A Trial of an Anamnesis-based Score Applied as a Diagnostic Tool for Cow's Milk Protein Allergy in Children.

ABSTRACT: This study presents an anamnesis-based questionnaire as a diagnostic tool for cow's milk protein allergy (CMPA) in children. We applied 24 dichotomous yes/no questions to 51 cases diagnosed by oral challenge and 31 controls. All patients were recruited at the pediatric gastroenterologist outpatient practice. Patients with CMPA presented with a family history of atopy/autoimmunity, cesarean delivery, use and/or change of formulas, use of antacids/antibiotics in the first 6 months of life, an overly clean caregiver, multisystem clinical presentation, and the absence of seasonal symptoms. The CMPA group had an average score of 10.4 versus 3.2 for the control group. We identified a cut-off score of 7, which had 94.4% sensitivity and 96.9% specificity to distinguish CMPA from the control population. Cases were younger and showed different symptoms than controls. This study shows the usefulness of an anamnesis-based clinical score to guide the diagnosis of CMPA in children.

[Recurrent right iliac fossa pain in children: two cases report related to food allergy]. / Dolor recurrente en fosa iliaca derecha en niños: reporte de dos casos asociados a alergia alimentaria.

OBJECTIVE: To present two cases of food allergy of uncommon presentation and discuss the diagnostic approach to give in these cases: Case N° 1: 11-year-old girl, afflicting pain in the right iliac fossa 3 months ago. BACKGROUND: Prematurity, atopy (dermatitis, rhinitis, cramping). Sister and mother are atopic too. The physical exam show exquisite pain on right iliac fossa at palpation. Laboratory: Urine normal, parasitological serial negative. EDN (neurotoxin derived from eosinophils) fecal >3210 ng/ml (V. N. < 360 ng/ml). Colonoscopy: lymphoid hyperplasia of ileum. Case N° 2: Child of 9 years of age. Right fossa iliac painful three months ago, predominantly nocturnal and with irradiation to right thigh. A child psychiatrist may prescribe antidepressants. Personal History: Breastfeeding and formula since newborn. Atopy: asthma, atopic dermatitis, infant colic. Family history: Mother allergic to food, father presents rhinitis. The physical examination: Pain on palpation in the right iliac fossa. Laboratory: Immunoglobulin E 160.5 IU/ml (V. N. < 90) Colonoscopy: lymphoid hyperplasia in the distal ileum. Both cases relieved by hypoallergenic diet. CONCLUSION: When both, ileal nodular lymphoid hyperplasia and atopy personal or familiar are present, we must be think in food allergy therapeutic.

Incidence and importance of Clostridium difficile in paediatric diarrhoea in Brazil.

Clostridium difficile strains were detected in 14 of 210 (6.7 %) faecal samples from children in Rio de Janeiro, Brazil, by cultivating faeces on cycloserine/cefoxitin/fructose agar after alcohol-shock. Two main groups of children were studied: inpatients (n = 96) and outpatients (n = 114). The inpatient group consisted of children on antibiotics or immunosuppressors who presented with diarrhoea and other children who did not present with diarrhoea and were not under an antibiotic or chemotherapeutic regimen. Among the outpatients, two groups were examined: namely, a group that comprised children who presented with diarrhoea and were occasionally under an antibiotic regimen and another group that comprised patients who were not taking antibiotics. After cytotoxic assay, toxigenic C. difficile (Cd tox+) strains were detected in 4.2 % of inpatients and 3.5 % of outpatients. Exclusion of other infectious causes of diarrhoea indicated a typical case of C. difficile-associated paediatric diarrhoea in the community. Among Cd tox+ isolates, no variations were detected by PCR for toxin A that employed primers NK9 and NKVO11. No resistance was found to metronidazole or vancomycin among strains that were isolated from children who presented with diarrhoea, but the MIC(50) and MIC(90) values for clindamycin were 6-8 and 16 microg ml(-1), respectively. Resistance to clindamycin seems to be more disseminated in strains from outpatients than in those from inpatients (P < 0.05). In conclusion, these data suggest that investigation for C. difficile infection should be taken into account in paediatric diarrhoea in both inpatients and outpatients in developing countries.

Primary fecal culture used as template for PCR detection of diarrheagenic E. coli virulence factors.

