Nutritional Status and GI Symptoms in Pediatric Patients with Cystic Fibrosis

BACKGROUND: Cystic fibrosis (CF) is a genetic disorder that affects many organ systems including the lungs and the gastrointestinal tract. Children with CF often suffer from exocrine pancreatic insufficiency (EPI), causing many issues including poor digestion and poor nutrient absorption. It is imperative that children with CF consume greater amounts of calories, fat, protein, and fat-soluble vitamins to maintain healthy BMI. Studies have shown that adequate nutritional status leads to less severe symptoms and increased ability to fight off infection. OBJECTIVE: The purpose of this study was to evaluate the nutritional intake and frequency of GI symptoms in CF participants compared to their non-CF siblings. METHODS: Participants with CF and their siblings without CF were recruited for this study. Each participant completed a food frequency questionnaire and a GI symptom questionnaire. Data from the food frequency questionnaire was analyzed to determine the approximate composition of each food or drink that was reported. These values were then compared to published dietary reference intakes (DRIs) specific to healthy individuals and children with CF. RESULTS: No significant difference was observed in macronutrient intake between CF and non-CF participants. Our CF participants were deficient in non-fermentable fiber (52%), vitamin A (48%), vitamin E (96%), and vitamin K (100%). CF participants consumed excessive calcium (87%), zinc (87%), sodium (87%), iron (91%), and magnesium (83%). Significant differences were observed between CF and non-CF nutrient intakes of zinc (p=0.05), iron (p=0.04), vitamin A (p=0.03), vitamin E (p=0.003), vitamin C (p=0.05), and vitamin B-12 (p=0.03). CF participants experienced more frequent GI symptoms than non-CF participants. Among CF participants, individuals with the homozygous f508del mutation experienced more frequent GI symptoms than those with the heterozygous f508del mutation. CONCLUSIONS: All participants were eating well and meeting their macronutrient goals. Some dietary deficiencies existed in CF participants, including non-fermentable fiber, and vitamins A, E, and K. Exploring their clinical effects will be a future area of focus. GI symptoms were common in participants with CF, highlighting the need for interventions in this area. Also, GI symptoms in homozygous f508del patients were more frequent than in heterozygous f508del patients. These findings will be used in larger analyses to assess links between dietary intake and composition of the gut microbiome.https://digitalcommons.unmc.edu/surp2021/1009/thumbnail.jp

Early respiratory viral infections in infants with cystic fibrosis

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Background Viral infections contribute to morbidity in cystic fibrosis (CF), but the impact of respiratory viruses on the development of airway disease is poorly understood. Methods Infants with CF identified by newborn screening were enrolled prior to 4 months of age to participate in a prospective observational study at 4 centers. Clinical data were collected at clinic visits and weekly phone calls. Multiplex PCR assays were performed on nasopharyngeal swabs to detect respiratory viruses during routine visits and when symptomatic. Participants underwent bronchoscopy with bronchoalveolar lavage (BAL) and a subset underwent pulmonary function testing. We present findings through 8.5 months of life. Results Seventy infants were enrolled, mean age 3.1 ± 0.8 months. Rhinovirus was the most prevalent virus (66%), followed by parainfluenza (19%), and coronavirus (16%). Participants had a median of 1.5 viral positive swabs (range 0–10). Past viral infection was associated with elevated neutrophil concentrations and bacterial isolates in BAL fluid, including recovery of classic CF bacterial pathogens. When antibiotics were prescribed for respiratory-related indications, viruses were identified in 52% of those instances. Conclusions Early viral infections were associated with greater neutrophilic inflammation and bacterial pathogens. Early viral infections appear to contribute to initiation of lower airway inflammation in infants with CF. Antibiotics were commonly prescribed in the setting of a viral infection. Future investigations examining longitudinal relationships between viral infections, airway microbiome, and antibiotic use will allow us to elucidate the interplay between these factors in young children with CF

In children, the microbiota of the nasopharynx and bronchoalveolar lavage fluid are both similar and different

RATIONALE: Sputum and bronchoalveolar lavage fluid (BALF) are often obtained to elucidate the lower airway microbiota in adults. Acquiring sputum samples from children is difficult and obtaining samples via bronchoscopy in children proves challenging due to the need for anesthesia and specialized procedural expertise; therefore nasopharyngeal (NP) swabs are often used as surrogates when investigating the pediatric airway microbiota. In adults, the airway microbiota differs significantly between NP and BALF samples however, minimal data exist in children. OBJECTIVES: To compare NP and BALF samples in children undergoing clinically indicated bronchoscopy. METHODS: NP and BALF samples were collected during clinically indicated bronchoscopy. Bacterial DNA was extracted from 72 samples (36 NP/BALF pairs); the bacterial V1-V3 region of the 16S rRNA gene was amplified and sequenced on the Illumina Miseq platform. Analysis was performed using mothur software. RESULTS: Compared to NP samples, BALF had increased richness and diversity. Similarity between paired NP and BALF (intra-subject) samples was greater than inter-subject samples (P = 0.0006). NP samples contained more Actinobacteria (2.2% vs 21%; adjusted P = 1.4 × 10-6 ), while BALF contained more Bacteroidetes (29.5% vs 3.2%; adjusted P = 1.2 × 10-9 ). At the genus level several differences existed, however Streptococcus abundance was similar in both sample types (NP 37.3% vs BAL 36.1%; adjusted P = 0.8). CONCLUSION: Our results provide evidence that NP samples can be used to distinguish differences between children, but the relative abundance of organisms may differ between the nasopharynx and lower airway in pediatric patients. Studies utilizing NP samples as surrogates for the lower airway should be interpreted with caution

