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1.  High-dose infliximab for treatment of pediatric ulcerative colitis: A survey of clinical practice 
AIM: To assess attitudes and trends regarding the use of high-dose infliximab among pediatric gastroenterologists for treatment of pediatric ulcerative colitis (UC).
METHODS: A 19-item survey was distributed to subscribers of the pediatric gastroenterology (PEDSGI) listserv. Responses were submitted anonymously and results compiled in a secure website.
RESULTS: A total of 113 subscribers (88% based in the United States) responded (101 pediatric gastroenterology attendings and 12 pediatric gastroenterology fellows). There were 46% in academic medical institutions and 39% in hospital-based practices. The majority (91%) were treating >10 patients with UC; 13% were treating >100 patients with UC; 91% had prescribed infliximab (IFX) 5 mg/kg for UC; 72% had prescribed IFX 10 mg/kg for UC. Using a 5-point Likert scale, factors that influenced the decision not to increase IFX dosing in patients with UC included: “improvement on initial dose of IFX” (mean: 3.88) and “decision to move to colectomy” (3.69). Lowest mean Likert scores were: “lack of guidelines or literature regarding increased IFX dosing” (1.96) and “insurance authorization or other insurance issues” (2.34). “Insurance authorization or other insurance issues” was identified by 39% as at least somewhat of a factor (Likert score ≥ 3) in their decision not to increase the IFX dose. IFX 10 mg/kg was more commonly used for the treatment of pediatric UC among responders based in the United States (75/100) compared to non-United States responders (6/13, P = 0.047). Induction of remission was reported by 78% of all responders and 81% reported maintenance of remission with IFX 10 mg/kg. One responder reported one death with IFX 10 mg/kg.
CONCLUSION: IFX 10 mg/kg is more commonly used in the United States to treat pediatric UC. Efficacy and safety data are required to avoid insurance barriers for its use.
PMCID: PMC3309912  PMID: 22468086
Immunosuppression; Inflammatory bowel disease; Ulcerative colitis; Children; Pharmacology
2.  Medical students’ conceptualizations of quality of life associated with children who have Inflammatory Bowel Disease 
To investigate second year medical students’ understanding of quality of life associated with childhood inflammatory bowel disease (IBD).
Cross-sectional study in a major teaching institution in San Francisco. A questionnaire was administered following an hour long gastroenterology lecture which featured two young patients with pediatric-onset IBD who addressed everyday life with the disease. Analyses of numerate responses to the questionnaire were paired with a content and thematic analysis of audiotape recordings of the patients’ commentaries.
Medical student responses to the patient interviews were very positive. Medical students gained a new awareness of the psychosocial complexities associated with living with a pediatric chronic illness and a new way of thinking about the meaning of “healthy.” Despite listening to two healthy young patients, however, the medical students still conceptualized pediatric IBD in mostly, although not exclusively, negative terms.
Medical students’ perceptions of pediatric IBD improved as a result of listening to the patient interviews. While this teaching modality effectively introduced students to a complex condition, it did not overcome their unfavorable impression of IBD’s impact on children’s lives. The symptoms associated with IBD have stigma attached to them, and these stereotypes influence how medical students perceive those living with this chronic illness. More research and training in this area is necessary.
PMCID: PMC3788836  PMID: 23752075
Chronic illness; pediatric IBD; quality of life; patient narratives; medical education
3.  Cytokine Profiles in Peripheral Blood of Children and Adults with Crohn’s Disease: A Pilot Study 
Increasing evidence suggests that cytokine dysregulation in T-helper 1 and T-helper 2 (Th1/Th2) subsets contributes to the pathogenesis of Crohn’s disease (CD). This pilot study examines the hypothesis that cytokine profiles differ between pediatric and adult CD patients. Production of Th1 cytokines interferon-gamma (IFN-γ) and tumor necrosis factor-alpha (TNF-α) and of Th2 cytokines interleukin-4 (IL-4) and interleukin-6 (IL-6) were analyzed in peripheral blood of patients with CD and healthy controls (n=20) using flow cytometry after in vitro stimulation. In both pediatric and adult subjects, frequencies of TNF-α CD4+ T cells were higher in CD patients than in controls (p=0.009, p=0.047, respectively). Percentages of cells expressing IL-4 were slightly increased (p=0.036) while those for IFN-γ were decreased (p=0.009) in pediatric CD patients compared with controls. As expected, the overall production of Th1 cytokines was higher in adults compared with pediatric subjects. When memory CD4+CD45RO+ T cells were considered, lower IFN-γ expression was observed in pediatric CD subjects compared with controls (p=0.009), matching the trend seen in the general CD4+ T cell population. The percentage of CD4+CD45RO+ T cells were increased in adult CD patients compared with pediatric CD patients (p=0.016). This study describes a peripheral blood Th1/Th2 cytokine imbalance in CD and suggests different immunological mechanisms between children and adults in disease pathogenesis.
