Alfredo Larrosa-Haro

Acute and recurrent pancreatitis in children: etiological factors

Objectives: To describe the clinical picture and outcome, and to assess the etiological factors of acute and recurrent pancreatitis in children.

Gastrointestinal occult hemorrhage and gastroduodenitis in cow's milk protein intolerance.

We are reporting on four infants with cows milk protein intolerance who presented with hypochromic anemia and occult gastrointestinal hemorrhage. Esophagogastroduodenoscopy revealed erosive gastritis or gastroduodenitis in all cases. Management with a cows milk-free diet led to a favorable clinical and hematological outcome; the endoscopic inflammatory image disappeared after the cows milk-free diet trial. Challenge with cows milk led to gastrointestinal symptoms and to impaired D-xylose absorption. The data presented suggest that some patients with cows milk intolerance may have gastroduodenitis resulting in occult gastrointestinal hemorrhage and hypochromic anemia.

Duodenal tube test in the diagnosis of biliary atresia

Background Biliary atresia (BA) is the main cause of severe liver damage in infants. Successful surgical treatment is related directly to an early and rapid diagnosis. The aim of this study was to determine specificity, sensitivity, and predictive value of the duodenal tube test (DTT) in the diagnosis of BA in a series of infants with cholestatic jaundice. Methods This was a descriptive study of a series of infants with cholestatic jaundice created to validate the sensitivity, specificity, and predictive value of the DTT in the diagnosis of BA. A total of 254 patients were identified from 1988 to 1998. The study cohort included 137 male infants (53.9%), and the mean age on admission was 8.3 weeks ± 2.47 weeks (standard deviation). Study protocol included liver function tests, liver ultrasound, metabolic screening and serology for viral hepatitis, and toxoplasma, rubella, cytomegalovirus, herpes, and others. A nasoduodenal tube was placed at the distal duodenum and the fluid was collected for 24 hours. DTT was considered bile positive when yellow biliary fluid was observed; the test was concluded at this time. When no yellow biliary duodenal fluid was observed, the collection was continued for 24 hours and, if negative, was reported as bile negative. The patients with a bile-positive DTT were not explored surgically, and the cholestasis workup was completed. Laparotomy and a surgical cholangiogram were indicated in patients with bile-negative DTT. If BA was verified, portoenterostomy was performed. The gold standard for BA diagnosis was the following: obstruction of the biliary tract confirmed by laparotomy and a surgical cholangiogram, and clinical outcome in patients without laparotomy (followed for a minimum of 18 months). Results The results are as follows. BA: bile-positive DTT, n = 3; bile-negative DTT, n = 108. No BA: bile-positive DTT, n = 134; bile-negative DTT, n = 9. The following values were also determined: sensitivity, 97.3%; specificity, 93.7%; positive predictive value, 92.3%; and negative predictive value, 98.5%. The final diagnoses were as follows: BA, n = 111 (43.7%); neonatal hepatitis syndrome, n =103 (40.6%); cholestasis associated with inspissated bile syndrome, n = 13 (5.1%); choledochal cyst, n = 11 (4.3%); galactosemia, n = 9 (3.5%); cirrhosis of unknown etiology, n = 5 (2%), and Alagille syndrome, n = 2 (0.8%). Conclusions The data obtained from this series validate the DTT as a useful clinical tool for the differential diagnosis of the infant with cholestasis, particularly for indicating laparotomy and cholangiogram to substantiate BA. This diagnostic test is quick and simple, and offers the clinician valuable information with which to determine whether surgical intervention is necessary.

Liver function test results predict nutritional status evaluated by arm anthropometric indicators.

