Nutritional status, growth and disease management in children with single and dual diagnosis of type 1 diabetes mellitus and coeliac disease

Background: The consequences of subclinical coeliac disease (CD) in Type 1 diabetes mellitus (T1DM) remain unclear. We looked at growth, anthropometry and disease management in children with dual diagnosis (T1DM + CD) before and after CD diagnosis.<p></p> Methods: Anthropometry, glycated haemoglobin (HbA1c) and IgA tissue transglutaminase (tTg) were collected prior to, and following CD diagnosis in 23 children with T1DM + CD. This group was matched for demographics, T1DM duration, age at CD diagnosis and at T1DM onset with 23 CD and 44 T1DM controls.<p></p> Results: No differences in growth or anthropometry were found between children with T1DM + CD and controls at any time point. Children with T1DM + CD, had higher BMI z-score two years prior to, than at CD diagnosis (p <0.001). BMI z-score change one year prior to CD diagnosis was lower in the T1DM + CD than the T1DM group (p = 0.009). At two years, height velocity and change in BMI z-scores were similar in all groups. No differences were observed in HbA1c between the T1DM + CD and T1DM groups before or after CD diagnosis. More children with T1DM + CD had raised tTg levels one year after CD diagnosis than CD controls (CDx to CDx + 1 yr; T1DM + CD: 100% to 71%, p = 0.180 and CD: 100% to 45%, p < 0.001); by two years there was no difference.<p></p> Conclusions: No major nutrition or growth deficits were observed in children with T1DM + CD. CD diagnosis does not impact on T1DM glycaemic control. CD specific serology was comparable to children with single CD, but those with dual diagnosis may need more time to adjust to gluten free diet

Comparison of clinical methods with the faecal gluten immunogenic peptide to assess gluten intake in coeliac disease

Objectives: Detection of faecal gluten immunogenic peptides (GIP) is a biomarker of recent gluten consumption. GIP levels can be used to monitor gluten intake and compliment clinical methods to evaluate compliance to gluten free diet (GFD). In this study, recent gluten intake was measured by GIP in CD children and compared to routine clinical measures to evaluate GFD compliance. Methods: GIP was measured in 90 samples from 63 CD children (44 previously and 19 newly diagnosed with follow-up samples at 6 and 12 months on GFD). Compliance to GFD was evaluated based on clinical assessment, tTG levels and Biagi score. Results: GIP was detectable in 16% of patients with previous CD diagnosis on GFD. BMI z-score (p=0.774), height z-score (p=0.723), haemoglobin concentration (p=0.233), age (p=0.448), gender (p=0.734) or disease duration (p=0.488) did not differ between those with detectable and non-detectable GIP. In newly diagnosed patients, on gluten containing diet, GIP was detectable in 95% of them. Following GFD initiation, GIP decreased (p<0.001); 17% and 27% had detectable levels at 6 and 12 months, respectively. Compared to GIP, the Biagi score, tTG and clinical assessment presented sensitivity of 17%, 42% and 17%. Likewise, GIP was detectable in 16%, 16%, 14% of patients evaluated as GFD compliant according to the Biagi score, tTG and clinical assessment. A combination of methods did not improve identification of patients who were non-compliant. Conclusions: Inclusion of faecal GIP measurements is likely to improve identification of GFD recent noncompliance in CD management and could be incorporated into current follow-up strategies

Alterations in intestinal microbiota of children with celiac disease at time of diagnosis and on a gluten-free diet

