Pedi-R-MAPP: The development of a nutritional awareness tool for use in remote paediatric consultations using a modified Delphi consensus.

BACKGROUND & AIMS: The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments, and provide practical guidance for nutritional care. The aim of this study was to modify the R-MAPP into a version suitable for children, Pediatric Remote Malnutrition Application (Pedi-R-MAPP), and provide a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. METHODS: A ten-step process was completed: 1) permission to modify adult R-MAPP, 2) literature search to inform the Pedi-R-MAPP content, 3) Pedi-R-MAPP draft, 4) international survey of HCP practice using TECS, 5) nutrition experts invited to participate in a modified Delphi process, 6) first stakeholder meeting to agree purpose/draft of the tool, 7) round-one online survey, 8) statements with consensus removed from survey, 9) round-two online survey for statements with no consensus and 10) second stakeholder meeting with finalisation of the Pedi-R-MAPP nutrition awareness tool. RESULTS: The international survey completed by 463 HCPs, 55% paediatricians, 38% dietitians, 7% nurses/others. When HCPs were asked to look back over the last 12 months, dietitians (n = 110) reported that 5.7 ± 10.6 out of every 10 appointments were completed in person; compared to paediatricians (n = 182) who reported 7.5 ± 7.0 out of every 10 appointments to be in person (p < 0.0001), with the remainder completed as TECS consultations. Overall, 74 articles were identified and used to develop the Pedi-R-MAPP which included colour-coded advice using a traffic light system; green, amber, red and purple. Eighteen participants agreed to participate in the Delphi consensus and completed both rounds of the modified Delphi survey. Agreement was reached at the first meeting on the purpose and draft sections of the proposed tool. In round-one of the online survey, 86% (n = 89/104) of statements reached consensus, whereas in round-two 12.5% (n = 13/104) of statements reached no consensus. At the second expert meeting, contested statements were discussed until agreement was reached and the Pedi-R-MAPP could be finalised. CONCLUSION: The Pedi-R-MAPP nutrition awareness tool was developed using a modified Delphi consensus. This tool aims to support the technological transformation fast-tracked by the COVID-19 pandemic by providing a structured approach to completing a remote nutrition focused assessment, as well as identifying the frequency of follow up along with those children who may require in-person assessment.

Relationship between chronic otitis media with effusion and overweight or obesity in children.

OBJECTIVES: Otitis media with effusion and obesity are both common in childhood and might share some immunological alterations. This study aimed to investigate the relationship between chronic otitis media with effusion and childhood overweight or obesity, including the potential effects of adenoid or tonsillar hypertrophy on that relationship. METHODS: This study included 60 children with chronic otitis media with effusion and 86 healthy children aged from 2 to 10 years. Measures of height and weight were used to calculate the body mass index, weight for height and weight z score. RESULTS: The prevalence of overweight or obesity was higher in children with chronic otitis media with effusion, according to the weight for height percentiles (p = 0.012). However, neither the presence of adenoid or tonsillar hypertrophy nor the degree of adenoid hypertrophy was associated with overweight or obesity. CONCLUSION: Overweight and obesity might be risk factors for developing chronic otitis media with effusion, or vice versa.

Acquired IgE-mediated food allergy after liver transplantation in children.

