Examining Risk Factors of Health-Related Quality of Life Impairments Among Adolescents with Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is a chronic, costly, and burdensome disease that is typically diagnosed during adolescence. Despite the use of effective treatments, rates of relapse and intestinal inflammation remain high and put patients at risk for long term physical and psychosocial health complications. Given the costs associated with IBD, it is critical to examine potential risk factors of poor health-related quality of life (HRQoL) among patients for the enhancement and further development of interventions. As such, the aim of the current study was to examine how sociodemographic and disease characteristics, psychosocial problems, and adherence behaviors impact HRQoL among a sample of youth with IBD. 107 adolescents with IBD and their caregiver completed self- and parent-report measures as part of a psychosocial screening service. Medical records were reviewed to obtain information regarding diagnosis, insurance, medication use, illness severity, and disease activity. Results revealed lower HRQoL scores among adolescents with more psychosocial problems (Est. = -3.08; p < .001), greater disease severity (Est. = -.40; p = .001), and those who identified as Black (Est. = -.38; p < .05). Greater disease severity (Est. = .13 p = .004), use of nonpublic insurance (Est. = .32 p = .004), and fewer psychosocial problems (Est. = -.13 p = .04) were associated with greater adherence behaviors. These findings suggest that implementing individually tailored, evidence-based psychological interventions focused on coping with psychosocial problems and symptoms may be important in enhancing adherence behaviors and HRQoL among adolescents with IBD.

The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper

Serum albumin and prealbumin, well-known visceral proteins, have traditionally been considered useful biochemical laboratory values in a nutrition assessment. However, recent literature disputes this contention. The aim of this document is to clarify that these proteins characterize inflammation rather than describe nutrition status or protein-energy malnutrition. Both critical illness and chronic illness are characterized by inflammation and, as such, hepatic reprioritization of protein synthesis occurs, resulting in lower serum concentrations of albumin and prealbumin. In addition, the redistribution of serum proteins occurs because of an increase in capillary permeability. There is an association between inflammation and malnutrition, however, not between malnutrition and visceral-protein levels. These proteins correlate well with patients' risk for adverse outcomes rather than with protein-energy malnutrition. Therefore, serum albumin and prealbumin should not serve as proxy measures of total body protein or total muscle mass and should not be used as nutrition markers. This paper has been approved by the American Society for Parenteral and Enteral Nutrition Board of Directors.

Outcomes Associated With Early vs Late Initiation of Exclusive Enteral Feeding Regimens Following Laparoscopic Gastrostomy Tube Placement in the Pediatric Patient

OBJECTIVES

Despite frequent placement of pediatric laparoscopic gastrostomy tubes (GTs), no rigorous evaluation of initial feeding and advancement regimens exists. Therefore, the aim of this study was to determine whether early enteral feeding after GT placement is associated with increased symptoms, procedural complications, or length of stay (LOS).

METHODS

In this retrospective cohort study, the records of all patients at a tertiary care pediatric hospital who had gastrostomy placement were reviewed. Only patients fed exclusively via gastrostomy were included. Feeding was monitored starting with the first postoperative feed and subsequently in 24-hour increments. Adverse events were recorded based on clinical documentation.

RESULTS

A total of 480 patients met inclusion criteria. Patients who started feeds between 24 and 36 hours had a shorter LOS compared with those who started at 36-48 hours (P = .0072) or >48 hours (P < .0001). Patients requiring ≥60 hours to reach goal feeds had significantly longer LOS than the other groups. There was no difference in the distribution of the LOS based on percentage of goal feeds initiated. Patients who required ≥60 hours to attain goal feeds had the most feeding complications.

CONCLUSIONS

More aggressive feeding advancement and earlier initiation of feeds were associated with decreased LOS without an associated increase in adverse clinical events.

Food Insecurity and Pediatric Malnutrition Related to Under- and Overweight in the United States: An Evidence Analysis Center Systematic Review

Both food insecurity and malnutrition are associated with adverse health outcomes in the pediatric population. However, the research on the relationship between these factors has been inconsistent, leading to uncertainty regarding whether or how evaluation of food insecurity should be incorporated into nutrition screening or the nutrition care process. The objective of this systematic review was to determine the association between food insecurity and malnutrition related to undernutrition or overnutrition (defined by anthropometrics) in the pediatric population in the United States. A literature search was conducted using Medline, Embase, and CINAHL databases for studies published from January 2002 through November 2017. A total of 23 studies (19 cross-sectional and 4 prospective cohort studies) met inclusion criteria and were included in qualitative analysis. In 6 studies, there was no overall relationship between food insecurity and underweight. All included studies examined the relationship between food insecurity status and overweight/obesity and results were mixed, with large cross-sectional studies demonstrating a positive relationship between food insecurity and overweight/obesity. There were no clear patterns according to subpopulation. Evidence quality was graded as fair due to heterogeneity in how food insecurity was measured and populations included as well as inconsistency in results. Use of a 2-item food insecurity screening tool may allow for efficient, effective screening of food insecurity in order to identify potential contributors overweight and obesity.

Aluminum Effects in Infants and Children

Aluminum has no known biological function; however, it is a contaminant present in most foods and medications. Aluminum is excreted by the renal system, and patients with renal diseases should avoid aluminum-containing medications. Studies demonstrating long-term toxicity from the aluminum content in parenteral nutrition components led the US Food and Drug Administration to implement rules for these solutions. Large-volume ingredients were required to reduce the aluminum concentration, and small-volume components were required to be labeled with the aluminum concentration. Despite these rules, the total aluminum concentration from some components continues to be above the recommended final concentration. The concerns about toxicity from the aluminum present in infant formulas and antiperspirants have not been substantiated but require more research. Aluminum is one of the most effective adjuvants used in vaccines, and a large number of studies have documented minimal adverse effects from this use. Long-term, high-concentration exposure to aluminum has been linked in meta-analyses with the development of Alzheimer disease.

