[Constipation in infants and children: How should it be treated?]. / Traitements de la constipation du nourrisson et de l'enfant.

Functional constipation is a common pediatric problem in general practice and even more so in pediatric gastroenterology clinics. Treatment is often delayed with psychosocial and digestive consequences. However, treatment is well codified and effective. Hyperosmotic mineral water, diet, and endoanal medications are not treatments for established constipation, whatever the age. The lactulose/lactitol-based medications are authorized and effective before 6 months of age and polyethylene-glycol for infants over 6 months. Mineral oil is less prescribed. The rule for treatment is a sufficient dose for a long time. In case of fecal impaction with or without fecal incontinence, the first stage is fecal disimpaction, using a high dose of PEG the first few days, or repeated phosphate enemas. Education regarding the adaptation of toilets and a daily bowel movement should restore colic motility and avoid relapses when the treatment is discontinued. Psychological concerns should be evaluated and treated.

Association of N-acetylcysteine and glucagon during percutaneous cholangiography in the treatment of inspissated bile syndrome.

Inspissated bile syndrome (IBS) is a rare neonatal disease. In the majority of cases, it resolves spontaneously and treatment is conservative. Follow-up is recommended with close monitoring of laboratory tests. When IBS does not resolve spontaneously, a catheter can be inserted into the gallbladder for cholangiography, which allows irrigation and drainage. Despite this treatment, some biliary tract obstruction may persist. We report on the case of a 3-month-old infant whose continuous biliary obstruction caused by IBS was successfully managed by interventional radiology with the association of N-acetylcysteine and glucagon. Even as first-line agents, these would allow more rapid clearance of gallstones and prevent infectious complications of indwelling catheters as well as decrease the need for surgery.

[Symptoms of Celiac disease in childhood]. / Les manifestations de la maladie cœliaque chez l'enfant.

The knowledge regarding celiac disease has increased dramatically in recent years, due to the availability of accurate serologic markers. Mass screening studies have shown that the prevalence of sensitization can be as high as 1/80. The range of symptoms is wide, from the classic growth failure, denutrition and diarrhea in infancy to clinically and histologically asymptomatic sensitized subjects. The interest of a routine mass screening is debated. The classical celiac disease in infancy is well known. Atypical symptoms and potentially associated disease are more frequent and potentially confounding. Physicians should be aware of any clue for celiac disease in atypical cases in order to improve the diagnostic yield, and therefore avoiding short or long term consequences.

[Capsule endoscopy in children: which are the best indications?]. / Quelles indications pour l'endoscopie du grêle par vidéocapsule en pédiatrie?

BACKGROUND AND STUDY AIMS: Capsule endoscopy (CE) is a novel and noninvasive means of investigating the small bowel. In children, the best CE indications have not yet been fully appraised. The aim of this study was to evaluate the diagnostic yield of CE in different pediatric pathologies. PATIENTS AND METHODS: We retrospectively reviewed every CE performed in children in two French pediatric hospitals between March 2002 and June 2009. Seventy-nine CEs were performed on 70 children (mean age, 10.6 years; range, 2.2-18.0); 52 boys and 18 girls. The indications were iron deficiency anemia (24%), obscure gastrointestinal bleeding (14%), polyposis syndromes (16%), suspected Crohn disease (15%), unresponsive Crohn disease (10%), graft-versus-host disease (10%), and other (10%). RESULTS: Of the 79 CEs, 69 reached the cecum (87%). Only one occlusion occurred in a case of stenosing Crohn disease, requiring surgical removal. In addition, technical difficulties led to an incomplete small bowel study in 12 cases (16%). The CE showed small bowel lesions in 42 cases (53%). The diagnostic yield was 27% in obscure gastrointestinal bleeding, 37% in iron-deficiency anemia, 42% in suspected Crohn disease, 88% in unresponsive Crohn disease, 62% in polyposis syndromes, and 88% in graft-versus-host disease. CONCLUSION: In children, CE is well tolerated and can be performed in children as young as 2.2 years of age. Its diagnostic yield is highest in polyposis syndromes, unresponsive Crohn disease, and graft-versus-host disease.

Prevention of relapse by mesalazine (Pentasa) in pediatric Crohn's disease: a multicenter, double-blind, randomized, placebo-controlled trial.

AIM: This study aimed to test the efficacy of mesalazine in maintaining remission in pediatric Crohn's disease (CD) following successful flare-up treatment. METHODS: In this double-blind, randomized, placebo-controlled trial, 122 patients received either mesalazine 50mg/kg per day (n=60) or placebo (n=62) for one year. Treatment allocation was stratified according to flare-up treatment (nutrition or medication alone). Recruitment was carried out over two periods, as the first period's results showed a trend favoring mesalazine. Relapse was defined as a Harvey-Bradshaw score more than or equal to 5. Time to relapse was analyzed using the Cox model. RESULTS: The one-year relapse rate was 57% (n=29) and 63% (n=35) in the mesalazine and placebo groups, respectively. We demonstrated a twofold lower relapse risk (P<0.02) in patients taking mesalazine in the medication stratum (first recruitment period), and a twofold higher risk in patients taking mesalazine in the nutrition stratum (second recruitment period), compared with the other groups. None of the children's characteristics, which differed across the two recruitment periods, accounted for the between-period variation in mesalazine efficacy. One serious adverse event was reported in each treatment group. CONCLUSION: Overall, mesalazine does not appear to be an effective maintenance treatment in pediatric CD.

