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Størdal K, Ma A, Beck CE. Reducing the use of proton pump inhibitors in infants with reflux symptoms. BMJ 2024; 385:e074588. [PMID: 38816024 DOI: 10.1136/bmj-2022-074588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Affiliation(s)
- Ketil Størdal
- Department of Paediatric Research, Faculty of Medicine, University of Oslo, Pb 4956 Nydalen, NO-0424 Oslo, Norway
- Department of Paediatrics, Oslo University Hospital, Oslo
| | | | - Carolyn E Beck
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto
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2
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Sultana Z, O Yildiz V, Jadcherla SR. Characteristics of esophageal refluxate and symptoms in infants compared between pre-treatment and on treatment with proton pump inhibitors. J Perinatol 2024; 44:87-93. [PMID: 37980392 DOI: 10.1038/s41372-023-01825-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE To examine longitudinal pH-impedance characteristics from those infants who remained on proton pump inhibitors therapy for gastroesophageal reflux disease (GERD) as parents/providers refused to discontinue therapy after 4 weeks. STUDY DESIGN Eighteen infants with acid reflux index >3% underwent treatment, and pH-impedance data were compared prior to and on proton pump inhibitors at 42 ± 1 and 46 ± 1 weeks' postmenstrual age, respectively. Esophageal acid and bolus exposure, symptoms and swallowing characteristics were examined. RESULTS Proton pump inhibitors reduces the acid-mediated effects of reflux but modifies impedance and clearance mechanisms (P < 0.05). Prolonged therapy did not reduce symptoms (P > 0.05). Infants evaluated while on proton pump inhibitors were 1.8 times more likely to have swallows before and after reflux. CONCLUSIONS Prescription of proton pump inhibitors for objectively determined GERD should have time limits, as prolonged treatment can result in prolonged esophageal bolus clearance time without relieving symptoms.
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Affiliation(s)
- Zakia Sultana
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Vedat O Yildiz
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sudarshan R Jadcherla
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
- Division of Neonatology and Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH, USA.
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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Chetta KE, Forconi M, Newton DA, Wagner CL, Baatz JE. HAMLET in human milk is resistant to digestion and carries essential free long chain polyunsaturated fatty acids and oleic acid. Food Chem 2023; 427:136752. [PMID: 37392621 PMCID: PMC10527475 DOI: 10.1016/j.foodchem.2023.136752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/19/2023] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
The oleic acid/alpha-lactalbumin complex HAMLET (human alpha-lactalbumin made lethal to tumors) is cytotoxic to various cancerous cell lines and is assembled from alpha-lactalbumin (ALA) and free oleic acid (OA). HAMLET is also cytotoxic to normal immature intestinal cells. It remains unclear if HAMLET, experimentally assembled with OA and heat, can spontaneously assemble in frozen human milk over time. To approach this issue, we used a set of timed proteolytic experiments to evaluate the digestibility of HAMLET and native ALA. The purity of HAMLET in human milk was confirmed by ultra high performance liquid chromatography coupled to tandem mass spectrometry and western blot to resolve the ALA and OA components. Timed proteolytic experiments were used to identify HAMLET in whole milk samples. Structural characterization of HAMLET was performed by Fournier transformed infrared spectroscopy and indicated a transformation of secondary structure with increased alpha-helical character of ALA upon binding to OA.
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Affiliation(s)
- Katherine E Chetta
- Department of Pediatrics, C.P. Darby Children's Research Institute, Medical University of South Carolina, Charleston, SC, United States; Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive, MSC 915, Charleston, SC 29425, United States.
| | - Marcello Forconi
- Department of Chemistry and Biochemistry, College of Charleston, Charleston, SC, United States
| | - Danforth A Newton
- Department of Pediatrics, C.P. Darby Children's Research Institute, Medical University of South Carolina, Charleston, SC, United States; Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive, MSC 915, Charleston, SC 29425, United States
| | - Carol L Wagner
- Department of Pediatrics, C.P. Darby Children's Research Institute, Medical University of South Carolina, Charleston, SC, United States; Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive, MSC 915, Charleston, SC 29425, United States
| | - John E Baatz
- Department of Pediatrics, C.P. Darby Children's Research Institute, Medical University of South Carolina, Charleston, SC, United States; Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive, MSC 915, Charleston, SC 29425, United States
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Xiao T, Zeng J, Zhao C, Hou Y, Wu T, Deng Z, Zheng L. Comparative Analysis of Protein Digestion Characteristics in Human, Cow, Goat, Sheep, Mare, and Camel Milk under Simulated Infant Condition. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2023; 71:15035-15047. [PMID: 37801409 DOI: 10.1021/acs.jafc.3c03123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
An infant in vitro digestion model was utilized to investigate protein digestion characteristics in human and diverse mammalian milk (i.e., cow, goat, sheep, mare, and camel milk) using electrophoresis and chromatography. Digestive differences among milks were mainly manifested in the infant gastric phase, as evidenced by varying degrees of protein digestion. Notably, proteins (i.e., lactoferrin, serum albumin, and immunoglobulin G-heavy chain) remained partially intact in human milk, whereas these proteins in animal milk were exclusively degraded after gastrointestinal digestion. The peptide spectra of human, mare, and camel milk were highly similar, with a predominant formation of low-intensity small peptides, whereas the other three milk showed the opposite phenomenon. Heatmap cluster analysis indicated that camel milk was the most comparable to human milk before digestion, yet sheep milk was the most similar to human milk regarding protein digestion behaviors following infant gastric digestion.
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Affiliation(s)
- Ting Xiao
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, P. R. China
| | - Junpeng Zeng
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, P. R. China
| | - Caidong Zhao
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, P. R. China
| | - Yanmei Hou
- Hyproca Nutrition Co., Ltd., Changsha, Hunan 410200, P. R. China
| | - Tong Wu
- Hyproca Nutrition Co., Ltd., Changsha, Hunan 410200, P. R. China
| | - Zeyuan Deng
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, P. R. China
- Institute for Advanced Study, Nanchang University, Nanchang 330031, P. R. China
| | - Liufeng Zheng
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, P. R. China
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5
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Hirsch S, Rosen R. The Real Relevance of Nonacid Reflux in Pediatric Patients. J Clin Gastroenterol 2023; 57:754-759. [PMID: 37436834 DOI: 10.1097/mcg.0000000000001868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/17/2023] [Indexed: 07/14/2023]
Abstract
Gastroesophageal reflux (GER) is one of the most common presenting complaints to pediatric gastroenterologists, and a wide variety of symptoms in children are potentially attributable to typical or atypical GER. While reflux diagnosis and treatment paradigms classically have focused on targeting acid, there is a growing recognition of the prevalence and significance of nonacid GER in both children and adults. This review explores the role of nonacid reflux in pediatric patients, including definitions, associations with symptoms, pathophysiologic mechanisms, and treatment implications.
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Affiliation(s)
- Suzanna Hirsch
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA
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Xu J, Wijenayaka S, Avci R, Cheng LK, Du P. Reconstruction of the human lower esophageal sphincter based on ultra-mill imaging for biomechanical analysis. Front Physiol 2023; 14:1128903. [PMID: 37546538 PMCID: PMC10399694 DOI: 10.3389/fphys.2023.1128903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/07/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction: The lower esophageal sphincter (LES) controls the passage into the stomach and prevents reflex of contents into the esophagus. Dysfunctions of this region typically involves impairment of muscular function, leading to diseases including gastro-esophageal reflux disease and achalasia. The main objective of this study was to develop a finite element model from a unique human LES dataset reconstructed from an ultra-mill imaging setup, and then to investigate the effect of anatomical characteristics on intraluminal pressures. Methods: A pipeline was developed to generate a mesh from a set of input images, which were extracted from a unique ultra-mill sectioned human LES. A total of 216 nodal points with cubic Hermite basis function was allocated to reconstruct the LES, including the longitudinal and circumferential muscles. The resultant LES mesh was used in biomechanical simulations, utilizing a previously developed LES mathematical model based on the Visible Human data to calculate intraluminal pressures. Anatomical and functional comparisons were made between the Ultra-mill and Visible human models. Results: Overall, the Ultra-mill model contained lower cavity (1,796 vs. 5,400 mm3) and muscle (1,548 vs. 15,700 mm3) volumes than the Visible Human model. The Ultra-mill model also developed a higher basal pressure (13.8 vs. 14.7 mmHg) and magnitude of pressure (19.8 vs. 18.9 mmHg) during contraction. Out of all the geometric transformations (i.e., uniform enlargement of volume, lengthening along the center-axis, dilation of the diameter, and increasing muscle thickness), the muscle volume was found to be the main contributor of basal and magnitude of pressures. Increases in length also caused proportional increases to pressures, while dilation of diameter had a less influential reverse effect. Discussion: The findings provide information on interindividual variability in LES pressure and demonstrates that anatomy has a large influence on pressures. This model forms the basis of more complex simulations involving food bolus transport and predicting LES dysfunctions.
