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BACKGROUND: The widely recognized burden of liver diseases makes training in pediatric hepatology (PH) imperative. The aim of this survey, which was part of a global survey on training in pediatric gastroenterology, hepatology and nutrition (PGHN) across Europe, was to assess the PH and liver transplantation (LT) infrastructure, staff and training programs in PGHN training centers. METHOD: Standardized questionnaires were collected from training centers via the presidents/representatives of the National Societies Network of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) from June 2016 to December 2019. RESULTS: A total of 100 PGHN training centers participated in the survey (14/100 were national referral centers in PH and/or LT). Dedicated PH clinics were available in 75%, but LT clinics in only 11%. Dedicated beds for PGHN inpatients were available in 47/95 (49%) centers. Full-time or part-time specialists for PH care were available in 31/45 (69%) and 11/36 (31%) centers, respectively. Liver biopsies (LB) were performed in 93% of centers by: a PGHN specialist (35%); an interventional radiologist (26%); a pediatric surgeon (4%); or a combination of them (35%). Dividing the annual number of LBs in the centers performing LBs by the number of trainees gave a median (range) of 10 (1-125) per trainee. Transient elastography was available in 60/92 (65%) of centers. CONCLUSIONS: The survey highlighted the differences and shortcomings in PH training across Europe. ESPGHAN should take initiatives together with National Societies to ensure the acquisition of PH knowledge and skills according to the ESPGHAN curriculum.An infographic is available for this article at: http://www.annalsgastro.gr/files/journals/1/earlyview/2022/Infographic-Hepatology-training-paper.pdf. ispartof: ANNALS OF GASTROENTEROLOGY vol:35 issue:2 pages:187-+ ispartof: location:Greece status: published

BACKGROUND: This survey evaluated the effects of the recognition of pediatric gastroenterology, hepatology and nutrition (PGHN) on European PGHN training centers. METHOD: Standardized questionnaires were collected from training centers via the presidents/representatives of the National Societies Network of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition, from June 2016 to December 2019. RESULTS: A total of 100 training centers from 19 countries participated in the survey: 55 from 12 countries where PGHN is formally recognized (Group 1) and 45 from 7 countries where it is not (Group 2). Training centers in Group 2 were less likely to have an integrated endoscopy suite, a written training curriculum and a training lead (P=0.059, P

Since the publication of the 2014 European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Working Group (WG) on Probiotics and Prebiotics guidelines for the management of acute gastroenteritis (AGE), new evidence concerning the efficacy of probiotics has become available. This document provides updated recommendations on the use of probiotics for the treatment of AGE in previously presumed healthy infants and children. A systematic literature search was performed. All pooled analyses were explicitly performed for the current report. The WG graded the recommendations and assessed the certainty of the supporting evidence using the Grading of Recommendations, Assessment Development, and Evaluations tool. The recommendations were formulated if at least 2 randomized controlled trials that used a given probiotic were available. Despite the large number of identified trials, the WG could not identify 2 randomized controlled trial of high quality for any strain that provided benefit when used for treating AGE. The WG made weak recommendations for (in descending order in terms of the number of trials evaluating any given strain): Saccharomyces boulardii (low to very low certainty of evidence); Lactobacillus rhamnosus GG (very low certainty of evidence); L reuteri DSM 17938 (low to very low certainty of evidence); and L rhamnosus 19070-2 and L reuteri DSM 12246 (very low certainty of evidence). The WG made a strong recommendation against L helveticus R0052 and L rhamnosus R0011 (moderate certainty of evidence) and a weak recommendation against Bacillus clausii strains O/C, SIN, N/R, and T (very low certainty of evidence).

OBJECTIVES: Few pediatric data on phenotypic aspects of eosinophilic esophagitis (EoE) are available. The pEEr registry was developed to prospectively characterize children with EoE from Europe and Israel. METHODS: pEEr is an ongoing prospective registry enrolling children with esophageal eosinophilia (≥15 eos/HPF). Anonymized data were collected from 19 pediatric centers. Data regarding demographics, clinical manifestations, endoscopy, histology, and therapies were collected. RESULTS: A total of 582 subjects (61% male) were analyzed. The median age at diagnosis was 10.5 years [interquartile range (IQR): 5.7-17.7], whereas the age at symptom onset was 9.2 years (IQR: 4.3-16.4), resulting in a median diagnostic delay of 1.2 years (IQR: 0.7-2.3). The diagnostic delay was longer below age

More than 10,000 preterm infants have participated in randomised controlled trials on probiotics worldwide, suggesting that probiotics in general could reduce rates of necrotising enterocolitis (NEC), sepsis, and mortality. However, answers to relevant clinical questions as to which strain to use, at what dosage, and how long to supplement, are not available. On the other hand, an increasing number of commercial products containing probiotics are available from sometimes suboptimal quality. Also, a large number of units around the world are routinely offering probiotic supplementation as the standard of care despite lacking solid evidence. Our recent network meta-analysis identified probiotic strains with greatest efficacy regarding relevant clinical outcomes for preterm neonates. Efficacy in reducing mortality and morbidity was found for only a minority of the studied strains or combinations. In the present position paper, we aim to provide advice which specific strains might potentially be used and which strains should not be used. Besides, we aim to address safety issues of probiotic supplementation to preterm infants, who have reduced immunological capacities and occasional indwelling catheters. For example, quality reassurance of the probiotic product is essential, probiotic strains should be devoid of transferable antibiotic resistance genes, and local microbiologists should be able to routinely detect probiotic sepsis. Provided all safety issues are met, there is currently a conditional recommendation (with low certainty of evidence) to provide either L. rhamnosus GG ATCC53103 or the combination of B. infantis Bb-02, B. lactis Bb-12, and Str. thermophilus TH-4 in order to reduce NEC rates.