[Oral rehydration solutions and acute diarrhoea: an update]. / Solutions de réhydratation orale et diarrhée aiguë: état des lieux.

Oral rehydration solutions (ORS) have been used since 1960 and avoided millions of children deaths due to acute diarrhoeas. It is the only treatment currently able to prevent and treat acute dehydration. In France, ORS are cost free due to a health insurance refund. Its composition is regulated by law and the efficacy of each available product is equivalent. These products should be available in every infant's home, even before any gastroenteritis episode occurs. Parents should be aware of the risks of gastroenteritis in infants, also parents should know how to use ORS. The principle of use is to propose ad libitum the ORS as long as the diarrhoea continues. Breast feeding should be continued if going on. In cases of bottle feeding, milk should be reintroduced after a few hours of rehydration. ORS are not well known, prescribed or used and that may explain for the most part the dehydration and deaths which occur in France. ORS are the only life-saving treatment for gastroenteritis, which has proved its efficacy for the past 50 years: it is time to use it on a routine basis.

[Evaluation of varicella complications through a retrospective hospital survey in a paediatric center over 16 years in France]. / Evaluation des complications de la varicelle à partir d'une enquête hospitalière rétrospective menée dans un service de pédiatrie pendant 16 ans en France.

OBJECTIVE: Evaluation of the varicella severity through a prevalence study of hospital admissions justified by a complication directly related to the onset of an acute episode of varicella. METHODS: Retrospective study in one paediatric center in France with a follow-up of a paediatric cohort from April 1987 to December 2002. This general paediatric hospital recruits children from a 400,000 inhabitants area. Inclusion criterion: diagnosis main or associated of varicella. EXCLUSION CRITERIA: congenital or acquired immunodepression, including long-term oral high dosage steroid therapy. RESULTS: Three hundred and forty-three (343) complications of varicella were reported in 309 children hospitalised for a symptom in relationship with varicella. Most of children (75%) were <2 years of age. The annual number of hospitalisations varied with a maximum of 44. An increase of the number of hospitalisations was reported since 1997 but particularly since 2000. Main complications were gastro-intestinal (75), neurological (68), bronchopulmonary (52), and skin and soft tissue infections (52). Superinfections of soft tissues such as Streptococcus pyogenes cellulitis and life-threatening complications, which occurred in children treated by a short-course of corticosteroïds for an acute episode such as an asthma crisis, were mostly noticed since 1995. Two deaths occurred. CONCLUSION: These data collected over 16 years as part of a retrospective survey of a paediatric cohort show that varicella, often considered as a mild disease, can be responsible for severe complications in young immunocompetent children. The digestive complications (30%) are the main complication in our study with existence of gingivitis-stomatitis but also lower digestive manifestations (erosive gastritis aspect through endoscopy). These data have all the more to be taken into account because a vaccine, developed for healthy children, is now available in France. A national survey of hospitalised varicella has been set up since March 2003.

Apolipoprotein B Arg3500Gln mutation prevalence in children with hypercholesterolemia: a French multicenter study.

BACKGROUND: Familial defective apolipoprotein B-100, a dominantly inherited form of hypercholesterolemia caused by a single Arg3500Gln mutation, is silent in childhood but may confer a high risk of cardiovascular disease in adulthood. The objective was to determine the prevalence of familial defective apolipoprotein B-100 in hypercholesterolemic French children and to provide a basis for targeting screening efforts in this population. METHODS: One hundred ninety children attending 13 pediatric clinics distributed throughout France were included based on the presence of type IIa hypercholesterolemia with a plasma low-density lipoprotein-cholesterol level of more than 130 mg/dL. The Arg3500Gln mutation was detected in dried blood spots using a polymerase chain reaction assay combined with enzymatic restriction. RESULTS: Three hyperlipidemia phenotypes were found: monogenic dominant pure hypercholesterolemia (n = 117), polygenic hypercholesterolemia (n = 43), and combined hyperlipidemia (n = 11). Three unrelated children were heterozygous for the Arg3500Gln mutation; all three had monogenic dominant pure hypercholesterolemia (3/94 families; 3.2%), yielding a prevalence of 1.83% (3/164) in hypercholesterolemic children, which is similar to prevalences reported in European adults. CONCLUSIONS: The familial defective apolipoprotein B-100 mutation was common (1/31) in children with a phenotype of familial hypercholesterolemia, supporting screening in this population with the goal of preventing premature cardiovascular events.

