Introduction. The multifactorial etiology of gastroenteritis emphasizes the need for different laboratory methods to identify or exclude infectious agents and evaluate the severity of diarrheal disease.Objective. To diagnose the infectious etiology in diarrheic children and to evaluate some fecal markers associated with intestinal integrity.Materials and methods. The study group comprised 45 children with diarrheal disease, tested for enteropathogens and malabsorption markers, and 76 children whose feces were used for fat evaluation by the traditional and acid steatocrit tests.Results. We observed acute diarrhea in 80% of the children and persistent diarrhea in 20%. Of the diarrheic individuals analyzed, 40% were positive for enteropathogens, with rotavirus (13.3%) and Giardia duodenalis (11.1%) the most frequently diagnosed. Among the infected patients, occult blood was more evident in those carrying pathogenic bacteria (40%) and enteroviruses (40%), while steatorrhea was observed in infections by the protozoa G. duodenalis (35.7%). Children with diarrhea excreted significantly more lipids in feces than non-diarrheic children, as determined by the traditional (p<0.0003) and acid steatocrit (p<0.0001) methods. Moreover, the acid steatocrit method detected 16.7% more fecal fat than the traditional method.Conclusions. Childhood diarrhea can lead to increasingly severe nutrient deficiencies. Steatorrhea is the hallmark of malabsorption, and a stool test, such as the acid steatocrit, can be routinely used as a laboratory tool for the semi-quantitative evaluation of fat malabsorption in diarrheic children.

Introduction. The multifactorial etiology of gastroenteritis emphasizes the need for different laboratory methods to identify or exclude infectious agents and evaluate the severity of diarrheal disease. Objective. To diagnose the infectious etiology in diarrheic children and to evaluate some fecal markers associated with intestinal integrity. Materials and methods. The study group comprised 45 children with diarrheal disease, tested for enteropathogens and malabsorption markers, and 76 children whose feces were used for fat evaluation by the traditional and acid steatocrit tests. Results. We observed acute diarrhea in 80% of the children and persistent diarrhea in 20%. Of the diarrheic individuals analyzed, 40% were positive for enteropathogens, with rotavirus (13.3%) and Giardia duodenalis (11.1%) the most frequently diagnosed. Among the infected patients, occult blood was more evident in those carrying pathogenic bacteria (40%) and enteroviruses (40%), while steatorrhea was observed in infections by the protozoa G. duodenalis (35.7%). Children with diarrhea excreted significantly more lipids in feces than non-diarrheic children, as determined by the traditional (p<0.0003) and acid steatocrit (p<0.0001) methods. Moreover, the acid steatocrit method detected 16.7% more fecal fat than the traditional method. Conclusions. Childhood diarrhea can lead to increasingly severe nutrient deficiencies. Steatorrhea is the hallmark of malabsorption, and a stool test, such as the acid steatocrit, can be routinely used as a laboratory tool for the semi-quantitative evaluation of fat malabsorption in diarrheic children.

ABSTRACT Background: Microscopy and enzyme-linked immunosorbent assay (ELISA) are routinely used for Cryptosporidium diagnosis, without differentiating the parasite species. Methods: Children’s feces were analyzed by modified Ziehl-Neelsen (mZN) and ELISA for Cryptosporidium diagnosis and by polymerase chain reaction-restriction fragment length polymorphism for species identification. Results: Cryptosporidium frequency was 2.6%. The sensitivity and specificity of ELISA were 85.7% and 99.7%, respectively, with excellent concordance with mZN (kappa=0.854). Parasite species were characterized as Cryptosporidium hominis (78.3%), Cryptosporidium felis (17.4%), and Cryptosporidium parvum (4.3%). Conclusions: Coproantigen ELISA is as efficient as mZN for Cryptosporidium diagnosis. Cryptosporidium genotyping suggests anthroponotic and zoonotic transmission to children.

