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.

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.

MR enterography in children with Crohn disease: results from the Belgian pediatric Crohn registry (Belcro).

INTRODUCTION: Magnetic Resonance enterography (MRE) is an imaging modality avoiding ionizing radiation and the discomfort associated with enteroclysis. The results of MRE at diagnosis in the patients of the Belgian pediatric Crohn registry (Belcro) are compared to endoscopical and histological results. METHODS: Results of MRE, endoscopy and histology were obtained from the medical charts and assigned to one of the following segments: jejunum, ileum, ascending colon, transverse colon, descending colon or rectosigmoid. MRE images were reviewed in a blinded way by 4 radiologists with specific interest in pediatric MRE. RESULTS: From the Belcro registry, twenty-two patients underwent a MRE during their work-up for Crohn disease. The results of endoscopy, histology and MRE were concordant (either all negative or positive) in the ileum in 16/18 patients and in the rectosigmoid, descending colon, transverse colon and ascending colon in resp 9, 8, 8 and 8/22 patients. In the non-concordant cases (MRE colon negative but endoscopy and/or histology positive), MRE could not reflect the subtle endoscopic or histologic lesions such as erosions that were described.In 4 cases where ileocaecal valve intubation was impossible ileal MRE findings were abnormal. MRE detected ileal stenosis, jejunal lesions and fistula in resp 4/22, 3/22 en 2/22 patients. The 100% and 75% interobserver agreement was resp 50-82% and 773-100% according to the different intestinal segments. CONCLUSIONS: MRE is a promising imaging modality avoiding radiation in Crohn disease. It should probably become the technique of first choice for the evaluation of extensive small bowel disease in children with Crohn disease.

Profile of pediatric Crohn's disease in Belgium.

AIM: A Belgian registry for pediatric Crohn's disease, BELCRO, was created. This first report aims at describing disease presentation and phenotype and determining associations between variables at diagnosis and registration in the database. METHODS: Through a collaborative network, children with previously established Crohn's disease and newly diagnosed children and adolescents (under 18 y of age) were recruited over a 2 year period. Data were collected by 23 centers and entered in a database. Statistical association tests analyzed relationships between variables of interest at diagnosis. RESULTS: Two hundred fifty-five patients were included. Median age at diagnosis was 12.5 y (range: 1.6-18 y); median duration of symptoms prior to diagnosis was 3 m (range: 1-12 m). Neonatal history and previous medical history did not influence disease onset nor disease behavior. Fifty three % of these patients presented with a BMI z-score < -1. CRP was an independent predictor of disease severity. Steroids were widely used as initial treatment in moderate to severe and extensive disease. Over time, immunomodulators and biological were prescribed more frequently, reflecting a lower prescription rate for steroids and 5-ASA. A positive family history was the sole significant determinant for earlier use of immunosuppression. CONCLUSION: In Belgium, the median age of children presenting with Crohn's disease is 12.5 y. Faltering growth, extensive disease and upper GI involvement are frequent. CRP is an independent predictive factor of disease activity. A positive family history appears to be the main determinant for initial treatment choice.

Seroprevalence of celiac disease in Belgian children and adolescents.

BACKGROUND: Celiac Disease (CD) has a high prevalence worldwide. Because the disease may be underdiagnosed in Belgium, we wanted to evaluate the seroprevalence of CD in children and adolescents. PATIENTS AND METHODS: Serum samples from 1159 apparently healthy children and adolescents aged between 1-19 years, were prospectively collected in 2006 by 15 Belgian diagnostic laboratories. In September 2009, all samples were analyzed for human tissue transglutaminase IgA antibodies (IgA tTG) and total IgA levels by, respectively a commercial ELISA and immunonephelometry. Sera, found positive, were assessed by immunofluorescence for the presence of IgA and IgG antiendomysium antibodies (IgA/IgG EMA). In patients with IgA deficiency IgG antibodies against deamidated gliadin peptides (IgG DGP) and IgG antiendomysium antibodies (IgG EMA) were determined. RESULTS: Ten of the 1159 individuals (0.86%) tested positive for IgA tTG. A further 0.86% showed borderline IgA tTG results. In almost two percent (198%) of the analyzed samples total IgA levels below the lower limit of normal were observed. Four out of eight positive IgA tTG samples tested positive for IgA EMA. All samples with borderline IgA tTG results were negative for IgA EMA. Twenty-six percent (6/23) of the IgA deficient samples showed positive IgG DGP antibodies, but none of those tested positive for IgG EMA. CONCLUSION: The seroprevalence of IgA tTG in this non-IgA deficient population (n = 1136) in Belgium is 1:114. The combined seroprevalence of IgA tTG and IgA EMA in that same population is 1:284. The seroprevalence based on positive IgA tTG or DPG IgG in, respectively, non-IgA deficient and IgA deficient subjects is 1:72 (n = 1159). These seroprevalences are similar to those found in neighbouring countries.

