Low mean impedance in 24-hour tracings and esophagitis in children: a strong connection.

Esophageal multiple intraluminal impedance baseline is an additional impedance parameter that was recently related to esophageal integrity. The aim of this study was to assess the relationship between mean esophageal impedance value and endoscopic findings in a large group of children. Children with symptoms of gastroesophageal reflux submitted to both endoscopy and impedance were included. Esophagitis was graded according to the Los Angeles classification. Mean impedance value was automatically calculated over 24-hour tracings. Data were adjusted for age through z-score transformation using percentiles normalized by the LMS (Lambda for the skew, Mu for the median, and Sigma for the generalized coefficient of variation) method. Nonparametric Mann-Whitney and Kruskal-Wallis tests, multiple, and stepwise regression were used. P-value <0.05 was considered as statistically significant. A total of 298 impedance tracings were analyzed. Endoscopic and histological esophagitis were detected in 30 and 29% patients, respectively. Median baseline z-score was significantly decreased both in proximal (P = 0.02) and distal (P = 0.01) esophagus in patients with endoscopic (but not histological) esophagitis. Patients with more severe esophagitis showed the lowest z-score. Bolus exposure index and the number of reflux episodes were the variables that were significantly associated with the baseline z-score. Impedance z-score is significantly decreased in infants and children with endoscopic esophagitis. Severity of esophagitis, bolus exposure index, and number of reflux episodes are factors influencing mean esophageal impedance.

[Management of Acute Gastroenteritis in Children]. / Traitement de la gastro-entérite aiguë chez L'Enfant.

Acute gastroenteritis remains one of the most frequent disorders in infants and children. The cornerstone of the treatment is oral rehydration, although the latter does not reduce the duration of the diarrhea, which is about four days. As a consequence, this quite benign condition of acute gastroenteritis in our countries still does have an important socio-economic impact. Therefore, recent European guidelines and recommendations consider the use of different medications and agents that reduce the duration of diarrhea.

ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents.

OBJECTIVES: This European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position statement provides a comprehensive guide for health care providers to manage percutaneous endoscopic gastrostomy tubes in a safe, effective, and appropriate way. METHODS: Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of evidence, recommendations reflect the expert opinion of the authors. Final consensus was obtained by multiple e-mail exchange and during 3 face-to-face meetings of the gastroenterology committee of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. RESULTS: Endoscopically placed gastrostomy devices are essential in the management of children with feeding and nutritional problems. The article focuses on practical issues such as indications and contraindications. CONCLUSIONS: The decision to place an endoscopic gastrostomy has to be made by an appropriate multidisciplinary team, which then provides active follow-up and care for the child and the device.

Algorithms for managing infant constipation, colic, regurgitation and cow's milk allergy in formula-fed infants.

UNLABELLED: Gastrointestinal symptoms, such as constipation, regurgitation and infant colic, occur in about half of infants. These symptoms are often functional, but they may also be caused by cow's milk protein allergy. We developed three algorithms for formula-fed infants, which are consensus rather than evidence-based due to the limited research available in the existing literature. CONCLUSION: We believe that these algorithms will help primary healthcare practitioners to recognise and manage these frequent gastrointestinal manifestations in infants.

Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN.

BACKGROUND: Constipation is a pediatric problem commonly encountered by many health care workers in primary, secondary, and tertiary care. To assist medical care providers in the evaluation and management of children with functional constipation, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition were charged with the task of developing a uniform document of evidence-based guidelines. METHODS: Nine clinical questions addressing diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. For therapeutic questions, quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Grading the quality of evidence for the other questions was performed according to the classification system of the Oxford Centre for Evidence-Based Medicine. During 3 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation. RESULTS: This evidence-based guideline provides recommendations for the evaluation and treatment of children with functional constipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants <6 months of age and the other for older infants and children. CONCLUSIONS: This document is intended to be used in daily practice and as a basis for further clinical research. Large well-designed clinical trials are necessary with regard to diagnostic evaluation and treatment.

