Indian Academy of Pediatrics Consensus Guidelines for Probiotic Use in Childhood Diarrhea

Justification: Several probiotic species and strains, single or combined, have been evaluated in childhood diarrheal disorders, and recommendations have ever been changing as newer trials are published. Therefore, there is a need to develop a guideline for Indian children describing the current role of probiotics in clinical practice. Objectives: To develop a guideline for the use of probiotics in children with diarrhea. Process: A national consultative group (NCG) was constituted by the Indian Academy of Pediatrics (IAP), consisting of subject experts. Sub-topics were allotted to various experts as paired groups for detailed review. Members reviewed the international and Indian literature for existing guidelines, systematic reviews, meta-analyses and trials. Thereafter, two virtual structured meetings of the group were held on 2nd and 22nd August, 2020. The management guidelines were formulated by the group and circulated to the participants for comments. The final guidelines were approved by all experts, and adopted by the IAP executive board. Recommendations: The NCG suggests Lactobacillus GG as a conditional recommendation with low-to-moderate level evidence or Saccharomyces boulardii as a conditional recom-mendation with very low-to-low level evidence as adjuvant therapy in acute diarrhea. The NCG also recommends the use of combination probiotics in neonatal necrotizing enterocolitis (NEC), as these reduce the risk of NEC stage II and above, late-onset sepsis, mortality and also time to achieve full feeds. The NCG does not recommend the use of any kind of probiotics in the therapy of acute dysentery, persistent diarrhea, Clostridium difficile diarrhea and chronic diarrheal conditions such as celiac disease, diarrheapredominant irritable bowel syndrome and inflammatory bowel disease in children. Risk of antibiotic-associated diarrhea (AAD) is high with some antibiotics and most of these cases present as mild diarrhea. The NCG recommends probiotics only in special situations of AAD. L. rhamnoses GG or S. boulardii may be used for the prevention of AAD. VSL#3, a combination probiotic, may be used as an adjuvant in active pouchitis, and for prevention of recurrences and maintenance of remission in pouchitis.

Management of Childhood Functional Constipation: Consensus Practice Guidelines of Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition and Pediatric Gastroenterology Chapter of Indian Academy of Pediatrics

Justification: Management practices of functional constipation are far from satisfactory in developing countries like India; availableguidelines do not comprehensively address the problems pertinent to our country.Process: A questionnaire-based survey was conducted among selected practising pediatricians and pediatric gastroenterologists inIndia, and the respondents agreed on the need for an Indian guideline on the topic. A group of experts were invited to present thepublished literature under 12 different headings, and a consensus was developed to formulate the practice guidelines, keeping in viewthe needs in Indian children.Objective: To formulate practice guidelines for the management of childhood functional constipation that are relevant to Indian children.Recommendations: Functional constipation should be diagnosed only in the absence of red flags on history and examination. Thosewith impaction and/or retentive incontinence should be disimpacted with polyethylene glycol (hospital or home-based). Osmoticlaxatives (polyethylene glycol more than 1 year of age and lactulose/lactitol less than 1 year of age) are the first line of maintenancetherapy. Stimulant laxatives should be reserved only for rescue therapy. Combination therapies of two osmotics, two stimulants or twoclasses of laxatives are not recommended. Laxatives as maintenance therapy should be given for a prolonged period and should betapered off gradually, only after a successful outcome. Essential components of therapy for a successful outcome include counselling,dietary changes, toilet-training and regular follow-up.

Classical Galactosemia Among Indian Children: Presentation and Outcome from a Pediatric Gastroenterology Center.

Objective: To analyze the presentation and predictors of outcome of children with galactosemia. Methods: Analysis of clinical, laboratory, microbiological profile and outcome of patients fulfilling the diagnostic criteria: i) clinical setting; ii) reduced erythrocyte Gal-1-PUT enzyme activity; and iii) unequivocal response to lactose-free diet. Results: 24 patients; median age of symptom onset and diagnosis: 10 (3-75) d and 55 (15-455) days, respectively. 71% had uncorrectable coagulopathy; 71% systemic infections; and 54% had ascites. Outcome: consisted of 87.5% survival with normalization of liver function tests at 5.5 (1-24) months follow-up. Conclusion: Despite delayed referral, high Pediatric end-stage liver disease scores and systemic infections, long-term outcome in galactosemia is rewarding. A subset of children have developmental delay.