PMCID: PMC3339044  PMID: 22167015
Inflammatory Bowel Disease; Th1/Th2 cytokines; flow cytometry; children; adults
4.  Gastroesophageal Reflux is Not Associated with Dental Erosion in Children 
Gastroenterology  2011;141(5):1605-1611.
Background & Aims
Dental erosion is a complication of gastroesophageal reflux (GER) in adults; in children, it is not clear if GER has a role in dental pathologic conditions. Dietary intake, oral hygiene, high bacterial load, and decreased salivary flow might contribute independently to GER development or dental erosion, but their potential involvement in dental erosion from GER is not understood. We investigated the prevalence of dental erosion among children with and without GER symptoms, and whether salivary flow rate or bacterial load contribute to location-specific dental erosion.
We performed a cross-sectional study of 59 children (ages 9–17 y) with symptoms of GER and 20 asymptomatic children (controls); all completed a questionnaire on dietary exposure. Permanent teeth were examined for erosion into dentin, erosion locations, and affected surfaces. The dentist was not aware of GER status, nor was the gastroenterologist aware of dental status. Stimulated salivary flow was measured and salivary bacterial load was calculated for total bacteria, Streptococcus mutans and Lactobacilli.
Controlling for age, dietary intake, and oral hygiene, there was no association between GER symptoms and dental erosion, by tooth location or affected surface. Salivary flow did not correlate with GER symptoms or erosion. Erosion location and surface were independent of total bacteria and levels of Streptococcus mutans and Lactobacilli.
Location-specific dental erosion is not associated with GER, salivary flow, or bacterial load. Prospective studies are required to determine the pathogenesis of GER-associated dental erosion and the relationship between dental caries to GER and dental erosion.
PMCID: PMC3202657  PMID: 21820389
tooth wear; mechanism; risk assessment; pediatrics
5.  Impact of Gluten-free Camp on Quality of Life of Children and Adolescents with Celiac Disease 
Pediatrics  2010;125(3):e525-e529.
A gluten-free camp allows children with celiac disease (CD) to enjoy a camp experience without concern and preoccupation with foods they eat or the stigma of their underlying disease. The objective of this study was to evaluate the impact of gluten-free camp on quality-of-life indicators for children and adolescents with CD.
Children aged 7 to 17 years with CD were administered a 14-question survey at the beginning and the end of a 7-day gluten-free camp. Surveys used a Likert scale to examine general well-being, emotional outlook, and self-perception for the week before each survey. Differences between the time points were compared. Data were analyzed by paired t test.
Of the 104 campers who attended camp, 77 (21 male) completed the survey at both time points. Most (70%) had been on a glutenfree diet (GFD) for <4 years. All seemed to benefit from camp, no longer feeling different from other kids or feeling frustrated with a restricted diet. A more beneficial impact was found for campers who were on a GFD for <4 years. Overall, campers reported an improvement in 11 of 14 questions, statistically significant (P <.05) for 8 of those 11 questions. Improvement was observed in each of the 3 categories of questions: well-being, self-perception, and emotional outlook.
Children who had CD and attended a week-long glutenfree camp demonstrated improvement in well-being, self-perception, and emotional outlook. The positive effects of camp were more apparent among campers who had been on a GFD for <4 years compared with those who had been on a GFD for ≥4 years, suggesting an adaptation to CD with time. A gluten-free camp that provides an environment of unrestricted foods can at least temporarily alleviate stress and anxiety around food and social interactions. Durability of these observations on return to daily life requires additional study.
PMCID: PMC3334335  PMID: 20156892
pediatric; sprue; quality of life
6.  Body Mass Index and Elbow Range of Motion in a Healthy Pediatric Population: A Possible Mechanism of Overweight in Children 
Childhood overweight has become a serious health problem among children and adolescents in the United States. No previous study, to our knowledge, has analyzed the effect of body mass index (BMI) on range of motion and carrying angle of the elbow joint in a healthy pediatric population. The primary objective of this study was to determine the effect of BMI on orthopedic parameters of the elbow joint, including range of motion, flexion, extension, and carrying angle.
Study Participants and Methods
Healthy children age 2 to 18 years (mean 12.0 ± 3.9 years) were recruited at an urban pediatric orthopedic clinic as pediatric orthopedic patients or as the siblings or friends of patients. Measures of range of motion (flexion and extension) and carrying angle of 226 elbows and of BMI from 113 study participants were analyzed.
