Acid suppression does not change respiratory symptoms in children with asthma and gastro-oesophageal reflux disease.

BACKGROUND: Epidemiological studies have shown an association between gastro-oesophageal reflux disease (GORD) and asthma, and oesophageal acid perfusion may cause bronchial constriction. However, no causative relation has been proven. AIM: To assess whether acid suppression would lead to reduced asthma symptoms in children with concomitant asthma and GORD. METHODS: Thirty eight children (mean age 10.8 years, range 7.2-16.8; 29 males) with asthma and a reflux index > or =5.0 assessed by 24 hour oesophageal pH monitoring were randomised to 12 weeks of treatment with omeprazole 20 mg daily or placebo. The groups were similar in age, gender, mean reflux index, and asthma severity. Primary endpoints were asthma symptoms (daytime wheeze, symptoms at night, in the morning, and during exercise) and quality of life (PAQLQ). Secondary endpoints were changes in lung function and the use of short acting bronchodilators. At the end of the study a repeated pH study was performed to confirm the efficacy of acid suppression. RESULTS: The change in total symptom score did not differ significantly between the omeprazole and the placebo group, and decreased by 1.28 (95% CI -0.1 to 2.65) and 1.28 (95% CI -0.72 to 3.27) respectively. The PAQLQ score increased by 0.62 (95% CI 0.29 to 0.95) in the omeprazole group compared to 0.50 (95% CI 0.29 to 0.70) in the placebo group. Change in lung function and use of short acting bronchodilators were similar in the groups. The acid suppression was adequate (reflux index <5.0) under omeprazole treatment. CONCLUSION: Omeprazole treatment did not improve asthma symptoms or lung function in children with asthma and GORD.

Recurrent abdominal pain in children revisited: irritable bowel syndrome and psychosomatic aspects. A prospective study.

BACKGROUND: Since Apley, more than 40 years ago, concluded that less than 10% of cases with recurrent abdominal pain (RAP) are of organic origin, medical technology has improved, the knowledge has expanded and new methods of investigation have been developed. The lack of organic findings in many children with RAP has led to the conclusion that psychological factors are important. METHODS: Forty-four children with RAP underwent an investigation programme to find organic abnormalities that might explain the symptoms. Current criteria for irritable bowel syndrome (IBS) in children were used to find out what proportion fulfilled these criteria, irrespective of the organic findings on clinical investigation. A standardized questionnaire, the CBCL (Child Behaviour Checklist), was used to evaluate emotional and behavioural disturbances in children referred for RAP. RESULTS: Thirteen out of 26 (50%) children with no signs of organic disease fulfilled the IBS criteria as opposed to 7 out of 18 (39%) children in the group with organic findings (P = 0.68). The total score for the CBCL was in the normal range for 32 out of 36 of the children. CONCLUSIONS: We found a high proportion of children fulfilling the IBS criteria in both groups, thus organic abnormalities have to be excluded before making the IBS diagnosis. The results of the CBCL forms did not show any difference between children with organic versus those with non-organic abnormalities, both groups within the normal range.

Recurrent abdominal pain in school children revisited: fitting adverse food reactions into the puzzle.

UNLABELLED: The diagnostic work-up of children seeking health care because of recurrent abdominal pain is a clinical challenge. Food hypersensitivity might be one of the aetiologies behind this symptom. Neither the understanding of possible immune mechanisms nor endoscopic or histological findings have yet contributed to reliable diagnostic tests. CONCLUSION: The possibility of adverse food reactions should be evaluated among other abnormalities behind recurrent abdominal pain in children. Still, the diagnosis of immunemediated food reactions depends on open or blinded food challenge.

Incidence of inflammatory bowel disease in children in southeastern Norway: a prospective population-based study 1990-94.

BACKGROUND: Most incidence studies of ulcerative colitis (UC) and Crohn disease (CD) have dealt with adults and there are have been few population-based prospective studies of the incidence of inflammatory bowel disease (IBD) in children. The aim of this study was to determine the incidence after re-evaluation of the diagnosis of UC and CD in childhood and adolescence in a prospective population-based survey. METHODS: From 1 January 1990 to 31 December 1993, all newly diagnosed patients with UC and CD under the age of 16 years were registered. On 1 January 1992 there were 174,482 children in the study population. The diagnosis was based on internationally accepted criteria and all clinical data were reviewed by two gastroenterologists independently of each other. All patients were subjected to a second evaluation 1 year after inclusion in the study. Patients initially diagnosed as indeterminate colitis (IND) were also reassessed. RESULTS: A total of 14 cases of UC, 13 cases of CD and 2 cases of IND were registered during the study period. At re-evaluation of the two patients diagnosed as IND, one was reclassified as having UC and one as having CD. This yielded a mean annual incidence of 2.14 (95% CI 1.20-3.54) per 100,000 for UC and 2.00 (95% CI 1.10-3.36) per 100,000 for CD. The male:female ratio in UC was 4.0 and 1.8 in CD. Median time interval from onset of symptoms to diagnosis was 4 months for UC and 5 months for CD. A high proportion of the children with UC (80%; 12/15) had extensive colitis. Four patients with CD had a first-degree relative with IBD. CONCLUSION: This study does not support an increased incidence of paediatric CD over the past decade. The incidence of paediatric UC seems to have remained stable over the past 30 years. In the CD group, we find a high incidence of IBD in first-degree relatives.

