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Objectives: To determine the prevalence of lactase deficiency among Malaysian children with recurrent abdominal pain and to describe their clinical characteristics.Methodology: Twenty-four children referred consecutively to the University of Malaya Medical Centre who fulfilled Apley's criteria (at least three episodes of abdominal pain severe enough to affect normal activity over a period longer than 3 months) were tested for lactase deficiency using a pocket breath test analyser (BreatH2 meter; Europa Scientific, Cheshire, England). Lactulose was used to check for hydrogen-producing capacity.Results: There were 14 males and 10 females in the study, consisting of five Malays, 14 Chinese and five Indians. Mean age was 9.9 years. Seventeen of the 24 children (70.8%) with recurrent abdominal pain who underwent the breath hydrogen test had a positive result. In those with a negative result, subsequent lactulose administration resulted in a positive rise in breath hydrogen. None of the 24 children developed abdominal pain during the test. All the Indian subjects, 71.4% of the Chinese subjects and 40% of the Malay subjects with recurrent abdominal pain had lactase deficiency. The proportion of boys and girls with lactase deficiency was similar (71.4 vs 70.0%, respectively). There was no significant difference between lactase sufficient and deficient children with recurrent abdominal pain with regard to sex, age, ethnic group and clinical features. Following a lactose-free diet, none of the children in the breath hydrogen positive and negative groups reported any appreciable difference in pain symptoms.Conclusions: The prevalence of lactase deficiency among this group of Malaysian children with recurrent abdominal pain was high, but lactase deficiency did not appear to play an important role in causing the symptoms. [ABSTRACT FROM AUTHOR]

Eleven infants who were suspected clinically of having cows' milk protein sensitive enteropathy were fed with a protein hydrolysate formula for six to eight weeks, after which they had jejunal and rectal biopsies taken before and 24 hours after challenge with cows' milk protein. When challenged six infants (group 1) developed clinical symptoms and five did not (group 2). In group 1 the lesions developed in both the jejunal mucosa (four infants at 24 hours and one at three days), and the rectal mucosa, and the injury was associated with depletion of alkaline phosphatase activity. Infants in group 2 were normal. It seems that rectal injury that develops as a direct consequence of oral challenge with the protein in reactive infants may be used as one of the measurements to confirm the diagnosis of cows' milk protein sensitive enteropathy. Moreover, ingestion of such food proteins may injure the distal colonic mucosa without affecting the proximal small gut in some infants. [ABSTRACT FROM AUTHOR]

The clinical response and the histological changes in the mucosa of the small bowel in response to continued feeding with cows' milk protein were assessed over a period of 2-6 weeks in 24 infants who had shown histological changes without immediate clinical symptoms after challenge with a diet containing cows' milk protein. Twenty of the 24 infants (83%) thrived well on cows' milk protein. Jejunal biopsy specimens taken six to eight weeks after the initial biopsy showed histological improvement in all 20 infants compared with biopsy specimens taken soon after the challenge, which had shown mucosal damage. The mucosa had returned to normal in 12, was mildly abnormal in seven, and moderately abnormal in one. Corresponding improvements in the activities of mucosal enzymes were seen. In four of the 24 infants (17%) symptoms developed between three and six weeks. Histological examination of the jejunal biopsy specimens showed that mucosal damage had progressed in two, and remained the same in two; moreover, the disaccharidase activities remained depressed. The present study shows that most infants with enteropathy caused by sensitivity to cows' milk protein but without clinical symptoms develop tolerance to the protein and the mucosa returns to normal despite continued feeding with cows' milk protein. [ABSTRACT FROM AUTHOR]

The effect of cows' milk protein (CMP) on the mucosal disaccharidases was investigated in 23 infants with acute infective enteritis. Jejunal biopsies performed before and after cows' milk provocation were subjected to histological examination and to mucosal disaccharidase enzyme (lactase, sucrase, and maltase) analyses. After milk challenge, changes in mucosal histology were observed in 18 infants, in 17 of them the levels of all 3 mucosal disaccharidases were much reduced. 10 of these infants developed diarrhoea and, in 6, the stools were positive for reducing sugar. It is concluded that CMP has a deleterious effect on the jejunal mucosa of young infants recovering from infective enteritis, so that in the management of young infants with sugar intolerance secondary to infective enteritis, CMP and lactose should be excluded from the diet. [ABSTRACT FROM AUTHOR]