Management guidelines of eosinophilic esophagitis in childhood.

OBJECTIVES: Eosinophilic esophagitis (EoE) represents a chronic, immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. With few exceptions, 15 eosinophils per high-power field (peak value) in ≥1 biopsy specimens are considered a minimum threshold for a diagnosis of EoE. The disease is restricted to the esophagus, and other causes of esophageal eosinophilia should be excluded, specifically proton pump inhibitor-responsive esophageal eosinophilia. This position paper aims at providing practical guidelines for the management of children and adolescents with EoE. METHODS: Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of an evidence base, recommendations reflect the expert opinion of the authors. Final consensus was obtained during 3 face-to-face meetings of the Gastroenterology Committee and 1 teleconference. RESULTS: The cornerstone of treatment is an elimination diet (targeted or empiric elimination diet, amino acid-based formula) and/or swallowed, topical corticosteroids. Systemic corticosteroids are reserved for severe symptoms requiring rapid relief or where other treatments have failed. Esophageal dilatation is an option in children with EoE who have esophageal stenosis unresponsive to drug therapy. Maintenance treatment may be required in case of frequent relapse, although an optimal regimen still needs to be determined. CONCLUSIONS: EoE is a chronic, relapsing inflammatory disease with largely unquantified long-term consequences. Investigations and treatment are tailored to the individual and must not create more morbidity for the patient and family than the disease itself. Better maintenance treatment as well as biomarkers for assessing treatment response and predicting long-term complications is urgently needed.

Extensive protein hydrolysate formula effectively reduces regurgitation in infants with positive and negative challenge tests for cow's milk allergy.

AIM: Cow's milk protein allergy (CMPA) is treated using an elimination diet with an extensive protein hydrolysate. We explored whether a thickened or nonthickened version was best for infants with suspected CMPA, which commonly causes regurgitation/vomiting. METHODS: Diagnosis of CMPA was based on a positive challenge test. We compared the efficacy of two casein extensive hydrolysates (eCH), a nonthickened version (NT-eCH) and a thickened version (T-eCH), using a symptom-based score covering regurgitation, crying, stool consistency, eczema, urticarial and respiratory symptoms. RESULTS: A challenge was performed in 52/72 infants with suspected CMPA and was positive in 65.4%. All confirmed CMPA cases tolerated eCH. The symptom-based score decreased significantly in all infants within a month, and the highest reduction was in those with confirmed CMPA. Regurgitation was reduced in all infants (6.4 ± 3.2-2.8 ± 2.9, p < 0.001), but fell more with the T-eCH (-4.2 ± 3.2 regurgitations/day vs. -3.0 ± 4.5, ns), especially in infants with a negative challenge (-3.9 ± 4.0 vs. -1.9 ± 3.4, ns). CONCLUSION: eCH fulfilled the criteria for a hypoallergenic formula, and the NT-eCH and T-eCH formulas both reduced CMPA symptoms. The symptom-based score is useful for evaluating how effective dietary treatments are for CMPA.

When should we use partially hydrolysed formulae for frequent gastrointestinal symptoms and allergy prevention?

UNLABELLED: Experts reviewed the literature to determine whether partially whey hydrolysed formulas (HF) offer benefits in the dietary management of frequent gastrointestinal symptoms and allergy prevention. Compared with standard cow's milk-based formulas, partially whey HF confer a limited protective effect against allergic disease in high-risk infants, particularly atopic dermatitis, but not respiratory allergies. No randomised clinical trials have been published on partially whey HF in infants with colicky symptoms. The group did not find sufficient evidence to support the use of partially whey HF in regurgitation, although recent data suggest that a thickened partially whey HF may be more effective. Partially whey HF, fortified with prebiotics and/or probiotics, with high levels of sn-2 palmitate in the fat blend or without palm oil, provide some benefit in functional constipation. CONCLUSION: Overall, partially whey HF may offer a useful alternative to intact protein in the dietary management of common functional gastrointestinal symptoms.

Behind the (impedance) baseline in children.