[Tetany--a first symptom of celiac disease]. / Tetani--debutsymptom ved cøliaki.

BACKGROUND: Seizures in children are usually caused by fever or epilepsy, though they may also be caused by electrolyte, vitamin or mineral disturbances. We describe a case of hypocalcaemic tetany with hypovitaminosis D. MATERIAL AND METHODS: The patient was a previously healthy eight months old girl of Indian origin. RESULTS: Investigations revealed that she suffered from coeliac disease. INTERPRETATION: Coeliac disease is a well-known disorder, characterised by enteropathy and malabsorption causing symptoms such as vomiting, diarrhoea and failure to thrive. Enteropathy and specific malnutrition may occur in the total absence of gastrointestinal symptoms.

Childhood Crohn's disease and the efficacy of enteral diets.

Enteral diets, both elemental and, more recently, polymeric (whole protein), are used as primary therapy in Crohn's disease and can induce disease remission without the concomitant use of immunosuppressive drugs. Controlled trials comparing enteral nutrition with corticosteroid therapy have given mixed results but suggest, at least in children, that they are as effective as corticosteroids in inducing remission. There is no clear consensus as to which dietary therapy is best. Elemental diets do not seem to be superior to polymeric whole protein-based diets, although further work is necessary. The effect of enteral diets does not seem to be related to the site of intestinal inflammation. Enteral nutrition is particularly appropriate in children and adolescents with Crohn's disease, improving nutrition and promoting growth and pubertal development, and avoiding the systemic toxicity of corticosteroid therapy. Most centers will use it as a first line of treatment. Supplementary enteral nutrition after primary therapy and remission induction may be associated with the prolongation of remission and promotion of linear growth. Pathways by which enteral diets may affect mucosal inflammation are discussed. Enteral diets may inhibit intestinal immune responses by reducing the number of cytokine-producing cells. Enteral nutrition may also boost immunosuppressive pathways, which then endogenously suppress ongoing inflammation. Enteral diets may promote epithelial healing and reepithelialization of Crohn's ulcers and may also reduce the bacterial load in the small bowel.

Cellular and regional expression of transcripts of the plasma membrane calcium pump PMCA1 in rabbit intestine.

The plasma membrane Ca(2+)-pumping adenosinetriphosphatase (PMCA) is the energy-dependent step in the active vitamin D-dependent absorption of dietary Ca2+ by the enterocyte. Studies of the various PMCA genes and splicing variants in humans and rats have indicated that the isoform known as PMCA1b is the predominant form expressed in small intestine. Using an oligonucleotide probe, we have studied the regional and cellular distribution of PMCA1 transcripts in rabbit intestinal tissues by in situ hybridization. On small intestinal RNA blots, this hybridized to species similar in size to those detected by PMCA1-specific cDNA probes; an additional larger transcript was present in rabbit than in rat or human. In situ hybridization signals were principally in the enterocyte population of the mucosa and were maximal in differentiating enterocytes on the lower part of the villus, a pattern similar to that previously demonstrated for other nutrient transporters. Reflecting the capacity of the different small intestinal segments to transport Ca2+, much higher levels of transcript were detected by both methods proximally (in duodenum) than distally (in jejunum and ileum) and were also higher in cecum and ascending colon mucosa than in descending colon. We conclude that as enterocytes differentiate in regions that absorb Ca2+, they express high levels of mRNA for PMCA1. These results confirm the importance of transcriptional regulation of this gene for active Ca2+ absorption.

H+/di-tripeptide transporter (PepT1) expression in the rabbit intestine.

