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Celiac disease is a multisystemic autoimmune disease induced by gluten in wheat, rye, and barley. It is characterized by polygenic predisposition, prevailing prevalence in members of the white population (1%), especially in close relatives (5–15%), very heterogeneous expression and frequent association with other autoimmune diseases (3–10%), as well as selective deficiency of IgA and Down, Turner, and Williams syndromes. The basis of the disease and the key finding in its diagnostics is gluten-sensitive enteropathy, i.e., non-specific inflammation of the small intestinal mucosa which resolves by gluten-free diet. In addition to enteropathy, whether symptomatic or asymptomatic, the disease is also characterized by various extraintestinal manifestations, and even very serious complications. Therapy is based on a lifelong glutenfree diet, so that the disorder, if diagnosed in time and treated consistently, has an excellent prognosis.

Introduction/Objective. Celiac disease (CD) is the result of a polygenic predisposition and gluten-containing diet. The aim of this study was to determine the prevalence and clinical forms of CD in siblings of children with verified disease. Methods. The study included 83 siblings, aged 1.5–27 (11.77 ± 6.2) years, of 64 children with CD diagnosed according to ESPGHAN criteria (1990/2012). In addition to a detailed history and clinical examination, serum levels of IgA and antibodies to tissue transglutaminase (AtTG) IgA and IgG classes were determined in all subjects. All with elevated AtTG levels underwent multiple duodenal enterobiopsy. The diagnosis of CD was confirmed by the finding of characteristic histological changes. Results. The diagnosis of CB was made in 13 of 83 subjects (15.67%). Nine of them had an asymptomatic form of the disease, while in the others the disease was clinically manifested – in three the form was classical, in one it was accompanied by severe malnutrition (-26.80%), and in one the manifestation was nonclassical (only short stature). Except for sideropenia and hypoferritinemia in four patients, of which two with hemoglobin below the reference value, standard laboratory findings were within normal limits. Conclusion. Our research shows that the prevalence of CD in siblings of children with verified disease is 15.67%. It is mostly detected in its asymptomatic form. In accordance with this, routine application of serological screening for CD in this population group is necessary for its timely diagnosis and treatment.

Introduction/Objective. The objective of the paper is to assess the applicability of serum anti-tissue transglutaminase (tTG) antibodies IgA and IgG concentration and HLA-DQ2/DQ8 typing as a non-invasive alternative to duodenal biopsy in diagnosing celiac disease (CD) in pediatric population. Methods. A prospective cohort study included a total of 179 pediatric patients aged 1–18 years. Determination of tTG IgA and tTG IgG antibodies and human leukocyte antigen (HLA) DQ2/DQ8 typing was performed for all patients. Histology of duodenal biopsies was interpreted by the modified Marsh scoring system. Results. The diagnosis of CD was confirmed in 101 (56%) patients of the studied population. In cases of CD, HLA-DQ2/DQ8 was positive in 100 patients (99%). The tTG IgA antibodies in concentration higher than 100 U/ml were detected in 77 (76.2%) of the CD patients and in significantly smaller number for tTG IgG [29 (28.7%)] (p < 0.001). Statistically highly significant association of duodenal lesions Marsh grade 3 with concentration of tTG IgA 10-fold higher than the upper level of normal (ULN) was established (p < 0.001) Conclusion. Concentration of tTG IgA 10-fold higher than ULN is significantly positively correlated with Marsh grade 3 histopathology findings. Specific antibodies determination in combination with HLA-DQ2/ DQ8 typing proves to be sufficient for a diagnosis of CD, supporting the fact that duodenal biopsy may be avoided in a significant majority of patients – 75%.

Gluten-related disorders are a heterogeneous group of clinical entities caused by intolerance to wheat, rye, and barley flour components. They occur in 3–5% of genetically predisposed persons and, based on pathogenic and clinical features, are classified into celiac disease, non-celiac gluten sensitivity, and wheat allergy. There are also specific entities such as dermatitis herpetiformis or gluten ataxia, which can occur either within the celiac disease or independently. This article based on the current knowledge shows the basic details of the pathogenesis, clinical expression, diagnosis, and treatment of these disorders.

Introduction/Objective. Nonclassical celiac disease (CD) is characterized by a very heterogeneous and non-specific clinical presentation. The aim of this study was to determine the basic symptoms and clinical signs of this CD subtype in children and adolescents Methods. The study was based on a sample of 58 children and adolescent, 38 female and 20 male, ages 1.75 to 17.75 (10.01±4.62) years with a nonclassical CD diagnosed according to the European Society for Pediatric Gastroenterology, Hepatology and Nutrition criteria from 1990 and 2012. Results. Except four patients who were between the ages of 1.75 to 2.50 years, all others were older than three years. The main clinical symptoms and signs suggestive of non-classical CD were anemia caused by iron deficiency (48.28%), short stature (34.48%), and intermittent abdominal pain (18.97%), anorexia with stagnation or weight loss (13.79%), and chronic constipation (6.9%). Thirty patients had one symptom or sign of the disease, 15 had two and 13 had three. In addition, 12 patients had dental enamel hypoplasia, 18 sideropenia without anemia and five mild isolated hypertransaminasemia. A gluten-free diet, apart from the dental enamel hypoplasia, has resulted in the withdrawal of all indicators of the disease. Conclusion. The main symptoms and clinical signs of nonclassical CD in children and adolescents were iron deficiency anemia, short stature and intermittent abdominal pain, and less frequently anorexia with stagnation or weight loss and chronic constipation. Excluding dental enamel hypoplasia, a gluten-free diet leads to a complete recovery of the patient.

