[From medical school to paediatric residency, stopping of at the MIR exam: something must change? A survey of fourth year pediatric residents]. / De las facultades de Medicina a la residencia de Pediatría, pasando por el examen de médico interno residente: ¿algo debe cambiar? Resultados de una encuesta en residentes de Pediatría de cuarto año.

INTRODUCTION: The Spanish medical education system has made a great contribution to the development of the National Health Service, but a need for an overall assessment process still remains. AIM: Evaluate several issues of under- and postgraduate (MIR) medical education of Spanish residents in Paediatrics. METHOD: An anonymous questionnaire with coded answers administered to 61 paediatric residents in the fourth year of specialty. RESULTS: Two thirds of residents think that the Medicine curriculum must change, with less theoretical education. Similarly a proportion of residents believes that the MIR Exam should introduce items on skills and abilities in addition to the current items. Resident tutors are considered positively in 90% of cases, but 35% of them failed in their assessment. Concepts related to evidence-based medicine are being introduced into undergraduate medical education (48% of answers) and postgraduate (69%), but we still found several areas for improvement: bibliographic information searching and critical appraisal of scientific documents. CONCLUSIONS: The quality of medical education (undergraduate and postgraduate) shows several issues that must change, mainly related to two current paradigms: the European Higher Education Area (EEHA) and Evidence-Based Medicine (EBM).

Cold urticaria and celiac disease.

Cold urticaria can be associated with blood and thyroid disorders, drugs, or infections. Celiac disease is an autoimmune enteropathy caused by permanent gluten intolerance. It is often associated with other autoimmune diseases, such as chronic idiopathic urticaria. Nevertheless, association with cold urticaria has not yet been described. A boy aged 3 years 8 months presented local urticaria-angioedema when exposed to cold temperatures. An ice cube test was positive and iron deficiency anemia was demonstrated. He later developed legume intolerance, rhinoconjunctivitis related to pollen sensitization, and asthma. Due to persistence of cold urticaria symptoms and refractory anemia, a test for immunoglobulin A autoantibodies to tissue transglutaminase and an intestinal biopsy were performed. Results of both tests were compatible with celiac disease.A study of human leukocyte antigen indicated a high risk phenotype (HLA, DR6/DR7; DQA 0501, 0201; DQB 0301, 0201). After 7 months of a gluten-free diet, the boy's anemia resolved and he is free of symptoms when exposed to cold. This is a first description of the possibility of an association between celiac disease and cold urticaria. A poor course of cold urticaria in the absence of evidence of another underlying condition should lead to suspicion of celiac disease.

[Prevention of childhood osteoporosis]. / Prevenció de la osteoporosis en la infancia.

Bone mineralization depends on genetic, nutritional, endocrine, metabolic and mechanical factors. Dairy products form the major source of dietary calcium and vitamin D, both of which are essential for optimal bone mineralization. Osteoporosis is defined as a reduction in bone mass; it is exacerbated by malnutrition, low weight, poor intake of vitamin D and calcium and lack of physical exercise. The purpose of this article is to encourage pediatricians to make an effort about the prevention of childhood osteoporosis.

[Case-control study of risk factors associated with constipation. The FREI Study]. / Estudio caso-control de los factores de riesgo asociados al estreñimiento. Estudio FREI.

