Pediatric Gastroenterology Research Articles

Removal of an embedded duodenal foreign body in a Schizophrenic adolescent with a guidewire-formed lasso

BackgroundForeign bodies (FBs) in the gastrointestinal tract are a common occurrence in pediatric patients, often requiring medical intervention for removal. Conventional extraction methods can be challenging, particularly when the FB is unusually large, long, abnormally positioned, or tightly embedded, presenting a gap in safe, non-surgical management techniques.Case presentationIn this report, we describe the innovative use of a lasso structure formed by a guidewire and biopsy forceps to successfully remove a tightly embedded toothbrush from the duodenum of a pediatric patient with schizophrenia, avoiding invasive surgical interventions, and the patient recovered well post-procedure without complications.ConclusionsThe success of this approach offers a promising alternative for clinicians managing similar cases, potentially reducing the need for surgical intervention and contributing to safer and more efficient treatment options for the removal of FBs in pediatric gastroenterology.

Comparison of the Bristol Stool Scale and modified version for children: Use by providers vs children: BSFS vs mBSFS-C.

Accurate report of stool form is essential to diagnosis and assessment of treatment response. The modified Bristol Stool Form Scale for Children ( mBSFS-C ) classifies stool form into 5 types and is reliable and valid. However, a direct comparison of provider's and children's ratings using the mBSFS-C vs the traditional Bristol Stool Form Scale ( BSFS ) that uses 7 stool form types has not been done. Pediatric gastroenterology providers and children rated the same 35 stool photos, reflecting diverse stool forms, using both scales. The order of photo presentation and scale use were randomized. For each photo, the most common rating (modal rating) was calculated for both scales and study samples. The percentage of child and provider ratings matching their respective modal ratings was determined. Twenty-one providers (21 faculty, 11 fellows, 3 nurse practitioners) and 200 children (mean age 12 ± 3 years) participated. No order effect (mBSFS-C vs BSFS used first) was observed. Of 1225 provider ratings using the mBSFS-C, 90.0% agreed with the provider's modal ratings vs 77.8% using the BSFS. Of 7,000 child ratings using the mBSFS-C, 84.6% agreed with the children's modal ratings vs 71.8% using the BSFS. Using providers' modal ratings as the reference, all mBSFS-C photograph modal ratings matched between children and providers (35/35 photos) whereas only 86% (30/35 photos) matched with the BSFS. 1) The mBSFS-C showed greater modal agreement among both providers and children compared to the BSFS; 2) Provider-child concordance was greater with the mBSFS-C than with the BSFS. Validation in other regions/populations is needed.

Discrepancy between Mexican paediatricians and ESPGHAN experts regarding cow's milk allergy

AbstractObjectivesCow's milk allergy (CMA) is a common food allergy in infants. Guidelines and recommendations for the diagnosis and management of CMA are based on scientific review of the available evidence. However, real‐world situations may oblige clinicians to adapt a different attitude.MethodsThis paper evaluated the opinion of 42 Mexican paediatricians on the 73 statements presented in the recent position paper of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Voting on the statements and their interpretation were identical for both groups (online and anonymous). Both groups were unaware of the other's outcome at the moment of the voting.ResultsWhile the ESPGHAN group accepted all 73 statements, the Mexican group rejected 19 statements. Two rejections were due to the mean and median being below the predefined and agreed‐upon cut‐off, and 17 were due to over 75% of participants disagreeing with the statements. The greatest discrepancy was observed regarding the role of vitamin D in preventing CMA.ConclusionWhile opinions on the prevalence, diagnosis and management of CMA were comparable between European paediatric gastroenterologists and Mexican general paediatricians for the majority of statements, significant differences were observed. It is essential to gather information from various regions and healthcare levels to enhance the impact of recommendations.

Publications by the Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition Members in PubMed-indexed Journals (1st June to 31st August 2024)

Publications by the Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition Members in PubMed-indexed Journals (1st June to 31st August 2024)

Esophageal food bolus impaction in children: A 15-year experience and a review.

