C. Sierra Salinas

Obesidad Infantil. Recomendaciones del Comité de Nutrición de la Asociación Española de Pediatría. Parte II. Diagnóstico. Comorbilidades. Tratamiento

En el presente articulo se revisan los criterios actuales para el diagnostico de la obesidad y de sus comorbilidades en la edad pediatrica, asi como el tratamiento en todas sus vertientes: dietetico, ejercicio fisico, farmacologico y quirurgico.

Colitis alérgica en lactantes exclusivamente amamantados al pecho

Introduccion La proctocolitis eosinofilica esta inducida por antigenos presentes en las proteinas de leche de vaca contenidas en las formulas o en la leche humana y, en los ultimos anos, se describen cada vez mas casos en lactantes pequenos alimentados exclusivamente con la leche materna. Pacientes y metodos Se presenta un estudio retrospectivo de los 13 casos de colitis alergica diagnosticados en nuestra unidad entre enero de 1997 y enero de 2004, todos ellos lactantes que estaban recibiendo exclusivamente leche materna. Resultados La sintomatologia de inicio fue siempre la digestive (12 debutaron con heces con moco y hebras de sangre) y en el 77 % de los casos aparecio entre los 0 y los 3 meses de edad. Los datos analiticos del componente alergico fueron negativos. Las lesiones se localizaron, principalmente (75 %), en las zonas descendente y sigma del colon. La anatomia patologica demostro datos inflamatorios agudos, con infiltracion por polimorfonucleares y aumento de eosinofilos. En todos los pacientes se inicio tratamiento excluyendo la leche de vaca y sus derivados en la dieta de la madre. En 10/13 no se evidencio mejoria, por lo que requirieron administracion exclusiva de hidrolizado extenso de proteinas. En 3 ninos se mantuvo lactancia mixta (sin proteinas vacunas + hidrolizado). Conclusiones El diagnostico exige exclusion de otras causas de colitis especifica y hallazgos endoscopicos y anatomopatologicos caracteristicos; ademas, se debe demostrar respuesta adecuada al tratamiento dietetico. Se debe pensar en esta patologia al afrontar el diagnostico de lactantes amamantados que presenten sangrado rectal sin afectacion del crecimiento o del estado general.

Enfermedad de Crohn metastásica

La enfermedad de Crohn es una condicion inflamatoria intestinal de origen desconocido, que en ocasiones cursa con manifestaciones cutaneas. Estas lesiones, que por lo habitual son inespecificas (eritema nudoso, eritema multiforme y pioderma gangrenoso) deben diferenciarse de las lesiones de piel que presentan el cuadro his-tologico tipico de la enfermedad de Crohn; la mayoria de estas lesiones corresponde a la extension por contiguidad con el tracto intestinal. En muy raras ocasiones se encuentra en la piel infiltracion granulomatosa no caseificante en zonas anatomicamente distantes de areas de enfermedad de Crohn gastrointestinal, separadas de estas por piel normal. Esta entidad, conocida como enfermedad de Crohn metastasica, puede aparecer como presentacion inicial de la enfermedad o lo que es aun mas infrecuente, en el curso de la enfermedad primaria. Se describe el caso de un nino varon de 9 anos de edad diagnosticado previamente de enfermedad de Crohn ileocolica y perianal. Desde hacia 3 anos recibia tratamiento con mesalacina, prednisona y 6-mercaptopurina. Consulto por edema de pene y escroto de 2 semanas de evolucion sin otros sintomas asociados. La ecografia testicular mostro engrosamiento de la pared escrotal con flujo aumentado en ese punto. La biopsia de piel escrotal revelo granulomas no caseificantes. La tecnicas especiales de tincion para determinar la presencia de germenes resultaron negativas. Se incremento la dosis de prednisona y se anadio metronidazol, con lo cual se obtuvo una notable mejoria de las lesiones. En la actualidad sigue tratamiento de mantenimiento al producirse exacerbacion de la afectacion genital al disminuir la dosis de corticoides.

