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Omecene NE, Wilcox N, Cox AL, Ham P, Ong R, Barber AT, Zimmerman KM. A review of proton pump inhibitor use in cystic fibrosis and considerations for deprescribing. Pediatr Pulmonol 2024. [PMID: 39193889 DOI: 10.1002/ppul.27229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 07/30/2024] [Accepted: 08/18/2024] [Indexed: 08/29/2024]
Abstract
Use of proton-pump inhibitors (PPIs) is common among people with cystic fibrosis (pwCF) both for the management of suspected GERD, as well as pancreatic enzyme replacement therapy augmentation. Despite their use, limited data exist to demonstrate a clinically significant impact of PPIs on key endpoints in pwCF. Furthermore, the advent of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy may modify the need for use. These notions, coupled with the potential for adverse outcomes associated with long-term PPI use in pwCF, should facilitate re-evaluation of long-term PPI use in pwCF and promote potential deprescribing. Despite limited data on PPI deprescribing in pwCF, it intuitively mirrors the existing guidance in adults in the general population, but with added consideration given to tapering strategy, and monitoring for CF-specific outcomes such as nutritional and respiratory status. The development of a monitoring and re-initiation plan is key to reducing deprescribing inertia. This review aims to summarize the evidence that details the concern for long-term use of PPIs and provide CF clinicians with rationale and guidance on how to approach deprescribing in their practice.
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Affiliation(s)
- Nicole E Omecene
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Nicole Wilcox
- Department of Pharmacy, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alexandra L Cox
- Department of Pharmacy, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Pearl Ham
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Ryan Ong
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Andrew T Barber
- Division of Pediatric Pulmonary and Sleep Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kristin M Zimmerman
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
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Zazzeron L, Alicandro G, Daccò V, Lanfranchi C, Bulfamante A, Sciarrabba CS, Corti F, Colombo C. Effects of prolonged proton pump inhibitor treatment on nutritional status and respiratory infection risk in cystic fibrosis: A matched cohort study. Dig Liver Dis 2023; 55:360-365. [PMID: 36253246 DOI: 10.1016/j.dld.2022.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/11/2022] [Accepted: 09/03/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Evidence on the effectiveness of proton pump inhibitors (PPI) as adjuvant therapy to improve maldigestion in people with cystic fibrosis (pwCF) is limited and there is increasing concern on possible side effects. METHODS We conducted a matched cohort study based on paediatric and adult pwCF who received PPI for ≥3 months. Treated patients were matched to a group of patients who never received PPI using a nearest neighbour propensity score matching based on sex, year of birth, CFTR genotype and pancreatic insufficiency. RESULTS The study included 160 pwCF: 80 treated and 80 untreated patients. Over a median follow-up of 2 years, no significant differences in changes in BMI z-score were detected between groups (adjusted mean difference: 0.06, 95% CI: -0.17-0.30). At baseline 25% (n = 20) of the treated patients and 22.5% (n = 18) of the untreated patients had a positive culture for P. aeruginosa (Pa). At follow-up percentages of Pa positive cultures increased to 47.5% (n = 38) in the treated group and to 26.3% (n = 21) in the untreated group (adjusted mean difference: 23.1%, 95% CI: 10.8-35.3). CONCLUSIONS Prolonged PPI therapy should be used cautiously in pwCF since it may increase the risk of respiratory infection by Pa. In addition, such treatment does not seem to improve nutritional status.
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Affiliation(s)
- Laura Zazzeron
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milano 20122, Italy
| | - Gianfranco Alicandro
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milano 20122, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
| | - Valeria Daccò
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milano 20122, Italy
| | - Chiara Lanfranchi
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milano 20122, Italy
| | - Anna Bulfamante
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milano 20122, Italy
| | - Calogero Sathya Sciarrabba
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milano 20122, Italy
| | - Fabiola Corti
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milano 20122, Italy
| | - Carla Colombo
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milano 20122, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy.
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Ng J, Friedmacher F, Pao C, Charlesworth P. Gastroesophageal Reflux Disease and Need for Antireflux Surgery in Children with Cystic Fibrosis: A Systematic Review on Incidence, Surgical Complications, and Postoperative Outcomes. Eur J Pediatr Surg 2021; 31:106-114. [PMID: 33202431 PMCID: PMC7853868 DOI: 10.1055/s-0040-1718750] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is associated with accelerated decline in lung health in children with cystic fibrosis (CF). Thus, antireflux surgery (ARS) is offered to a selected CF cohort with refractory GERD, but outcomes remain poorly investigated. This study aimed to determine the incidence of GERD in children with CF and to evaluate complications and outcomes of ARS. MATERIALS AND METHODS A systematic literature-based search was conducted using various online databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The number of GERD cases in pediatric CF cohorts who underwent diagnostic investigation(s) was recorded. Data on postoperative complications and outcomes (including symptoms, lung function, and nutritional status) following ARS were analyzed. RESULTS Ten articles (n = 289 patients) met the defined inclusion criteria (51% male; age range, 0.5 month-36 years). The overall incidence of GERD was 46% (range, 19-81%), derived from seven studies (n = 212 patients). Four publications (n = 82 patients) reported on ARS due to uncontrolled GERD. All ARSs were Nissen fundoplication (majority with gastrostomy placement). Major postoperative complications occurred in 15 (18%) patients, two required redo-ARS. Median follow-up time was 2 years (range, 3 months-6 years); 59% showed symptom improvement, and pulmonary exacerbations and decline in lung function were reduced. Nutritional status mainly improved in milder CF cases. There were no deaths related to ARS. CONCLUSION Approximately half of pediatric CF patients have GERD. Published data for children with CF are limited and heterogeneous in terms of GERD diagnosis and outcomes following ARS. However, ARS has shown to slow the deterioration of lung function in CF.
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Affiliation(s)
- Jessica Ng
- Department of Paediatric Surgery, Royal London Hospital, London, United Kingdom,Address for correspondence Florian Friedmacher, MD, MSc (RCSI), PhD Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University FrankfurtTheodor-Stern-Kai 7, 60590 Frankfurt/MainGermany
| | - Florian Friedmacher
- Department of Paediatric Surgery, Royal London Hospital, London, United Kingdom,Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt (Main), Germany
| | - Caroline Pao
- Department of Paediatric Surgery, Royal London Hospital, London, United Kingdom
| | - Paul Charlesworth
- Department of Paediatric Surgery, Royal London Hospital, London, United Kingdom
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4
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Galante G, Freeman AJ. Gastrointestinal, Pancreatic, and Hepatic Manifestations of Cystic Fibrosis in the Newborn. Neoreviews 2020; 20:e12-e24. [PMID: 31261070 DOI: 10.1542/neo.20-1-e12] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Gastrointestinal, pancreatic, and hepatic signs and symptoms represent the most common presentation of early disease among patients with cystic fibrosis and may be the initial indication of disease. Regardless of whether cystic fibrosis is diagnosed early by newborn screening or later by clinical course, the impact of gastrointestinal, pancreatic, and hepatic manifestations on early life is nearly ubiquitous. Conditions strongly linked with cystic fibrosis, such as meconium ileus and pancreatic insufficiency, must be recognized and treated early to optimize both short- and long-term care. Similarly, less specific conditions such as reflux, poor weight gain, and cholestasis are frequently encountered in infants with cystic fibrosis. In this population, these conditions may present unique challenges in which early interventions may have significant influence on both short- and long-term morbidity and mortality outcomes.
