Nausea and dyspepsia – frequent problems in pediatrics

Uvod i cilj: Mučnina i dispepsija su česti simptomi u djece. Javljaju se zasebno ili u kombinaciji s drugim simptoma, stanjima ili bolestima. Uzrok može biti organska bolest, ili češće funkcionalni probavni poremećaj. Riječ je o simptomima koji su često ponavljajući ili kronični, uzrokuju značajan morbiditet, česte posjete liječniku i opsežnu dijagnostiku, te negativno utječu na kvalitetu života bolesnika. Cilj ovog preglednog rada je prikazati etiologiju, mehanizme nastanka, važeće dijagnostičke kriterije i mogućnosti liječenja mučnine i dispepsije u svijetlu novih istraživanja i znanstvenih spoznaja. Zaključak: Prilikom pristupa djetetu sa simptomima mučnine i povraćanja važno je razlučiti radi li se o organskoj bolesti ili funkcionalnom poremećaju, definiranom prema Rimskim kriterijima. Ovisno o anamnezi i upozoravajućim simptomima, dijagnostička obrada treba biti racionalna. Liječenje je specifično ako je nađen organski uzrok, ili je orijentirano prema olakšavanju najizraženijeg simptoma u slučaju funkcionalnog poremećaja.Introduction and aim: Nausea and dyspepsia are frequent in children. They can occur as a single symptom, or overlap with other symptoms, conditions or diseases, whether organic, or more often, functional. Symptoms are usually chronic or reccurent, and cause significant morbidity, frequent hospital visits and broad diagnostic workup, thus having negative impact on patients’ quality of life. The aim of this review is to present etiology, mechanisms of development, current diagnostic criteria and treatment options for nausea and dyspepsia, based on new research. Conslusion: In the management of a child presenting with nausea or dyspepsia it is important to differentiate organic from functional disorder. Depending on symptoms and „red flags“, diagnostic workup should be rational. If possible, treatment should target organic disease, or it should relieve dominant symptoms

Molecular characteristics and zoonotic potential of rotaviruses

Rotavirusi su jedni od najvažnijih uzročnika akutnog gastroenteritisa kod ljudi i životinja, a između devet prepoznatih vrsta rotavirusA se posebno ističe zbog velike proširenosti i patogenosti. I danas, uz visoki pobol i hospitalizaciju oboljele djece u zemljama s visokimhigijenskim standardom, u zemljama u razvoju uzrokuju značajnu smrtnost. Takav je učinak posebno vidljiv kada dostupna cjepivanisu dio nacionalnog imunizacijskog programa. Zbog prirode svoga genoma rotavirusi izrazito brzo evoluiraju, prvenstveno zahvaljujućiučestaloj pojavi točkastih mutacija i genomskog preslagivanja. Stoga nije iznenađujuća visoka genetska heterogenost, patako danas poznajemo ukupno 36 genotipova G i 51 genotip P rotavirusa A. Kada izravno prijeđu vrsnu barijeru, rotavirusi uglavnomnisu sposobni učinkovito inficirati ili se širiti u novom domaćinu. No baš pojava genomskog preslagivanja omogućuje nastanaknovih, potencijalno emergentnih humano-animalnih reasortanata. Stoga je potreban stalni nadzor životinjskih sojeva rotavirusakako bi se dobila točna slika o životinjskim rezervoarima koji u budućnosti mogu biti odgovorni za unos novih rotavirusa uljudsku populaciju ili rotavirusnih gena u genetsku osnovu humanih sojeva. Sustavno praćenje molekularnih značajki rotavirusa kojicirkuliraju u određenom području od posebne je važnosti prije uvođenja nacionalnog imunizacijskog programa, ali i dok je aktivnaimunizacija u tijeku. Opsežnije istraživanje rotavirusa A u ekosustavu Republike Hrvatske je u tijeku, a omogućit će otkrivanje životinjskihrezervoara te pridonijeti boljem razumijevanju zoonotskog potencijala ovih virusa.Rotaviruses are one of the most important pathogens causing acute gastroenteritis in humans and animals. Among nine species,rotavirus A is particularly emphasised considering its prevalence and pathogenicity. Even today, apart from the substantial morbidityand hospitalisation rates in countries with high hygiene standards, it causes considerable mortality in developing countries. Suchimpact is especially evident if available vaccines are not included in the national immunisation program. Due to the nature of theirgenome, the evolution of rotaviruses is quite rapid owing to the accumulation of point mutations and genome reassortment. Therefore,the high heterogeneity and the fact that nowadays there are 36 G genotypes and 51 P genotypes of rotavirus A, is not surprising.When direct interspecies transmission occurs, rotaviruses are mostly not able to efficiently infect or transmit in the new host. However,genome reassortment can result in the generation of new, potentially emergent, human-animal reassortants. Thus, it is necessaryto continuously monitor the animal rotavirus strains in order to get complete perspective of the potential animal reservoirs thatcould be responsible for the introduction of novel rotaviruses in human population or rotavirus genes in the genetic backbone ofhuman strains. Systematic investigation of rotavirus molecular characteristics in a certain region is of special importance before theintroduction or during the implementation of national immunisation program. Comprehensive research that would evaluate theanimal reservoirs and the zoonotic potential of rotavirus A strains in Croatian ecosystem is currently in progress