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Closs ER, Lyamouri M, Øymar K, Størdal K. Regionale forskjeller i bruk av protonpumpehemmere hos barn. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2023; 143:22-0771. [PMID: 37341401 DOI: 10.4045/tidsskr.22.0771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Physiological gastroesophageal reflux in infancy is difficult to distinguish from reflux disease. International guidelines recommend restrictive use of acid suppression therapy for infants due to the lack of documented effect, but its use in infants and older children has increased in recent years. This study aims to describe change over time and geographic variation in the investigation and treatment of suspected gastroesophageal reflux disease. MATERIAL AND METHOD In aggregated data from the Norwegian Prescribed Drug Registry for the period 1.1.2007-31.12.2020, we examined regional differences in the number of proton pump inhibitors dispensed for children and adolescents. Data from the Norwegian Patient Registry were analysed to identify the use of 24-hour pH measurement and gastroscopy, which can support the suspicion of gastroesophageal reflux disease. RESULTS The number of proton pump inhibitors dispensed in the first year of life increased and was highest in South-Eastern Norway Regional Health Authority, with 10.1 per 1000 children in 2007 and 54.7 per 1000 children in 2020 (relative risk 5.4, 95 % confidence interval 4.6 to 6.4). The number dispensed in 2020 was 64 % higher in South-Eastern Norway Regional Health Authority compared to Northern Norway Regional Health Authority and Central Norway Regional Health Authority. There was little change in the number of gastroscopies, but use of 24-hour pH measurement fell by 52 % from 2016 to 2020. INTERPRETATION Use of proton pump inhibitors in infants has increased considerably despite the guidelines. Together with geographic variation, this may point towards overtreatment of physiological reflux in infants. Few investigations indicate that an increasing proportion are treated without supporting diagnostics.
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Affiliation(s)
| | | | - Knut Øymar
- Barne- og ungdomsklinikken, Stavanger universitetssjukehus, og, Klinisk institutt 2, Universitetet i Bergen
| | - Ketil Størdal
- Barneklinikken, Oslo universitetssykehus, og, Institutt for klinisk medisin, Universitetet i Oslo
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Patel N, Lin P, Stack M, Conrad JM, Fakioglu H, Abomoelak B, Horvath K, Mehta DI. Oral Care Associated With Less Microaspiration in Ventilated Cardiac Patients. JPGN REPORTS 2023; 4:e290. [PMID: 37181916 PMCID: PMC10174743 DOI: 10.1097/pg9.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/08/2022] [Indexed: 05/16/2023]
Abstract
Aspiration is common in mechanically ventilated patients and may predispose patients to aspiration pneumonia, chemical pneumonitis, and chronic lung damage. Pepsin A is a specific marker of gastric fluid aspiration and is often detected in ventilated pediatric patients. We investigated the effect of oral care and throat suctioning in the detection of pepsin A in tracheal aspirates (TAs) up to 4 hours after these procedures. Methods Twelve pediatric patients between age 2 weeks to 14 years who underwent intubation for cardiac surgery were enrolled in this study. Six of the 12 patients were consented before their surgery with initial specimen collected at the time of intubation and last one shortly before extubation (intubation duration < 24 hours). The remaining 6 patients were consented after cardiac surgery. All specimens were collected per routine care per respiratory therapy protocol and shortly before extubation (intubation duration > 24 hours). Tracheal fluid aspirates were collected every 4 to 12 hours in the ventilated patients. Enzymatic assay for gastric pepsin A and protein determination were performed. The time of oral care and throat suctioning within 4 hours prior was recorded prospectively. Results A total of 342 TA specimens were obtained from the 12 intubated pediatric patients during their course of hospitalization; 287 (83.9%) showed detectable total pepsin (pepsin A and C) enzyme activity (> 6 ng/mL) and 176 (51.5%) samples had detectable pepsin A enzyme levels (>6 ng/mL of pepsin A). Only 29 samples of 76 samples (38.2%) had evidence of microaspiration after receiving oral care, while 147 of 266 (55.3%) samples were pepsin A positive when no oral care was provided. Odds ratio is 0.50 (Cl 0.30-0.84), and the number needed to treat is 5.8 (Confidence interval 3.4-22.3). Testing air filters for pepsin was not beneficial. Conclusion Oral care is a highly effective measure to prevent microaspiration of gastric fluid in ventilated pediatric patients. The number needed to treat (5.8) suggests this is a very effective prevention strategy. Our study suggests that pepsin A is a useful and sensitive biomarker that allows identification of gastric aspiration.
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Affiliation(s)
- Nishant Patel
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
| | - Philip Lin
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
| | - Michael Stack
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Janet M. Conrad
- Pediatric Gastroenterology and Translational Research Laboratory, Cardiology Arnold Palmer Hospital for Children, Orlando, FL
| | - Harun Fakioglu
- Department of Pediatric Cardiology Arnold Palmer Hospital for Children, Orlando, FL
| | - Bassam Abomoelak
- Pediatric Gastroenterology and Translational Research Laboratory, Cardiology Arnold Palmer Hospital for Children, Orlando, FL
| | - Karoly Horvath
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
| | - Devendra I. Mehta
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
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Sawyer C, Sanghavi R, Ortigoza EB. Neonatal gastroesophageal reflux. Early Hum Dev 2022; 171:105600. [PMID: 35716649 PMCID: PMC9983357 DOI: 10.1016/j.earlhumdev.2022.105600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christopher Sawyer
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Rinarani Sanghavi
- Division Pediatric Gastroenterology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Eric B. Ortigoza
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States of America,Corresponding author. (E.B. Ortigoza)
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Lynch R, Buckin V. Ultrasonic analysis of effects of varying temperature, pH, and proteolytic enzymes on hydrolysis of lactose by neutral lactase formulations in infant milk and in the infant digestive system. Food Res Int 2022; 157:111004. [DOI: 10.1016/j.foodres.2022.111004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
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Duijsens D, Pälchen K, Guevara-Zambrano J, Verkempinck S, Infantes-Garcia M, Hendrickx M, Van Loey A, Grauwet T. Strategic choices for in vitro food digestion methodologies enabling food digestion design. Trends Food Sci Technol 2022. [DOI: 10.1016/j.tifs.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abrahamse E, Thomassen GGM, Renes IB, Wierenga PA, Hettinga KA. Assessment of milk protein digestion kinetics: effects of denaturation by heat and protein type used. Food Funct 2022; 13:5715-5729. [PMID: 35522150 DOI: 10.1039/d2fo00542e] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Knowledge about how molecular properties of proteins affect their digestion kinetics is crucial to understand protein postprandial plasma amino acid (AA) responses. Previously it was found that a native whey protein isolate (NWPI) and heat denatured whey protein isolate (DWPI) elicit comparable postprandial plasma AA peak concentrations in neonatal piglets, while a protein base ingredient for infant formula (PBI, a β-casein-native whey protein mixture) caused a 39% higher peak AA concentration than NWPI. We hypothesized that both whey protein denaturation by heat as well as changing protein composition by including β-casein, increases the rate of intact protein loss, and that changing the protein composition (by including β-casein), but not whey protein denaturation, yields a faster absorbable product release. Therefore NWPI (91% native), DWPI (91% denatured) and PBI hydrolysis was investigated in a semi-dynamic in vitro digestion model (SIM). NWPI and DWPI hydrolysis were also compared in a dynamic digestion model with dialysis (TIM-1) to exclude potential product inhibition effects that may occur in a closed vessel digestion model as SIM. In both models, the degree of hydrolysis (DH), loss of intact protein, and release of absorbable products (SIM: <0.5 kDa peptides and free AA, TIM-1: bioaccessible AA) were monitored. Additionally, in SIM, intermediate product amounts and their characteristics were determined. DWPI showed considerably faster intact protein loss, but similar DH and absorbable product release kinetics compared with NWPI in both models. Furthermore, more, relatively large, intermediate products were released from DWPI than from NWPI. PBI showed increased intact protein loss, similar DH, and absorbable product release kinetics, but more, relatively small, intermediate products than NWPI. In conclusion, both whey protein denaturation and β-casein inclusion increased the rate of intact protein loss without affecting absorbable product release during in vitro digestion. Our results suggest that intermediate digestion product characteristics are important in relation to postprandial AA responses.
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Affiliation(s)
- Evan Abrahamse
- Food Quality and Design, Wageningen University, Wageningen, Netherlands. .,Danone Nutricia Research, Utrecht, Netherlands
| | | | - Ingrid B Renes
- Danone Nutricia Research, Utrecht, Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Peter A Wierenga
- Laboratory of Food Chemistry, Wageningen University, Wageningen, Netherlands
| | - Kasper A Hettinga
- Food Quality and Design, Wageningen University, Wageningen, Netherlands.
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Abrahamse E, Thomassen GGM, Renes IB, Wierenga PA, Hettinga KA. Gastrointestinal Protein Hydrolysis Kinetics: Opportunities for Further Infant Formula Improvement. Nutrients 2022; 14:nu14071512. [PMID: 35406125 PMCID: PMC9003025 DOI: 10.3390/nu14071512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/24/2022] [Accepted: 04/01/2022] [Indexed: 12/10/2022] Open
Abstract
The postprandial plasma essential amino acid (AA) peak concentrations of infant formula (IF) are higher than those of human milk (HM) in infants. In addition, several HM proteins have been recovered intact in infant stool and appeared digestion resistant in vitro. We, therefore, hypothesized that gastrointestinal protein hydrolysis of IF is faster than HM and leads to accelerated absorbable digestion product release. HM and IF protein hydrolysis kinetics were compared in a two-step semi-dynamic in vitro infant digestion model, and the time course of degree of protein hydrolysis (DH), loss of intact protein, and release of free AA and peptides was evaluated. Gastric DH increase was similar for IF and HM, but the rate of intestinal DH increase was 1.6 times higher for IF than HM. Intact protein loss in IF was higher than HM from 120 min gastric phase until 60 min intestinal phase. Intestinal phase total digestion product (free AA + peptides <5 kDa) concentrations increased ~2.5 times faster in IF than HM. IF gastrointestinal protein hydrolysis and absorbable product release are faster than HM, possibly due to the presence of digestion-resistant proteins in HM. This might present an opportunity to further improve IF bringing it closer to HM.
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Affiliation(s)
- Evan Abrahamse
- Danone Nutricia Research, 3584 CT Utrecht, The Netherlands; (G.G.M.T.); (I.B.R.)
