Evaluation of Antibody Response to Polysaccharide Vaccine and Switched Memory B Cells in Pediatric Patients with Inflammatory Bowel Disease

BACKGROUND/AIMS: Inflammatory bowel disease (IBD) is a chronic disease of the gastrointestinal tract, whose etiologies are still unknown. This study was performed to evaluate the humoral immune response in terms of B cell functions in selected IBD patients. METHODS: Eighteen pediatric patients with IBD, including 12 cases of ulcerative colitis (UC) and six with Crohn disease (CD), were enrolled in this study. The pneumococcal vaccine was injected in all patients, and the IgG antibody level to the polysaccharide antigen was measured before and 4 weeks after injection. The B cell switch-recombination process was evaluated. RESULTS: Five patients with IBD (three CD and two UC) had defects in B cell switching, which was significantly higher than in controls (p=0.05). Ten patients had a specific antibody deficiency and exhibited a higher frequency of bacterial infection than the healthy group. The mean increased level of IgG after vaccination was lower in IBD patients (82.9+/-32.5 microg/mL vs 219.8+/-59.0 microg/mL; p=0.001). Among the patients who had an insufficient response, no significant difference in the number of switched memory B-cell was observed. CONCLUSIONS: A defect in B lymphocyte switching was observed in pediatric IBD patients, and especially in those patients with CD. Owing to an increased risk of bacterial infections in those patients with antibody production defects, pneumococcal vaccination could be recommended. However, not all patients can benefit from the vaccination, and several may require other prophylactic methods.

Probiotics for the treatment of pediatric helicobacter pylori infection: a randomized double blind clinical trial

Helicobacter pylori is recognized as a major etiological factor in the pathogenesis of gastritis and peptic ulcer disease. H. Pylori eradication has a failure rate of more than 30% in pediatric patients, particularly because of poor compliance, antibiotic resistance and occurrence of side-effects. This study was aimed to determine whether adding the probiotics to a standard anti-H. pylori regimen could minimize the gastrointestinal side-effect prevalence and improve the eradication rate. Double-blind randomized placebo controlled study conducted at Children's Medical Center in Tehran, Iran. Sixty six H. pylori positive children were treated with a triple drug treatment protocol [omeprazole+amoxycillin+furazolidon] and randomly allocated to receive either probiotic or placebo. All patients underwent esophagogastroduodenoscopy. H. pylori infection was diagnosed by either rapid urease test [RUT] or histology. H. pylori status was assessed after 4-8 weeks of the completion of treatment with stool H. pylori antigen test. The side effects of the treatment were determined in each group. Mean age of patients was 9.09 [range 3-14] years, 44 [65.7%] patients were boys [sex ratio 2:1]. All 66 patients completed the course of treatment and follow-up. The rate of H. pylori eradication was significantly higher in probiotic group [P=0.04]. In probiotic supplemented children there was a lower rate of nausea/vomiting [P=0.02] and diarrhea [P=0.039] during treatment. This study showed that probiotics have positive effect on the eradication of H. pylori infection. Adjuvant therapy with probiotic is recommended in order to reduce the frequency of antibiotic induced side-effects during treatment with antibiotics

Upper endoscopic findings in children with recurrent abdominal pain: high prevalence of hiatus hernia

Recurrent abdominal pain [RAP] by itself is one of the common reasons in child-aged patients to refer to a clinician. Some of these patients are presented with more serious features, so-called the "red flag". The most important issue in management of RAP is to distinguish the type of it, whether it is functional or organic. In this study we aimed to assess the redundancy of red-flagged RAP with findings of esophago-gastro-deudonoscopy. In a 2 year prospective study 150 consecutive children with RAP who showed red flags underwent esophago-gastro-deudonoscopy. The prevalence of each finding was recorded. Overall positive predictive value of predicting an endoscopic finding while having a red-flag was calculated. Among all the patients, 126 cases showed at least a positive finding in their endoscopy that corresponded to the positive predictive value of 84% for predicting the presence of an endoscopic finding according to red flags. Interestingly, 20% of patients showed hiatus hernia when surveyed. Comprehensive physical examination is needed to avoid performing esophago-gastro-deudonoscopy without indication in patients with recurrent abdominal pain