Interspecies transmission of porcine-originated G4P[6] rotavirus A between pigs and humans: a synchronized spatiotemporal approach

As a leading viral cause of acute gastroenteritis in both humans and pigs, rotavirus A (RVA) poses a potential public health concern. Although zoonotic spillover of porcine RVA strains to humans is sporadic, it has been detected worldwide. The origin of chimeric human–animal strains of RVA is closely linked to the crucial role of mixed genotypes in driving reassortment and homologous recombination, which play a major role in shaping the genetic diversity of RVA. To better understand how genetically intertwined porcine and zoonotic human-derived G4P[6] RVA strains are, the present study employed a spatiotemporal approach to whole-genome characterization of RVA strains collected during three consecutive RVA seasons in Croatia (2018–2021). Notably, sampled children under 2 years of age and weanling piglets with diarrhea were included in the study. In addition to samples tested by real-time RT-PCR, genotyping of VP7 and VP4 gene segments was conducted. The unusual genotype combinations detected in the initial screening, including three human and three porcine G4P[6] strains, were subjected to next-generation sequencing, followed by phylogenetic analysis of all gene segments, and intragenic recombination analysis. Results showed a porcine or porcine-like origin for each of the eleven gene segments in all six RVA strains. The G4P[6] RVA strains detected in children most likely resulted from porcine-to-human interspecies transmission. Furthermore, the genetic diversity of Croatian porcine and porcine-like human G4P[6] strains was propelled by reassortment events between porcine and porcine-like human G4P[6] RVA strains, along with homologous intragenotype and intergenotype recombinations in VP4, NSP1, and NSP3 segments. Described concurrent spatiotemporal approach in investigating autochthonous human and animal RVA strains is essential in drawing relevant conclusions about their phylogeographical relationship. Therefore, continuous surveillance of RVA, following the One Health principles, may provide relevant data for assessing the impact on the protectiveness of currently available vaccines

Guidelines for the diagnosis and treatment od chronic constipation in children – Recommendations from Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association

