Systematic review with meta-analysis: early infant feeding and coeliac disease--update 2015

BACKGROUND

New evidence emerged on early feeding practices and the risk of coeliac disease.

AIM

To systematically update evidence on these practices to find out whether there is a need to revise current recommendations.

METHODS

MEDLINE, EMBASE and the Cochrane Library were searched from July 2012 (end of last search) to February 2015 for studies of any design that assessed the effect of gluten consumption and breastfeeding on the development of coeliac disease and/or coeliac disease-related autoimmunity.

RESULTS

We identified 21 publications, including two, new, large, randomised controlled trials performed in high-risk infants. Exclusive or any breastfeeding, as well as breastfeeding at the time of gluten introduction, did not reduce the risk of developing coeliac disease during childhood. For infants at high risk of developing coeliac disease, gluten introduction at 4 months of age in very small amounts, or at 6 or 12 months of age, resulted in similar rates of coeliac disease diagnosis in early childhood. Later gluten introduction was associated with later development of coeliac specific autoimmunity and coeliac disease during childhood, but not total risk reduction. Observational studies indicate that consumption of a higher amount of gluten at weaning may increase the risk for coeliac disease development.

CONCLUSIONS

Infant feeding practices (breastfeeding, time of gluten introduction) have no effect on the risk of developing coeliac disease during childhood (at least at specific timeframes evaluated in the included studies), necessitating an update of current European recommendations.

The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease

Trying to conceive and being pregnant is an emotional period for those involved. In the majority of patients suffering from inflammatory bowel disease, maintenance therapy is required during pregnancy to control the disease, and disease control might necessitate introduction of new drugs during a vulnerable period. In this updated consensus on the reproduction and pregnancy in inflammatory bowel disease reproductive issues including fertility, the safety of drugs during pregnancy and lactation are discussed.

Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease

Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.

Systematic review: early infant feeding and the prevention of coeliac disease

BACKGROUND

PREVENTCD, Prevent Coeliac Disease, is an international project investigating the hypothesis of possible induction of tolerance to gluten in genetically predisposed children through introducing small quantities of gluten during the period of breastfeeding.

AIM

To summarise current knowledge on the possible relationship between early feeding practices and the risk of coeliac disease (CD).

METHODS

The Cochrane Library, MEDLINE, and EMBASE databases were searched in May 2011, and the search was updated in January 2012, and again in July 2012.

RESULTS

Breastfeeding (BF) and CD: some studies show a protective effect of BF, while others show no effect. No studies have shown a long-term preventive effect. BF at the time of gluten introduction and CD: Results from a meta-analysis of five observational case-control studies suggest that BF at gluten introduction is associated with a lower risk of CD compared with formula feeding. It is unclear whether BF provides a permanent protection or only delays the onset of CD. Timing of gluten introduction: The data suggest that both early (≤4 months) and late (≥7 months) introduction of gluten may increase the risk of CD. Amount of gluten at weaning (and later) and CD: One incident case-referent study documented that the introduction of gluten in large amounts compared with small or medium amounts increased the risk of CD.

CONCLUSIONS

In the absence of clear evidence, in order to decrease the risk of later coeliac disease, it is reasonable to avoid both early (<4 months) and late (≥7 months) introduction of gluten, and to introduce gluten while the infant is still being breastfed. Future studies may clarify the remaining uncertainties.

Prospective multicentre study on antibiotic resistance of Helicobacter pylori strains obtained from children living in Europe

AIM

To prospectively assess the antibacterial resistance rate in Helicobacter pylori strains obtained from symptomatic children in Europe.

METHODS

During a 4-year period, 17 paediatric centres from 14 European countries reported prospectively on patients infected with H pylori, for whom antibiotic susceptibility was tested.

RESULTS

A total of 1233 patients were reported from Northern (3%), Western (70%), Eastern (9%) and Southern Europe (18%); 41% originated from outside Europe as indicated by mother's birth-country; 13% were <6 years of age, 43% 6-11 years of age and 44% >11 years of age. Testing was carried out before the first treatment (group A, n = 1037), and after treatment failure (group B, n = 196). Overall resistance to clarithromycin was detected in 24% (mean, A: 20%, B: 42%). The primary clarithromycin resistance rate was higher in boys (odds ratio (OR) 1.58; 1.12 to 2.24, p = 0.01), in children <6 years compared with >12 years (OR 1.82, 1.10 to 3.03, p = 0.020) and in patients living in Southern Europe compared with those living in Northern Europe (OR 2.25; 1.52 to 3.30, p<0.001). Overall resistance rate to metronidazole was 25% (A: 23%, B: 35%) and higher in children born outside Europe (A: adjusted. OR 2.42, 95% CI: 1.61 to 3.66, p<0.001). Resistance to both antibiotics occurred in 6.9% (A: 5.3%, B: 15.3%). Resistance to amoxicillin was exceptional (0.6%). Children with peptic ulcer disease (80/1180, 6.8%) were older than patients without ulcer (p = 0.001).