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Bongiovanni A, Parisi GF, Scuderi MG, Licari A, Brambilla I, Marseglia GL, Leonardi S. Gastroesophageal reflux and respiratory diseases: does a real link exist? Minerva Pediatr 2019; 71:515-523. [PMID: 31129955 DOI: 10.23736/s0026-4946.19.05531-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Gastro-esophageal reflux disease (GERD) indicates a gastroesophageal reflux that causes symptoms such as pain, and needs medical therapy, and may result in complications such as erosive esophagitis, aspiration pneumonia. Here, we review if it exists a real link between clinical presentation of some respiratory diseases such as asthma, chronic cough, cystic fibrosis and laryngopharyngitis and GERD. EVIDENCE ACQUISITION This review was conducted employing 2 databases: PubMed and Science Direct. EVIDENCE SYNTHESIS Asthma may lead to reflux, and reflux could exacerbate asthma or cause asthma-like symptoms. Prevalence of GERD in children with asthma ranged from as low 32% to as high 80%. There are several studies where the use of proton pump inhibitors (PPIs) and histamine H2 receptor antagonists lead to inconclusive results. The relation of chronic unexplained cough to GERD remains controversial in children and pediatric guidelines do not currently recommend empirical GERD treatment trials for pediatric chronic cough. Gastroesophageal reflux is more frequent in patients with cystic fibrosis (CF) than general population. Although PPIs are regularly prescribed in approximately half of the patients with CF, there are no specific guidelines for treatment of reflux in CF and it was shown that chronic treatment with PPIs was correlated to possible increased risk of exacerbations. CONCLUSIONS The pathogenesis of GER-related respiratory symptoms is multifactorial. The causal relationship between these two conditions may be difficult to prove also with the aid of supporting tests. Multichannel intraluminal impedance associated with pH-metry (pH/MII) detect all gastroesophageal reflux episodes accompanied with a bolus movement and classify GER episodes according to their content (liquid, gas and mixed), pH value and proximal extension. There are no consistent evidences confirming the validity of medical therapy in reflux with respiratory symptoms.
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Affiliation(s)
- Annarita Bongiovanni
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giuseppe F Parisi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy -
| | - Maria G Scuderi
- Department of Medical, Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy
| | - Amelia Licari
- Department of Pediatrics, San Matteo Polyclinic Hospital, IRCCS and Foundation, University of Pavia, Pavia, Italy
| | - Ilaria Brambilla
- Department of Pediatrics, San Matteo Polyclinic Hospital, IRCCS and Foundation, University of Pavia, Pavia, Italy
| | - Gian L Marseglia
- Department of Pediatrics, San Matteo Polyclinic Hospital, IRCCS and Foundation, University of Pavia, Pavia, Italy
| | - Salvatore Leonardi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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6
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Cystic Fibrosis and gastroesophageal reflux disease. J Cyst Fibros 2018; 16 Suppl 2:S2-S13. [PMID: 28986024 DOI: 10.1016/j.jcf.2017.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 12/19/2022]
Abstract
Gastroesophageal reflux is common in children and adults with cystic fibrosis (CF). Pathological gastroesophageal reflux disease (GERD) is also frequent in patients of all ages with CF. This article reviews the pathophysiology, diagnostic work-up, management options, complications, and future directions in the evaluation and management of GERD - unique to and pertinent for - patients with CF in particular.
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Bolia R, Ooi CY, Lewindon P, Bishop J, Ranganathan S, Harrison J, Ford K, van der Haak N, Oliver MR. Practical approach to the gastrointestinal manifestations of cystic fibrosis. J Paediatr Child Health 2018; 54:609-619. [PMID: 29768684 DOI: 10.1111/jpc.13921] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/07/2018] [Accepted: 03/02/2018] [Indexed: 12/14/2022]
Abstract
Cystic fibrosis (CF) is the most common, life-shortening, genetic illness affecting children in Australia and New Zealand. The genetic abnormality results in abnormal anion transport across the apical membrane of epithelial cells in a number of organs, including the lungs, gastrointestinal tract, liver and genito-urinary tract. Thus, CF is a multi-system disorder that requires a multi-disciplinary approach. Respiratory disease is the predominant cause of both morbidity and mortality in patients with CF. However, there are significant and clinically relevant gastrointestinal, liver, pancreatic and nutritional manifestations that must be detected and managed in a timely and structured manner. The aim of this review is to provide evidence-based information and clinical algorithms to guide the nutritional and gastrointestinal management of patients with CF.
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Affiliation(s)
- Rishi Bolia
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Chee Y Ooi
- School of Women and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,miCF Research Centre and Department of Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Peter Lewindon
- Department of Gastroenterology, Lady Cilento Children's Hospital and Queensland Liver Transplant Service, Brisbane, Queensland, Australia
| | - Jonathan Bishop
- Department of Paediatric Gastroenterology, Starship Children's Hospital, Auckland, New Zealand
| | - Sarath Ranganathan
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Jo Harrison
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Kristyn Ford
- Department of Nutrition and Dietetics, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Natalie van der Haak
- Department of Nutrition and Dietetics, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Mark R Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
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8
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Freitas DA, Chaves GS, Santino TA, Ribeiro CT, Dias FA, Guerra RO, Mendonça KM. Standard (head-down tilt) versus modified (without head-down tilt) postural drainage in infants and young children with cystic fibrosis. Cochrane Database Syst Rev 2018; 3:CD010297. [PMID: 29684249 PMCID: PMC6494281 DOI: 10.1002/14651858.cd010297.pub3] [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: 11/06/2022]
Abstract
BACKGROUND Postural drainage is used primarily in infants with cystic fibrosis from diagnosis up to the moment when they are mature enough to actively participate in self-administered treatments. However, there is a risk of gastroesophageal reflux associated with this technique.This is an update of a review published in 2015. OBJECTIVES To compare the effects of standard postural drainage (15º to 45º head-down tilt) with modified postural drainage (15º to 30º head-up tilt) with regard to gastroesophageal reflux in infants and young children up to six years old with cystic fibrosis in terms of safety and efficacy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register. We also searched the reference lists of relevant articles and reviews. Additional searches were conducted on ClinicalTrials.gov and on the WHO International Clinical Trials Registry Platform for any planned, ongoing and unpublished studies.The date of the most recent literature searches: 19 June 2017. SELECTION CRITERIA We included randomised controlled studies that compared two postural drainage regimens (standard and modified postural drainage) with regard to gastroesophageal reflux in infants and young children (up to and including six years old) with cystic fibrosis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently identified studies for inclusion, extracted outcome data and assessed risk of bias. We resolved disagreements by consensus or by involving a third review author. We contacted study authors to obtain missing or additional information. The quality of the evidence was assessed using GRADE. MAIN RESULTS Two studies, involving a total of 40 participants, were eligible for inclusion in the review. We included no new studies in the 2018 update. The included studies were different in terms of the age of participants, the angle of tilt, the reported outcomes, the number of sessions and the study duration. The following outcomes were measured: appearance or exacerbation of gastroesophageal reflux episodes; percentage of peripheral oxygen saturation; number of exacerbations of upper respiratory tract symptoms; number of days on antibiotics for acute exacerbations; chest X-ray scores; and pulmonary function tests. One study reported that postural drainage with a 20° head-down position did not appear to exacerbate gastroesophageal reflux. However, the majority of the reflux episodes in this study reached the upper oesophagus (moderate-quality evidence). The second included study reported that modified postural drainage (30° head-up tilt) was associated with fewer number of gastroesophageal reflux episodes and fewer respiratory complications than standard postural drainage (30° head-down tilt) (moderate-quality evidence). The included studies had an overall low risk of bias. One included study was funded by the Sydney Children's Hospital Foundation and the other by the Royal Children's Hospital Research Foundation and Physiotherapy Research Foundation of Australia. Data were not able to be pooled by meta-analysis due to differences in the statistical presentation of the data. AUTHORS' CONCLUSIONS The limited evidence regarding the comparison between the two regimens of postural drainage is still weak due to the small number of included studies, the small number of participants assessed, the inability to perform any meta-analyses and some methodological issues with the studies. However, it may be inferred that the use of a postural regimen with a 30° head-up tilt is associated with a lower number of gastroesophageal reflux episodes and fewer respiratory complications in the long term. The 20° head-down postural drainage position was not found to be significantly different from the 20° head-up tilt modified position. Nevertheless, the fact that the majority of reflux episodes reached the upper oesophagus should make physiotherapists carefully consider their treatment strategy. We do not envisage that there will be any new trials undertaken that will affect the conclusions of this review; therefore, we do not plan to update this review.