BMI was negatively correlated with right and left elbow range of motion (r = −0.54, P <0.01; r = −0.43, P <0.01) and right and left elbow flexion (r = −0.59, P <0.01; r = −0.50, P <0.01). BMI had a positive correlation with right elbow extension (r = 0.20, P = 0.04). BMI did not correlate with left elbow extension or right or left carrying angle. After adjustment for age, sex, and ethnic group, BMI was associated with right (P <0.01) and left (P <0.01) elbow range of motion.
These data demonstrate that increased BMI in children is negatively correlated with range of motion of the elbow joint. Further studies are needed to evaluate the consequences of impaired range of motion associated with overweight on activity levels and energy expenditure in growing children and adolescents.
PMCID: PMC3252045  PMID: 18223380
Pediatric; Body mass index; Orthopedic surgery; Anthropometric; Elbow joint; Range of motion; Childhood overweight; Obesity
8.  Efficacy and Safety of Mesalamine Suppositories for Treatment of Ulcerative Proctitis in Children and Adolescents 
Inflammatory bowel diseases  2010;16(11):1931-1939.
Treatment of ulcerative proctitis has not been well studied in pediatric populations. We conducted an open-label trial to evaluate the clinical efficacy of a mesalamine suppository (500 mg) to treat pediatric patients with mild to moderate ulcerative proctitis.
Pediatric patients (5–17 years of age) with ulcerative proctitis were enrolled for baseline evaluations, including a flexible sigmoidoscopic (or colonoscopic) assessment with biopsies performed at study entry. Eligible patients were started on mesalamine suppositories (500 mg) at bedtime. Two follow-up visits were scheduled after 3 and 6 weeks of treatment. The dose could be increased to 500 mg twice daily at the week 3 follow-up visit if deemed appropriate by the investigator based on the Disease Activity Index (DAI) assessment. The primary outcome measure was a DAI derived from a composite score of stool frequency, urgency of defecation, rectal bleeding, and general well-being.
Forty-nine patients were included in the intent-to-treat analysis. The mean DAI value decreased from 5.5 at baseline to 1.6 and 1.5 at weeks 3 and 6, respectively (P < 0.0001). Only 4 patients had their dose increased to 500 mg twice daily at week 3. Forty-one patients experienced at least one adverse event, most of which were deemed mild and unrelated to study therapy. The most common treatment-emergent adverse events were gastrointestinal (n = 30, 61.2%).
This study showed that a daily bedtime dose of a 500 mg mesalamine suppository is safe and efficacious in children with ulcerative proctitis.
PMCID: PMC3252049  PMID: 20848454
mesalamine; ulcerative proctitis; pediatric patients; colitis; disease activity index; inflammatory bowel disease; colitis
9.  Use of Complementary Medicine in Pediatric Patients With Inflammatory Bowel Disease: Results From a Multicenter Survey 
We examined the use of complementary and alternative medicine (CAM) at 3 US pediatric medical centers, comparing a group of children with inflammatory bowel disease (IBD) with children presenting with chronic constipation.
Materials and Methods
Surveys were administered by postal mail and at pediatric IBD centers in San Francisco, Houston, and Atlanta from 2001 to 2003. A comparison group consisting of pediatric patients with chronic constipation also was surveyed. Data were analyzed by t tests and by exact tests of contingency tables.
In all, 236 surveys were collected from the IBD group; 126 surveys were collected from the chronic constipation comparison group. CAM therapies were used by 50% in the IBD group and 23% in the chronic constipation group. The overall regional breakdown of CAM use in IBD revealed no differences, although the types of CAM therapy used varied by site. The most commonly used CAM therapies in the IBD group were spiritual interventions (25%) and nutritional supplements (25%). Positive predictors for CAM use in IBD include the patient's self-reported overall health, an increase in the number of side effects associated with allopathic medications, white ethnicity, and parental education beyond high school.
This is the first US study to characterize CAM use in pediatric patients with IBD with another chronic gastrointestinal disorder. CAM use was twice as common with the IBD group compared with the chronic constipation group. Regional variations exist with the types of CAM therapy used. Practitioners should know that half of their pediatric patients with IBD may be using CAM in conjunction with or as an alternative to other treatments and that certain predictors can help identify those using CAM therapies.
