2016, Vol 12, No 3
Symptoms of pseudoallergy and histamine metabolism disorders
Pediatr Med Rodz 2016, 12 (3), p. 234–241
DOI: 10.15557/PiMR.2016.0023

Histamine intolerance is a poorly investigated type of hypersensitivity responsible for a number of often serious symptoms, erroneously interpreted as food allergy. Endogenous histamine originates from the histidine amino acid with the help of the histidine decarboxylase enzyme. Apart from the endogenous production histamine may be supplied to the body with food. Slow-maturing and fermenting products are characterised by particularly high levels of histamine. Some food products stimulate excessive release of histamine from stores in the body as well as containing significant amounts of it. These products include spices, herbs, dried fruits and a large group of food additives. Histamine intolerance is considered to be a condition in which the amount of histamine in the body exceeds its tolerance threshold, which leads to the development of adverse reactions. These reactions primarily include skin symptoms (pruritus, urticaria, skin reddening, acne lesions), angioedema, respiratory symptoms (nasal obstruction and watery discharge, sneezing, coughing, wheezing), gastrointestinal symptoms (abdominal cramps, diarrhoea, bloating), nervous system symptoms (headaches, fatigue, irritability, anxiety, panic attacks), cardiovascular symptoms (tachycardia, hypotension, chest pain), primary dysmenorrhoea and many more. It is estimated that nearly 1% of society is susceptible to histamine intolerance. The diagnosis of this disorder is based on observing at least two characteristic symptoms and their disappearance or improvement following histamine-free diet. A new, although not easily accessible diagnostic tool is assay for serum diamine oxidase activity, which correlates to a significant extent with symptoms of histamine intolerance. Normal activity of diamine oxidase is considered to be the amount of >80 HDU/mL, decreased activity – 40–80 HDU/mL and severely decreased activity – <40 HDU/mL. Currently the option of diamine oxidase supplementation is being considered as prevention for patients with the decreased activity of this substance.

Keywords: pseudoallergy, histamine intolerance, diamine oxidase, histidine, facial reddening
Obstructive sleep apnoea syndrome in children
Pediatr Med Rodz 2016, 12 (3), p. 242–248
DOI: 10.15557/PiMR.2016.0024

Sleep-related breathing disorders in children are a clinical problem which is more and more often diagnosed by doctors nowadays. They can be the basis for diagnosing obstructive sleep apnoea syndrome that causes a number of complications: lowering the quality of life, behavioural problems, complications involving cardiovascular system. The incidence of obstructive sleep apnoea syndrome in the paediatric population is estimated to be at the level of 2%. The symptoms of obstructive sleep apnoea syndrome can be divided into daytime and night ones. Night symptoms in children include: snoring, apnoea, breathing with open mouth (both during the day and at night), dry tongue and mouth during sleep, agitated sleep in unnatural positions. Among daytime symptoms of obstructive sleep apnoea syndrome there are: irritability, aggressiveness, hyperactivity, attention deficit disorder, delayed development and growth pattern (mainly failure to thrive), learning problems, morning headaches. Parents often do not connect the night and daytime symptoms with the possible development of obstructive sleep apnoea syndrome in their children. The main predisposing factor of obstructive sleep apnoea syndrome in children is adenotonsillar hypertrophy. Effective and in most cases preferred treatment for the management of obstructive sleep apnoea syndrome in children is adenotonsillectomy. Polysomnography and polygraphy are diagnostic tools helpful in the study of sleep-related disorders. The objective of this study was to systematise the knowledge on the epidemiology, aetiology, clinical image and prevention of obstructive sleep apnoea syndrome in children.

Keywords: obstructive sleep apnoea syndrome, sleep-related breathing disorders, polysomnography
Eosinophilic oesophagitis
Pediatr Med Rodz 2016, 12 (3), p. 249–255
DOI: 10.15557/PiMR.2016.0025

Eosinophilic oesophagitis is a chronic disease of the oesophagus. It is becoming more and more common and is observed to occur in both children and adults. This disease is characterized by eosinophilic infiltrations in the oesophageal mucus membrane and clinical signs of oesophageal dysfunction, such as swallowing disorders, food impaction and signs resembling refractory reflux disease. Pathogenetic mechanisms of eosinophilic oesophagitis are not known. Genetic and environmental factors are believed to be responsible. The clinical picture changes with age. In infants and young children, symptoms are non-specific, which creates a risk of overlooking the disease in differential diagnosis. School children present with abdominal pain, retrosternal pain and emesis, whereas adolescents usually report symptoms of reflux disease, dysphagia and episodes of food impaction. Dysphagia, which is rarely observed before puberty, occurs in most adults. The diagnosis of eosinophilic oesophagitis is based on clinical and histological findings. Elimination diets, local or systemic steroid therapy and endoscopic oesophageal dilation are used in treatment. Due to the chronic and recurrent nature of the disease, patients require permanent medical care, selection of appropriate and personalised steroid therapy and/or diet as well as periodical endoscopic checkups. The article presents updated information about eosinophilic oesophagitis. It discusses epidemiology, pathogenesis, clinical signs and symptoms depending on patients’ age as well as principles of diagnosis and treatment.