Probiotics have been proposed for a number of indications ranging from the hypothetical long-term immunomodulatory effects to proven benefits in the management of different clinical conditions. An increasing number of commercial products containing probiotics are available. In those products, irrespective if it is food, food supplement, medical food, or drug, the probiotic microorganisms have to be present in a sufficient number by the end of the shelf-life, to pass through the gastrointestinal tract resisting acid and bile, to colonize the gut, and to retain functional properties required to obtain the suggested beneficial effect. Finally, it should be contamination-free. Studies organized worldwide and summarized in this article have shown that inconsistencies and deviations from the information provided on the product label are surprisingly common. Frequently strains are misidentified and misclassified, products are occasionally contaminated, sometimes with even facultative or obligatory pathogens, strains are not viable, the labeled number of colonies cannot be verified, or the functional properties are diminished to the extent that preclude the proposed health benefit. As the probiotic preparations are commonly used for a wide range of conditions, the aim of the Working Group was to summarize results of the studies looking into the quality of the probiotic products and to raise the awareness of the important issue of their quality control. Based on the results obtained, we strongly suggest a more stringent quality control process. This process should ensure that the probiotic content as mentioned on the label meets the actual content throughout the shelf life of the product, while no contamination is present.

OBJECTIVES The aim of the study was to assess differences in the diagnosis and management of eosinophilic esophagitis (EoE) by European pediatric (PG) and adult gastroenterologists (AG), and their self-reported adherence to guidelines. METHODS A multiple-choice questionnaire gauged the diagnostic and management strategies of gastroenterologists treating children or adults in 14 European countries and the United Arab Emirates (UAE). RESULTS Questionnaires were completed by 465 PG and 743 AG. PG were significantly more likely to take biopsies in patients with symptoms of esophageal dysfunction (86.2% PG vs 75.4% AG, P

Probiotics and Preterm Infants - a position paper

This document provides recommendations developed by the ESPGHAN Working Group on Probiotics and Prebiotics on the role of probiotics in the prevention of nosocomial diarrhea in children based on a systematic review of previously completed systematic reviews and of subsequently published randomized controlled trials. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation guidelines. Recommendations were given only if at least 2 randomized controlled trials examined the same probiotic strain. Based on currently available evidence the Working Group recommends using Lactobacillus rhamnosus GG if the use of probiotics for preventing nosocomial diarrhea in children is considered.

Objectives: Several randomized controlled trials (RCTs) on the use of probiotics to reduce morbidity and mortality in preterm infants have provided inconsistent results. Although meta-analyses that group all of the used strains together are suggesting efficacy, it is not possible to determine the most effective strain that is more relevant to the clinician. We therefore used a network meta-analysis (NMA) approach to identify strains with greatest efficacy. Methods: A PubMed search identified placebo-controlled or head-to-head RCTs investigating probiotics in preterm infants. From trials that recorded mortality, necrotizing enterocolitis, late-onset sepsis, or time until full enteral feeding as outcomes, data were extracted and Bayesian hierarchical random-effects models were run to construct a NMA. Results: Fifty-one RCTs involving 11,231 preterm infants were included. Most strains or combinations of strains were only studied in one or a few RCTs. Only 3 of 25 studied probiotic treatment combinations showed significant reduction in mortality rates. Seven treatments reduced necrotizing enterocolitis incidence, 2 reduced late-onset sepsis, and 3 reduced time until full enteral feeding. There was no clear overlap of strains, which were effective on multiple outcome domains. Conclusions: This NMA showed efficacy in reducing mortality and morbidity only in a minority of the studied strains or combinations. This may be due to an inadequate number, or size, of RCTs, or due to a true lack of effect for certain species. Further large and adequately powered RCTs using strains with the greatest apparent efficacy will be needed to more precisely define optimal treatment strategies.

Commercial Probiotic Products

Backg round: The objective of this study was to investigate the history, clinical, laboratory, imaging data and outcome of children with biliary atresia in Slovenia. Methods: In an epidemiological single-arm retrospective study health records of infants born in Slovenia between October 1996 and October 2011, who were diagnosed with biliary atresia at the University Children's Hospital, University Medical Centre Ljubljana, were reviewed. Epi-demiological data and outcomes of patients with biliary atresia in Slovenia were studied. Results: In the 15-year period, 16 cases of biliary atresia were confirmed (1/20000 newborns). Two thirds of patients in our cohort were females. One child had associated laterality malformation. The majority of patients were born in autumn and winter months. The affected newborns were born mature with appropriate birth measures and healthy, but most of them became jaundiced in the first days of life. Primary surgery was done in 11 children at median age of 70 days. Of those children in whom the surgery was unsuccessful, 13 (81 %) underwent liver transplantation in foreignsurgical centres. Median age at liver transplantation was 9 months, median time from Kasai operation to liver transplantation was 5 months. Medianfollow-up was 9.75 years (range 1.2-15.4). Conclusions: In Slovenia, theincidence of biliary atresia is low and biliary atresia splenic malformation very rare. The observed seasonal incidence might suggest the viral aetiology.

