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Introduction Many parents in the UK are giving home blended diets (BD) via a gastrostomy (G) device as an alternative to commercial feeds. There are several anecdotal reports suggesting benefits from using BD but there are few studies addressing the risks/benefits in the UK. Aims Methods and objectives We studies a group of G fed children before and after a change from commercial feeds to BD to to investigate the benefits and complications. In addition we compared two groups of children fed BD and commercial feeds and recorded complications and risks. We also have collected stool specimens to look at future microbiome analysis of the 2 groups and a third sibling control group (microbiome analysis not yet available). Results Parents of 32 children (2–16 years) with neurodevelopmental problems receiving BD (>50% intake) completed a questionnaire detailing their experience before and after the institution of BD. There was no increase in complications in tube blockage or infection rates but a significant improvement (p Conclusion The change to BD resulted in no increase in complications/risks but improved overall quality of life for the children and families.

The aim of this study was to measure the effectiveness, safety, and use of anti-tumor necrosis Factor (TNF) therapy in pediatric inflammatory bowel disease in the United Kingdom (UK).Prospective UK audit of patients newly starting anti-TNF therapy. Disease severity was assessed using Physician Global Assessment +/or the Paediatric Crohn Disease Activity Index.A total of 37 centers participated (23/25 specialist pediatric inflammatory bowel disease sites). A total of 524 patients were included: 429 with Crohn disease (CD), 76 with ulcerative colitis (UC), and 19 with IBD unclassified (IBDU). Eighty-seven percent (488/562) of anti-TNF was infliximab; commonest indication was active luminal CD 77% (330/429) or chronic refractory UC/IBDU 56% (53/95); 79% (445/562) had concomitant co-immunosuppression. In CD (267/429 male), median time from diagnosis to treatment was 1.42 years (interquartile range 0.63-2.97). Disease (at initiation) was moderate or severe in 91% (156/171) by Physician Global Assessment compared to 41% (88/217) by Paediatric Crohn Disease Activity Index (Kappa (κ) 0.28 = only "fair agreement"; P 0.001.Where documented, 77% (53/69) of patients with CD responded to induction; and 65% (46/71) entered remission. A total of 2287 infusions and 301.96 years of patient' follow-up (n = 385) are represented; adverse events affected 3% (49/1587) infliximab and 2% (2/98) adalimumab infusions (no deaths or malignancies). Peri-anal abscess drainage was less common after anti-TNF initiation (CD), that is 26% (27/102) before, 7% (3/42) after (P = 0.01); however, pre and post anti-TNF data collection was not over equal time periods.Anti-TNFs are effective treatments, usually given with thiopurine co-immunosuppression. This study highlights deficiencies in formal documentation of effect and disparity between disease severity scoring tools, which need to be addressed to improve ongoing patient care.

Gastrointestinal dysmotility is common in children and young people with neurodisabling conditions. In this article we seek to highlight the increasing difficulties faced by paediatricians in managing intestinal failure in this patient group. It is becoming clear that, as the median age for survival increases, intestinal failure is a significant problem, and can in some cases become life-limiting. The ethical issues around starting children with life-limiting conditions on parenteral nutrition (PN) are extremely complicated, not least because we are ignorant of the mechanism of intestinal failure in these children, and indeed, which of these children might be able to return to enteral feeding after a period of PN. Our article highlights these issues, drawing on our experience of a particularly difficult case, which we hope will stimulate further discussion among paediatricians providing care for children with neurodisabling conditions.

With the growing number of children and young people with complex care needs or life-limiting conditions, alternative routes for nutrition have been established (such as gastrostomy feeding). The conditions of children and young people who require such feeding are diverse but could relate to problems with swallowing (dysphagia), digestive disorders or neurological/muscular disorders. However, the use of a blended diet as an alternative to prescribed formula feeds for children fed via a gastrostomy is a contentious issue for clinicians and researchers. From a rapid review of the literature, we identify that current evidence falls into three categories: (1) those who feel that the use of a blended diet is unsafe and substandard; (2) those who see benefits of such a diet as an alternative in particular circumstances (eg, to reduce constipation) and (3) those who see merit in the blended diet but are cautious to proclaim potential benefits due to the lack of clinical research. There may be some benefits to using blended diets, although concerns around safety, nutrition and practical issues remain.

Background and aim Preliminary data highlight the importance of appropriate transition for successful transfer of adolescents with IBD from paediatric to adult care. The aim of this study was to identify both the perceived needs of adolescent IBD patients and the barriers to successful transition from the perspective of professionals involved in their care. Methods A postal questionnaire was distributed to UK adult and paediatric gastroenterologists with an interest in IBD. The questionnaire utilised closed questions as well as ranked items on the importance of the various competencies of adolescents with IBD required for successful transition. Results Response rate of 62% and 49% for paediatric and adult gastroenterologists respectively was achieved. A structured transition service was perceived as very important by 80% paediatric compared to 47% adult gastroenterologists (p = 0.001). A higher proportion of adult than paediatric gastroenterologists identified inadequacies in the preparation of adolescents for transfer (79% and 42%, p = 0.001). The main areas of perceived deficiency in preparation identified were patient lack of knowledge about the condition and treatment, lack of self advocacy and co-ordination of care. Lack of resources, clinical time, and a critical mass of patients were the factors ranked highest by both groups as barriers to transition care. Both adult (65%) and paediatric gastroenterologists (62%) highlighted suboptimal training in adolescent medicine for adult gastroenterologists. Conclusions This survey highlights differences in the perception of adult and paediatric gastroenterologists in the management of transition care and perceived competencies for adolescents with IBD. Lack of training and inadequate resources are the main barriers identified for development of a successful transition service.

