Objectives and Study

In the paediatric population interest is growing in the use of a blended diet for the management of feeding intolerances. It is perceived to be better tolerated compared to commercially available whole protein enteral formulas. The medical nutrition industry have responded to this cultural shift in adopting blended diets and developed an enteral tube feed Compleat ® Paediatric that contain 14% food ingredients, 1g Fibre/ 100ml.

Another perceived factor believed to have an impact on feed tolerance relates to the mode in which nutrition is delivered in relation to intermittent bolus or continuous enteral feeding. This study aimed to evaluate the tolerance of different feeding modes (intermittent bolus/ continuous/ combination) in children who are fed with an 'enteral formula with food derived ingredients'.

Methods

Data was collected by paediatric dietitians from dietetic records over a month period on children who had switched to an enteral formula with food derived ingredients. Data was inputted to a Microsoft form to capture the impact of varying modes of feeding (intermittent bolus/continuous/ combination) on gastrointestinal and anthropometric outcomes.

Results

Forty-three children were recruited between March 2021 to July 2021 across four National Health Service Trusts. Children who were continuously fed saw the greatest reported improvement in retching, abdominal pain and loose stools. Children who were fed intermittent bolus reported the greatest increase in weight (p-value 0.003). Over 90% of dietitians reported nutritional goals were achieved after switching from a standard formula to an enteral formula with food-derived ingredients for both continuous and intermittent bolus feeding; children who were fed continuously reported the highest achievement to meet dietitian’s nutritional goals.

Conclusions

'Enteral formulas with food derived ingredients' are well tolerated and effective in achieving weight gain and meeting dietetic goals whether delivered continuously or as intermittent bolus feed. The clinical situation will determine the most appropriate and effective feeding mode.

Objectives and Study

To assess the effectiveness of nutritional supplementation during the first 1000-days to reduce the prevalence of low birth weight and stunting in children at 24 months of age.

Methods

In this cluster randomized controlled trial, we enrolled women from two rural districts of Pakistan during their pregnancy. Out of 29 clusters, we randomly allocated 6 clusters to the intervention and control each. Pregnant women received a monthly supply of 5 kg (i.e., 165 grams/day) of wheat soya blend plus (WSB+) during pregnancy and the first six months of their lactation period. In addition, their children received lipid-based nutrient supplement - medium-quantity (LNSMQ) between 6-23 months of age.

Results

Two thousand thirty pregnant women (1017 in the intervention group and 1013 in the control group) were enrolled. Monthly follow-ups were conducted. At 24 months of age, we captured data from 699 (78%) of 892 live births in the intervention group and 653 (76%) of 853 live births in the control group. There was a significant difference in mean length (49.4 cm vs 48.9 cm, p =0.027), weight (3.1 kg vs 3.0 kg, p =0.013), length for age z-scores (-1.2 vs -1.5, p =0.004) and weight for age z-scores (-1.2 vs -1.5, p =0.015) among infants in the intervention compared to control group. At 24 months of age, a significant difference in the prevalence of stunting (absolute difference, 10.2%, 95% CI 18.2 to 2.3, p =0.017) and underweight (absolute difference, 13.7%, 95% CI 20.3 to 7.0, p =0.001) were observed in the intervention as compared to the control group.

Conclusions

Provision of supplementation during the first 1000-days of life improved child linear growth and reduced stunting in children at 24 months. This intervention can be scaled-up in similar settings to lower the prevalence of low birthweight and stunting in children under two years of age.

Objectives and Study

To compare the clinical course of UC before and after the introduction of biologics, and to compare with the IBSEN study.

Methods

Patients under 18 years of age, who were diagnosed with UC and followed from January 2003 to October 2020, were included in the study. Group A (n = 48) was followed between January 2003 and October 2012, and Group B (n = 62) was followed between November 2012 and October 2020. We compared endoscopic remission, drug composition, relapse rate, steroidfree period, and the quality of life of each group. We plotted the clinical course of the included patients using the pediatric UC activity index score, and compared our patients with those in the IBSEN study.

