Persistent morbidity and mortality of protein calorie malnutrition in young infants with CF

Atypical presentation of cystic fibrosis in an infant

Dermatitis as an initial manifestation of cystic fibrosis (CF) is unusual. The eruption is usually first noted in the perineum anywhere from several days to few months after birth. It subsequently spreads to the extremities and trunk. We report a 2-month-old male baby who presented with failure to thrive, hypoproteinemia, anemia, and a cutaneous eruption resembling acrodermatitis enteropathica. Oral zinc supplementation resulted in temporary resolution of the dermatitis. A further workup revealed the diagnosis of CF. The rash was responsive to nutritional and pancreatic enzyme supplementation.

Gray hair and acrodermatitis enteropathica-like dermatitis: an unexpected presentation of cystic fibrosis

Presentation of cystic fibrosis (CF) with an acrodermatitis enteropathica-like skin rash, anemia, and hypoproteinemia without pulmonary disease is rarely reported before. We describe an 11-month-old boy with rash and edema as the presenting signs of cystic fibrosis. The interesting additional finding in our patient was the graying hair after 3 months of age. A reversal of the gray hair was observed by pancreatic enzyme replacement therapy. In conclusion, acrodermatitis-like eruption and hypoproteinemia can be a presenting sign of CF. Graying hair has not been noticed so far as a sign of CF in these patients.

Protein-energy malnutrition as the first manifestation of cystic fibrosis in infancy

BACKGROUND

The protein-energy malnutrition (PEM) that is characterized by hypoproteinemia, edema, and anemia has been reported in 5-13% of infants with cystic fibrosis (CF). Due to the surprising higher incidence of PEM as the first presenting manifestation of CF in Macedonia, the aim of the present study was to evaluate the possible risk factors in its development.

METHODS

Clinical and laboratory profiles (hemoglobin, red blood cell count, total serum protein, serum albumin and liver enzyme levels) and genotype data were analyzed in 115 newly diagnosed infants with CF, during the period 1990-2006.

RESULTS

PEM manifested in 39 CF infants (33%), usually within the first 5 months of life and in breast-fed infants. Mean hemoglobin, red blood cell count, total serum protein and serum albumin values in the PEM subgroup were, respectively, 76.0 g/L, 2.4 x 10(12)/L, 38.0 g/L and 16.6 g/L. Clinically significant liver involvement was found in 22 patients (56.4%) with PEM. Concerning the molecular basis of CF in these patients, PEM was always associated with triangle upF508, G542X, N1303K and other severe mutations.

CONCLUSION

PEM is a common manifestation of CF in infancy. Early infant age, breast-feeding, impaired liver function and the presence of severe cystic fibrosis transmembrane conductance regulator mutations are predisposing factors for the development of PEM.

A 4-month-old boy with acrodermatitis enteropathica-like symptoms

A 4-month-old boy was admitted for having diffuse eruption in the perianal region, legs, trunk hands, and face with failure to thrive, edema, hypoalbuminemia, and anemia. The patient was thought to have acrodermatitis enteropathica-like eruption due to malabsorption. The eruption completely resolved with enzyme supplement and proper nutrition and skin care.

Doll-like face: is it an underestimated clinical presentation of cystic fibrosis?

Cystic fibrosis (CF) is the most prevalant inheritable chronic disease in caucasian children. The clinical syndrome of kwashiorkor is well-recognized complication of CF. The edema of the face can be seen in kwashiorkor. As doll-like face is very rare and underestimated clinical presentation of CF patients complicated with hypoproteinemia we evaluated demographic features and laboratory characteristics of 5 patients diagnosed as CF with doll-like face.

METHODS

Between June 2005 and January 2008, 115 children were diagnosed as having CF enrolled in our center. Five infants were diagnosed as CF with doll-like face before the age of 6 months participitated in study.

RESULTS

The incidence of doll-like face younger than the 6 months of age were 9.4% in our center. 48 infants diagnosed as CF without doll-like face before the age of 6 months participitated in the study as controls (group2). Physical examination revealed doll-like face and pitting edema of lower extremities in group 1. Their weight and length were under the third centile. Laboratory findings of group 1 include: mean hemoglobin 7.6g/dl; mean total protein 4.4 g/dl; albumin 2.3 g/dl. When compared control group in order to; 11.4 g/dl (range 7.6-17.9); 6.2 g/dl (range 4.0-8.8); 4.7 g/dl (range 2.1-5.8). mean hemoglobin, total protein and albumin values were lower in group 1.

