The consensus of the Asociación Mexicana de Gastroenterología on the diagnosis and treatment of gastroesophageal reflux and gastroesophageal reflux disease in infants

Gastroesophageal reflux (GER) is a frequent normal phenomenon in children of any age. It is more common in infants, in whom the majority of episodes are short-lived and cause no other symptoms or complications, differentiating it from gastroesophageal reflux disease (GERD). The diagnosis and management of GER and GERD continue to be a challenge for the physician. Therefore, the aim of the Asociación Mexicana de Gastroenterología was to adapt international documents to facilitate their adoption by primary care physicians, with the goal of standardizing quality of care and reducing the number of diagnostic tests performed and inappropriate medication use. The ADAPTE methodology was followed, and the recommendations were approved utilizing the Delphi strategy. The executive committee carried out the review of the guidelines, position papers, and international reviews that met the a priori quality criteria and possible applicability in a local context. The recommendations were taken from those sources and adapted, after which they were approved by the working group. The consensus consists of 25 statements and their supporting information on the diagnosis and treatment of GER and GERD in infants. The adapted document is the first systematic effort to provide an adequate consensus for use in Mexico, proposing a practical approach to and management of GER and GERD for healthcare providers.

Helicobacter bizzozeronii infection in a girl with severe gastric disorders in México: case report

BACKGROUND

Gastric non-Helicobacter pylori helicobacters (NHPH) naturally colonize the stomach of animals. In humans, infection with these bacteria is associated with chronic active gastritis, peptic ulceration and MALT-lymphoma. H. bizzozeronii belongs to these NHPH and its prevalence in children is unknown.

CASE PRESENTATION

This case report describes for the first time a NHPH infection in a 20-month-old girl with severe gastric disorders in Mexico. The patient suffered from melena, epigastric pain, and bloating. Gastroscopy showed presence of a Hiatus Hill grade I, a hemorrhagic gastropathy in the fundus and gastric body, and a Forrest class III ulcer in the fundus. Histopathologic examination revealed a chronic active gastritis with presence of long, spiral-shaped bacilli in the glandular lumen. Biopsies from antrum, body and incisure were negative for presence of H. pylori by culture and PCR, while all biopsies were positive for presence of H. bizzozeronii by PCR. Most likely, infection occurred through intense contact with the family dog. The patient received a triple therapy consisting of a proton pump inhibitor, clarithromycin, and amoxicillin for 14 days, completed with sucralfate for 6 weeks, resulting in the disappearance of her complaints.

CONCLUSION

The eradication could not be confirmed, although it was suggested by clear improvement of symptoms. This case report further emphasizes the zoonotic importance of NHPH. It can be advised to routinely check for presence of both H. pylori and NHPH in human patients with gastric complains.

Treatment Approaches for Swallowing Disorders in Children

A swallowing disorder or dysphagia is defined as a disorder in the sequence of swallowing, during the oral or pharyngeal phase, which compromises the safety and/or efficiency of transit of the food bolus to the esophagus. The evaluation of neurodevelopment, nutrition, and preventive medicine actions are as important as the clinical evaluation of dysphagia, so they must be included and systematized in all pediatric evaluations; This evaluation can be divided into different parts: bedside swallowing evaluation, instrumental swallowing evaluation, and additional studies. The management of swallowing disorders requires a multidisciplinary team approach, depending on the child's age, cognitive and physical abilities, and the specific swallowing and feeding disorder, ensuring adequate and safe nutrition and improving the patient's quality of life.

Endoscopic Balloon Dilation of Gastric Stenosis secondary to Polyarteritis Nodosa and Arterial Thrombosis in an Adolescent

A 13-year-old female with polyarteritis nodosa underwent a partial gastrectomy for ischemic necrosis and gastric perforation following left gastric artery thrombosis. She later presented with vomiting, early satiety, weight loss, and severe malnutrition, when she was diagnosed with an occlusive gastric stricture. She successfully underwent repeated therapeutic endoscopic balloon dilations until the endpoint of 15-18 mm lumen was achieved without any complications, and her symptoms resolved.