We aimed to analyze the episodes of esophageal food bolus impaction (EFI) occurred over a time of 15 years in children admitted to a large pediatric emergency department (PED), documenting their clinical presentation, underlying pathology, management, biopsy rate, and follow-up visits. Additionally, to combine our institutional experience with the existing literature, a comprehensive review was conducted. We reviewed the medical records of all children presenting to our PED with EFI from 2010 to 2024. The comprehensive review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement for systematic reviews. Electronic databases including PubMed/Medline and EMBASE were screened. The data obtained was synthesized to map out the actual status and current literature on pediatric EFI. We identified 54 cases of EFI. Overall, 22 patients (41%) had underlying pathology. Previous episodes were reported in 14 cases (26%). Urgent endoscopy was performed in 31 cases (57%). The presence of underlying pathology was associated with the need for endoscopic removal (p = 0.013), as well as the history of previous episodes (p = 0.016). Biopsies were performed in 14 cases (26%). Pediatric gastroenterologists showed a higher rate of performed biopsies compared to surgeons, as well as higher rate of follow-up visits. An underlying disease was found during later clinical follow-up in 5 out of 54 cases of EFI (9%). A comprehensive review of 16 studies revealed high rates of underlying pathology and low rates of biopsies and follow-up visits among children with EFI. Increased vigilance in identifying underlying pathologies in children with EFI is crucial. The importance of performing biopsies, regardless of prior anatomical conditions, and the need for ongoing follow-up to ensure timely and accurate diagnoses should be addressed through shared protocols.

Next-generation sequencing in diagnosis of monogenic cholestatic liver disorders: A single-center experience

Introduction Cholestasis in childhood is a rare clinical condition, yet a definitive diagnosis is crucial for initiating treatment of these curable diseases and preventing related morbidity and mortality. The most common cause of infant cholestasis is biliary atresia (25-40%), followed by monogenic cholestatic diseases (25%), metabolic diseases (20%), and cryptogenic cholestasis. This study focuses on assessing the clinical utility of next-generation sequencing (NGS) panels, including clinical exome sequencing and whole exome sequencing, in diagnosing cholestatic diseases when the etiology cannot be elucidated through conventional methods. Materials and Methods We conducted a retrospective examination of pediatric patients who sought care at a single-center pediatric gastroenterology department between August 2020 and March 2022, and were diagnosed with cholestasis. A total of 36 patients underwent a thorough investigation to rule out infectious, toxic, metabolic, structural, chromosomal, and endocrine causes. Patients whose diagnoses were established through traditional investigations were excluded from the study. The remaining 14 patients underwent either whole exome sequencing or targeted next-generation sequencing methods. Results A definitive diagnosis was achieved for 12 patients, while two patients remained undiagnosed despite comprehensive genetic examinations. The most commonly encountered diseases in this cohort were progressive familial intrahepatic cholestasis, linked to mutations in the ABCB11, ATP8B1, and TJP2 genes, as well as Dubin-Johnson syndrome associated with ABCC2 mutations. Next-generation sequencing demonstrated a diagnostic accuracy of 85.7% in patients for whom a diagnosis could not be established through extensive traditional workup. Conclusion Next-generation sequencing emerges as a valuable diagnostic tool in cases of cholestasis where traditional methods fall short in providing a definitive diagnosis. Moreover, our study unveiled three previously undocumented variants in the ABCB11 [c.1165G>C; p.(Ala389Pro) and c.783+1G>A] and ABCC2 [c.4246_4247del; p.(Lys1416ValfsTer46)] genes.

Food insecurity in a diverse community pediatric gastroenterology clinic: Screening strategies and insights.

We aimed to evaluate the prevalence of food insecurity (FI) in the community pediatric gastroenterology(GI) subspecialty clinic at Texas Children's Hospital (TCH) West Campus and to assess the utilization of services through our partnership with a local food bank. From July 1, 2023, to February 29, 2024, all patients seen in the pediatric GI clinic at TCH West Campus were screened for FI using the validated Hunger Vital Sign tool and given the opportunity to consult with a local food bank representative. A retrospective chart review was then performed on patients who completed the implemented FI screening process. 13.4% of the total patients screened positive for FI. Hispanic patients (p < 0.0001), patients with the preferred language of Spanish (p < 0.0001), those enrolled in Medicaid or Children's Health Insurance Program (p < 0.0001), and patients with obesity (body mass index ≥ 30.0, p = 0.0003) were more likely to screen positive for FI. Poor weight gain/failure to thrive and steatotic liver disease were significantly more common in those with FI (p < 0.0001 and p = 0.0003, respectively), while celiac disease, abdominal pain, and blood in stool were more common in those without FI (p = 0.0003, 0.0475, and 0.0404, respectively). As a result of our implemented FI screening process, 68.4% of those screening positive opted for resource referral, with 50.7% successfully receiving assistance in combating FI. Identifying the potential impact of FI in common pediatric GI conditions calls for proactive screening and more holistic, patient-centered approaches in clinical practice.

