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The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position on the Role of the Registered Dietitian Nutritionist in the Care of the Pediatric Patient With Chronic Gastrointestinal Diseases. J Pediatr Gastroenterol Nutr 2023; 76:390-399. [PMID: 36580920 DOI: 10.1097/mpg.0000000000003695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The optimization of nutrition is essential for the growth and development of all children, including those with gastrointestinal (GI) conditions that can variably affect nutrient intake, absorption, or metabolism. Registered Dietitian Nutritionists (RDNs) are essential partners in delivering high quality care for pediatric GI disorders, but limited evidence is available to support the role of the RDN in the care of these patients. This position paper outlines the evidence supporting the role of the RDN in the management of chronic pediatric GI issues in both inpatient and outpatient settings. Gaps in the literature, opportunities for future research, and barriers to RDN access are discussed.
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Kliewer KL, Cassin AM, Venter C. Dietary Therapy for Eosinophilic Esophagitis: Elimination and Reintroduction. Clin Rev Allergy Immunol 2017; 55:70-87. [DOI: 10.1007/s12016-017-8660-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Groetch M, Venter C, Skypala I, Vlieg-Boerstra B, Grimshaw K, Durban R, Cassin A, Henry M, Kliewer K, Kabbash L, Atkins D, Nowak-Węgrzyn A, Holbreich M, Chehade M. Dietary Therapy and Nutrition Management of Eosinophilic Esophagitis: A Work Group Report of the American Academy of Allergy, Asthma, and Immunology. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:312-324.e29. [PMID: 28283156 DOI: 10.1016/j.jaip.2016.12.026] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/21/2016] [Indexed: 12/16/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic/immune-antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Dietary elimination therapy has been shown to be an effective, drug-free prescription for the treatment of EoE. A range of different dietary elimination therapies have been used. Regardless of the elimination diet chosen, dietary therapy requires in-depth nutrition assessment and management. Elimination diets are not without risk and may impact nutritional status, eating pleasure, and overall quality of life. With adequate guidance, dietary therapy can be effective and nutritionally balanced, and the adverse impact on lifestyle can be minimized. This work group report addresses the potential challenges of implementing an elimination diet for the management of EoE and provides instructions and tools for physicians, dietitians, and other allied health professionals to help guide them in planning elimination diets for both children and adults.
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Affiliation(s)
- Marion Groetch
- Division of Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Carina Venter
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Isabel Skypala
- Allergy Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK; Department of Paediatrics, Imperial College, London, UK
| | - Berber Vlieg-Boerstra
- Onze lieve Vrouwe Gasthuis (OLVG), Department of Paediatrics, Amsterdam, The Netherlands
| | - Kate Grimshaw
- Department of Nutrition and Dietetics, Southampton's Children's Hospital, Southampton, UK; Clinical and Experimental Sciences and Human Development in Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Raquel Durban
- Division of Food Allergy, Asthma and Allergy Specialists, PA, Charlotte, NC
| | - Alison Cassin
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michelle Henry
- Department of Medical Affairs, Fresenius Kabi USA, LLC, Lake Zurich, Ill
| | - Kara Kliewer
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynda Kabbash
- Department of Internal Medicine, Harvard Medical School, Boston, Mass; Department of Internal Medicine, New England Baptist Hospital, Boston, Mass
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program and Allergy & Immunology Section, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Anna Nowak-Węgrzyn
- Division of Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Mirna Chehade
- Departments of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Kruszewski PG, Russo JM, Franciosi JP, Varni JW, Platts-Mills TAE, Erwin EA. Prospective, comparative effectiveness trial of cow's milk elimination and swallowed fluticasone for pediatric eosinophilic esophagitis. Dis Esophagus 2016; 29:377-84. [PMID: 25721813 DOI: 10.1111/dote.12339] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease in which food antigens play a key role. Current therapeutic options are limited to long-term steroid medication and dietary elimination of multiple foods, each of which is challenging. Our objective was to compare single food elimination of cow's milk to swallowed fluticasone in pediatric EoE patients. This is a prospective, comparative effectiveness trial of newly diagnosed EoE patients (ages 2-18 years) treated with swallowed fluticasone (n = 24) or elimination of cow's milk (n = 20). The dual outcome measures of repeat esophageal biopsy (6-8 weeks) and change in Pediatric Quality of Life Inventor (PedsQL) EoE Module and Symptoms Scales were used to assess response to treatment. After 6-8 weeks of treatment, peak esophageal eosinophil counts decreased to below the threshold of 15 eosinophils/high-power field in 64% of patients treated with cow's milk elimination and 80% of patients treated with swallowed fluticasone (P = 0.4). Mean PedsQL EoE Module total scores (69 vs. 82; P < 0.005) and Total Symptoms scores (58 vs. 75; P = 0.001) showed significant improvement with cow's milk elimination. Among children treated with swallowed fluticasone, mean PedsQL EoE Module total scores (64 vs. 75; P < 0.05) and Total Symptoms scores (58 vs. 69; P < 0.01) were also significantly improved after 6-8 weeks of therapy. Removal of cow's milk from the diet is an effective single food elimination treatment for pediatric patients with EoE as assessed by statistically significant histologic and symptomatic improvement. Cow's milk elimination may be more desirable for EoE patients who do not want to take chronic, long-term steroid medications.