Objectives: To compare the anthropometric indicators based on weight and height with the anthropometric indicators based on arm measurements and to predict the anthropometric nutritional status with liver function tests (LFTs) in children with chronic liver disease (CLD). Patients and Methods: A cross-sectional study in a referral pediatric hospital enrolled 79 children with CLD (mean age 72.6 ± 61.8 months, 54% female). An independent variable of LFT was used to determine the outcome variable of nutritional status. Anthropometric indicators of height versus age, weight versus height, head circumference versus age, and arm indicators versus age were analyzed with Pearson correlation, the determination coefficient r2, and multiple regression. Results: A total of 44.3% of patients studied had growth impairment. The anthropomorphic indicator of weight for height identified malnutrition in 11.4%, compared with 43% identified by mid- to upper arm circumference (MUAC) and 40.5% identified with total arm area. MUAC (P < 0.001), total arm circumference (P < 0.001), arm muscle area (P = 0.009), and arm fat area (P = 0.023) identified more cases of z score less than −2 SD than weight/height. The presence of ascites misled weight-for-height measurements. Conjugated bilirubin and albumin had significant correlations with almost all of the anthropometric indicators. Alkaline phosphatase correlated significantly with all of the arm anthropometric indicators. A regression analysis led to 7 prediction models; the highest prediction of z score less than −2 SD was with triceps skinfold and conjugated bilirubin, albumin, and γ-glutamyltransferase; height-for-age z score less than −2 SD was predicted by measurements of conjugated bilirubin, prothrombin time, and alanine aminotransferase. Conclusions: The data presented underline the correlation between the liver damage severity evaluated by LFT and the nutritional status estimated by anthropometric indicators. In our view these observations reflect the close relationship between liver function and the degree of liver damage to growth and current nutritional status.

Socio-demographic factors associated with caustic substance ingestion in children and adolescents.

OBJECTIVE Caustic substance ingestion is a public health issue in some underdeveloped countries. Published information on socio-demographic factors related to this problem is scarce. The aim of this study was to evaluate the association of socio-demographic factors with caustic ingestion in children. METHODS DESIGN case-control study. Cases were children with caustic substance ingestion who were attended to during 2006 (n=94) at a pediatric referral hospital in Guadalajara, Mexico; the controls were a random sample of children who were hospitalized or seen as outpatients in the same pediatric referral hospital (n=641). The socio-demographic variables were studied using a validated questionnaire (Children Nutrition Organization Survey). STATISTICS OR, 95% CI and logistic regression. RESULTS Mean age of the cases was 3.2 years (SD 2.4) and 37.2% of cases were girls. Caustic ingestion occurred at home in 63.8% of cases and at a relatives home in 23.4% of cases. Alkaline products were ingested by 85.1%; containers had no warning labels in 72.3% of cases and no childproof safety caps in 92.6% of cases. The socio-demographic variables associated with caustic ingestion included higher family income, lower educational level of the mother, higher proportion of fathers working as independent professionals, extended family, mothers age <30 years, and mother working outside the home. CONCLUSIONS The observed family risk profile for caustic ingestion was higher family income, young working mother with low educational level, father working as independent professional, and extended family.

Secondary malnutrition and overweight in a pediatric referral hospital: associated factors.

Objectives: To establish the prevalence and identify the clinical and sociodemographic factors associated with malnutrition and overweight in a pediatric referral hospital. Patients and Methods: We studied a cross-sectional, random sample from a pediatric hospital. Malnutrition was defined as acute when the z score of weight/height was less than −2.0 and as chronic if in addition the height/age z score was less than −2.0. Overweight risk was defined as a body mass index percentile between 85 and 94, and overweight as a body mass index percentile of 95 or higher. Results: The study included 641 patients, with mean age 7.1 ± 4.9 years (56% male). The overall prevalence of acute malnutrition was 8% and chronic malnutrition 17.0%. Overweight risk was present in 15.4% and overweight in 12.2%. Acute malnutrition was predicted by conditions on admission (hospitalization: odds ratio [OR] 2.3, confidence interval [CI] 1.3–4.3; nonsurgical subspecialty: OR 2.1, CI 1.0–4.3) and number of siblings (1 child, single mother: OR 2.6, CI 1.3–5.0). Chronic malnutrition was predicted by age (infants vs preschoolers: OR 2.0, CI 1.1–3.6; infants vs school children: OR 3.1, CI 1.8–5.5) and illness duration (>30 days: OR 2, CI 1.1–3.7). Overweight risk was associated with age (>36 months: OR 2.0, CI 1.6–3.4) and the fathers educational level (college and university: OR 2.3, CI 1.3–4.3). Overweight was predicted by sex (boys: OR 2.0, CI 1.0–3.6) and age (>36 months: OR 1.7, CI 1.0–2.8). Conclusions: Overweight was as prevalent as malnutrition. Malnutrition was associated with clinical condition, age, family size, and illness duration, whereas overweight was related to age, sex, and fathers education. Overweight appears as a novel finding in the nutritional profile of pediatric referral hospitals in Mexico.