CONCLUSION

In a subgroup of patients, doll-like face may be the presenting manifestation of CF. Especially in developing countries clinicians should be aware of in patients with malnutrition and doll-like face and CF should be considered in differential diagnosis.

Cutaneous manifestations of cystic fibrosis

Cystic fibrosis is an autosomal recessive disease reported in 1 in 2500 live births in Northern American and Northern European Caucasian populations. Classic disease findings include chronic bacterial infection of airways and sinuses, malabsorption of fat, infertility in men, and elevated concentrations of chloride in sweat. Less well-recognized findings associated with cystic fibrosis include cutaneous findings, which can be primary or secondary manifestations of the disease process. Patients demonstrate more atopic and drug hypersensitivity reactions than the general population, but have similar rates of urticaria compared with the general population. In atypical presentations of cystic fibrosis, the nutrient deficiency dermatitis of the disease may aid with diagnosis, and notably can be the presenting sign. Other dermatologic manifestations of cystic fibrosis include early aquagenic skin wrinkling and cutaneous vasculitis, which can be associated with arthralgias. Familiarity with the nutrient deficiency dermatitis of this entity may play a role in the timely diagnosis of the disease, and the other cutaneous findings add to our understanding of the protean nature of its manifestations.

Acrodermatitis enteropathica–like eruption and failure to thrive as presenting signs of cystic fibrosis

We describe a female infant with an acrodermatitis enteropathica-like eruption as the presenting sign of rapidly fatal cystic fibrosis. The patient had growth retardation, developed an erythematous eruption unresponsive to oral zinc, and finally a generalized erosive dermatitis with associated edema, anemia and hypoproteinemia.

Cystic fibrosis presenting with haematological abnormalities

Although cystic fibrosis (CF) is common, the diagnosis (and subsequent treatment) may be delayed if the presentation is atypical. We present three cases of children with CF who presented with haematological abnormalities. In all cases, they underwent extensive and invasive investigations prior to the diagnosis.

Circulating markers to assess nutritional therapy in cystic fibrosis

Cystic fibrosis (CF) is the most commonly occurring lethal autosomal recessive disorder. The gene defect causes defective sodium and chloride transport across epithelial cells of the respiratory, hepatobiliary, gastrointestinal and reproductive tracts, resulting in thick mucus secretions. In the respiratory tract, mucus traps bacteria, causing repeated lung infections, progressive bronchiectasis and eventual death due to respiratory failure. In the gastrointestinal tract, mucus prevents pancreatic enzymes reaching the gut, leading to nutrient malabsorption. Careful nutritional management has a dramatic effect on growth and survival rates in CF. Appropriate nutritional support includes pancreatic enzyme replacement therapy, a high-fat/high-energy diet and essential nutrient supplementation, specifically fat-soluble vitamins and essential fatty acids (EFA). Long-term studies are required to examine the effects of nutritional interventions on key clinical outcomes in CF, such as the rate of decline of lung function. The use of circulating markers to assess the influence of nutritional therapy allows short-term intervention studies to predict the potential for clinical improvements. This article provides an overview of the biomarkers useful in the prediction of the efficacy of nutritional therapy on improvements in quality and quantity of life in CF.

Edema, anemia, hypoproteinemia, and acrodermatitis enteropathica: an uncommon initial presentation of cystic fibrosis

Cystic fibrosis is a genetic disorder characterized by chronic obstructive pulmonary disease, pancreatic exocrine deficiency, and abnormally high sweat electrolyte concentrations. Less frequently, the presenting features in infants may include edema, anemia, hypoproteinemia, and acrodermatitis enteropathica. Liver involvement may produce hepatomegaly and mild elevation of transaminases. This clinical symptom usually presents within the first 6 months of life and is associated with a high morbidity and mortality. Early recognition and institution of appropriate nutritional supplementation and pancreatic enzymes is essential to improve outcome. Since the sweat test may be falsely negative, emergency physicians must maintain a high index of suspicion to make the diagnosis of cystic fibrosis in an infant who presents with edema, anemia, hypoproteinemia, and acrodermatitis enteropathica.

Transition of care between paediatric and adult gastroenterology. Cystic fibrosis

Advancement in treatment has resulted in a dramatic increase in life expectancy of patients with cystic fibrosis (CF) to well beyond 30 years of age in most centres. What was once a fatal genetic disease in childhood now sees over a third of its CF populations in adult clinics. The improved survival is multifactorial, but most attribute the reasons to more aggressive nutritional care along with better management of the gastrointestinal and pulmonary systems. Many of the nutritional and GI issues of paediatric patients remain similar when they become adults, except that there is the added psychosocial stress associated with this transition. This chapter aims to highlight the gastrointestinal and nutritional issues manifesting at the different stages of life from infancy to adulthood, and the recommended management.