PMCID: PMC3250599  PMID: 19172124
Complementary and alternative medicine; Constipation; Inflammatory bowel disease; Survey study
10.  Extraintestinal Manifestations of Inflammatory Bowel Disease 
PMCID: PMC3245880  PMID: 18223370
Colitis; Crohn disease; Erythema nodosum; Growth; Pediatric; Sclerosing cholangitis; Thromboses
11.  Postoperative Outcome of Colectomy for Pediatric Patients With Ulcerative Colitis 
Few studies have reported on the surgical outcomes of colectomy in pediatric patients with ulcerative colitis (UC).
Patients and Methods
We conducted a retrospective chart review of all pediatric patients diagnosed with UC who underwent colectomy at UCSF between 1980 and 2005 to identify early (within 30 days) and later complications of surgery.
Complete medical records were available for 31 patients [12.4 ± 3.3 (range 6–19) years] with UC who underwent colectomy at UCSF Children’s Hospital. Total colectomy with ileal pouch anal anastomosis (IPAA) was performed in 21 of the 31 patients (12 without diverting ileostomy). Five of the 31 patients had an initial colectomy with IPAA and J-pouch performed later; 4 had an initial subtotal colectomy for urgent indications. Only one of 31 had IPAA with S-pouch. The median number of early postoperative complications was 1.0; 4 required additional surgery to treat complications. The most common early complications were small intestinal obstruction in 6 (19%) and wound infection in 4 (13%). Preoperative medications included corticosteroids in 25 (81%), 6-mercaptopurine/azathioprine in 10 (32%), and 5-aminosalicylates in 19 (61%). Medication exposure was not related to postoperative complications. Late complications included pouchitis in 12 (39%), anastomotic, anal, or rectal strictures in 5 (16%), and fistulas in 5 (16%); 1 (3%) was subsequently diagnosed as having Crohn disease.
Postcolectomy morbidity is common among pediatric patients with UC. Preoperative medications were not associated with postoperative complications. Investigations to determine preoperative factors affecting surgical outcomes and long-term satisfaction following this surgery in a large pediatric cohort are needed.
PMCID: PMC3119923  PMID: 20410838
adolescents; children; complications; corticosteroids; inflammatory bowel disease; pouchitis; prednisone; surgery
12.  Growth Hormone Treatment of Growth Failure in Pediatric Patients with Crohn’s Disease 
The Journal of pediatrics  2008;153(5):651-658.e3.
We determined the impact of human growth hormone (GH) injections on growth velocity in growth impaired children with Crohn’s Disease (CD).
Study design
Ten children and adolescents (12.6±4.5 years; 6 male) with CD and poor height growth were treated with open label recombinant GH 0.043 mg/kg/day SQ for one year. Patients were retrospectively matched with untreated patients (3 comparisons per case) by race, age, sex, and baseline height. Primary endpoint was height velocity; secondary endpoints were disease activity, body composition, and bone density by DEXA scan.
Mean height velocity in GH-treated patients increased by 5.33±3.40 (mean ± SD) cm/yr during the year of GH compared with 0.96±3.52 cm/yr in the comparison group (p=0.03). Height Z score increased in the treated group by 0.76±0.38 compared with 0.16±0.40 in the comparison group (p<0.01), and weight Z score increased 0.81±0.89 compared with 0.00±0.57 (p<0.01). Bone density revealed an increase of the lumbar spine Z score by 0.31±0.33 (p=0.03 vs baseline).
GH treatment increases height velocity and potentially enhances bone mineralization in children with CD. A randomized controlled trial in a large cohort of children is required to determine the ultimate impact of GH treatment.
PMCID: PMC2590584  PMID: 18589450
DEXA; bone density; height; inflammatory bowel disease; osteoporosis
13.  Pediatric Crohn disease patients exhibit specific ileal transcriptome and microbiome signature 
The Journal of Clinical Investigation  2014;124(8):3617-3633.
Interactions between the host and gut microbial community likely contribute to Crohn disease (CD) pathogenesis; however, direct evidence for these interactions at the onset of disease is lacking. Here, we characterized the global pattern of ileal gene expression and the ileal microbial community in 359 treatment-naive pediatric patients with CD, patients with ulcerative colitis (UC), and control individuals. We identified core gene expression profiles and microbial communities in the affected CD ilea that are preserved in the unaffected ilea of patients with colon-only CD but not present in those with UC or control individuals; therefore, this signature is specific to CD and independent of clinical inflammation. An abnormal increase of antimicrobial dual oxidase (DUOX2) expression was detected in association with an expansion of Proteobacteria in both UC and CD, while expression of lipoprotein APOA1 gene was downregulated and associated with CD-specific alterations in Firmicutes. The increased DUOX2 and decreased APOA1 gene expression signature favored oxidative stress and Th1 polarization and was maximally altered in patients with more severe mucosal injury. A regression model that included APOA1 gene expression and microbial abundance more accurately predicted month 6 steroid-free remission than a model using clinical factors alone. These CD-specific host and microbe profiles identify the ileum as the primary inductive site for all forms of CD and may direct prognostic and therapeutic approaches.