INTRODUCTION:Giardia duodenalis is an intestinal protozoan with a high prevalence in children of developing countries. Molecular studies revealed a great genetic diversity of G. duodenalis, with assemblages A and B found mainly in humans. Despite its importance, the information on the molecular epidemiology of human giardiasis is still limited in Brazil.OBJECTIVE:To characterize G. duodenalis molecular isolates in children from Salvador, Bahia, Brazil.MATERIALS AND METHODS:Giardia duodenalis positive fecal samples were obtained from 71 children from two day care centers and 39 users of a clinical analysis laboratory. Samples were analyzed by PCR-RFLP of the glutamate dehydrogenase (gdh) and beta-giardin genes and by the sequencing of beta-giardin.RESULTS:Of the 110 G. duodenalis samples, 80 (72.7%) amplified one or both target genes. Of these, 62 (77.5 %) were identified as assemblage A and 18 (22.5%) as assemblage B. The subassemblage AII was identified in 58.8% (n=47) of isolates followed by the sub-assemblage AI (18.8%, n=15), BIV (11.2%, n=9), and BIII (5.0%, n=4). The AII sub-assemblage was the most frequent in children of both day care centers whereas AI was found only in the group attended at the clinical laboratory. Sub-assemblage AII predominated in children under two years.CONCLUSIONS:The higher frequency of AII sub-assemblage suggests that anthroponotic transmission is more common in Salvador, but that zoonotic transmission pathways are also present and a change in susceptibility to different molecular patterns of Giardia may occur during child growth.

BACKGROUND:Giardia duodenalis is conventionally diagnosed in fecal samples using parasitological methods. However, sensitivity is poor when only a single sample is analyzed, due to intermittent excretion of cysts in feces. Alternatively, the serum antibodies to G. duodenalis can be used for parasite diagnosis and epidemiological studies to determine previous exposure. We compared the rate of G. duodenalis infection between serum anti-Giardia IgG and IgA antibodies and fecal examination in Brazilian children.METHODS:Fecal and serum samples were tested from 287 children at a clinical laboratory and from 187 children at daycare centers. Fecal samples were processed using conventional parasitological methods and coproantigen detection for Giardia diagnosis. Serum samples were tested using an in-house ELISA for detection of anti-Giardia IgG and IgA.RESULTS:G. duodenalis was found in 8.2% (N=39) of the 474 children analyzed. The sensitivity and specificity of ELISA were 80.0% and 90.0% for IgG and 80.0% and 83.3% for IgA, respectively. The total positivity rate of anti-Giardia IgG and IgA in the sera was 13.9% (N=66) and 23.6% (N=112). The agreement between the positivity of specific antibodies and the detection of G. duodenalis in feces was moderate for ELISA-IgG, kappa index (95% CI)=0.543 (0.422-0.664), and mild for ELISA-IgA, kappa index (95% CI)=0.283 (0.162-0.404). Among the children infected with other enteroparasites, 11.6% (N=10) and 24.4% (N=21) showed reactivity to anti-Giardia IgG and to IgA, respectively. This cross-reactivity was more frequent in samples from children infected with Endolimax nana and Entamoeba coli.CONCLUSIONS:The higher frequency of specific antibody reactivity compared with G. duodenalis diagnosis in feces could reflect continuous exposure of children to G. duodenalis infection, resulting in long-lasting immunological memory and/or cross-reactivity with other intestinal amoebas.

Rationale: To analyze whether the adequate protein supply has an influence on the results of strength and mobility in ICU patients.

