Symptoms and management of cow's milk allergy: perception and evidence.

Introduction: The diagnosis and management of cow's milk allergy (CMA) is a topic of debate and controversy. Our aim was to compare the opinions of expert groups from the Middle East (n = 14) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) (n = 13). Methods: These Expert groups voted on statements that were developed by the ESPGHAN group and published in a recent position paper. The voting outcome was compared. Results: Overall, there was consensus amongst both groups of experts. Experts agreed that symptoms of crying, irritability and colic, as single manifestation, are not suggestive of CMA. They agreed that amino-acid based formula (AAF) should be reserved for severe cases (e.g., malnutrition and anaphylaxis) and that there is insufficient evidence to recommend a step-down approach. There was no unanimous consensus on the statement that a cow's milk based extensively hydrolysed formula (eHF) should be the first choice as a diagnostic elimination diet in mild/moderate cases. Although the statements regarding the role for hydrolysed rice formula as a diagnostic and therapeutic elimination diet were accepted, 3/27 disagreed. The votes regarding soy formula highlight the differences in opinion in the role of soy protein in CMA dietary treatment. Generally, soy-based formula is seldom available in the Middle-East region. All ESPGHAN experts agreed that there is insufficient evidence that the addition of probiotics, prebiotics and synbiotics increase the efficacy of elimination diets regarding CMA symptoms (despite other benefits such as decrease of infections and antibiotic intake), whereas 3/14 of the Middle East group thought there was sufficient evidence. Discussion: Differences in voting are related to geographical, cultural and other conditions, such as cost and availability. This emphasizes the need to develop region-specific guidelines considering social and cultural conditions, and to perform further research in this area.

99mTc-human serum albumin scans in children with protein-losing enteropathy.

UNLABELLED: Protein-losing enteropathy (PLE) can be diagnosed scintigraphically using 99mTc-human serum albumin (HSA) scans. METHODS: To evaluate the usefulness of this method in detecting enteric protein loss, we retrospectively reviewed the 99mTc-HSA scans of 18 children presenting consecutively with PLE. RESULTS: Enteric 99mTc-HSA uptake was noted in 12 patients (8 boys, 4 girls) with a mean age of 7.4 y. Early dynamic images showed abdominal uptake that was most likely in the small bowel in 91% of the scans. Delayed images showed abnormal accumulation that was localized in the colon in 73% and in the small bowel in 27% of the scans. A 4-mo follow-up scan obtained in 3 patients showed reduced HSA uptake after a high-protein, low-fat, medium-chain triglyceride oil-based diet and fat-soluble vitamins. Mean serum albumin, total protein, gammaglobulin, and calcium levels were significantly decreased. Ten patients (from 4 families) were diagnosed to have primary intestinal lymphangectasia. One patient had active Salmonella enterocolitis, and 1 had giardiosis. 99mTc-HSA was normal in the remaining 6 patients (3 boys, 3 girls) with a mean age of 3.5 y (range, 2-5 y). Mean serum albumin, total protein, gammaglobulin, and calcium levels were less decreased than those of the first group. Five of these patients had primary intestinal lymphangactesia (associated with infantile systemic hyalinosis in 1 patient). The remaining patient had normal duodenal biopsy, and the cause of protein loss remained unknown. CONCLUSION: The 99mTc-HSA scan is useful in the evaluation of children with PLE, especially those with severe hypoproteinemia and hypoalbuminemia, presumably reflecting a high rate of protein loss.

Crigler-Najjar syndrome in Saudi Arabia.

Crigler-Najjar (CN) syndrome is a congenital familial nonhemolytic jaundice associated with high level of unconjugated bilirubin due to deficient uridine diphosphate glucuronosyltransferase (UDPG-T) activity in the liver. The aim of this report is to emphasize the need for increased awareness of this potentially fatal condition unless diagnosed early and managed appropriately. Between 1986-1994, 12 patients (8 males and 4 females) were diagnosed at our hospital with CN syndrome. Jaundice was detected in the first few days of life in all but one, in whom detection was delayed for two weeks and resulted in kernicterus. Exchange transfusions were necessary in six cases. Consanguinity was present in 11 patients, eight of whom were the offspring of first cousins. None of the patients responded to phenobarbital therapy alone, which reflects the severity of their disease. Six patients required only phototherapy while the remaining six patients required a combination of phenobarbital and phototherapy. Percutaneous liver biopsy, performed in 10 patients, showed minimal and focal cholestasis in eight, while the remaining two had a normal histological picture. Almost complete absence of the activity of UDPGT in the liver was reported in seven cases. Kernicterus developed in five cases. It is concluded that CN syndrome remains a potentially fatal condition unless diagnosed early and managed appropriately. The recent adoption of liver segment transplantation, whether orthotopic or living-related, has saved affected patients the daily long hours of phototherapy. One of our patients successfully underwent living-related segmental liver transplantation.

Pancreatic pseudocyst in paediatric systemic lupus erythematosus.

Pancreatitis is a rare complication of paediatric systemic lupus erythematosus (SLE). We describe a child with severe form of SLE who initially developed acute pancreatitis, subsequently complicated by extensive pancreatic pseudocyst. The treatment and outcome are discussed.

Geographic distribution of cystic fibrosis transmembrane regulator gene mutations in Saudi Arabia.

A descriptive study was undertaken to characterize the cystic fibrosis transmembrane regulator gene mutations (CFTR) in the Saudi Arabian cystic fibrosis (CF) population in relation to clinical presentation and demographic and ethnic origin. During the period October 1992 to September 1997, 70 patients from 46 families were diagnosed as having CF, based on a typical clinical picture and sweat chloride levels > 60 mmol/l and were screened for CFTR mutations. Twelve mutations were identified in 34 families, which constitutes 70% of the CF alleles in the study group. Pancreatic insufficiency (PI) was found in the following mutations: 1548delG in exon 10 (15%) which occurred mainly in native Saudi patients in the central province; 3120 + 1G-->A in intron 16 (10%) and H139L in exon 4 (7%), found mainly in native Saudis from the eastern province; delta F508 mutation (13%) which occurred mainly in expatriates of Middle Eastern origin from different provinces; L117X in exon 19 (2%); G115X in exon 4 (2%); 711 + 1G-->A in intron 5 (2%); N 1303K in exon 21 (2%) and 425del42 in exon 4 (1%); I1234V in exon 19 (13%) with a predominance of nasal polyps and a variable degree of PI and lung disease; R553X in exon 11 (1%), with electrolyte imbalance; and S549R in 11 (2%) with pancreatic sufficiency and minimal pulmonary disease. The clinical picture did not differ significantly between patients of different ethnic origins with the same CFTR mutation.