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   2020| May-August  | Volume 33 | Issue 2  
    Online since October 5, 2020

 
 
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ORIGINAL ARTICLES
Risk factors of delayed tolerance in children with cow milk protein allergy attending gastroenterology clinic in Alexandria University Children’s Hospital
Ahmed F Khalil, Manal M Abdel Gawad, Nada Mokhtar
May-August 2020, 33(2):55-63
DOI:10.4103/AJOP.AJOP_18_20  
Background Cow’s milk protein allergy (CMPA) is the most common type of food allergy. The prevalence is increasing in both developing and developed countries. The clinical presentations are variable in intensity and may involve many different organ systems. The diagnosis depends on positive response to an elimination diet, with recurrence of the symptoms upon re-challenge. CMPA usually resolves during early childhood, but some factors may delay the acquisition of tolerance. Aim The aim was to investigate the possible risk factors that may be associated with delayed tolerance to cow’s milk in patients with CMPA. Patients and methods The study included 95 patients aged 1 month to 3 years with proved CMPA attending the Gastroenterology Clinic at Alexandria University Children Hospital. Cases were recruited for 6 months, starting from January 1, 2018, to the end of June 2018. The demographic data, age at onset, clinical presentations, nutritional history, and family history of atopy were reported. The diagnosis was confirmed through elimination-re-challenge trial. All patients were treated by a milk-free diet with the use of appropriate milk substitutes according to the age. After a 6–9-month period of elimination, gradual re-introduction of milk was attempted, and the development of tolerance to milk was evaluated. Factors associated with delayed tolerance were compared in both the tolerant and intolerant groups. Results At their initial visit, the mean age of the studied patients was 8.5±4.9 months, and 17.9% were underweight. The mean age at onset of symptoms was 2.2±2.2 months, whereas the mean duration before diagnosis was 3.3±2.8 months. Overall, 85.3% were born via cesarean section. Chronic or delayed symptoms were reported in 93.7%. All patients had gastrointestinal symptoms. Chronic diarrhea was the commonest symptoms (90.53%) followed by vomiting (42%). In addition, 28.4% had cutaneous symptoms. Moreover, 81% were formula fed. Food protein-induced proctocolitis was the most common syndrome among patients with chronic symptoms. Overall, 85.26% of them were born via cesarean section. Early introduction of dairy products was encountered in 37.9%. In addition, 10% of the patients had cross-reaction to soy and 14.5% had multiple food allergy (MFA). Additionally, 56.8% had a family history of atopy. Overall, 68.42% tolerated cow milk after gradual re-introduction. Delayed diagnosis of CMPA symptoms, delayed introduction of complementary food, rural residence, family history of atopy, cross-reactivity to soya or MFA were associated with delayed tolerance to cow’s milk. Patients with immediate symptoms [immunoglobulin (Ig)E mediated] or food protein-induced enterocolitis syndrome or those with CMPA-associated eosinophilic gastrointestinal disorders showed delayed tolerance. Tolerance was achieved more frequently in patients with delayed (non-IgE mediated) symptoms, in patients with exclusive gastrointestinal symptoms, and in patients with food protein-induced proctocolitis. Conclusion The tolerance rate after 6–9 months of elimination was 63.2%, which is comparable to the international rates. IgE-mediated CMPA, food protein-induced enterocolitis syndrome, CMPA-associated eosinophilic gastrointestinal disorders, and MFA have delayed tolerance.
