Self-reported prescribing behaviour of vitamin D prophylaxis in healthy children by Belgian paediatricians

There is currently no consensus on the guidelines for vitamin D prophylaxis in healthy children. The purpose of this study was to investigate the prescribing behaviour of vitamin D prophylaxis among Belgian paediatricians. Between June and September 2022, a questionnaire was distributed by email to all Belgian paediatricians who are a member of at least one of three scientific or professional organisations, as well as to the heads of every Belgian paediatric or neonatal hospital ward. We analysed 426 completed questionnaires. All regions, age categories and subspecialties were represented. Vitamin D prophylaxis is always or frequently recommended by 98% of paediatricians. Fifty-eight per cent of paediatricians advise vitamin D prophylaxis up to the age of six years and 66% of paediatricians advise a daily dose of 400 IU. In nearly every hospital in Belgium (96%), there is a specific protocol for vitamin D prophylaxis for newborns; but not for the paediatric unit (only 30%). Nearly all Belgian paediatricians prescribe vitamin D prophylaxis to infants. Although not recommended by guidelines, 25(OH)D is frequently measured by paediatricians. Practices regarding duration and dosing of vitamin D prophylaxis show large variability. Most neonatal wards do have a protocol, whereas most paediatric wards do not.

Integrated gut metabolome and microbiome fingerprinting reveals that dysbiosis precedes allergic inflammation in IgE-mediated pediatric cow's milk allergy

BACKGROUND

IgE-mediated cow's milk allergy (IgE-CMA) is one of the first allergies to arise in early childhood and may result from exposure to various milk allergens, of which β-lactoglobulin (BLG) and casein are the most important. Understanding the underlying mechanisms behind IgE-CMA is imperative for the discovery of novel biomarkers and the design of innovative treatment and prevention strategies.

METHODS

We report a longitudinal in vivo murine model, in which two mice strains (BALB/c and C57Bl/6) were sensitized to BLG using either cholera toxin or an oil emulsion (n = 6 per group). After sensitization, mice were challenged orally, their clinical signs monitored, antibody (IgE and IgG1) and cytokine levels (IL-4 and IFN-γ) measured, and fecal samples subjected to metabolomics. The results of the murine models were further extrapolated to fecal microbiome-metabolome data from our population of IgE-CMA (n = 22) and healthy (n = 23) children (Trial: NCT04249973), on which polar metabolomics, lipidomics and 16S rRNA metasequencing were performed. In vitro gastrointestinal digestions and multi-omics corroborated the microbial origin of proposed metabolic changes.

RESULTS

During mice sensitization, we observed multiple microbially derived metabolic alterations, most importantly bile acid, energy and tryptophan metabolites, that preceded allergic inflammation. We confirmed microbial dysbiosis, and its associated effect on metabolic alterations in our patient cohort, through in vitro digestions and multi-omics, which was accompanied by metabolic signatures of low-grade inflammation.

CONCLUSION

Our results indicate that gut dysbiosis precedes allergic inflammation and nurtures a chronic low-grade inflammation in children on elimination diets, opening important new opportunities for future prevention and treatment strategies.

Exploring residents and supervisors' workplace learning needs during postgraduate medical education

Objectives

To identify the main enablers and challenges for workplace learning during postgraduate medical education among residents and their supervisors involved in training hospital specialists across different medical specialties and clinical teaching departments.

Methods

A qualitative explorative study using semi-structured focus group interviews was employed. A purposeful sampling method was utilized to invite participants who were involved in postgraduate medical education for hospital specialist medicine at two universities. Hospital physicians in training, also called residents (n=876) and supervisors (n=66), were invited by email to participate. Three focus groups were organized: two with residents and one with supervisors. Due to the COVID-19 pandemic rules prohibiting real group meetings, these focus groups were online and asynchronous. The data was analyzed following an inductive thematic analysis.

Results

The following overarching themes were identified: 1) the dual learning path, which balances working in the hospital and formal courses, 2) feedback, where quality, quantity, and frequency are discussed, and 3) learning support, including residents' self-directed learning, supervisors' guidance, and ePortfolio support.

Conclusions

Different enablers and challenges for postgraduate medical education were identified. These results can guide all stakeholders involved with workplace learning to develop a better understanding of how workplace learning can be optimized to improve the postgraduate medical education experience. Future studies could focus on confirming the results of this study in a broader, perhaps international setting and exploring strategies for aligning residencies to improve quality.

Reply to Davison, G. Comment on "Huijghebaert et al. Does Trypsin Oral Spray (Viruprotect®/ColdZyme®) Protect against COVID-19 and Common Colds or Induce Mutation? Caveats in Medical Device Regulations in the European Union. Int. J. Environ. Res. Public Health 2021, 18, 5066"

We have read the comment from Davison with great interest [...].

Apoptotic enteropathy, gluten intolerance, and IBD-like inflammation associated with lipotoxicity in DGAT1 deficiency-related diarrhea: a case report of a 17-year-old patient and literature review

We present a long-term follow-up in a 17-year-old girl with DGAT1-related diarrhea, an autosomal recessive disorder characterized by impaired triglyceride absorption. Neonatal presentation included severe congenital diarrhea, protein-losing enteropathy, and failure to thrive requiring total parenteral nutrition. Duodenal biopsies revealed apoptotic enteropathy and acute inflammation with the presence of macrophages and Touton giant cells, related to the intake of fat. She was able to switch to enteral nutrition on a fat-free diet. However, at age 10, she developed gluten-induced enteropathy and then IBD-like inflammation 5 years later. Immunohistochemistry was able to confirm the diagnosis, while DGAT1 sequencing remained inconclusive. This highlights the role of histopathology and immunohistochemistry, despite the increasing importance of genetic analysis in the diagnostic work-up. This report also illustrates that parenteral nutrition weaning is possible in DGAT1-related diarrhea, but gut barrier dysfunction might increase the risk of autoimmune intestinal disease.