Fruit Juice in Infants, Children, and Adolescents: Current Recommendations

Historically, fruit juice was recommended by pediatricians as a source of vitamin C and as an extra source of water for healthy infants and young children as their diets expanded to include solid foods with higher renal solute load. It was also sometimes recommended for children with constipation. Fruit juice is marketed as a healthy, natural source of vitamins and, in some instances, calcium. Because juice tastes good, children readily accept it. Although juice consumption has some benefits, it also has potential detrimental effects. High sugar content in juice contributes to increased calorie consumption and the risk of dental caries. In addition, the lack of protein and fiber in juice can predispose to inappropriate weight gain (too much or too little). Pediatricians need to be knowledgeable about juice to inform parents and patients on its appropriate uses.

Are Diet and Constipation Related in Children?

Constipation is a common complaint in childhood, and the etiology of many healthcare referrals. Despite literature documenting the high frequency of this problem, there is little research directly relating the food consumed and the eventual stool consistency. There is literature suggesting the importance of adequate fiber intake in children to maintain soft stools. Other dietary modifications actually have not been shown to be helpful or are not based on actual clinical studies. The presence of dietary allergies may also contribute to etiology of constipation. More studies to provide further linkages between diet and constipation are clearly needed.

Nutrition in Children and Adolescents

Nutrition is a critical factor for appropriate child and adolescent development. Appropriate nutrition changes according to age. Nutrition is an important element for prevention of disease development, especially for chronic diseases. Many children and adolescents live in environments that do not promote optimum nutrition. Families must work to provide improved food environments to encourage optimum nutrition. Early primordial prevention of risk factors for chronic disease, such as cardiovascular disease, is important, and dietary habits established early may be carried through adult life.

Malnutrition diagnoses in hospitalized patients: United States, 2010

Malnutrition is common among hospitalized patients in the United States, and its coded prevalence is increasing. Malnutrition is known to be associated with increased morbidity, mortality and healthcare costs. Although national data indicate that the number of malnutrition diagnoses among hospital discharges has been steadily rising, an in-depth examination of the demographic and clinical characteristics of these patients has not been conducted. We examined data from the 2010 Healthcare Cost and Utilization Project (HCUP), the most recent nationally-representative data describing U.S. hospital discharges. Using ICD-9 codes, we constructed a composite variable indicating a diagnosis of malnutrition. Based on our definition, 3.2% of all U.S. hospital discharges in 2010 had this diagnosis. Relative to patients without a malnutrition diagnosis, those with the diagnosis were older, had longer lengths of stay and incurred higher costs. These patients were more likely to have 27 of 29 comorbidities assessed in HCUP. Finally, discharge to home care was twice as common among malnourished patients, and a discharge of death was more than 5 times as common among patients with a malnutrition diagnosis. Taken together, these nationally representative, cross-sectional data indicate that hospitalized patients discharged with a diagnosis of malnutrition are older and sicker and their inpatient care is more expensive than their counterparts without this diagnosis.

Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions

Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English-language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non-illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness-related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence-based nutrition practices.

Copper metabolism and pediatric cholestasis

PURPOSE OF REVIEW

Copper is an essential trace mineral but both deficiency and toxicity need to be avoided. Copper is regulated via excretion by the biliary system and caution was recommended when administered in patients with cholestasis. Recent clinical reports indicate that despite the cholestasis, copper should not be withheld from parenteral nutrition.

RECENT FINDINGS

Transporters involved in regulating copper levels have been identified. This explains the processes that regulate copper levels and the diseases that result from transporter defects. Monitoring copper ideally requires a liver biopsy but there are reports that in infants serum copper levels correlate with the liver copper. The published cautions about copper in cholestatic patients on parenteral nutrition led to the removal of copper from the solutions. Subsequently, multiple reports of clinical copper deficiency developing in these patients including infants were published. Newer literature indicates no elevation in infant copper levels despite normal copper parenteral nutrition supplementation in the presence of cholestasis.

SUMMARY

Copper is essential and levels are regulated in response to an individual's needs. The liver excretion of copper is the primary regulating method but clinically cholestasis does not result in elevated levels in infants. The best clinical approach to parenteral nutrition copper is careful monitoring even in the presence of cholestasis.

Comparison of oral prednisone and topical fluticasone in the treatment of eosinophilic esophagitis: a randomized trial in children

BACKGROUND & AIMS

Although eosinophilic esophagitis is recognized increasingly, outcome data guiding therapy are limited. We conducted a prospective randomized trial comparing oral prednisone (P) and swallowed fluticasone (F) for histologic and clinical response.

METHODS

Patients were randomized to receive P or F for 4 weeks, followed by an 8-week weaning protocol. Esophageal histology was evaluated at baseline and after 4 weeks of therapy. Clinical assessments were performed at weeks 0, 4, 12, 18, and 24.

RESULTS

Eighty patients with eosinophilic esophagitis were enrolled: 40 in the P arm and 40 in the F arm. Histologic improvement was seen in 30 of 32 P and 34 of 36 F patients, with a greater degree of histologic improvement in the P group. All P and 35 of 36 F patients were free of presenting symptom(s) at week 4. Symptom relapse was seen in 45% of patients by week 24. Kaplan-Meier analysis showed no difference between P and F with regard to relapse rate (P = .7399). No significant difference in time to relapse was found between groups (P = .2529). Systemic adverse effects were noted in 40% of the P arm, whereas esophageal candidal overgrowth was seen in 15% of the F arm.

