Risk Factors of Cancer in Pediatric-Onset Inflammatory Bowel Disease in Denmark and Finland

OBJECTIVES

Pediatric-onset inflammatory bowel disease (pIBD) increases the risk of developing several different cancer forms. In this case-control study, we aimed to assess the impact of medical treatment and disease activity on the risk of developing disease-associated cancer (DAC) and treatment-associated cancer (TAC).

METHODS

In a previous study, we identified 27 cases of DAC (colorectal cancer, small bowel cancer, and cholangiocarcinoma) and 28 TAC (lymphoma and skin cancer) in 6689 patients with pIBD in Denmark and Finland during the period 1992-2015. In this study, the patient charts were reviewed manually. Cancer-free patients from another population-based pIBD cohort were included as controls. We recorded data on phenotype, medical treatment, surgery, and relapses. Logistic regression was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) to estimate the relative risk.

RESULTS

We included 16 cases with DAC, 21 with TAC, and 331 controls. For DAC, lower frequencies of IBD-relapses were associated with an increased risk of cancer (OR 0.2 [95% CI: 0.04-0.8]). For TAC, we found an increased risk in patients receiving thiopurines at any point during the follow-up period (aOR: 11.7 [95% CI: 2.1-116.2]) and an association with proportion of follow-up time being exposed to thiopurines (aOR 5.6 [95% CI: 1.1-31.5]).

CONCLUSIONS

In this nation-wide study, covering all pIBD patients from Denmark and Finland, we found that pIBD patients treated with thiopurines had an increased risk of TAC.

Changes in Incidence and Management of Acute Appendicitis in Children-A Population-Based Study in the Period 2000-2015

INTRODUCTION

 Recent studies suggest that the epidemiology and management of appendicitis have changed during the last decades. The purpose of this population-based study was to examine this in the pediatric population in Denmark.

MATERIALS AND METHODS

 Data were retrieved from the Danish National Patient Registry, the Danish Civil Registration System, and the Statbank Denmark. Patients aged 0 to 17 years diagnosed with appendicitis and appendectomized during the period 2000 to 2015 were included. The primary outcome was the annual incidences of appendicitis. Secondary outcomes were the annual percent of patients with appendicitis having a laparoscopic appendectomy, delay from admission to surgery, length of postoperative hospital stay, and 30-day postoperative mortality.

RESULTS

 A total of 24,046 pediatric cases of appendicitis were identified. The annual incidence steadily declined until 2008 (-29%, all ages) and then remained stable. The surgical approach of choice changed from being open appendectomy in 2000 (97%) to laparoscopic appendectomy in 2015 (94%). Simultaneously, the duration of postoperative hospital stay declined from 41 hours (median) to 17 hours. Delay from admission until surgery did not change during the period. Only one child died within the 30-day postoperative period.

CONCLUSION

 In accordance with other recent studies from Western countries, we found significant changes in the incidence of acute appendicitis including a decline in all age groups except those below 5 years of age, a shift toward laparoscopic appendectomy, and decreasing time spent in the hospital during the years 2000 to 2015.

Complicated Disease and Response to Initial Therapy Predicts Early Surgery in Paediatric Crohn's Disease: Results From the Porto Group GROWTH Study

INTRODUCTION

The ability to predict risk for poor outcomes in Crohn's disease [CD] would enable early treatment intensification. We aimed to identify children with CD with complications at baseline and throughout the study period who are at risk for surgery 2 years from diagnosis.

METHODS

Newly diagnosed children with CD were enrolled into a prospective, multicentre inception cohort. Disease characteristics and serological markers were obtained at baseline and week 12 thereafter. Outcome data including disease activity, therapies, complications and need for surgery were collected until the end of 104 weeks. A chi-square automatic interaction detection [CHAID] algorithm was used to develop a prediction model for early surgery.

RESULTS

Of 285 children enrolled, 31 [10.9%] required surgery within 2 years. Multivariate analysis identified stricturing disease at baseline (odds ratio [OR] 5.26, 95% confidence interval [CI] 2.02-13.67 [p = 0.001]), and Paediatric Crohn's Disease Activity Index [PCDAI] >10 at week 12 (OR 1.06, 95% CI 1.02-1.10 [p = 0.005]) as key predictors for early surgery. CHAID demonstrated that absence of strictures at diagnosis [7.6%], corticosteroid-free remission at week 12 [4.1%] and early immunomodulator therapy [0.8%] were associated with the lowest risk of surgery, while stricturing disease at diagnosis [27.1%, p < 0.001] or elevated PCDAI at week 12 [16.7%, p = 0.014] had an increased risk of surgery at follow-up. Anti-OmpC status further stratified high-risk patients.

DISCUSSION

A risk algorithm using clinical and serological variables at diagnosis and week 12 can categorize patients into high- and low-risk groups from diagnosis.

Plasma calprotectin is superior to serum calprotectin as a biomarker of intestinal inflammation in ulcerative Colitis

Background and aims: Despite promising results, only a few studies have been published on serum calprotectin as a biomarker in IBD. Recently, plasma measurements of calprotectin have been shown to be more reliable than serum measurements. In this study, we aim to assess plasma and serum calprotectin measurements as biomarkers of disease activity in paediatric and adult ulcerative colitis.Methods: Paediatric (5-18 years) and adult (>18 years) patients scheduled for colonoscopy due to suspected or confirmed ulcerative colitis were included prospectively. Stool and blood samples were collected at time of colonoscopy and patient symptom scores were recorded. At colonoscopy the Ulcerative Colitis Endoscopic Index of Severity was recorded. Histology was graded according to the Geboes score.Results: 84 patients where included; 30 paediatric and 54 adult patients. Plasma calprotectin had a stronger correlation to all outcome variables than serum calprotectin. Plasma calprotectin correlated positively to disease extent (Rho = 0.53, p < .0001), symptoms scores (Rho = 0.54, p = .002, only in the paediatric cohort), endoscopic scores (Rho = 0.39, p = .0003), histological scores (Rho 0.28, p = .01) and, when using endoscopic assessment of severity as reference, could discriminate active disease from patients in remission (p = .03).Conclusions: While more studies are needed to assess if plasma calprotectin can discriminate healthy individuals from ulcerative colitis, this study indicates that plasma calprotectin can be used as a biomarker of disease activity, especially in cases where faecal calprotectin measurements are cumbersome either due to patient compliance or logistical requirements.

The incidence of cancer and mortality in paediatric onset inflammatory bowel disease in Denmark and Finland during a 23-year period: a population-based study

BACKGROUND

Recent studies report increased risks of both cancer and mortality in paediatric onset inflammatory bowel disease (pIBD) but the reproducibility of this is unknown.

AIM

To estimate the risk of cancer and mortality in the Danish and Finnish pIBD population in a 23-year period compared to the general population.

METHODS

The pIBD population was defined as individuals registered in the national patient registries with a diagnosis of Crohn's disease (CD), ulcerative colitis (UC) or IBD-unclassified before their 18th birthday from 1992 to 2014. This cohort was cross referenced with the national cancer and mortality registries identifying all pIBD patients who subsequently developed cancer and/ or died and followed up to the end of 2014. Risk estimates are presented as standardised incidence ratios calculated based on incidence figures from the populations.

