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Pinto R.B.,Pediatric Gastroenterology Unit | Schneider A.C.S.,Federal University of Rio Grande do Sul | da Silveira T.R.,Federal University of Rio Grande do Sul
World Journal of Hepatology | Year: 2015

Several conditions, especially chronic liver diseases, can lead to cirrhosis in children and adolescents. Most cases in clinical practice are caused by similar etiologies. In infants, cirrhosis is most often caused by biliary atresia and genetic-metabolic diseases, while in older children, it tends to result from autoimmune hepatitis, Wilson's disease, alpha-1-antitrypsin deficiency and primary sclerosing cholangitis. The symptoms of cirrhosis in children and adolescents are similar to those of adults. However, in pediatric patients, the first sign of cirrhosis is often poor weight gain. The complications of pediatric cirrhosis are similar to those observed in adult patients, and include gastrointestinal bleeding caused by gastroesophageal varices, ascites and spontaneous bacterial peritonitis. In pediatric patients, special attention should be paid to the nutritional alterations caused by cirrhosis, since children and adolescents have higher nutritional requirements for growth and development. Children and adolescents with chronic cholestasis are at risk for several nutritional deficiencies. Malnutrition can have severe consequences for both pre- and post-liver transplant patients. The treatment of cirrhosis-induced portal hypertension in children and adolescents is mostly based on methods developed for adults. The present article will review the diagnostic and differential diagnostic aspects of end-stage liver disease in children, as well as the major treatment options for this condition. © 2015 Baishideng Publishing Group Inc. Source

Tauman R.,Tel Aviv University | Levine A.,Pediatric Gastroenterology Unit | Avni H.,Tel Aviv Medical Center | Nehama H.,Municipality of Tel Aviv Yafo | And 2 more authors.
Pediatrics | Year: 2011

OBJECTIVE: Behavioral insomnia and feeding difficulties are 2 prevalent conditions in healthy young children. Despite similarities in nature, etiology, prevalence, and age distribution, the association between these 2 common disorders in young children has not been examined thus far. PATIENTS AND METHODS: Children aged 6 to 36 months with either behavioral insomnia or feeding disorders were recruited. Children aged 6 to 36 months who attended the well-care clinics were recruited and served as controls. Sleep and feeding were evaluated by using a parental questionnaire. RESULTS: Six hundred eighty-one children were recruited. Fifty-eight had behavioral insomnia, 76 had feeding disorders, and 547 were controls. The mean age was 17.0 ± 7.6 months. Parents of children with feeding disorders considered their child's sleep problematic significantly more frequently compared with controls (37% vs 16%, P = .0001 [effect size (ES): 0.66]). They reported shorter nocturnal sleep duration and delayed sleep time compared with controls (536 ± 87 vs 578 ± 88 minutes, P = .0001) and 9:13 ± 0.55 PM vs 8:26 ± 1.31 PM, P = .003). Parents of children with behavioral insomnia described their child's feeding as "a problem" more frequently compared with controls (26% vs 9%, P = .001 [ES: 0.69]). They reported being more concerned about their child's growth (2.85 ± 1.1 vs 2.5 ± 1.0, P = .03) and reported higher scores of food refusal compared with controls (3.38 ± 0.54 vs 3.23 ± 0.44, P = .04). CONCLUSIONS: Problematic sleep and feeding behaviors tend to coexist in early childhood. Increased awareness of clinicians to this coexistence may allow early intervention and improve outcome. Copyright © 2011 by the American Academy of Pediatrics. Source

Turner D.,Hebrew University of Jerusalem | Levine A.,Tel Aviv University | Weiss B.,Tel Aviv University | Hirsh A.,Tel Aviv University | And 2 more authors.
Endoscopy | Year: 2010