Development of an integrated competency framework for postgraduate paediatric training: a Delphi study

Competency-based education (CBE) has transformed medical training during the last decades. In Flanders (Belgium), multiple competency frameworks are being used concurrently guiding paediatric postgraduate CBE. This study aimed to merge these frameworks into an integrated competency framework for postgraduate paediatric training. In a first phase, these frameworks were scrutinized and merged into one using the Canadian Medical Education Directives for Specialists (CanMEDS) framework as a comprehensive basis. Thereafter, the resulting unified competency framework was validated using a Delphi study with three consecutive rounds. All competencies (n = 95) were scored as relevant in the first round, and twelve competencies were adjusted in the second round. After the third round, all competencies were validated for inclusion. Nevertheless, differences in the setting in which a paediatrician may work make it difficult to apply a general framework, as not all competencies are equally relevant, applicable, or suitable for evaluation in every clinical setting. These challenges call for a clear description of the competencies to guide curriculum planning, and to provide a fitting workplace context and learning opportunities.Conclusion: A competency framework for paediatric post-graduate training was developed by combining three existing frameworks, and was validated through a Delphi study. This competency framework can be used in setting the goals for workplace learning during paediatric training. What is Known: •Benefits of competency-based education and its underlying competency frameworks have been described in the literature. •A single and comprehensive competency framework can facilitate training, assessment, and certification. What is New: •Three existing frameworks were merged into one integrated framework for paediatric postgraduate education, which was then adjusted and approved by an expert panel. •Differences in the working environment might explain how relevant a competency is perceived.

Belgian Consensus Recommendations to Prevent Vitamin K Deficiency Bleeding in the Term and Preterm Infant

Neonatal vitamin K prophylaxis is essential to prevent vitamin K deficiency bleeding (VKDB) with a clear benefit compared to placebo. Various routes (intramuscular (IM), oral, intravenous (IV)) and dosing regimens were explored. A literature review was conducted to compare vitamin K regimens on VKDB incidence. Simultaneously, information on practices was collected from Belgian pediatric and neonatal departments. Based on the review and these practices, a consensus was developed and voted on by all co-authors and heads of pediatric departments. Today, practices vary. In line with literature, the advised prophylactic regimen is 1 or 2 mg IM vitamin K once at birth. In the case of parental refusal, healthcare providers should inform parents of the slightly inferior alternative (2 mg oral vitamin K at birth, followed by 1 or 2 mg oral weekly for 3 months when breastfed). We recommend 1 mg IM in preterm <32 weeks, and the same alternative in the case of parental refusal. When IM is perceived impossible in preterm <32 weeks, 0.5 mg IV once is recommended, with a single additional IM 1 mg dose when IV lipids are discontinued. This recommendation is a step towards harmonizing vitamin K prophylaxis in all newborns.

Successful liver transplantation in hyperornithinemia-hyperammonemia-homocitrullinuria syndrome: Case report

BACKGROUND

HHH syndrome is a rare autosomal recessive disorder of the urea cycle, caused by a deficient mitochondrial ornithine transporter. We report the first successful liver transplantation in HHH syndrome performed in a seven-year-old boy. The patient presented at 4 weeks of age with hyperammonemic coma. The plasma amino acid profile was suggestive of HHH syndrome, and the diagnosis was confirmed when sequencing of the SLC25A15 gene identified two mutations p.R275Q and p.A76D. Although immediate intervention resulted in normalization of plasma ammonia levels within 24 hours, he developed cerebral edema, coma, convulsions, and subsequent neurological sequelae. Metabolic control was difficult requiring severe protein restriction and continued treatment with sodium benzoate and L-arginine. Despite substantial developmental delay, he was referred to our center for liver transplantation because of poor metabolic control. Following cadaveric split liver transplantation, there was complete normalization of his plasma ammonia and plasma amino acid levels under a normal protein-containing diet. This excellent metabolic control was associated with a markedly improved general condition, mood and behavior, and small developmental achievements. Twelve years after liver transplantation, the patient has a stable cognitive impairment without progression of spastic diplegia.

CONCLUSION

This first case of liver transplantation in HHH syndrome demonstrates that this procedure is a therapeutic option for HHH patients with difficult metabolic control.

Disparities in the gut metabolome of post-operative Hirschsprung's disease patients

Hirschsprung's disease (HD) is a congenital structural abnormality of the colon seen in approximately 1 to 5000 live births. Despite surgical correction shortly after presentation, up to 60% of patients will express long-term gastrointestinal complaints, including potentially life-threatening Hirschsprung-associated enterocolitis (HAEC). In this study fecal samples from postoperative HD patients (n = 38) and their healthy siblings (n = 21) were analysed using high-resolution liquid chromatography-mass spectrometry aiming to further unravel the nature of the chronic gastrointestinal disturbances. Furthermore, within the patient group, we compared the faecal metabolome between patients with and without a history of HAEC as well as those diagnosed with short or long aganglionic segment. Targeted analysis identified several individual metabolites characteristic for all HD patients as well as those with a history of HAEC and long segment HD. Moreover, multivariate models based on untargeted data established statistically significant (p < 0.05) differences in comprehensive faecal metabolome in the patients' cohort as a whole and in patients with a history of HAEC. Pathway analysis revealed the most impact on amino sugar, lysine, sialic acid, hyaluronan and heparan sulphate metabolism in HD, as well as impaired tyrosine metabolism in HAEC group. Those changes imply disruption of intestinal mucosal barrier due to glycosaminoglycan breakdown and dysbiosis as major metabolic changes in patients' group and should be further explored for potential diagnostic or treatment targets.

Parental Catastrophizing and Goal Pursuit in the Context of Child Chronic Pain: A Daily Diary Study

Background: Despite daily variability in children's chronic pain experiences, little is known about how parents' emotions and goals toward their child's pain are influenced by these daily changes. This diary study examined how daily child pain intensity (as perceived by parents) moderates the associations between parental catastrophic thoughts about child pain on the one hand, and daily parental distress and parents' goals with regard to their child's pain (pain control vs. activity engagement) on the other hand.

