La recomendación de lactancia materna exclusiva hasta los 6 meses de vida: algunas consideraciones / The recommendation of exclusive breastfeeding until 6 months of age: Some considerations

La recomendación global de la Organización Mundial de la Salud (OMS) de dar "lactancia exclusivamente materna durante los primeros 6 meses de vida" es considerada por las madres y los profesionales sanitarios un objetivo nutricional idóneo para cualquier lactante, si así se desea y no hay impedimento para efectuarla. Es importante destacar que el llamado "Tercer Mundo", con millones de desfavorecidos, era y es el objetivo fundamental de la difusión y puesta en marcha de un programa de salud de la OMS muy amplio, en el que se incluye dicha recomendación. Las circunstancias socioeconómicas y culturales en los países de nuestro ámbito occidental son diferentes, con una historia bien establecida, por lo que las recomendaciones de la European Society for Paediatric Gastroenterology, Hepatology and Nutrition son compatibles con la citada recomendación de la OMS respecto a la introducción de la alimentación complementaria desde los 4 meses. Por ello, esta recomendación debe aplicarse con flexibilidad en nuestro ámbito pediátrico y vigilar los riesgos de ferropenia que puede conllevar

The global recommendation of the World Health Organization (WHO) to give "exclusively breastfeeding during the first six months of life" is considered by mothers and health professionals a nutritional goal suitable for any mother who can and wants to make it. It is important to point out that the so-called "Third World", with millions of disadvantaged people, was and is the fundamental objective of the dissemination and implementation of a very broad WHO health program, which includes this recommendation. The socioeconomic and cultural circumstance in our western area is different and with a history, well established with recommendations from the ESPGHAN, which have made compatible said WHO recommendation with the introduction of complementary feeding since 4 months. Therefore, this recommendation should be applied with flexibility in our pediatric field and monitor the risks of iron deficiency that may result

Intolerancia a la lactosa / Lactose intolerance

La intolerancia a la lactosa (IL) es el síndrome de malabsorción más frecuente en la infancia y adolescencia. Se manifiesta con dolor, molestias abdominales, diarrea, flatulencia, distensión abdominal, náuseas e incluso vómitos. La lactosa es un disacárido presente en la leche que se hidroliza gracias a la acción de la lactasa-floricina-hidrolasa (LPH). Así, la IL se produce cuando, por diferentes circunstancias (transitorias como las infecciones o genéticas), la LPH disminuye/pierde su función induciendo una carencia en la digestión de la lactosa. Puesto que en esta situación se produce (en muchos casos) una retirada de lácteos, debe controlarse especialmente la ingestión de calcio y, por la particular dependencia de este, la densidad mineral ósea (DMO). La DMO es un factor relevante para prevenir la osteoporosis y, dado que una buena masa ósea en la etapa adulta dependerá del acopio efectuado durante la infancia, se debe prestar especial atención a los aspectos nutricionales. Para ello, existen diferentes opciones dietéticas como leche sin lactosa o de baja concentración además de bebidas vegetales o alimentos ricos en calcio; sin embargo, estas dos últimas opciones son inadecuadas nutricionalmente como sustitutivas de la leche (AU)

Lactose intolerance (LI) is the most common malabsorption syndrome in childhood and adolescence. It manifests itself as pain, abdominal trouble, diarrhoea, flatulence, abdominal distension, nausea and even vomiting. Lactose is a disaccharide present in milk which is hydrolysed through the action of lactase-phlorizin hydrolase (LPH). Thus, LI occurs when, for different reasons (transitory infections or genetic), the LPH diminishes/loses its function, inducing a deficiency in lactose digestion. As in this situation dairy products are often withdrawn, special care must be taken to monitor calcium intake and, due to its particular dependence on this, bone mineral density (BMD). BMD is an important factor in preventing osteoporosis and, as good bone mass in adulthood will depend on that built up in childhood, special attention must be paid to nutritional aspects. There are different dietary options for this purpose, such as lactose-free milk or milk with a low lactose content, as well as plant-based drinks or calcium-rich foods; however, the latter two options are nutritionally inadequate as milk substitutes (AU)

Anticuerpos antimúsculo liso sin hepatitis autoinmune / Positive smooth muscle antibody without autoimmune hepatitis

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Eficacia, tolerancia y seguridad a largo plazo del polietilenglicol 3350 con electrolitos en el tratamiento del estreñimiento funcional en niños / Efficacy, tolerance and safety of polyethylene glycol 3350 plus electrolytes for the treatment of functional constipation in children