Red flags of organic recurrent abdominal pain in children: study on 100 subjects

A variety of sign, symptoms and laboratory findings are more common in children with organic abdominal pains. This study was performed to evaluate the prevalence of organic and functional abdominal pains and relation of red flags to organic pains in 100 children with recurrent abdominal pain [RAP]. One hundred consecutive patients with RAP were enrolled in the study. A complete interview and physical examination was made for each patient, accompanied by a series of laboratory, clinical and paraclinical examinations. The data were recorded and analyzed. Logistic regression analysis was used to model and formulize correlations between sign, symptoms, and laboratory findings with organic and functional abdominal pain. Among 100 patients [52% male, 48% female, Age: 9.29 +/- 3.17] diagnostic works up revealed organic pain for 57 patients. The most common symptoms of the patients included constipation, diarrhea, chest pain, cough, headache, vomiting, hematuria, and dysuria. Fecal incontinence, delayed puberty, organomegaly, jaundice, and family history of inflammatory bowel disease were reported in none of the patients with RAP. Fever, pain not located in periumbilical area, nocturnal pain, elevated erythrocyte sedimentation rate, weight loss, growth disorder, and abdominal tenderness were among the red flags which revealed diagnosis of organic pain in this study. A series of red flags could increase likelihood of finding organic pain in children with RAP

case of lipoid congenital adrenal hyperplasia presenting with cholestasis

Lipoid congenital adrenal hyperplasia, is the rarest and usually the most severe form of adrenal steroidogenic defect,which may presents as infantile cholestasis. Here we present a 45 days old infant who came to our attention with cholestasis and severe intractable vomiting and electrolyte disturbances. Evaluation resulted in diagnosis of congenital adrenal hyperplasia. Hydrocortisone and flodrocortisone improved the symptoms including jaundice and vomiting. Hyponatremia and hyperkalemia also resolved with above mentioned treatment. Congenital adrenal hyperplasia as one of the causes of neonatal cholestasis should be kept in mind, whenever there are also electrolytes abnormalities

Prevalence of celiac disease in Iranian children with recurrent abdominal pain referred to a pediatric referral center

Clinical features of Iranian children with celiac disease [CD] are still unknown and there is scant information about atypical presentation of celiac disease from Iran. The aim of this study was to determine prevalence of CD in Iranian children presenting with functional abdominal pain [FAP]. In this cross-sectional study, 301 children affected by FAP were screened for CD by anti-tissue transglutaminase antibody [tTG IgA]. IgA antibody was also measured to exclude IgA deficiency. The antibodies were measured by enzyme linked immunosorbent assay. Diagnosis of CD was confirmed by duodenal biopsy that was scored according to the Marsh classification in cases with abnormal titer of tTG antibody. A total of 301 children [138 males, 163 females] with FAP were studied. Endoscopic duodenal biopsy was taken for patients with positive and borderline tTG test. Two out of 301 cases were IgA deficient and celiac disease was suspected for one of them based on histological findings. Four out of 299 patients with normal IgA had abnormal tTG titer; intermediate ranges [16-23 U/ml] were detected in 1 and positive ranges [>/=24 U/ml] in 3 cases. CD was suggested in all patients with abnormal titer of tTG [1.33%] based on histological findings. The prevalence of celiac disease in children with FAP is estimated 1.3% [nearly 2 times higher than in normal population] in Iran

Role of synbiotics in the treatment of childhood constipation: a double-blind randomized placebo controlled trial

Constipation is a common problem in children. There is some clinical evidence for the role of probiotics and prebiotics in the treatment of constipated children. This is the first study on the therapeutic effect of synbiotics [combination of probiotics and prebiotic] in treatment of childhood constipation. In a double-blind randomized placebo controlled study 102 children aged 4-12 years with functional constipation were assessed according to Rome III criteria for 4 weeks. They were divided into 3 groups: group A, received 1.5 ml/kg/day oral liquid paraffin plus placebo, group B, 1 sachet symbiotic per day plus placebo and group C, 1.5 ml/kg/day oral liquid paraffin plus 1 sachet symbiotic per day. Frequency of bowel movements [BMs], stool consistency, number of fecal incontinence episodes, abdominal pain, painful defecation per week, success of treatment and side effects were determined in each group before and after treatment. The frequency of BMs per week increased in all groups [P<0.001], but it differed between groups and was higher in group C [P=0.03]. Stool consistency increased and number of fecal incontinence episodes, abdominal pain and painful defecation per week decreased in all groups similarly and there was statistically no difference between them. No side effects were reported in group B; the main side effect in group A and C was seepage of oil [P<0.001]. Treatment success was similar in all groups without any significant difference between them [P=0.6]. This study showed that synbiotics have positive effects on symptoms of childhood constipation without any side effects

