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Di Nardo G, Barbara G, Borrelli O, Cremon C, Giorgio V, Greco L, La Pietra M, Marasco G, Pensabene L, Piccirillo M, Romano C, Salvatore S, Saviano M, Stanghellini V, Strisciuglio C, Tambucci R, Turco R, Zenzeri L, Staiano A. Italian guidelines for the management of irritable bowel syndrome in children and adolescents : Joint Consensus from the Italian Societies of: Gastroenterology, Hepatology and Pediatric Nutrition (SIGENP), Pediatrics (SIP), Gastroenterology and Endoscopy (SIGE) and Neurogastroenterology and Motility (SINGEM). Ital J Pediatr 2024; 50:51. [PMID: 38486305 PMCID: PMC10938778 DOI: 10.1186/s13052-024-01607-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/11/2024] [Indexed: 03/18/2024] Open
Abstract
The irritable bowel syndrome (IBS) is a functional gastrointestinal disorder (FGID), whose prevalence has widely increased in pediatric population during the past two decades. The exact pathophysiological mechanism underlying IBS is still uncertain, thus resulting in challenging diagnosis and management. Experts from 4 Italian Societies participated in a Delphi consensus, searching medical literature and voting process on 22 statements on both diagnosis and management of IBS in children. Recommendations and levels of evidence were evaluated according to the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus was reached for all statements. These guidelines suggest a positive diagnostic strategy within a symptom-based approach, comprehensive of psychological comorbidities assessment, alarm signs and symptoms' exclusion, testing for celiac disease and, under specific circumstances, fecal calprotectin and C-reactive protein. Consensus also suggests to rule out constipation in case of therapeutic failure. Conversely, routine stool testing for enteric pathogens, testing for food allergy/intolerance or small intestinal bacterial overgrowth are not recommended. Colonoscopy is recommended only in patients with alarm features. Regarding treatment, the consensus strongly suggests a dietary approach, psychologically directed therapies and, in specific conditions, gut-brain neuromodulators, under specialist supervision. Conditional recommendation was provided for both probiotics and specific fibers supplementation. Polyethylene glycol achieved consensus recommendation for specific subtypes of IBS. Secretagogues and 5-HT4 agonists are not recommended in children with IBS-C. Certain complementary alternative therapies, antispasmodics and, in specific IBS subtypes, loperamide and rifaximin could be considered.
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Affiliation(s)
- Giovanni Di Nardo
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Giovanni Barbara
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Osvaldo Borrelli
- Neurogastroenterology & Motility Unit, Gastroenterology Department, Great Ormond Street Hospital for Children, London, UK
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Valentina Giorgio
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luigi Greco
- General Pediatrician, Heath Care Agency of Bergamo, Bergamo, Italy
| | | | - Giovanni Marasco
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, Magna Graecia University, Catanzaro, Italy
| | - Marisa Piccirillo
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Silvia Salvatore
- Pediatric Department, "F. Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Michele Saviano
- General Pediatrician, Heath Care Agency of Naples, Naples, Italy
| | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rossella Turco
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Letizia Zenzeri
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University Federico II, Via S. Pansini 5, Naples, 80131, Italy.
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Gomes N, Ferreira-Sa L, Alves N, Dallago B, Moraes A, Carvalho JL, Nitz N, Hagström L, Braz S, Machado ER, Gurgel-Gonçalves R, Hecht M. Uncovering the effects of Giardia duodenalis on the balance of DNA viruses and bacteria in children's gut microbiota. Acta Trop 2023; 247:107018. [PMID: 37673134 DOI: 10.1016/j.actatropica.2023.107018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/28/2023] [Accepted: 09/01/2023] [Indexed: 09/08/2023]
Abstract
The neglected parasitosis giardiasis is one of the most common intestinal infections worldwide, affecting mainly infants and young children. Giardia duodenalis may disturb the local microbiome, leading to intestinal ecosystem disorders, and altering different processes in the host, such as the immune response. Nevertheless, the alterations promoted by G. duodenalis on the human gut microbiome have not been thoroughly investigated. Here, we characterized the gut microbiota of G. duodenalis-infected children and determine the main alterations promoted by the parasite. To do so, fecal samples of 26 infected and four uninfected children aged 2 to 6 years old were processed for High Efficiency Microarray analysis, in order to describe their bacterial and viral profiles. Then, we quantified the total bacterial population by qPCR and assessed fecal calprotectin levels, which are closely related with gut inflammation. A total of 286 bacteria's species and 17 viruses' strains were identified. Our results revealed no statistically significant differences between G. duodenalis positive and negative groups in the taxa's phyla and families. However, bacterial species diversity was increased in children infected with G. duodenalis (p < 0.05), while the total number of bacteria was decreased (p < 0.05). Considering the virome analysis, 17 different strains were identified, 88% being bacteriophages. The correlation analysis revealed an important disruption in the balance of DNA virus and bacteria within the intestinal microbiota of Giardia-positive children. Our findings constitute the first description of the gut virome of Giardia-infected children and suggest that G. duodenalis infection exerts a modulatory effect on the gut microbiome, promoting local inflammation and altering the equilibrium of the parasite-microbiota-host triad. This highlights the importance of considering polymicrobial associations and understanding the broader context of giardiasis. Overall, our study provides new insights into the complex interactions between intestinal parasites and the microbiota, which may have implications for the development of novel therapeutic interventions in the future.
