Saudi Experts Consensus on Diagnosis and Management of Pediatric Functional Constipation / 대한소아소화기영양학회지

Although functional gastrointestinal disorders (FGIDs) are very common in pediatric patients, there is a scarcity of published epidemiologic data, characteristics, and management patterns from Saudi Arabia, which is the 2nd largest Arabic country in terms of area and the 6th largest Arabic country in terms of population, with 10% of its population aged <5 years. Functional constipation (FC) is an FGID that has shown a rising prevalence among Saudi infants and children in the last few years, which urges us to update our clinical practices. Nine pediatric consultants attended two advisory board meetings to discuss and address current challenges, provide solutions, and reach a Saudi national consensus for the management of pediatric constipation. The pediatric consultants agreed that pediatricians should pay attention to any alarming signs (red flags) found during history taking or physical examinations. They also agreed that the Rome IV criteria are the gold standard for the diagnosis of pediatric FC. Different therapeutic options are available for pediatric patients with FC. Dietary treatment is recommended for infants with constipation for up to six months of age. When non-pharmacological interventions fail to improve FC symptoms, pharmacological treatment with laxatives is indicated. First, the treatment is aimed at disimpaction to remove fecal masses. This is achieved by administering a high dose of oral polyethylene glycol (PEG) or lactulose for a few days. Subsequently, maintenance therapy with PEG should be initiated to prevent the re-accumulation of feces. In addition to PEG, several other options may be used, such as Mg-rich formulas or stimulant laxatives. However, rectal enemas and suppositories are usually reserved for cases that require acute pain relief. In contrast, infant formulas that contain prebiotics or probiotics have not been shown to be effective in infant constipation, while the use of partially hydrolyzed formula is inconclusive. These clinical practice recommendations are intended to be adopted by pediatricians and primary care physicians across Saudi Arabia.

Pediatric air gun shot injury

Air guns [AGs] use air or another compressed gas to propel a projectile. Different injuries may occur in children due to their body structure, which is lessresistant with thin soft tissue coverage that can be easily penetrated by an AG shot. We present 3 cases of pediatric AG shot injury. The first-case had right lumber deep tissue penetration of AG pallet without internal damage, the second-case had a complex course of pellet into the perineum, and the third-case was shot in the left shoulder. All cases were accidentally shot. The shooters were all children, and relatives of the victims. All patients were generally stable on arrival. Two cases were operated, and one received conservative management. On follow up, no complications were noted. At first sight, AGs and air rifles may appear relatively harmless, but they are potentially lethal and children should not be allowed to play with them.

Toe tourniquet syndrome

Toe tourniquet syndrome refers to external, mechanical, circumferential constriction of the toes. We report a series of 4 infants with toe tourniquet syndrome from Saudi Arabia who presented during wintertime with very similar symptoms [approximately 48 hours of inconsolable crying and irritability], similar involved region [toes], and similar constricting agent [hairs]. Immediate removal of the hair fibers was carried out in all patients, fortunately followed by fast healing with no signs of tissue necrosis. The prompt diagnosis and treatment of the condition were vital in attaining the good outcome and preventing ischemic complications

Study of non-organ specific antibodies in children with genotype 4 chronic hepatitis C

Adult studies established a relationship between hepatitis C virus [HCV] infection and the presence of non-organ specific antibodies [NOSAs]. Most studies were carried out on genotypes 1 and 2. Only a few studies addressed that issue in pediatrics. No studies have been carried out on autoimmunity and genotype 4 in children. We aim to investigate NOSAs in 80 Egyptian children with chronic HCV infection along with studying the underlying genotype of HCV, and correlating autoimmunity with the epidemiological, clinical, biochemical, and virological features. HCV RNA was assayed by the polymerase chain reaction and viral genotypes were determined. NOSAs were measured and liver biopsies were taken for histopathological examination. Genotype 4 was the only detected genotype in the included 80 patients. Anti-smooth muscle antibodies [ASMA] were the only detected antibodies in 32 [40%] patients, always with V specificity [vessels only] at titers ranging from 1:20 and 1:160. Anti nuclear antibodies [ANA] and liver-kidney microsomal antibodies 1 [LKMA 1] were not detected in any of our patients. Epidemiologic and clinical features did not significantly differ between autoantibody positive and negative patients. Among biochemical features, significantly high levels of total bilirubin, albumin, immunoglobulins, alkaline phosphatase, and gamma glutamyl transpeptidase were found in the antibody positive group. Genotype 4 HCV is the prevailing genotype in Egyptian children with chronic HCV infection. A consistent proportion of these children with chronic HCV infection circulate non-organ specific autoantibodies. The prevalence of ASMA and the absence of ANA and LKMA 1 might be related to the unique situation in Egypt with unique prevalence of genotype 4. More studies are warranted on larger pediatric population to validate these findings.

Outpatient blind percutaneous liver biopsy in infants and children: is it safe?