Stroga vegetarijanska prehrana z izogibanjemvseh živil živalskega izvora pomeni tveganje zapomanjkanje več hranil: železa, cinka, kalcija,joda, vitaminov B12, B2, A, D, n-3 dolgoverižnihvečkrat nenasičenih maščobnih kislin, zlastidokozaheksaenojske kisline (DHA, C22: 6n-3),beljakovin in energije. Smernice Evropskegazdruženja za pediatrično gastroenterologijo, hepatologijoin prehrano (ESPGHAN) in slovenskesmernice odsvetujejo strogo vegetarijansko alivegansko prehrano za otroke. Večina mladostnikovv Evropi, tudi v Sloveniji, uživa občutnoprenizke količine zelenjave. Članek predstavljaprednosti živil rastlinskega izvora za preprečevanjedebelosti pri otrocih in mladostnikih. Pravtako so predstavljene druge zdravstvene prednostizadostnega vnosa rastlinski živil, zlasti preprečujebolezni srca in ožilja na t. i. primeru sredozemskeprehrane. Medtem ko je pomembno, dase odsvetuje zelo stroga vegetarijanska prehranaza dojenčke, otroke in mladostnike, nosečnice indoječe matere, je prav tako pomembno spodbujanjeuživanja rastlinskih živil v t. i. vsejedi prehraniotrok in mladostnikov, ki bi morala postatipomemben del strategije javnega zdravja.

Irritable bowel syndrome (lES) is a functional bowel disorder characterized byabdominal pain or discomfort with altered frequency of defecation and stool consistency. Some people with lES also experience urgency for bowel movements,feeling of incomplete sto ol evacuation, straining and cramping during defecation, presence of mucus in sto ol, abdominal disten ti on and flatulence. lES is believed to be the consequence of several factors: altered bowel motility and sensitivity (visceral hypersensitivity), altered brain-gut axis function, low-grade mucosal inflammation, disturbed balance of intestinalmicrobiota, chemical irritation, action of psychogenic factors and (at least in some case s) genetic predisposition. When there are no alarm signs, the diagnosis of lES can be made on the basis of clinical presentation alone. When alarm signs, such as rectal bleeding, fever, high erythrocyte sedimentation rate, weight loss, failure to thrive (children) or positive family history for organic bowel disease (chronic inflammatory bowel disease, cancer) are present, accurate diagnostics is necessary. When treating patiems with IBS, education and a trustful patient-doctor relationship are necessary, with emphasis on IBS being a benign disorder that only rarely leads to seriousconsequences.Some patients benefit from excluding nutrients that are known to cause discomfort from their dieto However, most patients do not need a specific dieto Special probiotics having effects validated by high-quality clinical trials may be useful in treating patients with IBS. When memal factors play an important part, psycho therapy mayaIso have a role. The use ofmedications, however, is reserved only for resistant forms of IBS.

Peutz-Jeghers syndrome (PJS) is an unusual hamartomatous polyposis of the gastro intestinal (GI) tract, with pigmentation around lips and macules on thebuccal mucosa. The case of a 10-year-old girl who presented with intussusception is reported. A polyp was found to be the cause of an invagination. Histologically it was a hamartoma. PJS is a rare syndrome inherited in an autosomal dominant pattern. Most patients have recurrent episodes of polyp induced bowel intussusception which requires repeated laparotomies. In addition, these patients have an increased risk of malignant disease in gastrointestinal and also non-gastrointestinal sites. To prevent cancer and short bowel syndrome, aggressive screening is recommended. Upper and lower endoscopy should be performed every two years from 10 years of age. Extra-intestinal surveillance for cancers, including abdominal and pelvic ultrasound, as well as testicular and breast examinations once yearly should be introduced in the second decade of life.

Cronic constipation is a common problem in children. The paper presents organic causes of constipation and the major risk factors for constipation, which are to be considered in the absence of evident organic causes. Good knowledge of normal rhythm and frequency of bowel movements appropriate for the child's age is a prerequisite for correct diagnosis of cronic constipation. The disorder is frequently associated with encopresis and anal bleeding. The principal diagnostic aproach to constipation is presented, as well as the main aspects of proper therapy, which should include the following: fiber-rich diet, counselling, training in bowel routine, medication and the use of bio feedback technique.

OBJECTIVES/BACKGROUND: Disease-related malnutrition is common in patients with chronic diseases and has detrimental effects, therefore, skills in nutrition care are essential core competencies for paediatric digestive medicine. The aim of this survey, conducted as part of a global survey of paediatric gastroenterology, hepatology and nutrition (PGHN) training in Europe, was to assess nutrition care-related infrastructure, staff, and patient volumes in European PGHN training centres. METHODS: Standardized questionnaires related to clinical nutrition (CN) care were completed by representatives of European PGHN training centres between June 2016 and December 2019. RESULTS: One hundred training centres from 17 European countries, Turkey, and Israel participated in the survey. Dedicated CN clinics exist in 66% of the centres, with fulltime and part-time CN specialists in 66% and 42%, respectively. Home tube feeding (HTF) and home parenteral nutrition (HPN) programmes are in place in 95% and 77% of centres, respectively. Twenty-four percent of centres do not have a dedicated dietitian and 55% do not have a dedicated pharmacist attached to the training centre. Even the largest centres with >5000 outpatients reported that 25% and 50%, respectively do not have a dedicated dietitian or pharmacist. Low patient numbers on HTF and HPN of