CONCLUSION

The primary resistance rate of H pylori strains obtained from unselected children in Europe is high. The use of antibiotics for other indications seems to be the major risk factor for development of primary resistance.

European evidence based consensus on the diagnosis and management of Crohn's disease: special situations

This third section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn's disease.

Challenges and opportunities in Pan-European collaboration for researchers from Central and Eastern Europe

Ten Central and Eastern [NLG4] European countries have recently joined the European Union. This historical enlargement provided a good opportunity to discuss the challenges and opportunities in Pan-European Research Collaboration for researchers from Central/Eastern Europe. This paper summarises examples of productive research collaboration between East and West, current challenges [NLG5], and ideas on how to facilitate better collaboration. A short overview of training, mobility and career development opportunities, covered by the Marie Curie actions, is also presented.

Renal artery stenosis associated with Crohn disease

Although extraintestinal complications involving skin, joints, eyes and liver are common in children with inflammatory bowel disease, hypertension is rare. We report data from a 16-year-old boy with renovascular hypertension and Crohn disease. To our knowledge, a patient with renal artery stenosis associated with Crohn disease has not been previously reported. Possible causes of renal vascular lesion in Crohn disease are discussed.

Epidemiology of coeliac disease in children in one Croatian county: possible factors that could affect the incidence of coeliac disease and adherence to a gluten-free diet (Part II)

Coeliac disease is a life-long disorder characterised by small-intestinal mucosal damage caused by gluten. The treatment, gluten-free diet, leads to mucosal restoration and reduces the risk of malignant and non-malignant complications. According to our recent results, cumulative incidence in Croatian children is 1:519 life-births. Coeliac disease presents early, mostly with typical symptoms. We investigated possible influences of breast-feeding duration and time of gluten introduction on such presentation of the disease. Study included coeliacs born in Medimurje between 1985 and 1994 (N = 31). Patients' adherence to treatment was also studied. Although short breast-feeding (mean 2.9 months) and early gluten introduction (mean 4.9 months) were shown, no correlation was found between those factors and time of the disease presentation. Concerning adherence to gluten-free diet, only 50% of patients maintained it strictly, 23% irregularly, while 27% were on normal diet. In order to improve it, regular follow-ups are recommended.

[The role of zinc in the initial treatment of Wilson's disease in children]

Wilson's disease (WD) is an inherited disease of copper accumulation, caused by a failure of biliary excretion of excess copper. Accumulated copper causes tissue damage. The chelating drugs penicillamine and trientine have been the mainstay of therapy and most patients with WD were treated with the potentially toxic cupriuretic agents. A more recent approach has used zinc, which blocks the absorption of copper and increases copper excretion in the stool, and long term administration induces a negative copper balance. Until recently, most patients have been treated initially with cupriuretic agents to remove excess of copper, and then maintained with oral zinc. Recently, zinc has been used for initial treatment as well and for treatment of the presymptomatic patients. So far, zinc therapy has demonstrated exceptional efficacy and lack of toxicity. In this article we present our data on the long-term follow-up of three children with WD, whose initial as well as consecutive treatment was zinc sulphate. The results demonstrate the efficacy of zinc therapy in treating the presymptomatic patient and in initial treatment of symptomatic children with WD. Our data also indicate low toxicity. However, pediatric patients must be closely monitored due to tendency to stop the treatment when becoming asymptomatic.

Lactobacillus GG administered in oral rehydration solution to children with acute diarrhea: a multicenter European trial

BACKGROUND

The probiotic Lactobacillus GG is effective in promoting a more rapid recovery of acute, watery diarrhea in children with rotavirus enteritis. Very limited information is available, however, on the potential role of such agents in non-rotaviral diarrheal episodes. Furthermore, no evidence is available concerning the efficacy of Lactobacillus GG administered in the oral rehydration solution during oral rehydration therapy. A multicenter trial was conducted to evaluate the efficacy of Lactobacillus GG administered in the oral rehydration solution to patients with acute-onset diarrhea of all causes.

METHODS

Children 1 month to 3 years of age with acute-onset diarrhea were enrolled in a double-blind, placebo-controlled investigation. Patients were randomly allocated to group A, receiving oral rehydration solution plus placebo, or group B, receiving the same preparation but with a live preparation of Lactobacillus GG (at least 10(10) CFU/250 ml). After rehydration in the first 4 to 6 hours, patients were offered their usual feedings plus free access to the same solution until diarrhea stopped.