OBJETIVO: Evaluar la seguridad renal del tratamiento con polietilenglicol 3350 con electrolitos durante 1, 3 y 6 meses, la tolerancia digestiva y la dosis de eficacia. PACIENTES Y MÉTODOS: Fueron evaluados 3 grupos de 30 pacientes sanos, 2-10 años (media 6,2) con estreñimiento funcional (criterios de Roma III), con 1, 3 y 6 meses de tratamiento. La eficacia fue evaluada por el número de deposiciones/semana y la consistencia de las heces (escala de Bristol). La natriuria y la osmolaridad urinaria se midieron al inicio, 1, 3 y 6 meses. Los principios inmediatos en heces (análisis de reflexión de infrarrojos [FENIR]) y un test de hidrógeno espirado fueron efectuados en el grupo de un mes de tratamiento. RESULTADOS: La dosis efectiva fue de 0,37 g/kg/día (rango 0,18-0,8). El número de deposiciones/semana en la inclusión (2,4 ± 0,64) muestra diferencia significativa (p < 0,001) vs. (6,21 ± 1,5) tras el tratamiento. También se demostró una diferencia significativa en la puntuación en la escala de Bristol (1,9 ± 0,75 vs. 4,9 ± 1,1 [p < 0,001]). La ingesta media de sodio fue de 112 mg (5 mg/kg/día [rango de 4-12 mg/kg/día]). Los valores de sodio y osmolaridad en orina fueron normales en todos los grupos sin diferencia estadística con respecto a controles (90 niños sanos sin tratamiento). Los valores de FENIR fueron normales en todos los pacientes. La prueba de aliento con hidrógeno fue normal, con una media de 7 ppm. CONCLUSIÓN: No se observaron parámetros bioquímicos renales adversos ni alteraciones digestivas. La tolerancia y la eficacia demostraron ser óptimas. El polietilenglicol 3350 con electrolitos puede ser recomendado con seguridad para el tratamiento del estreñimiento funcional en los niños a corto y largo plazo

OBJECTIVE: To assess the renal safety of treatment with polyethylene glycol 3350 with electrolytes at 1, 3 and 6 months, its gastrointestinal tolerance and dose effectiveness. PATIENTS AND METHODS: Three groups of 30 healthy patient aged 2-10 years (mean 6.2 years) who suffered functional constipation (Rome III criteria) with 1, 3 and 6 months of treatment were evaluated. Efficacy was evaluated by the change in the number of stools per week and stool consistency (Bristol scale). Urine screens, sodium and osmolality, were performed at the beginning and after 1, 3 and 6 months of treatment. Stool sample NIRA (near-infrared reflectance analysis) and hydrogen breath test analysis samples were performed on the one-month treatment group. RESULTS: The mean dose was 0.37 g/kg/day (range 0.18 to 0.8) titrated according to age, weigh tand response. The number of stools per week during treatment (2.4±0.64) showed a significant difference (P<0.001) vs (6.21±1.5) after treatment. There was also a significant difference in the Bristol scale score (1.9±0.75 vs 4.9±1.1 [P<0.001]). The mean sodium intake was 112 mg (5 mg/kg/day [range 4-12 mg/kg/day]). The values of sodium and urine osmolality were normal in all groups with no statistical difference compared to normal control values (90 healthy children without treatment). NIRA values were normal in all patients. The hydrogen breath test was normal with a median of 7 ppm. CONCLUSION: There were no adverse renal biochemical parameters or gastrointestinal disorders. Tolerance and efficacy was shown to be optimal. Polyethylene glycol 3350 with electrolytes can be safely recommended for the treatment of functional constipation in children in the short and long term

[Efficacy, tolerance and safety of polyethylene glycol 3350 plus electrolytes for the treatment of functional constipation in children]. / Eficacia, tolerancia y seguridad a largo plazo del polietilenglicol 3350 con electrolitos en el tratamiento del estreñimiento funcional en niños.

OBJECTIVE: To assess the renal safety of treatment with polyethylene glycol 3350 with electrolytes at 1, 3 and 6 months, its gastrointestinal tolerance and dose effectiveness. PATIENTS AND METHODS: Three groups of 30 healthy patient aged 2-10 years (mean 6.2 years) who suffered functional constipation (Rome III criteria) with 1, 3 and 6 months of treatment were evaluated. Efficacy was evaluated by the change in the number of stools per week and stool consistency (Bristol scale). Urine screens, sodium and osmolality, were performed at the beginning and after 1, 3 and 6 months of treatment. Stool sample NIRA (near-infrared reflectance analysis) and hydrogen breath test analysis samples were performed on the one-month treatment group. RESULTS: The mean dose was 0.37g/kg/day (range 0.18 to 0.8) titrated according to age, weight and response. The number of stools per week during treatment (2.4±0.64) showed a significant difference (P<.001) vs (6.21±1.5) after treatment. There was also a significant difference in the Bristol scale score (1.9±0.75 vs 4.9±1.1 [P<.001]). The mean sodium intake was 112mg (5mg/kg/day [range 4-12mg/kg/day]). The values of sodium and urine osmolality were normal in all groups with no statistical difference compared to normal control values (90 healthy children without treatment). NIRA values were normal in all patients. The hydrogen breath test was normal with a median of 7ppm. CONCLUSION: There were no adverse renal biochemical parameters or gastrointestinal disorders. Tolerance and efficacy was shown to be optimal. Polyethylene glycol 3350 with electrolytes can be safely recommended for the treatment of functional constipation in children in the short and long term.

