Bruggink, Janneke L M

Burgerhof, Johannes G M

de Kleine, Ruben H J

Hulscher, Jan B F

Nomden, Mark

Verkade, Henkjan J

English

University of Groningen

   University of GroningenUnusual Long Absence of Isolated Biliary Atresia in COVID LockdownNomden, Mark; de Kleine, Ruben H J; Bruggink, Janneke L M; Verkade, Henkjan J;Burgerhof, Johannes G M; Hulscher, Jan B FPublished in:Journal of Pediatric Gastroenterology and NutritionDOI:10.1097/MPG.0000000000003313IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2022Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Nomden, M., de Kleine, R. H. J., Bruggink, J. L. M., Verkade, H. J., Burgerhof, J. G. M., & Hulscher, J. B. F.(2022). Unusual Long Absence of Isolated Biliary Atresia in COVID Lockdown: Coincidence or Association?Journal of Pediatric Gastroenterology and Nutrition, 74(1), e17-e18.https://doi.org/10.1097/MPG.0000000000003313CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 29-04-2023 Copyright © ESPGHAN and NASPGHAN. All rights reserved.COVID-19 Outbreak, Lockdown andImpact on Pediatric Nutritional Status:A Preliminary ObservationT o the Editor: We would like to share ideas on the impact ofCOVID-19 outbreak and lockdown on pediatric nutritionalstatus. Lockdown can influence health status. During a schoolclosures, the parental care is very important. The effect might bedifferent in different settings. A report from an area with highlyeducated and rich population might show a possibility of adjustmentto problem by parents. For example, Strisciuglio et al (1) showedthat there was a short period of problem in caring children duringthe first month before improvement. The effect of COVID-19 andlockdown might be totally different in areas with high poverty rate.Socioeconomic background of the family of the children is animportant parameter in the analysis on the effect of lockdown. Forexample, the lockdown might result in underweight among childrenfrom poor communities and the parents have no money and abilityto care their children. In contrast, a problem of obesity might bedetected in children from rich families (2).Here, the authors would like to share our preliminary obser-vation from an area that COVID-19 has been attached since early 2020and there are already more than 1 million cumulative confirmedCOVID-19 cases at present. The area is a rural area in Indochina(GPS location 14.874786541289744, 102.83783914044895) wherepediatric undernutrition is an important local public health problem(3). Local public data (http://healthkpi.moph.go.th/kpi2/kpi/) fromroutine annual pediatric health survey (ages 6–14 years, overall popu-lation 823,853) are retrospectively analyzed. Regarding primary datacollection, the standard pediatric anthropometric examination is doneby the village primary health center, which is run by a village primaryhealth care officer, who is a governmental worker of Ministry of PublicHealth and has a degree of Bachelor of Public Health or higher degree.In each year, the pediatric anthropometric survey is done and recordedin each village during July. During COVID-19 outbreak, full functionof the village primary care center still remained. The regular monitoringof pediatric nutritional status in the village was regularly done, similarto the previous period without COVID-19 outbreak.Prevalence of pediatric nutritional problem is shown inTable 1. During the 4-year period, 2018, 2019, 2020 and 2021,overall coverage rate of children examination are equal to 63.27%,65.22%, 61.43% and 64.4% of the overall pediatric population,respectively. From the 4-year data, the effect of COVID-19 outbreakis observed. When the disease starts in early 2020, the prevalence ofabnormal pediatric nutritional status did not increase in the year 2020;however, the pediatric underweight and overweight problemssignificantly increase in the year 2021. When COVID-19 has existedfor a long time, a significant impact occurs. During COVID-19outbreak, school has been closed for a long time and outdoor sportor exercise activities are prohibited. Some children might be in poorfamilies and cannot receive sufficient food. On the other hand, somechildren from rich families might experience different situation. Thecomplexity of pediatric nutritional problem in rural area of devel-oping countries can be repeatedly demonstrated (3). COVID-19outbreak and lockdown can have an impact on pediatric nutritionalstatus; however, a local socioeconomic background can play import-ant role in modifying the direction of effect.Rujittika Mungmunpuntipantip, ySim Sai Tin,and zViroj WiwanitkitPrivate Consultant, Bangkok ThailandyShantour Medical Center, Shantou, ChinazDr DY Patil University, Pune, IndiaThe authors report no conflicts of interest.REFERENCES1. Strisciuglio C, Martinelli M, Lu P, et al. Overall impact of COVID-19outbreak in children with functional abdominal pain disorders: resultsfrom the first pandemic phase. J Pediatr Gastroenterol Nutr 2021. [Epubahead of print].2. Joob B, Wiwanitkit V. COVID-19, school closings, and weight gain.Obesity (Silver Spring) 2020;28:1006.3. Wiwanitkit V, Sodsri P. Underweight schoolchildren in a rural school nearthe Thai-Cambodian border. Southeast Asian J Trop Med Public Health2003;34:458–61.Unusual Long Absence of IsolatedBiliary Atresia in COVID Lockdown:Coincidence or Association?T o the Editor: Isolated biliary atresia (IBA) is a rare cholan-giopathy of unknown origin. IBA is hypothesized to becaused by exposure to an unidentified external agent, with subsequentimmune mediated destruction of bile ducts (1). During the COVID-19-related lockdown, early 2020, a decrease in pediatric infections(eg, otitis media and gastroenteritis), was observed in the Netherlands(2). Simultaneously in this period, we observed an