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Litwin A, Le Thi TG, Pancheva R, Niseteo T, Hauer AC, Kindermann A, Lacaille F, Nicastro E, Czubkowski P, Ikrath K, Gerasimidis K, Koletzko S. Anthropometric assessment: ESPGHAN quality of care survey from paediatric hospitals in 28 European countries. J Pediatr Gastroenterol Nutr 2024; 78:936-947. [PMID: 38284746 DOI: 10.1002/jpn3.12136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/19/2023] [Accepted: 01/11/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Assessment of anthropometric data is essential for paediatric healthcare. We surveyed the implementation of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) evidence-based guidelines and practical recommendations on nutritional care, particularly regarding anthropometric measurements. METHODS Paediatric hospitals from 28 European countries provided pseudonymized data through online questionnaires on hospital characteristics and their standards of nutritional care. Practical tasks assessed an unbiased collection and reporting of anthropometric measurements in random patients' files and discharge letters. RESULTS Of 114 hospitals (67% academic), 9% have no nutritionist/dietitian available, 18% do not provide standard policy to assess weight and height and 15% lack training for nursing staff for accurate performance. A wall-mounted stadiometer to measure standing height and equipment for sitting weight is unavailable in 9% and 32%, respectively. Infant length is measured by one instead of two healthcare professionals and with a tape instead of a rigid length measuring board in 58% and 15% of hospitals, respectively. The practical tasks reviewed 1414 random patients, thereof 446 younger than 2 years of age. Missing documentation occurred significantly more often for height versus weight and their percentiles in infants ≤2 years versus older children, and in general paediatric versus gastrointestinal patients, with no difference between academic and nonacademic hospitals. Review of documented anthropometric data in discharge letters disclosed that consultants significantly underestimated the deficits in their units compared to documented data. CONCLUSIONS The survey revealed significant gaps in performance and documentation of anthropometry in the participating hospitals. A resurvey will assess changes in quality of care over time.
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Affiliation(s)
- Anna Litwin
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital Munich, Munich, Germany
| | - Thu Giang Le Thi
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital Munich, Munich, Germany
| | - Rouzha Pancheva
- Department of Hygiene and Epidemiology, Faculty of Public Health, Research Group NutriLect, Varna, Bulgaria
- Department of Neuroscience, Research Institute, Prof. Paraskev Stoyanov Medical University, Varna, Bulgaria
| | - Tena Niseteo
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Almuthe Christina Hauer
- Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands
| | - Florence Lacaille
- Pediatric Gastroenterology-Nutrition and Hepatology Units, Hôpital Necker-Enfants Malades, Paris, France
| | - Emanuele Nicastro
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutrition Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Katharina Ikrath
- The European Society for Paediatric Gastroenterology Hepatology and Nutrition, Geneva, Switzerland
| | | | - Sibylle Koletzko
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital Munich, Munich, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
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Krijger A, Schiphof-Godart L, Elstgeest L, van Rossum C, Verkaik-Kloosterman J, Steenbergen E, Ter Borg S, Lanting C, van Drongelen K, Engelse O, Kindermann A, Detmar S, Frenkel C, Raat H, Joosten K. Development and evaluation study of FLY-Kids: a new lifestyle screening tool for young children. Eur J Pediatr 2023; 182:4749-4757. [PMID: 37580556 PMCID: PMC10587277 DOI: 10.1007/s00431-023-05126-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/09/2023] [Accepted: 07/18/2023] [Indexed: 08/16/2023]
Abstract
Evaluating, discussing, and advising on young children's lifestyles may contribute to timely modification of unhealthy behaviour and prevention of adverse health consequences. We aimed to develop and evaluate a new lifestyle screening tool for children aged 1-3 years. The lifestyle screening tool "FLY-Kids" was developed using data from lifestyle behaviour patterns of Dutch toddlers, age-specific lifestyle recommendations, target group analyses, and a Delphi process. Through 10 items, FLY-Kids generates a dashboard with an overview of the child's lifestyle that can be used as conversation aid. FLY-Kids was completed by parents of children aged 1-3 years attending a regular youth healthcare appointment. Youth healthcare professionals (YHCP) then used the FLY-Kids dashboard to discuss lifestyle with the parents and provided tailored advice. Parents as well as YHCP evaluated the tool after use. Descriptive and correlation statistics were used to determine the usability, feasibility, and preliminary effect of FLY-Kids. Parents (N = 201) scored an average of 3.2 (out of 9, SD 1.6) unfavourable lifestyle behaviours in their children, while 3.0% complied with all recommendations. Most unfavourable behaviours were reported in unhealthy food intake and electronic screen time behaviour. Parents and YHCP regarded FLY-Kids as usable and feasible. The number of items identified by FLY-Kids as requiring attention was associated with the number of items discussed during the appointment (r = 0.47, p < 0.001). Conclusion: FLY-Kids can be used to identify unhealthy lifestyle behaviour in young children and guide the conversation about lifestyle in preventive healthcare settings. End-users rated FLY-Kids as helpful and user-friendly. What is Known: • A healthy lifestyle is important for optimal growth, development and overall health of young children (1-3 years). • Evaluating, discussing and advising on young children's lifestyles may contribute to timely modification of unhealthy behaviour and prevention of adverse health consequences. What is New: • The new lifestyle screening tool FLY-Kids generates a dashboard with an overview of young children's lifestyle that can be used as conversation aid between parents and youth healthcare professionals. • As parents and youth healthcare professionals rated FLY-Kids as helpful and user-friendly, and the number of items identified by FLY-Kids as requiring attention was associated with the number of items discussed during the appointment, FLY-Kids can be considered guiding the lifestyle discussion in preventive healthcare settings.
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Affiliation(s)
- Anne Krijger
- Department of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, PO Box 2060, 3000 CB, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lieke Schiphof-Godart
- Department of Medical Informatics, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Liset Elstgeest
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Reinier Academy, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Caroline van Rossum
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | | | - Elly Steenbergen
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Sovianne Ter Borg
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Caren Lanting
- Netherlands Organisation for Applied Scientific Research TNO, Unit Healthy Living, Child Health Expertise Group, Leiden, The Netherlands
| | | | - Ondine Engelse
- Dutch Knowledge Centre for Youth Health, Utrecht, The Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Symone Detmar
- Netherlands Organisation for Applied Scientific Research TNO, Unit Healthy Living, Child Health Expertise Group, Leiden, The Netherlands
| | - Carolien Frenkel
- Association of Dutch Infant and Dietetic Foods Industries, The Hague, The Netherlands
| | - Hein Raat
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Koen Joosten
- Department of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, PO Box 2060, 3000 CB, Rotterdam, The Netherlands.
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3
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Krom H, van Mameren J, Remijn L, de Nennie K, Dumont E, van der Gaag E, van Leeuwen MCC, Mulkens S, Schakelaar C, Kindermann A. Impact of COVID-19 Pandemic on Young Children With Feeding and Eating Problems and Disorders and Their Families. J Pediatr Gastroenterol Nutr 2022; 75:529-534. [PMID: 35836323 PMCID: PMC9470045 DOI: 10.1097/mpg.0000000000003563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The incidence of feeding and eating problems and disorders (FEPD) in children increased during the coronavirus disease 2019 (COVID-19) pandemic. The aim of this study was to assess the impact of the COVID-19 pandemic on young children with FEPD and their parents. METHODS Cross-sectional survey: parents of children with FEPD (0-11 years) in the Netherlands completed an online questionnaire (January-April 2021). This questionnaire included 4 demographic questions (including criteria of pediatric feeding disorder [PFD] and/or avoidant/restrictive food intake disorder [ARFID]) and 11 questions related to experienced impact of the COVID-19 pandemic. Parental responses regarding children with FEPD (including PFD and ARFID) were compared with those of healthy controls (HCs). RESULTS In total, 240 children (median age, 5.5 years; interquartile range [IQR], 3.5-7.9 years; 53.3% female) were included; 129 children with FEPD and 111 HC. Most children with FEPD fulfilled criteria for PFD (n = 119; 92.2%) and/or ARFID (n = 117; 90.7%). Parents of children with FEPD reported more stress (of their child [ P = 0.014] and parental stress [ P = 0.014]), worse eating by the child ( P < 0.001), more negative relations within the family ( P = 0.006), and less support from the environment ( P = 0.001) compared with parents of HC during the COVID-19 pandemic than before. CONCLUSIONS It seems that the COVID-19 pandemic had great impact on young children with FEPD and their parents because parents of children with FEPD reported significantly more perceived stress within both the child and parents, more difficult eating behavior of the child, more negative behavior between family members, and less support from the environment as compared with HC.
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Affiliation(s)
- Hilde Krom
- From the Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- the SeysCentra, Malden, The Netherlands
| | - Joost van Mameren
- the Multidisciplinary Advisory Board, Patient organization "Nee-eten," Haarlem, The Netherlands
- the Institute of Physics, University of Amsterdam, Amsterdam, The Netherlands
| | - Lianne Remijn
- the Multidisciplinary Advisory Board, Patient organization "Nee-eten," Haarlem, The Netherlands
- the HAN University of Applied Sciences, Academy of Health Studies, Nijmegen, The Netherlands
| | - Katinka de Nennie
- the Multidisciplinary Advisory Board, Patient organization "Nee-eten," Haarlem, The Netherlands
- the Pediatric Dietetic Practice Katinka de Nennie, Gouda/Zoetermeer, The Netherlands
| | - Eric Dumont
- the SeysCentra, Malden, The Netherlands
- the Multidisciplinary Advisory Board, Patient organization "Nee-eten," Haarlem, The Netherlands
- the Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
- the Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Ellen van der Gaag
- the Multidisciplinary Advisory Board, Patient organization "Nee-eten," Haarlem, The Netherlands
- the Pediatric Department Hospital Group Twente, Almelo-Hengelo, The Netherlands
| | | | - Sandra Mulkens
- the SeysCentra, Malden, The Netherlands
- the Multidisciplinary Advisory Board, Patient organization "Nee-eten," Haarlem, The Netherlands
- the Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
- the Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Chantal Schakelaar
- the Multidisciplinary Advisory Board, Patient organization "Nee-eten," Haarlem, The Netherlands
- the Isa Power, Udenhout, The Netherlands
| | - Angelika Kindermann
- From the Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- the Multidisciplinary Advisory Board, Patient organization "Nee-eten," Haarlem, The Netherlands
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4
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van Wassenaer EA, van Rijn RR, Zwetsloot SLM, de Voogd FAE, van Schuppen J, Kindermann A, de Meij TGJ, van Limbergen JE, Gecse KB, D'Haens GR, Benninga MA, Koot BGP. Intestinal Ultrasound to Assess Ulcerative Colitis Disease Activity in Children: External Validation and Comparison of 2 Intestinal Ultrasound Activity Indices. Inflamm Bowel Dis 2022:6712311. [PMID: 36149272 PMCID: PMC10393203 DOI: 10.1093/ibd/izac197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND There is currently no consensus on the definition of an abnormal intestinal ultrasound (IUS) for children with ulcerative colitis (UC). This cross-sectional study aimed to externally validate and compare 2 existing IUS indices in children with UC. METHODS Children undergoing colonoscopy for UC assessment underwent IUS the day before colonoscopy, assessed with the Mayo endoscopic subscore. The UC-IUS index and the Civitelli index were compared with the Mayo endoscopic score in the ascending, transverse, and descending colon. The area under the receiver-operating characteristic curve for detecting a Mayo endoscopic score ≥2 of both scores was compared and sensitivity and specificity were calculated. RESULTS A total of 35 UC patients were included (median age 15 years, 39% female). The area under the receiver-operating characteristic curve was higher for the UC-IUS index in the ascending colon (0.82 [95% confidence interval (CI), 0.67-0.97] vs 0.76 [95% CI, 0.59-0.93]; P = .046) and transverse colon (0.88 [95% CI, 0.76-1.00] vs 0.77 [95% CI, 0.60-0.93]; P = .01). In the descending colon, there was no difference (0.84 [95% CI, 0.70-0.99] vs 0.84 [95% CI, 0.70-0.98]). The optimal cutoff for the UC-IUS was <1 point to rule out a Mayo endoscopic score ≥2 (sensitivity: 88%, 100%, and 90% in the ascending, transverse, and descending colon, respectively) and a Mayo endoscopic score ≥2 could be detected using a cutoff of >1 (specificity: 84%, 83%, and 87%, respectively). For the Civitelli index, in our cohort, the optimal cutoff was <1 to rule out a Mayo endoscopic score ≥2 (sensitivity 75%, 65%, and 80%, respectively) and a cutoff >1 to detect a Mayo endoscopic score ≥2 (specificity 89%, 89%, and 93%, respectively). CONCLUSIONS In this cohort, the UC-IUS index performed better than the Civitelli index. The UC-IUS index had both a high sensitivity and specificity in this cohort, when using 1 point as cutoff for a Mayo endoscopic score ≥2.