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Affiliation(s)
- Nélio Gomes
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Lana Ferreira-Sa
- Laboratory of Medical Parasitology and Vector Biology Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Nayra Alves
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Bruno Dallago
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Aline Moraes
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Juliana Lott Carvalho
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil; Genomic Sciences and Biotechnology Program, Catholic University of Brasília, Distrito Federal, Brazil
| | - Nadjar Nitz
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Luciana Hagström
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Shélida Braz
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Eleuza Rodrigues Machado
- Laboratory of Medical Parasitology and Vector Biology Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Rodrigo Gurgel-Gonçalves
- Laboratory of Medical Parasitology and Vector Biology Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Mariana Hecht
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil.
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Hong L, Huang Y, Jiang S, Han J, Li S, Zhang L, Zhou Q, Cao X, Yu W, Yang Y, Cao Y. Postnatal Dynamics and Clinical Associations of Fecal Calprotectin in Very Preterm Infants: Implications for Necrotizing Enterocolitis and Feeding Intolerance. Clin Transl Gastroenterol 2023; 14:e00604. [PMID: 37272666 PMCID: PMC10461937 DOI: 10.14309/ctg.0000000000000604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 05/17/2023] [Indexed: 06/06/2023] Open
Abstract
INTRODUCTION To elucidate the postnatal dynamics and clinical associations of fecal calprotectin (FC) in very preterm infants, with a focus on necrotizing enterocolitis (NEC) and feeding intolerance (FI). METHODS We performed a prospective observational cohort study in infants with a gestational age of <32 weeks or birth weight <1,500 g with weekly feces collection. The relationships between FC, NEC, and FI were investigated, adjusting for demographic and clinical factors. RESULTS A total of 1,086 fecal samples were collected from 194 preterm infants. Postnatal FC levels of non-NEC infants were highly variable and followed an age-dependent patterned progression. FC levels were elevated in patients with NEC before and at NEC onset, distinguishing them from non-NEC infants and those at sepsis onset. Among infants without NEC or sepsis, those with FI exhibited lower FC concentrations throughout hospitalization and displayed a significant delay in reaching high FC levels after meconium compared with non-FI infants. The age to reach the first high nonmeconial FC levels was positively associated with the time to achieve full enteral feeding. DISCUSSION Postnatal FC dynamics among premature infants followed a patterned progression but were disturbed in patients with NEC and FI. Because of the high variations, the use of FC levels in NEC diagnosis should be implemented with caution in clinical practice. FC may help understand FI and feeding progression in very preterm infants. Further research is needed to validate these findings and explore the potential clinical applications of FC in this population.
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Affiliation(s)
- Luyang Hong
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
| | - Yihuang Huang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
| | - Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Shanghai, China.
| | - Junyan Han
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
| | - Shujuan Li
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
| | - Lan Zhang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
| | - Qi Zhou
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
| | - Xincheng Cao
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
| | - Weiyin Yu
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
| | - Yi Yang
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Shanghai, China.
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China;
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Shanghai, China.
