Journal of Pediatric Gastroenterology and Nutrition最新文献

Interactions between the gut microbiome and bile acids are complex and are linked to outcomes in pediatric liver disease by mechanisms that are incompletely understood. In adults, primary bile acids are synthesized in the liver and secreted into the intestine, where complex communities of gut microbes deconjugate, oxidize, epimerize, and 7α-dehydroxylate bile acids into a diverse array of unconjugated, secondary, allo-, iso-, and oxo-bile acids. In contrast, the infant gut microbiota contains a simple, Bifidobacterium-dominant community that transitions to a more diverse, adult-like community as additional microbes colonize the gut. This microbial succession gradually confers deconjugation, oxidation, epimerization, and 7α-dehydroxylation activities that mature the bile acid pool from a profile dominated by primary bile acids early in life to a more diverse, adult-like bile acid profile in later childhood. Altered bile acid profiles in pediatric cholestatic disorders have the potential to change the developmental trajectory of the microbiome. Conversely, alterations in the gut microbiome may re-shape the bile acid pool and hepatic bile acid metabolism. Understanding the mechanisms underlying these interactions will increase our understanding of liver pathophysiology and will motivate new therapeutic strategies for pediatric hepatic disorders. This review aims to highlight differences between the pediatric and adult intestinal microbiome and bile acid pool, and to discuss interactions between gut microbes and bile acids that are critical in early life and that may impact outcomes in infants and children with cholestatic liver disease, including biliary atresia.

Objectives: Exocrine pancreatic insufficiency (EPI) reflects inadequate pancreatic enzyme(s) and/or bicarbonate secretion, leading to malabsorption. We aim to compare different assessment tools for exocrine pancreatic function and correlate them with the endoscopic pancreatic function test (ePFT) as a reference standard.

Methods: Combined retrospective and prospective analysis of clinical data for children who underwent clinically indicated ePFTs. We compared ePFT against patient symptoms, laboratory results, magnetic resonance cholangiopancreatography with secretin 49/53 magnetic resonance imaging, among those, 35/49 with secretin enhanced magnetic resonance cholangiopancreatography (sMRCP), or endoscopic ultrasound (EUS 36/53) findings with the ePFT results.

Results: A total of 53 patients who underwent ePFT between September 2018 and April 2023 were included. 30 were Female (57%). Median age when ePFT was performed was 14 years (range: 4-21 years). Primary indication for ePFT: Acute recurrent or chronic pancreatitis (74%), Pancreas atrophy (9%), Other (post- pancreatic surgery, malnutrition with low fecal elastase-1 (FE-1) (17%). Patients with high pancreatic enzyme activities had a higher volume of pancreatic fluid secretion on ePFT. They also had larger pancreatic anteroposterior diameter and pancreas parenchyma volume, as well as higher post-secretin enteric fluid volume increment on sMRCP compared to those with low enzyme activities. Our findings also underscore the importance of lipase in maintaining and promoting weight gain in pediatric patients. In our patient cohort, the FE-1 level was lower in patients with low pancreatic enzyme activities. Our study showed that steatorrhea is associated with low pancreatic enzyme activities, whereas abdominal pain and unintentional weight loss might be nonspecific to EPI. No significant correlations were observed from blood cell counts, blood electrolytes, lipase, albumin, bilirubin, alanine aminotransferase, serum lipids, fat-soluble vitamins, prothrombin time, hemoglobin A1C, and EUS with pancreatic enzymes or bicarbonate concentration.

Conclusions: sMRCP is a promising noninvasive modality in assessing exocrine pancreatic function in children.

This review is intended to evaluate the severity of Coronavirus Disease 2019 (COVID-19) in hospitalized pediatric patients with obesity. The increased risk of hospitalization in pediatric patients with obesity highlights the need for a thorough investigation into the impact of COVID-19 in this vulnerable population, given the significant public health challenges obesity presents in this age group. The review followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. A systematic search was conducted in the PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online), LILACS (scientific health information from Latin America and the Caribbean countries), Web of Science, Embase, and Scopus databases for relevant articles published between December 2019 and November 2021. Observational studies (cross-sectional and cohort) involving pediatric patients with obesity who tested positive for COVID-19, were hospitalized, and had outcomes related to disease severity parameters such as intensive care unit (ICU) admission, length of ICU stay, and mechanical ventilation) were included. The quality of evidence from the included studies was assessed using the Newcastle‒Ottawa Scale. Extracted data included the author, year, country, study design, aim, population, outcomes/severity, and primary results. Eight studies were included in the review. A narrative synthesis was conducted to qualitatively summarize the findings, highlighting that obesity is a potential aggravating factor in the clinical presentation of COVID-19 among hospitalized pediatric patients. The findings revealed a positive association between the pediatric population with obesity and COVID-19 severity, particularly among adolescents, who were at greater risk of developing severe illness. This association was also evident in higher rates of ICU admission and increased use of mechanical ventilation.