In order to examine the intestinal expression of the recently cloned H+/di-tripeptide transporter (PepT1), oligonucleotide probes were synthesized and their specificity confirmed by Northern blot analysis of rabbit jejunal RNA. In situ hybridization studies, using these probes, show that PepT1 is expressed all along the small intestine and at a very much reduced level in the colon. In contrast, PepT1 mRNA was not detected in the stomach, sacculus rotundus or caecum. Microscopic examination of tissue sections showed PepT1 expression to be restricted to intestinal epithelium with no detectable expression in the lamina propria, muscularis mucosae, muscularis or serosa. The accumulation of PepT1 mRNA along the crypt-villus axis was also investigated. In all regions of the small intestine (in duodenum, jejunum and ileum), PepT1 mRNA was undetectable in deeper epithelial cells of the crypts. Expression was first detectable at or near the crypt-villus junction, the amount of PepT1 mRNA increasing rapidly in the lower villus to a maximum approximately 100-200 microns from this point. Along the length of the small intestine PepT1 mRNA was most abundant in duodenal and jejunal enterocytes, with lower levels in the ileal epithelium. PepT1 expression is greatly depressed in the follicle-associated epithelium of the Peyer's patch relative to both interfollicular and adjacent "normal" villi. These data are discussed in the context of the known physiological role of PepT1 in the gastrointestinal tract.

Increasing values of serum acid phosphatase in a child with Mycoplasma pneumoniae-associated hemophagocytic histiocytic syndrome.

We describe a 3 1/2-year-old boy with disseminated histiocytic disease probably induced by Mycoplasma pneumoniae. In this patient, acid phosphatase was elevated in serum and was also detected histochemically in the infiltrating histiocytes. The serum acid phosphatase levels increased as his histiocytosis progressed, apparently mirroring the activity of the disease. This observation suggests that serum acid phosphatase levels should be evaluated further to determine whether they will be a useful indicator of disease in children with different histiocytosis syndromes.

Social-medical aspects of cystic fibrosis in Norway. I. Characterization of the material.

The families of 90 children with cystic fibrosis and the families of 1977 control children have answered extensive questionnaires, which are the basis for this study. In the first part of the study the two groups are compared for some important factors, to detect differences that would make further analysis of the material questionable. The two groups were commensurable concerning their economic situation, standard of housing, ages of children, and the family situation in general. The educational level of the parents in the two groups did differ, the parents of children with cystic fibrosis having less education. The parents of children with cystic fibrosis were more dissatisfied with their situation than those in the control group. These differences are probably a result of having cystic fibrosis in the family; consequently, it is concluded that the two groups can well be compared.

Social-medical aspects of cystic fibrosis in Norway. II. Economy and housing situation.

The economic status of families with a child cystic fibrosis is compared with the situation for control families. The housing situation for the two groups is also evaluated. The study is based on questionnaires. The families with children with cystic fibrosis have a higher income than the controls, but they also have greater expenses. The increase is not only in expenses related to the treatment of cystic fibrosis but also in the general expenses related to having children, in the group of families with cystic fibrosis. The housing expenses are also greater in the families with children with cystic fibrosis; this is probably due to the fact that home treatment of cystic fibrosis adds certain demands to the quality of the housing conditions for these families.

Social-medical aspects of cystic fibrosis in Norway. III. The education and occupation of mothers.

On the basis of questionnaires answered by the parents of 90 children with cystic fibrosis (CF) an analysis has been made of the education situation and the professional activity of the mothers of children with CF. The findings are compared with those obtained from mothers without CF children and with those of the fathers of CF children. There are striking differences between the CF mothers and the controls with regard to their possibility of having a career. Even greater differences are evident when the mothers in families with CF children are compared with the fathers in the same families. The education and professional career of the fathers of CF children are generally not influenced by having a chronically disabled child to care for, whereas the mothers to a large extent have felt compelled to give up their education or their professional career.

Social-medical aspects of cystic fibrosis in Norway. IV. A comparison of the parents' and the professionals' judgement of the severity of the handicap.

To obtain information about their knowledge and their degree of acceptance of their child's condition, the parents of children with cystic fibrosis were asked to give a general judgement of their child's handicap. The study was based on questionnaires answered by the parents of 90 children with cystic fibrosis. One pediatrician and one social worker independently gave their judgement on the same issues. The parents judged 61% of the children as lightly handicapped, 33% as moderately, and 6% as seriously affected, while the professional judgement was 43%, 37% and 19%, respectively. The study indicates that the parents tend to judge their child's condition as less severe than the professionals. The difference of opinion is greatest in the group of seriously affected children.

Neuroleptic malignant syndrome superimposed on tardive dyskinesia.

A 30-year-old man with a 3-year history of tardive dyskinesia developed a neuroleptic malignant syndrome while having reserpine and lithium; his symptoms worsened following three doses of neuroleptic medication and improved with bromocriptine. The pre-existing dyskinesia made the presentation confused, and delayed proper diagnosis.