The PCR technique applied to primary fecal cultures (PFC-PCR) was compared to the usual method employing isolated colonies (IC-PCR) in order to assess its sensitivity in the detection of virulence markers of diarrheagenic Escherichia coli in fecal samples obtained from children with diarrhea. Among the 149 samples analysed, PFC-PCR detected 81(54.4%) samples presenting one or two virulence markers, while IC-PCR detected only 59 (39.6%) positive samples. The markers detected in order of frequency were: pAA, LT-I, eaeA, ST-I, daaE, and ipaH. The PFC-PCR method of detection of diarrheagenic E. coli virulence markers proved to be reliable and more sensitive (p<0.05) than the usual method employing isolated colonies. It has also the advantage of being faster and less expensive than the detection methods in current use.

Dolor recurrente en fosa iliaca derecha en niños: reporte de dos casos asociados a alergia alimentaria / Recurrent right iliac fossa pain in children: two cases report related to food allergy

Objetivo: Presentar dos casos de alergia alimentaria de presentación poco común y discutir el enfoque diagnóstico de DAR en niños Casos: Caso N° 1: Niña de 11 años, aqueja dolor en fosa iliaca derecha hace 3 meses. Antecedentes: Prematuridad, atopía (dermatitis, rinitis, cólicos). Hermana y madre atópicas. Al examen físico: Dolor exquisito a la palpación de fosa iliaca derecha, cuerda cólica bilateral. Piel seca. Laboratorio: Hematobiometría sin alteraciones. Examen de orina normal, parasitológico seriado (-). EDN (neurotoxina derivada de eosinófilos) fecal >3210 ng/ml (V.N. <360 ng/ml). Colonoscopía: hiperplasia linfoidea de íleon. Caso N° 2: Niño de 9 años. Dolor en fosa iliaca derecha hace tres meses dolor abdominal localizado en fosa iliaca derecha, a predominio nocturno y con irradiación a muslo derecho. Un psiquiatra infantil le prescribe antidepresivos. Antecedentes personales: Lactancia mixta. Atopía: Asma, dermatitis atópica, cólicos de lactante. Antecedentes familiares: Madre alérgica a alimentos, padre presenta rinitis. Al examen físico: Cuerda cólica bilateral. Dolor a la palpación en fosa iliaca derecha. Laboratorio: Inmunoglobulina E 160,5 UI/ml (V.N. < 90). Colonoscopía: Hiperplasia linfoidea en íleon distal. Ambos casos mejoraron con dieta hipoalergénica. Conclusión: En presencia de hiperplasia nodular linfoide de íleon y antecedentes familiares y/o personales de atopía, debemos considerar en el diagnóstico diferencial de dolor abdominal recurrente de fosa iliaca derecha a la alergia alimentaria. La dieta de eliminación es diagnóstica y terapéutica a su vez.

Objective: To present two cases of food allergy of uncommon presentation and discuss the diagnostic approach to give in these cases: Case N° 1: 11-year-old girl, afflicting pain in the right iliac fossa 3 months ago. Background: Prematurity, atopy (dermatitis, rhinitis, cramping). Sister and mother are atopic too. The physical exam show exquisite pain on right iliac fossa at palpation. Laboratory: Urine normal, parasitological serial negative. EDN (neurotoxin derived from eosinophils) fecal >3210 ng/ml (V. N. < 360 ng/ml). Colonoscopy: lymphoid hyperplasia of ileum. Case N° 2: Child of 9 years of age. Right fossa iliac painful three months ago, predominantly nocturnal and with irradiation to right thigh. A child psychiatrist may prescribe antidepressants. Personal History: Breastfeeding and formula since newborn. Atopy: asthma, atopic dermatitis, infant colic. Family history: Mother allergic to food, father presents rhinitis. The physical examination: Pain on palpation in the right iliac fossa. Laboratory: Immunoglobulin E 160.5 IU/ml (V. N. < 90) Colonoscopy: lymphoid hyperplasia in the distal ileum. Both cases relieved by hypoallergenic diet. Conclusion: When both, ileal nodular lymphoid hyperplasia and atopy personal or familiar are present, we must be think in food allergy as differential diagnosis of recurrent abdominal pain of right iliac fosse in children. The elimination diet is diagnostic and therapeutic.

Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: a consensus report.