A non‐Caucasian 5‐month‐old boy born at term to unrelated parents (weight 3.900 g) was healthy and exclusively breastfed until 4 months of age when he developed an erythematous eruption on the chest. The child was evaluated and diverse diagnoses were proposed: atopic dermatitis, contact dermatitis and scabies. The lesions were treated with several topical formulations including corticosteroids, antibiotics and antifungals, with no resolution. Following this, the rash became generalized and the patient further developed cough and wheeze; therefore, oral antibiotics were prescribed. However, as his general condition worsened, and he also developed edema on his lower limbs, he was transferred to Teaching Hospital Edgard Santos, Salvador, Bahia, Brazil. Upon admission, the patient was very irritable with generalized edema, wheezing and diffuse erythematous papules with overlying scaling or peeling of skin involving face, chest, limbs and genital area [Figures 1 and 2]. Body weight and length recorded were 7.090 kg and 62.2 cm, and his nutritional evaluation showed a weight/ age (W/A) Z‐score = +0.99; height/age (H/A) Z‐score = −1.75 and weight/height (W/H) Z‐score = −0.52. Mucosal examination was normal and no abnormalities were found. Abnormal laboratory values were as follows: hemoglobin 9.7 g/dL, albumin 1.8 g/ dL, aspartate aminotransferase 116 IU/L, alanine transaminase 60 IU/L, Na+ 133 mEq/L. Blood, urine and faecal cultures were negative. Initial diagnosis was drug eruption with secondary hypoalbuminemia. However, cystic fibrosis was investigated for and he presented two positive sweat tests (chloride 99/98 and 86/85 mEq/L). The steatocrit value was 22% and oropharyngeal cultures isolated Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas aeruginosa. A genetic test was performed and the mutations F508del and 3120+1G>A were identified. Fecal elastase‐1 level was lower than 15 μE1/g. Pancreatic enzyme replacement was instituted, as well as vitamins, antibiotics and nutritional therapy. The patient exhibited improvement in skin lesions, edema and nutritional status. He was discharged in good clinical condition after 37 days of hospitalization. Currently, he is 7 years old and is being followed‐up as an outpatient at the same multidisciplinary cystic fibrosis clinic with good nutritional status: W/A Z‐score = 0.6; H/A Z‐score = −0.1; body mass index Z‐score = +1.38, and stable clinical parameters [Figures 3 and 4].

Palm olein is used in infant formula fat blends in order to match the fatty acid profile of human milk. While the effects on fatty acid balance have been evaluated, the use of palm olein in combination with palm kernel oil and supplementation with docosahexaenoic acid (DHA) and arachidonic acid (ARA) has not been similarly assessed in infants. This study evaluated the effects of infant formulas containing different fat compositions on the balance of fat, fatty acids, and calcium.

Techniques for Giardia diagnosis based on microscopy are usually applied as routine laboratory testing; however, they typically exhibit low sensitivity. This study aimed to evaluate Giardia duodenalis and other intestinal parasitic infections in different pediatric groups, with an emphasis on the comparison of Giardia diagnostic techniques. Feces from 824 children from different groups (diarrheic, malnourished, with cancer and from day care) were examined by microscopy and ELISA for Giardia, Cryptosporidium sp. and Entamoeba histolytica coproantigen detection. Giardia-positive samples from day-care children, identified by either microscopy or ELISA, were further tested by PCR targeting of the β-giardin and Gdh genes. Statistically significant differences (P<0.05) were observed when comparing the frequency of each protozoan among the groups. Giardia duodenalis was more frequent in day-care children and Cryptosporidium sp. in diarrheic and malnourished groups; infections by Entamoeba histolytica were found only in children with diarrhea. Considering positivity for Giardia by at least one method, ELISA was found to be more sensitive than microscopy (97% versus 55%). To examine discrepancies among the diagnostic methods, 71 Giardia-positive stool samples from day-care children were tested by PCR; of these, DNA was amplified from 51 samples (77.4%). Concordance of positivity between microscopy and ELISA was found for 48 samples, with 43 confirmed by PCR. Parasite DNA was amplified from eleven of the 20 Giardia samples (55%) identified only by ELISA. This study shows the higher sensitivity of ELISA over microscopy for Giardia diagnosis when a single sample is analyzed and emphasizes the need for methods based on coproantigen detection to identify this parasite in diarrheic fecal samples.

