Ketogenic diet in childhood epilepsy: clinical algorithm in a tertiary care center.

Background: Dietary therapies play a crucial role in managing patients, especially those who have specific types of epilepsy, display adverse effects, or are not responding to pharmacological treatments. The ketogenic diet (KD) is a high-fat, restricted carbohydrate, and adequate protein regimen. The KD has proven to be an effective nonpharmacological treatment for drug-resistant epilepsy (DRE) by generating ketones that act as an alternative fuel source for the brain, thereby reducing the occurrence of seizures. The advantages of KD have been attributed to its universal availability, numerous administration techniques, and affordability. Objective: This article presents the KD algorithm developed by a multidisciplinary team of experts at the Children's Hospital, Ain Shams University, Egypt. The algorithm serves as a guide for implementing the KD in the treatment of DRE in children. The algorithm has been previously validated through a study. Methods: The algorithm consists of seven essential stages: (1) referral of patients to the Complex Epilepsy Committee, (2) pre-diet assessment of patients, (3) referral of patients to the Clinical Nutrition (CN) team, (4) diet selection and initiation, (5) seizure follow-up and diet fine-tuning, (6) diet reassessment after 3 months, and (7) evaluation of the KD journey after 24 months. Results: The KD algorithm was systematically developed and proved highly influential in facilitating the implementation of the KD. The algorithm yielded significant health benefits in pediatric patients. Conclusion: The KD algorithm provides a systematic approach to implementing the ketogenic diet and has demonstrated positive health outcomes in pediatric patients.

A Survey to Identify the Current Management of Cow's Milk Disorders and the Role of Goat Milk-Based Formulas in the Middle East and North Africa Region.

BACKGROUND: Cow's milk allergy (CMA) and cow's milk intolerance (CMI) are the major cow's milk disorders observed in infants and young children. This study investigates, for the first time, physician knowledge regarding CMA and CMI prevalence, diagnosis, and management in the Middle East and North Africa (MENA) region. In addition, we explore the role of goat milk-based formula as an alternative in infants suffering from CMI. METHOD: This cross-sectional survey was conducted from December 2020 to February 2021. A convenience sample of 2500 MENA-based physicians received the questionnaire, developed by a working group of pediatric experts. RESULTS: 1868 physicians completed the questionnaire, including pediatric specialists (80.8%), training physicians (0.2%), dermatologists (0.1%), family/general physicians (12.9%), neonatologists (3.6%), neurosurgeons (0.2%), allergy nurse specialists (0.3%), pharmacists (2.1%), and public health workers (0.1%). Differentiation between CMA and CMI was recognized by the majority of respondents (80.7%), for which the majority of respondents (35.4%) identified that the elimination and challenge test was the best test to differentiate CMA from CMI, whereas 30.7% and 5.4% preferred the immunoglobulin E (IgE) test and skin prick test, respectively. In addition, 28.5% of respondents reported that there is no confirmatory test to differentiate CMA from CMI. The majority of respondents (47.3%) reported that amino acid-based formula (AAF)/ extensively hydrolyzed formula (EHF) is the cornerstone for the management of CMA. However, most respondents (33.7%) reported that lactose avoidance was best for the management of CMI. Overall, 65% of the respondents were aware of nutritionally adapted goat's milk formula as an alternative to cow's milk products and 37% would recommend its routine use in infants (≤2 years of age). CONCLUSION: The results of this survey demonstrate that the majority of physicians are aware of the underlying pathophysiology and management of CMA and CMI. However, a significant proportion of physicians do not follow the clinical guidelines concerning CMA/CMI diagnosis and management. Notably, this survey identified that goat's milk formulas may offer a suitable alternative to AAF/EHF in infants with CMI as they contain ß-casein protein which is easily digestible. In addition, goat's milk formulas contain higher levels of oligosaccharides and medium-chained fatty acids compared with standard cow's milk formulas, yet further clinical trials are warranted to support the inclusion of goat's milk formulas in clinical guidelines.

Local Foods Can Increase Adequacy of Nutrients Other than Iron in Young Urban Egyptian Women: Results from Diet Modeling Analyses.