Objectives: Functional constipation (FC) is a common problem in childhood and the first-line therapy is macrogol. The role of FC in the onset of inflammatory bowel disease (IBD) is poorly understood. Our main aim was to investigate the prevalence of FC in children before the diagnosis of IBD.

Methods: This is a cross-sectional observational study in pediatric IBD-patients. We collected data on demographics, clinical and endoscopic characteristics at IBD diagnosis, and on the presence of FC and its treatment before IBD diagnosis.

Results: A total of 238 children with IBD, 104 (44%) with Crohn disease (CD), 130 (56%) with ulcerative colitis (UC) and 4 (0.016%) with IBD Unclassified (IBD-U) were enrolled. The mean age was 174 ± 47 months, 56% were male. Forty-seven out of 238 (19.7%) had a FC history before the IBD diagnosis and 31 out of these 47 patients (65%) received macrogol therapy. In the FC group, we found a delay in the diagnosis of IBD compared to the group with no FC [median (interquartile range [IQR]): 5 months (2.5-9.5) and 2 months (0-4), respectively, p ≤ 0.001]. The difference in terms of endoscopic localization was statistically significant in UC patients presenting FC (p = 0.026) with a prevalence of proctitis and left side colitis (30% and 15%, respectively).

Conclusion: In conclusion our study highlighted a prevalence of constipation in pediatric IBD patients at diagnosis of 19.7%, which must be taken into account to avoid diagnostic delay and which is associated with limited extent of disease in UC pediatric patients.

Objective: There is an absence of a comprehensive clinical instrument to assess and track the development of non-ideal feeding practices and lifestyle behaviours in early childhood. Our primary aim was to develop and validate an assessment instrument, called Feeding, Lifestyle, Activity Goals (FLAGs), designed to serve as a feeding, lifestyle and activity behaviour checklist for children aged 0-2 years.

Methods: This study took place between January and May 2023. Experts evaluated content validity using the criteria of relevance, clarity, simplicity and ambiguity, to calculate the item content validity index (I-CVI) and scale CVI (S-CVI) (acceptable cutoff ≥ 0.80). Face validity was assessed by caregivers. Repeated assessments were also performed to determine test-retest reliability based on intra-class correlation (ICC) (acceptable cutoff > 0.75). Construct validity was established through principal component analysis (PCA), and internal consistency was measured using Cronbach's α coefficient (acceptable cutoff ≥ 0.70).

Results: FLAGs consists of 19 items, with a I-CVI of 1.00 in 12 out of 19 items, and S-CVI average of >0.90 for relevance, simplicity and clarity. Among 198 caregivers, 99.0% responded 'agree' and 'strongly agree' in the criteria of clarity and ambiguity; 99.5% in criterion of relevance, and 100% in criterion of simplicity. PCA showed a two-component structure (55.9% variance). Overall Cronbach's α was 0.71. Participants repeated FLAGs assessment on an average of 9 days apart, with ICC of 0.861 (p < 0.001) for the total FLAGs scores.

Conclusions: We have developed an instrument which assesses an infant's feeding and lifestyle behaviour from 0 to 2 years, and this has been assessed to have acceptable validity and reliability.

Objectives: Celiac disease (CeD) requires long-term follow. The role of laboratory testing other than celiac serology during follow up is unclear. We aimed to determine which laboratory tests are required during follow up based on the prevalence of abnormal tests and timing of abnormalities appearance.

Methods: Retrospective chart-review of children diagnosed with CeD between 1999 and 2018 was conducted. Demographic, clinical and laboratory data were recorded from diagnosis and during follow-up.