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Cyclic vomiting syndrome in children: a single-center experience
Ahmed F Khalil
May-August 2020, 33(2):64-73
DOI:10.4103/AJOP.AJOP_20_20  
Background Cyclic vomiting syndrome (CVS) is a functional disorder characterized by recurrent episodes of intractable vomiting separated by symptom-free periods. The onset starts at any age from infancy to adulthood. Little is known about its etiology. The diagnosis is based on the fulfillment of Rome IV criteria. CVS is usually a misrecognized disorder, and delayed diagnosis is very common. Aim The purpose was to evaluate the prevalence, clinical characteristics, prereferral management, and response to treatment among children with proved CVS in our institution. Patients and methods This was a retrospective study that included all children with CVS attending the Gastroenterology Clinic at Alexandria University Children’s Hospital between January 2016 and the end of June 2019. All patients were followed up for at least 6 months. The diagnosis is based on the fulfillment of Rome IV criteria. The following data were retrieved from the medical records including demographic information, evaluation steps performed for diagnosis, analysis of CVS characteristics, prereferral management, and finally, the treatment algorithm and response to treatment during follow-up. Results The study included 79 patients, and two-thirds of them were females. They constituted 2–5% of the cases referred yearly to our clinic. Evaluation for possible organic cause was indicated in 22.7%. No abnormalities were found in the barium studies. Other investigations including gastroscopies were not diagnostic for other organic causes. The mean age at onset of symptoms was 6±3.3 years. Overall, 25.3% of patients reported specific triggers, and 62.5% reported recognizable prodromes. The episodes were stereotypic among all patients. Overall, 52% experienced the start of the episodes at night. The interval between episodes was 2.5±1.8 months. The mean duration of each episode was 2.4±2 days. Listlessness and pallor were the commonest during the vomiting phase. The vomiting was bilious in 65.8%and contained blood in 50.8%. Personal history of migraine was positive in 9%. Family history of migraine and motion sickness was positive in two-thirds. The mean duration before referral of the patients was 12.5+8 months. Overall, 78% of the episodes were interpreted as episodes of gastroenteritis, food poisoning, or acid peptic disorders. Moreover, 54.4% were admitted at least once. The overall response to the first-line prophylactic therapy is 89.3%, with no significant adverse effects. Conclusion The prevalence and clinical characteristics were similar to other similar reports. Barium studies are not necessary in most of the patients. CVS is prevalent yet an underdiagnosed health problem. Propranolol is effective and safe and may be considered as a first-line prophylaxis in patients older than 5 years of age.
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Functional echocardiographic evaluation of the effect of placental transfusion in full-term newborns who need resuscitation
Magdy Badereldin, Aly AbdelMohsen, Asmaa Emad, Adham A Badib
May-August 2020, 33(2):45-54
DOI:10.4103/AJOP.AJOP_17_20  
Background At the time of delivery, newborn babies have to pass through transitional changes in many of their life supporting systems. A more successful transition at the level of the cardiovascular system, hence an overall better transition, could be reached if placental transfusion is implicated. Aim To study the feasibility of doing intact umbilical cord milking (I-UCM) as a method of placental transfusion in term neonates who were born depressed and needed resuscitation and to study its hemodynamic effects using echocardiography. Patients and methods A randomized controlled study involving 66 patients over a period of 6 months was conducted. The studied population was assigned to receiving I-UCM or immediate cord clamping. Laboratory parameters, resuscitation interventions, and finally, functional echocardiographic were studied in both groups. Results It was feasible to perform I-UCM in the delivered babies in the assigned group. Such group was found to have faster time for the first breath (45 vs. 60 s), higher Apgar score (5, 8, 10 vs. 4, 7, 9), and no need for more advanced resuscitation interventions compared with the group with immediate cord clamping. Higher levels of hemoglobin (17.20 vs. 15.85) were noticed with less need to transfusion in the intervention group. Better echocardiographic assessments were shown regarding ejection fraction, tricuspid annular plane systolic excursion, and lower incidence of pulmonary hypertension in the I-UCM group (70 vs. 66%, 1.02 vs. 0.87 cm, and 33.3 vs. 62.5%, respectively). Conclusions The practicality of UCM was easy and feasible in both depressed and nondepressed newborns. UCM as a method for placental does not affect resuscitative measures and results in better cardiac performance in asphyxiated babies.
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Diagnosis of children with persistent and atypical noisy breathing by using flexible bronchoscopy
Mai N.A Abonewair, Fatma A Ali, Maher M Ahmed, Mostafa A Mohamed
May-August 2020, 33(2):81-87
DOI:10.4103/AJOP.AJOP_22_20  
Background Noisy breathing is a very common complaint among children. It may carry a risk for life-threatening problems. Flexible bronchoscopy (FB) has become one of the most widely used diagnostic tools used by pediatric pulmonologists. Several forces are needed to be explored to help refine its use and reduce its complications. Aim The paper aimed to evaluate the use of pediatric bronchoscopy as a safe diagnostic tool for persistent and/or atypical noisy breathing children, the possible complications, and how it helps to change the management. Patients and methods A total of 100 children, aged from 1 month to 16 years, with persistent and/or noisy breathing were included in a prospective study using FB (May 2016 to May 2019) at a Tertiary Care Medical Center (Sohag University Hospital). The authors evaluated how bronchoscopy contributed to the patients’ diagnosis, what were the complications and limits in the center, and how the authors could deal with them. Results Overall, 37% of patients had malacia disorders, 22% had airway inflammation, 20% had foreign body aspiration, 6% vocal cord dysfunction, 6% subglottic stenosis, 4% tracheal stenosis, 1% subglottic hemangioma, and in three cases, no abnormalities could be detected. Minor complications occurred in 20% of cases; the most common was desaturation (10%), followed by exaggerated cough reflex, laryngeal spasm, and bronchospasm. Conclusion FB provided rapid and definitive diagnosis (confirming, ruling out, and discovering unexpected diagnosis) for the patients. It is a safe procedure and should be considered in the evaluation of children with persistent or atypical noisy breathing.