PMCID: PMC4109533  PMID: 25003194
14.  Use of Food Labels, Awareness of Nutritional Programs and Participation in the Special Supplemental Program for Women, Infants and Children (WIC): Results from the National Health and Nutrition Examination Survey (2005-6) 
Maternal & child nutrition  2011;9(3):299-308.
Use of nutritional labels in choosing food is associated with healthier eating habits including lower fat intake. Current public health efforts have focused on the revamping of nutritional labels to make them easier to read and use for the consumer.
To assess the frequency of use of nutritional labels and awareness of the United States Department of Agriculture (USDA) nutritional programs by women eligible and participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as surveyed in the National Health and Nutrition Examination Survey (NHANES) 2005-6 .
Many low-income women do not regularly use the nutrition facts panel information on the food label and less than half had heard of the United States Department of Agriculture’s (USDA) Dietary Guidelines for Americans (38.9%). In multivariate logistic regression, we found that WIC participation was associated with reduced use of the nutrition facts panel in choosing food products (OR 0.45, 95%CI 0.22-0.91), the health claims information (OR 0.54, 95%CI 0.32-0.28) and the information on carbohydrates when deciding to buy a product (OR 0.44, 95%CI 0.20-0.97) in comparison with WIC eligible non-participants.
Any intervention to improve use of nutritional labels and knowledge of the USDA’s nutritional programs needs to target low-income women, including WIC participants. Future studies should evaluate possible reasons for the low use of nutrition labels among WIC participants.
PMCID: PMC4008321  PMID: 22171961
15.  The intestinal microbiome, probiotics and prebiotics in neurogastroenterology 
Gut Microbes  2013;4(1):17-27.
The brain-gut axis allows bidirectional communication between the central nervous system (CNS) and the enteric nervous system (ENS), linking emotional and cognitive centers of the brain with peripheral intestinal functions. Recent experimental work suggests that the gut microbiota have an impact on the brain-gut axis. A group of experts convened by the International Scientific Association for Probiotics and Prebiotics (ISAPP) discussed the role of gut bacteria on brain functions and the implications for probiotic and prebiotic science. The experts reviewed and discussed current available data on the role of gut microbiota on epithelial cell function, gastrointestinal motility, visceral sensitivity, perception and behavior. Data, mostly gathered from animal studies, suggest interactions of gut microbiota not only with the enteric nervous system but also with the central nervous system via neural, neuroendocrine, neuroimmune and humoral links. Microbial colonization impacts mammalian brain development in early life and subsequent adult behavior. These findings provide novel insights for improved understanding of the potential role of gut microbial communities on psychological disorders, most particularly in the field of psychological comorbidities associated with functional bowel disorders like irritable bowel syndrome (IBS) and should present new opportunity for interventions with pro- and prebiotics.
PMCID: PMC3555881  PMID: 23202796
probiotic; prebiotic; neurogastroenterology; immune; human trials; biomarkers; gastrointestinal tract; microbiota; microbiome
16.  Targeted MRI contrast agents for pediatric hepatobiliary disease 
PMCID: PMC3744898  PMID: 22193178
Magnetic resonance imaging; contrast agent; liver and biliary disease
17.  Bimodal Distribution of Risk for Childhood Obesity in Urban Baja California, Mexico 
In Mexico, higher socioeconomic status (SES) has been found to be associated with increased risk for obesity in children. Within developed urban areas, however, there may be increased risk among lower SES children. Students in grades 4–6 from five public schools in Tijuana and Tecate, Mexico, were interviewed and weight, height and waist circumference (WC) measurements were taken. Interviews consisted of questions on food frequency, food insecurity, acculturation, physical activity and lifestyle practices. Multivariate logistic models were used to assess risk factors for obesity (having a body mass index [BMI] ≥95th percentile) and abdominal obesity (a WC >90th percentile) using Stata 11.0. Five hundred and ninety students were enrolled; 43.7% were overweight or obese, and 24.3% were obese and 20.2% had abdominal obesity. Independent risk factors for obesity included watching TV in English (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.06–2.41) and perceived child food insecurity (OR 1.57, 95% CI 1.05–2.36). Decreased risk for obesity was associated with female sex (OR 0.64, 95% CI 0.43–0.96), as was regular multivitamin use (OR 0.63, 95% CI 0.42–0.94). Risk obesity was also decreased with increased taco consumption (≥1×/week; OR 0.64, 95% CI 0.43–0.96). Independent risk factors for abdominal obesity included playing video games ≥1×/week (OR 1.18, 95% CI 1.11–2.96) and older age group (10–11 years, OR 2.47, 95% CI 1.29–4.73 and ≥12 years, OR 2.21, 95% CI 1.09–4.49). Increased consumption of tacos was also associated with decreased risk for abdominal obesity (≥1×/week; OR 0.56, 95% CI 0.40–1.00). We found a bimodal distribution for risk of obesity and abdominal obesity in school aged children on the Mexican border with the United States. Increased risk for obesity and abdominal obesity were associated with factors indicative of lower and higher SES including watching TV in English, increased video game playing and perceived food insecurity. Increased consumption of tacos (≥1×/week) was associated with decreased risk, possibly suggesting an association with children from middle income families. Regular multivitamin use was protective and future studies may focus on micronutrient supplementation as a means to prevent obesity in children or further investigate factors associated with vitamin use. Additionally, future studies need to examine the processes of acculturation on both sides of the US–Mexican border that contribute to increased risk for obesity in children in relation to SES.