Background: There are no current recommendations for bowel cleansing before colonoscopy in children. The Israeli Society of Pediatric Gastroenterology and Nutrition (ISPGAN) established an iterative working group to formulate evidence-based guidelines for bowel cleansing in children prior to colonoscopy. Method: Data were collected by systematic review of the literature and via a national-based survey of all endoscopy units in Israel. Based on the strength of evidence, the Committee reached consensus on six recommended protocols in children. Guidelines were finalized after an open audit of ISPGAN members. Results: Data on 900 colonoscopies per year were accrued, which represents all annual pediatric colonoscopies performed in Israel. Based on the literature review, the national survey, and the open audit, several age-stratified pediatric cleansing protocols were proposed: two PEG-ELS protocols (polyethylene-glycol with electrolyte solution); Picolax-based protocol (sodium picosulphate with magnesium citrate); sodium phosphate protocol (only in children over the age of 12 years who are at low risk for renal damage); stimulant laxative-based protocol (e.g. bisacodyl); and a PEG 3350-based protocol. A population-based analysis estimated that the acute toxicity rate of oral sodium phosphate is at most 3/7320 colonoscopies (0.041%). Recommendations on diet and enema use are provided in relation to each proposed protocol. Conclusion: There is no ideal bowel cleansing regimen and, thus, various protocols are in use. We propose several evidence-based protocols to optimize bowel cleansing in children prior to colonoscopy and minimize adverse events. © Georg Thieme Verlag KG Stuttgart · New York. Source

Levine A.,Pediatric Gastroenterology Unit | Wine E.,University of Alberta
Inflammatory Bowel Diseases | Year: 2013

Crohn's disease is a complex inherited disorder of unknown pathogenesis with environmental, genetic, and microbial factors involved in the development of the disease. A remarkable feature of this disease, especially, but not limited to childhood, is the effective response to exclusive enteral nutrition therapy and the observed benefit from exclusion of normal diet (principle of exclusivity). We reviewed the possible mechanisms of action of enteral nutrition for induction of remission and provided a hypothetical model (herein termed bacterial penetration cycle) that integrates dietary components, bacteria, susceptibility genes, and the innate immune response in the pathogenesis of Crohn's disease. Copyright ©; 2013 Crohn's & Colitis Foundation of America, Inc. Source

Turner D.,Hebrew University of Jerusalem | Levine A.,Wolfson Medical Center | Kolho K.-L.,University of Helsinki | Shaoul R.,Pediatric Gastroenterology Unit | Ledder O.,Hebrew University of Jerusalem
Journal of Crohn's and Colitis | Year: 2014

Background: The results of previous studies on the effectiveness of antibiotics in ulcerative colitis (UC) seem more effective when used orally. In this retrospective, multicenter study, we aimed to report our experience of using a combination of 3-4 antibiotics in children with moderate-severe refractory UC and IBD-unclassified including metronidazole, amoxicillin, doxycycline, and if during hospital admission, also vancomycin (MADoV). Methods: All children treated during 2013 with the antibiotic cocktail for 2-3. weeks in an attempt to alleviate inflammation in refractory colitis were included. Doxycycline was substituted with oral gentamycin or ciprofloxacin in children younger than 8. years or when an allergy was known to one of the drugs. Children were assessed using the PUCAI and CRP weekly for 3. weeks. Results: All 15 included children had moderate to severe disease with refractory disease course to multiple immunosuppressants (mean age 13.6. ±. 5.1. years, median disease duration 2 (IQR 0.8-3.2) years, 11 females (73%), and 13 (87%) extensive disease; 14 (93%) were corticosteroid-dependent or resistant, and 12 (80%) refractory to anti-TNF therapy). The cocktail was definitely effective in 7 of the 15 included children (47%) who entered complete clinical remission (PUCAI. <. 10) without additional interventions. Questionable or partial short-term response was noted in another 3 (20%), totaling 67% of patients. Conclusion: The use of oral wide-spectrum antibiotic cocktail in pediatric UC seems promising in half of patients, refractory to other salvage therapy. A pediatric randomized controlled trial to assess this intervention is underway. © 2014 European Crohn's and Colitis Organisation. Source

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