Mineral balance during nutritional supplementation in adolescents with Crohn disease and growth failure

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.

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.

Intensive enteral nutrition support in paediatric bone marrow transplantation

This study retrospectively analyses the experience with an intensive enteral feeding protocol in children undergoing BMT at the National Paediatric BMT Centre, Our Lady's Hospital for Sick Children, Crumlin, Dublin. Fifty-three patients were transplanted between January 1996 and December 1998; 42 patients received allogeneic transplants, (19 unrelated) and 11 were autologous. Indications included ALL (21), ANLL (3), CML (3), JCML (1), MPS (5), WAS (2), AA/FA (6), NHL/HD (3) and solid tumours (9). Nasogastric (NG) tubes were inserted electively either during conditioning or within the first week when voluntary oral intake had decreased. Nineteen patients were commenced on a whole protein-based formula, 28 on a semi-elemental preparation and two were commenced on an elemental feed. All were maintained on an elemental formula during the period of maximal gut toxicity. Tubes which were vomited were promptly replaced and morphine infusions were routinely employed until mucositis had resolved. Of 49 evaluable patients, 42 (86%) were maintained exclusively on enteral nutrition and seven required parenteral nutrition. Seven patients weighed <85% ideal body weight (IBW) at discharge (range 75-84), only one of whom was <85% IBW at 3 months. Twenty-two patients continued on NG feeds following discharge (median 41 days). No patient had veno-occlusive disease. The programme was overwhelmingly endorsed by patients and/or parents but required intensive multidisciplinary counselling to ensure success.

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.

Nutritional support in children undergoing bone marrow transplantation

Nutritional status and 'well-being' were compared prospectively in 39 children (mean age 8.1 years) who received nutritional support following bone marrow transplantion (BMT): 20 received enteral tube feeding (ETF; six received parenteral nutrition [PN] subsequently) and 19 with oral mucositis received PN (one received ETF subsequently). Poor nutritional status (height for age and/or weight for height and/or mid-arm circumference z-scores <-1) was present in 18 patients and was associated with a longer hospital stay (P = 0. 01). Both ETF and PN groups were comparable with respect to age, pretransplant nutritional status and conditioning regimens. No significant deterioration in anthropometric indices in either group occurred following BMT. However, significant correlations were found between the duration of ETF (and not PN) and improvements in nutritional status. Furthermore, PN was associated with more frequent exocrine pancreatic insufficiency than ETF (P = 0.001). Oral mucositis was associated with poorer 'well being' at the start of PN compared with ETF (P < 0.0001), but this was reversed by the end of PN. Bone marrow recovery, hospital stay and positive blood cultures were similar in the two groups. Hypomagnesaemia, hypophosphataemia and biochemical zinc deficiency were common in both groups but hypoalbuminaemia and biochemical selenium deficiency were worse in the PN group. In conclusion, both ETF and PN are effective in maintaining nutritional status post-BMT. When ETF is tolerated, it is associated with better nutritional response. With the existing ETF and PN regimens close monitoring of the trace element and mineral status is required.

Enteral nutrition after bone marrow transplantation

Nutritional insult after bone marrow transplantation (BMT) is complex and its nutritional management challenging. Enteral nutrition is cheaper and easier to provide than parenteral nutrition, but its tolerance and effectiveness in reversing nutritional depletion after BMT is poorly defined. Nutritional status, wellbeing, and nutritional biochemistry were prospectively assessed in 21 children (mean age 7.5 years; 14 boys) who received nasogastric feeding after BMT (mean duration 17 days) and in eight children (mean age 8 years, four boys) who refused enteral nutrition and who received dietetic advice only. Enteral nutrition was stopped prematurely in eight patients. Greater changes in weight and mid upper arm circumference were observed in the enteral nutrition group, while positive correlations were found between the duration of feeds and increase in weight and in mid upper arm circumference. Vomiting and diarrhoea had a similar incidence in the two groups, while fever and positive blood cultures occurred more frequently in the dietetic advice group. Diarrhoea occurring during enteral nutrition was not associated with fat malabsorption, while carbohydrate malabsorption was associated with rotavirus infection only. Enteral feeding did not, however, affect bone marrow recovery, hospital stay, general wellbeing, or serum albumin concentrations. Hypomagnesaemia, hypophosphataemia, zinc and selenium deficiency were common in both groups. In conclusion, enteral nutrition, when tolerated, is effective in limiting nutritional insult after BMT. With existing regimens nutritional biochemistry should be closely monitored in order to provide supplements when required.