Results

After 2 years of treatment, colonoscopy evaluation revealed different outcomes in the two treatment groups. Remission was confirmed in 14 patients (29.2%) of Group A, and in 31 patients (50.0%) of Group B (P < 0.012). The median cumulative corticosteroid-free period was 3.0 years in Group A and 4.4 years in Group B. Steroid-free period of Group B was significantly longer than that of Group A (P < 0.001). There was a statistically significant difference between the two groups in evaluation of the relapse rate during the observation period (P < 0.001). The plotted clinical course graphs of Group A showed similar proportions to the graphs in the IBSEN study. However, in Group B, the proportion of patients corresponding to curve 1 (remission or mild severity after initial high activity) was high at 76% (47/62).

Conclusions

The incidence of relapse has decreased and the steroid-free period has increased after the introduction of the biological agent. The clinical course also showed a different pattern from that of IBSEN study. The active use of biological agents may change the long-term disease course in moderate to severe pediatric UC.

Objectives and Study

The study aimed to determine quantitatively the nutrition-related knowledge, perceptions, and practices of primary caregivers with infants/children following a therapeutic diet for classical galactosaemia in the United Kingdom (UK). The secondary objective was to determine the perceived challenges (or barriers) faced by caregivers whose infants/children follow a galactose-restricted diet in the UK.

Methods

A descriptive, cross-sectional study with an analytical component was conducted using a novel online questionnaire among 98 eligible members of the Galactosaemia Support Group charity. The Metabolic Support UK charity also advertised the survey link on its official social media platforms and emailed their eligible members as a supplementary recruitment strategy. Data collection took place between April and July 2022. Forty-three caregivers participated in the study, and the response rate was 44%.

Results

Almost all caregivers (98%) had a high level of dietary knowledge. Caregivers’ knowledge scores (M= 17.9, SD = 1.7) were positively correlated with educational level (r = 0.383, p = 0.013). High attitudinal scores of 31–45 points (M= 32.5, SD = 5.5) obtained by most caregivers (65%) revealed an overall positive attitude towards the galactosaemia diet. Negative perceptions of being unable to feed their child breastmilk at birth (49%) were apparent, and this perception was positively correlated with caregivers’ intentions to feed their child breastmilk (r = 0.450, p = 0.003). Concerns about the safety of their child in social settings were a barrier for 79% of caregivers, while 47% felt that their child was excluded in social settings because of the diet. Significant associations (p<0.001) between the age of the galactosaemic child and the number, as well as the type, of barriers faced by caregivers were found.

Conclusions

Healthcare interventions should focus on exploring caregivers’ perceptions and barriers related to the galactosaemia diet and provide psychological support to these families to facilitate lifelong dietary compliance.

Objectives and Study

Despite a limited evidence-base, medium-chain triglyceride (MCT) supplementation is widely used and recommended in expert-opinion papers but with no consensus on what concentration to give. The objective of this scoping review was to understand the extent and type of evidence relating to the impact of MCTs on fat absorption, growth, nutritional status and clinical outcomes in children with cholestatic liver disease.

Methods

Nine databases were searched including MEDLINE, Embase, CINAHL, PubMed, AMED, Cochrane Library, Global Health, Scopus and Proquest since inception with hand-searching of five key conferences for the previous ten years and forward/backward citation searching of relevant papers. Studies were included that investigated oral or enteral MCT supplementation in children under 18 years with cholestatic liver disease. There were no limits on language. Two independent reviewers performed screening and data extraction.

Results

Following title and abstract screening (1202 papers) and full-text review (39 papers), 24 papers were included. There were 21 observational studies (315 patients in total on MCT) and three small RCTs (19 patients in total on MCT) (Figure 1). Fourteen were published between 1965 and 1990. The papers investigated outcomes including: fat absorption, growth, magnesium/calcium absorption and essential fatty acid status. Compared to no MCT, MCT supplementation was associated with greater fat absorption (9/9) and growth (3/5). Compared to low MCT, high MCT was associated with greater fat absorption (1/1) and magnesium and calcium absorption (1/1) but there was no difference in growth (4/4). Very high MCT supplementation (87-100%) was associated with essential fatty acid deficiency (EFAD) (5/5).

Conclusions

The limited, mostly observational evidence from more than 30 years ago points to greater fat absorption on MCT and a risk of EFAD on very high MCT. High quality RCTs are required, particularly examining the impact of MCT supplementation at different concentrations (including 0%) on growth, nutritional status and clinical outcomes.

