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Este artigo de revisão de literatura avalia os efeitos neurobiológicos e psicológicos dos procedimentos estéticos. Foram selecionados vinte estudos científicos relevantes nas bases de dados PubMed e Cochrane. Os resultados indicam que os procedimentos estéticos podem melhorar significativamente a autoestima, satisfação com a aparência e bem-estar psicológico dos pacientes. As mudanças neurobiológicas em áreas do cérebro relacionadas à ansiedade e ao estresse sugerem que os efeitos psicológicos dos procedimentos estéticos podem estar relacionados à mudança na atividade cerebral. No entanto, ainda há lacunas no conhecimento em relação aos mecanismos neurobiológicos subjacentes aos efeitos psicológicos dos procedimentos estéticos. Os procedimentos mais comuns, como botox, preenchimentos e cirurgias plásticas, estão relacionados à melhoria na autoestima e na satisfação com a aparência. A prática ética e responsável na medicina estética é fundamental para garantir a segurança dos pacientes. A revisão de literatura contribui para o avanço do conhecimento científico sobre o tema e destaca a importância de orientar pacientes e profissionais de saúde sobre os efeitos neurobiológicos e psicológicos dos procedimentos estéticos. Conclui-se que os procedimentos estéticos podem ser uma opção válida para melhorar a aparência e o bem-estar psicológico, desde que sejam realizados por profissionais qualificados e éticos. Futuras pesquisas devem focar em investigar os mecanismos neurobiológicos subjacentes aos efeitos psicológicos dos procedimentos estéticos e fornecer orientação mais precisa para pacientes e profissionais de saúde.

Specific partially hydrolysed whey-based infant formulas (pHF-W) have been shown to decrease the risk of atopic dermatitis (AD) in infants. Historically, AD has been associated primarily with milk allergy, however, defective skin barrier function can be a primary cause of AD. We aimed to ascertain whether oral supplementation with pHF-W can improve skin barrier function. The effect of pHF-W was assessed on transepidermal water loss (TEWL) and antibody productions in mice epicutaneously exposed to Aspergillus fumigatus. Human primary keratinocytes were stimulated in vitro, and the expression of genes related to skin barrier function was measured. Supplementation with pHF-W in neonatal mice led to a significant decrease in TEWL and total IgE, but not in allergen-specific antibody levels. The whey hydrolysate was sufficient to decrease both TEWL and total IgE. Aquaporin-3 gene expression, linked with skin hydration, was modulated in the skin of mice and human primary keratinocytes following protein hydrolysate exposure. Skin barrier improvement may be an additional mechanism by which pHF-W may potentially reduce the risk of AD development in infants. Further human studies are warranted to confirm the clinical efficacy of these observations.

Maternal nutritional status during pregnancy and the nutrients to which infants are exposed through breastmilk and complementary foods influence infant immune system development. Micronutrients, including iron, zinc, vitamins A, C, D, and E exert important influences on immune system development during the neonatal period. An expert panel meeting was convened to provide insights on strategies to prevent and mitigate micronutrients deficiencies (MNDs) which impact the developing immune system. This review article provides evidence-based correlation between the role of nutrition and immunity, and provides recommendations on the current and future trends to prevent and treat MNDs in the Indian context.

Background The prevalence of obesity and type 2 diabetes continues to increase. These conditions disproportionately affect minorities and are associated with poor nutrition early in life. Current food-consumption patterns can inform pending dietary guidelines for infants and toddlers. Objective The aim of this study was to describe infant feeding, complementary feeding, and food and beverage consumption patterns of 0- to 23.9-mo-olds in the general population. Methods The Feeding Infants and Toddlers Study 2016 is a cross-sectional survey of caregivers of children aged 400 food groups was calculated. Differences in the percentage consuming between Hispanic, non-Hispanic white, and non-Hispanic black children aged 0–23.9 mo were evaluated with the use of ORs and 95% CIs. Results Eighty-three percent of 0- to 23.9-mo-olds (n = 2635) were ever breastfed, 34% of 0- to 3.9-mo-olds (n = 305) and 15% of 4- to 5.9-mo-olds (n = 295) were exclusively breastfed, and 24% of 12- to 14.9-mo-olds (n = 412) consumed breast milk on the day of the recall. Complementary foods were more likely to be introduced before 4 mo in formula-fed infants (27%) than in infants who did not consume formula (5%). Half of 4- to 5.9-mo-olds consumed iron-fortified infant cereal, but few consumed iron-rich meats. Among toddlers (12–23.9 mo; n = 1133), >20% consumed no servings of fruit or vegetables on the day of the recall, approximately half consumed 100% fruit juice, and one-quarter to one-third consumed a sugar-sweetened beverage (SSB). Conclusions Breastfeeding initiation and duration have improved, but exclusivity remains low. Low consumption of iron-rich foods, fruit, and vegetables and lack of variety in vegetable consumption are problems. Efforts to reduce the consumption of SSBs and 100% fruit juice are warranted in early childhood.

