Saskia Vande Velde

Clinical practice: vegetarian infant and child nutrition

The aim of this review is to give insight on the benefits and risks of vegetarianism, with special emphasis on vegetarian child nutrition. This eating pattern excluding meat and fish is being adopted by a growing number of people. A vegetarian diet has been shown to be associated with lower mortality of ischaemic heart disease and lower prevalence of obesity. Growth in children on a vegetarian diet including dairy has been shown to be similar to omnivorous peers. Although vegetarianism in adolescents is associated with eating disorders, there is no proof of a causal relation, as the eating disorder generally precedes the exclusion of meat from the diet. A well-balanced lacto-ovo-vegetarian diet, including dairy products, can satisfy all nutritional needs of the growing child. In contrast, a vegan diet, excluding all animal food sources, has at least to be supplemented with vitamin B(12), with special attention to adequate intakes of calcium and zinc and energy-dense foods containing enough high-quality protein for young children. The more restricted the diet and the younger the child, the greater the risk for deficiencies.The aim of this review is to give insight on the benefits and risks of vegetarianism, with special emphasis on vegetarian child nutrition. This eating pattern excluding meat and fish is being adopted by a growing number of people. A vegetarian diet has been shown to be associated with lower mortality of ischaemic heart disease and lower prevalence of obesity. Growth in children on a vegetarian diet including dairy has been shown to be similar to omnivorous peers. Although vegetarianism in adolescents is associated with eating disorders, there is no proof of a causal relation, as the eating disorder generally precedes the exclusion of meat from the diet. A well-balanced lacto-ovo-vegetarian diet, including dairy products, can satisfy all nutritional needs of the growing child. In contrast, a vegan diet, excluding all animal food sources, has at least to be supplemented with vitamin B12, with special attention to adequate intakes of calcium and zinc and energy-dense foods containing enough high-quality protein for young children. The more restricted the diet and the younger the child, the greater the risk for deficiencies.

A systematic review on bowel management and the success rate of the various treatment modalities in spina bifida patients.

Study design:Systematic review.Objectives:To determine the different treatment modalities aimed at achieving fecal continence in spina bifida (SB) patients and their effectiveness.Setting:International literature.Method:Electronic databases were searched (‘Pubmed’, ‘Web of science’, ‘CINAHL’ and ‘Cochrane’) identifying studies published since the mid-eighties and screened for relevance according to the Centre for Reviews and Dissemination procedure guidelines. A total of 37 studies were selected for inclusion.Results:Studies on toilet sitting, biofeedback, anal plug, retrograde colon enemas (RCE) and antegrade colon enemas were found. Fecal continence was achieved in 67% of SB patients using conservative methods (n=509). In patients using RCE (n=190) an 80% continence rate was reached. Patients following surgical treatment (n=469) reached an 81% continence rate, however, 23% needed redo surgery because of complications. Better fecal continence was associated with an improved quality of life, which was negatively influenced by the amount of time spent on bowel management.Conclusion:Evidence favors an individually tailored stepwise approach with surgery as a final step in case of failure of conservative measures. Continued specialized support throughout life remains important to maintain continence. Cross-over and comparative trials are needed in order to optimize treatment.

Solid food refusal as the presenting sign of vitamin B12 deficiency in a breastfed infant

Dietary vitamin B12 (vitB12) deficiency, although common in the elderly, is rare in childhood. We report on an exclusively breastfed 8-month-old infant, presenting with persistent refusal of solid foods. Three months later, developmental regression and failure to thrive led to the diagnosis of vitB12 deficiency, as a consequence of a subclinical pernicious anaemia with vitB12 deficiency in the mother. Treating the infant with parenteral vitB12 induced prompt recovery including acceptance of weaning food. Conclusion: This case illustrates refusal of complementary foods as a presenting symptom of vitB12 deficiency in a breastfed infant. Symptoms, diagnostic tests and treatment of vitamin B12 deficiency are reviewed. Early diagnosis and treatment are important to prevent irreversible neurological damage.

Clinical zinc deficiency as early presentation of Wilson disease.

ABSTRACT Wilson disease is a rare autosomal recessive disorder of the copper metabolism caused by homozygous or compound heterozygous mutations in the ATP-ase Cu(2+) transporting polypeptide (ATP7B) gene. The copper accumulation in different organs leads to the suspicion of Wilson disease. We describe a child with clinical zinc deficiency as presenting symptom of Wilson disease, which was confirmed by 2 mutations within the ATP7B gene and an increased copper excretion.

