The effect of disease, drug, and diet on whole body protein metabolism in adolescents with Crohn disease and growth failure

Systematic review: Sarcopenia in paediatric inflammatory bowel disease

BACKGROUND

Low skeletal muscle mass (MM) and deteriorated function (sarcopenia) can be a frequent complication in paediatric inflammatory bowel disease (IBD).

AIM

To conduct a systematic review of the paediatric IBD literature on skeletal muscle function and mass and identify interventions that could affect them.

METHODS

Systematic searches (EMBASE, Medline, Cochrane library central for registered control trials and Web of Science) were conducted using the terms 'lean body mass' (LM), 'fat free mass' (FFM) or 'MM' and 'IBD'.

RESULTS

Fourteenth studies were included, presenting data from 439 Crohn's disease (CD), 139 ulcerative colitis (UC) and 2 IBD-unclassified participants compared with healthy matched or unmatched groups or reference populations. Six out of 14 studies reported lower LM, whilst 7 studies observed lower MM and FFM in CD patients compared to healthy controls. Research in UC patients reported lower LM in 3 studies, lower MM in 3 studies and lower FFM in 4 studies. Three prospective studies measured the impact of enteral feeding and showed improvement on disease activity and LM or FFM, while one retrospective study did not show any impact on LM.

CONCLUSION

Despite the variety of experimental approaches and methods used to assess sarcopenia, most studies showed reduction in MM, LM and FFM in IBD. Nutritional intervention may have a positive effect on LM and FFM. Future research should focus on standardizing the terminology and methodologies used in assessing body composition and investigating sarcopenia in diseased and matched healthy control cohorts in adequately powered studies with a longitudinal design.

Body composition in children with chronic inflammatory diseases: A systematic review

BACKGROUND & AIMS

Aberrations in body composition are expected in children suffering from chronic inflammatory conditions. The objective is to examine whether children with inflammatory bowel disease (IBD: Crohn's disease and ulcerative colitis), coeliac disease, asthma and juvenile idiopathic arthritis (JIA) have an altered body composition as compared to healthy children.

METHODS

A systematic review, registered in Prospero (registration number: CRD42018107645), was conducted according to PRISMA guidelines. We conducted a search of three databases, Pubmed, Cochrane and Scopus. An assessment of the quality of the study was performed.

RESULTS

Data from 50 studies, 32 with IBD, 8 with coeliac disease, 2 with asthma and 8 with JIA, involving 2399 children were selected for review after applying the eligibility criteria. In all but 4 studies, children with Crohn's disease exhibited decreased amounts of fat mass and fat free mass. Reductions in fat mass were also evident in studies in children with coeliac disease. It is uncertain whether body composition is altered in children with asthma or JIA.

CONCLUSIONS

Children with Crohn's disease manifest with lowered adiposity and lean mass and therefore are likely to be at risk for suffering malnutrition-related clinical complications. Apart from Crohn's disease, data examining body composition in children with chronic inflammatory conditions are scarce and there is a paucity of reports examining the relationship between inflammation and body composition. Interpretation of the current study results is hampered by the low quality of the studies and due to the fact that the analyses have been habitually secondary outcomes.

Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND AND AIMS

A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients.

METHODS

A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature.

RESULTS

A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD.

CONCLUSIONS

This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.

Whole Body Protein Turnover and Net Protein Balance After Pediatric Thoracic Surgery: A Noninvasive Single-Dose 15 N Glycine Stable Isotope Protocol With End-Product Enrichment

BACKGROUND

We used the 15 N glycine urinary end-product enrichment technique to quantify whole body protein turnover following thoracic surgery.

MATERIALS AND METHODS

A single dose of 15 N glycine (2 mg/kg) was administered orally on postoperative day 1 to children (1-18 years) following thoracic surgery. 15 N enrichment of ammonia and urea was measured in mixed urine after 12 and 24 hours, respectively, and protein synthesis, breakdown, and net balance determined. Nitrogen balance (dietary intake minus urinary excretion) was calculated. Urinary 3-methylhistidine:creatinine ratio was measured as a marker of skeletal muscle protein breakdown.

RESULTS

We enrolled 19 subjects-median (interquartile range): age, 13.8 years (12.2-15.1); weight, 49.2 kg (38.4-60.8)-who underwent thoracotomy (n = 12) or thoracoscopic (n = 7) surgery. Protein synthesis and breakdown by 15 N enrichment were 7.1 (5.5-9) and 7.1 (5.6-9) g·kg-1 ·d-1 with ammonia (12 hours) as the end product, and 5.8 (3.8-6.7) and 6.7 (4.5-7.6) with urea (24 hours), respectively. Net protein balance by the 15 N glycine and urinary urea nitrogen methods were -0.34 (-0.47, -0.3) and -0.48 (-0.65, -0.28) g·kg-1 ·d-1 , respectively (rs = 0.828, P < .001). Postoperative change in 3-methylhistidine:creatinine ratio did not correlate significantly with protein breakdown or balance.

CONCLUSION

The single-dose oral administration of 15 N glycine stable isotope with measurement of urinary end-product enrichment is a feasible and noninvasive method to investigate whole body protein turnover in children. After major surgery, children manifest increased protein turnover and net negative balance due to increased protein breakdown.