Objective There are no specific data available regarding paediatric endoscopy provision in the UK and anecdotal experiences suggest that such provision varies widely between the units. The aim of our study was to identify the current provision of paediatric endoscopy services in the UK, the number of endoscopies performed in each unit, the number of operators performing these endoscopies and whether endoscopies were performed under sedation or general anaesthesia. Methods and results An email questionnaire was sent to all 31 units in the UK performing paediatric endoscopies and responses were received from 25 centres (81%). The median number of total endoscopies (upper and lower) per unit each year was 332 (range 64-2040). The median number of gastrosopy per consultant in each centre was 101 (range 20-288) and median number of colonoscopies performed per consultant per year was 49 (range 10-215). 18 of the 25 centres performed all endoscopies under general anaesthesia with 7 centres using sedation as well as general anaesthesia. Percutaneous endoscopic gastrostomy insertion (PEG) was performed in 24 out of 25 centres with the service undertaken by paediatric surgeons in 11 centres. 11 centres provided formal out of hours endoscopy services. Conclusion There is wide variation in paediatric endoscopy provision and the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) endoscopy working group is collaborating with the Joint Advisory Group (JAG) to provide specific standards for paediatric endoscopy services in the UK.

OBJECTIVE To determine whether there is a continued increase in the incidence of coeliac disease (CD) in the population of Cardiff and the Vale of Glamorgan between 1996 and 2005 compared with previous data for 1981-1995, and to describe the presenting features during this time. DESIGN Retrospective case-finding study using pathology, dietetic and clinical records held in hospitals and general practice within Cardiff and the Vale of Glamorgan. All local consultants including those at private hospitals were contacted. Incidence rates were calculated using the Welsh Assembly Government's mid-year estimates. RESULTS In total, 347 newly diagnosed cases of CD (42 children, 305 adults) were detected. Compared with previous published data, incidence rates in adults per 100 000 have increased from 3.08 at the end of 1995 to 11.13 in 2005. In children, the disease incidence has trebled to 6.89 per 100 000. There have been some changes in presenting symptoms, with a marked preponderance of abdominal pain and bloating in women (P

There is paucity of data on the transition of adolescents with inflammatory bowel disease (IBD) from paediatric to adult services. IBD nurses could play a crucial role in coordinating transition care. In this article, Yasmine Houston, James O Lindsay, Huw Jenkins, Sarah McCartney, Tariq Ahmad, Ian Arnott, Nick Croft, Richard Russell and Shaji Sebastian report on a survey of 106 IBD nurses regarding their views and experiences of transition care.

To assess the efficacy and safety of polyethylene glycol 3350 plus electrolytes (PEG+E) for the treatment of chronic constipation in children.Randomised, double blind, placebo controlled crossover trial, with two 2-week treatment periods separated by a 2-week placebo washout.Six UK paediatric departments.51 children (29 girls, 22 boys) aged 24 months to 11 years with chronic constipation (lastingor =3 months), defined asor =2 complete bowel movements per week and one of the following: pain on defaecation on 25% of days;or =25% of bowel movements with straining;or =25% of bowel movements with hard/lumpy stools. 47 children completed the double blind treatment.Number of complete defaecations per week (primary efficacy variable), total number of complete and incomplete defaecations per week, pain on defaecation, straining on defaecation, faecal incontinence, stool consistency, global assessment of treatment, adverse events and physical examination.The mean number of complete defaecations per week was significantly higher for children on PEG+E than on placebo (3.12 (SD 2.05) v 1.45 (SD 1.20), respectively; p0.001). Further significant differences in favour of PEG+E were observed for total number of defaecations per week (p = 0.003), pain on defaecation (p = 0.041), straining on defaecation (p0.001), stool consistency (p0.001) and percentage of hard stools (p = 0.001). Treatment related adverse events (all mild or moderate) occurred in similar numbers of children on PEG+E (41%) and placebo during treatment (45%).PEG+E is significantly more effective than placebo, and appears to be safe and well tolerated in the treatment of chronic constipation in children.

