Novel approaches to the nutritional management of the allergic infant

The increased prevalence of atopic diseases, i.e. atopic eczema, allergic rhinitis and asthma, has been described as the epidemic of the 21st century in Western societies. New approaches in the fight against allergic diseases are clearly called for, the target being the persistence of the allergic responder pattern beyond infancy. The advantage afforded by elimination diets lies in the silencing of specific allergic inflammation induced by an offending food. Novel nutritional approaches, beyond the treatment of food allergies, have recently attracted research interest subsequent to the identification of the immunomodulatory potential of specific dietary compounds. Dietary lipids as immunomodulators may prevent allergic sensitization by down-regulating inflammatory response whilst protecting the epithelial barrier. Probiotic bacteria have been shown to reinforce the different lines of gut defence: immune exclusion, immune elimination and immune regulation. On this basis, the strategy against allergic disease proposed here is based on the administration of tolerogenic gut-processed peptide fragments of a specific protein, in addition to the use of specific dietary compounds such as fatty acids and antioxidants, and introducing a microbial stimulus for the immature immune system by means of cultures of beneficial live micro-organisms characteristic of the healthy infant gut microbiota.     

Novel approaches to the nutritional management of the allergic infant

The increased prevalence of atopic diseases, i.e. atopic eczema, allergic rhinitis and asthma, has been described as the epidemic of the 21st century in Western societies. New approaches in the fight against allergic diseases are clearly called for, the target being the persistence of the allergic responder pattern beyond infancy. The advantage afforded by elimination diets lies in the silencing of specific allergic inflammation induced by an offending food. Novel nutritional approaches, beyond the treatment of food allergies, have recently attracted research interest subsequent to the identification of the immunomodulatory potential of specific dietary compounds. Dietary lipids as immunomodulators may prevent allergic sensitization by down-regulating inflammatory response whilst protecting the epithelial barrier. Probiotic bacteria have been shown to reinforce the different lines of gut defence: immune exclusion, immune elimination and immune regulation. On this basis, the strategy against allergic disease proposed here is based on the administration of tolerogenic gut-processed peptide fragments of a specific protein, in addition to the use of specific dietary compounds such as fatty acids and antioxidants, and introducing a microbial stimulus for the immature immune system by means of cultures of beneficial live micro-organisms characteristic of the healthy infant gut microbiota.     

Nutritional approaches for the primary prevention of allergic disease: An update

The dramatic rise in early childhood allergic diseases indicates the specific vulnerability of the immune system to early life environmental changes. Dietary changes are at the centre of lifestyle changes that underpin many modern inflammatory and metabolic diseases, and therefore are an essential element of prevention strategies. Although modern dietary changes are complex and involve changing patterns of many nutrients, there is also an interest in the early life effects of specific nutrients including polyunsaturated fatty acids, oligosaccharides (soluble fibre), antioxidants, folate and other vitamins that have documented effects on immune function as well as metabolism. A better understanding of nutritional programming of immune health, nutritional epigenetics and the biological processes sensitive to nutritional exposures in early life may lead to dietary strategies that provide more tolerogenic conditions during early immune programming and reduce the burden of many inflammatory diseases, not just allergy.     

Inflammatory bowel disease

Till about 3 decades ago, inflammatory bowel disease (IBD) was considered as non-existent in our country. However, since that time several reports of IBD, mainly ulcerative colitis have been published. More recently, Crohn’s disease is also being reported from the country. This trend of UC appearing first in a population followed by CD also appears to be true in other developing nations. A substantial increase in the rates of CD over UC in the last few decades is reported from developed nations as well. Of the other epidemiological factors, an increased risk of CD and lower risk of UC in smokers is established in adults. However, it appears that smoking increases the risk of IBD in children. The etiology of IBD remains elusive. Within the triad of genetics, immunity and antigen responsible for the development of IBD, maximum advances have been made in the field of immune aberrations and this is being exploited to treat the disease. It is well established that IBD results from a disordered immune system in the gut, in response to an unidentified antigen in a predisposed individual. The immune response is enhanced and revolves around antigen-presenting cells, CD 4 T-lymphocytes and tumor necrosis factor alpha. CD results from an enhanced Th1 activity. The pathogenesis of UC is less clear but appears to be humoral. Advances in diagnostics include the availability of serology, ultrasound and nuclear scans, none of which have been tried in our setting where infectious diseases and tuberculosis is rampant. Growth failure and the importance of nutrition in IBD, especially CD, cannot be underemphasized. In many situations nutritional interventions have been used solely as a form of therapy for CD. Newer steroid molecules with minimal systemic effects are also being considered. Other treatment options highlighted are the use of immunosuppressive agents, biologic agents and role of surgery.     