unusual gap lengthbetween subsequent new IBA cases; the gap length between birth-dates of two subsequent IBA patients was 174 days. We determinedfrom our national BA registry that between 2000 and 2020, themedian gap length between two IBA patients had been 32 days. Wecalculated the probability of every gap length occurring, assuming aPoisson distribution of IBA cases and a negative exponential distri-bution of gap length (3). The probability that a gap length of 174 dayswas 2.6%, thus below the standard accepted level of significance.Between 2000 and 2020, a gap length of at least 174 days betweensubsequent IBA patients had occurred another four times (Fig. 1);however, the essence and uniqueness of our current observation is thata long gap length occurred simultaneously with a lockdown thatcontributed to a decreased number of paediatric infections. One cantherefore speculate that the increased gap length of subsequent IBATABLE 1. Data on pediatric nutritional statusPediatric nutritional status(prevalence, %) 2018 2019 2020 2021Normal 66.5 61.5 65.7 58.07Underweight 33.5 38.5 34.3 41.93Overweight 11.8 13.6 12.5 14.5Total number of childrenmeasured per year521,252 537,317 506,092 530,561Underweight: weight for age<–2 standard deviations (SD) of the WHOChild Growth Standards median; overweight: weight for height >þ2 SD ofthe WHO Child Growth Standards median (according to WHO Interpret-ation Guide, https://www.who.int/nutrition/nlis_interpretation_guide.pdf).LETTERS TO THE EDITORJPGN  Volume 74, Number 1, January 2022 e17 Copyright © ESPGHAN and NASPGHAN. All rights reserved.patients in this period is not coincidental but may rather be related to adecreased societal burden of infections which have been implied inthe pathogenesis of IBA. We therefore propose further research on theincidence of IBA in other European countries in relation to lockdown-related restrictions.The authors report nothing to declare.Financial Support: No financial support was received by NeS-BAR. It is a study group on BA but it does not grant usfinancial support.Mark Nomden, yRuben H.J. de Kleine,Janneke L.M. Bruggink,zHenkjan J. Verkade, §Johannes G.M. Burgerhof, andJan B.F. HulscherSection of Paediatric Surgery, Department of Surgery,University Medical Centre GroningenySection of Hepato-pancreatic-biliary Surgery and LiverTransplantation, Department of Surgery,University Medical Centre GroningenzSection of Paediatric Gastroenterology and Hepatology,Department of Paediatrics, Beatrix Children’s Hospital, UniversityMedical Centre Groningen§Department of Epidemiology, University Medical CentreGroningen, University of Groningen, Groningen,The NetherlandsREFERENCES1. Mack CL, Feldman AG, Sokol RJ. Clues to the etiology of bile duct injuryin biliary atresia. Semin Liver Dis 2012;32:307–16.2. Hooiveld M, Hendriksen J, Korevaar J. Wekelijkse surveillance cijfers. Nivelzorgregistraties eerste lijn. www.nivel.nl/surveillance. 2020. AccessedSeptember 20, 2020.3. Koehrsen W. The Poisson Distribution and Poisson Process Explained.Towards Data Science. 2019. https://towardsdatascience.com/the-poisson-distribution-and-poisson-process-explained-4e2cb17d459. [Accessed 25January 2021].Performance Characteristics, Intra- andInter-Operator Agreement of TransientElastography in Pediatric NonalcoholicFatty Liver DiseaseT o the Editor: We note with concern that Mandelia et al (1,2)misrepresent our conclusions on the precision of transientelastography (TE). In concluding that TE has precision they statethat their findings in 51 children with nonalcoholic fatty liverdisease (NAFLD) are similar to the findings in our study of 235healthy children and 65 children with cystic fibrosis; however, wefound that TE lacks precision (2). Furthermore, a review of theresults reported by Mandelia et al (1), in particular the supple-mentary material, confirms that TE lacks precision.Bland and Altman (3–7) are unequivocal in their descriptionof measurement agreement analysis that the data must follow anormal distribution with a narrow standard deviation, and reportingguidelines make these requirements explicit (5–7).We reported the mean difference between paired measure-ments in healthy children was 0.044 kPa with a standard deviation(SD) of 0.414 (2). Evidently, a SD of 0.414 is wide in the context ofa mean of the paired differences of 0.044 kPa, confirming poorprecision. Consistent with reporting guidelines we display thedistribution of the data as a histogram and the agreement betweenpaired measurements as Bland and Altman plots.In contrast, Mandelia et al (1) report that TE is reliable inchildren with NAFLD with low failure rates despite reporting afailure rate of 20%, which must be considered moderate-to-high.The mean difference between paired measurements by the expertoperator 0.4 kPa (SD 1.1) and two different operators 0.9 kPa (SD 1.6)indicates that the paired differences are substantial. The data also hasa wide standard deviation confirming significant disagreementbetween paired measurements. This lack of agreement is furtheremphasized in the 95% limits of agreement which ranged from1.8FIGURE 1. Bar graph representing the number of observed gap lengths (in days) between the birthdays of two subsequent IBA patients.Categories of gap lengths are divided into 25-day segments. Probabilities of gap length occurrence were calculated according to the followingformula: P(T> x) ¼ e  [161/7671]x, with x representing gap length in days, T representing time, and P representing probability. Gap lengths of143 days or more had a probability of occurring of <5%. IBA patients born between 1 January 2000 and 31 December 2020 are included(n¼161). IBA¼ isolated biliary atresia.Letters to the Editor JPGN  Volume 74, Number 1, January 2022e18 www.jpgn.org