Uvod i cilj: Kronična opstipacija, prvenstveno funkcijska, jedna je od najčešćih gastrointestinalnih tegoba u djece i jedan od najčešćih razloga posjeta gastroenterologu. S ciljem adekvatne dijagnoze i liječenja Hrvatsko društvo za pedijatrijsku gastroenterologiju, hepatologiju i prehranu (HDPGHP) revidiralo je smjernice za dijagnostiku i liječenje kronične opstipacije u djece. Metode: Prilikom kreiranja novih smjernica pretražena je dostupna znanstvena i stručna literatura, uključujući i smjernice relevantnih europskih društava. Rezultati: U detalje su razrađene smjernice za dijagnostiku i liječenje kronične opstipacije u djece s predloženim postupnicima i praktičnim savjetima o dozama lijekova. Zaključci: Dijagnoza funkcijske opstipacije postavlja se na temelju kliničke slike i fizikalnog pregleda i vrlo dobro liječi osmotskom laksativnom terapijom.Introduction and aim: Chronic constipation, primarily functional, is one of the most common gastrointestinal problems in children and one of the most common reasons for referral to gastroenterologist. With the aim to promote adequate diagnosis and treatment, the Croatian Society of Pediatric Gastroenterology, Hepatology and Nutrition (HDPGHP) has revised guidelines for the diagnosis and treatment of constipation in children. Methods: The available scientific and clinical literature, including the guidelines of relevant European societies, was searched before creating the guidelines. Results: This manuscript represents guidelines for the diagnosis and treatment of chronic constipation in children and contains detailed algorithm and practical advice on therapy including doses. Conclusions: Functional constipation is diagnosed based on clinical symptoms and physical examination and can be adequately managed with osmotic laxative therapy

Vegetarian and vegan diet in children – guidelines of the Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association

Utjecaj vegetarijanske i veganske prehrane na zdravlje djece sve češće razmatraju ne samo pedijatri nego i drugi stručnjaci koji se bave zbrinjavanjem djece. Zato je cilj ovih smjernica, na temelju predočenih i sažetih znanstvenih dokaza o učinku vegetarijanske i veganske prehrane na zdravlje djece i adolescenata, iznijeti upute Hrvatskog društva za pedijatrijsku gastroenterologiju, hepatologiju i prehranu Hrvatskoga liječničkog zbora. Vegetarijanska, a posebice veganska prehrana, ne znači samo dokidanje mesa ili namirnica životinjskog podrijetla, već mora biti uravnotežena prehrana prilagođena djetetu. Ovakvo dijete iziskuje kontinuirani nadzor i ovlaštenog liječnika primarne zdravstvene zaštite i pedijatrijskog nutricionista, pri čemu obojica u tom pogledu moraju biti posebno educirani. Budući da ograničavanje broja namirnica koje dijete konzumira znatno povisuje rizik od nutritivnog deficita, roditelji koji se odluče na ovakvu prehranu i svi profesionalci koji zbrinjavaju ovu djecu moraju biti svjesni mogućih nutritivnih rizika koji su u dječjoj dobi puno viši nego u odraslih.The influence of vegetarian and vegan diet on children’s health has been discussed not only by pediatricians but also by other professionals who take care of children. Therefore, the aim of this recommendations, based on presented and summarized scientific evidences on the effect of vegetarian and vegan diet on children’s and adolescents’ health, was to state the instructions of the Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association. Vegetarian, and especially vegan diet, is not only the omission of meat and other food of animal origin, but has to represent balanced nutrition adjusted for children. Such a child requires continuous supervision not only by primary health physician but also by pediatric nutritionist, who both have to be specially educated in the field. As restrictions in diet significantly increase the risk for nutritional deficiencies, parents who decide to follow such a diet, and all professionals who take care of such children, have to be aware of possible nutritional risks that are much bigger than in adulthood

Vegetarijanska i veganska prehrana u dječjoj dobi - smjernice Hrvatskog društva za pedijatrijsku gastroenterologiju, hepatologiju i prehranu Hrvatskog liječničkog zbora [Vegetarian and vegan diet in children - guidelines of the Croatian society for pediatric gastroenterology, hepatology and nutrition of the Croatian Medical Association]

The influence of vegetarian and vegan diet on children’s health has been discussed not only by pediatricians but also by other professionals who take care of children. Therefore, the aim of this recommendations, based on presented and summarized scientific evidences on the effect of vegetarian and vegan diet on children’s and adolescents’ health, was to state the instructions of the Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association. Vegetarian, and especially vegan diet, is not only the omission of meat and other food of animal origin, but has to represent balanced nutrition adjusted for children. Such a child requires continuous supervision not only by primary health physician but also by pediatric nutritionist, who both have to be specially educated in the field. As restrictions in diet significantly increase the risk for nutritional deficiencies, parents who decide to follow such a diet, and all professionals who take care of such children, have to be aware of possible nutritional risks that are much bigger than in adulthood