Heroin withdrawal leads to metabolic alkalosis in an infant with cystic fibrosis

We report here the first case of heroin withdrawal leading to metabolic alkalosis and the diagnosis of cystic fibrosis (CF) in a 2-month-old male infant. A 2-month-old infant presented with lethargy after breast-feeding. There was no history of vomiting or diarrhoea, but he did have a history of poor drinking and irritability. At presentation there was no heat wave (average temperature: 17.1°C). The parents were healthy and unrelated. He was born after an uncomplicated pregnancy and received phototherapy in the neonatal period for an indirect hyperbilirubinemia. On admission he weighed 4.4 kilo (25th percentile) and was 55.5 cm long (25–50 percentile). He was irritable with a high-pitched cry and normal consciousness. He developed hypertonia and opisthotonus and had an increased respiration and heart rate. The blood results revealed a severe metabolic alkalosis (pH: 7.54; bicarbonate: 60.7 mmol/L), hyponatriemia (Na: 125 mmol/L), hypochloremia (Cl: 57 mmol/L) and hypokaliemia (2 mmol/L). Repeated interviews with the parents revealed that they had used heroin 2 days prior to their son’s admission. During pregnancy the mother used only marihuana but no hard drugs. According to the mother this was the first episode of heroin use since the delivery. Toxicological screening showed the presence of opiates in the stomach contents and blood of the infant as well as in the breast milk and urine of the mother. The infant was started on methadone for the narcotic withdrawal syndrome. A few days after admission the infant developed respiratory symptoms. The chest radiography revealed bilateral infiltrates. This together with the initial metabolic alkalosis indicated CF. This diagnosis was confirmed with two positive sweat tests (sweat chloride was 78 and 83 mmol/L) and genetic analysis (deltaF508/R334W). The infant is pancreatic sufficient (faecal elastase−1: 475).

C-ANCA/Proteinase 3-Positive Colitis in Children: A Distinctive Form of Inflammatory Bowel Disease or Vasculitis With Colitis as Initial Presentation?

Aim: Anti-neutrophil cytoplasmic antibodies (ANCAs) detected by indirect immunofluorescence have been found in patients with inflammatory bowel disease (IBD). Nevertheless, specific antibodies against proteinase-3 (PR3) are rare in this context. Methods: Sera from 30 consecutive pediatric patients with IBD were evaluated for ANCA-indirect immunofluorescence and its specific antibodies to investigate whether PR3-ANCA positivity (PR3-ANCA+) identifies a distinct IBD subtype. Results: The 5 PR3-ANCA+ patients (17%) showed significantly more concomitant biliary disease and severe anal blood loss (P < 0.05). None had vasculitis features at diagnosis nor during follow-up. Conclusions: This pilot study demonstrates significant clinical differences between the PR3-ANCA–positive and –negative IBD subset.

Pharmacokinetics of two formulations of omeprazole administered through a gastrostomy tube in patients with severe neurodevelopmental problems

AIMS Omeprazole is often administered through a gastrostomy tube as either (i) a Multiple Unit Pellet System (MUPS®) tablet disintegrated in water (MUPS® formulation), or (ii) a suspension in 8.4% sodium bicarbonate (suspension formulation). This bioavailability study evaluates this practice in tube-fed patients with severe neurodevelopmental problems. METHODS Nonblinded, two-phase cross-over trial. RESULTS In seven of 10 patients, bioavailability was higher for the suspension formulation than for the MUPS® formulation. Median (90% confidence interval) area under the plasma concentration-time curve ratio (MUPS® over suspension) was 0.5 (0.06-2.37). CONCLUSIONS In this population, omeprazole MUPS® formulation has no apparent advantage over the more easily administered suspension formulation.