- Food Quality and Design Group, Wageningen University and Research, 6708 WG Wageningen, The Netherlands;
- Correspondence:
| | | | - Ingrid B. Renes
- Danone Nutricia Research, 3584 CT Utrecht, The Netherlands; (G.G.M.T.); (I.B.R.)
- Department of Pediatrics, Emma Children’s Hospital, Amsterdam UMC—Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Peter A. Wierenga
- Laboratory of Food Chemistry, Wageningen University and Research, 6708 WG Wageningen, The Netherlands;
| | - Kasper A. Hettinga
- Food Quality and Design Group, Wageningen University and Research, 6708 WG Wageningen, The Netherlands;
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Wollmer E, Ungell AL, Nicolas JM, Klein S. Review of paediatric gastrointestinal physiology relevant to the absorption of orally administered medicines. Adv Drug Deliv Rev 2022; 181:114084. [PMID: 34929252 DOI: 10.1016/j.addr.2021.114084] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/13/2021] [Accepted: 12/13/2021] [Indexed: 12/11/2022]
Abstract
Despite much progress in regulations to improve paediatric drug development, there remains a significant need to develop better medications for children. For the design of oral dosage forms, a detailed understanding of the specific gastrointestinal (GI) conditions in children of different age categories and how they differ from GI conditions in adults is essential. Several review articles have been published addressing the ontogeny of GI characteristics, including luminal conditions in the GI tract of children. However, the data reported in most of these reviews are of limited quality because (1) information was cited from very old publications and sometimes low quality sources, (2) data gaps in the original data were filled with textbook knowledge, (3) data obtained on healthy and sick children were mixed, (4) average data obtained on groups of patients were mixed with data obtained on individual patients, and (5) results obtained using investigative techniques that may have altered the outcome of the respective studies were considered. Consequently, many of these reviews draw conclusions that may be incorrect. The aim of the present review was to provide a comprehensive and updated overview of the available original data on the ontogeny of GI luminal conditions relevant to oral drug absorption in the paediatric population. To this end, the PubMed and Web of Science metadatabases were searched for appropriate studies that examined age-related conditions in the oral cavity, esophagus, stomach, small intestine, and colon. Maturation was observed for several GI parameters, and corresponding data sets were identified for each paediatric age group. However, it also became clear that the ontogeny of several GI traits in the paediatric population is not yet known. The review article provides a robust and valuable data set for the development of paediatric in vitro and in silico biopharmaceutical tools to support the development of age-appropriate dosage forms. In addition, it provides important information on existing data gaps and should provide impetus for further systematic and well-designed in vivo studies on GI physiology in children of specific age groups in order to close existing knowledge gaps and to sustainably improve oral drug therapy in children.
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Schimmoeller ME, Wulf KL, Walker C, Barrett-Reis B, Vurma M. Use of probiotics in the NICU: Evaluating the stability of a three-strain probiotic blend in various media for enteral feeding. J Neonatal Perinatal Med 2022; 15:351-356. [PMID: 34974440 DOI: 10.3233/npm-210796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND There is little published data on how to prepare probiotic supplements for enteral delivery in the NICU. The objective of this study was to determine how a three-strain probiotic blend (Bb-02, TH-4® and BB-12®) would behave when mixed and held for 4 hours with saline water, sterile water, dextrose 5% in water (D5W), 24 kcal preterm formula, and human milk. METHODS A packet of a three-strain probiotic supplement was mixed with 3 mL of saline water, sterile water, D5W, 24 kcal preterm formula, and human milk (tested at 3 mL and 2 mL). Samples were stored at room temperature for 60 minutes then refrigerated for 180 minutes. Probiotic survival, using quantitative enumeration, and pH were monitored over 4 hours. Samples were passed through a 5 French (Fr) feeding tube at the end of the study to evaluate viscosity. RESULTS The largest variation in total cell count from 0-time was sterile water with a + 0.26 log(CFU)/mL change at 90 minutes and typical variation is considered±0.50 log units indicating no significant change between samples in 4 hours. Saline water had the lowest final pH at 4.88. All samples easily passed through a 5 Fr feeding tube. CONCLUSION The study showed minimal change in cell counts across solutions for 4 hours of storage, indicating health care facilities may be able to prepare probiotic supplements with a variety of solutions in pharmacies or milk rooms. This allows greater flexibility for probiotic delivery to preterm infants.
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Affiliation(s)
| | - K L Wulf
- Abbott Nutrition, Columbus, Ohio, USA
- Nationwide Children's Hospital, Columbus, Ohio, USA
| | - C Walker
- Abbott Nutrition, Columbus, Ohio, USA
| | | | - M Vurma
- Abbott Nutrition, Columbus, Ohio, USA
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Human milk triggers coagulation via tissue factor-exposing extracellular vesicles. Blood Adv 2021; 4:6274-6282. [PMID: 33351123 DOI: 10.1182/bloodadvances.2020003012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022] Open
Abstract
Almost a century ago, it was discovered that human milk activates the coagulation system, but the milk component that triggers coagulation had until now been unidentified. In the present study, we identify this component and demonstrate that extracellular vesicles (EVs) present in normal human milk expose coagulant tissue factor (TF). This coagulant activity withstands digestive conditions, mimicking those of breastfed infants, but is sensitive to pasteurization of pooled donor milk, which is routinely used in neonatal intensive care units. In contrast to human milk, bovine milk, the basis of most infant formulas, lacks coagulant activity. Currently, the physiological function of TF-exposing vesicles in human milk is unknown, but we speculate that these vesicles may be protective for infants. Another explanation could be nipple skin damage, which occurs in most breastfeeding women. Milk-derived TF-exposing EVs may seal the wound and thereby reduce bleeding and breast inflammation.
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Gewolb IH, Vice FL. Use of a non-invasive accelerometric method for diagnosing gastroesophageal reflux in premature infants. J Perinatol 2021; 41:1879-1885. [PMID: 33758392 PMCID: PMC8342305 DOI: 10.1038/s41372-021-01034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate the clinical usefulness of a non-invasive accelerometric device to diagnose GER in preterm babies. STUDY DESIGN An accelerometer was taped over the sub-xiphoid process in 110 preterm (GA 29.6 ± 3.3 wk) infants (133 studies). Low frequency, sub-audible signals were captured via digital recording (sampling rate 200 Hz), then re-sampled (rate = 60 Hz) to create a spectrogram (focused range 0-30 Hz). Mean amplitude in the focused range was calculated. RESULTS Of 85 studies with simultaneous pH-metry and accelerometry, 18 had concurrent positive and 23 had concurrent negative scores, 42 had negative pH scores when accelerometry was positive (≥1 µV), consistent with non-acid reflux. Eleven infants at high risk of aspiration received surgical interventions. All but 1 had negative pH scores while 10/11 had positive accelerometry. CONCLUSIONS The non-invasiveness of this accelerometric technique allows for GER screening and for repeated testing to assess efficacy of interventions.
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Affiliation(s)
- Ira H. Gewolb
- grid.17088.360000 0001 2150 1785Division of Neonatology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI USA
| | - Frank L. Vice
- grid.17088.360000 0001 2150 1785Division of Neonatology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI USA
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Lynch R, Burke A, Byrne J, Buckin V. Osmolality and molar mass of oligosaccharides in breast milks and infant formula during hydrolysis of lactose. Application of high-resolution ultrasonic spectroscopy. Food Chem 2020; 322:126645. [DOI: 10.1016/j.foodchem.2020.126645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
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Wang LJ, Hu Y, Wang W, Zhang CY, Bai YZ, Zhang SC. Gastroesophageal Reflux Poses a Potential Risk for Late Complications of Bronchopulmonary Dysplasia: A Prospective Cohort Study. Chest 2020; 158:1596-1605. [PMID: 32450238 DOI: 10.1016/j.chest.2020.05.523] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/17/2020] [Accepted: 05/09/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is the most common respiratory disorder in extremely low birth weight infants. Although most symptoms of BPD improve, some late complications exist, even with regular treatment. Gastroesophageal reflux (GER), also common in extremely premature infants, may be related to many cardiorespiratory symptoms. However, the potential of GER as a risk factor for late complications associated with BPD is still unclear. RESEARCH QUESTION The goal of this study was to determine if GER increases the risk of late complications of BPD in infants. STUDY DESIGN AND METHODS A multicenter prospective cohort of 131 infants (79 male subjects, 52 female subjects) with BPD was enrolled. The development of late complications was assessed over an 18-month follow-up period. Twenty-four-hour pH-multichannel intraluminal impedance and gastric sodium concentrations were analyzed in all infants at 36 weeks' postmenstrual age and at the last interview. Prevalence and risk factors of late complications of BPD were analyzed by using forward logistic regression. RESULTS The prevalence of late complications in BPD infants was 63.79% and included respiratory symptoms (49.14%), vomiting (38.79%), retinopathy of prematurity (25.86%), hypoxic-ischemic injury (3.45%), rehospitalization (26.72%), and sudden death (0.86%). Respiratory diseases constituted the most frequent complication. The prevalence of GER in BPD was 42.24% and included acid GER (18.10%) and duodenogastroesophageal reflux (DGER; 24.14%). Risk factors for respiratory symptoms were gestational age ≤ 30 weeks (OR, 3.213; 95% CI, 1.221-8.460), birth weight < 1,500 g (OR, 2.803; 95% CI, 1.014-7.749), invasive ventilation > 7 days (OR, 4.952; 95% CI, 1.508-16.267), acid GER (OR, 4.630; 95% CI, 1.305-16.420), and DGER (OR, 5.588; 95% CI, 1.770-17.648). Infants with BPD and DGER were more prone to late complications than those with acid GER or no reflux. INTERPRETATION The prevalence of late complications is high in infants with BPD. GER (and in particular, DGER) poses a tentative risk for these late complications. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03014453; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Luo-Jia Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China; Department of Pediatrics, Shanghai General Hospital of Shanghai Jiao Tong University, Shanghai, China
| | - Yu Hu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wei Wang
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang, China
| | - Chun-Yan Zhang
- Department of Pediatrics, the First Hospital of Jilin University, Changchun, China
| | - Yu-Zuo Bai
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shu-Cheng Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China.