RESULTS

One hundred forty children were enrolled in group A, and 147 in group B. There were no differences at admission between the groups in age, sex, previous types of feeding, previous duration of diarrhea, use of antibiotics, weight, height, weight-height percentile, prevalence of fever, overall status, degree of dehydration, and percentage of in- versus outpatients. Duration of diarrhea after enrollment was 71.9 +/- 35.8 hours in group A versus 58.3 +/- 27.6 hours in group B (mean +/- SD; P = 0.03). In rotavirus-positive children, diarrhea lasted 76.6 +/- 41.6 hours in group A versus 56.2 +/- 16.9 hours in groups B (P < 0.008). Diarrhea lasted longer than 7 days in 10.7% of group A versus 2.7% of group B patients (P < 0.01). Hospital stays were significantly shorter in group B than in group A.

CONCLUSIONS

Administering oral rehydration solution containing Lactobacillus GG to children with acute diarrhea is safe and results in shorter duration of diarrhea, less chance of a protracted course, and faster discharge from the hospital.

Epidemiology of coeliac disease in children in one Croatian county: the cumulative incidence over ten-year period and the way of clinical presentation (Part I)

Coeliac disease is a permanent intolerance to gluten, producing small-intestinal lesions. Its incidence in European countries varies from 1:400 to 1:2000, while there are no such epidemiological data for Croatia. Therefore, we investigated the incidence of coeliac disease for ten-year period in one well-defined region. Also, data concerning age at diagnosis and symptoms at the disease onset were collected. The cumulative incidence was 1.9:1000 life-births. The disease presented typically in more than 60% of cases. In 65% of patients, symptoms appeared during the first 2 years of life, while, when diagnosed, 45% were below 2 years. Also, it was shown that coeliac disease presented significantly later in children diagnosed during the last five years (p < 0.05). In conclusion, coeliac disease in Croatia is more frequent than previously suspected. It presents early, mostly with classical symptoms, although a tendency towards later ages of diagnosis was observed during the last few years.

Multi-indicator survey on children's nutrition in Croatia (MICS) (up to 5 years of age)

Multi-Indicator Survey (MICS) on children in Croatia was supported by UNICEF's Zagreb Office. The purpose of this research was to establish the present situation in terms of breastfeeding, nutrition and prevention of the most significant health problems in primary health care i.e. acute respiratory and diarrhoeal diseases in children (ARI/CDD), and the level of knowledge. The survey for MICS in Croatia included altogether 370 segments, and from each 40 households were selected. This resulted in 14,800 households being selected for the final sample. 1563 (or 10.6%) of households selected had children under 5 years of age. In the whole sample there were altogether 1937 children under 5 years of age. Having summarized all relevant data, several general conclusions and assumptions may be drawn. The breast-feeding rate is very low, and therefore unsatisfactory. At the age of 4 months, more than 50% of all mothers have already stopped breast-feeding their infants, and only 20% of infants were breast-fed after the age of 6 months. We noticed an unfavourable trend towards a decrease in the rate of breast-feeding in war areas. The was has negatively affected breast-feeding. The prevalence of feeding using diluted cow's milk during the first six months is very high (30% in the first, and 60% in the second six months). On the basis of this research, further activities should be planned.

Chromosome aberrations in coeliac and non-coeliac enteropathies

The frequency of chromosomal aberrations in peripheral blood lymphocytes was assessed in three groups of children: untreated coeliac disease (n = 20); non-coeliac disease enteropathies (n = 15); controls (n = 15). The mean frequency of aberrant cells and the total number of aberrations per 100 metaphases was increased in the coeliac disease group compared with controls by factors of 5 and 6, respectively (p < 0.01 for both). Aberrant cells and total aberrations were similarly increased in the non-coeliac disease enteropathy group by a factor of 3.7 in each case (p < 0.05). However, the frequency of aberrations in the two enteropathy groups was not significantly different. Children with coeliac disease, similar to affected adults, have evidence of increased chromosomal instability. However, similarly increased chromosomal aberrations are seen in children with non-coeliac disease enteropathies, indicating that the abnormality is not specific for coeliac disease.

