The Need for Culturally Appropriate Food Allergy Management Strategies: The Indian Milk Ladder.

BACKGROUND: Cow's milk allergy (CMA) is one of the most common and complex food allergies affecting children worldwide and, with a few exceptions, presents in the first few months of life. Baked-milk-containing diets are well tolerated in the majority of milk-allergic children and allow dietary restrictions to be relaxed. In addition, the early introduction of tolerated forms of allergenic foods to an infant's diet in small amounts may enhance the outgrowth of their milk allergy through oral tolerance induction. The methods of milk introduction vary widely across the globe. METHODS: We convened an expert group to develop a comprehensive milk ladder based on the calculated milk protein content of Indian foods. To validate the milk ladder, the foods chosen for the ladder were analyzed and the ladder was re-evaluated based on the cooked milk protein content. RESULTS: Combining expert consensus and validation of milk protein content, we created the world's first milk ladder containing Indian foods. This is the first ladder that provides information on the timing and temperature of cooking, with validated milk protein content. CONCLUSIONS: This is the first milk ladder based on the unique features of Indian food habits built by the consensus of Indian experts along with international collaboration with laboratory quantification of milk protein in each step. We believe the "The Indian Milk Ladder" will be a very helpful tool for pediatricians helping manage CMA in children as well as their parents and caregivers, not only in India, but in countries world-wide where these foods are commonly consumed.

Long Tubular Duplication of the Small Intestine - Lessons Learnt from a Common Presentation of a Rare Disease.

Long tubular duplication of the small intestine is one of the most difficult surgical challenges. The presence of heterotopic gastric mucosa necessitates resection of the duplicated bowel, but shared vascularity with the normal adjoining bowel makes the task daunting. We present a case of long tubular small intestinal duplication with certain special surgical and perioperative challenges which were successfully managed.

Changing trend in the spectrum of upper gastrointestinal bleeding in children-A multicentre experience.

In children, upper gastrointestinal bleeding (UGIB) is an uncommon, but potentially serious, condition with diverse etiologies. A prospective study had been undertaken to find out any changing trend in the etiology and outcome of pediatric UGIB in Eastern India. This retrospective analysis of case records of children, presenting in outpatient or emergency with hematemesis and/or melena from 2 tertiary GI centers of Kolkata, was undertaken to find out the etiologies of bleed and the outcome of management. A total of 180 children were evaluated including 30 (16.7%) infants. The predominant cause of GGIB was gastroduodenal ulcer and erosions (60%) followed by variceal bleeding (19.4%). Vascular lesions were detected in 4 (2%). Hyperplastic antral polyp was an unusual etiology in 3 (1.7%) infants. Various endotherapies were needed in 28% of cases. No mortality was noted. Melena, hemoglobin below 8 gm%, the need for volume replacement, and packed red blood cells transfusion on admission were associated with significant endoscopic lesions, which needed endotherapies. This study, comprising the largest cohort among Indian published series, found an etiology of pediatric upper GI bleed, different from the one, previously depicted. This may be a reflection either of regional variations or a changing trend over time.

Unifocal Gastric Langerhans Cell Histiocytosis in a Child-A Unique Case to Remember.

Langerhans cell histiocytosis (LCH) is the most common of the histiocytic disorders and occurs when the body accumulates too many CD1a/CD 207 positive Langerhans cells, a subset of the histiocytes in certain parts of the body where they can form tumors or damage organs. LCH is not a very common diagnosis in the pediatric age group. More than two-thirds of cases have the single-system disease with bones or skin as the commonly involved sites. Here, we present a 4-year-old child who had acute abdominal pain as chief complaint and etiological workup eventually led to a diagnosis of gastric LCH without affection of any other organ system. To the best of our knowledge, this is the first report of a unifocal gastric LCH in a child.

Acute Pancreatitis in COVID-19-associated Multisystem Inflammatory Syndrome of Children-A Single Center Experience.

A multisystem inflammatory syndrome in children (MIS-C) was identified as an entity temporally associated with the present COVID-19 pandemic. This inflammatory syndrome affects various organ systems including the gastrointestinal and hepatobiliary systems. The following study was undertaken to primarily detect the fraction of children who had pancreatitis as major organ involvement during the development of MIS-C. The secondary objective was to evaluate their clinical and investigational profile as well as the outcome of management. METHODS: A retrospective chart analysis of all children admitted in a tertiary pediatric center from April to December 2020, diagnosed as COVID-19 associated MIS-C, was done. Those presenting with acute pancreatitis were detected and detailed clinical features, investigations, treatments, as well as outcomes, were recorded. RESULTS: A total of 17 children were diagnosed as MIS-C associated with SARS-CoV-2 in the above-mentioned period. Among them, 9 (53%) children had pancreatitis right from the start of the illness; 5 (56%) children with pancreatitis presented with shock. A very high CRP and cardiac involvement were observed in all. A severe reduction of myocardial contractility was associated with poor outcomes. Necrotic pancreatitis was not noted in any of them. A mortality of 22% was documented in this group and a 3-month outcome among those who survived displayed complete resolution of all cardiac as well as pancreatic abnormalities. CONCLUSION: Acute pancreatitis can be an essential cause of abdominal symptoms in COVID-19-related MIS-C. Pancreatitis may be considered to be one of the parameters in the diagnostic criteria of MIS-C.