Background: The double burden of both under- and overnutrition during the first 1000 days is highly prevalent in Southeast Asia (SEA), with major implications for lifelong health. Tackling this burden requires healthcare professionals (HCPs) to acquire evidence-based current knowledge and counselling skills. We assessed the needs of HCPs in SEA and developed a continuing medical education/professional development (CME/CPD) program using an e-learning platform to reduce existing gaps., Methods: European, Thai and Malaysian universities collaborated with SEA national nutrition associations in the Early Nutrition eAcademy Southeast Asia (ENeA SEA) project. We assessed HCPs' needs using questionnaires and mapped CME/CPD programmes and regulations through stakeholder questionnaires. Using a co-creation approach, we established an e-learning platform. Evaluation in users was undertaken using questionnaires., Results: HCPs in SEA reported major training gaps relating to the first 1000 days of nutrition and limited impact of existing face-to-face training. Existing pre/postgraduate, residency and CME/CPD programmes did not adequately address the topic. To address these gaps, we produced a targeted e-learning platform with six modules and CME-tests. National ministries, Thai and Malaysian universities, and professional associations endorsed the training platform. To date, over 2600 HCPs have registered. Evaluation shows high acceptance and a very positive assessment., Conclusions: Dedicated e-learning can reduce major gaps in HCP training in SEA regarding nutrition during the first 1000 days of life at scale and is highly valued by both users and key stakeholders.

Objective: Despite a substantial consistency in recommendations for the management of children with acute gastroenteritis (AGE), a high variability in clinical practice and a high rate of inappropriate medical interventions persist in both developing and developed countries.The aim of this study was to develop a set of clinical recommendations for the management of nonseverely malnourished children with AGE to be applied worldwide., Methods: The Federation of International Societies of Pediatric Gastroenterology, Hepatology, and Nutrition (FISPGHAN) Working Group (WG) selected care protocols on the management of acute diarrhea in infants and children aged between 1 month and 18 years. The WG used a 3-step approach consisting of: systematic review and comparison of published guidelines, agreement on draft recommendations using Delphi methodology, and external peer-review and validation of recommendations., Results: A core of recommendations including definition, diagnosis, nutritional management, and active treatment of AGE was developed with an overall agreement of 91% (range 80%-96%). A total of 28 world experts in pediatric gastroenterology and emergency medicine successively validated the set of 23 recommendations with an agreement of 87% (range 83%-95%). Recommendations on the use of antidiarrheal drugs and antiemetics received the lowest level of agreement and need to be tailored at local level. Oral rehydration and probiotics were the only treatments recommended., Conclusions: Universal recommendations to assist health care practitioners in managing children with AGE may improve practitioners' compliance with guidelines, reduce inappropriate interventions, and significantly impact clinical outcome and health care-associated costs.