BACKGROUND: Nutrition transition and recent changes in lifestyle in Middle Eastern countries have resulted in the double burden of malnutrition. In Egypt, 88% of urban women are overweight or obese and 50% are iron deficient. Their energy, sugar, and sodium intakes are excessive, while intakes of iron, vitamin D, and folate are insufficient. OBJECTIVE: This study aimed to formulate dietary advice based on locally consumed and affordable foods and determine the need for fortified products to meet the nutrient requirements of urban Egyptian women. METHODS: Food intakes were assessed using a 4-d food diary collected from 130 urban Egyptian women aged 19-30 y. Food prices were collected from modern and traditional markets to calculate diet cost. Population-based linear and goal programming analyses (Optifood tool) were used to identify "limiting nutrients" and to assess whether locally consumed foods (i.e., consumed by >5% of women) could theoretically improve nutrient adequacy at an affordable cost (i.e., less than or equal to the mean diet cost), while meeting recommendations for SFAs, sugars, and sodium. The potential of hypothetical fortified foods for improving intakes of micronutrients was also assessed. RESULTS: Iron was the most limiting nutrient. Daily consumption of fruits, vegetables, milk or yogurt, meat/fish/eggs, and tahini (sesame paste) were likely to improve nutrient adequacy for 11 out of 12 micronutrients modeled. Among fortified foods tested, iron-fortified rice, milk, water, bread, or yogurt increased the minimized iron content of the modeled diet from 40% to >60% of the iron recommendation. CONCLUSIONS: A set of dietary advice based on locally consumed foods, if put into practice, can theoretically meet requirements for most nutrients, except for iron for which adequacy is harder to achieve without fortified products. The acceptability of the dietary changes modeled needs evaluation before promoting them to young Egyptian women.

The Interaction of Social, Physical and Nutritive Factors in Triggering Early Developmental Language Delay in a Sample of Egyptian Children.

BACKGROUND: Language acquisition and child development during the early years of life depend on multiple interacting factors. AIM: To explore potential factors that can impact language development in 2 groups of Egyptian children, one with normal language development and the second with delayed development. Also, to explore to what extent can the involvement of impaired motor development potentiate the risk of developmental language delay. METHODS: This cross-sectional case-control study involved Egyptian children belonging to the middle socioeconomic class between 18 and 36 months of age. Children were classified according to their performance on language domain of Bayley Scales of Infant and Toddler Development (Bayley-III) into two groups, infants with the average or above score (control group) and those having below-average scores (cases). Motor development was assessed on the same scale. Factors affecting language development were tested, including socio-demographic, obstetric, and maternal medical factors in addition to Infant Feeding Practices. RESULTS: The independent factors lowering the language scores were early introduction of complementary food, low family income, history of delivery problems, pregnancy-related diseases of the mother, and maternal education. Impaired motor development appears as a further highly significant risk factor to the previously mentioned factors. CONCLUSION: In Egyptian children, delayed language development is severely affected by the interaction of medical, social and nutritional factors. Providing adequate maternal health care during pregnancy and childbirth, regular developmental monitoring at each child visit, and screening for such risk factors, can reduce size of the problem and promote child's social and psychological development.

Potential Risk Factors of Developmental Cognitive Delay in the First Two Years of Life.

BACKGROUND: The first two years of life constitute a critical period of rapid change. The events during this phase prepare the child for subsequent developmental competency. AIM: To determine the potential risk factors that affect an infant's cognitive development in the first two years of life in a sample of Egyptian infants. SUBJECTS AND METHODS: A cross-sectional comparative study included 655 male and female infants. Their age ranged from 3 - 24 months. Bayley Scales of Infant and Toddler Development (Bayley III) were used for cognitive assessment. Perinatal and nutritional data were recorded. Levels of serum Zinc, Copper, Iron, vitamin B12 and complete blood count (CBC) were assessed in a subsample of 193 infants. RESULTS: Infants having below the average cognitive composite score (CCS) represented 38.47% of the whole sample. The risk of having a low average (CCS) was determined by multiple factors. Poor maternal education and low family income were the most significant social risk factors (OR = 2.19, p = 0.0003; OR = 1.64, p = 0.002 respectively). Prematurity and complicated labor represented significant perinatal risks (OR = 1.22, p = 0.005; OR = 2.39, p =0.001respectively). Bottle feeding versus breastfeeding in the first six months of life was the most significant nutritional predictor of low average (CCS) (OR = 1.79, p = 0.001). Infants with low average (CCS) had significantly lower levels of serum zinc and vitamin B12 than those with average scores. CONCLUSION: Multiple factors appear to interact affecting the early cognitive development of Egyptian infants. Prematurity, complicated labour, poor maternal education, low family income and micronutrient deficiency are the main risk factors. Studying these factors is of great value in directing governmental intervention efforts.