Utilidad de la entero-resonancia magnética en el estudio de la enfermedad de Crohn pediátrica / MRI enterography in the assessment of paediatric Crohn’s disease

Objetivo: Evaluar la utilidad de la resonancia magnética intestinal con contraste oral (RMI) para el estudio de extensión y actividad de la enfermedad de Crohn (EC) pediátrica, comparando los hallazgos con índices clínicos, tests biológicos, endoscopia y otras técnicas de imagen. Pacientes y métodos: Fueron valoradas las RMI efectuadas en pacientes menores de 18 años diagnosticados de EC. Para la preparación se administró 500-1000ml de polietilenglicol una hora antes de las imágenes (1,5-TMR). Se realizaron secuencias T2 HASTE con o sin Fat SAT, T2 true-FISP, T1 Fat-SAT VIBE pre/posgadolinio, HASTE dinámico y difusión. Se valoraron el engrosamiento de pared intestinal, la hipercaptación mucosa y las complicaciones extraintestinales. Se establecieron 5 patrones de RMI: normal, fibrosis, actividad leve, moderada y severa-transmural. Los hallazgos se compararon con PCDAI, parámetros inflamatorios, resultados endoscópicos e histológicos. Resultados: Incluimos para la evaluación 22 estudios. El 82% presentaba una distensión intestinal óptima. Observamos efectos secundarios leves en el 12% de los pacientes. Encontramos una relación significativa entre los patrones de RMI versus PCDAI (p=0,002), VSG (p=0,006) y PCR (p=0,047); no hallamos relación estadísticamente significativa (p=0,571) con la histología. La RMI valoró correctamente la extensión de la enfermedad a nivel ileal (80%) y a nivel cólico (66%). Un 86,4% de los estudios mostraron complicaciones extraintestinales, sin presentar relación estadística con la clasificación de RMI (p=0,274). Conclusiones: Existe una relación estadísticamente significativa entre nuestros patrones de RMI y PCR, VSG y PCDAI. La RMI presenta excelente concordancia con las ileoscopias. La RMI valora zonas no accesibles mediante endoscopia y permite el diagnóstico de complicaciones extraintestinales sin irradiación (AU)

Objective: To determine the usefulness of MRI enterography for assessing the extension and activity of paediatric Crohn's disease. MRI findings were compared with clinical, biological, endoscopic and other imaging data. Patients and methods: Studies of MRI enterography use in patients younger than 18 years of age were reviewed. Patients received 500-1000mL of polyethylene glycol one hour before examination (1.5-TMR). T2 HASTE sequences with or without fat saturation, T2 true-FISP, T1 with fat saturation, pre- and post gadolinium-enhanced VIBE sequences, and dynamic and diffusion HASTE were acquired. Thickening of the bowel wall, mucosal enhancement, and extra-luminal complications were evaluated. Five MRI patterns (normal, fibrosis, mild, moderate, and severe transmural activity) were defined. Findings were compared with PCDAI scores, inflammatory parameters, and endoscopic and histological results. Results: Twenty-two studies were reviewed. Optimal intestinal distension was present in 82% of the cases. Mild side effects were observed in 12% of patients. There was a significant relationship between MRI patterns and PCDAI scores (P=0.002), sedimentation rate (P=0.006) and serum PCR levels (P=0.047) and a non-significant relationship with the histology (P=0.571). MRI enterography correctly assessed the ileal (80%) and colonic (66%) extension. Extra-luminal complications unrelated to MRI classification (P=0.274) were reported in 86.4% of studies. Conclusions: There was a significant relationship between MRI patterns and PCR, sedimentation rate, and PCDAI scores. MRI enterography showed excellent agreement with ileoscopies, and allowed endoscopically non-accessible areas to be assessed, as well as the diagnosis of extra-luminal complications without irradiation (AU)

[MRI enterography in the assessment of paediatric Crohn's disease]. / Utilidad de la entero-resonancia magnética en el estudio de la enfermedad de Crohn pediátrica.

OBJECTIVE: To determine the usefulness of MRI enterography for assessing the extension and activity of paediatric Crohn's disease. MRI findings were compared with clinical, biological, endoscopic and other imaging data. PATIENTS AND METHODS: Studies of MRI enterography use in patients younger than 18 years of age were reviewed. Patients received 500-1000mL of polyethylene glycol one hour before examination (1.5-TMR). T2 HASTE sequences with or without fat saturation, T2 true-FISP, T1 with fat saturation, pre- and post gadolinium-enhanced VIBE sequences, and dynamic and diffusion HASTE were acquired. Thickening of the bowel wall, mucosal enhancement, and extra-luminal complications were evaluated. Five MRI patterns (normal, fibrosis, mild, moderate, and severe transmural activity) were defined. Findings were compared with PCDAI scores, inflammatory parameters, and endoscopic and histological results. RESULTS: Twenty-two studies were reviewed. Optimal intestinal distension was present in 82% of the cases. Mild side effects were observed in 12% of patients. There was a significant relationship between MRI patterns and PCDAI scores (P=.002), sedimentation rate (P=.006) and serum PCR levels (P=.047) and a non-significant relationship with the histology (P=.571). MRI enterography correctly assessed the ileal (80%) and colonic (66%) extension. Extra-luminal complications unrelated to MRI classification (P=.274) were reported in 86.4% of studies. CONCLUSIONS: There was a significant relationship between MRI patterns and PCR, sedimentation rate, and PCDAI scores. MRI enterography showed excellent agreement with ileoscopies, and allowed endoscopically non-accessible areas to be assessed, as well as the diagnosis of extra-luminal complications without irradiation.