Characteristics of Upper Gastrointestinal Tract Involvement in Korean Pediatric Crohn's Disease: A Multicenter Study

PURPOSE

Crohn's disease (CD) can involve any site of the gastrointestinal tract (GIT). However, the characteristics of upper GIT involvement in CD are unclear, especially in the Eastern pediatric population. This study aimed to estimate the prevalence of upper GIT involvement and identify the clinical features of Korean children with CD.

METHODS

This was a retrospective multicenter cohort study that included 52 pediatric patients with CD who underwent esophagogastroduodenoscopy and biopsy. The clinical symptoms and endoscopic and histologic features of the upper GIT were identified according to the presence or absence of upper gastrointestinal symptoms.

RESULTS

Among the 52 patients, upper GIT involvement was noted in 50.0% (26/52). The mean age at CD diagnosis was 14.1±2.1 years. Gastric ulcer was the most common lesion (19.2%) found on upper GIT endoscopy, followed by duodenal ulcers (15.4%). Chronic inflammation was the most common histopathologic feature (75.0%), followed by gastric erosion (17.3%). Granuloma was found in 9.6% of patients. Helicobacter pylori infection was identified in 5.8% of patients. Endoscopic and histologic findings were not significantly different, but the mean values of erythrocyte sedimentation rate (60.7±27.1 vs. 43.0±27.6 mm/h, p=0.037) and C-reactive protein (16.5±28.2 vs. 6.62±13.4 mg/dL, p=0.014) were significantly different between patients with and without upper gastrointestinal CD symptoms.

CONCLUSION

Upper GIT involvement was relatively common in pediatric patients with CD irrespective of upper gastrointestinal symptoms, and H. pylori infection was relatively uncommon. The results of this study should aid the establishment of regional guidelines for upper GIT examination.

Nutrition in Pediatric Inflammatory Bowel Disease: From Etiology to Treatment. A Systematic Review

Nutrition is involved in several aspects of pediatric inflammatory bowel disease (IBD), ranging from disease etiology to induction and maintenance of disease. With regards to etiology, there are pediatric data, mainly from case-control studies, which suggest that some dietary habits (for example consumption of animal protein, fatty foods, high sugar intake) may predispose patients to IBD onset. As for disease treatment, exclusive enteral nutrition (EEN) is an extensively studied, well established, and valid approach to the remission of pediatric Crohn’s disease (CD). Apart from EEN, several new nutritional approaches are emerging and have proved to be successful (specific carbohydrate diet and CD exclusion diet) but the available evidence is not strong enough to recommend this kind of intervention in clinical practice and new large experimental controlled studies are needed, especially in the pediatric population. Moreover, efforts are being made to identify foods with anti-inflammatory properties such as curcumin and long-chain polyunsaturated fatty acids n-3, which can possibly be effective in maintenance of disease. The present systematic review aims at reviewing the scientific literature on all aspects of nutrition in pediatric IBD, including the most recent advances on nutritional therapy.

Systematic review: Body composition in children with inflammatory bowel disease

BACKGROUND

Paediatric inflammatory bowel disease (IBD) is associated with weight loss, growth restriction and malnutrition. Bone mass deficits are well described, little is known about other body composition compartments.

AIMS

To define the alterations in non-bone tissue compartments in children with IBD, and explore the effects of demographic and disease parameters.

METHODS

A systematic search was carried out in the PubMed (www.ncbi.nlm.nih.gov/pubmed) and Web of Science databases in May 2014 (limitations age <17 years, and composition measurements compared with a defined control population).

RESULTS

Twenty-one studies were included in this systematic review, reporting on a total of 1479 children with IBD [1123 Crohn's disease, 243 ulcerative colitis], pooled mean age 13.1 ± 3.2 years, and 34.9% female. Data were highly heterogeneous, in terms of methodology and patients. Deficits in protein-related compartments were reported. Lean mass deficits were documented in 93.6% of Crohn's disease and 47.7% of ulcerative colitis patients when compared with healthy control populations. Lower lean mass was common to both sexes in Crohn's disease and ulcerative colitis, deficits in females with persisted for longer. Fat-related compartment findings were inconsistent, some studies report reductions in body fat in new diagnosis/active Crohn's disease.

CONCLUSIONS

It is clear that almost all children with Crohn's disease and half with ulcerative colitis have reduced lean mass, however, body fat alterations are not well defined. To understand what impact this may have on health and disease in children with IBD, further studies are needed to identify in which tissues these deficits lie, and to quantify body fat and its distribution.

Vitamin and mineral supplement adherence in pediatric inflammatory bowel disease

OBJECTIVE

Although vitamin and mineral supplementation for nutritional deficiencies is a common component of pediatric inflammatory bowel disease (IBD) management, little is known about supplement adherence in this group. This study described adherence to multivitamin, iron, and calcium supplements among 49 youth aged 11-18 years with IBD. Additionally, the study examined relationships between supplement knowledge and adherence.

METHODS

Participants completed supplement adherence ratings using a validated interview. Knowledge was assessed using an open-ended question from the same interview; responses were later categorized into 1 of 3 knowledge sophistication categories (low, moderate, or high).

RESULTS

Mean adherence rates ranged from 32 to 44% across supplements. Youth who did not know the reason for supplementation (approximately 25% of the sample) displayed substantially poorer adherence than did those with moderate or high levels of knowledge, across all supplements.

CONCLUSIONS

Findings highlight the importance of evaluating and addressing nonadherence to vitamin and mineral supplements in youth with pediatric IBD.