[Incidence of symptomatic celiac disease in French children]. / Incidence de la maladie coeliaque symptomatique de l'enfant en France.

OBJECTIVE: The study was carried out by the GFHGNP to determine the annual incidence of symptomatic celiac disease in children. PATIENTS AND METHODS: The diagnostic criteria were: symptomatic patients diagnosed under 15 years of age during 1996, villous atrophy and positivity of antigliadin and/or other antibodies. Cases were collected from referral centers, general hospital pediatric departments and private pediatricians with endoscopic practice. RESULTS: The study involved roughly half of the French pediatric population in 41 out of the 95 French districts. In all, 124 patients were collected: 76 girls and 48 boys. By geographical areas, in 30 districts where collection of data was complete which counted 186,285 births, the yearly incidence varied from 1/1731 births to 1/3110. (0.57@1000 to 0.32@1000). On the whole there were 77 cases i.e. an annual incidence of 1/2419 or 0.41@1000 (confidence interval 95%: 0.32 to 0.50@1000). Lower incidences were observed in the district of Paris: 1/4865 (0.21@1000) and Lyon: 1/3310 (0.27@1000). Those lower incidences could be explained by the difficulties of collecting the data in the biggest urban areas. The first signs occurred before one year of age in 73% of the cases, during the second year of life in 20.5% and after 3 in only 6.5%. The diagnosis was made before 2 years of age in 77% of the cases and after 3 in only 13%. In order of frequency symptoms were: failure to thrive (80%), diarrhea (59%), anorexia (59%), abdominal distension (57%), weight under 2 standard deviations (43%), short stature (43%). CONCLUSION: Compared with previous studies in two French districts between 1975 and 1990, the annual incidence of symptomatic celiac disease in children appears to be on the rise. The usual clinical signs continue to be observed.

[Esophageal bezoar in a child treated with sucralfate]. / Bézoard oesophagien chez un enfant traité par sucralfate.

BACKGROUND: Sucralfate is widely used in stress bleeding prophylaxis in intensive care units as it causes relatively few side effects. Its use in patients with risk factors may lead to the formation of esophageal bezoar. We describe the first known pediatric case of sucralfate esophageal bezoar. CASE REPORT: A 11-year-old girl presented with severe encephalitis complicated by seizures. She was treated in an intensive care unit by restrictive hydration associated with sucralfate, morphinic compound, phenobarbital and curare. At day 10, enteral feeding through a nasogastric tube was started. Five days later, an esophageal bezoar was diagnosed, which disappeared after discontinuing sucralfate, morphinic compound, curare and enteral feeding. CONCLUSIONS: Risk factors, similar to those reported in adults with esophageal bezoars, were found in this patient ie, plurimedication, dehydration, impaired gastric motility. Caution should be taken when combining enteral feeding and sucralfate whenever any additional risk factor is present.

[Syncope during bathing in infants, a pediatric form of water-induced urticaria?]. / Malaises au bain chez le nourrisson, une forme pédiatrique de l'urticaire aquagénique?

BACKGROUND: Apparent life-threatening events in infants are a difficult and frequent problem in pediatric practice. The prognosis is uncertain because of risk of sudden infant death syndrome. CASE REPORTS: Eight infants aged 2 to 15 months were admitted during a period of 6 years; they suffered from similar maladies in the bath: on immersion, they became pale, hypotonic, still and unreactive; recovery took a few seconds after withdrawal from the bath and stimulation. Two diagnoses were initially considered: seizure or gastroesophageal reflux but this was doubtful. The hypothesis of an equivalent of aquagenic urticaria was then considered; as for patients with this disease, each infant's family contained members suffering from dermographism, maladies or eruption after exposure to water or sun. All six infants had dermographism. We found an increase in blood histamine levels after a trial bath in the two infants tested. The evolution of these "aquagenic maladies" was favourable after a few weeks without baths. After a 2-7 year follow-up, three out of seven infants continue to suffer from troubles associated with sun or water. CONCLUSION: "Aquagenic maladies" could be a pediatric form of the aquagenic urticaria.

[Sleeping position, prevention of sudden death syndrome and gastroesophageal reflux]. / Position de sommeil, prévention de la mort subite du nourrisson et reflux gastrooesophagien.

Based on results of epidemiological studies, dorsal or lateral sleeping positions are now recommanded in the prevention of sudden infant death syndrome (SIDS). This raises an ethical question about the attitude towards the ventral positioning therapy for gastroesophageal reflux (GOR). The consensus conference considers that the ventral position should only be recommanded in GOR when the benefit appears to outweigh the risk of SIDS that it induces. The conference proposes that for infants with simple uncomplicated reflux, sleeping in the prone position should not be introduced in the first line treatment. Prone positioning should be restricted to complicated cases resistant to dietary and medical measures.