Gluten free diet in children: an approach to nutritionally adequate and balanced diet

Gluten-free diet.(GFD) is the cornerstone treatment for celiac disease (CD). GFD implies a strict and lifelong elimination from the diet.of gluten, the storage protein found in wheat, barley, rye and hybrids of these grains, such as kamut and triticale. The absence of gluten in natural and processed foods, despite being the key aspect of GFD, may lead to nutritional consequences, such as deficits and imbalances. The nutritional adequacy of GFD is particularly important in children, this the age being of maximal energy and nutrient requirements for growth, development and activity. In recent years, attention has focused on the nutritional quality of gluten-free products (GFPs) available in the market. It is well recognized that GFPs are considered of lower quality and poorer nutritional value compared to the gluten-containing counterparts. The present review focuses on the nutritional adequacy of GFD at the pediatric age, with the aim being to increase awareness of the potential complications associated with this diet. to identify strategies in order to avoid them and to promote a healthier diet.and lifestyle in children with CD

Dietary Intakes and Nutritional Issues in Neurologically Impaired Children

Neurologically impaired (NI) children are at increased risk of malnutrition due to several nutritional and non-nutritional factors. Among the nutritional factors, insufficient dietary intake as a consequence of feeding difficulties is one of the main issues. Feeding problems are frequently secondary to oropharyngeal dysphagia, which usually correlates with the severity of motor impairment and presents in around 90% of preschool children with cerebral palsy (CP) during the first year of life. Other nutritional factors are represented by excessive nutrient losses, often subsequent to gastroesophageal reflux and altered energy metabolism. Among the non-nutritional factors, the type and severity of neurological impairment, ambulatory status, the degree of cognitive impairment, and use of entiepileptic medication altogether concur to determination of nutritional status. With the present review, the current literature is discussed and a practical approach for nutritional assessment in NI children is proposed. Early identification and intervention of nutritional issues of NI children with a multidisciplinary approach is crucial to improve the overall health and quality of life of these complex children

Efficacy of the gluten free diet in the management of functional gastrointestinal disorders : a systematic review on behalf of the Italian Society of Paediatrics

Background: Functional gastrointestinal disorders (FGIDs) are characterized by chronic/recurrent gastrointestinal symptoms not related to organic disorders. Due to the limited treatment options and to the perception of subjects with FGIDs suffering from a food intolerance, in recent years there has been an increase in the self-prescription of elimination diets, especially gluten free diet (GFD), for the treatment of these disorders. For this reason, we decided to perform this systematic review with the aim to evaluate the available evidence on the effects of a GFD on gastrointestinal symptoms, in subjects with FGIDs. Methods: Cochrane Library and MEDLINE (via PubMed) databases were searched, from inception to March 2018, using the MeSH terms "functional gastrointestinal disorder OR irritable bowel syndrome AND gluten". We included all the clinical trials published in English and evaluating the effects of a GFD in subjects with FGIDs diagnosed according to the Rome II, III, and IV criteria. Results: Eleven trials were eligible (3 prospective trials, 8 single or double-blind placebo-controlled trials), with 10/11 trials including adult subjects with irritable bowel syndrome (IBS) or FGIDs. Most of the prospective studies found an effect of GFD on gastrointestinal symptoms control. Nevertheless, 1 trial failed to find an association between gluten and GI symptoms when FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) content was simultaneously reduced in the diet, and 2 trials reported a worsening of symptoms during placebo administration. The results of the different trials are difficult to compare due to discrepancies in the study protocols regarding the amount and type of gluten administered, the duration of the gluten challenge, the type of placebo used, and the duration of the challenge itself. Conclusions: According to our results, gluten may contribute to the occurrence of gastrointestinal symptoms in patients with FGIDs, particularly in those with IBS. Nevertheless, the results of the currently available trials are difficult to compare due to the lack of standardization in the study designs. For this reason, it is still not possible to recommend the use of the GFD in the routine management of FGIDs

Nutritional status in neurologically impaired children and its relation with bone mineralization