PMCID: PMC3535143  PMID: 22669641
Obesity; Mexico; Acculturation; SES
18.  Solitary Rectal Ulcer Syndrome in Children and Adolescents 
To describe the presenting symptoms, endoscopic and histologic findings, and clinical courses of pediatric patients diagnosed with solitary rectal ulcer syndrome (SRUS).
We describe 15 cases of SRUS diagnosed at our institution over a 13-year period. Cases were identified by review of a pathology database and chart review and confirmed by review of biopsies. Data were collected by retrospective chart review.
Presenting symptoms were consistent but non-specific, most commonly including blood in stools, diarrhea alternating with constipation, and abdominal/perianal pain. Fourteen of 15 patients had normal hemoglobin/hematocrit, ESR, and albumin at diagnosis. Endoscopic findings, all limited to the distal rectum, ranged from erythema to ulceration and polypoid lesions. Histology revealed characteristic findings. Stool softeners and mesalamine suppositories improved symptoms, but relapse was common.
SRUS in children presents with non-specific symptoms and endoscopic findings. Clinical suspicion is required, and diagnosis requires histologic confirmation. Response to current treatments is variable.
PMCID: PMC3719860  PMID: 22094902
solitary rectal ulcer syndrome; rectal bleeding; pediatrics; constipation; rectum; prolapse
19.  Maternal sociodemographic characteristics and the use of the Iowa Infant Attitude Feeding Scale to describe breastfeeding initiation and duration in a population of urban, Latina mothers: a prospective cohort study 
The World Health Organization recommends exclusive breastfeeding until 6 months of age. Maternal attitudes toward infant feeding are correlated with chosen feeding method and breastfeeding duration. The Iowa Infant Feeding Attitude Scale (IIFAS) has been used to assess attitudes towards breastfeeding prenatally and is predictive of breastfeeding decisions in certain population groups.
In a cohort of pregnant Latina women recruited from two hospitals in the San Francisco Bay Area (n=185), we administered the IIFAS prior to delivery. Information regarding feeding choice, maternal sociodemographic information, and anthropometrics were collected at 6 months and 1 year postpartum. Analysis of predictors for breastfeeding initiation, breastfeeding at 6 and 12 months and exclusive breastfeeding at 6 months were evaluated using multivariate logistic regression adjusting for potential confounders.
In our cohort of Latina mothers, breastfeeding a previous infant was associated with breastfeeding initiation (OR 8.29 [95% CI 1.00, 68.40] p = 0.05) and breastfeeding at 6 months (OR 18.34 [95% CI 2.01, 167.24] p = 0.01). College education was associated with increased exclusive breastfeeding at 6 months (OR 58.67 [95% CI 4.97, 692.08] p = 0.001) and having other children was associated with reduced breastfeeding at six months (OR 0.08 [95% CI 0.01, 0.70] p = 0.02). A higher IIFAS score was not associated with breastfeeding initiation, breastfeeding at 6 or 12 months or exclusive breastfeeding at 6 months of age.
Initial choices about breastfeeding will likely influence future breastfeeding decisions, so breastfeeding interventions should specifically target new mothers. Mothers with other children also need additional encouragement to maintain breastfeeding until 6 months of age. The IIFAS, while predictive of breastfeeding decisions in other population groups, was not associated with feeding decisions in our population of Latina mothers.