Objectives: The aim of the study was to review the evidence regarding the clinical use and value of fecal calprotectin (FC) measurements in different gastrointestinal disorders in children. Methods: A literature search was conducted in the PubMed, MEDLINE, EMBASE, and Cochrane databases until October 31, 2019. Subtopics were identified and each assigned to individual authors. Results: A total of 28 recommendations were voted on using the nominal voting technique. Recommendations are given related to sampling, measurement methods, and results interpretation. The 14 authors anonymously voted on each recommendation using a 9-point scale (1 strongly disagree to 9 fully agree). Consensus was considered achieved if at least 75% of the authors voted 6, 7, 8, or 9. Conclusions: Consensus was reached for all recommendations. Limitations for the use of FC in clinical practice include variability in extraction methodology, performance of test kits as well as the need to establish local reference ranges because of the influence of individual factors, such as age, diet, microbiota, and drugs. The main utility of FC measurement at present is in the diagnosis and monitoring of inflammatory bowel disease (IBD) as well as to differentiate it from functional gastrointestinal disorders (FAPDs). FC, however, has neither utility in the diagnosis of infantile colic nor to differentiate between functional and organic constipation. A rise in FC concentration, may alert to the risk of developing necrotizing enterocolitis and help identifying gastrointestinal involvement in children with Henoch-Schonlein purpura. FC measurement is of little value in Cow's Milk Protein Allergy, coeliac disease (CD), and cystic fibrosis. FC does neither help to distinguish bacterial from viral acute gastroenteritis (AGE), nor to diagnose Helicobacter Pylori infection, small intestinal bacterial overgrowth (SIBO), acute appendicitis (AA), or intestinal polyps.