Avaliação nutricional de crianças e adolescentes hospitalizados é pouco relatada na literatura médica. Objetivo: Avaliar perfil nutricional de crianças e adolescentes admitidas na emergência pediátrica de um hospital particular, Salvador, Bahia. Metodologia: Trata-se de estudo de corte transversal com coleta retrospectiva de dados. Foram avaliados Índices de Massa Corporal de 320 pacientes na admissão, entre fevereiro de 2012 e abril de 2013. Foi utilizada a curva de crescimento Idade X Índice de Massa Corporal (z-score). Dividiram-se quatro grupos, segundo critérios de faixa etária. O Grupo A correspondeu a crianças com menos de 1 ano, Grupo B, 1 a 5 anos, Grupo C, 6 a 10 anos, e Grupo D, com crianças acima de 10 anos. Resultados: O Grupo A incluiu 101 crianças (31,56%), das quais 49 (48,51%) apresentaram peso adequado para a idade, e 52 (51,49%) apresentaram peso inadequado para idade. Grupo B ficou representado por 136 crianças (42,50%), sendo 74 (54,41%) delas com peso adequado, e 62 (45,59%) com peso inadequado. Já o Grupo C foi composto de 50 crianças (15,63%), incluindo 24 (48,00%) com peso adequado, e 26 (52,00%) com peso inadequado. O Grupo D englobou 33 crianças e adolescentes (10,31%), dos quais 21 (63,64%) apresentaram peso adequado, 12 (36,36%) apresentaram peso inadequado. Conclusões: As faixas etárias incluídas nos grupos A e B responderam juntas, por 74,06% dos pacientes que procuraram a referida emergência pediátrica. Os grupos A e C possuem maior proporção de crianças com peso inadequado no momento da admissão na referida emergência pediátrica.

Background: Earlier we reported on growth and adiposity in a cross-sectional study of disadvantaged Brazilian preschoolers. Here we extend the work on these children, using structural equation modelling (SEM) to gather information on the complex relationships between the variables influencing height and adiposity. We hope this information will help improve the design and effectiveness of future interventions for preschoolers.Methods: In 376 preschoolers aged 3-6 years attending seven philanthropic daycares in Salvador, we used SEM to examine direct and indirect relationships among biological (sex, ethnicity, birth order, maternal height and weight), socio-economic, micronutrient (haemoglobin, serum selenium and zinc), and environmental (helminths, de-worming) variables on height and adiposity, as reflected by Z-scores for height-for-age (HAZ) and body mass index (BMIZ).Results: Of the children, 11 % had HAZ < -1, 15 % had WHZ < -1, and 14 % had BMIZ > 1. Of their mothers, 8 % had short stature, and 50 % were overweight or obese. Based on standardized regression coefficients, significant direct effects (p < 0.05) for HAZ were maternal height (0.39), being white (-0.07), having helminth infection (-0.09), and serum zinc (-0.11). For BMIZ, significant direct effects were maternal weight (0.21), extremely low SES (-0.15), and haemoglobin (0.14). Indirect (p < 0.05) effects for HAZ were sex (being male) (-0.02), helminth infection (-0.01), de-worming treatment (0.01), and serum selenium (-0.02), and for BMIZ were extremely low SES (-0.001), helminth infection (-0.004), and serum selenium (0.02).Conclusions: Of the multiple factors influencing preschoolers' growth, helminth infection was a modifiable risk factor directly and indirectly affecting HAZ and BMIZ, respectively. Hence the WHO de-worming recommendation should include preschoolers living in at-risk environments as well as school-aged children.

Nutrients such as docosahexaenoic acid (DHA), prebiotics and β-glucan have been associated with reduced incidence of respiratory illnesses and allergic manifestations (AM). Our objective was to assess if consumption of a cow’s milk-based beverage with these and other nutrients supports respiratory, gastrointestinal, and skin health in otherwise well-nourished, healthy children.

Nutritional assessment of hospitalized children and adolescents is less registered in medical literature. Objective: To access nutritional profile of admitted children and adolescents from a pediatric emergency of a private hospital, in Salvador, Bahia. Methodology: It was a cross-section with retrospective data collection study, in which the children Body Mass Index were measured, at the Day of admission, between february 2011 and april 2012. The growth curve Age x Body Mass Index (z score) was applied. Four groups were divided, in terms of age range. Group A included children less than 1 year-old. Group B, 1 to 5 years old, Group C, 6 to 10 years old, and Group D, with children above 10 years old. Results: 320 children were evaluated. The Group A included 101 children (31.56%), 49 (48.51%) presented appropriate weight and 52 (51.49%) presented inappropriate weight. The Group B included 136 children (42.50%), 74 (54.41%) with appropriate weight and 62 (45.59%) with inappropriate weight. The Group C included 50 children (15.63%), 24 (48,00%) with appropriate weight and 26 (52,00%) with inappropriate weight. Finally, the Group D included 33 children (10.31%), 21 (63.6%) with appropriate weight and 12 (36.36%) with inappropriate weight. Conclusions: The age ranges included in Groups A and B were together 74.06% of the patients from that pediatric emergency. The groups A and C had higher proportion of children with