Salud y vitamina D: Un puzle incompleto / Health and vitamin D: an incomplete puzzle

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Seguridad y eficacia del polietilenglicol 3350 con electrolitos en el tratamiento del estreñimiento funcional en niños / Safety and efficacy of polyethylene glycol 3350 plus electrolytes for the treatment of functional constipation in children

Introducción: El objetivo del trabajo ha sido evaluar la seguridad del PEG 3350 con electrolitos (PEG+E) a nivel renal y digestivo. Objetivo secundario: valorar su eficacia y dosis de efectividad. Pacientes y métodos: Quince pacientes con estreñimiento funcional (criterios de Roma III) y función renal normal fueron evaluados. La mediana de edad fue de 6,2 años (r=2-9). Sobres pediátricos de PEG+E fueron administrados durante 4 semanas (4ST) La dosis media administrada fue de 0,44g/kg/día. La natruria y osmolaridad urinaria se midieron al inicio y a las 4ST. La determinación de principios inmediatos en heces mediante FENIR (análisis de reflexión de infrarrojos) y una prueba de hidrógeno espirado fueron efectuadas a las 4ST. La eficacia del tratamiento fue evaluada mediante el cambio en el número de deposiciones por semana y la consistencia de las heces (escala de Bristol). Resultados: A las 4ST el número de deposiciones por semana fue de 5,29±1,68 vs 2,46±0,71 al inicio (p<0,001). La puntuación de la escala de Bristol fue de 4,5±0,91 tras 4TS vs 2,47±1,24 al inicio (p<0,001). No se encontraron diferencias estadísticas entre los valores de sodio y osmolalidad en orina al inicio vs 4ST. Los valores de FENIR fueron normales en todos los pacientes. La prueba del aliento de hidrógeno fue normal con una mediana de 7ppm. Conclusiones: No se observaron efectos adversos renales ni alteraciones digestivas. El PEG+E puede ser recomendado para el tratamiento del estreñimiento funcional en los niños (AU)

Introduction: Polyethylene glycol 3350 plus electrolytes (PEG+E) efficacy has been validated in some studies, but not many have evaluated its safety in children. The aim of our study was to evaluate the safety; renal, malabsorption or excessive production of gas and efficacy of PEG+E treatment in our paediatric population. Patients and methods: Fifteen patients who suffered functional constipation (Rome III criteria) were evaluated. Median age was 6.2 years (r 2-9). All patients had normal renal function. PEG+E were administered for 4weeks (4WP). The mean dose was 0.44g/kg/day, titrated according to age, weight and response. Urine screens (sodium and osmolality) were performed at the beginning and 4WP. Stool sample NIRA (near-infrared reflectance analysis) and hydrogen breath test analysis samples were performed at 4WP. To analyse the efficacy of the treatment, the number of stools per week and stool form type (Bristol stool scale) were recorded. Results: The number of stools per week was higher after 4weeks (2.46±0.71 vs 5.29±1.68, P<0.001), as well as the stool form score (2.47±1.24 vs 4.5±0.91, P<0.001). No statistical differences were obtained between urine sodium and urine osmolality values at the beginning and 4WP. After 4WP the NIRA median values were normal in all patients [fat 4.45% (range (r) 3.6-7.09); nitrogen 0.78% (r 0.4-1); sugars 1.4% (r 0.47-2.35) and water 68% (r 59-74)]. Median breath hydrogen test was 7ppm (r 2-18). Conclusions: No adverse effects on biochemistry values or gastrointestinal disturbances were observed. PEG+E can be recommended for the treatment of functional constipation in children (AU)

[Safety and efficacy of polyethylene glycol 3350 plus electrolytes for the treatment of functional constipation in children]. / Seguridad y eficacia del polietilenglicol 3350 con electrolitos en el tratamiento del estreñimiento funcional en niños.

INTRODUCTION: Polyethylene glycol 3350 plus electrolytes (PEG+E) efficacy has been validated in some studies, but not many have evaluated its safety in children. The aim of our study was to evaluate the safety; renal, malabsorption or excessive production of gas and efficacy of PEG+E treatment in our paediatric population. PATIENTS AND METHODS: Fifteen patients who suffered functional constipation (Rome III criteria) were evaluated. Median age was 6.2 years (r 2-9). All patients had normal renal function. PEG+E were administered for 4 weeks (4WP). The mean dose was 0.44 g/kg/day, titrated according to age, weight and response. Urine screens (sodium and osmolality) were performed at the beginning and 4WP. Stool sample NIRA (near-infrared reflectance analysis) and hydrogen breath test analysis samples were performed at 4WP. To analyse the efficacy of the treatment, the number of stools per week and stool form type (Bristol stool scale) were recorded. RESULTS: The number of stools per week was higher after 4 weeks (2.46 ± 0.71 vs 5.29 ± 1.68, P<.001), as well as the stool form score (2.47 ± 1.24 vs 4.5 ± 0.91, P<.001). No statistical differences were obtained between urine sodium and urine osmolality values at the beginning and 4WP. After 4WP the NIRA median values were normal in all patients [fat 4.45% (range (r) 3.6-7.09); nitrogen 0.78% (r 0.4-1); sugars 1.4% (r 0.47-2.35) and water 68% (r 59-74)]. Median breath hydrogen test was 7 ppm (r 2-18). CONCLUSIONS: No adverse effects on biochemistry values or gastrointestinal disturbances were observed. PEG+E can be recommended for the treatment of functional constipation in children.

