Kinetics of hepatitis B surface antigen in pregnant women with and without tenofovir disoproxil fumarate.

Tenofovir disoproxil fumarate (TDF) is the preferred treatment to prevent mother-to-infant transmission in highly viremic HBV-infected women. Data on hepatitis B surface antigen (HBsAg) levels in pregnant women are lacking. We aimed to investigate prepartum and postpartum HBsAg kinetics and its correlation with HBV DNA in pregnant women. HBV-infected mothers with HBV DNA ≥7.5 log10  IU/ml were tested for HBsAg and HBV DNA from baseline to 6 months postpartum. Of the 186 pregnant women with comparable baseline HBsAg and HBV DNA, 101 received TDF from the third trimester until 1 month postpartum. At delivery, TDF group had mildly lower HBsAg (4.32 ± 0.47 vs. 4.54 ± 0.35 log10  IU/ml, p = .0004) and markedly lower HBV DNA (4.26 ± 0.97 vs. 8.11 ± 0.70 log10  IU/ml, p < .0001) than the control group. In the TDF group, mean reduction of HBsAg and HBV DNA from baseline to delivery were 0.22 ± 0.38 and 3.96 ± 0.93 log10  IU/ml. HBsAg reduction had a positive correlation (r = .309; p = .0017) with HBV DNA reduction, and was predictive of HBV DNA reduction ≥3 log10  IU/ml (area under the receiver operating characteristic curve, 0.67; 95% confidence interval, 0.50-0.82). At 6 months postpartum, TDF and control group had comparable HBsAg and HBV DNA. In conclusion, HBsAg decreased slightly at delivery in pregnant women receiving TDF. For monitoring the effect of antiviral therapy during pregnancy, HBV DNA is a better marker than HBsAg. Our data provided valuable information regarding monitoring HBV-infected pregnant women using antiviral therapy.

A Rare Case of Malrotation and Midgut Volvulus with Whirlpool Sign.

We report a rare case of midgut malrotation and volvulus with "whirlpool sign" in a new-born infant. The "whirlpool sign" is an imaging characteristic of midgut volvulus and has a high predicting value for volvulus. Malrotation or malrotation with volvulus can be effectively diagnosed based on these characteristics. Ultrasound diagnosis has the advantage of no radiation exposure. Color Doppler documenting the reversal or aberrant superior mesenteric vein/superior mesenteric artery axis is not only predictive but also diagnostic of malrotation of gut. The rapid and accurate diagnosis of volvulus by ultrasound helps to establish the diagnosis of malrotation in time and thus allows for urgent surgical intervention to avoid bowel necrosis.

Occult Hepatitis B Virus Infection in Immunized Infants Born to Untreated and Tenofovir-Treated Highly Viremic Mothers.

Tenofovir disoproxil fumurate (TDF) therapy during late pregnancy in highly viremic mothers can reduce residual overt hepatitis B virus (HBV) infections of their infants that occur despite immunoprophylaxis.1,2 Occult HBV infection (OBI) has been defined as the presence of HBV DNA in liver or sera in subjects seronegative for hepatitis B surface antigen (HBsAg).3 OBI has been found in varying proportions of immunized infants born to HBsAg-positive mothers.4-6 We aimed to investigate the impact of maternal TDF therapy during pregnancy on vertically acquired OBI.

A Rare Case of Choledochal Cyst Presented as Sudden and Severe Abdominal Pain.

We report a pediatric case of Type 1C choledochal cyst presented as acute biliary colic pain. Choledochal cyst is an abnormal expansion of the biliary tract. The Type 1 choledochal cyst is the cystic dilation of the common bile duct. The Type Ic choledochal cyst is the fusiform dilatation of the common bile duct with an anomalous pancreaticobiliary junction. Patients with choledochal cysts may have the formation of cholelithiasis due to chronic biliary stagnation and repeated inflammation. Cholelithiasis may fall into the common bile duct to cause biliary colic. Abdominal sonography can be used as a preliminary examination.

One-year-old Boy with Gallbladder Stone: A Case Report and Literature Review.

Gallstone is a rare disease in children. It might cause complications such as cholecystitis, cholangitis, and gallstone pancreatitis due to obstruction of biliary duct or secondary infection. We report a case of a 1-year, 7-month-old boy with incidental finding of gallbladder stone, who received ceftriaxone treatment after diagnosing with Salmonella enterocolitis. Herein, we review the incidence, etiology, risk factors, and management of ceftriaxone-related gallstones in children. In conclusion, these patients are suggested to receive expectant management with close follow-up instead of surgical intervention.