Unusual Long Absence of Isolated Biliary Atresia in COVID Lockdown:Coincidence or Association?

University of GroningenUnusual Long Absence of Isolated Biliary Atresia in COVID LockdownNomden, Mark; de Kleine, Ruben H J; Bruggink, Janneke L M; Verkade, Henkjan J;Burgerhof, Johannes G M; Hulscher, Jan B FPublished in:Journal of Pediatric Gastroenterology and NutritionDOI:10.1097/MPG.0000000000003313IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2022Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Nomden, M., de Kleine, R. H. J., Bruggink, J. L. M., Verkade, H. J., Burgerhof, J. G. M., & Hulscher, J. B. F.(2022). Unusual Long Absence of Isolated Biliary Atresia in COVID Lockdown: Coincidence or Association?Journal of Pediatric Gastroenterology and Nutrition, 74(1), e17-e18.https://doi.org/10.1097/MPG.0000000000003313CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 31-12-2025 Copyright © ESPGHAN and NASPGHAN. All rights reserved.COVID-19 Outbreak, Lockdown andImpact on Pediatric Nutritional Status:A Preliminary ObservationT o the Editor: We would like to share ideas on the impact ofCOVID-19 outbreak and lockdown on pediatric nutritionalstatus. Lockdown can influence health status. During a schoolclosures, the parental care is very important. The effect might bedifferent in different settings. A report from an area with highlyeducated and rich population might show a possibility of adjustmentto problem by parents. For example, Strisciuglio et al (1) showedthat there was a short period of problem in caring children duringthe first month before improvement. The effect of COVID-19 andlockdown might be totally different in areas with high poverty rate.Socioeconomic background of the family of the children is animportant parameter in the analysis on the effect of lockdown. Forexample, the lockdown might result in underweight among childrenfrom poor communities and the parents have no money and abilityto care their children. In contrast, a problem of obesity might bedetected in children from rich families (2).Here, the authors would like to share our preliminary obser-vation from an area that COVID-19 has been attached since early 2020and there are already more than 1 million cumulative confirmedCOVID-19 cases at present. The area is a rural area in Indochina(GPS location 14.874786541289744, 102.83783914044895) wherepediatric undernutrition is an important local public health problem(3). Local public data (http://healthkpi.moph.go.th/kpi2/kpi/) fromroutine annual pediatric health survey (ages 6–14 years, overall popu-lation 823,853) are retrospectively analyzed. Regarding primary datacollection, the standard pediatric anthropometric examination is doneby the village primary health center, which is run by a village primaryhealth care officer, who is a governmental worker of Ministry of PublicHealth and has a degree of Bachelor of Public Health or higher degree.In each year, the pediatric anthropometric survey is done and recordedin each village during July. During COVID-19 outbreak, full functionof the village primary care center still remained. The regular monitoringof pediatric nutritional status in the village was regularly done, similarto the previous period without COVID-19 outbreak.Prevalence of pediatric nutritional problem is shown inTable 1. During the 4-year period, 2018, 2019, 2020 and 2021,overall coverage rate of children examination are equal to 63.27%,65.22%, 61.43% and 64.4% of the overall pediatric population,respectively. From the 4-year data, the effect of COVID-19 outbreakis observed. When the disease starts in early 2020, the prevalence ofabnormal pediatric nutritional status did not increase in the year 2020;however, the pediatric underweight and overweight problemssignificantly increase in the year 2021. When COVID-19 has existedfor a long time, a significant impact occurs. During COVID-19outbreak, school has been closed for a long time and outdoor sportor exercise activities are prohibited. Some children might be in poorfamilies and cannot receive sufficient food. On the other hand, somechildren from rich families might experience different situation. Thecomplexity of pediatric nutritional problem in rural area of devel-oping countries can be repeatedly demonstrated (3). COVID-19outbreak and lockdown can have an impact on pediatric nutritionalstatus; however, a local socioeconomic background can play import-ant role in modifying the direction of effect.Rujittika Mungmunpuntipantip, ySim Sai Tin,and zViroj WiwanitkitPrivate Consultant, Bangkok ThailandyShantour Medical Center, Shantou, ChinazDr DY Patil University, Pune, IndiaThe authors report no conflicts of interest.REFERENCES1. Strisciuglio C, Martinelli M, Lu P, et al. Overall impact of COVID-19outbreak in children with functional abdominal pain disorders: resultsfrom the first pandemic phase. J Pediatr Gastroenterol Nutr 2021. [Epubahead of print].2. Joob B, Wiwanitkit V. COVID-19, school closings, and weight gain.Obesity (Silver Spring) 2020;28:1006.3. Wiwanitkit V, Sodsri P. Underweight schoolchildren in a rural school nearthe Thai-Cambodian border. Southeast Asian J Trop Med Public Health2003;34:458–61.Unusual Long Absence of IsolatedBiliary Atresia in COVID Lockdown:Coincidence or Association?T o the Editor: Isolated biliary atresia (IBA) is a rare cholan-giopathy of unknown origin. IBA is hypothesized to becaused by exposure to an unidentified external agent, with subsequentimmune mediated destruction of bile ducts (1). During the COVID-19-related lockdown, early 2020, a decrease in pediatric infections(eg, otitis media and gastroenteritis), was observed in the Netherlands(2). Simultaneously in this period, we observed an unusual gap lengthbetween subsequent