Chapter 4. The Relationship Between the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition.

This chapter is based on the memories of those who shaped the relationship between the European and the North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition. The first joint meeting of the 2 Societies took place in Paris in 1978, followed by 1 in New York in 1985, 1 in Amsterdam in 1990, 1 in Houston in 1994, and the last one in Toulouse in 1998. The formation of the Federation of the International Societies for Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) preceded the First World Congress of all Societies, which took place in Boston in 2000. The success of this meeting was followed by world congresses in Paris in 2004, Iguassu in 2008, Taiwan in 2012, and Montreal in 2016. NASPGHAN and ESPGHAN jointly took on the direction of the Journal of Pediatric Gastroenterology and Nutrition in 1991. Communication between the 2 Societies is extremely active, with members participating in many joint projects.

Practices of Introduction of Complementary Feeding and Iron Deficiency Prevention in the Middle East and North Africa.

BACKGROUND: Iron deficiency (ID) with or without anemia is associated with impaired mental and psychomotor development. Given the paucity of information on physicians' knowledge and practices on iron (Fe) supplementation and impact of ID in the Middle East and North Africa, it was felt important to conduct a survey. METHOD: A group of expert physicians developed a questionnaire that was randomly distributed among Middle East and North Africa doctors to assess their knowledge and practices on introduction of complementary feeding, impact of ID, its prevention, and their impression on prevalence of ID. Descriptive statistics were used. RESULTS: We received 2444 completed questionnaires. Thirty-nine percent of physicians do not follow the European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines regarding age of introduction of complementary feedings. Approximately 62% estimate the prevalence of ID anemia to be 40% to 70%; however, only 17% always monitor hemoglobin between 9 and 12 months of age, 43% do so "almost" always, whereas 36% do so "rarely" or (4%) "never." For the prevention of ID in infants older than 6 months of age, almost all recommend introducing Fe supplements. Ninety-seven percent agree that untreated ID during infancy may have long-term negative effects on cognitive function, whereas 53.26% consider that Fe-enriched infant cereals result in staining of the baby teeth, constipation, and dark stools. CONCLUSIONS: Although there is awareness of the impact of ID, there are some misconceptions regarding age of introduction of complementary feedings, surveillance of Fe status, and side effects of Fe-enriched infant cereals. There is a need for educational initiatives focusing on prevention of Fe deficiency.

Complementary Feeding: Beyond Nutrition.

In this article, we will summarize the key non-nutritional aspects of the introduction of complementary feeding. Intestinal maturation related to starch digestion is relatively complete by the time complementary feeding is recommended to be initiated. A much more complex maturation is needed, however, from the neurodevelopmental standpoint as the infants need to be able to hold their head and trunk and be able to coordinate tongue movement followed by swallowing. Issues can arise in infants with a history of medical problems as well as when caretakers cannot handle the initial difficulties or want to impose certain rigidity to the learning process. The introduction of complementary feedings is also part of the early steps in introduction to human socialization. In that regard, it sets up the infant to internalize and accept the diversity of food textures and food choices. Early refusal of some food items is common and should not be interpreted as being disliked. Multiple attempts should be made to incorporate new food items. To accomplish these dynamics, caregivers need comprehensive education and relevant information.

Review shows that parental reassurance and nutritional advice help to optimise the management of functional gastrointestinal disorders in infants.

AIM: Regurgitation, infantile colic and functional constipation are common functional gastrointestinal disorders (FGIDs) during infancy. Our aim was to carry out a concise review of the literature, evaluate the impact of these common FGIDs on infants and their families, and provide an overview of national and international guidelines and peer-reviewed expert recommendations on their management. METHODS: National and international guidelines and peer-reviewed expert recommendations on the management of regurgitation, infantile colic and functional constipation were examined and summarised. RESULTS: Regurgitation, infantile colic and functional constipation cause frequent parental concerns, lead to heavy personal and economic costs for families and impose a financial burden on public healthcare systems. Guidelines emphasise that the first-line management of these common FGIDs should focus on parental education, reassurance and nutritional advice. Nutritional advice should stress the benefits of continuing breastfeeding, while special infant formulas may be considered for non-breastfed infants with common FGIDs. Drug treatment is seldom required, with the exception of functional constipation. CONCLUSION: By providing complete and updated parental education, reassurance and nutritional advice, healthcare professionals can optimise the management of FGIDs and related symptoms and reduce the inappropriate use of medication or dietary interventions.

Low-impedance Baseline Values Predict Severe Esophagitis.