A Case Report and Literature Review of Scrub Typhus With Acute Abdomen and Septic Shock in a Child-The Role of Leukocytoclastic Vasculitis and Granulysin.

Scrub typhus is becoming a clinically important cause of acute undifferentiated febrile illness in Taiwan. The incubation period is between 6 and 21 days after exposure. It is transmitted by chiggers (larva of trombiculid mite) in long grasses and in dirt-floor homes, with infection characterized by a flu-like illness of fever, headache, and myalgia lasting approximately 1 week. It has various systemic manifestations, including GI symptoms. In some, the illness progresses to multiorgan dysfunction syndrome and death. We report on a 13-year-old boy who lived in Taipei City and who had initially tentative diagnosis of acute pyrexia of unknown origin with high fever up to 40.3°C for 1 week, but later had thrombocytopenia and diffuse abdominal pain with peritoneal sign suspected acute appendicitis. During the clinical course, septic shock and disseminated intravascular coagulopathy (DIC) were noted. There were skin rash in his trunk and extremities and an eschar with black crust surrounded by a scaling erythematous rim on his right buttock. In addition, we got the information of his travel history in Green Island and Orchid Island for 10 days.With the correct antibiotics, vancomycin, meropenem, and doxycycline, the patient was getting better and corresponding with high level of granulysin and tumor necrosis factor-alpha. The diagnosis of scrub typhus was confirmed by the biopsy of eschar and high quantitative real-time polymerase chain reaction values of Orientia tsutsugamushi (16sRNA and 56 kDa) tested by Centers for Disease Control and Prevention, Taiwan. Histopathological findings of the eschar revealed the leukocytoclastic vasculitis, crust and thrombus formation with many gram-negative microorganisms, O. tsutsugamushi demonstrated by 47 kDa monoclonal antibody immunohistochemical stain and electromicroscopy. OUTCOMES: After the careful selection of appropriate antibiotics including meropenem, vancomycin, and doxycycline, he recovered and was subsequently discharged 7 days after admission. LESSON SUBSECTIONS: This case highlights that scrub typhus infection can mimic acute abdomen and septic shock with DIC. This rare presentation of acute abdomen and septic shock with thrombocytopenia and DIC caused by scrub typhus should remind physicians to be alert to the possibility of acute abdomen and febrile illness resulting from scrub typhus.

Quantitative maternal hepatitis B surface antigen predicts maternally transmitted hepatitis B virus infection.

Despite immunoprophylaxis, hepatitis B virus (HBV) transmission in highly viremic mothers remains a global health issue. Using quantitative maternal surface antigen (HBsAg) to predict HBV infection in infants has not been investigated. We enrolled 526 mother-infant pairs with positive maternal HBsAg under current immunoprophylaxis. Maternal viral load and quantitative HBsAg were measured in the peripartum period. Infant HBsAg seropositivity for more than 6 months was defined as chronic infection. Rates of chronic infection in infants at various maternal HBsAg levels were estimated using a multivariate logistic regression model. Results showed that maternal HBsAg was positively correlated with maternal viral load (r = 0.69; P < 0.001) and accurately predicted maternal viral load above 6, 7, and 8 log10 IU/mL with an area under the receiver operating characteristic curve (AUC) of 0.97, 0.98, and 0.95. Nineteen infants were chronically infected. After adjustment for the other risk factor, maternal HBsAg level was significantly associated with risk of infection (adjusted odds ratio for each log10 IU/mL increase, 15.02; 95% confidence interval [CI], 3.89-57.94; P < 0.001). The AUC for predicting infection by quantitative maternal HBsAg was comparable to that by maternal viral load (0.89 vs. 0.87; P = 0.459). Estimated rates of infection at maternal HBsAg levels of 4, 4.5, and 5 log10 IU/mL were 2.4% (95% CI, 0.1-4.6; P = 0.04), 8.6% (95% CI, 4.5-12.7; P < 0.001), and 26.4% (95% CI, 12.6-40.2; P < 0.001). CONCLUSION: Quantitative maternal HBsAg predicts infection in infants as well as maternal viral load does. Antiviral therapy may be considered in pregnant women with an HBsAg level above 4-4.5 log10 IU/mL to interrupt mother-to-infant transmission. (Hepatology 2016;64:1451-1461).