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Affiliation(s)
- Diana A Freitas
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho, 3000, Bairro Lagoa Nova, Natal, Rio Grande do Norte, Brazil, 59078-970
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9
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Abstract
A number of risk factors have been identified for deterioration of lung disease in children with Cystic Fibrosis (CF), and current management strategies are based on the prevention and treatment of such elements. Further challenge ensues when a patient has co-morbid disease in addition to CF, particularly when faced with rapidly deteriorating pulmonary status. It is difficult to measure the contribution of other pathologies to this decline and optimisation of both CF care and co-morbidity is paramount. This review explores the challenges faced when treating children with CF and co-morbid conditions, focussing on gastroesophageal reflux disease pre- and post-lung transplantation.
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10
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Abstract
Gastro-oesophageal reflux is associated with a wide range of respiratory disorders, including asthma, isolated chronic cough, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease and cystic fibrosis. Reflux can be substantial and reach the proximal margins of the oesophagus in some individuals with specific pulmonary diseases, suggesting that this association is more than a coincidence. Proximal oesophageal reflux in particular has led to concern that microaspiration might have an important, possibly even causal, role in respiratory disease. Interestingly, reflux is not always accompanied by typical reflux symptoms, such as heartburn and/or regurgitation, leading many clinicians to empirically treat for possible gastro-oesophageal reflux. Indeed, costs associated with use of acid suppressants in pulmonary disease far outweigh those in typical GERD, despite little evidence of therapeutic benefit in clinical trials. This Review comprehensively examines the possible mechanisms that might link pulmonary disease and oesophageal reflux, highlighting the gaps in current knowledge and limitations of previous research, and helping to shed light on the frequent failure of antireflux treatments in pulmonary disease.
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11
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Hauser B, De Schepper J, Malfroot A, De Wachter E, De Schutter I, Keymolen K, Vandenplas Y. Gastric emptying and gastro-oesophageal reflux in children with cystic fibrosis. J Cyst Fibros 2016; 15:540-7. [PMID: 26778614 DOI: 10.1016/j.jcf.2015.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is common in patients with cystic fibrosis (CF). The aim of this study was to investigate the relationship between gastric emptying (GE) and GOR in children with CF. METHODS Multichannel intraluminal impedance-pH monitoring (MII-pH) to measure GOR and GE breath test (GEBT) to measure GE were performed in 28 children with symptoms suggestive for GOR disease (GORD) (group 1). GEBT was performed in another 28 children with/without GOR symptoms who agreed to undergo GEBT but not MII-pH (group 2). RESULTS In group 1, we found increased acid GOR (AGOR) in 46.4% and delayed GE (DGE) in 21.4% but no relationship between increased AGOR and DGE. There was no DGE in group 2. We found DGE in 10.7% and rapid GE in 12.5% of the whole group. CONCLUSIONS Almost half of the children with CF and symptoms suggestive for GORD have increased AGOR and almost a quarter has DGE. However, there was no relation between GOR and GE.
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Affiliation(s)
- Bruno Hauser
- Department of Paediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Jean De Schepper
- Department of Paediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Anne Malfroot
- Department of Paediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elke De Wachter
- Department of Paediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Iris De Schutter
- Department of Paediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kathelijn Keymolen
- Centre for Medical Genetics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Yvan Vandenplas
- Department of Paediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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12
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Freitas DA, Dias FAL, Chaves GSS, Ferreira GMH, Ribeiro CTD, Guerra RO, Mendonça KMPP. Standard (head-down tilt) versus modified (without head-down tilt) postural drainage in infants and young children with cystic fibrosis. Cochrane Database Syst Rev 2015; 2015:CD010297. [PMID: 25756796 PMCID: PMC6481451 DOI: 10.1002/14651858.cd010297.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postural drainage is used primarily in infants with cystic fibrosis from diagnosis up to the moment when they are mature enough to actively participate in self-administered treatments. However, there is a risk of gastroesophageal reflux associated with this technique. OBJECTIVES To compare the effects of standard postural drainage (greater (30° to 45° head-down tilt) and lesser (15° to 20° head-down tilt)) with modified postural drainage (greater (30º head-up tilt) or lesser (15º to 20º head-up tilt)) with regard to gastroesophageal reflux in infants and young children up to six years old with cystic fibrosis in terms of safety and efficacy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register. We also searched the reference lists of relevant articles and reviews. Additional searches were conducted on ClinicalTrials.gov and on the WHO International Clinical Trials Registry Platform for any planned, ongoing and unpublished studies.The date of the most recent literature searches: 20 January 2015. SELECTION CRITERIA We included randomised controlled studies that compared two postural drainage regimens (standard and modified postural drainage) with regard to gastroesophageal reflux in infants and young children (up to and including six years old) with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two review authors independently selected the studies to be included in the review, assessed their risk of bias and extracted data. MAIN RESULTS Two studies, including 40 participants, were eligible for inclusion in the review. The studies were different in terms of the age of participants, the angle of tilt, the reported outcomes, the number of sessions and the study duration. The following outcomes were measured: appearance or exacerbation of gastroesophageal reflux episodes; percentage of peripheral oxygen saturation; number of exacerbations of upper respiratory tract symptoms; number of days on antibiotics for acute exacerbations; chest X-ray scores; and pulmonary function tests. One study reported that postural drainage with a 20° head-down position did not appear to exacerbate gastroesophageal reflux. However, the majority of the reflux episodes reached the upper oesophagus. The second included study reported that modified postural drainage (30º head-up tilt) was associated with fewer number of gastroesophageal reflux episodes and fewer respiratory complications than standard postural drainage (30º head-down tilt). The included studies had an overall low risk of bias. Data were not able to be pooled by meta-analysis due to differences in the statistical presentation of the data. AUTHORS' CONCLUSIONS The available evidence regarding the comparison between the two regimens of postural drainage is still weak due to the small number of included studies, the small number of participants assessed, the inability to perform any meta-analyses and some methodological issues with the studies. However, it may be inferred that the use of a postural regimen with a 30° head-up tilt is associated with a lower number of gastroesophageal reflux episodes and fewer respiratory complications in the long term. The 20º head-down postural drainage position was not found to be significantly different from the 20º head-up tilt modified position. Nevertheless, the fact that the majority of reflux episodes reached the upper oesophagus should make physiotherapists carefully consider their treatment strategy.