Small intestinal bacterial overgrowth: could it be associated with chronic abdominal pain in children with allergic diseases?

BACKGROUND AND AIMS

small intestinal bacterial overgrowth (SIBO) is a well-known cause of chronic abdominal pain (CAP) during the pediatric age. On the other hand, children with a history of some allergic disorder present CAP more frequently. The aim of this study was to determine the association between the presence of allergic diseases and SIBO in patients diagnosed with CAP.

MATERIALS AND METHODS

this was an observational, analytical, retrospective study. Children with CAP who had undergone a lactulose hydrogen breath test to determine the presence of SIBO were included in the study. All patients underwent an evaluation for allergies by means of a skin prick test or the determination of specific IgE, according to clinical diagnosis. The study groups were established according to the presence of SIBO and the results of the allergic evaluation were statistically compared between the groups.

RESULTS

seventy patients were included (41 females and 29 males) and SIBO was diagnosed in 35 patients. In addition, 71.4% of children with SIBO were found to have an allergic disease, in contrast with 28.6% of children without SIBO (p = 0.001). The odds ratio for having any type of allergy in patients with SIBO was 5.45 (95% CI, 1.96-15.17; p = 0.001).

CONCLUSIONS

we found an association between SIBO and allergic disease, especially allergic rhinitis, cow's milk protein allergy and asthma. Thus, SIBO should be ruled out in pediatric patients with CAP and allergic disease.

Technical opinion of the Asociación Mexicana de Gastroenterología on soy plant-based beverages

There has been a recent increase in the consumption of cow's milk substitutes, specifically plant-based beverages, which have erroneously been named "plant milks". Plant-based beverages do not have a standard of identity, and so their nutritional composition can vary from one brand to another, even within the same category. The aim of the present narrative review was to produce a technical opinion to serve as a frame of reference for sustaining the recommendation of soy plant-based beverages. Nutrition and gastroenterology experts that belong to the Asociación Mexicana de Gastroenterología jointly commented on and analyzed themes on plant-based beverages, and on soy drinks in particular, including their nutritional characteristics, consumption in children, and potential growth and development alterations, as well as soy drink consumption in adults and its association with gastrointestinal alterations and other conditions. Plant-based beverages, including those made from soy, are not a replacement for breastmilk or breastmilk substitutes. Soy beverages are considered safe and can enrich the varied diet of its consumers, as long as they are considered an additional liquid portion of the diet. They can be ingested by adults and children above two years of age that present with cow's milk protein allergy or lactose intolerance.

The Importance of Lactose in the Human Diet: Outcomes of a Mexican Consensus Meeting

Lactose is a unique component of breast milk, many infant formulas and dairy products, and is widely used in pharmaceutical products. In spite of that, its role in human nutrition or lactose intolerance is generally not well-understood. For that reason, a 2-day-long lactose consensus meeting with health care professionals was organized in Mexico to come to a set of statements for which consensus could be gathered. Topics ranging from lactase expression to potential health benefits of lactose were introduced by experts, and that was followed by a discussion on concept statements. Interestingly, lactose does not seem to induce a neurological reward response when consumed. Although lactose digestion is optimal, it supplies galactose for liver glycogen synthesis. In infants, it cannot be ignored that lactose-derived galactose is needed for the synthesis of glycosylated macromolecules. At least beyond infancy, the low glycemic index of lactose might be metabolically beneficial. When lactase expression decreases, lactose maldigestion may lead to lactose intolerance symptoms. In infancy, the temporary replacing of lactose by other carbohydrates is only justified in case of severe intolerance symptoms. In those who show an (epi)genetic decrease or absence of lactase expression, a certain amount (for adults mostly up to 12 g per portion) of lactose can still be consumed. In these cases, lactose shows beneficial intestinal-microbiota-shaping effects. Avoiding lactose-containing products may imply a lower intake of other important nutrients, such as calcium and vitamin B12 from dairy products, as well as an increased intake of less beneficial carbohydrates.