Background & Aims: It is not clear whether alterations in the intestinal microbiota of children with celiac disease cause the disease or are a result of disease and/or its treatment with gluten-free diet (GFD). Methods: We obtained 167 fecal samples from 141 children (20 with new-onset celiac disease, 45 treated with a GFD, 57 healthy children, and 19 unaffected siblings of children with celiac disease) in Glasgow, Scotland. Samples were analyzed by 16S rRNA sequencing and diet-related metabolites were measured by gas chromatography. We obtained fecal samples from 13 of the children with new-onset CD after 6 and 12 months on GFD. Relationships between microbiota with diet composition, gastrointestinal function, and biomarkers of GFD compliance were explored. Results: Microbiota α diversity did not differ among groups. Microbial dysbiosis was not observed in children with new-onset celiac disease. In contrast, 2.8% (Bray-Curtis dissimilarity index, P=.025) and 2.5% (UniFrac distances, P=.027) of the variation in microbiota composition could be accounted for by the GFD. Between 3% to 5% of all taxa differed among all group comparisons. Eleven distinctive operational taxonomic units composed a microbe signature specific to celiac disease with high diagnostic probability. Most of the operational taxonomic units that differed between patients on GFD with new-onset celiac disease vs healthy children were associated with nutrient and food group intake (from 75% to 94%), and with biomarkers of gluten ingestion. Fecal levels of butyrate and ammonia decreased during the GFD. Conclusions: Although several alterations in the intestinal microbiota of children with established celiac disease appear to be effects of a GFD, there are specific bacteria that are distinct biomarkers of celiac disease. Studies are needed to determine whether these bacteria contribute to pathogenesis of celiac disease

Prehabilitation:The impact of preoperative exclusive enteral nutrition on paediatric patients with Crohn Disease

Exclusive enteral nutrition (EEN) is effective in inducing remission in paediatric Crohn Disease (CD) and has been shown to reduce inflammation and improve outcomes in adult CD patients when used before resectional surgery. This retrospective study demonstrates that preoperative EEN is achievable in paediatric CD patients undergoing right hemicolectomy and is associated with positive peri-operative outcomes. Seventeen patients (8 who received preoperative EEN and 9 who did not) were included in the study. Six of 8 (75.0%) managed EEN orally; 1 via nasogastric tube and another via a previously sited gastrostomy. Use of preoperative EEN was associated with a decreased rate of moderate/severe disease on resection pathology (5/8 [62.5%] vs 9/9 [100%]; P = 0.04). Larger studies are required to determine the wider potential benefits of preoperative EEN on postoperative outcomes within paediatric practice.</p

Micronutrient deficiencies in children with coeliac disease; a double-edged sword of both untreated disease and treatment with gluten-free diet

Introduction: In coeliac disease (CD) micronutrient deficiencies may occur due to malabsorption in active disease and diminished intake during treatment with a gluten-free diet (GFD). This study assessed the micronutrient status in children with CD at diagnosis and follow-up. Methods: Fifteen micronutrients were analysed in 106 blood samples from newly diagnosed CD and from patients on a GFD for &lt;6 months, 6-12 months and with longstanding disease (&gt;12 months). Predictors of micronutrient status included: demographics, disease duration, anthropometry, gastrointestinal symptoms, raised tissue transglutaminase antibodies (TGA), multivitamin use and faecal gluten immunogenic peptide (GIP). Micronutrient levels were compared against laboratory reference values. Results: At CD diagnosis (n=25), low levels in ≥10% of patients were observed for: vitamins E (88%), B1 (71%), D (24%), K (21%), A (20%) and B6 (12%), ferritin (79%), and zinc (33%). One year post-diagnosis, repletion of vitamins E, K, B6 and B1 was observed (&lt;10% patients). In contrast, deficiencies for vitamins D, A and zinc did not change significantly post-diagnosis. Copper, selenium and magnesium did not differ significantly between diagnosis and follow-up. All samples for B2, folate, vitamin C (except for one sample) and B12 were normal. A raised TGA at follow-up was associated with low vitamins A and B1 (raised vs normal TGA; vitamin A: 40% vs 17%, p=0.044, vitamin B1: 37% vs 13%, p=0.028). Low vitamin A (p=0.009) and vitamin D (p=0.001) were more common in samples collected during winter. There were no associations between micronutrient status with GIP, body mass index, height, socioeconomic status, or gastrointestinal symptom. Multivitamin use was less common in patients with low vitamin D. Conclusions: Several micronutrient deficiencies in CD respond to a GFD but others need to be monitored long-term and supplemented where indicated