RESULTS

Six thousand six hundred and eight-nine patients with pIBD were identified (median age at follow-up 22.3 years; median follow-up: 9.6 years [interquartile range: 4.8-16.0]). Seventy-two subsequently developed cancer and 65 died. The standardised incidence ratio of cancer in general was 2.6 (95% CI: 1.8-3.7) and 2.5 (95% CI: 1.8-3.4) in CD and UC, respectively. The standardised mortality ratios were 2.2 (95% CI: 1.4-3.4) and 3.7 (95% CI: 2.7-5.0) in CD and UC, respectively. The leading causes for mortality were cancer, suicide and infections.

CONCLUSIONS

We found an increased risk of cancer and mortality in pIBD. This underlines the importance of cancer surveillance programs and assessment of mental health in the standard of care in adolescent pIBD patients.

Serum Calprotectin in Adolescents With Inflammatory Bowel Disease-A Pilot Investigation

OBJECTIVES

Fecal calprotectin (FC) is a well-integrated parameter in the monitoring of adolescent patients with inflammatory bowel disease (IBD). However, measurement of FC is limited by day-to-day-variation and by the feces consistency. Furthermore, adolescents are often noncompliant to deliver fecal sampling leading to suboptimal monitoring. Consequently, we see the need of a substitute biomarker whenever measurement of FC fails and aimed to investigate serum calprotectin (SC) in adolescents with IBD.

METHODS

In cross sectional data from 19 ulcerative colitis (UC) patients <18 years old, a Spearman correlation was used to analyze the correlation between SC, FC, C-reactive protein (CRP) and endoscopic and symptom scores. In longitudinal data collected from 20 UC and Crohn disease (CD) patients (10-17 years old), Mixed Effect Models (MEM) were used to analyze the association between SC, FC, CRP, and symptom scores.

RESULTS

We found positive correlations between SC (19 samples) and the endoscopic score, symptom score, and CRP (r = 0.56, P = 0.01; r = 0.64, P = 0.003; r = 0.97, P < 0.0001). We found no significant correlation between SC and FC. In 27 samples from UC patients, the association of SC with FC and CRP were positive and significant (P = 0.004, estimate = 0.32; P = 0.0001, estimate = 0.002). The association between SC and symptom score was insignificant. In 49 samples from CD patients, the association between SC and CRP was significant (P = 0.02, estimate = 0.002) whereas associations between SC and FC and symptom score were insignificant.

CONCLUSIONS

In the current pilot study, we found a correlation between SC and the endoscopically assessed inflammation in UC. SC may have the potential to improve disease monitoring of adolescent patients.

Response to treatment is more important than disease severity at diagnosis for prediction of early relapse in new-onset paediatric Crohn's disease

BACKGROUND

Paediatric Crohn's disease is characteried by frequently relapsing disease which may lead to hospitalisations and complications.

AIM

To develop predictive models for early relapse following first remission.

METHODS

The GROWTH CD prospective inception cohort was designed to predict risk for early disease relapse and poor outcomes. Newly diagnosed children underwent endoscopies and imaging. They were phenotyped and followed at scheduled visits through 78 weeks for relapses. Twenty-eight dichotomous and continuous variables were assessed at baseline and week 12, including phenotype, inflammatory markers, disease activity (PCDAI) and other markers. Clinical relapses defined as PCDAI >10 after remission were recorded using a relapse form. Logistic regression & risk modelling was performed.

RESULTS

We enrolled 282 eligible patients of whom 178 (63.6%) patients achieved steroid free remission by week 12. Disease complications developed in 22/76(29%) of patients with relapse compared to 20/206 (9.7%) without relapse (P = 0.01). Multivariable analysis demonstrated that while variables from age/gender at diagnosis were not predictive, week 12 variables including PCDAI >5 (P = 0.02), CRP >20 mg/L (P = 0.02), and faecal calprotectin >400 µg/g (P = 0.03) as optimal cut-offs were associated with increased risk of relapse. A prediction model for patients in remission including gender, age, week 12 PCDAI, calprotectin and CRP had sensitivity 43%, specificity 92%, PPV 78%, NPV 71% for relapse.

CONCLUSIONS

Early relapses were associated with a higher risk for disease complications at followup. Relapse prediction based on week 12 disease activity or inflammation is superior to prediction using data from diagnosis.

Biochemical Markers, Genotype, and Inflammation in Pediatric Inflammatory Bowel Disease: A Danish Population-Based Study

BACKGROUND

Our aim was to characterize the biochemical markers at diagnosis in patients with inflammatory bowel disease (IBD), to assess the utility of these to predict disease course and investigate if genotype influences biochemical markers of inflammation.

SUMMARY

Patients were included from a population-based pediatric IBD cohort from Eastern Denmark. Data on biochemical markers and medical as well as surgical treatment were registered at diagnosis, 30 days, 6 and 12 months after diagnosis. Fifty-two single nucleotide polymorphisms (SNPs) known to be associated with IBD were selected for genotyping based on previous genetic studies. Key messages: A total of 190 IBD patients (97 ulcerative colitis [UC], 87 Crohn's disease [CD], and 6 IBD unclassified) were included. UC patients with extensive disease had higher C-reactive protein, erythrocyte sedimentation rate, and platelet count at diagnosis compared to UC patients with less extensive disease. No similar differences between disease extent groups were found in CD. Low albumin at diagnosis was associated with an increased risk of surgery in both UC (OR 1.35; 95% CI: 1.05-1.75) and CD patients (OR 1.23; 95% CI: 1.01-1.48) and increased use of azathioprine and anti-tumor necrosis factor alpha use in the total IBD cohort (OR 1.15; 95% CI: 1.04-1.27 and OR 1.19 [1.08-1.34]). One SNP (rs4986791 in the TLR-4 locus) and 2 SNPs (rs6785049 in the Pregnane-x-receptor gene and rs10500264 in the SLCA10 gene) were associated with a change in albumin and hemoglobin over time respectively in our IBD cohort. Our study confirms albumin to be a marker of severe disease course. Furthermore, the patient's genotype possibly affects the inflammatory response. Future studies in larger pediatric cohorts are needed to confirm our findings.

Diagnostic Yield of Next-generation Sequencing in Very Early-onset Inflammatory Bowel Diseases: A Multicentre Study

BACKGROUND AND AIMS

An expanding number of monogenic defects have been identified as causative of severe forms of very early-onset inflammatory bowel diseases [VEO-IBD]. The present study aimed at defining how next-generation sequencing [NGS] methods can be used to improve identification of known molecular diagnosis and to adapt treatment.

METHODS

A total of 207 children were recruited in 45 paediatric centres through an international collaborative network [ESPGHAN GENIUS working group] with a clinical presentation of severe VEO-IBD [n = 185] or an anamnesis suggestive of a monogenic disorder [n = 22]. Patients were divided at inclusion into three phenotypic subsets: predominantly small bowel inflammation, colitis with perianal lesions, and colitis only. Methods to obtain molecular diagnosis included functional tests followed by specific Sanger sequencing, custom-made targeted NGS, and in selected cases whole exome sequencing [WES] of parents-child trios. Genetic findings were validated clinically and/or functionally.

RESULTS

Molecular diagnosis was achieved in 66/207 children [32%]: 61% with small bowel inflammation, 39% with colitis and perianal lesions, and 18% with colitis only. Targeted NGS pinpointed gene mutations causative of atypical presentations, and identified large exonic copy number variations previously missed by WES.

CONCLUSIONS

Our results lead us to propose an optimised diagnostic strategy to identify known monogenic causes of severe IBD.