Method: Participants were 25 parents of 20 different children (N = 18; 90% girls). Children, aged 8–14 years (M = 9.5, SD = 2.09), experienced either chronic headache or functional abdominal pain with an average pain duration of 22.5 months (SD = 24.5 months). Daily parental responses (i.e., perceived child pain intensity, distress and goal endorsement) were collected through a 3-week daily diary (resulting in 413 valid diary reports). Parents completed the Pain Catastrophizing Scale for Parents prior to starting the diary (PCS-P general) and a daily measure (PCS-P daily) included in the diary. To account for the interdependence of the data, the data were analyzed using multilevel modeling.

Results: Perceived daily child pain intensity moderated the impact of parental general and daily catastrophic thoughts on parents' daily distress. Only for parents experiencing low general catastrophic thoughts an increase in distress was observed on days when they perceived their child's pain intensity as high. For all parents, high levels of perceived child pain intensity were related to more distress on days where parents reported high levels of catastrophic thinking (i.e., PCS-P daily). Perceived daily child pain intensity also moderated the impact of parental general catastrophic thinking on parents' daily endorsement of goals. Parents with high levels of general catastrophic thinking reported a lower focus on child pain control on days when child pain intensity was perceived to be low. Parents with low general catastrophic thinking reported lower endorsement of the activity engagement goal on days where the child's pain intensity was perceived to be low.

Conclusion: These findings highlight the complexity of daily fluctuations in parental distress and goals regarding their child's pain. Clinical implications and future directions are critically assessed.

Two cases of DCDC2-related neonatal sclerosing cholangitis with developmental delay and literature review

Ciliopathies are a group of clinical and molecular heterogeneous conditions with pleiotropic manifestations affecting the central nervous system, renal, liver, skeletal, and ocular systems. Biallelic pathogenic variants in DCDC2 cause a ciliopathy primarily presenting with neonatal sclerosing cholangitis (NSC). Pathogenic variants in DCDC2 have further been reported in the context of nephronophthisis and non-syndromic recessive deafness. Polymorphisms in DCDC2 have also been associated with dyslexia and DCDC2 has a role in neuronal development. We report on two unrelated patients with DCDC2-related NSC with additional central nervous system impairment manifesting as microcephaly, global developmental delay, and axial hypotonia. Histological findings of our patients can mimic biliary atresia or congenital hepatic fibrosis. We further show that transmission electron microscopy in patients with NSC does not always show absence of primary cilia. Hence patients with DCDC2 pathogenic variants should also undergo an evaluation of neuromotor development. Review of all reported patients further reveals a risk for supra-aortic arterial aneurysms.

Does Trypsin Oral Spray (Viruprotect®/ColdZyme®) Protect against COVID-19 and Common Colds or Induce Mutation? Caveats in Medical Device Regulations in the European Union

BACKGROUND

nasal or oral sprays are often marketed as medical devices (MDs) in the European Union to prevent common cold (CC), with ColdZyme^®/Viruprotect^® (trypsin/glycerol) mouth spray claiming to prevent colds and the COVID-19 virus from infecting host cells and to shorten/reduce CC symptoms as an example. We analyzed the published (pre)-clinical evidence.

METHODS

preclinical: comparison of in vitro tests with validated host cell models to determine viral infectivity. Clinical: efficacy, proportion of users protected against virus (compared with non-users) and safety associated with trypsin/glycerol.

RESULTS

preclinical data showed that exogenous trypsin enhances SARS-CoV-2 infectivity and syncytia formation in host models, while culture passages in trypsin presence induce spike protein mutants. The manufacturer claims >98% SARS-CoV-2 deactivation, although clinically irrelevant as based on a tryptic viral digest, inserting trypsin inactivation before host cells exposure. Efficacy and safety were not adequately addressed in clinical studies or leaflets (no COVID-19 data). Protection was obtained among 9-39% of users, comparable to or lower than placebo-treated or non-users. Several potential safety risks (tissue digestion, bronchoconstriction) were identified.

CONCLUSIONS

the current European MD regulations may result in insufficient exploration of (pre)clinical proof of action. Exogenous trypsin exposure even raises concerns (higher SARS-CoV-2 infectivity, mutations), whereas its clinical protective performance against respiratory viruses as published remains poor and substandard.

Primum non nocere: lingual frenotomy for breastfeeding problems, not as innocent as generally accepted

The frenotomy or surgical release of the lingual frenulum is performed with increasing frequency. Restricted tongue mobility, ankyloglossia, is the main indication for this procedure. This clinical diagnosis is often used as synonym for tongue-tie which is blamed for many feeding difficulties resulting in an increase in performed frenotomies. Until recently, little was known about the anatomical structure and normal variation of the tongue-tie. Different grading systems have been developed. Some are exclusively based on appearance of the tongue-tie; others also include functional elements. There is, however, no established relation between the tongue-tie score and the observed feeding problems or outcomes following frenotomy. Therefore, caution is warranted before submitting babies to this procedure.Conclusion: This narrative review aims to give an overview of current knowledge and concerns regarding the tongue-tie, which need to be considered before referral for a frenotomy. What is Known: • The presence of a tongue-tie is associated with a higher frequency of breastfeeding problems. • Hence, frenotomy is advocated and increasingly performed in infants with breastfeeding problems. Current tongue-tie classifications do not allow to predict breastfeeding problems. What is New: • New anatomy insights caution for possible complications resulting from this seemingly innocent practice of frenotomy. • Frenotomy should only be performed after multidisciplinary evaluation of feeding problems, following exclusion and remediation of other causative factors.

Medical devices that look like medicines: safety and regulatory concerns for children in Europe

INTRODUCTION

Medical devices (MedDevs) and medicines are assessed (and monitored) differently before and after launch. There are products for repeated oral ingestion that are marketed in the European Union as MedDevs.

OBJECTIVES AND METHODS

To illustrate the consequences of these differences in assessment, we compared the leaflet information of three MedDevs with the standards for medicines and with published evidence at launch. As examples, gelatin tannate (GT), its combination with tyndalised probiotics (TP) (GTTP) for diarrhoea and a gel containing hyaluronic acid (HA)/chondroitin sulfate (CS)/poloxamer (Pol407) (HACSPol) for gastro-oesophageal reflux disease were examined.