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Affiliation(s)
- Elsa A van Wassenaer
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Sabrina L M Zwetsloot
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Floris A E de Voogd
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlandsand
| | - Joost van Schuppen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Angelika Kindermann
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Tim G J de Meij
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Johan E van Limbergen
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - K B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlandsand
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlandsand
| | - Marc A Benninga
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bart G P Koot
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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5
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van der Krogt JMA, Verkuil F, van Gulik EC, Hemke R, van den Berg JM, Schonenberg-Meinema D, Kindermann A, Dolman KM, Benninga MA, Kuijpers TW, Maas M, Nusman CM. Comparison of contrast-enhanced MRI features of the (teno)synovium in the wrist of patients with juvenile idiopathic arthritis and pediatric controls. Rheumatol Int 2021; 42:1257-1264. [PMID: 34811568 PMCID: PMC9203396 DOI: 10.1007/s00296-021-05041-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/26/2021] [Indexed: 11/12/2022]
Abstract
To directly compare and describe the differences between juvenile idiopathic arthritis (JIA) patients and pediatric controls regarding features of the synovial and tenosynovial membrane on contrast-enhanced magnetic resonance imaging (MRI) of the wrist. T1-weighted contrast-enhanced MRI scans of 25 JIA patients with clinically active wrist arthritis and 25 children without a history of joint complaints nor any clinical signs of joint inflammation were evaluated by two readers blinded to clinical data. The synovium was scored at five anatomical sites based on thickening of the synovium (0–3 scale) and synovial enhancement (0–2 scale). Thickening and/or enhancement of the tenosynovium was scored at four anatomical sites using a 0–3 scale. Significantly higher scores for synovial thickening (median 4 vs. 1, p < 0.001) and synovial enhancement (median 4 vs. 1, p < 0.001) are found in the wrist of JIA patients as compared to controls. JIA patients experienced the highest synovial scores at the mid-/inter-carpal, 2nd –5th carpometacarpal, and radiocarpal joints. No significant difference in tenosynovial scores is found between both groups (median 0 vs. 0, p = 0.220). This study highlights the higher synovial thickening/enhancement scores on contrast-enhanced MRI of the wrist in JIA patients compared to pediatric controls. Tenosynovial thickening and/or enhancement was rarely present in both groups. In JIA patients, synovial thickening and enhancement were particularly present at three anatomical sites. These results substantially support rheumatologists and radiologists when navigating through MRI of the wrist in search for JIA disease activity.
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Affiliation(s)
- Jeffrey M A van der Krogt
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Amsterdam UMC), Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - F Verkuil
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Amsterdam UMC), Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam University Medical Centers (Amsterdam UMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - E Charlotte van Gulik
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Amsterdam UMC), Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam University Medical Centers (Amsterdam UMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Robert Hemke
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Amsterdam UMC), Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J Merlijn van den Berg
- Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam University Medical Centers (Amsterdam UMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Dieneke Schonenberg-Meinema
- Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam University Medical Centers (Amsterdam UMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Centers (Amsterdam UMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Koert M Dolman
- Department of Pediatrics, OLVG Hospital, Location West, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Centers (Amsterdam UMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam University Medical Centers (Amsterdam UMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Amsterdam UMC), Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Charlotte M Nusman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Amsterdam UMC), Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam University Medical Centers (Amsterdam UMC), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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6
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Krom H, van Oers HA, van der Sluijs Veer L, van Zundert SMC, Otten MAGM, Haverman L, Benninga MA, Kindermann A. Health-Related Quality of Life and Distress of Parents of Children With Avoidant Restrictive Food Intake Disorder. J Pediatr Gastroenterol Nutr 2021; 73:115-124. [PMID: 33872291 DOI: 10.1097/mpg.0000000000003150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Health-related quality of life (HRQOL) of children with avoidant restrictive food intake disorder (ARFID) is impaired. AIM To measure HRQOL and distress of parents of children with ARFID. METHODS Cross-sectional cohort study. Parents of children with ARFID, visiting our multidisciplinary feeding team, completed questionnaires on the online Quality of Life in Clinical Practice portal; the Questionnaire for Adult's Health Related Quality of Life to assess parental HRQOL and the Distress Thermometer for Parents. Reference groups of parents of healthy (HC) and chronically ill children (CIC) were used. RESULTS Eighty-five mothers and 62 fathers of 89 children with ARFID (58% female, median age 1.9 years) were included (response rate 68%). No differences were found regarding HRQOL in 11 of 12 domains between parents of children with ARFID and HC. Mothers of children with ARFID reported significantly higher HRQOL regarding pain and fathers a significantly lower HRQOL on depressive emotions compared to HC. No differences were found in overall and clinical distress scores between parents of children with ARFID and HC/CIC. Mothers of children with ARFID had significantly higher distress scores regarding cognitive problems compared to HC and parenting problems in children <2 years compared to HC/CIC. Significantly higher distress scores on parenting problems in children <2 years were found in fathers of children with ARFID compared to HC/CIC. CONCLUSION Most HRQOL and distress scores of parents of children with ARFID were comparable to reference groups. Since parents of children with ARFID perceive a lack of understanding and support from the environment, professionals should suggest peer support through patient's organizations. Furthermore, it is important to offer professional support since parents indicated that they would like to talk to a professional about their situation.
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Affiliation(s)
- Hilde Krom
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
| | - Hedy A van Oers
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam Reproduction and Development, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Liesbeth van der Sluijs Veer
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam Reproduction and Development, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Suzanne M C van Zundert
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Dietetics, Amsterdam, The Netherlands
| | - Marie-Anne G M Otten
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Rehabilitation, Amsterdam, The Netherlands
| | - Lotte Haverman
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam Reproduction and Development, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Marc A Benninga
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
| | - Angelika Kindermann
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
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7
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Diederen K, Li JV, Donachie GE, de Meij TG, de Waart DR, Hakvoort TBM, Kindermann A, Wagner J, Auyeung V, Te Velde AA, Heinsbroek SEM, Benninga MA, Kinross J, Walker AW, de Jonge WJ, Seppen J. Exclusive enteral nutrition mediates gut microbial and metabolic changes that are associated with remission in children with Crohn's disease. Sci Rep 2020; 10:18879. [PMID: 33144591 PMCID: PMC7609694 DOI: 10.1038/s41598-020-75306-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/13/2020] [Indexed: 12/12/2022] Open
Abstract
A nutritional intervention, exclusive enteral nutrition (EEN) can induce remission in patients with pediatric Crohn's disease (CD). We characterized changes in the fecal microbiota and metabolome to identify the mechanism of EEN. Feces of 43 children were collected prior, during and after EEN. Microbiota and metabolites were analyzed by 16S rRNA gene amplicon sequencing and NMR. Selected metabolites were evaluated in relevant model systems. Microbiota and metabolome of patients with CD and controls were different at all time points. Amino acids, primary bile salts, trimethylamine and cadaverine were elevated in patients with CD. Microbiota and metabolome differed between responders and non-responders prior to EEN. EEN decreased microbiota diversity and reduced amino acids, trimethylamine and cadaverine towards control levels. Patients with CD had reduced microbial metabolism of bile acids that partially normalized during EEN. Trimethylamine and cadaverine inhibited intestinal cell growth. TMA and cadaverine inhibited LPS-stimulated TNF-alpha and IL-6 secretion by primary human monocytes. A diet rich in free amino acids worsened inflammation in the DSS model of intestinal inflammation. Trimethylamine, cadaverine, bile salts and amino acids could play a role in the mechanism by which EEN induces remission. Prior to EEN, microbiota and metabolome are different between responders and non-responders.
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Affiliation(s)
- Kay Diederen
- Department of Pediatric Gastroenterology and Nutrition, Amsterdam UMC, Location AMC & VUmc, Amsterdam, The Netherlands
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, Location AMC, Meibergdreef 69, 1105BK, Amsterdam, The Netherlands
| | - Jia V Li
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | | | - Tim G de Meij
- Department of Pediatric Gastroenterology and Nutrition, Amsterdam UMC, Location AMC & VUmc, Amsterdam, The Netherlands
| | - Dirk R de Waart
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, Location AMC, Meibergdreef 69, 1105BK, Amsterdam, The Netherlands
| | - Theodorus B M Hakvoort
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, Location AMC, Meibergdreef 69, 1105BK, Amsterdam, The Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology and Nutrition, Amsterdam UMC, Location AMC & VUmc, Amsterdam, The Netherlands
| | - Josef Wagner
- Pathogen Genomics Group, Wellcome Sanger Institute, Hinxton, Cambridgeshire, UK
| | - Victoria Auyeung
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Anje A Te Velde
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, Location AMC, Meibergdreef 69, 1105BK, Amsterdam, The Netherlands
| | - Sigrid E M Heinsbroek
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, Location AMC, Meibergdreef 69, 1105BK, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Amsterdam UMC, Location AMC & VUmc, Amsterdam, The Netherlands
| | - James Kinross
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alan W Walker
- The Rowett Institute, University of Aberdeen, Aberdeen, UK
| | - Wouter J de Jonge
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, Location AMC, Meibergdreef 69, 1105BK, Amsterdam, The Netherlands
| | - Jurgen Seppen
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, Location AMC, Meibergdreef 69, 1105BK, Amsterdam, The Netherlands.
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8
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Sedaghat-Hamedani F, Trebing J, Kindermann A, Kayvanpour E, Tan K, Preussler S, Sluka S, Gi W, Dieterich C, Weitmann K, Eschenhagen T, Hoffmann W, Katus H, Meder B. The clinical atlas of cardiomyopathies: data from the prospective DZHK TORCH study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Cardiomyopathies (CMPs) are leading causes of heart failure (HF) and sudden cardiac death (SCD). Comparative data of the multiple cardiomyopathy forms are largely missing. The TranslatiOnal Registry for CardiomyopatHies (TORCH) is the largest prospective multicentre CMP registry world-wide. Enrolled patients are comprehensively phenotyped by clinical examinations, state-of-the-art imaging, and molecular investigations. In this study, we present the baseline and 1-year follow-up data.
Methods
TORCH is a national, prospective, multicentre registry within the German Centre for Cardiovascular Research (DZHK) and includes 2300 patients with non-ischemic (primary and secondary) CMP from 20 centres. The minimum follow up was one year. The DZHK-wide harmonization of datasets and SOPs ensure a high level of data quality and comparability across different CMP forms.
Results
Dilated cardiomyopathy (DCM) has the highest prevalence with 64% of all enrolled patients, followed by hypertrophic cardiomyopathy (HCM) with 16%. At baseline, patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) were treated more often with ICD implantation and showed high rates of adequate ICD therapies (65.8%, p<0.05 and 47.8%, p<0.05, respectively). The prevalence of stroke or transient ischemic attack (TIA) was in multivariate analysis significantly higher (p<0.05) in left ventricular non-compaction cardiomyopathy (LVNC, 14.9%), while atrial fibrillation was lower than in other cardiomyopathy forms. Patients with amyloidosis had the worst outcome (HR: 6; 95% CI: 2.5–14.5, P<0.05) with annual mortality of >15% and 12% receiving heart transplantation. In DCM, reverse remodelling with improvement of functional parameters and biomarkers was more often observed in idiopathic and inflammatory cases compared to familial ones. HCM patients had the most favourable outcome.
Conclusion and outlook
TORCH is the largest prospective study focusing on CMPs. We provided for the first time prospectively the clinical data of patients with diverse cardiomyopathies with outcome. Furthermore, comparing the different CMP forms on the clinical and molecular level will be an important step to enable translational research projects.
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Centre for Cardiovascular Research (DZHK)
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Affiliation(s)
| | - J Trebing
- University Hospital of Heidelberg, Heidelberg, Germany
| | - A Kindermann
- University Hospital of Heidelberg, Heidelberg, Germany
| | - E Kayvanpour
- University Hospital of Heidelberg, Heidelberg, Germany
| | - K Tan
- University Hospital of Heidelberg, Heidelberg, Germany
| | - S Preussler
- University of Heidelberg, Institute of Medical Biometry and Informatics, Heidelberg, Germany
| | - S Sluka
- University of Greifswald, Greifswald, Germany
| | - W.T Gi
- University Hospital of Heidelberg, Heidelberg, Germany
| | - C Dieterich
- University Hospital of Heidelberg, Heidelberg, Germany
| | - K Weitmann
- University of Greifswald, Greifswald, Germany
| | - T Eschenhagen
- The University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - W Hoffmann
- University of Greifswald, Greifswald, Germany
| | - H.A Katus
- University Hospital of Heidelberg, Heidelberg, Germany
| | - B Meder
- University Hospital of Heidelberg, Heidelberg, Germany
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9
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van Wassenaer EA, de Voogd FAE, van Rijn RR, van der Lee JH, Tabbers MM, van Etten-Jamaludin FS, Kindermann A, de Meij TGJ, Gecse KB, D’Haens GR, Benninga MA, Koot BGP. Bowel ultrasound measurements in healthy children - systematic review and meta-analysis. Pediatr Radiol 2020; 50:501-508. [PMID: 31838567 PMCID: PMC7067709 DOI: 10.1007/s00247-019-04567-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/13/2019] [Accepted: 10/30/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ultrasound (US) is a noninvasive method of assessing the bowel that can be used to screen for bowel pathology, such as Inflammatory Bowel Disease, in children. Knowledge about US findings of the bowel in healthy children is important for interpreting US results in cases where disease is suspected. OBJECTIVE To assess the bowel wall thickness in different bowel segments in healthy children and to assess differences in bowel wall thickness among pediatric age categories. MATERIALS AND METHODS We conducted a systematic search in the PubMed, Embase, Cochrane, and CINAHL databases for studies describing bowel wall thickness measured by transabdominal US in healthy children. We excluded studies using contrast agent. We calculated the pooled mean and standard deviation scores and assessed differences among age categories (0-4 years, 5-9 years, 10-14 years, 15-18 years), first with analysis of variance (ANOVA) and further with subsequent Student's t-tests for independent samples, corrected for multiple testing. RESULTS We identified 191 studies and included 7 of these studies in the systematic review. Reported bowel wall thickness values ranged from 0.8 mm to 1.9 mm in the small bowel and from 1.0 mm to 1.9 mm in the colon. The mean colonic bowel wall thickness is larger in children ages 15-19 years compared to 0-4 years (range in difference: 0.3-0.5 mm [corrected P<0.02]). CONCLUSION The reported upper limit of bowel wall thickness in healthy children is 1.9 mm in the small bowel and the colon, and mean thickness increases slightly with age in jejunum and colon. These values can be used as guidance when screening for bowel-related pathology in children.