CONCLUSIONS

Systemic and topical corticosteroids were effective in achieving initial histologic and clinical improvement. P resulted in a greater degree of histologic improvement, without evidence of an associated clinical advantage over F in terms of symptom resolution, relapse rates, or time to relapse. Symptom relapse was common to both groups upon therapy discontinuation, highlighting the need for maintenance treatment protocols.

At what age is a suction rectal biopsy less likely to provide adequate tissue for identification of ganglion cells?

OBJECTIVE

The objective of this study was to determine at what age suction rectal biopsy is less likely to provide adequate tissue to detect submucosal ganglion cells in a child being evaluated for Hirschsprung disease.

PATIENTS AND METHODS

Children > or =1 year of age undergoing a rectal biopsy at a single children's hospital had 1 biopsy each obtained simultaneously with a suction biopsy device and a grasp biopsy forceps. The biopsies were examined by 2 pathologists for adequacy of the submucosa (none, scant, adequate, or ample) and the presence of ganglion cells. The 2 specimens were compared with each other.

RESULTS

One hundred fifty-two children 1 to 17 years of age were included. Fifty-three were female. Subjects were grouped into 4 age categories: 1 to 3 years (group A), 4 to 6 years (group B), 7 to 9 years (group C), and > or =10 years (group D). Similar numbers of patients were recruited for each group. Ganglion cells were identified in 73% and 90% by the suction and grasp devices, respectively, in group A. In groups B through D, ganglion cells were identified in 50% to 53% vs 92% to 97% of the suction and grasp biopsies, respectively (P < 0.001). Submucosa was present in 88% (suction) vs 98% (grasp) in group A, 70% vs 95% in group B, 69% vs 94% in group C, and 45% vs 92% in group D.

CONCLUSION

The suction rectal biopsy is less likely to provide adequate submucosa for identification of ganglion cells after 3 years of age.

Screening for celiac disease in asymptomatic children with Down syndrome: cost-effectiveness of preventing lymphoma

BACKGROUND

Studies demonstrate an increased prevalence of celiac disease in persons with Down syndrome, leading some organizations and authors to recommend universal screening of children with Down syndrome. However, many children with Down syndrome are asymptomatic, and the long-term implications of screening are unknown. The complication of celiac disease that leads to mortality in the general population is non-Hodgkin's lymphomas.

OBJECTIVES

The purpose of this research in asymptomatic children with Down syndrome was to (1) calculate the number needed to screen to prevent a single case of lymphoma and (2) present a cost-effectiveness study of screening.

METHODS

We constructed a decision tree using probabilities derived from the published literature for Down syndrome or from the general population where Down syndrome-specific data were not available. Celiac disease was determined by serologic screening and confirmation with intestinal biopsy. Sensitivity analysis was used to alter probability estimates affecting the cost of preventing lymphoma.

RESULTS

Using our baseline values, the no-screen strategy is dominant; that is, screening not only costs more but also results in fewer quality-adjusted life-years. A screening strategy costs more than $500,000 per life-year gained. Screening all asymptomatic children with Down syndrome for celiac disease costs almost $5 million to prevent a single case of lymphoma.

CONCLUSION

These analyses do not support the cost-effectiveness of screening, and more data are needed before recommendations to screen asymptomatic children with Down syndrome for celiac disease can be made.

Cysteinyl leukotriene levels in esophageal mucosal biopsies of children with eosinophilic inflammation: are they all the same?

OBJECTIVES

Allergic eosinophilic esophagitis (AEE) is characterized by intense eosinophilic inflammation of the esophageal mucosa. Cysteinyl leukotrienes (CysLT) are eosinophil chemoattractants. We studied CysLT levels in esophageal mucosa of children with AEE and controls.

METHODS

CysLT levels (pg CysLT/microg protein) were quantified by Enzyme-linked Immunosorbent Assay (ELISA) on endoscopically obtained esophageal mucosal biopsies.

RESULTS

Twelve children with AEE (eight boys, mean age 6.6 yr, range 1.0-14.5 yr) and 10 controls (six boys, mean age 9.56 yr, range 1.08-15.08 yr) were enrolled. None were on anti-LT or corticosteroid therapy. All controls had histologically normal mucosal biopsies of the esophagus, stomach, and duodenum. Patients with AEE had intense eosinophilic inflammation of the esophageal mucosa (mean 39 eosinophils/hpf, range 15-70 eosinophils/hpf) and a normal 24-h pH probe study. CysLT levels were similar between the two groups: mean levels were 12.44 (median 10.87, range 2.54-28.29) in AEE patients and 9.52 (median 9.26, range 1.71-21.64) in controls. CysLT levels did not correlate with the degree of esophageal eosinophilic inflammation. Incidentally, five patients with eosinophilic gastroduodenitis, in addition to esophagitis, were enrolled; their CysLT levels were statistically higher than those of controls.

CONCLUSIONS

This is the first study to examine CysLT levels in esophageal mucosal biopsies of children with AEE and normal children. CysLT levels in AEE patients are similar to those in controls, and independent of the severity of inflammation. While this would argue against the use of CysLT antagonists in the treatment of AEE, further studies into the expression of the CysLT receptor itself are needed.

Gastrointestinal factors in autistic disorder: a critical review

Interest in the gastrointestinal (GI) factors of autistic disorder (autism) has developed from descriptions of symptoms such as constipation and diarrhea in autistic children and advanced towards more detailed studies of GI histopathology and treatment modalities. This review attempts to critically and comprehensively analyze the literature as it applies to all aspects of GI factors in autism, including discussion of symptoms, pathology, nutrition, and treatment. While much literature is available on this topic, a dearth of rigorous study was found to validate GI factors specific to children with autism.

Nocturnal acid breakthrough in children with reflux esophagitis taking proton pump inhibitors

OBJECTIVES

We aimed to determine if nocturnal acid breakthrough occurs in children receiving proton pump inhibitors for reflux esophagitis, and to compare the healing of esophagitis in children with nocturnal acid breakthrough receiving proton pump inhibitors +/- ranitidine.