Follow-up and transition practices in esophageal atresia: a review of European Reference Network on rare Inherited and Congenital Anomalies (ERNICA) centres and affiliates

PurposeThe purpose of this study was to understand the provision and distribution of esophageal atresia (EA) follow-up (FU) and transition services across European Reference Network for rare Inherited and Congenital Anomalies (ERNICA) member and affiliate centers.MethodsA REDCap questionnaire was sent to clinical leads of 18 ERNICA members and 14 affiliate centers.Results29 of 32 centers responded (91%), the majority of which were highly specialized. Two-thirds had a dedicated EA clinic with a specialist multi-disciplinary team (MDT), offered to selected/complex patients only in 40% of centers. ERNICA centers were more likely to offer an MDT FU clinic than affiliates, with lack of resources most cited as a barrier to uptake (67%). Delivery of routine investigations was heterogeneous, particularly provision of three endoscopies over the course of FU (24%). Only 55% had a dedicated transition pathway, more prevalent in ERNICA centers (81% vs. 30%; p < 0.01). Self-reported awareness of ERNICA and European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidance for FU and transition was poor (28%).ConclusionDespite the existence of European follow-up and transition guidelines, their delivery is not uniform and may be limited by lack of awareness of the guidelines and a lack of resources.

Regional differences in diagnosis and management of cow's milk allergy.

Various guidelines for the diagnosis and management of cow's milk allergy (CMA) have been published. This study aimed to compare voting outcomes of experts from Mexico, the Middle East, and the European Society of Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) on statements regarding CMA. The 3 expert groups voted on the same 10 statements. Each participant voted anonymously using a score of 0-9 (≥6 meant agreement; <5 reflected disagreement). If <75% of the participants agreed with the statement, it was rejected. None of the groups was aware of the voting outcomes of another group. There was broad consensus amongst the 3 groups. Agreement was reached that infant colic as a single manifestation is not suggestive of CMA. All groups confirmed that an extensively hydrolysed formula is the preferred elimination diet in mild/moderate CMA cases; however, hydrolysed rice formula is an alternative. Amino acid-based formulas should be reserved for infants with severe symptoms. The discrepancy in voting outcomes regarding soy formulas highlights the differences in opinions. Two of 13 ESPGHAN experts (15%), 1 of 14 Middle East experts (7%), and 6 of 26 Mexican experts (23%) disagreed with the statement that soy formula should not be the first choice for the diagnostic elimination diet but can be considered in some cases for economic, cultural, and palatability reasons. All of the ESPGHAN and Mexican experts agreed that there was no added value of probiotics, prebiotics, or synbiotics to the efficacy of elimination diets on CMA, whereas 3 of 14 Middle East experts (21%) determined that there was sufficient evidence. Although all statements were accepted by the 3 groups, there were relevant differences illustrating variations according to geography, culture, cost, and formula availability. These findings emphasize the need for region-specific guidelines.

Growth Status of Bangladeshi Children in Functional Constipation: Experience From A Tertiary Care Hospital