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Affiliation(s)
- Elsa A. van Wassenaer
- grid.7177.60000000084992262Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Floris A. E. de Voogd
- grid.7177.60000000084992262Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rick R. van Rijn
- grid.7177.60000000084992262Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna H. van der Lee
- grid.7177.60000000084992262Pediatric Clinical Research Office, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands ,Knowledge Institute of the Dutch Association of Medical Specialists, Utrecht, the Netherlands
| | - Merit M. Tabbers
- grid.7177.60000000084992262Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | | | - Angelika Kindermann
- grid.7177.60000000084992262Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Tim G. J. de Meij
- grid.12380.380000 0004 1754 9227Pediatric Gastroenterology Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - K. B. Gecse
- grid.7177.60000000084992262Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Geert R. D’Haens
- grid.7177.60000000084992262Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc A. Benninga
- grid.7177.60000000084992262Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bart G. P. Koot
- grid.7177.60000000084992262Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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10
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van Wassenaer EA, de Voogd FAE, van Rijn RR, van der Lee JH, Tabbers MM, van Etten-Jamaludin FS, Gecse KB, Kindermann A, de Meij TGJ, D’Haens GR, Benninga MA, Koot BGP. Diagnostic Accuracy of Transabdominal Ultrasound in Detecting Intestinal Inflammation in Paediatric IBD Patients-a Systematic Review. J Crohns Colitis 2019; 13:1501-1509. [PMID: 31329839 PMCID: PMC7142400 DOI: 10.1093/ecco-jcc/jjz085] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Currently used non-invasive tools for monitoring children with inflammatory bowel disease [IBD], such as faecal calprotectin, do not accurately reflect the degree of intestinal inflammation and do not provide information on disease location. Ultrasound [US] might be of added value. This systematic review aimed to assess the diagnostic test accuracy of transabdominal US in detecting intestinal inflammation in children with IBD in both diagnostic and follow-up settings. METHODS We systematically searched PubMed, Embase [Ovid], Cochrane Library, and CINAHL [EBSCO] databases for studies assessing diagnostic accuracy of transabdominal US for detection of intestinal inflammation in patients diagnosed or suspected of IBD, aged 0-18 years, with ileo-colonoscopy and/or magnetic resonance enterography [MRE] as reference standards. Studies using US contrast were excluded. Risk of bias was assessed with QUADAS-2. RESULTS The search yielded 276 records of which 14 were included. No meta-analysis was performed, because of heterogeneity in study design and methodological quality. Only four studies gave a clear description of their definition for an abnormal US result. The sensitivity and specificity of US ranged from 39-93% and 90-100% for diagnosing de novo IBD, and 48-93% and 83-93% for detecting active disease during follow-up, respectively. CONCLUSIONS The diagnostic accuracy of US in detecting intestinal inflammation as seen on MRE and/or ileo-colonoscopy in paediatric IBD patients remains inconclusive, and there is currently no consensus on defining an US result as abnormal. Prospective studies with adequate sample size and methodology are needed before US can be used in the diagnostics and monitoring of paediatric IBD.
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Affiliation(s)
- Elsa A van Wassenaer
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands,Corresponding author: Elsa A. van Wassenaer, MD, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands.
| | - Floris A E de Voogd
- Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Rick R van Rijn
- Amsterdam UMC, University of Amsterdam, Radiology, Amsterdam, The Netherlands
| | - Johanna H van der Lee
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Clinical Research Office, Amsterdam, The Netherlands
| | - Merit M Tabbers
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | | | - Krisztina B Gecse
- Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Angelika Kindermann
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Tim G J de Meij
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Geert R D’Haens
- Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Marc A Benninga
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Bart G P Koot
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
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11
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Krom H, Elshout G, Hellingman CA, Kindermann A, van Schuppen J, Tabbers MM. [Foreign body ingestion in children]. Ned Tijdschr Geneeskd 2019; 163:D4281. [PMID: 31750640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Foreign body ingestion occurs frequently in children and may lead to severe complications and mortality. In this article, three cases are presented. A 2-year-old boy swallowed a plastic toy helmet. He had no symptoms and physical examination was normal, and the toy was found in the stool within three days. Similarly, a 6-year-old girl swallowed two magnets and was asymptomatic. Physical examination was normal and a radiograph showed a foreign body which had passed the stomach. Due to the location, endoscopic removal by gastroduodenoscopy was not possible and surgical removal unnecessary. The magnets were secreted in the stool within two days. A 10-year-old boy with VACTERL association and psychiatric history, swallowed a button battery. After a delay in presentation, a radiograph showed a button battery mid-esophageal, which was endoscopically removed. He also needed dilatation due to esophageal stenosis. The above cases are all illustrative of the topic covered in the guideline 'Ingestion of foreign bodies in children aged 0-18 years', which was developed on behalf of the Dutch Pediatric Association and published in March 2019.
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Affiliation(s)
- Hilde Krom
- Emma Kinderziekenhuis, Amsterdam UMC, locatie AMC-UvA, Afd. Kinder-mdl, Amsterdam
- Contact: H. Krom
| | | | | | - Angelika Kindermann
- Emma Kinderziekenhuis, Amsterdam UMC, locatie AMC-UvA, Afd. Kinder-mdl, Amsterdam
| | - Joost van Schuppen
- Emma Kinderziekenhuis, Amsterdam UMC, locatie AMC-UvA, Afd. Radiologie en Nucleaire Geneeskunde, Amsterdam
| | - Merit M Tabbers
- Emma Kinderziekenhuis, Amsterdam UMC, locatie AMC-UvA, Afd. Kinder-mdl, Amsterdam
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12
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van Wassenaer EA, Meester VL, Kindermann A, Koot BGP, Benninga MA, de Meij TGJ. Premedication with intravenous steroids does not influence the incidence of infusion reactions following infliximab infusions in pediatric inflammatory bowel disease patients—a case-control study. Eur J Clin Pharmacol 2019; 75:1445-1450. [DOI: 10.1007/s00228-019-02715-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/04/2019] [Indexed: 02/03/2023]
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13
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Krom H, van der Sluijs Veer L, van Zundert S, Otten M, Benninga M, Haverman L, Kindermann A. Health related quality of life of infants and children with avoidant restrictive food intake disorder. Int J Eat Disord 2019; 52:410-418. [PMID: 30734346 PMCID: PMC6594067 DOI: 10.1002/eat.23037] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/20/2019] [Accepted: 01/22/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study was to compare health related quality of life (HRQOL) in infants and children with avoidant restrictive food intake disorder (ARFID) to healthy and chronically ill controls. METHOD A cross-sectional study was conducted in children who meet ARFID criteria at our tertiary care pediatric feeding clinic (September 2014 to July 2016). Before consultation, parents of patients (n = 100) were asked to complete questionnaires to determine HRQOL: the TNO-AZL Preschool Children Quality of Life (0-5 years), and "Pediatric Quality of Life Inventory" (6-7 and 8-10 years). HRQOL of ARFID patients was compared to both healthy (0-5 years n = 241; 6-7 years n = 61; 8-10 years n = 192) and chronically ill (0-5 years n = 79; 6-7 years n = 11; 8-10 years n = 26) controls. RESULTS The prevalence of ARFID was 64%. HRQOL of ARFID patients aged 0-5 years (n = 37) was significantly lower on 6/12 scales (appetite, lungs, stomach, motor functioning, positive mood and liveliness) compared to healthy controls (P < .01), and on 4/12 scales (appetite, stomach, motor functioning, and liveliness) compared to chronically ill controls (P < .01). The ARFID patients scored significantly better on the problem behavior scale compared to healthy and chronically ill controls (P < .01). ARFID patients aged 6-7 (n = 9) had significantly lower scores in 3/6 scales (total score, psychosocial health, and school functioning) (P < .01), and aged 8-10 (n = 2) had a significantly lower school functioning scale (P < .01) compared to healthy controls. CONCLUSION HRQOL of children with ARFID is decreased on multiple scales. The effect on HRQOL should be incorporated in clinical practice, and clinical studies should add HRQOL as an outcome measure.
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Affiliation(s)
- Hilde Krom
- Department of Pediatric Gastroenterology, Hepatology, and NutritionEmma Children's Hospital, Amsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | | | - Suzanne van Zundert
- DieteticsEmma Children's Hospital, Amsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Marie‐Anne Otten
- RehabilitationEmma Children's Hospital, Amsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology, and NutritionEmma Children's Hospital, Amsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Lotte Haverman
- Psychosocial DepartmentEmma Children's Hospital, Amsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Hepatology, and NutritionEmma Children's Hospital, Amsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
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14
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Krom H, van Zundert SM, Otten MAG, van der Sluijs Veer L, Benninga MA, Kindermann A. Prevalence and side effects of pediatric home tube feeding. Clin Nutr 2019; 38:234-239. [DOI: 10.1016/j.clnu.2018.01.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 11/27/2022]
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15
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Diederen K, Krom H, Koole JCD, Benninga MA, Kindermann A. Diet and Anthropometrics of Children With Inflammatory Bowel Disease: A Comparison With the General Population. Inflamm Bowel Dis 2018; 24:1632-1640. [PMID: 29697827 DOI: 10.1093/ibd/izy027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is a lack of knowledge regarding the diet of children with inflammatory bowel disease (IBD). Therefore, we investigated dietary intake in pediatric IBD compared to the general population and assessed anthropometrics and food avoidance. METHODS In this cross-sectional cohort study, patients younger than 18 years with IBD were included (2014-2017). Dietary intake (total energy, macro nutrients, food types) was assessed using a Food Frequency Questionnaire (FFQ) and compared with a matched reference population (n = 306). RESULTS There were 102 patients included (55% male, median age 15.0 years). Median height Z-score was -0.39 (interquartile range [IQR]: -1.17 to 0.26). Growth failure (height Z-scores<-1.64) was present in 11% of patients. Median BMI Z-score was 0.36 (IQR: -0.70 to 0.96). Acute malnutrition (weight-for-height Z-score<-2) was present in 3% of patients. Energy intake was lower in pediatric IBD compared to the reference population (mean kilojoule/day: 8286 vs 9794, P < 0.001). Protein intake did not differ, while fat intake was higher in pediatric IBD (mean gram/day: 101 vs 91, P < 0.001), with higher intake of vegetable oils/fats. Carbohydrate intake was lower in pediatric IBD (mean gram/day: 267 vs 305, P < 0.001), with lower intake of food types high in sugar. Food avoidance was reported in 53% of patients, with frequent avoidance of spicy (46%), high-fat food (30%), and dairy (30%). CONCLUSIONS The diet of children with IBD differs from the general pediatric population, with lower energy intake and high rates of food avoidance. Evaluation of the dietary intake alongside anthropometrics may be important to prevent nutrition deficiencies and promote health.