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Introduction: Celiac disease is an autoimmune disease caused by an inadequate immune response in contact with gluten in genetically predisposed individuals. Barriers to maintaining a strict gluten-free diet arise due to several factors, the most common of which are: inadequate information, insufficient education about the disease, food contamination. Aim of the research: To determine the ways of informing parents about the celiac disease that has been diagnosed in their children, as well as to learn about the necessary procedures to improve information about gluten-free diet. Subjects and method: The study included a sample of 116 parents whose children are diagnosed with celiac disease and who are on a gluten-free diet. The place of research is the Institute for Maternal and Child Health of Serbia "Dr Vukan Cupic" in New Belgrade and the University Children's Clinic in Belgrade. The research instrument used is the Questionnaire on Parents' Awareness of Celiac Disease, which was created for the purposes of this research. Results with discussion: The results of the study show that 47.14% of parents of children with celiac disease ask for information about the proper nutrition of their children and gluten-free foods from the doctor of the institution where the child was diagnosed with the disease. In order to better understand the diagnosis of celiac disease in their child, 53.01% of parents most often chose to talk to the doctor who treats the child. Conclusion: Information on proper nutrition of children and gluten-free foods, as well as specific information on celiac disease, is requested from the doctor of the institution where the disease was diagnosed in the child and where they go for check-ups. Many complications caused by unrecognized celiac disease could be prevented by timely diagnosis and proper posture of the child, which contributes to good and adequate information.

Introduction/Objective Isolated hypertransaminasemia (IHTS) is a common, benign, and transient appearance in patients with celiac disease (CD). The aim of this study is to determine the frequency of IHTS in children up to two years old with clinically classical CD, as well as its connection with the onset of the first symptoms of the disease, the age of diagnosis, the clinical and laboratory nutritional parameters, and the degree of damage of small intestinal mucosa. Methods The study was based on a sample of 82 children, 55 female and 27 male, ages 7–24 (14.28 ± 4.41) months. The diagnosis of CD was based on the revised ESPGHAN criteria and the activity of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) by standard laboratory methods. Results IHTS was found in 39 (47.56%) patients, 27 of whom (69.23%) had elevated levels of both transaminases and 12 of only one – eight of AST and four of ALT. The increase in relation to the aforementioned reference value for ALT was 1.1–10.08 (1.67 ± 1.73), and for AST it was 1.08–7.91 (1.56 ± 1.29) times. In patients with IHTS compared to those with normal transaminasemia, the age of onset of CD was significantly lower (9.83 ± 3.69 vs. 12.95 ± 4.43 months, p = 0.001), as well as the age of diagnosis (12.97 ± 3.88 vs. 15.47 ± 4.56 months; p = 0.01), while the differences in the other observed parameters were not significant. Conclusions IHTS occurs in almost half of children up to two years old with classical CD. Hypertransaminasemia is in most cases mild and significantly more frequent in patients with earlier clinical expression of the CD.

Introduction/Objective. The classic type of celiac disease (CD) is most common in children under two years of age. The aim of this study was to investigate whether breastfeeding, particularly breastfeeding during gluten introduction, and timing of gluten introduction, influence the onset of CD at this age. Methods. We retrospectively analyzed medical records of 93 children, 40 in the first and 53 in the second year, with a classic CD diagnosed at the University Children’s Hospital, Belgrade between 2000 and 2010. The diagnosis of CD was based on the criteria of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) from 1989. Results. Duration of breastfeeding reduced the onset of the CD in the first year p = 0.039 (OR = 1.43 95% CI 1.019–1.899). Also, breastfeeding at the time of gluten introduction significantly delayed the age at diagnosis (F = 1.671, t = 2.39, p = 0.029). The timing of gluten introduction did not affect the age of occurrence of CD in these group of children. Conclusion. Longer breastfeeding, and breastfeeding at the time of gluten introduction, postponed the onset of classic CD in patients up to two years. The association between the occurrence of CD and the time of introduction of gluten in this age group of patients has not been established.

Introduction/Objective. Anemia is the most common extraintestinal manifestation of celiac disease (CD) in children. The aim of this study was to determine the frequency, severity and type of anemia in children with a classical CD, as well as the differences between anemic and non-anemic patients in their age, duration of illness, percentile body length or height, percentage of body weight (BW) deviation compared to ideal, and the degree of damage to the small intestine mucosa. Methods. The study was based on a sample of 90 children, 56 females and 34 males, ages 7–90 (18.23 Ѓ} 12.7) months with classical CD. The diagnosis of CD is based on the ESPGHAN criteria from 1990 and 2012, and of anemia on the 2011 WHO reference values. Results. Anemia was found in 47 (52.22%) patients, of which it was mild in 23 cases [hemoglobin (Hb) 100–109 g/L] and moderately severe in 24 (Hb 70–99 g/L), in 34 (72.34%) it was microcytic [mean cell volume (MCV) < 70 fl] and normocytic (MCV 70–87 fl) in 13 patients. Low serum iron levels (< 10.7 μmol/L) were found in 68 (75.56%), and hypoferritinemia (< 16 ng/ml) in 77 (85.56%) patients. Except for a greater deficit of BW in patients with anemia compared to those without anemia (-14.64 ± 9.60 vs. -8.56 ± 11.87%, p < 0.01), differences in other defined features were not significant. Conclusion. Mild or moderate iron deficiency anemia occurs in slightly more than half of children with a classical type CD. In anemic compared to non-anemic patients, there is a significantly higher BW deficit, while differences in other characteristics typical for this type of disease are not significant.