BACKGROUND: Children represent one of the patient groups most affected by constipation. Our objective was to identify and describe the risk factors associated with childhood constipation. PATIENTS AND METHODS: The study had a case-control, retrospective, open and multicenter design. Clinical data on possible risk factors were collected through an ad-hoc questionnaire. Two groups were studied: children with and without constipation. RESULTS: Nine hundred twenty-one children were recruited; of these, 898 (97.6%) were included in the statistical analysis. There were 408 (45.4%) children in the constipated group and 490 (54.5%) in the non-constipated group. Most of the children with constipation (53.6%) had a maternal history of constipation compared with 21.4% of children without constipation (p < 0.05). More than half (53.2%) of the constipated children reported a lack of regularity in their toilet habits while 64.9 % of the children without constipation went to the toilet regularly. Toilet training started slightly earlier (at 3 years) in children without constipation (93.2%) than in those with the disorder (83.8%) (p < 0.05). At school, 57.4% of the children with constipation never used the toilet compared with 26.8% of those without constipation (p < 0.05). A total of 73.4% of children with constipation drank less than four glasses of water per day compared with 47.1% of those without constipation (p < 0.05). Consumption of vegetables and legumes in the diet was significantly lower in children with constipation than in those without (p < 0.05). The risk factors linked to childhood constipation found in this study were a familial history of constipation, irregular toilet habits, low dietary fiber contents and no fruit intake. The main preventive factors against constipation were water and vegetable consumption and training on the use of the toilet at school. CONCLUSIONS: Daily toilet training and dietary changes are needed to prevent constipation among children and to achieve regular defecation. This preventive intervention should be reinforced at school.

[Microbiota and gastrointestinal diseases]. / Microbiota y enfermedades gastrointestinales.

The bacterial colonisation is established immediately after birth, through direct contact with maternal microbiota, and may be influenced during lactation. There is emerging evidence indicating that quantitative and qualitative changes on gut microbiota contribute to alterations in the mucosal activation of the immune system, leading to intra- or extra-intestinal diseases. A balance between pathogenic and beneficial microbiota throughout childhood and adolescence is important to gastrointestinal health, including protection against pathogens, inhibition of pathogens, nutrient processing (synthesis of vitamin K), stimulation of angiogenesis, and regulation of host fat storage. Probiotics can promote an intentional modulation of intestinal microbiota favouring the health of the host. A review is presented on the modulation of intestinal microbiota on prevention, and adjuvant treatment of some paediatric gastrointestinal diseases.

[The introduction of gluten into the infant diet. Expert group recommendations]. / La introducción del gluten en la dieta del lactante. Recomendaciones de un grupo de expertos.

At present there is a degree of uncertainty regarding when, how and in what form gluten should be introduced into the infant diet. For years the recommendations of the ESPGHAN Committee on Nutrition have prevailed, which include avoiding early introduction, before 4 months, and late, after 7 months, and gradually introducing gluten into the diet while the infant is being breastfed, with the aim of reducing the risk of celiac disease, diabetes and gluten allergy. However, 2 independent studies published in The New England Journal of Medicine in October 2014 reached the conclusion that the age of introduction of gluten does not modify the risk of developing celiac disease, and that breastfeeding at any age does not confer protection against celiac disease development. On the other hand, according to available scientific evidence, the introduction of foods other than breast milk or formula into the infants diet is generally recommended around 6 months of age, since the introduction before 4 months could be associated with an increased risk of food allergy and autoimmune diseases, and delaying it beyond 7 months would not have a protective effect. In this context, a group of experts has considered it appropriate to produce a consensus document based on the current scientific evidence and present general recommendations for daily clinical practice on the introduction of gluten into the diet.

Study of gastrointestinal polypeptides controlling gastric acid secretion in patients with primary antibody deficiency.

