RESUMEN
OBJECTIVE: To assess the benefits of pancreatic enzyme replacement therapy (PERT) in children with complicated severe acute malnutrition. STUDY DESIGN: We conducted a randomized, controlled trial in 90 children aged 6-60 months with complicated severe acute malnutrition at the Queen Elizabeth Central Hospital in Malawi. All children received standard care; the intervention group also received PERT for 28 days. RESULTS: Children treated with PERT for 28 days did not gain more weight than controls (13.7 ± 9.0% in controls vs 15.3 ± 11.3% in PERT; P = .56). Exocrine pancreatic insufficiency was present in 83.1% of patients on admission and fecal elastase-1 levels increased during hospitalization mostly seen in children with nonedematous severe acute malnutrition (P <.01). Although the study was not powered to detect differences in mortality, mortality was significantly lower in the intervention group treated with pancreatic enzymes (18.6% vs 37.8%; P < .05). Children who died had low fecal fatty acid split ratios at admission. Exocrine pancreatic insufficiency was not improved by PERT, but children receiving PERT were more likely to be discharged with every passing day (P = .02) compared with controls. CONCLUSIONS: PERT does not improve weight gain in severely malnourished children but does increase the rate of hospital discharge. Mortality was lower in patients on PERT, a finding that needs to be investigated in a larger cohort with stratification for edematous and nonedematous malnutrition. Mortality in severe acute malnutrition is associated with markers of poor digestive function. TRIAL REGISTRATION: ISRCTN.com: 57423639.
Asunto(s)
Terapia de Reemplazo Enzimático/métodos , Insuficiencia Pancreática Exocrina/terapia , Desnutrición Aguda Severa/terapia , Peso Corporal , Preescolar , Femenino , Humanos , Lactante , Mortalidad Infantil , Tiempo de Internación , Malaui , Masculino , Páncreas , Proyectos Piloto , Estudios Prospectivos , Resultado del Tratamiento , Aumento de PesoRESUMEN
BACKGROUND: The WHO Guidelines for the inpatient treatment of severely malnourished children include a recommendation to provide sensory stimulation or play therapy for children with severe acute malnutrition (SAM). This systematic review was performed to synthesize evidence around this recommendation. Specifically, the objective was to answer the question: "In children with severe acute malnutrition, does psychosocial stimulation improve child developmental, nutritional, or other outcomes?" METHODS: A review protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO 2016: CRD42016036403). MEDLINE, Embase, CINAHL, and PsycINFO were searched with terms related to SAM and psychosocial stimulation. Studies were selected if they applied a stimulation intervention in children with SAM and child developmental and nutritional outcomes were assessed. Findings were presented within a narrative synthesis and a summary of findings table. Quality of the evidence was evaluated using the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. FINDINGS: Only two studies, both non-randomized controlled trials, met the selection criteria for this review. One was conducted in Jamaica (1975) with a follow-up period of 14 years; the other was done in Bangladesh (2002) with a six-month follow-up. At the individual study level, each of the included studies demonstrated significant differences in child development outcomes between intervention and control groups. Only the study conducted in Bangladesh demonstrated a clinically significant increase in weight-for-age z-scores in the intervention group compared to the control group. CONCLUSIONS: The evidence supporting the recommendation of psychosocial stimulation for children with SAM is not only sparse, but also of very low quality across important outcomes. High-quality trials are needed to determine the effects of psychosocial stimulation interventions on outcomes in children with SAM.
Asunto(s)
Trastornos de la Nutrición del Niño/psicología , Sistemas de Apoyo Psicosocial , Desnutrición Aguda Severa/psicología , Adolescente , Bangladesh , Niño , Desarrollo Infantil/fisiología , Trastornos de la Nutrición del Niño/epidemiología , Preescolar , Guías como Asunto/normas , Humanos , Lactante , Recién Nacido , Jamaica , Ensayos Clínicos Controlados no Aleatorios como Asunto , Estado Nutricional , Evaluación de Resultado en la Atención de Salud , Estudios Prospectivos , Desnutrición Aguda Severa/terapiaRESUMEN
OBJECTIVES: To assess whether pancreatic function is impaired in children with severe acute malnutrition, is different between edematous vs nonedematous malnutrition, and improves by nutritional rehabilitation. STUDY DESIGN: We followed 89 children with severe acute malnutrition admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi. Stool and blood samples were taken on admission and 3 days after initial stabilization to determine exocrine pancreatic function via fecal elastase-1 (FE-1) and serum trypsinogen and amylase levels. RESULTS: A total of 33 children (37.1%) had nonedematous severe acute malnutrition, whereas 56 (62.9%) had edematous severe acute malnutrition. On admission, 92% of patients showed evidence of pancreatic insufficiency as measured by FE-1 <200 µg/g of stool. Patients with edematous severe acute malnutrition were more likely to have low FE-1 (98% vs 82.8%, P = .026). FE-1 levels remained low in these individuals throughout the assessment period. Serum trypsinogen was elevated (>57 ng/mL) in 28% and amylase in 21% (>110 U/L) of children, suggesting pancreatic inflammation. CONCLUSION: Exocrine pancreatic insufficiency is prevalent in children with severe acute malnutrition and especially in children with edematous severe acute malnutrition. In addition, biochemical signs suggestive of pancreatitis are common in children with severe acute malnutrition. These results have implications for standard rehabilitation treatment of children with severe acute malnutrition who may benefit from pancreatic enzyme replacement therapy. TRIAL REGISTRATION: ISRCTN.com: 13916953.