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Gewolb IH, Vice FL. A New, Noninvasive Accelerometric Method for Diagnosing Acid andNon-Acid Gastroesophageal Reflux in Premature Infants: Proof of Concept. J Med Device 2019; 13:0445051-445057. [PMID: 32280407 DOI: 10.1115/1.4044902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/09/2019] [Indexed: 02/01/2023] Open
Abstract
Non-acid reflux is common in premature neonates. Current methods of diagnosing gastroesophageal reflux (GER) such as pH probes, multichannel impedance monitoring, X-rays, or endoscopy are either invasive or unable to diagnose non-acid reflux. Passage of a naso-esophageal tube is uncomfortable. Imaging studies are of short duration and may miss reflux entirely. Herein, we present proof of concept of a noninvasive accelerometric device that detects acid and non-acid reflux in premature infants. An accelerometer was taped over the subxiphoid process in patients suspected of having GER who were already scheduled for pH probe or multichannel impedance monitoring. The largest cohort was preterm infants, but term infants and toddlers were also studied. Low-frequency subaudible signals were obtained on a digital recorder (sampling rate 200 Hz) signals. Fast Fourier transforms graphically displayed the frequency and amplitude of signals. Data were then resampled at a rate of 60 Hz to create a spectrogram with a focused range of 0-30 Hz representing reflux-associated events. Proof of concept was attained through successful comparison with results from concurrent pH probes, multichannel impedance recordings, and ultrasound studies. We have thus validated accelerometry as a noninvasive method for assessing both acid and non-acid GER. The noninvasiveness of this diagnostic modality allows for repeated testing to assess the efficacy of anti-reflux medications, even when patients remain on antacids. This technology allows for more rational management of patients with GER and represents a major advance in the diagnosis and treatment of GER.
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Affiliation(s)
- Ira H Gewolb
- Division of Neonatology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI 48824
| | - Frank L Vice
- Division of Neonatology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI 48824
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21
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Gan J, Zheng J, Krishnakumar N, Goonatilleke E, Lebrilla CB, Barile D, German JB. Selective Proteolysis of α-Lactalbumin by Endogenous Enzymes of Human Milk at Acidic pH. Mol Nutr Food Res 2019; 63:e1900259. [PMID: 31271254 PMCID: PMC7231428 DOI: 10.1002/mnfr.201900259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/03/2019] [Indexed: 01/01/2023]
Abstract
SCOPE The use of human milk products is increasing for high-risk infants. Human milk contains endogenous enzymes that comprise a dynamic proteolytic system, yet biological properties of these enzymes and their activities in response to variations including pH within infants are unclear. Human milk has a neutral pH around 7, while infant gastric pH varies from 2 to 6 depending on individual conditions. This study is designed to determine the specificity of enzyme-substrate interactions in human milk as a function of pH. METHODS AND RESULTS Endogenous proteolysis is characterized by incubating freshly expressed human milk at physiologically relevant pH ranging from 2 to 7 without the addition of exogenous enzymes. Results show that the effects of pH on endogenous proteolysis in human milk are protein-specific. Further, specific interactions between cathepsin D and α-lactalbumin are confirmed. The endogenous enzyme cathepsin D in human milk cleaves α-lactalbumin as the milk pH shifts from 7 to 3. CONCLUSIONS This study documents that selective proteolysis activated by pH shift is a mechanism for dynamic interactions between human milk and the infant. Controlled proteolysis can guide the use of human milk products based on individual circumstance.
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Affiliation(s)
- Junai Gan
- Department of Food Science and Technology, University of California, Davis, CA, USA
| | - Jingyuan Zheng
- Department of Nutrition, University of California, Davis, CA, USA
| | - Nithya Krishnakumar
- Department of Food Science and Technology, University of California, Davis, CA, USA
| | | | - Carlito B. Lebrilla
- Department of Chemistry, University of California, Davis, CA, USA
- Foods for Health Institute, University of California, Davis, CA, USA
| | - Daniela Barile
- Department of Food Science and Technology, University of California, Davis, CA, USA
- Foods for Health Institute, University of California, Davis, CA, USA
| | - J. Bruce German
- Department of Food Science and Technology, University of California, Davis, CA, USA
- Foods for Health Institute, University of California, Davis, CA, USA
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22
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van Lennep M, Singendonk MMJ, Dall'Oglio L, Gottrand F, Krishnan U, Terheggen-Lagro SWJ, Omari TI, Benninga MA, van Wijk MP. Oesophageal atresia. Nat Rev Dis Primers 2019; 5:26. [PMID: 31000707 DOI: 10.1038/s41572-019-0077-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Oesophageal atresia (EA) is a congenital abnormality of the oesophagus that is caused by incomplete embryonic compartmentalization of the foregut. EA commonly occurs with a tracheo-oesophageal fistula (TEF). Associated birth defects or anomalies, such as VACTERL association, trisomy 18 or 21 and CHARGE syndrome, occur in the majority of patients born with EA. Although several studies have revealed signalling pathways and genes potentially involved in the development of EA, our understanding of the pathophysiology of EA lags behind the improvements in surgical and clinical care of patients born with this anomaly. EA is treated surgically to restore the oesophageal interruption and, if present, ligate and divide the TEF. Survival is now ~90% in those born with EA with severe associated anomalies and even higher in those born with EA alone. Despite these achievements, long-term gastrointestinal and respiratory complications and comorbidities in patients born with EA are common and lead to decreased quality of life. Oesophageal motility disorders are probably ubiquitous in patients after undergoing EA repair and often underlie these complications and comorbidities. The implementation of several new diagnostic and screening tools in clinical care, including high-resolution impedance manometry, pH-multichannel intraluminal impedance testing and disease-specific quality of life questionnaires now provide better insight into these problems and may contribute to better long-term outcomes in the future.
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Affiliation(s)
- Marinde van Lennep
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Maartje M J Singendonk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesu Children's Hospital-IRCCS, Rome, Italy
| | - Fréderic Gottrand
- CHU Lille, University Lille, National Reference Center for Congenital Malformation of the Esophagus, Department of Pediatric Gastroenterology Hepatology and Nutrition, Lille, France
| | - Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Discipline of Paediatrics, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Suzanne W J Terheggen-Lagro
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Pulmonology, Amsterdam, The Netherlands
| | - Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Center for Neuroscience, Flinders University, Adelaide, South Australia, Australia
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands.
| | - Michiel P van Wijk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Pediatric Gastroenterology, Amsterdam, The Netherlands
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Variations in gastrointestinal lipases, pH and bile acid levels with food intake, age and diseases: Possible impact on oral lipid-based drug delivery systems. Adv Drug Deliv Rev 2019; 142:3-15. [PMID: 30926476 DOI: 10.1016/j.addr.2019.03.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/27/2019] [Accepted: 03/25/2019] [Indexed: 12/21/2022]
Abstract
The lipids and some surfactants present in oral lipid-based drug delivery systems are potential substrates for the various lipases involved in gastrointestinal (GI) lipolysis. The levels of these enzymes, together with pH and biliairy secretion, are important parameters that condition the fate of lipid-based formulations (LBF) and the dispersion, solubilization and absorption of lipophilic drugs in the GI tract. Since in vitro methods of digestion are now combined with dissolution assays for a better assessment of LBF performance, it is essential to have a basic knowledge on lipase, pH and bile acid (BA) levels in vivo to develop relevant in vitro models. While these parameters and their variations in healthy subjects are today well documented, in vivo data on specific populations (age groups, patients with various diseases, patients with treatment affecting GI tract parameters, …) are scarce and obtaining them from clinical studies is sometimes difficult due to ethical limitations. Here we collected some in vivo data already available on the levels of digestive lipases, gastric and intestinal pH, and BAs at various ages and in patients with exocrine pancreatic insufficiency, a pathological situation that leads to drastic changes in GI tract parameters and impacts pharmacological treatments.
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Pulsed-Field Gel Electrophoresis Used for Typing of Extended-Spectrum-β-Lactamases- Producing Escherichia coli Isolated from Infant ҆S Respiratory and Digestive System. MACEDONIAN VETERINARY REVIEW 2018. [DOI: 10.2478/macvetrev-2018-0016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Abstract
Escherichia coli infections are becoming increasingly difficult to treat because of emerging antimicrobial resistance, mostly to expanded-spectrum cephalosporins, due to the production of extended-spectrum β-lactamases (ESBLs).Despite extensive studies of ESBL- producing E.coli in adult patients, there is a lack of information about the epidemiology and spread of ESBL organisms in pediatric population. The aim of this study was to examine the gastrointestinal tract as an endogenous reservoir for the respiratory tract colonization with ESBL- E. coli in children, hospitalized because of the severity of the respiratory illness. The study group consists of 40 children with ESBL-producing E. coli strains isolated from the sputum and from the rectal samples. A control group of 15 E. coli isolated from rectal swabs of healthy children were included in the analysis. The comparison of the strains was done by using antimicrobial susceptibility patterns of the stains, and pulsed field gel electrophoresis was performed for molecular typing, using XbaI digestion. 90% of the compared pairs of strains in the study group were with identical antimicrobial susceptibility patterns and indistinguishable in 79.2% by the obtained PFGE – profiles.33.3% (5/15) of confirmed E. coli strains from the control group were found to be ESBL – producers. Resulting band profiles of all isolates demonstrated presence of 12 pulsotypes, with 100% similarity within the pulsotypes. Although, some isolates obtained from different patients were genetically indistinguishable, these strains were not hospital acquired, as none of the patients satisfied the criteria for hospital acquired pneumonia, and there was a lack of an obvious transmission chain. All ESBL –E. coli isolated from sputum in clinical cases were obtained from patients under the age of one. According to the resistance profile of the compared pairs and the PFGE comparison of all isolates, it can be concluded that the gastrointestinal tract is the main reservoir of ESBL-E. coli. Small age in infants is a risk factor for translocation of bacteria, enabling the colonization of the respiratory tract.