BackgroundIncreasing dietary fiber intake in children may improve overall diet quality. The purpose of this study was to compare nutrient intakes and sources of fiber between young children with low and high fiber intakes utilizing data from the Feeding Infants and Toddlers Study (FITS) 2016.MethodsThe FITS 2016 was a nationwide, cross sectional survey of caregivers designed to assess food and nutrient intakes, feeding behaviors, and dietary patterns among infants and young children living in the U.S. Energy adjusted macro and micronutrient intakes (nutrients/1000 kcals) of children with energy adjusted fiber intakes (g/1000 kcals) in the highest quartile were compared to those in the lowest quartile with paired t-tests. Sources of fiber for each quartile were ranked according to percent of total fiber intake.ResultsChildren with fiber intakes in the highest quartile had significantly lower intakes of total fat (mean difference ranged from 7.4–9.6 g,p p p p p p ConclusionEncouraging intake of fruits, vegetables, legumes, nut butters, and at least 75% of grains as whole grains may help young children improve dietary fiber intake and overall diet quality.

A growing, global conversation, regarding realities and challenges that parents experience today is ever-present. To understand recent parent’s attitudes, beliefs, and perceptions regarding infant feeding, we sought to systematically identify and synthesize original qualitative research findings. Following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework, electronic databases were searched with a priori terms applied to title/abstract fields and limited to studies published in English from 2015 to 2019, inclusive. Study quality assessment was conducted using the Critical Appraisal Skills Programme (CASP) checklist, and thematic analyses performed. Of 73 studies meeting inclusion criteria, four major themes emerged. (1) Breastfeeding is best for an infant; (2) Distinct attitudes, beliefs, and perceptions of mothers that breastfeed, and those that could not or chose not to breastfeed, are evident; (3) Infant feeding behaviors are influenced by the socio-cultural environment of the family, and (4) Parent’s expectations of education and support addressing personal infant feeding choices from health care providers are not always met. This systematic review, guided by constructs within behavioral models and theories, provides updated findings to help inform the development of nutrition education curricula and public policy programs. Results can be applied within scale-up nutrition and behavioral education interventions that support parents during infant feeding.

Background. For infants who are partially or exclusively fed infant formula, many options exist with compositional differences between formulas making choices difficult for caregivers and healthcare professionals. The protein in routine infant formulas differs by the source, fraction of cow’s milk protein used, and degree of hydrolysis. All commercially available regulated infant formulas support growth and development, but different stool patterns have been observed based on formula composition. A pooled analysis of seven clinical trials was conducted to examine growth, stool consistency, and stool frequency of infants fed an intact cow’s milk-based formula (CMF) or a partially hydrolyzed whey formula (PHF-W) from a single manufacturer. Methods. Individual subject data from seven infant formula growth studies (3 CMF, 4 PHF-W) were pooled and analyzed. All studies included healthy, full-term, formula-fed infants enrolled at 14 days of age with outcomes assessed over 4 months. Gains in weight and length to 4 months were analyzed using linear regression accounting for clustering within study. Outcomes of caregiver-reported stool consistency and frequency were analyzed using a longitudinal multinomial model. Results. Data from 511 infants were included (197 CMF, 314 PHF-W). There were no differences in weight gain between groups. There was no difference in length gain in girls fed PHF-W while boys fed PHF-W had a significant difference of +0.016 cm/month compared to boys fed CMF. Infants fed PHF-W had a significantly higher probability of soft and lower probability of hard stools as compared to infants fed CMF at each time point (p Conclusions. Infants fed CMF and PHF-W exhibit appropriate growth with comparable gains in weight and length through 4 months. More soft and fewer hard stools are observed in infants fed PHF-W compared to CMF. This difference could help to inform decision-making when choosing an infant formula.

Background The introduction of starch into an infant's diet is an important milestone in the feeding journey. Intestinal maturity and the presence of digestive enzymes are necessary for the physiologic breakdown of starch and other complementary foods. However, little is known about the consumption patterns of starch containing foods during complementary feeding. Method The 2008 Feeding Infants and Toddlers Study (FITS) is a cross-sectional 24-hour dietary intake survey of a nationally representative sample of infants, toddlers, and preschoolers from birth to 48 months of age. We looked at the age-based prevalence of consumption of starch-containing foods during complementary feeding. Results We found that about 90% of infants were consuming starch by 6 and 8.9 months, with less than half of infants being exposed to complementary foods from multiple food groups under 6 months. The most common food source of starch was iron-fortified infant cereals, followed by vegetables and fruits. Rice and oats were the most prevalent cereal types, while sweet potatoes, peas and squash were the most commonly consumed starch-containing vegetables. Bananas were the leading starch-containing fruit that was consumed. Around 9 and 11 months, the prevalence of iron-fortified cereals declined and were replaced with lower iron-containing ready-to-eat cereals. There was also a drop in the prevalence of fruit and vegetable consumption once the infant became a toddler. Most bread products consumed by toddlers were not whole grain, but their cereal choices were often whole grain. Other sources of starch were mixed dishes, which contained grains like bread or pasta combined with other types of foods. Conclusions Starch enters the infant's diet around the time of complementary feeding, though earlier exposure may occur from certain carbohydrate components of infant formula. Most infants are exposed to starch from grains, followed by vegetables and fruits.

