Purpose:Infantile colic diagnostic criteria were established by Rome IV. A universally accepted management remains to be established. We aimed to evaluate diagnostic criteria, management strategies, and perceived regional prevalence of infantile colic in Pakistan, as well as its effect on physicians and parents.Methods:A questionnaire was distributed amongst 1,256 physicians.Results:We received 800 replies. Wessel and Rome IV criteria were used by most physicians for diagnosis; however, the response "any infant who cries a lot" was selected by older physicians (48% of those over 60 years), physicians in rural areas (32%), physicians practicing in private clinics (27%), and general physicians (30%). Estimated prevalence of infantile colic ranges from 21-40%. Reassurance was the most widely recommended management strategy followed by herbal teas (51%), switching to a different formula (49%), probiotics (28%) and antibiotics (26%), discontinuation of breastfeeding (14%), elimination of dairy products from the breastfeeding mothers' diet (6%), and the administration of colic drops (1%). Most physicians considered the negative impact of colic on their personal lives and the parents as mild-to-moderate. Notably, 38% of percent of physicians routinely screened for maternal depression, and 45% of physicians were aware of the association between infantile colic and shaken baby syndrome.Conclusion:Most physicians in Pakistan diagnose and manage infantile colic according to the established guidelines. However, the guidelines pertaining to treatment planning are not followed. Educational efforts directed toward general physicians and doctors practicing in rural areas and clinics must be implemented to avoid unnecessary testing and treatment burden.

From *Hospital Italiano, Buenos Aires, Argentina †St. Gilesmedical (London & Berlin) & University of Applied Sciences, Bremen, Germany ‡Former Medical Director Marie Curie Hospice, Hampstead, London, United Kingdom. Address correspondence and reprint requests to Carlos Lifschitz, MD, Hospital Italiano Servicio de Gastroenterologia Infantil, Tte. Gral. Juan Domingo Perón 4190, CABA., CP C1199ABB, Buenos Aires, Argentina (e-mail: [email protected]).

The World Health Organization recommended a formulation of oral rehydration salts as the intervention of choice for the treatment of acute gastroenteritis. While of value for the replacement of fluids and electrolytes, the formulation does not reduce stool volume, frequency, or symptom duration. This may prevent wide acceptance. To increase tolerability, shorten the duration of diarrhea and improve parental quality of life, several modifications to the original formula have been proposed. These include; low osmolarity, rice-based, glucose polymers as an alternative to glucose, the addition of probiotics, prebiotics and/or zinc, and various other ingredients. Here we summarize evidence regarding such changes and additions.

Visión general de las posibles causas e impacto del cólico infantil en la vida del bebé afectado y su familia.

BackgroundConventional therapy can result in remission in mild-moderate pediatric Crohn's disease (CD). However, some patients experience loss of response to biological drugs despite increased dosage.MethodsWe planned to determine that CD exclusion diet plus partial enteral nutrition offers additional benefits in asymptomatic children with CD having elevated fecal calprotectin. A randomized, open-label, pilot, controlled interventional study was conducted in children with CD while on medical treatment and elevated fecal calprotectin on routine testing. Patients continued their medications and were randomized into a group that received CD exclusion diet plus partial enteral nutrition for 12 weeks and one that continued a regular diet.ResultsTwenty-one patients participated: 11 received CD exclusion diet plus partial enteral nutrition and 10, regular diet. Median fecal calprotectin in the CD exclusion diet plus partial enteral nutrition decreased in 9/11 to 50% of baseline, remaining practically unchanged in the regular diet, except for two patients (p = 0.005). Body mass index z-score increased in the CD exclusion diet plus partial enteral nutrition. Only 1/11 patients in the CD exclusion diet plus partial enteral nutrition group, while 4/10 in the regular diet, experienced clinical relapse (p = 0.149). Only one patient in the CD exclusion diet plus partial enteral nutrition, while eight in the regular diet, were considered to need their biologic treatment intensified (p = 0.005); 2/11 in the CD exclusion diet plus partial enteral nutrition had the dose or frequency of the biologic reduced vs. none (0/10) in the regular diet group. The short Pediatric Crohn's Disease Activity Index and anthropometry showed no significant changes in either group.ConclusionsDiet therapy could be a useful addition to medications in children with CD in apparent remission, but elevated fecal calprotectin.Trial registrationClinical trial number: NCT05034458.

