Symptoms and management of cow's milk allergy: perception and evidence.

Introduction: The diagnosis and management of cow's milk allergy (CMA) is a topic of debate and controversy. Our aim was to compare the opinions of expert groups from the Middle East (n = 14) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) (n = 13). Methods: These Expert groups voted on statements that were developed by the ESPGHAN group and published in a recent position paper. The voting outcome was compared. Results: Overall, there was consensus amongst both groups of experts. Experts agreed that symptoms of crying, irritability and colic, as single manifestation, are not suggestive of CMA. They agreed that amino-acid based formula (AAF) should be reserved for severe cases (e.g., malnutrition and anaphylaxis) and that there is insufficient evidence to recommend a step-down approach. There was no unanimous consensus on the statement that a cow's milk based extensively hydrolysed formula (eHF) should be the first choice as a diagnostic elimination diet in mild/moderate cases. Although the statements regarding the role for hydrolysed rice formula as a diagnostic and therapeutic elimination diet were accepted, 3/27 disagreed. The votes regarding soy formula highlight the differences in opinion in the role of soy protein in CMA dietary treatment. Generally, soy-based formula is seldom available in the Middle-East region. All ESPGHAN experts agreed that there is insufficient evidence that the addition of probiotics, prebiotics and synbiotics increase the efficacy of elimination diets regarding CMA symptoms (despite other benefits such as decrease of infections and antibiotic intake), whereas 3/14 of the Middle East group thought there was sufficient evidence. Discussion: Differences in voting are related to geographical, cultural and other conditions, such as cost and availability. This emphasizes the need to develop region-specific guidelines considering social and cultural conditions, and to perform further research in this area.

Vitamin D deficiency and insufficiency in Africa and the Middle East, despite year-round sunny days.

Exposure to sunlight, specifically ultraviolet B (UVB), is essential for cutaneous vitamin D synthesis. Despite significant daily sunlight availability in Africa and the Middle East, persons living in these regions are frequently vitamin D insufficient or deficient. Vitamin D insufficiency (25-hydroxyvitamin D (25(OH)D) between 15 and 20 ng/mL (37.5-50 nmol/L)) has been described in various population groups, ranging from 5% to 80%. Risk factors include traditional dress and avoidance of sunlight exposure, and multiple dietary factors as a result of specific cultural beliefs. Vitamin D resistance due to calcium deficiency mechanisms has been described in similar population groups, which may lead to hypovitaminosis D. Should the new diseases related to hypovitaminosis D prove to be truly associated, Africa and the Middle East will become an epicentre for many of these conditions. Urgent attention will need to be paid to cultural dress and dietary behaviours if hypovitaminosis D is to be taken seriously. Should such factors not be correctable, new strategies for supplementation or food fortification will have to be devised.

Enhanced blood lymphocytes apoptosis in children with inflammatory bowel disease.

The aim of this work was to measure peripheral lymphocyte apoptosis during IBD flare and remission. Subjects and Methods. Flow-cytometric assessment of apoptosis of peripheral blood lymphocytes (PBL) was assessed in 30 children with IBD (16 with ulcerative colitis and 14 with Crohn's disease) compared to 22, age and sex matched, healthy children. This was carried out during a flare, whether in newly diagnosed or relapsing patients, and after achievement of remission. Clinical findings, complete blood count, liver transaminases, and kidney functions were assessed. Results. Early apoptotic and late apoptotic/necrotic lymphocytes were significantly higher during IBD flare compared to controls (P ≤ 0.01 and <0.01, resp., in ulcerative colitis and P ≤ 0.01 and <0.01, resp., in Crohn's disease patients). Remission values were significantly decreased but did not come back to the control levels. Early apoptotic values were significantly related to joint involvement in IBD patients (P < 0.0001). Conclusions. We can speculate a systemic nature of IBD as evident by enhanced peripheral lymphocyte apoptosis. This is related, to a great extent, to the disease process as it is more deranged in flare than in remission. Relation of this derangement to extraintestinal manifestations needs a special attention.

Fate and ultra-structural features of chicken skin mucosa around juvenile polyps.