Keywords: eosinophils, oesophagitis, eosinophilic oesophagitis
Implementation of new parameters in 24-hour pH monitoring and impedance
Pediatr Med Rodz 2016, 12 (3), p. 256–263
DOI: 10.15557/PiMR.2016.0026

24-hour oesophageal multichannel impedance and pH monitoring is the gold standard in the diagnostic process of gastroesophageal reflux disease. Together with oesophagogastroduodenoscopy, it enables to distinguish different kinds of this disease and implement appropriate treatment. Recently, thanks to impedance, it was attempted to evaluate new parameters that could be helpful in diagnosis of gastroesophageal reflux disease and its differentiation from functional heartburn. One of these parameters is baseline impedance. It is measured when no swallows and refluxes occur in the oesophagus, i.e. when the oesophageal wall stays still. Postreflux swallow-induced peristaltic wave (PSPW) index is another parameter measured in 24-hour oesophageal multichannel intraluminal impedance and pH-monitoring. It is a quotient of the number of reflux episodes with postreflux swallow-induced peristaltic wave and the total number of reflux episodes. It was proven that baseline impedance and postreflux swallow-induced peristaltic wave index are correlated with oesophageal mucosa integrity. Values of these parameters differ in healthy volunteers, patients with functional heartburn as well as with erosive and nonerosive gastroesophageal reflux disease. They may be useful in the diagnosis, but also in making decisions about pharmacological or surgical treatment. These parameters are not evaluated during 24-hour oesophageal multichannel impedance and pH-monitoring on a routine basis. Since the available studies have been carried out on small groups of patients, there is a need for further investigation to assess the diagnostic value of baseline impedance and PSPW.

Keywords: gastroesophageal reflux disease, reflux, baseline impedance, postreflux swallow-induced peristaltic wave
Treatment of urinary tract infection in children
Pediatr Med Rodz 2016, 12 (3), p. 264–275
DOI: 10.15557/PiMR.2016.0027

Urinary tract infection is the most frequent bacterial infection in children. Its prevalence in the population younger than 14 years of age has been estimated at 5–10%. Its high recurrence, especially in patients with risk factors, poses a significant problem. The risk factors most common in the group of children ≤3 years are congenital defects blocking the flow of urine to the bladder, whereas in older children they most typically include a tendency for constipation and dysfunction of the lower urinary tract. The clinical picture is variable and depends on the child’s age, immunity status, pathogen virulence and localisation of infection. The mildest form of urinary tract infection is asymptomatic bacteriuria, whereas more severe presentations include acute pyelonephritis, acute focal bacterial nephritis and urosepsis. Prognosis is usually good, but under certain circumstances hypertension, proteinuria and chronic kidney disease may develop. Therefore, early introduced appropriate treatment is essential. According to the Polish Society for Paediatric Nephrology guidelines, asymptomatic bacteriuria does not warrant treatment, whereas febrile patients (>38°C) under 24 months old with a suspicion for urinary tract infection must be promptly administered antibiotic therapy, after a urine specimen has been obtained for culture. For many years, urinary tract infection has remained a topic of controversy in terms of therapy duration and administration route. Inpatient treatment of children under 3 months of age is an accepted rule. Acute pyelonephritis necessitates a longer therapy, lasting from 7 to 10 days, whereas the duration of treatment of lower urinary tract infection has been cut down to 3 up to 5 days. Routine prophylactic antimicrobial therapy is not recommended following the initial urinary tract infection episode, yet should be considered in special circumstances. Alternative prophylactic methods, such as immunostimulating agents, probiotics or cranberry, may be used, but their efficacy has not been confirmed in large clinical studies.