Estudio del comportamiento reológico in vitro de las fórmulas antirregurgitación / Thickened infant formula, rheological study of the “in vitro” properties

Introducción: La adición de espesantes a las fórmulas denominadas fórmulas antirregurgitación (F-AR) tiene como objetivo aumentar la viscosidad para el tratamiento del reflujo gastroesofágico no complicado. Objetivo: Determinar la viscosidad y el comportamiento reológico de las diferentes F-AR de inicio del mercado español, y compararlas con una fórmula de inicio estándar y tras su espesamiento con cereales sin gluten (10g/100ml). Método: La viscosidad de las muestras se determinó con un reómetro Bohlim CS de estrés controlado en condiciones basales (25°C, pH 7) y tras 30 y 60min de incubación en condiciones de simulación de fisiología gástrica (FG) (37°C, pH 4 y 10g/100ml de pepsina); la viscosidad se expresó en centipoises (cP). Resultados: Todas las fórmulas demostraron un aumento de la viscosidad tanto en condiciones basales como en condiciones de FG. Las fórmulas que contenían harina de semilla de algarrobo con una concentración de 2,9g/100g y un cociente de proteínas similar al de la leche de vaca (80% de caseína/20% de lactosuero) mostraron la viscosidad más alta y mantenida (70 y 90cP), con diferencias significativas con respecto a la fórmula de inicio en todas las mediciones. Cuando este espesante estaba en fórmulas con un cociente proteico similar al de la leche materna (40% de caseína/60% de lactosuero), la viscosidad alcanzada fue menor, y sólo con una concentración de 4,7g/100g se alcanzaron viscosidades superiores a 50cP, con diferencias significativas versus la fórmula de inicio. Las fórmulas que contenían almidones (arroz, patata y maíz) alcanzaron una viscosidad menor de 50cP y menos mantenida, y no alcanzaron una diferencia significativa. La viscosidad alcanzada tras la adición de cereales tanto en condiciones basales como en condiciones de FG fue similar a la alcanzada con las fórmulas más efectivas con espesantes. La concentración lipídica no se implicó en el distinto comportamiento reológico de las fórmulas. Conclusión: La viscosidad de las F-AR depende del agente empleado, la concentración de éste y el cociente proteico. No todas alcanzan una viscosidad de 50cP, valor hipotético por conseguir, dado que representaría doblar la viscosidad de la fórmula de inicio. Futuros estudios son necesarios para determinar el grado de viscosidad ideal y cómo conseguirlo (AU)

Introduction: Thickened infant formulas, specially formulated to increase the viscosity, are commonly used in the treatment of regurgitation in the non-complicated gastroesophageal reflux. Objective: To analyse viscosity and the rheological behaviour of different thickened standard formulas on the Spanish market compared to a standard formula with or without the addition of 10g/100mL of gluten-free cereals. Methods: Viscosity of the samples was evaluated in a Bohlim CS-1o controlled-stress rheometer and was performed at basal conditions (25°C, pH 7) and at simulated gastric conditions (37°C, pH 4 and 10g/100mL of pepsin) at time 0, 30 and after 60min of incubation. Values were expressed as centipoises (cp) (1cp=1/100p). Results: All formulas show a viscosity increase both in basal conditions and in gastric simulated conditions but the behaviour is very heterogeneous. Formulas containing bean gum (carob seed flour) with 2.9g/100g and a protein ratio similar to cow's milk (80 casein/20 whey) showed the highest and consistent viscosity (70cp and 90cp), with significant differences compared to the standard formula in all the measurements. When this thickener is in formulas with a protein ratio similar to breast milk (40 casein/60 whey) the viscosity was lower and reached 50cp only with the thickener at a concentration of 4.7gr/100g, achieving significant differences versus standard formula. The formulas with starch thickeners (rice, potatoes and corn) achieved a lower and less consistent viscosity, with no significant difference. The viscosity reached after the addition of cereals both in basal conditions and in gastric simulated conditions was similar to that achieved with more effective thickeners. Lipid concentration is not involved in viscosity and rheological behavior. Conclusion: The viscosity of the thickened infant formula depends on the agent used, concentration and protein ratio. Not all reach a viscosity of 50cp, hypothetical value to reach, since it doubles the viscosity of a standard formula. The ideal viscosity to be reached and the role of other components of the formula in the viscosity and rheological behaviour is still unclear (AU)

[Thickened infant formula, rheological study of the "in vitro" properties]. / Estudio del comportamiento reológico in vitro de las fórmulas antirregurgitación.