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T-tube ventilation should be rationalized in pediatric intensive care unit: a comparative study between T-tube and pressure support ventilation during spontaneous breathing trial
Dalia A Abdelrahman, Ahmed M Tawfik, Mohammad Walaa, Ahmad Abbas
May-August 2020, 33(2):74-80
DOI:10.4103/AJOP.AJOP_21_20  
Background Shifting from mechanical ventilation to spontaneous breathing during weaning phase is very critically challenging, and its success depends on many factors including the adopted weaning strategy in each center. Few studies have compared the used weaning procedures in pediatric age groups and their effect on the vital signs as stress predictors during spontaneous breathing trial (SBT). Aim The aim was to compare between t-piece weaning tool and pressure support ventilation (PSV) during SBT in mechanically ventilated pediatric patients to assess patients’ suffering. Patients and methods This prospective cohort study was carried out in the pediatric chest and anesthesia ICUs, Zagazig University Hospitals, Egypt, over a 6-month period (from May to October 2018). A total of 104 ventilated patients aged from 2 months to 18 years were enrolled in this study. All patients were subjected to full clinical assessment, as well as comparative methods between PSV and T-tube (TT) ventilation during weaning process. Results It was found that cardiac arrhythmias accounted for 71.2% of the patients weaned on TT in the form of sinus tachycardia compared with 9.6% of the patients on PSV, with significant difference between the two groups (P<0.001). Moreover, there was a significance increase in the mean arterial blood pressure among patients on TT during weaning process, with increase in the work of breathing (P<0.001). PSV mode had significantly lower PCO2 than TT during weaning (P<0.001). The failure rate was higher when using TT during SBT in comparison with PSV, with more exposure to another weaning trials. Conclusion The authors concluded that PSV has less stressful effects on patients during SBT process. TT weaning procedure has higher failure rate than PSV.
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Ocular manifestations in children and adolescents with sickle cell disease attending a Pediatric Hematology Unit in Damanhur Teaching Hospital
Saad S Abo-Zied, Hosam-Eldin M Elgemaey, Hala M Abd-Aal
May-August 2020, 33(2):88-93
DOI:10.4103/AJOP.AJOP_23_20  
Background Sickle cell disease (SCD) is the most common genetic disease worldwide. It is usually accompanied with painful crisis. Microvascular occlusions are common and affect different systems, among which is the ocular manifestations. Aim This study aimed to assess retinal changes in patients with SCD and its correlation with hematological parameters and if there is a link between a pretransfusion hemoglobin level and ocular manifestations or not. Patients and methods This study was conducted in the Pediatric Hematology Unit of Damanhur Teaching Hospital including patients coming regularly to sickle cell OPD for follow-up, those who were admitted for sickle cell crisis in internal medicine ward, as well as obstetrics/gynecology patients who were found to be sickle cell positive (SS pattern). In this cross-sectional study, 30 steady-state patients (60 eyes) aged 2–26 years (22 children and eight young adults) with an established diagnosis of SCD (16 with homozygous SS and 14 with S/b thalassemia) underwent complete ophthalmic examination with dilated fundoscopy. Hematologic investigations and ophthalmic investigations (visual acuity, slit-lamp biomicroscopy, and fundoscopy) were done and compared. For statistical analysis, SPSS software was used. Results The study showed that 70% of the patients with SCD with hemoglobin less than or equal to 7 g or less had ocular abnormalities in the form of nonproliferative retinopathy, proliferative retinopathy, and refractive errors. Recommendations Based on these observations, we recommend that all children with SCD (SS, S/B) should have regular ophthalmic examination including fundoscopic examination to screen for sickle cell retinopathy beginning at the age of 12 years.