Association of Ethnicity With Multisystem Inflammatory Syndrome in Children Related to SARS-CoV-2 Infection: An International Case-Referent Study.

Background: It has been suggested that children and infants can develop multisystem inflammatory syndrome in children (MIS-C) in response to a SARS-CoV-2 infection and that Black children are overrepresented among cases. The aim of the current study was to quantify the association between Black, Asian, or other non-White genetic background and COVID-19-related MIS-C in children and infants. Methods: Eight different research groups contributed cases of MIS-C, potentially related to SARS-CoV-2 infection. Several sensitivity analyses were performed, including additional data available from the literature. Analyses were stratified by geographical region. Results: Seventy-three cases from nine distinct geographical regions were included in the primary analyses. In comparison to White children, the relative risk for developing MIS-C after SARS-CoV-2 infection was 15 [95% confidence interval (CI): 7.1 to 32] for Black children, 11 (CI: 2.2 to 57) for Asian, and 1.6 (CI: 0.58 to 4.2) for other ethnic background. Conclusion: Pediatricians should be aware of the fact that the risk of COVID-19-related MIS-C is severely increased in Black children.

Isolated gastrointestinal histoplasmosis: A rare diagnosis of pediatric chronic abdominal pain.

Gastrointestinal (GI) histoplasmosis usually occurs as a part of disseminated histoplasmosis in immunocompromised or elderly subjects. Isolated histoplasmosis involving the GI tract in an immunocompetent host is very rare. It is also not considered as an etiology for chronic abdominal pain in children. Here we present an 8-year-old boy with abdominal pain and weight loss who underwent treatment for tuberculosis but on reinvestigation was diagnosed as GI histoplasmosis. He responded well to treatment and achieved good catch up growth.

Effect of Saccharomyces boulardii CNCM-I 3799 and Bacillus subtilis CU-1 on Acute Watery Diarrhea: A Randomized Double-Blind Placebo-Controlled Study in Indian Children.

PURPOSE: To assess the effect of combination probiotic Saccharomyces boulardii CNCM-I 3799 and Bacillus subtilis CU-1 in outpatient management of acute watery diarrhea in children. METHODS: A randomized double-blind placebo-controlled study was conducted in 180 participants aged six months to five years with acute mild to moderate diarrhea. All were enrolled from six centers across India and centrally randomized to receive S. boulardii CNCM-I 3799 and B. subtilis CU-1 or a placebo along with oral rehydration salts and zinc supplementation. Each participant was followed up for three months to assess recurrence of diarrhea. RESULTS: The mean duration of diarrhea in the probiotic and placebo groups were 54.16 hours and 59.48 hours, respectively. The difference in the duration of diarrhea in those administered with probiotic or placebo within 24 hours of diarrhea onset was 25.21 hours. Furthermore, the difference in duration of diarrhea was 13.84 hours (p<0.05) for participants who were administered with probiotics within 48 hours. There were no significant differences in the stool frequencies between the two arms. After three months, 15% in the probiotic group and 18.5% in the placebo group reported episodes of diarrhea. The mean duration of diarrhea was considerably lower in the probiotic group, 31.02 hours versus 48 hours in placebo (p=0.017). CONCLUSION: S. boulardii CNCM-I 3799 and B. subtilis CU-1 combination was effective in reducing the duration of diarrhea when administered within 48 hours of diarrhea onset. Similarly, it reduced recurrence of diarrhea and its intensity in the subsequent three months.

Polyethylene Glycol Plus Electrolytes with Stimulant Laxative in Paediatric Faecal Disimpaction: A Randomised Controlled Study.

Functional constipation is common in the paediatric population all over the world. Effective disimpaction to evacuate the impacted faecal matter forms an essential initial step in the management of constipation. Though different regimens of polyethylene glycol 3350 with electrolytes (PEG+E) are accepted as the prime medication for disimpaction, response is not always satisfactory. A randomised prospective study was undertaken, in a tertiary paediatric Gastroenterology centre to find out the outcome of a 2-day disimpaction when a stimulant laxative sodium picosulphate was added to PEG3350+E (PEG+E+PS group) and comparing it with the outcome using PEG3350+E (PEG+E group) alone. Hundred and one children were randomised into two groups to receive PEG+E+PS and PEG+E. Results revealed that PEG+E+PS group proved significantly superior to PEG+E group in most of the efficacy-parameters in terms of disimpaction as well as long-term management of constipation. Though stimulant laxatives are being used for disimpaction, comparative data are lacking. This was the 1st such comparative study looking at the efficacy of these two processes of disimpaction along with long term effect on treatment.

Spontaneous rupture of the bile duct associated with pancreatitis. A rare presentation.

CONTEXT: Spontaneous rupture of the bile duct, although rare, has been described as a known surgical cause of jaundice in infancy after biliary atresia. CASE REPORT: This article describes a four-year-old girl who presented with severe abdominal pain and features suggestive of acute pancreatitis, who developed gradual distension of the abdomen, and was found to have a ruptured bile duct, producing biliary peritonitis. She was managed with laparoscopic drainage of the peritoneal cavity. However, in view of the persistent biliary drainage, an ERCP was performed followed by stent placement for a bile duct leak. She was subsequently diagnosed as having a choledochal cyst. CONCLUSION: A high index of suspicion, appropriate investigation, such as MRCP, combined with early drainage can help in reaching an early diagnosis, and reduced morbidity and mortality in this rare disorder.