Background: Constipation is one of the common complaints of children with long-term hazardous consequences. It is a frequent cause of hospital visit in both primary and specialized care which needs proper evaluation and management. Recently in few studies, impairment of growth status has been reported as a result of functional constipation. But the relation is not well evaluated, especially in the pediatric population of our country. Aim: To assess the growth status of Bangladeshi children in functional constipation. Methods: This analytical study was conducted at the department of Pediatric Gastroenterology and Nutrition, BSMMU, Dhaka. A total 150 children aged 2-18 years were enrolled in this study. Children were divided into two groups, 75 having functional constipation (FC) and 75 healthy children with no constipation. Samples were collected randomly from pediatric out-patient department of BSMMU with consent of parents and child’s approval. Diagnosis of functional constipation was made by Rome IV criteria. Children with any red flag sign, chronic disease and on treatment of constipation were excluded from the study. Growth status (weight, height &amp; BMI) was evaluated by using growth charts. Data collected in semi-structured questionnaire and analyzed by SPSS 23.0. Results: We evaluated 75 constipated children with the mean age of 7.61±3.50 years and 75 healthy children with the mean age of 7.40±3.88 years. The mean weight of children with functional constipation was 22.8±10.01 kg, mean height 117.7 ±18.4 cm and BMI 15.6±2.3 kg/m2. The mean weight of children with no constipation was 28.6± 13.72 kg, mean height 124.49±23.3 cm and BMI 18.11±2.9 kg/m2,demonstrated significant difference between two sets. In functional constipation group, on weight for age and height for age chart, 28% and 24% children were below the 3rd centile respectively and 18.6% children had BMI below 5th centile. All these parameters (weight, height, BMI) were statistically significant in compare to children without constipation and p value is &lt;.05. Presenting features of functional constipation were anorexia (64%), abdominal pain (73.3%), hard stool (84%), blood mixed hard stool (13.3%) and nausea (34%). Conclusion: Growth impairment occurs in children with functional constipation in comparison to children without constipation. Children aged 2 to 18 years with functional constipation may have decelerated weight, height and BMI growth. And this observation needs further large-scale multicenter study for ensuring optimal growth of children with constipation. J Shaheed Suhrawardy Med Coll 2023; 15(1): 73-77

Oral rehydration in diarrhea: from history to current guidelines. A review

Acute gastroenteritis (AGE) is usually defined as a change in stool consistency (liquid or unformed) and/or an increase in the frequency of bowel movements, which can also be accompanied by vomiting and fever. Fever increases the metabolic rate by more than 1.5 times; for every 1°C increase in body temperature, fluid loss increases by 10%. AGE is a common cause of morbidity and mortality among infants and children. The prognosis is favorable if the condition is recognized promptly and appropriate treatment is started. The main goal of AGE therapy is to restore water balance and prevent dehydration, which can be achieved with an oral rehydration solution. The composition and proportion of the components of rehydration agents are described in the guidelines of the European Society for Paediatric Gastroenterology Hepatology and Nutrition, of which the Russian Society of Pediatric Gastroenterologists is a collective member, and such agents are fully consistent with the balanced formulations of RehydroStandard and Rehydron Bio rehydration agents. The latter includes the probiotic strain Lactobacillus rhamnosus GG, well studied and recommended by the European Society for Paediatric Gastroenterology Hepatology and Nutrition for acute intestinal infections since this strain reduces the duration and severity of diarrhea according to the results of studies. Rehydron Bio and RehydroStandard can be recommended for use in clinical pediatric practice.

Standardized Approach to Pediatric Post-COVID Syndrome and Its Impact on Children and Adolescents: A Perspective From a Tertiary Center.

Pediatric post-COVID syndrome (pPCS) affects a notable number of children. This study aims to describe its clinical manifestations, biopsychosocial impact and management strategies. A prospective, single-center study was conducted to analyze data of pPCS patients presenting to our institution between May 2021 and November 2022. Functional impact was evaluated by assessing school absenteeism and by using the Adolescent Depression Rating Scale (ADRS), Pediatric Quality of Life Inventory (PedsQL) and Fatigue Severity Scale. Among the 50 patients included [median age (interquartile range): 14.0 (12.9-15.8) years; females: 70%], the most common symptoms were extreme fatigue (84%), exertion intolerance (82%), orthostatism (66%), dyspnea (66%) and headache (66%); 25% had an abnormal Schellong test. Median (interquartile range) ADRS, PedsQL and Fatigue Severity Scale scores were 3.0 (1.0-5.0), 56% (49%-71%) and 45.0 (32.0-53.0), respectively. Sixty percent experienced partial (34%) or complete (26%) school absenteeism. The most common referrals to specialized consultations were child psychiatry (48%), pulmonology (46%), physiotherapy (36%) and an ear-nose-throat specialist (24%). Eighty percent had a typical form of pPCS, whereas 20% had a clinical presentation suggestive of a functional disorder triggered by COVID-19. The latter had more frequent thoracic pain (P = 0.012) and more referrals to pediatric neurology (P = 0.01), gastroenterology (P = 0.011), ophthalmology (P = 0.037) and child psychiatry (P = 0.035), but less to pulmonology (P = 0.014). School absenteeism and social withdrawal were also more common in this group, with more severe PedsQL and ADRS scores. pPCS is associated with a significant socio-educational burden that should be taken into account in medical, social and educational care.