Differences in Outcomes Over Time With Exclusive Enteral Nutrition Compared With Steroids in Children With Mild to Moderate Crohn's Disease: Results From the GROWTH CD Study

BACKGROUND

Exclusive enteral nutrition [EEN] and corticosteroids [CS] induce similar rates of remission in mild to moderate paediatric Crohn's disease [CD], but differ with regard to mucosal healing. Our goal was to evaluate if EEN at diagnosis was superior to CS for improving long-term outcomes.

METHODS

We prospectively followed newly diagnosed children aged < 17 years, with mild to moderate CD at baseline, for 2 years in the GROWTH CD study. Patients were evaluated at baseline and at 8, 12, 78, and 104 weeks. Remission, relapses, complications [fibrostenotic disease, penetrating disease, and active perianal disease] and growth were recorded throughout the study. A propensity score analysis was performed.

RESULTS

A total of 147 children [mean age 12.9 ± 3.2 years], treated by EEN [n = 60] or CS [n = 87] were included. New complications developed in 13.7% of CS [12/87] versus 11.6% of EEN [7/60], p = 0.29. Remission was achieved in 41/87 [47%] in CS and 38/60 [63%] EEN, p = 0.036. Median time to relapse did not differ [14.4 ± 1 months with CS, 16.05 ± 1.1 EEN, p = 0.28]. Mean height Z scores decreased from Week 0 to Week 78 with CS [-0.34 ± 1.1 to -0.51 ± 1.2, p = 0.01], but not with EEN [-0.32 ± 1.1 to -0.22 ± 0.9, p = 0.56]. In a propensity score analysis, EEN was superior to CS for inducing remission [p = 0.05] and trended to superiority for height Z score [p = 0.055].

CONCLUSIONS

Use of EEN was associated with higher remission rates and a trend toward better growth but with similar relapse and complication rates in new-onset mild to moderate paediatric CD.

Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease

Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.

Genetic susceptibility and genotype-phenotype association in 588 Danish children with inflammatory bowel disease

AIM

To investigate the association between known inflammatory bowel disease (IBD)-associated genetic variants and development of paediatric IBD, and specific clinical sub-phenotypes.

MATERIAL AND METHODS

In this case-control study we included IBD patients <18 years of age at diagnosis from the Danish National Patient Registry and healthy children <18 years of age were randomly selected from the Danish Central Office of Civil Registration. The latter had filled out a questionnaire regarding health status, and DNA was obtained from blood samples and the buccal mucosa. Patient files were retrieved and clinical information was extracted. DNA was obtained from Guthrie cards from the Danish National Neonatal Screening Biobank (PKU-biobanken) at Statens Serum Institut and from blood samples.

RESULTS

A total of 588 IBD patients (244 Crohn's disease (CD), 318 ulcerative colitis (UC) and 26 IBD-unclassified (IBDU)) and 543 healthy controls were included. We found an association between CD and rs22411880 (ATG16L1, odds ratio (OR)=1.7 [1.1-1.7], p=0.003), rs5743289 (NOD2, OR=1.4 [1.1-1.9], p=0.009) and the paediatric specific rs1250550 (ZMIZ1, OR=0.7 [0.5-0.9], p=0.01). None of the investigated 41 SNPs were associated with disease localisation, medical treatment or surgery after correcting for multiple analyses.

CONCLUSION

We found an association between CD and three previously published genetic variants and replicated the association with the paediatric specific ZMIZ1 gene. No Bonferroni corrected significant genotype-phenotype associations were found. For future studies aimed at finding predictors for disease course in (paediatric) IBD, it will be worthwhile to include a combination of genetic, clinical and serological markers.

ESPGHAN revised porto criteria for the diagnosis of inflammatory bowel disease in children and adolescents

BACKGROUND

The diagnosis of pediatric-onset inflammatory bowel disease (PIBD) can be challenging in choosing the most informative diagnostic tests and correctly classifying PIBD into its different subtypes. Recent advances in our understanding of the natural history and phenotype of PIBD, increasing availability of serological and fecal biomarkers, and the emergence of novel endoscopic and imaging technologies taken together have made the previous Porto criteria for the diagnosis of PIBD obsolete.

METHODS

We aimed to revise the original Porto criteria using an evidence-based approach and consensus process to yield specific practice recommendations for the diagnosis of PIBD. These revised criteria are based on the Paris classification of PIBD and the original Porto criteria while incorporating novel data, such as for serum and fecal biomarkers. A consensus of at least 80% of participants was achieved for all recommendations and the summary algorithm.

RESULTS

The revised criteria depart from existing criteria by defining 2 categories of ulcerative colitis (UC, typical and atypical); atypical phenotypes of UC should be treated as UC. A novel approach based on multiple criteria for diagnosing IBD-unclassified (IBD-U) is proposed. Specifically, these revised criteria recommend upper gastrointestinal endoscopy and ileocolonscopy for all suspected patients with PIBD, with small bowel imaging (unless typical UC after endoscopy and histology) by magnetic resonance enterography or wireless capsule endoscopy.

CONCLUSIONS

These revised Porto criteria for the diagnosis of PIBD have been developed to meet present challenges and developments in PIBD and provide up-to-date guidelines for the definition and diagnosis of the IBD spectrum.

Environmental factors and risk of developing paediatric inflammatory bowel disease -- a population based study 2007-2009

BACKGROUND AND AIMS

To identify environmental risk factors for developing inflammatory bowel disease (IBD) in children <15 years of age.

METHODS

IBD patients and randomly selected healthy controls from a well defined geographical area in Denmark were prospectively recruited in the period 1.1.2007-31.12.2009. Data regarding socioeconomic status, area of residence, living conditions, infections and diet were obtained by a questionnaire.

RESULTS

A total of 118 IBD patients (59 Crohn's disease (CD), 56 ulcerative colitis (UC) and 3 IBD unclassified (IBDU)) and 477 healthy controls filled out the questionnaire. The response rates were 91% in patients and 45% in controls, respectively. Several risk factors for IBD were identified: IBD in first degree relatives (IBD: OR (odds ratio): 6.1 (95%CI: 2.5-15.0), CD (OR: 6.8 (2.3-20.2)) and UC (OR: 6.1 (2.3-16.0))); bedroom sharing (IBD: OR: 2.1 (1.0-4.3), CD (OR: 3.6 (1.3-9.4))); high sugar intake (IBD: OR: 2.5 (1.0-6.2), CD (OR: 2.9 (1.0-8.5))); prior admission to a hospital for gastrointestinal infections (IBD: 7.7 (3.1-19.1), CD (7.9 (2.5-24.9)) and UC (7.4 (2.5-21.6))); stressful events (IBD: 1.7 (1.0-2.9)). Protective factors were daily vs. less than daily vegetable consumption (CD: 0.3 (0.1-1.0), UC (0.3 (0.1-0.8))) and whole meal bread consumption (IBD: OR: 0.5 (0.3-0.9), CD (0.4 (0.2-0.9))). An increased risk of diagnosis of CD compared to UC was shown for patients living in more urban areas (OR: 1.3 (1.1-1.6)).

CONCLUSION

We identified several risk and protective factors for developing IBD. Studies on the influence of environmental factors are important in our understanding of aetiology and phenotypes of paediatric IBD.

Disease phenotype at diagnosis in pediatric Crohn's disease: 5-year analyses of the EUROKIDS Registry

BACKGROUND

It has been speculated that pediatric Crohn's disease (CD) is a distinct disease entity, with probably different disease subtypes. We therefore aimed to accurately phenotype newly diagnosed pediatric CD by using the pediatric modification of the Montreal classification, the Paris classification.