new IBA cases; the gap length between birth-dates of two subsequent IBA patients was 174 days. We determinedfrom our national BA registry that between 2000 and 2020, themedian gap length between two IBA patients had been 32 days. Wecalculated the probability of every gap length occurring, assuming aPoisson distribution of IBA cases and a negative exponential distri-bution of gap length (3). The probability that a gap length of 174 dayswas 2.6%, thus below the standard accepted level of significance.Between 2000 and 2020, a gap length of at least 174 days betweensubsequent IBA patients had occurred another four times (Fig. 1);however, the essence and uniqueness of our current observation is thata long gap length occurred simultaneously with a lockdown thatcontributed to a decreased number of paediatric infections. One cantherefore speculate that the increased gap length of subsequent IBATABLE 1. Data on pediatric nutritional statusPediatric nutritional status(prevalence, %) 2018 2019 2020 2021Normal 66.5 61.5 65.7 58.07Underweight 33.5 38.5 34.3 41.93Overweight 11.8 13.6 12.5 14.5Total number of childrenmeasured per year521,252 537,317 506,092 530,561Underweight: weight for age<–2 standard deviations (SD) of the WHOChild Growth Standards median; overweight: weight for height >þ2 SD ofthe WHO Child Growth Standards median (according to WHO Interpret-ation Guide, https://www.who.int/nutrition/nlis_interpretation_guide.pdf).LETTERS TO THE EDITORJPGN  Volume 74, Number 1, January 2022 e17 Copyright © ESPGHAN and NASPGHAN. All rights reserved.patients in this period is not coincidental but may rather be related to adecreased societal burden of infections which have been implied inthe pathogenesis of IBA. We therefore propose further research on theincidence of IBA in other European countries in relation to lockdown-related restrictions.The authors report nothing to declare.Financial Support: No financial support was received by NeS-BAR. It is a study group on BA but it does not grant usfinancial support.Mark Nomden, yRuben H.J. de Kleine,Janneke L.M. Bruggink,zHenkjan J. Verkade, §Johannes G.M. Burgerhof, andJan B.F. HulscherSection of Paediatric Surgery, Department of Surgery,University Medical Centre GroningenySection of Hepato-pancreatic-biliary Surgery and LiverTransplantation, Department of Surgery,University Medical Centre GroningenzSection of Paediatric Gastroenterology and Hepatology,Department of Paediatrics, Beatrix Children’s Hospital, UniversityMedical Centre Groningen§Department of Epidemiology, University Medical CentreGroningen, University of Groningen, Groningen,The NetherlandsREFERENCES1. Mack CL, Feldman AG, Sokol RJ. Clues to the etiology of bile duct injuryin biliary atresia. Semin Liver Dis 2012;32:307–16.2. Hooiveld M, Hendriksen J, Korevaar J. Wekelijkse surveillance cijfers. Nivelzorgregistraties eerste lijn. www.nivel.nl/surveillance. 2020. AccessedSeptember 20, 2020.3. Koehrsen W. The Poisson Distribution and Poisson Process Explained.Towards Data Science. 2019. https://towardsdatascience.com/the-poisson-distribution-and-poisson-process-explained-4e2cb17d459. [Accessed 25January 2021].Performance Characteristics, Intra- andInter-Operator Agreement of TransientElastography in Pediatric NonalcoholicFatty Liver DiseaseT o the Editor: We note with concern that Mandelia et al (1,2)misrepresent our conclusions on the precision of transientelastography (TE). In concluding that TE has precision they statethat their findings in 51 children with nonalcoholic fatty liverdisease (NAFLD) are similar to the findings in our study of 235healthy children and 65 children with cystic fibrosis; however, wefound that TE lacks precision (2). Furthermore, a review of theresults reported by Mandelia et al (1), in particular the supple-mentary material, confirms that TE lacks precision.Bland and Altman (3–7) are unequivocal in their descriptionof measurement agreement analysis that the data must follow anormal distribution with a narrow standard deviation, and reportingguidelines make these requirements explicit (5–7).We reported the mean difference between paired measure-ments in healthy children was 0.044 kPa with a standard deviation(SD) of 0.414 (2). Evidently, a SD of 0.414 is wide in the context ofa mean of the paired differences of 0.044 kPa, confirming poorprecision. Consistent with reporting guidelines we display thedistribution of the data as a histogram and the agreement betweenpaired measurements as Bland and Altman plots.In contrast, Mandelia et al (1) report that TE is reliable inchildren with NAFLD with low failure rates despite reporting afailure rate of 20%, which must be considered moderate-to-high.The mean difference between paired measurements by the expertoperator 0.4 kPa (SD 1.1) and two different operators 0.9 kPa (SD 1.6)indicates that the paired differences are substantial. The data also hasa wide standard deviation confirming significant disagreementbetween paired measurements. This lack of agreement is furtheremphasized in the 95% limits of agreement which ranged from1.8FIGURE 1. Bar graph representing the number of observed gap lengths (in days) between the birthdays of two subsequent IBA patients.Categories of gap lengths are divided into 25-day segments. Probabilities of gap length occurrence were calculated according to the followingformula: P(T> x) ¼ e  [161/7671]x, with x representing gap length in days, T representing time, and P representing probability. Gap lengths of143 days or more had a probability of occurring of <5%. IBA patients born between 1 January 2000 and 31 December 2020 are included(n¼161). IBA¼ isolated biliary atresia.Letters to the Editor JPGN  Volume 74, Number 1, January 2022e18 www.jpgn.org