Family impact of Rotavirus Gastroenteritis in Taiwan and Vietnam: an Ethnographic Study.

BACKGROUND: Prior to the introduction of rotavirus vaccines, rotavirus was the leading cause of severe gastroenteritis in infants and young children, and it continues to be the leading cause in countries without vaccination programs. Rotavirus gastroenteritis results in substantial economic burden and has a pronounced effect on the family of those who are ill. Both in Taiwan and in Vietnam, rotavirus illness is viewed as a priority disease. This study assessed, in Taiwan and Vietnam, the impact of rotavirus gastroenteritis on the family among a group of parents whose children had recently been hospitalized for this illness. METHODS: In the first half of 2013, parents of children who had been hospitalized due to rotavirus infection were recruited from hospitals in Taiwan (n = 12) and Vietnam (n = 22), and participated in focus group sessions or in-depth ethnographic interviews. RESULTS: In both countries, the results point to a substantial burden on the parents concerning emotions and logistics of daily tasks, and to considerable disruptions of the family routine. Taiwanese parents reported satisfaction with the health care system, a great deal of effort to suppress emotions, a fair amount of knowledge about rotavirus, and little extra costs related to the illness. On the other hand, parents in Vietnam expressed concern about the emotional well-being of and the health care treatments for their children, were less knowledgeable regarding rotavirus infection, and experienced a substantial financial burden due to indirect costs that were related to accessing treatment. CONCLUSIONS: Families in Taiwan and Vietnam suffer from a considerable economic and emotional burden related to rotavirus gastroenteritis. One way to substantially reduce this burden is to provide universal and affordable rotavirus vaccination to susceptible children, especially since cost-effectiveness studies have demonstrated that universal vaccination would be safe and efficacious against severe rotavirus gastroenteritis in these countries.

Clinicopathologic analysis of coxsackievirus a6 new variant induced widespread mucocutaneous bullous reactions mimicking severe cutaneous adverse reactions.

BACKGROUND: The cutaneous manifestations of human enterovirus (HEV) infection are usually limited, such as hand-foot-mouth disease. By comparison, Stevens-Johnson syndrome (SJS) is a life-threatening severe cutaneous adverse reaction (SCAR), mainly caused by drugs. During the HEV outbreaks in 2010-2012 in Taiwan, we identified 21 patients who developed widespread blistering mucocutaneous reactions without any suspected drug causality. METHODS: We screened possible pathogen(s) for detecting human herpes virus (HHV1-HHV7), HEV, or Mycoplasma pneumoniae infections using throat swab virus cultures, real-time PCR, DNA sequencing, immunochemistry and electron microscopy analyses. RESULTS: Coxsackievirus A6 (CVA6) DNA was identified in the blistering skin lesions in 6 of 21 patients. Cytotoxic T lymphocytes and natural killer cells expressing granulysin predominantly infiltrated into the skin lesions, sharing the histopathological features with SJS. Intact CVA6 viral particles were identified in the blister fluids and skin lesions by electron microscopy. The phylogenetic analysis of the viral genome showed the CVA6 DNA sequence sharing higher similarity (97.6%-98.1%) to CVA6 strains reported from Finland at 2008. CONCLUSIONS: This study identifies a new variant of CVA6 as the causative agent for severe mucocutaneous blistering reactions mimicking SCAR. An awareness of this unusual presentation of HEV infection is needed in the epidemic area.

Effects of maternal screening and universal immunization to prevent mother-to-infant transmission of HBV.