Incidence and Geographical Variability of Pediatric Inflammatory Bowel Disease in Croatia: Data From the Croatian National Registry for Children With Inflammatory Bowel Disease

The aim of this study was to determine the annual incidence and geographic distribution of pediatric inflammatory bowel disease (IBD) in Croatia. This is a prospective, cohort, multicenter observational study based on the data obtained from the Croatian national registry for children with IBD. Children and adolescents younger than 18 years diagnosed with IBD, in time period between June 1, 2016, and May 31, 2017, were recruited. In total, 51 new cases were identified ; 19 Crohn’s disease, 28 ulcerative colitis, and 8 IBD- unclassified. Male preponderance of all 3 types of the disease was noticed. The median age at diagnosis was 14.8 years. The calculated annual incidence of pediatric IBD per 100 000 persons per year was 7.05 (2.63 for Crohn’s disease, 3.87 for ulcerative colitis, and 0.55 for IBD- unclassified). A north to south gradient was observed with almost 2 times higher incidence in the northern region of the country

IBD phenotype at diagnosis, and early disease-course in pediatric patients in Croatia: data from the Croatian national registry

Background: Pediatric inflammatory bowel disease (IBD) presents with extensive phenotype. The aim of this study was to determine the phenotype of pediatric IBD patients in Croatia at diagnosis and follow-up. Methods: Children were prospectively recruited into Croatian IBD national registry. Data on diagnostic evaluation, therapy and 1-year follow-up were collected. Results: A total of 51 newly diagnosed patients were recruited (19 Crohn's disease (CD), 28 ulcerative colitis (UC) and 4 IBD-unclassified (IBD-U)). Most common location in CD was ileocolonic disease (52.6%), and pancolitis in UC (53.6%). The recommended complete diagnostic algorithm was performed only in 29.4% of patients. First-line therapy used in CD was exclusive enteral nutrition for remission induction (84.2%) and azathioprine for maintenance (73.7%). In patients with UC, aminosalicylates were the most common drug used (89.3%). By the end of the first year 41.2% of CD and 53.9% of UC patients had one or more relapses and required treatment escalation. Conclusion: Our data confirm extensive intestinal involvement in pediatric IBD and relatively high relapse rate during the first year of follow-up. More effort should be invested on the national level to implement more stringent adherence to the current European guidelines. Impact: The key message of our article is that pediatric IBD in Croatia shows extensive intestinal involvement with high relapse rates in first year of follow-up. It is the first cohort study reporting on the phenotype of pediatric IBD in Croatia, but also investigates adherence to diagnostic and therapeutic European guidelines which is not commonly reported. The study is national based, thus having the greatest impact on Croatian health care,stressing out that more effort should be invested on the national level to implement more stringent adherence to the current European guidelines

Celiac disease – new guidelines, what is new? – diagnostic algorithm from Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association