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Affiliation(s)
- Kay Diederen
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Hilde Krom
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Jeffrey C D Koole
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
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16
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Heida A, Dijkstra A, Muller Kobold A, Rossen JW, Kindermann A, Kokke F, de Meij T, Norbruis O, Weersma RK, Wessels M, Hummel T, Escher J, van Wering H, Hendriks D, Mearin L, Groen H, Verkade HJ, van Rheenen PF. Efficacy of Home Telemonitoring versus Conventional Follow-up: A Randomized Controlled Trial among Teenagers with Inflammatory Bowel Disease. J Crohns Colitis 2018; 12:432-441. [PMID: 29228230 DOI: 10.1093/ecco-jcc/jjx169] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/07/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Conventional follow-up of teenagers with inflammatory bowel diseases [IBD] is done during scheduled outpatient visits regardless of how well the patient feels. We designed a telemonitoring strategy for early recognition of flares and compared its efficacy with conventional follow-up. METHODS We used a multicentre randomized trial in patients aged 10-19 years with IBD in clinical remission at baseline. Participants assigned to telemonitoring received automated alerts to complete a symptom score and send a stool sample for measurement of calprotectin. This resulted in an individual prediction for flare with associated treatment advice and test interval. In conventional follow-up the health check interval was left to the physician's discretion. The primary endpoint was cumulative incidence of disease flares. Secondary endpoints were percentage of participants with a positive change in quality-of-life and cost-effectiveness of the intervention. RESULTS We included 170 participants [84 telemonitoring; 86 conventional follow-up]. At 52 weeks the mean number of face-to-face visits was significantly lower in the telemonitoring group compared to conventional follow-up [3.6 vs 4.3, p < 0.001]. The incidence of flares [33 vs 34%, p = 0.93] and the proportion of participants reporting positive change in quality-of-life [54 vs 44%, p = 0.27] were similar. Mean annual cost-saving was €89 and increased to €360 in those compliant to the protocol. CONCLUSIONS Telemonitoring is as safe as conventional follow-up, and reduces outpatient visits and societal costs. The positive impact on quality-of-life was similar in the two groups. This strategy is attractive for teenagers and families, and health professionals may be interested in using it to keep teenagers who are well out of hospital and ease pressure on overstretched outpatient services. TRIAL REGISTRATION NTR3759 [Netherlands Trial Registry].
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Affiliation(s)
- Anke Heida
- Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Alie Dijkstra
- Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Anneke Muller Kobold
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - John W Rossen
- Department of Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Angelika Kindermann
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital Academic Medical Centre, Meibergdreef, Amsterdam, The Netherlands
| | - Freddy Kokke
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Wilhelmina Children's Hospital, Lundlaan, Utrecht, The Netherlands
| | - Tim de Meij
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, VU Medical Centre, De Boelelaan, Amsterdam, The Netherlands
| | - Obbe Norbruis
- Department of Paediatrics, Isala Clinic, Dokter van Heesweg, Zwolle, The Netherlands
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Margreet Wessels
- Department of Paediatrics, Rijnstate Hospital, Wagnerlaan, Arnhem, The Netherlands
| | - Thalia Hummel
- Department of Paediatrics, Medisch Spectrum Twente, Koningsplein, Enschede, The Netherlands
| | - Johanna Escher
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Erasmus Medical Center-Sophia Children's Hospital, Wytemaweg, Rotterdam, The Netherlands
| | - Herbert van Wering
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Amphia Hospital, Langendijk, Breda, The Netherlands
| | - Daniëlle Hendriks
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Juliana Children's Hospital/Haga, Els Borst-Eilersplein, The Hague, The Netherlands
| | - Luisa Mearin
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Leiden University Medical Centre, Albinusdreef, Leiden, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein, The Netherlands
| | - Henkjan J Verkade
- Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Patrick F van Rheenen
- Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
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17
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Krom H, Visser M, Hulst JM, Wolters VM, Van den Neucker AM, de Meij T, van der Doef HPJ, Norbruis OF, Benninga MA, Smit MJM, Kindermann A. Serious complications after button battery ingestion in children. Eur J Pediatr 2018; 177:1063-1070. [PMID: 29717359 PMCID: PMC5997112 DOI: 10.1007/s00431-018-3154-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 01/08/2023]
Abstract
UNLABELLED Serious and fatal complications after button battery ingestion are increasing worldwide. The aim of this study is to describe serious complications after battery ingestion in children in the Netherlands.All pediatric gastroenterologists in the Netherlands performing upper endoscopies were asked to report all serious complications after battery ingestion in children (0-18 years) between 2008 and 2016 retrospectively.Sixteen serious complications were reported: death after massive bleeding through esophageal-aortal fistula (n = 1), esophageal-tracheal fistula (n = 5), stenosis after (suspected) perforation and mediastinitis (n = 5), (suspected) perforation and mediastinitis (n = 3), vocal cord paralysis (n = 1), and required reintubation for dyspnea and stridor (n = 1). The median time interval between ingestion and presentation was 5 (IQR 2-258) h. All children were ≤ 5 (median 1.4; IQR 0.9-2.1) years. Vomiting (31.3%), swallowing/feeding problems (31.3%), and fever (31.3%) were the most common presenting symptoms; however, 18.8% of the patients were asymptomatic (n = 1 missing). All batteries were button batteries (75% ≥ 20 mm; 18.8% < 20 mm; n = 1 missing). The batteries were removed by esophagogastroduodenoscopy (50%) and rigid endoscopy (37.5%) or surgically (12.5%). CONCLUSION Sixteen serious complications occurred after small and large button batteries ingestion between 2008 and 2016 in both symptomatic and asymptomatic children in the Netherlands. Therefore, immediate intervention after (suspected) button battery ingestion is required. What is Known: • Button battery ingestion may result in serious and fatal complications. • Serious and fatal complications after button battery ingestion are increasing worldwide. What is New: • Sixteen serious complications after button battery ingestion occurred during 2008-2016 in children in the Netherlands. • Serious complications were also caused by small batteries (< 20 mm) in the Netherlands and also occurred in asymptomatic Dutch children.
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Affiliation(s)
- Hilde Krom
- Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands.
| | - Margot Visser
- Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - Jessie M. Hulst
- Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Victorien M. Wolters
- Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Tim de Meij
- VU University Medical Center, Amsterdam, Netherlands
| | | | | | - Marc A. Benninga
- Emma Children’s Hospital, Academic Medical Center, Amsterdam, Netherlands
| | - Margot J. M. Smit
- Juliana Children’s Hospital, Haga Teaching Hospital, Den Haag, Netherlands
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18
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Holtman GA, Lisman-van Leeuwen Y, Kollen BJ, Norbruis OF, Escher JC, Walhout LC, Kindermann A, de Rijke YB, van Rheenen PF, Berger MY. Diagnostic test strategies in children at increased risk of inflammatory bowel disease in primary care. PLoS One 2017; 12:e0189111. [PMID: 29211800 PMCID: PMC5718464 DOI: 10.1371/journal.pone.0189111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 11/20/2017] [Indexed: 01/13/2023] Open
Abstract
Background In children with symptoms suggestive of inflammatory bowel disease (IBD) who present in primary care, the optimal test strategy for identifying those who require specialist care is unclear. We evaluated the following three test strategies to determine which was optimal for referring children with suspected IBD to specialist care: 1) alarm symptoms alone, 2) alarm symptoms plus c-reactive protein, and 3) alarm symptoms plus fecal calprotectin. Methods A prospective cohort study was conducted, including children with chronic gastrointestinal symptoms referred to pediatric gastroenterology. Outcome was defined as IBD confirmed by endoscopy, or IBD ruled out by either endoscopy or unremarkable clinical 12 month follow-up with no indication for endoscopy. Test strategy probabilities were generated by logistic regression analyses and compared by area under the receiver operating characteristic curves (AUC) and decision curves. Results We included 90 children, of whom 17 (19%) had IBD (n = 65 from primary care physicians, n = 25 from general pediatricians). Adding fecal calprotectin to alarm symptoms increased the AUC significantly from 0.80 (0.67–0.92) to 0.97 (0.93–1.00), but adding c-reactive protein to alarm symptoms did not increase the AUC significantly (p > 0.05). Decision curves confirmed these patterns, showing that alarm symptoms combined with fecal calprotectin produced the diagnostic test strategy with the highest net benefit at reasonable threshold probabilities. Conclusion In primary care, when children are identified as being at high risk for IBD, adding fecal calprotectin testing to alarm symptoms was the optimal strategy for improving risk stratification.
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Affiliation(s)
- Gea A. Holtman
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- * E-mail:
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Boudewijn J. Kollen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Obbe F. Norbruis
- Department of Pediatrics, Isala Hospital, Zwolle, The Netherlands
| | - Johanna C. Escher
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Laurence C. Walhout
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children’s Hospital ⁄ Academic Medical Center, Amsterdam, the Netherlands
| | - Yolanda B. de Rijke
- Department of Clinical Chemistry, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Patrick F. van Rheenen
- Department of Pediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marjolein Y. Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Diederen K, Sahami SS, Tabbers MM, Benninga MA, Kindermann A, Tanis PJ, Oomen MW, de Jong JR, Bemelman WA. Outcome after restorative proctocolectomy and ileal pouch–anal anastomosis in children and adults. Br J Surg 2017; 104:1640-1647. [DOI: 10.1002/bjs.10678] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 05/23/2017] [Accepted: 07/13/2017] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Studies comparing the outcome of ileal pouch–anal anastomosis (IPAA) in children and adults are scarce. This complicates decision-making in young patients. The aim of this study was to compare adverse events and pouch function between children and adults who underwent IPAA.
Methods
This cross-sectional cohort study included all consecutive children (aged less than 18 years) and adults with a diagnosis of inflammatory bowel disease or familial adenomatous polyposis who underwent IPAA in a tertiary referral centre between 2000 and 2015. Adverse events were assessed by chart review, and pouch function by interview using a pouch function score (PFS).
Results
In total, 445 patients underwent IPAA: 41 children (median age 15 years) and 404 adults (median age 39 years), with a median follow-up of 22 (i.q.r. 8–68) months. Being overweight (P = 0·001), previous abdominal surgery (P = 0·018), open procedures (P < 0·001) and defunctioning ileostomy (P = 0·014) were less common among children than adult patients. The occurrence of anastomotic leakage, surgical fistulas, chronic pouchitis and Crohn's of the pouch was not associated with paediatric age at surgery, nor was pouch failure. The development of anastomotic strictures was associated with having IPAA surgery during childhood (odds ratio 4·22, 95 per cent c.i. 1·13 to 15·77; P = 0·032). Pouch function at last follow-up was similar in the children and adult groups (median PFS 5·0 versus 6·0 respectively; P = 0·194).
Conclusion
Long-term pouch failure rates and pouch function were similar in children and adults. There is no need for a more cautious attitude to use of IPAA in children based on concerns about poor outcome.
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Affiliation(s)
- K Diederen
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - S S Sahami
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M M Tabbers
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - M A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - A Kindermann
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M W Oomen
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - J R de Jong
- Department of Paediatric Surgery, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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20
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Staphorst MS, Benninga MA, Bisschoff M, Bon I, Busschbach JJV, Diederen K, van Goudoever JB, Haarman EG, Hunfeld JAM, Jaddoe VVW, de Jong KJM, de Jongste JC, Kindermann A, Königs M, Oosterlaan J, Passchier J, Pijnenburg MW, Reneman L, de Ridder L, Tamminga HG, Tiemeier HW, Timman R, van de Vathorst S. The child's perspective on discomfort during medical research procedures: a descriptive study. BMJ Open 2017; 7:e016077. [PMID: 28765130 PMCID: PMC5642655 DOI: 10.1136/bmjopen-2017-016077] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The evaluation of discomfort in paediatric research is scarcely evidence-based. In this study, we make a start in describing children's self-reported discomfort during common medical research procedures and compare this with discomfort during dental check-ups which can be considered as a reference level of a 'minimal discomfort' medical procedure. We exploratory study whether there are associations between age, anxiety-proneness, gender, medical condition, previous experiences and discomfort. We also describe children's suggestions for reducing discomfort. DESIGN Cross-sectional descriptive study. SETTING Paediatric research at three academic hospitals. PATIENTS 357 children with and without illnesses (8-18 years, mean=10.6 years) were enrolled: 307 from paediatric research studies and 50 from dental care. MAIN OUTCOME MEASURES We measured various generic forms of discomfort (nervousness, annoyance, pain, fright, boredom, tiredness) due to six common research procedures: buccal swabs, MRI scans, pulmonary function tests, skin prick tests, ultrasound imaging and venepunctures. RESULTS Most children reported limited discomfort during the research procedures (means: 1-2.6 on a scale from 1 to 5). Compared with dental check-ups, buccal swab tests, skin prick tests and ultrasound imaging were less discomforting, while MRI scans, venepunctures and pulmonary function tests caused a similar degree of discomfort. 60.3% of the children suggested providing distraction by showing movies to reduce discomfort. The exploratory analyses suggested a positive association between anxiety-proneness and discomfort. CONCLUSIONS The findings of this study support the acceptability of participation of children in the studied research procedures, which stimulates evidence-based research practice. Furthermore, the present study can be considered as a first step in providing benchmarks for discomfort of procedures in paediatric research.