Safety and cost of infliximab for the treatment of Belgian pediatric patients with Crohn's disease.

Biologicals have become an important component in the treatment of Crohn's disease in children. Their increased and long term use raises safety concerns. We describe safety and cost of infliximab in Belgian pediatric Crohn's disease patients. All patients on infliximab as part of the present or past treatment for Crohn's Disease until January 1st 2011 were selected from an existing database. Information on disease phenotype, medication and adverse events were extracted. Adverse events occurred in 25.9% of patients exposed to infliximab of which 29.6% were severe. In total 31.7% of patients stopped infliximab therapy. The main reasons for discontinuation were adverse events in 45.4% and loss of response in 30.3%. No malignancies or lethal complications occurred over this 241 patient year observation period. Immunomodulators were concomitant medication in 75% of patients and were discontinued subsequently in 38.4% of them. The cost of infliximab infusions per treated patient per year in the Belgian health care setting is approximately 9 474 euro, including only medication and hospital related costs. Even though infliximab is relatively safe in pediatric CD on the short term, close follow-up and an increased awareness of the possible adverse reactions is highly recommended. Adverse reactions appeared in 25.9% of all patients and were the main reason for discontinuation. Treatment cost has to be balanced against efficacy and modifications in disease course. In the Belgian health care system, the medication is available to all patients with moderate to severe CD.

Improvement of the eradication rate of Helicobacter pylori gastritis in children is by adjunction of omeprazole to a dual antibiotherapy.

AIM: The possible improvement of efficacy and tolerability of a 7-day dual antibiotherapy amoxicillin-clarithromycin (AC) on the eradication of Helicobacter pylori (H. pylori) gastritis in children by the adjunction of omeprazole (OAC) was studied. METHODS: Forty-six children presenting with H. pylori gastritis, assessed at inclusion by endoscopy, H. pylori urease test, histology and/or culture were randomised to a twice-daily regimen of AC or OAC. A (13)C-urease breath test was performed 4-6 weeks after the end of the treatment period to evaluate H. pylori eradication. RESULTS: A larger proportion of patients was H. pylori negative (69%) in the OAC regimen treatment 4-6 weeks after eradication treatment compared with those who received dual AC therapy (15%). A total of seven patients (three in the OAC and four in the AC group) reported adverse events (AEs). Only vomiting was reported in more than one patient (one in each treatment regimen) and only one AE was severe (urticaria: in the OAC group, but considered not related to treatment). CONCLUSION: A larger eradication rate of H. pylori was obtained in the triple OAC group than in the dual AC group. Both therapy regimens can be safely administered to children for 7 days.

[The nutrition situation of young children in Flanders]. / Onderzoek naar de voedingssituatie van jonge kinderen in Vlaanderen.

Knowledge of the present feeding habits and the impact of different information channels are mandatory for developing an appropriate feeding policy. The" Socio-Economisch Instituut (SEIN)", the "Universiteit Hasselt", and paediatricians of the Virga Jesse Hospital conducted a study on the feeding habits of young children between the age of 0 and 2 years in Flanders. This study was ordered by Kind en Gezin. Special attention was paid to breastfeeding. The study uses qualitative and quantitative methods. The qualitative research is limited to questions about breastfeeding such as which factors influence initiating, maintaining and ending breastfeeding. The quantitative research investigates through diaries the dietary composition, the eating habits and the parental educational support. Parents of young children aged 3, 6, 12 and 24 months throughout Flanders were questioned. The response rate was 71%, resulting in 2925 diaries that were analyzed. The study gives a comprehensive profile of the dietary habits of young children in the Flanders. Overall, feeding habits in these young infants seem to be appropriate. Concrete proposals to promote breastfeeding and to further improve healthy feeding habits in this age group are made.

Protein malnutrition due to replacement of milk by rice drink.

UNLABELLED: We present the case of an 8-month-old boy with failure to thrive and hypoalbuminaemia due to protein malnutrition caused by the replacement of milk by a rice drink. All symptoms resolved with an appropriate feeding. CONCLUSION: Rice drinks are no alternatives to infant milk formulas and carry a serious risk for the development of protein malnutrition.

The ICF syndrome: new case and update.

The ICF syndrome: New case and update: We report the clinical progress in a 5-year-old boy with the <> (ICF) syndrome. Early diagnosis and intervention has led to a good outcome. DNMT3B mutation analysis was negative, supporting genetic heterogeneity in this condition.

[Pitfalls to avoid in the cleaning and shaping of the pulp canal]. / Pièges à éviter lors du nettoyage et de la mise en forme de la cavité pulpaire.