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Balamtekin N, Erdal H, Gençkardeşler E, Arslan M. Reliability of anti-tissue transglutaminase antibodies in children with malnutrition. Scand J Gastroenterol 2021; 56:378-381. [PMID: 33590788 DOI: 10.1080/00365521.2021.1882554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Serological markers are used in the diagnosis of celiac disease. Among these, the most widely used are tissue transglutaminase antibodies (anti-TG2 antibodies). It has been suggested that the mechanisms that are set in motion by malnutrition cause the tight connections between enterocytes to expand, which allows gluten-derived peptides to pass through the epithelium. This causes the production of anti-TG2 antibodies without the presence of celiac disease. METHODS The patients who were examined for malnutrition and had their anti-TG2 antibody levels measured at the same time, were accepted into the study. The patients who were investigated for suspected celiac disease, showed no signs of malnutrition, and had their anti-TG2 antibody levels measured were accepted into a control group. RESULTS The study population consisted of 126 children with mild malnutrition (54.8% female, 7.44 ± 5.38 years); 89 children with moderate malnutrition (54.8% female, 7.62 ± 5.43 years), and a control group of 200 children (53.2% female, 7.72 ± 5.05 years). According to the results, anti-TG2 IgG levels were significantly higher among patients in the mild and moderate malnutrition groups compared to patients in the control group (p = .02 and p = .01, respectively). However, there was no significant difference between the mild and moderate malnutrition groups (p > .05). CONCLUSIONS Malnutrition does not affect anti-TG2 IgA levels in children. However, anti-TG2 IgG levels increase in children suffering from malnutrition. When examining celiac disease, especially in people with a background IgA deficiency, doctors should consider whether malnutrition may be the cause of the increase in serum anti-TG2 IgG levels without celiac disease.
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Affiliation(s)
- Necati Balamtekin
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Harun Erdal
- Department of Internal Medicine, Division of Gastroenterology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Emira Gençkardeşler
- Department of Pediatrics, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Melike Arslan
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
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Guidance on the interpretation of faecal calprotectin levels in children. PLoS One 2021; 16:e0246091. [PMID: 33571226 PMCID: PMC7877663 DOI: 10.1371/journal.pone.0246091] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/13/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Faecal calprotectin (FCP) is a powerful tool to predict inflammatory bowel disease (IBD) in patients with gastrointestinal symptoms. In the paediatric patient population, the reference value of < 50 μg/g and the influence of age on FCP levels result in a high number of redundant investigations and specialist referrals. We assessed paediatric FCP levels, their diagnostic value and corresponding referral pathways from primary and secondary care. METHODS We analysed two cohorts from a precisely defined catchment area: one consisted of all FCPs measured in this area (n = 2788). The second cohort-a subset of the first cohort-consisted of FCP values and corresponding clinical data from children who were referred for possible IBD to our department (n = 373). RESULTS In the first cohort, 47% of FCP levels were > 50 μg/g, 15% were ≥ 250 μg/g. Children < 1y had significantly (p < 0.001) higher FCP than older children. In the second cohort, 6.7% of children with an FCP of < 250 μg/g (or 8.6% with an FCP of < 600 μg/g) had IBD-all featured symptoms suggestive of IBD (e.g. bloody diarrhoea, nocturnal abdominal pain, weight loss) or abnormal blood tests. 76% of patients in whom raised FCP (> 50 μg/g) was the sole reason for being referred for suspected IBD did not have IBD. CONCLUSION Children with an FCP < 600 μg/g and without matching symptoms suggestive of IBD are unlikely to have IBD. A higher FCP reference value may provide cost-effective improvement that could avoid redundant investigations and specialist referrals. A guideline for specialist referrals is proposed.
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CisarÒ F, Pizzol A, Rigazio C, Calvo PL. Fecal calprotectin in the pediatric population: a 2020 update. Minerva Pediatr 2020; 72:514-522. [PMID: 32731735 DOI: 10.23736/s0026-4946.20.06002-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Calprotectin is a calcium and zinc-binding protein, formed by a hetero complex of S100A8 and S100A9 proteins, which belong to the S-100 protein family consisting in more than 20 different proteins with a tissue-specific expression pattern. This protein is secreted extracellularly from stimulated neutrophils or released by cell disruption or death. The presence of calprotectin in feces quantitatively relates to neutrophil migration toward the gastrointestinal (GI) tract; thus, it represents a useful marker of intestinal inflammation. Fecal calprotectin (FC) has been proven largely useful for determining the inflammatory origin of GI symptoms differentiating between organic and non-organic diseases. Indeed, increased FC levels are also seen in gastroenteritis, microscopic colitis, polyps, malignancies and cystic fibrosis. To date, there are many evidences regarding usefulness in the detection of fecal calprotectin for the management of gastrointestinal disorders, both in children and adults but, especially in the pediatric population, still clear indications for its use are lacking. Its incorporation in primary care reduces the risk of missing an organic disease and facilitates the indication for expensive and invasive investigations as colonoscopy. We herein review and discuss the last evidence on the usefulness of FC in children, with its current indications and future prospective.
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Affiliation(s)
- Fabio CisarÒ
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy -
| | - Antonio Pizzol
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
| | - Caterina Rigazio
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
| | - Pier L Calvo
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
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