Sabrina Cardile

Current topics in the diagnosis and management of the pediatric non organic feeding disorders (NOFEDs).

Non-Organic Feeding Disorders (NOFEDs) are frequently encountered in children younger than 6 years old. NOFED are characterized by feeding aversion, failure to advance to age-appropriate foods, food selectivity and negative mealtime behaviors. Parents of children with feeding disorders often use abnormal feeding behaviors, such as intrusive feeding. Persistent inadequate caloric intake leads to non-organic failure to thrive in up to 40-50% of cases. Managing children with NOFED is a challenge for even the most experienced pediatric specialists. Management by a multidisciplinary team, as outpatient or inpatient should address both nutritional support and feeding behavior modification. Even in the absence of failure to thrive, children with behavioral feeding problems are at risk of negative health, social and emotional outcomes, including nutrient deficiencies, social and family disruption or conflict. The aims of the current review are to present an update of the definition, classification, etiology, epidemiology of NOFED, as well as clinical presentation, evaluation and management of this condition and non-organic failure to thrive, often associated with NOFED.

Italian survey on non-steroidal anti-inflammatory drugs and gastrointestinal bleeding in children

AIM To investigate gastrointestinal complications associated with non-steroidal anti-inflammatory drug (NSAIDs) use in children. METHODS A retrospective, multicenter study was conducted between January 2005 and January 2013, with the participation of 8 Italian pediatric gastroenterology centers. We collected all the cases of patients who refer to emergency room for suspected gastrointestinal bleeding following NSAIDs consumption, and underwent endoscopic evaluation. Previous medical history, associated risk factors, symptoms and signs at presentation, diagnostic procedures, severity of bleeding and management of gastrointestinal bleeding were collected. In addition, data regarding type of drug used, indication, dose, duration of treatment and prescriber (physician or self-medication) were examined. RESULTS Fifty-one patients, including 34 males, were enrolled (median age: 7.8 years). Ibuprofen was the most used NSAID [35/51 patients (68.6%)]. Pain was the most frequent indication for NSAIDs use [29/51 patients (56.9%)]. Seven patients had positive family history of Helicobacter pylori (H. pylori) infection or peptic ulcer, and 12 had associated comorbidities. Twenty-four (47%) out of 51 patients used medication inappropriately. Hematemesis was the most frequent symptom (33.3%). Upper gastrointestinal endoscopy revealed gastric lesions in 32/51 (62%) patients, duodenal lesions in 17 (33%) and esophageal lesions in 8 (15%). In 10/51 (19.6%) patients, a diagnosis of H. pylori gastritis was made. Forty-eight (94%) patients underwent medical therapy, with spontaneous bleeding resolution, while in 3/51 (6%) patients, an endoscopic hemostasis was needed. CONCLUSION The data collected in this study confirms that adverse events with the involvement of the gastrointestinal tract secondary to NSAID use are also common in children.

Natural history of pancreatic involvement in paediatric inflammatory bowel disease.

BACKGROUND Few case reports describe the clinical features of pancreatic involvement in inflammatory bowel disease. AIM To investigate prevalence and disease course of inflammatory bowel disease children with pancreatitis and with exclusive hyperamylasemia and hyperlipasemia. METHODS We used a web-registry to retrospectively identify paediatric inflammatory bowel disease patients with hyperamylasemia and hyperlipasemia. Participants were re-evaluated at 6 months and 1 year. RESULTS From a total of 649 paediatric patients, we found 27 with hyperamylasemia and hyperlipasemia (4.1%). Eleven patients (1.6%) fulfilled diagnostic criteria for acute pancreatitis. Female gender was significantly associated with acute pancreatitis (p=0.04). Twenty-five children (92.5%) had colonic disease. At 6 months 1/11 children with acute pancreatitis (9%) showed acute recurrent pancreatitis, while 1 patient (9%) had persistent hyperamylasemia and hyperlipasemia. At 12 months, 1 patient showed chronic pancreatitis (9.1%). Of the 16 children with exclusive hyperamylasemia and hyperlipasemia, 4 developed acute pancreatitis (25%), while 1 patient (6.2%) still presented exclusive hyperamylasemia and hyperlipasemia at 6 months. At 12 months, 11/16 patients (68.7%) reached a remission of pancreatic involvement, whereas 5 remaining patients (32.3%) had persistent hyperamylasemia and hyperlipasemia. CONCLUSIONS In inflammatory bowel disease children, acute pancreatitis is more common in colonic disease and in female gender. Pancreatic function should be monitored, considering that pancreatic damage may evolve.

Pancreatic involvement in pediatric inflammatory bowel diseases.