Non-specific abdominal pain (NSAP) is a common reason for admission to paediatric medical and surgical units, although the vast majority of cases are managed in primary care or in an outpatient setting. The paper by Thornton et al 1 aims to determine the relative risk of subsequent organic and functional gastrointestinal disorders over a 12-year period using linked English Hospital Episodes statistics. During this period, 268 623 children were discharged from hospital with a code for ‘abdominal and pelvic pain’ without further specification. Just under 6% were readmitted over a 10-year period as either inpatients or as day cases and a diagnosis of an organic condition was made. A further 5% were admitted during the same time period and given a label of what the authors describe as ‘a functional disorder’. The authors have identified some of the strengths and weaknesses of this study including the accuracy of coding and the fact that many children with NSAP are diagnosed and treated …

Objective. To examine the impact of an implementation program on adherence to a guideline for the management of acute gastroenteritis. Design. Using four retrospective audits over a 10-year period, the authors examined the change in practice and maintenance of that change following a targeted implementation program for the clinical guideline. Setting. Tertiary children's hospital in South Wales. Participants. 447 children aged less than 5 years, admitted to hospital with acute gastroenteritis, comprising four cross-sectional samples (106 in 1999, 153 in 2002, 99 in 2004, 89 in 2009). Main outcome measures. Age of child, hydration status, method of rehydration and duration of admission, for each audit, with an implementation strategy delivered after the second audit. Results. In 1999 and 2002, intravenous rehydration was used in 20% and 15% of cases, respectively. After the implementation program in 2004, compared to 1999, there was a significant decrease in the intravenous rehydration rate to 4% in 2004 (p

Toddler diarrhoea is a term coined many years ago to describe a young child who passes several loose stools a day but who is otherwise healthy with excellent growth and normal examination. It could be argued that it is not an appropriate diagnostic term as it potentially stops the clinician from thinking about the possible causes of loose stools in this clinical situation. This article, which follows a debate between the authors on the topic at the 2010 Royal College of Paediatrics and Child Health Annual meeting, discusses the differential diagnoses of a young child presenting with the so-called toddler diarrhoea.

Background: There has been a growing recognition that coeliac disease is much more common than previously recognised, and this has coincided with the increasingly widespread use of serological testing. Aim: To determine whether the age at presentation and the clinical presentation of coeliac disease have changed with the advent of serological testing. Methods: A 21-year review of prospectively recorded data on the mode of presentation of biopsy confirmed coeliac disease in a single regional centre. Presenting features over the past 5 years were compared with those of the previous 16 years. Between 1983 and 1989 (inclusive), no serological testing was undertaken; between 1990 and 1998, antigliadin antibody was used with occasional use of antiendomysial antibody and antireticulin antibody. From 1999 onwards, anti-tissue transglutaminase was used. Results: 86 patients were diagnosed over the 21-year period: 50 children between 1999 and 2004 compared with 25 children between 1990 and 1998 and 11 children between 1983 and 1989. The median age at presentation has risen over the years. Gastrointestinal manifestations as presenting features have decreased dramatically. In the past 5 years, almost one in four children with coeliac disease was diagnosed by targeted screening. Conclusion: This study reports considerable changes in the presentation of coeliac disease—namely, a decreased proportion presenting with gastrointestinal manifestations and a rise in the number of patients without symptoms picked up by targeted screening. Almost one in four children with coeliac disease is now diagnosed by targeted screening. Most children with coeliac disease remain undiagnosed. Paediatricians and primary care physicians should keep the possibility of coeliac disease in mind and have a low threshold for testing, so that the potential long-term problems associated with untreated coeliac disease can be prevented.

The prevalence of osteopenia in children with inflammatory bowel disease (IBD) is unknown. The effect of nutritional state, disease activity, and steroid therapy on bone mineral content (BMC) of whole body, lumbar spine, and left femoral neck measured by dual energy x ray absorptiometry in 32 children with IBD was assessed by comparison with 58 healthy local school children. Using the control data, a predicted BMC was calculated taking into account bone area, age, height, weight, and pubertal stage. The measured BMC in children with IBD was expressed as a percentage of this predicted value (% BMC). Mean (SD) % BMC was significantly reduced for the whole body and left femoral neck in the children with IBD (97.0 (4.5)% and 93.1 (12.0)% respectively, p < 0.05). Of the children with IBD, 41% had a % BMC less than 1 SD below the mean for the whole body and 47% at the femoral neck. Reduction in % BMC was associated with steroid usage but not with the magnitude of steroid dose, disease activity, or biochemical markers of bone metabolism. In conclusion, osteopenia is relatively common in childhood IBD and may be partly related to the previous use of steroids.

A double blind randomised controlled trial in small for gestational age (SGA) infants, whose intestinal mucosa was shown to be functionally impaired as a result of intrauterine undernutrition, was carried out to investigate the hypothesis that nucleotide supplementation of a milk formula could improve catchup growth. Anthropometric data were collected on 74 infants, 39 randomly allocated to the nucleotide supplemented group (group N) and 35 to a standard formula group (group S). From study entry to 2 months of age, infants in group N had significantly higher mean rates of weight gain (106.3 compared with 94.7 g/kg baseline weight/week) and length gain (21.8 v 19.7 mm/m baseline length/week). Over the whole six months for which the trial formula was provided group N had significantly higher mean rates of gain of weight (80.1 compared with 71.8 g/kg baseline weight/week), length (16.2 compared with 15.0 mm/m baseline length/week), and head circumference (11.8 compared with 10.8 mm/m baseline head circumference/week). Catchup growth in SGA infants is therefore improved by nucleotide supplementation of infant formula.