Autism spectrum disorders (ASDs) are common and clinically heterogeneous neurodevelopmental disorders. Gastrointestinal disorders and associated symptoms are commonly reported in individuals with ASDs, but key issues such as the prevalence and best treatment of these conditions are incompletely understood. A central difficulty in recognizing and characterizing gastrointestinal dysfunction with ASDs is the communication difficulties experienced by many affected individuals. A multidisciplinary panel reviewed the medical literature with the aim of generating evidence-based recommendations for diagnostic evaluation and management of gastrointestinal problems in this patient population. The panel concluded that evidence-based recommendations are not yet available. The consensus expert opinion of the panel was that individuals with ASDs deserve the same thoroughness and standard of care in the diagnostic workup and treatment of gastrointestinal concerns as should occur for patients without ASDs. Care providers should be aware that problem behavior in patients with ASDs may be the primary or sole symptom of the underlying medical condition, including some gastrointestinal disorders. For these patients, integration of behavioral and medical care may be most beneficial. Priorities for future research are identified to advance our understanding and management of gastrointestinal disorders in persons with ASDs.

Are attention deficit hyperactivity disorder and chronic fatigue syndrome allergy related? what is fibromyalgia?

Despite the progress made in the field of allergy-immunology in recent years, there are a group of diseases that the allergist-immunologist may be called on to manage in which their precise etiologies have not been identified but that appear to be initiated or exacerbated by allergic mechanisms. Attention deficit hyperactivity disorder (ADHD), chronic fatigue syndrome (CFS), and fibromyalgia (FM) fall into this category of disorders. Although the precise etiology of ADHD still remains unknown, the most prevalent theory is that it represents a neurobiologically based developmental disability leading to inadequate production of the neurotransmitter dopamine. In patients with CFS, there appears to be a fundamental dysfunction of the neuroendocrine-immunological system with deficiencies of immunological and neurological function, which, together with chronic viral infection, may lead to a sequence of events responsible for the symptoms of this disorder. FM appears to be a variant of CFS with a predominance of hypothalamic pituitary axis dysfunction. The disorder is characterized by chronic widespread pain and the finding of 11/18 tender points on examination. Now, there is emerging evidence to suggest that adverse reactions to foods or food components also may be associated with behavioral disturbances that may play a role in each of these disorders. An understanding of the interactive responses involved in the neuroendocrine-immunological network is essential for a comprehension of the pathophysiology of ADHD, CFS, and FM and the role of allergies appears to be an important triggering event in each of the disorders.

Gastrointestinal immunopathology and food allergy.

OBJECTIVE: To review the current data that support the pivotal function of the gastrointestinal immune system in health and disease and its critical role in the pathogenesis of a wide variety of clinical disorders associated with food allergy (FA). DATA SOURCES: Internet-based literature search and our own data. STUDY SELECTION: The studies included in this review were selected based on the expert opinion of the authors. RESULTS: In contrast to the beneficial expressions of gastrointestinal-associated lymphoid tissue, which are seen with relevance to newer methods of delivery of vaccines directly applied to the gastrointestinal mucosal surfaces (eg, oral poliovirus, rotavirus, Salmonella typhi vaccines), the adverse consequences of a mucosal immune response gone astray are evidenced in many diseases such as FA. A classification of clinical disorders associated with FA based on classic mechanisms of immunologic injury is presented, which includes the following: (1) IgE-mediated, (2) non-IgE-mediated, and (3) mixed IgE- and non-IgE-mediated disorders. Our study of immunologic disturbance in patients with non-IgE FA revealed a pattern of increased CD4+ and decreased TH1 cell counts in peripheral blood mononuclear cells in contrast to patients with celiac disease, where a pattern of increased CD8+ and TH1 cell counts in peripheral blood mononuclear cells and increased CD8+ cell counts was seen. CONCLUSIONS: The gastrointestinal immune response thus plays a pivotal role in maintaining protective immunity in health and a critical role in the pathogenesis of a wide variety of clinical disorders associated with FA.

Abnormalities of Th1 function in non-IgE food allergy, celiac disease, and ileal lymphonodular hyperplasia: a new relationship?