PMCID: PMC3711781  PMID: 23835065
Breastfeeding; Latina; Lower socioeconomic status; Obesity
20.  The Efficacy of the Web-Based Childhood Obesity Prevention Program in Chinese American Adolescents (Web ABC Study) 
To examine the feasibility and efficacy of a theory-driven and family-based program delivered online to promote healthy lifestyles and weights in Chinese American adolescents.
A randomized controlled study of a Web-based intervention was developed and conducted in 54 Chinese American adolescents (ages, 12–15 years) and their families. Data on anthropometry, blood pressure, dietary intake, physical activity, and knowledge and self-efficacy regarding physical activity and nutrition were collected at baseline and 2, 6, and 8 months after the baseline assessment. Data were analyzed using linear mixed modeling.
The intervention resulted in significant declines in waist-to-hip ratio and diastolic blood pressure and increases in vegetable and fruit intake, level of physical activity, and knowledge about physical activity and nutrition.
This Web-based behavior program for Chinese American adolescents and their families appears feasible and effective in the short term. Longer term effects remain to be determined. This type of program can be adapted for other minority ethnic groups who are at high risk for overweight and obesity and have limited access to programs that promote healthy lifestyles.
PMCID: PMC3143380  PMID: 21783046
computer; Internet; overweight prevention; healthy lifestyles; family-based; randomized clinical trial; dietary intake; BMI
21.  Transitioning the Adolescent Inflammatory Bowel Disease Patient: Guidelines for the Adult and Pediatric Gastroenterologist 
Inflammatory bowel diseases  2010;17(10):2169-2173.
Twenty percent of inflammatory bowel disease (IBD) patients present in the pediatric years, with recent reports suggesting a rising incidence in the pediatric age group. This highlights the need for both pediatric and adult gastroenterologists to better understand issues related to the process of transition from pediatric to adult care. Research from other disciplines outside of IBD provide evidence that the transition period can be associated with poorer health outcomes and that a structured transition program may improve patient compliance and disease control. Recent data from the IBD literature support a need for transition clinics. The ideal model of a transition program has not been established. Controlled trials are not available to measure the impact of a structured transition program on clinically relevant endpoints such as disease control and hospital admissions. As local resources and availability of staffing and funding are highly variable, we have summarized some practical guidelines for the adult and pediatric gastroenterologist that can be used as an aid to help adolescents through the transition process even without the support of an established transition clinic.
PMCID: PMC3320668  PMID: 21910179
inflammatory bowel disease; pediatrics; transition process
22.  Adolescent nutritional awareness and use of food labels: Results from the national nutrition health and examination survey 
BMC Pediatrics  2012;12:55.
Awareness of federal nutrition programs and use of the nutrition facts label are associated with reduced risk for obesity and increased intake of fruits and vegetables. Relationships between nutrition programs, use of food labels and risk for overweight and obesity have rarely been evaluated in adolescents.
Using the National Health and Nutrition Examination Survey from 2005–6, we evaluated the frequency of nutrition awareness of USDA and CDC nutrition programs and use of food labels in adolescents. Risk for overweight (BMI ≥ 85-94th percentile) and obesity (BMI ≥ 95th percentile) was assessed in relation to nutrition awareness and label reading.
Most adolescents (92.4%) were aware of the Food Guide Pyramid. Fewer (43.5%) were aware of the 5-A-Day Program, and even less (29.3%) were aware of the Dietary Guidelines for Americans. Less than 25% of adolescents decided which foods to purchase by reading material on the nutrition facts label. There were significant racial and ethnic differences in awareness of federal nutrition programs with Mexican-Americans having the lowest levels of awareness of the US Dietary Guidelines for Americans and the Food Guide Pyramid in comparison with other groups. Non-Hispanic whites had higher and African-American adolescents had lower frequencies of reading fat information on the nutrition label in comparison to Mexican-American and other Hispanics. Awareness of other nutrition programs or of other information on the nutrition facts label was not associated with increased or decreased risk for overweight or obesity.
Use of the nutrition facts panel information is low among US adolescents. Additionally, less than half of adolescents are aware of federal nutrition programs including the Dietary Guidelines for Americans. Future studies should evaluate avenues to make nutrition information more accessible to young Americans.
PMCID: PMC3407473  PMID: 22639924
23.  Inflammatory Bowel Disease in African-American Children Compared to Other Racial/Ethnic Groups in a Multi-Center Registry 
Background and Aims
Few epidemiological investigations characterize inflammatory bowel disease (IBD) in non-Caucasian children. Our study compared IBD characteristics between African-Americans and non-African-Americans enrolled in a multi-center pediatric IBD registry with endoscopic- and pathology-based diagnosis.