Guidelines from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) for diagnosis and treatment of coeliac disease (CD) have not been revisited for 20 years. During this time, the perception of CD has changed from a rather uncommon enteropathy presenting in childhood, with obvious gastrointestinal symptoms, to a much more common multiorgan disease with a strong genetic predisposition (mainly associated with human leucocyte antigen (HLA)-DQ2 and HLA-DQ8). Previous ESPGHAN diagnostic criteria1 stated that histological confirmation of the typical changes of CD in the small intestine were mandatory for diagnosis and that a gluten challenge, and rebiopsy would need to be performed in those children under the age of 2 years diagnosed as having CD. Since that time, largely because of the increasing availability of specific serological testing, it has become clear that CD may present with a large variety of non-specific signs and symptoms, rather than a specific gastrointestinal presentation.

In infants, adequate colonic function is vital in preventing electrolyte and water depletion. In certain species, short-chain fatty acids have been shown to increase colonic Na absorption. Using an in vitro voltage-clamp technique, we have studied the characteristics of electrolyte transport in isolated preparations of human left-sided colonic mucosa and investigated the effect of acetate on epithelial Na movement. In the basal state, there was net Na absorption that was entirely electrogenic. The addition of mucosal acetate resulted in a significant increase in net Na absorption that was markedly inhibited by amiloride, suggesting that, in the young child, the presence of short-chain fatty acids promotes colonic salvage of Na and that such salvage of Na may be via an amiloride-sensitive Na channel and involve stimulation of sodium-hydrogen exchange.

right © 2010 by From the Department Hospital for Children enterology, Chelsea zDepartment of Pae Hospital, Southampton St George’s Universit Edinburgh, and the D Cardiff, UK. The nutritional supplemen George’s House, Croy Ltd, 100 Wavertree B Supported, in part, by Hepatology, and Nutri and the National Asso The authors report no co Copyright # 2010 by E Hepatology, and Nut Gastroenterology, He DOI: 10.1097/MPG.0b01

In recent years, serum antibodies to gliadin (AGA) have been reported to be useful markers of coeliac disease. IgA AGA have also been found in intestinal secretions and saliva in coeliac disease and may offer a convenient, non-invasive screening test. In order to test this hypothesis, salivary and serum AGA were measured in children with coeliac disease proved by biopsy and compared with several control groups. Measurement of salivary IgA AGA provided excellent discrimination between those children with coeliac disease and the control groups, and our study suggests that it may provide a rapid, non-invasive method of screening for this disease before intestinal biopsy.

A prospective study was undertaken throughout Wales over the period from 1 January 1995 to 30 March 1997, to determine the incidence of childhood inflammatory bowel disease (IBD). Thirty-eight (24 male) new cases of IBD were reported. Twenty (16 male) of the reported cases had Crohn's disease, 11 (5 male) had ulcerative colitis (UC) and 7 (3 male) indeterminate colitis. Crohn's disease occurred four times more often in boys than girls, whereas there was no sex difference in the incidence for UC and indeterminate colitis. The median age at presentation was 12 (range 1.5–16) years and there was no difference in the age of presentation or the duration of symptoms prior to diagnosis in any of the types of IBD. Conclusion The overall incidence (95% confidence intervals) for IBD in Wales was 2.6 (1.87–3.48) cases per 100,000 per year. The incidence for Crohn's disease was 1.36 (0.86–2.04) cases per 100,000 per year, for UC 0.75 (0.39–1.28) cases per 100,000 per year and for indeterminate colitis 0.48 (0.2–0.92) cases per 100,000 per year.

To evaluate whether fecal calprotectin (FC) and fecal lactoferrin (FL) can be used as noninvasive markers in children and young people (4-17 years) with active inflammatory bowel disease (IBD).Stool samples were collected from 3 groups of children: those with active IBD, control individuals with other gastrointestinal (GI) diseases (GI control) and control individuals with no GI disease (non-GI control). The number of patients for the FC assay was as follows: IBD = 26, GI control = 30, non-GI control = 25. The number of patients for the FL assay was as follows: IBD = 24, GI control = 26, non-GI = 24. FC and FL were measured by use of enzyme-linked immunoassays.The median concentrations of FC and FL in isolation, and their interaction, were significantly higher in the IBD group than in the GI and non-GI control groups (P0.001). Although the area under the curve, sensitivity, and specificity for FC, FL, and FC x FL interaction were significantly better than chance, FL consistently had the lowest area under the curve, and FC x FL consistently had the highest area under the curve.FC and FL are both significantly elevated in children with IBD, and the interaction of these 2 biomarkers may produce a better initial diagnostic test compared with their use in isolation.

Rectal electrolyte transport was measured in nine children (median age 160 days) with ileostomies, using a nonequilibrium dialysis technique. Rectal sodium absorption and potassium secretion were significantly higher in children with a subnormal sodium balance compared with children with a positive sodium balance. Rectal sodium absorption and potassium secretion were unchanged after ileostomy closure. These data indicate that rectal electrolyte transport in children can adapt to even modestly impaired sodium balance.