INTRODUCTION: Thickened infant formulas, specially formulated to increase the viscosity, are commonly used in the treatment of regurgitation in the non-complicated gastroesophageal reflux. OBJECTIVE: To analyse viscosity and the rheological behaviour of different thickened standard formulas on the Spanish market compared to a standard formula with or without the addition of 10 g/100mL of gluten-free cereals. METHODS: Viscosity of the samples was evaluated in a Bohlim CS-1o controlled-stress rheometer and was performed at basal conditions (25 degrees C, pH 7) and at simulated gastric conditions (37 degrees C, pH 4 and 10 g/100mL of pepsin) at time 0, 30 and after 60 min of incubation. Values were expressed as centipoises (cp) (1 cp=1/100 p). RESULTS: All formulas show a viscosity increase both in basal conditions and in gastric simulated conditions but the behaviour is very heterogeneous. Formulas containing bean gum (carob seed flour) with 2.9 g/100g and a protein ratio similar to cow's milk (80 casein/20 whey) showed the highest and consistent viscosity (70 cp and 90 cp), with significant differences compared to the standard formula in all the measurements. When this thickener is in formulas with a protein ratio similar to breast milk (40 casein/60 whey) the viscosity was lower and reached 50 cp only with the thickener at a concentration of 4.7 gr/100g, achieving significant differences versus standard formula. The formulas with starch thickeners (rice, potatoes and corn) achieved a lower and less consistent viscosity, with no significant difference. The viscosity reached after the addition of cereals both in basal conditions and in gastric simulated conditions was similar to that achieved with more effective thickeners. Lipid concentration is not involved in viscosity and rheological behaviour. CONCLUSION: The viscosity of the thickened infant formula depends on the agent used, concentration and protein ratio. Not all reach a viscosity of 50 cp, hypothetical value to reach, since it doubles the viscosity of a standard formula. The ideal viscosity to be reached and the role of other components of the formula in the viscosity and rheological behaviour is still unclear.

Hábitos de bebida en la edad pediátrica: repercusión nutricional / Drinking habits in the pediatric age: nutritional repercussion

Nuestros niños y adolescentes están dejando de consumir agua corriente como bebida habitual para saciar sus necesidades vitales, debido a la gran oferta y disponibilidad de “ refrescos” y zumos de frutas. Ello puede suponer cambios en la ingesta de nutrientes, por exceso o por defecto y conllevar efectos adversos, como desviaciones nutricionales, riesgo de caries, osteopenia y diarrea o dolor abdominal, por mal absorción de algunos de los componentes. El objetivo del trabajo ha sido conocer los hábitos de ingesta de bebidas refrescantes y zumos en edades comprendidas entre 2 y 18 años en nuestro medio, valorar su repercusión nutricional y posibles consecuencias patológicas (AU)

Our children and adolescents are no longer consuming drinking water as the usual drink to satisfy their life needs, due to the large offer and availability of “refreshments” and fruit juices. The means changes in the intake of nutrient, either by excess or by lack of them and entails adverse effects, such as nutritional deviations, risk of cavities, osteopenia and diarrhea or stomach pain, due to malabsorption of some of al the intake habits of refreshments and juices in age groups from 2 to 18 years in our setting, to evaluate their nutritional repercussion and possible pathological consequences (AU)

[Optimising azathioprine treatment: determination of thiopurine methyltransferase activity and thiopurine metabolites]. / Optimización del tratamiento con azatioprina: determinación de la actividad de tiopurina metiltransferasa y las concentraciones de metabolitos tiopurínicos.

INTRODUCTION: Individualised doses of azathioprine (AZA) may be prescribed by monitoring the levels of the enzyme thiopurine methyltransferase (TPMT). The measurements of thiopurine metabolites of AZA, 6-thioguanine (6-TGN) and 6-methylmercaptopurine (6-MMP), have also been reported as new markers of AZA activity. OBJECTIVES: To describe TPMT phenotype in our population and to establish a relationship between thiopurine metabolites,and therapeutic activity and adverse effects. MATERIAL AND METHODS: Data on TPMT were retrospectively collected from 107 patients, and 6-TGN and 6-MMP levels in 18 patients currently on treatment with AZA (Crohn's disease 5, ulcerative colitis 5, autoimmune hepatitis 5). RESULTS: Mean value of TPMT was 20.19U/ml. None of the patients had a TPMT activity<5U/ml. Of the 18 patients on treatment, 13 showed sub-therapeutic levels of 6-TGN (<235pmol/8x10(8) red blood cells). Clinical remission was maintained in 45% of patients. Mean levels of 6-TGN in patients with clinical remission were 259pmol/8x10(8) red blood cells versus 209pmol/8x10(8) red blood cells in non-responders (p=0.37). There was an inverse relationship (r=-0.28) between TPMT and 6-TGN levels. Toxic effects occurred in 6 of 18 patients, with leukopenia in 5 and hyperamylasemia in 1. CONCLUSIONS: Determination of TPMT and monitoring of thiopurine metabolites allows AZA treatment to be optimised, although further studies are necessary to establish therapeutic effectiveness and toxicity ranges.