Introduction: Celiac disease (CD) is a chronic enteropathy with various clinical presentations.The objectives of this study were to describe the symptoms at diagnosis, to assess the nutritional status at debut and after 1 year of follow-up and estimate the prevalence of the disease.Methods: This was a descriptive and retrospective study.Five hundred and forty-two patients under 18 years with biopsy compatible CD were included in the study.Symptoms presented at diagnosis and anthropometric data, serum calcium, phosphorus, magnesium, albumin, and Vitamin D at diagnosis, 6 and 12 months of follow-up were analyzed.The prevalence was estimated in patients covered by the Italian Hospital Health Insurance during the period 2007-2017.Results: About 75% were symptomatic at diagnosis, the most frequent symptoms were diarrhea and abdominal pain.About 6% of the patients had a Z-score for weight <-2 at diagnosis, 3% at 6 months, and 1% at 12 months.Regarding height, 6% had a Z-score lower than -2 at diagnosis and 0.7% at 6 months.No patients had a Z-score lower than -2 for body mass index.Nor were patients with a median weight/length adequateness lower than 90 registered.Serum micronutrient levels were normal, except for Vitamin D, which was below normal both at diagnosis and at follow-up.The prevalence of CD in children and adolescents covered by the Italian Hospital Health Insurance was 0.4% (95% CI 0.32-0.48).Conclusions: The most frequent symptoms at diagnosis were classical gastrointestinal.Growth retardation was found in a low percentage of children.The prevalence reported was similar than in the previous studies.

The paper explains how subjective well-being can be measured, how the resulting data are being used to document human progress and how health care can be changed to take advantage of what has been learned. The evaluations that people make of their own lives document, and permit the explanation of, life satisfaction levels that differ greatly among countries and communities. Research seeking to explain these happiness differences, and their related differences in mortality and morbidity, exposes the importance of the social context. There is an opportunity and need to change health care from the diagnosis and treatment of illness to the fostering of wellness. The importance of the social context in the successful design and delivery of health and happiness is so great as to support a prescription to turn points due to having more people with someone to count on in times of trouble. This social support effect alone is more than the estimated impact of the 18-fold increase in GDP per capita required to shift the poorest country to the world average.

Background: Iron deficiency (ID) with or without anemia is associated with impaired mental and psychomotor development. Given the paucity of information on physicians' knowledge and practices on iron (Fe) supplementation and impact of ID in the Middle East and North Africa, it was felt important to conduct a survey. Method: A group of expert physicians developed a questionnaire that was randomly distributed among Middle East and North Africa doctors to assess their knowledge and practices on introduction of complementary feeding, impact of ID, its prevention, and their impression on prevalence of ID. Descriptive statistics were used. Results: We received 2444 completed questionnaires. Thirty-nine percent of physicians do not follow the European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines regarding age of introduction of complementary feedings. Approximately 62% estimate the prevalence of ID anemia to be 40% to 70%; however, only 17% always monitor hemoglobin between 9 and 12 months of age, 43% do so "almost'' always, whereas 36% do so "rarely'' or (4%) "never.'' For the prevention of ID in infants older than 6 months of age, almost all recommend introducing Fe supplements. Ninety-seven percent agree that untreated ID during infancy may have long-term negative effects on cognitive function, whereas 53.26% consider that Fe-enriched infant cereals result in staining of the baby teeth, constipation, and dark stools. Conclusions: Although there is awareness of the impact of ID, there are some misconceptions regarding age of introduction of complementary feedings, surveillance of Fe status, and side effects of Fe-enriched infant cereals. There is a need for educational initiatives focusing on prevention of Fe deficiency.

Regurgitation, infantile colic and functional constipation are common functional gastrointestinal disorders (FGIDs) during infancy. Our aim was to carry out a concise review of the literature, evaluate the impact of these common FGIDs on infants and their families, and provide an overview of national and international guidelines and peer-reviewed expert recommendations on their management. National and international guidelines and peer-reviewed expert recommendations on the management of regurgitation, infantile colic and functional constipation were examined and summarised. Regurgitation, infantile colic and functional constipation cause frequent parental concerns, lead to heavy personal and economic costs for families and impose a financial burden on public healthcare systems. Guidelines emphasise that the first-line management of these common FGIDs should focus on parental education, reassurance and nutritional advice. Nutritional advice should stress the benefits of continuing breastfeeding, while special infant formulas may be considered for non-breastfed infants with common FGIDs. Drug treatment is seldom required, with the exception of functional constipation. By providing complete and updated parental education, reassurance and nutritional advice, healthcare professionals can optimise the management of FGIDs and related symptoms and reduce the inappropriate use of medication or dietary interventions.

In this article, we will summarize the key non-nutritional aspects of the introduction of complementary feeding. Intestinal maturation related to starch digestion is relatively complete by the time complementary feeding is recommended to be initiated. A much more complex maturation is needed, however, from the neurodevelopmental standpoint as the infants need to be able to hold their head and trunk and be able to coordinate tongue movement followed by swallowing. Issues can arise in infants with a history of medical problems as well as when caretakers cannot handle the initial difficulties or want to impose certain rigidity to the learning process. The introduction of complementary feedings is also part of the early steps in introduction to human socialization. In that regard, it sets up the infant to internalize and accept the diversity of food textures and food choices. Early refusal of some food items is common and should not be interpreted as being disliked. Multiple attempts should be made to incorporate new food items. To accomplish these dynamics, caregivers need comprehensive education and relevant information.

