Ji Hyuk Lee

Infliximab therapy in children with Crohn’s disease: a one‐year evaluation of efficacy comparing ‘top‐down’ and ‘step‐up’ strategies

Background:  The aim of this study was to evaluate the efficacy of ‘top‐down’ regimens for the treatment of paediatric Crohn’s disease (CD) and to compare it with the effects of ‘step‐up’ treatment.

Probiotic bacteria, B. longum and L. acidophilus inhibit infection by rotavirus in vitro and decrease the duration of diarrhea in pediatric patients

BACKGROUND AND OBJECTIVES Evidence suggests that specific probiotics may be antagonistic to enteric pathogens and enhance immunity, and thus, provide a means of preventing or treating diarrheal diseases. In the present study, we aimed to evaluate the efficacy of probiotic strains isolated from Koreans for the treatment of viral gastroenteritis in young children and against rotavirus in vitro. METHODS In vitro antiviral activities of probiotic isolates on rotavirus infection were investigated in the Vero cell using a plaque reduction assay. Then several probiotic strains with the high antiviral activity were chosen for further clinical trials. Twenty-nine pediatric patients who presented with symptoms of viral gastroenteritis were enrolled in a double-blind trial and randomly assigned at admission to receive six probiotic strains (Bifidobacterium longum, B. lactis, Lactobacillus acidophilus, L. rhamnosus, L. plantarum, and Pediococcus pentosaceus) at a dose of 10(9) colony forming units/g or a comparable placebo twice daily for 1 week. RESULTS AND CONCLUSIONS Of the tested probiotic strains, B. longum isolated from an infant showed the greatest inhibitory effect and L. acidophilus showed the second-highest inhibitory effect. These probiotics significantly shortened the duration of diarrhea as compared with a placebo (6.1 ± 0.5 vs 7.2 ± 1.9, P = 0.030) and did not induce any adverse effects. Our findings suggest that the probiotic strains selected in the present study may be useful for the treatment of acute rotaviral gastroenteritis or as an alternative therapy without adverse effects.

Utility of fractional exhaled nitric oxide (FENO) measurements in diagnosing asthma

BACKGROUND To facilitate the use of fractional exhaled nitric oxide (F(E)NO) as a clinical test, F(E)NO measurements need more clarification. AIM We sought to evaluate the yield of F(E)NO measurement for the diagnosis of asthma and identify the determinants of F(E)NO in children. METHODS Two hundred forty five consecutive steroid-naïve patients aged 8-16 years with symptoms suggestive of asthma were included. Children were evaluated using F(E)NO measurements, questionnaires, skin prick tests, spirometries, and methacholine challenge tests. RESULTS Asthma was diagnosed in 167 children. The sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) of F(E)NO measurements for the diagnosis of asthma at the best cutoff value of 22 ppb were 56.9%, 87.2%, 90.5%, and 48.6%, respectively. At a cutoff value of 42 ppb, specificity and PPV were all 100% but at the cost of very low sensitivity (23.4%) and NPV (37.9%). Both atopy and asthma were identified as independent risk factors associated with high F(E)NO. The association of asthma with high F(E)NO was found only in atopic children because F(E)NO was low in non-atopic children regardless of asthma status. Although highest F(E)NO was observed in atopic asthmatic patients, 28% of these patients had F(E)NO values lower than 22 ppb. CONCLUSION Atopic asthmatic patients with low F(E)NO values and non-atopic asthmatic patients were responsible for false-negative cases that might contribute to low sensitivity of F(E)NO measurements in diagnosing asthma. High specificity of F(E)NO measurements may help identify patients with atopic asthma among subjects with respiratory symptoms.

Initial location determines spontaneous passage of foreign bodies from the gastrointestinal tract in children.