METHODS

This is a prospective, double-blind study. Endoscopic and histologic esophagitis were scored 0-4 and 0-3, respectively. Patients were treated with a proton pump inhibitor twice daily and esophagogastric pH monitoring was performed at week 3. Patients with nocturnal acid breakthrough were randomized. One group received ranitidine and the other received placebo at bedtime in addition to proton pump inhibitor therapy. Endoscopy was performed on all patients (with pH monitoring on patients with nocturnal acid breakthrough) during the 17th week of therapy.

RESULTS

We enrolled 18 patients, ages 1 to 13 years (mean = 10.3 years). Mean baseline endoscopic and histologic scores were 3.1 +/- 1.4 and 1.8 +/- 0.7, respectively. Mean dose of proton pump inhibitor was 1.3 mg/kg +/- 0.6. Nocturnal acid breakthrough was documented in 16/18 (89%) patients. Seven patients received ranitidine and 9 received placebo. The reflux index improved: mean of 14.3 at baseline, 2.0 at week 3 (P = 0.0001), and 5.1 at week 17 (P = 0.09). Nocturnal acid breakthrough persisted in 9/12 (75%) patients, 3 of whom received ranitidine at bedtime. Esophagitis improved in all patients following therapy: mean endoscopy and histology scores were 1.6 +/- 1.8 (P = 0.0020) and 0.8 +/- 0.9 (P = 0.0013), respectively. Symptoms significantly improved from a mean score of 2.0 at baseline to 0.4 at week 17 (P = 0.0001).

CONCLUSIONS

Nocturnal acid breakthrough is common in pediatric patients treated with proton pump inhibitors. Reflux index remains normal in spite of nocturnal acid breakthrough. Symptoms and esophagitis continued to improve during therapy in spite of nocturnal acid breakthrough. There appears to be no additional benefit to supplementation with ranitidine at bedtime.

Fetal intestinal fibroblasts respond to insulin-like growth factor (IGF)-II better than adult intestinal fibroblasts

Background

We compared IGF responses of fetal and adult intestinal fibroblasts to identify a developmental difference in the IGF-axis. Intestinal fibroblasts were isolated from maternal and fetal jejunum. Media was conditioned at confluence and one week afterwards. The proliferative response at confluence to 5 nM IGF-I or -II was compared.

Results

There were no significant differences in IGFBP expression at confluence. Post-confluence, fetal fibroblasts had no significant changes in IGFBP-2 and IGFBP-3 expression. Post-confluent maternal fibroblasts had increased IGFBP-3 levels that were significant compared to the fetal fibroblasts. IGF-I increased in post-confluent fetal fibroblasts, while in maternal fibroblasts it decreased (p < 0.001). IGF-II secretion decreased significantly in post-confluent maternal fibroblasts (p < 0.05). Maternal fibroblasts proliferated more with IGF-I than IGF-II (p < 0.001). Fetal fibroblasts responded to IGF-II slightly better than IGF-I and significantly greater than maternal cells (p < 0.001).

Conclusion

Fetal intestinal fibroblasts respond to IGF-II with greater proliferation and do not have the increased IGFBPs seen post-confluence in adult intestinal fibroblasts.

Assessment of the effectiveness of biofeedback in children with dyssynergic defecation and recalcitrant constipation/encopresis: does home biofeedback improve long-term outcomes

The purpose of this study was to determine whether biofeedback benefits children with dyssynergic defecation and constipation/encopresis, and whether home biofeedback improves long-term outcomes. Thirty-six patients with chronic constipation who had failed at least 6 months of conventional treatment and demonstrated dyssynergic defecation at anorectal manometry were randomized to biofeedback in the laboratory alone (group 1, n=24) or in the laboratory and at home (group 2, n=12) and followed up at 2, 4, and a mean of 44 months. Thirty patients were available for long-term follow-up. Bowel movements increased in all from a mean of 1.4/week to 5.1, 5.8, and 5.1 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Soiling decreased in all from a mean of 5.5/week to 0.6, 0.1, and 1 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Laxative use decreased from a mean of 4.1 days/week to 0.6, 0.3, and 0.7 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Twenty-seven of 30 parents ranked their satisfaction a mean of 2.2 (range 1-excellent to 3-good). There were no significant differences in outcomes between the laboratory alone group and the laboratory plus home group. Biofeedback is beneficial for some children with chronic constipation and dyssynergic defecation. Supplemental home biofeedback does not improve long-term outcomes.

White specks in the esophageal mucosa: An endoscopic manifestation of non-reflux eosinophilic esophagitis in children

BACKGROUND

White specks in the esophageal mucosa have been observed in children with eosinophilic esophagitis. The aim of this study was to determine the relationship between white specks in the esophageal mucosa and allergic (non-reflux) eosinophilic esophagitis.

METHODS

Endoscopic data, pH probe results, and histopathology reports for children with esophageal endoscopic abnormalities seen during a 17-month period were reviewed. Eosinophilic esophagitis was grouped according to the number of eosinophils per high power field (non-allergic, <15 eosinophils/high power field; allergic, > or =15 eosinophils/high power field).

RESULTS

Of 1041 endoscopies performed during the study period, 153 revealed evidence of eosinophilic esophagitis. Of these 153, 61 had fewer than 15 eosinophils/high power field and 92 had 15 or more eosinophils/high power field. At 31 of the 153 procedures, white specks were noted in the esophageal mucosa. The sensitivity of white specks in the esophageal mucosa for allergic eosinophilic esophagitis was only 30%, but the specificity was 95%. pH probe testing was performed in 21 patients with white specks and was normal in all.