OBJECTIVE: Chicken skin mucosa (CSM) is a common finding around juvenile polyps in children. Its ultrastructural features and fate after polypectomy are not yet clear. The aim was to study ultra-structural features and outcome of this CSM compared to that of the polyps and distant endoscopically normal mucosa. MATERIAL AND METHODS: From 240 children with juvenile polyps, 45 needed a second colonoscopy. Thirty six patients showing CSM represented the cohort of this study. One polyp only was studied in each patient. The histologic features of the CSM were compared to normal and polyp mucosa. The fate of CSM was evaluated in the second colonoscopy. RESULTS: The mean numbers of intraepithelial lymphocytes, as well as lamina propria inflammatory cellular infiltrates were significantly higher in polyp mucosa than in CSM. Goblet cells were significantly higher in CSM compared to normal mucosa with marked depletion in the polyp mucosa. The muscularis mucosae thickness was significantly higher in CSM compared to polyps (p<0.0001) and both showed higher values than the normal mucosa. The CSM almost disappeared within a month period following polypectomy. CONCLUSIONS: The polyp showed the most intense mucosal inflammatory reaction. CSM with the unique thickening of muscularis mucosae especially around larger polyps almost disappeared after polypectomy. So these results suggest that CSM is a benign compensatory reaction induced by the mechanical effect of the polyp.

Cow's milk allergy related pediatric constipation: appropriate time of milk tolerance.

Cow's milk allergy (CMA) has different clinical presentations according to age. The study aimed to evaluate the extent of CMA as a cause of pediatric constipation and determine the appropriate timing of tolerance to cow milk in such patients. The study included 60 patients suffering from chronic functional constipation, 27 of whom did not respond to 2 month laxative therapy (group I). Thirty age and sex matched apparently healthy infants and children were studied as a control group (group II). Serum specific IgE to cow milk proteins was measured. Withdrawal of cow milk and dairy products for a 1 month period was then followed by cow milk re-challenge over 2 wk. Patients were classified into: responders to this schedule (cow milk allergic=group Ia; n=21) and non-responders (non-cow milk allergic=group Ib; n=6). Eighteen CMA patients continued the study where nine of them underwent milk reinstitution after 6 months and another nine patients after 12 months of elimination. The frequency of CMA among constipated patients was 77.7%. Mean values of serum specific IgE to whole cow milk protein and beta-lactoglobulins were significantly higher in constipated patients (0.82+/-0.08, 0.79+/-0.13 IU/ml, respectively) compared with controls (0.26+/-0.14, 0.27+/-0.14 IU/ml, respectively) and in group Ia (0.99+/-0.08, 0.95+/-0.14 IU/ml, respectively) compared with group Ib (0.39+/-0.06, 0.37+/-0.10 IU/ml, respectively). Serum specific IgE was positive in 85.7% of CMA group, predominantly in class 2. Tolerance to cow milk was achieved after 6 months in only 22.2% compared with 88.8% after 12 months of elimination. In conclusion, CMA is shown to be a significant etiologic factor for constipation in infants and young children. Serum levels of IgE to cow milk proteins are helpful although not definitive for diagnosis. Based on this limited study, tolerance is better achieved after 12 months of strict cow's milk elimination.

Serum ghrelin in infants with protein-energy malnutrition.

BACKGROUND: Ghrelin is an appetite and weight physiologic controller. The question is whether there is a relation between ghrelin and protein-energy malnutrition (PEM). Our aim was to assess serum ghrelin in these patients and its relation to different patient variables. METHODS: A cross-sectional study was conducted on 30 PEM infants (12 marasmic=Ia, 10 kwashiorkor=Ib and 8 marasmic kwashiorkor=Ic) and 15 age and sex matched controls (II). Plasma ghrelin was measured in all subjects using radioimmunoassay with thorough medical history and clinical assessment. RESULTS: The mean serum ghrelin levels were significantly higher among the 3 patient subgroups than controls with no significant inter-subgroup differences. The presence of intestinal parasitic infestations or edema, type of milk feeding and gender had no significant effects on serum ghrelin levels. CONCLUSION: Serum ghrelin is elevated in PEM as an adapting consequence of the malnutrition rather than a primary event. Although this elevation may not be helpful to correct the growth failure because of deficient nutrients, it may prove to have a role in the catch up phenomenon after the recovery. Further research should be directed toward therapeutic trials of ghrelin in the recovery phase.

Rotavirus fecal antigen retrieval in infantile intussusception.

This study was designed to assess the plausibility of an association between natural rotavirus infection and intussusception. It was conducted on 21 infants suffering from acute gastroenteritis (GE) complicated by intussusception who were compared to another 40 age- and sex-matched infants suffering from acute GE characterized by watery nonmucoid diarrhea without surgical complications. All enrolled patients were subjected to detailed history documentation, thorough clinical examination and laboratory investigations, complete stool analysis, and detection of rotavirus antigen in stools using the ELISA technique. Plain abdominal X-ray and ultrasound were also performed. The results of this study revealed 24 positive cases for rotavirus antigen in the stools of the acute uncomplicated GE patients (60.0%), while there were only ten positive cases in the intussusception group (47.6%). No significant difference in severity was detected between the two groups studied, especially in terms of signs of dehydration and need for IV fluids (p > 0.05). Most of the rotavirus positive cases among the intussusception group presented either in February or December (p < 0.05) with no significant seasonal pattern among the acute GE group (p > 0.05). In conclusion, rotavirus antigen retrieval from stools of GE patients complicated with intussusception was not statistically different from those detected among acute uncomplicated GE. Additionally, there was no association between seasonality or severity of rotavirus positive cases in acute GE patients and those with intussusception. It is thus prudent to say that wild rotavirus infection in GE patients does not carry an extra risk for the occurrence of intussusception.

