Role of Pediatricians in Promoting and Supporting Breastfeeding: A Position Paper of the International Pediatric Association Strategic Advisory Group on Infant, Child, and Adolescent Nutrition.

BACKGROUND: Promoting and supporting breastfeeding is an important public health intervention with multiple benefits for both infants and mothers. Even modest increases in the prevalence and duration of breastfeeding could significantly reduce healthcare costs and improve maternal and child health outcomes. However, widespread adoption of breastfeeding recommendations remains poor in most settings, which contributes to widening health and social inequalities. Pediatricians have a duty to advocate for improving child health, including promoting and supporting breastfeeding. SUMMARY: This paper, from the International Pediatric Association Special Advisory Group on Nutrition, considers common barriers to breastfeeding and addresses how pediatricians can better promote and support breastfeeding, both at an individual level and by influencing practice and policy. All pediatricians need to understand the basics of breastfeeding, including lactation physiology, recognize common breastfeeding problems, and advise mothers or refer them for appropriate support; training curricula for general pediatricians and all pediatric subspecialties should reflect this. Even in the situation where their day-to-day work does not involve direct contact with mothers and infants, pediatricians can have an important influence on policy and practice. They should support colleagues who work directly with mothers and infants, ensuring that systems and environments are conducive to breastfeeding and, where appropriate, milk expression. Pediatricians and pediatric organizations should also promote policies aimed at promoting and supporting breastfeeding at local, regional, national, and international levels. KEY MESSAGES: Pediatricians have a duty to promote and support breastfeeding, regardless of their day-to-day role and responsibilities. Pediatric training curricula should ensure that all trainees acquire a good understanding of breastfeeding so they are able to effectively support mothers in their personal practice but also influence breastfeeding practice and policy at a local, regional, national, and international level.

International Latin American Survey on Pediatric Intestinal Failure Team.

There is little data on the experience of managing pediatric Intestinal Failure (IF) in Latin America. This study aimed to identify and describe the current organization and practices of the IF teams in Latin America and the Caribbean. An online survey was sent to inquire about the existence of IF teams that managed children on home parenteral nutrition (HPN). Our questionnaire was based on a previously published European study with a similar goal. Twenty-four centers with pediatric IF teams in eight countries completed the survey, representing a total number of 316 children on HPN. The median number of children on parenteral nutrition (PN) at home per team was 5.5 (range 1-50). Teams consisted of the following members: pediatric gastroenterologist and a pediatric surgeon in all teams, dietician (95.8%), nurse (91.7%), social worker (79.2%), pharmacist (70.8%), oral therapist (62.5%), psychologist (58.3%), and physiotherapist (45.8%). The majority of the centers followed international standards of care on vascular access, parenteral and enteral nutrition, and IF medical and surgical management, but a significant percentage reported inability to monitor micronutrients, like vitamins A (37.5%), E (41.7%), B1 (66.7%), B2 (62.5%), B6 (62.5%), active B12 (58.3%); and trace elements-including zinc (29.2%), aluminum (75%), copper (37.5%), chromium (58.3%), selenium (58.3%), and manganese (58.3%). Conclusion: There is wide variation in how IF teams are structured in Latin America-while many countries have well-established Intestinal rehabilitation programs, a few do not follow international standards. Many countries did not report having an IF team managing pediatric patients on HPN.

[Ibero-latinamerican clinical practical guidelines on pediatric caustic esophagitis: Physiopathology and clinical-endoscopic diagnosis (1st Part)]. / Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: Fisiopatología y diagnóstico clínico-endoscópico (1a Parte).

Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) successive papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

[Ibero-Latinamerican Clinical Practical Guidelines on pediatric caustic esophagitis: Therapeutical aspects (Part 2)]. / Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: Aspectos terapéuticos (2a. Parte).

Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) separate papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: aspectos terapéuticos (2a. Parte) / Ibero-Latinamerican Clinical Practical Guidelines on pediatric caustic esophagitis: therapeutical aspects (Part 2)

Resumen: La ingestión de cáusticos representa un grave problema médico-social por las consecuencias devastadoras e irreversibles que puede producir en el tracto digestivo superior. En Iberoamérica no se han publicado datos fidedignos sobre la incidencia o la prevalencia de lesiones inducidas por cáusticos. La información disponible sobre la presentación clínica, diagnóstico, tratamiento y pronóstico se basa en series retrospectivas de casos y, de hecho, su manejo clínico se sustenta en muchos casos fundamentalmente en la opinión de expertos. Recientemente como una iniciativa de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP) y con la co laboración de colegas de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediá trica (SEGHNP), hemos diseñado una Guía de Práctica Clínica (GPC) la cual incluye una serie de enunciados y recomendaciones dirigidos a optimizar la atención a los pacientes y que se basan en la revisión sistemática de la evidencia. En dos (2) manuscritos sucesivos nos hemos enfocado primero, en los aspectos fisiopatológicos y de diagnóstico clínico-endoscópico de la esofagitis cáustica en niños (1a. Parte) y en segundo lugar, en los aspectos más relevantes del tratamiento (2a. Parte). Esperamos esta guía se convierta en una herramienta útil para el clínico en el difícil proceso de toma de decisio nes a la hora de evaluar un paciente posterior a la ingesta de una sustancia cáustica.

Abstract: Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) separate papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: fisiopatología y diagnóstico clínico-endoscópico (1a Parte) / Ibero-latinamerican clinical practical guidelines on pediatric caustic esophagitis: physiopathology and clinical-endoscopic diagnosis (1st Part)

Resumen: La ingestión de cáusticos representa un grave problema médico-social por las consecuencias devastadoras e irreversibles que puede producir en el tracto digestivo superior. En Iberoamérica no se han publicado datos fidedignos sobre la incidencia o la prevalencia de lesiones inducidas por cáusticos. La información disponible sobre la presentación clínica, diagnóstico, tratamiento y pronóstico se basa en series retrospectivas de casos y, de hecho, su manejo clínico se sustenta en muchos casos fundamentalmente en la opinión de expertos. Recientemente como una iniciativa de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP) y con la co laboración de colegas de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediá trica (SEGHNP), hemos diseñado una Guía de Práctica Clínica (GPC) la cual incluye una serie de enunciados y recomendaciones dirigidos a optimizar la atención a los pacientes y que se basan en la revisión sistemática de la evidencia. En dos (2) manuscritos sucesivos nos hemos enfocado primero, en los aspectos fisiopatológicos y de diagnóstico clínico-endoscópico de la esofagitis cáustica en niños (1a. Parte) y en segundo lugar, en los aspectos más relevantes del tratamiento (2a. Parte). Esperamos esta guía se convierta en una herramienta útil para el clínico en el difícil proceso de toma de decisio nes a la hora de evaluar un paciente posterior a la ingesta de una sustancia cáustica.

Abstract: Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) successive papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

Amino acid formula as a new strategy for diagnosing cow's milk allergy in infants: is it cost-effective?

AIMS: To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow's milk allergy (CMA). MATERIALS AND METHODS: This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤24 months) with suspected CMA. The rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed. RESULTS: The mean cost per patient of the new amino acid formula strategy was R$3,341.57, while the cost of the current Brazilian guidelines strategy was R$3,641.08. The mean number of symptom-free days per patient, which was used as an indicator of effectiveness, was 900.6 and 875.7 days, respectively. The new strategy is, therefore, dominant. In the sensitivity analysis, the dominance was maintained with parameter variation. LIMITATIONS: In the absence of information in the literature, some premises were defined by a panel of specialists. CONCLUSIONS: The new strategy, which uses an amino acid formula in the elimination diagnostic diet followed by an oral food challenge, is a dominant pharmacoeconomic approach that has a lower cost and results in an increased number of symptom-free days.

Composition of Follow-Up Formula for Young Children Aged 12-36 Months: Recommendations of an International Expert Group Coordinated by the Nutrition Association of Thailand and the Early Nutrition Academy.

BACKGROUND: There are no internationally agreed recommendations on compositional requirements of follow-up formula for young children (FUF-YC) aged 1-3 years. AIM: The aim of the study is to propose international compositional recommendations for FUF-YC. METHODS: Compositional recommendations for FUF-YC were devised by expert consensus based on a detailed literature review of nutrient intakes and unmet needs in children aged 12-36 months. RESULTS AND CONCLUSIONS: Problematic nutrients with often inadequate intakes are the vitamins A, D, B12, C and folate, calcium, iron, iodine and zinc. If used, FUF-YC should be fed along with an age-appropriate mixed diet, usually contributing 1-2 cups (200-400 ml) of FUF-YC daily (approximately 15% of total energy intake). Protein from cow's milk-based formula should provide 1.6-2.7 g/100 kcal. Fat content should be 4.4-6.0 g/100 kcal. Carbohydrate should contribute 9-14 g/100 kcal with >50% from lactose. If other sugars are added, they should not exceed 10% of total carbohydrates. Calcium should provide 200 mg/100 kcal. Other micronutrient contents/100 kcal should reach 15% of the World Health Organization/Food and Agriculture Organization recommended nutrient intake values. A guidance upper level that was 3-5 times of the minimum level was established. Countries may adapt compositional requirements, considering recommended nutrient intakes, habitual diets, nutritional status and existence of micronutrient programs to ensure adequacy while preventing excessive intakes.