Oral tacrolimus for pediatric steroid-resistant ulcerative colitis

BACKGROUND Ulcerative colitis (UC) occurring during childhood is generally extensive and is associated with severe flares that may require intravenous steroid treatment. In cases of corticosteroid resistance is necessary to introduce a second-line treatment to avoid or delay surgery. AIMS To describe the efficacy and safety of oral tacrolimus for the treatment of severe steroid-resistant UC. METHODS We performed a retrospective study that included all patients under age 18 suffering from severe steroid-resistant UC treated with oral tacrolimus during the period January 1998 to October 2012 and with a follow-up period after treatment of 24 months or more. RESULTS A total of ten patients were included. The age at baseline was 9.4±4.9 years, and the time from diagnosis was 1.3 months (IQR, 1-5.7). Seven of the patients were in their first flare of disease. All of them received an oral dose of 0.12 mg/kg/day of tacrolimus divided in two doses. Trough plasma levels of tacrolimus were maintained between 4 and 13 ng/ml. Response was seen in 5/10 patients at 12 months, colectomy was eventually performed in 60% of patients during the follow-up period. CONCLUSIONS Tacrolimus is useful in inducing remission in patients with severe steroid-resistant UC, preventing or delaying colectomy, and allowing the patient and family to prepare for a probable surgery. Tacrolimus may also be used as a treatment bridge for corticosteroid-dependent patients until the new maintenance therapy takes effect.

La nutrición enteral exclusiva continua siendo el tratamiento de primera línea en la enfermedad de Crohn pediátrica en la era de los biológicos

INTRODUCTION Exclusive enteral nutrition (EEN) has been to be more effective than corticosteroids in achieving mucosal healing without their side effects. OBJECTIVES To determine the efficacy of EEN in terms of inducing clinical remission in newly diagnosed CD children and to study the efficacy of this therapeutic approach in improving the degree of intestinal mucosa inflammation. MATERIALS AND METHODS The medical records of patients with newly diagnosed Crohns disease treated with EEN were reviewed retrospectively. The degree of mucosal inflammation was assessed by fecal calprotectin (FC). Remission was defined as a PCDAI<10. RESULTS Forty patients (24 males) were included, the age at diagnosis was 11.6 ± 3.6 years. Of the 34 patients who completed the EEN period, 32 (94% per-protocol analysis) achieved clinical remission. This percentage fell to 80% in the intention-to-treat analysis. The compliance rate was 95%. Duration of EEN was 6.42 weeks (IQR 6.0-8.14). FC was significantly higher in patients with moderate and severe disease. Median baseline FC levels (680 μg/g) decreased significantly to 218 μg/g (P<0.0001) after EEN. We found a statistically significant correlation between FC and PCDAI (rho=0.727; P<0.0001). Early use of thiopurines (< 8 weeks) versus subsequent use was not associated with improved outcomes during the follow-up. CONCLUSIONS EEN administered for 6-8 weeks is effective for inducing clinical remission and decreasing the degree of mucosal inflammation. We did not find differences in terms of maintenance of remission in patients treated early with thiopurines.

Eficacia y seguridad de tacrolimus oral para el tratamiento de la enfermedad inflamatoria intestinal pediátrica

BACKGROUND In certain clinical situations, such as acute and severe episodes of ulcerative colitis (UC) or Crohns Disease (CD), that do not respond to conventional intravenous steroid treatment, we need potent, fast-acting drugs to induce clinical remission and avoid surgery. OBJECTIVES To evaluate the efficacy and safety of oral tacrolimus treatment of acute and severe UC or CD to induce their remission, and also to assess its efficacy in delaying or avoiding surgery. MATERIAL AND METHODS We present a retrospective study that included all patients under 18 years of age with acute and severe bouts of CD (colonic or ileocolonic location) or UC who were treated with oral tacrolimus at our institution from January 1998 to December 2007. RESULTS We included a total of 8 patients (4 males and 4 females), 6 presented with UC and 2 had CD. The mean age of our patients at the start of the treatment was 11.8 years (range 2.75-16.58 y) and the mean time from diagnosis to the start of tacrolimus therapy was 4 months (range 1-96 m). An initial response was obtained in 50% of patients. Plasma trough levels of tacrolimus remained between 5-11 ng/ml. Six of the eight patients (75%) required surgery. In one patient with UC and in another with CD, surgery was avoided. In 2 of the 6 patients with UC, surgery was postponed beyond 6 months. CONCLUSIONS Tacrolimus is useful in inducing clinical remission in patients with acute and severe bouts of UC or CD, and so can avoid or delay the surgery; it may also be used as a bridging agent until the new maintenance therapy with other immunosuppressants is effective.