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Affiliation(s)
- Mira S Staphorst
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Paediatrics, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Paediatrics, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Margriet Bisschoff
- Departments of Paediatrics and Child Psychiatry, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Irma Bon
- Department of Paediatrics, VU University Medical Center (VUmc), Amsterdam, The Netherlands
| | - Jan J V Busschbach
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Kay Diederen
- Department of Paediatrics, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Johannes B van Goudoever
- Department of Paediatrics, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
- Department of Paediatrics, VU University Medical Center (VUmc), Amsterdam, The Netherlands
| | - Eric G Haarman
- Department of Paediatrics, VU University Medical Center (VUmc), Amsterdam, The Netherlands
| | - Joke A M Hunfeld
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Vincent V W Jaddoe
- Departments of Paediatrics and Child Psychiatry, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Karin J M de Jong
- Department of Pedodontology, Academic Center Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands
| | - Johan C de Jongste
- Departments of Paediatrics and Child Psychiatry, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Angelika Kindermann
- Department of Paediatrics, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Marsh Königs
- Section of Clinical Neuropsychology, VU University, Amsterdam, The Netherlands
| | - Jaap Oosterlaan
- Section of Clinical Neuropsychology, VU University, Amsterdam, The Netherlands
| | - Jan Passchier
- Department of Clinical Psychology/EMGO+, VU University, Amsterdam, The Netherlands
| | - Mariëlle W Pijnenburg
- Departments of Paediatrics and Child Psychiatry, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Liesbeth Reneman
- Department of Paediatrics, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Lissy de Ridder
- Departments of Paediatrics and Child Psychiatry, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Hyke G Tamminga
- Department of Paediatrics, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Henning W Tiemeier
- Departments of Paediatrics and Child Psychiatry, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Reinier Timman
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Suzanne van de Vathorst
- Department of Ethics and Philosophy, Erasmus University Medical Centre, Rotterdam, The Netherlands
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21
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Holtman GA, Lisman-van Leeuwen Y, van Rheenen PF, Kollen BJ, Escher JC, Kindermann A, de Rijke YB, Berger MY. Evaluation of point-of-care test calprotectin and lactoferrin for inflammatory bowel disease among children with chronic gastrointestinal symptoms. Fam Pract 2017; 34:400-406. [PMID: 27535331 DOI: 10.1093/fampra/cmw079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Faecal calprotectin is considered to be a valid test for ruling out inflammatory bowel disease (IBD) in children with chronic gastrointestinal symptoms in specialist care. In contrast, faecal lactoferrin has higher specificity. The recent availability of both as point-of-care tests (POCTs) makes them attractive for use in primary care. OBJECTIVE To evaluate the test characteristics of calprotectin and lactoferrin POCTs for diagnosing IBD in symptomatic children. METHODS We defined two prospective cohorts of children with chronic gastrointestinal symptoms: (i) children presenting to primary care (primary care cohort); (ii) children referred for specialist care (referred cohort). Baseline POCT results were compared with the outcome of either endoscopic assessment or 12 months follow-up. Clinicians were blinded to the POCT results. RESULTS In the primary care cohort, none of the 114 children had IBD, and the calprotectin and lactoferrin POCTs had specificities of 0.95 (0.89-0.98) and 0.98 (0.93-0.99), respectively. In the referred cohort, 17 of the 90 children had IBD: the sensitivity of POCT calprotectin and POCT lactoferrin were both 0.94 (0.72-0.99); and the specificity was 0.93 (0.84-0.97) and 0.99 (0.92-1.00), respectively. The POCT calprotectin could reduce the referral rate by 76% and POCT lactoferrin by 81%, while missing one child with IBD (6%). CONCLUSION A diagnostic test strategy in primary care using a simple POCT calprotectin or lactoferrin has the potential to reduce the need for referral for further diagnostic work-up in specialist care, with a low risk of missing a child with IBD.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Boudewijn J Kollen
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Angelika Kindermann
- Department of Paediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, PO Box 22700, 1100 DE Amsterdam, The Netherlands
| | - Yolanda B de Rijke
- Department of Clinical Chemistry, Erasmus MC, University Medical Centre, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
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22
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Diederen K, Hoekman DR, Leek A, Wolters VM, Hummel TZ, de Meij TG, Koot BGP, Tabbers MM, Benninga MA, Kindermann A. Raised faecal calprotectin is associated with subsequent symptomatic relapse, in children and adolescents with inflammatory bowel disease in clinical remission. Aliment Pharmacol Ther 2017; 45:951-960. [PMID: 28138990 DOI: 10.1111/apt.13950] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/27/2016] [Accepted: 12/29/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Reliable data on inflammatory biomarkers for predicting relapse of paediatric inflammatory bowel disease (IBD) are lacking. AIM To investigate the predictive value of faecal calprotectin (FC) and CRP for symptomatic relapse in pediatric IBD in clinical remission. METHODS In this cross-sectional cohort study, patients <18 years with Crohn's disease or ulcerative colitis in clinical remission ≥3 months were included. At baseline, clinical and biochemical disease activity were assessed using the abbreviated-Pediatric Crohn's Disease Activity Index or Pediatric Ulcerative Colitis Activity Index, and FC and CRP respectively. Disease course over the subsequent 12 months was retrospectively assessed. RESULTS In total, 114 patients (56% males; median age 14.9 years) were included. Baseline FC was higher in patients that developed symptomatic relapse [median (IQR), relapse 370 μg/g (86-1100) vs. remission 122 μg/g (40-344), P = 0.003]. Baseline FC was predictive of symptomatic relapse within 6 months [HR per 250 μg/g (95% CI): 1.46 (1.21-1.77), P < 0.001], with good predictive accuracy (AUC: 0.82). Optimal FC cut-off was 350 μg/g, with positive and negative predictive value of 41% and 96%. Baseline CRP was higher in patients that developed symptomatic relapse [median (IQR), relapse 1.0 μg/g (0.6-5.0) vs. remission 1.0 μg/g (0.4-2.0), P = 0.033]. Baseline CRP was predictive of symptomatic relapse within 6 months from baseline [HR per 1 mg/L (95% CI): 1.10 (1.02-1.19), P = 0.011], with fair predictive accuracy (AUC: 0.72). Optimal CRP cut-off was 1.0 mg/L, with positive and negative predictive value of 21% and 94%. CONCLUSIONS Faecal calprotectin and CRP are predictive of symptomatic relapse and may be valuable in management of paediatric IBD in clinical remission.
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Affiliation(s)
- K Diederen
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - D R Hoekman
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - A Leek
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - V M Wolters
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Z Hummel
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, The Netherlands
| | - T G de Meij
- Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - B G P Koot
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - M M Tabbers
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - M A Benninga
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - A Kindermann
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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23
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Krom H, Sprangers F, van den Berg R, Benninga MA, Kindermann A. Transverse Myelitis as Manifestation of Celiac Disease in a Toddler. Pediatrics 2017; 139:peds.2016-1381. [PMID: 28153851 DOI: 10.1542/peds.2016-1381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2016] [Indexed: 11/24/2022] Open
Abstract
We present a 17-month-old girl with rapidly progressive unwillingness to sit, stand, play, and walk. Furthermore, she lacked appetite, vomited, lost weight, and had an iron deficiency. Physical examination revealed a cachectic, irritable girl with a distended abdomen, dystrophic legs with paraparesis, disturbed sensibility, and areflexia. An MRI scan revealed abnormal high signal intensity on T2-weighted images in the cord on the thoracic level, without cerebral abnormalities, indicating transverse myelitis (TM). Laboratory investigations revealed elevated immunoglobulin A antibodies against gliadin (1980.0 kU/L; normal, 0-10.1 kU/L) and tissue transglutaminase (110.0 kU/L; normal, 0-10.1 kU/L). Gastroscopy revealed villous atrophy in the duodenal biopsies and lymphocytic gastritis according to Marsh IIIb, compatible with celiac disease (CD). After the start of a gluten free diet and methylprednisolone, she recovered completely. To our knowledge, this is the first pediatric case of TM as manifestation of CD. We suggest that all children with TM or other neurologic manifestations of unknown origin should be screened for CD.
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Affiliation(s)
- Hilde Krom
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam, Netherlands;
| | | | - René van den Berg
- Department of Radiology, Academic Medical Centre, Amsterdam, Netherlands
| | - Marc Alexander Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam, Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam, Netherlands
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24
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Abstract
UNLABELLED Enteral nutrition is effective in ensuring nutritional requirements and growth. However, when tube feeding lasts for a longer period, it can lead to tube dependency in the absence of medical reasons for continuation of tube feeding. Tube-dependent children are unable or refuse to start oral activities and they lack oral skills. Tube dependency has health-, psychosocial-, and economy-related consequences. Therefore, the transition to oral feeding is of great importance. However, this transition can be very difficult and needs a multidisciplinary approach. Most studies for treatment of tube dependency are based on behavioral interventions, such as family therapy, individual behavior therapy, neuro-linguistic programming, and parental anxiety reduction. Furthermore, oral motor therapy and nutritional adjustments can be helpful in tube weaning. The use of medication has been described in the literature. Although mostly chosen as the last resort, hunger-inducing methods, such as the Graz-model and the Dutch clinical hunger provocation program, are also successful in weaning children off tube feeding. CONCLUSION The transition from tube to oral feeding is important in tube-dependent children but can be difficult. We present an overview for the prevention and treatment of tube dependency. What is known: • Longer periods of tube feeding can lead to tube dependency. • Tube weaning can be very difficult. What is new: • Weaning as soon as possible and therefore referral to a multidisciplinary team are recommended. • An overview of treatment options for tube dependency is presented in this article.
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Affiliation(s)
- Hilde Krom
- Emma Children's Hospital, Box 22666, 1100 DD, Amsterdam, The Netherlands.
| | - J. Peter de Winter
- 0000 0004 0568 6419grid.416219.9Spaarne Hospital, Box 770, 2130 AT Hoofddorp, The Netherlands
| | - Angelika Kindermann
- 0000 0004 0529 2508grid.414503.7Emma Children’s Hospital, Box 22666, 1100 DD Amsterdam, The Netherlands
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25
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Tuijnenburg P, Cuadrado E, Bosch AM, Kindermann A, Jansen MH, Alders M, van Leeuwen EMM, Kuijpers TW. Humoral Immunodeficiency with Hypotonia, Feeding Difficulties, Enteropathy, and Mild Eczema Caused by a Classical FOXP3 Mutation. Front Pediatr 2017; 5:37. [PMID: 28289675 PMCID: PMC5326763 DOI: 10.3389/fped.2017.00037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 02/10/2017] [Indexed: 11/13/2022] Open
Abstract
We describe here the case of a boy who presented with pulmonary infections, feeding difficulties due to velopharyngeal insufficiency and gastroesophageal reflux, myopathy, and hypotonia soon after birth. Later, he was also found to have an elevated immunoglobulin (Ig) E and mild eczema and was diagnosed with inflammatory bowel disease. Further immunological screening at the age of 7 years showed low B and NK cell numbers but normal CD4+ and CD8+ T cells and notably, normal numbers of CD4+ regulatory T (Treg) cells. Serum IgG, IgA, and IgM were low to normal, but he had a deficient response to a pneumococcal polysaccharide vaccine and thus a humoral immunodeficiency. To our surprise, whole exome sequencing revealed a mutation in forkhead box protein 3 (FOXP3), encoding an essential transcription factor for the development and function of Treg cells. This classical mutation is associated with immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome. Further in vitro studies indeed showed defective function of Treg cells despite normal FOXP3 protein expression and nuclear localization. The boy underwent hematopoietic stem cell transplantation at 11 years of age and despite the temporary development of diabetes while on prednisone is now doing much better, IgE levels have declined, and his fatigue has improved. This case illustrates that a classical pathogenic mutation in FOXP3 can lead to a clinical phenotype where the diagnosis of IPEX syndrome was never considered because of the lack of diabetes and the presence of only mild eczema, in addition to the normal Treg cell numbers and FOXP3 expression.