Results: The cohort included 500 children with CeD [59.8% females, median(IQR) age at diagnosis 5.7(3.7-8.9) years]. Mean follow-up time was 5.5 years (range 1.5-16.2). The most frequently abnormal laboratory tests at time of diagnosis were low ferritin (64.3%), vitamin D (33.6%), zinc (29.9%), hemoglobin (29.2%), and folate (14.7%). In 74 (14.8%) patients, anemia developed only during follow up, while in another 46 patients, anemia resolved after diagnosis and reappeared later (after a mean ± SD 2.8 ± 2.1 years from CeD diagnosis, for the entire group). Abnormal values that developed during follow up were low folate in 40 patients (3.9 ± 2.6 years), and abnormal liver enzymes in 18 patients (3.1 ± 2.7 years). Elevated TSH during follow-up was observed in 14/280 (5%) patients, after a mean ± SD of 2.2 ± 1.6 years from diagnosis. Patients diagnosed as teenagers (12-18 years) had shorter intervals to reappearance of anemia and folate deficiency.

Conclusions: Multiple laboratory abnormalities may occur in pediatric patients with CeD, both at diagnosis and during long-term follow-up. We suggest continued monitoring of hemoglobin, ferritin, folate, liver, and thyroid function in addition to celiac serology during follow-up of CeD.

Objectives: Food insecurity (FI), limited or uncertain access to adequate food, impacts every state, county, and community in the United States. The goals of this quality improvement (QI) initiative were to first achieve greater than 90% compliance with FI screening for patients seen at pediatric GI clinics within 1 year and second increase the proportion of families identified as FI connected with resources to 50% at follow-up visits.

Methods: Using plan-do-study-act cycles, interventions were implemented to (1) educate, (2) create a screening process, (3) optimize communication with EMR utilization, and (4) connect families to resources. Descriptive statistics on all variables collected were performed. Differences between the FI and food secure groups were assessed using the Mann-Whitney test for continuous variables and the Chi-squared test for categorical variables. QIMacros® Quality Improvement/SPC Software for Excel was used to create process control charts to show improvement.

Results: During the timeframe from August 29, 2022, to February 29, 2024, 2946 visits were completed in the GI clinic, and 58% (1731 patients) were screened for FI. Of the patients that were screened for FI, 13% screened positive. Compliance with FI screening improved to 90%, and connection to resources improved to 75%. Race, ethnicity, preferred language, and insurance were all significantly associated with FI, p < 0.001 CONCLUSIONS: This QI initiative demonstrates standardized FI screening improves FI identification and connection to resources.

Protein, carbohydrates, and fats comprise the macronutrient components of infant formulas. While all infant formulas in the United States meet specific nutrition standards, the macronutrient composition of formulas is diverse. Each macronutrient in the formula may play a role in treating or managing the disease. In addition, many formulas are marketed as resembling the composition of human milk or improving symptoms such as colic and irritability. For these and other reasons, families are often interested in different formula properties. When choosing a formula for their infant families, they may reach out to clinicians for advice. Therefore, clinicians need to understand the macronutrient composition of the formulas their patients are using. This manuscript discusses the macronutrient composition of term infant formulas and indications of the use of different macronutrient components.

Objectives: The etiology of biliary atresia (BA) is unclear and potentially involves viral triggers. We aimed to compare the incidence of BA in the United States before and during the coronavirus disease 2019 (COVID-19) pandemic, focusing on potential associations with viral circulation disruptions caused by nonpharmaceutical interventions (NPIs).

Methods: We queried the Pediatric Health Information System® (PHIS) for all patients discharged with BA between January 1, 2010, and January 31, 2024. Using CDC WONDER, we calculated monthly and overall incidence rates of BA per 1,000,000 live births. We fit a Poisson regression model to assess the association between the widespread implementation of stay-at-home orders (using April 1, 2020, as the cutoff date) and the incidence of BA, accounting for national natality fluctuations.

Results: We identified 3456 newborns with BA from 42 hospitals; 2997 (86.7%) were born before and 459 (13.3%) were born during the pandemic. The mean monthly number of newborns with BA was 24.0 (95% confidence interval, 23.0-25.0) for an overall incidence rate of 74.4 (71.5-77.4) per 1,000,000 live births. We did not identify a statistically significant year-to-year contrast in the incidence of BA before (incidence rate ratio [IRR] = 0.995 [0.983-1.008]; p = 0.49) or after the cutoff date (IRR = 0.999 [0.895-1.116]; p = 0.99). In addition, we did not identify sufficient evidence that trends differed between the two periods (IRR = 1.00 [0.893-1.128]; p = 0.95).

Conclusions: The NPIs implemented during the COVID-19 pandemic were not significantly associated with changes in the incidence or temporal pattern of BA.