BACKGROUND: In recent years, the number of studies regarding newly-diagnosed food allergies after liver transplantation has been increasing. In this study, we aimed to investigate the frequency, aetiology, risk factors, and severity of IgE-mediated food allergies after liver transplantation in children. METHODS: Paediatric patients who underwent liver transplantation at Inonu University Faculty of Medicine, Organ Transplantation Institute were included in the study. RESULTS: Forty-nine paediatric patients were enrolled in the study; 26 (53.1%) were female, the median age at transplantation was five years, and median follow-up time after transplantation was 16 months. Six patients (12.2%) developed IgE-mediated food allergies after transplantation; four had urticaria and/or angio-oedema and two developed anaphylaxis after food intake. Patients with and without IgE-mediated food allergies were similar in terms of sex, age at transplantation, comorbid atopic disease, immunosuppressant therapy with tacrolimus, and blood tacrolimus level (p>0.05 for each). Serum total IgE levels ≥100 IU/mL (p=0.02) and peripheral eosinophilia (p=0.026) were more common in the patients who developed IgE-mediated food allergies. In five of the six patients who developed IgE-mediated food allergies, reaction occurred within the first year after transplantation; the risk of developing a reaction was 2.7 times higher within the first year after transplantation than in subsequent years (95% CI, 1.546-4.914; p=0.026). No Epstein-Barr virus or cytomegalovirus infections were detected in any of the patients who developed IgE-mediated food allergies after liver transplantation. CONCLUSION: The risk of developing IgE-mediated food allergies is approximately three times higher within the first year after transplantation than in subsequent years.

Serum nitric oxide levels in children with Wilson's disease.

BACKGROUND: It is known that the synthesis of nitric oxide (NO) is increased in cirrhosis. In humans, NO levels were investigated mostly in adult cirrhotics with portal hypertension. Because there is no study investigating NO status in childhood cirrhosis and because Wilson's disease (WD) has some specific properties due its copper overload with powerful prooxidant action, we aimed to determine serum NO levels in children with untreated WD and to investigate the probable relationship between NO level and both clinical presentation and the severity of the disease. METHODS: Twenty children with newly diagnosed WD and sex and age matched 14 healthy children were included. Serum NO levels were determined by spectrophotometric method using Griess reaction. RESULTS: Serum NO level of children with WD and of healthy children were 156.8 +/- 28.2 and 135.6 +/- 21.17 micromol/l respectively (p = 0.024). Serum NO level was not different in respect with the clinical presentation, such as presence of ascites, neurological involvement, cholestasis or haemorrhagic diathesis. Severity of the disease did not influence the serum NO level. Serum NO levels of patients with low and normal ceruloplasmin levels were not different. CONCLUSION: It was demonstrated that serum NO level was higher in children with WD compared to healthy children. Because we could not find a correlation between raised NO and any clinical or biochemical findings in the present study, we concluded that NO could not be used as a prognostic or predicting factor in children with WD.

Serum leptin levels in children with acute viral hepatitis A / Niveles de leptina en plasma en niños con hepatitis viral a aguda

OBJECTIVES: In acute viral hepatitis A (AVH-A), involvement of the liver is through cytotoxic cells and cytokine levels are increased Immune response of the host determines the severity of the disease. Leptin stimulates cytokines, therefore, the authors hypothesized that the relationship between leptin and cellular immunity might cause different clinical presentations of the disease. METHODS: Twenty-eight children with AVH-A and 10 healthy children formed the basis of the study. Serum leptin, C-reactive protein (CRP) and alpha-1-antitrypsin (A1AT) levels were determined RESULTS: There was significant positive correlation between body mass index (BMI) and leptin levels both in patients and controls (p = 0.003 and p = 0.001 respectively). No significant difference in serum leptin, CRP or A1AT levels between patients and controls was detected (p > 0.05). Presence of icterus or fulminant hepatic failure (FHF) did not affect serum leptin level (p > 0.05). Mean A1AT level was significantly higher in children with FHF (p < 0.05). On the 30th day of admission, mean BMI, weight and leptin levels increased (p < 0.01, p < 0.01 and p < 0.05 respectively) and mean A1AT level decreased (p < 0.01). CONCLUSION: Leptin levels are not altered in children with AVH-A. In the convalescence period, leptin increased parallel to BMI. It is suggested that expected increment in leptin due to inflammation might be balanced with the decrease due to loss of appetite during acute illness or it might be entirely due to loss of production.

Serum leptin levels in children with acute viral hepatitis A.