[Zinc deficiency in mucoviscidosis]

Zinc deficiencies can induce dermatitis in subjects presenting cystic fibrosis.

CASE REPORT

A patient, Clement, presented with a digestive form of cystic fibrosis. At four months of age, he presented a dermatitis similar to acrodermatitis enteropathica. Early clinical diagnosis and treatment led to a rapid response to zinc sulfate therapy.

DISCUSSION

Less intestinal absorption, malnutrition, and diet are just some of the numerous reasons for the zinc deficiency in this case. Biological support is not necessary to begin the treatment.

Malnutrition-associated rash of cystic fibrosis

Rash is a rare presenting sign of cystic fibrosis (CF) complicated by protein-calorie malnutrition. We measured essential fatty acid (EFA) levels in the serum of a 4-month-old girl with an erythematous, desquamating, periorificially accentuated rash in association with malnutrition and her 2-year-old sister who was diagnosed concurrently with CF but had no rash or signs of malnutrition. Both patients had biochemical evidence of EFA deficiency, suggesting that development of the rash is multifactorial. Clinical presentation, management, and possible modes of pathogenesis of the rash are reviewed. Pathogenesis of the rash appears to involve a complex interaction among deficiencies of EFAs, zinc, protein, and possibly copper, leading to disordered prostaglandin metabolism or cytokine production, or free radical-induced damage to cellular membranes due to a lack of nutrient-derived protective antioxidants.

Innate lung defenses and compromised Pseudomonas aeruginosa clearance in the malnourished mouse model of respiratory infections in cystic fibrosis

Cystic fibrosis (CF) is characterized by dysfunction of the digestive and respiratory tracts resulting in generalized malnutrition and chronic respiratory infections. Chronic lung infections with Pseudomonas aeruginosa, intense neutrophil-dominated airway inflammation, and progressive lung disease are the major cause of high morbidity and mortality in CF. Here we investigated the effects of malnutrition in CF on innate lung defenses, susceptibility to P. aeruginosa colonization, and associated inflammation, using aerosol models of acute and chronic infections in normal, malnourished, and transgenic mice. CFTR(m1Unc-/-) knockout mice displayed body weight variations and showed variable pulmonary clearance of P. aeruginosa. This variability was not detected in bitransgenic CFTR(m1Unc-/-)(FABP-hCFTR) mice in which the intestinal defect had been corrected. Diet-induced protein calorie malnutrition in C57BL/6J mice resulted in impaired pulmonary clearance of P. aeruginosa. Tumor necrosis factor alpha (TNF-alpha) and nitrite levels detected upon exposure to P. aeruginosa aerosols were lower in the lungs of the malnourished C57BL/6J mice relative than in lungs of mice fed a normal diet. The role of TNF-alpha and reactive nitrogen intermediates in P. aeruginosa clearance was tested in TNF-alpha and inducible nitric oxide synthase (iNOS) knockout mice. P. aeruginosa clearance was diminished in transgenic TNF-alpha- and iNOS-deficient mice. In contrast to the effects of TNF-alpha and iNOS, gamma interferon knockout mice retained a full capacity to eliminate P. aeruginosa from the lung. Malnutrition also contributed to excessive inflammation in C57BL/6J mice upon chronic challenge with P. aeruginosa. The repeatedly infected malnourished host did not produce interleukin-10, a major anti-inflammatory cytokine absent or diminished in the bronchoalveolar fluids of CF patients. These results are consistent with a model in which defective CFTR in the intestinal tract leads to nutritional deficiency which in turn contributes to compromised innate lung defenses, bacterial colonization, and excessive inflammation in the CF respiratory tract.

Physiological and psychosocial contributors to malnutrition in children with cystic fibrosis: review

Malnutrition was once thought to be an inevitable consequence of cystic fibrosis (CF). It is now considered preventable but still contributes considerable morbidity in children. Malnutrition is linked to poorer pulmonary function, reduced survival and quality of life. As the anticipated lifespan of children with CF continues to lengthen, the prevention of malnutrition attains greater importance. This review explores the complex organic and psychosocial factors implicated in the aetiology of malnutrition associated with CF.