Comparing oral route paraffin oil versus rectal route for disimpaction in children with chronic constipation; a randomized control trial

Functional constipation is a common and challenging problem in pediatrics. Fecal disimpaction prior to maintenance therapy is recommended to ensure successful treatment. The aim of this study was to compare the efficacy and patient's compliance of the two methods of paraffin oil administration [oral and rectal route] with the purpose of disimpaction in treatment of children with functional constipation. A total of 80 children [49 males and 31 females] aged 1-12 years, with functional constipation according to Rome III criteria, whose rectal examination confirmed fecal impaction were divided into two groups randomly. Group I received 3 ml/kg/day paraffin oil orally and group II received 3ml/kg/day paraffin oil rectally during 3 consequent days. Successful treatment was defined as no detectable fecal impaction in rectal examination after at most 72 hours. Patient compliance and family satisfaction also was evaluated using a scored questionnaire. Response to the treatment in both groups was with 92.5% and 82.5% in group I and II, respectively. So, there was no significant difference between the two methods of therapy. Family satisfying and compliance were obviously more achieved in group 1 [87.5% vs 57.5%] than in Group 2 [P<0.001]. No parents in group I complained about type of treatment while 12.5% of parents in group II were unsatisfied with the mode of paraffin oil administration. The most common side effect of paraffin oil in both groups was anal oil seepage [27.5%]. Nausea and abdominal pain were more common side effects in group 1 and 2 respectively. It seems that using paraffin oil per oral route in comparison with rectal route could be a preferred option for disimpaction in children causing less anxiety to the family

Reinfection rate after successful Helicobacter pylori eradication in children

Reinfection rate of Helicobacter pylori after successful eradication is low in developed countries. This study was performed to determine the reinfection rate of H. pylori during a follow up period of 12 months in Iranian children. In this prospective study, children with H. pylori infection were treated with triple omeprazole based regimen. Patients with negative [13]C urea breath test [UBT] performed after 8 weeks of therapy, were followed up by the same test after 1 year. Thirty seven patients, aged 5 to 17 years, were studied. Among them 25 [67.5%] were boys. After eradication therapy of H. pylori, 34 patients had negative [13]C UBT. Reinfection occurred in 5 [14.7%] patients. Reappearance or continuing symptoms after treatment were associated with higher rate of recurrence [P=0.042]. Recurrence rate of H. pylori was high in our children. Successful eradication significantly decreased complaints and further symptoms. Follow up and reevaluation of patients is necessary especially when there are symptoms after eradication

Success rate of furazolidone-based triple therapy for eradication of helicobacter pylori in children

Helicobacter pylori [H. Pylori] is now recognized as a major etiological factor in the pathogenesis of gastritis and peptic ulcer disease. There is concrete evidence that eradication of the bacterium reverses histological gastritis, and results in significant reduction of duodenal and gastric ulcer recurrence. Poor compliance and antibiotic resistance are the main causes for failure of anti H. pylori therapy. In this study we determined efficacy of omeprazole based triple therapy with b.i.d. dosing of furazolidone, amoxicillin for 2 weeks and omeprazole in Iranian children. This prospective study included 37 children, in whom H. Pylori infection was diagnosed endoscopically. H.Pylori positive children were treated with a two weeks course of furazoidone [6 mg/kg/day] and amoxicillin [50 mg/kg/day] plus omeprazole [1-2 mg/kg/day]. Eradication was assessed by 13C UBT. Mean age of patients was 10.2 yr [5-15 yr], 25 [67.5%] patients were boys. H. Pylori was eradicated in 34 children [per patient 91.9%, per protocol 86%]. Side effects occurred in 3 [8.1%] patients, but these were mild and it was not necessary to discontinue treatment. Three children [8.1%] remained H. pylori positive. Our study showed that the association of furazolidone plus amoxicillin with a proton-pump inhibitor could be a valuable alternative for eradication of H. Pylori infection in children. It is an effective, affordable treatment that allows good compliance and produces low adverse effect rates