Influencia del gasto energético en la obesidad infantil

Objetivos Estudiar las diferencias en el gasto energetico en reposo (GER) en funcion de sus determinantes (sexo, peso, masa grasa, masa magra) y la oxidacion de los sustratos energeticos entre ninos obesos y no obesos. Pacientes y metodos Se ha estudiado una muestra de 71 ninos, 39 obesos y 32 controles, con rango de edad entre 4,1 y 13,6 anos, de los cuales 37 eran mujeres y 34 varones, a los que se realiza medida del gasto energetico mediante calorimetria indirecta de circuito abierto. La oxidacion de sustratos se calculo a partir del consumo de oxigeno, produccion de anhidrido carbonico y excrecion de nitrogeno ureico uri-nario. Se determino la composicion corporal por antropometria. Resultados El GER (kcal/dia) ajustado en funcion de los parametros antropometricos y de composicion corporal es superior en ninos que en ninas. El GER en valor absoluto es significativamente superior en los obesos (1.512,82 234,47 frente a 1.172,59 190,20), y al expresarlo en funcion de sus determinantes, sigue siendo mayor en los obesos o se iguala en ambos grupos. Los obesos presentan mayor porcentaje de oxidacion de grasas (57,15 10,68 frente a 51,08 13,61; p 0,04), menor porcentaje de oxidacion dehidratos de carbono (30,10 9,85 frente a 36,34 13,61 p 0,03) y menor cociente respiratorio (0,79 0,03 fren-te a 0,82 0,04; p 0,02). No existen diferencias en los porcentajes de oxidacion de hidratos de carbono, grasas y proteinas segun el sexo. Conclusiones Del estudio se han extraido las siguientes conclusiones: a)el GER ajustado en funcion de los parametros antropometricos y de composicion corporal es significativamente superior en el sexo masculino que en el femenino;b)el GER es superior en los obesos, y sigue siendolo al estan darizarlo en funcion de la masa corporal magra, yc)los ninos obesos presentan mayor porcentaje de oxidacion de grasas, menor porcentaje de oxidacion de hidratos de car-bono y un cociente respiratorio menor que los ninos no obesos. Objectives To study differences in resting energy expenditure (REE) according to its determining factors (sex, weight, body fat mass, lean body mass) and in the oxidation of energy substrates in obese and non obese children. Patients and methods We studied 71 children (39 obese and 32 non-obese) aged from 4.1 to 13.6 years. The male/female ratio was 34/37. Energy expenditure (EE) was measured by usingopen circuit indirect calorimetry. The oxidation of energy substrates was calculated from oxygen consumption, car-bon dioxide production, and urinary nitrogen excretion from urea. Body composition was determined by anthro-pometry.

Plasma citrulline as a marker of loss of enterocitary mass in coeliac disease in childhood