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Study of the thyroid functions in patients with chronic kidney disease at Alexandria University Children’s Hospital
Salem F.S Garbadi, Mohammed A.-E Thabet, Shaymaa E.A.M Ahmed
May-August 2020, 33(2):94-100
DOI:10.4103/AJOP.AJOP_24_20  
Introduction The relationship between kidney and thyroid has been found since many years. Thyroid hormones directly affect the kidney through influencing the renal growth and development, glomerular filtration rate (GFR), renal transport systems, sodium and water homeostasis, and any impairment in thyroid functions can lead to or aggravate kidney disorders. On the contrary, the kidney plays an important role in thyroid hormone metabolism, degradation, and excretion so any disturbance in the hypothalamic–pituitary–thyroid axis has been correlated with reduced kidney functions. The earliest and the most common thyroid function abnormality in patients with chronic kidney disease (CKD) is a low triiodothyronine (T3) level (especially total T3 than free T3). This is called ‘low T3 syndrome.’ Moreover, CKD has an increased incidence of primary hypothyroidism and subclinical hypothyroidism. Detailed knowledge of all these interactions is extremely important for both the nephrologists and endocrinologists to plan the optimal management of the patient. Aim The purpose of the work was to study the thyroid functions in children with CKD (including patients on dialysis) attending Alexandria University Children’s Hospital. Patients and methods The study was a cross-sectional prospective study. The age of the studied cases ranged from 2 to 15 years. Overall, 52 male and 33 female patients were subjected to detailed history taking and full clinical examination. All patients were evaluated for serum creatinine, blood urea, serum thyroid-stimulating hormone, free triiodothyronine (FT3), and free thyroxine (FT4). Results A total of 55 (64.7%) cases had normal thyroid functions, 18 (21.2%) cases had low T3 syndrome, 10 (11.8%) cases had subclinical hypothyroidism, and two (2.4%) had hypothyroidism. No significant correlation between eGFR and thyroid-stimulating hormone levels was found, but there was a significant positive correlation between levels of free T3 and eGFR. Conclusion The low T3 syndrome is a relatively common thyroid disorder among children with CKD followed by subclinical hypothyroidism (11.8%). We recommend regular monitoring of thyroid functions in children with CKD for early detection of any disturbance to reduce the morbidity and mortality of CKD.
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Evaluation of bone mineral density in type I diabetic children attending the diabetes clinic of Alexandria University Children’s Hospital
Salma M Saleh Elsayed, Mohamed H Gouda, Doaa M Emara, Shaymaa Elsayed A Meguid
May-August 2020, 33(2):101-106
DOI:10.4103/AJOP.AJOP_25_20  
Introduction Type 1 diabetes mellitus (T1DM) is associated with reduced bone mineral density (BMD). Potential pathogenic mechanisms of T1DM-related bone damage may include the deficiency of insulin and insulin-like growth factors. Early identification of reduced BMD is useful in reducing the bone loss and fracture risk. We can get a quick, noninvasive, and accurate quantitation of bone mass by using dual-energy X-ray absorptiometry (DEXA scan). Aim The aim was to assess BMD in children with T1DM of 5-year duration or more and to evaluate its relation with the glycemic control. Patients and methods This study included 30 children with T1DM attending the diabetic clinic in Alexandria University Children’s Hospital, Egypt. They were compared with 30 apparently healthy children of matched age and sex. Thorough history taking and clinical examination were done with emphasis on age and duration of diabetes and history of fractures. Laboratory investigations were done including renal functions, serum calcium (Ca), phosphorus (P), alkaline phosphatase, and glycosylated hemoglobin (HbA1C). BMD was assessed by DEXA scan at the spine (L2–L4) and at the femur. Results The mean age of the diabetic cases was 12.2 years, with mean of 7.6 years as duration of diabetes. There was no significant difference between the two groups regarding the serum levels of Ca and P, but alkaline phosphatase was significantly higher in diabetic cases than in controls. A total of nine diabetic cases (30%) had low bone density (Z score < −2 SD by DEXA scan). The diabetic cases had lower mean BMD results than in control group. Conclusion Reduced BMD is common in children with T1DM. The authors recommend assessing children with T1DM by DEXA scan for early identification of reduced BMD to reduce the fracture risk.
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