Chronic Cough as the Presenting Symptom of Eosinophilic Esophagitis

A 14-year-old male initially presented to the Emergency Department (ED) for a chronic, persistent cough and chest pain with concurrent history of asthma and gastroesophageal reflux disease (GERD). He had been trialed on several medications before this visit for cough, without resolution of symptoms. Despite seeing several specialists after this ED visit and being evaluated for infectious causes and other pulmonary issues, he was eventually found to have eosinophilic esophagitis (EoE). It is not often that EoE is suspected based on cough alone, but with other GERD-like symptoms EoE should be considered

Safety of intravenous tobramycin in combination with a variety of anti-pseudomonal antibiotics in children with cystic fibrosis

Objectives: Previous studies have examined renal safety of once daily intravenous tobramycin in individuals with cystic fibrosis. This has been mainly in combination with ceftazidime in an adolescent or adult population. In this report, we describe our institutional experience of once daily intravenous tobramycin in combination with a variety of second anti-pseudomonal antibiotics in children with cystic fibrosis. Methods: We present a retrospective review including children with cystic fibrosis, who were admitted for a pulmonary exacerbation from January 2009 to December 2011, and treated using intravenous tobramycin. A literature review of once daily intravenous aminoglycoside dosing in cystic fibrosis was performed to compare our results to existing literature. Results: A total of 35 subjects were divided into once daily dosing (n = 20) versus multiple daily dosing (n = 15) groups. Mean age was 11.3 years (± 5.7) for the once daily dosing group and 13.1 years (± 4.4) for the multiple daily dosing group (p = 0.34). All subjects had normal baseline serum creatinine at admission (once daily dosing 0.49 ± 0.14 mg/dL vs multiple daily dosing 0.62 ± 0.23 mg/dL, p = 0.07). All subjects received intravenous tobramycin, and most received piperacillin-tazobactam as their second anti-pseudomonal antibiotic (once daily dosing 45% and multiple daily dosing 40%). There was no significant change in serum creatinine in either group during antibiotic treatment (once daily dosing 0.08 ± 0.12 mg/dL vs. multiple daily dosing 0.06 ± 0.10 mg/dL, p = 0.43). All subjects had significant improvement in lung function following intravenous antibiotic therapy. Conclusion: We show that both once daily dosing and multiple daily dosing of intravenous tobramycin in combination with a variety of second anti-pseudomonal antibiotics were safe in terms of nephrotoxicity in children with cystic fibrosis. These findings are important given existing literature mainly examines once daily tobramycin in combination with ceftazidime, a cephalosporin, and the majority of our patients were on tobramycin with piperacillin-tazobactam, an extended spectrum penicillin plus beta-lactam. This contributes new information not previously examined in a pediatric cystic fibrosis population

Association between early respiratory viral infections and structural lung disease in infants with cystic fibrosis

Background: Infants with cystic fibrosis (CF) develop structural lung disease early in life, and viral infections are associated with progressive lung disease. We hypothesized that the presence of respiratory viruses would be associated with structural lung disease on computed tomography (CT) of the chest in infants with CF. Methods: Infants with CF were enrolled before 4 months of age. Multiplex PCR assays were performed on nasal swabs to detect respiratory viruses during routine visits and when symptomatic. Participants underwent CT imaging at approximately 12 months of age. Associations between Perth–Rotterdam Annotated Grid Morphometric Analysis for CF (PRAGMA-CF) CT scores and respiratory viruses and symptoms were assessed with Spearman correlation coefficients. Results: Sixty infants were included for analysis. Human rhinovirus was the most common virus detected, on 28% of tested nasal swabs and in 85% of participants. The median (IQR) extent of lung fields that was healthy based on PRAGMA-CF was 98.7 (0.8)%. There were no associations between PRAGMA-CF and age at first virus, or detection of any virus, including rhinovirus, respiratory syncytial virus, or parainfluenza. The extent of airway wall thickening was associated with ever having wheezed (ρ = 0.31, p = 0.02) and number of encounters with cough (ρ = 0.25, p = 0.0495). Conclusions: Infants with CF had minimal structural lung disease. We did not find an association between respiratory viruses and CT abnormalities. Wheezing and frequency of cough were associated with early structural changes