Chemomechanical instrumentation of the root canal system is without doubt the most important but most challenging part of endodontic treatment. The first essential in cleaning and shaping is gaining direct access to the root canals. A properly prepared endodontic access opening can eliminate many of the technical problems encountered in root canal treatment. Excessive calcification in the root canal system and performing root canal treatment through existing artificial crowns however can be a challenge for the clinician. Secondly, enlargement of a curved root canal often results in loss of working length, incomplete removal or extrusion of the root canal content and unwanted alterations in the canal shape, such as transportation (stripping, zipping, elbow formation), ledge formation and perforation. This article focuses on the causes and effects of procedural errors during root canal cleaning and shaping. Each of these complications is addressed in a manner designed to prevent problems rather than to manage them once they are recognized. Throughout the immense amount of literature published the last 30 years on this topic, concensus is obtained concerning the preferential procedure of cleaning and shaping the root canal.

MRI diagnosis of osteomyelitis of the cuboid bone in two infants.

We describe two infants in whom MRI diagnosed osteomyelitis of the cuboid bone when conventional X-rays were negative. Neoplastic, traumatic and ischaemic aetiologies could be excluded with the initial MR examinations.

Omeprazole in infants with cimetidine-resistant peptic esophagitis.

Twelve neurologically normal infants (age 2.9+/-0.9 months) with peptic esophagitis (grade 2) who did not respond to cimetidine (in addition to positioning, cisapride, and Gaviscon) were treated with omeprazole, 0.5 mg/kg once a day, for 6 weeks. The effectiveness of omeprazole was evaluated in all infants by clinical assessment and endoscopy before and after treatment and by 24-hour gastric pH monitoring during treatment in seven infants. Omeprazole therapy led to a marked decrease in symptoms, endoscopic and histologic signs of esophagitis, and intragastric acidity.

Phosphoserine phosphatase deficiency in a patient with Williams syndrome.

Decreased serine levels were found in plasma and cerebrospinal fluid (CSF) of a boy with pre- and postnatal growth retardation, moderate psychomotor retardation, and facial dysmorphism suggestive of Williams syndrome. Fluorescence in situ hybridisation with an elastin gene probe indicated the presence of a submicroscopic 7q11.23 deletion, confirming this diagnosis. Further investigation showed that the phosphoserine phosphatase (EC 3.1.3.3.) activity in lymphoblasts and fibroblasts amounted to about 25% of normal values. Oral serine normalised the plasma and CSF levels of this amino acid and seemed to have some clinical effect. These data suggest that the elastin gene and the phosphoserine phosphatase gene might be closely linked. This seems to be the first report of phosphoserine phosphatase deficiency.

Peripheral blood T and B lymphocyte subpopulations in infants with acute respiratory syncytial virus brochiolitis.

Most data concerning immunopathogenetic mechanisms involved in respiratory syncytial virus (RSV) infection are derived from animal studies. In infants with RSV bronchiolitis the target organ i.e. the airway is hard to explore. We looked for specific alterations in peripheral blood lymphocyte subpopulations in infants hospitalized for RSV bronchiolitis. Flow cytometric analysis with a large panel of monoclonals was performed on peripheral blood lymphocytes in thirty-two infants (mean age: 4.9 months) admitted for RSV bronchiolitis. Data collected on admission were compared with age-matched control values and also with results obtained at the end of the first week of hospitalization. Differences between age-groups (older or younger than 4 months) and between clinical subgroups (clinical severity score more or less than 6) were looked for. In the group of infants as a whole, regardless of age and clinical score the number of CD4+ cells on admission was significantly elevated compared to normal values for age (p<.0001) including a high fraction of the naive suppressor-inducer subpopulation (CD4+/CD45RA+) and a low fraction of the reciprocal memory helper-inducer subpopulation (CD4+/CD29+). Within the CD8+ cell population the number of T cells with cytotoxic activity (CD8+/S6F1+) was significantly elevated (p<.0001) as were other types of cytotoxic cells. A significant decrease (p<.0001) in the proportion of the precursor/suppressor-effector subpopulation (CD8+/S6F1-) was seen. Absolute numbers and percentages of CD19+ B cells were significantly elevated (p<.0001) with a significant increase in the CD5+ subfraction (p<.0001) as well as in the CD10+ subfraction (p<.0001). In the older age group immunophenotypic cytotoxicity was more pronounced with increased clinical score. During recovery the CD45RA+:CD29+ ratio tended to normalize within the CD4+ T cells. Within the B lymphocyte subsets significant increase in the CD19+/CD5+ fraction (p<.05) was seen. We conclude that there are significant changes in the number of peripheral blood lymphocyte subsets in infants with RSV bronchiolitis as compared to age-related controls. We hope that present data could be useful in further exploration of RSV immunology in humans. A possible link between RSV bronchiolitis and the subsequent development of atopy is mentioned.