ARTS repository - University of Groningen

   University of GroningenUnusual Long Absence of Isolated Biliary Atresia in COVID LockdownNomden, Mark; de Kleine, Ruben H J; Bruggink, Janneke L M; Verkade, Henkjan J;Burgerhof, Johannes G M; Hulscher, Jan B FPublished in:Journal of Pediatric Gastroenterology and NutritionDOI:10.1097/MPG.0000000000003313IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2022Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Nomden, M., de Kleine, R. H. J., Bruggink, J. L. M., Verkade, H. J., Burgerhof, J. G. M., & Hulscher, J. B. F.(2022). Unusual Long Absence of Isolated Biliary Atresia in COVID Lockdown: Coincidence or Association?Journal of Pediatric Gastroenterology and Nutrition, 74(1), e17-e18.https://doi.org/10.1097/MPG.0000000000003313CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 13-02-2023 Copyright © ESPGHAN and NASPGHAN. All rights reserved.COVID-19 Outbreak, Lockdown andImpact on Pediatric Nutritional Status:A Preliminary ObservationT o the Editor: We would like to share ideas on the impact ofCOVID-19 outbreak and lockdown on pediatric nutritionalstatus. Lockdown can influence health status. During a schoolclosures, the parental care is very important. The effect might bedifferent in different settings. A report from an area with highlyeducated and rich population might show a possibility of adjustmentto problem by parents. For example, Strisciuglio et al (1) showedthat there was a short period of problem in caring children duringthe first month before improvement. The effect of COVID-19 andlockdown might be totally different in areas with high poverty rate.Socioeconomic background of the family of the children is animportant parameter in the analysis on the effect of lockdown. Forexample, the lockdown might result in underweight among childrenfrom poor communities and the parents have no money and abilityto care their children. In contrast, a problem of obesity might bedetected in children from rich families (2).Here, the authors would like to share our preliminary obser-vation from an area that COVID-19 has been attached since early 2020and there are already more than 1 million cumulative confirmedCOVID-19 cases at present. The area is a rural area in Indochina(GPS location 14.874786541289744, 102.83783914044895) wherepediatric undernutrition is an important local public health problem(3). Local public data (http://healthkpi.moph.go.th/kpi2/kpi/) fromroutine annual pediatric health survey (ages 6–14 years, overall popu-lation 823,853) are retrospectively analyzed. Regarding primary datacollection, the standard pediatric anthropometric examination is doneby the village primary health center, which is run by a village primaryhealth care officer, who is a governmental worker of Ministry of PublicHealth and has a degree of Bachelor of Public Health or higher degree.In each year, the pediatric anthropometric survey is done and recordedin each village during July. During COVID-19 outbreak, full functionof the village primary care center still remained. The regular monitoringof pediatric nutritional status in the village was regularly done, similarto the previous period without COVID-19 outbreak.Prevalence of pediatric nutritional problem is shown inTable 1. During the 4-year period, 2018, 2019, 2020 and 2021,overall coverage rate of children examination are equal to 63.27%,65.22%, 61.43% and 64.4% of the overall pediatric population,respectively. From the 4-year data, the effect of COVID-19 outbreakis observed. When the disease starts in early 2020, the prevalence ofabnormal pediatric nutritional status did not increase in the year 2020;however, the pediatric underweight and overweight problemssignificantly increase in the year 2021. When COVID-19 has existedfor a long time, a significant impact occurs. During COVID-19outbreak, school has been closed for a long time and outdoor sportor exercise activities are prohibited. Some children might be in poorfamilies and cannot receive sufficient food. On the other hand, somechildren from rich families might experience different situation. Thecomplexity of pediatric nutritional problem in rural area of devel-oping countries can be repeatedly demonstrated (3). COVID-19outbreak and lockdown can have an impact on pediatric nutritionalstatus; however, a local socioeconomic background can play import-ant role in modifying the direction of effect.Rujittika Mungmunpuntipantip, ySim Sai Tin,and zViroj WiwanitkitPrivate Consultant, Bangkok ThailandyShantour Medical Center, Shantou, ChinazDr DY Patil University, Pune, IndiaThe authors report no conflicts of interest.REFERENCES1. Strisciuglio C, Martinelli M, Lu P, et al. Overall impact of COVID-19outbreak in children with functional abdominal pain disorders: resultsfrom the first pandemic phase. J Pediatr Gastroenterol Nutr 2021. [Epubahead of print].2. Joob B, Wiwanitkit V. COVID-19, school closings, and weight gain.Obesity (Silver Spring) 2020;28:1006.3. Wiwanitkit V, Sodsri P. Underweight schoolchildren in a rural school nearthe Thai-Cambodian border. Southeast Asian J Trop Med Public Health2003;34:458–61.Unusual Long Absence of IsolatedBiliary Atresia in COVID Lockdown:Coincidence or Association?T o the Editor: Isolated biliary atresia (IBA) is a rare cholan-giopathy of unknown origin. IBA is hypothesized to becaused by exposure to an unidentified external agent, with subsequentimmune mediated destruction of bile ducts (1). During the COVID-19-related lockdown, early 2020, a decrease in pediatric infections(eg, otitis media and gastroenteritis), was observed in the Netherlands(2). Simultaneously in this period, we observed an unusual gap lengthbetween subsequent new IBA cases; the gap length between birth-dates of two subsequent IBA patients was 174 days. We determinedfrom our national BA registry that between 2000 and 2020, themedian gap length between two IBA patients had been 32 days. Wecalculated the probability of every gap length occurring, assuming aPoisson distribution of IBA cases and a negative exponential distri-bution of gap length (3). The probability that a gap length of 174 dayswas 2.6%, thus below the standard accepted level of significance.Between 2000 and 2020, a gap length of at least 174 days betweensubsequent IBA patients had occurred another four times (Fig. 1);however, the essence and uniqueness of our current observation is thata long gap length occurred simultaneously with a lockdown thatcontributed to a decreased number of paediatric infections. One cantherefore speculate that the increased gap length of subsequent IBATABLE 1. Data on pediatric nutritional statusPediatric nutritional status(prevalence, %) 2018 2019 2020 2021Normal 66.5 61.5 65.7 58.07Underweight 33.5 38.5 34.3 41.93Overweight 11.8 13.6 12.5 14.5Total number of childrenmeasured per year521,252 537,317 506,092 530,561Underweight: weight for age<–2 standard deviations (SD) of the WHOChild Growth Standards median; overweight: weight for height >þ2 SD ofthe WHO Child Growth Standards median (according to WHO Interpret-ation Guide, https://www.who.int/nutrition/nlis_interpretation_guide.pdf).LETTERS TO THE EDITORJPGN  Volume 74, Number 1, January 2022 e17 Copyright © ESPGHAN and NASPGHAN. All rights reserved.patients in this period is not coincidental but may rather be related to adecreased societal burden of infections which have been implied inthe pathogenesis of IBA. We therefore propose further research on theincidence of IBA in other European countries in relation to lockdown-related restrictions.The authors report nothing to declare.Financial Support: No financial support was received by NeS-BAR. It is a study group on BA but it does not grant usfinancial support.Mark Nomden, yRuben H.J. de Kleine,Janneke L.M. Bruggink,zHenkjan J. Verkade, §Johannes G.M. Burgerhof, andJan B.F. HulscherSection of Paediatric Surgery, Department of Surgery,University Medical Centre GroningenySection of Hepato-pancreatic-biliary Surgery and LiverTransplantation, Department of Surgery,University Medical Centre GroningenzSection of Paediatric Gastroenterology and Hepatology,Department of Paediatrics, Beatrix Children’s Hospital, UniversityMedical Centre Groningen§Department of Epidemiology, University Medical CentreGroningen, University of Groningen, Groningen,The NetherlandsREFERENCES1. Mack CL, Feldman AG, Sokol RJ. Clues to the etiology of bile duct injuryin biliary atresia. Semin Liver Dis 2012;32:307–16.2. Hooiveld M, Hendriksen J, Korevaar J. Wekelijkse surveillance cijfers. Nivelzorgregistraties eerste lijn. www.nivel.nl/surveillance. 2020. AccessedSeptember 20, 2020.3. Koehrsen W. The Poisson Distribution and Poisson Process Explained.Towards Data Science. 2019. https://towardsdatascience.com/the-poisson-distribution-and-poisson-process-explained-4e2cb17d459. [Accessed 25January 2021].Performance Characteristics, Intra- andInter-Operator Agreement of TransientElastography in Pediatric NonalcoholicFatty Liver DiseaseT o the Editor: We note with concern that Mandelia et al (1,2)misrepresent our conclusions on the precision of transientelastography (TE). In concluding that TE has precision they statethat their findings in 51 children with nonalcoholic fatty liverdisease (NAFLD) are similar to the findings in our study of 235healthy children and 65 children with cystic fibrosis; however, wefound that TE lacks precision (2). Furthermore, a review of theresults reported by Mandelia et al (1), in particular the supple-mentary material, confirms that TE lacks precision.Bland and Altman (3–7) are unequivocal in their descriptionof measurement agreement analysis that the data must follow anormal distribution with a narrow standard deviation, and reportingguidelines make these requirements explicit (5–7).We reported the mean difference between paired measure-ments in healthy children was 0.044 kPa with a standard deviation(SD) of 0.414 (2). Evidently, a SD of 0.414 is wide in the context ofa mean of the paired differences of 0.044 kPa, confirming poorprecision. Consistent with reporting guidelines we display thedistribution of the data as a histogram and the agreement betweenpaired measurements as Bland and Altman plots.In contrast, Mandelia et al (1) report that TE is reliable inchildren with NAFLD with low failure rates despite reporting afailure rate of 20%, which must be considered moderate-to-high.The mean difference between paired measurements by the expertoperator 0.4 kPa (SD 1.1) and two different operators 0.9 kPa (SD 1.6)indicates that the paired differences are substantial. The data also hasa wide standard deviation confirming significant disagreementbetween paired measurements. This lack of agreement is furtheremphasized in the 95% limits of agreement which ranged from1.8FIGURE 1. Bar graph representing the number of observed gap lengths (in days) between the birthdays of two subsequent IBA patients.Categories of gap lengths are divided into 25-day segments. Probabilities of gap length occurrence were calculated according to the followingformula: P(T> x) ¼ e  [161/7671]x, with x representing gap length in days, T representing time, and P representing probability. Gap lengths of143 days or more had a probability of occurring of <5%. IBA patients born between 1 January 2000 and 31 December 2020 are included(n¼161). IBA¼ isolated biliary atresia.Letters to the Editor JPGN  Volume 74, Number 1, January 2022e18 www.jpgn.org