Objectives: The natural history of paediatric inflammatory bowel diseases (IBDs) is poorly understood. We aim to describe the disease course in this cohort and generate prognostic information for patients and clinicians. Materials and Methods: Patient records from 6 tertiary paediatric gastroenterology centres were reviewed to generate data concerning original diagnosis, change in diagnosis, family history, surgical interventions, growth, and presence of extragastrointestinal manifestations. Results: Data were collected on 116 children with Crohn disease (CD), 74 with ulcerative colitis (UC), and 20 with indeterminate colitis (IC), followed for a mean period of 3.42, 3.3, and 2.9 years from date of diagnosis, respectively. A male predominance is demonstrated in CD. Revision of diagnosis in patients with IC is mainly to UC, with most children receiving a definitive diagnosis within 2 years of initial presentation. Of the children with UC, 17.6% underwent 1 or more major operations with a median time to surgery of 1.92 years. Of children with CD, 11.6% underwent 1 or more major intraabdominal procedures with a median time to surgery of 1.83 years. We recorded a positive family history in 2.7%, 8.2%, and 10% of cases for CD, UC, and IC, respectively. For both boys and girls with CD, but only for boys with UC, height standard deviation score became more negative over time. Conclusions: This retrospective study quantifies certain distinctions between IBDs diagnosed in paediatric and adult populations. We document a trend toward male predominance in children with CD. We also note impaired linear growth in children with CD, whereas it appears maintained in girls with UC. We also have recorded a low incidence of IBDs in the families of this cohort and suggest that environmental influences may be of greater importance. We document that major intraabdominal surgery may be required in about 15% of patients with either UC or CD within 2 years of diagnosis, and that the majority of those diagnosed initially with IC will be reclassified as either UC or CD within 2 years.

Coeliac disease (CD) is common in children with an estimated prevalence of approximately 1:100. The clinical presentation has altered over the last decade, with most children manifesting non-specific or mild symptoms. The accuracy of serological testing has improved dramatically with targeted assessment of children with conditions known to be associated with CD leading to the detection of asymptomatic cases. The diagnosis of CD still requires upper gastrointestinal endoscopy and small bowel biopsy, and management requires a life-long gluten-free diet to avoid long-term complications.

Introduction The incidence of paediatric inflammatory bowel disease (IBD) has risen significantly across Europe in the last 20 years, although our own data had suggested that this had plateaued by 2004. We have now studied the data from the same area over the last decade and compared them with our previous studies (1983–2003). Methods All cases of IBD Results See Table 1. Between 2004 and 2014, there were 57 new patients compared to 39 (1996–2003) and 28 (1983–1993). The overall incidence of IBD was 5.9 per 100,000 per year, Crohn’s disease (CD) 3.7 per 100,000 per year and Ulcerative colitis (UC) 2.07 per 100,000 per year compared with 5.4 per 100,000 per year for 1996 to 2003. There was no statistically significant difference between the two time periods (p value of 0.675). The median age at diagnosis remains at 12 years with a male to female ratioof 1.7:1. Conclusion The incidence of paediatric IBD in a defined geographical area within our region has remained similar for more than 15 years with a slight increase in the incidence of UC, suggesting that the previous exponential rise in incidence has reached a stable state.

Crohn’s disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) of unknown aetiology and most epidemiologists accept that there has been real increase in incidence of IBD in the developed countries during the last century.1,2 Few studies have looked at the incidence and prevalence of childhood IBD across Europe.3,4 A Scottish study looking at the incidence of IBD (between 1968 and 1983) revealed a more than threefold increase in CD and a marginal fall in UC,5 with a recent report from the same country suggesting a continued rise in the incidence of both juvenile onset CD and UC.6 A study of IBD in the UK carried out in 1999–2000 by the British Paediatric Surveillance Unit (BPSU) suggested an estimated incidence of 5.3 per 100 000 children under the age of 16, equivalent to approximately 700 new cases per annum in the UK and Republic of Ireland, with CD being at least twice as common as UC.7 In a retrospective study from South Wales, UK, the reported incidence of childhood CD increased from 1.3 to 3.11 …

Ulcerative colitis and Crohn disease may present before the age of 20 years in 25% to 30% of all patients with inflammatory bowel disease. Reported incidence figures vary considerably depending on the collection of data. Multicenter, multinational collaboration is needed when studying pediatric inflammatory bowel disease. The essential first step is uniformity in the work-up and criteria used for diagnosis. The Porto diagnostic criteria presented here provide the tool that is needed. These criteria are the result of consensus reached by the ESPGHAN inflammatory bowel disease working group. Diagnosis of Crohn disease, ulcerative colitis and indeterminate colitis is based on clinical signs and symptoms, endoscopy and histology and radiology. Every child suspected of inflammatory bowel disease should undergo a complete diagnostic program consisting of colonoscopy with ileal intubation, upper gastrointestinal endoscopy and (in all cases except in definite ulcerative colitis) radiologic contrast imaging of the small bowel. Multiple biopsies from all segments of the gastrointestinal tract are needed for a complete histologic evaluation. A diagnosis of indeterminate colitis cannot be made unless a full diagnostic program has been performed.