Objective. To assess the prevalence of food allergy in children presenting to a multidisciplinary feeding program. Methods. A retrospective chart review was conducted from 302 patients. We recorded history of food reaction, family history of any atopic disease, radioallergosorbent testing, prematurity, birth weight, breastfeeding history, Z-scores, age, and gastrointestinal mucosal biopsy reports with eosinophilic infiltrate. Three categories of possible food allergy were stratified based on increasing evidence of allergy. Results. Possible food allergy was found for 18% (n = 54), likely food allergy for 6% (n = 18), and very likely food allergy for 16% (n = 47) for a total of 40% classified in a food allergy group. Having been breastfed correlated with likelihood of food allergy but tube-feeding dependence did not. Conclusion. This study revealed a higher proportion of children in a feeding program with food allergy compared to the general population, but larger prospective studies are needed to confirm the association.

The prevalence of allergic conditions (atopic conditions) has been increasing and affects up to a third of the global population. The effects of early nutrition on the development of allergic conditions and its role in their dietary management is well-recognized. The purpose of this chapter is to review the role of early nutrition on specific allergic conditions, focused on atopic dermatitis, the most common allergic disease in infancy, and on emerging evidence related to the role of nutrition in food protein induced enterocolitis syndrome and eosinophilic esophagitis. Implications of nutrition during this early period of growth and development has the potential to impact the quality of life of children and their long-term health.

OBJECTIVES: Infant cereal consumption among 6–11.9 month old infants has declined from 72% in 2002 to 52% in 2016. This is especially concerning for breastfed infants since infant cereal is a top source of iron and other key nutrients. The purpose of this study is to determine how infant cereal consumption impacts nutrient intakes of breastfed infants. METHODS: FITS 2016 is a cross sectional survey of caregivers across the U.S. assessing food and nutrient intakes. A 24 hour dietary recall was administered to caregivers of children aged 0–47.9 months (n = 3235). For this analysis, only infants aged 6–11.9 months who were either breastfed (no infant formula provided, n = 296) or mixed fed (breastmilk and infant formula provided, n = 102) were included. If any amount of infant cereal was consumed, the infant was considered a cereal user. Dietary supplements were excluded to determine usual nutrient intakes from diet only. Infants were categorized as a breastfed cereal user, breastfed non-user, mixed fed cereal user, or mixed fed non-user. The percentage of infants with dietary nutrient intakes below the adequate intake (AI) or estimated average requirement (EAR) were analyzed for significant differences between cereal users and non-users among breastfed and mixed fed infants using paired T-tests. RESULTS: Among breastfed infants, a significantly higher percentage of cereal users had intakes above the EAR or AI level for iron, vitamin C, thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12, calcium, phosphorus, magnesium, vitamin A, zinc, potassium, and choline compared to non-users (See Figure 1). Among mixed fed infants, a significantly higher percentage of cereal users had intakes above the EAR or AI level for iron, magnesium, and choline (See Figure 2). Most infants had inadequate intakes of vitamin D. CONCLUSIONS: Breastfed and mixed fed infants who consume infant cereal are more likely to have adequate intakes of iron, choline, and magnesium than their non-infant cereal consuming counterparts. Among breastfed infants, infant cereal consumers are also more likely to consume adequate amounts of 12 other nutrients compared to non-users. Infant cereal is a source of many key nutrients and is an important complementary food, especially for breastfed infants. FUNDING SOURCES: Nestlé Research Center, Switzerland. SUPPORTING TABLES, IMAGES AND/OR GRAPHS

Human milk oligosaccharides are important components of breast milk. We evaluated feeding tolerance of the human milk oligosaccharide 2′-fucosyllactose (2′FL) in a 100% whey, partially hydrolyzed infant formula with the probiotic Bifidobacterium animalis ssp lactis strain Bb12 ( B lactis; Test) as compared with the same formula without 2′FL (Control) in a randomized controlled trial of healthy infants enrolled at 2 weeks of age (±5 days). After 6 weeks of feeding the assigned formula, the primary outcome of tolerance was assessed using the Infant Gastrointestinal Symptom Questionnaire. Stooling, vomiting, spit-up, crying, and fussing were compared between groups. Seventy-nine infants were enrolled and 63 completed the study per protocol (30 Test, 33 Control). Infant Gastrointestinal Symptom Questionnaire scores were similar between groups (Test 20.9 ± 4.8, Control 20.7 ± 4.3, P = .82). Partially hydrolyzed infant formula with 2′FL and B lactis is tolerated well, as confirmed by a validated multi-symptom index.