Introdução: A avaliação nutricional é um eficiente indicador das condições gerais de saúde da criança, especialmente durante a hospitalização. Entretanto, ela é pouco relatada na literatura. Objetivo: Avaliar o estado nutricional de crianças internadas em um hospital público e um hospital particular na Bahia. Metodologia: Trata-se de um estudo tipo coorte transversal, pelo qual foram avaliados os Índices de Massa Corporal (IMC) de 100 crianças internadas em um hospital público e 77 em um hospital particular, bem como de suas respectivas mães, no dia da admissão, entre Junho e Agosto de 2013. Foi utilizada a curva de crescimento Idade x IMC (z-score). Resultados: Das 177 crianças, 65 apresentaram IMC alterado, quatro delas com magreza acentuada, 12, magreza, 24 apresentaram risco de sobrepeso, 19 tinham sobrepeso e seis eram obesas. O risco de sobrepeso e sobrepeso foram as alterações mais frequentes no hospital público e o risco de sobrepeso, a mais frequente no hospital particular. Total de 56,3% das crianças acima do peso apresentaram mães igualmente acima do peso, enquanto que a concordância de eutrofia entre filhos e suas mães foi de 58,9%. Conclusão: Risco de sobrepeso foi a alteração mais frequente, no geral, o que está de acordo com a atual situação de transição nutricional do país. Parece haver associação entre estado nutricional da criança e das suas mães. Há necessidade deavaliação nutricional sistemática em todas as crianças hospitalizadas.

Objective The aim of the current study was to evaluate the safety of a new reduced protein (2.1 g/100 kcal) infant formula containing 4 g/L of 90% galacto-oligosaccharides (GOS) and 10% fructo-oligosaccharides (FOS). Methods Healthy term infants from Brazil were enrolled. Those born to human immunodeficiency virus (HIV)-positive mothers were randomized to a test ( n = 65) or control ( n = 63) formula group. Infants born to HIV-negative mothers were either exclusively breast-fed ( n = 79) or received a mixed diet (breast milk and test formula, n = 65). Between 2 weeks and 4 months of age, infants were exclusively fed according to their assigned group. Anthropometric measurements were taken at baseline, 1, 2, 3, 4, 6, 8, 10, and 12 months. Digestive tolerance was evaluated during the first 4 months. The primary outcome was mean daily weight gain between 2 weeks and 4 months in the test formula and breast-fed groups. Results Data from all infants ( N = 272) were used in the intention-to-treat (ITT) analysis and data from 230 infants were used in the per-protocol (PP) analysis. The difference in mean daily weight gain between 2 weeks and 4 months in the test formula and breast-fed groups was 1.257 g/day (onesided 95% confidence interval [CI]: -0.705 to inf, P < 0.001) in the PP analysis, showing that the lower bound of the 95% CI was above the -3.0 g/day non-inferiority margin. Results were similar in the ITT analysis. Symptoms of digestive tolerance and frequency of adverse events were similar in the two groups. Conclusions The formula containing 2.1 g/100 kcal protein and GOS and FOS was safe and tolerated well.

Segmental absence of the intestinal musculature is a rare cause of acute abdomen most likely associated with intestinal perforation and sepsis in neonates and adults. We present a case of a 10-year-old boy who developed acute abdomen and was treated with right hemicolectomy and partial resection of the ileum. The ileum showed a 20-cm-long stenotic segment showing prominent thinning of the intestinal wall. This case occurred in an older child, which appears to be rare when comparing the literature. The bowel defect was also the largest described to date, indicating the potential effect of an atonic segment leading to obstructive disease.