Background: Rotavirus (RV) is a major agent of gastroenteritis and an important cause of child death worldwide. Immunization (RVI) has been available since 2006, and the Federation of International Societies of Gastroenterology Hepatology and Nutrition (FISPGHAN) identified RVI as a top priority for the control of diarrheal illness. A FISPGHAN working group on acute diarrhea aimed at estimating the current RVI coverage worldwide and identifying barriers to implementation at local level., Methods: A survey was distributed to national experts in infectious diseases and health-care authorities (March 2015-April 2016), collecting information on local recommendations, costs and perception of barriers for implementation., Results: Forty-nine of the 79 contacted countries (62% response rate) provided a complete analyzable data. RVI was recommended in 27/49 countries (55%). Although five countries have recommended RVI since 2006, a large number (16, 33%) included RVI in a National Immunization Schedule between 2012 and 2014. The costs of vaccination are covered by the government (39%), by the GAVI Alliance (10%) or public and private insurance (8%) in some countries. However, in most cases, immunization is paid by families (43%). Elevated cost of vaccine (49%) is the main barrier for implementation of RVI. High costs of vaccination (rs=-0.39, p=0.02) and coverage of expenses by families (rs=0.5, p=0.002) significantly correlate with a lower immunization rate. Limited perception of RV illness severity by the families (47%), public-health authorities (37%) or physicians (24%) and the timing of administration (16%) are further major barriers to large- scale RVI programs., Conclusions: After 10years since its introduction, the implementation of RVI is still unacceptably low and should remain a major target for global public health. Barriers to implementation vary according to setting. Nevertheless, public health authorities should promote education for caregivers and health-care providers and interact with local health authorities in order to implement RVI., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: Acute gastroenteritis (AGE) is a major cause of child mortality and morbidity. This study aimed at systematically reviewing clinical practice guidelines (CPGs) on AGE to compare recommendations and provide the basis for developing single universal guidelines., Methods: CPGs were identified by searching MEDLINE, Cochrane-Library, National Guideline Clearinghouse and Web sites of relevant societies/organizations producing and/or endorsing CPGs., Results: The definition of AGE varies among the 15 CPGs identified. The parameters most frequently recommended to assess dehydration are skin turgor and sunken eyes (11/15, 73.3%), general appearance (11/15, 66.6%), capillary refill time, and mucous membranes appearance (9/15, 60%). Oral rehydration solution is universally recognized as first-line treatment. The majority of CPGs recommend hypo-osmolar (Na 45-60 mmol/L, 11/15, 66.6 %) or low-osmolality (Na 75 mmol/L, 9/15, 60%) solutions. In children who fail oral rehydration, most CPGs suggest intravenous rehydration (66.6%). However, nasogastric tube insertion for fluid administration is preferred according by 5/15 CPGs (33.3%). Changes in diet and withdrawal of food are discouraged by all CPGs, and early refeeding is strongly recommended in 13 of 15 (86.7%). Zinc is recommended as an adjunct to ORS by 10 of 15 (66.6%) CPGs, most of them from low-income countries. Probiotics are considered by 9 of 15 (60%) CPGs, 5 from high-income countries. Antiemetics are not recommended in 9 of 15 (60%) CPGs. Routine use of antibiotics is discouraged., Conclusions: Key recommendations for the management of AGE in children are similar in CPGs. Together with accurate review of evidence-base this may represent a starting point for developing universal recommendations for the management of children with AGE worldwide.

Introduction: Little is known about the epidemiology, causes and outcomes of neonatal cholestasis in the Asian population beyond Japan and Taiwan., Methods: This was a prospective, observational study on patients with neonatal cholestasis who were referred to the University of Malaya Medical Centre, Malaysia, between November 1996 and May 2004., Results: Biliary atresia (BA) (29 percent) and idiopathic neonatal hepatitis (38 percent) were the two commonest causes of neonatal cholestasis (n is 146) that were referred. Out of the 39 patients (27 percent of the total) who died at the time of review, 35 succumbed to end-stage liver disease. Three of the four patients (three BA, one progressive familial intrahepatic cholestasis [PFIC]) who had a living-related liver transplant (LT) died after the surgery (two BA, one PFIC). Six (four percent) of the remaining 107 survivors had liver cirrhosis. The overall four-year survival rates for patients with native liver and LT as well as those with native liver alone for all cases of neonatal cholestasis were 72 percent and 73 percent, respectively, while the respective survival rates for BA were 38 percent and 36 percent., Conclusion: BA and idiopathic neonatal hepatitis are important causes of neonatal cholestasis in Malaysian infants. In Malaysia, the survival rate of patients with neonatal cholestasis, especially BA, is adversely affected by the lack of a timely LT.

We report two Malaysian siblings with neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD). The younger sibling, a six-month-old Chinese girl, presented with prolonged neonatal jaundice, and was investigated for biliary atresia. Urine metabolic screen showed the presence of urinary-reducing sugars, and she was treated with a lactose-free formula. NICCD was suspected based on the clinical history, examination and presence of urinary citrulline. Mutation study of the SLC25A13 gene showed the compound heterozygotes, 851del4 and IVS16ins3kb, which confirmed the diagnosis of NICCD in the patient and her three-year-old female sibling, who also had unexplained neonatal cholestasis. Long-term dietary advice, medical surveillance and genetic counselling were provided to the family. The diagnosis of NICCD should be considered in infants with unexplained prolonged jaundice. DNA-based genetic testing of the SLC25A13 gene may be performed to confirm the diagnosis retrospectively. An awareness of this condition may help in early diagnosis using appropriate metabolic and biochemical investigations, thus avoiding invasive investigations in infants with neonatal cholestasis caused by NICCD.