Introduction Cow9s milk protein (CMP) intolerance affects 2–3% of all infants and generally resolves in the first 3 to 4 years of life. A maternal CMP free diet is indicated for those breast feeding. European guidelines state ‘Infants with cow9s milk protein allergy who are not breast fed should receive a dietary product with highly reduced allergenicity based on “extensively” hydrolysed protein or, in selected cases, a product based on an amino acid mixture’.1 Only about 10% of infants with CMPI require an AAF; for example, those with failure of EHF or anaphylaxis. The vast majority of these Hypoallergenic formulae are prescribed for CMPI with only a few cases for intestinal failure. Aim We wished to study prescribing practices for such formulae throughout Wales. Methods. Data on prescribing practices for Hypoallergenic Formulae throughout Wales were obtained from NHS Wales Prescribing Services for 2009 and analysed by the 22 Local Health Board areas. Results There were 26 971 prescriptions for specialty formula in Wales in 2009: lactose-free 7886, soya 5001, and 14 084 hypoallergenic formula-EHF 9442 and AAF 4642. The average percentage for the hypoallergenic formula prescriptions was EHF 67% and AAF 33%. However there was a huge variation between areas with the percentage of prescriptions for EHF ranging from 40–92% and AAF ranging from 8 to 60%. Only 1/22 areas had a prescribing rate for AAF of 10% or less. Conclusion There is an eightfold variation in the prescribing of AAF within Wales which is unlikely to be due to patient variation. European guidelines are not being followed in most areas. This may have considerable clinical and financial implications.

Introduction Preliminary data highlight the importance of appropriate transition for successful transfer of adolescents with IBD from paediatric to adult care. However, the ideal transition service has not been defined. The aim of this study was to identify both the perceived needs of adolescent IBD patients and the barriers to successful transition from the perspective of professionals involved in their care. Methods A postal questionnaire was distributed to UK adult and paediatric gastroenterologists with an interest in IBD. The questionnaire utilised closed questions as well as ranked items on the importance of the various competencies of adolescents with IBD required for successful transition. The data is presented as mean scores±SD for aspects of the competencies. Results The response rate for paediatric and adult gastroenterologists was 53.7% (71/132) and 49.3% (358/729) respectively (p=NS). A structured transition service was perceived as very important by 80.28% paediatric gastroenterologists compared to only 47.55 adult gastroenterologists (p=0.001). The suggested median age for initiation and completion of transition by both groups was 16 and 18 years respectively. A higher proportion of adult than paediatric gastroenterologists identified inadequacies in the preparation of adolescents for transfer 79.1% and 42.2% p=0.001). The main areas identified by adult gastroenterologists were patient lack of knowledge about the condition and treatment (35.4%) and co-ordination of care (40.1%) while paediatric gastroenterologists identified lack of self advocacy (30.9%) and co-ordination (29.5%). Lack of resources, clinical time and a critical mass of patients were the factors ranked highest by both paediatric and adult gastroenterologists as barriers to transition care. A significant proportion of adult (65.2%) and paediatric gastroenterologists (61.9%) highlighted suboptimal training for adult gastroenterologists in the care of adolescents and young adults with chronic diseases. Transition services appear to be more established in teaching hospital settings although there were marked regional differences. Conclusion This survey highlights differences in the perception of adult and paediatric gastroenterologists in the management of transition care for adolescents with IBD. The perceived competencies that patients require also differed between the two groups of healthcare professionals. Lack of training and inadequate resources are the main barriers identified for development of a successful transition service. This survey provides data which may have implications in developing structured transition care services across the country.

Objective To determine the incidence and presenting features of coeliac disease and dermatitis herpetiformis in the population of South Glamorgan between 1981 and 1995. Design Retrospective case-finding study using pathology, dietetic and clinical records, data from hospital activity analysis, general practice records and a Coeliac Society questionnaire. Incidence rates were calculated using the Registrar General's mid-year estimates. Setting Regional hospitals, South Glamorgan, Wales. Participants All new cases of coeliac disease or dermatitis herpetiformis. Main outcome measures Crude incidence rates (per quinquennia) for both children and adults. Age, sex, family history, symptoms at the time of diagnosis and time to diagnosis from symptom onset. Results In total, 137 cases of coeliac disease (27 children, 110 adults) and 19 cases of dermatitis herpetiformis were detected. In adults with coeliac disease, incidence rates have risen from 1.32 to 3.08 per 100 000 with a 3:1 female predominance. Almost 50% of adults were over fifty years old when diagnosed and 25% had no abdominal symptoms. In children, the disease incidence has remained stable but with a rising trend in mean age at diagnosis and higher likelihood of atypical symptoms in older children. There has been no change in the incidence of dermatitis herpetiformis. Only 8.3% of all patients had an affected first-degree relative. Conclusions In contrast to other reports of declining incidence, coeliac disease in children has remained constant in South Glamorgan, but has markedly increased in adults, particularly women. Presentation may be at any age, often with atypical symptoms, which may delay diagnosis.

Background: The technetium white cell scan (WCS) may be a useful investigation for patients with inflammatory bowel disease (IBD). In a retrospective study we assessed the use of the WCS as an initial imaging investigation in evaluating children with suspected IBD. Methods: Over a 3-year period, 60 WCS were performed on 55 patients (25 boys, median age 12.1 years, age range 1.5-18 years) with known or suspected IBD. There were two clinical groups: those with previously diagnosed IBD (histologically and radiologically) and in clinical relapse (13 patients), and newly presenting patients with suspected IBD (42 patients). Results: Eighteen scans were performed on the 13 patients presenting with relapse. Seventeen were positive and one patient, subsequently shown to have an inactive stricture, had a negative scan. Seven of the 42 newly presenting patients had abnormal scans, confirmed to be due to IBD by a combination of histology and barium examinations. Of the remaining 35 scans, three were abnormal and 32 were normal. None of these patients were subsequently proven to have IBD. These results show that in detecting active IBD, a positive WCS has a 100% sensitivity (24/24) and a 91% specificity (32/35) in the diagnosis of IBD. Conclusions: Our results show that the WCS is very useful as an initial imaging investigation in evaluating patients with suspected IBD to select patients for further investigation.

