Fecal calprotectin level in healthy children aged less than 4 years in South Korea

Can Faecal Zonulin and Calprotectin Levels Be Used in the Diagnosis and Follow-Up in Infants with Milk Protein-Induced Allergic Proctocolitis?

OBJECTIVE

The aim of our study was to investigate whether a 1-month-long milk-free diet results in a reduction in faecal calprotectin (FC) and faecal-zonulin-related proteins (FZRP) in children with milk-protein-induced allergic proctocolitis (MPIAP).

MATERIALS AND METHODS

This is a single-centre, prospective, observational cohort study involving 86 infants with MPIAP, aged 1-3 months, and 30 healthy controls of the same age. The FC and FZRP were marked using the ELISA method (IDK® Calprotectin or Zonulin ELISA Kit, Immunodiagnostik AG, Bensheim, Germany). The diagnosis of MPIAP was confirmed with an open milk challenge test.

RESULTS

FFC and FZRP proved useful in evaluating MPIAP treatment with a milk-free diet, and the resolution of allergic symptoms and a significant (p = 0.0000) decrease in the concentrations of both biomarkers were observed after 4 weeks on the diet. The FC and FZRP concentrations were still higher than in the control group. A high variability of FC concentrations was found in all the study groups. An important limitation is the phenomenon of FZRP not being produced in all individuals, affecting one in five infants.

CONCLUSIONS

FC and FZRP can be used to monitor the resolution of colitis in infants with MPIAP treated with a milk-free diet, indicating a slower resolution of allergic inflammation than of allergic symptoms. The diagnosis of MPIAP on the basis of FC concentrations is subject to considerable error, due to the high individual variability of this indicator. FZRP is a better parameter, but this needs further research, as these are the first determinations in infants with MPIAP.

Recent developments in the assessment and management of inflammatory bowel disease in childhood: a narrative review

Background and Objective

The landscape of paediatric inflammatory bowel disease (pIBD) continues to evolve in an era of increasing incidence. There have been rapid developments in understanding, as we begin to perceive IBD as a spectrum of conditions, alongside advancements in monitoring and treatment. The objective of this article was to provide an overview of recent advances and challenges in the management of pIBD, with a focus on sustainable healthcare, personalised therapy, genomics, new drugs and avenues for future optimisation.

Methods

We present a narrative review that synthesises and summarises recent research (2017-2022) related to pIBD. We undertook a structured search of the literature (PubMed and Medline) and additional articles were identified through manual searches of reference lists. Evidence tables were compiled for disease outcomes.

Key Content and Findings

In this review we outline current practice, integrating clinical guidelines and contemporary research. We discuss initial investigations (including suggested threshold for paediatric faecal calprotectin), specialist investigations for disease monitoring [with reference to video capsule endoscopy (VCE) and therapeutic drug levels] and outline new and established treatment options. Biomarkers and genomic testing are examined as important tools for individualising care and identifying potential therapeutic targets, including for top-down therapy. Despite these advances, significant challenges remain, including the need for further research to understand the mechanisms of disease and the translation of these advances into real-world improvements in practice.

Conclusions

Recent advances in understanding of the pathogenesis of pIBD, alongside genomic and pharmacological developments have added more tools to the armamentarium for the treatment of these conditions and highlighted ongoing areas of research need.

Management and monitoring of pediatric inflammatory bowel disease in the Asia-Pacific region: A position paper by the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology, and Nutrition (APPSPGHAN) PIBD Working Group: Surgical management, disease monitoring, and special considerations

Disease phenotype of pediatric inflammatory bowel disease (PIBD) in children from the Asia-Pacific region differs from that of children from the West. Many parts of Asia are endemic for tuberculosis, making diagnosis and management of pediatric Crohn's disease a challenge. Current available guidelines, mainly from Europe and North America, may not be completely applicable to clinicians caring for children with PIBD in Asia due to differences in disease characteristics and regional resource constraints. This position paper is an initiative from the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN) that aims to provide an up-to-date, evidence-based approach to PIBD in the Asia-Pacific region. A group of pediatric gastroenterologists with a special interest in PIBD performed an extensive literature search covering epidemiology, disease characteristics and natural history, management, and monitoring. Attention was paid to publications from the region with special consideration to a resource-limited setting. This current position paper deals with surgical management, disease monitoring, immunization, bone health, and nutritional issues of PIBD in Asia. A special section on differentiating pediatric Crohn's disease from tuberculosis in children is included. This position paper provides a useful guide to clinicians in the surgical management, disease monitoring, and various health issues in children with IBD in Asia-Pacific region.