BackgroundInflammatory bowel diseases (IBDs) are a group of chronic diseases affecting the gastrointestinal tract, with a disabling course. The incidence of IBDs is increasing in different geographical areas, indicating its emergence as a global disease, especially in children. Many patients with IBDs develop extraintestinal manifestations (EIMs) during follow-up, as IBDs have a potential risk of systemic involvement..Data sourcesA systematic review of the literature was made to analyze latest studies on pancreatic involvement in children with IBD including our experience in assessing possible implications and its future application.ResultsThe involvement of the hepatobiliary system is considered a rare EIM of children with IBD, with an incidence much higher than that in the general population. Isolated pancreatic hyperenzymemia, which occurs in the absence of typical symptoms and/or characteristic imaging findings, may be found in many patients with IBD. The frequent causes of pancreatitis are drugs, bilio-pancreatic disorders, immunologic disturbances and pancreatic auto-antibodies, although in some cases idiopathic forms have been described.ConclusionsIt is important to establish a correct diagnostic approach based on etiology and to assess the most appropriate therapeutic strategy, thus avoiding complications and improving the quality of life of children with IBD.

Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology

There are many causes of gastrointestinal bleeding (GIB) in children, and this condition is not rare, having a reported incidence of 6.4%. Causes vary with age, but show considerable overlap; moreover, while many of the causes in the pediatric population are similar to those in adults, some lesions are unique to children. The diagnostic approach for pediatric GIB includes definition of the etiology, localization of the bleeding site and determination of the severity of bleeding; timely and accurate diagnosis is necessary to reduce morbidity and mortality. To assist medical care providers in the evaluation and management of children with GIB, the “Gastro-Ped Bleed Team” of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) carried out a systematic search on MEDLINE via PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) to identify all articles published in English from January 1990 to 2016; the following key words were used to conduct the electronic search: “upper GIB” and “pediatric” [all fields]; “lower GIB” and “pediatric” [all fields]; “obscure GIB” and “pediatric” [all fields]; “GIB” and “endoscopy” [all fields]; “GIB” and “therapy” [all fields]. The identified publications included articles describing randomized controlled trials, reviews, case reports, cohort studies, case-control studies and observational studies. References from the pertinent articles were also reviewed. This paper expresses a position statement of SIGENP that can have an immediate impact on clinical practice and for which sufficient evidence is not available in literature. The experts participating in this effort were selected according to their expertise and professional qualifications.

Clinical utility of esomeprazole for treatment of gastroesophageal reflux disease in pediatric and adolescent patients

Gastroesophageal reflux is a common condition in the pediatric population, with an increasing incidence in the last few years. It can be defined as an effortless retrograde movement of gastric contents into the esophagus related to complex multifactorial pathogenesis, involving anatomical, hormonal, environmental, and genetic factors. In some cases, it may be associated with esophageal or extraesophageal symptoms (heartburn and regurgitation), and is defined as gastroesophageal reflux disease (GERD). The therapeutic approach to gastroesophageal reflux in infants and children is often conservative, including changes in lifestyle (eg, posture and thickening of meals). If these children remain symptomatic after lifestyle changes (nutrition, feeding, and positional modification), or present with clinical red flags (poor weight gain, recurrent respiratory symptoms, or hematemesis) and complications of GERD (esophagitis, bleeding, stricture, Barrett’s esophagus, or adenocarcinoma) it may be necessary to set up a proper diagnostic protocol. Proton pump inhibitors have been recommended as the most effective acid suppression therapy for adults and pediatric patients. Esomeprazole, the S-isomer of omeprazole, is the only single-isomer proton pump inhibitor available. The paper assesses the safety and tolerability of esomeprazole in pediatric and adolescent patients.