INTRODUCTION: Celiac disease is an immune-conditioned systemic disease that occurs as a result of the consumption of gluten and related proteins. It arises as a combination of a variety of clinical symptoms and signs such as the presence of serum antibodies typical of celiac disease, specific genetic writing and a different degree of enteropathy. OBJECTIVE: To evaluate the clinical features of celiac disease in children and adolescents such as: the age in which the disease is diagnosed, the time has elapsed since the onset of the first symptoms to the diagnosis, the clinical manifestation of the disease, the results of the small intestine biopsy and the results of the success of the gluten-free diet. Subjects and Method: The study included a sample of 116 children diagnosed with celiac disease who are on gluten-free diet. at least a year The research site is the Institute for Health Care of Mother and Child of Serbia "Dr Vukan Cupic" and University Clinic in Belgrade. The research used a specially designed Documentation Sheet. Results: In the observed sample, diagnosis of celiac disease was established in 50%subjects at the age of up to 2 years of age. A period from the onset of the first symptoms to the established diagnosis, has lasted for three months in children 48.28%. The disease was manifested in 47.83% of children as chronic diarrhea and weight loss. Total atrophy of the intestinal tract was detected in 41 35.34% subjects. Laboratory analyzes of blood to monitor the success of the child showed a positive result in 25.86% subjects. CONCLUSION: Illness covers all ages, both sexes. Various symptoms of illness can be long hidden. Mucosal damage is due to gluten exposure. Control of laboratory findings confirms the improvement of the condition of patients and the recovery of the absorption function of the bowel, confirms the positive response to the introduced gluten-free diet.

Introduction. Elevated cardiac troponin gives excellent accuracy in the identification of myocardial damage in children, but it can also be elevated in a series of other diseases. Case report. We presented two children thirteen years of age with a high serum level of troponin-I after an acute episode of supraventricular tachycardia. We analyzed troponin- I levels in correlation with the maximum heart rate, duration of tachycardia and systolic left ventricular function (ejection fraction and fractional shortening). Conclusion. Abnormal troponin level can be seen in children with sustained supraventricular tachycardia and normal heart. Caution is advised in diagnosing cardiac dysfunction in children with supraventricular tachycardia and elevated troponin levels.

Celiac disease is an autoimmune disease, which occurs due to inadequate immune response in genetically predisposed individuals in contact with gluten contained in wheat, rye, barley and oats. Removing gluten from the nutrition can be a difficult task, because wheat and other grains that contain gluten are widely used in people's daily nutrition, across the world By this paper we want to evaluate the available literature, and make a review of gluten-free diet effect on the way of life of children with celiac disease Following aspects such as cross-contamination with grains containing gluten, high prices, low availability of gluten-free products and improper labeling of food can jeopardize the treatment ie. respect of gluten free diet. Survey of literature indicates that the gluten-free diet brings a lot of social compromise in the lives of children and families who have a member with this problem in the daily life of the organization. The high incidence of psychological problems such as anxiety, depression, fears, feelings of sadness and low tolerance for frustration was observed in children with celiac disease. For better and healthier life of patients with celiac disease, the constant supervision over the production and trade of gluten-free products is needed. In addition to the aforementioned, continuous education of health workers, pharmacists, caterers, hoteliers and traders about the disease. is. required as well as a broader social activity and greater involvement of social institutions.

Clostridium difficile (CD) is the most common cause of nosocomial diarrhea in adults with high rates of morbidity and mortality. The epidemiology of CD infection (CDI) has changed in the last few decades associated with increasing severity of the infection rate related to the occurrence of NAP1 hypervirulent strain and the emergence of the disease among ambulatory patients and the wider community. Although little is known about CDI in pediatric patients, CD is surprisingly recognized as an important pathogen in children. In this review article, we direct attention to the recent findings on the incidence and epidemiology of pediatric CDI, including the risk factors for infection, with special emphasis on the importance of CDI in infants and a population of children suffering from chronic gastrointestinal diseases or cancer. Despite recent pharmacotherapeutic protocols successfully used in children with CDI, we would like to draw attention to precautionary and preventive measures in terms of both unnecessary testing and uncritical use of antibiotics as the most important risk factors.

Introduction. Streptococcus pneumoniae is the second most common cause of meningitis in children, producing more serious complications than other bacteria. Streptococcus pneumoniae infections are a rare trigger of glomerulonephritis. We presented a case of glomerulonephritis developing concurrently with meningitis in a young male child. Case report. Gross haematuria, significant proteinuria, hypertension and decreased level of C3 alongside the signs of central nervous system involvement occurred in a male patient of 5 years and 3 months of age. Spontaneous resolution of renal affliction parameters followed the successful treatment of meningitis. The disease course was strongly suggestive of postinfectious glomerulonephritis, although it manifested at the same time as meningitis. The absence of the latent period might point to the development of IgA nephropathy, but since the renal function was stable, without any abnormalities in urine tests documented during follow-up, our opinion is that this was rather the case of postinfectious nephropathy. Conclusion. The presented case is a unique clinical form of postinfectious glomerulonephritis. An accurate diagnosis of this entity should ensure the adequate treatment and follow-up of these patients.