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Affiliation(s)
- Paul Tuijnenburg
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands; Department of Experimental Immunology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Eloy Cuadrado
- Department of Hematopoiesis, Sanquin Research and Landsteiner Laboratory, University of Amsterdam , Amsterdam , Netherlands
| | - Annet M Bosch
- Department of Metabolic Disorders, Emma Children's Hospital, Academic Medical Center (AMC), University of Amsterdam , Amsterdam , Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center (AMC), University of Amsterdam , Amsterdam , Netherlands
| | - Machiel H Jansen
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands; Department of Experimental Immunology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Marielle Alders
- Department of Clinical Genetics, Academic Medical Center (AMC), University of Amsterdam , Amsterdam , Netherlands
| | - Ester M M van Leeuwen
- Department of Experimental Immunology, Academic Medical Center (AMC), University of Amsterdam , Amsterdam , Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands; Department of Clinical Genetics, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
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Holtman GA, Lisman-van Leeuwen Y, Kollen BJ, Norbruis OF, Escher JC, Kindermann A, de Rijke YB, van Rheenen PF, Berger MY. Diagnostic Accuracy of Fecal Calprotectin for Pediatric Inflammatory Bowel Disease in Primary Care: A Prospective Cohort Study. Ann Fam Med 2016; 14:437-45. [PMID: 27621160 PMCID: PMC5394359 DOI: 10.1370/afm.1949] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 03/16/2016] [Indexed: 02/03/2023] Open
Abstract
PURPOSE In specialist care, fecal calprotectin (FCal) is a commonly used noninvasive diagnostic test for ruling out inflammatory bowel disease (IBD) in children with chronic gastrointestinal symptoms. The aim of this study was to evaluate the diagnostic accuracy of FCal for IBD in symptomatic children in primary care. METHODS We studied 2 prospective cohorts of children with chronic diarrhea, recurrent abdominal pain, or both: children initially seen in primary care (primary care cohort) and children referred to specialist care (referred cohort). FCal (index test) was measured at baseline and compared with 1 of the 2 reference standards for IBD: endoscopic assessment or 1-year follow-up. Physicians were blinded to FCal results, and values greater than 50 μg/g feces were considered positive. We determined specificity in the primary care cohort and sensitivity in the referred cohort. RESULTS None of the 114 children in the primary care cohort ultimately received a diagnosis of IBD. The specificity of FCal in the primary care cohort was 0.87 (95% CI, 0.80-0.92). Among the 90 children in the referred cohort, 17 (19%) ultimately received a diagnosis of IBD. The sensitivity of FCal in the referred cohort was 0.99 (95% CI, 0.81-1.00). CONCLUSIONS The findings of this study suggest that a positive FCal result in children with chronic gastrointestinal symptoms seen in primary care is not likely to be indicative of IBD. A negative FCal result is likely to be a true negative, which safely rules out IBD in children in whom a primary care physician considers referral to specialist care.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Boudewijn J Kollen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Obbe F Norbruis
- Department of Pediatrics, Isala Hospital, Zwolle, The Netherlands
| | - Johanna C Escher
- Department of Pediatric Gastroenterology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children's Hospital ⁄ Academic Medical Center, Amsterdam, The Netherlands
| | - Yolanda B de Rijke
- Department of Clinical Chemistry, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, Beatrix Children's Hospital ⁄ University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Diederen K, Hoekman DR, Hummel TZ, de Meij TG, Koot BGP, Tabbers MM, Vlieger AM, Kindermann A, Benninga MA. The prevalence of irritable bowel syndrome-type symptoms in paediatric inflammatory bowel disease, and the relationship with biochemical markers of disease activity. Aliment Pharmacol Ther 2016; 44:181-8. [PMID: 27110920 DOI: 10.1111/apt.13636] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 02/29/2016] [Accepted: 03/30/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND A large proportion (25-46%) of adults with inflammatory bowel disease in remission has symptoms of irritable bowel syndrome (IBS), which are thought to reflect ongoing inflammation. Data on paediatric inflammatory bowel disease patients are lacking. AIM To investigate (i) the prevalence of IBS-type symptoms in paediatric inflammatory bowel disease patients in remission and (ii) the relationship of IBS-type symptoms with biochemical markers of disease activity. METHODS This cross-sectional study included all patients (<18 years) with Crohn's disease or ulcerative colitis attending the out-patient clinic of one of three Dutch hospitals between March 2014 and June 2015. Clinical disease activity was determined using the abbreviated-PCDAI or PUCAI. Biochemical disease activity was assessed using faecal calprotectin and serum CRP. IBS-symptoms were assessed using physician-administered Rome III-questionnaires. RESULTS We included 184 patients (92 female; mean age: 14.5 years) (Crohn's disease: 123, ulcerative colitis: 61). The prevalence of IBS-type symptoms in children with inflammatory bowel disease in clinical remission was 6.4% (95% CI: 2.5-11.1%; Crohn's disease: 4.5%; ulcerative colitis: 10.8%). Prevalence of IBS-type symptoms in children with faecal calprotectin <250 μg/g was 16.1% (95% CI: 7.6-25.8%; Crohn's disease: 16.7%; ulcerative colitis: 10.8%). No difference in faecal calprotectin or CRP was found between patients in clinical remission with or without IBS-type symptoms (faecal calprotectin: IBS+ median 58 μg/g, IBS- 221 μg/g, P = 0.12; CRP: IBS+ median 1.4 mg/L, IBS- 1.1 mg/L, P = 0.63). CONCLUSIONS The prevalence of IBS-type symptoms in children with inflammatory bowel disease is highly dependent on the definition of remission. Nonetheless, the prevalence is much lower than that previously reported in studies in adult inflammatory bowel disease patients. IBS-type symptoms appear to be unrelated to gastrointestinal inflammation.
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Affiliation(s)
- K Diederen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - D R Hoekman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - T Z Hummel
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, The Netherlands
| | - T G de Meij
- Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - B G P Koot
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - M M Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - A M Vlieger
- Department of Pediatrics, St Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - A Kindermann
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - M A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
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Schwarzer A, Bontems P, Urruzuno P, Kalach N, Iwanczak B, Roma-Giannikou E, Sykora J, Kindermann A, Casswall T, Cadranel S, Koletzko S. Sequential Therapy for Helicobacter pylori Infection in Treatment-naïve Children. Helicobacter 2016; 21:106-13. [PMID: 26123402 DOI: 10.1111/hel.12240] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
UNLABELLED The goal of first-line Helicobacter pylori therapy is to reach an eradication rate of 90% to avoid further investigations, antibiotic use, and spreading of resistant strains. AIM To evaluate the eradication rate of high-dose sequential therapy in treatment-naïve children and to assess factors associated with failure. METHODS Prospective data assessed in a registry from nine European centers between October 2009 and December 2011. Children with biopsy-proven Helicobacter pylori infection were prescribed 5 days of esomeprazole and amoxicillin, followed by 5 days of esomeprazole, clarithromycin, and metronidazole according to bodyweight. Eradication was assessed after 8-12 weeks. Primary endpoint was the eradication rate in children who received at least one dose and had follow-up data. Multivariate analysis evaluated potential factors for treatment success including sex, age, center, migrant status, antibiotic resistance, and adherence to therapy. RESULTS Follow-up was available in 209 of 232 patients (age range 3.1-17.9 years, 118 females). Primary resistance occurred for clarithromycin in 30 of 209 (14.4%), for metronidazole in 32 (15.3%), for both antibiotics in 7 (3.3%), and culture failed in 6 (2.9%). Eradication was achieved in 168 of 209 children (80.4%, 95% CI 75.02-85.78), in 85.8% with no resistance, 72.6% with single resistance, and 28.6% with double resistance. Independent factors affecting eradication rate included resistance to clarithromycin (adjusted ORs 0.27 (0.09-0.84), p = .024), to metronidazole (0.25 (0.009-0.72), p = .010) or to both (0.04 (0.01-0.35), p = .004), and intake of ≤ 90% of prescribed drugs (0.03 (0.01-0.18), p < .001). CONCLUSION A high-dose 10-day sequential therapy cannot be recommended in treatment-naïve children.
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Affiliation(s)
- Andrea Schwarzer
- Dr. v. Haunersches Kinderspital, Ludwig-Maximilians-University, Munich, Germany
| | - Patrick Bontems
- Department of Pediatric Gastroenterology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Nicolas Kalach
- Saint Antoine Pediatric Clinic, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University, Lille, France
| | - Barbara Iwanczak
- Department of Pediatrics, Medical University of Wrocław, Wrocław, Poland
| | | | - Josef Sykora
- Department of Paediatrics, Faculty Hospital, Charles University, Plezn, Czech Republic
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas Casswall
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Samy Cadranel
- Department of Pediatric Gastroenterology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Sibylle Koletzko
- Dr. v. Haunersches Kinderspital, Ludwig-Maximilians-University, Munich, Germany
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Hoekman DR, Brandse JF, de Meij TG, Hummel TZ, Löwenberg M, Benninga MA, D'Haens GR, Kindermann A. The association of infliximab trough levels with disease activity in pediatric inflammatory bowel disease. Scand J Gastroenterol 2016; 50:1110-7. [PMID: 25865965 DOI: 10.3109/00365521.2015.1027264] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Low serum trough levels (TLs) of infliximab (IFX) and antibodies to IFX (ATIs) are associated with the loss of therapeutic response in adults with inflammatory bowel disease (IBD) receiving IFX. Until now, pediatric data are scarce. Therefore, we aimed to cross-sectionally investigate the association between ATIs and IFX TLs, and clinical and biochemical disease activity in children receiving IFX for IBD. MATERIAL AND METHODS Children aged <18 years receiving IFX maintenance treatment for Crohn's disease (CD) or ulcerative colitis (UC) at three Dutch hospitals were included. Prior to two consecutive IFX infusions, IFX TLs and ATI levels were measured. Clinical disease activity was determined by Pediatric Crohn's Disease Activity Index (PCDAI) and Pediatric Ulcerative Colitis Activity Index (PUCAI), for CD and UC, respectively. Biochemical disease activity was assessed by serum C-reactive protein (CRP) and fecal calprotectin (FC). Clinical remission was defined as a PUCAI or PCDAI score of <10. Therapeutic range of IFX was considered 3-7 µg/ml. RESULTS Thirty-nine patients were included (31 CD; 16 females). Median age was 15 years. Median IFX TL was 3.5 µg/ml [IQR 2-7]. Subtherapeutic and supratherapeutic TLs were found in 38% and 23% of children, respectively. ATIs were detected in four patients. A correlation was found between IFX TL and CRP [rs = -0.51; p < 0.01] and FC [rs = -0.49; p < 0.01]. However, when only clinical disease activity was considered, no difference in median TL was found between remission and active disease (resp. 3.5 µg/ml [IQR 2-5] and 2.3 µg/ml [IQR 0.3-4.6]; p = 0.2). CONCLUSIONS IFX TLs are related to biochemical markers of disease activity. This could provide a rationale for monitoring TLs in children receiving IFX for IBD.
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Affiliation(s)
- Daniël R Hoekman
- Department of Pediatric Gastroenterology and Nutrition, Academic Medical Center , Amsterdam , The Netherlands
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Nusman CM, Hemke R, Benninga MA, Schonenberg-Meinema D, Kindermann A, van Rossum MAJ, van den Berg JM, Maas M, Kuijpers TW. Contrast-enhanced MRI of the knee in children unaffected by clinical arthritis compared to clinically active juvenile idiopathic arthritis patients. Eur Radiol 2015; 26:1141-8. [PMID: 26233246 PMCID: PMC4778146 DOI: 10.1007/s00330-015-3912-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 06/26/2015] [Accepted: 06/30/2015] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To evaluate enhancing synovial thickness upon contrast-enhanced magnetic resonance imaging (MRI) of the knee in children unaffected by clinical arthritis compared with clinically active juvenile idiopathic arthritis (JIA) patients. A secondary objective was optimization of the scoring method based on maximizing differences on MRI between these groups. METHODS Twenty-five children without history of joint complaints nor any clinical signs of joint inflammation were age/sex-matched with 25 clinically active JIA patients with arthritis of at least one knee. Two trained radiologists, blinded for clinical status, independently evaluated location and extent of enhancing synovial thickness with the validated Juvenile Arthritis MRI Scoring system (JAMRIS) on contrast-enhanced axial fat-saturated T1-weighted MRI of the knee. RESULTS Enhancing synovium (≥2 mm) was present in 13 (52 %) unaffected children. Using the total JAMRIS score for synovial thickening, no significant difference was found between unaffected children and active JIA patients (p = 0.091). Additional weighting of synovial thickening at the JIA-specific locations enabled more sensitive discrimination (p = 0.011). CONCLUSIONS Mild synovial thickening is commonly present in the knee of children unaffected by clinical arthritis. The infrapatellar and cruciate ligament synovial involvement were specific for JIA, which-in a revised JAMRIS-increases the ability to discriminate between JIA and unaffected children. KEY POINTS • Synovial inflammation is the primary disease feature in juvenile idiopathic arthritis (JIA). • Appearance of the synovium on contrast-enhanced MRI in unaffected children is unknown. • Validation of existing scoring methods requires comparison between JIA and unaffected children. • Mild enhancing synovial thickening was detected in half of the unaffected children. • Location-weighting for JIA-specific locations increased discriminative value of the scoring methods (p = 0.011).
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Affiliation(s)
- Charlotte M Nusman
- Department of Radiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Robert Hemke
- Department of Radiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Dieneke Schonenberg-Meinema
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marion A J van Rossum
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Pediatric Rheumatology, Reade, Dr. Jan van Breemenstraat 2, Amsterdam, The Netherlands
| | - J Merlijn van den Berg
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Hematology, Immunology, Rheumatology and Infectious Disease, Emma Children's Hospital AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Haisma SM, Lijftogt T, Kindermann A, Damen G, de Ridder L, Escher JC, Mearin ML, de Meij T, Hendriks D, George E, Hummel T, Norbruis O, van Rheenen P. Methotrexate for maintaining remission in paediatric Crohn's patients with prior failure or intolerance to thiopurines: a multicenter cohort study. J Crohns Colitis 2015; 9:305-11. [PMID: 25656249 DOI: 10.1093/ecco-jcc/jjv031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS Methotrexate [MTX] is an immunomodulating drug that can be used to maintain remission in patients with Crohn's disease [CD], but data on efficacy and tolerability in children and teenagers are scarce. We evaluated the long-term efficacy and tolerability of MTX monotherapy after thiopurine therapy in paediatric CD patients. METHODS A multicenter cohort of paediatric MTX users who stopped thiopurines due to ineffectiveness or intolerance between 2002 and 2012 were included and followed for at least 12 months. Relapse-free use was defined as steroid and biologics-free clinical remission after the introduction of MTX, and included intentional discontinuation of successful therapy before the end of the observation period. RESULTS A total of 113 patients with CD in remission were followed while on MTX monotherapy, of whom 75 [66%] had failed on thiopurines and 38 [34%] had stopped thiopurines due to side effects. Median age at the introduction of MTX was 14 years [range 7 to 17], and 93% used the subcutaneous route. Kaplan-Meier analysis showed that 52% of the study cohort were still in steroid- and biologics-free remission after 12 months of MTX monotherapy, with a difference that did not reach significance between thiopurine-intolerant and thiopurine-failing patients [p = 0.21, log-rank test]. CONCLUSIONS The findings of this cohort study suggest that MTX is an effective immunomodulator to maintain remission after stopping thiopurines. MTX maintenance should be considered before stepping up to anti-tumor necrosis factor alpha therapy. MTX is probably somewhat more effective in patients who stopped thiopurines due to side effects than in those who failed on thiopurines.