Screening of R122H and N29I mutations in the PRSS1 gene and N34S mutation in the SPINK1 gene in Mexican pediatric patients with acute and recurrent pancreatitis.

Objectives The study’s objective was to assess the association between the PRSS1 R122H and N29I and the SPINK1 N34S mutations and acute pancreatitis (AP) and recurrent pancreatitis in Mexican pediatric patients. Methods The N34S and R122H mutations were detected using polymerase chain reaction–restriction fragment length polymorphism, and the N29I mutation was detected using allele-specific polymerase chain reaction in 92 pancreatitis patients (58 AP and 34 recurrent pancreatitis patients) and 144 controls. Results We found 1 mutated allele in 4 (4.3%) of 92 pancreatitis patients and none in the controls. All 4 patients bearing mutations had AP, with a frequency of 6.8% (4/58). Three (5.2%) of 58 patients were heterozygous for the N34S mutation, and 1 (1.7%) of 58 patients was heterozygous for the N29I mutation. The comparison between the AP and control groups revealed both a significant number of patients carrying any mutations in the screened genes (P = 0.008) and bearing the N34S mutation (P = 0.023). Moreover, we found that the N34S G allele increased the risk of developing AP (odds ratio, 10.3; confidence interval, 1.1–248.8). Conclusions Patients bearing the N34S G allele exhibited a 10-fold increased risk of developing AP compared with controls, suggesting that the SPINK1 N34S mutation represents an etiologic risk factor for AP in our Mexican pediatric patients.

Seasonal variation of enteropathogens in infants and preschoolers with acute diarrhea in western Mexico.

The present study estimates the prevalence of some enteropathogens in infants and preschoolers with acute diarrhea. From 2006 to 2007, 5459 consecutive stool samples were evaluated. Cryptosporidium parvum was the parasite identified with the higher frequency (5.1%), followed by Giardia lamblia (1.2%). Campylobacter jejuni was isolated in 858 cases (15.7%) and was the most frequent enteropathogen overall. The rates of C parvum, Shigella, and Salmonella were higher in the summer. Rotavirus had the expected winter peak and it was the third enteropathogen because of its frequency. Overall frequency of stool-reducing substances was 15.6% and was associated with a rotavirus-positive test.

Utilidad del estudio de las heces para el diagnóstico y manejo de lactantes y prescolares con diarrea aguda

Objective. To analyze the results of a stool work-up protocol in a series of infants and preschoolers with acute diarrhea.

Effectiveness of Enteral Versus Oral Nutrition With a Medium-Chain Triglyceride Formula to Prevent Malnutrition and Growth Impairment in Infants With Biliary Atresia

Objectives: The aim of this study was to compare the effectiveness of oral (PO) versus enteral nutrition (EN) medium-chain triglyceride (MCT) containing–formula to prevent malnutrition and growth impairment in infants with biliary atresia (BA) waiting for a liver transplant. Methods: A total of 15 infants, 3 to 9 months old with BA were included. They were randomly assigned to either PO or EN. For 12 weeks, both groups received an MCT formula fortified with glucose polymers and corn oil to reach a caloric density between 0.8 and 1 kcal/mL. The formula given to the PO group was administered ad libitum and that given via EN was infused through a nasogastric tube to reach 140% of the energy intake recommended by the Dietary Recommended Intake guidelines. Protein intake was adjusted to 4 to 5 g/kg present weight. Outcome variables were growth and nutritional status evaluated periodically by anthropometric indicators. Biochemical and hematological variables were evaluated through the study. Results: Baseline clinical, nutritional, biochemical, and hematological variables showed no differences between the study groups. Baseline length/age was <−2 SD in 10 of the 15 patients; in the PO group, it fell <−3 SD, whereas in the EN group, it remained stable. Head circumference z score dropped 0.6 SD in the PO group, whereas in the EN group it remained stable. Triceps skinfold values improved in the infants taking EN, P < 0.001. The frequency of adverse effects—respiratory infection and diarrhea—was higher in the EN group. No biochemical or hematological differences were observed between the study groups throughout the study. Conclusions: A 12-week EN trial with an MCT-fortified formula prevented malnutrition and growth impairment in infants with BA waiting for a liver transplant.