Impedance baseline is a new parameter recently related to esophageal integrity. The aim of this study was to assess the effect of different factors on impedance baseline in pediatric patients. We analyzed the impedance baseline of 800 children with symptoms of gastroesophageal reflux. Mean impedance baseline was automatically calculated throughout 24-hour tracings. The presence of different age groups and of esophagitis was evaluated. Unpaired t-test, Spearman rank correlation, polynomial, and regression plot were used for statistical analysis. Age-related percentile curves were created. We considered a P-value<0.05 as statistically significant. Impedance baseline was significantly (P<0.001) lower in younger compared to older children up to 48 months. The mean increase of baseline per month was much higher in the first 36 months of life (47.5 vs. 2.9 Ohm in Channel 1 and 29.9 vs. 2.3 Ohm in Channel 6, respectively) than in older ages. Patients with esophagitis showed significantly decreased impedance baseline (P<0.05). Infants (especially in the first months of life) and young children present a significantly lower impedance baseline compared to older children both in proximal and distal esophagus. The presence of esophagitis may also determine a decreased impedance baseline regardless of the age of the patients.

Why do clinical guidelines for probiotics differ?

Clinical guidelines are recommendations for healthcare providers regarding patients with specific conditions. These guidelines should be based on practice experience and the best available research evidence. However, guidelines developed by various health organisations worldwide often do not agree with each other. This is also true for the current guidelines for the clinical use of probiotics. This article aims to provide examples of conflicting clinical guidelines for probiotics, define reasons for this phenomenon, describe standard tools for improving their quality, and suggest ways to enhance the development and assessment of suitable clinical guidelines for the appropriate clinical use of probiotics in specific conditions.

Symptoms and management of cow's milk allergy: perception and evidence.

Introduction: The diagnosis and management of cow's milk allergy (CMA) is a topic of debate and controversy. Our aim was to compare the opinions of expert groups from the Middle East (n = 14) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) (n = 13). Methods: These Expert groups voted on statements that were developed by the ESPGHAN group and published in a recent position paper. The voting outcome was compared. Results: Overall, there was consensus amongst both groups of experts. Experts agreed that symptoms of crying, irritability and colic, as single manifestation, are not suggestive of CMA. They agreed that amino-acid based formula (AAF) should be reserved for severe cases (e.g., malnutrition and anaphylaxis) and that there is insufficient evidence to recommend a step-down approach. There was no unanimous consensus on the statement that a cow's milk based extensively hydrolysed formula (eHF) should be the first choice as a diagnostic elimination diet in mild/moderate cases. Although the statements regarding the role for hydrolysed rice formula as a diagnostic and therapeutic elimination diet were accepted, 3/27 disagreed. The votes regarding soy formula highlight the differences in opinion in the role of soy protein in CMA dietary treatment. Generally, soy-based formula is seldom available in the Middle-East region. All ESPGHAN experts agreed that there is insufficient evidence that the addition of probiotics, prebiotics and synbiotics increase the efficacy of elimination diets regarding CMA symptoms (despite other benefits such as decrease of infections and antibiotic intake), whereas 3/14 of the Middle East group thought there was sufficient evidence. Discussion: Differences in voting are related to geographical, cultural and other conditions, such as cost and availability. This emphasizes the need to develop region-specific guidelines considering social and cultural conditions, and to perform further research in this area.

Double-blind comparative trial with 2 antiregurgitation formulae.