CONCLUSIONS

This report describes a new endoscopic finding associated with allergic eosinophilic esophagitis in children. Eosinophilic esophagitis tends to be severe when white specks are present (> or =15 eosinophils/high power field) and is not associated with pathologic gastroesophageal reflux, as demonstrated by pH probe testing.

Comparison of serological markers of inflammatory bowel disease with clinical diagnosis in children

BACKGROUND

Our purpose was to study the concordance of serological tests for inflammatory bowel disease with clinical diagnosis established by traditional testing in children.

METHODS

All children seen in our division who had IBD Diagnostic System (ie, pANCA, ASCA IgA, and ASCA IgG) performed over a 21-month period (June 1998 to February 2000) were identified. Their medical records were reviewed for basic demographics, test results (endoscopy, histology, and radiology), IBD Diagnostic System results, and patient symptoms/medications. Results of the IBD Diagnostic System were compared with several patient characteristics including age, sex, absence/presence of symptoms, medication use, disease activity and duration.

RESULTS

One hundred seven patients were divided into 6 groups based on clinical diagnosis and IBD Diagnostic System results. The sensitivity, specificity and +/- predictive values of the IBD Diagnostic System for ulcerative colitis were 69.2, 95.1, 90.0, and 87.1%, respectively, and for Crohn's disease were 54.1, 96.8, 90.9, and 80.8%, respectively. Overall, the results of the IBD Diagnostic System were concordant with the clinical diagnosis in 76 of the 107 (71%) patients.

CONCLUSIONS

In our experience, the specificity of IBD Diagnostic System is better than the sensitivity; the sensitivity is better for ulcerative colitis than Crohn's disease (69.2% vs 54.1%). The low sensitivity, especially for Crohn's disease, precludes the possibility that the IBD Diagnostic System can replace traditional studies when evaluating for inflammatory bowel disease. Though we do not exclude inflammatory bowel disease solely by IBD Diagnostic System results, it is reassuring to note that all patients without clinical evidence of inflammatory bowel disease also had negative IBD Diagnostic System results.

Impact of sedation and anesthesia on the rectoanal inhibitory reflex in children

OBJECTIVE

The study objective was to determine whether the rectoanal inhibitory reflex (RAIR) can be elicited during limited anorectal manometry (ARM) performed under general anesthesia (GA).

METHODS

In this retrospective study, patients with intractable constipation who underwent ARM under GA from November 1999 to March 2002 were evaluated. Rectal biopsy specimens were examined for the presence of ganglion cells.

RESULTS

Eighty consecutive patients aged 5 months to 16 years were evaluated. Three patients with Hirschsprung disease were excluded from analysis. Ganglion cells were found in rectal biopsy specimens from 76 patients. RAIR was positive in 69 (90%) and negative in 8 (10%). Forty-five patients received preoperative medications: midazolam (n = 36), midazolam + atropine (n = 3), atropine (n = 1), midazolam + glycopyrrolate (n = 3), and glycopyrrolate (n = 2). Different combinations of general anesthetic medications were used. Ten patients received neuromuscular blockers. The use of preoperative midazolam or atropine did not affect the presence or absence of RAIR; however, the proportion of patients with negative RAIR was higher in those receiving glycopyrrolate (P = 0.007) than in those receiving other medications. There was no significant difference in the effect of the general anesthetic agents or neuromuscular blockers used on the presence or absence of RAIR.

CONCLUSIONS

The rectoanal inhibitory reflex in children can be elicited even when anorectal manometry is performed under general anesthesia. Glycopyrrolate, an anticholinergic, appears to inhibit the demonstration of the RAIR.

Complications after outpatient upper GI endoscopy in children: 30-day follow-up

OBJECTIVE

Upper GI endoscopy (UGE) is a common procedure performed for evaluation and treatment of various upper GI tract disorders in children. Limited comprehensive data are available on the complications of UGE in adults and particularly in children. The goals of this study were to identify complications and adverse events reported by patients and their parents after outpatient UGE under general anesthesia (GA).

METHODS

Pediatric patients who underwent outpatient UGE under GA between April, 2000 and April, 2001 at the James Whitcomb Hospital for Children were identified. The interviewer obtained verbal consent and performed standardized telephone interviews 30 days after the outpatient UGE.

RESULTS

A total of 393 patients participated in this survey. Of the patients, 165 (42%) had one or more complications or adverse events. The most common ones reported by patients or parents 30 days after the UGE under GA were sore throat or hoarseness (34.6%), fatigue (6.6%), cough (4.1%), headache (3.3%), excessive gas or burping (2.8%), nausea (2.5%), emesis (2.3%), abdominal pain (2%), fever (2%), behavior problems (1.8%), upper respiratory symptoms (1.3%), excessive drowsiness (0.5%), nosebleed (0.3%), perioral rash (0.3%), and chest pain (0.3%). Ten of 165 patients with complications or adverse events after UGE sought medical assistance.

CONCLUSIONS

Approximately one third of pediatric patients complained of sore throat or hoarseness after UGE under GA. All other reported complications or adverse events were infrequent. We conclude that UGE under GA is safe and well tolerated in pediatric patients.

The insulin-like growth factor axis in children with inflammatory bowel disease

BACKGROUND

The insulin-like growth factor (IGF) axis consists of two IGFs and six IGF-binding proteins (IGFBPs) that regulate proliferation and differentiation of many cell types. Malnutrition and inflammation alter the IGF axis. The authors evaluated circulating IGFs and IGFBPs in patients with inflammatory bowel disease (IBD) at the time of presentation and compared them with values obtained during remission.

METHODS

Seventeen newly diagnosed pediatric IBD patients were studied on presentation and during remission. Nutritional status was assessed by body mass index (BMI) and serum protein assay. The Lloyd-Still and Green IBD clinical scoring system was used. IGF-I and IGF-II levels were measured by radioimmunoassay, and IGFBP-3 levels were measured by immunoradiometric assay. IGFBPs were quantified on ligand blots with a PhosphorImager.