BACKGROUND: Non-IgE mechanisms may also be involved food allergy (FA). Our group has been studying the immunopathogenesis clinical entities in children with gastro-intestinal symptoms and in whom biopsies of the terminal ileum show lymphoid tissue masses referred to as ileal lymphonodular hyperplasia. Our more recent studies have demonstrated Th1/Th2 cytokine profiles associated with non-IgE FA and other clinical entities. OBJECTIVE: We investigated 12 subjects with non-IgE FA (group 1) and 4 subjects with celiac disease (group 2). Cytokine profiles and immunologic studies of lymphocytes in peripheral blood and from gastro-intestinal biopsy tissues from patients in groups 1 and 2 were also evaluated. METHODS: Group 1 consisted of 12 children with clinical symptoms of anorexia, diarrhea, and abdominal pain. The diagnosis of non-IgE FA was established by positive double-blind, placebo-controlled food challenge and reduced or negative immediate-type skin testing and negative IgE radioallergosorbent tests. Group 2 consisted of four patients with celiac disease and three adult females with biopsy-proven clinical symptoms of celiac disease. RESULTS: In group 1, peripheral blood CD4 and CD8 lymphocyte distributions were normal, with a predominance of CD4+ cells with a decreased intracellular Th1 cytokine pattern and a normal Th2 intracellular cytokine pattern. In contrast, all four patients in group 2 not only displayed abnormal CD4 and CD8 peripheral blood lymphocyte distributions (CD8 > CD4), but also an abnormal predominance of CD4+ cells with an increased Th1 and a normal Th2 cytokine pattern. A similar abnormal pattern of CD4 > CD8 ratio was observed in intestinal biopsies. All 12 patients in group 1 showed lymphonodular hyperplasia in each of the biopsies and by ileoscopy. CONCLUSIONS: These studies suggest that abnormalities in Th1 function may not only play a role in some patients with non--IgE-mediated FA in whom decreased Th1 function is seen, but also in patients with celiac disease in whom an increased Th1 function is seen. The studies also suggest that lymphonodular hyperplasia may be a hallmark histologic lesion in patients with non--IgE-mediated FA.

Developmental immunology: clinical application to allergy-immunology.

BACKGROUND: An increase in prevalence of allergic diseases has been seen at an unprecedented rate in many countries throughout the world. Associated with this increase in allergic disease has been a disturbing increase in morbidity and mortality of such diseases as asthma despite the availability of several new therapeutic agents over the past 2 to 3 decades. The search for both environmental factors, eg, new allergens, as well as biologic markers of genetic susceptibility, eg, respiratory viruses, has yielded considerable promise for an explanation for this rising prevalence of allergic disease. OBJECTIVE: To present a central unifying hypothesis based upon recent knowledge concerning the developing human immune system and its interaction with external environmental factors, particularly viral infections, as a basis for a clearer understanding of the changing faces of the allergic diseases throughout the lifespan of the individual. DATA SOURCES: English language articles were selected from PubMed, as well as selected abstracts that would have immediate, practical clinical implications. RESULTS: Review of the current literature strongly suggests a relationship between delayed acquisition of Th1 function in the allergy-prone infant, not only as a predictive marker of susceptibility to the development of allergic disease but also as an explanation for the unique vulnerability of these infants to viral infection, eg, bronchiolitis. Furthermore, viral infection during early development in the allergy-prone infant appears to facilitate allergic sensitization in early infancy. This interesting triad of immune deficiency, viral infection, and atopic genetic susceptibility may provide a basis for early detection of allergic disease and may offer new intervention strategies for the prevention of allergic and infectious disease in the young infant.

IgE and non-IgE food allergy.

BACKGROUND: Food allergy (FA) is characterized by an abnormal immunologic reactivity to food proteins. The gastro-intestinal tract serves not only a nutritive function but also is a major immunologic organ. Although previously thought to be triggered primarily by an IgE-mediated mechanism of injury, considerable evidence now suggests that non-IgE mechanisms may also be involved in the pathogenesis of FA. OBJECTIVE: To review the immunologic disturbances that occur in FA and to correlate these with the clinical manifestations expressed in affected target organs based upon a classification of IgE and non-IgE mechanisms. METHODS: Data collected from a computerized MEDLINE search were used for the analysis of the following topics: immediate GI hypersensitivity, oral allergy syndrome, acute urticaria and angioedema, acute bronchospasm, celiac disease, cow's milk enteropathy, dietary protein enterocolitis, breast milk colitis, proctolitis, proctitis, dermatitis herpetiformis, Heiner syndrome, eosinophilic gastroenteritis, atopic dermatitis, asthma, attention-deficit-hyperactivity disorder and behavioral disorders, as well as systems affected by mucosal associated lymphoid tissue-mediated injury of associated lymphoid tissues and the immunologic deviation to Th1 or Th2 mechanisms of FA. CONCLUSIONS: The results of this review allow the construction of a central, unifying hypothesis for a new classification of FA as follows: the clinical manifestations of FA, expressed in affected target organs, may be the result of immunologic injury mediated by interaction of food antigens with contiguous elements of mucosal associated lymphoid tissue. These appear to be modulated by relative imbalances of the Th1/Th2 paradigm, which may be the ultimate determinant governing the expression of FA as IgE-mediated, non--IgE-mediated, or mixed forms of IgE/non-IgE mechanisms of FA.