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Affiliation(s)
- P G Kruszewski
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - J M Russo
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - J P Franciosi
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours Children's Hospital, Orlando, Florida, USA
| | - J W Varni
- Colleges of Architecture and Medicine, Texas A&M University, College Station, Texas, USA
| | - T A E Platts-Mills
- Division of Allergy and Immunology, University of Virginia, Charlottesville, Virginia, USA
| | - E A Erwin
- Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, Ohio, USA
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Current Approach to the Management of Eosinophilic Esophagitis in Adults. ACTA ACUST UNITED AC 2015; 13:441-51. [DOI: 10.1007/s11938-015-0069-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Ballou S, Taft T, Keefer L. Disease-specific self-efficacy in the eosinophilic gastrointestinal disorders. J Health Psychol 2015; 20:1027-36. [PMID: 24157935 PMCID: PMC8454211 DOI: 10.1177/1359105313506028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Eosinophilic gastrointestinal disorders (EGIDs) are chronic inflammatory conditions with increasing global prevalence. Self-efficacy is important for patients' ability to manage chronic disease. We sought to evaluate disease-specific self-efficacy in the EGIDs via a modified version of the Inflammatory Bowel Disease Self-Efficacy Scale (IBD-SES). Ninety-one Participants reported demographic, clinical, and psychosocial variables. The IBD-SES demonstrated excellent reliability and validity in this population. Self-efficacy was higher in men, patients with less severe disease, and those who had consulted a dietitian. The IBD-SES is a useful measure of disease-specific self-efficacy in the EGIDs. Further research is necessary to understand the role of self-efficacy in the management of these illnesses.
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Affiliation(s)
- Sarah Ballou
- Northwestern University Feinberg School of Medicine, USA
| | - Tiffany Taft
- Northwestern University Feinberg School of Medicine, USA
| | - Laurie Keefer
- Northwestern University Feinberg School of Medicine, USA
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Mehta P, Furuta GT. Eosinophils in Gastrointestinal Disorders: Eosinophilic Gastrointestinal Diseases, Celiac Disease, Inflammatory Bowel Diseases, and Parasitic Infections. Immunol Allergy Clin North Am 2015. [PMID: 26209893 DOI: 10.1016/j.iac.2015.04.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The gastrointestinal (GI) tract provides an intriguing organ for considering the eosinophil's role in health and disease. The normal GI tract, except for the esophagus, is populated by eosinophils that are present throughout the mucosa, raising the possibility that eosinophils participate in innate mechanisms of defense. However, data from clinical studies associates increased numbers of eosinophils with inflammatory GI diseases, prompting concerns that eosinophils may have a deleterious effect on the gut. We present clinical features of 4 disease processes that have been associated with eosinophilia and suggest areas requiring investigation as to their clinical significance and scientific relevance.
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Affiliation(s)
- Pooja Mehta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Ave B290, Aurora, CO 80045, USA
| | - Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Ave B290, Aurora, CO 80045, USA.
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Yang M, Geng L, Chen P, Wang F, Xu Z, Liang C, Li H, Fang T, Friesen CA, Gong S, Li D. Effectiveness of dietary allergen exclusion therapy on eosinophilic colitis in Chinese infants and young children ≤ 3 years of age. Nutrients 2015; 7:1817-27. [PMID: 25768952 PMCID: PMC4377883 DOI: 10.3390/nu7031817] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 02/06/2015] [Accepted: 02/16/2015] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic colitis is a well recognized clinical entity mainly associated with food allergies. Empiric treatment options include dietary allergen exclusion (extensively hydrolyzed protein formula and elimination diet), anti-allergy medications (antihistamines and leukotriene receptor antagonists) and corticosteroids. We evaluated the effectiveness of dietary antigen exclusion on clinical remission of eosinophilic colitis in infants and young children. We retrospectively reviewed charts of all infants and children ≤3 years of age who were diagnosed with eosinophilic colitis (defined as mucosal eosinophilia ≥20 hpf−1) from 1 January 2011 to 31 December 2013 at a tertiary children’s hospital in China. Forty-nine children were identified with eosinophilic colitis. Elemental formula, simple elimination diet or combination therapy resulted in clinical improvement in 75%, 88.2% and 80% of patients, respectively. In conclusion, eosinophilic colitis in infants and children ≤3 years of age responded well to dietary allergen exclusion.