[Guía latinoamericana para el diagnóstico y tratamiento de alergia a las proteínas de la leche de vaca (GL-APLV)].

Cow's milk allergy (CMA) is an immune-based disease that has become an increasing problem. The diagnosis and management of CMA varies from one clinical setting to another and represents a challenge in pediatric practice. In addition, because nonallergic food reactions can be confused with CMA symptoms, there is an overdiagnosis of the disease. In response to these situations, pediatric specialties from recognized institutions throughout Latin America decided to develop a clinical guideline for diagnosis and management of cow's milk allergy. These guidelines include definitions, epidemiology, pathophysiology overview, clinical and evidencebased recommendations for the diagnosis and treatment of CMA. They also include prevention and prognosis sections and identify gaps in the current knowledge to be addressed through future research.

Alergia ao leite de vaca: achados do ultrassom com Doppler colorido em neonatos com hematoquezia / Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia

OBJETIVO: o ultrassom (US) tem sido uma importante ferramenta de diagnóstico para identificar várias causas de hemorragia gastrointestinal. Neonatos com alergia ao leite de vaca (ALV) podem apresentar hematoquezia, e a confirmação do diagnóstico pode ser difícil. O objetivo deste estudo é descrever achados com ultrassom em escala de cinza e com Doppler colorido em pacientes com ALV. MÉTODOS: estudamos, retrospectivamente, 13 neonatos com ALV. Todos eles apresentaram hematoquezia severa e dor abdominal e foram submetidos a um estudo com US, com o diagnóstico de colite alérgica. O diagnóstico teve como base os achados clínicos, a recuperação após a dieta de exclusão do neonato ou da mãe, no caso de amamentação exclusiva, e o teste de provocação oral positivo. RESULTADOS: a idade média variou de um a seis meses (média = 3,53). Sete dos 13 neonatos (53,8%) passaram novamente por ultrassonografia em escala de cinza e com Doppler colorido após a dieta de exclusão. Dentre eles, 12 dos 13 (92,3%) mostraram anormalidades no US e no ultrassom com Doppler colorido (USDC) no início. Os achados positivos que sugeriram colite foram paredes intestinais espessas e aumento na vascularização, principalmente no cólon descendente e sigmoide. Os resultados da colonoscopia e histopatológicos foram compatíveis com colite alérgica. Após uma mudança na dieta, os 13 neonatos se recuperaram e seus testes de provocação oral foram positivos. CONCLUSÃO: o US com Doppler pode ser muito útil para diagnosticar a colite secundária, como a ALV, e para excluir várias outras doenças abdominais que podem imitar essa doença.

OBJECTIVE: ultrasound (US) has been an important diagnostic tool to identify several causes of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hematochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. METHODS: we retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of allergic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. RESULTS: the mean age ranged from 1 to 6 months (mean = 3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, especially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. CONCLUSION: Doppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia.

OBJECTIVE: ultrasound (US) has been an important diagnostic tool to identify several causes of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hematochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. METHODS: we retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of allergic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. RESULTS: the mean age ranged from 1 to 6 months (mean=3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, especially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. CONCLUSION: Doppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Mejora en la reperfusión del infarto de miocardio en Argentina / Improvement in Reperfusion of Myocardial Infarction in Argenitna