RESULTS

Applying standards for medicines, product composition is insufficiently defined in the MedDev leaflet (eg, plant origin, polymerisation grade, dose and ratio of the relevant constituents). As no age limit is mentioned in the leaflets, all 3 products allow use in children from birth onwards, although published clinical documentation in children was poor (GT) or lacking (GTTP and HACSPol). MedDev leaflets do not mention adverse events (AEs), while literature search suggests safety concerns such as tannic acid (TA) cytotoxicity, potentially more diarrhoea/AEs with TP, use of doses higher than established safe (TA and HA) and lack of chronic toxicity studies for oral Pol407. None refers to interactions with medicines, although some ingredients may affect medicine absorption.

CONCLUSION

Although these MedDevs require repeated oral intake as do medicines, their assessment and monitoring differ significantly from the standards for medicines. Compared with medicines, MedDevs for repeated oral use are poorly labelled and rely on very limited clinical information at market release.

Intra-patient variability in tacrolimus exposure in pediatric liver transplant recipients: Evolution, risk factors, and impact on patient outcomes

BACKGROUND

This study aims to investigate the evolution and factors associated with TAC IPV and its impact on patient outcomes in pediatric LT recipients.

METHODS

This is a retrospective study including 41 children. The TAC IPV was expressed as the coefficient of variation and was calculated for years 1-5 following LT. The number of missed clinic appointments was used as a surrogate marker for therapy adherence.

RESULTS

We identified a decrease in the TAC IPV during the first 3 years after LT (P < 0.01). Serum albumin in the first year (P = 0.03), hematocrit (P = 0.02) and total bilirubin (P = 0.04) in the third year, and therapy adherence (P < 0.01) in the fifth year were associated with TAC IPV. High TAC IPV was associated with biopsy-proven acute allograft rejection (P = 0.04) and the need for biopsy during the first year (P = 0.02). There was a borderline association between TAC IPV and donor-specific antibodies (P = 0.08) and CMV viremia (P = 0.07). High TAC IPV was a predictor of need for liver biopsy and AR with an odds ratio of 1.04 (95% CI 1.0-1.1; P = 0.03) and 1.04 (95% CI 1.0-1.1; P = 0.05), respectively.

CONCLUSIONS

Our results highlight the impact of biological factors on TAC IPV during the early LT follow-up and later also therapy adherence. High TAC IPV may be associated with adverse patient outcomes.

A Novel Double-Blind, Placebo-Controlled Food Challenge Matrix for Milk and Raw Egg

BACKGROUND

The double-blind, placebo-controlled food challenge (DBPCFC) is still considered to be the gold standard in food allergy diagnosis. This test is however not common practice in routine due to several practical limitations, especially for non-IgE-mediated food allergy with its typical delayed food allergic reactions.

OBJECTIVE

The aim of this study was to develop and evaluate DBPCFC matrices for the diagnosis of milk and egg allergies which can be applied at home for the diagnosis of delayed food allergic reactions. The main focus was the blinding of milk and raw egg and the development of matrices which can be prepared and consumed conveniently at home with a sufficiently long shelf life (+/- 6 months or longer).

METHODS

A sensory test evaluated the blinding of the egg and milk in the matrices. The microbiological analysis confirmed the safety and stability of the developed matrices. To assess the applicability of the matrices, a pilot DBPCFC study for milk including 7 patients was conducted.

RESULTS

Sensory tests confirmed that the masking of the allergenic ingredients was sufficient. Microbial safety and stability of the matrices were confirmed up to 6 months of storage at ambient temperatures in the dark. The DBPCFC for milk showed different outcomes and proved its applicability for use at home.

CONCLUSION

A novel stable DBPCFC matrix for milk and raw egg has been developed that allows convenient use at the patients' home.

The predictive value of colon transit time and anorectal manometry in the approach of faecal continence in children with spina bifida

PURPOSE

The aim of this study is to analyse colon transit time (CTT) and anorectal manometry (ARM) in children with spina bifida (SB) as a predictor for achieving spontaneous faecal continence.

METHODS

SB patients (2.5-7 years old) followed at the SB Reference Centre Ghent University Hospital underwent CTT and/or ARM before starting bowel management. A standardized questionnaire about the presence of constipation and faecal incontinence was completed. CTT was measured using a 6-day pellet abdominal X-ray method. ARM was performed in nonsedated children using a latex-free catheter.

RESULTS

Twenty-two patients were studied, with a median age of 4.57 years. They all underwent a CTT study, 17 (77%) also agreed to ARM. 10/22 patients (45.5%) were constipated. 5/22 patients (22.7%) became spontaneously continent, 10/22 (45.5%) became pseudocontinent with bowel management, the others remained incontinent. SB patients had a significant prolonged CTT compared to healthy controls. In the group with an abnormal CTT study (12 patients), none of the patients developed faecal continence spontaneously, irrespective of the ARM result. In case of a normal CTT study (10 patients), 7 agreed to ARM. All children with normal resting pressure (4 patients) gained continence spontaneously. The 3 children with abnormal low resting pressure remained incontinent.

CONCLUSIONS

This prospective study confirms the predictive value of normal CTT and normal resting pressure, in the evolution towards spontaneous faecal continence. If CTT is abnormal, irrespective of the ARM, bowel management will be necessary to obtain pseudo-continence. In these cases, ARM is not a designated examination.

Physicochemical stable standard all-in-one parenteral nutrition admixtures for infants and children in accordance with the ESPGHAN/ESPEN guidelines

OBJECTIVE

Because there are almost no standard all-in-one parenteral nutrition admixtures available for infants and children, the aim was to develop standard two-compartment parenteral nutrition bags for different weight categories based on the ESPGHAN/ESPEN (European Society of Paediatric Gastroenterology, Hepatology and Nutrition/European Society for Clinical Nutrition and Metabolism) guidelines. The 1 g/kg/d lipid version for the 3 to 10 kg weight category (PED1) was assessed for short- and long-term physicochemical stability with the ability to add additional electrolytes (PED1+E).