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 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.

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.

Bioavailability of calcium and phosphorus in human milk fortifiers and formula for very low birth weight infants

Growth, 96-hour balance of nutrients (nitrogen, fat, calcium (Ca), phosphorus (P), and magnesium), metabolizable energy, and serum biochemical markers of mineral status (Ca and P concentrations and alkaline phosphatase activity) were measured in 22 very low birth weight infants to investigate the bioavailability of minerals from specialized formula and from human milk fortifiers. The intakes of Ca and P were similar between group FORM ("Preemie" SMA) and group CMF (1:1 wt/wt, human milk and Similac Natural Care or Similac Special Care). The intakes of nitrogen, energy, fat, and magnesium differed between groups. Group CMF had significantly greater fecal losses and significantly lower absorption and retention of Ca and P in comparison with those of group FORM. Retention of Ca and P in both groups, however, was greater than 25% below intrauterine estimates of accretion. Retention rates of Ca, P, and magnesium were not correlated with their respective intakes. Weight gain during the balance study and during the entire study interval was significantly less in group CMF. The ratio of Ca retention to either weight gained or nitrogen retained was lower in group CMF, which suggested that the low retention of Ca was related less to the slower rate of growth in these infants than to their greater fecal losses of Ca. Although the cause of the greater fecal losses of Ca and P in this group is unclear, the data suggest an insolubility of the mineral sources. Our results indicate that sole reliance on the absolute mineral concentrations of the milk selected for very low birth weight infants may be unrealistic; the bioavailability of Ca and P from particular mineral sources should be evaluated.

Improved mineral balance in very low birth weight infants fed fortified human milk

Enhanced calcium and phosphorus retention was achieved in 16 very low birth weight infants (birth weight 1117 +/- 42 g, gestation 29 +/- 0.2 weeks) fed a preparation of fortified human milk augmented with calcium lactate and monobasic and dibasic phosphate salts. Measurements of growth and macronutrient utilization were similar to those obtained in a previous study of infants fed a preparation of fortified human milk that contained lower levels of calcium and phosphorus. However, unlike the relative hypophosphatemia, hypophosphaturia, and hypercalciuria noted in the infants in our earlier study, normal serum and urine phosphorus and urine calcium values were observed in this study. Postnatal calcium and phosphorus retentions correlated significantly with respective intakes, the absorption of fat, and the retention of nitrogen. The relationships among calcium and phosphorus intake and retention predict that 160 mg/kg/d and 94 mg/kg/d, respectively, must be fed to achieve retention equivalent to intrauterine estimates. Although postnatal retention of calcium and phosphorus may be increased to levels accumulated by the fetus, technical considerations for the preparation of a formula with sufficiently high levels of calcium and phosphorus must be resolved.

Inflammatory bowel disease in children

Ulcerative colitis and Crohn's disease are chronic intestinal disorders with diverse presentations that must be familiar to pediatricians. The subtlety of clinical signs and symptoms may be overshadowed by extraintestinal complications. An awareness of diagnostic techniques and the necessity of an integrated approach of medical and surgical management is emphasized. Potential complications may affect prognosis and require their own specific therapy. The management of these disorders entails an individualized assessment of the extent and severity of intestinal involvement, extraintestinal complications, as well as ongoing medical, nutritional, and emotional support.