Pedi-R-MAPP: The development of a nutritional awareness tool for use in remote paediatric consultations using a modified Delphi consensus.

BACKGROUND & AIMS: The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments, and provide practical guidance for nutritional care. The aim of this study was to modify the R-MAPP into a version suitable for children, Pediatric Remote Malnutrition Application (Pedi-R-MAPP), and provide a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. METHODS: A ten-step process was completed: 1) permission to modify adult R-MAPP, 2) literature search to inform the Pedi-R-MAPP content, 3) Pedi-R-MAPP draft, 4) international survey of HCP practice using TECS, 5) nutrition experts invited to participate in a modified Delphi process, 6) first stakeholder meeting to agree purpose/draft of the tool, 7) round-one online survey, 8) statements with consensus removed from survey, 9) round-two online survey for statements with no consensus and 10) second stakeholder meeting with finalisation of the Pedi-R-MAPP nutrition awareness tool. RESULTS: The international survey completed by 463 HCPs, 55% paediatricians, 38% dietitians, 7% nurses/others. When HCPs were asked to look back over the last 12 months, dietitians (n = 110) reported that 5.7 ± 10.6 out of every 10 appointments were completed in person; compared to paediatricians (n = 182) who reported 7.5 ± 7.0 out of every 10 appointments to be in person (p < 0.0001), with the remainder completed as TECS consultations. Overall, 74 articles were identified and used to develop the Pedi-R-MAPP which included colour-coded advice using a traffic light system; green, amber, red and purple. Eighteen participants agreed to participate in the Delphi consensus and completed both rounds of the modified Delphi survey. Agreement was reached at the first meeting on the purpose and draft sections of the proposed tool. In round-one of the online survey, 86% (n = 89/104) of statements reached consensus, whereas in round-two 12.5% (n = 13/104) of statements reached no consensus. At the second expert meeting, contested statements were discussed until agreement was reached and the Pedi-R-MAPP could be finalised. CONCLUSION: The Pedi-R-MAPP nutrition awareness tool was developed using a modified Delphi consensus. This tool aims to support the technological transformation fast-tracked by the COVID-19 pandemic by providing a structured approach to completing a remote nutrition focused assessment, as well as identifying the frequency of follow up along with those children who may require in-person assessment.

Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition.

The number of surviving children born prematurely has increased substantially during the last 2 decades. The major goal of enteral nutrient supply to these infants is to achieve growth similar to foetal growth coupled with satisfactory functional development. The accumulation of knowledge since the previous guideline on nutrition of preterm infants from the Committee on Nutrition of the European Society of Paediatric Gastroenterology and Nutrition in 1987 has made a new guideline necessary. Thus, an ad hoc expert panel was convened by the Committee on Nutrition of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition in 2007 to make appropriate recommendations. The present guideline, of which the major recommendations are summarised here (for the full report, see http://links.lww.com/A1480), is consistent with, but not identical to, recent guidelines from the Life Sciences Research Office of the American Society for Nutritional Sciences published in 2002 and recommendations from the handbook Nutrition of the Preterm Infant. Scientific Basis and Practical Guidelines, 2nd ed, edited by Tsang et al, and published in 2005. The preferred food for premature infants is fortified human milk from the infant's own mother, or, alternatively, formula designed for premature infants. This guideline aims to provide proposed advisable ranges for nutrient intakes for stable-growing preterm infants up to a weight of approximately 1800 g, because most data are available for these infants. These recommendations are based on a considered review of available scientific reports on the subject, and on expert consensus for which the available scientific data are considered inadequate.

The knowledge and expectations about IBD - difference between pediatric patients and their parents.

BACKGROUND AND STUDY AIMS: The aim of this prospective survey was to determine and compare the knowledge of children with inflammatory bowel disease (IBD) and their parents about their disease. Furthermore, patients and parents were ask to provide the main source for disease related information and to give opinion for possible improvement. PATIENTS AND METHODS: This was a prospective survey which included children with IBD with ≥ 12 years of age and their parents. Only ambulatory patients treated in tertiary medical center were included. RESULTS: 38 child/parent pairs (79% mothers) were enrolled. Major differences between parents and children were in a) internet search where majority of parents (n = 28 ; 73.7%) and only 17 (44.7%) children gathered disease related information over the internet (p = 0.01) ; b) need for participation in patients' organization (97.4% parents comparing 55.3% children would like to participate ; p<0.001) and c) clinical practice with time reserved for child/adolescent to be with his/her physician alone (78.9% of parents encourage this practice comparing to 2.6% of children ; p <0.001). CONCLUSION: This study shows significant difference between children/adolescents with IBD and their parents in several aspects that should be acknowledged before initiating changes into the clinical practice.