METHODS

The lipid compartment A and the all-in-one admixture of A + B + vitamins + trace elements were assessed physically by visual inspection, Sudan red test, pH measurement, and lipid droplet size distribution. Chemical stability for compartment A was evaluated by quantitative analyses of non-esterified fatty acids and peroxide content. The glucose-amino acid-electrolyte compartment B was evaluated physically by visual inspection, measuring particle contamination and pH. Chemical stability was assessed by discoloration, quantitative analyses of glucose, and the amino acids L-cysteine, L-tyrosine, and L-tryptophan.

RESULTS

No phase separation or coalescence occurred, and the mean droplet size diameter did not exceed 0.5 µm. Peroxide content and non-esterified fatty acids concentration of compartment A remained well below the limit of acceptation. No precipitation was detected for compartment B; only a slight yellow discoloration was noted at 80 d. Concentrations of glucose, L-tyrosine, and L-tryptophan remained stable; only L-cysteine decreased significantly from its initial concentration.

CONCLUSION

The two-compartment PED1 and PED1+E admixtures are stable up to 80 d 2° to 8°C + 24 h room temperature (RT) with an additional 7 d 2° to 8°C + 48 h RT after mixing and addition of vitamins and trace elements.

Are antihistamines effective in children? A review of the evidence

BACKGROUND AND AIMS

During the last decades, much attention has been paid to off-label and unlicensed prescriptions in paediatrics. However, on-label prescribing can also cause health issues. In this paper, the case of first-generation H₁-antihistamines is investigated, notably the range of indications for which products are licensed in different European countries and the evidence base (or lack thereof) for each indication, as well as reported adverse drug reactions.

METHODS

Review of the Summary of Product Characteristics of first-generation H₁-antihistamines with a focus on paediatric use. This is plotted against the evidence available in the literature.

RESULTS

This investigation shows a large variability in labelled indications and licensing ages when compared in five different European countries. Moreover, most of the indications are not based on clinical trials evaluating efficacy and safety of these drugs in children.

CONCLUSIONS

Many of the licensed indications of first-generation antihistamines do not appear to be evidence based.

Drug administration via enteral feeding tube in residential care facilities for individuals with intellectual disability: A focus group study on guideline implementation

People with profound intellectual disabilities often receive medication through enteral feeding tube (EFT). In a previous study, we found that current guidelines concerning medication preparation and administration through EFT are often not followed in residential care facilities (RCFs) for individuals with intellectual disabilities. The present qualitative study aimed to identify barriers and facilitators experienced by RCF staff members to following guidelines on medication administration via EFT, by conducting focus group interviews. Time constraints, lack of knowledge, lack of clear administration instructions, lack of necessary materials, and limited gastric fluid tolerance in certain residents were identified as barriers to following guidelines. Other influencing factors were the number of staff members, residents, and medications; habits; and the residents' comfort and well-being. To optimize care for this vulnerable patient population with EFT, an intervention can be set up focusing on improving staff members' medication-related knowledge and providing clear administration instructions and the necessary materials.

Analysis of drug use in institutionalized individuals with intellectual disability and tube feeding

OBJECTIVES

Little is known about the medication used by people with intellectual disabilities (ID) and enteral feeding tube (EFT). However, in light of the complexity associated with drug administration through EFT, data on medication use in this population may be helpful in the development of practical guidelines and staff training initiatives.

METHODS

A cross-sectional, observational study was conducted in six Belgian residential care facilities (RCFs) for individuals with ID. Anonymized medication records of all residents receiving chronic medication through EFT were collected (n = 156). All chronic drugs were categorized according to the ATC classification, and medication records were checked for potential major drug-drug interactions (DDI).

RESULTS

The 156 residents used a total of 1029 chronic drugs via EFT, with a median of six drugs per resident (range 1-14). A total of 148 different drug molecules were identified, belonging to 38 main ATC therapeutic groups (ATC level 2). Antiepileptics, drugs for constipation and drugs for acid-related disorders were the most frequently used groups. Seventy-four of the 156 screened medication records (47%) contained at least one potential DDI; in total, 116 potential interactions were identified, which represent 38 different interacting drug pairs.

CONCLUSION

This study describes medication use through EFT among people with ID in Belgian RCFs, with antiepileptics being the most frequently used group. Our study also demonstrated that a high number of drugs is administered through EFT, and that the number of potential DDIs is high. These observations warrant an increased attention for drug administration through the EFT in individuals with ID.

Development and validation of a spina bifida-specific pediatric quality of life questionnaire: the Spina Bifida Pediatric Questionnaire, SBPQ

PURPOSE

Based on existing questionnaires and patient interview, a health-related quality of life (HRQoL) questionnaire in spina bifida (SB) children is created and validated, the Spina Bifida Pediatric Questionnaire (SBPQ).

METHODS

SB patients from the SB reference centre Ghent University Hospital, Belgium, with mental ability between 6 and 18 years old and their parents were asked to participate in the study, together with a control group.

RESULTS

Thirty-nine patients and parents answered the questionnaire once, 20 patients and their parents the test-retest. Thirty-five controls answered the questionnaire once, 34 controls and their parents the test-retest. The final questionnaire was retained when 3 consecutive patients approved all items. Visual clues were added for children with a mental ability below 10 years of age. The test-retest showed a good to excellent agreement for child self-report in 5 domains (not for social functioning), for parent proxy report in all domains (6), for control self-report in 4 domains (not for domain home) and for control parent proxy report in all domains (5). Internal consistency reliability was good in child self-report and in parent proxy report, except for physical functioning in child self-report. There was parent-child agreement for 4 out of 6 domains. Regarding social and emotional functioning, QoL was rated lower by parents than by children themselves.

CONCLUSION

A SB HRQoL questionnaire was developed and validated. Because of visual aid, this questionnaire can be used by both young children and adolescents.