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Eichenwald EC, Cummings JJ, Aucott SW, Goldsmith JP, Hand IL, Juul SE, Poindexter BB, Puopolo KM, Stewart DL. Diagnosis and Management of Gastroesophageal Reflux in Preterm Infants. Pediatrics 2018; 142:peds.2018-1061. [PMID: 29915158 DOI: 10.1542/peds.2018-1061] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Gastroesophageal reflux (GER), generally defined as the passage of gastric contents into the esophagus, is an almost universal phenomenon in preterm infants. It is a common diagnosis in the NICU; however, there is large variation in its treatment across NICU sites. In this clinical report, the physiology, diagnosis, and symptomatology in preterm infants as well as currently used treatment strategies in the NICU are examined. Conservative measures to control reflux, such as left lateral body position, head elevation, and feeding regimen manipulation, have not been shown to reduce clinically assessed signs of GER in the preterm infant. In addition, preterm infants with clinically diagnosed GER are often treated with pharmacologic agents; however, a lack of evidence of efficacy together with emerging evidence of significant harm (particularly with gastric acid blockade) strongly suggest that these agents should be used sparingly, if at all, in preterm infants.
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Affiliation(s)
| | - James J. Cummings
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan Wright Aucott
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jay P. Goldsmith
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ivan L. Hand
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sandra E. Juul
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Karen M. Puopolo
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dan L. Stewart
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Johnson T, Bonner J, Tucker G, Turner D, Jamei M. Development and applications of a physiologically-based model of paediatric oral drug absorption. Eur J Pharm Sci 2018; 115:57-67. [DOI: 10.1016/j.ejps.2018.01.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 12/18/2017] [Accepted: 01/03/2018] [Indexed: 11/30/2022]
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Rossor T, Andradi G, Bhat R, Greenough A. Investigation and management of gastro-oesophageal reflux in United Kingdom neonatal intensive care units. Acta Paediatr 2018; 107:48-51. [PMID: 28901635 DOI: 10.1111/apa.14073] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/30/2017] [Accepted: 09/08/2017] [Indexed: 11/30/2022]
Abstract
AIM In 2004, wide variation in the investigation and management of gastro-oesophageal reflux (GOR) of infants on UK major neonatal units was demonstrated. Our aim was to resurvey neonatal practitioners to determine current practice and whether it was now evidence based. METHODS A questionnaire was sent to all 207 UK neonatal units. RESULTS Responses were obtained from 84% of units. The most frequent 'investigation' was a trial of therapy (83% of units); pH studies were used in 38%, upper GI contrast studies in 19% and multichannel intraluminal impedance (MII)/pH studies in 5%. Only six units suggested a threshold for an abnormal pH study and two units for an abnormal MII study. Infants were commenced on antireflux medication without investigation always in 32% of units, often in 29%, occasionally in 19% and only never in 1%. Gaviscon was used as first line treatment in 60% of units, and other medications included ranitidine in 53%, thickening agents in 27%, proton pump inhibitors in 23%, domperidone in 22% and erythromycin in 6%. CONCLUSION There remains a wide variation in diagnostic and treatment strategies for infants with suspected GOR on neonatal intensive care units, emphasising the need for randomised trials to determine appropriate GOR management.
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Affiliation(s)
- Thomas Rossor
- Division of Asthma, Allergy and Lung Biology; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; King's College London; London UK
| | - Gwendolyn Andradi
- Division of Asthma, Allergy and Lung Biology; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; King's College London; London UK
| | - Ravindra Bhat
- Neonatal Intensive Care Centre; King's College Hospital NHS Foundation Trust; London UK
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma; King's College London; London UK
- NIHR Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust and King's College London; London UK
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Prachuapthunyachart S, Jarasvaraparn C, Gremse DA. Correlation of Gastroesophageal reflux disease Assessment Symptom Questionnaire to impedance-pH measurements in children. SAGE Open Med 2017; 5:2050312117745221. [PMID: 29276590 PMCID: PMC5734562 DOI: 10.1177/2050312117745221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/06/2017] [Indexed: 11/15/2022] Open
Abstract
Background Esophageal multichannel intraluminal impedance-pH monitoring has become one of the preferred tests to correlate observed reflux-like behaviors with esophageal reflux events. The Gastroesophageal reflux disease Assessment Symptom Questionnaire is a validated tool used to distinguish infants with gastroesophageal reflux disease from healthy children. The aim of this study was to determine whether the Gastroesophageal reflux disease Assessment Symptom Questionnaire composite symptom scores and individual symptom scores correlate with outcomes in esophageal multichannel intraluminal impedance-pH monitoring. Methods A total of 26 patients with gastroesophageal reflux disease-associated symptoms, aged 0-2 years, for whom both esophageal multichannel intraluminal impedance-pH monitoring and Gastroesophageal reflux disease Assessment Symptom Questionnaire survey results were available were included in the study. Gastroesophageal reflux disease Assessment Symptom Questionnaire score data were collected from a 7-day recall of parent's responses about the frequency and severity of gastroesophageal reflux disease symptoms, which determined the individual symptom scores. The composite symptom scores is the sum of all individual symptom scores. Multichannel intraluminal impedance-pH study results were compared to Gastroesophageal reflux disease Assessment Symptom Questionnaire data using Pearson correlation. Results Among 26 patients, a total number of 2817 (1700 acid and 1117 non-acid) reflux episodes and 845 clinical reflux behaviors were recorded. There were significant correlations between the reflux index and the individual symptom scores for coughing/gagging/choking (r2 = 0.2842, p = 0.005), the impedance score and individual symptom scores for coughing/gagging/choking (r2 = 0.2482, p = 0.009), the reflux symptom index for acid reflux-related coughing/gagging/choking and the individual symptom scores for coughing/gagging/choking (r2 = 0.1900, p = 0.026), the impedance score and individual symptom scores for vomiting (r2 = 0.1569, p = 0.045), and the impedance score and the composite symptom scores (r2 = 0.2916, p = 0.004). However, there were no significant correlations between fussiness, irritability, or abdominal pain-related multichannel intraluminal impedance-pH results and the individual symptom scores for abdominal pain. Conclusion The impedance scores from multichannel intraluminal impedance-pH studies correlate with coughing/gagging/choking and vomiting in infants with gastroesophageal reflux disease. There are no significant correlations among the reflux index and impedance score versus the Gastroesophageal reflux disease Assessment Symptom Questionnaire scores for abdominal pain. We conclude that in infants with gastroesophageal reflux disease, multichannel intraluminal impedance-pH studies are more likely to demonstrate an association between gastroesophageal reflux disease and symptoms of coughing, gagging, or choking compared to an association between gastroesophageal reflux disease and pain in infants.
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Affiliation(s)
| | | | - David A Gremse
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of South Alabama, Mobile, AL, USA
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30
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Witkowski PT, Perley CC, Brocato RL, Hooper JW, Jürgensen C, Schulzke JD, Krüger DH, Bücker R. Gastrointestinal Tract As Entry Route for Hantavirus Infection. Front Microbiol 2017; 8:1721. [PMID: 28943870 PMCID: PMC5596106 DOI: 10.3389/fmicb.2017.01721] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/24/2017] [Indexed: 12/21/2022] Open
Abstract
Background: Hantaviruses are zoonotic agents that cause hemorrhagic fevers and are thought to be transmitted to humans by exposure to aerosolized excreta of infected rodents. Puumala virus (PUUV) is the predominant endemic hantavirus in Europe. A large proportion of PUUV-infected patients suffer from gastrointestinal symptoms of unclear origin. In this study we demonstrate that PUUV infection can occur via the alimentary tract. Methods: We investigated susceptibility of the human small intestinal epithelium for PUUV infection and analyzed the resistance of virions to gastric juice. As model for intestinal virus translocation we performed infection experiments with human intestinal Caco-2 monolayers. In animal experiments we infected Syrian hamsters with PUUV via the intragastric route and tested seroconversion and protective immunity against subsequent Andes virus challenge. Results: PUUV retained infectivity in gastric juice at pH >3. The virus invaded Caco-2 monolayers in association with endosomal antigen EEA1, followed by virus replication and loss of epithelial barrier function with basolateral virus occurrence. Cellular disturbance and depletion of the tight junction protein ZO-1 appeared after prolonged infection, leading to paracellular leakage (leak flux diarrhea). Moreover, animal experiments led to dose-dependent seroconversion and protection against lethal Andes virus challenge. Conclusions: We provide evidence that hantavirus can infect the organism via the alimentary tract and suggest a novel aspect of hantavirus infection and pathogenesis. Significance: Hantaviruses are zoonotic pathogens causing severe hemorrhagic fevers worldwide. They are transmitted to humans by small mammals. To date, these viruses were thought to infect exclusively through the airborne route by inhalation of aerosols from infectious animal droppings or by rodent bites. In our work we could show that the alimentary tract is an alternative path of infection for hantaviruses, meaning a new association of virus and disease. These findings have impact on current textbook knowledge and bring many implications for hantavirus epidemiology and outbreak prevention measures.