INTRODUCTION Plasma citrulline is not incorporated in endogenous or exogenous proteins so it is a theoretical marker of villous atrophy. Our aim was to correlate plasma citrulline levels with severity of villous atrophy in celiac patients. METHODS Observational case-control study longitudinal in children 16 month-old to 14 year-old: 48 with untreated celiac disease, 9 celiac children under gluten free diet and 35 non-celiac healthy children. Plasma amino acids concentration is determined, expressed in μmol/L, and so are other clinical and analytical data. RESULTS No statistically significative difference found in the referring to BMI, age or renal function. Small increase in fecal fat in celiac children. Citrulline, arginine and glutamine are significantly lower in cases (17.7 μmol/l, 38.7 μmol/l, 479.6 μmol/l respectively) than in controls (28.9 μmol/l, 56.2 μmol/l, 563.7 μmol/l). Citrulline levels are significantly lower in the severe degrees of atrophy than in mild ones (13.8 μmol/l vs. 19.7 μmol/l, p < 0.05), not happening so with rest of amminoacids. SUMMARY Postabsortive mean of plasma citrulline is a good marker of reduction in enterocyte mass in celiac patients with villous atrophy; secondary reduction in plasma arginine too. Just a small histological alteration in intestinal biopsy is enough to differentiate citrulline in cases and controls and besides it can be seen that high levels of atrophy present with lower plasma citrulline.

Disminución de la densidad mineral ósea y otros factores de riesgo en niños prepuberales con fractura del antebrazo distal

AIM To investigate the relationship between bone mineral density (BMD), age, sex, anthropometric measurements, dietary calcium intake and daily physical activity, in prepubertal children with distal forearm fracture (DFF). METHODS 160 children (80 males, 80 females) 3-10 years of age with DFF; control group of 160 children (age-sex matched) were studied. Age, sex, weight, height, tricipital skin fold thickness (TS), body mass index, daily calcium intake, and level of physical activity (extra-school physical exercise: low <1hour/day, high >1hour/day) registered. BMD assessed by peripheral DXA densitometer. RESULTS Most fractures were caused by mild-moderate precipitating trauma by accidental fall (85.6%), with radius fracture in most cases (87.5%). BMI was higher in patients (19.14 kg/m(2)+/-3.50 vs. 17.46 kg/m(2)+/-2.67; p<0.0001). TS thickness was similar in both groups (20.28 mm+/-8.24 vs. 19.61 mm+/-6.60; p>0.05). Physical activity was lower in study group (extra-school physical activity >1h: 21.25% vs. 46.87%; p<0.001). Daily calcium intake was not associated with DFF incidence (918.75 mg/day+/-338.04 vs. 886.13 mg/day+/-382.77; p>0.05). BMD was lower in fractured children (0.2591 g/cm(2)+/-0.0413 vs. 0.2801 g/cm(2)+/-0.0300; p<0.0001) SUMMARY Our results suggest that significantly reduced bone mineral density, overweight and low physical activity are potential risk factors for fracture of the distal forearm, whilst low dietary intakes of calcium do not seem to be associated. The current epidemic of infantile overweight might explain the increased incidence of fractures of the distal forearm.

La composición de la microbiota duodenal en niños con enfermedad celíaca activa está influenciada por el grado de enteropatía

OBJECTIVES To establish whether the duodenal mucosa microbiota of children with active coeliac disease (CD) and healthy controls (HC) differ in composition and biodiversity. MATERIAL AND METHODS Samples of duodenal biopsies in 11 CD patients were obtained at diagnosis, and in 6 HC who were investigated for functional intestinal disorders of non-CD origin. Total duodenal microbiota and the belonging to the genus Lactobacillus using PCR-denaturing gradient gel electrophoresis (DGGE) were analysed. The banding patterns obtained in the resulting gels were analysed to determine the differences between the microbiota of CD patients and HC (FPQuest 4.5) while environmental indexes (richness, diversity and habitability) were calculated with the Past version 2.17 program. RESULTS The intestinal microbiota of patients with Marsh 3c lesion showed similarity of 98% and differs from other CD patients with other type of histologic lesion as Marsh3a, Marsh3b and Marsh2. The main differences were obtained in ecological indexes belonging to the genus Lactobacillus, with significant richness, diversity and habitability reduction in CD patients. In CD bands were categorized primarily with Streptococcus, Bacteroides and E.coli species. In HC the predominant bands were Bifidobacterium, Lactobacillus and Acinetobacter, though the Streptococcus and Bacteroides were lower. CONCLUSIONS The celiac patients with major histological affectation presented a similar microbiota duodenal. The ecological indexes applied to the genus Lactobacillus were significantly reduced in CD.