Dietary lipid intake only partially influences variance in serum phospholipid fatty acid composition in adolescents: impact of other dietary factors

The present study aimed to assess the correlation between food and fatty acid (FA) intake and the serum phospholipid (PL) FA status in European adolescents and explored the percentage of variation in serum PL FA that could be attributed to dietary habits. Participants included 528 adolescents recruited in the HELENA Study. Dietary intake was assessed by two, self-administered, non-consecutive 24-h recalls. PL FA concentrations were measured in fasting venous serum samples. Reduced rank regressions were applied to examine the combined effect of food intakes. Results indicated that the variance in serum PL FA in adolescents, that could be explained by diet varied from 7.0% for MUFA to 14.2% for n-3FA. The variance in the long-chain n-3FA was mainly explained by fish intake but also by coffee and tea consumption. In conclusion this study indicated that dietary intake influences the serum PL FA status to a limited amount but that also other factors interfere. However, dietary intake is important as it is among those factors that could be modified. Furthermore, the results suggest that the overall dietary habits should be considered instead of only the consumption of single foods or nutrients, as the medium of the food or concomitant intake of foods and nutrients might interact and as such influence absorption or metabolism.

Prevention of overweight in children younger than 2 years old: a pilot cluster-randomized controlled trial

OBJECTIVE

The aim of the present study was to evaluate the effects of a 1-year family-based healthy lifestyle intervention implemented through day-care centres on toddlers' BMI Z-scores and reported activity- and dietary-related behaviours.

DESIGN

Pilot cluster-randomized controlled trial.

SETTING

Seventy child-care centres in three different intervention communities and three paired-matched control communities in Flanders, Belgium.

SUBJECTS

A sample of 203 Belgian toddlers aged 9-24 months was included in the study. Objectively assessed weight and height were used to calculate BMI Z-scores. A parental-report questionnaire was used to assess children's lifestyle behaviours.

RESULTS

Positive intervention effects were found on BMI Z-score. No intervention effects were found for activity- and dietary-related behaviours targeted by the intervention. In both intervention and control groups, daily consumption of water, soft drinks, sweets and savoury snacks increased while daily consumption of fruit and vegetables decreased over 1 year. Daily physical activity remained stable but screen-time behaviour increased in both groups over time.

CONCLUSIONS

The study showed that a family-based healthy lifestyle intervention implemented through day-care centres can lead to healthier weight outcomes in toddlers. In both groups, an unhealthier lifestyle pattern was observed over 1 year which underlines the importance of the early childhood period as the focus of future behavioural interventions.

Microsomal protein per gram of liver (MPPGL) in paediatric biliary atresia patients

The microsomal protein per gram of liver (MPPGL) is an important scaling factor in the in vitro-in vivo extrapolation of metabolic data obtained in liver microsomes. This study aimed to determine the MPPGL in four biliary atresia patients (0.6-1.6 years old) undergoing liver transplantation, as it is known that the MPPGL is affected by age and possibly by liver disease. Due to the presence of bilirubin in the homogenates and microsomes, the NADPH-cytochrome reductase activity was used to determine the recovery factor, rather than methods using the dithionite difference spectrum. A mean value of 18.73 (± 2.82) mg/g (geometric mean ± SD, n = 4) was observed, which is lower than the expected MPPGL based on the age of the patients (26.60 ± 0.40 mg/g). This suggests a decreased amount of microsomal protein in the livers of biliary atresia patients. Moreover, no differences in MPPGL between different zones of the liver could be detected.

Post-transplant food allergy in children is associated with liver and not with renal transplantation: a monocentric comparative study

Food allergy is increasingly reported after paediatric liver transplantation. The underlying physiopathological mechanism remains incompletely understood. Therefore, we aimed to determine the incidence, clinical presentation, possible risk factors, and prognosis of post-transplant food allergy in children currently followed after liver and renal transplantation. The study population consists of 49 liver and 21 renal transplant patients transplanted between the age of 22 months and 15 years. Data were collected retrospectively from medical records and via a doctor's questionnaire taken from the parents in a monocentric setting. Post-transplant food allergy has developed in 13 liver transplant patients and in none of the renal transplant recipients. Within the liver transplant group, median age at liver transplantation is significantly lower in the food-allergic (10 months) versus non-food-allergic group (3.3 years; p = 0.002). The use of tacrolimus as primary maintenance immunosuppression is associated with food allergy (p = 0.032) and mean donor age is significantly lower in the food-allergic group (p = 0.009). Compared to the renal transplant group, median age at transplantation is significantly lower in the liver patients (p < 0.001). No significant differences are found in primary immunosuppressive regimens between renal and liver transplant patients.

CONCLUSION

Post-transplant food allergy is an important clinical problem in children after liver transplantation which does not affect renal transplant patients despite similar immunosuppressive regimens. Within the group of liver transplant recipients, tacrolimus use, young age at time of transplant and younger donor age were associated with the development of food allergy.

In vitro cytochrome p450 activity decreases in children with high pediatric end-stage liver disease scores

To improve the modeling and simulation of pharmacokinetics in pediatric patients, research into developmental and disease-specific determinants is needed. This article describes the evaluation of the activity of in vitro cytochrome P450 (P450), an important enzyme family in drug metabolism, in children with hepatic dysfunction. The activity of six P450 isoforms (CYP1A2, 2C9, 2C19, 2D6, 2E1, and 3A4) was evaluated in 31 patients with different pathologies, predominantly biliary atresia (n = 23). Hypervariable activity was observed for all the isoforms. Compared with average adult activity, low activity levels were seen for CYP1A2, 2C19, 2E1, and 3A4. For CYP2E1 and 3A4, a positive correlation between activity and abundance was observed. Age, comedication, and genotype could not be used as predictors for P450 activity in this patient population. In contrast, the pediatric end-stage liver disease score was negatively correlated with the ln(activity). This finding suggests a decrease in P450 activity with deteriorating hepatic function. Moreover, the activity of all isoforms was correlated, demonstrating a concomitant decrease of all isoforms in young patients with liver disease. To our knowledge, this is the first study to evaluate P450 activity in children with hepatic impairment. The presented data may provide support in the further optimization of a disease-specific model in this patient population.