Impact of Inflammatory Bowel Disease upon Growth in Children and Adolescents

The inflammatory bowel diseases (IBDs) are chronic inflammatory processes affecting the gastrointestinal tract. When diagnosed in childhood and adolescence, IBD almost always impacts adversely upon the nutritional state of the patient. Weight loss and impaired linear growth may be present at diagnosis or subsequently. Further potential nutritional consequences in childhood IBD include malnutrition, anaemia, osteopaenia, and delayed puberty. Understanding the nutritional aspects of IBD is paramount in growing children, especially those entering and advancing through puberty. This paper focuses upon the nutritional impacts of IBD in children and adolescents.

Effects of recombinant human growth hormone on protein turnover in the fasting and fed state in adolescents with Crohn disease

The primary purpose of this study was to test whether recombinant human growth hormone (rhGH) supplementation would enhance protein synthesis and accretion of lean body mass. Eight adolescents (six males and two females; 17.2 +/- 2.6 years; age range, 13.7-21.2 years) participated in a randomized double-blind placebo-controlled cross-over trial of rhGH. We employed stable isotopes to measure proteolysis and protein synthesis during fasting and fed conditions during two 6-month treatment conditions. We also measured bone mineral density (BMD), markers of bone turnover, and body composition. Whole-body proteolysis, phenylalanine catabolism, and protein synthesis did not differ during treatment with rhGH vs. placebo. Enteral nutrition suppressed proteolysis and increased protein synthesis similarly during placebo and rhGH treatments. We conclude that rhGH is unlikely to provide sufficient metabolic benefit to warrant its use as an adjunct treatment in clinically stable adolescents with Crohn disease. A high prevalence of vitamin D deficiency and suboptimal BMD existed, which deserves further investigation and clinical attention.

Growth retardation in pediatric Crohn's disease: pathogenesis and interventions

Growth retardation (GR) may pose a significant challenge to the quality of life and the proper management of children and adolescents with Crohn's disease (CD). It can occur in a significant proportion of patients, and may precede clinical evidence of bowel disease. Current evidence suggests that GR is a complex interaction between nutritional status, inflammation, disease severity, and genotype, which causes resistance to the effects of growth hormone. Recent research has identified a key role for the inflammatory cytokines TNF alpha, IL-6, and IL1 beta. This review summarizes current knowledge as well as gaps in our understanding of the mechanisms involved and the usefulness of the different treatment modalities in promoting growth in CD patients.

Acute effects of enteral nutrition on protein turnover in adolescents with Crohn disease

Adults with inactive Crohn disease have been shown to have normal rates of protein turnover when compared with healthy adults. It is not known whether this is true for adolescents with inactive Crohn disease, when rate of protein synthesis must be greater than that of breakdown for normal development. The objective of this study was to determine whether enteral nutrition acutely suppresses proteolysis and increases protein synthesis in adolescents with inactive Crohn disease. Six adolescents (five males/one female; mean age, 15.8 +/- 1.9 y; range, 13.2-17.6 y; mean bone age, 14.6 +/- 1.8 y; range, 12.5-17 y) participated. Leucine (Leu) and phenylalanine (Phe) kinetics were measured using stable isotopes under fasted and fed conditions during a single study visit. In response to enteral nutrition, the endogenous rates of appearance (Ra) of Leu and Phe (reflecting proteolysis) decreased significantly by 40%. The percentages of splanchnic uptake of Leu and Phe were 35 +/- 10% and 13 +/- 12%, respectively. Under fed conditions, utilization of Phe for protein synthesis increased significantly. We conclude that in clinically stable adolescents with Crohn disease, enteral nutrition promotes anabolism by suppressing proteolysis and increasing protein synthesis. Rates of suppression of proteolysis were similar to those reported previously in normal children.

Osteoporosis in pediatric patients suffering from chronic inflammatory bowel disease with and without steroid treatment

BACKGROUND

Children and adolescents suffering from inflammatory bowel disease (IBD) are at risk of developing osteoporosis as a result of treatment with corticosteroids as well as of nonsteroidal factors like inflammation and malnutrition. To study the impact of these factors on development of osteopathy, we compared the rate of osteoporosis in steroid-naive and steroid-treated pediatric IBD patients.

METHODS

In 90 patients (50 girls) with IBD (34 steroid-naive, 53 steroid-treated, 3 not known) aged 8.8 to 19.2 (14.4 +/- 2.2) years and 52 controls (27 girls) aged 6.1 to 17.6 (12.9 +/- 3.0) years, bone mineral density (BMD) of the lumbar spine was assessed with dual energy x-ray absorptiometry. Areal BMD values were transformed into volumetric densities called bone mineral apparent density (BMAD) and expressed as standard deviation scores (SDS) on the basis of the BMAD values of the controls.

RESULTS

The rate of osteoporotic patients (BMAD-SDS < -2) was 8% in girls and 20% in boys. There was a similar proportion of osteoporosis in steroid-naive (12%) and steroid-treated (11%) patients. SDS of body height showed a significant positive correlation with BMD-SDS but not with BMAD-SDS in almost all patient subgroups, indicating an interfering dependency of BMD from bone size.

CONCLUSIONS

The prevalence of osteoporosis in pediatric patients with IBD is approximately the same as in adult patients. Osteoporosis is already present before steroid treatment. Data of dual energy x-ray absorptiometry measurements should be transformed into volumetric parameters to compensate for short stature. Otherwise, a lot of growth-stunted patients may be falsely diagnosed as osteopenic.