A 7 year old male with a history of congenital neutropenia and growth hormone deficiency presented with abdominal pain, fevers, and diarrhea. Imaging and endoscopy revealed significant inflammation of the ascending colon with stenosis at the level of the hepatic flexure. A right hemicolectomy was performed, and pathologic findings were consistent with diffuse intestinal ganglioneuromatosis. Due to recurrent mass effect at the intestinal anastomotic site detected radiologically, a second intestinal resection was performed 7 months later. Genetic testing was negative for mutations in the RET protooncogene, NF1 and PTEN tumor suppressor genes. We report a case of diffuse intestinal ganglioneuromatosis in a child with congenital neutropenia.

Budesonide (BUD) is being used in pediatric Crohn disease (CD) because it is believed to have the potential to reduce corticosteroid-related toxicity; however, few data are available describing its use. The aim of the present study was to describe BUD use in an inception cohort of pediatric patients with CD.Data were derived from the prospective Pediatric IBD Collaborative Research Group Registry established in 2002 in North America. Use of BUD in children with CD was examined.BUD was used in 119 of 932 (13%) of children with newly diagnosed CD, with 56 of 119 (47%) starting BUD ≤ 30 days of diagnosis (26/56 with ileum and/or ascending colon [IAC] disease). BUD was used as monotherapy (9%), in combination with 5-aminosalicylates (77%), or in combination with immunomodulators (43%). Forty-three percent (24/56) went on to receive conventional corticosteroid at some point following their first BUD course. For the 63 of 119 (53%) who started BUD beyond the diagnosis period, 51 of 63 (81%) also received prednisone, with BUD used as a means of weaning from prednisone in 17 of 63 (27%). Patients with IAC disease who received BUD ≤ 30 days of diagnosis were just as likely to have received conventional corticosteroids by 1 year as were those who did not receive BUD ≤ 30 days of diagnosis. Two-thirds (77/119) of patients received BUD for ≤ 6 months.BUD is being used among pediatric patients newly diagnosed as having CD, although the majority does not have disease limited to the IAC. BUD monotherapy was rare, and further data are required to better define the role of BUD in the treatment of pediatric CD.

Background: Antitumor necrosis factor alpha (aTNF) therapies are commonly used in the treatment of pediatric inflammatory bowel disease (IBD). However, inhibition of the TNF-alpha pathway predisposes to serious infections, including histoplasmosis, which is the most common invasive fungal infection in individuals on aTNF therapy and carries a high mortality rate when associated with delayed diagnosis. Few data exist on the frequency, presentation, and appropriate treatment of pediatric patients with histoplasmosis on aTNF therapy. Methods: Following Institutional Review Board approval, cases were identified then reviewed with their primary gastroenterologist and infectious disease specialists. Results: Herein we describe histoplasmosis in five pediatric patients receiving aTNF therapy for IBD in an endemic area. Conclusions: Histoplasmosis is an important complication of treatment with TNF-alpha neutralizing agents. Children with IBD treated with aTNF therapy who develop the infection may present with minimal pulmonary symptoms. While discontinuation of aTNF therapy is important initially, few data exist to determine when and how aTNF therapy can be reinstituted. Recognition of Histoplasma capsulatum is often delayed due to the overlap of symptoms with some of the extraintestinal manifestations of IBD and other more prevalent infectious complications. (Inflamm Bowel Dis 2011;)

Background: We evaluated the psychometric performance of the Pediatric Ulcerative Colitis Activity Index (PUCAI) in a real-life cohort from the Pediatric IBD Collaborative Research Group. Methods: Two consecutive visits of 215 children with ulcerative colitis (UC) were included (mean age 11.2 ± 3.6 years; 112 (52%) males; 63 (29%) newly diagnosed and the others after disease duration of 24 ± 15.6 months). Validity was assessed using several constructs of disease activity. Distributional and anchor-based strategies were used to assess the responsiveness of the PUCAI to change over time following treatment. Results: Reflecting feasibility, 97.6% of 770 eligible registry visits had a completed PUCAI score versus only 47.6% for a contemporaneously collected Pediatric Crohn's Disease Activity Index (odds ratio = 45.8, 95% confidence interval [CI] 28.6–73.5) obtained for children with Crohn's disease accessioned into the same database. The PUCAI score was significantly higher in patients requiring escalation of medical therapy (45 points [interquartile range, IQR, 30–60]) versus those who did not, (0 points [IQR 0–10]; P < 0.001), and was highly correlated with physician's global assessment of disease activity (r = 0.9, P < 0.001). The best cutoff to differentiate remission from active disease was 10 points (area under receiver operating characteristic curve [AUC] 0.94; 95% CI 0.90–0.97). Test–retest reliability was excellent (intraclass correlation coefficient = 0.89; 95% CI 0.84–0.92, P < 0.001) as well as responsiveness to change (AUC 0.96 [0.92–0.99]; standardized response mean 2.66). Conclusion: This study on real-life, prospectively obtained data confirms that the PUCAI is highly feasible by virtue of the noninvasiveness, valid, and responsive index. The PUCAI can be used as a primary outcome measure to reflect disease activity in pediatric UC. (Inflamm Bowel Dis 2009)

