Detection of Enteropathogens in Human Immunodeficiency Virus and Non-Human Immunodeficiency Virus-Infected Children with Acute Diarrhea in an Indonesian Tertiary Hospital Using Multiplex Real-Time Polymerase Chain Reaction.

Purpose: Diarrhea is one of the leading causes of mortality in children living in developing countries. The etiology of acute diarrhea in each healthcare center varies depending on place, time, and population. This study aimed to identify pathogen patterns in human immunodeficiency virus (HIV)-infected and non-HIV children suffering from acute diarrhea, using multiplex real time reverse transcriptase polymerase chain reaction (RT-PCR), in an Indonesian tertiary hospital. Methods: This cross-sectional study was conducted at Dr. Cipto Mangunkusumo National Hospital from March 2019 to April 2020. Results: The study showed that multiplex RT-PCR results were positive in 58.9% of the specimens, with more positive results in HIV-infected children than in non-HIV-infected children (70% vs. 54.7%). Altogether 72 enteropathogens were detected from all specimens. Enteropathogens in non-HIV children with acute diarrhea consisted of bacteria (70.6%) and viruses (29.4%) with a predominance of enteroaggregative Escherichia coli (25.4%), followed by Campylobacter spp. (11.8%), enteropathogenic E. coli (9.8%), Norovirus GII (7.8%), and Clostridium difficile (7.8%). Enteropathogens in HIV-infected children consisted of viruses (57.1%), bacteria (28.6%), and parasites (14.3%) comprising Norovirus GII (24%), Cryptosporidium spp. (14.3%), Campylobacter spp. (14.3%), Norovirus GI (14.3%), and Astrovirus (14.3%). Cryptosporidium spp. was the only parasite found in this study and was found only in HIV-infected children. In non-HIV children with acute diarrhea, most pathogens were invasive bacteria, while in HIV-infected children, more viral and parasite infections occurred, primarily caused by opportunistic pathogens. Conclusion: The pattern of enteropathogens can help clinicians determine further examinations and appropriate empirical antimicrobial therapy for the patient.

Association Between Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire Score, Endoscopy and Biopsy in Children with Clinical Gastroesophageal Reflux Disease: A Prospective Study.

Purpose: Gastro esophageal reflux disease (GERD) is a burdensome disease affecting many children. A clinical examination is reported to be unreliable to diagnose GERD in children. This study aimed to investigate the relationship between the Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire (PGSQ) and endoscopic and histopathological findings in children with symptoms suggesting GERD. Changes in the PGSQ score in children with esophagitis as response to one month therapy were recorded as secondary outcome. Methods: This is a prospective cohort study in the pediatric outpatient clinic in an Indonesian tertiary hospital. Children aged 2-17 years old with clinical symptoms suspected of GERD are included in the study. Blinded endoscopic and histopathological examination was performed in all patients before one month proton pump inhibitors (PPI) therapy. The PGSQ information was collected at inclusion and after one month PPI treatment. Results: Fifty-eight subjects were included. Esophagitis was found in 60.9% of subjects according to endoscopy and 58.6% according to histology. There was no significant relationship between the PGSQ score and endoscopic (p=0.781) nor biopsy (p=0.740) examinations. The PGSQ showed a low diagnostic value compared to endoscopy and biopsy (area under the curve [AUC] 0.477, p=0.477, 95% confidence interval [CI] 0.326-0.629 and AUC 0.474, p=0.740 (95% CI 0.321-0.627 respectively). The PGSQ improved significantly post one month of PPI treatment. Conclusion: The PGSQ cannot be used to diagnose esophagitis in children with clinical symptoms suggesting GERD. However, the PGSQ can be used to monitor the treatment response in children with esophagitis.

Selenium status and fungi in the protein-losing enteropathy of persistent diarrhea.

BACKGROUND AND OBJECTIVES: A vicious cycle of infection, malabsorption, and malnutrition has been implicated in the perpetuation of diarrheal disease. This study examined whether persistent diarrhea is associated with changes in selenium status and stool alpha-1 antitrypsin (AAT) concentration. METHODS AND STUDY DESIGN: This cross-sectional study included 30 children aged 1-12 years with persistent diarrhea who were hospitalized in Cipto Mangunkusumo Hospital and Fatmawati Hospital, Jakarta, and 30 apparently healthy children who were matched by age and sex and lived in a rural area of Jakarta. Clinical examinations, blood routine tests, erythrocyte glutathione peroxidase (GPX) activity and plasma selenium levels as well as AAT in fresh stool samples were performed in all the subjects. RESULTS: Of 30 children with persistent diarrhea, 17 had moderate malnutrition and 13 had severe malnutrition. The mean plasma selenium was significantly lower in children with persistent diarrhea than in children without diarrhea (86.0 µg/L [95% CI: 76.1-95.9] vs 110 µg/L [95% CI: 104-116, p<0.0001). The mean stool AAT concentration was significantly higher in children with persistent diarrhea than in those without diarrhea (115 mg/dL [95% CI: 38.5-191] vs 16 mg/dL [95% CI: 4.0-13.5, p<0.0001]). Selenium correlated with AAT (p=0.05). Fecal fungi were persistently present. CONCLUSIONS: Although selenium status in both groups was optimal for the obtained plasma GPX activity, children with persistent diarrhea exhibited lower plasma selenium levels. This study suggests that the decrease in the plasma selenium level may be the consequence of protein loss and that fungi may be involved.

