 5.0) correlated positively with overweight (OR 4.9, 95% CI 2.2–11.0).

Infections and Risk of Celiac Disease in Childhood: A Prospective Nationwide Cohort Study

Objectives:Studies on early life infections and risk of later celiac disease (CD) are inconsistent but have mostly been limited to retrospective designs, inpatient data, or insufficient statistical power. We aimed to test whether early life infections are associated with increased risk of later CD using prospective population-based data.Methods:This study, based on the Norwegian Mother and Child Cohort Study, includes prospective, repeated assessments of parent-reported infectious disease data up to 18 months of age for 72,921 children born between 2000 and 2009. CD was identified through parental questionnaires and the Norwegian Patient Registry. Logistic regression was used to estimate odds ratios adjusted for child’s age and sex (aOR).Results:During a median follow-up period of 8.5 years (range, 4.5–14.5), 581 children (0.8%) were diagnosed with CD. Children with ≥10 infections (≥fourth quartile) up to age 18 months had a significantly higher risk of later CD, as compared with children with ≤4 infections (≤first quartile; aOR=1.32; 95% confidence interval (CI)=1.06–1.65; per increase in infectious episodes, aOR=1.03; 95% CI=1.02–1.05). The aORs per increase in specific types of infections were as follows: upper respiratory tract infections: 1.03 (95% CI=1.02–1.05); lower respiratory tract infections: 1.12 (95% CI=1.01–1.23); and gastroenteritis: 1.05 (95% CI=0.99–1.11). Additional adjustments for maternal CD, education level, smoking, birth weight, prematurity, infant feeding practices, birth season, and antibiotic treatment yielded largely unchanged results.Conclusions:This is the first large-scale population-based cohort study of this association. Our results are in line with immunological data suggesting that early life infections may have a role in CD development. However, non-causal explanations for this association due to surveillance bias and reverse causation cannot be excluded.

Gastroesophageal reflux disease in children: association between symptoms and pH monitoring.

Objective. The prevalence of symptoms associated with gastroesophageal reflux disease (GERD) in patients with abnormal results of pH monitoring has been investigated in adults and infants. A questionnaire suitable for children between 7 and 16 years of age has been proposed, but this tool has so far not been validated. In the present study the items of the questionnaire are validated against results from an esophageal 24-h study of pH. Material and methods. Ninety-nine children aged from 7 to 16 years referred from two outpatient clinics for suspected GERD completed the 7-point questionnaire regarding symptoms during the week prior to a pH study. The frequency of symptoms was investigated in patients with abnormal versus normal pH (reflux index >/<5.0). A group of healthy children (n=284) served as controls to estimate the frequency of symptoms in the normal population. Results. It was found that 37/99 (37%) of patients had an abnormal pH study result. Regurgitation/vomiting yielded the best symptom discrimination, and was reported by 46% with abnormal versus 24% with normal pH-study results (p=0.029). A weighted score including the five best discriminating symptoms was positive in 75% versus 44% (OR 3.78, CI 1.52–9.37, p=0.006). In a comparison of children with abnormal pH studies and healthy controls, a correct diagnosis based on five symptoms could be obtained in 75% and 94%, respectively. Conclusions. A relatively weak association was found between reflux symptoms and a positive pH study in 7–16-year-old children referred for pH monitoring. Thus, the questionnaire is not a diagnostic tool, and its potential use is limited to epidemiological studies.

Epidemiology of coeliac disease and comorbidity in Norwegian children.

Objectives: The aim of this study was to describe the occurrence of clinically diagnosed coeliac disease in children ages 0 to 12 years in Norway, including regional variation and coexisting type 1 diabetes mellitus, thyroid disease, and Down syndrome. Methods: The Norwegian Patient Register (NPR) contains individual-level hospital data from 2008 onward. Small-bowel biopsies for establishing the coeliac disease diagnosis are only performed at public hospitals reporting to the NPR. Data on all hospital contacts during 2008–2011 when a diagnosis of coeliac disease was registered were retrieved from the NPR for patients born between 1999 and 2011, allowing estimation of the proportion registered with coeliac disease at ages 0 to 12 years in a cohort study. Results: A total of 3006 individuals (58.2% girls) were recorded as having coeliac disease among 797,360 children, corresponding to a proportion of 3.8/1000 (95% confidence interval [CI] 3.7–3.9/1000) children, 4.5 (CI 4.3–4.7) among girls and 3.1 (CI 2.9–3.3/1000) among boys (P < 0.001). The proportion increased with age up to approximately 6 years and was 5.0/1000 (CI 4.5–5.6) at the age of 12 years, and was slightly higher in the south/west (3.9/1000) as compared to the middle/north (3.5/1000) regions of Norway (P = 0.013). A total of 214 of 3006 (7.1%) patients with coeliac disease were registered with coexisting conditions: type 1 diabetes mellitus (n = 142, 4.7%), Down syndrome (n = 47, 1.6%), or thyroid disease (n = 41, 1.4%). Conclusions: In this first nationwide study of clinically diagnosed coeliac disease in Norwegian children, we found a high occurrence, comparable with that in Sweden. Comorbidity was common, but routine screening of high-risk groups contributed to a limited number of cases.

Antiretroviral treatment initiation among HIV-infected pregnant women with low CD4+ cell counts in Gaborone, Botswana.

Background:Botswana has the most comprehensive public program in Africa for providing antiretroviral therapy to treat HIV and prevent mother-to-child transmission (PMTCT). Botswana guidelines prioritize CD4+ cell count testing during pregnancy and initiation of highly active antiretroviral treatment (HAART) for women who qualify for treatment. We analyzed rates of HIV testing, CD4+ cell count testing, and HAART initiation during pregnancy. Methods:From October 2007 through June 2008, we reviewed obstetric and laboratory records of women at Princess Marina Hospital in Gaborone, Botswana. Results:We recorded information from 3056 women. Of 2675 women eligible for the PMTCT program, 2623 (98%) had a documented HIV status, of whom 793 (30%) were HIV infected. Among women who were treatment naive at pregnancy conception, 397 (59%) had recorded CD4+ cell counts, of whom 62 (16%) had a CD4+ cell count <200 cells per cubic millimeter. Among this subset, 23 (37%) initiated HAART during pregnancy, 26 (42%) received zidovudine prophylaxis, and 13 (21%) received no therapy. Conclusions:We observed low rates of CD4+ cell count testing and HAART initiation during pregnancy. Antenatal clinics should prioritize CD4+ cell count testing and referral of women who qualify for HAART to maximize benefits of maternal treatment and PMTCT.