RESULTS

Body mass index and IBD clinical scores improved after treatment: 18.7 +/- 3.0 versus 21.3 +/- 3.0 kg/m (P = 0.023) and 74.6 +/- 16.7 versus 93.1 +/- 7.4 (P< 0.001), respectively. Protein changes were insignificant. IGFBP-3 levels increased from time of first evaluation to remission: 3,470 +/- 850 versus 4,700 +/- 473 ng/mL (P< 0.001). The ratio of IGFBP-3 to IGFBP-2 increased from first evaluation to remission: 1.7 +/- 1.9 versus 3.9 +/- 1.9 (P= 0.003). IGF-I and IGF-II levels also increased: 139 +/- 167 versus 223 +/- 118 ng/mL (P= 0.011) and 307 +/- 111 versus 386 +/- 73 ng/mL (P= 0.007), respectively.

CONCLUSIONS

Circulating IGFBP-3 levels were low during active IBD and increased at remission in parallel with the IGF-I levels. The IGFBP-3 to IGFBP-2 ratio was altered in the presence of active disease in a manner that would reduce IGF-I action. This abnormality improved after treatment.

The role of esophagogastroduodenoscopy in the initial evaluation of childhood inflammatory bowel disease: a 7-year study

OBJECTIVES

To assess the role of esophagogastroduodenoscopy in the evaluation of children with suspected inflammatory bowel disease.

METHODS

All children with inflammatory bowel disease who underwent esophagogastroduodenoscopy during their initial evaluation at our institution during a 7-year period (December 1993 to November 2000) were included in the study.

RESULTS

The study included 115 patients: 81 with Crohn disease (mean age, 11.34 years; 42 males) and 34 with ulcerative colitis (mean age, 11.79 years; 20 males). Abnormal findings on esophagogastroduodenoscopy were noted in 64% of patients with Crohn disease and 50% of children with ulcerative colitis; histologic abnormalities were found in 81.6% and 70.6% of the patients, respectively. Granulomas were found in the upper gastrointestinal tracts of 23 of 81 patients (28.4%), with the most common site being the gastric mucosa. Nine of these 23 patients had granulomas solely in the upper gastrointestinal tract. Additional unsuspected pathology noted included: candidiasis, hiatal hernia, Helicobacter pylori infection, and giardiasis.

CONCLUSIONS

Endoscopic and histologic abnormalities were found in the upper gastrointestinal tracts of a significant number of children with inflammatory bowel disease. While the mechanism(s) underlying these abnormalities in patients with ulcerative colitis is unclear, the pathology can contribute to the patient's clinical condition. Pathology in the upper gastrointestinal tract should not exclude a diagnosis of ulcerative colitis. Granulomas, confirming the diagnosis of Crohn disease, were found in the upper gastrointestinal tracts of 28% of our patients with Crohn disease. In some cases, granulomas were found solely in the upper gastrointestinal tracts. Based on our data, esophagogastroduodenoscopy with biopsy should be performed in all pediatric patients with suspected inflammatory bowel disease.

Lactase deficiency: not more common in pediatric patients with inflammatory bowel disease than in patients with chronic abdominal pain

OBJECTIVE

Lactase deficiency is commonly found in adults with inflammatory bowel disease (IBD). Our aim was to determine its prevalence in children with IBD.

METHODS

We conducted a retrospective and descriptive analysis of patients with symptomatic IBD whose mucosal lactase activity was measured on duodenal biopsies obtained during gastrointestinal endoscopic evaluations. Age- and gender-matched controls were chosen randomly from a group with chronic abdominal pain.

RESULTS

One hundred twelve patients with IBD were identified from January 1994 to December 2000. Seventy-nine (71%) had Crohn disease, and 33 (29%) had ulcerative colitis. Forty-five (40%) of all IBD patients (29 with Crohn disease and 16 with ulcerative colitis) had low lactase activity levels (< 15 microM/min/gm). The prevalence of lactase deficiency in patients with IBD was 37% (38 of 103) in white patients and 78% (7 of 9) in blacks. Thirty-four of 112 controls (30%) had lactase deficiency. IBD patients were more likely to be lactase deficient than the controls, but the difference was not statistically significant ( = 0.162). Normal duodenal histology was found in 67% of lactase-deficient IBD patients compared with 82% in lactase-sufficient IBD patients. The frequency of duodenal inflammation did not differ significantly between lactase-deficient and -sufficient patients with IBD ( = 0.068).

CONCLUSIONS

More than one third of pediatric patients with IBD have lactase deficiency, which is not significantly different from non-IBD patients with chronic abdominal pain. The majority of lactase-deficient patients with IBD have normal duodenal biopsy results. Lactase activity from small bowel biopsy specimens can be measured at the time of initial endoscopy. Reevaluation, either by small bowel biopsy or the breath hydrogen test, may then be considered during follow-up of symptomatic patients.

Insulin-like growth factor binding protein-4 expression is dependent on the carbohydrate in the media in HT-29 cells

HT-29 are colonic carcinoma cells that follow a unique pattern of differentiation dependent on the medium's carbohydrate source. This study compared levels of insulin-like growth factor (IGF)-II and IGF binding protein (IGFBP)-4 when HT-29 cells were grown with standard glucose-containing medium versus galactose-containing (glucose-free) medium. Serum-free media conditioned for 24h were collected at low density, pre-confluence, confluence, and 48-h post-confluence. Ligand blotting of the conditioned galactose medium demonstrated low IGFBP-4 levels until the cells approached confluence, when the levels increased significantly. In standard medium, IGFBP-4 levels increased with increasing cell numbers except for a transient decrease at confluence. Radioimmunoassay showed little change in IGF-II concentrations, although HT-29 cells grown with galactose had lower IGF-II concentrations. HT-29 cells treated with retinoic acid had dose-dependent increases in IGFBP-4 and reduced IGF-II expression. These studies suggest that HT-29 cell differentiation correlates with an increase in IGFBP-4 levels.