The perinatal factors that influence the excretion of fecal calprotectin in premature-born children

This study aimed to provide additional information on the influence of perinatal factors on fecal (f)-calprotectin values in preterm infants. Calprotectin was determined from the first spontaneous stool (analyzed on the Alegria device by using the enzyme-linked immunosorbent assay [ELISA] method) obtained from neonates at a mean age of 3.41 ± 2.44 days of life. We analyzed 114 subjects who had a body weight of 1847.67 ± 418.6 g and were born at a gestational age of 32.6 ± 2.43 weeks, without intestinal and other congenital anomalies or any diseases other than those related to premature birth. The values of f-calprotectin are in a positive correlation with female subjects, intrauterine growth restriction, significant ductus arteriosus, enteral feeding intolerance, postnatal prolonged use of broad-spectrum antibiotics, and values ​​of bicarbonates (analyzed in a sample of capillary arterial blood). Measurement of f-calprotectin in the first 7 days after birth can help to early detect the intestinal distress or early staging of necrotizing enterocolitis in premature infants.

Efficacy of Fecal Calprotectin Combined With Stool Hemoglobin in Differentiating Bacterial Origin in Acute Gastroenteritis

OBJECTIVES

Differentiating bacterial origin in acute gastroenteritis (AGE) is important to improve outcomes. Fecal calprotectin is a sensitive screening tool for gut mucosal inflammation. This study aimed to evaluate the diagnostic efficacy and cutoff level of fecal calprotectin in distinguishing bacterial origin in pediatric AGE.

METHODS

Patients who were diagnosed with AGE at 1 to 18 years between January 2015 and January 2020 were retrospectively analyzed. A polymerase chain reaction test was applied to stool samples to detect viruses and bacteria. The level of fecal calprotectin was determined using an enzyme-linked immunosorbent assay test.

RESULTS

Eighty patients were enrolled in this study. The most common viral pathogen was norovirus, and bacterial pathogen was Clostridium perfringens. The median fecal calprotectin level was 686 μg/g (interquartile range [IQR], 140-1192 μg/g) in all patients, 560 μg/g (IQR, 60-669 μg/g) in patients with viral pathogens, and 985 μg/g (IQR, 272-1984 μg/g) in those with bacterial pathogens (P = 0.019). The stool hemoglobin concentration (337.29 vs 84.83 ng/mL, P = 0.016) and C-reactive protein (4.06 vs 0.45 mg/dL, P = 0.082) levels were higher in patients with bacterial pathogens than in those with viral pathogens. For identifying bacterial pathogens, the area under the receiver operating characteristic curve of fecal calprotectin was 0.739 (95% confidence interval, 0.584-0.894); combination with stool hemoglobin improved diagnostic efficacy, and the area under the receiver operating characteristic curve was 0.870. The optimal cutoff values of fecal calprotectin and stool hemoglobin were 815 μg/g and 158 ng/mL, respectively.

CONCLUSIONS

The combination of stool hemoglobin and fecal calprotectin may be a useful marker for detecting bacterial etiology in pediatric AGE.

The Use of Fecal Calprotectin Testing in Paediatric Disorders: A Position Paper of the European Society for Paediatric Gastroenterology and Nutrition Gastroenterology Committee

OBJECTIVES

The aim of the study was to review the evidence regarding the clinical use and value of fecal calprotectin (FC) measurements in different gastrointestinal disorders in children.

METHODS

A literature search was conducted in the PubMed, MEDLINE, EMBASE, and Cochrane databases until October 31, 2019. Subtopics were identified and each assigned to individual authors.

RESULTS

A total of 28 recommendations were voted on using the nominal voting technique. Recommendations are given related to sampling, measurement methods, and results interpretation. The 14 authors anonymously voted on each recommendation using a 9-point scale (1 strongly disagree to 9 fully agree). Consensus was considered achieved if at least 75% of the authors voted 6, 7, 8, or 9.

CONCLUSIONS

Consensus was reached for all recommendations. Limitations for the use of FC in clinical practice include variability in extraction methodology, performance of test kits as well as the need to establish local reference ranges because of the influence of individual factors, such as age, diet, microbiota, and drugs. The main utility of FC measurement at present is in the diagnosis and monitoring of inflammatory bowel disease (IBD) as well as to differentiate it from functional gastrointestinal disorders (FAPDs). FC, however, has neither utility in the diagnosis of infantile colic nor to differentiate between functional and organic constipation. A rise in FC concentration, may alert to the risk of developing necrotizing enterocolitis and help identifying gastrointestinal involvement in children with Henoch-Schönlein purpura. FC measurement is of little value in Cow's Milk Protein Allergy, coeliac disease (CD), and cystic fibrosis. FC does neither help to distinguish bacterial from viral acute gastroenteritis (AGE), nor to diagnose Helicobacter Pylori infection, small intestinal bacterial overgrowth (SIBO), acute appendicitis (AA), or intestinal polyps.