Keywords: urinary tract infection, children, treatment
Bulimia nervosa – its prevalence, symptoms and treatment with special attention to oral health
Pediatr Med Rodz 2016, 12 (3), p. 276–284
DOI: 10.15557/PiMR.2016.0028

Bulimia nervosa is a serious and complex health problem encountered by many professionals, including general practitioners and dentists. The aim of the study was to describe the problem of bulimia (its prevalence, symptoms, special situations, treatment), with particular emphasis on the aspect of the oral health. The paper presents the causes and factors contributing to the disease, diagnostic criteria, the onset and the possible course of the disease, dental and oral mucosa pathologies due to bulimia as well as other comorbidities (including diabetes). The paper is of descriptive nature. The research method was based on the analysis of the available literature on bulimia nervosa supplemented by our own experience. It was concluded based on the analysed sources that appropriate diagnosis and treatment of bulimia nervosa is possible only with the cooperation of many specialists: psychiatrists or paediatric psychiatrists, dentists and general practitioners as well as other doctors if necessary. Psychotherapy is a necessary and integral aspect of treatment. Early treatment onset is essential for good treatment outcomes. Due to the low sense of illness, some patients would never meet a psychiatrist if not for the intervention of a family doctor or a dentist.

Keywords: bulimia nervosa, enamel erosion, dentist, diabetes, psychotherapy
An assessment of fractional exhaled nitric oxide in children with allergic rhinitis
Pediatr Med Rodz 2016, 12 (3), p. 285–295
DOI: 10.15557/PiMR.2016.0029

Allergic rhinitis is an inflammatory condition of the nasal mucosa usually elicited by IgE-mediated response to allergen exposure. It is currently considered the most common allergic disease. Epidemiological research conducted in Poland between 2006 and 2008 identified allergic rhinitis in 23.6% of children aged 6–7 years, 24.6% of children aged 13–14 years and 21% of adults aged 20–44 years. It has been suggested by many authors that the inflammatory process in allergic rhinitis patients involves both, upper and lower respiratory tract. The aim of the study was to demonstrate the presence of lower respiratory tract inflammation based on fractional exhaled nitric oxide measurement. A total of 60 children were included in a 3-year follow-up study between 2011 and 2014 in the Department of Paediatrics, Paediatric Nephrology and Allergology at the Military Institute of Medicine, and the Outpatient Allergy Clinic. The study group of allergic rhinitis patients included 37 children (17 girls and 20 boys aged 6–18 years, mean age 10.4 years), while the reference group included 23 children (11 girls and 12 boys aged 6–12 years, mean age 10.8 years). Fractional exhaled nitric oxide levels were normal in most patients. No statistically significant differences in fractional exhaled nitric oxide were found between the study group (group I) and the reference group (group II), which would indicate the absence of inflammatory processes in the lower airways in the observed children.

Keywords: fractional exhaled nitric oxide (FeNO), allergic rhinitis (AR), asthma, children
Evaluation of the correlation between transcutaneous measurement and concentration of bilirubin in the blood serum of a newborn
Pediatr Med Rodz 2016, 12 (3), p. 296–302
DOI: 10.15557/PiMR.2016.0030

Aim: Due to the potential toxicity of high concentrations of bilirubin, newborns are monitored in terms of the potential emergence of a group at risk of the development of severe hyperbilirubinaemia and, rarely, encephalopathy and kernicterus. The transcutaneous measurement of bilirubin, as a non-invasive method, is applied in neonatal centres. The paper presents an evaluation of the correlation between the transcutaneous measurement and the concentration of bilirubin in the blood serum of a newborn, taking into consideration the reduction of the necessity to carry out blood tests related to the transcutaneous measurement. Material and method: The analysis comprised 1,076 medical histories of newborns hospitalised at the Department of Neonatology of the Municipal Hospital in Zabrze in the period from 1 January to 31 December 2013 (a primary referral centre). The inclusion criteria for the study were: performing a simultaneous transcutaneous measurement and a blood serum concentration measurement of bilirubin, gestational age ≥35 Hbd and birth weight >2,500 g. 272 children were qualified for the study. Results: Boys constituted 51.7%, and girls 48.3% of the research group. The mean gestational age was 38.7 Hbd and the mean birth weight was 3,323.4 g; 67.8% of the children were born by natural labour and 32.2% – by caesarean section. The mean Apgar score in the 5th minute was 9.8 points. The measurement of the concentration of bilirubin was performed on average on the 3.9 day of life. The mean transcutaneous measurement was 9.67 mg% (2.7–17.2 mg%) and the mean concentration of bilirubin in the blood serum was 13.18 mg% (7.0–19.8 mg%); the difference was 3.5 mg% (p < 0.0001). A statistically significant positive correlation was found between the concentrations of bilirubin obtained in the transcutaneous measurement and the concentrations in the blood serum (according to Spearman, r = 0.58; p < 0.01). Conclusion: It seems that the standardisation of the relationship between the concentration of bilirubin in the transcutaneous measurement and the evaluation of the concentration in the blood serum may significantly affect the reduction of the necessity to perform punctures, the limiting of the child’s stress and pain, the reduction of the risks of infection and it may be of high economic importance.