Objective: The purpose of this study was to follow the natural course of spontaneous passage (SP) of ingested foreign bodies (FBs) in children. Methods: The medical records of 249 patients who ingested FBs were reviewed. In addition, they were studied by telephone questionnaires to follow up spontaneously passed FB. The factors associated with SP such as age, the type, size, and initial location of the FBs were analyzed. Results: Foreign bodies were spontaneously passed in 145 patients (58.2%), endoscopic removal was performed in 100 patients (40.2%), and operative removal was performed in 4 patients (1.6%). Most SP FBs were passed within 5 days. The SP rates (SPRs) according to the initial location were the following: 12.2% for the esophagus (P < 0.0001), 71.4% for the stomach, 85.7% for the small bowel, and 96.4% for the colon. There was no significant difference in the SPR according to age. When coins and disk batteries that required early endoscopic removal were excluded, the SPR was 63.4% for FBs less than 10 mm, 80.4% for FBs 10 to 20 mm, 72.8% for FBs 20 to 30 mm, and 50.0% for FBs more than 30 mm (P = 0.091). The initial location of the FB (odds ratio, 33.7; 95% confidence interval, 14.4-79.0) and the size of the FB (odds ratio, 3.5; 95% confidence interval, 1.0-11.6) were independent predictors of SP by multivariate analysis. Conclusions: Most FBs in the gastrointestinal tract are spontaneously passed without complication, and the initial location of FBs was found to be the main determining factor for SPR. Ingested FBs, in children, even sharp or relatively large FBs, can be spontaneously passed when they are located below the esophagus.

Norovirus: A Possible Cause of Pneumatosis Intestinalis

Objective: Pneumatosis intestinalis (PI) in children is associated with immunosuppression, mucosal disruption from trauma, obstructive pulmonary disease, congenital heart disease, and gastrointestinal infections. Our study is the first report of norovirus infection–associated PI. Patients and Methods: A retrospective review was performed in pediatric patients (older than 30 days) with PI from March 2005 to April 2009. Since December 2008, in addition to routine stool examinations, reverse-transcriptase polymerase chain reaction testing for calicivirus (norovirus and sapovirus), adenovirus, astrovirus, and enterovirus has been performed. Results: Twenty-seven patients with PI were identified. The median age was 1.4 (range 0.2–14.8 years). Seventeen patients (63.0%) were immunocompromised hosts. Pathogens were identified in 5 immunocompromised patients (5/27 and 5/8 since December 2008). Of note, norovirus was identified in 4 patients (80%, 4/5) during the cold weather season. The genotype of noroviruses in these patients was GII-4. Among 27 patients with PI, 10 patients (37.0%) developed PI in the spring and 11 (40.7%) in the winter. Twenty-four patients survived (88.9%, 24/27). None of the patients with norovirus or rotavirus infection died. Conclusions: Our data suggest that norovirus infection may contribute to the development of PI in immunocompromised hosts.

The effects of three alternative treatment strategies after 8 weeks of proton pump inhibitor therapy for GERD in children

Objectives The purpose of this 24-week treatment study was to evaluate the effects of three treatment strategies after 8 weeks of lansoprazole therapy for gastroesophageal reflux disease in children. Design Open-labelled, uncontrolled, prospective study. Setting Samsung Medical Center, Seoul, Korea. Methods 37 erosive reflux disease (ERD) and 20 non-erosive reflux disease (NERD) patients were divided into three groups by symptom assessment at 8 weeks: (1) observation without treatment in the ‘symptoms-resolved’ group, (2) ‘on-demand’ treatment for an additional 16 weeks in the ‘symptoms-attenuated’ group and (3) continuous treatment in the ‘symptoms-persistent’ group. Results For ERD, six (100%) out of six patients in the ‘symptoms-resolved’ group remained improved at weeks 16 and 24. Sixteen (72.7%) out of 22 patients in the ‘symptoms-attenuated’ group had improvement of symptoms at 16 weeks, and 18 (81.8%) patients at 24 weeks. Six (66.7%) out of nine patients in the ‘symptoms-persistent’ group remained improved at weeks 16 and 24. For NERD, seven (100%) out of seven patients in the ‘symptoms-resolved’ group remained improved at weeks 16 and 24. Eight (80.0%) out of 10 patients in the ‘symptoms-attenuated’ group remained improved at week 16, and 10 (100.0%) patients at week 24. None out of three patients in the ‘symptoms-persistent’ group remained improved at weeks 16 and 24. Conclusions The selection of each alternative for long-term management according to the results of the assessment of symptoms at week 8 was useful and well tolerated. ‘On-demand’ therapy was equally effective. The 16-week therapy had the same efficacy as the 24-week therapy with regard to long-term lansoprazole treatment.