OBJECTIVES: In acute viral hepatitis A (AVH-A), involvement of the liver is through cytotoxic cells and cytokine levels are increased Immune response of the host determines the severity of the disease. Leptin stimulates cytokines, therefore, the authors hypothesized that the relationship between leptin and cellular immunity might cause different clinical presentations of the disease. METHODS: Twenty-eight children with AVH-A and 10 healthy children formed the basis of the study. Serum leptin, C-reactive protein (CRP) and alpha-1-antitrypsin (A1AT) levels were determined RESULTS: There was significant positive correlation between body mass index (BMI) and leptin levels both in patients and controls (p = 0.003 and p = 0.001 respectively). No significant difference in serum leptin, CRP or A1AT levels between patients and controls was detected (p > 0.05). Presence of icterus or fulminant hepatic failure (FHF) did not affect serum leptin level (p > 0.05). Mean A1AT level was significantly higher in children with FHF (p < 0.05). On the 30th day of admission, mean BMI, weight and leptin levels increased (p < 0.01, p < 0.01 and p < 0.05 respectively) and mean A1AT level decreased (p < 0.01). CONCLUSION: Leptin levels are not altered in children with AVH-A. In the convalescence period, leptin increased parallel to BMI. It is suggested that expected increment in leptin due to inflammation might be balanced with the decrease due to loss of appetite during acute illness or it might be entirely due to loss of production.

Tuberculous meningitis in Turkish children: an evaluation of 38 cases.

Thirty-eight cases of tuberculous meningitis in children were studied. Mortality was 28.9%; most of these presented with stage III disease. Tuberculous meningitis (TBM) still ranks as one of the most important communicable diseases in terms of morbidity and mortality. It is universally fatal if not treated and has high morbidity and mortality, if not recognized early. According to WHO's data, 1.3 million new TB cases under 15 year olds were reported. In Turkey, the TB prevalence is 0.4 %. According to data from the Turkish Ministry of Health, the number of admissions to hospitals dropped from 108 per 100,000 in 1971 to 51 per 10,000 in 1988. Early diagnosis and treatment of TBM are essential in order to prevent late sequelas and death. The diagnosis of TBM may be delayed because many patients initially have vague, seemingly minor, signs and symptoms. In this study, the clinical and laboratory findings of 38 patients with the diagnosis of TBM in our hospital were reviewed, retrospectively, during the past five years. Our purpose was to stress the importance of TBM as a public health problem in Turkey, particularly in the Eastern of Turkey.

Autoimmune hepatitis triggered by Brucella infection or doxycycline or both.

Autoimmune hepatitis is a disorder of unknown aetiology in which progressive destruction of the hepatic parenchyma occurs, often progressing to cirrhosis. Hepatitis A, Ebstein-Barr virus and measles virus have been identified as triggers for autoimmune hepatitis in susceptible individuals. There are also reports about herbal medicine and minocycline. A case with autoimmune hepatitis triggered by Brucella infection or doxycycline, or both, is presented. An 11-year-old female patient treated with six weeks of doxycycline and three weeks of streptomycine for brucellosis presented with histologically proven autoimmune hepatitis (AH) and responded to corticosteroid treatment. Since neither brucellosis nor doxcycyline as triggering factors for AH have been described so far, these two entities are discussed and the literature reviewed.

Sero-epidemiology of hepatitis B infection in an urban paediatric population in Turkey.

The hepatitis B virus (HBV) seroprevalence rate is known to be 25-60% in Turkey with the highest prevalence in the east and south-east. There are insufficient data on sero-epidemiology of HBV infection in children living in East Turkey. The objective of this study was to estimate the seroprevalence of HBV infection in 6-17 year olds living in the largest city in East Turkey, and to correlate the serological results with epidemiological data. A total of 1091 serum samples were tested for hepatititis B surface antigen (HBsAg), antibody to HBsAg (anti-HBs) and antibody to hepatitis B core antigen (anti-HBc) using a commercially available enzyme-linked immunosorbent assay. The overall seroprevalence rate was 9.7% and was correlated with age (P = 0.011). No statistical difference was detected between subjects with or without risk factors (P = 0.77). The seroprevalence of HBsAg was 1.8%, and it was higher in children with a low socio-economic status (P = 0.047). The educational status of the parents and sibling size did not affect the rate of total seroprevalence or HBsAg seroprevalence. Although we found that the HBV seroprevalence rate in East Turkey was not as high as reported previously, we emphasize the importance of screening children in order to identify asymptomatic patients in Turkey until HBV infection is entirely eradicated with vaccination programmes.