Kljub temu, da so številne raziskave in metaanalize pokazale, da je zdravljenje otrok in mladostnikov z aktivno Crohnovo boleznijo (CB) s popolno enteralno prehrano (PEP) primerljivo učinkovito s kortikosteroidi (KS) in bolj uspešno v vzpostavitvi sluznične remisije ter ima po smernicah Evropskega združenja za pediatrično gastroenterologijo, hepatologijo in prehrano ESPGHAN-a prednost pred zdravljenjem s KS, se v klinični praksi še vedno premalo uporablja. Najpomembnejši vzrok je v nesodelovanju bolnikov, za katere je vzdrževanje zahtevnega protokola zdravljenja, brez uživanja običajne hrane, težka naloga. Zato je vse bolj aktualno raziskovanje učinkovitosti zdravljenja z delno enteralno prehrano (DEP), kjer lahko bolniki poleg enteralne formule zaužijejo tudi nekaj običajne hrane. Dosedanje raziskave zdravljenja z DEP so ocenjevale le klinični odziv na zdravljenje, nobena raziskava do sedaj še ni raziskala učinka DEP na sluznično vnetje. Zato je bil primarni namen naše raziskave oceniti ne le klinični, temveč tudi endoskopski odziv na 6-tedensko zdravljenje z novim protokolom zdravljenja z DEP in ga primerjati s standardnim zdravljenjem s PEP. Nov protokol zdravljenja smo zasnovali z namenom izboljšanja sodelovanja bolnikov in dovoljuje, da bolniki poleg enteralne formule (75% energijskega vnosa) zaužijejo en obrok hrane dnevno s protivnetno dieto. Od začetka junija 2017 do konca februarja 2021 smo na Kliničnem oddelku za gastroenterologijo, hepatologijo in nutricionistiko (KOGHN) obravnavali 54 otrok in mladostnikov s klinično in endoskopsko potrjeno aktivno CB, ki so bili kandidati za zdravljenje z enteralno prehrano. Petnajst bolnikov smo izključili na podlagi izključitvenih kriterijev, 3 so odklonili prehransko zdravljenje in so bili zdravljeni s KS, 3 so bili zdravljeni z drugo vrsto enteralne formule, ker jim ni ustrezal okus formule, ki smo jo zaradi lastnosti in uradne registracije, da je namenjena za zdravljenje CB, izbrali kot testno. V »intention to treat« (ITT) analizo smo vključili 33 bolnikov z aktivno CB, 14 bolnikov v skupino z zdravljenjem z DEP in 19 v skupino s PEP. V skupini bolnikov z DEP je 13 bolnikov in v skupini s PEP 16 bolnikov zaključilo 6-tedensko prehransko zdravljenje in so bili vključeni v »per protocol« (PP) analizo. V PEP skupini so bili bolniki zdravljeni s polimerično enteralno formulo (Alicalm, Nutricia, Nizozemska) po standardnem protokolu s 100% energijskim vnosom, v DEP skupini pa s 75% energijskim vnosom v obliki iste enteralne formule v kombinaciji z enim obrokom dnevno s protivnetno dieto. Protivnetno dieto (PVD) smo zasnovali na podlagi CDED (angl. »Crohn’s Disease Exclusion Diet«), ki smo jo prilagodili slovenskim razmeram. CDED temelji na hipotezi, da je najpomembnejši mehanizem delovanja PEP v izključitvi določenih sestavin hrane, ki negativno vplivajo na vnetje črevesa, predvsem na črevesno pregrado in mikrobioto. Naša PVD se od CDED razlikuje po tem, da vključuje uživanje lokalno pridelane zelenjave in sadja. CDED dovoljuje uživanje riža in krompirja, naša PVD dodatno tudi ajde in prosa. PVD za razliko od CDED izključuje ocvrte jedi ter vzpodbuja uživanje zdravih rastlinskih olj, predvsem olivnega olja. Klinično remisijo, opredeljeno s kliničnim kazalcem aktivnosti CB (angl. »Pediatric CD Activity Index« (PCDAI)) < 10, je imelo v DEP skupini po ITT analizi 78,5% in v PEP skupini 68,4% bolnikov, med skupinama ni bilo statistično pomembne razlike (p = 0,698). Po PP analizi je bilo po končanem 6-tedenskem zdravljenju z DEP protokolom 84,6% bolnikov v klinični remisiji in v PEP skupini 81,3% (p = 0,999). Endoskopsko remisijo, opredeljeno z endoskopskim kazalcem aktivnosti CB (angl. »Simple Endoscopic Score-for Crohn’s Disease« (SES-CD)) ? 2, je po 6-tedenskem zdravljenju doseglo 53,8% bolnikov v DEP in 50,0% v PEP skupini (p = 0,999). Sluznično remisijo (SES-CD = 0) smo po končanem zdravljenju ugotovili pri 38,5% bolnikov v DEP in pri 43,8% v PEP skupini (p = 0,999). Povprečne vrednosti PCDAI in SES-CD so od začetka do konca 6-tedenskega zdravljenja statistično pomembno upadle v obeh skupinah, med skupinama ni bilo statistično značilne razlike v upadu PCDAI (p = 0,881) in SES-CD (p = 0,750). Od laboratorijskih izvidov so se tekom zdravljenja v obeh skupinah statistično pomembno znižale povprečne vrednosti sedimentacije eritrocitov, CRP, povprečne vrednosti trombocitov in povprečne koncentracije fekalnega kalprotektina. Med skupinama bolnikov, zdravljenih z DEP in s PEP, ni bilo statistično pomembnih razlik v upadu omenjenih laboratorijskih parametrov. Po 6-tedenskem zdravljenju pa nismo ugotovili pomembnega povišanja povprečnih vrednosti koncentracije hemoglobina v krvi in povprečnih vrednosti antropometričnih parametrov v nobeni od skupin. Rezultati naše raziskave so pokazali, da je bilo zdravljenje z novim protokolom zdravljenja z DEP primerljivo učinkovito v vzpostavitvi klinične in endoskopske remisije v primerjavi s standardnim zdravljenjem s PEP. Nov protokol zdravljenja je enostaven in dovoljuje bolnikom, da poleg enteralne formule dnevno zaužijejo en obrok hrane z manjšimi prehranskimi omejitvami, kar doprinese k boljši kakovosti življenja. Raziskovalno delo kot prispevek k znanosti vključuje zasnovo novega protokola zdravljenja z DEP s 75% energijskim vnosom z enteralno formulo in enim obrokom dnevno s protivnetno dieto. Naša raziskava je do sedaj prva in edina, ki je ugotavljala ne le klinični, temveč tudi endoskopski odziv na zdravljenje z DEP. NNumerous clinical studies and meta-analysis have confirmed that exclusive enteral nutrition (EEN) is as effective as corticosteroids (CS) for induction of remission in active pediatric Crohn’s disease (CD). Moreover, EEN was shown to be more effective than CS in achieving mucosal healing (MH), therefore consensus guidelines of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommend EEN as a first-line therapy in children with active CD. Despite the numerous benefits of EEN, this treatment strategy is still underused in clinical practice. The most important barrier, preventing widespread use of EEN, is patient compliance. Adhering to the EEN regimen is difficult for most patients as they are only allowed to consume liquid enteral formula during the 6–8-week treatment period. Recently, partial enteral nutrition (PEN) has come into the forefront of pediatric CD treatment research, as it allows patients to consume some solid food alongside the enteral formula, improving the quality of life and patient compliance. So far, all previous studies on PEN have only evaluated the clinical response to PEN treatment, furthermore, no study has evaluated the effect of PEN on mucosal healing in CD. Therefore, the primary goal of our study was to evaluate not only the clinical outcomes of PEN, but the endoscopic remission and mucosal healing rates after a 6-week treatment course with PEN, as well as to compare the outcomes of PEN treatment to the standard EEN treatment protocol. At our Department of Pediatric Gastroenterology, Hepatology and Nutrition, from June 2017 until the end of February 2021, 54 children and adolescents with clinically and endoscopically confirmed active CD were screened for inclusion into our study. Fifteen patients were excluded based on the exclusion criteria. Additionally, three patients were excluded as they chose CS over nutritional treatment and another 3 patients due to being treated with a different enteral nutrition formula which wasn’t part of the treatment protocol. Finally, 33 patients were included into our study on intention to treat (ITT) analysis. Nineteen patients were included into the EEN and 14 into the PEN group. Thirteen patients in the PEN group and 16 patients in the EEN group concluded 6 weeks of nutritional treatment and were therefore included into per protocol (PP) analysis. All patients in the EEN group were treated with the same polymeric enteral formula (Alicalm, Nutricia, Nehterlands) in accordance with the standard treatment protocol, where 100% of daily energy requirements are covered with an enteral formula. In the PEN group, 75% of daily energy requirements were supplied by an enteral formula, while children were allowed one meal per day from an anti-inflammatory diet (AID). The AID was based on the CD Exclusion Diet (CDED), which was modified to fit the Slovenian dietary habits. CDED is grounded on recent scientific findings and excludes dietary components that negatively affect either intestinal permeability or the microbiome. Our AID differs from CDED in that it allows patients to consume locally sourced fruit and vegetables. CDED permits the consumption of rice and potatoes, our AID additionally allows buckwheat and millet, but excludes fried foods and promotes the use of healthy vegetables oils, especially olive oil. On ITT analysis, clinical remission (Pediatric CD Activity Index < 10) was achieved in 78.5% of patients in the PEN and 68.4% of patients in the EEN group (p=0.698), respectively. On per protocol analysis 84.6% of patients in the PEN and 81.3% of patients in the EEN group achieved clinical disease remission (p = 0.999). Endoscopic remission, defined as Simple Endoscopic Score for CD (SES-CD) ⡤ 2, was observed in 53.8% of patients in the PEN and in 50.0% of patients in the EEN group (p = 0.999) and mucosal healing (SES-CD = 0) was found in 38.5% of patients in the PEN and in 43.8% of patients in the EEN group (p = 0.999). Mean PCDAI and SES-CD index values significantly decreased in both groups and no difference between groups was observed (p = 0.881 for PCDAI p = 0.750 for SES-CD). Furthermore, a statistically significant decrease in mean erythrocyte sedimentation rate, C-reactive protein, mean thrombocyte count and fecal calprotectin was found in both groups with no significant differences between the two groups in the change of the abovementioned parameters during a 6-week treatment course. During the treatment period, no statistically significant increases in the patients’ mean blood hemoglobin levels or anthropometric parameters were observed for either group. In our study, our novel PEN treatment protocol, allowing one meal per day from an anti-inflammatory diet, was comparable in effectiveness to standard EEN treatment in inducing clinical and endoscopic remission in pediatric patients with active CD. Our PEN protocol allows patients to consume one meal per day alongside the enteral nutrition formula, which positively impacts the patients’ quality of life. Our research project contributes to scientific research with the development of a novel nutritional treatment protocol, which combines 75% of daily required energy intake from an enteral formula with one allowed meal per day from an anti-inflammatory diet. Furthermore, our study is the first to assess not only clinical but also endoscopic remission and mucosal healing rates in the treatment of CD with partial enteral nutrition.