This chapter is based on the memories of those who shaped the relationship between the European and the North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition. The first joint meeting of the 2 Societies took place in Paris in 1978, followed by 1 in New York in 1985, 1 in Amsterdam in 1990, 1 in Houston in 1994, and the last one in Toulouse in 1998. The formation of the Federation of the International Societies for Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) preceded the First World Congress of all Societies, which took place in Boston in 2000. The success of this meeting was followed by world congresses in Paris in 2004, Iguassu in 2008, Taiwan in 2012, and Montreal in 2016. NASPGHAN and ESPGHAN jointly took on the direction of the Journal of Pediatric Gastroenterology and Nutrition in 1991. Communication between the 2 Societies is extremely active, with members participating in many joint projects.

Aim: Regurgitation, infantile colic and functional constipation are common functional gastrointestinal disorders (FGIDs) during infancy. Our aim was to carry out a concise review of the literature, evaluate the impact of these common FGIDs on infants and their families, and provide an overview of national and international guidelines and peer-reviewed expert recommendations on their management. Methods: National and international guidelines and peer-reviewed expert recommendations on the management of regurgitation, infantile colic and functional constipation were examined and summarised. Results: Regurgitation, infantile colic and functional constipation cause frequent parental concerns, lead to heavy personal and economic costs for families and impose a financial burden on public healthcare systems. Guidelines emphasise that the first-line management of these common FGIDs should focus on parental education, reassurance and nutritional advice. Nutritional advice should stress the benefits of continuing breastfeeding, while special infant formulas may be considered for non-breastfed infants with common FGIDs. Drug treatment is seldom required, with the exception of functional constipation. Conclusion: By providing complete and updated parental education, reassurance and nutritional advice, healthcare professionals can optimise the management of FGIDs and related symptoms and reduce the inappropriate use of medication or dietary interventions.

Objectives: Prolonged suppression of gastric acid secretion by proton pump inhibitors (PPIs) may alter the bacterial microbiota of the upper gastrointestinal tract and lead to small bowel bacterial overgrowth (SBBO). Published reports have shown conflicting results on the association between PPI therapy and risk of SBBO development. We evaluated whether long-term PPI treatment is associated with presence of SBBO as determined by breath hydrogen (H2) and methane (CH4) excretion. We also assessed the differences in H2/CH4 excretion patterns in patients taking PPI compared with those not taking the medication and searched for the potential predictors of a positive breath test result. Material and methods: This was a prospective cohort study that included 67 PPI-treated patients (PPIT) and 62 not-receiving PPI (C, comparison). PPIT and C underwent a glucose H2/CH4 breath test (HMBT) to determine the presence of SBBO. Results: The prevalence of SBBO was significantly higher in PPIT compared to C (44.8% versus 21%, p = 0.005, OR = 3.06, 95% CI 1.40–6.66) as determined by H2 and CH4 excretion. We found that PPIT had all H2 test parameters (baseline H2 levels, maximum peak of H2 as well as mean H2 through the whole test) significantly higher than C. Even those PPIT who did not meet the criteria of breath test positivity had statistically higher breath H2 levels compared to C. Although we did not observe significant differences in CH4 excretion between groups, 19.4% of PPIT and 12.9% of C would have had a false-negative HMBT results had CH4 not been taken into account. Conclusions: Long-term PPI use was found to be significantly associated with SBBO development as determined by breath H2 and CH4 excretion. CH4 determination reduces the number of falsely negative test results.

Small bowel bacterial overgrowth (SBBO) was diagnosed in 22.5% of 40 children treated for 3 months with a proton pump inhibitor (PPI). Compared with those without SBBO, children with SBBO had higher frequency of abdominal pain, bloating, eructation, and flatulence. Patients with gastrointestinal symptoms after PPI treatment should be evaluated for SBBO rather than empirically prolonging PPI therapy.

Up to 50% of infants present with symptoms of regurgitation, infantile colic and/or constipation during the first 12 months of life. Although they are often classed as functional disorders, there is an overlap with cows' milk allergy. We present practical algorithms for the management of such disorders, based on existing evidence and general consensus, with a particular focus on primary health care. Management consists of early recognition of warning signs of organic disease, parental reassurance and nutritional strategies. The proposed algorithms aim to help healthcare providers manage frequent gastrointestinal and cows' milk-related symptoms in infants safely and effectively.

Up to 50% of infants present with symptoms of regurgitation, infantile colic and/or constipation during the first 12 months of life. Although they are often classed as functional disorders, there is an overlap with cows' milk allergy. We present practical algorithms for the management of such disorders, based on existing evidence and general consensus, with a particular focus on primary health care. Management consists of early recognition of warning signs of organic disease, parental reassurance and nutritional strategies.ConclusionThe proposed algorithms aim to help healthcare providers manage frequent gastrointestinal and cows' milk-related symptoms in infants safely and effectively.