Ulcerative Colitis: Making the Diagnosis

Ulcerative colitis is an inflammatory condition of the colon. The diagnosis of ulcerative colitis is based on clinical presentation, endoscopic evaluation, and histologic parameters in the absence of demonstrable alternate etiology. The differential diagnosis remains broad, and infection in particular must be considered and excluded. Although laboratory and radiographic findings can aid in the diagnosis of ulcerative colitis, endoscopy remains the gold standard for diagnosis. A correct diagnosis and disease staging are imperative because these factors affect treatment options and prognosis.

Concentration of fecal calprotectin in 11,255 children aged 0-18 years

OBJECTIVES

Fecal calprotectin is a valued surrogate marker for intestinal inflammation. It has been argued that calprotectin levels are higher in early age than in later life hampering the use of calprotectin in young children.

SUBJECTS AND METHODS

To study age-related variation, we used data from our laboratory information system on consecutive, unselected fecal calprotectin measurements from 2014 to 2017 in all children aged 0 to 18 years. From each individual, the first measurement was included and repeated measurements were excluded. Fecal calprotectin was quantitated in the major clinical laboratory in southern Finland, HUSLAB with an ELISA kit from Calpro AS (Calpro/Calprolab, Oslo, Norway). Currently, the assay is performed on two automatic pipetting analysers (Dynex DS2, Chantilly, USA) according to the instructions of the manufacturer.

RESULTS

There were altogether 11,255 fecal calprotectin results from as many children. The median level of fecal calprotectin was 51 mg/kg in infants < 1 year of age (95^th percentile 648 mg/kg; n = 239). This was 3-4-fold higher when compared to yearly age groups from 1 to 10 years (total number of children included 5,691). Across yearly age groups from 11 to 18, the median values varied from 11 to 19 mg/kg (total number of included children 5,325). The proportion of samples above the routine cut-off for an elevated concentration >100 mg/kg increased with increasing age.

CONCLUSIONS

Fecal calprotectin values in children beyond the first year of life are in general low and comparable in children and adolescents.

Can fecal calprotectin serve as a screen for necrotizing enterocolitis in infants?

BACKGROUND

Researchers are debating if fecal calprotectin results are useful for infant patients, especially in screening for necrotizing enterocolitis (NEC). Currently, none of the FDA-approved calprotectin assays provide a cut-off for infant patients. We retrospectively analyzed data from a reference laboratory and university hospital to investigate if a cut-off could be established for infant patients.

METHODS

Data from a national reference laboratory of 5144 test results for fecal calprotectin were analyzed for infant patients, and a cut-off was estimated based on the distribution of results. Additionally, a literature proposed cut-off of 226 μg/g was also considered. Validation of either cut-off was attempted by review of the electronic medical record of our university hospital for 110 infant patients with results for fecal calprotectin.

RESULTS

Infants had a high percentage of elevated fecal calprotectin results when using the adult cut-offs set by the manufacturer. A cut-off of 247 μg/g was estimated based on the reference laboratory results for infants 0-2 months old, which is similar to a literature proposed cut-off of 226 μg/g. However, the positive predictive value (PPV) for both cut-offs was <0.6 when retrospectively analyzing data from a university hospital.

CONCLUSION

Due to the low PPVs, the two infant-specific cut-offs for fecal calprotectin would not be useful to screen for NEC in infants at our university hospital.

Effect of Supplementation of Zinc, Glutamine, Fiber, and Prebiotics in Presumed Healthy Indonesian Children Aged 1-3 Years

PURPOSE

Impaired intestinal mucosal integrity may affect the gastrointestinal function, especially in relation to nutrition, absorption, and barrier function. The purpose of this study was to measure the prevalence of impaired intestinal mucosal integrity in presumed healthy children aged 1-3 years and assess the effects of zinc, glutamine, fiber, and prebiotic supplementation in them.

METHODS

A cross-sectional study was conducted in 200 children aged 1-3 years in Pasar Minggu, South Jakarta, Indonesia. A randomized double-blind parallel group method clinical trial was then performed to assess the effects of zinc, glutamine, fiber, and prebiotic supplementation.

RESULTS

Elevated calprotectin was found in 91/200 subjects (45.5%) at the onset of the study. After 10 months, 144 subjects completed the study: 72 subjects received the trial formula, whereas the other 72 received the standard formula. A transitory decrease in fecal calprotectin (FC) was observed after 6 months in the subgroup with normal FC levels, who were fed the test formula (p=0.012).

CONCLUSION

The prevalence of impaired intestinal mucosal integrity in this group of Indonesian children aged 1-3 years was high. Supplementation with zinc, glutamine, fiber, and prebiotics during 6 months reduced FC only in those who had low levels at baseline but not in those with impaired integrity.