Background and study aims The ability to perform endoscopy procedures safely and effectively is a key aspect of quality clinical care in Pediatric Gastroenterology, Hepatology and Nutrition (PGHN). The aim of this survey, which was part of a global survey on PGHN training in Europe, was to assess endoscopy training opportunities provided across Europe. Methods Responses to standardized questions related to endoscopy training were collected from training centers across Europe through the presidents/representatives of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition National Societies from June 2016 to December 2019. Results A total of 100 training centers from 19 countries participated in the survey. In 57 centers, the endoscopy suit was attached to the PGHN center, while in 23, pediatric endoscopies were performed in adult endoscopy facilities. Ninety percent of centers reported the availability of specialized endoscopy nurses and 96 % of pediatric anesthetists. Pediatric endoscopies were performed by PGHN specialists in 55 centers, while 31 centers reported the involvement of an adult endoscopist and 14 of a pediatric surgeon. Dividing the number of procedures performed at the training center by the number of trainees, ≤ 20 upper, lower, or therapeutic endoscopies per trainee per year were reported by 0 %, 23 %, and 56 % of centers, respectively, whereas ≤ 5 wireless capsule endoscopies per trainee per year by 75 %. Only one country (United Kingdom) required separate certification of competency in endoscopy. Conclusions Differences and deficiencies in infrastructure, staffing, and procedural volume, as well as in endoscopy competency assessment and certification, were identified among European PGHN training centers limiting training opportunities in pediatric endoscopy. ispartof: ENDOSCOPY INTERNATIONAL OPEN vol:10 issue:10 pages:E1371-E1379 ispartof: location:Germany status: published

International audience; Acute diarrhoea is a leading cause of morbidity and mortality in the paediatric population. Racecadotril is an antisecretory drug recommended as an adjuvant anti-diarrhoeal treatment.In the small bowel, the enzyme neutral endopeptidase (NEP) inhibits the action of enkephalins, which prevent water and electrolyte hypersecretion. By inhibiting NEP, racecadotril allows enkephalins to exhibit their antisecretory effects. Consequently, racecadotril reduces the secretion of water and electrolytes in the small intestine, without having an effect on intestinal motility. No serious adverse events related to racecadotril have been reported.Racecadotril has proven its efficacy as an adjuvant anti-diarrhoeal drug with a good safety profile. Its addition to oral rehydration solution (ORS) appears clinically beneficial and potentially leads to health care savings.

OBJECTIVES: Recommendations for diagnosing and treating eosinophilic esophagitis (EoE) are evolving; however, information on real world clinical practice is lacking. To assess the practices of pediatric gastroenterologists diagnosing and treating EoE and to identify the triggering allergens in European children. METHODS: Retrospective anonymized data were collected from 26 European pediatric gastroenterology centers in 13 countries. Inclusion criteria were: Patients diagnosis with EoE, completed investigations prescribed by the treating physician, and were on stable medical or dietary interventions. RESULTS: In total, 410 patients diagnosed between December 1999 and June 2016 were analyzed, 76.3% boys. The time from symptoms to diagnosis was 12 ± 33.5 months and age at diagnosis was 8.9 ± 4.75 years. The most frequent indications for endoscopy were: dysphagia (38%), gastroesophageal reflux (31.2%), bolus impaction (24.4%), and failure to thrive (10.5%). Approximately 70.3% had failed proton pump inhibitor treatment. The foods found to be causative of EoE by elimination and rechallenge were milk (42%), egg (21.5%), wheat/gluten (10.9%), and peanut (9.9%). Elimination diets were used exclusively in 154 of 410 (37.5%), topical steroids without elimination diets in 52 of 410 (12.6%), both diet and steroids in 183 of 410 (44.6%), systemic steroids in 22 of 410 (5.3%), and esophageal dilation in 7 of 410 (1.7%). Patient refusal, shortage of endoscopy time, and reluctance to perform multiple endoscopies per patient were noted as factors justifying deviation from guidelines. CONCLUSIONS: In this "real world" pediatric European cohort, milk and egg were the most common allergens triggering EoE. Although high-dose proton pump inhibitor trials have increased, attempted PPI treatment is not universal.