Accuracy of infant admission lengths

OBJECTIVE

A variety of methods are used to assess the length of infants at hospital admission. A tape-measure technique is commonly used; however, this measure is potentially inaccurate. We aimed to assess accuracy of tape measurement of infant lengths by comparison with the more accurate length-board technique.

METHODS

During a 1-year period, 25 infants who were younger than 36 months were seen for a nutrition consultation. The length obtained at admission was compared with that obtained with a length-board by a trained dietitian.

RESULTS

Overall, the lengths varied enough both positively and negatively that no overall statistical difference was seen; however, the average difference between the tape measure and the length-board was 2.23 cm. The change in length resulted in a change in the weight-for-length percentile range in 13 of 25 patients.

CONCLUSION

The more accurate length-board measurement should be applied at the time of admission of an infant.

Secretory activity of bovine ovarian granulosa cells transfected with sense and antisense insulin-like growth factor (IGF) binding protein-3 and the response to IGF-I, GH, LH, oxytocin and oestradiol

The aim of our in vitro experiments was to examine if IGF binding protein (IGFBP)-3 is involved in control of bovine ovarian secretory activity. For this purpose we performed the transfection of bovine granulosa cells with cDNA sense and antisense constructs increasing or inhibiting IGFBP-3 synthesis. The release of IGFBP-3, progesterone, oxytocin, IGF-I and prostaglandins F (PGF) and E (PGE) by control and transfected cells was compared. The transfected ovarian cells were cultured with and without bLH (100 ng/ml), bGH (100 ng/ml), IGF-I (10 ng/ml), oxytocin (10 ng/ml) and oestradiol-17beta (100 ng/ml). The concentration of IGFBP-3 produced was assessed using ligand and western blotting and secretion of progesterone, oxytocin, IGF-I, PGF and PGE was evaluated using RIA/IRMA techniques. Transfection of cells with the sense IGFBP-3 cDNA construct resulted in the expected increase in IGFBP-3 release, whereas the antisense IGFBP-3 construct induced the expected reduction in IGFBP-3 output. The granulosa cells transfected to overexpress IGFBP-3 had an increase in IGF-I, PGF and PGE release, and a decrease in basal and hormone- or growth factor-induced accumulation of progesterone and oxytocin. The granulosa cells transfected to have reduced IGFBP-3 expression gave primarily significant opposite findings. The present results suggest the involvement of IGFBP-3 in control of bovine ovarian steroid, peptide hormone, growth factor and prostaglandin release. IGFBP-3 is a physiological stimulator of IGF-I and prostaglandin release and an inhibitor of steroid and peptide hormone output.

The transfection-induced overexpression of IGF-binding protein-4 affects the secretory activity of porcine ovarian granulosa cells and their response to hormones and IGF-I

The aim of our studies was to examine whether IGF-binding protein (IGFBP)-4 is involved in the control of the secretion of various ovarian substances and also the mediation of the effects of several hormones and growth factors on this secretion. For this purpose, we carried out the transfection of porcine granulosa cells with a cDNA sense construct, increasing IGFBP-4 synthesis. We then compared the release of IGFBP-3, progesterone, oxytocin and IGF-I by control and transfected cells cultured with and without porcine LH (100 ng/ml), porcine GH (100 ng/ml), IGF-I (10 ng/ml), oxytocin (10 ng/ml) and estradiol-17beta (100 ng/ml). The concentration of IGFBP-4 produced was assessed using ligand blotting, and the release of progesterone, oxytocin, IGF-I and IGFBP-3 was evaluated using RIA/IRMA techniques. It was observed that GH, IGF-I, estradiol, LH and oxytocin alter the progesterone, oxytocin, IGF-I and IGFBP-3 release by porcine ovarian granulosa cells. Transfection of these cells with an IBFBP-4 cDNA expression construct significantly increased the IGFBP-4 accumulation in cell-conditioned medium. Furthermore, this transfection significantly reduced progesterone, oxytocin and IGFBP-3 release, and increased IGF-I output in cells cultured in the absence or presence of GH, IGF-I, estradiol and LH. The addition of oxytocin, but not of other tested substances, fully or partially prevented the effects of IGFBP-4 overexpression on IGFBP-3, IGF-I, but not on progesterone release. The present results suggested that IGFBP-4, as well as GH, IGF-I, estradiol, LH and oxytocin, is a potent regulator of porcine ovarian steroid (progesterone), nonapeptide hormone (oxytocin), growth factor (IGF-I) and growth factor-binding protein (IGFBP-3) release. IGFBP-4 is an inhibitor of basal progesterone, oxytocin and IGFBP-3 release and a stimulator of IGF-I output by porcine ovarian cells. The action of IGFBP-4 on the ovary can be mediated by (1) inhibition of oxytocin release, (2) suppression of receptor/postreceptor events induced by other hormones and IGF-I and (3) stimulation of IGF-I release.

Regulation of the insulin-like growth factor axis by increasing cell number in intestinal epithelial (IEC-6) cells

Insulin-like growth factor binding protein-2 (IGFBP-2) production as a function of cell number by intestinal epithelial cells (IEC-6) was regulated such that the IGFBP-2 concentration in 24-h conditioned medium reached a maximum, which was maintained despite increasing cell number. Northern blot analysis revealed that this effect could largely be attributed to decreasing IGFBP-2 mRNA. In contrast to IGFBP-2, secretion of IGF-II and accumulation of IGF-II mRNA by IEC-6 cells correlated positively with cell number. The highest level of IGF-II protein detected by immunoblotting of conditioned medium occurred in post-confluent cells. IGF-I stimulated the cells to grow to a high cellular density and inhibited IGFBP-2 secretion in a concentration-dependent fashion. We conclude that expression of IGF-II and IGFBP-2 are regulated in IEC-6 cells by cellular density, and IGF-II may act as a survival factor at high cell density.