Keywords: transcutaneous bilirubin measurement, hyperbilirubinaemia, newborn
Should a paediatrician perform abdominal ultrasonography in children of parents with polycystic kidney disease?
Pediatr Med Rodz 2016, 12 (3), p. 303–309
DOI: 10.15557/PiMR.2016.0031

Autosomal dominant polycystic kidney disease produces symptoms mainly in adulthood. Renal cysts and/or elevated blood pressure can be the first signs of the disease in children. Because of the lack of a targeted therapy, early diagnosis and implementation of actions to slow its progression are the essence of treatment. Aim: The aim of the study was to assess the clinical course of autosomal dominant polycystic kidney disease in children. Material and methods: The study involved the assessment of 28 patients with autosomal dominant polycystic kidney disease diagnosed before the age of 18. The disease was diagnosed during a routine abdominal ultrasound scan in 24 patients and during a scan conducted due to abdominal pain reported by patients in 4 cases. Two patients had the disease diagnosed based on the Ravine criteria, whereas an ultrasound image and family history helped establish the diagnosis in 26 cases. The children enrolled had blood pressure measured, serum creatinine concentration determined and general urinalysis performed. Results: The median age at the diagnosis was 5 years. The family history was positive in 89.3% (25) of patients. Siblings had the disease in 46.43% (13) of cases. None of the children presented with abnormalities in urinalysis or creatinine levels. Two patients were diagnosed with arterial hypertension and in 1 child blood pressure was elevated above the 97th percentile. Urine albumin-to-creatinine ratio exceeding 30 mg/g was observed in 20.8% of children. Conclusions: Autosomal dominant polycystic kidney disease in children is asymptomatic. There are no irregularities either in urinalysis or renal function parameters. An abdominal ultrasound examination, which is inexpensive and non-invasive, is worth considering in all children of parents with autosomal dominant polycystic kidney disease in order to implement early nephroprotection.

Keywords: polycystic kidney disease, children, ultrasonography, early detection
An analysis of hospitalisations in the paediatric unit of a provincial hospital with special emphasis on lower respiratory diseases
Pediatr Med Rodz 2016, 12 (3), p. 310–317
DOI: 10.15557/PiMR.2016.0032

Pneumonia is a common cause of paediatric hospitalisations. Aim: The aim of the study was to assess the hospitalisation structure of a non-specialised paediatric unit as well as to perform a thorough evaluation of paediatric patients hospitalised due to pneumonia. Attention was also paid to recent changes in the clinical picture of pneumonia. Material and methods: A retrospective analysis of medical records of children treated in the paediatric unit of the Janusz Korczak Provincial Specialist Hospital between 2011 and 2012, with particular emphasis on patients hospitalised due to pneumonia (ICD-10 codes J12–J18), was performed. Results: Pneumonia accounted for 12.7% of all hospitalisations in the non-specialised paediatric unit between 2011 and 2012; most of hospitalisations occurred during the winter and early spring months, with a peak incidence in March. Bronchial obstruction occurred in 39.9% of cases, mainly in infants. Extensive inflammatory lesions were noted in X-ray reports in only 26% of patients; inflammatory lesions were mostly described as interstitial lesions or patchy densities in the pulmonary hilar region in other cases. X-ray images were interpreted as normal in up to 24.6% of children, which did not reflect the typical auscultatory changes. Cefuroxime sodium was the most commonly used first-line antibiotic (51.5%), followed by macrolides (34%), including macrolides in combination with β-lactam antibiotics in 26% of cases, and third-generation cephalosporins (25.7%). Conclusions: Lower respiratory diseases, mainly pneumonia often accompanied by bronchial obstruction, were the most common cause of paediatric hospitalisations in the paediatric unit of the provincial hospital. Interstitial lesions and perihilar densities seem to be the most typical radiological image in children. Adjustment of antibiotic therapy to the current guidelines and recommendations allows better treatment optimisation.