BACKGROUND: gastric abnormalities are a common feature in patients with primary antibody deficiency. The most important problem is the high incidence of stomach cancer found in these patients. Chronic atrophic gastritis with pernicious anemia is also a common finding that predisposes to gastric adenocarcinoma. The aim of the present study was to identify factors predictive of high risk for developing gastric cancer in patients with primary antibody deficiency. PATIENTS AND METHODS: we studied gastric hormones (gastrin, somatostatin and gastrin-releasing peptide, GRP) in 47 patients (23 children and 24 adults) with primary antibody deficiency. In accordance with the World Health Organization (WHO) classification, patients were diagnosed as having X-linked agammaglobulinemia (Bruton disease) in 13 cases, common variable immunodeficiency in 28, and hypogammaglobulinemia with hyperIgM in 6. Gastric biopsy was performed in 22 patients (16 children and 6 adults). Hormone determinations were carried out by radioimmunoassay. RESULTS: baseline serum gastrin levels were normal or increased compared with controls, but the response to stimulation with a hyperproteic diet was delayed in 18 patients and lower than in controls in 7. In 4 adult patients, all with pernicious anemia, gastric biopsy revealed chronic atrophic gastritis involving the stomach corpus and antrum (type B gastritis). The absence of a normal response of gastrin secretion to stimulation with a hyperproteic diet may be explained by this finding. Serum somatostatin and GRP levels were higher than in controls. No correlations were found between these findings and patient age, type of immunodeficiency or duration of clinical manifestations.

Study of gastrointestinal polypeptides controlling gastric acid secretion in patients with primary antibody deficiency.

BACKGROUND: Gastric abnormalities are a common feature in patients with primary antibody deficiency. The most important problem is the high incidence of stomach cancer found in these patients. Chronic atrophic gastritis with pernicious anemia is also a common finding that predisposes to gastric adenocarcinoma. The aim of the present study was to identify factors predictive of high risk for developing gastric cancer in patients with primary antibody deficiency. PATIENTS AND METHODS: We studied gastric hormones (gastrin, somatostatin and gastrin-releasing peptide, GRP) in 47 patients (23 children and 24 adults) with primary antibody deficiency. In accordance with the World Health Organization (WHO) classification, patients were diagnosed as having X-linked agammaglobulinemia (Bruton disease) in 13 cases, common variable immunodeficiency in 28, and hypogammaglobulinemia with hyperIgM in 6. Gastric biopsy was performed in 22 patients (16 children and 6 adults). Hormone determinations were carried out by radioimmunoassay. RESULTS: Baseline serum gastrin levels were normal or increased compared with controls, but the response to stimulation with a hyperproteic diet was delayed in 18 patients and lower than in controls in 7. In 4 adult patients, all with pernicious anemia, gastric biopsy revealed chronic atrophic gastritis involving the stomach corpus and antrum (type B gastritis). The absence of a normal response of gastrin secretion to stimulation with a hyperproteic diet may be explained by this finding. Serum somatostatin and GRP levels were higher than in controls. No correlations were found between these findings and patient age, type of immunodeficiency or duration of clinical manifestations.

[Guidelines for the treatment of functional constipation]. / Recomendaciones para el tratamiento del estreñimiento funcional.

Constipation is common in childhood. It can affect around 5-30% of the child population, depending on the criteria used for diagnosis. The currently recommended treatment is based on three main points: a) explanation, b) disimpaction and c) maintenance therapy consisting of diet changes, behavioural modification, and the use of laxatives. In the last decades treatment on disimpaction have changed radically from the rectal route to the oral route with polyethylene glycol 3350 (PEG), the most used and accepted regimen nowadays. Treatment and care should take into account the individual needs and preferences of the patient. Good communication is essential, to allow patients to reach informed decisions about their care. Maintenance therapy consists of dietary interventions, toilet training, and laxatives to obtain daily painless defaecation in order to prevent re-accumulation of stools. Maintenance therapy should be start as soon as the child's bowel is disimpacted. Early intervention with oral laxatives may improve complete resolution of functional constipation. Enemas using phosphate, mineral oil, or normal saline are effective in relieving rectal impaction, but carry the risk of mechanical trauma and are not recommended for maintenance therapy in the paediatric population. Among osmotic agents, polyethylene glycol 3350 plus electrolyte solutions appear to be the first-line drug treatment to use in children of any age, as it is safe, effective, and well-tolerated. Recommended doses ranges from 0.25 to 1.5g/kg. Advances in the understanding of the gastrointestinal enteric nervous system and epithelial function have led to the development of new substances that bind to serotonin receptors or are chloride channel activators.