Growth of preschool children from poor urban households of NE Brazil can be affected by multiple factors through complex pathways. Structural equation modelling examined the direct and indirect inter‐relationships between socio‐demographic, biological, environmental, and nutritional factors on z‐scores for height‐for‐age (HAZ) and body‐mass‐index (BMIZ) in a cross‐sectional study of 264 disadvantaged preschoolers aged 3‐6 years in 7 philanthropic daycares in Salvador. Statistically significant (p<0.05) direct effects, as shown by standardized regression coefficients, for i) HAZ were maternal height (0.38), being white (‐0.10), of high birth order (‐0.16), and having a helminth infection (‐0.08); and for ii) BMIZ were maternal weight (0.21), haemoglobin (0.14), and extremely low SES (‐0.19). Significant (p<0.05) indirect effects for i) HAZ were sex (‐0.02) and serum Se (‐0.02); and for ii) BMIZ was having a helminth infection (‐0.003). One of the most complex indirect pathways influencing both stature and ponderal growth involved helminths, which acted on serum Se and then serum Zn. In conclusion, multiple factors influence linear growth and body mass indices of these preschoolers, of which treatment of helminth infections with deworming is a modifiable risk factor with the potential to enhance somatic growth.Grant Funding Source: Funded by University of Otago Research Fund and Nutrition Department PBRF fund

Nutrients such as docosahexaenoic acid (DHA), prebiotics, and beta-glucan have been associated with reduced incidence of respiratory illnesses and allergic manifestations. Our objective was to assess if a cow's milk-based formula enriched with these and other nutrients, including zinc, vitamin A, and iron, reduced the incidence of respiratory infections and diarrheal disease and secondarily the occurrence of allergic manifestations (AM) in healthy children. In this double-blind, randomized, controlled trial, healthy children (1-4yrs) from 2 daycare centers in Brazil were fed 3 servings per day of a follow-up formula (FF; n=125) containing DHA, the prebiotics polydextrose (PDX) and galactooligosaccharides (GOS), and beta-glucan, or a control cow's milk (C; n=131) for up to 28 weeks. The occurrence of respiratory infection, diarrheal disease, and allergic manifestation was assessed by study pediatricians and analyzed with the Cochran-Mantel-Haenszel test. The FF group had fewer episodes of AM, which included allergic rhinitis, conjunctivitis, wheezing, allergic cough, eczema, and urticaria, compared to the C group (p=0.021). The hazard ratio for AM was lower in the FF group compared to control (HR, 0.64; 95% CI 0.47-0.89; p=0.007). There was no difference in the incidence of respiratory infections and diarrheal disease between groups. A cow's milk-based formula containing DHA, PDX/GOS, and beta-glucan, and enriched with micronutrients including zinc, vitamin A, and iron, when consumed 3 times per day for 28 weeks by 1-to-4 year-old children, was associated with fewer episodes of allergic manifestations in the skin and the respiratory tract, as compared to cow's milk.

Objectives: Constipation affects up to 30% of children. Insufficient fiber intake is associated with functional constipation and changes in dietary composition, such as the addition of prebiotics, may improve stool pattern. There are few studies suggesting some effect of dietary management in childhood constipation. We obtained information on the incidence of constipation as part of a recently completed randomized trial designed to assess the effect of a follow-up formula with prebiotics on the occurrence of acute respiratory infections and diarrheal disease in children from two daycare centers in Brazil. Methods: In this double-blind, randomized, controlled trial, healthy 1-4 year old children were fed 3 servings/day of a cow’s milk-based follow-up formula fortified with micronutrients, docosahexaenoic acid, yeast beta-glucan, and the prebiotics polydextrose (PDX) and galactooligosaccharides (GOS) (FF; n=125) or an unfortified cow's milk-based beverage (C; n=131) for 28 weeks. A child was considered constipated if at least 2 of the 3 following symptoms were present for at least 2 uninterrupted weeks: presence of hard stools, difficulty or pain to defecate, and an interval of more than 72 hours without defecation. The children who met these criteria were categorized by age at study entry (12-24 months or 25-48 months) and compared using the Fisher’s exact test. Results: Twenty four of the 158 children in the 25-48 month age category (15%) met the criteria for constipation. Fewer children in this age category remained constipated at the end of the study in the FF group compared to the control group (Table). The difference was not statistically significant (p=0.27), most likely due to the small number of participants in each formula group who met the criteria for constipation. In the 12-24 month age category, 8 of 98 children (8%) met the criteria for constipation. However, all were in the control group, and 5 of the 8 (63%) remained constipated at the end of the study. Conclusion: These results suggest that dietary modification such as addition of the prebiotic fibers PDX and GOS may alleviate functional constipation in children.