   University of GroningenUnusual Long Absence of Isolated Biliary Atresia in COVID LockdownNomden, Mark; de Kleine, Ruben H J; Bruggink, Janneke L M; Verkade, Henkjan J;Burgerhof, Johannes G M; Hulscher, Jan B FPublished in:Journal of Pediatric Gastroenterology and NutritionDOI:10.1097/MPG.0000000000003313IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2022Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Nomden, M., de Kleine, R. H. J., Bruggink, J. L. M., Verkade, H. J., Burgerhof, J. G. M., & Hulscher, J. B. F.(2022). Unusual Long Absence of Isolated Biliary Atresia in COVID Lockdown: Coincidence or Association?Journal of Pediatric Gastroenterology and Nutrition, 74(1), e17-e18.https://doi.org/10.1097/MPG.0000000000003313CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 01-02-2024 Copyright © ESPGHAN and NASPGHAN. All rights reserved.COVID-19 Outbreak, Lockdown andImpact on Pediatric Nutritional Status:A Preliminary ObservationT o the Editor: We would like to share ideas on the impact ofCOVID-19 outbreak and lockdown on pediatric nutritionalstatus. Lockdown can influence health status. During a schoolclosures, the parental care is very important. The effect might bedifferent in different settings. A report from an area with highlyeducated and rich population might show a possibility of adjustmentto problem by parents. For example, Strisciuglio et al (1) showedthat there was a short period of problem in caring children duringthe first month before improvement. The effect of COVID-19 andlockdown might be totally different in areas with high poverty rate.Socioeconomic background of the family of the children is animportant parameter in the analysis on the effect of lockdown. Forexample, the lockdown might result in underweight among childrenfrom poor communities and the parents have no money and abilityto care their children. In contrast, a problem of obesity might bedetected in children from rich families (2).Here, the authors would like to share our preliminary obser-vation from an area that COVID-19 has been attached since early 2020and there are already more than 1 million cumulative confirmedCOVID-19 cases at present. The area is a rural area in Indochina(GPS location 14.874786541289744, 102.83783914044895) wherepediatric undernutrition is an important local public health problem(3). Local public data (http://healthkpi.moph.go.th/kpi2/kpi/) fromroutine annual pediatric health survey (ages 6–14 years, overall popu-lation 823,853) are retrospectively analyzed. Regarding primary datacollection, the standard pediatric anthropometric examination is doneby the village primary health center, which is run by a village primaryhealth care officer, who is a governmental worker of Ministry of PublicHealth and has a degree of Bachelor of Public Health or higher degree.In each year, the pediatric anthropometric survey is done and recordedin each village during July. During COVID-19 outbreak, full functionof the village primary care center still remained. The regular monitoringof pediatric nutritional status in the village was regularly done, similarto the previous period without COVID-19 outbreak.Prevalence of pediatric nutritional problem is shown inTable 1. During the 4-year period, 2018, 2019, 2020 and 2021,overall coverage rate of children examination are equal to 63.27%,65.22%, 61.43% and 64.4% of the overall pediatric population,respectively. From the 4-year data, the effect of COVID-19 outbreakis observed. When the disease starts in early 2020, the prevalence ofabnormal pediatric nutritional status did not increase in the year 2020;however, the pediatric underweight and overweight problemssignificantly increase in the year 2021. When COVID-19 has existedfor a long time, a significant impact occurs. During COVID-19outbreak, school has been closed for a long time and outdoor sportor exercise activities are prohibited. Some children might be in poorfamilies and cannot receive sufficient food. On the other hand, somechildren from rich families might experience different situation. Thecomplexity of pediatric nutritional problem in rural area of devel-oping countries can be repeatedly demonstrated (3). COVID-19outbreak and lockdown can have an impact on pediatric nutritionalstatus; however, a local socioeconomic background can play import-ant role in modifying the direction of effect.Rujittika Mungmunpuntipantip, ySim Sai Tin,and zViroj WiwanitkitPrivate Consultant, Bangkok ThailandyShantour Medical Center, Shantou, ChinazDr DY Patil University, Pune, IndiaThe authors report no conflicts of interest.REFERENCES1. Strisciuglio C, Martinelli M, Lu P, et al. Overall impact of COVID-19outbreak in children with functional abdominal pain disorders: resultsfrom the first pandemic phase. J Pediatr Gastroenterol Nutr 2021. [Epubahead of print].2. Joob B, Wiwanitkit V. COVID-19, school closings, and weight gain.Obesity (Silver Spring) 2020;28:1006.3. Wiwanitkit V, Sodsri P. Underweight schoolchildren in a rural school nearthe Thai-Cambodian border. Southeast Asian J Trop Med Public Health2003;34:458–61.Unusual Long Absence of IsolatedBiliary Atresia in COVID Lockdown:Coincidence or Association?T o the Editor: Isolated biliary atresia (IBA) is a rare cholan-giopathy of unknown origin. IBA is hypothesized to becaused by exposure to an unidentified external agent, with subsequentimmune mediated destruction of bile ducts (1). During the COVID-19-related lockdown, early 2020, a decrease in pediatric infections(eg, otitis media and gastroenteritis), was observed in the Netherlands(2). Simultaneously in this period, we observed an unusual gap lengthbetween subsequent new IBA cases; the gap length between birth-dates of two subsequent IBA patients was 174 days. We determinedfrom our national BA registry that between 2000 and 2020, themedian gap length between two IBA patients had been 32 days. Wecalculated the probability of every gap length occurring, assuming aPoisson distribution of IBA cases and a negative exponential distri-bution of gap length (3). The probability that a gap length of 174 dayswas 2.6%, thus below the standard accepted level of significance.Between 2000 and 2020, a gap length of at least 174 days betweensubsequent IBA patients had occurred another four times (Fig. 1);however, the essence and uniqueness of our current observation is thata long gap length occurred simultaneously with a lockdown thatcontributed to a decreased number of paediatric infections. One cantherefore speculate that the increased gap length of subsequent IBATABLE 1. Data on pediatric nutritional statusPediatric nutritional status(prevalence, %) 2018 2019 2020 2021Normal 66.5 61.5 65.7 58.07Underweight 33.5 38.5 34.3 41.93Overweight 11.8 13.6 12.5 14.5Total number of childrenmeasured per year521,252 537,317 506,092 530,561Underweight: weight for age<–2 standard deviations (SD) of the WHOChild Growth Standards median; overweight: weight for height >þ2 SD ofthe WHO Child Growth Standards median (according to WHO Interpret-ation Guide, https://www.who.int/nutrition/nlis_interpretation_guide.pdf).LETTERS TO THE EDITORJPGN  Volume 74, Number 1, January 2022 e17 Copyright © ESPGHAN and NASPGHAN. All rights reserved.patients in this period is not coincidental but may rather be related to adecreased societal burden of infections which have been implied inthe pathogenesis of IBA. We therefore propose further research on theincidence of IBA in other European countries in relation to lockdown-related restrictions.The authors report nothing to declare.Financial Support: No financial support was received by NeS-BAR. It is a study group on BA but it does not grant usfinancial support.Mark Nomden, yRuben H.J. de Kleine,Janneke L.M. Bruggink,zHenkjan J. Verkade, §Johannes G.M. Burgerhof, andJan B.F. HulscherSection of Paediatric Surgery, Department of Surgery,University Medical Centre GroningenySection of Hepato-pancreatic-biliary Surgery and LiverTransplantation, Department of Surgery,University Medical Centre GroningenzSection of Paediatric Gastroenterology and Hepatology,Department of Paediatrics, Beatrix Children’s Hospital, UniversityMedical Centre Groningen§Department of Epidemiology, University Medical CentreGroningen, University of Groningen, Groningen,The NetherlandsREFERENCES1. Mack CL, Feldman AG, Sokol RJ. Clues to the etiology of bile duct injuryin biliary atresia. Semin Liver Dis 2012;32:307–16.2. Hooiveld M, Hendriksen J, Korevaar J. Wekelijkse surveillance cijfers. Nivelzorgregistraties eerste lijn. www.nivel.nl/surveillance. 2020. AccessedSeptember 20, 2020.3. Koehrsen W. The Poisson Distribution and Poisson Process Explained.Towards Data Science. 2019. https://towardsdatascience.com/the-poisson-distribution-and-poisson-process-explained-4e2cb17d459. [Accessed 25January 2021].Performance Characteristics, Intra- andInter-Operator Agreement of TransientElastography in Pediatric NonalcoholicFatty Liver DiseaseT o the Editor: We note with concern that Mandelia et al (1,2)misrepresent our conclusions on the precision of transientelastography (TE). In concluding that TE has precision they statethat their findings in 51 children with nonalcoholic fatty liverdisease (NAFLD) are similar to the findings in our study of 235healthy children and 65 children with cystic fibrosis; however, wefound that TE lacks precision (2). Furthermore, a review of theresults reported by Mandelia et al (1), in particular the supple-mentary material, confirms that TE lacks precision.Bland and Altman (3–7) are unequivocal in their descriptionof measurement agreement analysis that the data must follow anormal distribution with a narrow standard deviation, and reportingguidelines make these requirements explicit (5–7).We reported the mean difference between paired measure-ments in healthy children was 0.044 kPa with a standard deviation(SD) of 0.414 (2). Evidently, a SD of 0.414 is wide in the context ofa mean of the paired differences of 0.044 kPa, confirming poorprecision. Consistent with reporting guidelines we display thedistribution of the data as a histogram and the agreement betweenpaired measurements as Bland and Altman plots.In contrast, Mandelia et al (1) report that TE is reliable inchildren with NAFLD with low failure rates despite reporting afailure rate of 20%, which must be considered moderate-to-high.The mean difference between paired measurements by the expertoperator 0.4 kPa (SD 1.1) and two different operators 0.9 kPa (SD 1.6)indicates that the paired differences are substantial. The data also hasa wide standard deviation confirming significant disagreementbetween paired measurements. This lack of agreement is furtheremphasized in the 95% limits of agreement which ranged from1.8FIGURE 1. Bar graph representing the number of observed gap lengths (in days) between the birthdays of two subsequent IBA patients.Categories of gap lengths are divided into 25-day segments. Probabilities of gap length occurrence were calculated according to the followingformula: P(T> x) ¼ e  [161/7671]x, with x representing gap length in days, T representing time, and P representing probability. Gap lengths of143 days or more had a probability of occurring of <5%. IBA patients born between 1 January 2000 and 31 December 2020 are included(n¼161). IBA¼ isolated biliary atresia.Letters to the Editor JPGN  Volume 74, Number 1, January 2022e18 www.jpgn.org