Objectives and Study

To explore associations of adherence to dietary patterns up to age 2 years with risk of celiac disease autoimmunity (CDA) and celiac disease (CeD).

Methods

Data were retrieved from 6,677 participants enrolled in The Environmental Determinants of Diabetes in the Young (TEDDY) study, a longitudinal observational birth cohort with a 15-year follow-up on type 1 diabetes and CeD. Children were annually screened for tissue transglutaminase autoantibodies (tTGA) from age 2 years. Dietary patterns were based on intake of 27 food groups assessed by 22,410 3-day food records from age of 9 to 24 months. The primary outcome, CDA, was defined as being persistently tTGA positive confirmed in at least 2 consecutive samples. The secondary outcome, CeD, was defined as an intestinal biopsy showing Marsh >2 or having a mean level of tTGA >100 units if a biopsy was not performed. Associations of adherence to dietary patterns with the study outcomes were estimated by Cox regression models adjusted for daily gluten intake.

Results

A total of 1287 (19.3%) children developed CDA and 527 (7.9%) CeD during follow-up to mean age 11.0 years (SD 3.6). At age 9 months, a dietary pattern high in vegetable fats and milk, and low in infant formula and breastmilk was associated with reduced risk of CDA (HR 0.88, 95% CI [0.81, 0.99], P=.04, per 5-unit increase). A dietary pattern high in wheat, vegetable fats, and juices, and low in milk, meat, and oats at age 24 months, was associated with increased risk of CDA (HR 1.18, 95% CI [1.05, 1.33], P<.001) and CeD (HR 1.24, 95% CI [1.03, 1.50], P=.03, per 5-unit increase).

Conclusions

Associations between dietary patterns in the first 2 years of life and risk of CDA and CeD indicate that additional dietary factors besides the gluten amount impact disease risk in genetically predisposed children.

Objectives and Study

Standard capsule endoscopy (CE) is ineffective for upper gastrointestinal (GI) tract examination because it does not allow operator-controlled navigation of the capsule. Magnetically assisted capsule endoscopy (MACE) may offer a solution to these problems. This pilot study is aimed to evaluate the feasibility of MACE system in pediatric Crohn’s disease (CD) and if magnetic steering could enhance capsule gastric emptying when compared with standard CE.

Methods

Pediatric CD patients already studied by standard small bowel CE were enrolled. All participants swallowed a magnetically assisted CE and an external magnetic field navigator was used to guide the capsule through the upper GI tract. Maneuverability, completeness of the MACE examination and differences in the esophageal transit time (ETT), gastric transit time (GTT) and pyloric transit time (PTT) between standard CE and MACE were assessed.

Results

Ten patients [mean age 11,4 years (range 6-15); 60% male] were enrolled. Maneuverability was defined as good and fair in 60% and 40% of participants, respectively. Completeness of MACE examination was 95%, 65% and 92,5% in the esophagus, proximal and distal stomach, respectively. Transpyloric passage of the capsule under magnetic control was successfully performed in 80% of patients.

Magnetic intervention significantly increased ETT (P < 0.001) and reduced GTT and PTT (P = 0.002). No significant adverse events occurred.

Conclusions

MACE is a safe and feasible technique in children. Magnetic steering enhances capsule gastric emptying and facilitates capsule transpyloric passage when compared with standard CE.

Objectives and Study

Antibody response in human milk (HM) following maternal immunization with BNT162b2 mRNA vaccine is important for neonate protection during early infancy. We aimed to evaluate the antibody response of IgG/IgA/IgM at different lactation stages and to determine the optimal vaccination timing during pregnancy.

Methods

This is a prospective cohort study conducted in Israel between April 2021 and July 2022. We recruited women post-partum who received the BNT162b2 COVID-19 mRNA-vaccine during the second or the third trimester of pregnancy. HM samples, colostrum (day 0-3), transitional milk (4-14 days), mature milk (above 14 days) were collected post-delivery.

