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Riddle S, Karpen H. Special Populations-Surgical Infants. Clin Perinatol 2023; 50:715-728. [PMID: 37536774 DOI: 10.1016/j.clp.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Congenital gastrointestinal disorders and other surgical diagnoses share many common problems: increased nutritional requirements to prevent catabolism, enhance wound healing, and provide optimal growth; impaired motility and altered intestinal flora leading to feeding intolerance requiring long-term parenteral nutrition; gastroesophageal reflux and poor feeding mechanics requiring tube feedings and support; growth failure; poor barrier function and risk of infection; and other long-term sequelae. Consequently, the surgical "at-risk" infant requires specialized nutritional support to meet their increased requirements to ensure adequate growth and meet the increased demands from critical illness.
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Affiliation(s)
- Stefanie Riddle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Heidi Karpen
- Emory University School of Medicine/Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, ECC Room 324, Atlanta, GA 30322, USA
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2
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Proton pump inhibitor use and mortality in patients with cirrhosis: a meta-analysis of cohort studies. Biosci Rep 2021; 40:224145. [PMID: 32406491 PMCID: PMC7276520 DOI: 10.1042/bsr20193890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Proton pump inhibitor (PPI) is commonly used in patients with cirrhosis. However, some studies demonstrated that PPI use was associated with adverse outcome in patients with cirrhosis. We aimed to perform a meta-analysis of cohort studies to evaluate the association between PPI use and mortality in cirrhotic patients. Methods: Relevant studies were obtained via search of PubMed and Embase databases. A randomized-effect model was used to pool the results. Subgroup analyses were performed to evaluate the source of heterogeneity. Results: Overall, 21 cohort studies with 20,899 patients and 7457 death events were included. The pooled results with a randomized-effect model showed that PPI use was associated with significantly increased risk of mortality in patients with cirrhosis (adjusted relative risk [RR] = RR: 1.39, P<0.001) with considerable heterogeneity (I2=73%). Subgroup analyses showed that characteristics such as patient ethnicity, sample size, definition of PPI use, and complications of patients did not affect the association. However, the association between PPI use and mortality was independent of study characteristics including patient ethnicity, sample size, complications, definition of PPI use, and follow-up duration. However, the association between PPI use and mortality in cirrhotic patients was significant in retrospective studies (RR: 1.40, P<0.001), but not in prospective studies (RR: 1.34, P=0.33). Conclusions: PPI use may be associated with moderately increased mortality in cirrhotic patients. Although prospective cohort studies are needed to validate our findings, PPI should only prescribed to cirrhotic patients with indications for the treatment.
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Shankar S, Rosenbaum J. Chronic diarrhoea in children: A practical algorithm-based approach. J Paediatr Child Health 2020; 56:1029-1038. [PMID: 32725734 DOI: 10.1111/jpc.14986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/05/2020] [Accepted: 05/10/2020] [Indexed: 12/17/2022]
Abstract
Diarrhoea is a leading cause of morbidity and mortality world-wide. Most diarrhoeal episodes are acute and infectious in origin. Diarrhoea lasting for longer than 4 weeks with no discernible infectious aetiology warrants thorough evaluation. The aim of this review is to elucidate an approach to evaluation of diarrhoea based on its pathophysiologic mechanisms with focus on aetiology, investigation and management of chronic diarrhoea. It includes a brief description of normal fluid homeostasis in the gut and pathophysiology of diarrhoea. Further, diarrhoea is classified as 'watery', 'fatty' and 'bloody' based on stool characteristics. Relevant history, physical examination findings, first and second-line investigations which help in differentiating the different types of diarrhoea are listed and an algorithmic approach to individual types of diarrhoea has been devised. Principles of management and recent advances in diagnostics and therapeutics of diarrhoea are briefly discussed.
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Affiliation(s)
- Sahana Shankar
- Consultant Pediatric Gastroenterologist, Department of Pediatrics, Mazumdar Shaw Medical Centre, Narayana Health, Bangalore, India.,Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jeremy Rosenbaum
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
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Davis ET, Strogach I, Carobene M, Shaul E, Thompson J. Paradoxical Elevation of Both Serum B12 and Methylmalonic Acid Levels in Assessing B12 Status in Children With Short-Bowel Syndrome. JPEN J Parenter Enteral Nutr 2020; 44:1257-1262. [PMID: 31985849 DOI: 10.1002/jpen.1764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/04/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Measurement of vitamin B12 (B12) levels is routinely used to monitor B12 sufficiency. However, its accuracy may not be reliable in patients with short-bowel syndrome (SBS). The presence of elevated methylmalonic acid (MMA) levels can also be used as a marker for B12 deficiency. Therefore, our aim was to analyze serum B12 and MMA levels simultaneously in a cohort of children with SBS to evaluate the accuracy of these markers in the assessment of B12 status. METHODS Children ages 1-18 with intestinal failure were eligible for enrollment. MMA and B12 levels were checked simultaneously in all patients, with 93 sets of labs obtained over 2 years. Fifty percent of the patients were receiving parenteral nutrition. B12 injections were administered to 14 patients who had simultaneously elevated MMA and B12, and a repeat MMA level was measured 4-6 weeks after injection. Data were collected retrospectively. RESULTS Forty-eight percent of the lab pairs showed evidence of both elevated MMA and high or normal B12, which contradicted the expected inverse relationship of these markers. There was a statistically significant decrease in mean MMA values after treatment with B12 injections (412.7 vs 1037.5, P = 0.001). CONCLUSION Paradoxical elevation of MMA with normal or elevated serum B12 is common in children with SBS. Caution should be used when interpreting serum B12 and MMA values in this setting. This may be related to effects of small-bowel bacterial overgrowth, a condition commonly seen in these patients.