NARCIS 

Unusual Long Absence of Isolated Biliary Atresia in COVID Lockdown: Coincidence or Association?

Mark Nomden

Ruben H.J. de Kleine

Janneke L.M. Bruggink

Henkjan J. Verkade

Johannes G.M. Burgerhof

Jan B.F. Hulscher

Crossref

   University of GroningenUnusual Long Absence of Isolated Biliary Atresia in COVID LockdownNomden, Mark; de Kleine, Ruben H J; Bruggink, Janneke L M; Verkade, Henkjan J;Burgerhof, Johannes G M; Hulscher, Jan B FPublished in:Journal of Pediatric Gastroenterology and NutritionDOI:10.1097/MPG.0000000000003313IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2022Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Nomden, M., de Kleine, R. H. J., Bruggink, J. L. M., Verkade, H. J., Burgerhof, J. G. M., & Hulscher, J. B. F.(2022). Unusual Long Absence of Isolated Biliary Atresia in COVID Lockdown: Coincidence or Association?Journal of Pediatric Gastroenterology and Nutrition, 74(1), e17-e18.https://doi.org/10.1097/MPG.0000000000003313CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 20-11-2022 Copyright © ESPGHAN and NASPGHAN. All rights reserved.COVID-19 Outbreak, Lockdown andImpact on Pediatric Nutritional Status:A Preliminary ObservationT o the Editor: We would like to share ideas on the impact ofCOVID-19 outbreak and lockdown on pediatric nutritionalstatus. Lockdown can influence health status. During a schoolclosures, the parental care is very important. The effect might bedifferent in different settings. A report from an area with highlyeducated and rich population might show a possibility of adjustmentto problem by parents. For example, Strisciuglio et al (1) showedthat there was a short period of problem in caring children duringthe first month before improvement. The effect of COVID-19 andlockdown might be totally different in areas with high poverty rate.Socioeconomic background of the family of the children is animportant parameter in the analysis on the effect of lockdown. Forexample, the lockdown might result in underweight among childrenfrom poor communities and the parents have no money and abilityto care their children. In contrast, a problem of obesity might bedetected in children from rich families (2).Here, the authors would like to share our preliminary obser-vation from an area that COVID-19 has been attached since early 2020and there are already more than 1 million cumulative confirmedCOVID-19 cases at present. The area is a rural area in Indochina(GPS location 14.874786541289744, 102.83783914044895) wherepediatric undernutrition is an important local public health problem(3). Local public data (http://healthkpi.moph.go.th/kpi2/kpi/) fromroutine annual pediatric health survey (ages 6–14 years, overall popu-lation 823,853) are retrospectively analyzed. Regarding primary datacollection, the standard pediatric anthropometric examination is doneby the village primary health center, which is run by a village primaryhealth care officer, who is a governmental worker of Ministry of PublicHealth and has a degree of Bachelor of Public Health or higher degree.In each year, the pediatric anthropometric survey is done and recordedin each village during July. During COVID-19 outbreak, full functionof the village primary care center still remained. The regular monitoringof pediatric nutritional status in the village was regularly done, similarto the previous period without COVID-19 outbreak.Prevalence of pediatric nutritional problem is shown inTable 1. During the 4-year period, 2018, 2019, 2020 and 2021,overall coverage rate of children examination are equal to 63.27%,65.22%, 61.43% and 64.4% of the overall pediatric population,respectively. From the 4-year data, the effect of COVID-19 outbreakis observed. When the disease starts in early 2020, the prevalence ofabnormal pediatric nutritional status did not increase in the year 2020;however, the pediatric underweight and overweight problemssignificantly increase in the year 2021. When COVID-19 has existedfor a long time, a significant impact occurs. During COVID-19outbreak, school has been closed for a long time and outdoor sportor exercise activities are prohibited. Some children might be in poorfamilies and cannot receive sufficient food. On the other hand, somechildren from rich families might experience different situation. Thecomplexity of pediatric nutritional problem in rural area of devel-oping countries can be repeatedly demonstrated (3). COVID-19outbreak and lockdown can have an impact on pediatric nutritionalstatus; however, a local socioeconomic background can play import-ant role in modifying the direction of effect.Rujittika Mungmunpuntipantip, ySim Sai Tin,and zViroj WiwanitkitPrivate Consultant, Bangkok ThailandyShantour Medical Center, Shantou, ChinazDr DY Patil University, Pune, IndiaThe authors report no conflicts of interest.REFERENCES1. Strisciuglio C, Martinelli M, Lu P, et al. Overall impact of COVID-19outbreak in children with functional abdominal pain disorders: resultsfrom the first pandemic phase. J Pediatr Gastroenterol Nutr 2021. [Epubahead of print].2. Joob B, Wiwanitkit V. COVID-19, school closings, and weight gain.Obesity (Silver Spring) 2020;28:1006.3. Wiwanitkit V, Sodsri P. Underweight schoolchildren in a rural school nearthe Thai-Cambodian border. Southeast Asian J Trop Med Public Health2003;34:458–61.Unusual Long Absence of IsolatedBiliary Atresia in COVID Lockdown:Coincidence or Association?T o the Editor: Isolated biliary atresia (IBA) is a rare cholan-giopathy of unknown origin. IBA is hypothesized to becaused by exposure to an unidentified external agent, with subsequentimmune mediated destruction of bile ducts (1). During the COVID-19-related lockdown, early 2020, a decrease in pediatric infections(eg, otitis media and gastroenteritis), was observed in the Netherlands(2). Simultaneously in this period, we observed an unusual gap lengthbetween subsequent new IBA cases; the gap