Izhodišče: Metabolični sindrom (MS) je kompleksna, z življenjskim slogom pogojena bolezen, njena pogostnost pa v razvitem svetu narašča. Gre za sklop metaboličnih motenj, ki so posledica prepleta okoljskih in genetskih dejavnikov. Črevesna mikrobiota je s 1014 bakterijskimi celicami vpletena v fiziologijo gostitelja in zato pomemben element metaboličnih motenj. Prehrana sodi med najpomembnejše dejavnike, ki vplivajo na sestavo črevesne mikrobiote, zato raziskovalci intenzivno preučujejo prehranske učinkovine in diete, s katerimi bi lahko uravnavali sestavo črevesne mikrobiote in posredno izboljšali metabolično stanje pacientov. Med takšne prehranske učinkovine spadajo ječmenovi betaglukani, polisaharidi, ki na podlagi kliničnih raziskav izboljšajo tako lipidni kot glukozni metabolizem. Namen: Namen naše študije je bil ugotoviti, ali uživanje ječmenovih betaglukanov lahko spremeni sestavo črevesne mikrobiote in istočasno izboljša z MS povezane klinične kazalce. Metode: Izvedli smo dvojno slepo, s placebom kontrolirano in randomizirano klinično študijo s preiskovanci z diagnosticiranim MS ali visokim tveganjem za razvoj MS. Preiskovanci so štiri tedne uživali kruh s 6 g dodanih betaglukanov (testna skupina) ali kruh brez dodanih betaglukanov (kontrolna skupina). Pred prehransko intervencijo in ob koncu smo izvedli antropometrične meritve, krvne preiskave maščob, oralni glukoza tolerančni test (OGTT) ter odvzeli vzorce blata za analize sestave črevesne mikrobiote in ugotavljanje vsebnosti kratkoverižnih maščobnih kislin. Stanje inzulinske rezistence smo ovrednotili z modeloma HOMAIR in QUICKI. Koncentracijo kratkoverižnih maščobnih kislin v blatu smo določili s plinsko kromatografijo. Sestavo črevesne mikrobiote smo preučevali s kombinacijo kvalitativnih in kvantitativnih metod, ki so omogočale analizo 16S rRNK molekul: gelsko elektroforezo v gradientu denaturanta (DGGE), verižno reakcijo s polimerazo v realnem času (RT-PCR) in s sekvenciranjem naslednje generacije, pri katerem smo uporabili tehnologijo Illumina Miseq. Rezultati: V študijo je bilo vključenih 43 prostovoljcev z MS oz. visokim tveganjem za razvoj MS. V testni skupini, ki je štiri tedne ob sicer običajni dieti dnevno uživala 6 g ječmenovih betaglukanov, se je značilno znižala koncentracija celokupnega holesterola v krvi in zmanjšal obseg pasu. Vpliva na druge metabolične parametre nam ni uspelo dokazati. Značilno se je spremenila vsebnost kratkoverižnih maščobnih kislin (KMK) v blatu, in sicer v testni skupini s povišanjem vsebnosti propionske kisline. Z analizo sekvenc 16S rRNK smo pokazali, da se po prehranski intervenciji z betaglukani spremeni sestava črevesne mikrobiote. Pri testni skupini smo opazili značilno znižanje tako mikrobne pestrosti kot bogatosti. Poleg tega smo po intervenciji z betaglukani opazili značilen padec v številu sekvenc iz redu Coriobacteriales in tistih, ki pripadajo bakterijskemu redu Clostridiales. Pri preučevanju sestave črevesne mikrobiote pri preiskovancih, ki so bili uvrščeni v testno skupino, smo pred prehransko intervencijo odkrili značilne razlike v sestavi črevesne mikrobiote med tistimi preiskovanci, pri katerih se je koncentracija holesterola značilno znižala (holesterol odzivna skupina), in tistimi, pri katerih se ni. Pri prvih so bile v večjem številu zastopane bakterijske skupine, ki sodijo med t. i. »koristne« bakterije, npr. Bifidobacterium bifidum, Bifidobacterium fecale in Akkermansia municiphila. Sklep: Štiritedensko uživanje betaglukanov je vplivalo na koncentracijo maščob v krvi in spremenilo sestavo črevesne mikrobiote pri preiskovancih z diagnosticiranim MS ali povečanim tveganjem za razvoj MS. Zmanjšanje bogatosti in pestrosti potrjuje, da so betaglukani sposobni spreminjanja sestave črevesne mikrobiote, vendar je odziv na prehransko intervencijo močno odvisen od posameznika. Značilne spremembe posameznih bakterijskih skupin črevesne mikrobiote in povečanje vsebnosti kratkoverižnih maščobnih kislin nakazujejo potencialno ugodne učinke uživanja betaglukanov. S preučevanjem začetne sestave črevesne mikrobiote in opaženimi značilnimi razlikami v njeni sestavi pri holesterol odzivni skupini smo pokazali, da je metabolični odziv na dieto lahko odvisen tudi od specifične sestave črevesne mikrobiote posameznika. Background: Metabolic syndrome (MS) is a complex lifestyle disease that is almost exponentially increasing in western world. Gut microbiota is with 1014 bacterial cells involved in certain human physiological processes and is important factor of metabolic disorders. Diet is one of the main elements contributing to gut microbiota composition and one of the possible ways to improve the metabolic status of patients. In recent years many investigations have been performed concerning diets and active components, that could positively control gut microbiota composition and improve metabolic status of patients. Dietary fibres are known to improve glucose and lipid metabolism and modulate gut microbiota composition. Barley beta-glucans have been used to improve cholesterol levels and postprandial glucose response but have been poorly investigated in trials focusing on gut microbiota till now. Aims: The purpose of this study was to investigate if a 4-week dietary intervention with beta-glucans could positively change gut microbiota composition and improve metabolic syndrome parameters at the same time. Methods: Double blind, placebo-controlled and randomised clinical trial was performed with participants with high risk for MS development or with diagnosed MS. Participants consumed bread with 6 g added beta-glucans (test group) or without added beta-glucans (control group). Before and at the end of the trial anthropometric measurements, lipid profile analyses, and oral glucose tolerant test (OGTT) were performed, and faecal samples were retrieved for gut microbiota composition and short-chain fatty acids analyses. HOMAIR in QUICKI indexes were employed for insulin resistance determination. Short-chain fatty acids were extracted from faecal samples and analysed with gas chromatography. Changes in gut microbiota composition were investigated with combination of qualitative and quantitative molecular methods analysing 16S rRNA molecules: denaturing gradient gel electrophoresis (DGGE), real-time polymerase chain reaction (RT-PCR), and the next generation sequencing based on Illumina MiSeq paired end technology. Results: 43 participants with high risk for metabolic syndrome (MS) development or with diagnosed MS successfully finished the trial. Total plasma cholesterol levels decreased in test group, but not in placebo group. Short chain fatty acids composition in faeces significantly changed with increase of propionic acid in the test group. The microbiome analysis showed a decrease in microbial diversity and richness in the test group and a decrease in order Coriobacteriales. Furthermore, a decrease of a single unclassified Clostridiales group was observed. We further examined the differences in the so-called pre-intervention gut microbiota composition within cholesterol responsive and unresponsive group. Interestingly, sequences from several bacterial groups, commonly perceived as health associated, such as Bifidobacterium bifidum, Bifidobacterium fecale and Akkermansia municiphila, were present in higher numbers. Conclusion: Dietary intervention with beta-glucans has showed positive improvements in blood lipid profile and in gut microbiota composition with participants with high risk for MS development or with diagnosed MS. A decrease in richness and diversity of gut microbiota showed that beta-glucans are able to alter gut microbiota composition. However, the response on dietary intervention is individually depended. Changes in abundance of certain bacterial groups and increase of short-chain fatty acids after intervention showed that beta-glucans potentially exert positive effects on gut microbiota composition. Investigating pre-intervention gut microbiota composition with observed changes in gut microbiota composition in cholesterol responsive group, suggests that diet response could be depended on individual gut microbiota composition.