We analyzed growth outcomes in children newly diagnosed with Crohn disease and determined whether growth abnormalities persist despite current therapies.Clinical and growth data were prospectively obtained on an inception cohort younger than 16 years old at diagnosis and Tanner I to III during the study.In all, 176 children (mean age 10.1 years; 65% male) with mild (33%) or moderate/severe (67%) disease at diagnosis were studied. Disease activity at 1 year was inactive/mild (89%) or moderate/severe (11%). First-year treatments included immunomodulators (60%), corticosteroids (77%), 5-aminosalicylates (61%), infliximab (15%), and enteral nutrition (10%). By 2 years, 86% had received immunomodulators and 36% infliximab. Mean height z scores at diagnosis, 1 year, and 2 years were -0.49 +/- 1.2 standard deviations (SDs), -0.50 +/- 1.2, and -0.46 +/- 1.1, respectively. Of the subjects, 10%, 8%, and 6.5% had height z scores less than -2 SD at diagnosis, 1 year, and 2 years. A height velocity z score less than -1SD was seen in 45% of subjects at 1 year and 38% at 2 years. The mean height velocity z score, however, increased between 1 and 2 years from -0.71 to 0.26 (P0.03). Corticosteroid use greater than 6 months in the first year was associated with abnormal height velocity at 1 year (adjusted odds ratio = 4.5; 95% confidence interval [CI] = 2.2-9.6). No statistically significant effect on height velocity z scores was noted when comparing those receiving or not receiving infliximab.Growth delay persists in many children with CD following diagnosis, despite improved disease activity and the frequent use of immunomodulators and biologics. Additional strategies to improve growth outcomes require development.

Upwards of 100,000 children and adolescents are affected by inflammatory bowel disease (IBD) in the United States, and the incidence of IBD appears to be increasing worldwide. Although the diagnosis and differentiation of Crohn's disease or ulcerative colitis is still based on clinical, radiographic, endoscopic, and histological findings, newer less invasive serological tests are being employed to help distinguish these disorders and provide prognostic information to possibly guide therapy. Videocapsule endoscopy has increased our ability to detect previously unrecognized small bowel inflammation in selected patients. Whereas initial therapy has historically included aminosalicylates and corticosteroids, recent data suggest the limited efficacy of aminosalicylates in Crohn's disease and the high likelihood or corticosteroid dependence in patients with either Crohn's disease or ulcerative colitis. The early use of immunomodulators has become standard-of-care in both disorders and has decreased corticosteroid dependence. The advent of biologic therapy, primarily with infliximab, has dramatically improved short-term outcomes in both Crohn's disease and ulcerative colitis. Longer-term data on whether infliximab changes the natural history of these disorders (eg, requirement for surgery) awaits further study. As more aggressive therapy is being increasingly employed, rare complications such as lymphoma or opportunistic infection have developed.

Iron deficiency (ID) affects 13.5% of 1–2 years old children in the US and may have a negative impact on neurodevelopment and behavior. Iron-fortified infant cereal is the primary non-heme iron source among infants aged 6–11.9 months. The objective of this study was to compare iron intakes of infant cereal users with non-users. Data from the Feeding Infants and Toddlers Study 2008 were used for this analysis. Based on a 24-h recall, children between the ages of 4–17.9 months were classified as ‘cereal users’ if they consumed any amount or type of infant cereal and ‘non-users’ if they did not. Infant cereal was the top source of dietary iron among infants aged 6–11.9 months. The majority of infants (74.6%) aged 6–8.9 months consumed infant cereal, but this declined to 51.5% between 9–11.9 months and 14.8% among 12–17.9 months old toddlers. Infant cereal users consumed significantly more iron than non-users across all age groups. Infants and toddlers who consume infant cereal have higher iron intakes compared to non-users. Given the high prevalence of ID, the appropriate use of infant cereals in a balanced diet should be encouraged to reduce the incidence of ID and ID anemia.