Introduction. Infective mononucleosis is most commonly caused by Epstein-Barr virus (EBV), and in smaller percentage by cytomegalovirus (CMV). Objective. The aim of this paper was to determine the clinical and laboratory differences between EBV and CMV infectious mononucleosis in children. Methods. Cohort retrospective analytical research was conducted. We used data from medical history in six years period and monitored anamnestic data, frequency of inspection and palpation obtained data during physical examination, several laboratory tests, abdomen ultrasonography examination finding and emergence of disease complications. Statistical processing of data has been performed using SPSS 20. Results. Total number of examined children was 137, out of which 85.4% were with EBV and 14.6% with CMV infection. Affected children were most commonly younger than eight years. Boys were affected more often. There was no difference in frequency of high temperature, sore throat, bad breath, and respiratory symptomatology between examined children. Differences were discovered in frequency of stomachaches, eyelid swelling, skin rash and fatigue. Differences were not proven in the frequency of angina, lymphadenopathy and splenohepatomegaly between the groups. Values of transaminases and lactic dehydrogenases significantly decreased after seven days of hospitalization in both groups. In children with EBV, values of transaminases declined faster than in children with CMV. Anemia and bacterial superinfection of pharynx were most common disease complications. Thrombocytopenia was more common in children with CMV infection. Average duration of hospitalization was 6.7 days. Conclusion. In children with CMV abdominal pain, eyelid swelling, skin rash, fatigue and thrombocytopenia were more common. In children with EBV values of transaminases declined significantly faster.

Food allergy represents a highly up-to-date and continually increasing problem of modern man. Although being present in all ages, it most often occures in children aged up to three years. Sensitization most often occurs by a direct way, but it is also possible to be caused by mother’s milk, and even transplacentally. Predisposition of inadequate immune response to antigen stimulation, reaginic or nonreaginic, is of nonselective character so that food allergy is often multiple and to a high rate associated with inhalation and/ or contact hypersensitivity. Also, due to antigen closeness of some kinds of food, cross-reactive allergic reaction is also frequent, as is the case with peanuts, legumes and tree nuts or cow’s, sheep’s and goat’s milk. Most frequent nutritive allergens responsible for over 90% of adverse reactions of this type are proteins of cow’s milk, eggs, peanuts, tree nuts, wheat, soy, fish, shellfish, crustaceans, and cephalopods. Allergy intolerance of food antigens is characterized by a very wide spectrum of clinical manifestations. Highly severe systemic reactions, sometimes fatal, are also possible. The diagnosis of food allergy is based on a detailed personal and family medical history, complete clinical examination, and corresponding laboratory and other examinations adapted to the type of hypersensitivity and the character of patient’s complaints, and therapy on the elimination diet. A positive effect of elimination diet also significantly contributes to the diagnosis. Although most children “outgrow” their allergies, allergy to peanuts, tree nuts, fish, shellfish, crustaceans, and cephalopods are generally life-long allergies.

Introduction. Hypocalcemic seizures are uncommon in the post-neonatal period. We report an infant with hypocalcemic seizures caused by severe deficiency of vitamin D. Case Outline. A five-month-old male infant was admitted to hospital in March 2013 with recurrent generalized afebrile seizures resistant to clonazepam therapy. At the clinical examination, the infant showed characteristic rachitic signs, so that after a blood sample was taken for laboratory testing, the infant was given infusion of 2 ml/kg of 10% of calcium gluconate at a rate of 0.5 ml/min. The treatment resulted in immediate termination of seizures and normalization of the consciousness of the infant. Blood sample analysis showed extremely low levels of free and total calcium (0.36/1.24 mmol/l) and 25(OH)D (

Acute diarrhea (AD) is the most frequent gastroenterological disorder, and the main cause of dehydration in childhood. It is manifested by a sudden occurrence of three or more watery or loose stools per day lasting for seven to 10 days, 14 days at most. It mainly occurs in children until five years of age and particularly in neonates in the second half-year and children until the age of three years. Its primary causes are gastrointestinal infections, viral and bacterial, and more rarely alimentary intoxications and other factors. As dehydration and negative nutritive balance are the main complications of AD, it is clear that the compensation of lost body fluids and adequate diet form the basis of the child’s treatment. Other therapeutic measures, except antipyretics in high febrility, antiparasitic drugs for intestinal lambliasis, anti-amebiasis and probiotics are rarely necessary. This primarily regards uncritical use of antibiotics and intestinal antiseptics in the therapy of bacterial diarrhea. The use of antiemetics, antidiarrhetics and spasmolytics is unnecessary and potentially risky, so that it is not recommended for children with AD.

Introduction. Vitamin D intoxication represents a rare and potentially serious pathological condition caused by the excess of calcium and phosphorus. We are presenting an infant with vitamin D intoxication due to excessive daily administration, as well as therapeutic procedures that prevented its adverse effects. Case Outline. A 1.5-month-old female infant, born at term, exclusively breastfed and without any complaints and abnormalities of physical findings, was observed due to the data that during the preceding month, by her mother’s mistake, she had received about 200,000 IU of vitamin D3. Laboratory analyses showed a high serum level of 25(OH)D (>400 nmol/L) and calcium (2.72 mmol/L), lowered PTH (6.6 pg/ml) and high urinary calcium/creatinine ratio (1.6), while other findings, including urotract ultrasonography image, were within normal limits. Treatment based on the discontinuation of vitamin D administration, infant’s forced water intake, as well as the application of 2-month prednisolone and 4-month phenobarbitone and furosemide, resulted in complete normalization of the laboratory indicators of vitamin D overdose, as well as the prevention of its adverse effects. Conclusion. By timely recognition and adequate treatment, including triple therapy with prednisolone, phenobarbitone and furosemide, adverse effects of acute vitamin D intoxication can be prevented.

