Recurrent abdominal pain in childhood: the functional element.

Many children report chronic abdominal pain that is severe and disruptive to normal lifestyle and schooling. Assessment and management depends on indentifying those with underlying organic disease, such as chronic infection, celiac disease or inflammatory bowel disease, but avoiding unnecessary invasive investigations. In those with a functional gut disorder, the aim of therapy is reassurance, a return to normal activity and symptom control. We address the evidence for the use of investigative and management strategies in situations where recurrent abdominal pain is likely to be a functional disorder. Epidemiological studies of European and American populations show that organic causes are uncommon, and that chronic abdominal pain is a risk factor for functional gut disorders in adulthood. There is a paucity of high quality therapeutic trials, none showing conclusive evidence of benefit. Psychological interventions, such as cognitive behavioral and family therapy are effective, reducing symptoms and improving school attendance. Asian studies suggest gastrointestinal infection, such as giardiasis, are common causes of recurrent abdominal pain, but that functional abdominal pain is also prevalent.

Measured versus predicted energy expenditure in children with inactive Crohn's disease.

INTRODUCTION: The aim of the study was to assess if the estimated average requirements for energy for normal children (EAR) and the Schofield equation could reliably predict energy requirements in children with inactive Crohn's disease (CD). METHODS: Twenty-three children with inactive CD were studied, median age 14.3 years (range 7.8-16.9). Resting energy expenditure (REE) was measured by indirect calorimetry and compared with that predicted using the Schofield equation (BMR). Total energy expenditure (TEE) was measured using REE and a 3-day activity diary and compared with EAR. RESULTS: REE ranged from 79% to 136% of BMR. Mean REE was not significantly greater than mean BMR (P=0.25 2-tailed t-test). TEE ranged from 72% to 163% of estimated average requirements for energy for children of that weight (EARw). EARw tended to underestimate TEE in large children and overestimate TEE in small children (Bland-Altman plot R=0.5, P=0.002). EARw was a poor predictor of TEE (R=0.35, P=0.1). EAR underestimated energy requirements by >500 kcal/day in 40% of the children. CONCLUSIONS: The Schofield equation and EAR are unreliable methods of predicting total energy requirements in children with inactive CD with a significant potential to underestimate energy needs. When energy requirements were greater than EAR it was due to physical activity and body habitus rather than raised REE.

Recent advances in the medical therapy of Crohn's disease in childhood.

Crohn's disease (CrD) is characterised by an ongoing inflammatory response in the gut, in the absence of an obvious trigger. The treatment of CrD in children, during relapse and remission, requires special consideration of growth and development. This review addresses the use of present medical management strategies, including enteral nutrition, corticosteroids, immunosuppression and anti-TNF-alpha therapies. Anti-inflammatory IL-11 and leukocyte adhesion inhibitors have shown only moderate clinical efficacy in adults. Emerging treatments directed against the inflammatory cascade under investigation include inhibitors of IL-6 and -12, IFN-gamma and MAPKs. Probiotics and colony stimulating factors aim to stimulate the innate immune system. Research data from clinical trials are reviewed and summarised in respect of their potential within paediatric practice.

Energy intakes of children with Crohn's disease treated with enteral nutrition as primary therapy.

BACKGROUND: Enteral nutrition (EN) is widely used and is effective in the treatment of children with Crohn's disease given as an exclusive feed for 6-8 weeks. Current dietetic practice during EN is to recommend an energy intake based on estimated average requirement (EAR) for energy for age. AIMS: To examine factors affecting energy intake and weight gain during EN in relation to disease site and nutritional status. METHODS: A retrospective cohort study examining energy intake and weight gain during the exclusive EN feeding period in 40 patients newly diagnosed with Crohn's in relation to EAR, nutritional status, disease site. RESULTS: All patients improved clinically and gained weight during EN with improvement in the CRP as a marker of the systemic inflammatory response. Energy intake was higher than EAR in 82% (33/40 patients), with the median 117.5% of EAR. Weight gain correlated with body mass index standard deviation score (P = 0.001) at start of treatment, but not energy intake or CRP. CONCLUSION: Estimated average requirement underestimates energy intakes in most children with newly diagnosed Crohn's disease. During EN, an energy intake in the range of 100-149% (median 117.5%) EAR for energy for age may be required. Energy balance studies in children with active disease are required.

Ultrasound scanning may reduce the need for barium radiology in the assessment of small-bowel Crohn's disease.

AIM: Bowel wall thickening on transabdominal ultrasound scanning (USS) correlates well with Crohn's disease (CD) activity. However, the role of USS in the assessment of CD has not been fully defined. This study compared USS and barium follow-through (BaFT) in the assessment of CD. METHODS: A retrospective case series was undertaken of 24 children with CD who underwent USS and BaFT during the same period of clinical disease activity. RESULTS: For terminal ileum abnormality, all 13 cases with abnormal USS had abnormality on BaFT. USS did not detect five cases with affected terminal ileum and two cases with isolated proximal small-bowel CD. CONCLUSION: BaFT is a more sensitive indicator of small-bowel CD than USS. USS has good positive predictive value of distal small-bowel CD, but BaFT should be performed in the presence of a normal USS where there is strong clinical evidence of CD.