The role of nutrition in the etiology of inflammatory bowel disease

Many foods have been implicated in theories about the etiology of inflammatory bowel disease. While evidence has accumulated that nutritional factors as part of overall lifestyle changes may play a role in the growing incidence, no specific dietary recommendations except the promotion of breastfeeding can currently be given to decrease the risk of developing Crohn's disease or ulcerative colitis. For the treatment of Crohn's disease in children and adolescents, however, enteral feeding with a semi-elemental diet seems to be as effective as corticosteroids in inducing and maintaining remission. In the meta-analyses, advantages of one formula over the other are evened out, and more research is warranted into the anti-inflammatory properties of different nutrients, such as polyunsaturated fatty acids, butyrate, glutamine, and cytokines, such as transforming growth factors-beta. Unfortunately, for practical reasons, nutritional therapy remains underutilized, even though pediatric patients are most vulnerable to the harmful effects of nutrient deficiencies on growth, pubertal development, and bone health. There is hope that in the future the new field of nutrigenomics may enable physicians to more accurately tailor a specific diet to the patient genotype.     

Nutrition support for pediatric patients with inflammatory bowel disease: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology And Nutrition

Impairment of growth and malnutrition are significant complications of inflammatory bowel disease (IBD) in pediatric patients. Since this topic was last reviewed in these pages (), a number of studies have further explored the epidemiology and pathogenesis of these nutritional complications of IBD in an effort to provide more effective interventions to prevent the long-term consequences of chronic nutrient deficiencies in childhood. In addition, during the past 15 years, the use of selected nutrients and microorganisms (probiotics) as primary or adjunctive therapy for the treatment of IBD has become an emerging area of great interest. The following is a Clinical Report from the Nutrition and Inflammatory Bowel Disease Committees of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.     

Turner Syndrome with Ulcerative Colitis

Turner syndrome is a chromosomal disease frequently associated with autoimmune disorders including diabetes mellitus, thyroid disease and inflammatory bowel disease (IBD). Although the etiology of IBD has not been fully elucidated, genetic analysis has recently revealed several susceptibility genes. Recently, cases with Turner syndrome associated with IBD have been reported. We report here a 13-yr-old girl with Turner syndrome associated with ulcerative colitis. The patient was undergoing growth hormone treatment and presented with abdominal discomfort and bloody diarrhea. Her karyotype pattern was 46,X,i(Xq). Barium enema revealed punctate collections of barium suggesting microulcerations in the descending and sigmoid colon with loss of haustra. Flexible sigmoidoscopy showed that the mucosa was erythematous and friable upon touch and that the wall had frank hemorrhage and inflammatory polyp formation from the anal verge through the splenic flexure. Histologically, mucosal and submucosal inflammation was prominent, suggesting cryptitis and crypt abscess formation. Based on these findings, she was diagnosed as having ulcerative colitis, and 5-aminosalicylic acid, prednisolone and dietary therapy were initiated. Our observations in this patient suggest that X chromosome abnormality may influence the development of IBD and that screening for gastrointestinal disease in patients with Turner syndrome may help lengthen life expectancy in these patients.     

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??Inflammatory bowel disease??IBD?? is a chronic and recurrent gastrointestinal inflammatory disease that can present at any age. There has been a dramatic increase in the incidence of pediatric IBD over the past 50 years. Very-early-onset IBD??VEO-IBD?? is defined as onset of IBD within the first 6 years of life??which constitutes 4% to 10% of pediatric IBD cases. It is generally accepted that many patients with VEO-IBD are associated with a greater degree of genetic susceptibility??and many of these diseases are classified as primary immunodeficiencies??PID??. Monogenic defects have been found to alter intestinal immune homeostasis via several mechanisms??including dysfunction of innate immune system??dysfunction of adaptive immunity or disruption of the epithelial barrier. Due to the differences in the prognosis and medical management??an early diagnosis of an IBD combined with immunodeficiency should be made via genetic analysis. A proper treatment can be selected to achieve the effect of early intervention??thus improving the prognosis.     