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Affiliation(s)
- Min Yang
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center of Guangzhou Medical University, Guangzhou 510623, China.
| | - Lanlan Geng
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center of Guangzhou Medical University, Guangzhou 510623, China.
| | - Peiyu Chen
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center of Guangzhou Medical University, Guangzhou 510623, China.
| | - Fenghua Wang
- Department of Pathology, Guangzhou Women and Children's Medical Center of Guangzhou Medical University, Guangzhou 510623, China.
| | - Zhaohui Xu
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center of Guangzhou Medical University, Guangzhou 510623, China.
| | - Cuiping Liang
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center of Guangzhou Medical University, Guangzhou 510623, China.
| | - Huiwen Li
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center of Guangzhou Medical University, Guangzhou 510623, China.
| | - Tiefu Fang
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center of Guangzhou Medical University, Guangzhou 510623, China.
| | - Craig A Friesen
- Division of Gastroenterology, Children's Mercy Hospitals and Clinics, Kansas City 64108, MO, USA.
| | - Sitang Gong
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center of Guangzhou Medical University, Guangzhou 510623, China.
| | - Dingyou Li
- Division of Gastroenterology, Children's Mercy Hospitals and Clinics, Kansas City 64108, MO, USA.
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Abstract
BACKGROUND/AIMS Whereas most children and adults respond to traditional eosinophilic esophagitis (EoE) treatments, such as exclusion of dietary allergens or the use of topical steroids, a small fraction may not. METHODS Based on clinical experience and a review of the literature, the aim of this work is to provide practical advice for caring for 'refractory' patients with EoE. RESULTS The approach to this type of patient continues to evolve and decision-making should consider a number of issues including the patient's age, lack of a complete understanding of the natural history of this disease, risks of monitoring, and side effects of treatments. Next, one needs to define the term 'refractory' in that this can refer either to persistent symptoms or to continued inflammation in the face of presumably effective drug or diet therapy. Before considering alternative treatments, it is important to rule out any other cause of persistent symptoms. For instance, could they be related to an occult esophageal narrowing not identified at the time of endoscopy? Esophagrams may be necessary to identify localized or longitudinal narrowing that could be amenable to dilation. If symptoms and inflammation persist and no narrowing is appreciated, an elemental diet can be considered; however, the long-term use of this in older children and adults may be difficult. Prednisone or systemic steroids may be indicated to induce remission, but side effects and complications associated with chronic use are limiting. Finally, the use of immunosuppression or biological agents has been reported in case reports and studies; use of these may be limited by side effects or the need to utilize compassionate use protocols. CONCLUSIONS As the scope of esophageal eosinophilia continues to evolve, the clinical and molecular characterization of new clinical phenotypes will be important so that new therapeutic targets can be identified.
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Affiliation(s)
- Vincent A. Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati Center for Eosinophilic Disorder, Department of Pediatrics, University of Cincinnati College of Medicine, Interdisciplinary Feeding Team, Cincinnati Children's Hospital Medical Center
| | - Glenn T. Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, USA, National Jewish Health, Denver, CO
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Groetch M, Henry M, Feuling MB, Kim J. Guidance for the nutrition management of gastrointestinal allergy in pediatrics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:323-31. [PMID: 24565537 DOI: 10.1016/j.jaip.2013.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 05/06/2013] [Accepted: 05/06/2013] [Indexed: 11/16/2022]
Abstract
Food allergies and their related elimination diets have been associated with an increased risk of inadequate nutrient intake and poor growth in the pediatric population. In recognition of these nutritional risks, the National Institute of Allergy and Infectious Diseases Guidelines for the Diagnosis and Management of Food Allergy in the United States recommend nutrition counseling and close growth monitoring for all children with food allergy. The care of children with gastrointestinal food allergic disorders can be complicated and is best performed with a structured approach in which medical and nutrition needs are addressed simultaneously. Children with gastrointestinal food allergy may be at greater nutritional risk because of decreased dietary intake. For these children, it is important to perform a comprehensive nutrition assessment to identify nutrition-related problems and to develop and implement a plan that meets the patient's needs within the context of the elimination diet. We provide an overview of the nutritional risks and strategies to assess nutritional status in pediatric patients with gastrointestinal food allergy.
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Affiliation(s)
| | | | | | - Jennifer Kim
- Icahn School of Medicine at Mount Sinai, New York, NY
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