Nutritional risk screening of hospitalized children aged < 3 years.

BACKGROUND: Identification of children at risk of malnutrition is not easily achieved in hospital settings. AIMS: To assess the merits of using the Screening Tool for Risk on Nutritional status and Growth (STRONGkids) as a nutrition screening tool in hospitalized children aged < 3 years and correlate it with the severity of their nutritional derangements. METHODS: This cross-sectional study was conducted on 500 children aged < 3 years admitted to the Children's Hospital, Ain Shams University, Cairo, Egypt. STRONGkids score was used to assess the risk for nutritional derangements and World Health Organization growth charts were used to define underweight, wasted and stunted patients upon admission and discharge. RESULTS: According to STRONGkids score, 19.6% of patients were low risk, 42.6% were moderate risk and 37.8% were high risk. Out of the enrolled patients, 62.4% were underweight, 58.4% were stunted and 57.8% were wasted. Among the 66 patients with severe wasting, nutritional status improved in 6.06% while deterioration was observed in 13.0% of the moderately wasted patients. STRONGkids score was worse among those who deteriorated, which together with its significant positive correlation with the duration of hospital stay, emphasized that STRONGkids score can be a predictive tool. CONCLUSIONS: The use of STRONGkids screening tool can ensure early identification of children vulnerable to malnutrition, ensuring prompt interventions that may contribute to overall improvements in patient care, as well as shortening hospitalization period.

Determinants of Exclusive Breastfeeding in a Sample of Egyptian Infants.

BACKGROUND: Breastfeeding is an optimum, healthy, and economical mode of feeding an infant. However, many preventable obstacles hinder exclusive breastfeeding in the first six months of life. AIM: We aimed to assess the social-, maternal- and infant-related factors disturbing exclusive breastfeeding in the first six months of life. METHODS: It is a retrospective study included 827 dyads of mothers and infants older than 6 months (411 exclusively breastfed, 311 artificially-fed and 105 mixed feds). Mothers were interviewed to obtain sociodemographic information, maternal medical history and perinatal history and a detailed history of infant feeding. RSULTS: Many factors were found to support the decision for artificial feeding rather than exclusive breastfeeding, including maternal age < 25 years (OR = 2.252), child birth order > 3rd (OR = 2.436), being a primi-para (OR = 1.878), single marital status (OR = 2.762), preterm infant (OR = 3.287) and complicated labor (OR = 1.841). Factors in favor of mixed feeding included cesarean section (OR = 2.004) and admission to the Neonatal Intensive Care Unit (OR = 1.925). CONCLUSIONS: Although it isn't a community-based study and its results can't be generalised, plans to improve health and development of children are preferable to include the following: health education and awareness programs about the importance of exclusive breastfeeding should be directed for young and first-time mothers. Improved antenatal care to reduce perinatal and neonatal problems; and training, monitoring, and supervising community health care workers to recognise labour complications and provide support and knowledge to lactating mothers.

The role of probiotics in children with autism spectrum disorder: A prospective, open-label study.

