Systematic review: Body composition in children with inflammatory bowel disease

BACKGROUND

Paediatric inflammatory bowel disease (IBD) is associated with weight loss, growth restriction and malnutrition. Bone mass deficits are well described, little is known about other body composition compartments.

AIMS

To define the alterations in non-bone tissue compartments in children with IBD, and explore the effects of demographic and disease parameters.

METHODS

A systematic search was carried out in the PubMed (www.ncbi.nlm.nih.gov/pubmed) and Web of Science databases in May 2014 (limitations age <17 years, and composition measurements compared with a defined control population).

RESULTS

Twenty-one studies were included in this systematic review, reporting on a total of 1479 children with IBD [1123 Crohn's disease, 243 ulcerative colitis], pooled mean age 13.1 ± 3.2 years, and 34.9% female. Data were highly heterogeneous, in terms of methodology and patients. Deficits in protein-related compartments were reported. Lean mass deficits were documented in 93.6% of Crohn's disease and 47.7% of ulcerative colitis patients when compared with healthy control populations. Lower lean mass was common to both sexes in Crohn's disease and ulcerative colitis, deficits in females with persisted for longer. Fat-related compartment findings were inconsistent, some studies report reductions in body fat in new diagnosis/active Crohn's disease.

CONCLUSIONS

It is clear that almost all children with Crohn's disease and half with ulcerative colitis have reduced lean mass, however, body fat alterations are not well defined. To understand what impact this may have on health and disease in children with IBD, further studies are needed to identify in which tissues these deficits lie, and to quantify body fat and its distribution.

Recognition, assessment and management of eosinophilic oesophagitis

Eosinophilic oesophagitis (EO) is a chronic immune/antigen-mediated oesophageal disease, with the immune reaction most likely directed to foods but on occasion also to aeroallergens. Clinically, it is characterised by symptoms of oesophageal dysfunction in subjects who typically have other indicators of an atopic tendency. Older children (and adults) frequently present with dysphagia and can have strictures (which may require dilatation). The diagnosis is dependent on an eosinophil-predominant oesophageal inflammation, with 15 or more eosinophils per high-powered field, now generally accepted as a necessary cut-off level of infiltration, which together with other clinical data (eg, oesophageal pH/impedance studies) can help discriminate EO from other potential causes of symptoms such as gastro-oesophageal reflux disease. Recommended therapies, which may need to be long term, are dietary antigen exclusion (with elemental feeds or an exclusion diet) and/or topical corticosteroids.

Update of the management of inflammatory bowel disease

Up to 25% of patients with Crohn's disease and ulcerative colitis present before the age of 18 years. Although the pathophysiology of inflammatory bowel disease presenting in childhood does not differ fundamentally from that presenting in adulthood, managing these younger patients requires special consideration in light of growth and the potential long term consequences of both the disease and its treatments. Therapeutic approaches have changed in recent years, and there is a fuller appreciation of the role (and risks) of anti-tumour necrosis factor monoclonal therapy.

Blood tests and histological correlates in children with eosinophilic oesophagitis

AIM

To determine the relationship between blood tests and oesophageal histology in Eosinophilic oesophagitis (EoE).

METHODS

All children diagnosed with EoE at one hospital from 2000 to 2009 were considered for inclusion in this study. Three blood test results were analysed, blood eosinophil count, serum total immunoglobulin E (IgE) and radioallergosorbent tests (RAST) to common food allergens. Oesophageal histology was prospectively re-reviewed, and mean eosinophil counts were enumerated. Blood test results were correlated with oesophageal eosinophil counts using Spearman's rank test.

RESULTS

Forty children (70% boys) were included in this study, median age at diagnosis 6.5 years (range 0-15). At the time of diagnosis, 78% of children had a raised blood eosinophil count, 90% had a raised serum total IgE and 83% had one or more positive RAST tests. The mean oesophageal eosinophil count was significantly correlated with both blood eosinophil count (p=0.008) and serum total IgE level (p=0.008).

CONCLUSION

This study shows that blood tests are often abnormal in children with EoE at the time of diagnosis. Our data demonstrate an association between histological abnormalities and blood test results in children with EoE.

UK incidence of achalasia: an 11-year national epidemiological study

AIM

To determine the incidence and examine the epidemiology of achalasia before the age of 16 years in the UK from 1998 to 2008.

METHODS

25 regional paediatric surgery referral centres were asked to provide demographic and epidemiological data on cases of childhood achalasia from 1998 to 2008. Incidence rates were calculated from national population estimates. The data collection method was validated in one centre.

RESULTS

228 patients from 24 centres were diagnosed with achalasia before 16 years in the UK from 1998 to 2008. The mean incidence from 1998 to 2008 was 0.18/10(5) children/year. Where additional data was provided (69-81% of cases) 56% of children were male and the mean age of diagnosis was 10.9 years. Logistic regression analysis showed a rising incidence, with an OR of 1.12 (95% CI 1.06 to 1.16) for having achalasia in each successive year. The validation of this methodology showed that 95% of true cases and no false cases were identified.

CONCLUSIONS

The mean incidence of childhood achalasia in the UK from 1998 to 2008 is at least 0.18/10(5) children/year; this has risen over the last 11 years and compared to the only other study published in 1988.

Reduced quality of life in children with gastro-oesophageal reflux disease

AIM

To assess self-reported Quality of life (QoL) in children with Gastro-oesophageal reflux disease (GORD) aged 5-18 and compare this with both disease and healthy control children in a prospective consecutive sample.

METHODS

All children attending a tertiary paediatric gastroenterology clinic from February 2009 to May 2009 with GORD, chronic constipation and inflammatory bowel disease (IBD) were asked to complete the validated PedsQL generic QoL assessment (self-report) at their clinic appointment. The PedsQL considers physical, emotional, social and school domains and is scored from 0 to 100. Healthy children were also recruited from the same site. Groups were compared using the independent samples Student's t-test.

RESULTS

A total of 184 children completed the assessment [103 (56%) male, mean age 10.7 years +/- 3.3] including 40 children with GORD, 44 with chronic constipation, 59 with IBD and 41 healthy children. QoL was significantly lower in the GORD group compared with both children with IBD (74 vs. 82) and healthy children (74 vs. 84), and was comparable to that of children with chronic constipation (74 vs. 74).

CONCLUSIONS

Self-reported QoL in children with GORD attending a tertiary paediatric gastroenterology clinic is significantly reduced compared with both healthy children and children with IBD.

Neonatal inflammatory intestinal diseases: necrotising enterocolitis and allergic colitis

The occurrence in the neonatal period and into early infancy of two inflammatory conditions, necrotising enterocolitis (NEC), and allergic colitis, that do not occur in later life highlight the peculiar vulnerability of the gastrointestinal tract in the newborn period to otherwise innocuous insults. The pathogenesis of the relatively benign allergic colitis as a mucosal inflammatory process driven by dietary antigens is relatively well characterised, and its treatment with dietary manipulation is well established. For NEC, hypoxic/ischaemic insult, mucosal immaturity, and its interaction with the intestinal microflora are understood to be the main factors in pathogenesis. Thus far, the most productive interventions have been in preventative approaches, in particular feeding strategies, to reduce the incidence of the condition whilst establishing adequate growth and progression onto enteral feeding. For established NEC, supportive medical therapy or surgical intervention remains the mainstay or treatment, although novel therapies, such as platelet-activating factor (PAF) inhibitors and epidermal growth factor (EGF), have shown some promise in animal models of the condition.