Optimización del tratamiento con azatioprina: determinación de la actividad de tiopurina metiltransferasa y las concentraciones de metabolitos tiopurínicos / Optimising azathioprine treatment: determination of thiopurine methyltransferase activity and thiopurine metabolites

Introducción: la determinación de la enzima tiopurina metiltransferasa (TPMT) nos permite pautar la dosis inicial individualizada de azatioprina (AZA). Las determinaciones de los metabolitos tiopurínicos de la AZA, la 6-tioguanina (6-TGN) y la 6-metilmercaptopurina (6-MMP) se han descrito como nuevos marcadores de la actividad del fármaco. Objetivos: describir el fenotipo de TPMT en nuestra población y relacionar los valores de los metabolitos tiopurínicos con la actividad terapéutica y los efectos adversos. Material y métodos: se recogieron retrospectivamente los valores de TPMT de 107 pacientes y de 6-TGN y 6-MMP de 18 pacientes en tratamiento con AZA (8 con enfermedad de Crohn, 5 con colitis ulcerosa y 5 con hepatitis autoinmune). Resultados: la media de determinación de TPMT fue 20,19U/ml. Ninguno presentó actividad de TPMT menor que 5U/ml. De los 18 pacientes, 13 mostraron concentraciones subterapéuticas de 6-TGN (<235pmol/8×108 hematíes). El 45% de los pacientes mantuvieron remisión clínica. La media de concentración de 6-TGN en los pacientes en remisión fue 259pmol/8×108 hematíes frente a 209pmol/8×108 hematíes en los no respondedores (p=0,37). Hay una relación inversa (r=−0,28) entre los valores de TPMT y los de 6-TGN. En 6/18 pacientes encontramos toxicidad: 5 con leucocitopenia y uno con hiperamilasemia. Conclusiones: la determinación de TPMT y la monitorización de los metabolitos tiopurínicos nos permite optimizar tratamiento con AZA, aunque son necesarios nuevos estudios que permitan el correcto conocimiento de los intervalos de efectividad terapéutica y toxicidad (AU)

Introduction: Individualised doses of azathioprine (AZA) may be prescribed by monitoring the levels of the enzyme thiopurine methyltransferase (TPMT). The measurements of thiopurine metabolites of AZA, 6-thioguanine (6-TGN) and 6-methylmercaptopurine (6-MMP), have also been reported as new markers of AZA activity. Objectives: To describe TPMT phenotype in our population and to establish a relationship between thiopurine metabolites,and therapeutic activity and adverse effects. Material and methods: Data on TPMT were retrospectively collected from 107 patients, and 6-TGN and 6-MMP levels in 18 patients currently on treatment with AZA (Crohn’s disease 5, ulcerative colitis 5, autoimmune hepatitis 5). Results: Mean value of TPMT was 20.19U/ml. None of the patients had a TPMT activity<5U/ml. Of the 18 patients on treatment, 13 showed sub-therapeutic levels of 6-TGN (<235pmol/8×108 red blood cells). Clinical remission was maintained in 45% of patients. Mean levels of 6-TGN in patients with clinical remission were 259pmol/8×108 red blood cells versus 209pmol/8×108 red blood cells in non-responders (p=0.37). There was an inverse relationship (r=−0.28) between TPMT and 6-TGN levels. Toxic effects occurred in 6 of 18 patients, with leukopenia in 5 and hyperamylasemia in 1. Conclusions: Determination of TPMT and monitoring of thiopurine metabolites allows AZA treatment to be optimised, although further studies are necessary to establish therapeutic effectiveness and toxicity ranges (AU)

Optimización de la función intestinal en pacientes con fibrosis quística mediante la administración de probióticos / Improvement of intestinal function in cystic fibrosis patients using probiotics

Introducción: La fibrosis quística puede cursar con inflamación de la mucosa intestinal y síndrome de hipercrecimiento bacteriano (SHB). Se ha argumentado que los probióticos actúan como inmunomoduladores, antiinflamatorios y reguladores de la microbiota. El objetivo del presente estudio es conocer la prevalencia de SHB en pacientes con fibrosis quística y tratar de optimizar la función intestinal mediante la administración de probióticos. Pacientes y método: Fueron valorados 20 pacientes afectados de fibrosis quística, con una edad media de 10,33 años (rango, 5-17 años). El estudio del SHB se efectuó en 10 pacientes mediante el test de hidrógeno espirado tras una sobrecarga de dextrosa al 20 %, a dosis de 2 g/kg. Tras la prueba se administró Lactobacillus rhamnosus LGG a dosis de1011 ufc dos veces al día durante 4 semanas. La determinación de grasa, nitrógeno, agua y azúcares en las heces se efectuó antes y después del tratamiento mediante análisis de reflexión de infrarrojos (FENIR). Resultados: Cinco pacientes (50%) presentaron SHB. En los valores de H2 se detectó una correlación positiva con respecto a las cifras de esteatorrea (R = 0,57) y de azúcares (R = 0,52). Los valores del FENIR pretratamiento frente a postratamiento, expresados en gramos, fueron: grasa 6,2 +/- 3,3 frente a 4,9 +/- 2,1 (p < 0,5), azúcares 6,7 +/- 3,6 frente a 5 +/- 2,6(p < 0,05) y nitrógeno 0,87 +/- 0,27 frente a 0,91 +/- 0,14 (NS). En 13 pacientes (81,25 %) se evidenció una mejoría de la comodidad intestinal y del aspecto de las deposiciones, yen 9 pacientes (56,25 %) disminuyó el número de deposiciones. Conclusiones: El tratamiento con probióticos mejora la función intestinal en los pacientes afectados de fibrosis quística desde el punto de vista clínico y bioquímico. Su administración podría ser pautada de una manera regular sobre todo en casos de SHB (AU)