OBJECTIVE: There are limited data on the efficacy of probiotics in children with ASD, therefore, this study aims to evaluate the efficacy and tolerability of probiotics in an Egyptian cohort of children with ASD. METHODS: Gastrointestinal (GI) flora were assessed by quantitative real-time PCR of stool samples of 30 autistic children from 5 to 9 years old. GI symptoms of autistic children were assessed with a modified six-item Gastrointestinal Severity Index (6-GSI) questionnaire, and autistic symptoms were assessed with Autism Treatment Evaluation Checklist (ATEC) before and after 3 months of supplementation of probiotics nutritional supplement formula (each gram contains 100 × 106 colony forming units of three probiotic strains; Lactobacillus acidophilus, Lactobacillus rhamnosus and Bifidobacteria longum). RESULTS: After probiotic supplementation, the stool PCR of autistic children showed increases in the colony counts of Bifidobacteria and Lactobacilli levels, with a significant reduction in their body weight as well as significant improvements in the severity of autism (assessed by the ATEC), and gastrointestinal symptoms (assessed by the 6-GSI) compared to the baseline evaluated at the start of the study. CONCLUSIONS: We concluded that probiotics have beneficial effects on both behavioral and GI manifestations of ASD. Probiotics (a non-pharmacological and relatively risk-free option) could be recommended for children with ASD as an adjuvant therapy. At this stage, this study is a single center with a small number of patients and a great deal of additional wide-scale randomized controlled trials are needed to critically confirm the efficacy of probiotics in ASD. TRIAL REGISTRATION NUMBER: UMIN-CTR Study Design: Trial Number UMIN000026157.

Early Life Predictors of Socio-Emotional Development in a Sample of Egyptian Infants.

INTRODUCTION: Emotional problems are amongst the most critical concerns to be intentionally handled to enhance the wellbeing and development of children. OBJECTIVE: To determine the predictors of socio-emotional development of Egyptian infants related to infant feeding practices, aspects of infant and maternal health and socioeconomic status. SUBJECTS AND METHODS: A cross-sectional comparative study included 322 breast fed, 240 bottle fed and 93 mixed fed infants, from 6-24 months of age, who were enrolled in the Well-Baby Clinic of the National Research Centre and from pediatric outpatient facilities in urban Cairo. Assessment of socio-emotional development was performed using Bayley Scales of Infant and Toddler Development (Bayley III). Detailed maternal and infant history was recorded. Levels of serum zinc, copper, iron, vitamin B12 and complete blood count (CBC) were assessed in a subsample of 193 infants. RESULTS: The risk of having below average socio-emotional composite score was nearly two and half times among formula-fed infants than among breast-fed infants. By binary logistical regression analysis, predictors of below average socio-emotional score were a lower serum zinc value, being formula fed during the first half-year and introduction of complementary food before the age of six months (p< 0.05). CONCLUSION: Exclusive breastfeeding and to a lesser extent mixed feeding during the first half year is correlated with above average socio-emotional development. Maternal education and zinc status were also determinants of better infant mental health. Our endeavors ought to be directed towards integrated interventions addressing multiple risks to children's development.

Middle East Consensus Statement on the Prevention, Diagnosis, and Management of Cow's Milk Protein Allergy.

Presented are guidelines for the prevention, diagnosis, and treatment of cow's milk protein allergy (CMPA) which is the most common food allergy in infants. It manifests through a variety of symptoms that place a burden on both the infant and their caregivers. The guidelines were formulated by evaluation of existing evidence-based guidelines, literature evidence and expert clinical experience. The guidelines set out practical recommendations and include algorithms for the prevention and treatment of CMPA. For infants at risk of allergy, appropriate prevention diets are suggested. Breastfeeding is the best method for prevention; however, a partially hydrolyzed formula should be used in infants unable to be breastfed. In infants with suspected CMPA, guidelines are presented for the appropriate diagnostic workup and subsequent appropriate elimination diet for treatment. Exclusive breastfeeding and maternal dietary allergen avoidance are the best treatment. In infants not exclusively breastfed, an extensively hydrolyzed formula should be used with amino acid formula recommended if the symptoms are life-threatening or do not resolve after extensively hydrolyzed formula. Adherence to these guidelines should assist healthcare practitioners in optimizing their approach to the management of CMPA and decrease the burden on infants and their caregivers.

Language skills and intelligence quotient of protein energy malnutrition survivors.