Introduction. Cystic fibrosis (CF) is a multisystemic autosomal recessive disease most frequently recognized by characteristic respiratory and/or digestive manifestations. Exceptionally rare, as is the case with the infant we are presenting, the initial sign of the disease can be nutritional deficiency dermatitis (NDD). Case Outline. A three-month-old male infant of young and healthy non-consanguineous parents, born at term after the first uneventful pregnancy, was hospitalized due to atopic dermatitis (AD)-like skin changes, failure to thrive and normochromic anemia (Hb 60 g/L). As exclusively breast-fed, failure to thrive was attributed to hypogalactia and skin changes to nutritional allergy, so that, besides exclusion of cow’s milk protein and other highly allergenic foods in mother’s diet, hypoallergenic milk formula was added to the child’s diet. However, dietetic measures were without effect, and the child was re-hospitalized at age 4.5 months, this time in the condition of severe malnutrition with hypoproteinemic edemas, extensive dermatitis, moderate hepatosplenomegaly and recurrent normochromic anemia (Hb 57 g/L). After plasma-free erythrocyte transfusion, correction of hypoalbuminemia and two-week parenteral and semi-elementary nutrition resulted in gradual recovery of the child, also including the resolution of skin changes. Having in mind the clinical course of the disease, as well as the response to applied therapeutic measures, CF was suspected as the cause of the child’s problems, which was also confirmed by a high level of sweat chlorine (92 mmol/L) and DNA analysis (∆F508/∆F508). Conclusion. Our experience indicates that NDD, as the initial manifestation of CF, should be also kept in mind in differential diagnosis of the infant’s AD-like changes.

Introduction. In the last few years the use of cardiac troponin I and T, as diagnostic and prognostic factors of ischemic myocardial injury both in adult and neonatal medicine has been of great interest. Objective. The objective of our research was to investigate the significance of cardiac troponin I (sTnI) as an early indicator of the presence and severity of hypoxic-ischemic encephalopathy (HIE) in newborns. Methods. We analyzed 55 term newborns with HIE diagnosed based on clinical findings and ultrasonographic examination of the central nervous system. Serum concentration of sTnIultra was determined by immunoenzyme method during the first 24-48 hours after birth, and the obtained findings were compared with the values of identical parameter in 36 healthy term newborns. Results. During the first 24-48 hrs after birth, serum concentration of sTnI-ultra was significantly higher (r0.12 μg/l indicated the development of significant cerebral damage with the sensitivity of 75% and specificity of 72.2%, while the sTnI-ultra level of >0.13 μg/l was a significant mortality predictor with sensitivity of 76.9% and specificity of 73.8%. Conclusion. The second generation cardiac troponin I assay highly correlates with clinical and ultrasonographic findings in neonates with HIE, so that it can be used as a significant diagnostic and prognostic indicator of this pathological condition.

Introduction. Pseudo-Bartter syndrome encompasses a heterogenous group of disorders similar to Bartter syndrome. We are presenting an infant with pseudo-Bartter syndrome caused by congenital chloride diarrhoea. Case Outline. A male newborn born in the 37th gestational week (GW) to young healthy and non-consanguineous parents. In the 35th GW a polyhydramnios with bowel dilatation was verified by ultrasonography. After birth he manifested several episodes of hyponatremic dehydration with hypochloraemia, hypokalaemia and metabolic alkalosis, so as Bartter syndrome was suspected treatment with indomethacin, spironolactone and additional intake of NaCl was initiated. However, this therapy gave no results, so that at age six months he was rehospitalized under the features of persistent watery diarrhoea, vomiting, dehydration and acute renal failure (serum creatinine 123 μmol/L). The laboratory results showed hyponatraemia (123 mmol/L), hypokalaemia (3.1 mmol/L), severe hypochloraemia (43 mmol/L), alcalosis (blood pH 7.64, bicarbonate 50.6 mmol/L), high plasma renin (20.6 ng/ml) and aldosterone (232.9 ng/ml), but a low urinary chloride concentration (2.1 mmol/L). Based on these findings, as well as the stool chloride concentration of 110 mmol/L, the patient was diagnosed congenital chloride diarrhoea. In further course, the patient was treated by intensive fluid, sodium and potassium supplementation which resulted in the normalization of serum electrolytes, renal function, as well as his mental and physical development during 10 months of follow-up. Conclusion. Persistent watery diarrhoea with a high concentration of chloride in stool is the key finding in the differentiation of congenital chloride diarrhoea from Bartter syndrome. The treatment of congenital chloride diarrhoea consists primarily of adequate water and electrolytes replacement.

Introduction. Bronchial hyperresponsiveness (BHR) is a factor in predicting bronchial asthma independently of inflammation markers. Objective. The aims were to determine the frequency and important predictive facts of BHR and the effect of prophylaxis by Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) on BHR in asthmatic children. Methods. BHR in 106 children was evaluated by the bronchoprovocation test with methacholine. Results. The prevalence rate of symptomatic BHR is 18% for crucial point of PC20=4.1±3.03 mg/ml and PD20=3.22±2.59 μmol methacholine. On average asthmatic children express moderate BHR, which persists even two years after administering prophylaxis. After two years bronchial reactivity is significantly smaller, the change of FEV1 is significantly smaller, the velocity of change of slope dose response curve (sDRC) is faster and the provocative concentration of methacholine that causes wheezing is 2-3 times lower. A mild sDRC shows milder bronchoconstriction after two years. The fast change of bronchial reactivity in 41% of asthmatic children is contributed to aero-pollution with sulfur dioxide and/ or, possible insufficient and/or inadequate treatment during two years of administering prophylaxis. A simultaneous effect of allergens from home environment and grass and tree pollens and of excessive aero-pollution on children’s airways is important in the onset of symptomatic BHR. After two years of treatment by GINA and NAEPP children do not show asthma symptoms or show mild asthma symptoms, however bronchial sensitivity remains unchanged. Conclusion. Optimal duration of anti-inflammatory treatment in asthmatic children who show moderate bronchial hyperresponsiveness should be longer than two years.