Importancia de la microbiota gastrointestinal en pediatría

Las enfermedades del tubo gastrointestinal forman parte importante de la morbilidad y de la mortalidad mundiales; incluyen desde las enfermedades infecciosas, alérgicas, inflamatorias crónicas (como la enfermedad de Crohn y la colitis ulcerativa) hasta padecimientos considerados como funcionales, como el síndrome de intestino irritable. En algunas de ellas el tratamiento puede ser difícil, ya que en ocasiones pueden existir diferentes teorías en relación a las mismas y en las que se han encontrado múltiples factores tanto psicosociales como genéticos. En los últimos años ha cobrado gran importancia el papel que desempeña la microbiota intestinal en la génesis de algunas de ellas. Desde el siglo XV se describió la presencia de microorganismos en el tubo gastrointestinal, pero fue hasta que se originó la biología molecular cuando se logró un mejor conocimiento de la función y la composición del ecosistema gastrointestinal, el cual contribuye de manera importante para los procesos de digestión y absorción de sustratos de la dieta, así como para las funciones inmunológicas y protectoras de la microbiota gastrointestinal en cada organismo, lo que resulta esencial para comprender su participación en el tratamiento y en la prevención de múltiples enfermedades. 

Histopathologic findings in children diagnosed with cow's milk protein allergy

BACKGROUND

Cow's milk protein allergy is the most common cause of food allergy. The challenge test, either open or doubled-blind with a placebo control, is regarded as the criterion standard. Endoscopy and histologic findings are considered a method that can aid in the diagnosis of this entity.

AIMS

The aim of this study was to describe the histopathologic findings in children suspected of cow's milk protein allergy that were seen at our hospital.

MATERIAL AND METHODS

A descriptive, observational study was conducted on 116 children clinically suspected of presenting with cow's milk protein allergy that were seen at the Department of Gastroenterology and Nutrition of the Instituto Nacional de Pediatría. Upper endoscopy and rectosigmoidoscopy with biopsies were performed and the findings were described.

RESULTS

Of the 116 patients, 64 (55.17%) were girls and 52 (44.83%) were boys. The rectum was the site with the greatest presence of eosinophils per field in both groups, followed by the duodenum. In general, more than 15 eosinophils were found in 46% of the patients.

CONCLUSIONS

Between 40 and 45% of the cases had the histologic criterion of more than 15 to 20 eosinophils per field and the rectosigmoid colon was the most affected site. Therefore, panendoscopy and rectosigmoidoscopy with biopsy and eosinophil count are suggested.

Intraepithelial giardia intestinalis: a case report and literature review

The giardiasis is a neglected parasitic disease. The WHO has estimated more than 280 million of human infections each year; however, intraepithelial giardiasis is a rare entity, there are only 5 reports showing invasive giardiasis. A pediatric female patient with chronic abdominal pain, diarrhea, or pasty stools, without fever, was seen in the Gastroenterology and Nutrition Service. The stool studies were negative for pathogens and lactose hydrogen breath test was positive. The presumptive clinical diagnosis was giardiasis and the patient was empirically treated with nitazoxanide. But, the patient persisted with abdominal pain and pasty stools. Endoscopy was indicated to search for Helicobacter and Giardia. Guardian and patient gave written informed consent. Hematological profile was normal. The endoscopy was performed under general anesthesia and the biopsies and duodenal aspirate were obtained. The microscopic analyses of duodenal fluid showed Giardia trophozoites. Electron microscopic analysis was negative for Helicobacter pylori, but Giardia trophozoites with a typical crescent shape within the tissue were found. The patient was treated with tinidazole, subsequent tests showed that lactose absorption was normal, stool examinations were negative for Giardia and abdominal pain had stopped. This case suggest that intraepithelial giardiasis could be a common entity but unseen because the giardiasis diagnosis is usually made on fecal samples. Future studies are necessary to determine the role of intraepithelial trophozoites in giardiasis pathogenic mechanisms.

[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.

[Primary intestinal lymphangiectasia: twenty years of experience at a Mexican tertiary care hospital]

BACKGROUND

Primary intestinal lymphangiectasia is a rare congenital disease described by Waldmann in 1961 that is a consequence of obstruction of the lymphatic drainage of the small bowel with secondary lymph vessel dilation. This distorts the architecture of the villi and causes a leakage of lymph into the intestinal lumen, resulting in protein-losing enteropathy and malabsorption.