Results

Sixty-two lactating women were included. Late colostrum showed the highest median (IQR) antibody concentration of vaccine-specific IgG (1.098 μg/mL [0.489-2.424], IgA (46.19 μg/mL, [30.89-77.54] and IgM (0.144 μg/mL, [0.089-0.356]). Timing of maternal immunization affected the antibody response in transition and mature milk. IgA concentrations were the highest of all isotypes in women immunized during the second trimester versus the third trimester in transitional and mature milk (median [IQR], 13.8 μg/mL [10.32-22.3] vs 9.915 μg/mL [6.199-11.82], P = .01 and 13.06 μg/mL [8.232-18.41] vs 8.51 μg/mL [5.125-12.6], P = .006 respectively). IgG levels were higher when immunization occurred during the third trimester versus second trimester in transitional and mature milk (median [IQR] 0.66 μg/mL [0.538-1.167] vs 0.188 μg/mL [0.128-0.261] and 0.451 μg/mL [0.215-0.704] vs 0.125 μg/mL [0.094-0.208], P < .001, respectively).

Conclusions

Our results suggest that maternal immunization with the BNT162b2 mRNA-vaccine during the second trimester of pregnancy provides a higher concentration of vaccine-specific IgA throughout lactation stages.

Objectives and Study

Sacral nerve stimulation (SNS) is being increasingly recommended in children with refractory constipation. The sparse pediatric data on the efficacy of SNS in constipation is conflicting, and this has led to ambiguity over the use of SNS for treating children with constipation.

The aim of our study is to determine the outcomes of pediatric patients with idiopathic constipation who underwent SNS placement.

Methods

Electronical medical records of all patients with idiopathic constipation who had SNS placed for refractory idiopathic constipation, were reviewed. Data retrieved included demographics, symptoms, imaging, colonic manometry results, treatment, and complications.

Results

Twenty patients (60% females, median age 10.2 years (IQR: 7.5, 14.4) with intractable idiopathic constipation and SNS placement met inclusion criteria. Mean follow-up was of 22.7 months (range 7-42) after SNS placement. Colonic manometry was abnormal in 6 (30%) with no high-amplitude propagating contractions in the distal colon. Six (30%) patients underwent SNS placement after cecostomy, while 2 (10%) patients had cecostomy placement (for antegrade enemas - ACE) after SNS placement. Six patients (30%) had sigmoidectomy (2 of them post SNS placement). Three (15%) patients had their SNS removed due to failure to respond. Number of bowel movements increased in 4 (20%), stool consistency improved in 1 (5%), soiling episodes resolved in 1 (5%) and decreased in 7 (35%) patients. Laxatives and enemas were reduced in 10 (50%) patients. One (16.6%) patient with SNS placement after cecostomy had increase in bowel movements and 2 (33.3%) had improvement in soiling. SNS placement did not cause improvement in patients with prior sigmoid resection.

Conclusions

This is the largest pediatric study with the longest follow-up data on the efficacy of SNS in refractory idiopathic constipation. Despite concomitant antegrade enemas in 8 (40%), and sigmoid resection in 6 (30%), placement of SNS did not uniformly improve outcomes of idiopathic constipation in children.

Objectives and Study

Ingredients that focus on reducing the risk of obesity by maintaining a healthy gut microbiota and preventing obesity-related adverse effects may represent a management option appropriate in the pediatric population. The purpose of this study was to determine the effects of specialized nutrition carbohydrates for preventing obese-associated dysbiosis, as well as avoiding excessive fat deposition in an animal model of childhood obesity induced by feeding a high fat diet (HFD).

Methods

Growing rats were assigned to one of the three nutritional groups: LEAN group fed on standard rodent diet; OBE group fed on HFD containing rapid-digesting CHO; and SDC group fed on HFD containing slow-digesting CHO. A linear mixed-effects model was used to determine the abundance changes of gut microbiota, analyzed by 16S rRNA-based metagenomics. Short-chain fatty acids production was analyzed in feces by UPLC-MS/MS system. The effect of the diets on the lipid and glucose homeostasis were also analyzed.

Results

The specialized carbs ingredients (SDC) prevented the obese-associated dysbiosis, showing differences at the phylum levels (decreasing Firmicutes and increasing Bacteroidetes) and at the genus level (increasing Alistipes, Bifidobacterium, and Bacteroides) as compared to OBE group. Associated to these changes, the SDC group showed higher levels of acetate and propionate than OBE group. In the SDC group, body weight gain, body composition, insulin and leptin resistances and vascular risk factors were significant lower as compared to obesogenic group and closer to the values found in the lean group. Liver steatosis and systemic inflammation were observed after the consumption of OBE diet. Conversely, the SDC diet significantly prevented these obesity-associated comorbidities.