Very early onset inflammatory bowel disease

Very early onset inflammatory bowel disease (VEO-IBD) represents a unique and growing subset of patients with inflammatory bowel disease (IBD). Some VEO-IBD patients present with immunodeficiency and possess loss of function genetic mutations involving immune pathways that cause their IBD. A search for Mendelian causes of IBD is likely most beneficial when the presentation involves extra-intestinal autoimmunity or involves intestinal histopathology that is atypical for IBD. While a subset of these young patients will have highly aggressive courses (and likely present with immunodeficiency), the majority of patients with VEO-IBD appear to have disease courses similar to that of their older counterparts. Most notably, many of these young children will require long courses of immunosuppression simply as a result of the profoundly early presentation—thus increasing their long-term risks of cancer and opportunistic infections.     

儿童炎症性肠病与免疫缺陷

炎症性肠病（IBD）是指原因不明的一组慢性非特异性、 反复发作的肠道炎症性疾病。儿童IBD的发病率在过去的50年里明显增高。一般将发病年龄＜6岁的IBD称为极早发IBD（VEO-IBD）,占儿童IBD的4%～10%。VEO-IBD被认为与遗传因素相关性更大,单基因突变检出率更高。该部分具有单基因突变的VEO-IBD,其受累基因很多归为原发性免疫缺陷病。这些基因缺陷导致固有免疫、适应性免疫、上皮屏障等多方面功能损伤,从而导致VEO-IBD的发生。由于不同类型原发性免疫缺陷病合并IBD的治疗手段及预后有所不同,可通过基因测序技术实现早期诊断,选择合适的治疗方法,从而实现早期干预,改善患者的预后。     

Immunology of inflammatory bowel disease: summary of the proceedings of the Subcommittee on Immunosuppressive Use in IBD.

As outlined, scanty data exist with regard to immunologic therapy in children with IBD despite the fact that the pediatric population affords a unique opportunity for clinical evaluation. Children are less affected by modifying conditions such as smoking, alcohol ingestion, and the long-term use of medications, and because of their specific needs for ponderal and linear growth, children might benefit most from immunological therapy that has been proven to be steroid sparing. Therefore, clinical trials to evaluate the efficacy of 6-MP and/or azathioprine in growing children with Crohn's disease would appear to provide a fruitful avenue for collaborative research. Efforts to organize a multicenter evaluation of these agents have been initiated. The studies are crucial in evaluating the efficacy and safety of immunosuppressive therapy in the pediatric population with IBD.     

Complementary and alternative medicine (CAM) practices and dietary patterns in children with inflammatory bowel disease in Singapore and Malaysia

Background

The use of complementary and alternative medicine (CAM) has been associated with adverse effects and self-imposed dietary restrictions. The prevalence of its use in Asian children with inflammatory bowel disease (IBD) is unknown. We aimed to determine the prevalence, types, and factors associated with the use of CAM among children with IBD from Singapore and Malaysia, and to ascertain if dietary restriction was prevalent in patients who used CAM.

Cancer and pediatric inflammatory bowel disease

Cancer in children may be mistakenly diagnosed as inflammatory bowel disease (IBD), and specific cancers may develop in patients who truly have IBD. Ulcerative colitis patients historically carry an increased risk of colorectal adenocarcinoma, but current practices of surveillance and early surgery may have an impact on this. Crohn's disease patients require surveillance for colon cancer, but are also likely to be at increased risk for small bowel tumors and lymphoma. Some malignancies affecting IBD patients are sequelae of immunomanipulation, performed in the interest of IBD therapy itself. Knowing the cancer risks associated with IBD and those associated with agents used for IBD treatment, and practicing long-term surveillance for these tumors, are central components of caring for patients with IBD. Lessons learned from the fields of oncology and bone marrow transplantation may provide future directions and potential cures in IBD.     