Microbiota y enfermedades gastrointestinales / Microbiota and gastrointestinal diseases

La colonización bacteriana se establece inmediatamente después del nacimiento, por contacto directo con la microbiota materna, y puede modificarse durante la lactancia. Están apareciendo datos indicativos de que modificaciones cuantitativas y cualitativas de la microbiota intestinal son capaces de estimular cambios en la activación del sistema inmune que pueden conducir a la aparición de enfermedades gastrointestinales o extraintestinales. El equilibrio entre la microbiota patógena y beneficiosa durante la niñez y la adolescencia es importante para la salud gastrointestinal, incluyendo la protección frente a patógenos, la inhibición de patógenos, el procesamiento de nutrientes (síntesis de vitamina K), el estímulo de la angiogénesis y la regulación del almacenamiento de la grasa corporal. También los probióticos pueden modular la microbiota intestinal para favorecer la salud del huésped. Este artículo es una revisión sobre la acción moduladora de la microbiota intestinal en la prevención y el tratamiento coadyuvante de las enfermedades gastrointestinales pediátricas

The bacterial colonisation is established immediately after birth, through direct contact with maternal microbiota, and may be influenced during lactation. There is emerging evidence indicating that quantitative and qualitative changes on gut microbiota contribute to alterations in the mucosal activation of the immune system, leading to intra- or extra-intestinal diseases. A balance between pathogenic and beneficial microbiota throughout childhood and adolescence is important to gastrointestinal health, including protection against pathogens, inhibition of pathogens, nutrient processing (synthesis of vitamin K), stimulation of angiogenesis, and regulation of host fat storage. Probiotics can promote an intentional modulation of intestinal microbiota favouring the health of the host. A review is presented on the modulation of intestinal microbiota on prevention, and adjuvant treatment of some paediatric gastrointestinal diseases

[An evidence based Iberic-Latin American guideline for acute gastroenteritis management in infants and prescholars]. / Manejo de la gastroenteritis aguda en menores de 5 años: un enfoque basado en la evidencia Guía de práctica clínica Ibero-Latinoamericana.

Acute gastroenteritis (AG) morbidity and mortality rates in infants and prescholars continue to be high in developing countries. Authors want to develop an evidence-based document that supports decision making regarding AG therapy in infants and children younger than 5 y/o. A systematic review of the literature was performed (May, 2008). Evidence grading was established according to Oxford guidelines and Latin American experts submitted their opinions on the recommendations generated. Oral rehydration solutions are the threatment's keystone for children with AG, showing lesser complications due to therapy than IV fluids. AG is no contraindication of a normal diet. Racecadotril, zinc and smectite can contribute to AG treatment, as well as Lactobacillus GG and Saccharomycces boulardii. No other drugs are recommended. It is recommended to treat children presenting AG with oral rehydration solutions among racecadotril, zinc or smectite as well as some probiotics.

La introducción del gluten en la dieta del lactante. Recomendaciones de un grupo de expertos / The introduction of gluten into the infant diet. Expert group recommendations

En el momento actual existe una situación de indefinición con respecto a cuándo, cómo y de qué forma debe introducirse el gluten en la dieta del lactante. Durante años ha prevalecido la recomendación del Comité de Nutrición de la ESPGHAN de evitar tanto la introducción precoz, antes de los 4 meses, como la tardía, después de los 7 meses, y de introducir el gluten gradualmente mientras el lactante recibe leche materna; se pretendía con ello reducir el riesgo de enfermedad celiaca, diabetes y alergia al gluten. Sin embargo, 2 estudios independientes publicados en octubre de 2014 en The New England Journal of Medicine llegan a la conclusión de que la edad de introducción del gluten no modifica el riesgo de desarrollar la enfermedad celiaca y que la lactancia materna a cualquier edad tampoco confiere protección. Por otra parte, según la evidencia científica disponible, en general, se recomienda la introducción de otros alimentos en la dieta distintos de la leche materna o de fórmula alrededor de los 6 meses de edad, ya que la introducción antes de los 4 meses se asociaría a un riesgo aumentado de enfermedades autoinmunes y alergia alimentaria, y retrasarla más allá de los 7 meses no tendría efecto protector. En este contexto, un grupo de expertos ha considerado pertinente elaborar un documento de consenso basado en las evidencias científicas actuales y establecer unas recomendaciones generales para la introducción del gluten en la práctica clínica diaria (AU)