Pulmonary implications in inflammatory bowel disease: not a rare event

Extraintestinal manifestations (EIM) in inflammatory bowel disease (IBD) may involve any organ system. Antitumor necrosis factor alpha (anti-TNF-α) agents have been used for more than 15 years for the treatment of IBD, both in Crohn’s disease (CD) and in ulcerative colitis (UC). Despite its favorable safety profile in children and adults, a small percentage of patients experienced adverse infectious and noninfectious complications, including lung effects. This is an Editorial comment to published manuscript ‘Review of pulmonary adverse effects of infliximab therapy in Crohn’s disease’.[1] Anti TNF-α is a T-helper type-1 pro-inflammatory cytokine that plays a key role in the integrated host defense system against infectious diseases. This cytokine is physiologically antagonized by TNF-binding proteins, and the four anti-TNF agents currently approved in IBD are the monoclonal antibodies infliximab (IFX; Remicade), adalimumab (ADM; Humira), certolizumab pegol (CZP; Cimzia), and golimumab (GLM; Simponi). As immunomodulatory therapies, anti-TNF agents lower the ability of the immune system to ward off infections. TNF-targeted therapy has provided disease-modifying treatment and relief to patients suffering from rheumatoid arthritis, IBD, and other immune conditions.[2] The increasing frequency of prescriptions, and number of indications for these therapies have been accompanied by a growing number of reported side effects. The most common adverse events are injection site and infusion reactions.[3] Most reactions are acute, nonimmune, and mild–moderate and can be classified as acute and delayed, based on timing of onset. Prevalence varies widely in literature, ranging between 3% and 29%. Injection site reactions are a frequent side effect of selfinjectable anti-TNF agents, with an incidence ranging from 1% to 40%, and most occur during the induction phase.[4] Extraintestinal symptoms in IBD patients can be divided into two groups: EIM (peripheral and axial artrhopathies, erythema nodosum, primary sclerosing cholangitis, and uveitis) and extraintestinal complications (peripheral neuropathies, kidney stones, etc.), or IBD drug-related side effects.[5] The drugs that can cause extraintestinal complications in IBD more often include 5-aminosalicilate agents (5-ASA), azathioprine (AZA), methotrexate (MTX), and anti-TNF agents. Pulmonary involvement in patients with anti-TNF therapy is more frequent in CD and is often under-recognized for the presence of asymptomatic complications, such as alterations in lung function tests and/or bronchoalveolar lavage (BAL) abnormalities. [6] Anti-TNF-α-induced lung injury (ATILI) was defined according to the following criteria: (1) new lung lesions that developed after anti-TNF-α therapy; (2) exclusion of infection or other pulmonary disease; (3) BAL fluid negative for infections, including bacteria, mycobacteria, Pneumocystis jirovecii, and fungi; and (4) resolution of infiltrates after discontinuation of causative anti-TNF agents, with or without steroids. Lee HS et al. identified an incidence of 0.6% of ATILI among 1002 IBD patients who were treated using anti-TNF therapy.[7] Symptoms such as malaise, fever, loss of weight, persistent cough, wheezing, asthma, shortness of breath, limitations of exercise, purulent expectoration, hemoptysis, or chest pain, but also a simple alteration of lung function tests, should raise suspicion of pulmonary involvement in IBD patients, especially those treated with biologics.[8] Radiological examinations, including chest X-ray, and high-resolution computed tomography, spirometry, BAL, bronchoscopy, and biopsy can help in the diagnosis, and in distinguishing the different forms of pulmonary involvement. Infectious complications of TNF inhibition such as reactivation of latent tuberculosis (TB) or newly acquired bacterial infections should be excluded from the definition of ATILI. A retrospective study of a large US health-care organization showed that patients receiving TNFtargeted therapy have a two-fold higher risk of developing a bacterial infection than patients receiving MTX.[9] The modern classification of ATILI can include three conditions: (1) sarcoidosis, (2) interstitial lung disease, and (3) miscellaneous pulmonary complications. In 2010, Ramon-Casals et al. [10] reported 38 cases of sarcoidosis or ‘sarcoid-like’ ganulomatosis disease during anti-TNF-α therapy out of 1370 adult patients with systemic autoimmune diseases undergoing use of biological agents. The most frequent case reports of new-onset sarcoidosis are associated with etanercept (ETN), IFX, and ADM, and in rheumatology literature.[11] Initial symptoms can be nonspecific, and include dyspnea, nonproductive cough, erythema nodosum, parotid enlargement, and neuroocular manifestations. Radiological findings are mediastinal and hilar adenopathy, and, less frequently, upper lobe opacities. The diagnosis can be confirmed histologically by the presence of well-formed non-necrotizing granulomas. There

72nd Congress of the Italian Society of Pediatrics

Child and youth migrations are a particularly dramatic and a daily aspect of the more general problem of contemporary migration flows. Behind and within each of the stories of these children accompanied and unaccompanied migrant children, as UN calls them in a bureaucratic jargon school becomes a treasure trove of identity splinters through biographies and fragments of a past that can return visibility to what would be irreparably forgotten otherwise. School has the opportunity to welcome, support, accompany these children and young new citizens towards the inclusion. School has, also, the opportunity to learn an anthropological view of the presence of migrant children from these life stories, thus activating action-research processes. This action-research will develop new teaching strategies, new approaches based on questions, on an open dialogue, on the paradigms of responsibility, commitment and diversity. A unique opportunity to develop diversity education and citizenship skills, too often mentioned but poorly practiced. Above all, thanks to the sharing and revival of significant life stories and emotionally touching, you can develop emotional intelligence skills, so necessary in an often deregulated age of complexity, which always produces more and more “wasted lives”, above all, thanks to the sharing and reintroduction of significant and emotionally touching life stories. Through a generous listening of students’ lives, and dialogic practices, school could generate new narrations of migration processes, thus replacing those narrations made up of stereotypical clichés, believes, petty and selfish believes of an overlapping lawlessness, of cruelty and hypocritical welcome. These new narrations tell of possibilities, of mutual discoveries, of processes of successful inclusion, of present-future to build together. “The dialogical as Arnkil and Seikkula say is not a method or a set of techniques but it is an attitude, a way of seeing, which is based on recognizing and respecting the otherness of the other, and on going to meet them.” Applying the integrated dialogic approach to coaching as a lifestyle means to mobilize psychological resources of both people who are directly involved and the whole community and local social network, it means being able to stimulate dialogue. Stories of wanderings and landings, escapes and refuges, of scared identities and unpredictable cultural metamorphosis, of so much suffering, are intertwined and interdependent to the dreamed and