Asunto(s)
Insuficiencia Pancreática Exocrina/epidemiología , Pancreatitis/epidemiología , Desnutrición Aguda Severa/complicaciones , Amilasas/sangre , Preescolar , Estudios de Cohortes , Femenino , Humanos , Tiempo de Internación , Masculino , Elastasa Pancreática/metabolismo , Pruebas de Función Pancreática , Prevalencia , Tripsinógeno/sangreRESUMEN
OBJECTIVE: To evaluate rectal sensitivity in patients with pediatric constipation (PC) and nonretentive fecal soiling (FNRFS) using pressure-controlled distention (barostat). STUDY DESIGN: Thresholds for rectal sensitivity (first sensation, urge to defecate, and pain), and rectal compliance were determined using a barostat. RESULTS: A total of 69 patients with PC (50 males; mean age, 10.9 +/- 2.2 years) and 19 patients with FNRFS (15 males; mean age, 10.0 +/- 1.9 years) were compared with 22 healthy volunteers (HVs) (11 males; mean age, 12.7 +/- 2.6 years). Sensitivity thresholds were not significantly different among the 3 groups. Rectal compliance was increased in 58% of the patients with PC (P < .0001 vs HVs). Rectal compliance did not differ between patients with FNRFS and HVs. Children with PC with abnormal rectal function required significantly larger rectal volumes at urge to defecate. CONCLUSIONS: Increased compliance is the most prominent feature in patients with PC. Because of higher compliance in these children, larger stool volumes are required to reach the intrarectal pressure of the urge to defecate. Children with FNRFS have normal rectal function.
Asunto(s)
Estreñimiento/fisiopatología , Defecación/fisiología , Recto/fisiopatología , Adolescente , Niño , Adaptabilidad , Femenino , Humanos , Masculino , Manometría/instrumentación , Manometría/métodos , SensaciónRESUMEN
OBJECTIVE: To compare the diagnostic accuracy of contrast enema (CE), anorectal manometry (ARM), and rectal suction biopsy (RSB) for the detection of Hirschsprung's disease (HD). STUDY DESIGN: Following a prospective protocol, infants suspected of HD underwent all 3 index tests. Children with positive results on 2 or more index tests or who continued to have severe bowel problems underwent a full thickness biopsy as reference standard. Clinical follow-up was the reference standard in all other children. RESULTS: Between 2000 and 2003, 111 consecutive patients (67 boys; median age, 5.3 months) in whom HD was suspected were enrolled. HD was found in 28 patients. RSB had the highest sensitivity (93%) and specificity (100%) rates, but values were not significantly different from CE (sensitivity, 76%; specificity, 97%) or from ARM (sensitivity, 83%; specificity, 93%). Inconclusive test results occurred in 8 infants with CE, in 15 infants with ARM because of agitation, and in 2 infants with RSB. CONCLUSION: RSB is the most accurate test for diagnosing HD, and it has the lowest rate of inconclusive test results.
Asunto(s)
Canal Anal/patología , Enema , Enfermedad de Hirschsprung/diagnóstico , Recto/patología , Biopsia/métodos , Niño , Preescolar , Medios de Contraste , Diatrizoato de Meglumina , Femenino , Estudios de Seguimiento , Enfermedad de Hirschsprung/cirugía , Humanos , Lactante , Recién Nacido , Masculino , Manometría , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y Especificidad , SucciónRESUMEN
OBJECTIVES: To evaluate the prevalence of pediatric functional gastrointestinal disorders with the use of the Rome II criteria and to compare these data with the classic Iowa criteria. STUDY DESIGN: Patients recorded defecation and encopresis frequency. A standard history was taken and a physical examination including a rectal examination was done. The prevalence of both criteria was assessed and compared. RESULTS: One hundred ninety-eight consecutive patients (age, 0.66 to 15.76 years; 131 male subjects) were included. According to the Rome II criteria, 64%, 18%, and 21% of patients fulfilled the criteria for functional constipation, functional fecal retention, and functional nonretentive fecal soiling, respectively. Using the classic criteria, 74% and 18% of patients fulfilled the criteria for pediatric constipation and solitary encopresis, respectively; 16% of the patients fulfilling the pediatric constipation criteria were not recognized by the Rome II constipation criteria. Fair agreement was found between functional nonretentive fecal soiling and solitary encopresis. Encopresis was present in 79% of constipated children. CONCLUSIONS: The Rome criteria are restrictive and exclude several children with constipation. We recommend including encopresis and rectal digital examination and excluding arbitrary age limits and retentive behavior in the revision of the Rome criteria.