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Affiliation(s)
- Peter T Witkowski
- Institute of Virology, Charité - Universitätsmedizin BerlinBerlin, Germany
| | - Casey C Perley
- Virology Division, United States Army Medical Research Institute of Infectious DiseasesFort Detrick, MD, United States
| | - Rebecca L Brocato
- Virology Division, United States Army Medical Research Institute of Infectious DiseasesFort Detrick, MD, United States
| | - Jay W Hooper
- Virology Division, United States Army Medical Research Institute of Infectious DiseasesFort Detrick, MD, United States
| | - Christian Jürgensen
- Division of Hepatology and Gastroenterology, Charité - Universitätsmedizin BerlinBerlin, Germany
| | - Jörg-Dieter Schulzke
- Institute of Clinical Physiology, Charité - Universitätsmedizin BerlinBerlin, Germany
| | - Detlev H Krüger
- Institute of Virology, Charité - Universitätsmedizin BerlinBerlin, Germany
| | - Roland Bücker
- Institute of Clinical Physiology, Charité - Universitätsmedizin BerlinBerlin, Germany
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Felice VD, O'Mahony SM. The microbiome and disorders of the central nervous system. Pharmacol Biochem Behav 2017; 160:1-13. [PMID: 28666895 DOI: 10.1016/j.pbb.2017.06.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 06/12/2017] [Accepted: 06/26/2017] [Indexed: 02/07/2023]
Abstract
Alterations of the gut microbiota have been associated with stress-related disorders including depression and anxiety and irritable bowel syndrome (IBS). More recently, researchers have started investigating the implication of perturbation of the microbiota composition in neurodevelopmental disorders including autism spectrum disorders and Attention-Deficit Hypersensitivity Disorder (ADHD). In this review we will discuss how the microbiota is established and its functions in maintaining health. We also summarize both pre and post-natal factors that shape the developing neonatal microbiota and how they may impact on health outcomes with relevance to disorders of the central nervous system. Finally, we discuss potential therapeutic approaches based on the manipulation of the gut bacterial composition.
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Affiliation(s)
- Valeria D Felice
- Department of Pharmacology and Therapeutics, University College Cork, Cork, Ireland
| | - Siobhain M O'Mahony
- APC Microbiome Institute, University College Cork, Cork, Ireland; Department of Anatomy and Neuroscience, University College Cork, Cork, Ireland.
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Bar-Sever Z. Scintigraphic Evaluation of Gastroesophageal Reflux and Pulmonary Aspiration in Children. Semin Nucl Med 2017; 47:275-285. [PMID: 28417856 DOI: 10.1053/j.semnuclmed.2016.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Gastroesophageal reflux (GER) and pulmonary aspiration are encountered in children of all ages. Signs, symptoms, and complications vary from mild and transient to severe life-threatening conditions. This review will present relevant clinical information on these conditions as well as common diagnostic procedures. The role of scintigraphic techniques used in the evaluation of these conditions will be discussed in detail including protocols and performance in comparison to other diagnostic methods.
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Affiliation(s)
- Zvi Bar-Sever
- Department of nuclear medicine, Schneider Children's Medical Center, Petah Tikva, Israel.
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Fortunato JE, D'Agostino RB, Lively MO. Pepsin in saliva as a biomarker for oropharyngeal reflux compared with 24-hour esophageal impedance/pH monitoring in pediatric patients. Neurogastroenterol Motil 2017; 29. [PMID: 27604397 DOI: 10.1111/nmo.12936] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/06/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pepsin in saliva is a proposed biomarker for oropharyngeal reflux. Pepsin may be prevalent in saliva from subjects with gastro-esophageal reflux and may correlate with proximal reflux by intraluminal impedance/pH monitoring (MII/pH). METHODS Patients (3 days to 17.6 years, n=90) undergoing 24-hour MII/pH monitoring and asymptomatic controls (2 months to 13.7 years, n=43) were included. Salivary pepsin was determined using a pepsin enzyme-linked immunosorbent assay. Eight saliva samples were collected from patients undergoing 24-hr MII/pH: (i) before catheter placement, (ii) before and 30 minutes after each of three meals, and (iii) upon awakening. One sample was collected from each control. KEY RESULTS In MII/pH subjects, 85.6% (77/90) had at least one pepsin-positive sample compared with 9.3% (4/43) in controls. The range of pepsin observed in individual subjects varied widely over 24 hours. The average pepsin concentration in all samples obtained within 2 hours following the most recent reflux event was 30.7±135 ng/mL, decreasing to 16.5±39.1 ng/mL in samples collected more than 2 hours later. The frequency of pepsin-positive samples correlated significantly with symptom index (rS =0.332, P=.0014), proximal (rS =0.340, P=.0010), and distal (rS =0.272, P=.0095) MII events. CONCLUSIONS & INFERENCES Concentration of salivary pepsin may not be an accurate measure of severity of reflux because of the wide range observed in individuals over 24 hours. Saliva samples must be obtained soon after a reflux event. Defining a regimen for optimal saliva collection may help to achieve the goal of using salivary pepsin as a biomarker for oropharyngeal reflux. CLINICAL TRIAL REGISTRY NCT01091805.
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Affiliation(s)
- J E Fortunato
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - R B D'Agostino
- Department of Biostatistical Sciences, Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - M O Lively
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Dose-Finding Study of Omeprazole on Gastric pH in Neonates with Gastro-Esophageal Acid Reflux Using a Bayesian Sequential Approach. PLoS One 2016; 11:e0166207. [PMID: 28002471 PMCID: PMC5176365 DOI: 10.1371/journal.pone.0166207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 10/19/2016] [Indexed: 11/23/2022] Open
Abstract
Objective Proton pump inhibitors are frequently administered on clinical symptoms in neonates but benefit remains controversial. Clinical trials validating omeprazole dosage in neonates are limited. The objective of this trial was to determine the minimum effective dose (MED) of omeprazole to treat pathological acid reflux in neonates using reflux index as surrogate marker. Design Double blind dose-finding trial with continual reassessment method of individual dose administration using a Bayesian approach, aiming to select drug dose as close as possible to the predefined target level of efficacy (with a credibility interval of 95%). Setting Neonatal Intensive Care unit of the Robert Debré University Hospital in Paris, France. Patients Neonates with a postmenstrual age ≥ 35 weeks and a pathologic 24-hour intra-esophageal pH monitoring defined by a reflux index ≥ 5% over 24 hours were considered for participation. Recruitment was stratified to 3 groups according to gestational age at birth. Intervention Five preselected doses of oral omeprazole from 1 to 3 mg/kg/day. Main outcome measures Primary outcome, measured at 35 weeks postmenstrual age or more, was a reflux index <5% during the 24-h pH monitoring registered 72±24 hours after omeprazole initiation. Results Fifty-four neonates with a reflux index ranging from 5.06 to 27.7% were included. Median age was 37.5 days and median postmenstrual age was 36 weeks. In neonates born at less than 32 weeks of GA (n = 30), the MED was 2.5mg/kg/day with an estimated mean posterior probability of success of 97.7% (95% credibility interval: 90.3–99.7%). The MED was 1mg/kg/day for neonates born at more than 32 GA (n = 24). Conclusions Omeprazole is extensively prescribed on clinical symptoms but efficacy is not demonstrated while safety concerns do exist. When treatment is required, the daily dose needs to be validated in preterm and term neonates. Optimal doses of omeprazole to increase gastric pH and decrease reflux index below 5% over 24 hours, determined using an adaptive Bayesian design differ among neonates. Both gestational and postnatal ages account for these differences but their differential impact on omeprazole doses remains to be determined.
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Combined Multichannel Intraluminal Impedance and pH Measurement in Detecting Gastroesophageal Reflux Disease in Children. J Pediatr Gastroenterol Nutr 2016; 63:e98-e106. [PMID: 27574881 DOI: 10.1097/mpg.0000000000001396] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate and compare multichannel intraluminal impedance-pH (MII-pH) monitoring with standard investigations including pH testing for detecting gastroesophageal reflux disease (GERD) in children. METHODS A retrospective review of all MII-pH studies performed between July 2007 and March 2013 at Sydney Children's Hospital. Results from MII-pH testing, esophagogastroduodenoscopy (EGD), barium meal and pepsin assay, symptoms, underlying comorbidities, age, and medication usage were evaluated. RESULTS An additional 47.18% of children had GERD detected by MII-pH testing, which would have been missed by pH testing alone. Based on symptomatology, 50.49% of children with respiratory symptoms as a result of GERD and 47.54% of those with gastrointestinal symptoms would have been missed by pH testing alone. GERD was detected in an additional 39.47% of children with neurological impairment, 44.44% for those with cystic fibrosis, and 52.17% for those with esophageal atresia-tracheoesophageal fistula by MII-pH. In patients with persistent symptoms on anti-reflux medication, GERD would have been missed by pH testing alone in 50.40%. GERD was detected in an additional 62.79% of infants and 42.76% of older children by MII-pH compared with pH testing alone. With reference to MII-pH, the sensitivity of other standard investigations, pH testing (32.35%), barium meal (25.00%), EGD (45.26%), and pepsin assay (48.89%) was significantly lower in the detection of GERD in children. Of all abnormal MII-pH results, 51.1% were abnormal because of symptom association alone. CONCLUSIONS Combined MII-pH testing is superior to standard investigations such as 24-hour pH testing, barium meal, EGD, and pepsin assay in detecting GERD in children, particular because of its ability to associate symptoms with acid and non-acid reflux events.