length between birth-dates of two subsequent IBA patients was 174 days. We determinedfrom our national BA registry that between 2000 and 2020, themedian gap length between two IBA patients had been 32 days. Wecalculated the probability of every gap length occurring, assuming aPoisson distribution of IBA cases and a negative exponential distri-bution of gap length (3). The probability that a gap length of 174 dayswas 2.6%, thus below the standard accepted level of significance.Between 2000 and 2020, a gap length of at least 174 days betweensubsequent IBA patients had occurred another four times (Fig. 1);however, the essence and uniqueness of our current observation is thata long gap length occurred simultaneously with a lockdown thatcontributed to a decreased number of paediatric infections. One cantherefore speculate that the increased gap length of subsequent IBATABLE 1. Data on pediatric nutritional statusPediatric nutritional status(prevalence, %) 2018 2019 2020 2021Normal 66.5 61.5 65.7 58.07Underweight 33.5 38.5 34.3 41.93Overweight 11.8 13.6 12.5 14.5Total number of childrenmeasured per year521,252 537,317 506,092 530,561Underweight: weight for age<–2 standard deviations (SD) of the WHOChild Growth Standards median; overweight: weight for height >þ2 SD ofthe WHO Child Growth Standards median (according to WHO Interpret-ation Guide, https://www.who.int/nutrition/nlis_interpretation_guide.pdf).LETTERS TO THE EDITORJPGN  Volume 74, Number 1, January 2022 e17 Copyright © ESPGHAN and NASPGHAN. All rights reserved.patients in this period is not coincidental but may rather be related to adecreased societal burden of infections which have been implied inthe pathogenesis of IBA. We therefore propose further research on theincidence of IBA in other European countries in relation to lockdown-related restrictions.The authors report nothing to declare.Financial Support: No financial support was received by NeS-BAR. It is a study group on BA but it does not grant usfinancial support.Mark Nomden, yRuben H.J. de Kleine,Janneke L.M. Bruggink,zHenkjan J. Verkade, §Johannes G.M. Burgerhof, andJan B.F. HulscherSection of Paediatric Surgery, Department of Surgery,University Medical Centre GroningenySection of Hepato-pancreatic-biliary Surgery and LiverTransplantation, Department of Surgery,University Medical Centre GroningenzSection of Paediatric Gastroenterology and Hepatology,Department of Paediatrics, Beatrix Children’s Hospital, UniversityMedical Centre Groningen§Department of Epidemiology, University Medical CentreGroningen, University of Groningen, Groningen,The NetherlandsREFERENCES1. Mack CL, Feldman AG, Sokol RJ. Clues to the etiology of bile duct injuryin biliary atresia. Semin Liver Dis 2012;32:307–16.2. Hooiveld M, Hendriksen J, Korevaar J. Wekelijkse surveillance cijfers. Nivelzorgregistraties eerste lijn. www.nivel.nl/surveillance. 2020. AccessedSeptember 20, 2020.3. Koehrsen W. The Poisson Distribution and Poisson Process Explained.Towards Data Science. 2019. https://towardsdatascience.com/the-poisson-distribution-and-poisson-process-explained-4e2cb17d459. [Accessed 25January 2021].Performance Characteristics, Intra- andInter-Operator Agreement of TransientElastography in Pediatric NonalcoholicFatty Liver DiseaseT o the Editor: We note with concern that Mandelia et al (1,2)misrepresent our conclusions on the precision of transientelastography (TE). In concluding that TE has precision they statethat their findings in 51 children with nonalcoholic fatty liverdisease (NAFLD) are similar to the findings in our study of 235healthy children and 65 children with cystic fibrosis; however, wefound that TE lacks precision (2). Furthermore, a review of theresults reported by Mandelia et al (1), in particular the supple-mentary material, confirms that TE lacks precision.Bland and Altman (3–7) are unequivocal in their descriptionof measurement agreement analysis that the data must follow anormal distribution with a narrow standard deviation, and reportingguidelines make these requirements explicit (5–7).We reported the mean difference between paired measure-ments in healthy children was 0.044 kPa with a standard deviation(SD) of 0.414 (2). Evidently, a SD of 0.414 is wide in the context ofa mean of the paired differences of 0.044 kPa, confirming poorprecision. Consistent with reporting guidelines we display thedistribution of the data as a histogram and the agreement betweenpaired measurements as Bland and Altman plots.In contrast, Mandelia et al (1) report that TE is reliable inchildren with NAFLD with low failure rates despite reporting afailure rate of 20%, which must be considered moderate-to-high.The mean difference between paired measurements by the expertoperator 0.4 kPa (SD 1.1) and two different operators 0.9 kPa (SD 1.6)indicates that the paired differences are substantial. The data also hasa wide standard deviation confirming significant disagreementbetween paired measurements. This lack of agreement is furtheremphasized in the 95% limits of agreement which ranged from1.8FIGURE 1. Bar graph representing the number of observed gap lengths (in days) between the birthdays of two subsequent IBA patients.Categories of gap lengths are divided into 25-day segments. Probabilities of gap length occurrence were calculated according to the followingformula: P(T> x) ¼ e  [161/7671]x, with x representing gap length in days, T representing time, and P representing probability. Gap lengths of143 days or more had a probability of occurring of <5%. IBA patients born between 1 January 2000 and 31 December 2020 are included(n¼161). IBA¼ isolated biliary atresia.Letters to the Editor JPGN  Volume 74, Number 1, January 2022e18 www.jpgn.org

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Unusual Long Absence of Isolated Biliary Atresia in COVID Lockdown:Coincidence or Association?

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