The role of combined 24-h multichannel intraluminal impedance-pH monitoring in the evaluation of children with gastrointestinal symptoms suggesting gastro-esophageal reflux disease.

BACKGROUND: The aim of this study was to determine the role of multichannel intraluminal impedance-pH (pH-MII) monitoring in the diagnosis of gastro-esophageal reflux disease (GERD) in children who presented with gastrointestinal (GI) symptoms in comparison with the results of pH-metry alone and endoscopy. METHODS: All children who underwent pH-MII monitoring due to GI symptoms, suggestive of GERD, from October 2013 to October 2015 in Children's Hospital Zagreb, were retrospectively enrolled in the study. The cohort was divided into three groups according to age - group 1: children <1 year of age; group 2: 1-9 years of age; and group 3: ≥9 years of age. KEY RESULTS: One hundred thirty-three patients met our inclusion criteria (73 female/60 male; mean age 9.2 years [0.19-18.0]). Gastro-esophageal reflux disease was determined in 44 of 133 patients (33.1%) by pH-MII and only in 21 of 133 patients (15.8%) by pH-metry alone. Endoscopy was performed in 77 (57.9%) children and esophagitis was found in 32/77 (41.6%). The finding of esophagitis significantly correlated with the number of total reflux episodes (coef. 0.42, p < 0.001), acidic (coef. 0.26, p = 0.02), weakly acidic (coef. 0.3, p = 0.008) and non-acidic (coef. 0.26, p = 0.02) reflux episodes detected by pH-MII; but, no correlation was found to reflux episodes detected by pH-metry alone (coef. 0.21, p = 0.07). CONCLUSIONS & INFERENCES: Compared with pH-metry alone, pH-MII performed significantly better in the detection of GERD in all age groups. On the basis of our data, pH-MII had a strong correlation with endoscopically confirmed esophagitis.

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

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

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

BACKGROUND: New evidence emerged on early feeding practices and the risk of coeliac disease. AIM: To systematically update evidence on these practices to find out whether there is a need to revise current recommendations. METHODS: MEDLINE, EMBASE and the Cochrane Library were searched from July 2012 (end of last search) to February 2015 for studies of any design that assessed the effect of gluten consumption and breastfeeding on the development of coeliac disease and/or coeliac disease-related autoimmunity. RESULTS: We identified 21 publications, including two, new, large, randomised controlled trials performed in high-risk infants. Exclusive or any breastfeeding, as well as breastfeeding at the time of gluten introduction, did not reduce the risk of developing coeliac disease during childhood. For infants at high risk of developing coeliac disease, gluten introduction at 4 months of age in very small amounts, or at 6 or 12 months of age, resulted in similar rates of coeliac disease diagnosis in early childhood. Later gluten introduction was associated with later development of coeliac specific autoimmunity and coeliac disease during childhood, but not total risk reduction. Observational studies indicate that consumption of a higher amount of gluten at weaning may increase the risk for coeliac disease development. CONCLUSIONS: Infant feeding practices (breastfeeding, time of gluten introduction) have no effect on the risk of developing coeliac disease during childhood (at least at specific timeframes evaluated in the included studies), necessitating an update of current European recommendations.

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

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

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

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

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

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

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

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

[Long-term effect of nutrition in early infancy]. / Dugorocni utjecaji rane dojenacke prehrane.

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

[The role of zinc in the initial treatment of Wilson's disease in children]. / Uloga cinka u inicijalnom lijecenju Wilsonove bolesti u djece.