ESPEN Guidelines on Enteral Nutrition: Gastroenterology

Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS). The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985. ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.

Surgery results in significant improvement in growth in children with Crohn's disease refractory to medical therapy

Inflammatory bowel disease (IBD) in children can cause significant impairment in linear growth, and delay in pubertal onset. The aim of this study was to assess the impact of surgery on linear growth in children with Crohn's disease (CD) who were resistant to medical therapy, and had documented evidence of growth impairment. We performed a retrospective study on eight consecutive patients with refractory disease who had attended the paediatric IBD clinic. All patients underwent surgery as part of their treatment. Height and weight were recorded at least 6 months prior to surgery, at the time of surgery, and 6 months post surgery. Growth velocities and height Z-scores were calculated. All patients had evidence of sustained growth suppression prior to surgery. Three patients had evidence of growth failure. There was a significant increase in height velocity from 0.15 cm/month before surgery to 0.54 cm/month after surgery (P = 0.006). There was also a significant decrease in the modified Harvey-Bradshaw index (HBI) of disease activity from 2.00 before surgery, to 0.84 after surgery (P = 0.003). Improvements in height Z-score and weight velocity after surgery were not significant on statistical analysis. Our study demonstrates that before surgery, children with CD refractory to therapy have sustained growth suppression, and in some cases may even have growth failure. Surgical intervention before puberty appears to result in a significant improvement in height velocity and disease activity. These findings need to be further investigated with carefully designed prospective studies.

Prise en charge nutritionnelle de la maladie de Crohn chez l'enfant et l'adolescent : bases physiopathologiques et mise en pratique

Growth retardation and delay in sexual maturation are the major complications of child-onset Crohn's disease (CD). Nutritional assessment and monitoring should comprise: weight and height measurement with calculation of respective velocities (growth velocity should be > or = 4-5 cm/year during the prepubertal period); pubertal staging; dietetic evaluation; laboratory analysis for mineral, vitamin and trace element deficiencies; bone age. At diagnosis, weight loss and growth delay are present in 80-90% and 1/3 of cases, respectively. In case of an acute flare-up in a CD child with normal nutritional status, nutritional therapy is limited to oral feeding, with a caloric intake at least equal to recommended dietary allowances for age and sex. A low-fiber diet is advised in case of small bowel stenosis. No diet has been shown as efficient in the long-term maintenance of remission. Exclusive enteral nutrition (EN) is an alternative to corticosteroids for the treatment of an acute flare-up of CD, especially in case of malnutrition. Prolonged nocturnal EN is of great interest for the treatment of growth retardation and delay of sexual maturation and in case of steroid-dependent or steroid-refractory CD. In case of steroid-dependent CD with no delay of growth and/or sexual maturation, immunomodulating agents are nowadays an alternative to long-term EN. Efficacy of polymeric solutions is identical to that of semi-elemental or elemental solutions. Parenteral nutrition is limited to an acute flare-up with resistance to medical treatment and/or EN, and contraindications to surgery; occlusion or fistula; short bowel syndrome.

TNF promoter polymorphisms and modulation of growth retardation and disease severity in pediatric Crohn's disease

OBJECTIVES

Delayed growth is common in pediatric Crohn's disease (CD). Multiple factors have been shown to affect growth in this situation, the most prominent being the presence and severity of inflammation and inadequate nutritional intake. Inflammation, anorexia, and weight loss are all manifestations of circulating TNF-alpha, which is elevated in CD. The ability to secrete TNF-alpha may be affected by polymorphisms in the TNF-alpha promoter. The aim of our study was to determine whether growth retardation and disease severity in pediatric onset CD are affected by TNF promoter genotype.

METHODS

Genotyping for TNF-alpha and NOD2/CARD15 single nucleotide polymorphisms was performed in 87 patients with detailed growth records. Parameters including disease location and disease severity were recorded, and the effect of these polymorphisms on Z-scores for height and weight at disease onset and during follow-up were analyzed.

RESULTS

Lower age of onset was linked to more height retardation, while the presence of colonic disease and the absence of ileal disease were more likely to predict the absence of growth retardation. The presence of two polymorphisms thought to decrease circulating TNF-alpha was associated with higher mean Z-scores for height and a trend toward less growth retardation. Two other polymorphisms were modestly associated with disease severity.

CONCLUSION

Polymorphisms in the TNF-alpha promoter may independently modulate growth and disease severity in pediatric onset CD. The effect of these polymorphisms does not appear to be mediated via weight loss, and is relatively modest.

Pediatric Crohn's disease and growth retardation: the role of genotype, phenotype, and disease severity

BACKGROUND

Delayed growth is a well-established feature of pediatric Crohn's disease. Several factors have been shown to affect growth, including disease location, severity, and treatment. The recently discovered NOD2 gene has been correlated to ileal location of Crohn's disease and subsequently could affect growth through the resulting phenotype or as an independent risk factor. The aim of our study was to determine if growth retardation is affected by genotype independently of disease location or severity.

METHODS

Genotyping for 3 NOD2 single-nucleotide polymorphisms was performed in 93 patients with detailed growth records. Parameters including disease location, disease severity, and NOD 2 genotype and their effect on z scores for height and weight at disease onset and during follow-up were analyzed.

RESULTS

NOD2 mutations were correlated with ileal location but not with disease severity or growth retardation. Ileal involvement was significantly associated with height retardation at disease onset and the lowest z score during follow-up. Use of steroids affected weight but not height. Regression models for growth variables revealed that the strongest association with impaired growth is with disease severity (weight- and height-failure odds ratios: 6.17 and 4.52, respectively).