METHODS

Information was collected from the EUROKIDS registry, a prospective, web-based registry of new-onset pediatric IBD patients in 17 European countries and Israel. When a complete diagnostic workup was performed (ileocolonoscopy, upper gastrointestinal [GI] endoscopy, small bowel imaging), CD patients were evaluated for ileocolonic disease extent, esophagogastroduodenal involvement, and jejunal/proximal ileal involvement. Disease behavior and the occurrence of granulomas were also analyzed.

RESULTS

In all, 582 pediatric CD patients could be classified according to the Paris classification. Isolated terminal ileal disease (± limited cecal disease) was seen at presentation in 16%, isolated colonic disease in 27%, ileocolonic disease in 53%, and isolated upper GI disease in 4% of patients. In total, 30% had esophagogastroduodenal involvement and 24% jejunal/proximal ileal disease. Patients with L2 disease were less likely to have esophagogastroduodenal involvement or stricturing disease than patients with L1 or L3 disease. Terminal ileal disease and stricturing disease behavior were more common in children diagnosed after 10 years of age than in younger patients. Granulomas were identified in 43% of patients.

CONCLUSIONS

Accurate phenotyping is essential in pediatric CD, as this affects the management of individual patients. Disease phenotypes differ according to age at disease onset. The Paris classification is a useful tool to capture the variety of phenotypic characteristics of pediatric CD.

Management of pediatric ulcerative colitis: joint ECCO and ESPGHAN evidence-based consensus guidelines

BACKGROUND AND AIMS

Pediatric ulcerative colitis (UC) shares many features with adult-onset disease but there are some unique considerations; therefore, therapeutic approaches have to be adapted to these particular needs. We aimed to formulate guidelines for managing UC in children based on a systematic review (SR) of the literature and a robust consensus process. The present article is a product of a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).

METHODS

A group of 27 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to ESPGHAN and ECCO members. A list of 23 predefined questions were addressed by working subgroups based on a SR of the literature.

RESULTS

A total of 40 formal recommendations and 68 practice points were endorsed with a consensus rate of at least 89% regarding initial evaluation, how to monitor disease activity, the role of endoscopic evaluation, medical and surgical therapy, timing and choice of each medication, the role of combined therapy, and when to stop medications. A management flowchart, based on the Pediatric Ulcerative Colitis Activity Index (PUCAI), is presented.

CONCLUSIONS

These guidelines provide clinically useful points to guide the management of UC in children. Taken together, the recommendations offer a standardized protocol that allows effective, timely management and monitoring of the disease course, while acknowledging that each patient is unique.

Diagnostic workup of paediatric patients with inflammatory bowel disease in Europe: results of a 5-year audit of the EUROKIDS registry

OBJECTIVE

In 2005, the Inflammatory Bowel Disease (IBD) Working Group of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition published consensus guidelines on the diagnostic workup of paediatric IBD, the Porto criteria. According to these guidelines, children suspected of having IBD should undergo an oesophagogastroduodenoscopy (OGD), ileocolonoscopy, and (except in cases of definitive ulcerative colitis) adequate imaging of the small bowel. To audit and evaluate the diagnostic workup of paediatric patients with IBD in Europe, the Working Group created EUROKIDS, a prospective, Web-based registry of newly diagnosed paediatric patients with IBD.

METHODS

Patients with IBD (ages 0-18 years) were registered in 44 centres in 18 countries. Data on diagnostic workup were analysed according to the year of diagnosis, type of IBD, and centre size. Diagnostic yield of OGD and ileal intubation were evaluated.

RESULTS

Between 2004 and 2009, 2087 newly diagnosed patients were correctly registered. Both OGD and ileocolonoscopy had been performed in 64% of all of the patients and increased significantly from year 1 (52 %) to 5 (71%, P  <  0.001). Small-bowel follow-through use decreased during the years (year 1 n = 213, year 5 n = 108; P < 0.001), whereas magnetic resonance imaging use increased (year 1 n  = 25, year 5 n  = 171; P < 0.001). Patients diagnosed as having Crohn disease (CD, 59%) and ulcerative colitis (58%) were more likely to have had a complete diagnostic workup than patients diagnosed as having IBD unclassified (45%). In CD, the diagnostic yield of OGD was 7.5% and the yield of ileal intubation was 13%.

CONCLUSIONS

The quality of diagnostic workup in paediatric patients with IBD increased steadily between 2004 and 2009. Small-bowel imaging by magnetic resonance imaging superseded the use of small-bowel follow-through. OGD and ileal intubation contributed to a definitive diagnosis of CD.

Pediatric inflammatory bowel disease: increasing incidence, decreasing surgery rate, and compromised nutritional status: A prospective population-based cohort study 2007-2009

BACKGROUND

The aim was to evaluate the incidence, treatment, surgery rate, and anthropometry at diagnosis of children with inflammatory bowel disease (IBD).

METHODS

Patients diagnosed between January 1, 2007 to December 31, 2009 in Eastern Denmark, Funen, and Aarhus were included from a background population of 668,056 children <15 years of age. For evaluation of incidence, treatment, and surgery rate, a subcohort from Eastern Denmark was extracted for comparison with a previously published population-based cohort from the same geographical area (1998-2006).

RESULTS

In all, 130 children with IBD: 65 with Crohn's disease (CD), 62 with ulcerative colitis (UC), and three with IBD unclassified (IBDU) were included. The mean incidence rates per 10(6) in 2007-2009 were: IBD: 6.4 (95% confidence interval [CI]: 5.4-7.7), CD: 3.2 (2.5-4.1), UC: 3.1 (2.4-4.0) and IBDU: 0.2 (0.05-0.5). Comparing the two cohorts from Eastern Denmark we found higher incidence rates for IBD (5.0 and 7.2 in 1998-2000 and 2007-2009, respectively, P = 0.02) and CD (2.3 versus 3.3, P = 0.04). Furthermore, we found a significant decrease in surgery rates (15.8/100 person-years versus 4.2, P = 0.02) and an increase in the rate of initiating immunomodulators (IM) within the first year (29.0/100 person-years versus 69.2, P < 0.001). IM use was associated with a trend towards a decreased surgery risk (relative risk [RR] 0.38; 0.15-1.0). Children with CD had poor nutritional status at diagnosis compared with the general pediatric population.

CONCLUSIONS

Over the past 12 years we found an increase in the incidence of IBD in children, an increasing use of IM, and decreasing 1-year surgery rates. CD patients had poor nutritional status.

Differences in phenotype and disease course in adult and paediatric inflammatory bowel disease--a population-based study

BACKGROUND

Few studies have compared phenotype and disease course in children and adults with inflammatory bowel disease (IBD).

AIM

  To compare phenotype, treatment and disease course in children (<15 years) and adults (≥18 years) with IBD.

METHODS

Two population-based cohorts comprising paediatric (2001-2006) and adult (2003-2004) patients from Copenhagen County and City were studied.

RESULTS

Twenty children and 106 adults with ulcerative colitis (UC), and 29 children and 67 adults with Crohn's disease (CD) were included. Median follow-up time was 4.8 years (children) and 5.2 years (adults). Children with UC had more extensive disease compared to adult patients [14 (70%) vs. 20 (19%), P<0.001]. The risks of starting systemic steroid treatment and AZA/MP were higher for paediatric UC patients compared to adult UC patients; hazard ratio (HR): 3.1 (95% CI: 1.8-5.3) and HR: 2.5 (1.3-5-9), respectively. Steroid dependency was more frequent in paediatric than in adult UC patients [9 (45%) vs. 9 (8%), P<0.001]. Mild disease course was less frequent in children with UC compared to adult patients [7 (35%) vs. 76 (72%), P=0.002]. Paediatric and adult CD patients did not differ regarding treatment or disease course. Cumulative 5-year surgery rates for paediatric and adult patients were 5% and 9% for UC (N.S.) and 18% and 21% for CD (N.S.), respectively.

