Diagnóstico y tratamiento de la esofagitis eosinofílica en niños. Revisión de la literatura y recomendaciones basadas en la evidencia. Grupo de trabajo de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición pediátrica (SLAGHNP).

During the last twenty years Eosinophilic Esophagitis has become one the most important causes of esophageal disfunction in children, food impactation in adolescents and young adults, therapeutic failure in patients with gastroesophageal reflux disease (GERD) and the most frecuent eosinophilic disease of the gastrointestinal tract. We present recommendations for the diagnosis and treatment of the disease based in a systematic review of the literature.

Fiber in enteral nutrition: why and what for? / La fibra en la nutrición enteral: ¿por qué y para qué?

Enteral formulas containing fiber, designed to be administered orally or by gavage, have been used for decades. Although their indication in the pediatric population does not have a global consensus, knowledge about the benefits of using fiber to promote healthier microbiota has grown in recent years. Different fiber types' physicochemical characteristics (solubility, viscosity, fermentability) determine their functions. The impact of fiber use on preventing specific chronic pathologies (cardiovascular disease, cancer, diabetes) has been reported in epidemiological studies. In controlled studies, changes in stool consistency, intestinal transit, and the composition and function of the microbiota have been observed since fiber produces fermentation metabolites such as short-chain fatty acids, which improve metabolic and immunological aspects. Different pediatric pathologies could benefit from the use of fiber.

Las fórmulas enterales que contienen fibra, diseñadas para ser administradas de forma oral o por sonda, han sido utilizadas durante décadas. Si bien su indicación en población pediátrica no cuenta con un consenso global, el conocimiento sobre los beneficios de la utilización de fibra en relación con el intestino, para promover una microbiota más saludable, ha crecido en los últimos años. Los diferentes tipos de fibra tienen características fisicoquímicas (solubilidad, viscosidad, fermentabilidad) que determinan sus funciones. El impacto del uso de fibra sobre la prevención de ciertas patologías crónicas (enfermedad cardiovascular, cáncer, diabetes) ha sido reportado en estudios epidemiológicos. En estudios controlados, se han observado cambios en la consistencia de las heces, en el tránsito intestinal y en la composición y función de la microbiota, ya que la fibra produce metabolitos de fermentación tales como ácidos grasos de cadena corta, lo cual mejora aspectos metabólicos e inmunológicos. Diferentes patologías pediátricas podrían verse beneficiadas por el uso de fibra.

[Cow's milk allergy: diagnostic process. Expert consensus]. / Alergia a las proteínas de la leche de vaca: proceso diagnóstico. Consenso interdisciplinario de expertos.

Cow's milk protein can cause food allergy. The different mechanisms of action involved, the clinical variability depending on the stage of pediatric life in which it manifests, leads to difficulties in its approach, with the risk of under- or over-diagnosis. Professionals from various areas intervene in this process and their interaction is recommended. That is why the objective of this consensus has been to reflect the updated knowledge in an interdisciplinary mode, generating recommendations for its correct diagnosis. We have worked with the Delphi method to add to the scientific evidence, the experience from neonatologists, pediatricians, experts in allergy, nutrition and gastroenterology. We think that this interdisciplinary approach will be of practical use and will promote more comprehensive care for these patients.

Las proteínas de la leche de vaca pueden causar alergia alimentaria. Los distintos mecanismos de acción involucrados y la variabilidad clínica según la etapa de la vida pediátrica en la que se manifieste ocasionan dificultades en su abordaje, con riesgo de sub- o sobrediagnóstico. En este proceso, intervienen profesionales de diversas áreas y es recomendable su interacción. Es por ello que el objetivo de este consenso ha sido reflejar el conocimiento actualizado desde la interdisciplina, generando recomendaciones para su correcto diagnóstico. Hemos trabajado con el método de Delphi para sumarle a la evidencia científica, la experiencia proveniente de neonatólogos, pediatras, especialistas en alergia, nutrición y gastroenterología. Pensamos que este enfoque interdisciplinario de trabajo va a resultar de utilidad práctica y promoverá una atención más integral de estos pacientes.

[Cow's milk allergy treatment. An expert consensus]. / Tratamiento de la alergia a la proteína de la leche de vaca. Consenso interdisciplinario de expertos.