BACKGROUND AND AIM: Many mothers consult physicians because of frequent infant regurgitation. Guidelines recommend reassurance and dietary treatment as first approaches. The aim of the present study was to test and compare the efficacy of 2 antiregurgitation formulae (ARF). METHODS: A prospective, double-blind, randomized cross-over trial was performed for a 1-month period in 115 formula-fed infants (ages 2 weeks-5 months) comparing 2 ARF (ARF-1: nonhydrolyzed protein, locust bean gum; ARF-2: specific whey hydrolysate, locust bean gum, specially treated starch). The primary endpoint was the incidence of regurgitation. RESULTS: At inclusion, mean age was 9.1 weeks; anthropometric parameters did not differ between the groups. According to the intention-to-treat analysis, the mean number of episodes of regurgitation decreased from 8.25 to 2.32 with ARF-1 and to 1.89 with ARF-2 (statistically significant difference between both ARF, P = 0.0091). The mean score of regurgitated volume decreased significantly more with ARF-2 than with ARF-1 (P = 0.0265). There was no significant difference in stool frequency and consistency between both groups. CONCLUSIONS: The efficacy of both ARF was demonstrated by the decreased number and volume of regurgitations. ARF-2 was statistically more effective than ARF-1. Comparative trials enable the selection of the best therapeutic option.

Hospital-related undernutrition in children: still an often unrecognized and undertreated problem.

AIM: To evaluate the nutritional status of hospitalized children in Belgian hospitals and to analyse the impact of undernutrition on the degree of weight loss and duration of hospitalization. METHODS: In each hospital (one tertiary and three secondary hospitals), 100 consecutively hospitalized children were eligible for inclusion. Of these, 379 were included for analysis. Body weight, length and mid-upper arm circumference were measured at admission and body weight also at discharge. RESULTS: The median (range) age was 2.1 (0.8-17) years. On admission, 29 (7.7%) children were chronically malnourished and, depending on the parameter, between 2.4% and 9.8% acutely undernourished, while 12.1% had at least one subnormal parameter. Median (range) duration of hospitalization was four (1-64) days. Median (range) weight change was 0.0% (-15.6% - +13.9%). Weight loss of >2% was significantly (p < 0.05) more prevalent in tertiary (20.0%) than in secondary (10.2%) hospitals. Median hospital duration was 50% longer for chronically malnourished children (6.0 vs 4.0 days; p < 0.01). Only 36 children received a nutritional intervention. CONCLUSION: Acute undernutrition and chronic undernutrition remain frequent findings in hospitalized children in Belgium. Children with chronic undernutrition had a 50% longer hospital stay. Hospital-related undernutrition is an often unrecognized problem, because only one-third of the acutely malnourished children received nutritional support.

Baseline esophageal impedance according to different time intervals.

Baseline impedance (BImp) reflects esophageal integrity. The study aims to identify the optimal method to calculate BImp. Mean BImp was calculated in 20 consecutive multichannel intraluminal impedance recordings including and excluding impedance events (IEs) (reflux, swallows, and gas episodes) in all channels during the full recording and during the first period of 1 minute without an IE every hour (method 1), every 2 hours (method 2), or 4 hours (method 3). BImp obtained during the total recording was set at 100%, and the variation (difference in BImp for the different methods) and variability (difference in BImp during one analysis period) were assessed. All children underwent endoscopy. No child had esophagitis. The mean difference over the six channels, in percentage, between BImp over the total recording with and without IE was ≈ 1.2% and comparable for each channel (range -5.87-6.99%). A mean of 980 IE were excluded in each tracing, and it took between 4 and 24 hours to delete all events in one tracing. The difference of BImp obtained with and without IE was mainly caused by the gas episodes at the upper and swallows in the lower channel. The mean BImp according to the three 1-minute analysis methods was comparable with the mean BImp according to the 24-hour analysis. The automatic determination of the mean BImp over the total tracing including the IE is an adequate method. In isolated tracings with numerous IE, the calculation of the mean BImp over 1 minute every 4 hours is an alternative option. Companies should develop software to calculate the mean BImp during the whole registration deleting all IE for the analysis.

Diagnostic approach and management of cow's-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines.