Introduction: In some cases, cystic fibrosis may include intestinal inflammation and bacterial overgrowth. Probiotics are considered as immunomodulatory, anti-inflammatory and microbiotic regulator substances. The aim of our study is to determine the prevalence of bacterial overgrowth in cystic fibrosis patients and try to improve the intestinal function with the administration of probiotics. Patients and method: We examined 20 patients with cystic fibrosis (mean age10.33, range 5 to 17 years). The expired hydrogen test with a 2 g/kg of 20 % dextrose overload was performed on 10 patients. After the test, Lactobacillus rhamnosus LGG1011 CFU was administered twice daily for four weeks. Faecal near infrared spectroscopy (FENIR) of water, fat, nitrogen and sugar content in faeces was performed before and after probiotics administration. Results: Five patients (50 %) showed bacterial overgrowth. Weobtained a positive correlation between the hydrogen test and steator rhea (R = 0.57) and sugar in faeces (R = 0.52).The FENIR results pre-treatment vs post-treatment were: fat 6.2 g +/- 3.3 g vs. 4.9 g +/- 2.1 g (p < 0.05), sugar6.7 g +/- 3.6 g vs. 5 g +/- 2.6 g (p < 0.05) and nitrogen 0.87 g +/- 0.27 g vs. 0.91 g +/- 0.14 g (NS) respectively. Thirteen patients (81.25 %) had improved stool appearance and intestinal comfort and nine (56.25 %) decreased the number of daily stools. Conclusions: Probiotics improved not only clinical but also biochemical intestinal function in cystic fibrosis patients. These could be given as a regular treatment in this type of patients and in those with bacterial overgrowth (AU)

Macroamilasemia en pediatría / Macroamylasaemia in paediatrics

La macroamilasemia es una entidad que debe sospecharse ante cualquier paciente que presente concentraciones elevadas de amilasa plasmática sin datos clínicos ni de investigaciones complementarias que demuestren la existencia de una afección pancreática o parotídea. Se caracteriza por la elevación de amilasa plasmática debido a macrocomplejos circulantes de alto peso molecular, formados por una molécula de amilasa unida generalmente a una inmunoglobulina. En ausencia de enfermedad renal, una hiperamilasemia sin aumento de amilasuria orienta hacia este diagnóstico, que se confirma al identificar a los componentes de la macromolécula. Es una entidad infrecuente en pediatría. Se ha descrito como un hallazgo casual asociado a dolor abdominal y a enfermedad celíaca. Se presentan 2 casos pediátricos de macroamilasemia, así como las pruebas necesarias para su diagnóstico. El conocimiento de esta anomalía bioquímica permite distinguirla de otras situaciones que cursan con elevación de amilasa, con el fin de evitar exploraciones complementarias y tratamientos invasivos innecesarios (AU)

Macroamylasaemia should be considered in any patient with high plasma amylase, no clinical signs and negative additional investigations for pancreatic or parotid diseases. It is characterised by an increase in serum amylase due to circulating high molecular mass macrocomplexes, most often formed due the binding of the amylase to an immunoglobulin. With a normal renal function, a hyper-amylasaemia without an increase in urine amylase suggests the diagnosis, and is confirmed by identifying the macromolecular components. It is an uncommon entity in paediatrics. It has been described as a casual finding associated to abdominal pain and to celiac disease. We report two paediatric cases of macroamylasaemia, and a review of the tests needed for its diagnosis. The better understanding of this biochemical anomaly allows us to differentiate it from other situations associated to hiperamylasaemia, in order to avoid additional invasive explorations and unnecessary treatments (AU)

Prevalence and dietetic management of mild gastrointestinal disorders in milk-fed infants.

AIM: To assess the prevalence of mild gastrointestinal disorders in milk-fed infants in paediatric practice, and to evaluate the effectiveness and satisfaction with dietetic treatment. METHODS: A cross-sectional epidemiological study was first carried out. A total of 285 paediatricians included 3487 children seen during a period of one week. In a second phase an observational, prospective and multicentre study was conducted and 2069 milk-fed infants with mild gastrointestinal disorders (colic, constipation, regurgitation and diarrhoea) were included. There was a baseline visit (start of treatment) and a final visit four weeks later. The effectiveness of the various Novalac formulas, as well as the satisfaction of the parents/tutors and paediatricians with the dietetic treatment were assessed at the final visit. RESULTS: The prevalence of mild gastrointestinal disorders was 27.8% of all paediatrician consultations (9.2%, 7.8%, 6.1% and 4.6% in relation to colic, constipation, regurgitation and diarrhoea, respectively). The several Novalac adapted milk formulas resolved 88.4% of the mild gastrointestinal disorders. Depending on the type of disorder, differences in response rate were observed. The highest effectiveness was recorded with respect to diarrhoea (92.6%), followed by constipation (91.6%), colic (87.6%) and regurgitation (81%). Overall, 91% of the paediatricians and 88.8% of the parents/tutors were satisfied or very satisfied with the Novalac adapted milk formulas. CONCLUSION: Mild gastrointestinal disorders show a high prevalence in paediatric practice. The Novalac adapted milk formulas have been shown to be effective in treating mild gastrointestinal disorders in milk-fed infants in the context of routine clinical practice.