Saúde bucal para pediatras: protocolo para abordagem da família e monitoramento da saúde bucal da criança / Bucal health for the pediatrician: a protocol for dealing with the family and monitoring bucal health of children

Este estudo tem como objetivo, partindo de uma revisão da literatura, demonstrar a possibilidade e a importância da interação entre médicos pediatras e cirugiões-dentistas, em especial odontopediatras, para a manutenção e o monitoramento da saúde bucal de bebês e crianças. Para tal propósito foi sugerido um Protocolo Clínico que procura adequar os procedimentos relacionados com a manutenção da saúde bucal às rotinas realizadas pelos pediatras na sua prática clínica diária. Acreditamos que a adoção das medidas sugeridas e explicitadas no protocolo desenvolvido poderão constituir-se em um diferencial para os pediatras que o adotarem...

Fluorose dentária: um enfoque para o médico pediatra / Dental fluorosis: an update for the Pediatrician

A fluorose dentária é um distúrbio na formação do esmalte dental causado pela ingestão crônica de altas concentrações de flúor durante o período de desenvolvimento dos dentes permanentes. Os dentes permanentes que em sua formação foram expostos à excessiva concentração de flúor, ao erupcionarem poderão apresentar defeitos estéticos, cujas manifestações clínicas vão desde manchas esbranquiçadas opacas até pigmentações amareladas ou castanhas, com perda de estrutura nos casos mais graves. Dentre os principais fatores de risco para o desenvolvimento desta alteração destacam-se: consumo de água de abastecimento fluoretada, utilização de dentifrícios com flúor, suplementos alimentares e certas bebidas contendo fluoretos, por crianças em fase de desenvolvimento dos dentes permanentes. A maneira mais eficaz de prevenção da fluorose é o controle da ingestão de fluoretos. A divulgação entre os médicos pediatras dos conhecimentos disponíveis sobre a etiologia da fluorose e as fontes de ingestão de flúor constitui importante aliado na prevenção desta alteração...

Características endoscópicas, histológicas e inmunológicas de la mucosa digestiva en niños autistas con síntomas gastrointestinales / Endoscopical histological and inmunological characteristics of the digestive mucosa in autistic children with gastrointestinal symptoms

El autismo es un desorden del neurodesarrollo cuya etiología es desconocida. Se evalúa la función y estructura de la mucosa digestiva buscando asociación entre cambios histológicos y etiopatogenia. Describir los hallazgos endoscópicos, histológicos e inmunológicos de la mucosa digestiva de niños autistas y controles con similares síntomas gastrointestinales. 45 niños autistas 1,98 años +/- 1,37,32 varones, 13 hembras; 57 controles, 3,28 años +/- 2,57, 30 varones, 27 hembras. Historia clínica, laboratorio, estudios endoscópicos, análisis histológico e inmunohistoquímica. Histológicos: inflamación crónica del esófago, estómago, duodeno y colon en autistas; duodeno: incremento linfocitos intraepiteliales p<0.001, colon mayor infiltrado linfoplasmocitario p=0.001. Autistas más esofagitis por reflujo (88,88%). Gastritis crónica activa, hiperplasia nodular linfoide (HNL) e infección por H. Pylori (55,56%) diferencia significativa entre grupos p<0.001, p=0.01. Duodenitis crónica activa con HNL 38/45; 23/45 infección por Giardia intestinalis, 26/45 alteración en vellosidades intestinales, un celíaco. Asociación entre la presencia de HNL e infección por H. Pylori en estómago, en duodeno por Giardia intestinalis p=0.002 Ileites crónica activa con HNL sin infección en 6, colitis Crónica activa con HNL 33/45. Los niños autistas presentan alta incidencia de enfermedad gastrointestinal con alteraciones endoscópicas, histológicas e inmunológicas. Observamos alteraciones inmunológicas e inmunohistoquímicas en biopsias digestivas compatibles con la respuesta de reacción alérgica tipo Th2, menor proporción CD8>CD4 sugiere reacción alérgica tipo Th1. La reacción alérgica presentada por este grupo de pacientes autistas es de tipo mixto.

Reidrataçäo oral (RO) nas diarréias agudas: algumas consideraçöes históricas e fisiológicas / Oral rehydration in acute diarrheas: some historical and physiological considerations

Faz-se uma revisäo sobre hidrataçäo oral nas diarréias agudas, considerando-se primordialmente os aspectos históricos e fisiológicos deste procedimento, que apesar de näo ser uma inovaçäo em Medicina, passou por várias fases de aperfeiçoamento, sendo hoje uma das maiores armas no controle da desidrataçäo, principalmente nos países subdesenvolvidos