Anabolic effects of growth hormone treatment in young children with cystic fibrosis

BACKGROUND

Malnutrition is commonly found in children with Cystic Fibrosis (CF) and is characterized by poor weight gain and linear growth. Almost one-third of children with CF are below 5th percentile for weight and height. Intensive nutritional supplementation may not result in sustained improvement in weight gain and linear growth.

OBJECTIVE

To evaluate the anabolic effects of GH, Humatrope (Eli Lilly, 0.05 mg/kg/day) was administered to five children with CF (3 males/2 females) for an average period of 2 years.

METHODS

All patients were maintained on caloric intake of 1.3-2.0 times the recommended daily allowance. Patients underwent standard growth hormone (GH) stimulation studies and measurement of IGF-1 and IGFBP-3.

RESULTS

The mean +/- SE for age and skeletal age were 3.2 +/- 0.85 years and 2.0 +/- 0.45 years, respectively. Growth was assessed by determining both weight and height, which were normalized for age and sex by calculating Z scores using HANES I reference data. Differences in Z scores between clinic visits (delta Z) were calculated for both weight and height to determine changes in growth velocity. The mean Z scores for weight and height were markedly attenuated in CF children as compared with healthy children (-1.95 +/- 0.23 and -2.8 +/- 0.27, respectively). The mean +/- SE for maximum stimulated GH value, IGF-1 and IGFBP-3 were 9.2 +/- 1.2 ng/dl, 67 +/- 6 ng/ml, and 1.7 +/- 0.22 mg/L, respectively. GH treatment improved weight and height Z scores (-0.11 +/- 0.05 and -0.94 +/- 0.18, p < 0.01) significantly. The delta Z scores for weight and height were significantly increased during first and second year of GH treatment (p < 0.02). Also, the average values of IGF-1 and IGFBP-3 were significantly increased as compared to pretreatment values (186 +/- 37 ng/ml and 3.0 +/- 0.22 mg/L, p < 0.01).

CONCLUSIONS

GH treatment significantly improves weight and linear growth in young patients with CF. These data suggest that anabolic effects of GH may be beneficial for treatment of malnutrition in children with CF.

Essential fatty acid deficiency and predisposition to lung disease in cystic fibrosis

Essential fatty acid (EFA) deficiency is a predisposing factor for pulmonary infection with Staphylococcus aureus and Pseudomonas aeruginosa, the two major pathogenic microorganisms in cystic fibrosis (CF).

OBJECTIVE

The goal of this study was to investigate the essential fatty acid status of CF patients from infancy to 20 years old.

MATERIALS AND METHODS

Plasma fatty acid profiles for phospholipid (PL) were determined for cord (n = 6), 4 months (n = 40), 16 months (n = 25), 3 y (n = 8), 5-10 y (n = 10), and 10-20 y (n = 10) aged CF patients and compared to their respective control; cord (n = 22), 1-36 months (n = 38) and adult (n = 100). Significance was established by Student's t-test (p < 0.05).

RESULTS

The plasma PL fatty acid profile for all CF patients, except cord, revealed consistent deficiency in omega 3 and omega 6 EFAs. These deficiencies were most marked at infancy and more pronounced for patients with meconium ileus.

CONCLUSIONS AND RELEVANCE

EFA deficiency may contribute to the predisposition of CF infants to develop respiratory disease and to the excess cytotoxic activity found in bronchoalveolar lavage fluid at 2 months of age in the majority of screened infants.

Cystic fibrosis presenting as kwashiorkor with florid skin rash

Two infants with a florid erythematous rash and generalised oedema, hypoalbuminaemia, and anaemia were found to have cystic fibrosis. This rare presentation is associated with false negative sweat tests, delays in diagnosis, and a considerable mortality. It is proposed that this presentation represents a manifestation of kwashiorkor secondary to malabsorption. The recognition that these infants have kwashiorkor provides some insight into the pathogenesis and management of their illness.