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Affiliation(s)
- Sjoukje-Marije Haisma
- University of Groningen, University Medical Center Groningen, Department of Pediatric Gastroenterology, Groningen, The Netherlands
| | - Thijs Lijftogt
- University of Groningen, University Medical Center Groningen, Department of Pediatric Gastroenterology, Groningen, The Netherlands
| | - Angelika Kindermann
- Emma's Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerard Damen
- Department of Pediatrics, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Lissy de Ridder
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johanna C Escher
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M Luisa Mearin
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Tim de Meij
- VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Daniëlle Hendriks
- Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | | | | | - Obbe Norbruis
- Isala, Princess Amalia Department of Pediatrics, Zwolle, The Netherlands
| | - Patrick van Rheenen
- University of Groningen, University Medical Center Groningen, Department of Pediatric Gastroenterology, Groningen, The Netherlands
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Nusman CM, Hemke R, Benninga M, Kindermann A, van Rossum M, Kuijpers T, Maas M. Contrast-enhanced MRI of the knee in asymptomatic pediatric controls compared to juvenile idiopathic arthritis patients to validate synovitis scores. Pediatr Rheumatol Online J 2014. [PMCID: PMC4184188 DOI: 10.1186/1546-0096-12-s1-p14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Holtman GA, Lisman-van Leeuwen Y, Kollen BJ, Escher JC, Kindermann A, Rheenen PFV, Berger MY. Challenges in diagnostic accuracy studies in primary care: the fecal calprotectin example. BMC Fam Pract 2013; 14:179. [PMID: 24274463 PMCID: PMC4222604 DOI: 10.1186/1471-2296-14-179] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 11/21/2013] [Indexed: 01/02/2023]
Abstract
Background Low disease prevalence and lack of uniform reference standards in primary care induce methodological challenges for investigating the diagnostic accuracy of a test. We present a study design that copes with these methodological challenges and discuss the methodological implications of our choices, using a quality assessment tool for diagnostic accuracy studies (QUADAS-2). Design The study investigates the diagnostic value of fecal calprotectin for detecting inflammatory bowel disease in children presenting with chronic gastrointestinal symptoms in primary care. It is a prospective cohort study including two cohorts of children: one cohort will be recruited in primary care and the other in secondary/tertiary care. Test results of fecal calprotectin will be compared to one of the two reference standards for inflammatory bowel disease: endoscopy with histopathological examination of mucosal biopsies or assessment of clinical symptoms at 1-year follow-up. Discussion According to QUADAS-2 the use of two reference standards and the recruitment of patients in two populations may cause differential verification bias and spectrum bias, respectively. The clinical relevance of this potential bias and methods to adjust for this are presented. This study illustrates the importance of awareness of the different kinds of bias that result from choices in the design phase of a diagnostic study in a low prevalence setting. This approach is exemplary for other diagnostic research in primary care.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice, FA21, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands.
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de Bie C, Kindermann A, Escher J. Use of exclusive enteral nutrition in paediatric Crohn's disease in The Netherlands. J Crohns Colitis 2013; 7:263-70. [PMID: 22820027 DOI: 10.1016/j.crohns.2012.07.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 06/22/2012] [Accepted: 07/03/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A six-week course of exclusive enteral nutrition (EEN) is recommended as first treatment in active paediatric Crohn's disease (CD). We aimed to assess short-term and long-term outcome of EEN, and to identify predictive factors of treatment success. METHODS The medical records of newly diagnosed paediatric CD patients initiating EEN as remission induction therapy between January 2008 and October 2011 were retrospectively studied. Treatment outcome was assessed using a previously described pattern recognition model. RESULTS 77 CD patients (median age 13.9 years, 57% male) initiated a six-week course of EEN, combined with azathioprine maintenance treatment in 92%. Patients received EEN as either hyperosmolar sip feeds or polymeric formula by nasogastric tube. In patients completing a six-week course of EEN (n=58), complete remission was achieved in 71%, partial remission in 26%, and no response in 3%. Complete remission rates were higher in children presenting with isolated ileal/ileocaecal disease and malnutrition. Nineteen patients discontinued EEN before the intended treatment period due to worsening of symptoms (n=9) or adherence issues (n=10). Non-adherence occurred more often in older children, females, children from non-Dutch parents, and patients taking hyperosmolar sip feeds compared with polymeric formula by nasogastric tube. The likelihood of relapsing disease within the first year after EEN treatment was 59%. CONCLUSION A six-week course of EEN is effective in newly diagnosed paediatric CD, with response rates that seem to be influenced by disease location and nutritional status, but not by type of formula. Non-adherence occurs frequently and limits the success of this treatment in everyday clinical practice.
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Affiliation(s)
- Charlotte de Bie
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
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Mourad-Baars PECN, Kindermann A, Venmans LMAJ, Tabbers MM. [Guideline on Helicobacter pylori infection in children]. Ned Tijdschr Geneeskd 2013; 157:A6915. [PMID: 24252409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In 2012, at the request of the Dutch Society of Paediatrics, a multidisciplinary working group developed a guideline entitled 'Helicobacter pylori infection in children aged 0-18 years'. The 2011 international guideline served as the guiding principle for this. The guideline includes recommendations on which children should be tested for H. pylori infection, the diagnostic tests to be used, the type of treatment to be given, and how follow-up should be conducted. Children can be tested and treated in both primary and secondary care. A gastroscopy is indicated if the presence of H. pylori in a child has been confirmed by a non-invasive test and two attempts at eradication have failed, and/or there are alarm symptoms that may point to the symptoms having a different underlying cause. A seven-day course of triple eradication therapy can be prescribed. As the level of resistance is low in the Netherlands, this therapy can be used in both the first and second instance without the pattern of resistance being known.
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Hummel TZ, ten Kate FJW, Reitsma JB, Benninga MA, Kindermann A. Additional value of upper GI tract endoscopy in the diagnostic assessment of childhood IBD. J Pediatr Gastroenterol Nutr 2012; 54:753-7. [PMID: 22584746 DOI: 10.1097/mpg.0b013e318243e3e3] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES For the choice of treatment in children with inflammatory bowel disease (IBD), it is important to make a distinction between Crohn disease (CD) and ulcerative colitis (UC). To look for pathognomonic features of CD, upper gastrointestinal tract (UGT) endoscopy has become part of the routine evaluation of children with suspected IBD; however, pathological changes can also be found in the UGT in patients with UC. The aims of the present study were to establish the role of UGT involvement in the diagnostic assessment of suspected IBD in children and to detect histopathological changes in the UGT mucosa, which can distinguish CD from non-CD (UC and non-IBD). METHODS Biopsies (colon, ileum, duodenum, stomach, esophagus) from children suspected of having IBD who underwent endoscopy between 2003 and 2008 were reassessed by a blinded, expert pathologist. The histological findings of the UGT were compared with the diagnosis based on ileocolonic biopsies and the final diagnosis. RESULTS In 11% of the children with CD, the diagnosis was based solely on the finding of granulomatous inflammation in the UGT. Focal cryptitis of the duodenum and focally enhanced gastritis were found significantly more frequently in children with CD compared with children with UC and non-IBD, with a specificity and positive predictive value of 99% and 93% and 87.1% and 78.6%, respectively. CONCLUSIONS Histology on ileocolonic biopsies alone is insufficient for a correct diagnosis of CD or UC in children. UGT endoscopy should, therefore, be performed in the diagnostic assessment of all children suspected of having IBD.
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Affiliation(s)
- Thalia Z Hummel
- Department of Pediatric Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.
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Bontems P, Kalach N, Iwanczak B, Casswall T, Koletzko S, Oderda G, Martinez-Gomez M, Urruzuno P, Kindermann A, Sykora J, Veres G, Roma-Giannikou E, Pehlivanoglu E, Mégraud F, Cadranel S. Étude cas-témoins des facteurs de risque d’ulcères ou d’érosions gastriques et duodénaux chez les enfants. Arch Pediatr 2011. [DOI: 10.1016/j.arcped.2011.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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De Bie CI, Hummel TZ, Kindermann A, Kokke FTM, Damen GM, Kneepkens CMF, Van Rheenen PF, Schweizer JJ, Hoekstra JH, Norbruis OF, Tjon A Ten WE, Vreugdenhil AC, Deckers-Kocken JM, Gijsbers CFM, Escher JC, De Ridder L. The duration of effect of infliximab maintenance treatment in paediatric Crohn's disease is limited. Aliment Pharmacol Ther 2011; 33:243-50. [PMID: 21083595 DOI: 10.1111/j.1365-2036.2010.04507.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Infliximab is effective for induction and maintenance of remission in children with moderately to severely active Crohn's disease (CD). AIM To evaluate the long-term efficacy of infliximab treatment in paediatric CD. METHODS In this observational, multicentre study, all paediatric CD patients in The Netherlands treated with infliximab from October 1992 to November 2009 and with minimal follow-up of 3 months since start of infliximab, were studied. RESULTS One hundred and fifty-two CD patients [81M; median age at start of infliximab 15.0 years (IQR 13.1-16.4)] received a median number of 10.5 infliximab infusions (IQR 6-21). Median follow-up after start of infliximab was 25 months (IQR 13-40). Kaplan-Meier analysis showed that the cumulative probability of losing response to infliximab in patients who initially required repeated infusions was 13%, 40% and 50% after 1, 3 and 5 years, respectively. Seventy-four patients (49%) needed dose adjustments, with a median time to any adjustment of 6 months. CONCLUSIONS Duration of effect of infliximab is limited as 50% of patients on infliximab maintenance treatment lose their therapeutic response after 5 years. Dose adjustments after start of infliximab are frequently needed to regain therapeutic benefit. These findings emphasise the need for effective, long-term treatment strategies for paediatric CD.
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Affiliation(s)
- C I De Bie
- Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.
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Abstract
his review summarizes the articles published on Helicobacter pylori infection in children between April 2008 and March 2009. Recent evidence highlights the decreasing prevalence trend of H. pylori infection and supports both intrafamilial and extrafamilial transmission. The association with various symptoms is still being debated. Interestingly, H. pylori infection seems inversely associated with allergic diseases. Monoclonal stool antigen tests are widely used and accurate for the diagnosis of H. pylori infection, but less accurate in young children. The new biprobe real-time PCR assay applied to stools showed a poor sensitivity in children. Using the urea hydrolysis rate next to the delta over baseline values, the (13)C-urea breath test provides excellent results for all age children, even for young children. Treatment of H. pylori infection remains a challenge, considering suboptimal efficacy of current therapy. Among emerging alternatives, sequential treatment appears promising. The adjunction of probiotics to conventional regimens, although eliciting great interest, has shown limited therapeutic benefit.
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Affiliation(s)
- Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma's Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
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Raphaël MF, Van Wijk R, Schweizer JJ, Schouten-van Meeteren NAY, Kindermann A, van Solinge WW, Smiers FJ. Pyruvate kinase deficiency associated with severe liver dysfunction in the newborn. Am J Hematol 2007; 82:1025-8. [PMID: 17654506 DOI: 10.1002/ajh.20942] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Significant hyperbilirubinaemia, anemia, and splenomegaly are common features in patients with severe haemolysis due to pyruvate kinase (PK) deficiency. Until now, severe neonatal PK deficiency has not been associated with fatal liver disease at this age. We present two neonatal cases of severe PK deficiency complicated with progressive fatal liver disease. The patients presented with severe haemolysis, progressive cholestasis, and hepatosplenomegaly, and both patients ultimately developed liver failure at a very young age. Despite extensive investigations, no specific explanation for liver disease and failure was found. We suggest that the PK deficiency itself directly led to liver dysfunction.
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Affiliation(s)
- Martine F Raphaël
- Department of Paediatric Haematology and Oncology, Wilhelmina Children's Hospital, University Medical Center of Utrecht, The Netherlands.