Objectives and study: Malnutrition and low bone mineral density (BMD) are common in neurologically impaired (NI) children, in particular in children with cerebral palsy (CP). The two conditions are related, as it is known that poor nutritional status can negatively impact on bone mineralization. The aim of our study was to assess nutritional status, bone health and the relation between the two conditions in our population of NI children. Methods: A total of 26 NI subjects (mean age 9,9 + 3,7 years, M:F ratio 11:15, all Caucasian except for one Hispanic), were enrolled between November 2014 and March 2015. Diagnoses were: cerebral palsy (CP) 42.3% (n=11), epilepsy of various etiology associated with mild or no motor impairment (epilepsy without CP) 57.7% (n=15). Patients receiving vitamin D supplementation were excluded. All subjects underwent: 1) Nutritional assessment including feeding history, anthropometric evaluation of weight, height, body mass index (BMI) and triceps skinfold thickness (TST); 2) Biochemical analyses for bone metabolism and serum markers of bone turnover including parathormone (PTH), 25-hydroxy-vitamin D (25OHvitD), bone alkaline phosphatase (BAP) and carboxy-terminal collagen (CTX); 3) BMD measurement at lumbar spine (L1-L4) with Dual Energy X-ray Absorptiometry (DEXA). Results: Feeding difficulties were encountered in 42.3% of total patients, in 90,9% of children with CP. Nutrient intakes were compared to recommended dietary intakes for Italian population (LARN 2014), insufficient intake of energy, protein and calcium were found in 26,9%, 3.8%, 69,2% of total patients. A poor nutritional status (BMI< 10th c.le and/or TST< 10thc.le) was found in 38,5% of total patients, in 72,7% of children with CP. Vitamin D insufficiency (25OHvitD < 20 ng/dl) was found in 65,4% of total subjects, in 81,8% of children with CP. Values of CTX and BAP were significantly higher in epileptic children without CP compared to children with CP (p=0,0396 and 0,048 respectively). Results of nutritional status and bone metabolism are shown in table 1. A poor bone mineralization (BMD z-score < 2) was found in the lumbar spine of 38% of the total and in 73% of children with CP. Correlation analyses found positive correlation between BMD z-score and the anthropometric parameters BMI z-score and TST (r=0.8205; p< 0,0001 and r=0.7374; p< 0,0001 respectively). Negative correlation was also found between BMD z-score and severity of motor impairment measured by Gross Motor Function Classification Scale- GMFCS (r= -0,7216 p< 0,05). Conclusion: Our data confirm a high prevalence of malnutrition, vitamin D insufficiency and poor bone mineralization in NI children, particularly in those with CP. We also confirm that nutritional status and motor impairment are factors that negatively impact on bone mineralization. Disclosure of interest: None declared

Nutrition in Pediatric Inflammatory Bowel Disease: From Etiology to Treatment : A Systematic Review

Nutrition is involved in several aspects of pediatric inflammatory bowel disease (IBD), ranging from disease etiology to induction and maintenance of disease. With regards to etiology, there are pediatric data, mainly from case-control studies, which suggest that some dietary habits (for example consumption of animal protein, fatty foods, high sugar intake) may predispose patients to IBD onset. As for disease treatment, exclusive enteral nutrition (EEN) is an extensively studied, well established, and valid approach to the remission of pediatric Crohn's disease (CD). Apart from EEN, several new nutritional approaches are emerging and have proved to be successful (specific carbohydrate diet and CD exclusion diet) but the available evidence is not strong enough to recommend this kind of intervention in clinical practice and new large experimental controlled studies are needed, especially in the pediatric population. Moreover, efforts are being made to identify foods with anti-inflammatory properties such as curcumin and long-chain polyunsaturated fatty acids n-3, which can possibly be effective in maintenance of disease. The present systematic review aims at reviewing the scientific literature on all aspects of nutrition in pediatric IBD, including the most recent advances on nutritional therapy

Interessamento entesitico in bambini e adolescenti con malattia infiammatoria cronica intestinale: uno studio ecografico

Background: joint involvement is the most common extraintestinal manifestation in paediatric IBD patients. Several studies in adult population have shown that enthesis ultrasound (US) has a high sensitivity in the diagnosis of enthesitis. Objectives: The objective is to evaluate, using a high frequency ultrasound probe, the prevalence of subclinical entheseal involvement in paediatric IBD patients. Methods: 27 paediatric IBD patients [12 Crohn's disease, 13 ulcerative colitis and 2 IBD type unclassified; 15 females and 12 males, mean age of 13,7 years (ranging 7,2-21,0 years)] without clinical signs or symptoms of musculo-skeletal involvement were consecutively investigated with US (ESAOTE MyLAB 70 6-18 MHz linear array transducer) and compared with 24 healthy controls matched for age and sex. Twelve enthesis were scored according to the Madrid Sonographic Enthesis Index (MASEI) in both groups. Results: no patients reached the MASEI score value suggestive for an early spondyloarthritis involvement but the average MASEI score was significantly higher in IBD patients compared to controls (3.15\ub12.84 vs 0.96\ub11.12, p=0.0006).There was also a significantly higher percentage of patients with at least one enthesis with power Doppler (PD) score 652 (37% vs 16%; p= 0.037) and at least one enthesis with dishomogeneous echostructure (59% vs 0%; p= 0.000). No differences were found in terms of erosions, calcifications and structural thickness. In IBD patients, no correlation was found between MASEI total score and sex, age, disease duration and clinical activity scores. Conclusions: US detectable enthesopathy is frequent even in paediatric IBD patients

Assessment of disease activity with magnetic resonance enterography in pediatric Crohn&apos;s Disease