Enteral nutrition is an important mode of treatment for Crohn’s disease in children. Percutaneous endoscopic gastrostomy has been little used, even though it can facilitate the administration of an unpalatable elemental diet to an anorexic, undernourished patient. Its use is reported in 10 children with Crohn’s disease. The gastrostomy was found to be more acceptable than a nasogastric tube and was associated with only minor complications. As a consequence of improved delivery of enteral nutrition, in the year after the insertion of the gastrostomy there was a reduction in prednisolone dosage in all patients, with six patients being able to stop prednisolone completely. The SD score for height also improved significantly. It is suggested that percutaneous endoscopic gastrostomy is both useful and safe in the management of Crohn’s disease in children, particularly when compliance with an elemental diet is likely to be poor. (Arch Dis Child 1997;76:141‐143)

A retrospective study of the incidence and prevalence of paediatric inflammatory bowel disease over an 11 year period was undertaken in South Glamorgan. Over this time the incidence of Crohn's disease more than doubled from 1.30 cases per 100,000 childhood population per year in the period 1983-1988, to 3.11 cases per 100,000 population per year in the period 1989-1993. In contrast, the incidence of ulcerative colitis remained the same throughout the study period at 0.71 per 100,000 per year. In 1993 the prevalence of Crohn's disease in the childhood population was 16.6 per 100,000 and of ulcerative colitis, 3.42 per 100,000.

P126 UK inflammatory bowel disease (IBD) audit: inpatient data from paediatric patients with Crohn’s disease S.G. Mitton1 *, A. Protheroe2, M. Auth3, R.M. Beattie4, C.P. Charlton5, M. Elawad6, J. Fell7, M. Furman8, M. Green9, H. Jenkins10, D. Mitchell11, A. Thomas12, F. Torrente13, I. Arnott14, M. Roughton2, R.K. Russell15. 1St Georges University London, Child Health, London, United Kingdom, 2Royal College of Physicians, Clinical Effectiveness and Evaluation Unit, London, United Kingdom, 3Alder Hey Children’s NHS Foundation Trust, paedaitric gastroenterology, Liverpool, United Kingdom, 4Southampton Children’s Hospital, Paediatric Gastroenterology Unit, Southampton, United Kingdom, 5Nottingham Children’s hospital, Paediatric Gastroenterology, Nottingham, United Kingdom, 6Great Ormand Street hospital, Gastroenterology, London, United Kingdom, 7Chelsea & Westminster hospital, Paediaitric Gastroenterology Unit, London, United Kingdom, 8Royal Free Hospital, Paediaitric Gastroenterology Unit, London, United Kingdom, 9Leicester Royal Infirmary Children’s hospital, Paediatric Gastroenterology, Leicester, United Kingdom, 10University hospital of Wales, Child Health, Cardiff, United Kingdom, 11Sheffiled Childrens hospital, Paediatric Gastroenterology, Sheffield, United Kingdom, 12Royal Manchester Children’s Hospital, Paediaitric Gastroenterology Unit, Manchester, United Kingdom, 13Addenbrooke’s hospital, paed gastroenterology unit, Cambridge, United Kingdom, 14Western General Hospital, Gastroenterology, Edinburgh, United Kingdom, 15Yorkhill Hospital, Department of Paediatric Gastroenterology, Glasgow, United Kingdom

Little objective evidence has been published to support the claim that constipation is an important contributory factor in recurrent urinary tract infection (UTI) in childhood. Using a radiological scoring system, two observers assessed faecal loading from abdominal radiographs of children with proved UTIs. There was a significant increase in the degree of faecal loading in children with UTI when compared with controls (r = 0.237). This difference was mainly accounted for by girls with recurrent (greater than five) UTIs. This study confirms an association between recurrent UTI and faecal loading. Further studies are needed to establish if there is a causal relationship and benefits from treatment.

An infant with unexplained sideroblastic anaemia and severe protracted diarrhoea due to autoimmune gut disease is reported. Despite treatment with an exclusion diet and immunosuppressive agents she developed a severe systemic vasculitic illness. Intensive treatment with plasmapheresis resulted in resolution of the vasculitic process but the child subsequently died after overwhelming septicaemia.