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Holder pasteurization impacts the proteolysis, lipolysis and disintegration of human milk under in vitro dynamic term newborn digestion. Food Res Int 2016. [DOI: 10.1016/j.foodres.2015.11.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Neonatal Histamine-2 Receptor Antagonist and Proton Pump Inhibitor Treatment at United States Children's Hospitals. J Pediatr 2016; 174:63-70.e3. [PMID: 27131401 PMCID: PMC4925209 DOI: 10.1016/j.jpeds.2016.03.059] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/15/2016] [Accepted: 03/23/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine treatment frequency and duration of histamine-2 receptor antagonist (H2RA)/proton pump inhibitor (PPI) use among infants hospitalized within US children's hospital neonatal intensive care units and evaluate diagnoses/demographic factors associated with use. STUDY DESIGN We retrospectively analyzed a cohort of neonatal intensive care unit infants admitted to 43 US children's hospitals within the Pediatric Health Information System database between January 2006 and March 2013 to determine H2RA/PPI treatment frequency, timing/duration of treatment, factors associated with use, percent of infants remaining on treatment at discharge, and interhospital prescribing variation. We used a modified Poisson regression to calculate the adjusted probability of infants ever receiving H2RAs/PPIs in relation to diagnosis, gestation, and sex. RESULTS Of the 122 002 infants evaluated, 23.8% (n = 28 989) ever received an H2RA or PPI; 19.0% received H2RAs (n = 23 187), and 10.5% (n = 12 823) received PPIs. Extremely preterm infants and term infants were the most likely to receive H2RA and PPI treatment. Infants with gastroesophageal reflux disease (relative risk [RR] = 3.13) and congenital heart disease (RR = 2.41) had the highest H2RA/PPI treatment probabilities followed by those with an ear, nose, and throat diagnosis (RR = 2.34; P < .05). The majority of treated infants remained treated at discharge. CONCLUSIONS Despite limited evidence and increasing safety concerns, H2RAs/PPIs are frequently prescribed to extremely preterm neonates and those with congenital anomalies and continued through discharge. Our findings support the need for innovative studies to examine the comparative effectiveness and safety of H2RA/PPIs vs no treatment in these high-risk neonatal populations.
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Hallal C, Chaves VS, Borges GC, Werlang IC, Fontella FU, Matte U, Goldani MZ, Carvalho PR, Trotta EA, Piva JP, Barros SGS, Goldani HAS. Acid and Weakly Acidic Gastroesophageal Reflux and Pepsin Isoforms (A and C) in Tracheal Secretions of Critically Ill Children. Chest 2015; 148:333-339. [PMID: 25654241 DOI: 10.1378/chest.14-1967] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux (GER) and pulmonary aspiration are frequent in patients in the ICU. The presence of pepsin in airways seems to be the link between them. However, pepsin isoforms A (gastric specific) and C (pneumocyte potentially derived) need to be distinguished. This study aimed to evaluate GER patterns and to determine the presence of pepsin A and C in tracheal secretions of critically ill children receiving mechanical ventilation. METHODS All patients underwent combined multichannel intraluminal impedance-pH (MII-pH) monitoring. Tracheal secretion samples were collected to determine the presence of pepsin. Pepsin A and C were evaluated by Western blot. MII-pH parameters analyzed were number of total GER episodes (NGER); acid, weakly acidic, and weakly alkaline GER episodes; and proximal and distal GER episodes. RESULTS Thirty-four patients (median age, 4 months; range, 1-174 months) were included. MII-pH monitoring detected 2,172 GER episodes (77.0% were weakly acidic; 71.7% were proximal). The median NGER episodes per patient was 59.5 (25th-75th percentile, 20.3-85.3). Weakly acidic GER episodes per patient were significantly more frequent than acid GER episodes per patient (median [25th-75th percentile], 43.5 [20.3-68.3] vs 1.0 [0-13.8], respectively; P < .001). Only three patients had an altered acid reflux index (44.9%, 12.7%, and 13.6%) while not taking antacid drugs. Pepsin A was found in 100% of samples and pepsin C in 76.5%. CONCLUSIONS The majority of GER episodes of children in the ICU were proximal and weakly acidic. All patients had aspiration of gastric contents as detected by pepsin A in tracheal fluid. A specific pepsin assay should be performed to establish gastropulmonary aspiration because pepsin C was found in > 70% of samples.
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Affiliation(s)
- Cristiane Hallal
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil; Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil.
| | - Veridiana S Chaves
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Gilberto C Borges
- Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Isabel C Werlang
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Fernanda U Fontella
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Ursula Matte
- Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Marcelo Z Goldani
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Paulo R Carvalho
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Eliana A Trotta
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Jefferson P Piva
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Sergio G S Barros
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil
| | - Helena A S Goldani
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil; Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
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A comprehensive review on in vitro digestion of infant formula. Food Res Int 2015; 76:373-386. [DOI: 10.1016/j.foodres.2015.07.016] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 06/30/2015] [Accepted: 07/10/2015] [Indexed: 11/22/2022]
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Hoque M, Nanduri R, Gupta J, Mahajan S, Gupta P, Saleemuddin M. Oleic acid complex of bovine α-lactalbumin induces eryptosis in human and other erythrocytes by a Ca(2+)-independent mechanism. Biochim Biophys Acta Gen Subj 2015; 1850:1729-39. [PMID: 25913522 DOI: 10.1016/j.bbagen.2015.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/08/2015] [Accepted: 04/16/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Complexes of oleic acid (OA) with milk α-lactalbumin, received remarkable attention in view of their selective toxicity towards a spectrum of tumors during the last two decades. OA complexes of some structurally related/unrelated proteins are also tumoricidal. Erythrocytes are among the few differentiated cells that are sensitive and undergo hemolysis when exposed to the complexes. METHODS The effects of OA complex of bovine α-lactalbumin (Bovine Alpha-lactalbumin Made LEthal to Tumor cells, BAMLET) on human, goat and chicken erythrocytes on calcein leakage, phosphatidylserine exposure, morphological changes and hemolysis were studied by confocal microscopy, FACS analysis, scanning electron microscopy and measuring hemoglobin release. RESULTS Erythrocytes exposed to BAMLET undergo eryptosis-like alterations as revealed by calcein leakage, surface phosphatidylserine exposure and transformation to echinocytes at low concentrations and hemolysis when the concentration of the complex was raised. Ca(2+) was not essential and restricted the alterations when included in the medium. The BAMLET-induced alterations in human erythrocytes were prevented by the cation channel inhibitors, amiloride and BaCl2 but not by inhibitors of thiol proteases, sphingomyelinase and by the antioxidant N-acetyl cysteine. CONCLUSIONS The work shows for the first time that low concentrations of BAMLET induces eryptosis in erythrocytes by a novel mechanism not requiring Ca(2+) and hemolysis by detergent-like action by the released OA at higher concentrations. GENERAL SIGNIFICANCE The study points out to the need for a comprehensive evaluation of the toxicity of OA complexes of α-lactalbumin and other proteins towards erythrocytes and other differentiated cells before being considered for therapy.
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Affiliation(s)
- Mehboob Hoque
- Interdisciplinary Biotechnology Unit, Aligarh Muslim University, Aligarh 202002, India
| | | | - Jyoti Gupta
- Interdisciplinary Biotechnology Unit, Aligarh Muslim University, Aligarh 202002, India
| | - Sahil Mahajan
- CSIR-Institute of Microbial Technology, Chandigarh 160036, India
| | - Pawan Gupta
- CSIR-Institute of Microbial Technology, Chandigarh 160036, India
| | - M Saleemuddin
- Interdisciplinary Biotechnology Unit, Aligarh Muslim University, Aligarh 202002, India.
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[Influence of chest physiotherapy on gastro-œsophageal reflux in children]. Rev Mal Respir 2015; 32:493-9. [PMID: 25725980 DOI: 10.1016/j.rmr.2015.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 12/24/2014] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Chest physiotherapy is regularly prescribed for children, particularly in cystic fibrosis. Gastro-oesophageal reflux is common in this disease and is associated with certain chest physiotherapy manoeuvres. AIM OF THE STUDY To evaluate the influence of two chest physiotherapy techniques on gastro-oesophageal reflux in children. MATERIAL AND METHOD Twenty-nine children were investigated by routine pHmetry. During the examination, they performed two chest physiotherapy manoeuvres in a seated position for 10 minutes each with a 5 minutes rest between them. The two manoeuvres used were a slow expiration technique (ELPr) and positive expiratory pressure (PEP). It was a prospective study and the order of manoeuvres was randomised. The pH traces were analysed blindly when all the studies had been completed. RESULTS In the sample, 21% of children had gastro-oesophageal reflux during the physiotherapy session. No relationship was found between reflux during physiotherapy and pathological reflux (P=0.411) nor the physiotherapy technique used (P=0.219). CONCLUSION The use of these two chest physiotherapy techniques in children in a seated position can produce gastro-oesophageal reflux.
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Juma NA, Forsythe SJ. Microbial Biofilm Development on Neonatal Enteral Feeding Tubes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 830:113-21. [DOI: 10.1007/978-3-319-11038-7_7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Bourlieu C, Ménard O, Bouzerzour K, Mandalari G, Macierzanka A, Mackie AR, Dupont D. Specificity of infant digestive conditions: some clues for developing relevant in vitro models. Crit Rev Food Sci Nutr 2014; 54:1427-57. [PMID: 24580539 DOI: 10.1080/10408398.2011.640757] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Digestion of nutrients is an essential function of the newborn infant gut to allow growth and development and understanding infant digestive function is essential to optimize nutrition and oral drug delivery. Ethical considerations prohibit invasive in vivo trials and as a consequence in vitro assays are often conducted. However, the choice of in vitro model parameters are not supported by an exhaustive analysis of the literature and do not mimic precisely the digestive conditions of the infant. This review contains a compilation of the studies which characterized the gastroduodenal conditions in full-term or preterm infants of variable postnatal age from birth up to six months. Important data about healthy full-term infants are reported. The enzymatic (type of enzymes and level of activity) and nonenzymatic (milk-based diet, frequency of feeding, bile salt concentrations) conditions of digestion in infants are shown to differ significantly from those in adults. In addition, the interindividual and developmental variability of the digestive conditions in infants is also highlighted.