CONCLUSIONS

Severity of disease is correlated with growth failure for both height and weight. Location of disease is a weaker predictor of disordered growth and is correlated with growth retardation but not growth failure. The NOD2 genotype was not correlated with growth retardation or growth failure.

Inflammatory bowel disease in early childhood and adolescence: special considerations

Several aspects of IBD overlap between pediatric and adult population. Those include nutritional issues, bone density, and medical and surgical therapies. Some aspects like natural course of the disease, and epidemiology and genetics are more easily examined and researched in the pediatric population. Others like pubertal and growth delay, and transition of health care are unique to pediatric patients. This article examines some of the similarities, as well as differences of IBD in these two populations.

Treatment of inflammatory bowel disease in childhood: best available evidence

The physician treating children with inflammatory bowel disease is confronted with a number of specific problems, one of them being the lack of randomized, controlled drug trials in children. In this review, the role of nutritional therapy is discussed with a focus on primary treatment, especially for children with Crohn's disease. Then, the available medical therapies are highlighted, reviewing the evidence of effectiveness and side effects in children, as compared with what is known in adults. Nutritional therapy has proven to be effective in inducing and maintaining remission in Crohn's disease while promoting linear growth. Conventional treatment consists of aminosalicylates and corticosteroids, whereas the early introduction of immunosuppressives (such as azathioprine or 6-mercaptopurine) is advocated as maintenance treatment. If these drugs are not tolerated or are ineffective, methotrexate may serve as an alternative in Crohn's disease. Cyclosporine is an effective rescue therapy in severe ulcerative colitis, but only will postpone surgery. A novel strategy to treat Crohn's disease is offered by infliximab, a monoclonal antibody to the proinflammatory cytokine tumor necrosis factor (TNF)-alpha. Based on the best-available evidence, suggested usage is provided for separate drugs with respect to dosage and monitoring of side effects in children.

Growth, body composition, and nutritional status in children and adolescents with Crohn's disease

OBJECTIVE

To examine growth, body composition, and nutritional status in a large sample of children, adolescents, and young adults with Crohn's disease (CD).

METHODS

One hundred thirty-two subjects (48 females) with CD, aged 5 to 25 years, and 66 healthy control subjects (37 females) of similar age. Growth, nutritional status, and body composition were measured by anthropometry and dual-energy x-ray absorptiometry. Genetic potential of linear growth was predicted using the adjusted heights of Himes et al. Pubertal status and skeletal age were assessed. Average Pediatric Crohn's Disease Activity Index (PCDAI) and lifetime steroid exposure (in milligrams per day) were obtained from medical charts. The variables were examined in relation to gender and measures of disease activity.

RESULTS

Males and females with CD did not differ by age, disease duration, or PCDAI. Males with CD had significantly lower values for growth and nutritional status than control subjects (z-scores for weight: -0.66 +/- 1.18 vs. 0.26 +/- 0.95, P = 0.00002; height -0.81 +/- 1.14 vs. 0.28 +/- 0.93, P = 0.00001; adjusted height -1.05 +/- 1.03 vs. 0.40 +/- 1.03, P = 0.00001) and delayed skeletal age of 0.9 +/- 1.6 years. Impaired linear growth in the males was present regardless of pubertal stage. Associations between disease severity indicators and growth parameters were more consistent for females.

CONCLUSIONS

Crohn's disease is associated with impaired growth. Despite similarities in disease duration, activity, and lifetime steroid exposure, growth in males was more impaired. Gender may confer risk for impaired growth in CD.

Bone mineral metabolism in pediatric inflammatory bowel disease

The development of reliable techniques to measure bone densitometry and evolving effective drug treatment have kindled great interest in the diagnosis and treatment of osteoporosis in adults with inflammatory bowel disease. A number of studies have examined the prevalence of abnormal bone mineral metabolism in children and adolescents. Studies, conducted over the past decade, indicate a greater likelihood of clinically significant problems in Crohn's disease than in ulcerative colitis. Corticosteroids have been proven to impair bone mineral status. It is increasingly clear that inflammation and other factors play a bigger role than malabsorbtion of minerals or vitamin D in most patients. As the use of the bisphonate class of drugs is limited in pediatric patients, there is a need to emphasize the role of diet and exercise in children and teenagers, particularly in those affected by inflammatory bowel disease.

Serum leptin in children and young adults with inflammatory bowel disease

BACKGROUND

Pediatric inflammatory bowel disease is often associated with growth failure and inadequate energy intake. Although several circulating cytokines are known to be elevated in inflammatory bowel disease, the mechanism for the related anorexia has not been described. Leptin is a newly recognized circulating protein that is an important regulator of appetite and energy metabolism; leptin levels are elevated in several animal models of inflammation. This study was conducted to determine whether serum leptin levels are elevated in young patients with inflammatory bowel disease.

METHODS

One hundred twelve children and young adults with Crohn's disease or ulcerative colitis were studied prospectively. Forty-two patients with other gastrointestinal illnesses were used as control subjects. Height, weight, erythrocyte sedimentation rate, serum albumin concentration, and clinical information were collected prospectively, and leptin was measured by radioimmunoassay of stored serum.

RESULTS

No significant differences in leptin levels were found among disease groups or control subjects. Body mass index and gender were the only independent predictors of serum leptin in all groups examined. Disease activity varied inversely with serum leptin in patients with Crohn's disease, but these differences were explained entirely by variations in body mass index.