Hepatitis B virus infection in children of HBV-related chronic liver disease patients: a study of intra-familial HBV transmission.

BACKGROUND: HBV-infected patients are potential sources of intra-familial transmission. We studied HBV transmission and molecular characteristics within families of HBV-related chronic liver disease (CLD) patients. METHODS: Family members [index cases (ICs), spouses, and 1-18-year-old children] of HBV-related CLD patients were tested for HBsAg, anti-HBc, and anti-HBs. HBsAg-positive subjects were tested for HBeAg/anti-HBe. Anti-HBc-positive children together with their family members were further investigated for HBV DNA. Sequences of positive isolates were analyzed over surface, precore (PC) and basal core promoter (BCP) regions. RESULTS: Among 94 children of 46 ICs, the prevalence of HBsAg, anti-HBc, and anti-HBs was 10 (10.6 %), 19 (20.2 %), and 46 (48.9 %), respectively. Thirty-eight (40.4 %) children were seronegative, indicating susceptibility to HBV infection. HBV DNA was identified in all ICs, 4 spouses, and 16 children. Having both parents with HBsAg positive and at least two HBV carriers in the households were significant risk factors of intra-familial transmission. HBV genotype/subtype distributions were comparable between children and ICs/spouses, with predominance of genotype B. The majority of HBV DNA sequences found in children were identical to their corresponding ICs-particularly mothers-including mutation patterns in the surface, PC, and BCP regions. Recognized mutations associated with HBsAg detection and/or vaccination failure, T140I, T143S/M, G145R, and Y161F, were identified in 20 subjects; while mutations linked to HBeAg-defective variants, PC G1896A and BCP A1762T/G1764A, were found in 7 and 11 subjects, respectively. CONCLUSIONS: Children of HBV-related CLD patients were at increased risk of HBV infection through multi-modal transmission routes despite negative parental HBsAg and HBeAg status.

Growth of Indonesian Infants Compared With World Health Organization Growth Standards.

OBJECTIVES: The ability of the World Health Organization (WHO) growth standards to represent the growth of South East Asian infants has been questioned. The aim of this study was to provide contemporary data on the growth of Indonesian breast-fed and formula-fed infants, compared with the WHO growth standards. METHODS: A prospective cohort study of 160 normal healthy infants was undertaken in a suburban area of South Jakarta, Indonesia. Infants from 2 to 6 weeks of age were recruited, and they consumed exclusively either breast milk or infant formula for at least 6 months, with follow-up until 12 months of age. RESULTS: Overall, the infants in the present study were lighter (weight-for-age), were shorter (length-for-age), and had smaller head circumferences (head circumference-for-age) than the average WHO Growth Reference Study population but were of similar proportion (weight-for-length). Compared with the WHO Growth Reference Study, the z scores for weight-for-age, length-for-age, and head circumference-for-age in the Indonesian children fell from birth to 6 weeks of age and then increased until 3 months of age in both the breast-fed and the formula-fed infants. At 6 weeks of age, the weight-for-age z scores fell below -2 standard deviations for 16 (20.5%) breast-fed and 40 (51.3%) formula-fed infants, and the length-for-age z scores fell below -2 standard deviations for 31 (39.7%) breast-fed and 41 (52.6%) formula-fed infants. CONCLUSION: The WHO growth standards do not reflect the growth of the present cohort of Indonesian infants and may overestimate the levels of underweight and stunted children.

Comparison of stool microbiota compositions, stool alpha1-antitrypsin and calprotectin concentrations, and diarrhoeal morbidity of Indonesian infants fed breast milk or probiotic/prebiotic-supplemented formula.