The study was conducted on 33 children aged 3-6 years who suffered from protein energy malnutrition (PEM) during infancy in comparison to 30 matching children to assess the long-term deficits in cognition and language skills. The patients' files were revised to record their admission and follow-up data and history, clinical examination, intelligence quotient and language assessment were done. The study revealed that 2-5 years from the acute attack the PEM patients were still shorter than the controls and their cognitive abilities were poorer. Their mental ages and language skills were mostly determined by their height and the duration of follow-up during their acute illness. Additionally their diet after the 3-5 years is still defective and does not meet their recommended daily allowance. These observations urge us to continue following these patients for longer durations to make sure no permanent damage occurs due to the PEM insult to the growing brain.

A trial to assess the efficacy of glutamic acid in prevention of vincristine-induced neurotoxicity in pediatric malignancies: a pilot study.

Vincristine is considered as a backbone of therapy in the induction and consolidation phases of pediatric malignancies. Neurotoxicity is a principal side effect of its use. This study is a randomized single-blinded placebo-controlled clinical trial to evaluate the role of glutamic acid in ameliorating neurotoxicity in pediatric patients with hematologic and solid tumors receiving vincristine during induction course. Fifty-four patients in the glutamic acid group received glutamic acid 1.5 grams daily orally in 3 divided doses during the 4-week induction with vincristine in a dose of 1.5 mg/m² IV weekly. Placebo group (40 patients) received oral placebo 3 times daily in the same way as the glutamic acid group. The onset of neurotoxicity was significantly earlier in placebo group than in glutamic acid group regarding tendon Achilles reflex, Patellar reflex, parasthesia, and increased frequency of constipation. This was statistically significant mostly in third and fourth visits, no severe cases of strength and mental alteration side effects in both groups. Glutamic acid was well tolerated with no gastrointestinal side effects in patients. This study suggests that the coadministration of oral glutamic acid with repetitive intravenous bolus injections of vincristine resulted in a reduction of its neurotoxicity.

Effect of honey on gastric emptying of infants with protein energy malnutrition.

BACKGROUND: Patients with protein-energy malnutrition (PEM) have delayed gastric emptying time (GET) which may affect nutritional rehabilitation. This study was designed to examine the effect of honey on GET during nutritional rehabilitation of PEM patients. PATIENTS AND METHODS: Thirty patients were enrolled and randomly assigned to one of two equal groups. One group received conventional nutritional rehabilitation therapy and the other received honey in addition. They were compared with 20 age- and sex-matched controls. History taking, clinical examination and laboratory tests were performed for enrolled cases and GET was assessed using abdominal ultrasonography. These parameters were performed before and 2 weeks after nutritional rehabilitation. RESULTS: The GET was significantly delayed in the PEM groups compared with the controls. Further significant delay occurred in the honey supplemented group after nutritional rehabilitation, while the un-supplemented group showed significant shortening of GET. The improvement of anthropometric measurements and laboratory parameters was equally noticed in the two PEM groups upon nutritional rehabilitation but their rate of change was distinctly higher, although non-significant, in the group supplemented with honey. CONCLUSION: Honey supplementation increased GET in PEM patients with positive effect on the improvement in the anthropometric measurements and serum albumin which makes us wonder that this delay in GET might be primarily a compensatory phenomenon and it was augmented by the use of honey. Larger scale studies with longer term follow up are recommended to further clear this point and assess any changes in the absorptive indices in honey supplemented PEM patients.

Cognitive functions in protein-energy malnutrition: in relation to long chain-polyunsaturated fatty acids.