Clinical practice: vegetarian infant and child nutrition

The aim of this review is to give insight on the benefits and risks of vegetarianism, with special emphasis on vegetarian child nutrition. This eating pattern excluding meat and fish is being adopted by a growing number of people. A vegetarian diet has been shown to be associated with lower mortality of ischaemic heart disease and lower prevalence of obesity. Growth in children on a vegetarian diet including dairy has been shown to be similar to omnivorous peers. Although vegetarianism in adolescents is associated with eating disorders, there is no proof of a causal relation, as the eating disorder generally precedes the exclusion of meat from the diet. A well-balanced lacto-ovo-vegetarian diet, including dairy products, can satisfy all nutritional needs of the growing child. In contrast, a vegan diet, excluding all animal food sources, has at least to be supplemented with vitamin B(12), with special attention to adequate intakes of calcium and zinc and energy-dense foods containing enough high-quality protein for young children. The more restricted the diet and the younger the child, the greater the risk for deficiencies.

Solid food refusal as the presenting sign of vitamin B12 deficiency in a breastfed infant

Dietary vitamin B(12) (vitB(12)) deficiency, although common in the elderly, is rare in childhood. We report on an exclusively breastfed 8-month-old infant, presenting with persistent refusal of solid foods. Three months later, developmental regression and failure to thrive led to the diagnosis of vitB(12) deficiency, as a consequence of a subclinical pernicious anaemia with vitB(12) deficiency in the mother. Treating the infant with parenteral vitB(12) induced prompt recovery including acceptance of weaning food.

CONCLUSION

This case illustrates refusal of complementary foods as a presenting symptom of vitB(12) deficiency in a breastfed infant. Symptoms, diagnostic tests and treatment of vitamin B(12) deficiency are reviewed. Early diagnosis and treatment are important to prevent irreversible neurological damage.

Pharmacokinetics of two formulations of omeprazole administered through a gastrostomy tube in patients with severe neurodevelopmental problems

AIMS

Omeprazole is often administered through a gastrostomy tube as either (i) a Multiple Unit Pellet System (MUPS®) tablet disintegrated in water (MUPS® formulation), or (ii) a suspension in 8.4% sodium bicarbonate (suspension formulation). This bioavailability study evaluates this practice in tube-fed patients with severe neurodevelopmental problems.

METHODS

Nonblinded, two-phase cross-over trial.

RESULTS

In seven of 10 patients, bioavailability was higher for the suspension formulation than for the MUPS® formulation. Median (90% confidence interval) area under the plasma concentration-time curve ratio (MUPS® over suspension) was 0.5 (0.06-2.37).

CONCLUSIONS

In this population, omeprazole MUPS® formulation has no apparent advantage over the more easily administered suspension formulation.

Colonic transit time in mentally retarded persons

INTRODUCTION

Constipation is frequently seen in patients with mental retardation (MR). Its pathophysiology is poorly understood. Measurement of colon transit time (CTT) differentiates between retentive and non-retentive constipation.

AIM

To determine total and segmental CTT in MR patients compared to healthy controls.

METHOD

Of 250 residents, 60 patients older then 16, without swallowing disorder or scoliosis, are randomly chosen, 58 participated (intelligence quotient < 50, median age 35.5 year, 29 male). Constipation was defined as less than three defecations a week. Controls are 32 non-constipated age-matched healthy volunteers (median age 29 year, 19 male). CTT is measured by daily administration of ten radio-opaque markers during 6 days and abdominal X-ray on day 7. CTT is calculated using Bouchoucha's [7] method.

RESULTS

Compared to controls, total CTT is significantly (P < 0.001) longer in MR (median 22.8 h vs. 57.6 h, respectively). Of the MR patients, 21/58 (36%) are constipated. The mental retardated and constipated (MRC) have a significant prolonged CTT in all segments (P < 0.01; median right CTT 19.2 h vs. 4.8 h; left CTT 14.4 h vs. 4.8 h; rectosigmoidal CTT 42 h vs. 9.6 h), whereas in mental retarded non-constipated (MRNC) persons, the rectosigmoidal CTT is prolonged (median 21.6 h vs. 9.6 h).

CONCLUSION

Patients with moderate to deep MR have a significantly prolonged total CTT. In MRNC persons, rectosigmoidal CTT prolongation suggests a defecation problem. In MRC, CTT is prolonged in all segments, suggesting diffuse colonic inertia problem.

An 8-year follow-up of treated obese children: children's, process and parental predictors of successful outcome

OBJECTIVE

This study presents an 8-year outcome of overweight children who were treated in an outpatient program and aims to identify child and familial variables associated with long-term weight regulation.

METHODS

A total of 90 children participated with a mean age of 10.1 years +/- 2.6 at baseline and a mean adjusted BMI (actual BMI/50th percentile of BMI for age and gender x 100) of 153.1 +/- 20.7% at baseline participated in the 8-year follow-up (retrieval rate 71%; response rate 89%). Children's and parental factors, administered at baseline and at follow-up were related to the success of the treatment.

RESULTS

The children obtained a mean reduction of 8% in adjusted BMI at the 8-year follow-up. A total of 59 children (66%) were successful in obtaining weight control (i.e. maintaining their original % adjusted BMI); 40% even decreased their adjusted BMI by 10% or more. Analyses revealed that the child's age, the degree of overweight at baseline and the child's global self-worth were positive predictors of long-term weight loss 8 years after treatment, whereas psychopathology in the mother was a negative predictor. The total explained variance was R(2) = 35%.

DISCUSSION

Treatment of childhood obesity by means of a multidisciplinary cognitive-behavioural program enables the majority of children to control their weight in the long term. In order to predict the success of the treatment, it is recommended to take into account the child's age, its degree of overweight, its global self-worth and the occurrence of maternal psychopathology.

Vitamin K, an update for the paediatrician

INTRODUCTION

This review summarizes current knowledge on vitamin K for the paediatrician. Vitamin K is a fat-soluble vitamin, present in plants as phylloquinone and produced by bacteria as menaquinone. It is acting as a co-factor for gamma-glutamyl carboxylase. This enzyme is responsible for post-translational modification of some glutamate side chains to gamma-carboxyglutamate. The majority of gamma-carboxylated proteins function in blood coagulation; others play a role in calcium homeostasis.