Uvod i cilj: Celijakija je imunosno posredovana, kronična sistemska bolest uzrokovana glutenom i srodnim prolaminima koja se pojavljuje u genetski predisponiranih osoba, a liječi se strogom, doživotnom prehranom bez glutena. To je jedna od najčešćih gastrointestinalnih i sistemskih bolesti s prevalencijom od 1%, ali nerijetko se, zbog različitih kliničkih prezentacija, ne prepoznaje ili se dijagnosticira kasno, ponekad i nakon višegodišnjeg trajanja simptoma. S ciljem ranijeg prepoznavanja te ujednačavanja dijagnostike, liječenja i daljnjeg praćenja oboljele djece, Hrvatsko društvo za dječju gastroenterologiju, hepatologiju i prehranu HLZ-a (HDPGHP) odlučilo je izraditi ovaj postupnik. Metode: Postupnik se temelji na europskim smjernicama, spoznajama dobivenim pretragom dostupne znanstvene i stručne literature te na stručnom mišljenju članova Upravnog odbora HDPGHP. Rezultati: U detalje su razrađene smjernice za dijagnostiku i liječenje celijakije u dječjoj dobi s predloženim postupnikom. Zaključak: Pravovremeno prepoznavanje i postavljanje dijagnoze celijakije te pravilno liječenje dovodi do nestanka simptoma i oporavka djeteta, sprječava razvoj komplikacija i poboljšava kvalitetu života.Introduction and aim: Celiac disease is immune mediated, chronic systemic disorder elicited by gluten and related prolamines in genetically susceptible individuals that is treated with strict, life-long gluten-free diet. It is one of the most common gastrointestinal and systemic diseases with the prevalence of 1%, but often, due to different clinical presentations, it is not recognized or diagnosed with delays, sometimes after several years of having symptoms. In order to identify patients earlier and to harmonize the diagnostic procedures, treatment and follow-up of children with celiac disease, the Croatian Medical Association, Croatian Society of Pediatric Gastroenterology, Hepatology and Nutrition (HDPGHP) decided to develop this algorithm. Methods: The algorithm is based on European guidelines, the knowledge gained from searching available scientific and clinical literature and on expert opinion of HDPGHP Board members. Conclusion: Timely recognition and diagnosis of celiac disease and proper treatment lead to the disappearance of symptoms and recovery of the child, prevents the development of complications and improves quality of life

Inflammatory bowel disease in children – from the diagnosis to the treatment Recommendations from Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association

Uvod i cilj: Dijagnoza kronične upalne bolesti crijeva, u svakog četvrtog oboljelog postavlja se u dječjoj dobi, tj. prije navršene osamnaeste godine života. Svjedoci smo značajnog porasta incidencije posljednjeg desetljeća, odnosno danas se ubraja među najčešće kronične gastroenterološke bolesti dječje dobi. Nedavno je određena incidencija i u našoj državi, koja je potvrdila da je ukupna incidencija 7,05/100,000 djece do navršene 18. godine života, što je slično ostalim razvijenim zemljama svijeta. Metode: S ciljem ranog otkrivanja te kako bi se olakšalo liječenje kronične upalne bolesti crijeva u svjetlu dostupnih novih terapija, Hrvatsko društvo za pedijatrijsku gastroenterologiju, hepatologiju i prehranu Hrvatskog liječničkog zbora izradilo je smjernice za dijagnostiku i konzervativno liječenje ovih bolesti. Prilikom kreiranja smjernica pretražena je dostupna znanstvena i stručna literatura, uključujući i smjernice relevantnih europskih društava. Rezultati: U detalje su razrađene smjernice za dijagnostiku i liječenje Crohnove bolesti i ulceroznog kolitisa sa predloženim algoritmima, praktičnim savjetima o dozama lijekova te mogućim nuspojavama. Zaključci: Pravovremena dijagnoza te odgovarajuća terapija smanjuju komplikacije bolesti te omogućuju adekvatan rast i razvoj djece oboljele od IBD-a.Introduction and aim: In every fourth person with inflammatory bowel disease (IBD), the diagnosis is made in childhood, before the age of eighteen. We are witnessing a significant increase in the incidence in the last decade and today IBD is one of the most common chronic gastrointestinal diseases of childhood. Recently, incidence in Croatia has been determined (7.05/100,000 children below 18 years), confirming that the incidence resembles those in developed countries. Material and methods: With the aim to enable early diagnosis and assure adequate treatment with currently emerging new therapies, the Croatian Society of Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association has developed guidelines for the diagnosis and pharmacological treatment of IBD in children, taking into account relevant European guidelines, scientific literature and expert opinions of members of this society who are providing long-term care of these patients. Results: These guidelines represent detailed recommendation for the diagnosis and treatment of Crohn’s disease and ulcerative colitis with proposed diagnostic and therapeutic algorithms, medication dosing regimens and possible side effects. Conclusion: Early diagnosis and personally tailored therapy are key factors in preventing disease complication and for and for assuring normal growth and development in children with IBD