Search

Although the need for effective long-term follow-up for patients with celiac disease (CD) has been recognized by many expert groups, published practice guidelines have not provided a clear approach for the optimal management of these patients. In an attempt to provide a thoughtful and practical approach for managing these patients, a group of experts in pediatric CD performed a critical review of the available literature in 6 categories associated with CD to develop a set of best practices by using evidence-based data and expert opinion. The 6 categories included the following: bone health, hematologic issues, endocrine problems, liver disease, nutritional issues, and testing. Evidence was assessed by using standardized criteria for evaluating the quality of the data, grade of evidence, and strength of conclusions. Over 600 publications were reviewed, and 172 were chosen for inclusion. The thorough review of the results demonstrated that the quality of the data available was often insufficient to provide unequivocal best practices. However, using the available data and the clinical experience of the panel, a practical framework for the management of children with CD was created. These recommendations were developed by our expert panel and do not necessarily reflect the policy of the American Academy of Pediatrics. The potential usefulness of these best practices is underscored by the fact that consensus, measured by the outcome of anonymous voting, was reached by the panel for 24 of the 25 questions. We hope that these best practices may be useful to the pediatric gastroenterology and larger general pediatric communities.

To determine how closely US pediatricians follow the 1985 American Academy of Pediatrics Committee on Nutrition's recommendations on oral therapy for acute diarrhea, a questionnaire was administered to four groups: New England private practitioners, pediatricians from 27 states attending a postgraduate course, representatives of departments of pediatrics at US schools of medicine, and housestaff at Boston Children's and Massachusetts General hospitals. The responses from departments of pediatrics and housestaff were not significantly different from those of community practitioners in most categories. The reported rate of use of glucose-electrolyte solutions recommended by the American Academy of Pediatrics was not different from the use of nonphysiologic, high-osmolar, low-salt solutions such as sodas and juices. The usage rate for glucose-electrolyte solutions meeting the American Academy of Pediatrics-recommended carbohydrate-to-sodium ratio of less than 2:1 was less than 30%. Other findings included the general lack of agreement on the use of a single type of therapy and the common use of oral therapy only for mild or no dehydration. Although the American Academy of Pediatrics recommends that feeding be reintroduced in the first 24 hours of a diarrheal episode, the majority of respondents withhold feeding until the second day or later. These findings indicate that educational programs on oral therapy during acute diarrhea are needed in the United States.

As Dr O'Banion points out, most of the oral therapy solutions available in the United States are classified as maintenance solutions by the American Academy of Pediatrics (AAP). However, as mentioned in the paper, these solutions have proven to be very effective treatment for children with dehydration in this country. Solutions conforming to the AAP recommendations as rehydration solutions are not as widely available in this country. The WHO/UNICEF oral rehydration salts formulation, which is supplied as inexpensive packets throughout the world, is not found easily in the US.

I appreciate the chance to clarify what may be a misconception of Dr Kepfer and also others who had read my recent article. The American Academy of Pediatrics Committee on Nutrition recommends that glucose electrolyte solutions be used for rehydration and maintenance therapy for children with acute diarrhea. One such solution is the oral rehydration salt (ORS) solution recommended by the World Health Organization and the United Nations International Children's Emergency Fund, but this solution is not readily available in the United States, as Dr Kepfer notes. However, as mentioned in the introduction to the paper, a number of successful clinical trials of other similar glucose electrolyte solutions have been reported in the United States.

In Reply.— The findings of Ms Simpson and Drs McIntyre and Ste-Marie are very interesting and raise some intriguing questions. What was the outcome of therapy in these children? Were there differences in outcome related to the therapy used? Their findings also raise the question of whether more optimal therapy would reduce admissions from their Emergency Room or return visits from children sent home. Such data would make an even stronger case for the need to improve case management practices.

Severe retardation of linear growth occurs in a minority of children with Crohn's disease. It appears to be associated with increased disease activity and decreased caloric intake. Why some children are affected and others are not is unknown, but some degree of growth retardation is probably more prevalent than is generally appreciated. The use of somatomedin-C levels may be of some future value in predicting which children will be affected. Growth failure is often difficult to treat and requires vigorous medical and nutritional support. No current treatment is without attendant problems. Proper and frequent assessment of growth and development will help ensure intervention while growth potential still exists in these children. Large cooperative studies are needed to compare the effects of various treatment plans on the growth velocity and ultimate stature of children with Crohn's disease-related growth retardation.