CONCLUSIONS

Paediatric UC patients had more extensive disease, were more often treated with systemic steroids and AZA, had a higher frequency of steroid dependency and a more severe disease course compared to adult UC patients. No differences were found when comparing paediatric and adult CD patients.

Steroid dependency and pediatric inflammatory bowel disease in the era of immunomodulators--a population-based study

BACKGROUND

The aim was to investigate the impact of systemic steroid treatment (SST) and immunomodulators (IM) on disease course in children with inflammatory bowel disease (IBD).

METHODS

All IBD patients in eastern Denmark <15 years of age diagnosed in the period 1998-2006 starting their first SST within 2 years of diagnosis were included.

RESULTS

In all, 205 IBD patients were included (105 Crohn's disease [CD], 100 ulcerative colitis [UC]). Eighty-seven CD (83%) and 77 (77%) UC patients started SST. In CD, 55 (63%), 25 (29%), and 7 (8%) had a complete response (CR), partial response (PR), or no response (NR), respectively, 30 days after initiation of SST. Fifty (58%) had a prolonged response (PRO) and 32 (37%) were steroid-dependent (SD). In UC, 49 (64%), 22 (28%), and 6 (8%) had CR, PR, and NR, respectively, and 38 (49%) and 38 (49%) were PRO and SD. The cumulative risk of surgery 1 year after starting SST was 11.5% and 7.8% for CD and UC patients, respectively. After a median follow-up period of 5.1 years, no difference in the risk of surgery or periods of activity and remission was found between PRO and SD in CD or UC. IM use was associated with a milder disease course in UC patients.

CONCLUSIONS

No difference in surgery rates or disease course was found between SD and PRO. Surgery rates were lower than rates from studies predating the era of IM, indicating a putative effect of IM on disease course.

[Detection of rotavirus infection in Danish children]

INTRODUCTION

Rotavirus (RV) is the most frequent causative agent of severe diarrhoea in infants and young children worldwide, also in Denmark. However, the actual number of diagnosed RV cases among Danish children is unknown. If a new RV-vaccine is to be introduced in Denmark, updated data on RV disease burden is important and the validity of potential surveillance systems needs to be explored.

MATERIAL AND METHODS

We established a nation-wide database on all children below the age of 5 years who had a RV-positive sample detected from 2001 to 2004 at one of the 13 laboratories in Denmark performing RV diagnostics. Hospital discharge diagnoses among the RV-positive children were retrieved from the Danish Hospital Discharge Register (DHDR).

RESULTS

A total of 1,789 children < 5 years were registered with 1,800 episodes of RV-diarrhoea. The overall Danish annual incidence rate (IR) of RV-episodes in the 2001-2004 period was calculated to 1.3 per 1,000 children < 5 years. IR varied considerably between counties, the highest being estimated in the county of Copenhagen (IR = 2.6 per 1,000 children < 5 years) and the lowest in the county of Vejle. According to the DHDR, 1,072 RV-positive episodes were associated with hospitalisation, but only 32% were correctly diagnosed as RV-gastroenteritis.

CONCLUSION

The low IR of RV-episodes among Danish children, the geographic variation and the diagnostic inaccuracy of hospitalised RV-episodes indicates an incomplete and uneven examination of RV-episodes in Denmark.

[Infant botulism]

Infant botulism is a rare disease that affects infants below the age of 12 months following absorption of neurotoxins produced by ingested Clostridium botulinum spores. The clinical manifestations are caused by symmetrical cranial nerve palsies followed by descending, symmetric flaccid paralysis of voluntary muscles. Presenting symptoms include constipation, lethargy, mydriasis and ptosis. The diagnosis is made on the basis of clinical examination and confirmed by isolating the toxin in serum or stools. Treatment consists of supportive intensive care and treatment with antitoxins.

Changes in the epidemiology of acute appendicitis and appendectomy in Danish children 1996-2004

PURPOSE

Aim of the study was to describe changes in the epidemiology of acute appendicitis in Danish children between 0-19 years of age for the period 1996-2004.

METHODS

The study was based on discharge diagnoses taken from the Danish National Patient Registry of all 28 274 patients with a diagnosis of acute uncomplicated or complicated appendicitis, and/or a registered procedure code of appendectomy. These data were computed together with data on the background population, and incidences were calculated.

RESULTS

A significant decrease in the incidence of acute uncomplicated appendicitis was found for all age groups (range, 13-36%). The decrease was present for both sexes, but most prominent in girls. The incidence of complicated acute appendicitis decreased by 10%.

CONCLUSION

The incidence of acute appendicitis is declining. The incidence of uncomplicated appendicitis appears to be declining more rapidly than that of complicated appendicitis. This finding does not necessarily imply poorer management of the disease, but-as suggested by others-could be due to different behaviours of uncomplicated and complicated appendicitis.

Treatment of gastroduodenal ulcers with cimetidine in combination with low-dose propantheline

Fifty-eight adult outpatients with endoscopically verified gastric, prepyloric or duodenal ulcers completed a double-blind trial of treatment with either cimetidine, 1 g daily, plus propantheline, 45 mg daily (group A) or cimetidine, 1 g daily, plus placebo (group B). After neither three nor six weeks of treatment was there any significant difference between the two groups with regard to ulcer healing or symptomatic relief. The ulcers of 22 (79%) of the 28 patients in group A and 25 (83%) of the 30 patients in group B were healed after six weeks, and 93% of the patients in both groups became painfree. We were thus not able to show any advantage in combining cimetidine treatment for ulcer healing with low-dose propantheline. In a small open trial the patients with healed ulcers received prophylactic treatment for 12 months with 1) cimetidine 800 mg daily, 2) cimetidine 400 mg at bedtime plus propantheline 45 mg daily or 3) propantheline 90 mg daily. No significant differences were found between the ulcer recurrence rates, but it cannot be excluded that a larger number of patients in each group might have yielded real differences.

Nutrition, anthropometry, gastrointestinal dysfunction, and circulating levels of tumour necrosis factor alpha receptor I and interleukin-1 receptor antagonist in children during stem cell transplantation

To evaluate anthropometry, nutrition and gastrointestinal dysfunction, and to characterize the relation between these parameters and the inflammatory activity evaluated by plasma levels of soluble tumour necrosis factor alpha receptor I (sTNFRI) and interleukin-1 receptor antagonist (IL-1Ra) levels during stem cell transplantation (SCT) in children. Clinical assessments and blood sampling were performed on days -3, 0, +7, +15 and +31 in eight children undergoing SCT. Energy intake, anthropometry, gastrointestinal dysfunction (WHO toxicity score) and sTNFRI and IL-1Ra were evaluated. The energy intake was below recommended levels. There was a loss of lean body mass (arm muscle area)(median, 2031 mm(2) (day -3) vs 1477 mm(2) (day 31); p = 0.04), and of fat mass (arm fat area) (791 mm(2) (day -3) vs 648 mm(2) (day +31); p = 0.04). sTNFRI was elevated throughout the course of transplantation, and peaked after the day of graft infusion (day 0). sTNFRI levels at day 0 predicted changes in weight SDS (r = 0.65; p = 0.05), triceps skinfold SDS (r = 0.85; p = 0.007) and gastrointestinal dysfunction (r = 0.88; p = 0.004). Likewise, IL-1Ra levels at day 0 correlated with the gastrointestinal dysfunction (r = 0.83; p = 0.01) and with the change in weight SDS (r = 0.77; p = 0.03). This study suggests that pretransplant levels of inflammatory markers are associated with posttransplant symptoms of gastrointestinal dysfunction and loss of both fat and lean body mass. Future studies should address if the use of conditioning regimens with limited proinflammatory cytokine inducing activity, anti-inflammatory agents, or more optimised nutritional support can reduce the burden of such posttransplant complications.