The study retrieved data entered from January 2000–October 2003 on children 1 to 17 years old, inclusive, followed by a consortium of academic and community U.S. pediatric gastroenterology practices. Analyses examined racial/ethnic differences by comparing the proportions of African-Americans and non-African-Americans in: each diagnostic disease classification (any IBD, Crohn's disease, ulcerative colitis, indeterminate colitis); age group (<6y, 6–12y or >12y) at diagnosis or symptom onset; presence of extraintestinal manifestations, Z-scores for height and weight, immunomodulatory therapy, anatomic disease location and abnormal hemoglobin, albumin or sedimentation rate at diagnosis.
1,406 patients had complete data, 138 (10%) of whom were African-American. African-Americans more often: were >12y of age at diagnosis (52% vs. 37%, OR 1.82, 95% CI 1.28–2.59) and symptom onset (46% vs. 30%, OR 1.99, 95% CI 1.40–2.84); had Crohn's disease (78% vs. 59%, OR 2.36, 95% CI 1.56–3.58); had low hemoglobin at diagnosis (39% vs. 17%, OR 3.15, 95% CI 1.92–5.17).
IBD in African-American children and adolescents presents more commonly with CD and at older ages compared to non-African-Americans. Racial/ethnic differences in the epidemiology of IBD, particularly CD, among American youths require further investigation.
PMCID: PMC3273485  PMID: 18848910
24.  Common variants at five new loci associated with early-onset inflammatory bowel disease 
Nature Genetics  2009;41(12):1335-1340.
The inflammatory bowel diseases (IBD) Crohn’s disease and ulcerative colitis are common causes of morbidity in children and young adults in the western world. Here we report the results of a genome-wide association study in early-onset IBD involving 3,426 affected individuals and 11,963 genetically matched controls recruited through international collaborations in Europe and North America, thereby extending the results from a previous study of 1,011 individuals with early-onset IBD1. We have identified five new regions associated with early-onset IBD susceptibility, including 16p11 near the cytokine gene IL27 (rs8049439, P = 2.41 × 10−9), 22q12 (rs2412973, P = 1.55 × 10−9), 10q22 (rs1250550, P = 5.63 × 10−9), 2q37 (rs4676410, P = 3.64 × 10−8) and 19q13.11 (rs10500264, P = 4.26 × 10−10). Our scan also detected associations at 23 of 32 loci previously implicated in adult-onset Crohn’s disease and at 8 of 17 loci implicated in adult-onset ulcerative colitis, highlighting the close pathogenetic relationship between early- and adult-onset IBD.
PMCID: PMC3267927  PMID: 19915574
25.  Safety, Efficacy, and Pharmacokinetics of Balsalazide in Pediatric Patients with Mild-to-Moderate Active Ulcerative Colitis: Results of a Randomized, Double-Blind Study 
A multicenter, double-blind study was conducted to evaluate the safety, efficacy and pharmacokinetics of balsalazide in pediatric patients with mild-to-moderate UC.
Sixty-eight patients, 5 to 17 years of age, with mild-to-moderate active UC based on the modified Sutherland UC activity index (MUCAI), were randomized to receive oral balsalazide 2.25 or 6.75 g/day for 8 weeks. The primary endpoint was clinical improvement (reduction of the MUCAI score by ≥3 points from baseline). Clinical remission (MUCAI score of 0 or 1 for stool frequency) and histological improvement after 8 weeks were also assessed. Pharmacokinetic parameters for balsalazide, 5-aminosalicylic acid, and N-acetyl-5-aminosalicylic acid were determined at 2 weeks. Adverse events and laboratory changes were monitored throughout the study.
Clinical improvement was achieved by 45% and 37% of patients and clinical remission by 12% and 9% of patients receiving 6.75 and 2.25 g/day, respectively. Improvement in histologic grade was achieved by 8 of 16 (50%) and 3 of 10 (30%) patients receiving 6.75 and 2.25 g/day, respectively. No significant differences were seen in efficacy. Pharmacokinetics in 12 patients were characterized by large inter-subject variability and low systemic exposure. Adverse events were similar between the treatment groups, the most common being headache and abdominal pain. No clinically significant changes were observed in laboratory values, including those indicative of hepatic or renal toxicity.
Balsalazide is well-tolerated and improves the signs and symptoms of mild-to-moderate active UC in pediatric patients 5 to 17 years of age.
PMCID: PMC3258511  PMID: 19633577
pharmacokinetics; 5-aminosalicylates; Inflammatory Bowel Disease; Ulcerative colitis; children; adolescents

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