Probiotics in preterm infants, ambulatory ASUC and coeliac disease in Sudanese children

In the 2nd blog of 2022, we take a look at a trio of recently published articles in BMJOG covering a wide range of luminal gastroenterology. In our first article we look at the evidence for modulation of the luminal microbiome of the preterm infant using single and multiple strains of probiotics. Secondly we discuss the potentially controversial paper on management of acute severe colitis in an ambulatory setting (certainly has triggered some Twitter discussions….), before finally looking at the application of diagnostic tests for coeliac disease in a less studied population (children with type 1 diabetes in Sudan). These articles also allow us to highlight some of the excellent publications and guidelines related to these topics, notably the BSG guidelines on management of ASUC (with COVID-19 modifications), the ESPGHAN guidelines on diagnosis of coeliac disease in children and the use of probiotics in preterm infants (ESPGHAN joint position paper).

Athalye-Jape at al discuss their trial on multistrain probiotics versus single-strain probiotics in extremely preterm infants. Infants born under 28 weeks gestational age were randomised to a three-strain or single strain probiotic, a reference group of placebo was also included from a previous study. Primary outcome was time to full feed, with secondary outcomes looking at microbiome and SCFA composition in the stool at two timepoints. A total of 173 infants were randomised. Median time to full feeds was comparable (11 (IQR 8–16) vs 10 (IQR 8–16) days, p=0.92). Faecal propionate and butyrate levels were significantly raised at the second time point of sampling, compared to baseline. All considered clinical outcomes were comparable between groups. Overall, both probiotic groups were effective in reducing dysbiosis (increased bifidobacteria and reducedgammaproteobacteria), compared to placebo. This study highlights the need for consensus and evidence on the use of probiotics in preterm infants, something where controversy has been close to the surface for some time. Further evidence and reading can be found in the ESPGHAN position statement, which highlights the low quality evidence available to make firm recommendations.

In their publication on the potential of ambulatory management of ASUC Sebastian et al report on the data from PROTECT (an observations COVID-19 IBD study), including 764 patients. Conventional management of ASUC would be as an inpatient, often with intravenous therapy (corticosteroid, anti-TNF etc.). In their report only 37% of sites used a potential ambulatory pathway for ASUC, 2% of all patients were managed as ambulatory from diagnosis, with a further 54 patients managed discharged to an ambulatory pathway. The remaining patients were managed conventionally as inpatients. Interestingly colectomy rates were comparable for all three groups- conventional 15.0% (104/695) vs initially ambulatory 13.3% (2/15) vs discharged to ambulatory 13.0% (7/54), respectively, p=0.96. Importantly 40% of patients who were initially managed as ambulatory from diagnosis. This study is not without controversy and highlights an emerging UK ambulatory practice which challenges conventional treatment strategies. However, this should not be interpreted as high quality evidence on safety and further prospective studies are needed. It may be that for selected patients, ambulatory management of ASUC can occur as an outpatient, but for most this, inpatient therapy will remain mandated. BSG guidelines on management of ASUC can be found in a comprehensive publication in Gut, included within the consensus guidelines for management of IBD in adults, alongside adaptations made during the COVID-19 pandemic.

Finally, Ibaid et al report on their experience of determining the prevalence of coeliac disease in Sudanese patients with type 1 diabetes mellitus. The authors measured IgA tTG in 373 children with diabetes and 100 children without diabetes. HLA DQ2/DQ8 haplotype was assessed through targeted PCR. Nearly 7% of the children with diabetes, screened for coeliac disease were tTG positive and 76% of those were confirmed on histology. HLA DQ2/DQ8 was positive in 96% of those with coeliac disease and diabetes. The authors conclude that serological screening for coeliac disease in those with diabetes is of utility in the absence of histological examination, with a tTG >10x the upper limit of normal providing accurate diagnosis. HLA DQ2/DQ8 screening was largely pointless given the high prevalence of this haplotype in patients with diabetes. This study nicely highlights the utility of 2020 ESPGHAN guidelines in making serological diagnosis of coeliac disease in specific situations. There is now a possibility that these guidelines will leak into adult practice, although they have not yet been formally adopted.

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