Is Colonoscopy Necessary in Children Suspected of Having Colonic Polyps

BACKGROUND/AIMS The clinical spectrum, histology, and endoscopic features of colonic polyps in the pediatric age group were studied to evaluate the role of colonoscopy in children suspected of having colonic polyps. METHODS Seventy-six patients with colorectal polyps were studied. Investigations included barium enema (n=6), sigmoidoscopy (n=17), and colonoscopy (n=53) at the initial visit. Colonoscopy was also performed in 23 patients who received barium enema or sigmoidoscopy. Data related to age, gender, family history, signs, symptoms, size, location, polyp types, and associated diseases were collected and analyzed. RESULTS Among the 76 patients, juvenile polyps were detected in 58 (76.3%), potentially premalignant polyposis in 17 (22.4%), familial adenomatous polyposis in 11 (14.5%), Peutz-Jegher syndrome in 4 (5.3%), and juvenile polyposis syndrome in 2 (2.6%). Twenty-two patients (28.9%) had polyps in the upper colon. All patients with potentially malignant polyps had polyps in both the upper colon and rectosigmoid colon. CONCLUSIONS Although most of the children with colorectal polyps had juvenile polyps, a significant number of cases showed multiple premalignant and proximally located polyps. This finding emphasizes the need for a colonoscopy in such patients. Thus, the risk of malignant change, particularly in children with multiple polyps, makes surveillance colonoscopy necessary.

Polyunsaturated Fatty Acids in Children

Polyunsaturated fatty acids (PUFAs) are the major components of brain and retina, and are the essential fatty acids with important physiologically active functions. Thus, PUFAs should be provided to children, and are very important in the brain growth and development for fetuses, newborn infants, and children. Omega-3 fatty acids decrease coronary artery disease and improve blood flow. PUFAs have been known to have anti-inflammatory action and improved the chronic inflammation such as auto-immune diseases or degenerative neurologic diseases. PUFAs are used for metabolic syndrome related with obesity or diabetes. However, there are several considerations related with intake of PUFAs. Obsession with the intake of unsaturated fatty acids could bring about the shortage of essential fatty acids that are crucial for our body, weaken the immune system, and increase the risk of heart disease, arrhythmia, and stroke. In this review, we discuss types, physiologic mechanism of action of PUFAs, intake of PUFAs for children, recommended intake of PUFAs, and considerations for the intake of PUFAs.

Increased cow's milk protein–specific IgG4 levels after oral desensitization in 7- to 12-month-old infants

BACKGROUND Cows milk protein (CMP)-specific IgG4 responses and the efficacy of oral desensitization in infants with cows milk allergy (CMA) warrant more clarification. OBJECTIVE To explore whether CMP-specific IgG4 responses develop during infancy and whether regular CM exposure is efficacious for inducing a CMP-specific IgG4 response accompanying CM desensitization in 7- to 12-month-old infants. METHODS CM-specific IgE and CMP (α-lactalbumin, β-lactoglobulin, and casein)-specific IgG4 levels were measured in 262 CM-sensitized children. Of these, 31 infants 7 to 12 months old with challenge-proved CMA were randomly assigned to oral desensitization or an elimination diet and evaluated 6 months later. RESULTS CMP-specific IgG4 levels in 7- to 12-month-old infants were higher than in those younger than 6 months but comparable to those in children older than 12 months. CMP-specific IgG4 levels in 7- to 12-month-old infants with CMA were significantly lower than in those without CMA. Fourteen of 16 patients receiving oral desensitization could accept daily doses of 200 mL of CM, whereas all but 3 dropout patients receiving the elimination diet still showed allergic symptoms at the follow-up food challenge. In patients who became desensitized, CM-specific IgE levels were lower than at baseline, whereas CMP-specific IgG4 levels were significantly increased. In patients receiving the elimination diet, CM-specific IgE and CMP-specific IgG4 levels remained unchanged. CONCLUSION CMP-specific IgG4 responses did not develop sufficiently in 7- to 12-month-old infants with CMA. Oral desensitization in 7- to 12-month-old infants with CMA was associated with the upregulation of CMP-specific IgG4 responses accompanying the alleviation of CMA symptoms.

Castleman’s disease associated with a cerebellar chordoid meningioma and intestinal lymphangiectasia

Castleman’s disease (CD) is a rare nonneoplastic lymphoproliferative disorder of unknown etiology. It is characterized by enlarged hyperplastic lymph nodes, usually presenting as a localized mass. Although an intracranial location is very uncommon, it should be considered in the differential diagnosis of a chordoid meningioma. We describe a pediatric case of CD with a cerebellar chordoid meningioma and intestinal lymphangiectasia.