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

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

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

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

BACKGROUND: PREVENTCD, Prevent Coeliac Disease, is an international project investigating the hypothesis of possible induction of tolerance to gluten in genetically predisposed children through introducing small quantities of gluten during the period of breastfeeding. AIM: To summarise current knowledge on the possible relationship between early feeding practices and the risk of coeliac disease (CD). METHODS: The Cochrane Library, MEDLINE, and EMBASE databases were searched in May 2011, and the search was updated in January 2012, and again in July 2012. RESULTS: Breastfeeding (BF) and CD: some studies show a protective effect of BF, while others show no effect. No studies have shown a long-term preventive effect. BF at the time of gluten introduction and CD: Results from a meta-analysis of five observational case-control studies suggest that BF at gluten introduction is associated with a lower risk of CD compared with formula feeding. It is unclear whether BF provides a permanent protection or only delays the onset of CD. Timing of gluten introduction: The data suggest that both early (≤4 months) and late (≥7 months) introduction of gluten may increase the risk of CD. Amount of gluten at weaning (and later) and CD: One incident case-referent study documented that the introduction of gluten in large amounts compared with small or medium amounts increased the risk of CD. CONCLUSIONS: In the absence of clear evidence, in order to decrease the risk of later coeliac disease, it is reasonable to avoid both early (<4 months) and late (≥7 months) introduction of gluten, and to introduce gluten while the infant is still being breastfed. Future studies may clarify the remaining uncertainties.

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

AIM: To prospectively assess the antibacterial resistance rate in Helicobacter pylori strains obtained from symptomatic children in Europe. METHODS: During a 4-year period, 17 paediatric centres from 14 European countries reported prospectively on patients infected with H pylori, for whom antibiotic susceptibility was tested. RESULTS: A total of 1233 patients were reported from Northern (3%), Western (70%), Eastern (9%) and Southern Europe (18%); 41% originated from outside Europe as indicated by mother's birth-country; 13% were <6 years of age, 43% 6-11 years of age and 44% >11 years of age. Testing was carried out before the first treatment (group A, n = 1037), and after treatment failure (group B, n = 196). Overall resistance to clarithromycin was detected in 24% (mean, A: 20%, B: 42%). The primary clarithromycin resistance rate was higher in boys (odds ratio (OR) 1.58; 1.12 to 2.24, p = 0.01), in children <6 years compared with >12 years (OR 1.82, 1.10 to 3.03, p = 0.020) and in patients living in Southern Europe compared with those living in Northern Europe (OR 2.25; 1.52 to 3.30, p<0.001). Overall resistance rate to metronidazole was 25% (A: 23%, B: 35%) and higher in children born outside Europe (A: adjusted. OR 2.42, 95% CI: 1.61 to 3.66, p<0.001). Resistance to both antibiotics occurred in 6.9% (A: 5.3%, B: 15.3%). Resistance to amoxicillin was exceptional (0.6%). Children with peptic ulcer disease (80/1180, 6.8%) were older than patients without ulcer (p = 0.001). CONCLUSION: The primary resistance rate of H pylori strains obtained from unselected children in Europe is high. The use of antibiotics for other indications seems to be the major risk factor for development of primary resistance.

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

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

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

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

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

UNLABELLED: Considerable success in the management of chronic diarrhoea has been reported using a modular diet (MD), with gradual increments in every nutrient toward a full-strength formula. As the commercially prepared constituents are unavailable in Croatia, we have developed a home-made MD based on boiled minced chicken meat, sunflower oil emulsion, sucrose and cornflour. A full range of vitamins and minerals are added. The value of this MD was compared to a semi-elemental formula (SF) Pregomin. Eighteen infants with severe chronic diarrhoea were randomly assigned to receive either MD of SF. Both groups were comparable with respect to sex, age, and degree of malnutrition. Duration of diarrhoea, feed tolerance, anthropometry, and biochemistry were compared after 4 weeks of treatment. RESULTS: (1) diarrhoea was significantly shorter (3 vs 7 days; P < 0.01) and nutritional recovery started earlier (5 vs 9 days; P < 0.01) in MD group; (2) median weight gain in the SF group was 100 g/week, compared to 171 g/week in MD group (P < 0.05); (3) in two patients from the SF group, diarrhoea persisted, but they achieved complete recovery when changed to MD. CONCLUSION: A MD made in the hospital kitchen was superior to a SE formula in the treatment of chronic diarrhoea of infancy.