We aim to investigate the safety of outpatient blind percutaneous liver biopsy [BPLB] in infants and children with chronic liver disease [CLD]. BPLB was performed as an outpatient procedure using the aspiration Menghini technique in 80 infants and children, aged 2 months to 14 yrs, for diagnosis of their CLD. Patients were divided into three groups: Group 1 [<1 year], group 2 [1-6 yrs], and group 3 [6-14 yrs]. The vital signs were closely monitored 1 hr before biopsy, and then 1, 2, 6, and 24 hrs after biopsy. Twenty-four hours pre-and post-biopsy complete blood counts, liver enzymes, prothrombin time [PT], and abdominal ultrasonography, searching for a biopsy-induced hematoma, were done for all patients. No mortality or major morbidities were encountered after BPLB. The rate of minor complications was 17.5% including irritability or "pain" requiring analgesia in 10%, mild fever in 5%, and drowsiness for>6 hrs due to oversedation in 2.5%. There was a statistically significant rise in the 1-hr post-biopsy mean heart and respiratory rates, but the rise was non-significant at 6 and 24 hrs except for group 2 where heart rate and respiratory rates significantly dropped at 24 hrs. No statistically significant difference was noted between the mean pre-biopsy and the 1, 6, and 24-hrs post-biopsy values of blood pressure in all groups. The 24-hrs post-biopsy mean hemoglobin and hematocrit showed a significant decrease, while the 24-hrs post-biopsy mean total leucocyte and platelet counts showed non-significant changes. The 24-hrs post-biopsy mean liver enzymes were non-significantly changed except the 24-hrs post-biopsy mean PT which was found to be significantly prolonged, for a yet unknown reason[s]. Outpatient BPLB performed by the Menghini technique is safe and well tolerated even in infants and young children. Frequent, close monitoring of patients is strongly recommended to achieve optimal patient safety and avoid potential complications

Diarrhea in neutropenic children with cancer: an Egyptian center experience, with emphasis on neutropenic enterocolitis

Diarrhea is a frequent complication in patients with cancer. It may be caused by several factors including conventional gastrointestinal pathogens, suppression of normal intestinal flora as well as noninfectious causes such as mucositis and bowel ischemia, with neutropenic enterocolitis [NE] being the most serious. To study diarrhea in neutropenic cancer patients in the pediatric age group, with its underlying etiologies and risk factors especially the bacterial causes with special concern on NE. The study was carried out at the Pediatric Hematology and Oncology Units, Zagazig University Hospitals, Egypt, from Januray 2009 to September 2010. Neutropenic cancer patients who developed diarrhea were grouped into 2 groups: group [1], with NE, and group [2], with neutropenic diarrhea rather than NE, On the first day of diarrhea, patients were subjected to: complete blood count, blood cultures [if febrile], stool microscopy [for red and white blood cells, ova and parasites], and stool culture [for specific pathogens]. Abdominal ultrasonography was carriad out within 3 days of the onset of diarrhea. A total of 200 children

Acute respiratory syncytial virus bronchiolitis potential effect on development of childhood atopic diseases

This study aimed to evaluate the potential effect of Respiratory Syncytial Virus [RSV]-associated respiratory tract infection on the development of childhood atopic diseases. The study comprised 90 children [59 males and 31 females; with mean age of 21 +/- 6.9] hospitalized with acute upper respiratory tract infection [URI] with or without acute bronchiolitis [AB] in Children Hospital, and Al Amin Hospitals, Al Taief, KSA over a period of 6 months. Symptoms included, cough sneezing coryza, running nose and eyes, fever, difficulty in breathing, headache and malaise. Symptoms severity was assessed as absent [0], mild [1], moderate [2], or severe [3]. Patients' atopic status was assessed by skin prick testing. Nasopharyngeal lavage [NPL] was performed and the obtained NPL fluid was used for determination of RSV-specific IgA antibody activity. Blood samples were obtained for ELISA estimation of serum levels of interferon-gamma [INF- gamma], interleukins [IL] 4, 10 and 12. Clinical evaluation defined 28 infants [31.1%] with acute bronchiolitis [AB group] and 62 infants [68.9%] with URI. Patients developed AB were significantly [p<0.05] younger than those with URI but with no gender predilection Skin prick testing detected 17 atopic infants [18.9%]; 10 infants in AB group [35.7%] and 7 in URI group [11.3%] with a significant difference in favor of AB group, [x[2]=7.353, P<0.01]. The mean total symptom score was 11.7 +/- 4.2 and patients developed BA had a significantly [p<0.05] higher symptom score than those with URI. NPL proved a reliable and reproducible means of collecting nasal secretions during an acute URI with no significant associated complications. The NPL fluid of all patients with AB was positive for RSV antibodies, while detected in 43 specimens obtained from infants with URI; 5 atopic [71.4%] and 38 non-atopic [69.1%] with a total detection rate of RSV antibodies of 71 of 90 specimens [71.9%]. Serum levels of IL-4 and IL-10 showed a significant [p<0.05] increase and levels of INF- gamma and IL-12 were significantly decreased in AB group compared to URI group with a significant [p<0.05] decrease of serum INF- gamma in atopic compared to non-atopic patients in AB group only. The IL-4/IFN- gamma and IL-10/IL-12 ratios in AB group were significantly higher as a total and in both atopic and non-atopic patients compared to its counterpart in patients with URI with a positive significant correlation between IL-4/IFN- gamma [r=0.437, p=0.02] and IL-10/IL-12 [r=0.440, p=0.019] ratios in patients with AB and their severity symptoms. Using receiver operating characteristic [ROC] curve defined IL-4/IFN- gamma as a specific and IL-10/IL-12 as a sensitive predictors of severity of AB with AUC=0.827 and 0.442, respectively and serum IFN- gamma level as the most sensitive predictor and IL-4/IFN- gamma ratio as the most specific predictor of the development of atopy secondary to URI irrespective of the development of AB or not with AUO=0.267 and 0.725, respectively. It could be concluded that RSV-induced acute bronchiolitis is associated with local respiratory immune imbalance towards T2/T1, a picture suggestive of liability to develop allergic respiratory diseases later on and the ratio between serum levels of IL-4 and INF- gamma could be used as a specific predictor of the probability of future development of allergic respiratory diseases