The treatment of cow's milk protein allergy is based on the complete elimination of cow's milk protein from the diet. To achieve remission of symptoms and future tolerance, exclusion must be total. In formula fed infants the extensively hydrolysed formula is the most appropriate option in mild or moderate forms, while those based on amino acids are reserved for the most severe cases. The treatment time, the acquisition of tolerance and the moment for the oral provocation test will vary according to the clinical picture, the immunological mechanism involved and the age of the patient. The aim of this consensus has been to reflect the updated knowledge together with the experience of neonatologists, pediatricians, experts in allergy, nutrition and gastroenterology.

El tratamiento de la alergia a las proteínas de la leche de vaca se basa en la eliminación completa de las proteínas de leche de vaca de la dieta del niño y de la madre en los que reciben leche materna. Para lograr la remisión de los síntomas y la tolerancia futura, la exclusión debe ser total. En los niños que reciben fórmula, esta deberá tener hidrolizado extenso de proteínas en las formas leves o moderadas, mientras que aquellas a base de aminoácidos se reservan para los casos más graves. El tiempo de tratamiento, la adquisición de tolerancia y el momento para la prueba de provocación oral van a variar según el cuadro clínico, el mecanismo inmunológico implicado y la edad del paciente. El objetivo de este consenso ha sido reflejar el conocimiento actualizado junto con la experiencia de neonatólogos, pediatras, especialistas en alergia, nutrición y gastroenterología.

Acute Diarrhoea in Children: Determination of Duration Using a Combined Bismuth Hydroxide Gel and Oral Rehydration Solution Therapy vs. Oral Rehydration Solution.

Oral rehydration salt (ORS) treatment in young children with acute diarrhoea (AD) has contributed to decrease mortality associated with dehydration although effective strategies to reduce morbidity associated with this disease are required. The aim of this study was to evaluate the diarrhoea duration when using combined colloidal bismuth hydroxide gel (CBHG) and oral rehydration salt treatment compared with ORS therapy in children with AD. We designed a double-blind, randomised prospective study with treatment and control groups. Patients aged one to 12 years, with no prior pathology and with AD of less than 48 h were included. The Chi-squared and Mann-Whitney tests were used, as well as the Cox proportional hazards model and the Kaplan-Meier estimator. Patients were randomised into an ORS and CBHG treatment group and a control group for ORS plus placebo. (Average age: 3.2 years). The result of the post-treatment evaluation with respect to the average duration of AD was 25.5 h for the treated group vs. 41.5 h for the control group (p = 0.015). The average number of stools was 4.8 in the treated group and 8.2 in the control group (p = 0.032). We conclude that the use of CBHG plus ORS significantly reduced the duration of AD, the number of stools and the percentage of children with persistent AD after 24 h of treatment compared to the control group. AD remitted almost twice as fast in patients treated with CBHG and ORS compared to those who received ORS plus placebo.

[Prenatal and postnatal nutrition: long term impact on health]. / Nutrición pre y posnatal: impacto a largo plazo en la salud.

Nutrition in early stages of life is one of the most influential environmental factors for the good development of organs and systems and the wellbeing of the child. Epigenetic mechanisms can explain how prenatal and postnatal nutrition affects genes expression with the subsequent risk of immune and metabolic diseases. The objective of this paper is to update the knowledge of the role the nutritional status and dietary practices of pregnant women and the child's feeding patterns over the first year of life have in the risk of future diseases.

Prevalence of celiac disease: multicentric trial among pediatric population from five urban districts in Argentina.

INTRODUCTION: No published material on the prevalence of celiac disease (CD) in the pediatric population of Argentina has been found up to date. Objective. To estimate the prevalence of CD in a pediatric population (hospital-based sample) from 5 urban districts of Argentina. METHODS: In a cross-sectional descriptive study, we analyzed serum samples from 2219 children, aged 3-16 years old, which had been requested for pre-surgical tests and for physical aptitude certificates for sports in the province of Buenos Aires, and cities of Buenos Aires, Córdoba, Santa Fe and Salta. Children with a previous and accurate diagnosis of CD were also included. IgA class tissue transglutaminase antibodies were determined using serum samples, and those samples which turned out positive were also tested for IgA class endomysium antibodies. A small intestine biopsy was proposed for those who had a positive serology. RESULTS: Between May 2008 and August 2009, 29 positive serologies were found. A total of 22 duodenum biopsies were performed, and 21 turned out compatible with CD. Out of 2219 children, 7 had a previous diagnosis. A prevalence of 1.26% (1:79 children), with female gender predominance (p < 0.023) was found. Ninety percent of the celiac children were over 6 years old (p < 0.021). Silent celiac disease predominated but there was a 33% of symptomatic cases. CONCLUSIONS: The results of the trial show a higher prevalence of CD than expected. The finding of symptomatic patients (33%) suggests the undertaking of different activities to spread the knowledge on this disease and promote the indication for serology test, to avoid complications by means of an early diagnosis.