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Affiliation(s)
- Diana A Freitas
- Federal University of Rio Grande do NorteDepartment of Physical TherapyAvenida Senador Salgado Filho3000, Bairro Lagoa NovaNatalBrazil59078‐970
| | - Fernando AL Dias
- Federal University of ParanáDepartment of PhysiologyCentro Politécnico, Jardim das AméricasCaixa Postal 19031CuritibaBrazil81531‐980
| | - Gabriela SS Chaves
- Federal University of Minas GeraisRehabilitation Science ProgramBelo HorizonteBrazil
| | - Gardenia MH Ferreira
- Federal University of Rio Grande do NortePhD Program in Physical TherapyAvenida Senador Salgado Filho 3000, Lagoa NovaNatalBrazil59072‐970
| | - Cibele TD Ribeiro
- Federal University of ParanáDepartment of PhysiologyCentro Politécnico, Jardim das AméricasCaixa Postal 19031CuritibaBrazil81531‐980
| | - Ricardo O Guerra
- Federal University of Rio Grande do NortePhD Program in Physical TherapyAvenida Senador Salgado Filho 3000, Lagoa NovaNatalBrazil59072‐970
| | - Karla MPP Mendonça
- Federal University of Rio Grande do NortePhD Program in Physical TherapyAvenida Senador Salgado Filho 3000, Lagoa NovaNatalBrazil59072‐970
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13
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Prasad SA, Main E. Routine airway clearance in asymptomatic infants and babies with cystic fibrosis in the UK: obligatory or obsolete? PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/108331906x98886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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14
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Doumit M, Krishnan U, Jaffé A, Belessis Y. Acid and non-acid reflux during physiotherapy in young children with cystic fibrosis. Pediatr Pulmonol 2012; 47:119-24. [PMID: 22241570 DOI: 10.1002/ppul.21524] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 07/03/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastro-esophageal reflux (GOR) may contribute to lung disease in children with cystic fibrosis (CF). There is conflicting evidence regarding the effect of chest physiotherapy (CPT) in the head-down position on GOR. Furthermore, there is currently no evidence on the impact of physiotherapy on GOR as assessed by pH-multichannel intraluminal impedance (pH-MII). AIMS (1) To characterize GOR in young children with CF. (2) To determine whether the head-down position during physiotherapy exacerbates GOR. METHODS Children were studied using pH-MII monitoring over 24-hr, during which they received two 20-min sessions of CPT. One session was performed in "modified" drainage positions with no head-down tilt and the alternate session in "gravity-assisted" drainage positions, which included 20° head-down tilt. RESULTS Twenty children with CF (8 males), median age 12 months (range 8-34) were recruited. A total of 1,374 reflux episodes were detected in all children, of which 869 (63%) were acid and 505 (37%) were non-acid. Seventy-two percent of the episodes migrated proximally. During CPT, there was no significant difference between total number of reflux episodes in the modified or gravity-assisted positions, median [inter-quartile range (IQR)] 1 (0-2.5) compared to 1 (0.75-3) episode, respectively, P = 0.63. There was also no significant difference between the number of reflux episodes which migrated proximally, median (IQR) 1 (0-2) compared to 0 (0-2) episodes, respectively, P = 0.75. CONCLUSION In young children with CF, GOR is primarily acidic and proximal migration is common. Physiotherapy in the head-down position does not appear to exacerbate GOR. The impact of GOR on lung disease remains to be elucidated.
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Affiliation(s)
- Michael Doumit
- Sydney Children's Hospital, Sydney, Australia. University of New South Wales, Sydney, Australia.
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15
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van der Doef HPJ, Kokke FTM, van der Ent CK, Houwen RHJ. Intestinal obstruction syndromes in cystic fibrosis: meconium ileus, distal intestinal obstruction syndrome, and constipation. Curr Gastroenterol Rep 2011; 13:265-70. [PMID: 21384135 PMCID: PMC3085752 DOI: 10.1007/s11894-011-0185-9] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Meconium ileus at birth, distal intestinal obstruction syndrome (DIOS), and constipation are an interrelated group of intestinal obstruction syndromes with a variable severity of obstruction that occurs in cystic fibrosis patients. Long-term follow-up studies show that today meconium ileus is not a risk factor for impaired nutritional status, pulmonary function, or survival. DIOS and constipation are frequently seen in cystic fibrosis patients, especially later in life; genetic, dietary, and other associations have been explored. Diagnosis of DIOS is based on suggestive symptoms, with a right lower quadrant mass confirmed on abdominal radiography, whereas symptoms of constipation are milder and of longer standing. In DIOS, early aggressive laxative treatment with oral laxatives (polyethylene glycol) or intestinal lavage with balanced osmotic electrolyte solution and rehydration is required, which now makes the need for surgical interventions rare. Constipation can generally be well controlled with polyethylene glycol maintenance treatment.
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Affiliation(s)
- Hubert P J van der Doef
- Department of Pediatric Gastroenterology [KE.04.133.1], University Medical Center Utrecht, Postbox 85090, 3508 AB Utrecht, The Netherlands.
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16
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Giavi S, Megremis S, Papadopoulos NG. Lymphocyte stimulation test for the diagnosis of non-IgE-mediated cow's milk allergy: a step closer to a noninvasive diagnostic tool? Int Arch Allergy Immunol 2011; 157:1-2. [PMID: 21894022 DOI: 10.1159/000327833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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17
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Stafler P, Davies JC, Balfour-Lynn IM, Rosenthal M, Bush A. Bronchoscopy in cystic fibrosis infants diagnosed by newborn screening. Pediatr Pulmonol 2011; 46:696-700. [PMID: 21365781 DOI: 10.1002/ppul.21434] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 12/12/2010] [Accepted: 12/16/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is evidence of early functional and structural changes in babies with cystic fibrosis (CF) diagnosed on newborn screening (NBS). The aim of the present study was to determine the yield of bronchoalveolar lavage (BAL) microbiology and cytology, and 24 hr pH monitoring in a group of CF infants diagnosed on NBS. METHODS Infants referred to a tertiary pediatric respiratory center between July 2007 and November 2009 underwent surveillance fiber-optic bronchoscopy (FOB), BAL, and insertion of a 24 hr dual pH probe under a single general anesthetic. RESULTS We studied 33 infants, median age of 100 days (47-215 days) at the time of FOB. In 9 of 33 (27%) bacterial organisms were identified. Seven of the nine patients (78%) were asymptomatic and only one had had a positive cough swab prior to FOB. Neutrophilia was identified in 18/27 (67%) cases with a median of 11% (6-73%). 13/31 (42%) had an abnormal pH study with a pH index >12%. CONCLUSIONS The high yield of microbiology, cytology, and pH probe investigations in NBS infants justifies invasive surveillance. Longitudinal studies to determine if early aggressive treatment results in improved outcome are awaited.