Feeding practices and nutrition recommendations for infants with cystic fibrosis

Cystic fibrosis (CF) is an autosomal recessive disease characterized clinically by recurrent respiratory tract infections and malabsorption caused by pancreatic insufficiency. Typically diagnosed during infancy or childhood, CF impairs weight gain and growth, increases susceptibility to infection, and decreases longevity. Until recently, no guidelines for infant feedings were available. A consensus report prepared through the Cystic Fibrosis Foundation summarizes guidelines for the optimal nutrition management of patients with CF. This study identified current feeding practices and nutrition recommendations of dietitians who treat infants with CF and compared them with the recommendations of the consensus report. A survey was developed and sent to dietitians (n = 130) who work in accredited cystic fibrosis centers. Eighty-six dietitians (66%) responded after two mailings, and 75 usable surveys were analyzed. The survey investigated practitioners' recommendations for infant formulas, energy intake, nutritional supplements, and pancreatic enzyme supplementation. Protein hydrolysate infant formulas were recommended by most respondents (69%). Energy intake greater than 130% of the Recommended Dietary Allowances (RDAs) was recommended for well-nourished infants with CF and greater than 140% of the RDAs for malnourished infants with CF at 1 year of age. Formula additives, including fat and carbohydrate modules, were used by all respondents and were frequently added to infant foods to increase caloric density. Enteric coated pancreatic enzymes were used by the majority (76%) of dietitians. These findings indicate that most dietitians follow the nutrition guidelines established by the Cystic Fibrosis Foundation consensus report for goals for energy and protein intake, use of nutritional supplements, and replacement of pancreatic enzymes in infants with CF.

Pancreatic insufficiency, growth, and nutrition in infants identified by newborn screening as having cystic fibrosis

To evaluate the impact of early pancreatic insufficiency on growth and nutritional status in cystic fibrosis, we studied 49 infants identified by a newborn screening program. Pancreatic insufficiency, determined by increased 72-hour fecal fat excretion, was present in 59% (23/39) of infants at diagnosis (7.0 +/- 0.8 weeks; mean +/- SEM). Before initiation of pancreatic enzyme replacement, growth and nutritional status of pancreatic-insufficient (n = 16) and pancreatic-sufficient (n = 13) infants were compared. Pancreatic-insufficient infants gained less weight from birth to diagnosis (13.4 +/- 3.4 vs 22.3 +/- 4.0 gm/day; p = 0.05), had decreased triceps skin-fold thicknesses (4.5 +/- 0.3 vs 6.1 +/- 0.4 mm; p less than 0.005), and had lower blood urea nitrogen (3.07 +/- 0.42 vs 4.62 +/- 0.65 mg/dl; p = 0.02) and albumin (2.99 +/- 0.14 vs 3.54 +/- 0.14 gm/dl; p less than 0.01) levels despite higher gross calorie (154 +/- 8 vs 116 +/- 13 kcal/kg per day; p less than 0.01) and protein intakes (2.81 +/- 0.21 vs 2.14 +/- 0.33 gm/kg per day; p = 0.03). Fecal nitrogen loss was correlated with fat loss (r = 0.79; p less than 0.001). Fat malabsorption was present in 79% (30/38) and 92% (33/36) of infants tested at 6 months and 12 months of age, respectively, indicating that pancreatic insufficiency persists and increases in frequency throughout infancy. We conclude that pancreatic insufficiency is prevalent in young infants with cystic fibrosis and has a significant impact on growth and nutrition.

Early respiratory course in infants with cystic fibrosis: relevance to newborn screening

Respiratory morbidity and mortality during infancy are important problems in the care of CF patients whether they are diagnosed conventionally or through newborn screening. Although the mechanisms of lung disease in CF remain to be elucidated, two potential pathophysiologic mechanisms--viral infection and undernutrition--can be associated with respiratory morbidity in infancy. Colonization of some infants with Pseudomonas and the presence of early mucus casts and cytokines in bronchoalveolar lavage suggest that pathophysiologic processes that are important in later life may begin in infancy. The early respiratory abnormalities, morbidity and mortality seen in CF indicate the need for future investigations of the respiratory course and interventional trials in infancy.

Diet for cystic fibrosis. Nutritional requirements and prescriptions

Diet plays no direct role in neutralizing the effects of the basic defect in cystic fibrosis, but it can prevent some of the acquired damage caused by complications. Adequate caloric intake provides the energy needed for exercise and cell metabolism, a strong diaphragm, normal cellular immunity, and a positive psychological outlook. Clinical management is aimed at achieving good nutrition. Patient education about nutrition and use of dietary supplements should be started immediately upon diagnosis. Careful clinical examinations and regular follow-up are necessary to detect complications that will interfere with good nutrition. Complications must be treated aggressively. Psychological and social stresses need to be recognized, and psychological referral may be necessary. The clinician's best tools to achieve these goals are the patient's dietary and gastrointestinal history, the anthropometric measurements taken at each office visit, regular patient assessment, and constant attention to detail in monitoring and charting the course of disease. Extraordinary measures, such as nighttime feedings by nasogastric or gastrostomy tube and intravenous hyperalimentation, may be necessary. For best results, these measures must be started before pulmonary complications threaten survival.