Introduction. Idiopathic ulcerative colitis (IUC) represents a rare disease of childhood. It usually occurs at age over 10 years, and below that exceptionally rarely. Objective. The aim of the paper was to analyze the clinical signs, symptoms and therapeutic procedures in children with IUC. Methods. The aims of the paper were based on a sample of 17 children (11 male and 6 female, mean age 11.90±3.50 years; range 3.8-17.5 years) with IUC. The disease diagnosis was based on characteristic endoscopic and pathohistological findings. Results. The basic signs of the disease involved chronic mucosal haemorrhagic diarrhoea which was confirmed in 16 of 17 patients, with body weight deficiency (10), recurrent abdominal pain (6), fever (5), slowed-down maturation (5), marked anorexia (4), and tenesmus (3). Two patients had recurrent aphthous stomatitis, 2 anal fissures, 2 arthralgia, one autoimmune hepatitis and one pyoderma gangrenosum. None of the children had longitudinal growth retardation. Elevated sedimentation rate and C-reactive protein in blood were registered in 11, sideropenia in 10, anaemia in 6 and hypoalbuminemia in 3 patients. The remission of proctosigmoiditis and left-sided colitis was achieved with aminosalicylates, and of pancolitis with the combination of aminosalicylates and glucocorticoids, except in cases of steroid-dependent colitis, which additionally required azathioprine. Conclusion. The main signs of IUC in children are chronic mucous haemorrhagic diarrhoea, body weight loss and sideropenic anaemia, while the basic therapy consists of aminosalicylates, and in more severe cases of the disease the initial use of glucocorticoids and later azathioprine.

Anticholinergic drugs block muscarinic effect of acetylcholine on the receptors of postjunctional membranes and so inhibit the answer of the postganglionic parasympathetic nerve. The loss of M2 muscarinic receptors function occurs in asthmatics and it contributes to bronchial hyperresponsiveness and it is not a chronic feature of asthma, instead it characterizes asthma exacerbation. The loss of M2 muscarinic receptor function in children and adults happens during antigen bronchoprovocation or during exposition of asthmatics to ozone. After inhalation, ipratropium bromide (IB) can be found in a small quantity in circulation and it links less readily to muscarinic receptors on airway smooth muscles as related to its absorption after intravenous application. In the stepwise approach of asthma inhaled anticholinergics is recommended if the symptoms of the disease cannot be adequately controlled by a regular inhalation of antiinflammatory drugs with β2-agonist and oral steroids. The improvement of the airway inspiratory capacity is more elevated than the improvement of FEV1 after inhalation of IB. IB has similar effect as salbutamol and it is recommended to control a stable chronic obstructive disease. During our numerous investigations and up-to-date experience in the usage of 5-7 μg/kg/body mass of IB repeated every 4-6 hours in combination with salbutamol, we did not notice adverse effects of the drug in infants. IB is recommended for hospital treatment of children. .

Introduction. Gluten-free diet (GFD) presents the basis of coeliac disease (CD) treatment. If strictly applied, the disorders of the small bowel mucosa and other disease signs rapidly resolve. Objective. The goal of the study was to evaluate the effect of GFD on the growth and nutritional status of children with the classical form of CD. In addition, we analyzed the differences between these parameters with the duration and the patients' compliance with GFD. Methods. The study goals were achieved on a sample of 90 children, 56 female and 34 male, aged 0.5-7.5 (1.53±1.05) years, with the classic CD diagnosed on the basis of typical pathohistological findings of the small bowel mucosa and clinical recovery of patients on GFD. The duration of the patients' follow-up was 1.08-8.75 (3.03±1.14) years, i.e. until the age of 2.5-15 (4.59±1.78) years. The initial and control values of body height (BH) in relation to matched values for age and gender were expressed in percentiles, while the deviation in body weight (BW) for the matched values of height and gender was expressed in percentages. The referent haemoglobin (Hb) rate in blood, as a laboratory indicator of nutritional status in children aged up to 5 years was ≥110 g/L, and for those aged above 5 years it was ≥115 g/L. Compliance with GFD was based on the pathohistological findings of the small bowel mucosa or determination of tissue transglutaminase. Results. Over the studied period, the effect of GFD was highly significant, both on the increase of BH percentiles (37.62±26.26 vs. 57.22±25.29; p

Introduction. Secondary lactose intolerance (SLI) belongs to the rarer manifestations of gluten-sensitive enteropathy (GSE). It occurs in more severe forms of the disease and its presence contributes significantly to the degree of its expression. Objective. The goal of the study was to determine the frequency of SLI in infants with clinically classic form of GSE, as well as its relationship with the duration, severity and age at the diagnosis of the basic disease and the degree of small bowel mucosa damage. Methods. The study was based on a sample of 42 infants, 30 female and 12 male, aged 7-12 months (x=9.98±1.69), with a clinically classic form of GSE. The diagnosis of GSE was established based on the characteristic pathohistological appearance of small bowel mucosa and clinical improvement of patients on gluten-free diet, while SLI on pathological lactose or milk tolerance test. The assessment of basic disease severity was based on body mass divergence in relation to the standard value, as well as on Hb and serum iron levels, while the degree of small bowel mucosa damage was determined according to the modified Marsh criteria. Results. SLI was verified in 8/42 or 19.05% of patients. In addition to the symptoms and clinical signs of GSE, all the patients with SLI also featured the problems characteristic of lactose tolerance disorders, i.e. watery diarrhoea, borborygmus and meteorism occurring after milk meals. In addition, all had perianal erythema (6 with erosive changes), as well as destructive enteropathy (5 subtotal and 3 total). The difference in the duration of the basic disease, age at diagnosis, as well as in the degree of body mass deviation from the standard value between the lactose-tolerant and lactose-intolerant infants was not found. In addition, no difference in Hb and serum iron levels or in the degree of small bowel mucosa damage was found between the two groups. Conclusion. Our findings indicate that SLI presents a relatively frequent occurrence in infants with clinically classic GSE, as well as that it occurs independently to the duration, severity and age at diagnosis of the basic disease and the degree of small bowel mucosa damage.