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Affiliation(s)
- Patrick Stafler
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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18
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Abdulnour-Nakhoul S, Nakhoul HN, Kalliny MI, Gyftopoulos A, Rabon E, Doetjes R, Brown K, Nakhoul NL. Ion transport mechanisms linked to bicarbonate secretion in the esophageal submucosal glands. Am J Physiol Regul Integr Comp Physiol 2011; 301:R83-96. [PMID: 21474426 DOI: 10.1152/ajpregu.00648.2010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The esophageal submucosal glands (SMG) secrete HCO(3)(-) and mucus into the esophageal lumen, where they contribute to acid clearance and epithelial protection. This study characterized the ion transport mechanisms linked to HCO(3)(-) secretion in SMG. We localized ion transporters using immunofluorescence, and we examined their expression by RT-PCR and in situ hybridization. We measured HCO(3)(-) secretion by using pH stat and the isolated perfused esophagus. Using double labeling with Na(+)-K(+)-ATPase as a marker, we localized Na(+)-coupled bicarbonate transporter (NBCe1) and Cl(-)-HCO(3)(-) exchanger (SLC4A2/AE2) to the basolateral membrane of duct cells. Expression of cystic fibrosis transmembrane regulator channel (CFTR) was confirmed by immunofluorescence, RT-PCR, and in situ hybridization. We identified anion exchanger SLC26A6 at the ducts' luminal membrane and Na(+)-K(+)-2Cl(-) (NKCC1) at the basolateral membrane of mucous and duct cells. pH stat experiments showed that elevations in cAMP induced by forskolin or IBMX increased HCO(3)(-) secretion. Genistein, an activator of CFTR, which does not increase intracellular cAMP, also stimulated HCO(3)(-) secretion, whereas glibenclamide, a Cl(-) channel blocker, and bumetanide, a Na(+)-K(+)-2Cl(-) blocker, decreased it. CFTR(inh)-172, a specific CFTR channel blocker, inhibited basal HCO(3)(-) secretion as well as stimulation of HCO(3)(-) secretion by IBMX. This is the first report on the presence of CFTR channels in the esophagus. The role of CFTR in manifestations of esophageal disease in cystic fibrosis patients remains to be determined.
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Affiliation(s)
- Solange Abdulnour-Nakhoul
- Southeast Louisiana Veterans Health Care Network, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
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Cohen-Cymberknoh M, Shoseyov D, Kerem E. Managing cystic fibrosis: strategies that increase life expectancy and improve quality of life. Am J Respir Crit Care Med 2011; 183:1463-71. [PMID: 21330455 DOI: 10.1164/rccm.201009-1478ci] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The survival of patients with cystic fibrosis (CF) continues to improve. The discovery and cloning of the CFTR gene more than 21 years ago led to the identification of the structure and function of the CFTR chloride channel. New therapies based on the understanding of the function of CFTR are currently under development. The better clinical status and improved survival of patients with CF is not only a result of understanding of the molecular mechanisms of CF but also a result of the development of therapeutic strategies that are based on insights into the natural course of the disease. Current CF treatments that target respiratory infections, inflammation, mucociliary clearance, and nutritional status are associated with improved pulmonary function and reduced exacerbations. Patients benefit from treatment at a specialized CF center by a multidisciplinary dedicated team with emphasis being placed on frequent visits, periodic testing, and monitoring adherence to therapy. The purpose of this review is to survey recent developments in CF care that are responsible for the improved survival and quality of life of patients with CF.
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Affiliation(s)
- Malena Cohen-Cymberknoh
- Department of Pediatrics and CF Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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20
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van der Doef HPJ, Arets HGM, Froeling SP, Westers P, Houwen RHJ. Gastric acid inhibition for fat malabsorption or gastroesophageal reflux disease in cystic fibrosis: longitudinal effect on bacterial colonization and pulmonary function. J Pediatr 2009; 155:629-33. [PMID: 19683256 DOI: 10.1016/j.jpeds.2009.06.040] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Revised: 05/28/2009] [Accepted: 06/17/2009] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To investigate bacterial colonization and pulmonary function longitudinally in patients with cystic fibrosis (CF) receiving drugs for gastric acid (GA) inhibition for fat malabsorption or for gastroesophageal reflux disease (GERD). STUDY DESIGN A retrospective cohort study of 218 pediatric patients with CF was performed. Multilevel modeling was used to perform longitudinal analysis of forced expiratory volume in 1 second (FEV(1)), forced vital capacity (FVC), maximum expiratory flow at 50% of FVC (MEF(50)), and maximal mid-expiratory flow between 25% and 75% of FVC (MMEF(25-75)). Cox regression was used to calculate Pseudomonas aeruginosa- and Staphylococcus aureus-free survival. RESULTS Patients with CF and GA inhibition had a significantly smaller yearly decline of MEF(50) and MMEF(25-75) compared with control subjects. Other pulmonary function parameters and P aeruginosa or S aureus acquisition or colonization were not different from that of control subjects. GERD was associated with a significantly reduced pulmonary function (FEV(1) and FVC) and an earlier acquisition of P aeruginosa and S aureus. CONCLUSIONS GA inhibition did not affect pulmonary function or bacterial acquisition and therefore is not contraindicated in patients with CF. GA inhibition might improve pulmonary function with time, because the decline of MEF(50) and MMEF(25-75) was less pronounced. GERD was associated with a reduced pulmonary function and an earlier acquisition of P aeruginosa and S aureus. Therefore the diagnosis and treatment of GERD should be aggressively pursued in patients with CF.
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Affiliation(s)
- Hubert P J van der Doef
- Department of Pediatric Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands.
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21
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Fathi H, Moon T, Donaldson J, Jackson W, Sedman P, Morice AH. Cough in adult cystic fibrosis: diagnosis and response to fundoplication. Cough 2009; 5:1. [PMID: 19149907 PMCID: PMC2634760 DOI: 10.1186/1745-9974-5-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 01/18/2009] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux is one of the most common causes of chronic cough in the general population. Reflux occurs frequently in patients with cystic fibrosis (CF). We undertook laparoscopic Nissen fundoplication in adult CF patients with a clinical diagnosis of reflux cough who had failed conventional medical therapies. OBJECTIVE We determined the response to the surgical route in the treatment of intractable reflux cough in CF. METHOD Patients with refractory cough were assessed by 24 h pH monitoring and oesophageal manometry. Pre-and post-operation cough, lung function and exacerbation frequency were compared. Cough was assessed by the Leicester Cough Questionnaire (LCQ), lung function by spirometry and exacerbation frequency was defined by comparing the postoperative epoch with a similar preoperatively. RESULTS Significant abnormalities of oesophageal function were seen in all patients studied. 6 patients (2 females), with the mean age of 34.5 years consented to surgery. Their mean number of reflux episodes was 144.4, mean DeMeester score was 39.2, and mean lower oesophageal sphincter pressure 12.4 mmHg. There was a small change in the FEV1 from 1.03 L to 1.17 (P = 0.04), and FVC improved from 2.62 to 2.87 (P = 0.05). Fundoplication lead to a marked fall in cough with the total LCQ score increasing from 11.9 to 18.3 (P = 0.01). Exacerbation events were reduced by 50% post operatively. CONCLUSION Whilst there is an obvious attention to respiratory causes of cough in CF, reflux is also a common cause. Fundoplication is highly effective in the control of reflux cough in CF. Significant reduction in exacerbation frequency may indicate that reflux with possible aspiration is a major unrecognised contributor to airway disease.