Maternal dietary intake in pregnancy and lactation and allergic disease outcomes in offspring

As the prevalence of allergic disease dramatically rises worldwide, prevention strategies are increasingly being considered. Given the potential modulatory effect of nutritional factors on disease, altering maternal diet during pregnancy and/or lactation has been considered in preventing allergic disease in offspring. Although there are a number of observational studies that have examined possible associations between maternal diet and allergic outcomes in offspring, interventional trials are limited. Furthermore, there is a paucity of studies that have prospectively studied maternal dietary intake as well as measuring maternal and infant biologic samples (blood, urine, breast milk) and their relation to allergic outcomes in infants. There is also a particular need to define terminology such as ‘fruit and vegetables intake’, ‘healthy diet’, and ‘diet diversity’ in order to make studies comparable. In this review, we discuss current evidence of maternal dietary factors during pregnancy and/or lactation that may play a role in the offspring developing allergic disease, including factors such as overall dietary intake patterns, specific whole food consumption (fish, fruit and vegetables, and common allergic foods), and individual immunomodulatory nutrient intakes. Additionally, we discuss the limitations of previous studies and propose improvements to study design for future investigation.     

Epidemiology of inflammatory bowel diseases in childhood

Inflammatory Bowel Disease (IBD) is common in most industrialised countries and childhood IBD accounts for nearly 30% of total cases. Various studies, mostly from Europe and USA have reported epidemiological characteristics of childhood IBD. The incidence figures vary greatly from region to region and within a region over time. Almost all reported studies have documented an increase in the incidence, mainly of Crohn’s disease over the last few decades. The reasons for the increase are not clear but epidemiological observations have led to many postulates. Incidence in developing countries is perceived to be low, but limited data suggest that it may not be as uncommon as previously thought. IBD can occur at any age but is rare in infancy. Among childhood IBD, early onset IBD appears to be different epidemiologically and is characterised by predominance of colonic involvement and high positive family history. It has become apparent that only about 25% of childhood Crohns disease presents with classical triad of abdominal pain, diarrhoea and weight loss. Pediatricians should be aware of atypical manifestations and should maintain high index of suspicion. Though epidemiological studies of childhood IBD done so far have contributed towards understanding of IBD, they have differed in study design, population, time period, age group and case definitions. Unfortunately there are no uniform, clear diagnostic criteria which are evidence based. To address this problem, recently the IBD working group of European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) has published “The Porto Criteria” which details a consensus based diagnostic criteria for the diagnosis of childhood IBD. This should bring uniformity in ascertainment of newly diagnosed IBD cases. An European multicentre prospective database has also been established to facilitate future epidemiological studies.     

Control of Protein Synthesis and Its Relationship to the Bioenergetics of Growth

A key goal of nutritional therapies designed to prevent or treat protein energy malnutrition (PEM) is achievement of adequate growth rates and thus positive balances of protein and energy. Positive protein balance is the net result of protein turnover, i.e., of recycling protein through energy-requiring anabolic and catabolic pathways. Thus, protein turnover is inexorably linked to energy metabolism and to energy balance. A long-standing hypothesis is that new tissue synthesis is predominantly a postprandial event. Thus, postprandial rates of protein turnover may regulate the bioenergetics of growth. Traditional methods to evaluate nutritional therapies for diarrhea and PEM, i.e., metabolic balance, ¹⁵N-labeled amino acids, fecal output, illness duration, or change in body weight, are not specific to studies of the regulation of acute protein turnover and growth by nutritional intervention. Newer techniques based on ¹³C-labeled amino acids should be applied to evaluate nutritional interventions such as dietary substrate ratios, protein quality, feeding frequencies, or ratios of dietary protein to energy in terms of their abilities to optimize postprandial protein turnover and thus nutritional management of diarrhea or PEM.     

Television and children's consumption patterns. A review of the literature

The recent increase in childhood obesity has, among other things, focused attention on the role that television may play. This paper summarizes results of studies published in peer review journals since 1970 with data pertaining to the relationship between television use and children's food intake. Studies fall into four categories: content analyses; effects of television advertising on children's food behaviors; television and pediatric obesity, with effects on children's dietary intake and physical activity; and television use and children's food consumption patterns. Content analyses have shown that food is the most frequently advertised product category on children's TV. The majority of these ads target highly sweetened products, but more recently, the proportion from fast food meal promotions has been growing. Controlled studies on children's choices have consistently shown that children exposed to advertising choose advertised food products at significantly higher rates than do those not exposed. Purchase request studies have documented associations between number of hours of TV watched and number of requests from the child to the mother for specific food items, as well as the presence of those items in the home. Greater TV use has been associated with higher intakes of energy, fat, sweet and salty snacks, and carbonated beverages and lower intakes of fruit and vegetables. Several large studies have documented associations between number of hours of TV watched and both the prevalence and incidence of obesity. The combination of lifestyle factors that accompany heavy television use appear to place children at risk of obesity and poor nutritional status.     