DATA

Newborn babies are at particular risk of vitamin K deficiency, as placental transfer is limited and human milk is a poor source. Vitamin K prophylaxis at birth effectively prevents vitamin K deficiency bleeding (VKDB), formerly known as "haemorrhagic disease of the newborn". Recent epidemiological studies provide data on the effectiveness of different administration routes and dosing schemes. Infants of mothers taking drugs that inhibit vitamin K are at risk of early VKDB and should receive 1 mg intramuscular (i.m.) as soon as possible after birth. Classic VKDB is prevented by intramuscular as well as by oral administration of 1 mg vitamin K. In exclusively breast-fed infants, single i.m. administration at birth is also effectively preventing (rare) late VKDB but single oral administration is not. If given orally, prophylaxis should be continued by either weekly administration of 1 mg till 12 weeks or repeating 2 mg at weeks 1 and 4. Daily administration of 25 microg offers insufficient protection. The only infants not fully protected in this way are those with yet unrecognised liver disease.

CONCLUSIONS

Further work is needed before firm recommendations can be made regarding dose in preterm infants and in patients with fat malabsorption/cholestasis or regarding the role of vitamin K in the prevention of osteoporosis.

Discussing patient management online: the impact of roles on knowledge construction for students interning at the paediatric ward

The objectives of this study are to explore the use of asynchronous discussion groups during medical students' clinical rotation in paediatrics. In particular, the impact of role assignment on the level of knowledge construction through social negotiation is studied. Case-based asynchronous discussion groups were introduced to enhance reflection and critical thinking on patient management and treatment, and to offer an exercise in evidence-based medical practice. Groups of approximately 4-5 students were asked to discuss 4 authentic cases during clinical rotation in paediatrics. 49 students interning at the paediatric ward participated in this study. With respect to role assignment, differences between groups (1) with a student or an instructor as moderator and (2) with or without a developer of alternatives for patient management were explored. A content analysis was performed to explore the different levels of social construction of knowledge. The results of multilevel logit analyses show a significant difference in knowledge construction through social negotiation between conditions with a student moderator and conditions where the instructor is moderating, but only when a developer of alternatives is involved. No significant difference was revealed between student-moderated and instructor-moderator groups without a developer of alternatives. It can be concluded that when both the moderator and developer role are assigned to students, their contributions are more likely to reflect a high level of knowledge construction.

Helicobacter pylori infection: further evidence for the role of feco-oral transmission

BACKGROUND

Helicobacter pylori infection is recognized as a major cause of chronic digestive diseases with a major public health impact, yet the knowledge of transmission pathways is limited. We studied the transmission in employees taking care of institutionalized persons with mental disabilities with a documented high prevalence of H. pylori.

MATERIALS AND METHODS

Six hundred and seventy-one health-care workers were screened for H. pylori serology. For each employee, information was collected on age, sex, father's and mother's education level, number of household members and number of children sleeping in the same bedroom during childhood, as well as lifestyle factors such as smoking and tropical journeys and occupational exposure data such as type of contact with inhabitants (changing napkins with stools, washing inhabitants, feeding inhabitants, personal contact) and seniority in the institution.

RESULTS

Seroprevalence for H. pylori increased significantly with age. In univariate analysis, risk factors for H. pylori positivity were (age-adjusted): father's education, mean length of employment, smoking, contact with fecal materials of inhabitants, washing and feeding of inhabitants. Controlling for confounders, in multiple logistic regression analysis, only fecal contact remained as a significant risk factor for H. pylori infection.

CONCLUSIONS

In health-care workers caring for a population with a high prevalence of H. pylori infection, there is an association with fecal transmission. This, however, does not rule out the possibility of other ways of transmission.

Transient exocrine pancreatic insufficiency as a possible complication of an enterovirus infection

Exocrine pancreatic insufficiency is an exceptional problem in children, mostly associated with diseases like cystic fibrosis, Shwachman-Diamond syndrome or chronic pancreatitis, as is the case in idiopathic fibrosing pancreatitis. Many viral infections are known to cause acute pancreatitis. Most of them, however, are transient with no remaining damage. The differential diagnosis of persisting diarrhoea after gastrointestinal infection does not routinely include a search for exocrine pancreatic insufficiency.

CONCLUSION

This is the first description of a child with a transient but severe exocrine pancreatic insufficiency probably induced by an ordinary enterovirus infection

Inpatient treatment of obese children: a multicomponent programme without stringent calorie restriction

This prospective clinical case-control study describes the effect of an inpatient multicomponent treatment programme for obese children and adolescents on their weight and psychological well being. We studied 38 patients and 38 controls on the waiting list, matched for age and gender, referred because of obesity, with a median age of 13 years (range 10-17 years) and a median adjusted body mass index (BMI) of 173% (range 130%-257%). The treatment consisted of a 10-month inpatient programme focussing on attaining a healthy lifestyle by increasing physical activity and offering a healthy diet within a cognitive-behavioural framework. At base line, at the end of the treatment, 6 months and 14 months after completion of the treatment, the adjusted BMI was calculated and psychological variables were measured with the Dutch Eating Behaviour Questionnaire, the Eating Disorder Inventory and the Self-Perception Profile for Children. All patients lost weight during treatment (median -48% of the adjusted BMI, range -4% to -102%), in contrast to the non-treated control subjects (median +6%, range -29% to +27%). The children treated developed a higher self-esteem and were more capable of coping with external eating stimuli. They did not develop anorexia nor bulimia nervosa. At the 6-months follow-up, a median increase in the adjusted BMI of +6% (range -19% to +37%) was found; with an additional increase of +4% (range -30% to +41%) at 14-months follow-up.

CONCLUSION

a multicomponent long-term inpatient treatment programme is a valuable treatment option for obese children, with a lasting effect up to 14 months post-treatment. Nevertheless, more research is needed to characterise those children who regain weight after treatment and how this may be prevented.