AIM

To describe the clinical, biochemical, radiologic, endoscopic, and histologic characteristics in children with primary intestinal lymphangiectasia.

METHOD

A retrospective observational, descriptive, cross-sectional study was conducted that reviewed the case records of children diagnosed with primary intestinal lymphangiectasia that were seen at the Department of Gastroenterology and Nutrition of the Instituto Nacional de Pediatría within the time frame of January 1, 1992 to September 30, 2012.

RESULTS

Four patients were found that presented with primary intestinal lymphangiectasia. Three of them had been diagnosed before 3 years of age. All the patients presented with chronic diarrhea, edema, lymphopenia, hypocalcemia, and hypogammaglobulinemia, and 3 patients presented with hypocholesterolemia. Bowel transit time, endoscopy, and intestinal biopsies were characteristic of this pathology.

CONCLUSIONS

Intestinal lymphangiectasia should be suspected when there is a clinical picture of chronic diarrhea and protein-losing enteropathy accompanied with edema at any level, as well as hypoalbuminemia, hypocalcemia, lymphopenia, hypogammaglobulinemia, and hypocholesterolemia, which are the main biochemical findings of this pathology. All children presenting with intestinal lymphangiectasia should undergo an upper gastrointestinal series with bowel transit time and endoscopy with biopsies taken at the level of the duodenum. Treatment includes diet and the periodic administration of albumin and gamma globulin.

[24-h intraesophageal pH determination in children allergic to cow's milk protein at a tertiary care hospital]

BACKGROUND

Cow's milk protein allergy (CMPA) is being seen more frequently on a daily basis in pediatric consultations. It shares symptoms with gastroesophageal reflux (GER), which can complicate the differential diagnosis.

AIMS

To attempt to corroborate the presence of acid GER in children with CMPA, as well as to find a characteristic profile through the 24-hour pH monitoring study in children with GER and CMPA METHODS: The intraesophageal pH monitoring studies performed on 47 children with CMPA were reviewed. The measurements in all the studies were carried out within a 24-hour period using Digitrapper® equipment with a multi-use GeroFlex® catheter, after calibration with pH 7 and pH 1 buffer solutions.

RESULTS

Of the 47 children, 23 were boys (32.4%) and 24 were girls (33.8%) and the mean age was 5±3.7 years. Fourteen of the 47 children (29%) presented with GER, according to the result of the 24-hour intraesophageal measurement. Only 2 of the 47 patients studied fit the phasic profile.

CONCLUSIONS

The findings show the existing relation between the two pathologies. Nevertheless, it is important to determine the presence of non-acid or weak acid reflux, because their existence can increase this association.

[Clinical trial on the effect of buphenine, aminophenazone and diphenylpyraline hydrochloride in treating the common cold in children of 6 to 24 months of age]

INTRODUCTION

Acute respiratory infections are the second leading cause of morbidity in children under 18 years. Several drugs have been used with variable efficacy and safety, trying to reduce the associated symptoms and improve quality of life.

OBJECTIVE

To evaluate the efficacy and safety of buphenine, aminophenazone and diphenylpyraline hydrochloride when compared with placebo for the control of symptoms associated with common cold in children 6-24 months of age.

MATERIAL AND METHODS

Randomized clinical trial, double blind, placebo controlled, in 100 children < 24 months of any gender, with symptoms associated to common cold. They received the drug under study vs. placebo for seven days. Both groups received acetaminophen. The change on common cold related symptoms were evaluated. Statistic analysis was made with STATA 11.0 for Mac.

RESULTS

Fifty-three children were randomized to study drug and forty-seven to placebo. Age of children in each group was similar (12.2 +/- 5.8 months vs. 12.7 +/- 5.8 months, p NS). There were significant differences between groups in relation to rhinorrea and sneezing resolution, with better results in Flumil group and no adverse events observed.

CONCLUSIONS

The results in this study indicates that Flumil is a safe and effective drug for control of symptoms present in the common cold in children aged 6-24 months.