BACKGROUND & AIMS: Mother-to-infant transmission is the major cause of hepatitis B virus (HBV) infection among immunized children. There has been much debate about screening pregnant women and administering hepatitis B immunoglobulin (HBIG) to newborns. We analyzed the rate of HBV infection among children born to hepatitis B surface antigen (HBsAg)-positive mothers and whether HBIG administration reduces transmission. METHODS: We analyzed data from 2356 children born to HBsAg-positive mothers, identified through prenatal maternal screens. In addition to HBV vaccines, HBIG was given to all 583 children with hepatitis B e antigen (HBeAg)-positive mothers and to 723 of 1773 children with HBeAg-negative mothers. Serology tests for HBV were performed from 2007 to 2009, when children were 0.5-10 years old. RESULTS: A significantly greater percentage of children with HBeAg-positive mothers tested positive for antibodies against the hepatitis B core protein (16.76%) and HBsAg (9.26%) than children with HBeAg-negative mothers (1.58% and 0.29%, respectively; P < .0001 and <.001). Among the HBV-infected children, the rate of chronicity also was higher among children with HBeAg-positive mothers than children with HBeAg-negative mothers (54% vs 17%; P = .002). Similar rates of antibodies against the hepatitis B core protein (0.99% and 1.88%; P = .19) and HBsAg (0.14% and 0.29%; P = .65) were noted in children born to HBeAg-negative mothers who were or were not given HBIG. Infantile fulminant hepatitis developed in 1 of 1050 children who did not receive HBIG (.095%). CONCLUSIONS: Children born to HBeAg-positive mothers are at greatest risk for chronic HBV infection (9.26%), despite immunization. Administration of HBIG to infants born to HBeAg-negative mothers did not appear to reduce the rate of chronic HBV infection, but might prevent infantile fulminant hepatitis. Screening pregnant women for HBsAg and HBeAg might control mother-to-infant transmission of HBV.

Differentiating roseola infantum with pyuria from urinary tract infection.

BACKGROUND: The aim of this study was to identify factors for differentiating roseola infantum from urinary tract infection (UTI) and to describe a cohort of infants diagnosed with roseola infantum and sterile pyuria. METHODS: The medical records of infants diagnosed with roseola infantum or UTI were examined. Multivariate analysis was performed to identify factors associated with UTI. Demographic and clinical variables were compared between infants who had roseola infantum with or without sterile pyuria. RESULT: There were 301 infants included: 158 in the roseola group (21, 13.3% with sterile pyuria) and 143 in the UTI group. The relative risk of UTI over roseola infantum: increased with leukocytosis (white blood cell [WBC] count >10,000/mm(3), odds ratio [OR] = 85.62) and pyuria (OR = 18.97); decreased with age (OR = 0.90); increased in boys (OR = 2.48); increased with WBC count 4000-10,000/mm(3) (OR = 4.24); and decreased with duration of fever (OR = 0.84). There was a significantly higher proportion of girls in the roseola pyuria group (81.0%) compared with the no pyuria group (44.5%, P = 0.002). A significantly higher proportion of infants in the roseola pyuria group (76.2%) received antibiotics than infants in the no pyuria group (38.0%, P = 0.002). CONCLUSION: Leukocytosis is the strongest predictor of UTI over roseola infantum. Sterile pyuria may occur in infants with roseola infantum.

Clinical manifestations in children with ruptured appendicitis.

OBJECTIVES: Appendicitis is the most common abdominal condition leading to urgent surgery in children. With the goal of identifying signs and symptoms that will allow prompt diagnosis of rupture of the appendix and thus decrease associated morbidities, our aim was to determine factors associated with ruptured appendicitis in children diagnosed with appendicitis. METHODS: The medical records of children aged 17 years or younger with a postoperative diagnosis of acute appendicitis treated at Cathay General Hospital, Taipei, Taiwan, from January 2002 and May 2009, were retrospectively reviewed. The patients were divided into with and without ruptured appendicitis. RESULTS: Of the 228 patients, 140 had a postoperative pathological diagnosis of a nonperforated appendix, and 88 had a diagnosis of perforated appendix, resulting in a perforation rate of 38.6%. Younger age, longer duration of abdominal pain, fever, muscle guarding, and elevated C-reactive protein level were significantly associated with a perforated appendix. CONCLUSIONS: Younger age, longer duration of abdominal pain, fever, muscle guarding, and elevated C-reactive protein level are significantly associated with a perforated appendix; these factors should be closely considered in the evaluation of individuals with suspected appendicitis.

Choledochal cysts in infants and children: experiences over a 20-year period at a single institution.

This analysis was undertaken to compare the clinicopathological features of infants with choledochal cysts to those of older children with these entities and to evaluate the surgical outcomes for both subject groups. The medical records of all children admitted to the Cathay General Hospital with choledochal cysts over a 20-year period were retrospectively reviewed. Twenty-five subjects were included and divided into the infant (<1 year at presentation; 8 subjects) and classical pediatric (1-18 years at presentation; 17 subjects) groups. Anatomical subtypes were: IA (16), IC (6), and IVA (3). The median biliary amylase value was markedly elevated for the pediatric group but not for the infant group. Most (82.4%) patients in the pediatric group, but none in the infant group, presented with abdominal pain. Jaundice and clay-colored stool were present in all patients in the infant group but only 35% of those in the pediatric group. All patients underwent choledochocystectomy and Roux-en-Y hepaticojejunostomy with good outcomes. Neonates/infants with choledochal cysts present differently from older children with these entities. Amylase measurements may serve to distinguish biliary atresia with cystic dilatation from choledochal cyst in neonates/infants. Prognosis following radical cyst excision and reconstruction with Roux-en-Y hepaticojejunostomy is excellent.