Colorectal polyps: a clinical, endoscopic and pathologic study in Iranian children

To study the clinical presentation, histology and colonoscopic features of lower gastrointestinal polyps in Iranian children. Medical reports of children with colorectal polyps were retrospectively reviewed from 1996 to 2005 at the Children's Medical Center Hospital, Iran. A total of 563 cases were studied. Data related to age, sex, family history, signs and symptoms, the size, location, polyp types and associated lesions were collected and analyzed. The mean age of children was 5.66 +/- 2.88 years [range 2 months to 17 years], with a male-to-female ratio of 1.61:1.0. The highest incidence was between ages 2 and 10 years [85.1%]. Rectal bleeding was the presenting symptom in 78.5% cases. The polyps were solitary in 94% of cases. A majority of polyps [86.3%] were juvenile and 86.7% located in the rectosigmoid area. Three percent of cases had a positive family history. One case of Turcot syndrome was also identified. Juvenile polyps remain the most common polyps in Iranian children. Although the presence of a solitary polyp in the rectosigmoid colon is more prevalent, in a significant number of cases they are multiple and located in proximal parts. Polyps must be removed even when asymptomatic because of their probable neoplastic potential

[ effect of baclofen on treatment of infancy gastro-esophageal reflux disorder]

Transient lower esophageal sphincter relaxation [TLESR] is the major cause of gastro-esophageal reflux disorder [GERD] in patient with reflux disease. GERD is the most common esophageal disorder in children. The GABA agonist baclofen decreases acid reflux through the inhibition of TLESRs and should similarly decrease non-acid reflux. The aim of this study was to evaluate the effect of baclofen on GERD in children. Thirty children with GERD were included in this clinical trial. Baclofen 0.25 mg/kg was given for three months. End points were assessed for weeks and months. Baclofen significantly improved the weight gain pattern and the mean of weight gain demonstrated a significant difference between base line value and weight on consequent months after therapy [P<0.0001]. Restlessness showed a significant improvement between baseline and threes month after treatment [P<0.001].Vomiting significantly decreased on follow up visits [P<0.001]. It is also increased the time and volume of feeding significantly 3 month after treatment [P<0.001]. We have not found serious complications. Baclofen reduces the symptom of TLESRs and may have a role in treating GERD

[Accidental caustic ingestion in children and its sequalae in esophagus; one year fallow up]

Accidental caustic ingestion can result in severe gastrointestinal injury, especially in esophagus, that has thinnest and most sensitive tissue with most contact in caustic ingestion. Endoscopy is the most direct equipment in evaluation of patients. The aim of this study was to evaluate the severity of esophageal injury due to different substances in children aged 1-6 yr at the Children's Medical Center in Tehran. In a prospective study [Oct 2002-Apr2003], 100 children were admitted because of accidental caustic ingestion. The ingested materials, their quantities, early symptoms and endoscopic findings were prospectively analyzed. Forty-two of 100 patients had ingested stronger materials, of these, 37 had esophageal burns higher than grade I; 58 patients ingested weaker materials, which had none or only grade I burn. Of 44 symptomatic patients, 37 had important burns. Between substance property and quantity and early symptoms with esophageal burns was coherence [P<0.05]. Totally 76/100 patients were symptomatic, and 39 patients had grade I, 17 grade IIa, 12 grade IIb, 4 grade IIIa, and 4 grade IIIb burns. Seventeen [17%] patients that developed esophageal stricture had all grade IIb burns. Esophageal injury happens after caustic ingestion with different severity. The stronger the ingested material, the severer the damage to esophagus and the more long time sequelae [stricture] is to expect