Aiming to find out a correlation between plasma LC-PUFA levels and neurodevelopmental status of malnourished infants, the present study was conducted on 42 infants suffering from PEM, with a mean age of 11.28 +/- 4.59 months. They were divided clinically into edematous and non-edematous groups. Fifteen age and sex matched well nourished apparently healthy infants were chosen to serve as controls. All patients were subjected to a 3-phase workup, while controls were subjected only to phase 1. Phase I: includes clinical assessment, laboratory investigations including plasma LC-PUFA levels and Neurodevelopmental assessment. In Phase II: An interventional program of 8 weeks duration; where all patients were receiving an initial supportive treatment followed by nutritional rehabilitation according to WHO guidelines, 1999 as well as developmental stimulation. According to the formula supplied to patients, they were randomly divided into either PUFA supplemented (+ve group) or nonBsupplemented (-ve group). In Phase III: All patients were re-assessed clinically and neurodevelopmentaly as well as re-evaluation for plasma LC-PUFA levels. The study revealed that, the mean plasma AA and DHA levels as well as the mean MDI and PDI scores of BSID-II were significantly lower in PEM patients compared to those levels after nutritional rehabilitation and to controls. Moreover, the mean MDI score was significantly lower in edematous subgroup compared to non-edematous one. Meanwhile, the mean rate of change in plasma DHA level was significantly higher in edematous subgroup compared to non-edematous one. However, there was no significant difference in the mean of rate of change in AA level or MDI and PDI scores between the 2 subgroups. Further, the mean rate of change in plasma AA and DHA levels as well as MDI score were significantly higher in PUFA +ve patients compared to PUFA Bve ones after nutritional rehabilitation. Finally, the study showed significant positive correlations between plasma AA and DHA levels and both MDI and PDI scores. From the course of this study we concluded that malnourished infants had impaired neurodevelopmental functions that could be related to the poor status of plasma LC-PUF. Thus, we recommend early intervention including nutritional rehabilitation and LC-PUFA supplementation as well as stimulation program, so as to have a better effect on future cognitive abilities of these infants.

Early detection of protein energy malnutrition in Sharkia Governorate.

UNLABELLED: The objective of this cross-sectional study was to assess the nutritional status of children, aged 6 to 36 months, in Sharkia Governorate aiming for early detection of malnourished cases. METHODS: the present study was carried out on 1000 children aged 6 to 36 months, selected by a multistage random sample from 6 villages in two districts in Sharkia Governorate. Data were gathered by an interview questionnaire to the child's mother or care giver at their homes. Anthropometric measurements as height, weight, mid-arm, head circumference and skin fold thickness were assessed. Body mass index was calculated. Dietary evaluation was done by a 24 hours recall for amounts and frequencies of food and was transferred to their recommended daily allowance (RDA). The studied children were classified into three groups according to their weight for age percentiles, underweight children, borderline malnourished children and normal weight children. Serum hemoglobin, pre-albumin and albumin were assessed for a randomly selected number of the studied group. RESULTS: the study showed that all anthropometric measurements were lower than normal in underweight and borderline subjects. The prevalence rates of wasting, stunting and underweight were 15%, 24.4% and 15.4% in the studied infants in Sharkia Governorate, respectively. The study revealed that nutrient intake of the study subjects was lower than the RDA for the energy intake from carbohydrates, vitamin D, and iron, while it was higher than the RDA for the energy intake from lipids and vitamin A and equal to the lower level of the normal range of RDA for the energy intake from proteins. Most of the protein intake was of plant origin. Caloric intake was less than RDA in underweight and border line children, but more than RDA in normal children (86%, 90% and 102%). The ratios of caloric intake to the required calories according to weight were 90%, 98% and 108% in the three groups respectively. Chronic cough and chronic and recurrent diarrhea were more complained by underweight and borderline children. Underweight children were more infested with oxyurius and entamoeba histolitica than the other 2 groups. Serum hemoglobin, albumin and plasma pre-albumin levels were within normal range with significantly lower values in underweight and borderline infants compared to normal children. By multiple linear regression analysis, the most important factors affecting BMI were carbohydrate, lipid and caloric intake, serum albumin, plasma pre-albumin, vitamin A and D intake and protein intake. CONCLUSION: There is a high prevalence of wasting ,stunting and underweight among infants and children of the studied sample in Sharkia governorate explained by the low socioeconomic status, unbalanced diet. Early changes of protein energy malnutrition were detected, in spite of the fact that serum hemoglobin, albumin and plasma pre-albumin levels were within normal range, they were significantly lower in underweight and borderline infants compared to normal children.