CONCLUSIONS

The determinants of serum leptin were the same in young patients with inflammatory bowel disease as in normal populations, indicating that alterations in leptin levels are unlikely to mediate the anorexia and growth failure associated with this disease.

Surgery for Crohn's disease in infants and children

The course of Crohn's disease is quite variable in children. To assess the frequency and indications for surgery with current medical therapy, the authors reviewed the cases of 204 children (ages, 0.2 to 18.8 years at diagnosis, median, 12.8 years) who had Crohn's disease treated at a single institution from December 1968 to January 1994, with a median of 3.8 years of follow-up (range, 0.0 to 22.2 years). Ninety-four children (46%) required surgical resection for the following indications: (1) failure of medical therapy with persistent symptoms or growth retardation (n = 44, 47%), (2) intraabdominal abscess or perforation (n = 15, 16%), (3) fistula formation (n = 13, 14%), (4) obstruction (n = 15, 16%), (5) hemorrhage (n = 4, 4%), and (6) appendectomy at exploration for diagnosis (n = 3, 3%). The probability for surgery 3 years after diagnosis is 28.8% and by 5 years is 47.2%. Resections included ileocolectomy (71 children), colectomy (n = 16), small bowel resection (n = 4), and appendectomy (n = 3). Fourteen fistulas in 13 children required surgical intervention (7 enteroenteral, 3 enterovesical, 2 enterovaginal, and 2 enterocutaneous). The median duration from diagnosis to surgery for the fistulas was 2.6 years (range 0.1 to 9.8 years). Forty patients experienced recurring disease after resection during follow-up with a median of 1.8 years (range 0.4 to 18.1 years). The authors found that the course of the disease was unpredictable, with some children requiring early surgical intervention and others continuing with medical therapy for years.

Increased energy expenditure in growing adolescents with Crohn's disease

Undernutrition is considered to have a central role in the pathogenesis of growth retardation in Crohn's disease. This may occur as a consequence of inadequate food intake, increased energy expenditure, or both. Ten growing adolescents with inactive Crohn's disease were assessed with respect to anthropometric parameters and resting energy expenditure, measured by indirect calorimetry during remission, repeated in relapse (N = 5), and compared to that predicted from the Harris-Benedict formula. Mean energy intake was assessed with seven-day diaries in five patients and compared to recommended intake for age, sex, weight, and physical activity. Ten healthy, growing, age- and sex-matched adolescents served as controls. Nine patients with inactive Crohn's disease, who had ceased growing, were matched for disease site and duration and acted as disease controls. Patients and disease controls had lower body mass index (19.2 +/- 0.6; 20.9 +/- 0.7) than healthy controls (23.7 +/- 0.6; P < 0.001). Percent body fat was lower in patients (13.2 +/- 1.9%) compared to healthy controls (20.5 +/- 2.4%; P < 0.05) but not to disease controls (17.0 +/- 2.6%). Patients had higher resting energy expenditure per kilogram of fat-free mass than disease or healthy controls (36.9 +/- 5.1; 32.9 +/- 2.6; 30.9 +/- 2.1 kcal; P < 0.02). Measured resting energy expenditure in patients, but not in disease or healthy controls, was higher than the predicted (measured: predicted 1.15, 1.03, 0.9, respectively; P < 0.03). Energy intake in patients was 97% of recommended intake but the measured ratio of energy intake/resting energy expenditure was lower than the predicted ratio (1.49 vs 1.71; P < 0.05). During subsequent relapse in five patients resting energy expenditure was unchanged. In growing adolescents with inactive Crohn's disease, there is increased energy expenditure that is not accompanied by an increase in energy intake. Relapse of disease does not appear to increase resting energy expenditure further but may "divert" energy from growth to disease activity. This suggests that nutritional therapy should be directed towards increasing caloric intake to maximize growth potential.

Resting energy expenditure before and after surgical resection of gut lesions in pediatric Crohn's disease

In pediatric Crohn's disease (CD), resection of gut lesions is necessary to remove stenoses and when frequent relapses occur despite nutritional support and medical treatment. After surgery, improved nutritional status and accelerated growth usually follow increased nutritional intake and lower doses of steroids. The aim of this study was to compare energy balance before and after surgery while nutritional intake and steroid therapy were unchanged. Eleven patients, aged 14.5 +/- 2.5 years and with mildly active CD, were explored 1 week before and 1 month after gut resection for stenosis (n = 7) and medical treatment failure (n = 4). Eleven matched children participated in the study as controls. Disease activity was assessed by the Pediatric Crohn's Disease Activity Index and serum orosomucoid concentration. Resting energy expenditure (REE) was measured by indirect calorimetry, and fat-free body mass (FFM) was measured by anthropometry. The patients' mean REE decreased from 46.6 +/- 10.5 kcal/kg FFM/day before surgery to 42.6 +/- 10.3 kcal/kg FFM/day after surgery, while the controls' mean REE was 39 +/- 7 kcal/kg FFM/day (analysis of variance, p = 0.02). After surgery, body weights were not significantly different, but the mean protein oxidation rate was reduced and arm muscle area was increased. Changes in REE per kilogram of FFM per day were not correlated with changes in orosomucoid serum concentrations (r2 = 0.35; p = 0.4). In conclusion, in children with mildly active CD, while nutritional intake and steroid therapy were maintained at preoperative levels, a significant decrease in REE and improved nitrogen utilisation were observed 1 month after resection of the CD gut lesion. This finding suggests better use of energy substrates when CD lesions are removed.