Keywords: pneumonia, hospitalisation, child
A relationship between dengue virus serotype and the clinical severity in paediatric patients from Gondokusuman region, Yogyakarta between 1995 and 1999
Pediatr Med Rodz 2016, 12 (3), p. 318–325
DOI: 10.15557/PiMR.2016.0033

Aim of the study: Dengue infection occurs almost all over subtropical and tropical countries. Dengue pathogenesis explaining its clinical manifestations is still unclear. Indonesia is a country with several hyperendemic regions. The study was aimed to investigate the incidence rate, sero-epidemiology, and the relationship between the serotype and the clinical severity of dengue viral infection in paediatric patients from Gondokusuman, Yogyakarta. Material and methods: It was an epidemiological research with prospective observational design reviewing febrile paediatric patients involved in “A Prospective Sero-epidemiology Study on Dengue Children Infection in Yogyakarta, Indonesia, 1995–1999 cohort study.” Febrile paediatric patients were diagnosed for dengue fever, dengue haemorrhagic fever, or dengue shock syndrome based on World Health Organization 1997 criteria. Serological diagnosis was performed using PRNT and serotype identification was performed by viral culture isolation and RT-PCR. Results: Laboratory data (PRNT, ELISA, RT-PCR and Isolation) showed that there were 220 children (130 males and 90 females) from 509 febrile patients among 2,149 paediatric subjects who were infected with dengue virus. Based on serotype identification, the following dengue virus serotype distributions were identified: DEN-1 26.81%, DEN-2 23.18%, DEN-3 22.72%, DEN-4 8.63%, and unidentified 18.63%. Clinical severities observed were as follows: dengue fever 78.6%, dengue haemorrhagic fever 18.2%, and dengue shock syndrome 3.2%. In the case of primary infection, only DEN-3 could cause severe clinical manifestations. Conclusions: Gondokusuman region in Yogyakarta could be classified as a hyperendemic region between 1995 and 1999, with the highest risk of severe clinical manifestations shown for DEN-3 during both, primary and secondary infection.

Keywords: dengue virus, serotype, dengue fever, dengue haemorrhagic fever, dengue shock syndrome
Rare cases of bezoars in the urinary tract in newborns and infants – a review of case reports
Pediatr Med Rodz 2016, 12 (3), p. 326–336
DOI: 10.15557/PiMR.2016.0034

Bezoars are foreign bodies in the form of round balls typically found in the alimentary tract, in the area of the stomach. They are created from residual material, e.g. from accidentally swallowed objects (buttons, coins) or some medicines as well as hair and vegetable fibres. Bezoars increase in size as the result of accumulation of undigested food wastes and are unable to pass through the subsequent alimentary tack sections. Bezoars mostly cause nonspecific abdominal pain. In rarer cases, they can be found in the urinary tract. In this case, they develop in the course of a fungal infection within the urinary tract or generalised infection. Their mass is usually made of Candida albicans hyphae. The major factor strongly predisposing to severe fungal infections is host immunosuppression caused by iatrogenic action of medicines that block the immune system as well as different diseases that weaken immunity. In this review, the authors present selected clinical cases of urinary tract bezoars along with the diagnostic and therapeutic management.

Keywords: bezoars, urinary tract, fungal infection complications, candidiasis, aspergillosis
Atypical inflammation of the soft tissue, most likely caused by Actinomyces infection – a case report
Pediatr Med Rodz 2016, 12 (3), p. 337–343
DOI: 10.15557/PiMR.2016.0035

Actinomycosis is a very rare cause of inflammation of the labial soft tissue in girls. It is characterised by hard inflammatory infiltrates accompanied by fibrosis, abscesses and fistulas. The non-specific course of the disease makes a correct diagnosis difficult. In this paper, we have presented diagnostic and therapeutic difficulties in the inflammation of the labial soft tissue of probable actinomycotic aetiology in a 7-year-old girl. The patient was hospitalised twice, including three surgical procedures due to labial tissue inflammation and abscess. Methicyllin-resistant Staphylococcus aureus was cultured from the abscess content. Systemic antibiotics from six different classes were used; however, no improvement in the local condition was achieved. The abscess was irrigated with gentamicin solution; steroid ointments and physical therapy were used, but with no effect. A suspicion of actinomycotic infection was raised due to the chronic course of the disease and poor response to treatment. Penicillin was administered for a total period of 3 months, resulting in rapid improvement and, ultimately, a complete recovery of the child. Although the actinomycotic aetiology was not confirmed by cultures or histopathological examination, the course of the therapy has allowed to suspect Actinomyces infection.

Keywords: actinomycosis, antibiotic therapy, inflammation, abscess