Cyclic vomiting syndrome in children: a nationwide survey of current practice on behalf of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) and Italian Society of Pediatric Neurology (SINP).

BACKGROUND: Cyclic Vomiting Syndrome (CVS) is a rare functional gastrointestinal disorder, which has a considerable burden on quality of life of both children and their family. Aim of the study was to evaluate the diagnostic modalities and therapeutic approach to CVS among Italian tertiary care centers and the differences according to subspecialties, as well as to explore whether potential predictive factors associated with either a poor outcome or a response to a specific treatment. METHODS: Cross-sectional multicenter web-based survey involving members of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) and Italian Society of Pediatric Neurology (SINP). RESULTS: A total of 67 responses were received and analyzed. Most of the respondent units cared for less than 20 patients. More than half of the patients were referred after 3 to 5 episodes, and a quarter after 5 attacks. We report different diagnostic approaches among Italian clinicians, which was particularly evident when comparing gastroenterologists and neurologists. Moreover, our survey demonstrated a predilection of certain drugs during emetic phase according to specific clinic, which reflects the cultural background of physicians. CONCLUSION: In conclusion, our survey highlights poor consensus amongst clinicians in our country in the diagnosis and the management of children with CVS, raising the need for a national consensus guideline in order to standardize the practice.

An overview of the clinical management of cyclic vomiting syndrome in childhood.

This narrative review provides an update on cyclic vomiting syndrome pathogenesis, diagnosis and management, based upon studies published after the 2008 North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) official recommendations. The review began with a comprehensive PubMed/Medline search for "cyclic vomiting syndrome", "periodic syndromes" and "pediatrics" from 2000 up to October 2017. Additional papers were identified by reviewing the re-ference lists of retrieved publications. Cyclic vomiting syndrome is a severe, debilitating disorder of the brain-gut axis with unclear pathogenesis, that significantly affects long-term quality of life of affected children and their families. The 2008 NASPGHAN recommendations defined the major clinical, diagnostic and therapeutic peculiarities. Over the last 10 years, advancements in pathogenesis and diagnostic criteria have been made, and new prophylactic and therapeutic strategies have been proposed. These aspects are discussed in this manuscript. For the pediatrician, the major aim is to have early clinical suspicion to avoid diagnostic delay and to start adequate, phase-related, symptom-tailored management.

Microbiota biodiversity in inflammatory bowel disease.

Gut microbiota plays a significant role in human health and energy balance, and provides protection against disease states. An altered balance between microbiota and its host (dysbiosis) would appear to contribute to the development of Inflammatory Bowel Disease (IBD), Crohn's Disease (CD) and Ulcerative Colitis (UC). CD and UC are chronic inflammatory diseases of the gastrointestinal tes.

Lactobacillus reuteri in children with functional abdominal pain (FAP).

AIM: Functional abdominal pain (FAP) is a frequent condition affecting 10-20% of children and can be considered within the classification of functional gastrointestinal disorders (FGID). The objective of this study was to determine the effect of daily supplementation with the probiotic Lactobacillus reuteri DSM 17938 in children with FAP. METHODS: The children (aged 6-16 years) were screened for FAP as defined in the Rome III criteria and 60 patients were recruited in this double-blind, randomised, placebo-controlled trial. The children were randomly allocated to receive either L. reuteri (2×10(8) CFU/day) or identical placebo for 4 weeks followed by a 4-week follow-up period without supplementation. Frequency and intensity of pain was self-recorded by the subjects. RESULTS: The L. reuteri-supplemented children had significantly lower pain intensity compared with the placebo controls. CONCLUSIONS: Supplementation with L. reuteri reduced perceived abdominal pain intensity, which may encourage clinicians to use this probiotic in children with FAP.

Partially hydrolyzed guar gum in pediatric functional abdominal pain.

AIM: To assess the effects of partially hydrolyzed guar gum (PHGG) diet supplement in pediatric chronic abdominal pain (CAP) and irritable bowel syndrome (IBS). METHODS: A randomized, double-blind pilot study was performed in sixty children (8-16 years) with functional bowel disorders, such as CAP or IBS, diagnosed according to Rome III criteria. All patients underwent ultrasound, blood and stool examinations to rule out any organic disease. Patients were allocated to receive PHGG at dosage of 5 g/d (n = 30) or placebo (fruit-juice n = 30) for 4 wk. The evaluation of the efficacy of fiber supplement included IBS symptom severity score (Birmingham IBS Questionnaire), severity of abdominal pain (Wong-Baker Face Pain Rating Score) and bowel habit (Bristol Stool Scale). Symptom scores were completed at 2, 4, and 8 wk. The change from baseline in the symptom severity scale at the end of treatment and at 4 wk follow-up after treatment was the primary endpoint. The secondary endpoint was to evaluate compliance to supplementation with the PHGG in the pediatric population. Differences within groups during the treatment period and follow-up were evaluated by the Wilcoxon signed-rank test. RESULTS: The results of the study were assessed considering some variables, such as frequency and intensity of symptoms with modifications of the bowel habit. Both groups were balanced for baseline characteristics and all patients completed the study. Group A (PHGG group) presented a higher level of efficacy compared to group B (control group), (43% vs 5%, P = 0.025) in reducing clinical symptoms with modification of Birmingham IBS score (median 0 ± 1 vs 4 ± 1, P = 0.025), in intensity of CAP assessed with the Wong-Baker Face Pain Rating Score and in normalization of bowel habit evaluated with the Bristol Stool Scale (40% vs 13.3%, P = 0.025). In IBS subgroups, statistical analysis shown a tendency toward normalization of bowel movements, but there was no difference in the prevalence of improvement in two bowel habit subsets. PHGG was therefore better tolerated without any adverse effects. CONCLUSION: Although the cause of pediatric functional gastrointestinal disorders is not known, the results show that complementary therapy with PHGG may have beneficial effects on symptom control.