Estudio multicéntrico sobre la epidemiologia de la Esofagitis Eosinofílica Pediátrica en América Latina / Multicenter study on the epidemiology of pediatric eosinophilic esophagitis in latinamerica

Objetivo: Evaluar las características epidemiológicas de un grupo de pacientes pediátricos con esofagitis eosinofílica (EEo) y las modalidades de tratamiento empleadas en Latinoamérica. Pacientes y métodos: Estudio multicéntrico, observacional, transversal. Se aplicó una encuesta a 36 Centros de Gastroenterología y Endoscopia Pediátrica de 10 países latinoamericanos con la finalidad de obtener información socio-demográfica y datos sobre el tratamiento utilizado para el manejo de los casos evaluados durante el periodo 2014-2016. Resultados: 372 casos de EEo pediátrica fueron evaluados durante el periodo 2014-2016 y 108 casos (29%) correspondieron al trimestre Abril-Junio 2016. 46,72% de los casos pertenecían al grupo de edad escolar y 71,8% consultaron por disfagia. 87,2% de los pacientes fueron manejados con dieta, 55,3% esteroides deglutidos (12,8% en monoterapia) y 6% recibió montelukast. No hubo reporte de pacientes en terapia con agentes biológicos. Conclusiones: los resultados sugieren un predominio del sexo masculino con una mayor incidencia de la enfermedad en la edad escolar y la adolescencia. Las manifestaciones clínicas más frecuentes son disfagia, vómitos y síntomas de reflujo gastroesofágico. El tratamiento más indicado por los especialistas en América Latina es la dieta seguido del uso de esteroides deglutidos. Los IBP también son ampliamente utilizados como terapia coadyuvante. Un estudio de prevalencia a nivel continental es necesario para evaluar el comportamiento de la enfermedad en diferentes regiones de América Latina.

Aims: To evaluate epidemiological features of pediatric patients with eosinophilic esophagitis in Latinamerica and therapeutical options indicated by pediatric gastroenterologists in our continent. Patients and methods: multicenter, observational, transversal study. 36 Centers of Pediatric Gastroenterology and Endoscopy from 10 latinamerican countries participated giving clinical and sociodemographic information about pediatric patients with EoE diagnosed and treated during the last two years (study period). Results: 372 cases of pediatric EoE were evaluated during period 2014-2016 (108 cases were evaluated during trimester April-June 2016). 46,72% of cases were school age children, with dysphagia been the main clinical symptom in 71,8% of patients. 87,2% of patients received diet as a main indication of treatment, 55,3% received swallowed steroids (12,8% as monotherapy) and 6% were treated with montelukast among others. There were no reports of patients under treatment with biological drugs. Conclusions: epidemiological features of our study group suggest a higher prevalence of pediatric EoE in male school age children and adolescents. Most frecuent clinical symptoms are dysphagia, vomiting and gastroesophageal reflux symptoms. Treatment is based mainly on diet and swallowed steroids. A continental prevalence study is necessary to evaluate the behavior of the disease in different regions of Latinamerica.

Prevalence of celiac disease: multicentric trial among pediatric population from five urban districts in Argentina / Prevalencia de enfermedad celíaca: estudio multicéntrico en población pediátrica de cinco distritos urbanos de la Argentina

Introduction. No published material on the preva lence of celiac disease (CD) in the pediatric population of Argentina has been found up to date. Objective. To estimate the prevalence of CD in a pediatric population (hospital-based sample) from 5 urban districts of Argentina. Methods. In a cross-sectional descriptive study, we analyzed serum samples from 2219 children, aged 3-16 years old, which had been requested for pre-surgical tests and for physical aptitude certifcates for sports in the province of Buenos Aires, and cities of Buenos Aires, Córdoba, Santa Fe and Salta. Children with a previous and accurate diagnosis of CD were also included. IgA class tissue transglu taminase antibodies were determined using serum samples, and those samples which turned out positive were also tested for IgA class endomysium an tibodies. A small intestine biopsy was proposed for those who had a positive serology. Results. Between May 2008 and August 2009, 29 positive serologies were found. A total of 22 duo denum biopsies were performed, and 21 turned out compatible with CD. Out of 2219 children, 7 had a previous diagnosis. A prevalence of 1.26% (1:79 children), with female gender predominance (p < 0.023) was found. Ninety percent of the celiac children were over 6 years old (p < 0.021). Silent celiac disease predominated but there was a 33% of symptomatic cases. Conclusions. The results of the trial show a higher prevalence of CD than expected. The finding of symptomatic patients (33%) suggests the undertak ing of different activities to spread the knowledge on this disease and promote the indication for serology test, to avoid complications by means of an early diagnosis.