Objectives and study: Magnetic Resonance Enterography (MRE) is considered the imaging test of choice in children affected by Crohns Disease (CD) in order to study the small bowel. Few studies in literature analyze the correlation between disease activity evidenced by MRE and the standardized reference indices of activity in a pediatric population. The primary aim of our study was to determine whether MRE can be used to evaluate the activity of disease in a pediatric population affected by CD, studying the correlation between the activity index obtained by means of MRE and the standardized reference indices commonly used in clinical practice. We also compared MRE and endoscopy in their definition of disease localization. Methods: We recruited 39 CD pediatric patients who underwent 79 MRE at the time of diagnosis or during follow-up. At the same time of MRE, serum C-reactive protein (CRP), fecal calprotectin and the clinical activity index for pediatric CD (PCDAI) were performed. To evaluate the correlation of these parameters with disease activity on MRE, we applied a Pediatric Magnetic Resonance Index of activity, called P-CDMRI, which includes 11 parameters, for a total score ranging from 0, suggestive of remission, to 25, indicative of the maximal disease activity. Forty-five MRE performed within two months from a full endoscopic examination were used to evaluate the concordance on disease location and activity as detected by the two methods. The Simplified Endoscopic Score for Crohn\u2019s disease (SES-CD) was used to evaluate endoscopic activity. Spearman correlation coefficients have been calculated between P-CDMRI and PCDAI and CRP and fecal calprotectin levels. We also considered the correlations between PCDAI the two most important RME variables, using the Kruskal Wallis test. p 640,05 values were considered statistically significant. Correlation coefficient values were interpreted as follows: 0.0, not correlated; 0.2, weakly correlated; 0.5, moderately correlated; 0.8, strongly correlated; and 1.0, perfectly correlated. MRE and endoscopy concordance in disease localization was evaluated with Cohen k statistics. Results: the P-CDMRI significantly correlated with the clinical (PCDAI, r = 0,690, p<0,001), laboratory (CRP, r = 0,436 p<0,001; fecal calprotectin, r = 0,390 p=0,008) and endoscopic (SES-CD, r = 0,445 p=0,003) indexes of activity. We observed a good concordance in the localization of the involved gastrointestinal tracts between MRE and endoscopy (K= 0,630 p<0,001). However, some discrepancies were observed, probably due to a better sensibility of endoscopy in detection of superficial lesions and a more precise evaluation of transmural involvement by MRE. Conclusion: Our study suggests that P-CDMRI is a good indicator of disease activity in CD pediatric patients, with significant correlations with the most commonly used clinical, laboratory and endoscopic parameters; it may thus be used to evaluate CD activity during the follow-up as well as the response to therapy. However, studies with a larger population of patients should be warranted to confirm these results. Disclosure of interest: \u201cNone Declared\u201d

Barrett&apos;s esophagus: proton pump inhibitors and chemoprevention II.

The following on proton pump inhibitors (PPIs) and chemoprevention in relation to Barrett's esophagus includes commentaries on 48-h pH monitoring, pH-impedence, bile acid testing, dyspepsia, long/short segment Barrett's esophagus, nonerosive reflux disease (NERD), functional heartburn, dual-release delivery PPIs, immediate-release PPIs, long-term PPI use, prokinetic agents, obesity, baclofen, nocturnal acid breakthrough, nonsteroidal anti-inflammatory drugs (NSAIDs), and new PPIs

Endo-therapies for biliary duct-to-duct anastomotic stricture after liver transplantation: outcomes of a nationwide survey

BACKGROUND: The most appropriate endo-therapeutic approach to biliary anastomotic strictures is yet to be defined. AIM: To retrospectively report on the endo-therapy of duct-to-duct anastomotic strictures during 2013 in Italy. METHODS: Data were collected from 16 Endoscopy Units at the Italian Liver Transplantation Centers (BASALT study group). RESULTS: Complete endo-therapy and follow-up data are available for 181 patients: 101 treated with plastic multistenting, 26 with fully covered self-expandable metal stenting (SEMS) and 54 with single stenting. Radiological success was achieved for 145 patients (80%), i.e. 88% of plastic multistenting, 88% of SEMS and 61% of single stenting (p&lt;0.001 vs plastic multistenting; p&lt;0.05 vs SEMS)]. After first-line endo-therapy failure, the patients underwent a second-line endo-therapy with plastic multistenting for 25%, fully covered SEMS for 53% and single stenting for 22% of cases, and radiological success was achieved for 84%, i.e. 100%, 85%, and 63% with plastic multistenting, SEMS and single stenting (p&lt;0.05 vs plastic multistenting or SEMS), respectively. Procedure-related complications occurred in 7.8% of ERCP. Overall clinical success was achieved in 87% of patients after a median follow-up of 25 months. CONCLUSION: Plastic multistenting is confirmed as the preferred first-line treatment, while fully covered SEMS as rescue option for biliary anastomotic strictures. Single stenting has sub-optimal results and should be abandoned. This article is protected by copyright. All rights reserved