OBJECTIVES: Childhood functional gastrointestinal disorders (FGIDs) are common conditions associated with significant morbidity and high healthcare costs. This multicenter study aimed at assessing the clinical approach to infants (0-6 months) and children/adolescents (4-18 years) with suspected FGIDs by pediatricians from the Mediterranean Area. METHODS: A survey evaluating the diagnostic approach, including the use of Rome II and III criteria, and the therapeutic management of some of the most prevalent FGIDs, such as irritable bowel syndrome (IBS), functional constipation (FC), and functional regurgitation (FR), was distributed to a sample of pediatricians. RESULTS: We collected 278 questionnaires from 9 countries (Croatia, Greece, Israel, Italy, Lebanon, Montenegro, Serbia, Slovenia, and Spain). Rome III criteria are used to diagnose FC by 28.8%. Treatment of FC is based on dietary modifications (97.5%) and osmotic laxatives (93.5%). Rome III criteria are used to diagnose FR by 22.3% of the responders, in contrast to 79.5% who rely on personal experience for diagnosis. Reported treatments mainly consist of reassurance (96.8%) and thickened feedings (77.3%). Nevertheless, 21.2% prescribe proton pump inhibitors or H2-blockers to infants with FR. Rome III criteria are used to diagnose IBS by only 25.9%. Moreover, 86% of the pediatricians base IBS therapy on the predominant symptom. The most prescribed treatments are analgesics (36.6%) for pain control, dietary advice (41.5%) for diarrhea-predominant IBS, and dietary advice (47.8%) for constipation-predominant IBS. CONCLUSIONS: Our data show that the use of Rome III diagnostic criteria is not sufficiently widespread among pediatricians, and that large variability remains in the management of FGIDs within the different Mediterranean countries surveyed.

AIM: Implementing international guidelines guarantees high standards of clinical care. A group of experts developed an algorithm to drive the management of common gastrointestinal symptoms in infancyby paediatricians and general practitioners. METHODS: The algorithm started from the evidence-based recommendations of the European Society of Gastroenterology, Hepatology and Nutrition and the European Society of Pediatric Infectious Diseases and an updated review of the literature. We used the structured quantitative method of nominal group technique to reach a consensus. RESULTS: A practical algorithm for the management of infants with acute diarrhoea was designed based on theconsensus reached for each statement. The management of an infant with acute diarrhoeashould include a sequence of actions: 1) a semi-quantitative estimate of infant dehydration through validated clinical scores, 2) rehydration therapy and early re-feedingwith breast milk or regular formula and 3) effective agents to reduce the severity and duration of the diarrhoea. Finally, in children with prolonged diarrhoea, the search for aetiology should include persistent infections or reinfections, cows' milk protein allergy and celiac diseases. Lactose should always be withdrawn. CONCLUSION: This algorithm provides an evidence-based sequence of interventions to optimisethe management of infants with acute diarrhoea. This article is protected by copyright. All rights reserved.

This article provides recommendations, developed by the Working Group (WG) on Probiotics of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition, for the use of probiotics for the prevention of antibiotic-associated diarrhea (AAD) in children based on a systematic review of previously completed systematic reviews and of randomized controlled trials published subsequently to these reviews. The use of probiotics for the treatment of AAD is not covered. The recommendations were formulated only if at least 2 randomized controlled trials that used a given probiotic (with strain specification) were available. The quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation guidelines. If the use of probiotics for preventing AAD is considered because of the existence of risk factors such as class of antibiotic(s), duration of antibiotic treatment, age, need for hospitalization, comorbidities, or previous episodes of AAD diarrhea, the WG recommends using Lactobacillus rhamnosus GG (moderate QoE, strong recommendation) or Saccharomyces boulardii (moderate QoE, strong recommendation). If the use of probiotics for preventing Clostridium difficile-associated diarrhea is considered, the WG suggests using S boulardii (low QoE, conditional recommendation). Other strains or combinations of strains have been tested, but sufficient evidence is still lacking.