Severe blue rubber bleb nevus syndrome in a neonate

We report on a child with blue rubber bleb nevus syndrome (BRBNS) presenting during the first days of life with severe bleeding from the upper gastrointestinal tract. Medical treatment with methylprednisolone, cyklokapron, interferon 1 alpha and numerous blood transfusions were given to control bleeding during the first 3 years of life. Afterwards repeated endoscopic electrocoagulation were performed over a period of one year resulting in a termination of bleeding episodes. At ten years of age the patient developed spastic diplegia with slight walking disabilities, coordination and fine motor problems. The case is unique because 1) it is the first neonatal case with BRBNS and severe gastrointestinal bleeding; 2) the patient was successfully treated by endoscopic electrocoagulation; and 3) the long-term follow-up. The use of electrocoagulation appears to have been effective and ablation of the stomach could be avoided until now.

Denmark: botulism in an infant or infant botulism?

A 4.5 months old, previously healthy Danish girl was admitted to a paediatric department after six days of passive behaviour and weak suck. Over the next days she became increasingly weak, developed bilateral ptosis, the muscle stretch reflexes were lost, and mydriasis with slow pupillary responses was noted. Botulism was suspected and confirmed by testing of patient serum in a bioassay. The condition of the patient improved following administration of botulism antiserum. The clinical picture was suggestive of intestinal (infant) botulism. However, botulism acquired from consumption of food with preformed neurotoxin could not be excluded.

Response pattern recognition in paediatric Crohn's disease patients treated with enteral nutrition

AIM

To describe the response pattern to enteral nutrition (EN) in paediatric patients with moderately to severely active Crohn's disease (CD).

MATERIAL AND METHODS

A previously described method for assessment of response pattern to various treatments for CD was used. Patients who received EN during the 10-year period 1995-2005 were prospectively registered. Patient data, clinical outcome, time to relapse and subsequent need for treatment were extracted from the files. Four weeks treatment with polymeric ready-to-use liquid formula was given. The clinical outcome was assessed by pattern recognition of the disease course 30 days (immediate response) and 90 days (long-term response) after start of EN.

RESULTS

Thirty-one patients (17/14 M/F), median age 14 years (range 7.5 -19.8 years), received 46 courses of EN. Thirty-seven courses (80%) were completed. Immediate response: twenty-five courses (67%) led to complete response (CR), 8 (22%) to partial response (PR) and in 4 courses (11%) no response (NR) was achieved. Long-term response: 21 courses (64%) led to prolonged response (PRO), defined as either maintenance of complete response (CR) or partial response (PR), while 12 courses (36%) were followed by loss of response (LR). The median time to relapse was 8.3 months (range 0.5-39 months).

CONCLUSION

We found our model of response pattern to be a useful instrument for the description of results obtained during EN in children with CD.

Incidence of ulcerative colitis and Crohn's disease in Danish children: Still rising or levelling out?

AIM

To describe the development in incidence and prevalence of paediatric inflammatory bowel disease (IBD) in Eastern Denmark during a six-year period.

METHODS

All patients <15 years with IBD in Eastern Denmark in the two following periods were included: 1) 1.1.1998-31.12.2000 and 2) 1.1.2002-31.12.2004. The mean background population (children <15 years) in Eastern Denmark was 421,898 persons in period 1 and 439,443 persons in period 2. Patients were identified using the ICD-10 classification (DK500-519). The following data were extracted from the files: diagnosis, change in diagnosis, age at diagnosis, localisation, extra-intestinal symptoms, surgery and county of residence. Incidence and prevalence for ulcerative colitis (UC), Crohn's disease (CD) and indeterminate colitis (IC) were calculated per 100,000 children <15 years.

RESULTS

98 patients (50 UC, 44 CD, 4 IC), median age 9.8 years (range 2-14) and 12.8 (range 0.5-14) for UC and CD, respectively, were identified in period 1. In the second period 145 patients (70 UC, 64 CD, 11 IC) were included with a median age of 11 years (range 1-14) and 12.5 (range 0.5-14) for UC and CD, respectively. The prevalence of IBD was 15.8 and 20.3 in 1998-2000 and 2002-2004, respectively. The incidence of IBD was 4.3 (UC: 1.8; CD: 2.3; IC: 0.2) and 6.1 (UC: 2.6; CD: 3.1; IC: 0.3), respectively, for the two periods (p>0.05).

CONCLUSIONS

In our study we found an insignificant increase in the incidence of both CD and UC, indicating that the previously reported rising incidence might be levelling out.

Genetic and environmental factors as predictors of disease severity and extent at time of diagnosis in an inception cohort of inflammatory bowel disease, Copenhagen County and City 2003-2005

BACKGROUND AND AIMS

The etiology of the inflammatory bowel diseases (IBD), Crohn's disease (CD) and ulcerative colitis (UC) remains unknown. We aimed to investigate the influence of genetic, serological, and environmental factors on phenotypic presentation of IBD at diagnosis in a population-based Danish inception cohort from 2003-2005.

METHODS

Three-hundred-forty-seven (62%) of 562 cohort patients were genotyped. ASCA and p/c-ANCA were determined and patients answered a questionnaire concerning environmental factors with possible influence on IBD.

RESULTS

Fourteen percent of CD patients vs. 11% of controls were positive for common CARD15 mutation (ns), whereas more CD patients than healthy controls were homozygous for the OCTN-TC haplotype (p=0.03). ASCA was more common in CD (22%) than UC (14%) (p=0.045) and was related to age and localization of CD. p-ANCA was more frequent in UC (p=0.00001) but was related to pure colonic CD (p=0.0001). Sugar consumption was significantly higher in CD patients than in UC patients (p=0.0001) and more CD patients than UC patients had undergone appendectomy prior to IBD diagnosis (p=0.03). A possible relation between tonsillectomy and disease severity in CD, and a relation between use of oral contraception and disease localization of UC to rectum/left-sided colon were found.

CONCLUSIONS

In this cohort of unselected IBD patients we found a very low frequency of mutations in IBD susceptibility genes and observed a greater impact of ASCA and ANCA than of genetic factors on disease phenotypes. In addition, several environmental factors seemed to influence disease occurrence and disease presentation in both UC and especially CD.

Incidence and cost of rotavirus hospitalizations in Denmark

Two models provide reliable estimates that can be used to assess vaccine need and effectiveness.

In anticipation of licensure and introduction of rotavirus vaccine into the western market, we used modeling of national hospital registry data to determine the incidence and direct medical costs of annual rotavirus-associated admissions over <11 years in Denmark. Diarrhea-associated hospitalizations coded as nonspecified viral or presumed infectious have demonstrated a marked winter peak similar to that of rotavirus-associated hospitalizations, which suggests that the registered rotavirus-coded admissions are grossly underestimated. We therefore obtained more realistic estimates by 2 different models, which indicated ≈2.4 and ≈2.5 (for children <5 years of age) and ≈4.9 and ≈5.3 (for children <2 years of age) rotavirus-associated admissions per 1,000 children per year, respectively. These admissions amount to associated direct medical costs of US $1.7–1.8 million per year. Using 2 simple models to analyze readily available hospital discharge data resulted in more consistent and reliable estimates.