Introducción. Hasta la fecha del estudio no se hallaron estudios poblacionales publicados sobre prevalencia de enfermedad celíaca en la población pediátrica argentina. Objetivo. Estimar la prevalencia de la enfermedad celíaca en población pediátrica a partir de una muestra de base hospitalaria de cinco distritos urbanos. Método. Diseño descriptivo de corte transversal. Bajo consentimiento informado, participaron 2219 niños, de 3 a 16 años, que realizaban estudios de laboratorio para exámenes prequirúrgicos o certificados de aptitud física deportiva del Conurbano bonaerense, y ciudades de Buenos Aires, Santa Fe, Córdoba y Salta. Se incluyeron niños con diagnóstico previo y certero de enfermedad celíaca dentro de esa población. Se determinaron anticuerpos antitransglutaminasa y, en las muestras positivas, anticuerpo antiendomisio. Se propuso biopsia de intestino delgado a quienes presentaron ambas serologías positivas. Resultados: 29 serologías fueron positivas. Se realizaron 22 biopsias de duodeno, 21 fueron compatibles con enfermedad celíaca y 7 presentaron diagnóstico previo. La prevalencia fue de 1,26% (1:79) IC 95% 0,84-1,81, con predominio del sexo femenino (p <0,039). El 90% de los niños celíacos hallados fueron mayores de 6 años. Las formas clínicas silentes predominaron, pero hubo un 33% de casos sintomáticos. Conclusión. Los resultados en la población estudiada muestran una prevalencia mayor que la esperada. El hallazgo de formas sintomáticas (33%) sugiere emprender acciones de difusión del conocimiento de la enfermedad y ampliar la indicación de serología para obtener diagnóstico precoz.

Prevalence of celiac disease: multicentric trial among pediatric population from five urban districts in Argentina / Prevalencia de enfermedad celíaca: estudio multicéntrico en población pediátrica de cinco distritos urbanos de la Argentina

Introduction. No published material on the preva lence of celiac disease (CD) in the pediatric population of Argentina has been found up to date. Objective. To estimate the prevalence of CD in a pediatric population (hospital-based sample) from 5 urban districts of Argentina. Methods. In a cross-sectional descriptive study, we analyzed serum samples from 2219 children, aged 3-16 years old, which had been requested for pre-surgical tests and for physical aptitude certifcates for sports in the province of Buenos Aires, and cities of Buenos Aires, Córdoba, Santa Fe and Salta. Children with a previous and accurate diagnosis of CD were also included. IgA class tissue transglu taminase antibodies were determined using serum samples, and those samples which turned out positive were also tested for IgA class endomysium an tibodies. A small intestine biopsy was proposed for those who had a positive serology. Results. Between May 2008 and August 2009, 29 positive serologies were found. A total of 22 duo denum biopsies were performed, and 21 turned out compatible with CD. Out of 2219 children, 7 had a previous diagnosis. A prevalence of 1.26% (1:79 children), with female gender predominance (p < 0.023) was found. Ninety percent of the celiac children were over 6 years old (p < 0.021). Silent celiac disease predominated but there was a 33% of symptomatic cases. Conclusions. The results of the trial show a higher prevalence of CD than expected. The finding of symptomatic patients (33%) suggests the undertak ing of different activities to spread the knowledge on this disease and promote the indication for serology test, to avoid complications by means of an early diagnosis.(AU)