An infected urachal cyst presenting as acute abdominal pain in a child: A case report.

INTRODUCTION: Urachal cyst is an exceptionally rare disease in children caused by the incomplete obliteration of the urachal remnant. Urachal cysts seldom cause symptoms unless a secondary infection occurs. The symptoms of an infected urachal cyst are nonspecific and may be similar to acute appendicitis or other acute abdominal conditions. However, complications attributable to a delayed diagnosis can endanger the life of a patient. PATIENT CONCERNS: A 5-year-old boy presented with a 3-day history of severe intermittent lower abdominal pain. DIAGNOSIS: Infected urachal cyst. INTERVENTIONS: The patient was treated with surgical resection of the urachus, followed by intravenous antibiotics during the hospitalization. OUTCOMES: The patient was discharged without incident 7 days after the operation. With his follow-up in our out-patient department, he recovered well without any sequelae in the 6 months post-surgery. CONCLUSION: We suggested using the abdominal echo scan to differentiate the urachal cyst because of its high sensitivity and nonradioactive characteristic, and computed tomography is a typical diagnostic tool for urachal cysts. The mainstream management of an infected urachal cyst remains surgical excision. Complete excision of urachal cysts is relatively easy in a pediatric patient and the risk of subsequent infection is low; however, patients tend to have a low, although possible, risk of potential malignant transformation over their lifetimes.

Unambiguous molecular detections with multiple genetic approach for the complicated chromosome 22q11 deletion syndrome.

BACKGROUND: Chromosome 22q11 deletion syndrome (22q11DS) causes a developmental disorder during the embryonic stage, usually because of hemizygous deletions. The clinical pictures of patients with 22q11DS vary because of polymorphisms: on average, approximately 93% of affected individuals have a de novo deletion of 22q11, and the rest have inherited the same deletion from a parent. Methods using multiple genetic markers are thus important for the accurate detection of these microdeletions. METHODS: We studied 12 babies suspected to carry 22q11DS and 18 age-matched healthy controls from unrelated Taiwanese families. We determined genomic variance using microarray-based comparative genomic hybridization (array-CGH), quantitative real-time polymerase chain reaction (qPCR) and multiplex ligation-dependent probe amplification (MLPA). RESULTS: Changes in genomic copy number were significantly associated with clinical manifestations for the classical criteria of 22q11DS using MPLA and qPCR (p < 0.01). An identical deletion was shown in three affected infants by MLPA. These reduced DNA dosages were also obtained partially using array-CGH and confirmed by qPCR but with some differences in deletion size. CONCLUSION: Both MLPA and qPCR could produce a clearly defined range of deleted genomic DNA, whereas there must be a deleted genome that is not distinguishable using MLPA. These data demonstrate that such multiple genetic approaches are necessary for the unambiguous molecular detection of these types of complicated genomic syndromes.

Simultaneous intussusception associated with adenovirus infection in monozygotic twins: A case report.

RATIONALE: Intussusception, a common cause of intestinal obstruction in children, typically requires medical reduction. Here, we describe the case of a pair of twins who had simultaneous intussusception and were positive for fecal adenovirus-strongly indicating that adenovirus infection may be a main cause of the intussusception. PATIENT CONCERNS: Two 1-year-old twin girls were brought to Cathay General Hospital one after another on the same day. Both presented with intermittent abdominal pain, abdominal distension, diarrhea, and loss of appetite. DIAGNOSES: Their laboratory data were adenovirus positivity in rectal swab culture. Intussusception was diagnosed through a lower gastrointestinal series. INTERVENTIONS: The twins were treated with reduction for intussusception. OUTCOMES: Both patients recovered well, without recurrence. LESSONS: Most cases of intussusception are idiopathic. However, some potential risk factors-as strongly suggested by the current cases-are genetic factors and adenovirus infection.