OBJECTIVES: This guideline provides recommendations for the diagnosis and management of suspected cow's-milk protein allergy (CMPA) in Europe. It presents a practical approach with a diagnostic algorithm and is based on recently published evidence-based guidelines on CMPA. DIAGNOSIS: If CMPA is suspected by history and examination, then strict allergen avoidance is initiated. In certain circumstances (eg, a clear history of immediate symptoms, a life-threatening reaction with a positive test for CMP-specific IgE), the diagnosis can be made without a milk challenge. In all other circumstances, a controlled oral food challenge (open or blind) under medical supervision is required to confirm or exclude the diagnosis of CMPA. TREATMENT: In breast-fed infants, the mother should start a strict CMP-free diet. Non-breast-fed infants with confirmed CMPA should receive an extensively hydrolyzed protein-based formula with proven efficacy in appropriate clinical trials; amino acids-based formulae are reserved for certain situations. Soy protein formula, if tolerated, is an option beyond 6 months of age. Nutritional counseling and regular monitoring of growth are mandatory in all age groups requiring CMP exclusion. REEVALUATION: Patients should be reevaluated every 6 to 12 months to assess whether they have developed tolerance to CMP. This is achieved in >75% by 3 years of age and >90% by 6 years of age. Inappropriate or overly long dietary eliminations should be avoided. Such restrictions may impair the quality of life of both child and family, induce improper growth, and incur unnecessary health care costs.

Effects of domperidone on QTc interval in infants.

AIM: To prospectively evaluate the effects of oral domperidone on the QTc interval in infants. METHODS: Infants (0-1 year) with a diagnosis of gastro-oesophageal reflux (GOR) disease were included. A 12-lead electrocardiography (ECG) was performed in all infants at baseline and 1 h after the intake of domperidone after 7-14 days; the corrected QTc interval was calculated by one investigator (MV) according to Bazett's formula. RESULTS: Forty-five infants were enrolled in this study. The mean gestational age was of 38.6 weeks (35.5-42.0), and the mean age at the start of domperidone was 75.3 days (19-218 days). No statistically significant difference in corrected QTc was observed between baseline and the second ECG (0.389 ± 0.02 vs. 0.397 ± 0.31; p 0.130)). A trend was observed regarding gender: Although there was no difference in QTc change in girls (p 0.622), there was a strong trend in boys (p 0.051). Two infants (both boys) had a clinically significant QTc prolongation (> 460 msec) without symptoms. The Spearman correlation test showed no relation between the QTc change and age (r: -0.05822; p 0.7284). There was no relation between domperidone dosage and QTc change. CONCLUSION: Overall, the group-analysis showed no statistical significant difference in QTc duration induced by domperidone. However, 2/45 (4.4%) infants had a prolonged QTc interval (> 460 msec) induced by domperidone. As a consequence, QTc measurement should be recommended in routine in infants when domperidone is started.

Impact of antisecretory treatment on respiratory symptoms of gastroesophageal reflux disease in children.

The effect of antisecretory treatment on extraesophageal symptoms of gastroesophageal reflux disease was evaluated. Seventy-eight children presenting with typical and extraesophageal symptoms of gastroesophageal reflux disease underwent a multichannel intraluminal impedance and pH monitoring (MII/pH). Children with a positive MII/pH were randomly treated with proton pump inhibitors (PPIs) or histamine H(2) -receptor antagonists (H(2) RAs) during 3 months. At the end of the treatment period, all patients were recalled. A second treatment period of 3 months was given to those patients who were not symptom-free after 3 months. Thirty-five of the forty-one (85.4%) children with a pathologic MII/pH presented with extraesophageal symptoms and were treated with PPIs (omeprazole; n:19) or H(2) RAs (ranitidine; n:16) for 12 weeks. After 3 months, 11/19 (57.9%) PPI-treated patients had a complete resolution of symptoms; 6/8 nonresponders were treated with PPI for another 3 months and became all symptom-free. The other two underwent a Nissen fundoplication. Only 5/16 (31.2 %) patients treated with H(2) RAs had a complete resolution of symptoms after 3 months; 1/11 was treated again with H(2) RAs during 3 months, and 10/11 were changed to PPIs. In 3/10, a partial resolution of symptoms was achieved, while in 7/10, a complete remission was obtained (P < 0.05). Antisecretory reflux treatment improves extraesophageal reflux symptoms. The efficacy of PPIs is superior to that of H(2) RAs in these children.