At present there is a degree of uncertainty regarding when, how and in what form gluten should be introduced into the infant diet. For years the recommendations of the ESPGHAN Committee on Nutrition have prevailed, which include avoiding early introduction, before 4 months, and late, after 7 months, and gradually introducing gluten into the diet while the infant is being breastfed, with the aim of reducing the risk of celiac disease, diabetes and gluten allergy. However, 2 independent studies published in The New England Journal of Medicine in October 2014 reached the conclusion that the age of introduction of gluten does not modify the risk of developing celiac disease, and that breastfeeding at any age does not confer protection against celiac disease development. On the other hand, according to available scientific evidence, the introduction of foods other than breast milk or formula into the infants diet is generally recommended around 6 months of age, since the introduction before 4 months could be associated with an increased risk of food allergy and autoimmune diseases, and delaying it beyond 7 months would not have a protective effect. In this context, a group of experts has considered it appropriate to produce a consensus document based on the current scientific evidence and present general recommendations for daily clinical practice on the introduction of gluten into the diet (AU)

[Results of the treatment of gastroesophageal reflux and peptic esophagitis using cisapride]. / Resultados del tratamiento del reflujo gastroesofágico y la esofagitis péptica con Cisapride.

Cisapride is a new prokinetic agent that acts at gastric emptying, esophagic peristalsis and the pressure of the low esophagic sphincter. In the present study we grave Cisapride for 12 weeks to 34 patients with severe pathologic gastroesophageal reflux and/or peptic esophagitis. The results show an important improvement of the clinic, pH monitoring, endoscopic and histologic alterations.

[Cystic fibrosis: nutritional considerations]. / Fibrosis quística: aspectos nutricionales.

During the last few decades, improved treatment measures and nutritional support in cystic fibrosis have increased survival and quality of life in these patients. There is a clear relationship between the development of malnutrition and worsening in respiratory function and both factors have been related to poor disease outcome. Malnutrition is a very frequent complication of this disease and is found in 20% of patients, due to negative energy-proteic balance. This disequilibrium can be explained by increased energy expenditure, high nutritional requirements and decreased oral intake. Periodic monitoring of clinical, anthropometrical and functional nutritional status is mandatory. Intake must be greater than requirements and specific nutritional support should be established when required. Patients with cystic fibrosis must receive a hypercaloric and hyperproteotic diet, with a high fat content, a normal quantity of carbohydrates and with pancreatic and liposoluble vitamin supplements in case of pancreatic insufficiency.

[Breast feeding in a metropolitan area: (II). Design for a promotion program]. / La lactancia materna en un área metropolitana: (II). Diseño de un programa de promoción.

Because of the importance of breast-feeding in the health of both the mother and child, and taking into consideration its poor situation at the present time, it seems fully justified to start a program to promote breast-feeding. This program basically will consist of training health professionals and in the improvement of both the mother's and hospital's practices. It is necessary to motivate health authorities and to curb the excess in formula promotion. Mass-media should be employed for the promotion of breast-feeding and a system should be implemented to obtain a proper record of the duration of breast-feeding.

[Nodular antritis and Helicobacter pylori infection in children]. / Antritis nodular e infección por Helicobacter pylori en el niño.