INTRODUCTION Hashimoto's thyroiditis (HT) is a common cause of goitre and hypothyroidism in children and adolescents. Spontaneous remission may occur in up to 50% patients, but the development of hypothyroidism is possible. OBJECTIVE We investigated the clinical manifestations, course and long-term outcome of HT. METHOD We reviewed charts of 43 children (36 females) with HT, mean age at presentation 12.3 years, and mean follow-up duration 4.6 years. RESULTS HT is five times more common in females. The common complaints leading to referral were goitre in 19 children (44.3%), diffuse in 17 children (89.5%). As to the prevalence of goitre, it accounted for significantly more referrals in females (14 girls, and 5 boys; 73.7% vs 26.3%, t-test; p

INTRODUCTION Malignant hyperthermia is a rare disease which is mainly an inherited autosomal dominant trait. It is characteristic for muscle rigidity, metabolism or respiratory acidosis, high values of serum creatine kinase. Then appears myoglobinuria which can lead to tubular necrosis and acute renal failure. CASE OUTLINE The male child, ten years old, hospitalized because of the high temperature, exhaustion and cough. On the second day of hospitalization, he has hyperthermia (39.8°C), dyspnoea, tachypnoea, was somnolent, occasionally raving, exhausted with the pains in the muscles which were rigid and painfully sensitive. During the night, the urine was dark red, but the diuresis was well. The next day, laboratory analyses showed high values of aspartate aminotransferase (4263 IU/l), alanine aminotransferase (1311 IU/l), lactate dehydrogenase (11787 IU/l), while the values of serum creatine kinase were so high that they could not be registered. The urine analysis showed the negative result on gall colours and haematuria and positive on myoglobin. During the following days, the patient had normal skin temperature, the pains in the muscles were gradually weakened and the urine cleared up. On the third day, the value of creatine kinase was measured and it was 178700 IU/l. During the next two weeks, the clinical finding was gradually normalized while the laboratory values of serum enzyme were gradually normalized only in twenty days. CONCLUSION Malignant hyperthermia is a serious clinical syndrome which can be found with, until then, a clinically healthy child (without chronic myopathy) and it appears with the high temperature or during the surgical interventions with anesthetics, which is especially dangerous.

INTRODUCTION Epilepsy is a highly prevalent disease affecting 0.5-1.5% of the world's population. One of the most frequently used antiepileptics are valproates. These medicines show a negative impact on haemostasis and peripheral blood count. OBJECTIVE The objective of the study was to examine the negative impact of valproates on haemostasis and peripheral blood count in children and to analyse whether these disturbances were dependent on the dosage of valproates and drug level in blood. METHOD A two-year research was conducted. The research included: 35 children using valproates, 12 children using the therapy of both valproates and carbamazepine and 30 healthy children. Complete peripheral blood count, screening tests of haemostasis (bleeding time, prothrombin time, prothrombin ratio, activated partial thromboplastin time, fibrinogen) and capacity of thrombocyte aggregation research were done in all the children. RESULTS We found significantly more common frequency of leukopenia and neutropenia in children using valproates in comparison with the healthy children group. We also found the more common frequency of eosinophilia in comparison with healthy children. The children with the valproate therapy have lower approximate values of the number of platelets, fibrinogen and platelet aggregation in comparison with healthy children, but they have a higher approximate value of bleeding time and prothrombin time. These disturbances are in correlation with the dosage and the level of the medicine in blood. CONCLUSION Valproates have a negative effect on certain blood count parameters and haemostasis in children. Drug dosage and blood drug level are correlated with their negative impact on haemostasis parameters.

Introduction: Gilbert’s syndrome represents the most frequent hereditary disorder of bilirubin metabolism. It occurs in 2-7% of subjects in general population, and is manifested by mild unconjugated hyperbilirubinaemia of benign nature. Objective. The study was conducted in order to analyse our experience related to the circumstances of disclosure, age at onset and sex distribution of Gilbert’s syndrome in children. Method. The diagnosis of Gilbert’s syndrome was based on the findings of mild unconjugated hyperbilirubinaemia in the absence of haemolysis and organic liver disease, as well as significant increase of bilirubin unconjugated fraction in serum after a 3-day hypocaloric diet (400 kcal/daily). Results. Of 58 subjects with Gilbert’s syndrome, there were 40 (68.97%) boys and 18 (31.03%) girls, indicating a 2.22 fold higher incidence of boys than girls. The age at diagnosis of the disorder was similar in boys and girls, and was 12.2-18 (X=14.71±1.55) years for boys and 10.5-16.4 (X=14.38±2.10) years for girls (p>0.05). Except for 3 girls aged below 12 years, in all other patients the diagnosis was made after that age; in 20, between age 12 and 14 years and in 14, between age 14 and 16 years, while in 10 patents, it was made at age between 16 and 18 years. In 20 (34.48%) subjects, hyperbilirubinaemia was disclosed on routine paediatric examination, in 19 (32.76%) when differentiating the cause of recurrent or acute abdominal pain, in 17 (29.3%) during febrile condition and in 2 during insufficient caloric intake. The values of unconjugated bilirubinaemia, both before a hypocaloric test and after a 3-day energy deprivation, were higher in boys than girls, but this difference was statistically significant only after the 3-day hypocaloric diet in age group between 16 and 18 years (p=0.038). Also, no significant difference was found in bilirubinaemia level between the different age groups either in boys or girls. Conclusion. According to our findings, in children, Gilbert’s syndrome is manifested only in puberty, and 2.22 times more often in boys than girls. It is most frequently revealed during a routine pediatric examination, as well as when investigating the cause of abdominal pain and fever. A significantly higher level of serum bilirubin in boys as related to girls is registered only after a hypocaloric diet in age group between 16 and 18 years. .

