Laura Badina

Food protein-induced enterocolitis syndrome caused by fish and/or shellfish in Italy.

The study describes the demographic features, culprit foods, clinical features and outcomes for children presenting with acute fish and/or shellfish food protein‐induced enterocolitis syndrome (FPIES) in four Italian paediatric allergy centres.

A comparison of three scales for measuring pain in children with cognitive impairment.

Pain is a neglected problem in children with cognitive impairments, and few studies compare the clinical use of specific pain scales. We compared the Non‐Communicating Childrens Pain Checklist Postoperative Version (NCCPC‐PV), the Echelle Douleur Enfant San Salvador (DESS) and the Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS). The first two were developed for children with cognitive impairment, and the third is a more general pain scale.

Attitudes of children with leukemia toward repeated deep sedations with propofol

Procedural sedation is generally recommended for children requiring repeated painful diagnostic or therapeutic procedures. A child with leukemia undergoes an average of 20 procedures such as lumbar puncture and bone marrow aspiration through the course of illness. No data are currently available about the psychological impact of repeated sedations on children. The objective of this study was to evaluate the attitudes of patients with leukemia toward repeated deep sedations using propofol. A questionnaire addressing sedation-related distress was given to 30 children with leukemia. Procedure-related distress was evaluated using the Amended Observational Scale of Behavioural Distress. Another questionnaire concerning the same issues was given to an historical group of 39 children who had undergone painful procedures without sedation in previous years. Fear and distress were significantly reduced in the sedation group compared with the historical one. Fear of sedation was reported by 17% of children of this group. Distressed behavior was observed in 27%. In conclusion, sedation-related distress was observed in a subgroup of patients; in these cases, specific strategies could be considered to reduce sedation-related distress.

Prevalence of celiac disease in patients with severe food allergy

The association between food allergy and celiac disease (CD) is still to be clarified. We screened for CD 319 patients with severe food allergy (IgE > 85 kU/l against food proteins and a history of severe allergic reactions) who underwent specific food oral immunotherapy (OIT), together with 128 children with mild allergy who recovered without OIT, and compared the prevalence data with our historical data regarding healthy schoolchildren. Sixteen patients (5%) with severe allergy and one (0.8%) with mild allergy tested positive for both genetic and serological CD markers, while the prevalence among the schoolchildren was 1%. Intestinal biopsies were obtained in 13/16 patients with severe allergy and in the one with mild allergy, confirming the diagnosis of CD. Sufferers from severe food allergy seem to be at a fivefold increased risk of CD. Our findings suggest that routine screening for CD should be recommended in patients with severe food allergy.

The Dietary Paradox in Food Allergy: Yesterday's Mistakes, Today's Evidence and Lessons for Tomorrow

During the last decades the prevalence of food allergy has significantly increased among children and antigen avoidance still remains the standard care for the management of this condition. Most reactions are IgE-mediated with a high risk of anaphylaxis requiring emergency medications in case of inadvertent ingestion. Recent studies showed that continuous administration of the offending food, rather than an elimination diet, could promote the development and maintenance of oral tolerance. Indeed, intestinal transit of food proteins and their interaction with gut-associated lymphoid tissue (GALT) is the essential prerequisite for oral tolerance. On the contrary, low-dose cutaneous exposure to environmental foods in children with atopic dermatitis and altered skin barrier facilitates allergic sensitization. The timing and the amount of cutaneous and oral exposure determine whether a child will have allergy or tolerance. Furthermore, previous preventive strategies such as the elimination diet during pregnancy and breastfeeding, prolonged exclusive breastfeeding and delayed weaning to solid foods did not succeed in preventing the development of food allergy. On the other hand, there could be an early narrow window of immunological opportunity to expose children to allergenic foods and induce natural tolerance. Finally, the gradual exposure to the offending food through special protocols of specific oral tolerance induction (SOTI) may be a promising approach to a proactive treatment of food allergy.

Measuring pain in children with cognitive impairment and cerebral palsy: a multiregional survey in the use of specific pain scales.