We have studied 115 patients infected with Helicobacter pylori (HP). Endoscopic nodular antritis and histologic lymphonodular hyperplasia was noted. The frequency of nodular antritis was compared between the 115 HP patients and a HP-negative age-matched control group. Nodular antritis was observed in 70.4% of the HP-positive patients and 11.3% of the HP-negative group (p <0.001). The specificity of nodular antritis was 86.1%. A significant association was found between the existence of nodular antritis and histologic lymphonodular hyperplasia (67.9%; p < 0.001). In conclusion, the endoscopic nodular antritis is a frequent and specific finding in children with HP infection and is associated with histologic lymphonodular hyperplasia.

[Primary saccharose-isomaltose deficit: a 20-year case load]. / Déficit primitivo de sacarasa-isomaltasa: observaciones en veinte años.

In the last twenty years we have diagnosed 9 cases of congenital sucrase-isomaltase deficiency. In all the cases the diagnosis was made before 9 months of age and was confirmed by quantitative determination of sucrase-isomaltase activity in jejunal mucosal homogenates. Malnutrition and dehydration were frequent findings. In 3 cases there was clinical intolerance to dextrinomaltose and to glucose polymers. In the 6 cases in which were performed, abnormal breath H2 test after an oral sucrose load was found. Lactase activity was above the mean in all cases and an important decrease of maltase activity was demonstrated. The enzymatic deficiency persisted even though the clinical tolerance to sucrase improved with age.

[Protein-losing enteropathy of cardiac origin: value of intestinal clearance of alpha-1-antitrypsin]. / Enteropatía pierde-proteínas de causa cardiaca: valor del aclaramiento intestinal de alfa-1-antitripsina (alpha-1-AT).

Two patients with protein-losing enteropathy of cardiac origin, one case due to constrictive pericarditis and another as a complication of a Fontan operation, are presented. In both cases the clinical symptomatology and the analytical pattern were very suggestive of loss of protein through the intestinal lumen. This was confirmed by the determination of fecal fecal alpha-1-antitrypsin (alpha-1-AT) and its intestinal clearance. The utility of both determinations as a simple and secure method in substitution of isotopic studies is emphasized.

[Value of the BUN/creatinine ratio in localizing digestive system hemorrhage in children]. / Valor del cociente BUN/creatinina (BUN/Cr) en la localización de la hemorragia digestiva del niño.

We have evaluated the usefulness of the BUN/Cr ratio in 62 children with gastrointestinal bleeding. For upper gastrointestinal hemorrhage, the calculated BUN/Cr ratios ranged from 10 to 66.6, with a mean value of 30.85. For lower gastrointestinal bleeders, the BUN/Cr ratios ranged from 12.5 to 28, with a mean value of 20.12. 18 patients with upper gastrointestinal hemorrhage had a BUN/Cr ratio greater than 30 and all patients with lower gastrointestinal hemorrhage had a ratio of less than 30. The patients with gastroduodenal peptic ulcer had the highest ratios. We concluded that the BUN/Cr ratio is useful to discriminate upper and lower bleeding sources, especially in patients with gastroduodenal ulcer.

[Primary peptic ulcer in infancy and childhood. Personal experience]. / Ulcera péptica primaria en la infancia. Nuestra experiencia.

We report a retrospective review of primary peptic ulcer peptic disease in 61 children. The follow-up period ranged from 1 month to 6 years. All cases were confirmed by endoscopic examination and related with radiological studies result. The number of ulcer peptic disease detected increased as much as the number of endoscopies were performed annually. In the last 20 patients pinch biopsies from antrum were taken looking for Campylobacter pylori, encountering 10 positives. The relation male:female were 2:1. Gastrointestinal bleeding had occurred in children below 6 years and abdominal pain was seen in older children. All of patients who had C. pylory infection had had recurrent abdominal pain. Three peptic ulcer were documented in patients with cystic fibrosis, which had the worse response to medical treatment. Others, had a satisfactory response.