Introduction Increasing numbers of children with coeliac disease (CD) have minor gastrointestinal symptoms (GI) or are diagnosed following screening of asymptomatic children in high risk groups. The diagnosis of CD is changing, and it is suggested that with improved accuracy of blood antibody testing, intestinal biopsy may not always be necessary. Methods We reviewed all patients with CD presenting to a regional centre between 2005-10 and compared the mode of presentation with previous data from the same area (1983-2004). In addition we reviewed the last 100 cases of proven CD to assess the accuracy of antibody testing. Results Median age at diagnosis was 13 years, compared with 8 years 1999-2004. 41% presented with specific GI symptoms, 23% with non-GI features and 36% were diagnosed after screening of high risk groups. Compared with previous studies from the same population, percentage of patients presenting with GI symptoms remained similar (42% v 41%) but patients diagnosed after targeted screening had increased (26% to 36%). Of the last 100 patients with a histological diagnosis of CD, IgA anti-TTG antibody levels (normal 0-10) were >200 in 12%, between 100 and 200 in 22%, between 50 and 100 in 57%, between 30 and 50 in 9%. All patients with a TTG level > 48 showed sub-total villous atrophy on small intestinal histology. Conclusion The frequency and median age at diagnosis of CD has continued to rise. Over 50% of patients presented with few or no symptoms. Current antibody testing appears to be accurate enough in our centre to suggest that histological confirmation may not be necessary to make a diagnosis in all cases.

Background Despite evidence supporting the use of nasogastric fluid rehydration in gastroenteritis, repeat audits in our unit from 1999 to 2002 demonstrated that the intravenous rehydration (IVR) rate was 15–20%. From 2002, nursing and medical staff attended regular teaching sessions including workshops to promote the clinical guidelines. An audit in 2003 demonstrated a reduction of IVR use to 4% and an increase in nasogastric rehydration (NGR) use from 0% to 39%. Aims To establish in 2009, whether the reduction in IVR in 2003 was maintained in the absence of further targeted education. Methods A retrospective audit of a random selection of notes from over one year of children below 5 years of age with gastroenteritis to examine their clinical hydration state and method of rehydration. Results Conclusion The percentage of clinically dehydrated patients remained similar between 2002 and 2009. The reduction in IVR from 1999 to 2003 has been maintained in 2009 without continued targeted education.

A father and son with profound reduction of exocrine pancreatic activity and little visible pancreatic tissue on ultrasound or computed tomography are described. Both have some degree of liver disease, which is more marked in the son. The disorder, apparently familial, does not correspond to any reported previously.

Childhood gastroenteritis remains a common reason for admission to British paediatric units, although the severity of the disease appears to be diminishing in recent years. We studied 215 infants and children with gastroenteritis admitted consecutively to four paediatric units in South Wales in order to determine the severity of the disease, the organisms isolated, the frequency of complications, and the adequacy of management before admission. Stool pathogens were isolated in 125 (58%) patients (viruses in 65, bacteria in 30, and protozoa in 19, with multiple infection found in 11). There was a low incidence of morbidity and complications, but prolonged diarrhoea (postenteritis syndrome) was present in 24 (11%) cases and 77 (36%) had received inappropriate treatment before admission. Contemporary gastroenteritis is thus a relatively mild disease in the acute phase, but management before admission to hospital is often inadequate, and prolonged diarrhoea may be a feature in a considerable number of cases.

Aldosterone is important in the regulation of sodium conservation by both kidney and colon. In the very preterm neonate marked urinary salt wasting occurs because of immature renal tubular function, but little is known of the ontogeny of colonic transport processes. Using an in vivo rectal dialysis technique, we have shown that in the human infant the colon has well developed salt conserving mechanisms from early in the last trimester of gestation and that aldosterone is an important regulatory hormone. Sodium transport mechanisms in the colon appear to develop before those in the kidney and it is possible that the colon is the major organ of sodium conservation in the preterm neonate.

The effect of diet on pancreatic exocrine function, measured by faecal chymotrypsin activity (FCA), was studied longitudinally in three groups of small for gestational age (SGA) infants in the first six months of life. The three groups comprised breastfed infants (group B), those randomly allocated to receive a standard infant formula (group S), or the same formula supplemented with nucleotides (group N). The three groups did not differ in their birthweight or gestational age. Nucleotide supplementation of infant formula improves catchup growth in SGA infants but whether this is due to effects on the gastrointestinal mucosa or the exocrine pancreas is not known. There were no differences in FCA at study entry but by one month group B had significantly lower values than the other groups, and this was maintained at 2, 4, and 6 months. Groups N and S did not differ significantly at any time point. Nucleotide supplementation of infant formula does not influence pancreatic exocrine function and its effect on growth is unlikely, therefore, to be mediated through the pancreas. This study shows that breast feeding is associated with lower FCA which may be related to the lower protein content of human milk. Reliable interpretation of FCA in young infants requires information about their diet. Keywords: chymotrypsin; small for gestational age; nucleotides; breast feeding; formula feed

Coeliac disease is a lifelong intolerance to dietary gluten. Untreated it can result in malabsorption, vitamin deficiencies, anaemia, and osteoporosis. Although histology remains the cornerstone of diagnosis, over the past decade serological testing for coeliac disease has facilitated the earlier recognition of coeliac disease and the detection of milder cases.1 Recent studies have suggested that tissue transglutaminase (TTG) antibodies may be used to detect coeliac disease in children with a genetic risk for it.2 Children at high risk for coeliac disease include those with a family history of coeliac disease, autoimmune thyroid disease, insulin dependent diabetes, Down’s syndrome, and Noonan’s syndrome. Serological prevalence data from a number of studies have indicated that coeliac disease may …