Introducción. Hasta la fecha del estudio no se hallaron estudios poblacionales publicados sobre prevalencia de enfermedad celíaca en la población pediátrica argentina. Objetivo. Estimar la prevalencia de la enfermedad celíaca en población pediátrica a partir de una muestra de base hospitalaria de cinco distritos urbanos. Método. Diseño descriptivo de corte transversal. Bajo consentimiento informado, participaron 2219 niños, de 3 a 16 años, que realizaban estudios de laboratorio para exámenes prequirúrgicos o certificados de aptitud física deportiva del Conurbano bonaerense, y ciudades de Buenos Aires, Santa Fe, Córdoba y Salta. Se incluyeron niños con diagnóstico previo y certero de enfermedad celíaca dentro de esa población. Se determinaron anticuerpos antitransglutaminasa y, en las muestras positivas, anticuerpo antiendomisio. Se propuso biopsia de intestino delgado a quienes presentaron ambas serologías positivas. Resultados: 29 serologías fueron positivas. Se realizaron 22 biopsias de duodeno, 21 fueron compatibles con enfermedad celíaca y 7 presentaron diagnóstico previo. La prevalencia fue de 1,26% (1:79) IC 95% 0,84-1,81, con predominio del sexo femenino (p <0,039). El 90% de los niños celíacos hallados fueron mayores de 6 años. Las formas clínicas silentes predominaron, pero hubo un 33% de casos sintomáticos. Conclusión. Los resultados en la población estudiada muestran una prevalencia mayor que la esperada. El hallazgo de formas sintomáticas (33%) sugiere emprender acciones de difusión del conocimiento de la enfermedad y ampliar la indicación de serología para obtener diagnóstico precoz.(AU)

Prevalencia de enfermedad celíaca: estudio multicéntrico en población pediátrica en cinco distritos urbanos de Argentina / Prevalence of celiac disease: multicentric trial among pediatric population in five urban districts of Argentina

INTRODUCCIÓN: Hasta la fecha del estudio no se hallaron estudios poblacionales publicados sobre prevalencia de EC en población pediátrica argentina. OBJETIVO: estimar la prevalencia de la EC en población pediátrica de cinco distritos urbanos. MÉTODOS: diseño descriptivo de corte transversal. Se invitó a participar a 2.230 niños, de 3 a 16 años, que realizaban estudios de laboratorio para exámenes prequirúrgicos o certificados de aptitud física deportiva. Se determinaron Anticuerpos Antitransglutaminasa, y en las muestras positivas Anticuerpo Antiendomisio. Se propuso biopsia de intestino delgado a quienes presentaron ambas serologías positivas. Se incluyeron niños con diagnóstico previo de EC que cumplían los criterios de inclusión. La prevalencia se expresó mediante el porcentajey su IC exacto. Las comparaciones entre grupos se efectuaron mediante la prueba exacta de Fisher. RESULTADOS: se testearon los sueros de 2.219 niños, 29 serologías fueron positivas. Se realizaron 22 biopsias de duodeno, 21 fueron compatibles con EC y 7 presentaron diagnóstico previo. La prevalencia fue de 1,26% (1:79)IC 95% 0,84-1.81, con predominio del sexo femenino (p<0,039) e importantes diferencias regionales. El 90% de los niños celíacos hallados fueron > 6 años. Las formas clínicas silentes predominaron pero hubo un 33% de casos sintomáticos. CONCLUSIÓN: los resultados en la población estudiada muestran una prevalencia mayor que estudios previos en adultos. El hallazgo de formas sintomáticas (33%) sugiere emprender acciones de difusión del conocimientode la enfermedad y ampliar la indicación de serología para obtener diagnóstico precoz.

INTRODUCTION: up the date of this study, published material about the prevalence of CD in pediatric population in Argentina has not been found. OBJECTIVE: to estimate CD prevalencein a pediatric population of 5 urban districts. METHODS: descriptive and cross sectional cut design. Were invited 2.230 children, between 3 and 16 years, which had been requested forpre-surgical studies and physical aptitude certificates for sports. IgA class tissue transglutaminase antibodies were determined and to positive samples IgA class endomysium antibodies. A small intestine biopsy was proposed for those who had both positive serology. Children with a previous diagnosis of CD who met the inclusion criteria were included. The prevalence was expressed by means of the percentage and its exact confidence interval and the comparisons between groups were performed using Fisher´s exact test. RESULTS: 2.219 children´s sera were studied. 29 were positive serologies. 22 duodenum biopsies were performed, 21 turned out compatible with CD. 7 children presented a previous diagnosis. A prevalence of 1.26% (1:79) CI 95% (0,84-1,81) was found, with female sex predominance ( p<0.039) and important regional differences as well. Ninety percent of the celiac children found were> 6 years Silent clinical manifestations predominated but there were 33% of symptomatic cases. CONCLUSIONS: the results in the study population showed a higher prevalence than previous studies in adults. The finding of symptomatic manifestations (33%)suggests actions to spread the knowledge of this disease promotingthe indication of serology for early diagnosis.