OBJECTIVES: The aim of the study was to determine whether esophageal baseline impedance (BI) values in children could be predictive of esophagitis. MATERIALS AND METHODS: Multichannel intraluminal impedance (MII) tracings of children 3 to 17 years of age suspected of having gastroesophageal reflux and esophagitis, who had also undergone upper endoscopy with multiple esophageal biopsies, were reviewed. Patients with eosinophilic esophagitis were excluded. Esophagitis was assessed by macroscopic and microscopic parameters. Esophageal histology was reported by 2 blinded independent pathologists unaware of the MII results. Mean BI was automatically calculated in the different MII channels (ch) by the specific software without removing any episode of increased/decreased BI. BI results were plotted against macroscopic and histological scores for each channel. RESULTS: Tracings of 87 children, 53 boys, were evaluated. Mean age was 7.4 years: 45 had histologic esophagitis, 8 macroscopic. Histologic mild esophagitis (grade 1) was observed in 30, and 15 had moderate to severe esophagitis (grade 2-3). Ten had grade 3 esophagitis. Eight had macroscopic esophagitis as well. RESULTS: in channel 6 of the MII, all 10 patients with grade 3 esophagitis and the 8 with macroscopic esophagitis had a BI <900 Ω/s (positive predictive value 100% and negative predictive value 100%), whereas none of those having a biopsy score of 0 to 2 or no endoscopic evidence of esophagitis had a mean BI below 2000 Ω/s. CONCLUSIONS: The evaluation of the BI measured in channel 6 gave us 100% prediction of grade 3 and macroscopic esophagitis. BI on channel 6 may be useful to predict severe esophageal mucosa inflammation and could potentially be used for follow-up evaluation, rather than repeating an upper endoscopy. In addition, it would seem that grade 3 esophagitis even in the absence of macroscopic esophagitis affects the integrity of the esophageal epithelium.

Small Bowel Bacterial Overgrowth in Children.

OBJECTIVES: The aim of study was to perform a comprehensive review of the pathogenesis, available diagnostic procedures, prevalence, clinical manifestations, and consequences of small bowel bacterial overgrowth (SBBO) as well as treatment options in the pediatric population. METHODS: A literature search including MEDLINE, PubMed, and Web of Science databases was performed. RESULTS: SBBO is found in a variety of childhood conditions in which the normal homeostatic mechanisms restricting bacterial colonization in the small bowel are disturbed by congenital or acquired anatomical abnormalities, diminished gastric acid secretion, congenital alteration of intestinal motility or acquired small bowel diseases, or other chronic disorders including primary or acquired immunodeficiency. Data show that SBBO may be an underrecognized cause of pediatric morbidity. Although several diagnostic tests for SBBO determination are available, each has its drawbacks and limitations. Indeed, there is still no "criterion standard" for SBBO diagnosis in the pediatric population. Owing to lack of established guidelines and few published interventional studies that assess the effectiveness of SBBO therapy, treatment of children with SBBO remains empiric and comprises antibiotic or probiotic therapy. CONCLUSIONS: Further research is needed to determine the clinical impact of SBBO and to establish diagnostic and therapeutic guidelines applicable to children.

Functional gastro-intestinal disorder algorithms focus on early recognition, parental reassurance and nutritional strategies.

UNLABELLED: Up to 50% of infants present with symptoms of regurgitation, infantile colic and/or constipation during the first 12 months of life. Although they are often classed as functional disorders, there is an overlap with cows' milk allergy. We present practical algorithms for the management of such disorders, based on existing evidence and general consensus, with a particular focus on primary health care. Management consists of early recognition of warning signs of organic disease, parental reassurance and nutritional strategies. CONCLUSION: The proposed algorithms aim to help healthcare providers manage frequent gastrointestinal and cows' milk-related symptoms in infants safely and effectively.

An international consensus report on a new algorithm for the management of infant diarrhoea.

AIM: Implementing international guidelines guarantees high standards of clinical care. A group of experts developed an algorithm to drive the management of common gastrointestinal symptoms in infancy by paediatricians and general practitioners. METHODS: The algorithm started from the evidence-based recommendations of the European Society of Gastroenterology, Hepatology and Nutrition and the European Society of Pediatric Infectious Diseases and an updated review of the literature. We used the structured quantitative method of nominal group technique to reach a consensus. RESULTS: A practical algorithm for the management of infants with acute diarrhoea was designed based on the consensus reached for each statement. The management of an infant with acute diarrhoea should include a sequence of actions: (i) a semiquantitative estimate of infant dehydration through validated clinical scores, (ii) rehydration therapy and early refeeding with breast milk or regular formula and (iii) effective agents to reduce the severity and duration of the diarrhoea. Finally, in children with prolonged diarrhoea, the search for aetiology should include persistent infections or reinfections, cows' milk protein allergy and coeliac diseases. Lactose should always be withdrawn. CONCLUSION: This algorithm provides an evidence-based sequence of interventions to optimise the management of infants with acute diarrhoea.