INTRODUCCIÓN: No existe evidencia de que la conformación de redes de atención y procesos de mejora de la calidad en Argentina se relacionen con mejores resultados en el tratamiento del infarto agudo de miocardio. OBJETIVOS: Evaluar las principales causas de demora o no reperfusión en pacientes con infarto agudo de miocardio y supradesnivel del ST, determinando si la conformación de redes de atención, derivación precoz y mejora de la calidad produce mejores resultados. MÉTODOS: Se realizó un análisis de línea de base, con registro inicial de pacientes en seis centros. En aquellos pacientes que no recibieron tratamiento apropiado (demora o falta de reperfusión), se analizaron las causas raíz. En cada centro se implementaron intervenciones ajustadas a estas causas. En la segunda fase del registro se evaluaron los resultados de las intervenciones. RESULTADOS: En la primera etapa del registro se incluyó a 193 pacientes. El primer lugar de recepción fueron las guardias externas (55,4%), seguidas de las ambulancias (25,9%). Un total de 81 pacientes (41,2%) no recibieron un tratamiento apropiado. Las principales causas fueron el desconocimiento de los pacientes y las demoras en el traslado y diagnóstico. Una vez implementadas las intervenciones, en la segunda etapa (con 226 pacientes) la proporción con demora o sin tratamiento adecuado se redujo al 32,3% (n=73,p=0,04). CONCLUSIONES: Fue factible identificar las principales causas de demora en el tratamiento del infarto agudo de miocardio con supradesnivel del ST e implementar redes de atención y ciclos de mejora. Esto puede mejorar los resultados de la reperfusión, que tiene un gran impacto en la mortalidad.

INTRODUCTION: There is no evidence that networking for care and quality improvement process in Argentina brings better results in the treatment of acute myocardial infarction. OBJECTIVES: To assess the main causes of delay or non-reperfusion in patients with acute myocardial infarction and elevated ST segment, determining whether the networking for care, early referral and quality improvement brings better results. METHODS: A base lineanalysis was performed, including initial patient records in six centers. For those patients who had not received appropriate treatment (delay or lack of reperfusion), root causes were explored. Case-related interventions were implemented in each center. The second stage of the record assessed intervention results. RESULTS: The first stage of the record included 193 patients. The first place of reception were emergency departments (55.4 percent), followed by ambulances (25.9 percent). A total of 81 patients (41.2 percent) did not receive appropriate treatment. This was mainly due to lack of information about patients and delays for transfer and diagnosis. In the second stage (with 226 patients), after the implementation of interventions, the rate with delay or without appropriate treatment was reduced to 32.3 percent (n=73, p=0.04). CONCLUSIONS: It was possible to identify the main causes of delay in the treatment of acute myocardial infarction with elevated ST segment, and to implement networks for care and improvement cycles. This can improve reperfusion results, which have a big impact on mortality.

Waist circumference in children and adolescents correlate with metabolic syndrome and fat deposits in young adults.

BACKGROUND & AIMS: To determine the relevance of waist circumference (WC) measurement and monitoring in children and adolescents as an early indicator of overweight, metabolic syndrome (MS) and cardiovascular problems in young adults in comparison with visceral and subcutaneous adiposity. METHODS: A cohort study with 159 subjects (51.6% female) started in 1999 with an average age of 13.2 years. In 1999, 2006 and 2008 weight, height, and WC were evaluated. In 2006 blood samples for laboratory diagnosis of MS were added. In 2008 abdominal computed tomography (ACT) to quantify the fat deposits were also added. RESULTS: The WC measured in children and adolescents was strongly correlated with body mass index (BMI) measured simultaneously. A strong correlation was established between WC in 1999 with measures of WC and BMI as young adults. WC strongly correlated with fat deposits in ACT. The WC in 1999 expressed more subcutaneous fat (SAT), while the WC when young adults expressed strong correlation with both visceral fat (VAT) and SAT. The correlation of WC with fat deposits was stronger in females. WC and not BMI in 1999 was significantly higher in the group that evolved to MS. CONCLUSIONS: The WC in children and adolescents was useful in screening patients for MS. WC expressed the accumulation of abdominal fat; especially subcutaneous fat.

Doppler US measurement of the superior mesenteric artery blood flow in children and adolescents.

BACKGROUND: Blood flow volume in the superior mesenteric artery (SMA) measured by pulsed Doppler has been used in adults to evaluate Crohn disease but has not been utilized in children and adolescents. OBJECTIVE: To establish a cutoff point for normal SMA blood flow using pulsed Doppler US measurement in healthy children and adolescents. MATERIALS AND METHODS: The study included healthy volunteers from an urban community, divided into two age groups, children (5-9 years) and adolescents (10-17 years). Anthropometric measurements included waist circumference and body surface area classified according to the z-score of body mass index. Heart rate, blood pressure, oxygen saturation and temperature were measured immediately before US evaluation. RESULTS: The average age of the 60 participants was 12.2 years. Of these, 21 (35%) were ages 5-9 years and 39 (65%) were ages 10-17 years; 21 (35%) were boys. Findings of the two examiners coincided for 58 of the 60 (96.7%) participants. SMA blood flow was significantly lower in the children (mean ± SD = 556 ± 122 ml/min) than in adolescents (mean ± SD 775 ± 311 ml/min) (P < 0.001). SMA blood flow showed statistically significant positive associations with body surface area. CONCLUSION: We found that superior mesenteric artery blood flow is significantly lower in children than in adolescents and is associated with body surface area.