Decreased neonatal hepatitis B virus (HBV) viremia by maternal tenofovir treatment predicts reduced chronic HBV infection in children born to highly viremic mothers.

BACKGROUND: Maternal anti-viral treatment prevents mother-to-infant transmission of hepatitis B virus (HBV), but the role of neonatal viremia on subsequent HBV infection is not clear. AIMS: To investigate the effect of maternal anti-viral treatment on neonatal serum HBV DNA and hepatitis B surface antigen (HBsAg) in infants born to highly viremic mothers and the roles of neonatal markers in predicting chronic HBV infection in children. METHODS: Serum HBV DNA and HBsAg were tested in children. Of the 201 pregnant mothers, 110 received tenofovir during the third trimester. Chronic infection in children was defined by HBsAg seropositivity at 6 or 12 months lasting more than 6 months. RESULTS: The maternal HBV viral loads from baseline to delivery were 8.25 ± 0.48 to 4.29 ± 0.98 log10  IU/mL; and 8.29 ± 0.49 to 8.12 ± 0.68 log10  IU/mL in the tenofovir and control group respectively. Of the 208 children, those in the tenofovir group had a lower rate of neonatal HBV DNA seropositivity at birth (5.22% vs 30.11%, P < 0.0001) and HBsAg seropositivity at 6 months (1.74% vs 11.83%, P = 0.003) and 12 months (1.74% vs 10.75%, P = 0.007). In a first multivariate analysis, maternal HBV DNA level at delivery (odds ratio = 1.70, P = 0.0172) and neonatal HBsAg positivity (odds ratio = 19.37, P < 0.0001) were significantly associated with children's chronic HBV infection. In a second model, neonatal HBV DNA positivity was a strong independent influence variable (odds ratio = 61.89, P = 0.0002). CONCLUSIONS: Maternal tenofovir therapy decreased maternal viral load and neonatal viremia. Positive neonatal HBV DNA was highly correlated with chronic HBV infection in children. Clinical Trial Identifier: NCT01312012.

Macrolide use shortens fever duration in Mycoplasma pneumoniae infection in children: a 2-year experience.

BACKGROUND AND PURPOSE: Mycoplasma pneumoniae infection is a major cause of community-acquired respiratory tract infection in children. We performed a retrospective study to evaluate clinical and demographic data and compare outcomes with and without macrolide treatment in children with M. pneumoniae infection. METHODS: A total of 139 patients were included in the study and classified into two groups according to whether or not they received macrolide therapy during hospitalization. Data collected included demographic, clinical and laboratory characteristics. RESULTS: Cases were most prevalent during September. Fever and cough were the most common presenting symptoms/signs. The time to fever subsidence did not differ significantly between azithromycin and erythromycin usage. We also found significantly longer fever duration in the group without macrolide usage. CONCLUSION: Treatment with macrolide shortens fever duration of M. pneumoniae infection in children.

Effectiveness of the IMFeD tool for the Identification and Management of Feeding Difficulties in Taiwanese children.

BACKGROUND: The Identification and Management of Feeding Difficulties (IMFeD™) tool was introduced in 2011 for management of children with feeding difficulties and has been used in various countries around the world. This study aimed to assess its acceptance and effectiveness in clinical practice in Taiwan. METHODS: This was a prospective, observational, multicenter study where subjects were followed over 3 months. Outpatients identified as picky eaters, having poor appetite, poor weight gain, or weight loss were enrolled. The acceptance and effectiveness of IMFeD tool were evaluated by caregivers and pediatricians. RESULTS: Among 423 children who completed the study (235 boys, 188 girls; 78.8% aged <5 years, 21.3% aged 6-10 years), the most common feeding difficulties were poor appetite in a fundamentally vigorous child (85.3%) and highly selective intake (70.2%). Mean percentiles for height and weight were 34.6 ± 25.3 and 20.3 ± 21.3 at enrolment, and increased by 5.4 and 5.9 (p < 0.0001) at the last visit, respectively. Most caregivers (86.5%) thought that the IMFeD tool helped them to understand and better identify picky eating behaviors. Pediatricians reported that the IMFeD tool was effective in 99.3% of patients for managing picky eaters in clinical practice. CONCLUSIONS: The IMFeD tool was effective in addressing differences in needs according to type of feeding difficulty by providing a systematic approach to manage feeding difficulty in Taiwanese children. It is applicable to the clinical practice and well-accepted by pediatricians and caregivers.