Electronic medical file exchange between on-duty care providers and the attending paediatrician: a Belgian paediatric pilot project.

The authors propose the introduction of a pilot project: "paediatric core file exchange in emergencies" (PCF-EXEM) which enables the exchange of medical data between the attending paediatrician (AP), holder of the medical record, and on-duty medical units (i.e. general practitioners, paediatricians, surgeons, emergency physicians,...). This project is based on two pillars: a protected server (PCF-server) containing paediatric core files (PCF), with important clinical data that should be available for the physician in order to quickly get a clear insight into the relevant clinical medical history of the child, and secondly, the possibility to provide feedback to the attending physician about the findings recorded during the on-call duty. The permanent availability of health data on the PCF-server and the possibility to provide feedback represent together the PCF-EXEM-project. This project meets the demand of the care providers to have relevant medical information permanently available in order to guarantee high quality care in emergency situations. The frail balance between the right to informative privacy and professional confidentiality on the one hand and the right to quality health care on the other hand has been taken into account. The technical and practical feasibility of this project is described. The objectives and vision of the PCF-EXEM project are conform to Belgian legislation concerning the processing of medical data and are in line with the still under consideration European projects which are focusing on interoperability and the development of a common access control to databanks containing health data for care providers. PCF-EXEM could therefore be a model for other EU countries as well.

The influence of the law on patient's rights on the practice of the Flemish paediatricians anno 2010.

BACKGROUND: The law on patients' rights in Belgium was issued in 2002. The new legal framework recommends the establishment of a true dialogue between physician and patient, and it assigns decisive priority to the adolescent rather than to the physician or his parents. PURPOSE AND METHODS: The purpose of this study is to map the current interpretation of the paediatrician and the realisation of the law in practice. The answers of 117 Flemish paediatricians to an anonymous questionnaire were analyzed. RESULTS: Only 7.8% of the paediatricians state that they know the law well. 15.5% experience the law as a burden. 20.9% have adopted a different attitude when rendering care to adolescents under impulse of this law. 6.2% say they do not strictly follow the law. 27.8% think that the emancipating thought is too far-reaching. Most paediatricians apply protocols to interpret the traditional values that are stamped as being good medical practice: high quality care (81%), free patient's choice (70.7%), adequate pain control (77.4%). On the other hand paediatricans seldom dispose of procedures regarding the more emancipated amenities in the law such as obtaining informed consent (16.4%), access to the medical file (24.8%) and safe-guarding the privacy (13%). In practice most of the physicians offer the possibility of a free choice in 80% of the cases. All questioned physicians strive for a high quality care, for adequate pain control and for a careful maintained medical file. 79.1% of the physicians transfer to the parents all medical information regarding the adolescent. Proper experience and expertise (80.7%), case by case completed, are most often used as the basis for the judgment about the competence of the adolescent. From the patient's side, little advance is taken to exercise his own rights. Barely 1% of the adolescents consulting a paediatrician use their legal right to autonomously consent to a medical intervention. In barely 0.16% access is requested to the medical file. Practically no complaints are received regarding the law on patients' rights (0.1% in intramural setting, versus 0.001% extramural). CONCLUSION: The law on patients' rights is, after 8 years of issuance, badly penetrated in the paediatric practice. On the one hand this is due to a poor knowledge of the law as well from the side of the physician as from the side of the adolescent and/or his parents. On the other hand 42.2% of the paediatricians experience difficulties with the practical interpretation of the law because of the lack of applicable guidelines. An important obstacle is the fact that more than a quarter of the paediatricians do not agree with the in the law foreseen autonomy of the adolescents. For that reason, paediatricians urgently need to be instructed in these matters. It is the moral duty of the Society of Paediatrics to organize workshops on these matters and develop clear guidelines concerning this law. Proper application of the legal context, the handling of the watertight procedures and the necessary communication in this respect is indispensable for the confidence and will lower the barrier for adolescents to use the healthcare system.