Serum Fas and Bcl-2 in patients with epilepsy.

OBJECTIVES: The present study aimed to investigate the levels of the biochemical markers of apoptosis (soluble Fas and Bcl-2) in the sera of children and adolescents with idiopathic epilepsy. MATERIALS AND METHODS: The study included 30 children and adolescents (mean age 8.03 +/- 4.49 years) with idiopathic epilepsy, 16 of them were newly diagnosed, and 15 clinically healthy control subjects. Of the included patients, 22 had focal seizures and eight had generalized seizures. In addition to laboratory and radiological investigations needed for diagnosis and follow-up, soluble Fas (s.Fas) and Bcl-2 were assayed in sera of patients and controls by enzyme-linked immunosorbent assay technique. RESULTS: Serum levels of s.Fas and Bcl-2 were significantly higher in the patients group than in the control group; however, their levels were comparable in patients with different seizure types. Levels of s.Fas correlated positively with seizure severity and negatively with the duration from the last attack. Bcl-2 levels were positively correlated to each of the duration of epilepsy, the severity of seizures and its frequency. There was a significant positive correlation between serum levels of s.Fas and that of Bcl-2 and both were significantly increased in patients with uncontrolled epilepsy. CONCLUSION: The present data demonstrate that markers of apoptosis, both the proapoptotic Fas and the anti-apoptotic Bcl-2, were proportionately elevated in sera of patients with idiopathic epilepsy, and their levels were related to the seizure severity and frequency.

Pancreatic size in protein energy malnutrition: a predictor of nutritional recovery.

BACKGROUND: Pancreatic exocrine dysfunction has been frequently recorded in protein energy malnutrition (PEM) because the pancreas requires optimal nutrition for enzyme synthesis. This pancreatic enzyme insufficiency may play a role in the continuation of PEM. OBJECTIVE: This study was designed to assess the pancreatic head size and exocrine pancreatic functions, namely serum amylase and lipase, in PEM and its subtypes and correlate any defect present with the various clinical and laboratory data of the PEM patients with special emphasis on the effect of nutritional rehabilitation. PATIENTS AND METHODS: A total of 33 cases of PEM; 15 marasmus, 10 kwashiorkor (KWO) and eight marasmic kwashiorkor (MKWO) were recruited from Ain Shams University children's hospital, together with 12 matched controls. The mean age of patients was 11.87 +/- 7.8 months and that of the controls was 14.83 +/- 7.7 months. Detailed history taking and thorough clinical examination with special emphasis on anthropometric measurements were taken for each studied infant as well as laboratory investigations which included; complete blood count, liver and kidney functions and serum amylase and lipase. Ultrasonographic assessment of pancreatic head size was performed for the cases and controls. Nutritional rehabilitation program was carried out for 3-6 months followed by reassessment of the cases. RESULTS: The pancreatic head size values were significantly lower in all subtypes of PEM (1.52 +/- 0.6, 2.73 +/- 0.12 and 3.00 +/- 0.54 cm(3) in the marasmus, KWO and MKWO respectively) compared to the controls (5.13 +/- 2.33 cm(3)). The serum amylase and lipase were also significantly lower in all subgroups of PEM when compared to the controls with significant improvement following nutritional rehabilitation coupled by a significant increase in pancreatic head size too. No significant differences were recorded when we compared the subgroups together except for a significant higher rate of change in serum amylase in edematous patients compared to nonedematous ones. The length of nutritional rehabilitation period, age of the patient, weight and serum albumin were the most determinant factors for pancreatic head size as evident from the multiple regression analysis study. CONCLUSION: The potentially correctable exocrine pancreatic insufficiency in cases of PEM should be carefully thought of when planning the nutritional rehabilitation program for such patients as it could be responsible for the serious continued morbidity issues that they face. We thus recommend that estimation of pancreatic head size and exocrine function should be included in the evaluation of PEM patients and they could also be used as a prognostic parameter. SPONSORSHIP: The patients enrolled were among those admitted and managed freely in the children's Hospital Faculty of Medicine Ain Shams University, including the use of the ultrasound apparatus, while the kits have been purchased by authors who contributed in financing the study.