BACKGROUND Methotrexate (MTX) use as an alternative to thiopurines in the treatment of Crohn's disease (CD) in children is increasing. This study was undertaken to assess safety and efficacy of MTX in children with CD. METHODS Patients treated with MTX with a minimum of 1-year follow-up were identified in the Pediatric IBD Collaborative Research Group Registry, a prospective inception cohort study started in 2002. The clinical efficacy and safety of MTX were analyzed retrospectively. RESULTS Two hundred ninety patients treated with MTX were identified. One hundred seventy-two patients received at least 3 months of MTX without thiopurine or biologicals and had ≥1 year of follow-up. Eighty-one of 172 patients (47%) received MTX as first immunomodulator (IMM), of which 22 (27%) achieved ≥12 months of sustained clinical remission without surgery, thiopurine, biologicals, or corticosteroids. Those receiving MTX as second IMM achieved similar remission rate (35%, P = not significant). Fourteen percent received MTX as first IMM in 2002 and 60% in 2010 (P = 0.005). Disease location did not affect outcomes. MTX doses were equivalent in both groups. Fifteen percent of patients developed an alanine aminotransferase >60 international units/liter and 12% developed a white blood cell

Inflammatory bowel disease-associated liver diseases (IBD-LDs) include autoimmune hepatitis (AIH), primary sclerosing cholangitis (PSC), and an overlap syndrome. Prospective unbiased multicenter data regarding the frequency of IBD-LD in patients with pediatric inflammatory bowel disease (IBD) are lacking. We examined early alanine aminotransferase (ALT) and γ-glutamyl transpeptidase (GGT) elevations in children diagnosed as having IBD and assessed the likelihood of IBD-LD.Data collected from the prospective observational Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry enrolling children of age16 years within 30 days of diagnosis. AIH, PSC, and overlap syndrome were diagnosed using local institutional criteria.A total of 1569 subjects had liver enzymes available. Of the total, 757 had both ALT and GGT, 800 had ALT only (no GGT), and 12 had GGT only (no ALT). Overall, 29 of 1569 patients (1.8%) had IBD-LD. IBD-LD was diagnosed in 1 of 661 (0.15%) of patients with both ALT and GGT ≤ 50 IU/L compared with 21 of 42 (50%) of patients with both ALT and GGT 50 (odds ratio 660, P 0.0001). Of the 29 patients with IBD-LD, 21 had PSC, 2 had AIH, and 6 had overlap syndrome. IBD-LD was more common in patients with ulcerative colitis and IBD-unclassified (indeterminate colitis) than in those with Crohn disease (4% vs 0.8%, respectively, P 0.001).Elevation of both ALT and GGT within 90 days after the diagnosis of IBD is associated with a markedly increased likelihood of IBD-LD. Both ALT and GGT levels should be measured in all of the pediatric patients newly diagnosed as having IBD.

Varying degrees of gut dysmotility accompany the musculoskeletal disabilities of most children with neurodevelopmental delay. The majority of children with cerebral palsy, the most extensively studied

Despite a paucity of published supporting data, 5-aminosalicylate (5-ASA) use in pediatric ulcerative colitis (UC) is common. The present study describes the use and outcome of a large multicenter inception cohort of children with UC treated with 5-ASA.Data were obtained from the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry, a prospective North American observational study of children newly diagnosed as having inflammatory bowel disease ages 16 years or younger. Patient data are recorded at diagnosis, 30 days, and then quarterly. Patients are managed by physician dictate, not protocol. Disease activity is classified by physician global assessment. The primary outcome examined was corticosteroid (CS) free, inactive UC at 1 year following initiation of 5-ASA within 30 days of diagnosis (with or without concomitant CS use) without the need for rescue therapy (immunomodulators, biologics, or colectomy).Study subjects included 213 patients newly diagnosed as having UC who received oral 5-ASA compounds (115 of whom also received CS) during the first 30 days after diagnosis, and no other oral therapies for the treatment of UC. Of these 213 patients, 86 (40%) were CS free and physician global assessment inactive at 1 year without rescue. Outcome was not associated with disease severity at diagnosis, demographic or laboratory factors examined, or initial dose of 5-ASA used.Forty percent of children taking 5-ASA as primary maintenance therapy at diagnosis are in CS-free remission after 1 year of treatment. Further pediatric studies will be needed to address whether increased adherence and/or higher dosing schedules will improve outcomes.