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Affiliation(s)
- Hosnieh Fathi
- Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
| | - Tanya Moon
- Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
| | - Jo Donaldson
- Dietetics Department, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
| | - Warren Jackson
- Gastro-Intestinal Physiology Laboratory, Castle Hill Hospital, Cottingham, East Yorkshire, HU16 5JQ, UK
| | - Peter Sedman
- Division of Upper Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, UK
| | - Alyn H Morice
- Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
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22
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Alexander CL, Urbanski SJ, Hilsden R, Rabin H, MacNaughton WK, Beck PL. The risk of gastrointestinal malignancies in cystic fibrosis: case report of a patient with a near obstructing villous adenoma found on colon cancer screening and Barrett's esophagus. J Cyst Fibros 2007; 7:1-6. [PMID: 17766191 DOI: 10.1016/j.jcf.2007.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Revised: 07/04/2007] [Accepted: 07/07/2007] [Indexed: 02/07/2023]
Abstract
The life expectancy for cystic fibrosis (CF) patients has increased dramatically over the last 30 years. Although the overall cancer risk for CF patients does not appear to be increased there is a marked increased risk of gastrointestinal malignancies especially in the post lung transplant population. CF patients that do develop gastrointestinal malignancies do so at an earlier age and there is often a lag in the diagnosis and management of these individuals. We present a 39 year old male CF patient that underwent a colonoscopy for colon cancer screening and a large, near obstructing, villous adenoma of his ileum was found. The polyp was removed successfully via endoscopy without incident and there was no evidence of malignancy. An upper endoscopy revealed a long segment of Barrett's esophagus with no evidence of dysplasia. We present this case as well as a detailed review of the literature on cancer risk in CF and a discussion of the mechanisms that may be involved. We also present the risk of GI malignancies in non-CF patients as a guide on how to assess and manage the risk of GI malignancies in this ever-changing patient population.
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Affiliation(s)
- C L Alexander
- Gastrointestinal Research Group and Inflammation Research Network, Institute of Infection, Immunity and Inflammation, University of Calgary, Calgary, Alberta, Canada
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23
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Littlewood JM, Wolfe SP, Conway SP. Diagnosis and treatment of intestinal malabsorption in cystic fibrosis. Pediatr Pulmonol 2006; 41:35-49. [PMID: 16288483 DOI: 10.1002/ppul.20286] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Intestinal malabsorption is severe and of early onset in virtually all people who have cystic fibrosis. The main cause is deficiency of pancreatic enzymes. Bicarbonate deficiency, abnormal bile salts, mucosal transport problems, motility differences, and anatomical structural changes are other contributory factors. Effective treatment should allow a normal to high-fat diet to be taken, control symptoms, correct malabsorption, and achieve a normal nutritional state and growth. Appropriate pancreatic enzyme replacement therapy will achieve normal or near-normal absorption in most people with cystic fibrosis. Early identification and treatment of intestinal malabsorption is critical to achieving optimal nutritional status. The occurrence of fibrosing colonopathy in a few patients on very high doses of those enzymes which have the copolymer Eudragit L30 D55 in their covering resulted in guidelines in the UK to avoid doses equivalent to more than 10,000 IU lipase per kg per day, and also to avoid preparations containing this copolymer in children and adolescents. For patients not responding to 10,000 IU lipase per kg per day review of adherence to treatment, change of enzyme preparation, variation in time of administration, and reduction in gastric acid may improve absorption. The importance of early investigation to exclude other gastrointestinal disorders as a cause of the patient's symptoms, rather than merely increasing the dose of enzymes, is stressed. With modern pancreatic enzymes in doses up to or only slightly in excess of 10,000 IU lipase per kg per day, adequate control of gastrointestinal symptoms and absorption can be achieved, and a normal nutritional state and growth rate maintained in most people with cystic fibrosis.
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Affiliation(s)
- James M Littlewood
- Regional Paediatric Cystic Fibrosis Unit, St. James's University Hospital, Leeds, UK.
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24
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Sinaasappel M, Stern M, Littlewood J, Wolfe S, Steinkamp G, Heijerman HGM, Robberecht E, Döring G. Nutrition in patients with cystic fibrosis: a European Consensus. J Cyst Fibros 2004; 1:51-75. [PMID: 15463811 DOI: 10.1016/s1569-1993(02)00032-2] [Citation(s) in RCA: 255] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This document is the result of an European Consensus conference which took place in Artimino, Tuscany, Italy, in March 2001 involving 33 experts on nutrition in patients with cystic fibrosis, organised by the European Cystic Fibrosis Society, and sponsored by Axcan-Scandipharm, Baxter, Dr Falk Pharma, Fresenius, Nutricia, SHS International, Solvay Pharmaceuticals (major sponsor). The purpose of the conference was to develop a consensus document on nutrition in patients with cystic fibrosis based on current evidence.
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Affiliation(s)
- M Sinaasappel
- Department of Paediatric Gastroenterology, Erasmus Medical Centre, Rotterdam, The Netherlands
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25
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Henry SM. Discerning differences: gastroesophageal reflux and gastroesophageal reflux disease in infants. Adv Neonatal Care 2004; 4:235-47. [PMID: 15368216 DOI: 10.1016/j.adnc.2004.05.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Gastroesophageal reflux (GER) is a frequently encountered problem in infancy; it commonly resolves spontaneously by 12 months of age. Caregivers are challenged to discriminate between physiologic GER and the much less common and more serious condition of pathologic gastroesophageal reflux disease (GERD). Pathologic GERD may require more extensive clinical evaluation and necessitate treatment. GERD may be primary or secondary; secondary GERD is associated with a number of genetic syndromes, chromosomal abnormalities, birth defects, or a host of neurologic conditions frequently seen in the newborn intensive care unit. This article reviews the unique anatomic, physiologic, developmental, and nutritional vulnerabilities of infants that make them susceptible to GER and GERD. The North American Society of Pediatric Gastroenterology and Nutrition have recently developed a comprehensive evidence-based clinical practice guideline that structures the diagnostic approach and treatment option in infants with suspected and confirmed GERD. These guidelines provide clear definitions of GER and GERD to aid the clinician in distinguishing between the 2 conditions. They emphasize the use of history and physical examination and discuss the indications for the use of other diagnostic procedures, such as upper gastrointestinal studies, nuclear medicine scintiscan, esophagogastroduodenoscopy with biopsy, and esophageal pH probe monitoring. Management of GERD begins with a nonpharmacologic approach; the emphasis is on positioning, a trial of a hypoallergenic formula, and thickening of feedings. When these measures fail to control symptoms, a trial of either histamine(2) antagonists or a proton pump inhibitor may be indicated. Finally, surgical treatment may be needed if all other management measures fail. New sleep recommendations for infants with GERD are now consistent with the American Academy of Pediatrics' standard recommendations. Prone sleep positioning is only considered in unusual cases, where the risk of death and complications from GERD outweighs the potential increased risk of sudden infant death syndrome (SIDS). The nursing care of infants with GER and GERD, as well as relevant issues for parent education and support, are reviewed and are essential elements in managing this common condition.