Divertículo de Meckel ao Doppler em cores: relato de dois casos / Color Doppler of Meckel's diverticulum: report of two cases

O divertículo de Meckel é a anomalia congênita mais comum do trato gastrintestinal e a hemorragia é a complicação mais frequente. Cintilografia, ultrassonografia modo B e com Doppler, e tomografia computadorizada podem ser utilizadas para detectar complicações. Descrevemos dois casos de divertículo de Meckel complicado detectados à ultrassonografia, cujos achados foram diferentes dos descritos na literatura.

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract and bleeding is its most frequent complication. Scintigraphy, B-mode and Doppler ultrasonography, and computed tomography may be utilized to detect complications. The present report describes two cases of complicated Meckel's diverticulum detected at ultrasonography whose findings were different from those described in the literature.

Gray-scale and color Doppler ultrasound findings in children with cow's milk allergy.

OBJECTIVE: The objective of our study was to evaluate whether gray-scale and color Doppler ultrasound can reveal intestinal inflammation in infants with cow's milk allergy (CMA). SUBJECTS AND METHODS: This study evaluated the clinical findings and grayscale and color Doppler sonograms of 34 infants. Seventeen 0- to 6-month-old infants with suspected CMA and 17 nonsymptomatic age-matched infants were evaluated by a blinded investigator who determined the percentage of vessel density and the thickness of different parts of the bowel. Clinical and sonographic variables were evaluated in the same regions of bowel considering three time points: presentation, after 4 weeks of feeding only amino acid-based formula, and after challenge test. Likelihood ratios and receiver operating characteristic (ROC) curves were used to define a cutoff point for vascular density percentage. RESULTS: The difference in the percentage of vessel density between patients with CMA (mean, 28.1%) and control infants (mean, 7.77%) was statistically significant. ROC analysis showed that a cutoff point of 18.7% could differentiate between patients with CMA and control infants with 81.8% sensitivity and 94.1% specificity. The area under the curve was 0.941. We found statistical differences in bowel wall thickness between control patients and patients with CMA. CONCLUSION: There was a significant increase in vessel density in infants younger than 6 months with CMA compared with healthy age-matched infants. The most appropriate cutoff point for vessel density was 18.7%. The results of this study suggest that Doppler ultrasound could be used as a screening tool to diagnose CMA.

A survey on clinical presentation and nutritional status of infants with suspected cow' milk allergy.

BACKGROUND: Cow's milk is the most common food allergen in infants and the diagnosis of cow's milk allergy is difficult, even with the use of several diagnostic tests. Therefore, elimination diets and challenge tests are essential for the diagnosis and treatment of this disorder. The aim of this study is to report the clinical presentation and nutritional status of children evaluated by pediatric gastroenterologists for the assessment of symptoms suggestive of cow's milk allergy. METHODS: An observational cross-sectional study was performed among 9,478 patients evaluated by 30 pediatric gastroenterologists for 40 days in 5 different geographical regions in Brazil. Clinical data were collected from patients with symptoms suggestive of cow's milk allergy. The nutritional status of infants (age < or = 24 months) seen for the first time was evaluated according to z-scores for weight-for-age, weight-for-height, and height-for-age. Epi-Info (CDC-NCHS, 2000) software was used to calculate z-scores. RESULTS: The prevalence of suspected cow's milk allergy in the study population was 5.4% (513/9,478), and the incidence was 2.2% (211/9,478). Among 159 infants seen at first evaluation, 15.1% presented with a low weight-for-age z score (< -2.0 standard deviation - SD), 8.7% with a low weight-for-height z score (< -2.0 SD), and 23.9% with a low height-for-age z score (< -2.0 SD). CONCLUSION: The high prevalence of nutritional deficits among infants with symptoms suggestive of cow's milk allergy indicates that effective elimination diets should be prescribed to control allergy symptoms and to prevent or treat malnutrition.