Medical Media in Pediatric Gastroenterology and Hepatology: Strategies for Effective Use by Consumers, Contributors, and Creators.

This review article explores the role of medical media in gastroenterology and hepatology, highlighting its benefits for enhancing clinical practice, education, and patient engagement. It also provides practical guidance for gastroenterologists and hepatologists on effectively implementing these tools in their daily practice. Recent findings highlight that medical media significantly boosts citation rates and dissemination of research, enhances promotional efforts, and fosters greater engagement from patients and trainees. These advances underscore the growing role of medical media in amplifying academic impact and improving educational outreach in gastroenterology and hepatology. Integrating medical media into pediatric gastroenterology and hepatology offers numerous benefits, from enhanced education and professional development to improved patient engagement. By understanding the roles of contributor, creator, and consumer and leveraging the right platforms and content types, pediatric gastroenterologists and hepatologists can effectively utilize medical media to advance their field and provide better care.

Comparison of different diagnostic methods in infants for differentiating idiopathic neonatal hepatitis from biliary atresia

Background: Biliary atresia (BA) and idiopathic neonatal hepatitis (INH) are two most common etiologies of neonatal cholestatic jaundice. It is important to distinguish INH from BA biliary atresia in an infant. The study was conducted to compare of different diagnostic methods in infants in differentiating INH and BA. Methods: This cross-sectional study was conducted at the Department of Pediatric Gastroenterology &amp; Nutrition, BSMMU during the period from July 2018 to June 2019 among infants with neonatal cholestasis. Total 50 cholestatitic cases were selected through purposive sampling. A thorough history and physical examination were done and liver enzymes were studied. Abdominal ultrasonography, hepatobiliary scintigraphy and liver biopsy were done in all cases. Clinical parameter and investigational sensitivity, specificity, and diagnostic precision were calculated. To diagnose BA and INH, liver biopsy was considered the gold standard. Results: Among the participants, 72% were diagnosed as BA and 28% were INH. More than half of patients were male. There exists significant difference of birth weight and term baby between BA and INH. Presence of persistent pale coloured stool was more commonly seen in patients with BA. Diagnostic accuracy of persistent pale coloured stool, birth weight (normal) and term baby were 94%, 92% &amp; 88% respectively. Sensitivity and specificity of Gammaglutamyl transpeptidase (GGT) in differentiating cases with BA and INH with cut point of ≥430.0 U/L were 86.1% and 85.7%, respectively. Hepatobiliary scintigraphy is found to have a better sensitivity than ultrasonography. GGT had diagnostic accuracy 86%, hepatobiliary scintigraphy had diagnostic accuracy 88% &amp; USG had diagnostic accuracy 80% for BA and INH. Conclusion: Among the studied clinical parameters persistent pale coloured stool was most accurate to suggest the presence of BA. Serum level of GGT at cut-off value ≥ 430 U/L may be used as a reliable laboratory parameter to differentiate INH and BA. Hepatobiliary scintigraphy found to have a good sensitivity for BA. Positive result of hepatobiliary scintigraphy may be used as BA in infants with cholestasis. JOPSOM 2023; 42(1):14-20

Coeliac Disease in Children—A Clinical Review Including Novel Treatment Agents

Coeliac disease (CD) affects almost of 1% of the population, yet remains undiagnosed in the majority. Though the demonstration of enteropathy in duodenal biopsy was traditionally the essential criterion for the diagnosis of coeliac disease, the guidelines published by the European Society of Paediatric Gastroenterology and Nutrition (ESPGHAN) in 2012, and revised in 2020, paved the way to a no-biopsy approach to diagnosis. In a select group of children meeting certain criteria, a definitive diagnosis of CD can now be made without the need for duodenal biopsies. This is being increasingly applied in clinical practice. It is well established that untreated coeliac disease is associated with several chronic adverse health conditions. At present, a strict gluten-free diet remains the only effective treatment for CD. The advances in our understanding of the pathogenesis of CD have led to a search for alternative treatment agents. Several investigational agents are in various phases of clinical trials at present. In this review, we outline the clinical aspects of coeliac disease and summarise various investigational treatment agents.