Dynamic Changes of Fecal Calprotectin and Related Clinical Factors in Neonates

Objective: Fecal calprotectin (FC) has been widely used for a clinical marker of intestinal inflammation in children and adults. However, the clinical usefulness has not been determined in neonates. The purpose of this study was to investigate the change of FC and associated clinical factors in neonates. Methods and Materials: In total, 146 neonates among 472 admissions to our NICU between 2018 and 2019 were included, and 242 stool samples were collected. FC was measured in the first, second, and third-fourth week after birth, respectively, using commercial ELISA. The clinical characteristics were reviewed from medical records. Statistical analyses were performed to analyze associated factors regarding on changes of fecal calprotectin. Results: A wide range from 5.5 to 6,000 mg/kg of FC was observed in neonates. FCs during neonatal period were not correlated with the gestational age at birth or birth weight. The meconial calprotectin was higher than FCs after 2 weeks of age (n = 134, 418.06 vs. 243.12 in the second week and 259.58 in the third week after birth). Meconial calprotectin was associated with birth weight and meconium stained amniotic fluid. FC during the neonatal period decreased with postnatal week (-464.93 ± 158.02 at third-fourth week after birth compared with the 1st week, P = 0.004) and breast milk (-337.27 ± 150.51 compared with formula milk, P = 0.026). Conclusion: Fecal calprotectin tended to decrease with postnatal week during the neonatal period, and breast milk could affect more decrease of FC.

The role of fecal calprotectin in pediatric disease

Fecal calprotectin (FC) is a calcium- and zinc-binding protein of the S100 family, mainly expressed by neutrophils and released during inflammation. FC became an increasingly useful tool both for gastroenterologists and for general practitioners for distinguishing inflammatory bowel disease (IBD) from irritable bowel syndrome. Increasing evidences support the use of this biomarker for diagnosis, follow-up and evaluation of response to therapy of several pediatric gastrointestinal diseases, ranging from IBD to nonspecific colitis and necrotizing enterocolitis. This article summarizes the current literature on the use of FC in clinical practice.

A Study of Fecal Calprotectin in Obese Children and Adults

BACKGROUND

Obesity is a complex, medical condition causally contributing to many chronic diseases and a number of efforts have been made to find the associated markers for novel prevention and treatment of obesity. Our study was to evaluate the relationship between gut immune response and obesity and overweight with use of fecal calprotectin (FC) both in adult and children groups.

METHODS

Fecal samples were obtained from 74 subjects: 14 non-obese and overweight children (PN), 13 obese and overweight children (PO), 20 non-obese and overweight adults (AN), and 27 obese and overweight adults (AO). FC was measured using a commercial Legend Max quantitative enzyme-linked immunosorbent assay (BioLegend). Mann-Whitney U-test was used for statistical analysis.

RESULTS

Median FC concentration was 7.9 μg/g (range, 1.9-28.9 μg/g) for PN, 5.0 μg/g (range, 2.6-29.6 μg/g) for PO, 9.5 μg/g (range, 0.8-28.9 μg/g) for AN, and 10.0 μg/g (range, 1.6-25.6 μg/g) for AO, respectively. In both adults and children age groups, the FC showed no statistically significant difference between AO and AN or PO and PN. However, FC showed statistically significant difference (P<0.05) between AO and PO while not significant between AN and PN.

CONCLUSION

FC level in AO was significantly higher than that in PO, suggestive of different pathophysiologic mechanism between children obesity and adults obesity.

Fecal calprotectin level in healthy children aged less than 4 years in South Korea

BACKGROUND

Fecal calprotectin (FC) is non-invasive inflammatory marker indicating various bowel diseases. However, the median-specific cut-off values and the standard deviations (SD) of the FC levels in each age group <4 years were not elucidated.

METHODS

Healthy volunteers were enrolled from four kindergartens. A questionnaire was used to confirm that the children met the inclusion criteria, and several demographics and history of bowel symptoms were collected. The FC level was measured.

RESULTS

A total of 234 healthy children aged between 6 months and 4 years were recruited. The median FC concentration of all participants was 245 μg/g (range 12-1033 μg/g, mean 68.5 μg/g, SD 123.12 μg/g). The children were divided into six age groups. The upper limit of 95% CI of median FC values was 135 μg/g in 7-12 months group, 65 μg/g in 13-18 months group, 55 μg/g in 19-24 months group, 40 μg/g in 25-30 months group, 21 μg/g in 31-36 months group, and 12 μg/g in 37-48 months group. A negative correlation trend was found between the age and the FC concentration.

CONCLUSION

This is the first study to present the FC median levels in the specific age groups <4 years in Korea. We found a FC level reduction with age, indicating a bowel maturation process and decreased intestinal permeability of the intestinal mucosa. In our study, FC levels reached the values of 50 μg/g around the age of 2 years.