Brain abscesses were neurosongraphically diagnosed in 3 out of 44 neonates who had confirmed purulent meningitis. In two cases, the cause was Proteus mirabillis, whereas in one the cause could not be isolated. The ultrasound finding indicated abscess cavities localized in the frontal (in one case bilaterally) and temporal regions of the CNS. Neurosurgical interventions were carried out on all of the neonates who had abscesses (including the evacuation of purulent cavity contents, and later on a ventriculoperitoneal shunt in two cases, because of the development of hydrocephalus). Follow-up on the operated infants revealed that one infant died at the age of 9 months; one, who had a bilateral abscess, demonstrated significant neurodevelopmental retardation in the third month of his life (so far it has not been brought under control); while the third one, whom we monitored until the age of 2, displayed regular psychomotor development (preserved intellect, motor skills, sight, and hearing).

Introduction. The disorder of cow milk protein intolerance is characterized by a wide spectrum of clinical manifestations caused by hypersensitivity of type I, II, or IV, and occurs in 2-3% of children, mostly infants. Objective. The aim of this study was to present our experiences and observations of clinical signs and symptoms of cow milk protein intolerance in infants aged below 12 months. Method. The investigation was carried out on a sample of 55 infants, aged between 1.5-9 months (x=4.2l±1.25), who had cow milk protein intolerance. Diagnosis of illness was based on characteristic anamnestic, clinical, and laboratory parameters, as well as on an adequate patient's response to antigen elimination. Results. The clinical presentation of cow milk protein intolerance was dominated by cutaneous problems, found in 40/55 (72.73%) infants, followed by digestive disorders, found in 31 (56.36%), while respiratory tract disorders were observed least frequently (14.55%). None of the patients developed anaphylactic shock. Changes involving only one system were found in 35 (63.64%) patients; of these 20 (36.36%) were cutaneous and 15 (27.27%) digestive. Twenty (36.36%) infants displayed multisystemic changes; of these 12 were cutaneus with digestive, 4 were cutaneus with respiratory, while 4 infants had cutaneous, digestive, and respiratory disorders. Of the 55 infants with cow milk protein intolerance, 26 (47.27%) had urticaria, 22 (40.00%) perioral erythema, 21 (38.18%) diarrhoea (15 haemorrhagic, 6 non-haemorrhagic), 13 (23.64%) vomiting, 12 (21.82%) Quincke's oedema, 12 (21.82%) eczema, 5 (9.09%) obstructive bronchitis, while 3 (5.45%) infants had laryngitis. In 5 (9.09%) patients we found a significant body weight deficit and in 3 (5.45%), sideropenic anaemia, while longitudinal growth retardation was not registered in any of the patients. Conclusion. Our study showed that the disorder of cow milk protein intolerance predominantly involved cutaneous disorders as well as combinations of cutaneous and digestive disorders, while respiratory system disorders proved to be relatively rare.

Klippel-Trenaunay-Weber syndrome (KTW) is a rare phacomatosis whose main characteristics are: cutaneous angiomas (vascular nevi), varicose veins (arteriovenous fistulae) and hemihypertrophy of bones and soft tissues. This is a case report of KTW syndrome which was diagnosed in the first days of life on the basis of characteristic vascular nevi on the skin of the trunk and extremities in addition to hypertrophy of the left part of the body. Neuroradiologically verified hemimegalencephaly associated with temporal hemangioma represents a special particularity in our case. Measures of monitoring the child as well as stimulating and therapeutic actions were the issues of discussion.

Numerous epidemiological studies, conducted in both developed and developing countries, have shown that the rotavirus is an important aetiological agent in severe diarrhoeal diseases among preschool children. In recent years, different biochemical techniques for the genetic and phenotypic analysis of rotaviruses have been developed. The aim of this study was to define the biological and genetic differences among rotaviruses isolated from the faeces of affected children, by using the Polyacrylamide Gel Electrophoresis technique, as well as to type the viruses and establish the number of strains circulating within our population. In total, 124 faeces samples from children up to 5 years of age were analysed. With the use of the ELISA test, rotaviruses were isolated in 10.3% of cases. The extraction of viral RNA was carried out directly from the faeces samples, which was followed by electrophoresis, and finally observation using a UV lamp, and documentation with a photo camera. The analysis of viral RNA, using Polyacrylamide Gel Electrophoresis (PAGE), revealed equal mobility in all segments of the genome. The results of our analysis demonstrated that the same strains of rotaviruses do circulate within our population. Such a result can be explained as a consequence of our years-long isolation as well as of the decreased mobility of our population. However, the results do not signify that the rotavirus genome in this region will not be susceptible to variations and that, consequently, new strains will not be created.