Diagnostic Outcome of Rome IV Criteria in Diagnosis of Functional Constipation among Infants and Children

Abstract Background Functional Constipation is one of the most prevalent functional gastrointestinal disorders (FGIDs) among children worldwide. Rome IV criteria is used to diagnose functional constipation. The use of Rome questionnaire for screening also reveals other associated FGIDs. Objective To assess the outcome of Rome IV criteria in diagnosis of functional constipation among infants and children and follow up of cases to uncover any organic causes among them. Methods Cross-sectional, controlled study on 121 patients diagnosed as constipation with no red flags, selected from Pediatric Gastroenterology &amp; General Clinics in Ain Shams University, Egypt. Patients were divided into 2 groups, below 4 years old (21 patients) and above 4 years old (100 patients) based upon the age stratification of the Rome criteria which was applied to all patients. Results There was nearly equal gender affection with a median age of 10 months among patients younger than 4 years, and a median age of 7 years old among patients older than 4 years. It was found that 38.1% of infants had a mixed diagnosis, where infant colic and regurgitation occurred in 9.5% and 33.3% of cases respectively. While among the group above 4 years old, Functional Dyspepsia represented the most common associated FGID (64%), followed by Aerophagia (8%), then Functional Vomiting (5%), while Abdominal Migraine and Functional Nausea represented 3% and 1% of all cases respectively. Upon follow up none of the patients developed any organic disease. Conclusion We concluded that diagnosis and follow up of patients using Rome IV is efficient in excluding organic diseases and diagnosing functional constipation (FC) and it avoids the need for further investigations. Moreover, Rome questionnaire was able to detect other FGIDs associated with constipation.

Extrahepatic Portal Vein Obstruction in Children.

Extrahepatic portal vein obstruction is the most common cause of portal hypertension in children. This study aimed to evaluate the causes, clinical, laboratory and endoscopic findings, treatment approaches, long-term results, and prognosis of extrahepatic portal vein obstruction in children. We retrospectively evaluated 82 patients who were followed up with the diagnosis of extrahepatic portal vein obstruction at Gazi University Pediatric Gastroenterology clinic between January 1, 2011, and October 31, 2021. Among our patients, 58.5% were male, median age at presentation was 36 months (range, 1 month to 6 years), and the follow-up period was 2 years (range, 1-14 years). The most common reasons for admission were gastrointestinal bleeding and splenomegaly. All patients diagnosed with incidentally detected obstruction were children under 5 years of age. The most frequently detected risk factors were history of umbilical vein catheterization (50%) and presence of procoagulant status (31%). Esophageal varices (94.8%), variceal bleeding (73.2%), hypersplenism (64.6%), and growth failure (13.4%) were the most common complications. Weight and/or height z-scores were lower in children with esophageal varices, variceal bleeding, and hypersplenism. Endoscopic treatments were more frequently applied to those with splenomegaly, thrombocytopenia, red color sign, and esophageal variceal bleeding. Rates of splenomegaly, hypersplenism, esophageal variceal bleeding, advanced varicose veins, and portal biliopathy were higher in patients who underwent portosystemic shunt surgery than in patients who did not undergo it. Morbidity and mortality rates of variceal bleeding in extrahepatic portal vein obstruction were lower than bleeding seen in cirrhotic prehepatic portal hypertension. In our study, no patients died from extrahepatic portal vein obstruction-related complications. One patient died from tuberculous meningitis.