To the Editors: W e greatly appreciated the article by Drendel et al about pain assessment for children in the emergency department. In particular, as stated by the authors, the issue of pain assessment in children with cognitive impairments is often challenging,1 and specific validated pain scales (such as the revised face, legs, activity, cry, consolability, the non-communicating children pain checklist, the echelle douleur enfant San Salvador) are required. Standard pain scales are not suited for this group of patients because the level of cognitive impairment significantly affects pain behavior. Though specific pain scales are available in the literature, we have reasons to believe that they are still not widely used in everyday clinical practice. We investigated the current method used to assess pain in noncommunicating children and in children with cerebral palsy and severe cognitive impairments in the northeast of Italy. This is an area including 3 regions (Veneto, Trentino Alto-Adige, and Friuli Venezia Giulia) with a total pediatric population (0Y18 years) estimated at about 1,300,000 children. We conducted a telephone interview with the physician on duty in 56 pediatric wards in the hospitals of the area (first-, second-, and third-level hospitals), including 4 university teaching hospitals and 6 pediatric surgeries. All telephone calls were performed in the afternoon to randomly approach the physician on duty and to avoid possible bias, such as referring only to the local pain expert. Of 56 pediatric wards, 55 answered. Of 55 centers, only 1 reported to use a specific pain scale for cognitively impaired children (specifically the echelle douleur enfant San Salvador), showing that pain in cognitively impaired children is almost never measured by means of appropriate scales. These data underline a startling lack of attention to pain management in this subset of particularly needy patients, in an area otherwise well known in the country for the highest standard of pediatric care and for a significant attraction rate of patients from other regions and from abroad. The area in which the investigation was performed is representative of the Italian reality because, even if it is geographically relatively small, it includes 4 university teaching hospitals and 6 pediatric surgeries. The number of institutions involved and the almost absolute rate of response (55/56) is a further guarantee of the representativeness of the study sample. To the best of our knowledge, we are not aware of other studies addressing the issue of the routine use of specific pain measurement tools in this group of children in other countries. We therefore have no elements to hypothesize that this reality is different in other western countries and more research should address this issue. The lack of an adequate measurement of pain in cognitively impaired children could result in undertreatment of pain, and this is relevant if we consider the strong evidence showing that these children experiencemore pain in comparison to healthy ones. The pain these patients experience could affect their long-term functioning as well because the impact of pain on adaptive functioning is higher the more severe their intellectual disability is and affects all areas of function (communication, daily living, social, and motor skills). In conclusion, these data show that, in this geographic area, the mean pediatricians’ attitude toward pain in children with cognitive deficiency is still penalized by the lack of appropriate measurement and acknowledgment of pain itself. There is a need for the development of a culture of attention to pain diagnosis, management, and prevention in noncommunicating children. Starting to use the appropriate pain scales for these children in everyday clinical practice is not only slightly more time consuming but also substantially inexpensive and simple, and it is a necessary starting point. At the moment, in fact, the very ones who are most at risk of experiencing pain are the most disarmed, with lesser chance of being treated. We believe that the diffusion of a specific culture in pain evaluation and pairment is still needed, representing a major issue in overcoming challenges and optimizing care. Disclosure: The authors declare no conflict of interest.

Early combined immunosuppression in Crohn's disease

1 D’Haens G, Baert F, Van Assche G, et al. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn’s disease: an open randomised trial. Lancet 2008; 371: 660–67. 2 Mackey AC, Green L, Liang LC, Dinndorf P, Avigan M. Hepatosplenic T cell lymphoma associated with infl iximab use in young patients treated for infl ammatory bowel disease. J Pediatr Gastroenterol Nutr 2007; 44: 265–67. 3 Lees CW, Ironside J, Wallace W, Satsangi J. Resolution of non-small cell lung cancer following withdrawal of anti-TNF therapy. N Engl J Med (in press). 4 Rennard SI, Fogarty C, Kelsen S, et al. The safety and effi cacy of infl iximab in moderate to severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2007; 175: 926–34. 5 Koebel CM, Vermi W, Swann JB, et al. Adaptive immunity maintains occult cancer in an equilibrium state. Nature 2007; 450: 903–07. Early combined immunosuppression in Crohn’s disease

Does infant gastro-oesophageal reflux really deserve medical attention?

Vandenplas et al 1 report the effectiveness of a specially designed bed for postural treatment of gastro-oesophageal reflux (GOR)-associated symptoms. This conclusion is in contrast with a Cochrane review that already concluded that supine position with elevation of the head does not have any effect on regurgitation and acid reflux in developmentally normal infants.2 In our opinion, the methodological …

A Precordial Rub in a Boy with a Severe Attack of Ulcerative Colitis

A case of a pneumomediastinum mimicking a pericarditis in a boy with an occult perforation due to ulcerative colitis is reported. Pneumomediastinum is a rare complication of severe attacks of ulcerative colitis, with or without the previous development of a toxic megacolon, that should be considered in the differential diagnosis.

Cooking influence in tolerance acquisition in egg-induced acute food protein enterocolitis syndrome

BACKGROUND Few studies on the age of resolution of Food Protein Induced Enterocolitis Syndrome (FPIES) induced by solid foods are available. In particular, for FPIES induced by egg, the mean age of tolerance acquisition reported in the literature ranges from 42 to 63 months. OBJECTIVE We have assessed whether the age of tolerance acquisition in acute egg FPIES varies depending on whether the egg is cooked or raw. METHODS We conducted a retrospective and multicentric study of children with diagnosis of acute egg FPIES seen in 10 Italian allergy units between July 2003 and October 2017. The collected data regarded sex, presence of other allergic diseases, age of onset of symptoms, kind and severity of symptoms, cooking technique of the ingested egg, outcome of the allergy test, age of tolerance acquisition. RESULTS Sixty-one children with acute egg FPIES were enrolled, 34 (56%) males and 27 (44%) females. Tolerance to cooked egg has been demonstrated by 47/61 (77%) children at a mean age of 30.2 months. For 32 of them, tolerance to raw egg has been demonstrated at a mean age of 43.9 months. No episodes of severe adverse reaction after baked egg ingestion have been recorded. CONCLUSIONS It is possible to perform an OFC with baked egg, to verify the possible acquisition of tolerance, at about 30 months of life in children with acute egg FPIES.