Home-made modular diet versus semi-elemental formula in the treatment of chronic diarrhoea of infancy: a prospective randomized trial

Considerable success in the management of chronic diarrhoea has been reported using a modular diet (MD), with gradual increments in every nutrient toward a full-strength formula. As the commercially prepared constituents are unavailable in Croatia, we have developed a home-made MD based on boiled minced chicken meat, sunflower oil emulsion, sucrose and cornflour. A full range of vitamins and minerals are added. The value of this MD was compared to a semi-elemental formula (SF) Pregomin. Eighteen infants with severe chronic diarrhoea were randomly assigned to receive either MD of SF. Both groups were comparable with respect to sex, age, and degree of malnutrition. Duration of diarrhoea, feed tolerance, anthropometry, and biochemistry were compared after 4 weeks of treatment.

RESULTS

(1) diarrhoea was significantly shorter (3 vs 7 days; P < 0.01) and nutritional recovery started earlier (5 vs 9 days; P < 0.01) in MD group; (2) median weight gain in the SF group was 100 g/week, compared to 171 g/week in MD group (P < 0.05); (3) in two patients from the SF group, diarrhoea persisted, but they achieved complete recovery when changed to MD.

CONCLUSION

A MD made in the hospital kitchen was superior to a SE formula in the treatment of chronic diarrhoea of infancy.

[Long-term effect of nutrition in early infancy]

Results of different studies performed in the last ten years stress the possibility that infant nutrition is the important determinant of later development, and that many adult chronic diseases may have the origins in the very first few years of life. According to the hypothesis of "long-term programming", if the lack of nutrients was present in the critical phase of human development it will have a long-lasting or permanent effect on the final outcome. This paper is the review of the latest findings and the present state of knowledge about the possible permanent influences of general undernourishment, lack of some nutrients and the type of infant nutrition on a) psychomotor development, b) development of chronic diseases in children, and c) development of chronic diseases in late adulthood.

Early determinants of cardiovascular risk factors in adults. A. Plasma lipids

The aim of the study was to examine the effect of birth weight, infant nutrition, body mass and social status from early childhood and adulthood on plasma lipid levels in 192 adult subjects examined in the first three years of life (mean age 1.4 years in males and 1.3 years in females) and again as adults (mean age 19.9 years in males and 19.6 in females). According to the results obtained, total cholesterol was significantly higher in adult male subjects breast fed for the shortest period of time (p < 0.05). Those males who were leanest in the first three years of life and fattest as adults had the highest levels of total cholesterol (p = 0.03) and LDL cholesterol (p = 0.02). Birth weight had no significant influence on plasma lipid levels in adults subjects. When data on nutrition, anthropometry and social status from both age periods were included in multivariate regression analyses, the most significant predictors of higher levels of total cholesterol and LDL cholesterol in males were lower adult height and poor social status in early childhood, while in females they were a shorter duration of breast feeding and earlier introduction of solids.

Early determinants of cardiovascular risk factors in adults. B. Blood pressure

The aim of this follow-up study was to investigate the effect of birth weight, infant nutrition, past and contemporary social status and anthropometry on systolic and diastolic blood pressure in adult subjects. There were 465 boys and girls, originating from three different regions of Croatia, examined in the first three years of life, and again approximately 18 years later. The analyses showed that birth weight was inversely related to systolic blood pressure in adult subjects. The highest systolic pressure was found in subjects with the lowest birth weight and the greatest current body mass index. Relative weight in the first three years of life was also inversely related to systolic blood pressure, but only in adult males. Neither the type of milk given, nor the duration of breast feeding and the time of weaning had any significant influence on blood pressure in adult subjects. According to multivariate regression analyses, the significant predictors of higher systolic and diastolic pressure in adult males were: lower father's height, greater current body mass index, lower birth weight and low original social status. In female subjects, the significant predictors were: lower birth weight, greater current body mass index and lower social class of origin. In conclusion, influences of poor environment acting in early childhood may be important determinants of blood pressure in adulthood.

Ontogeny of pancreatic exocrine function

Exocrine pancreatic proteolytic activity, determined by serial measurement of faecal chymotrypsin concentration, was investigated in 21 preterm infants (23-32 weeks' gestation) during the first 28 days of life. The overall chymotrypsin concentration range was similar to that already described in term infants showing that pancreatic chymotrypsin secretion is equally well developed at birth in the preterm infant. A chymotrypsin concentration peak, seen in term infants at 4 days, did not occur in this study until day 8, suggesting a slower initiation of pancreatic exocrine function in the preterm infant. Median faecal chymotrypsin concentrations, calculated for each baby using data from stools passed between day 2 and day 12 of life, were significantly lower in infants who were small for gestational age when compared with those who were an appropriate size for gestational age. The lower chymotrypsin concentration in infants who were small for gestational age suggests a deleterious effect of intrauterine growth retardation on pancreatic exocrine function which may be a factor in limiting postnatal catch up growth.