Small Bowel Bacterial Overgrowth Associated with Persistence of Abdominal Symptoms in Children Treated with a Proton Pump Inhibitor.

Small bowel bacterial overgrowth (SBBO) was diagnosed in 22.5% of 40 children treated for 3 months with a proton pump inhibitor (PPI). Compared with those without SBBO, children with SBBO had higher frequency of abdominal pain, bloating, eructation, and flatulence. Patients with gastrointestinal symptoms after PPI treatment should be evaluated for SBBO rather than empirically prolonging PPI therapy.

Prevalence and Health Outcomes of Functional Gastrointestinal Symptoms in Infants From Birth to 12 Months of Age.

OBJECTIVES: The aim of the study was to review published evidence and the opinion of practising clinicians on the prevalence and long-term health consequences of functional gastrointestinal symptoms in infants younger than 12 months. METHODS: PubMed was searched from inception to November 2014 to find articles reporting the prevalence and long-term health outcomes of infantile colic, regurgitation, functional constipation, functional diarrhoea, and dyschezia in infants younger than <12 months. A questionnaire was sent to practising clinicians worldwide, and a group of 15 international experts met to discuss the likely frequency and longer-term consequences of these symptoms. RESULTS: The literature search identified 30 studies reporting the prevalence of infantile colic (2%-73%), 13 that of regurgitation (3%-87%), 8 that of functional constipation (0.05%-39.3%), 2 that of functional diarrhoea (2%-4.1%), and 3 that of dyschezia (0.9%-5.6%). The studies varied in design, populations investigated, and definition of the symptoms. Questionnaires were received from 369 respondents. The experts agreed that the likely prevalences for colic, regurgitation, and functional constipation were 20%, 30%, and 15%, respectively. The limited data in the literature for functional diarrhoea and dyschezia suggest prevalences <10%. Infantile colic may be associated with future health problems in a subset of infants. CONCLUSIONS: Functional gastrointestinal symptoms appear to occur in a significant proportion of infants younger than 12 months and may have an impact on future health outcomes. Prospective collection of data according to agreed criteria is needed to obtain more accurate estimates of the prevalence and consequences of these symptoms.

Cow's milk allergy: evidence-based diagnosis and management for the practitioner.

UNLABELLED: This review summarizes current evidence and recommendations regarding cow's milk allergy (CMA), the most common food allergy in young children, for the primary and secondary care providers. The diagnostic approach includes performing a medical history, physical examination, diagnostic elimination diets, skin prick tests, specific IgE measurements, and oral food challenges. Strict avoidance of the offending allergen is the only therapeutic option. Oral immunotherapy is being studied, but it is not yet recommended for routine clinical practice. For primary prevention of allergy, exclusive breastfeeding for at least 4 months and up to 6 months is desirable. Infants with a documented hereditary risk of allergy (i.e., an affected parent and/or sibling) who cannot be breastfed exclusively should receive a formula with confirmed reduced allergenicity, i.e., a partially or extensively hydrolyzed formula, as a means of preventing allergic reactions, primarily atopic dermatitis. Avoidance or delayed introduction of solid foods beyond 4-6 months for allergy prevention is not recommended. CONCLUSION: For all of those involved in taking care of children's health, it is important to understand the multifaceted aspects of CMA, such as its epidemiology, presentation, diagnosis, and dietary management, as well as its primary prevention.

The impact of atopic dermatitis on quality of life.

Approximately 5-20% of children worldwide suffer from atopic dermatitis (AD), a kind of dermatitis characterized as an inflammatory, relapsing, noncontagious and itchy skin disorder. Children often develop AD during their first year of life. An increased rate of sensitization to both food and aeroallergens has been shown to coexist in patients with AD. Sensitization to well-known allergens such as cow's milk protein can occur on average in 50% of children with AD. In general, quality of life (QoL) is perceived as the quality of an individual's daily life, that is, an assessment of their well-being or lack thereof. QoL is a broad concept that includes such things as standard of living, community, and family life. Patients with skin diseases experience a wide range of symptoms ranging from trivial problems to major handicaps which affect their lives. The misery of living with AD cannot be overstated for it may have a profoundly negative effect on the health-related QoL of children and their families in many cases. Physicians taking care of children with AD should consult parents on how their child's illness has impacted their lifestyle and recommend professional intervention if deemed necessary.

Do parents and children agree? Quality-of-life assessment of children with inflammatory bowel disease and their parents.