Dysbiosis in the pathogenesis of pediatric inflammatory bowel diseases.

Inflammatory bowel diseases (IBDs) are chronic inflammatory conditions of the gastrointestinal tract that occur in genetically susceptible individuals. Crohn's disease (CD) and ulcerative colitis (UC) are two major types of IBD. In about 20-25% of patients, disease onset is during childhood and pediatric IBD can be considered the best model for studying immunopathogentic mechanisms. The fundamentals of IBD pathogenesis are considered a defective innate immunity and bacterial killing with overaggressive adaptive immune response. A condition of "dysbiosis", with alterations of the gut microbial composition, is regarded as the basis of IBD pathogenesis. The human gastrointestinal (GI) microbial population is a complex, dynamic ecosystem and consists of up to one thousand different bacterial species. In healthy individuals, intestinal microbiota have a symbiotic relationship with the host organism and carry out important metabolic, "barrier," and immune functions. Microbial dysbiosis in IBD with lack of beneficial bacteria, together with genetic predisposition, is the most relevant conditions in the pathogenesis of the pediatric IBD.

Proton pump inhibitors in pediatrics: evaluation of efficacy in GERD therapy.

Gastroesophageal reflux (GER) is defined as the passage of gastric contents into the esophagus. It occurs in healthy infants and can be considered physiological process. Uncomplicated GER can present with recurrent vomiting or regurgitation without any other symptoms and is usually managed by educating, reassuring, and guiding the parent without other intervention. GER disease (GERD) refers to the appearance of troublesome symptoms or complications (erosive esophagitis, ulceration, Barrett's esophagus) and may warrant acid suppression. Proton Pump Inhibitors (PPIs) are the most effective pharmacologic agents available for the treatment of children with GERD. In the pediatric practice only omeprazole, lansoprazole and esomeprazole are available over the first year of life. The empiric use in infants with nonspecific symptoms (excessive crying, regurgitation, feeding refusal, chronic cough) is frequent without randomized controlled study. Our paper will focus on the correct indications, dosages, duration of treatment and safety of PPI use in pediatric population.

Oral beclomethasone dipropionate in pediatric active ulcerative colitis: a comparison trial with mesalazine.

OBJECTIVE: The objective of the study was to evaluate the clinical efficacy of oral beclomethasone diproprionate (BDP) in inducing clinical and endoscopic remission in children with mild to moderate active ulcerative colitis (UC). PATIENTS AND METHODS: Thirty patients with active UC (pancolitis or left-sided colitis) were enrolled in an open-labeled, randomized, head-to-head study. Group 1 (n = 15) received oral BDP (5 mg/day) for 8 weeks, followed by maintenance therapy with oral mesalazine, 5-aminosalycilate (5-ASA); group 2 (n = 15) received oral 5-ASA (80 mg . kg . day). Assessments were carried out (at 4, 8, and 12 weeks) for clinical scores and for endoscopy (at 12 weeks), together with a final clinical assessment after 1 year follow-up. RESULTS: Patients treated with BDP showed a significant reduced clinical activity within 4 weeks (P < 0.001 vs pretreatment values) with 80% achieving clinical remission compared with 33% treated with only 5-ASA (P < 0.025). A significant reduction in clinical activity was achieved by 5-ASA after 8 weeks. Comparing clinical activity between BDP and 5-ASA, the former did significantly better at 8 (P < 0.003) and at 12 weeks (P < 0.015). In 73% of BDP-treated patients colonoscopy showed remission compared with 27% of 5-ASA (P < 0.025). Both treatments led to better scores compared with pretreatment values (P < 0.001, both). Erythrocyte sedimentation rate was significantly reduced (P < 0.025 or less) with both treatments, whereas C-reactive protein dropped significantly (P < 0.02) only in BDP. CONCLUSIONS: Oral BDP was well tolerated and acts significantly faster and more effectively than 5-ASA in inducing clinical remission and endoscopic improvement in pediatric mild-to-moderate UC.

Indeterminate colitis: a distinctive clinical pattern of inflammatory bowel disease in children.

Inflammatory bowel diseases such as Crohn disease and ulcerative colitis are frequently clinical conditions in children. Another clinical entity, indeterminate colitis, is considered a subgroup of pediatric inflammatory bowel disease. It is generally characterized by early onset in the first years of life, and clinical behavior is rapidly progressive to pancolitis. The definition of indeterminate colitis has changed over the years, but it is usually used to identify severe colitis with overlapping features of ulcerative colitis and Crohn disease. Ileal pouch-anal anastomosis is the surgical treatment of choice for patients with ulcerative colitis, but increased rates of complications have been found in indeterminate colitis. Therefore, it is better to be cautious in patients with indeterminate colitis who present with severe attacks and require surgery.