Infliximab dependency in a national cohort of children with Crohn's disease

AIM

The aim was to evaluate the pattern of responsiveness and to monitor side effects of episodic administration of infliximab in children with active Crohn's disease (CD) treated in Denmark from 1999 to 2003.

MATERIAL AND METHODS

The National Danish Crohn Colitis Database of infliximab was used to identify all Danish CD patients treated at pediatric departments with infliximab. The clinical outcome was assessed by pattern recognition of the disease course 30 days after the first infliximab infusion and 90 days after intended end of treatment.

RESULTS

During a 3 year period, infliximab was given to 24 CD patients (9 male/15 female) aged median 15.4 (range 9.8-18.6) years with a median disease duration of 26 (range 0.7-93) months and a median number of infusions of 6 (range 2-11). Five milligrams of infliximab per kilogram infusions were given intravenously. Immediate response was as follows: 8 (33%) patients achieved complete response (CR), 10 (42%) partial response (PR), and 6 (25%) no response (NR). Long-term response was as follows: 7 (29%) patients achieved prolonged response (PRO), defined as maintenance of CR or PR, 10 (42%) were infliximab dependent (ID), defined as relapse of symptoms requiring reinfusions of infliximab to regain CR or PR, and 6 (25%) had NR. Six (25%) patients needed surgery during or after treatment with infliximab. Side effects were seen in four (17%) patients. No serious events were noted.

CONCLUSION

Seventy-one percent of the children appeared to benefit (PRO or ID) from infliximab treatment with minor side effects when given episodically. Among these patients, two response patterns were recognized: PRO after ending infliximab treatment (29%) or dependency on reinfusions of infliximab (42%).

Anthropometry at the time of diagnosis in Danish children with inflammatory bowel disease

All patients below 15 y of age living in the eastern part of Denmark with a diagnosis of inflammatory bowel disease (IBD) during the period 1998-2000 were identified (n=94) and anthropometrical data at the time of diagnosis were evaluated.

CONCLUSION

The height-for-age and the BMI-for-age, as evaluated by z-scores, of children with ulcerative colitis (UC) did not differ from those of normal Danish children, but Crohn's disease (CD) children had significantly lower height and BMI values, both when compared to normal children and children with UC. In contrast to UC, CD is frequently complicated by malnutrition and growth retardation at the time of diagnosis.

Viral etiology and incidence of acute gastroenteritis in young children attending day-care centers

BACKGROUND

The purpose of the study was to investigate the frequency, morbidity and cause of acute gastroenteritis in children attending day-care centers in Denmark.

METHODS

Children with acute diarrhea (> or =2 consecutive loose stools in 24 hours, with duration of < or =7 days), recruited from 19 day-care centers, were included. Gastroenteritis viruses, group A rotavirus, sapoviruses, noroviruses and astroviruses were detected with reverse transcription-polymerase chain reaction assays. In addition, stool specimens were cultured for bacterial pathogens. Children who were brought to the clinic with acute diarrhea underwent a medical evaluation, including an estimation of dehydration.

RESULTS

Two hundred seven children (median age, 20.1 months; range, 9-44 months) were enrolled. During the 6-month study period, 98 diarrheal episodes in 95 children were reported. Of these, 48 were reported retrospectively in telephone interviews. The incidence of acute diarrheal episodes was 0.08 episode per child per month. A viral etiologic agent was identified in 69% of cases. Rotaviruses were identified in 17 cases (40%), sapoviruses in 8 (19%) and astroviruses in 3 (7%). One patient had a coinfection with rotavirus and astrovirus. Campylobacter jejuni was detected in 2 patients and Clostridium difficile was found in 5 patients, all coinfected with a virus. In clinical assessments, 9 patients (18%) showed signs of dehydration and were given oral rehydration solution; 6 of these were hospitalized.

CONCLUSIONS

Acute diarrhea among children attending day-care centers was common in wintertime. Rotaviruses were, expectedly, the most common causative agents, but sapoviruses were second to rotaviruses as etiologic agents in this population.

Colitic scid mice fed Lactobacillus spp. show an ameliorated gut histopathology and an altered cytokine profile by local T cells

BACKGROUND

Scid mice transplanted with CD4 T blast cells develop colitis. We investigated if the disease was influenced in colitic mice treated with antibiotic and fed Lactobacillus spp.

METHODS

Colitic scid mice were treated for 1 week with antibiotics (vancomycin/meropenem) followed or not followed by a 3-week administration of Lactobacillus reuteri DSM-12246 and Lactobacillus rhamnosus 19070-2 at 2x10 live bacteria/mouse/24 hours. After 12 weeks, the rectums were removed for histology, and CD4 T cells from the mesenteric lymph nodes (MLN) were polyclonally activated for cytokine measurements.

RESULTS

Irrespective of no treatment or treatments with antibiotics and probiotics, all mice transplanted with T cell blasts lost 10% of their body weight during the 12-week experimental period, whereas the nontransplanted mice had a 10% weight increase (P<0.001). All mice treated with antibiotics but not fed probiotics showed severe gut inflammation, whereas only 2 of the 7 mice fed probiotics showed signs of severe colitis (P<0.05). MLN-derived CD4 T cells from this latter group of mice showed lower levels of interleukin-4 secretion (P<0.05) and a tendency to higher interferon-gamma production than mice not fed probiotics.

CONCLUSIONS

Our data suggest that probiotics added to the drinking water may ameliorate local histopathological changes and influence local cytokine levels in colitic mice but not alter the colitis-associated weight loss.

[Gallstones in children]

Children of all ages may develop gallstones. Ultrasonography is the diagnostic method of choice if gallstones are suspected. In children having gallstones diagnosed as a result of ultrasonography carried out due to different indication expectant treatment is recommended. Children presenting with typical clinical signs of gallstone colic need an operation. Laparoscopic cholecystectomy is the recommended choice, as data are lacking on the risk of recurrence of gallstones after cholecystolithotomy. Postoperative complications are few in otherwise healthy children.

J-pouch ileoanal anastomosis in children and adolescents with ulcerative colitis: functional outcome, satisfaction and impact on social life

OBJECTIVES

The aim of this study was to evaluate, over a 10-year period, severe surgical complications, functional outcome, patient satisfaction and impact on social life after colectomy and J-pouch ileoanal anastomosis for children and adolescents <18 years with ulcerative colitis.

METHODS

Data were extracted retrospectively from medical records and obtained by mailed questionnaire.

RESULTS

Thirty patients (18 girls) with a median age of 15 years (range, 7-17 years) were identified. Two patients (7%) had the J-pouch removed because of intractable diarrhea. Twenty-seven of 28 patients with preserved J-pouch answered the questionnaire. The median follow-up was 3.7 years (range, 0.3-9.2 years). Surgical complications included eight of 30 patients (27%) with small bowel obstruction, one of 30 (4%) with intra-abdominal abscess and two of 30 (7%) with perforation of the small intestine. The median number of daytime bowel movements was six (range, 3-10) and the median number of nighttime bowel movements was one (range, 0-2). Twelve patients (44%) were completely continent for stool and mucus, 12 patients (44%) leaked now and then and three (12%) leaked often or always. Antibiotic treatment for pouchitis was given in 13 patients (48%). Seventeen patients (63%) were completely satisfied with the operation, nine patients (33%) found the result fairly good and one patient (4%) was not satisfied. Twenty-six patients (96%) reported their health as completely or fairly good.