BACKGROUND AND OBJECTIVES: Multi-item measures of inflammatory bowel disease (IBD) activity based on clinical, laboratory, and/or endoscopic variables do not take into consideration the impact on the patients' emotional aspects and adaptation to the disease. The aim of the present study was to evaluate concordance between parent and child ratings of health-related quality of life on the IMPACT-III questionnaire in children with IBD. METHODS: The IMPACT-III questionnaire was used to measure quality of life in 27 patients (mean age 14.2 ± 3 years, 40% girls) and one of their parents (82% mothers). Most of the patients had inactive disease at the time of the study. Differences between parent-proxy ratings and child ratings on the IMPACT-III were compared via paired-samples t tests, intraclass correlation coefficients, and standardized difference scores. RESULTS: Parent-proxy and patient ratings were similar on total IMPACT-III and its related domains (bowel symptoms, systemic symptoms, social functioning, body image, treatment/interventions), except that significant differences on emotional functioning ratings were found (P = 0.003). Intraclass correlation coefficients showed medium-to-large effect sizes (range 0.52-0.88) and standardized difference scores showed varying degrees of bias depending on the domain measured (range -0.64 to 0.32). CONCLUSIONS: Parents served as a good proxy for quality-of-life ratings in this population of pediatric patients with IBD. The degree of concordance between parent and child scores, however, varied, as observed in the present study in which parents underreported their child's health-related quality of life on the IMPACT-III emotional functioning domain.

Role of adjuvant Crohn's disease exclusion diet plus enteral nutrition in asymptomatic pediatric Crohn's disease having biochemical activity: A randomized, pilot study.

BACKGROUND: Conventional therapy can result in remission in mild-moderate pediatric Crohn's disease (CD). However, some patients experience loss of response to biological drugs despite increased dosage. METHODS: We planned to determine that CD exclusion diet plus partial enteral nutrition offers additional benefits in asymptomatic children with CD having elevated fecal calprotectin. A randomized, open-label, pilot, controlled interventional study was conducted in children with CD while on medical treatment and elevated fecal calprotectin on routine testing. Patients continued their medications and were randomized into a group that received CD exclusion diet plus partial enteral nutrition for 12 weeks and one that continued a regular diet. RESULTS: Twenty-one patients participated: 11 received CD exclusion diet plus partial enteral nutrition and 10, regular diet. Median fecal calprotectin in the CD exclusion diet plus partial enteral nutrition decreased in 9/11 to 50% of baseline, remaining practically unchanged in the regular diet, except for two patients (p = 0.005). Body mass index z-score increased in the CD exclusion diet plus partial enteral nutrition. Only 1/11 patients in the CD exclusion diet plus partial enteral nutrition group, while 4/10 in the regular diet, experienced clinical relapse (p = 0.149). Only one patient in the CD exclusion diet plus partial enteral nutrition, while eight in the regular diet, were considered to need their biologic treatment intensified (p = 0.005); 2/11 in the CD exclusion diet plus partial enteral nutrition had the dose or frequency of the biologic reduced vs. none (0/10) in the regular diet group. The short Pediatric Crohn's Disease Activity Index and anthropometry showed no significant changes in either group. CONCLUSIONS: Diet therapy could be a useful addition to medications in children with CD in apparent remission, but elevated fecal calprotectin. TRIAL REGISTRATION: Clinical trial number: NCT05034458.

Infantile Colic: A Survey of Physicians in Pakistan.

Purpose: Infantile colic diagnostic criteria were established by Rome IV. A universally accepted management remains to be established. We aimed to evaluate diagnostic criteria, management strategies, and perceived regional prevalence of infantile colic in Pakistan, as well as its effect on physicians and parents. Methods: A questionnaire was distributed amongst 1,256 physicians. Results: We received 800 replies. Wessel and Rome IV criteria were used by most physicians for diagnosis; however, the response "any infant who cries a lot" was selected by older physicians (48% of those over 60 years), physicians in rural areas (32%), physicians practicing in private clinics (27%), and general physicians (30%). Estimated prevalence of infantile colic ranges from 21-40%. Reassurance was the most widely recommended management strategy followed by herbal teas (51%), switching to a different formula (49%), probiotics (28%) and antibiotics (26%), discontinuation of breastfeeding (14%), elimination of dairy products from the breastfeeding mothers' diet (6%), and the administration of colic drops (1%). Most physicians considered the negative impact of colic on their personal lives and the parents as mild-to-moderate. Notably, 38% of percent of physicians routinely screened for maternal depression, and 45% of physicians were aware of the association between infantile colic and shaken baby syndrome. Conclusion: Most physicians in Pakistan diagnose and manage infantile colic according to the established guidelines. However, the guidelines pertaining to treatment planning are not followed. Educational efforts directed toward general physicians and doctors practicing in rural areas and clinics must be implemented to avoid unnecessary testing and treatment burden.