Exclusive enteral nutrition (EEN) is recommended for children with mild to moderate Crohn’s disease (CD), but implementation is challenging. We compared EEN with the CD exclusion diet (CDED), a ...whole-food diet coupled with partial enteral nutrition (PEN), designed to reduce exposure to dietary components that have adverse effects on the microbiome and intestinal barrier.
We performed a 12-week prospective trial of children with mild to moderate CD. The children were randomly assigned to a group that received CDED plus 50% of calories from formula (Modulen, Nestlé) for 6 weeks (stage 1) followed by CDED with 25% PEN from weeks 7 to 12 (stage 2) (n = 40, group 1) or a group that received EEN for 6 weeks followed by a free diet with 25% PEN from weeks 7 to 12 (n = 38, group 2). Patients were evaluated at baseline and weeks 3, 6, and 12 and laboratory tests were performed; 16S ribosomal RNA gene (V4V5) sequencing was performed on stool samples. The primary endpoint was dietary tolerance. Secondary endpoints were intention to treat (ITT) remission at week 6 (pediatric CD activity index score below 10) and corticosteroid-free ITT sustained remission at week 12.
Four patients withdrew from the study because of intolerance by 48 hours, 74 patients (mean age 14.2 ± 2.7 years) were included for remission analysis. The combination of CDED and PEN was tolerated in 39 children (97.5%), whereas EEN was tolerated by 28 children (73.6%) (P = .002; odds ratio for tolerance of CDED and PEN, 13.92; 95% confidence interval CI 1.68–115.14). At week 6, 30 (75%) of 40 children given CDED plus PEN were in corticosteroid-free remission vs 20 (59%) of 34 children given EEN (P = .38). At week 12, 28 (75.6%) of 37 children given CDED plus PEN were in corticosteroid-free remission compared with 14 (45.1%) of 31 children given EEN and then PEN (P = .01; odds ratio for remission in children given CDED and PEN, 3.77; CI 1.34–10.59). In children given CDED plus PEN, corticosteroid-free remission was associated with sustained reductions in inflammation (based on serum level of C-reactive protein and fecal level of calprotectin) and fecal Proteobacteria.
CDED plus PEN was better tolerated than EEN in children with mild to moderate CD. Both diets were effective in inducing remission by week 6. The combination CDED plus PEN induced sustained remission in a significantly higher proportion of patients than EEN, and produced changes in the fecal microbiome associated with remission. These data support use of CDED plus PEN to induce remission in children with CD. Clinicaltrials.gov no: NCT01728870.
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The management of IBD entails the use of various treatments (nutrition, medications, and surgery) in order to induce and maintain remission. The assessment of IBD disease activity is based on a ...combination of symptoms, clinical findings, imaging, and endoscopic procedures. As in any disease, reliable assessment of disease activity or severity is required in order to plan relevant follow-up, decide on appropriate investigations, determine the best treatment option and subsequently assess response to treatment. It is important for proper documentation, follow-up, assessment of response to treatment and communication, especially in patients with IBD, to talk the same language by using validated and widely used scores for disease activity, endoscopic and radiologic activity, and patient reported outcomes both for clinical practice and research. This review aims to highlight key tools available for the assessment of disease activity or severity in individuals (especially children) with IBD.
A literature search was performed using MEDLINE, Pubmed, and the Cochrane Library with the last search date of August 2020. Tools evaluating disease severity across various aspects (clinical, endoscopic, and radiological) were identified and discussed. Those tools validated and specific for children with IBD were included were available.
Over time a number of scoring systems have been developed to quantify clinical, endoscopic and imaging assessments in individuals with IBD. While some are exclusively for children or adults, others appear to have relevance to all age groups. In addition, some tools developed in adult populations are utilized in children, but have not expressly been validated in this age group.
Although some available scoring tools are appropriate for children with IBD, others require consideration. The development and use of pediatric-specific tools is relevant and appropriate to optimal care of children and adolescents with IBD.
Background. Partial enteral nutrition (PEN) may be helpful for the maintenance of remission in pediatric Crohn’s disease patients. Aims. To evaluate the efficacy of PEN treatment for preventing ...clinical relapse. Methods. We retrospectively assessed 42 pediatric Crohn’s disease patients who entered clinical remission on 4–12 weeks of exclusive enteral nutrition (EEN) and were maintained on PEN as a supplementary diet. We evaluated the efficacy of the treatment at different time points using the weighted Pediatric Crohn Disease Activity Index (wPCDAI), Physician Global Assessment, laboratory parameters, and growth of each patient. Additionally, we assessed the use of concomitant medications. Results. The median length of remission with PEN was 6 (0–36) months. Patients’ remission was maintained on PEN without concomitant medications for a median time of zero months (0–16). The mean body mass index in the PEN group increased from 18.1 to 18.8 after six months of PEN. The median wPCDAI decreased from 30 at diagnosis to 5.0 after EEN and increased to 7.5 after three months of PEN. Overall, the median wPCDAI decreased by 26.2. Conclusions. PEN treatment was partially effective in maintaining remission and was able to increase BMI and lower wPCDAI. Most patients required concomitant medication after PEN initiation.