AIM: The composition of faecal microbiota of babies is known to be influenced by diet. Faecal calprotectin and α1-antitrypsin concentrations may be associated with mucosal permeability and inflammation. We aimed to assess whether there was any difference after consumption of a probiotic/prebiotic formula on faecal microbiota composition, calprotectin and α1-antitrypsin levels, and diarrhoea in comparison with breast milk-fed Indonesian infants. METHODS: One hundred sixty infants, 2 to 6 weeks old, were recruited to the study. They were either breastfed or formula fed (80 per group). Faecal samples were collected at recruitment and 3 months later. Bacterial groups characteristic of the human faecal microbiota were quantified in faeces by quantitative polymerase chain reaction. Calprotectin and α1-antitrypsin concentrations were measured using commercial kits. Details of diarrhoeal morbidity were documented and rated for severity. RESULTS: The compositions of the faecal microbiota of formula-fed compared with breast milk-fed children were similar except that the probiotic strain Bifidobacterium animalis subsp. lactis DR10 was more abundant after 3 months consumption of the formula. Alpha1-antitrypsin levels were higher in breastfed compared with formula-fed infants. The occurrence of diarrhoea did not differ between the groups of babies. CONCLUSION: Feeding Indonesian babies with a probiotic/prebiotic formula did not produce marked differences in the composition of the faecal microbiota in comparison with breast milk. Detrimental effects of formula feeding on biomarkers of mucosal health were not observed.

Improved growth of toddlers fed a milk containing synbiotics.

Bifidobacterium longum (BL999), Lactobacillus rhamonosus (LPR), prebiotics (inulin and fructo-oligosaccharides), and long-chain polyunsaturated fatty acids (LCPUFA) are believed to have health benefits. In a randomized, double-blind, controlled trial we compared growth and development of toddlers fed milk containing synbiotics (BL999, LPR, and prebiotics) and LCPUFA or a control milk. Three hundred and ninety three healthy, 12 month-old toddlers were fed approximately 400 mL/day for 12 months. Anthropometric measurements were taken at 12, 14, and 16 months. Toddlers' response to measles and hepatitis A vaccine was measured at 16 months, and Bayley scale for motor, cognitive, and behavioral functions made at 24 months. The primary outcome was weight gain between 12 and 16 months. Secondary outcomes were gain in length, head circumference, and body mass index, gastrointestinal tolerance (stool characteristics), stool bacterial counts, safety, anti-vaccine IgG, and neurodevelopment. Weight gain was greater in the synbiotics group (mean±SD, 7.57±4.13 g/day) compared with the control group (6.64±4.08 g/day). The difference of 0.93 g/day (with a 95% confidence interval of 0.12 to 1.75) is significant (p=0.025). The gain in the synbiotics group resulted in a change in z-score weight-for-age closer to WHO Child Growth Standard. There was a significant increase in lactobacilli and enterococci counts between 12 months and 16 months in the synbiotic group. We conclude that in healthy toddlers milk containing synbiotics and LCPUFA provides better growth and promotes favorable gut colonization, as shown by higher Lactobacillus counts.

Intestinal parasitic infection of immunocompromised children with diarrhoea: clinical profile and therapeutic response.

BACKGROUND: Parasitic gastrointestinal infections have been variably reported among immunocompromised adults while data on children have been limited. This prospective cross-sectional study aimed to assess the clinical profile of intestinal parasitic infections among immunocompromised children with diarrhoea and their treatment response. METHODOLOGY: Two freshly voided stool samples taken for two consecutive days were examined by direct and formalin-ether concentrated smears. Modified Ziehl-Neelsen staining was used to detect Cryptosporidium, Isospora belli, and Cyclospora cayetanensis. Blastocystis hominis was identified using in vitro culture. Subjects positive for stool parasite(s) received standard therapy according to the aetiology and were evaluated afterward. RESULTS: Forty-two subjects from Jakarta, Indonesia were included in this study, mostly aged one to five years (78%) and HIV infected (52%). Parasites were found in 24/42 (57%) subjects in which B. hominis comprised the largest proportion (23/24 = 96%). Cryptosporidium was identified in two subjects who were HIV infected with CD4 percentages of < 15%. No helminth infestations were found. Parasites were most frequently found in preschool age children (16/23), in those with recurrent or watery diarrhoea (23/24 and 14/18, respectively), and in HIV subjects not receiving antiretrovirals (16/22). Of 13 subjects evaluated for response to a 10-day metronidazole course for B. hominis infection, seven achieved clinical remission and nine had their parasites eradicated. CONCLUSIONS: The prevalence of intestinal parasitic infection in immunocompromised children with persistent and/or recurrent diarrhoea is moderately high and dominated by B. hominis infection. Clinical remission and parasite eradication can be achieved in B. hominis infection treated with metronidazole.