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Kneepkens CMF, Kindermann A, Wijnaendts LCD. [Eosinophilic oesophagitis in young men with food swallowing complaints]. Ned Tijdschr Geneeskd 2005; 149:1597. [PMID: 16038166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
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de Haan SN, Kindermann A, Dahhan N, Bosman DK. [Diagnostic methods for Helicobacter pylori infection in children]. Ned Tijdschr Geneeskd 2005; 149:1326-9. [PMID: 16008035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
A Helicobacter pylori infection is usually acquired during early childhood. Poor socioeconomic circumstances form an important risk factor for this. An untreated infection may lead to peptic ulceration and, particularly in adults, to gastric cancer and mucosa associated lymphoid tissue (MALT) lymphoma. The gold standard for the diagnosis of H. pylori infection is gastroscopy with histology and culture of biopsy specimens. Non-invasive tests are serology, 13C-urea breath test and stool antigen test. The sensitivity and specificity of serology tests are low in children, but for both the 13C-urea breath test and the stool antigen test the sensitivity and specificity are high. A 'test and treat' approach is advised with due consideration for possible symptoms and the risk for peptic ulcers and gastric cancer at a more advanced age. The treatment results must be evaluated. If necessary, young children can be treated at a later age.
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Affiliation(s)
- S N de Haan
- Academisch Medisch Centrum, Emma Kinderziekenhuis, afd. Kindergastro-enterologie, Amsterdam
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Feydt-Schmidt A, Kindermann A, Konstantopoulos N, Demmelmair H, Ballauff A, Findeisen A, Koletzko S. Reinfection rate in children after successful Helicobacter pylori eradication. Eur J Gastroenterol Hepatol 2002; 14:1119-23. [PMID: 12362103 DOI: 10.1097/00042737-200210000-00013] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study was performed to determine the rate of Helicobacter pylori reinfection after its successful eradication in children living in Germany. DESIGN A total of 102 children (48 boys; 31 German and 71 other nationalities; age 1.8-18 years) with a negative (13)C-urea breath test 8 weeks after triple therapy were followed up by a (13)C-urea breath test every 6 months. The cohort included 11 children aged <6 years, 58 children aged > or =6 to 12 years, and 33 children > or =12 years. RESULTS The mean duration (+/- standard deviation) of follow-up was 15.5 +/- 11.9 months with a maximum of 4.9 years, representing 132 patient years. Only three children (aged 9.7-14.9 years, one German, two Turkish) tested positive at 6, 12, and 18 months, respectively. The calculated reinfection rate was 2.3% per person per year. CONCLUSION The risk of reinfection with H. pylori is low in children living in Germany. There is no evidence that the reinfection rate depends on the age, sex, or nationality of the child. The low reinfection rate indicates that it is unnecessary to screen or treat asymptomatic family members in order to prevent reinfection.
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Affiliation(s)
- Anne Feydt-Schmidt
- Dr von Haunersches Kinderspital, Ludwig-Maximilians-University Munich, Pettenkoferstrasse 8a, D-80336 Munich, Germany
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Kindermann A, Konstantopoulos N, Lehn N, Demmelmair H, Koletzko S. Evaluation of two commercial enzyme immunoassays, testing immunoglobulin G (IgG) and IgA responses, for diagnosis of Helicobacter pylori infection in children. J Clin Microbiol 2001; 39:3591-6. [PMID: 11574578 PMCID: PMC88394 DOI: 10.1128/jcm.39.10.3591-3596.2001] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Serological testing to diagnose Helicobacter pylori infection in children is still controversial, although commonly used in clinical practice. We compared the immunoglobulin G (IgG) and IgA results of two commercially available enzyme immunoassays (EIAs) (Pyloriset IgG and IgA and Enzygnost II IgG and IgA) for 175 children with abdominal symptoms divided into three age groups (0 to < or =6 years, n = 47; >6 to < or =12 years, n = 77; >12 years, n = 51). A child was considered H. pylori infected if at least two of three tests (histology, rapid urease test, 13C-urea breath test) or culture were positive and noninfected if all results were concordantly negative. Of 175 children, 93 (53%) were H. pylori negative and 82 were H. pylori positive. With the recommended cutoff values, the overall specificity was excellent for all four EIAs (95.7 to 97.8%) regardless of age. Sensitivity varied markedly between tests and was 92.7, 70.7, 47.5, and 24.4% for Enzygnost II IgG, Pyloriset IgG, Enzygnost II IgA, and Pyloriset IgA, respectively. Sensitivity was low in the youngest age group (25 to 33.3%), except for Enzygnost II IgG (91.6%). Receiver-operating curve analyses revealed that lower cutoff values would improve the accuracy of all of the tests except Enzygnost II IgG. Measurement of specific IgA, in addition to IgG, antibodies hardly improved the sensitivity. The specificity of commercial serological tests is high in children when the cutoff values obtained from adults are used. In contrast, sensitivity is variable, with a strong age dependence in some, but not all, tests. We speculate that young children may have a different immune response to H. pylori, with preferable responses to certain antigens, as well as lower titers than adults. The Pyloriset test may fail to recognize these specific antibodies.
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Kindermann A, Faus-Kessler T, Ballauff A, Findeisen A, Laske G, Demmelmair H, Jesch I, Koletzko S. Evaluation of a rapid whole blood test to detect Helicobacter pylori infection in children. Scand J Gastroenterol 2001; 36:572-6. [PMID: 11424314 DOI: 10.1080/003655201750162953] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rapid, patient near tests for detecting antibodies against Helicobacter pylori are offered for clinical use. We evaluated the BM-Test (Boehringer Mannheim, Germany; identical to the Helisal Rapid Blood Test) in children with recurrent abdominal pain. METHODS The BM-Test and 13C-urea breath test (UBT) were performed in 195 children (4-18 years). Symptoms were assessed using a 4-week diary. Upper endoscopy was performed in all UBT-positive children and in UBT-negative children with symptoms suggestive of organic disease. H. pylori status was considered positive if at least two of three methods (UBT, histology or rapid urease test) or culture were positive. RESULTS After exclusion of children with previous H. pylori therapy (n = 8) and undetermined H. pylori status (n = 1), 61/186 (33%) children were H. pylori positive. The BM-Test in relation to H. pylori status revealed a sensitivity of 54%, specificity of 90%, a likelihood ratio of 5.2 for a positive, and of 0.4 for a negative test result. Accuracy of the test was independent of ethnicity, gender, age, family history for ulcer disease, frequency or severity of abdominal symptoms, epigastric tenderness, type of blood sampling (capillary versus venous) and DOB values of the UBT. In eight previously treated children, the test gave one false-positive and three false-negative results. CONCLUSIONS Almost half of H. pylori-infected children and 10% of non-infected children were misclassified by the BM-Test. False-negative results are not related to young age or certain ethnic groups. The poor performance makes the test unsuitable for epidemiological and clinical use in children.
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Abstract
BACKGROUND The 13C-urea breath test for diagnosis of Helicobacter pylori infection has not been validated in infants and young children. The influence of age on the test results was studied by conventional validation against invasive methods and by mathematical estimation in a large pediatric population. METHODS The breath test was performed in 1499 children aged 2 months to 18 years. After a fasting period of 4 hours or more, 75 mg 13C-urea was ingested with cold apple juice, breath samples were taken at baseline and at 15 and 30 minutes. The distribution of the natural logarithms of the delta-over baseline (DOB) values were calculated, and the optimal cutoff values between positive and negative test results and gray zones with a risk of misclassification more than 10% were determined for both time points. In a subgroup of 149 children results of the breath test were compared with concordant results of histology and rapid urease test; 53 of them were less than 6 years of age. RESULTS Logarithmic results of 1499 breath tests revealed two normally distributed subgroups with minimal overlap. The calculated optimal cutoff values were 4.7/1000 at 15 minutes and 5.0/1000 at 30 minutes. At 30 minutes, only 2.6% of all results were in the calculated gray zone (2.6-6.5/1000). Age was negatively correlated to DOB values of both negative (r = -0.223) and positive results (r = -0.291; P < 0.001). Breath test-negative and -positive children 6 or less years of age had significantly higher mean DOB values (P < 0.02) and a larger proportion of results within the gray zone than older children. Compared with biopsy-based results, the least discrepancies occurred at a cutoff of 5.0/1000: 0 of 61 infected (sensitivity 100%) and 6 of 88 noninfected children. Because five of the false-positive results were obtained in children less than 6 years of age, specificity and positive predictive values were lower in this age group than in older patients (88.1% vs. 97.8% and 68.8% vs. 98.0%, respectively). CONCLUSIONS Under the applied conditions, the 13C-urea breath test shows an excellent separation between positive and negative results. Because of some overlap and a strong age effect, definition of a gray zone appears more meaningful than a threshold value. Because infants and young children have a high risk for false-positive breath test results, the values for cutoff and gray zones may have to be adapted. Further validation studies against invasive methods are warranted in this age group.
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Mitzdorf U, Beck K, Horton-Hausknecht J, Weidenhammer W, Kindermann A, Takács M, Astor G, Melchart D. Why do patients seek treatment in hospitals of complementary medicine? J Altern Complement Med 1999; 5:463-73. [PMID: 10537246 DOI: 10.1089/acm.1999.5.463] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This exploratory study evaluated patients' reasons for entering a complementary (alternative) medicine hospital by ranking 15 medical and psychosocial factors that were thought to influence this choice. SUBJECTS AND OUTCOME MEASURES Two hundred patients (200) from two complementary hospitals, one focusing on Traditional Chinese Medicine and one on the Western type of complementary medicine, completed an extensive questionnaire at the beginning of their inpatient treatment. The questionnaire covered personal background; disease parameters; attitude towards conventional medicine; previous experience with, and knowledge of, complementary therapies; expectations concerning the forthcoming treatment; health-related habits; personality traits; and social support. RESULTS Optimistic attitudes towards treatment and a positive appraisal of alternative doctors were frequently stated reasons (80%), as was the disease severity (long duration: 86%; acute progression or imminent surgery: 70%). Previous successes with complementary therapies, however, ranked relatively low (53%). Negative opinions concerning conventional therapies and conventional doctors' treatments were mentioned by 68% of the patients. Many patients felt themselves to be under considerable psychologic stress (74%). A majority (73%) was well informed about complementary therapies, and 65% were curious about the forthcoming therapies. Sixty-eight percent (68%) indicated good health behaviors. Fewer patients mentioned contemplative and/or religious attitudes (44%) or lack of social support (25%). Age primarily accounted for variations in the ranking weights of the two subgroups. The specific type of complementary medicine was of minor influence. In 14 out of 21 personality dimensions, the current patient group showed significant deviations from the healthy reference, which is in good agreement with findings from conventionally treated patients.
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Affiliation(s)
- U Mitzdorf
- Institut für Medizinische Psychologie, Ludwig-Maximilians-Universität München, Germany.
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Koletzko B, Demmelmair H, Hartl W, Kindermann A, Koletzko S, Sauerwald T, Szitanyi P. The use of stable isotope techniques for nutritional and metabolic research in paediatrics. Early Hum Dev 1998; 53 Suppl:S77-97. [PMID: 10102657 DOI: 10.1016/s0378-3782(98)00067-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Stable isotope methods are increasingly used in paediatrics for clinical diagnosis and research due to marked improvements in analytical technologies and better availability of suitable tracers. The safety of stable isotopes is of major importance for use in children. Large amounts of deuterium well above the doses applied under clinical conditions may induce adverse effects. In contrast, heavier stable isotopes such as 13C, 15N or 18O do not induce adverse effects even at the highest enrichments obtained, and they are safe. Breath tests with measurements of 13CO2 enrichment after oral application of a tracer can reliably evaluate helicobacter pylori infection and gastric emptying kinetics. Combined with an estimation of total CO2 production, 13CO2 breath tests allow estimation of the absorption and oxidation of 13C-labelled substrates, such as medium- and long-chain triglycerides, and demonstrates the beneficial effect of carnitine supplements on fat oxidation in primary carnitine deficiency. The study of metabolic processes may require the sampling of blood for isotopic analyses of metabolites of the applied tracer. Gas chromatography-isotope ratio mass spectrometry can detect tracer in individual components from small plasma samples. The high precision enabled us to utilize the small differences in natural 13C-enrichment between dietary fats to study fatty acid turnover in term infants, in whom the dietary fat source was switched to corn oil with a slightly higher 13C-content. With this approach we demonstrated active conversion of linoleic into arachidonic acid. We also applied biotechnologically produced, U-13C labelled linoleic and alpha-linolenic acids to infants and detected the conversion of these essential fatty acids to their longer chain polyunsaturated derivatives, with an apparent change of conversion activity with age. Moreover, it has become possible to measure tissue protein synthesis from small biopsy samples obtained in situ without surgery, such as forceps biopsies of rectal tumors. These few examples of recent developments demonstrate the great clinical and scientific potential of stable isotope methods in future paediatric applications.
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Affiliation(s)
- B Koletzko
- Kinderklinik nd Kinderpoliklinik, Klinikum Innenstadt, Ludwig-Maximilians University of Munich, Germany. berthold.koletzko.@kk-i.uni-muenchen.de
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