The global COVID-19 pandemic has led to healthcare resources being diverted or stretched, especially during periods of lock-down in affected countries. Disruptions to normal services have resulted in ...reduced or delayed provision of endoscopy in many countries, with consequent impacts on diagnosis or management of digestive diseases and upon endoscopy training. This review article aims to highlight key aspects of the impact of the pandemic upon endoscopy services, with a focus upon endoscopy in children.
Gastrointestinal mucositis occurs as a consequence of cytotoxic treatment. Quercetin (QCT) is a bioflavonoid that exerts significant antioxidant activity and anti-inflammatory as well as ...anti-malignancy properties.
To evaluate the effects of oral QCT consumption in preventing intestinal mucosal damage and stimulating intestinal recovery following methotrexate (MTX)-induced intestinal damage in a rat model.
Male Sprague-Dawley rats were divided into four groups: Control Group A (CONTR) - rats were treated with 2 cc of saline given by gavage for 6 days. Group B (CONTR-QCT) - rats were treated with QCT (100 mg/kg in 2 ml saline) given by gavage 3 days before and 3 days after intraperitoneal (IP) injection of saline. Group C (MTX) - rats were injected a single dose (25 mg/kg) of MTX IP. Group D (MTX-QCT) rats were treated with QCT (similar to Group B) 3 days before and 3 days after IP MTX injection. Intestinal mucosal parameters (bowel and mucosal weight, mucosal DNA and protein content, and villus height and crypt depth), enterocytes proliferation, and enterocyte apoptosis degree were investigated at sacrifice on the 4th day after MTX or saline injection.
Administration of QCT to MTX-treated rats resulted in: (1) significant decrease in intestinal injury score, (2) significant increase in intestinal and mucosal weight in jejunum and ileum, (3) increase on the protein content of the ileum, (4) increase in the villus height in the ileum, (5) increase of crypt depth of jejunum and ileum, and (6) increase in cell proliferation in the jejunum and ileum compared to MTX-nontreated group.
Administration of QCT prevents intestinal damage and improves intestinal recovery following MTX-induced intestinal damage in a rat. We surmise that the effect of QCT is based on induction of cell proliferation in the crypt rather than inhibition of apoptosis.
There is a substantial literature on the favorable outcome of propofol administration by non-anesthesiologists for endoscopy in adults; however, very few data are currently available on propofol ...sedation by pediatric gastroenterologists. Aims: to evaluate the safety of propofol sedation by pediatric gastroenterologists.
A retrospective chart review of all children who were sedated by pediatric gastroenterologists in three Northern Israeli hospitals over a 4 years period Demographic and medical characteristics and any data regarding the procedure were extracted from patient's records. The main outcome measurements were procedure completion and reported adverse events.
Overall, 1,214 endoscopic procedures for were performed during this period. Complete data was available for 1,190 procedures. All children sedated by pediatric gastroenterologists were classified as ASA I or II. Propofol dosage (in mg/kg) inversely correlated with patient age. The younger the child the higher the dose needed to reach a satisfactory level of sedation (
= -0.397,
< 0.001). The addition of fentanyl significantly decreased propofol dosage needed to provide optimal sedation,
< 0.001. Nine (0.7%) reversible adverse events were reported. All the procedures were successfully completed and all patients were discharged home.
We conclude that our approach is safe in children as it is in adults and can be implemented for children with ASA I, II.
Gluten in Celiac Disease-More or Less? Cohen, Inna Spector; Day, Andrew S; Shaoul, Ron
Rambam Maimonides medical journal,
01/2019, Letnik:
10, Številka:
1
Journal Article
Recenzirano
Odprti dostop
To date, the only known effective treatment for celiac disease is a strict gluten-free diet for life. We reviewed the literature to evaluate the upper limit for gluten content in food, which would be ...safe for patients with celiac disease. Patients with celiac disease should limit their daily gluten intake to no more than 10-50 mg. Most health authorities define gluten-free products as containing less than 20 parts per million gluten.
The management of coeliac disease involves the life-long adherence to a strict gluten free diet. There have been concerns about exposure to gluten or other cereal components that are not contained in ...foods. This manuscript reviews the available literature focused on the potential for exposure to non-food-based gluten and the potential relevance of this to the ongoing management of individuals with coeliac disease. The products of consideration included dental and oral hygiene products, cosmetics and packaging products. Each of these items has been considered, with caution noted in regards to dental products and potential concern about novel packaging applications. Accidental ingestion by younger children of items such as play-dough during play also requires care. In conclusion, there is currently little firm data to guide individuals with coeliac disease, other than caution about specific items.
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