Nutritional traditional and complementary medicine strategies in pediatric cancer: A narrative review

Traditional and complementary medicine (T&CM) strategies are commonly used by pediatric cancer patients. Nutritional approaches to T&CM include bioactive compounds, supplements, and herbs as well as dietary approaches. Pediatric cancer patients and their families commonly request and use nutritional T&CM strategies. We review the potential risks and benefits of nutritional T&CM use in pediatric cancer care and provide an overview of some commonly used and requested supplements, including probiotics, antioxidants, cannabinoids, vitamins, turmeric, mistletoe, Carica papaya, and others. We also discuss the role of specific diets such as the ketogenic diet, caloric restriction diets, whole‐food diets, and immune modulating diets. There is a growing body of evidence to support the use of some T&CM agents for the supportive care of children with cancer. However, further study is needed into these agents and approaches. Open communication with families about T&CM use is critical.     

Health supervision in the management of children and adolescents with IBD: NASPGHAN recommendations

Ulcerative colitis (UC) and Crohn disease (CD), collectively referred to as inflammatory bowel disease (IBD), are chronic inflammatory disorders that can affect the gastrointestinal tract of children and adults. Like other autoimmune processes, the cause(s) of these disorders remain unknown but likely involves some interplay between genetic vulnerability and environmental factors. Children, in particular with UC or CD, can present to their primary care providers with similar symptoms, including abdominal pain, diarrhea, weight loss, and bloody stool. Although UC and CD are more predominant in adults, epidemiologic studies have demonstrated that a significant percentage of these patients were diagnosed during childhood. The chronic nature of the inflammatory process observed in these children and the waxing and waning nature of their clinical symptoms can be especially disruptive to their physical, social, and academic development. As such, physicians caring for children must consider these diseases when evaluating patients with compatible symptoms. Recent research efforts have made available a variety of more specific and effective pharmacologic agents and improved endoscopic and radiologic assessment tools to assist clinicians in the diagnosis and interval assessment of their patients with IBD; however, as the level of complexity of these interventions has increased, so too has the need for practitioners to become familiar with a wider array of treatments and the risks and benefits of particular diagnostic testing. Nonetheless, in most cases, and especially when frequent visits to subspecialty referral centers are not geographically feasible, primary care providers can be active participants in the management of their pediatric patients with IBD. The goal of this article is to educate and assist pediatricians and adult gastroenterology physicians caring for children with IBD, and in doing so, help to develop more collaborative care plans between primary care and subspecialty providers.     

Skeletal health of children and adolescents with inflammatory bowel disease

Current evidence points to suboptimal bone health in children and adolescents with inflammatory bowel disease (IBD) when compared with their healthy peers. This compromise is evident from diagnosis. The clinical consequences and long-term outcome of this finding are still unknown. The mechanism of suboptimal bone health in children and adolescents with IBD lays mainly in reduced bone formation, but also reduced bone resorption, processes necessary for bone growth. Factors contributing to this derangement are inflammation, delayed growth and puberty, lean mass deficits, and use of glucocorticoids. We recognize that evidence is sparse on the topic of bone health in children and adolescents with IBD. In this clinical guideline, based on current evidence, we provide recommendations on screening and monitoring bone health in children and adolescents with IBD, including modalities to achieve this and their limitations; monitoring of parameters of growth, pubertal development, and reasons for concern; evaluation of vitamin D status and vitamin D and calcium intake; exercise; and nutritional support. We also report on the current evidence of the effect of biologics on bone health in children and adolescents with IBD, as well as the role of bone active medications such as bisphosphonates. Finally, we summarize the existing numerous gaps in knowledge and potential subjects for future research endeavors.