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Button BM, Heine RG, Catto-Smith AG, Phelan PD, Olinsky A. Chest physiotherapy, gastro-oesophageal reflux, and arousal in infants with cystic fibrosis. Arch Dis Child 2004; 89:435-9. [PMID: 15102635 PMCID: PMC1719900 DOI: 10.1136/adc.2003.033100] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Postural drainage chest physiotherapy in infants with cystic fibrosis (CF) exacerbates gastro-oesophageal reflux (GOR) and may contribute to a more rapid deterioration in lung function. AIMS To compare standard postural drainage chest physiotherapy (SPT) and a modified physiotherapy regimen (MPT) without head-down tilt, with regard to GOR, arousal state, and cardiorespiratory function. METHODS Twenty infants with CF underwent 30 hour oesophageal pH monitoring, during which four chest physiotherapy sessions were administered (day 1: MPT-SPT; day 2: SPT-MPT). Arousal state, heart rate, and oxygen saturation were documented for each of the physiotherapy positions (supine, prone, right lateral, and left lateral with (SPT) or without (MPT) 30 degrees head-down tilt). RESULTS Significantly more reflux episodes occurred during SPT than during MPT, but there were no significant differences in median episode duration or fractional reflux time. During SPT, left lateral positioning was associated with fewer reflux episodes compared to other positions. During supine and prone positioning, more reflux episodes occurred during SPT than during MPT. Infants were significantly more likely to be awake or cry during SPT. There was a significant association between crying and reflux episodes for SPT. Non-nutritive sucking was associated with a significant reduction in reflux episodes during SPT. Oxygen saturation during SPT was significantly lower during crying and other waking, and non-nutritive sucking during SPT was associated with a significant increase in oxygen saturation. CONCLUSIONS SPT is associated with GOR, distressed behaviour, and lower oxygen saturation.
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Affiliation(s)
- B M Button
- School of Physiotherapy, The University of Melbourne, Parkville, Victoria 3052, Australia
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27
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Dahms BB. Reflux esophagitis: sequelae and differential diagnosis in infants and children including eosinophilic esophagitis. Pediatr Dev Pathol 2004; 7:5-16. [PMID: 15255030 DOI: 10.1007/s10024-003-0203-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a common condition in infants and children and has many clinical mimics. Most pediatric pathology departments process many mucosal biopsies from the proximal gastrointestinal tract to evaluate the presence or absence of reflux esophagitis. Since this subject was last reviewed in the 1997 edition of Perspectives in Pediatric Pathology devoted to gastrointestinal diseases in children (Dahms BB. Reflux esophagitis and sequelae in infants and children. In: Dahms BB, Qualman SJ, eds. Gastrointestinal Disease. Perspectives in Pediatric Pathology, vol. 20. Basel: Karger, 1997;14-34), progress in the field has allowed recognition of additional presenting symptoms and treatments of GERD. Histologic criteria for diagnosing reflux esophagitis have not changed. However, the entity of eosinophilic esophagitis has emerged since 1997 and has been defined well enough to allow it to be distinguished from reflux esophagitis, with which it was probably previously confused. Refinements (though not simplification!) in the definition of Barrett esophagus are still in evolution. This review will summarize these newer concepts and briefly review the standards of diagnosis of reflux esophagitis.
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Affiliation(s)
- Beverly Barrett Dahms
- Department of Pathology, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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28
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Darviot-Duveau E. Question 3 Quelle démarche diagnostique devant des douleurs abdominales chez le patient atteint de mucoviscidose? Quelle demarche diagnostique devant des douleurs abdominales chez le patient atteint de mucoviscidose? Arch Pediatr 2003; 10 Suppl 3:459s-461s. [PMID: 14671960 DOI: 10.1016/s0929-693x(03)90011-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- E Darviot-Duveau
- Département de pédiatrie, urgences, CHU 4, rue Larrey, 49033 Angers, France
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29
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Turck D. Question 1 Quelle influence de l'état nutritionnel sur l'évolution de la mucoviscidose? Aspect physiopathologique des troubles nutritionnels au cours de la mucoviscidose. Arch Pediatr 2003; 10 Suppl 3:413s-420s. [PMID: 14671953 DOI: 10.1016/s0929-693x(03)90004-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- D Turck
- Centre de ressources et de compétences de la mucoviscidose, unité de gastroentérologie, hépatologie et nutrition, clinique de pédiatrie, hôpital Jeanne-de-Flandre et faculté de médecine, 59037 Lille, France
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30
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31
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Jackson R, Pencharz PB. Transition of care between paediatric and adult gastroenterology. Cystic fibrosis. Best Pract Res Clin Gastroenterol 2003; 17:213-35. [PMID: 12676116 DOI: 10.1016/s1521-6918(02)00150-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Reuben Jackson
- Department of Paediatrics, Division of GI/Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ont., Canada M5G 1X8
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Button BM, Heine RG, Catto-Smith AG, Olinsky A, Phelan PD, Ditchfield MR, Story I. Chest physiotherapy in infants with cystic fibrosis: to tip or not? A five-year study. Pediatr Pulmonol 2003; 35:208-13. [PMID: 12567389 DOI: 10.1002/ppul.10227] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
There is controversy about the need for postural drainage physiotherapy in asymptomatic infants with cystic fibrosis (CF). We aimed to compare the effectiveness of standard postural drainage chest physiotherapy (SPT) with a modified physiotherapy regimen without head-down tilt (MPT) in young infants with CF. Twenty newly diagnosed infants with CF (mean age, 2.1 months; range, 1-4) were randomized to SPT or MPT. Parents kept a detailed symptom and treatment diary for the following 12 months. Serial chest radiographs, taken at diagnosis, 12 months, 2(1/2) years, and 5 years after diagnosis, were assessed using the Brasfield score. Pulmonary function tests were compared between groups after 5 years. Of the 20 infants, 16 (80%) completed the review at 12 months, and 14 (70%) at 2(1/2) and 5 years. Patients receiving SPT had more days with upper respiratory tract symptoms than those on MPT (70 +/- 32.8 vs. 37 +/- 24.9 days; P = 0.04) and required longer courses of antibiotics (23 +/- 28.5 vs. 14 +/- 11.2 days; P = 0.05). Chest x-ray scores were similar at diagnosis but were worse at 2(1/2) years for those receiving SPT (P = 0.03). Forced vital capacity and forced expired volume in 1 sec (FEV(1)) at 5-6 years was lower for SPT than for MPT (P < 0.05). In conclusion, MPT was associated with fewer respiratory complications than SPT in infants with CF.
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Affiliation(s)
- Brenda M Button
- Department of Physiotherapy, Royal Children's Hospital, Melbourne, Australia.