Although it is known that extraintestinal manifestations (EIMs) commonly occur in pediatric inflammatory bowel disease (IBD), little research has examined rates of EIMs and their relation to other disease-related factors in this population. The purpose of this study was to determine the rates of EIMs in pediatric IBD and examine correlations with age, sex, diagnosis, disease severity, and distribution.Data were prospectively collected as part of the Pediatric IBD Collaborative Research Group Registry, an observational database enrolling newly diagnosed IBD patients16 years old since 2002. Rates of EIM (occurring anytime during the period of enrollment) and the aforementioned variables (at baseline) were examined. Patients with indeterminate colitis were excluded from the analysis given the relatively small number of patients.One thousand nine patients were enrolled (mean age 11.6 +/- 3.1 years, 57.5% boys, mean follow-up 26.2 +/- 18.2 months). Two hundred eighty-five (28.2%) patients experienced 1 or more EIMs. Eighty-seven percent of EIM occurred within the first year. Increased disease severity at baseline (mild vs moderate/severe) was associated with the occurrence of any EIM (P0.001), arthralgia (P = 0.024), aphthous stomatitis (P = 0.001), and erythema nodosum (P = 0.009) for both Crohn disease (CD) and ulcerative colitis (UC) during the period of follow-up. Statistically significant differences in the rates of EIMs between CD and UC were seen for aphthous stomatitis, erythema nodosum, and sclerosing cholangitis.EIMs as defined in this study occur in approximately one quarter of pediatric patients with IBD. Disease type and disease severity were commonly associated with the occurrence of EIMs.

Infliximab is effective in treating moderate/severe ulcerative colitis (UC) in adults. The aim of this study was to determine the outcome after treatment with infliximab in pediatric UC.We performed a multicenter cohort study of 332 pediatric patients with UC enrolled in the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry. Childrenor=16 years of age and newly diagnosed with UC are enrolled in the registry. Disease and medication information are collected prospectively from the treating physician at diagnosis, 30 days, and quarterly thereafter. No interventions were specified, per protocol.Of 332 patients, 52 (16%) received infliximab (23%3 months from diagnosis, 38% 3-12 months, 38%12 months). Mean age at infliximab initiation was 13.3+/-2.6 (range 6-17) years; 87% of patients had pancolitis. Median follow-up was 30 months. Continuous maintenance (CM) therapy was given in 65%, episodic in 21%, episodic converted to CM in 6%, and insufficient data in 8% of patients. Sixty-three percent of patients were corticosteroid refractory, and 35% were corticosteroid dependent. Concomitant medications at first infliximab infusion included corticosteroids (87%), thiopurines (63%), and 5-aminosalicylates (51%). Corticosteroid-free inactive disease by physician global assessment was noted in 12/44 (27%), 15/39 (38%), and 6/28 (21%) patients at 6, 12, and 24 months, respectively. Kaplan-Meier analysis showed that the likelihood of remaining colectomy free after treatment with infliximab was 75% at 6 months, 72% at 12 months, and 61% at 2 years.In this cohort of children with UC receiving infliximab, corticosteroid-free inactive disease was observed in 38 and 21% of patients at 12 and 24 months, respectively. By 24 months, 61% of patients had avoided colectomy.

Adalimumab, an anti-tumor necrosis factor immunoglobulin-1 antibody, is increasingly being reported as a potential treatment option for children with moderate-to-severe Crohn's disease (CD). The aim of this study was to characterize common indications, safety, tolerability, and clinical response to adalimumab in pediatric CD in a large, multicenter, patient cohort.Data were obtained using a retrospective, uncontrolled chart review at 12 sites of the Pediatric Inflammatory Bowel Disease Collaborative Research Group. Clinical, laboratory, and demographic data were obtained for CD patients who received at least one dose of adalimumab. Indication for adalimumab, concomitant medications, and clinical outcome at 3, 6, and 12 months for each patient were recorded using physician global assessment (PGA) and Pediatric CD Activity Index scores. Serious adverse events were identified.A total of 115 patients (54% female) received at least one dose of adalimumab. The mean age at the diagnosis of CD was 11.1+/-3.1 years, with the first adalimumab dose administered at 4.7+/-2.8 years after diagnosis. The most common dosing frequency was every other week with induction doses of 160/80 mg in 19%, 80/40 mg in 44%, and 40/40 mg in 15% of patients. Maintenance dosing was 40 mg every other week in 88% of patients. Mean follow-up after initial adalimumab dose was 10+/-8.6 months. Infliximab treatment preceded adalimumab in 95% of patients, with a mean of 12 infliximab infusions (range: 1-44). Infliximab discontinuation was due to loss of response (47%), infusion reaction or infliximab intolerance (45%), or preference for a subcutaneous medication (9%). Concomitant medications at the commencement of adalimumab were corticosteroids (38%), azathioprine/6-mercaptopurine (41%), and methotrexate (23%). Clinical response measured by PGA at 3, 6, and 12 months was 65, 71, and 70%, respectively, with steroid-free remission at 3, 6, and 12 months of 22, 33, and 42%, respectively. There were no malignancies, serious infections, or deaths in the study subjects.Adalimumab was a well-tolerated and effective rescue therapy for moderate-to-severe pediatric CD patients previously treated with infliximab. Adalimumab demonstrated a steroid-sparing effect, and70% of patients achieved rapid response that was sustained through 12 months.