Objective: The purpose of this study was to look at the correlation between recurrent abdominal pain and the presence of recent stressful life events among schoolchildren in a rural district in Malaysia., Method: This is a cross-sectional study of schoolchildren aged 9-15 years based in Kuala Langat, a rural district located in the south-west of the Malaysian state of Selangor. Schoolchildren were selected randomly and given questionnaires to fill in. This was followed by interview with the children on the same day by one of the authors (CCMB) to ensure consistency of response. Recurrent abdominal pain was defined as 'at least three episodes of abdominal pain, severe enough to affect their activities over a period longer than three months' [1]. The children were also asked to answer either 'yes' or 'no' to whether they had experienced various life events in the previous year., Results: A sample of 1462 schoolchildren (722 boys and 740 girls) aged between 9 and 15 years were included in the study. There were 768 Malays, 393 Chinese and 301 Indians. Of these 1462 children, 161 (11.0%) had recurrent abdominal pain. On performing multiple logistic regression analysis, two life events were significantly associated with recurrent abdominal pain: death of a family member (P = 0.008; odds ratio 0.61, 95% CI 0.43-0.88) and a change in occupation of an immediate family member (P = 0.003; odds ratio 0.53, 95% CI 0.35-0.81)., Conclusion: This study suggests that recurrent abdominal pain in children is associated with recent stressful life events in the children's lives.

Aim: To look at the predictors of health-care consultation for recurrent abdominal pain among urban schoolchildren in Malaysia., Methods: Recurrent abdominal pain was defined as at least three episodes of abdominal pain, severe enough to affect a child's activities over a period longer than 3 months. A health-care consulter was defined as a child who had been brought to see a doctor regarding recurrent abdominal pain at least once in the past year. Children aged between 9 and 15 years were randomly chosen from schools in the city of Petaling Jaya, given questionnaires to fill in and interviewed to determine whether they fulfilled the above criteria for having symptoms of recurrent abdominal pain and for being a consulter. Bivariate analysis and multiple logistic regression analysis were performed on the data obtained., Results: One hundred and forty-three (9.61%) children fulfilled the criteria for recurrent abdominal pain out of a total of 1488 schoolchildren interviewed. There were 65 (45.5%) consulters and 78 (54.5%) non-consulters. Among the consulters, the male to female ratio was 1:1.4, while among the non-consulters, the ratio was 1:1.1. On bivariate analysis, the Chinese had a significantly lower likelihood to consult a doctor (P = 0.02), while the other two races did not show any increase in consultation (Malays, P = 0.08; Indians, P = 0.21). Among those with severe pain, there was a significantly higher prevalence of consulters (P < 0.01). Furthermore, those whose sleep was interrupted by abdominal pain were more likely to consult (P < 0.01). Children who had consulted a doctor were more likely to be missing school because of abdominal pain (P < 0.01). Following multiple logistic regression analysis, ethnicity was no longer a significant predictor., Conclusions: Approximately 45.5% of schoolchildren with recurrent abdominal pain in an urban setting were brought to see a doctor. Predictors of recent health-care consultation were school absence, pain severity and interruption of sleep caused by abdominal pain.

A descriptive study was carried out on patients admitted for febrile convulsion over a two-year period to determine rate of lumbar puncture (LP) refusal, factors associated with LP refusal and outcome of such patients. From 77 patients indicated and requested for LP, 19 (25%) patients refused the procedure. Refusal of LP was significantly more common among the Malay ethnic group (p = 0.01) but not significantly associated with age,gender or whether the patient was admitted for a first or recurrent febrile convulsion. Half of the patients who refused LP had to be started empirically on antibiotics for meningitis. Patients who refused LP were also 8.5 times more likely to discharge themselves "at own risk" (AOR), compared to other patients with febrile convulsion (p = 0.004). In conclusion, LP refusal is a common problem in the local setting and is a hindrance to the proper management of patients with fever and seizure. Appropriate measures must be carried out to educate the public, particularly those from the Malay ethnic group on the safety and usefulness of the procedure. Reasons for patients discharging AOR following LP refusal also need to be addressed and problems rectified.