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Affiliation(s)
- Claire Bourlieu
- a INRA, UMR 1253, Science & Technology of Milk and Egg , 35000 , Rennes , France
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Gastric digestion of α-lactalbumin in adult human subjects using capsule endoscopy and nasogastric tube sampling. Br J Nutr 2014; 112:638-46. [PMID: 24967992 DOI: 10.1017/s0007114514001196] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In the present study, structural changes in the milk protein α-lactalbumin (α-LA) and its proteolysis were investigated for the potential formation of protein-fatty acid complexes during in vivo gastric digestion. Capsule endoscopy allowed visualisation of the digestion of the test drinks, with nasogastric tubes allowing sampling of the gastric contents. A total of ten healthy volunteers had nasogastric tubes inserted into the stomach and ingested test drinks containing 50 g/l of sucrose and 25 g/l of α-LA with and without 4 g/l of oleic acid (OA). The samples of gastric contents were collected for analysis at 3 min intervals. The results revealed a rapid decrease in the pH of the stomach of the subjects. The fasting pH of 2·31 (SD 1·19) increased to a pH maxima of pH 6·54 (SD 0·29) after ingestion, with a subsequent decrease to pH 2·22 (SD 1·91) after 21 min (n 8). Fluorescence spectroscopy and Fourier transform IR spectroscopy revealed partial protein unfolding, coinciding with the decrease in pH below the isoelectric point of α-LA. The activity of pepsin in the fasting state was found to be 39 (SD 12) units/ml of gastric juice. Rapid digestion of the protein occurred: after 15 min, no native protein was detected using SDS-PAGE; HPLC revealed the presence of small amounts of native protein after 24 min of gastric digestion. Mirocam® capsule endoscopy imaging and video clips (see the online supplementary material) revealed that gastric peristalsis resulted in a heterogeneous mixture during gastric digestion. Unfolding of α-LA was observed during gastric transit; however, there was no evidence of a cytotoxic complex being formed between α-LA and OA.
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Lueamsaisuk C, Lentle R, MacGibbon A, Matia-Merino L, Golding M. Factors influencing the dynamics of emulsion structure during neonatal gastric digestion in an in vitro model. Food Hydrocoll 2014. [DOI: 10.1016/j.foodhyd.2013.09.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Comparative performance of milk proteins and their emulsions under dynamic in vitro adult and infant gastric digestion. Food Hydrocoll 2013. [DOI: 10.1016/j.foodhyd.2013.01.017] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Barrett E, Kerr C, Murphy K, O'Sullivan O, Ryan CA, Dempsey EM, Murphy BP, O'Toole PW, Cotter PD, Fitzgerald GF, Ross RP, Stanton C. The individual-specific and diverse nature of the preterm infant microbiota. Arch Dis Child Fetal Neonatal Ed 2013; 98:F334-40. [PMID: 23303303 DOI: 10.1136/archdischild-2012-303035] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To examine the composition of the evolving microbiota of preterm infants at weeks 2 and 4 of life. SETTINGS The paediatric intensive care unit of the Cork University Maternity Hospital. METHODS The microbial diversity of faecal samples from 10 preterm infants was determined using 16S rRNA amplicon pyrosequencing technology. RESULTS In total, 452 863 sequences were obtained from 20 faecal samples collected from 10 preterm infants, allowing a level of analysis not previously reported. The preterm infant microbiota samples were dominated by Proteobacteria (46%), followed by Firmicutes (45%), while the phyla Actinobacteria (2%) and Bacteroidetes (7%) were detected at much lower levels at week 2 of life. This colonisation pattern was similar at week 4 of life. At the family level, Enterobacteriaceae were detected at 50% and 58% at weeks 2 and 4, respectively. The preterm infants were characterised by a lack of detectable Bifidobacterium and Lactobacillus genera commonly associated with the infant gut. In addition to the dominance of the Proteobacteria, a high level of interindividual variation was observed, indeed the relative proportions of different phyla, families and genera in different infants ranged from <1% to >90%. CONCLUSIONS The results indicate that in addition to an uncharacteristic microbiota relative to that reported for healthy term infants, there was a large interindividual variation in the faecal microbiota diversity of preterm infants suggesting that the preterm microbiota is individual-specific and does not display a uniformity among infants.
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Affiliation(s)
- Eoin Barrett
- Food Biosciences Department, Teagasc Food Research Centre, Moorepark, Fermoy, County Cork, Ireland
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Corvaglia L, Monari C, Martini S, Aceti A, Faldella G. Pharmacological therapy of gastroesophageal reflux in preterm infants. Gastroenterol Res Pract 2013; 2013:714564. [PMID: 23878533 PMCID: PMC3710644 DOI: 10.1155/2013/714564] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 05/22/2013] [Accepted: 06/12/2013] [Indexed: 02/07/2023] Open
Abstract
Although gastroesophageal reflux (GER) is a very common phenomenon among preterm infants, its therapeutic management is still an issue of debate among neonatologists. A step-wise approach should be advisable, firstly promoting nonpharmacological interventions and limiting drugs to selected infants unresponsive to the conservative measures or who are suffering from severe GER with clinical complications. Despite of this, a concerning pharmacological overtreatment has been increasingly reported. Most of the antireflux drugs, however, have not been specifically assessed in preterm infants; moreover, serious adverse effects have been noticed in association to their administration. This review mainly aims to draw the state of the art regarding the pharmacological management of GER in preterm infants, analyzing the best piecies of evidence currently available on the most prescribed anti-reflux drugs. Although further trials are required, sodium alginate-based formulations might be considered promising; however, data regarding their safety are still limited. Few piecies of evidence on the efficacy of histamine-2 receptor blockers and proton pump inhibitors in preterm infants with GER are currently available. Nevertheless, a significantly increased risk of necrotizing enterocolitis and infections has been largely reported in association with their use, thereby leading to an unfavorable risk-benefit ratio. The efficacy of metoclopramide in GER's improvement still needs to be clarified. Other prokinetic agents, such as domperidone and erythromycin, have been reported to be ineffective, whereas cisapride has been withdrawn due to its remarkable cardiac adverse effects.
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Affiliation(s)
- Luigi Corvaglia
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40126 Bologna, Italy
| | - Caterina Monari
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
| | - Silvia Martini
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
| | - Arianna Aceti
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
| | - Giacomo Faldella
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, via Massarenti 11, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40126 Bologna, Italy
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Savolainen-Kopra C, Simonen-Tikka ML, Klemola P, Blomqvist S, Suomenrinne S, Näntö-Salonen K, Simell O, Roivainen M. Human rhinoviruses in INDIS-study material-evidence for recovery of viable rhinovirus from fecal specimens. J Med Virol 2013; 85:1466-72. [DOI: 10.1002/jmv.23593] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2013] [Indexed: 01/12/2023]
Affiliation(s)
- Carita Savolainen-Kopra
- Department of Infectious Disease Surveillance and Control, Virology Unit; National Institute for Health and Welfare (THL); Helsinki Finland
| | - Marja-Leena Simonen-Tikka
- Department of Infectious Disease Surveillance and Control, Virology Unit; National Institute for Health and Welfare (THL); Helsinki Finland
| | - Päivi Klemola
- Department of Infectious Disease Surveillance and Control, Virology Unit; National Institute for Health and Welfare (THL); Helsinki Finland
| | - Soile Blomqvist
- Department of Infectious Disease Surveillance and Control, Virology Unit; National Institute for Health and Welfare (THL); Helsinki Finland
| | | | | | - Olli Simell
- Department of Pediatrics; University of Turku; Turku Finland
| | - Merja Roivainen
- Department of Infectious Disease Surveillance and Control, Virology Unit; National Institute for Health and Welfare (THL); Helsinki Finland
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van der Pol RJ, Smits MJ, Venmans L, Boluyt N, Benninga MA, Tabbers MM. Diagnostic accuracy of tests in pediatric gastroesophageal reflux disease. J Pediatr 2013; 162:983-7.e1-4. [PMID: 23219449 DOI: 10.1016/j.jpeds.2012.10.041] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 08/23/2012] [Accepted: 10/16/2012] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To systematically review the literature evaluating the diagnostic accuracy of commonly used diagnostic tests over conventional history taking and physical examination in children ≤ 18 months and >18 months suspected of gastroesophageal reflux disease (GERD). STUDY DESIGN We searched Medline, Embase, and the Cochrane database for studies assessing the diagnostic accuracy of pH-metry, pH-impedance, esophagogastroscopy, barium contrast study, scintigraphy, and empirical treatment as diagnostic tools. Quality was assessed according to Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews criteria. RESULTS Of the 2178 studies found, 6 studies were included, containing 408 participants (age 1 month-13.6 years) and 145 controls (age 1 month-16.9 years). Studies included children with GERD symptoms; 1 included an atypical presentation. In all the studies, the diagnostic accuracy of pH-metry was investigated, and in 2 studies esophagogastroscopy was investigated as well. Sensitivity and specificity were calculated in 3 studies. The range of reported sensitivity and specificity was broad and unreliable because of poor methodological quality according to Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews criteria and inadequate study design. CONCLUSION Diagnostic accuracy of tests in children suspected of GERD remains unclear and implications for practice are hard to give. There is an urgent need of well-designed randomized controlled trials where the effect of treatment according to specific signs and symptoms will be compared with the effect of treatment based on the results of additional diagnostic tests, for patient relevant outcomes.
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Affiliation(s)
- Rachel J van der Pol
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.
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