Pulmonary pseudomonas colonization in cystic fibrosis

Respiratory tract mucus plugging and Pseudomonas aeruginosa [PA] colonization in cystic fibrosis patients can influence the health indices, morbidity and mortality. Our aim was to evaluate the relation between pulmonary infection with PA and its effects on respiratory function test and some health-related parameters. This study was a cross-sectional study. Thirty CF patients, who were admitted to GI department of Children Medical Center because of gastrointestinal and/or pulmonary disturbances, were enrolled in this study. Management began by taking a medical history, physical examination, sputum or pharyngeal swab for culture and antibiogram, spirometric assessment for cooperative children [over 6 years old] and filling out a questionnaire for the abovementioned items and some health related parameters [weight, mean hospital stay days, mean absent days from school, and mean ICU admission time during the last year]. The mean [ +/- SD] age was 6.39 [ +/- 5.88] years [11 females, 19 males]. Pseudomonas aeruginosa grew in sputum or pharyngeal swab of 13 cases [43.3%], did not grow in 12 cases [40%] and other organisms grew in 5 cases [16.7%]. Mean of hospitalization period was higher in cases with positive culture [31.83 Vs 13.08 days, Paired sample t-test, P= 0. 005]. Mean [ +/- SD] predicted FEV1% was 34.6 [ +/- 28.0], but this difference was not significant in age, age of diagnosis, days of ICU hospitalization, absent days from school, days of using respiratory assistance equipments, days of antibiotics administration during the last year, body weight, predicted FEV1%, predicted FEV1/FVC% and predicted FEF 25-75%. Prevention and early treatment of PA colonization can reduce hospital stay and its cost. Further large controlled trials are required in this regard

Cerebral edema: a rare complication in galactosemia

A 34 day-old girl infant was admitted for poor feeding and cholestasis. She had a bulging fontanelle, with no evidence of intracranial infection or hemorrhage. Investigations demonstrated that she had galactosemia. Computed tomographic scans demonstrated the presence of diffuse cerebral edema. After treatment the edema resolved

Autoimmune hepatitis in children, clinical features and biochemical of Iranian children

There are only a very small number of reports which discuss subtype, sex distribution, clinical features and laboratory characteristics of autoimmune hepatitis in children. The aim of this study was both to define the clinical features, biochemical and histological findings and also to determine the age and sex related distribution of autoimmune hepatitis [AIH]. Data of 30 children presenting with AIH [20 girls and 10 boys] have been analyzed for their clinical, serological, and histological profile. The most common presenting signs or symptoms were jaundice [60%], abdominal mass [23.4%] and constitutional symptoms [weakness, anorexia and paleness] [6.7%]. About 10% of patients had an acute hepatitis like clinical presentation. Twenty two children [73.3%] [15 girls, 7 boys, 2.1:1] had AIH type 1 and 4 patients [13.3%] type 2 due to specific autoantibodies. Four children could not be classified. In liver biopsy, 100% of patients had interface hepatitis and fibrosis with or without cirrhosis were found in 60%. In our cohort the prevalence of AIH was 2:1 in girls. Type 1 was the most frequent diagnosis [73.3%] and was more prevalent in older children. Patients with type 2 were younger. The clinical presentation of AIH in children was unspecific and each type could only be differentiated by the determination of the specific autoantibodies

Autoimmune hepatitis in children, clinical features and biochemical of Iranian children

There are only a very small number of reports which discuss subtype, sex distribution, clinical features and laboratory characteristics of autoimmune hepatitis in children. The aim of this study was both to define the clinical features, biochemical and histological findings and also to determine the age and sex related distribution of autoimmune hepatitis [AIH]. Data of 30 children presenting with AIH [20 girls and 10 boys] have been analyzed for their clinical, serological, and histological profile. The most common presenting signs or symptoms were jaundice [60%], abdominal mass [23.4%] and constitutional symptoms [weakness, anorexia and paleness] [6.7%]. About 10% of patients had an acute hepatitis like clinical presentation. Twenty two children [73.3%] [15 girls, 7 boys, 2.1:1] had AIH type 1 and 4 patients [13.3%] type 2 due to specific autoantibodies. Four children could not be classified. In liver biopsy, 100% of patients had interface hepatitis and fibrosis with or without cirrhosis were found in 60%. In our cohort the prevalence of AIH was 2:1 in girls. Type 1 was the most frequent diagnosis [73.3%] and was more prevalent in older children. Patients with type 2 were younger. The clinical presentation of AIH in children was unspecific and each type could only be differentiated by the determination of the specific autoantibodies