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Affiliation(s)
- Esther T Davis
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Irina Strogach
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Macy Carobene
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Eliana Shaul
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - John Thompson
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
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Liu Y, Tran DQ, Rhoads JM. Probiotics in Disease Prevention and Treatment. J Clin Pharmacol 2019; 58 Suppl 10:S164-S179. [PMID: 30248200 DOI: 10.1002/jcph.1121] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/17/2018] [Indexed: 12/17/2022]
Abstract
Few treatments for human diseases have received as much investigation in the past 20 years as probiotics. In 2017, English-language meta-analyses totaling 52 studies determined the effect of probiotics on conditions ranging from necrotizing enterocolitis and colic in infants to constipation, irritable bowel syndrome, and hepatic encephalopathy in adults. The strongest evidence in favor of probiotics lies in the prevention or treatment of 5 disorders: necrotizing enterocolitis, acute infectious diarrhea, acute respiratory tract infections, antibiotic-associated diarrhea, and infant colic. Probiotic mechanisms of action include the inhibition of bacterial adhesion; enhanced mucosal barrier function; modulation of the innate and adaptive immune systems (including induction of tolerogenic dendritic cells and regulatory T cells); secretion of bioactive metabolites; and regulation of the enteric and central nervous systems. Future research is needed to identify the optimal probiotic and dose for specific diseases, to address whether the addition of prebiotics (to form synbiotics) would enhance activity, and to determine if defined microbial communities would provide benefit exceeding that of single-species probiotics.
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Affiliation(s)
- Yuying Liu
- Department of Pediatrics, Division of Gastroenterology, and the Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Dat Q Tran
- Department of Pediatrics, Division of Gastroenterology, and the Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - J Marc Rhoads
- Department of Pediatrics, Division of Gastroenterology, and the Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
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Rivera-Nieves D, Conley A, Nagib K, Shannon K, Horvath K, Mehta D. Gastrointestinal Conditions in Children With Severe Feeding Difficulties. Glob Pediatr Health 2019; 6:2333794X19838536. [PMID: 31020010 PMCID: PMC6469270 DOI: 10.1177/2333794x19838536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/25/2018] [Accepted: 02/21/2019] [Indexed: 12/27/2022] Open
Abstract
Feeding aversion in children may progress to severe feeding difficulties. While oral-motor and sensory issues are usually the leading causes, organic etiologies should be considered. This study aimed to assess the prevalence of gastrointestinal conditions in children with severe feeding difficulties. We conducted a retrospective study of 93 children requiring an intensive feeding program. The medical records, radiologic and diagnostic tests, use of gastric tube feedings, preexisting medical conditions, and medications were reviewed. Fifty-two percent (52%) had esophagitis, 26.2% gastritis, and 40.7% lactase deficiency in upper endoscopy. In those who underwent an upper endoscopy, 26% of patients that were also tested for small intestinal bacterial overgrowth were found to be positive. Allergy testing was abnormal in 56.6% of those tested, while 27.5% and 75% had abnormal gastric emptying times and pH impedance results, respectively. Constipation was present in 76.3%. Thirteen of 32 were weaned off tube feedings. We conclude that gastrointestinal conditions are common in children with feeding disorders and should be investigated prior to feeding therapy.
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Affiliation(s)
- Desiree Rivera-Nieves
- Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Anita Conley
- Feeding Difficulties Center, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Keri Nagib
- Feeding Difficulties Center, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Kaiya Shannon
- Feeding Difficulties Center, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Karoly Horvath
- Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL, USA.,Feeding Difficulties Center, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Devendra Mehta
- Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL, USA.,Feeding Difficulties Center, Arnold Palmer Hospital for Children, Orlando, FL, USA
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Avelar Rodriguez D, Ryan PM, Toro Monjaraz EM, Ramirez Mayans JA, Quigley EM. Small Intestinal Bacterial Overgrowth in Children: A State-Of-The-Art Review. Front Pediatr 2019; 7:363. [PMID: 31552207 PMCID: PMC6737284 DOI: 10.3389/fped.2019.00363] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/20/2019] [Indexed: 12/11/2022] Open
Abstract
Small intestinal bacterial overgrowth (SIBO) is a heterogenous and poorly understood entity characterised by an excessive growth of select microorganisms within the small intestine. This excessive bacterial biomass, in turn, disrupts host physiology in a myriad of ways, leading to gastrointestinal and non-gastrointestinal symptoms and complications. SIBO is a common cause of non-specific gastrointestinal symptoms in children, such as chronic abdominal pain, abdominal distention, diarrhoea, and flatulence, amongst others. In addition, it has recently been implicated in the pathophysiology of stunting, a disease that affects millions of children worldwide. Risk factors such as acid-suppressive therapies, alterations in gastrointestinal motility and anatomy, as well as impoverished conditions, have been shown to predispose children to SIBO. SIBO can be diagnosed via culture-dependant or culture-independent approaches. SIBO's epidemiology is limited due to the lack of uniformity and consensus of its diagnostic criteria, as well as the paucity of literature available. Antibiotics remain the first-line treatment option for SIBO, although emerging modalities such as probiotics and diet manipulation could also have a role. Herein, we present a state-of-the-art-review which aims to comprehensively outline the most current information on SIBO in children, with particular emphasis on the gut microbiota.
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Affiliation(s)
- David Avelar Rodriguez
- Pediatric Gastroenterology and Nutrition Unit, National Institute of Pediatrics, Mexico City, Mexico
| | | | | | | | - Eamonn Martin Quigley
- Lynda K. and David M. Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, TX, United States
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