Does adenotonsillectomy improve growth in children with obstructive adenotonsillar hypertrophy?

Faltering growth may be associated with adenotonsillar hypertrophy, but its pathophysiological mechanism is unclear. This study included 29 pre-pubertal children with obstructive adenotonsillar hypertrophy, and aimed to investigate the probable difference in energy intake and serum insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3) levels before and 6 months after adenotonsillectomy. Weight and height standard deviation scores, energy intake per kilogram and serum IGF-1 levels were found to be significantly higher 6 months after adenotonsillectomy, indicating that adenotonsillar hypertrophy is associated with poor growth.

Amitraz poisoning in children: retrospective analysis of 21 cases.

The clinical and laboratory findings of 21 children with amitraz poisoning were evaluated retrospectively. Poisoning route, signs and symptoms of poisoning, duration of hospitalization and outcome were recorded. The mean age was 3.5 +/- 1.9 years and the ratio of males to females was 1.63. In all cases poisoning was via the oral route. The time from ingestion to onset of symptoms was 30-180 min. Drowsiness (100%) and loss of consciousness (100%) were the most common clinical findings, followed by vomiting (61.9%). Hypotension was observed in 66.7% of cases, bradycardia in 61.9%, respiratory depression in 42.9%, hypothermia in 9.3%, and 14.3% had generalized seizures responsive to diazepam. Hyperglycaemia and glycosuria were detected in 47.6% and 38.1% of cases, respectively. Minimally elevated transaminases and alkaline phosphatase levels were detected in 23.8% of cases. All patients recovered completely and were discharged within 1.0-5.2 days (mean, 2.1 +/- 1.1).

Abetalipoproteinemia: a case report.

Abetalipoproteinemia is a rare autosomal recessive disorder characterized by steatorrhea, poor weight gain, acanthocytosis and retinitis pigmentosa. Here we peresent a six-month-old patient with abetaliporoteinemia. He had a history of chronic diarrhea from the first month of life. He was cachectic and his motor development was delayed. Microscopic examination of the stool revealed fat. Mild anemia with reticulocytosis, acanthocytosis, low triglyceride, low cholesterol, low-density lipoprotein, high-density lipoprotein, and apolipoprotein A and B were detected. Ophthalmological examination was normal. Peroral jejunal capsule biopsy revealed normal villi and significant lipid deposition in the cytoplasm of affected cells. The patient was given large doses of vitamins E and A.

Plasma and liver carnitine status of children with chronic liver disease and cirrhosis.

BACKGROUND: Carnitine is an essential cofactor in the transfer of long-chain fatty acids across the inner mitochondrial membrane for oxidation. As its synthesis is performed in the liver, alterations in carnitine metabolism is expected in liver diseases, especially in cirrhosis. METHODS: In this study, we investigated plasma and liver carnitine concentrations of 68 children with chronic liver disease, 36 of whom had cirrhosis as well. Carnitine level was determined by enzymatic method. RESULTS: Plasma and liver carnitine concentrations were not correlated. Mean plasma carnitine level of cirrhotic children was significantly lower than that of the control group (P<0. 0001). While there was no difference between liver carnitine concentrations of children with chronic liver disease and cirrhosis (P>0.05), mean plasma level of cirrhotics were lower (P<0.05). Plasma carnitine was correlated with albumin, triglyceride and gamma glutamyl transpeptidase (GGT) in patients with chronic liver disease (P<0.05). Liver carnitine was correlated with GGT in cirrhotic patients (P<0.005). Children with malnutrition had higher plasma and liver carnitine levels (P<0.05). The highest plasma and liver carnitine levels were detected in children with biliary atresia and criptogenic cirrhosis, respectively. Both the lowest plasma and liver carnitine levels were detected in Wilson's disease. CONCLUSION: Children with cirrhosis have low plasma carnitine concentrations. This finding is prominent in children with Wilson's disease. As carnitine is an essential factor in lipid metabolism, the carnitine supplementation for patients with cirrhosis in childhood, especially with Wilson's disease, seems to be mandatory.