Effect of Human Milk Fortifiers, Medium-chain Triglyceride Oil, Minerals, and Vitamin Supplements on the Osmolality of Pasteurized Donor Human Milk

Aim: We aimed to study the changes in osmolality of pasteurized donor human milk (PDHM) after the addition of four human milk fortifiers (HMFs), medium-chain triglyceride (MCT) oil, minerals, and vitamin supplements commonly used in neonates. Methods: The osmolality of 25 ml of PDHM was measured after the addition of 1 g each of HMF and 0.5 ml of MCT oil separately with a calibrated osmometer. The osmolality of 5 ml of PDHM was measured after the addition of minerals and vitamin supplements in therapeutic doses separately. All these measurements were carried out at 10 min, 30 min, and 2 h by a technician who was blinded to the fortifiers, minerals, and vitamin supplements used. Results: The osmolality of PDHM was 256 mOsm/kg (range = 256–259 mOsm/kg), which increased with all four HMFs tested, but remained below 450 mOsm/kg as recommended by the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN). Proprietary fortifiers increased the osmolality of PDHM to a maximum of 429 mOsm/kg (range = 306–429 mOsm/kg). However, there was no change in the osmolality with MCT oil. A maximum increase in osmolality was observed with the addition of calcium phosphate syrup to PDHM (1181 mOsm/kg). The addition of multivitamins and Vitamin D3 in therapeutic doses increased osmolality (range = 552–753 mOsm/kg) beyond the safety limits of ESPGHAN recommendation. Conclusions: HMFs increased the osmolality of PDHM but were within the safety limits of ESPGHAN recommendation. MCT oil did not affect the osmolality of PDHM. Minerals and vitamin supplements added in therapeutic dosages significantly increased the osmolality of PDHM. Minerals and vitamin supplements need to be appropriately diluted to keep osmolality below 450 mOsm/kg to ensure safety. Future research should focus on manufacturing fortifiers and supplements with low osmolality to ensure safety.

Testing Tolerance in Cow Milk Protein Allergy Patients: Milk Ladder or Direct Milk Administration?

Abstract Background Cow’s milk protein allergy (CMPA) is a major health concern; its prevalence is between 1.9% and 4.9% in the first year of life. Tolerance to cow’s milk is tested after at least 6 months of elimination diet through two common approaches which are the milk ladder method and direct milk administration. Aim To compare tolerance frequency between those who had milk products reintroduced via milk ladder to those who were directly exposed to pure milk antigen after 6 months of elimination diet, and to assess the factors affecting the overall tolerance frequency of cow’s milk after 6 months elimination diet. Methods A randomized controlled clinical trial involving 116 children recruited from the Pediatric Gastroenterology Clinic, Children’s Hospital, in Shams University, diagnosed as non-IgE mediated cow’s milk protein allergy proven by elimination re-challenge test and followed six months of elimination diet. The included children were randomly assigned into 2 groups, where one group had milk products reintroduced via 6 steps milk ladder, and the second group had direct milk antigen administration in gradual increments. They were followed up for 2 months after the introduction of milk or milk containing products to confirm resolution of allergy. Results The overall tolerance rate after 6 months elimination diet was 81% with no significant difference between the two approaches (Direct milk 84.5%, and milk ladder 77.6%), in addition, the regression analysis showed that weight was a significant factor influencing the resolution of CMPA patients, with normal weight patients having higher chance of resolution than underweight patients (odds ratio=3.73). Conclusion Non-IgE medicated CMPA has high rate of resolution after 6 months elimination diet. Both approaches of introduction were equivalent.

Rational application of the ESPGHAN 2022 recommendations for the follow-up of the paediatric coeliac patient: consensus document of scientific societies (SEGHNP, AEPAP, SEPEAP, SEEC, AEG, SEPD, SEMFYC, SEMG and SEMERGEN)

Coeliac disease is a common condition for which the only current treatment is a gluten-free diet. Adherence to this diet is not always easy and is associated with a reduction in quality of life for the patient and their family. Non-adherence is associated with complications of varying severity. The lack of control at the outpatient care level in a high percentage of these patients evinces the need to improve follow-up protocols and the approach to care delivery with coordination of paediatric gastroenterology units (PGU) and primary care paediatricians. With this aim in mind, the present document was developed by consensus to offer a set of recommendations adapted to our region, based on the recent recommendations published by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), and with participation of the pertinent scientific societies, including those concerning the adult population, for the management and follow-up of adolescents and the transition to adult care.