Conclusions

In this animal model of childhood obesity, the consumption of SDC might preserve the gut microbiota composition from dysbiosis and its adverse metabolic complications.

Objectives and Study

Primary sclerosing cholangitis related to inflammatory bowel disease (PSC-IBD) diagnosed under the age of 6 years (i.e.VEO-IBD) may have unique characteristics and disease course. We aimed to analyze the characteristics and natural history of children with VEO PSC-IBD and compare them to children diagnosed with PSC-IBD at an older age.

Methods

This was a multicenter, retrospective, study evaluating patients diagnosed with both IBD and PSC before (VEO-PSC-IBD) or after the age of 6 years (PSC-IBD), followed at 14 centers affiliated with the Porto IBD Interest group of ESPGHAN. Demographic, clinical, laboratory, endoscopic, and imaging data were collected at baseline and every six months thereafter for a minimum follow-up of 12 months. Outcomes were analyzed at 1, 3 and 5 years

Results

A total of 69 children with both IBD and PSC were included: 28 with VEO PSC-IBD [median age 5.2 years, 21 UC (75%)] and 41 with PSC-IBD [median age 15.7 years, 34 UC (83%)]. Most patients with UC presented with extensive disease at diagnosis (89% in VEO PSC-UC vs. 89% in PSC-UC, p=0.72). Both groups presented most often with mild intestinal disease at diagnosis (mean PUCAI of VEO IBD-PSC 34±16, vs 31±19 of IBD-PSC, p=0.11). A higher number of VEO-IBD-PSC patients were diagnosed with autoimmune SC than older children [24 (86%) vs. 27 (66%) PSC-IBD, p=0.04], whereas no other differences were found for PSC-related variables. The risk of developing biliary strictures and starting vancomycin after ursodehoxicolic acid was lower in the VEO-PSC-IBD group (Log-rank p=0.02 and p=0.02), while no difference was found for portal hypertension and liver transplantation at 5-year follow-up. No cases of cholangiocarcinoma or death were found.

Conclusions

IBD-PSC has similar baseline characteristics whether diagnosed as VEOIBD or thereafter. However, a milder disease course in terms of biliary complications and the need for PSC-related therapy escalation characterize the VEOIBD subcohort.

Objectives and Study

Pediatric feeding disorders (PFDs) are common, and their great phenotypic variability reflects the breadth of the associated nosological profiles. PFDs should be assessed and managed by multidisciplinary teams. Our study aimed to describe clinical signs of feeding difficulties in a group of PFD patients assessed by such a team, and to compare them with children in a control group.

Methods

In this case-control study, case group patients 1 to 6 years old were consecutively recruited through the multidisciplinary unit for the treatment of pediatric feeding difficulties based at Robert Debré Teaching Hospital in Paris, France. Children with an encephalopathy, severe neurometabolic disorder, or genetic syndrome (suspected or confirmed) were excluded. Members of the control group, consisting of children with no feeding difficulties (i.e., Montreal Children’s Hospital Feeding Scale scores below 60) or severe chronic diseases, were recruited from a day care center and 2 kindergartens. Data from medical histories and clinical examination related to mealtime practices, oral motor skills, neurodevelopment, sensory processing, and any functional gastrointestinal disorders (FGIDs) were recorded and compared between groups.

Results

In all, 244 PFD cases were compared with 109 controls (mean ages: cases, 3.42 [± 1.47]; controls, 3.32 [± 1.17]; P = 0.55). Use of distractions during meals was much more among PFD children (cases, 77.46%; controls, 5.5%; P < 0.001), as was conflict during meals. While the groups did not differ in their members’ hand-mouth coordination or ability to grab objects, cases began exploring their environments later; mouthing, especially, was less common in the case group (cases, n = 80 [32.92%]; controls, n = 102 [94.44%]; P < 0.001). FGIDs and signs of visual, olfactory, tactile, and oral hypersensitivity were significantly more frequent among cases.

Conclusions

Initial clinical assessments showed that, in the children with PFDs, normal stages of environmental exploration were altered, and that this was often associated with signs of sensory hypersensitivity and digestive discomfort.