Serum zinc status in chronic hepatitis B and its relationship to liver histology and treatment results.

BACKGROUND: It is known that cytotoxic T lymphocytes are responsible for viral clearance in chronic hepatitis B (HBV) infection. Zinc deficiency affects development of acquired immunity by preventing certain functions of T lymphocytes. We investigated the serum zinc levels and the relationship to liver histopathology and response to interferon alpha (IFN-alpha) and lamivudine combination therapy in 28 children with chronic HBV infection. METHODS: A course of IFN-alpha was injected as 5 million U/m2 subcutaneously, thrice a week for 6 months and lamivudine 4 mg/kg per day orally, for 1 year. Normalization of alanine aminotransferase (ALT), loss of HBV DNA, hepatitis B e antigen (HBeAg) seroconversion altogether was considered as end of therapy response (ETR). RESULTS: The ETR was achieved in eight (30.7%) patients. Serum zinc concentrations of 20 healthy children and patients was not significantly different (P>0.05). While pretreatment serum ALT, zinc, histological activity index (HAI) and portal inflammation scores were statistically higher in children who had ETR (P<0.005, P<0.05, P<0.05 and P<0.05, respectively), pretreatment serum HBV DNA was lower (P<0.005). Serum zinc level was correlated with HAI and portal inflammation scores (P<0.01 and P<0.01). CONCLUSION: This study showed the relationship of serum zinc status to liver histopathology and to the ETR and may be a preliminary study leading new studies focusing on zinc status in patients with chronic HBV infection.

Low plasma apolipoprotein A-I level: new prognostic criterion in childhood cirrhosis?

Apolipoprotein A-I (apo A-I) has been found to be decreased in adults with cirrhosis, but it has not been routinely used for prognostic purposes thus far. This study was performed to determine apo A-I levels in childhood cirrhosis and to establish some prognostic cut-off values. Apo A-I levels of 78 children with chronic liver disease, 38 of whom had cirrhosis as well, were studied. Mean values of cirrhotic, non-cirrhotic and healthy children were not different (p > .05). However, in cirrhotic children, the highest value was detected in the Child-Pugh A group, and it was different from those of the B and C groups (p < .05 and p < .001, respectively). Apo A-I was the lowest in the moderate risk group of Malatack's model, and was significantly different from the low risk group (p < .05). Apo A-I was inversely correlated with Malatack score, Child-Pugh score, total bilirubin, conjugated bilirubin, and prothrombin time (p < .01, p < .01, p < .01, p < .01, p < .05, respectively). In cirrhotic children with cholestasis, apo A-I was lower than in non-cholestatic children (p < .05). Apo A-I value < 80 mg/dl had 84% specificity and 84% negative predictive value for the high risk group of Malatack's model. Similarly, Apo A-I value < 83 mg/dl had 95% specificity and 87% negative predictive value for the Child-Pugh C group. We concluded that Apo A-I is a sensitive and specific parameter of poor prognosis in childhood cirrhosis.

Nasal mucociliary clearance and nasal and oral pH in patients with insulin-dependent diabetes.

We studied 32 patients with insulin-dependent diabetes mellitus to determine how their rate of mucociliary clearance and their levels of nasal and oral pH compared with those of 10 nondiabetic controls and how these rhinologic measurements varied within different subsets of diabetic patients. Although we found very few statistically significant differences in all our comparisons, we did find that nasal mucociliary clearance and oral pH levels in the diabetic patients were significantly different from those of healthy subjects.