Hyperimmunoglobulin E syndrome (HIE) is a rare condition characterised by marked elevation of serum IgE level, chronic dermatitis, intense pruritus, and recurrent serious infection. The major organism is usually S aureus. We report a case of an infant with HIE, who had pulmonary nocardiosis. The clinical features, immunological abnormalities, and radiological features of the condition are described. The child finally succumbed to the complications of pulmonary nocardiosis.

Two hundred and ninety five children admitted with acute gastroenteritis from January 1, 1996 to December 31, 1996 to the Paediatric unit, University of Malaya Medical Centre, Kuala Lumpur, were reviewed. Eighty-nine percent of children received treatment before admission. Information regarding the type of treatment received were available in 152 (52%) cases. Eighty percent of them were prescribed medications, 40% were prescribed glucose-electrolyte mixtures, and 13% were advised a change of formula. Only 18 children (12%) were advised to take glucose-electrolyte mixtures alone. The four most common prescribed drugs were: antibiotics (43%), antipyretics (39%), antidiarrhoeal agents (30%), and antiemetics (24%). The use of antibiotics, antiemetics and antidiarrhoeal drugs for children with acute gastroenteritis among primary care doctors appears to be common. The use of glucose-electrolyte mixtures was uncommon.

This is a report of 3 Chinese children with intestinal lymphangiectasia in Malaysia. Two children responded to a low fat diet and medium-chain triglyceride supplement. The third child has recurrent chylous ascites. None of the children has recurrent infections despite low CD4+ cells and low levels of IgG and IgA. Intestinal lymphangiectasia is a rare congenital disorder of the mesenteric lymphatic that leads to the obstruction of the lymphatics of the intestine and protein losing enteropathy. Restriction of dietary fat intake will usually result in remission. Recurrent chylous ascites is a problem and management can be difficult.

A case of Caroli's disease is presented and the findings of various imaging modalities are discussed with emphasis on the role of Technetium 99mTc diethyl-iminodiacetic acid scan in reaching the final diagnosis. The 'beaded' appearance of the dilated intrahepatic ducts seen in this scan is believed to be pathognomonic for this condition.

Enterokinase has a critical role in initiating proteolytic digestion by hydrolysing the conversion of pancreatic trypsinogen into trypsin. The enzyme is synthesised by enterocytes of the proximal small intestine and initially incorporated into the brush border from where it is released into the intestinal lumen by the action of pancreatic secretions. The aim of the study was to analyse enterokinase activity in the duodenal mucosa of infants with diarrhoeal disease including cow's milk protein-sensitive enteropathy. Our observations show that the mean depletion of enterokinase was only 17% compared to 60-80% for other brush border enzymes like disaccharidases, peptidases and alkaline phosphatases in infants with diarrhoea. This suggests that enterokinase activity in the small bowel enteropathies may be dependent not only on the degree of mucosal damage specifically but also on the extent of damage to the goblet cell population where the enzyme is synthesised. Thus the enterokinase activity was reduced in acute and chronic diarrhoea with marked mucosal damage where significant reduction of goblet cell population was evident but the enzyme was relatively little affected when the mucosa was damaged mildly.

The effect of cow's milk protein (CMP) challenge on the levels of alkaline phosphatase (ALP) in the upper jejunal mucosa and the serum were studied in 25 infants clinically suspected to have cow's milk allergy. Following CMP provocation 3 groups were identified. Group 1 consisted of 10 infants who had clinical and histological reaction to CMP challenge. All 10 infants had significant depletion in the levels of tissue and serum ALP. Group 2 consisted of 5 infants who had histological reaction but no clinical reaction. Tissue ALP was depressed in 3 but not in 2 following CMP challenge. Serum ALP were essentially unaltered in all 5. Group 3 consisted of 10 infants who clinically and histologically tolerated CMP challenge. Tissue and serum ALP were not depressed in any. Estimation of sucrase levels in the mucosa and xylose absorption before and after CMP challenge were also performed for comparison with changes of tissue and serum ALP levels. The clinical significance of the changes in serum ALP level is discussed.