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Balfour-Lynn IM. Asthma in cystic fibrosis. J R Soc Med 2003; 96 Suppl 43:30-4. [PMID: 12906323 PMCID: PMC1308785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Affiliation(s)
- Ian M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Royal Brompton & Harefield NHS Trust, Sydney Street, London SW3 6NP, UK.
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Nixon GM, Armstrong DS, Carzino R, Carlin JB, Olinsky A, Robertson CF, Grimwood K, Wainwright C. Early airway infection, inflammation, and lung function in cystic fibrosis. Arch Dis Child 2002; 87:306-11. [PMID: 12244003 PMCID: PMC1763045 DOI: 10.1136/adc.87.4.306] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To determine the relation between lower airway infection and inflammation, respiratory symptoms, and lung function in infants and young children with cystic fibrosis (CF). METHODS A prospective study of children with CF aged younger than 3 years, diagnosed by a newborn screening programme. All were clinically stable and had testing as outpatients. Subjects underwent bronchial lavage (BL) and lung function testing by the raised volume rapid thoracoabdominal compression technique under general anaesthesia. BL fluid was cultured and analysed for neutrophil count, interleukin 8, and neutrophil elastase. Lung function was assessed by forced expiratory volume in 0.5, 0.75, and 1 second. RESULTS Thirty six children with CF were tested on 54 occasions. Lower airway infection shown by BL was associated with a 10% reduction in FEV(0.5) compared with subjects without infection. No relation was identified between airway inflammation and lung function. Daily moist cough within the week before testing was reported on 20/54 occasions, but in only seven (35%) was infection detected. Independent of either infection status or airway inflammation, those with daily cough had lower lung function than those without respiratory symptoms at the time of BL (mean adjusted FEV(0.5) 195 ml and 236 ml respectively). CONCLUSIONS In young children with CF, both respiratory symptoms and airway infection have independent, additive effects on lung function, unrelated to airway inflammation. Further studies are needed to understand the mechanisms of airway obstruction in these young patients.
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Affiliation(s)
- G M Nixon
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Australia.
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Abstract
The diagnosis of "CF asthma" is problematic and it is difficult to determine which patients have a combination of CF and asthma and which have asthma like symptoms caused by inflammation of the CF lung. This may not matter, however; the relevance lies in the possible approaches to treatment.
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Affiliation(s)
- I M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Royal Brompton & Harefield NHS Trust, London SW3 6NP, UK.
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Abstract
Nutrition plays an essential role in the management of cystic fibrosis (CF), particularly in infants with their high energy requirement due to rapid growth. Most infants are already malnourished at the time of clinical diagnosis due to an energy imbalance with increased losses and needs not compensated by energy intake. Even in very young asymptomatic CF patients diagnosed by neonatal screening programs, nutritional deficits can be detected in a high proportion of infants, since about half of all CF patients have evidence of pancreatic insufficiency at the time of birth. This review provides recommendations for assessment of the nutritional status at diagnosis and nutritional management including supplementation with pancreatic enzymes during the first year of life.
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Affiliation(s)
- S Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. v. Haunerschen Kinderspital, Ludwig-Maximilians-Universität, Pettenkoferstr. 8a, D-80336, München, Germany.
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Hendriks JJ, Kester AD, Donckerwolcke R, Forget PP, Wouters EF. Changes in pulmonary hyperinflation and bronchial hyperresponsiveness following treatment with lansoprazole in children with cystic fibrosis. Pediatr Pulmonol 2001; 31:59-66. [PMID: 11180676 DOI: 10.1002/1099-0496(200101)31:1<59::aid-ppul1008>3.0.co;2-h] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
SUMMARY. In this prospective open study of 14 children with cystic fibrosis (CF), we evaluated the effect of 1 year adjuvant therapy with lansoprazole, a proton pump inhibitor (PPI), on growth, fecal fat loss, body composition and lung function. Only stable patients with pancreatic insufficiency were included, and their data were compared to those of a large Dutch pediatric normal reference population. During the use of the PPI, mean weight and height did not change significantly, while body mass index improved (P < 0.05). An immediate significant and persistent reduction of fecal acid steatocrit (P < 0.05) was demonstrated. Compared to normal Dutch children, the CF patients showed significantly decreased standard deviation scores (SDS) for total body fat (TBF, -0.966) and fat-free mass (FFM, -1.826). Under lansoprazole, TBF improved significantly (P < 0.05), while mean FFM remained unchanged. A significant improvement in total lung capacity (P < 0.05), residual volume (P = 0.055), and maximal inspiratory mouth pressure (P = 0.002) was also demonstrated. Hyperinflation tended to decrease during the use of a PPI. Daily recordings of peak expiratory flow (PEF) showed a maximal diurnal variability of 28% of recent best PEF and minimal morning PEF of 72% of recent best PEF, confirming that bronchial hyperresponsiveness is increased in CF. We conclude that adjuvant therapy with lansoprazole in young CF patients with persistent fat malabsorption, decreased fat losses and improved total body fat. Lung hyperinflation decreased, which may partly explain the improvement in inspiratory muscle performance. The simultaneous improvements in body composition and lung hyperinflation suggest a relationship between these two parameters. Further research is necessary to confirm such a relationship and to elucidate the mechanisms involved.
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Affiliation(s)
- J J Hendriks
- Department of Paediatrics, University Hospital and University of Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
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Abstract
Intestinal malabsorption is severe and of early onset in virtually all people who have cystic fibrosis. The main cause is deficiency of pancreatic enzymes, but bicarbonate deficiency, abnormalities of bile salts, mucosal transport and motility, and anatomical structural changes are other contributory factors. Appropriate pancreatic replacement therapy will achieve normal or near normal absorption in many patients. It is important to identify both malabsorption and evidence of a pancreatic lesion in all patients who are to receive pancreatic enzymes. All who have evidence of fat malabsorption are deemed pancreatic insufficient and candidates for enzyme replacement therapy. Effective treatment should allow a normal diet to be taken, control symptoms, correct malabsorption and achieve a normal nutritional state and growth. The occurrence of fibrosing colonopathy in some patients receiving very high doses of those enzymes that have the copolymer Eudragit L30 D55 in their covering has resulted in guidelines in the UK to avoid dosages greater than the equivalent of 10,000 IU lipase/kg/day for all patients and also to avoid preparations containing this copolymer in children and adolescents. For patients not responding to 10,000 IU lipase/kg/day, review of adherence to treatment, change of enzyme preparation, variation of the time of administration and reduction in gastric acid may improve absorption. The importance of excluding other gastrointestinal disorders as a cause of the patient's symptoms and the need for early investigations, rather than merely increasing the dosage of enzymes, is stressed. With modern enzymes, adequate control of gastrointestinal symptoms and absorption can be achieved at dosages of 10,000 IU lipase/kg/day or only slightly more, and a normal nutritional state and growth rate maintained in most patients with cystic fibrosis.
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Affiliation(s)
- J M Littlewood
- Regional Paediatric Cystic Fibrosis Unit, St James Hospital, Leeds, England.
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Anthony H, Paxton S, Catto-Smith A, Phelan P. Physiological and psychosocial contributors to malnutrition in children with cystic fibrosis: review. Clin Nutr 1999; 18:327-35. [PMID: 10634916 DOI: 10.1016/s0261-5614(99)80011-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- H Anthony
- School of Biological Sciences, University of Surrey, UK
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