Transplanted small bowel and expression of the insulin-like growth factor binding proteins

The insulin-like growth factor binding proteins (IGFBPs) act to modulate the growth and differentiation of the gastrointestinal mucosa by regulating cellular responses to the important mitogens, the insulin-like growth factors (IGFs). The transplanted small bowel must maintain the normal growth factor interrelationships and signaling pathways despite the potential of host rejection. Ostomy effluent of patients after small bowel or combined liver/small bowel transplantation was assayed for IGFBPs to investigate the effect of rejection on the IGF-IGFBP axis. Seventeen patients were studied over an 18-month period. The transplanted small bowel produced no measurable IGFBPs in the ostomy effluent under normal circumstances. However, when rejection was taking place the ostomy effluent was found to have measurable IGFBP levels in 6 of 12 episodes, the 6 episodes occurring in 6 different patients. Mostly, the IGFBPs present did not exhibit a serum-like pattern indicating the secretion of IGFBPs into the effluent was not the result of loss of mucosal barrier integrity. There were no statistically significant differences in protein content of the ostomy fluids in the presence or absence of rejection. Our results suggest that the gastrointestinal IGF axis is altered during some instances of transplanted small bowel rejection, with increased secretion of IGFBPs.

Intolerance to protein hydrolysate infant formulas: an underrecognized cause of gastrointestinal symptoms in infants

The purpose of this study was to determine the effectiveness of an amino acid-based infant formula in infants with continued symptoms suggestive of formula protein intolerance while they were receiving casein hydrolysate formula (CHF). Twenty-eight infants, 22 to 173 days of age, were enrolled; each had received CHF for an average of 40 days (10 to 173 days) and continued to have bloody stools, vomiting, diarrhea, irritability, or failure to gain weight, or a combination of these symptoms. Sigmoidoscopy with rectal biopsy was performed in all infants. The infants then received an amino acid-based infant formula, Neocate, for 2 weeks. After 2 weeks of treatment, 25 of the infants demonstrated resolution of their symptoms and underwent challenge with CHF. Of the 25 who were challenged, eight tolerated the CHF and the remainder had recurrence of their symptoms. The histologic features in these infants varied from eosinophilic infiltration to normal. We conclude that not all infants with apparent formula protein-induced colitis respond to CHF and that these infants may have resolution of their symptoms when fed an amino acid-based infant formula.

Expression of insulin-like growth factor-II and insulin-like growth factor binding proteins during Caco-2 cell proliferation and differentiation

The components of the insulin-like growth factor (IGF) axis and their roles in regulating proliferation and differentiation of the human colon adenocarcinoma cell line, Caco-2, have been investigated. Caco-2 cells proliferated in serum-free medium at 75% the rate observed in medium containing 10% fetal bovine serum. IGF-I (10 nM) increased Caco-2 cell growth in serum-free medium, but not to the rate seen with serum. Multiple IGF-II mRNA species were produced by Caco-2 cells, but IGF-I mRNA was undetectable. Secretion of radioimmunoassayable IGF-II corresponded with steady-state levels of IGF-II mRNA, neither of which was observed to change markedly over the course of 16 days of Caco-2 cell differentiation. Levels of sucrase-isomaltase mRNA, a marker for enterocytic differentiation, increased 12-fold between days 5 and 16 of culture. Northern blotting of total RNA and ligand blot and immunoblot analyses of serum-free conditioned medium revealed that Caco-2 cells produce several IGF binding proteins (IGFBPs), including IGFBP-2, -3, and -4, as well as a 31,000 M(r) species that was not identified. The pattern of IGFBP secretion changed dramatically during Caco-2 cell differentiation: IGFBP-3 and IGFBP-2 increased 8.5-fold and 5-fold, respectively, whereas IGFBP-4 and the 31,000 M(r) species decreased 43% and 90%. Caco-2 cell clones stably transfected with a human IGFBP-4 cDNA construct exhibited a 60% increase in steady-state level of IGFBP-4 mRNA, and secreted twice as much IGFBP-4 protein as controls. Moreover, IGFBP-4-overexpressing cells proliferated at only 25% the rate of control cells in serum-free medium, in conjunction with a 70% increase in expression of sucrase-isomaltase. In summary, these studies indicate that a complex IGF axis is involved in autocrine regulation of Caco-2 cell proliferation and differentiation.

Growth stimulation by transfection of intestinal epithelial cells with an antisense insulin-like growth factor binding protein-2 construct

IEC-6 cells, an intestinal epithelial cell line, produce insulin-like growth factor (IGF)-II and IGF-binding protein-2 (IGFBP-2). Exogenous IGFs stimulate and IGFBP-2 attenuates DNA synthesis. To investigate whether endogenously secreted IGFBP-2 inhibits proliferation, IEC-6 cells were transfected with a full-length rat IGFBP-2 cDNA antisense expression construct. The steady-state level of IGFBP-2 mRNA decreased by 54% in the antisense cDNA-transfected cells (denoted revBP2) compared with vector-transfected controls. Moreover, revBP2 cells secreted less IGFBP-2 than controls (maximally a 68% decrease). In serum-containing medium, revBP2 cells exhibited a 35% increase in log-phase proliferation rate and growth-arrested at a maximum density 14% higher than controls. We conclude that endogenous IGFBP-2 inhibits proliferation of IEC-6 cells, probably by sequestering IGFs.