Nutritional considerations and management of the child with inflammatory bowel disease

Crohn's disease and ulcerative colitis are chronic inflammatory diseases of the bowel often associated with significant malnutrition, particularly in children because of increased nutrient demands due to growth. We discuss the increasingly prominent role of nutritional support in inflammatory bowel disease (IBD). Issues that are addressed include the etiology of malnutrition in IBD, assessment and monitoring of patient nutritional status and the use of nutrition in the management of growth failure and as primary medical therapy.

Growth as a parameter of inflammation in Crohn's disease, using roentgen stereophotogrammetric analysis

Growth rate was measured in 12 children with Crohn's disease and growth retardation, using roentgen stereophotogrammetric analysis. The method was chosen as it provides an opportunity to record growth rate accurately during short periods of time. Growth was followed at variable intervals of 4-12 weeks depending on the clinical situation. Growth rate was shown to correlate with symptoms, laboratory tests and nitrogen balance. These findings indicate that growth, when it is affected, fluctuates in a similar way as albumin, acute phase proteins and symptoms, all assumed to reflect the disease activity. Short-term growth measurements appear to be helpful in monitoring the disease progress or response to therapy in children with Crohn's disease, particularly when growth retardation is the only manifestation of the disease.

Growth and puberty in chronic inflammatory bowel disease

The consequences of IBD during childhood and adolescence may be devastating in terms of loss of growth potential, particularly if there has been a clinical course of frequent relapses resulting in inadequate nutrition and associated with repeated courses of steroid treatment. There is to date, however, a paucity of data recording final adult heights in such patients. The anticipation of relapse should become easier with increasing awareness of the importance of parameters of growth and pubertal development. Early and intensive nutritional support, and the use of steroid-sparing agents should help reduce the frequency and severity of any height deficit. The performance and timing of surgery must take into account the child's status in terms of height velocity and pubertal development. The importance of inducing the remission before the onset of puberty is stressed and this remission should be sustained at all costs during the pubertal years so that valuable height is not lost as a consequence of a missed pubertal growth spurt. Thus, increasing awareness of the issues of growth and development in these patients should improve the accuracy of initial diagnosis and early recognition of relapse, such that these children are ensured the best possible provision for achieving their full height potential.

Growth failure in children with inflammatory bowel disease: a prospective study

BACKGROUND

Growth failure frequently complicates the clinical course of inflammatory bowel disease (IBD) in children. This study was designed to investigate the role of disease activity versus steroid therapy on growth faltering in this disorder.

METHODS

We studied growth failure and its relationship to disease activity and steroid therapy in 69 children who have IBD by prospectively monitoring height for a maximum of 3 years. Disease activity and steroid use were recorded at entry into the study.

RESULTS

The prevalence of growth failure was 24%, 23%, and 39% by height velocity, Z score, and height-for-age criteria, respectively; deficits were equally prevalent regardless of the stage of pubertal development. A delay in linear growth persisted throughout puberty and was not reversed after surgery. Patients who had Crohn's disease were twice as likely to have growth abnormalities than patients who had ulcerative colitis. We detected significant negative associations between linear growth and disease activity but not steroid therapy.

CONCLUSIONS

In a unique group of children, growth failure is an early, "prepatterned" manifestation of IBD. The inflammatory process, rather than steroid use, has a predominant influence on the development of growth faltering.

Improved growth and disease activity after intermittent administration of a defined formula diet in children with Crohn's disease

Growth failure is the most common extraintestinal manifestation of Crohn's disease in childhood, occurring in up to 50% to 88% of affected patients. Previous studies have shown malnutrition to be the most likely cause of the decrease in height and weight velocities in these children. The purpose of this study was to determine the effect of an intermittent defined formula diet on growth and disease activity in children with Crohn's disease and growth failure. Six Tanner stage I-II patients, mean age 13.6 years with height less than the 5th percentile or height velocity less than the 3rd percentile were enrolled in a 1-year prospective study. An isotonic, hydrolyzed whey, medium-chain triglyceride formula was given by nocturnal nasogastric infusion at a caloric equivalent of 50th percentile for age, as the exclusive nutrient source 1 out of 4 months during a 1-year period. A 2-week exclusion diet and a 2-week low-residue diet followed the defined formula diet before resuming the regular diet for 2 months. Patients served as their individual control based on observations of at least 1 year before the study. Height and weight velocity significantly increased. Prednisone intake significantly decreased, and significant improvement was seen in disease activity, albumin, and somatomedin C. The results indicate that an intermittent defined formula diet can improve growth failure and significantly decrease disease activity in children with Crohn's disease.

Surgery for Crohn's disease in childhood: influence of site of disease and operative procedure on outcome

Factors influencing outcome after surgery have been studied in 67 children requiring bowel resection or diversion of the faecal stream for Crohn's disease. Patients were divided into four groups on the basis of disease location at time of surgery, and mean follow-up was 4.5 years. All three children with panenteric disease (group 1) have relapsed. Best results were observed in cases with disease confined to the small bowel (group 2) and ileocaecal region (group 3), in whom surgery was followed by sustained remission in six out of seven and 24 out of 30 patients respectively. In the 27 children with colitis (group 4), results were mixed. Six of the seven patients who had staged colonic resections with a primary anastomosis relapsed, as did three out of four patients given a loop ileostomy to divert the faecal flow; in contrast, 15 out of 16 children who had a subtotal colectomy with ileostomy as the primary procedure have remained well, with only minor problems involving the rectal stump. An acceleration in growth velocity was observed during the first year after operation in 89 per cent of 40 children studied. Outcome after surgery for Crohn's disease in childhood depends mainly on disease location, but is influenced by the type of primary operation performed. In addition to symptomatic relief the principal early benefit of surgery is improved growth.