Dietary triggers of gut inflammation following exclusive enteral nutrition in children with Crohn’s disease: a pilot study

Background: The anti-inflammatory effect of exclusive enteral nutrition on the gut of children with Crohn’s disease is rapidly lost after food reintroduction. This study assessed disease dietary triggers following successful treatment with exclusive enteral nutrition. Methods: Nutrient intake, dietary patterns and dietary biomarkers in faeces (gluten immunogenic peptides, undigestible starch, short chain fatty acids) were assessed in 14 children with Crohn’s disease during early food reintroduction, following exclusive enteral nutrition. Groups above (Group A) and below (Group B) the median levels of faecal calprotectin after food reintroduction were assigned for comparative analysis. Results: Intakes of fibre, gluten-containing cereals and red and processed meat were significantly higher in Group A than Group B; (median [Q1, Q3], g/day; Fibre: 12.1 [11.2, 19.9] vs. 9.9 [7.6, 12.1], p = 0.03; Red and processed meat: 151 [66.7, 190] vs. 63.3 [21.7, 67], p = 0.02; gluten-containing cereals: 289 [207, 402] vs. 203 [61, 232], p = 0.035). A diet consisting of cereals and meat products was predictive (92% accuracy) of higher faecal calprotectin levels after food reintroduction. In faeces, butyrate levels, expressed as absolute concentration and relative abundance, were higher in Group A than Group B by 28.4 µmol/g (p = 0.015) and 6.4% (p = 0.008), respectively. Levels of gluten immunogenic peptide and starch in faeces did not differ between the two groups. Conclusions: This pilot study identified potential dietary triggers of gut inflammation in children with Crohn’s disease after food reintroduction following treatment with exclusive enteral nutrition. Trial registration: Clinical trials.gov registration number: NCT02341248; Clinical trials.gov URL: https://clinicaltrials.gov/ct2/show/NCT02341248 (retrospectively registered)

The epidemiology of anemia in pediatric inflammatory bowel disease: Prevalence and associated factors at diagnosis and follow-up and the impact of exclusive enteral nutrition

Background: Anemia is poorly studied in pediatric inflammatory bowel disease. This study explored the epidemiology and associated factors of anemia at diagnosis, after 1 year, and during treatment with exclusive enteral nutrition (EEN). Methods: Three cohorts were included: (1) a representative population of newly diagnosed inflammatory bowel disease children (n = 184); (2) patients currently receiving care with data available at diagnosis (n = 179) and after 1 year (n = 139); and (3) 84 children treated with EEN. Results: At diagnosis, 72% were anemic. Abnormal inflammatory markers were more common in Crohn's disease with severe anemia (severe versus no anemia [%]: raised C-reactive protein; 89% versus 48%; suboptimal albumin; 97% versus 29%; P , 0.002). Anemic children with Crohn's disease had shorter diagnosis delay and lower BMI than nonanemic patients (severe versus mild versus no anemia, median [interquartile range]; diagnosis delay [months]: 3 [3.9] versus 6 [10] versus 8 [18], P , 0.001; BMI z score [SD]: 21.4 [1.4] versus 21.3 [1.5] versus 20.2 [1.4], P = 0.003). Extensive colitis was associated with severe anemia in ulcerative colitis. The proportion of severely anemic patients decreased from 34% to 9% and mild anemia doubled at 1 year. After EEN, severe anemia decreased (32% to 9%; P , 0.001) and the hemoglobin concentration increased by 0.75 g/dL. This was observed only after 8 weeks of treatment. Disease improvement and low hemoglobin at EEN initiation but not weight gain were associated with hemoglobin improvement. Conclusions: Anemia is high at diagnosis and follow-up and should receive more attention from the clinical team; however, the focus should remain suppression of inflammatory process in active disease. © 2013 Crohn's & Colitis Foundation of America, Inc