Mogelijke valkuilen bij de interpretatie van de waterstofademtest bij kinderen

Children who present with chronic diarrhea, flatulence and/or abdominal pain possibly suffer from malabsorption of carbohydrates. Most frequently this depends on a lactase deficiency causing a carbohydrate overload in the colon. The fermentation of these carbohydrates by anaerobic bacteria can provoke osmotic diarrhea and gas production in the bowel. The hydrogen-breath test can easily be used to diagnose which kind of carbohydrates are causing the symptoms. When carbohydrates are digested by anaerobic bacteria, hydrogen is set free, which can be measured in exhaled breath. The results are plotted on a curve. Certain circumstances influence this test. False negative results are seen in 5 to 10% non-producers due to the absence of hydrogen producing bacteria in their colon flora or in case of recent antibiotic use. False positive results can be caused by the presence of undigestable oligosaccharides or carbohydrates in the colon or also in case of small intestinal bacterial overgrowth. It is necessary to evaluate test results in relation to symptoms during and shortly after the test procedure. These symptoms need to resemble the complaints which raised the suspicion on the carbohydrate malabsorption.

Normalisation of colon transit time in a spina bifida adolescent after neurosurgery for retethering

Dear Editor: In 2013,we published our study ‘Colon transit time and anorectal manometry in children and young adults with spina bifida’ [1]. In the above-mentioned study, colon transit time (CTT) and anorectal manometry (ARM) were used as diagnostic tools in relation to the eventual achievement of spontaneous faecal continence in spina bifida (SB) patients. In the study cohort, eight SB patients were spontaneously continent. Of these, seven had a normal colon transit time and one, a 15-year-old girl, had a delayed CTT (100.8 h). Later on, she developed urinary incontinence as result of the development of a neurogenic bladder. She started using clean intermittent catheterization (CIC) and regained urinary pseudocontinence. A MRI scan confirmed a retethering of the spinal cord. In January 2013 (2 months after the CTT), the girl underwent lumbosacral tethered cord release with resection of scar tissue, release of the conus medullaris and removal of fibrotic tissue for maximal relaxation of the conus medullaris. In May 2013, 4 months after neurosurgery, the CTT was repeated and revealed a decrease from 100.8 h before surgery to 88.8 h (normal values <2.4–86.4 h). In October 2013, 10 months after neurosurgery, the CTT further decreased to 81.6 h. Two of the three CTT X-rays were combined with a full spine control X-ray in order to reduce radiation exposure. She sustained her spontaneous faecal continence throughout this period. Three months after neurosurgery, the CIC was stopped as she had regained spontaneous urinary continence. In literature, there is no intrapersonal variation described on colon transit time. Therefore, any found difference can be due to intrapersonal variation. However, together with the gradual normalisation of colon transit time, clinical complaints became better and normalised, so tethered cord release will be of influence on both the technical examinations as the clinical condition. In the published article, a flowchart was created using CTT and ARM, and the negative predictive value of the CTT to become spontaneously faecal continent was calculated, based on the initial results. Including the new results both can be adjusted. The original negative predictive value of the CTT to become spontaneously continent was 95 %. The unexplained 5 % was due to this 15-year-old girl with spinal retethering which probably would have led to the development of faecal incontinence besides the urinary incontinence if it would not have been treated. The gradual normalisation of the CTT after neurosurgery increases the negative predictive value of CTT to 100 % if data are recalculated based upon the latest CTT. Thus, meaning that all spina bifida children with a delayed CTT, independent of the result of resting pressure of ARM, will need treatment to achieve faecal pseudo-continence. Moreover, in SB patients who are spontaneously faecal continent, a delay in CTT could indicate a retethering which should be ruled out. This observation supports the conclusion that there is a possible role for CTT in predicting and following the need for treatment to achieve faecal (pseudo-) continence in SB patients.

De percutane endoscopische gastrostomie (PEG)–sonde bij kinderen: een review

Abstract The percutaneous endoscopic gastrostomy inchildren: a review This article describes the use of the percutaneousendoscopic gastrostomy (PEG) tube in children.The PEG tube is a frequently used tool to improvethe nutritional status of children. The placementtechnique and the possible immediate complica-tions are described. The indications and contra-indications are detailed as well as the currentadvice in special situations such as children with aventriculoperitoneal drain, peritoneal dialysis andimmune dysfunctions. The late complications andtheir treatment are explained and illustrated. Finallydifferent types of the gastrostomy tube are illus-trated.Literatuur 1. G AUDERER MW, P ONSKY JL, I ZANT RJ Jr. Gastrostomy withoutlaparotomy: a percutaneous endoscopic technique. J PediatrSurg 1980; 15 : 872-875.2. G AUDERER MW. Percutaneous endoscopic gastrostomy and theevolution of contemporary long-term enteral access. Clin Nutr2002; 21 : 103-110.3. F ROHLICH T, R ICHTER M, C ARBON R, B