Background: Infliximab therapy has short-term benefits in children with moderate-to-severe Crohn's disease (CD). We assessed the long-term outcome of infliximab maintenance therapy in children with CD. Methods: We performed a multicenter cohort study of 729 pediatric patients with CD enrolled in the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry. Children younger than 16 years and newly diagnosed with CD were eligible for this study. Disease and medication information were collected prospectively from the treating physician at diagnosis, 30 days, and quarterly thereafter. No interventions were specified, per protocol. Results: In all, 202 of 729 patients received infliximab: 62%, 23%, and 15% within 1, 1–2, and >2 years of diagnosis, respectively. The mean age at infliximab initiation was 12.7 years. A total of 158 infliximab-treated patients received maintenance therapy, 29 episodic (8 converted to maintenance), and 15 had incomplete follow-up. Among 128 patients administered maintenance infliximab and followed for ≥1 year, concomitant medications at infliximab initiation included corticosteroids (52%) and immunomodulators (90%). By 1, 2, and 3 years

Background: We sought to characterize perianal disease and its treatment in pediatric patients newly diagnosed with Crohn's disease. Methods: Data were obtained from the Pediatric Inflammatory Bowel Disease (IBD) Collaborative Group Registry, a prospective, multicenter observational registry recording clinical and laboratory outcomes in children under 16 years of age newly diagnosed with IBD. Patients with Crohn's disease were selected who had data on perianal disease and at least 24 months of follow-up. The records of patients with a Pediatric Crohn's Disease Activity Index perianal subscore greater than 0 were reviewed, and patients with abscesses or fistulas were selected. The therapies used and the course of their perianal disease were then assessed. Results: Of the 276 patients identified, 41 had perianal lesions within 30 days of diagnosis. Thirteen of these had skin tags and fissures only, whereas 28 had fistulas and/or abscesses. The latter lesions resolved by 1 year in 20 patients, and 8 had chronic/recurrent perianal disease persisting for more than 1 year following diagnosis. Patients with fistulizing disease were much more likely to be treated and were treated earlier with antibiotics, infliximab, and immunomodulators than were nonfistulizing patients. Patients who developed chronic perianal disease were more likely to have low body mass indices and required more perianal surgery than did patients whose perianal disease resolved. Conclusions: Approximately 10% of newly diagnosed pediatric patients with Crohn's disease will have perianal fistulas and/or abscesses at the time of diagnosis. Most of these will resolve within a year with medical therapy alone. (Inflamm Bowel Dis 2008)

e s t c E a g p o e i t a e l b T a t t s P ediatric gastroenterology and nutrition continues to be a dynamic subspecialty. Ongoing research, at the bench and bedside, has led to evolutionary changes in both the diagnosis and the herapeutics of many gastrointestinal (GI) disorders. rom the development of hydrolyzed and elemental ormulas to the introduction of probiotics into infant ormulas, the science of clinical nutrition continues to volve. This review provides the primary care physician an pdate on common GI conditions and their treatment aradigms in this millennium, focusing on advances in he last decade or two.

Background In conjunction with the rising prevalence of obesity during the past several decades, the clinical profile of the obese child has changed. Hypothesis. Environmental influences and eating practices have had an impact on the presence of medical morbidities among obese children.Design Retrospective chart review of data collected from 90 children entering into a pediatric weight management program was performed. Fisher's exact tests and Wilcoxon rank sum tests were used to compare outcomes between subpopulations.Results There was greater elevation in systolic blood pressure among children who ate in front of the television ( P = .03) and a greater degree of fast-food consumption among children with more than 3 medical morbidities ( P = .02). Breast-feeding did not have a protective effect on the degree of obesity ( P = .02).Conclusion Aggressive assessment for symptoms should be an important part of evaluating the overweight child. Environmental influences and social feeding practices can counteract the protective effects of breast-feeding in infancy.

Objective To evaluate the presentation, therapeutic management, and long-term outcome of children with very early-onset (VEO) (≤5 years of age) inflammatory bowel disease (IBD). Study design Data were obtained from an inception cohort of 1928 children with IBD enrolled in a prospective observational registry at multiple centers in North America. Results One hundred twelve children were ≤5 years of age with no child enrolled at P = .04), and 11- to 16-year-olds (22.3%, P P = .01). Five years postdiagnosis, there was no difference in disease activity among the 3 groups. However, compared with the oldest group, a greater proportion of 1- to 5-year-olds with CD were receiving corticosteroids ( P P P P Conclusions Children with VEO-CD are more likely to have mild disease at diagnosis and present with a colonic phenotype with change to an ileocolonic phenotype noted at 6-10 years of age. Five years after diagnosis, children with VEO-CD and VEO-UC are more likely to have been administered corticosteroids and immunomodulators despite similar disease activity in all age groups. This may suggest development of a more aggressive disease phenotype over time.