Acceleration of linear growth following intestinal resection for Crohn disease

Twelve patients with Crohn disease aged from 11.3 to 17.1 years, underwent intestinal resection. Eight were prepubertal or in early puberty and 4 in mid or late puberty. Pre-operative assessment included acceleration and compression barium studies and total colonoscopy. In six patients the surgical indication was failure of medical management and in six intestinal obstruction. All but one were in remission 12 months after surgery. Height velocities in the eight pre and early pubertal patients increased dramatically during 6- and 12-month post operative measurement periods compared with preoperative growth. Height velocities in the mid and late pubertal patients showed much less increase. In selected patients, surgical treatment can induce remission resulting in catch-up growth and sustained growth acceleration. In prepubertal and early pubertal patients surgery is likely to improve final adult height.

Management of children and adolescents with inflammatory bowel disease

The management of children and adolescents with inflammatory bowel disease requires all the skills offered by the health care team. This article reviews the principles of therapy, the specifics of therapy, and the attitudes of the authors relating to long-term management of these patients. Specific recommendations relating to nutritional support for patients are also made. A pertinent updated bibliography is also given.

Home nocturnal supplemental nasogastric feedings in growth-retarded adolescents with Crohn's disease

We hypothesized that supplemental nutritional support delivered at home by nocturnal nasogastric feedings would result in accelerated growth in growth-retarded adolescents with Crohn's disease. Eight Tanner stage I adolescents with Crohn's disease, mean age 14 yr 5 mo, had a mean weight gain of 0.38 kg and height gain of 1.4 cm for the year before initiation of nasogastric feedings. All had been either asymptomatic or had only minimal symptoms in the year before the study, but were ingesting only 55%-80% of their daily required caloric intake. The subjects were taught to pass by themselves a nasogastric feeding tube, through which 1000-1500 ml of commercial, nonelemental isocaloric formula was infused during sleep to supplement their usual dietary intake. After 12 mo of nocturnal feedings, the subjects had a mean weight gain of 11.75 kg and a mean height gain of 6.98 cm. Six control subjects, matched for age and degree of growth and sexual retardation at the beginning of the study period, but who had refused the nasogastric feedings, had no change in weight and height during the same period of observation. We conclude that home nocturnal nasogastric feedings can achieve dramatic improvement in weight gain and linear growth in motivated adolescents with Crohn's disease and growth retardation.

Effects of parenteral nutrition on whole body and extremity composition in children and adolescents with active inflammatory bowel disease

The effect of parenteral nutrition (PN), combined with corticosteroid therapy, on body composition was evaluated in 22 pediatric patients with active and complicated inflammatory bowel disease (IBD). The patients were divided into two groups according to the duration of PN. Group A consisted of 14 patients who received PN for an average of 43 days (short term) whereas eight patients received PN for an average of 104 days (long term); group B. Nutritional assessments were performed before and following the PN periods. In addition, a follow-up assessment was performed 50 days after the cessation of PN for group A. Serial evaluations included; weight, height, disease activity score, arm anthropometry, subscapular skinfold (SSSF) thickness, 24-hr urinary creatinine, and computed tomography (CT) scan of the thigh. Following PN with a glucose-fat mixture used as a nonprotein energy source, there were significant (p less than 0.05) increases in weight, SSSF, and muscle mass (MM) in both groups. Disease activity declined in both groups and height increased in group B and at the follow-up assessment for group A. Considering extremity composition, both groups exhibited increases in midarm muscle area, midarm fat area, thigh muscle area, and thigh fat area. However, a differential distribution of incremental change was observed depending on the duration of PN. Fat deposition predominated in both the upper and lower extremities for group A. Group B patients, however, although showing a predominance of fat accumulation in the upper extremities, gained muscle and fat components equally in the lower extremities.(ABSTRACT TRUNCATED AT 250 WORDS)

Decreased height velocity in children and adolescents before the diagnosis of Crohn's disease

Severe linear growth retardation occurs in 20%-30% of children with Crohn's disease, yet, it is unknown how often decreased height velocity precedes the diagnosis. The height velocities of 50 children and prepubescent adolescents with Crohn's disease were reviewed. Decreased height velocity antedated the diagnosis in 44 patients. Twenty-one patients had a reduction in height velocity before intestinal symptoms were noted. Additionally, 17 of 32 patients with attenuated linear growth had a reduction in height velocity before any weight loss. Linear growth impairment in Crohn's disease, more common than previously recognized, may precede weight loss and can be the earliest indicator of disease.

Nutritional consequences of inflammatory bowel disease on growth

This review summarizes much of the current information concerning the problem of growth failure in children and adolescents with inflammatory bowel disease. Growth impairment is discussed as a dynamic process and ways of recognizing and monitoring subtle changes in growth velocity are presented. Factors which contribute to growth delay are described, with special attention to prolonged insufficient nutrient intake. Studies using different methods of nutritional intervention to reverse growth failure are presented as a guide to the management of this challenging group of patients.