CONCLUSIONS

The majority of patients with an intact J-pouch had an acceptable functional result with respect to defecation frequency, continence and number of pouchitis episodes. Most patients reported being satisfied with the procedure.

Glucagon-like peptide-2 (GLP-2) response to enteral intake in children during anti-cancer treatment

BACKGROUND

Intestinal dysfunction is frequent in cancer and during anti-cancer treatment. Glucagon-like peptide-2 (GLP-2) is secreted in a nutrition-dependent manner from the intestinal enteroendocrine L-cells. It accelerates crypt cell proliferation and nutrient absorption, inhibits enterocyte apoptosis and decreases mucosal permeability. Lack of GLP-2 may increase the risk of malabsorption and intestinal bacterial translocation. The aim of this study is to evaluate meal stimulated secretion of GLP-2 in children with cancer undergoing anti-cancer treatment.

METHODS

Plasma-GLP-2 analysis after an overnight fast and 1 hour after intake of a mixed test meal. Data on gastrointestinal toxicity, blood neutrophile counts and food records were included in the analysis.

RESULTS

Forty-four meal stimulation tests were performed in 25 children (median age, 6.0 years; range, 2.5-19) during anti-cancer treatment. Median GI toxicity score was 5 (range, 0-15), and mean energy intake was 62.4% of recommended values. P-GLP-2 values increased from mean (SD) 38 (18) to 63 (51) pmol/l (P < 0.0001). Twelve of the meal stimulation tests (28%) resulted in a p-GLP-2 increase >2 fold, which is assumed to be the lower limit of normal values. The increase was strongly dependent on the energy intake (r = 0.62, P < 0.0001), while toxicity score and neutrophile count had no significant influence (multiple regression).

CONCLUSION

In children treated with anti-cancer therapy, GLP-2 secretion seems to be normal if the enteral energy intake is sufficient. Insufficient GLP-2 secretion could influence the gastrointestinal problems seen in the children with a low enteral energy intake.

Effect of probiotics on gastrointestinal symptoms and small intestinal permeability in children with atopic dermatitis

OBJECTIVE

To determine whether probiotic lactobacilli may alleviate small intestinal inflammation and strengthen the intestinal barrier function in children with atopic dermatitis.

STUDY DESIGN

In a double-blinded, placebo-controlled, cross-over study, probiotic lactobacilli (Lactobacillus rhamnosus 19070-2 and L reuteri DSM 12246) were administered for 6 weeks to 41 children with moderate and severe atopic dermatitis. Gastrointestinal symptoms were registered before and during treatment and small intestinal permeability was measured by the lactulose-mannitol test.

RESULTS

During Lactobacillus supplementation, there was a significant decrease in the frequency of gastrointestinal symptoms (39% during the placebo period versus 10% during active treatment, P=.002). There was a positive association between the lactulose to mannitol ratio and the severity of the eczema (r=0.61, P=.02 after placebo and r=0.53, P=.05 after active treatment). After probiotic treatment, the lactulose to mannitol ratio was lower (0.073) than after placebo (0.110, P=.001).

CONCLUSIONS

Impairment of the intestinal mucosal barrier appears to be involved in the pathogenesis of atopic dermatitis. The study suggests that probiotic supplementation may stabilize the intestinal barrier function and decrease gastrointestinal symptoms in children with atopic dermatitis.

Case study of the distribution of mucosa-associated Bifidobacterium species, Lactobacillus species, and other lactic acid bacteria in the human colon

The distribution of mucosa-associated bacteria, bifidobacteria and lactobacilli and closely related lactic acid bacteria, in biopsy samples from the ascending, transverse, and descending parts of the colon from four individuals was investigated by denaturing gradient gel electrophoresis (DGGE). Bifidobacterial genus-specific, Lactobacillus group-specific, and universal bacterial primers were used in a nested PCR approach to amplify a fragment of the 16S rRNA gene. DGGE profiles of the bifidobacterial community were relatively simple, with one or two amplicons detected at most sampling sites in the colon. DGGE profiles obtained with Lactobacillus group-specific primers were complex and varied with host and sampling site in the colon. The overall bacterial community varied with host but not sampling site.

Effect of probiotic Lactobacillus strains in children with atopic dermatitis

BACKGROUND

Recent studies suggest that oral bacteriotherapy with probiotics might be useful in the management of atopic dermatitis (AD).

OBJECTIVE

The purpose of this investigation was to evaluate the clinical and anti-inflammatory effect of probiotic supplementation in children with AD.

METHODS

In a double-blind, placebo-controlled, crossover study, 2 probiotic Lactobacillus strains (lyophilized Lactobacillus rhamnosus 19070-2 and Lactobacillus reuteri DSM 122460) were given in combination for 6 weeks to 1- to 13-year-old children with AD. The patients' evaluations were registered after each intervention (ie, better, unchanged, or worse). The clinical severity of the eczema was evaluated by using the scoring atopic dermatitis (SCORAD) score. As inflammatory markers, eosinophil cationic protein in serum and cytokine production by PBMCs were measured.

RESULTS

After active treatment, 56% of the patients experienced improvement of the eczema, whereas only 15% believed their symptoms had improved after placebo (P =.001). The total SCORAD index, however, did not change significantly. The extent of the eczema decreased during active treatment from a mean of 18.2% to 13.7% (P =.02). The treatment response was more pronounced in allergic patients (at least one positive skin prick test response and elevated IgE levels), and in this group the SCORAD score decreased (P =.02 compared with nonallergic patients). During active treatment, serum eosinophil cationic protein levels decreased (P =.03). No significant changes in the production of the cytokines IL-2, IL-4, IL-10, or IFN-gamma were found.

CONCLUSIONS

A combination of L rhamnosus 19070-2 and L reuteri DSM 122460 was beneficial in the management of AD. The effect was more pronounced in patients with a positive skin prick test response and increased IgE levels.

A new mutation causing autosomal dominant periodic fever syndrome in a Danish family

We describe four members in a family of 8 individuals over 3 generations with the autosomal dominant inherited periodic fever syndrome tumor necrosis factor receptor-associated periodic syndrome (TRAPS). The patients had recurrent episodes of fever, abdominal pain, arthritis, and rash. We examined the gene coding for the tumor necrosis factor receptor TNFRSF1A in all first-degree family members. In all 4 symptomatic members of the family, a hitherto undescribed mutation C98Y (380G-->A) in the TNFRSF1A gene was identified. In contrast, this mutation was not found in the 4 family members reported to be healthy nor in 50 normal control patients. The youngest member of the family, a 2-year-old boy, was treated successfully with etanercept.

[Lactic bacteria and other probiotics in infections and inflammatory diseases in children. What do we believe? - What do we know?]

Probiotics are microorganisms which, when ingested, may have a positive effect in the prevention or treatment of a specific pathologic condition. Probiotics are used for a number of gastrointestinal and certain systemic infectious and inflammatory diseases. The efficacy of selected probiotics to promote recovery from acute viral gastroenteritis in young children is well-documented. However, the role of probiotics in systemic diseases, e.g. atopic dermatitis, need to be confirmed in larger randomised controlled trials. This paper describes the theoretical background for the use of probiotics and reviews results from randomised controlled trials describing the effect of probiotics, particularly in paediatric diseases.