Scientific Letter
Faecal microbiota transplant in a child with very early onset inflammatory bowel disease
Trasplante de microbiota fecal en niño con enfermedad inflamatoria intestinal de inicio muy precoz
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class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Gastroenterología y Nutrición Infantil, Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Laboratorio, Hospital Materno-Infantil, Málaga, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trasplante de microbiota fecal en niño con enfermedad inflamatoria intestinal de inicio muy precoz" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The intestinal dysbiosis found in patients with inflammatory bowel disease (IBD) has partly guided the development of treatment strategies. Faecal microbiota transplantation (FMT), which consists in the infusion of a faecal suspension from a healthy donor into the gastrointestinal tract of a recipient to cure a specific disease associated with changes in the intestinal microbiota, has proven efficient in the treatment of recurrent infection by <span class="elsevierStyleItalic">Clostridium difficile</span> in adults and children. This treatment modality could also contribute significantly to the control of IBD. Diverting ileostomy is a surgical intervention that has been used as a temporising therapy in children with refractory colitis to stabilise symptoms, improve nutritional status and taper or discontinue steroid therapy.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> We describe the first paediatric case of FMT via diverted ileostomy performed in Spain.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a boy aged 6 years and 7 months whose mother had Crohn disease. He had received a diagnosis of inflammatory bowel disease unclassified (IBDU) at age 2 years based on a history of recurrent episodes of bloody diarrhoea, anaemia and hypoalbuminaemia. Tests for the differential diagnosis of immunodeficiencies and monogenic inflammatory diseases were negative, and diagnostic tests for detection of infection including tuberculosis and cytomegalovirus were repeatedly negative, except in the assessment of 3 episodes of bloody diarrhoea, when the patient tested positive for <span class="elsevierStyleItalic">C. difficile</span> toxin. Three endoscopic examinations with histological examination of biopsy specimens did not provide significant findings that would allow the diagnostic classification of colitis. The patient did not respond to conventional treatment with mesalamine, systemic steroids, thiopurines and infliximab (with drug level monitoring revealing levels within the normal range for both). With the agreement of the family, the decision was made not to perform a colectomy, opting for the alternative of diverting ileostomy, and scheduling a FMT via the inferior stoma before closure of the ileostomy. The family provided informed consent, and the clinical ethics board of the hospital approved the procedure. Stringent criteria for donor selection were applied with the aim of preventing or reducing the severity of potential donor-related events in the recipient (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The procedure involved the preparation of a suspension of fresh donor faeces, which had been produced 3<span class="elsevierStyleHsp" style=""></span>h prior and stored at room temperature in a sterile container. In the hospital laboratory, a 50<span class="elsevierStyleHsp" style=""></span>g sample of the fresh faeces was blended in 150<span class="elsevierStyleHsp" style=""></span>mL of nonbacteriostatic physiological saline, the slurry filtered, and the resulting suspension collected in a sterile container. A sterile syringe was used to deliver 50<span class="elsevierStyleHsp" style=""></span>mL of the faecal suspension through the inferior stoma of the ileostomy. The patient remained in the supine position for 2<span class="elsevierStyleHsp" style=""></span>h after transplantation. Twenty days later, the patient underwent a second transplantation of faecal matter from the same donor following the same procedure. The patient tolerated the intervention very well. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> describes the progress of the patient after transplantation.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The case presented here is relevant in part due to the performance of diverting ileostomy in a child with severe colitis refractory to treatment, a technique that was recently described by Maxwell et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> for treatment of this type of situation. We did observe clinical improvement in our patient, with significant recovery of body weight and a moderate decrease in CRP. Once the patient had stabilised, FMT was performed with the aim of amplifying the benefits of treatment. There is still very little data on the use of FMT in paediatrics, especially for treatment of IBD. On the other hand, there are substantial methodological differences between published studies, which makes it difficult to draw valid conclusions. We are not aware of any previous publication reporting the delivery of the faecal suspension via ileostomy in paediatric patients. Although there is no consensus on the optimal delivery route, the evidence suggests that infusion via colonoscopy is superior to retention enema and the nasogastric and nasoenteric routes, not only because of patient acceptance but also because it achieves infusion of the entire colon.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> In our case, we considered that FMT through the stoma of the ileostomy offered the best possible conditions, as direct delivery of the faecal suspension to the terminal ileum guaranteed the gradual passage through the entire colon. After 2 infusions, there was a very satisfactory improvement of symptoms, probably due to the additive beneficial effects of ileal diversion and FMT. Few paediatric studies have been published on the use of FMT in children with colitis in the context of IBD, and their results are contradictory. In our case, unlike the studies mentioned above,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3–6</span></a> the suspension was delivered by direct infusion to the distal ileum and not via enema, colonoscopy or nasoenteric tube, as direct infusion probably increases the chances of anterograde deposition of the infusion at the colonic level, avoiding potential interferences during the gastrointestinal transit. Unfortunately, we are unable to present favourable outcome data for our patient. We do not know how many infusions of faecal solution he may have needed. Performance of randomised clinical trials in children is of the essence in order to clarify the numerous doubts we have at present.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sierra Salinas C, Vicioso Recio MI, Blasco-Alonso J, Serrano Nieto MJ, Navas-López VM. Trasplante de microbiota fecal en niño con enfermedad inflamatoria intestinal de inicio muy precoz. An Pediatr (Barc). 2018;89:184–186.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BMI, body mass index; CMV, cytomegalovirus; CRP, C-reactive protein; HIV, human immunodeficiency virus.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age >18 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI within normal range \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No personal or family history of autoimmune disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No evidence of current transmissible disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No evidence of psychiatric disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No use of antibiotic agents or proton pump inhibitors in the past 3 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Food diary to verify healthy diet \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stool cultures negative for pathogenic bacteria, parasites, <span class="elsevierStyleItalic">Clostridium difficile</span>, rotavirus, adenovirus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Faecal calprotectin <50<span class="elsevierStyleHsp" style=""></span>μg/g of faeces \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative for <span class="elsevierStyleItalic">Helicobacter pylori</span> stool antigen \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative serologic tests for hepatitis A, B and C, HIV, syphilis and CMV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal blood panel results (complete blood count, creatinine, electrolytes, transaminases, cholesterol, triglycerides, ferritin, albumin, immunoglobulins, CRP and vitamin D3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence of high-risk sexual behaviour (multiple partners, sex work) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No history of travel to endemic regions with a high prevalence of diarrheal diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1838781.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Donor screening criteria.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CRP, C-reactive protein; FMT, faecal microbiota transplantation; Hb, haemoglobin.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black"></th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hb, g/dL \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Platelets, /mm<span class="elsevierStyleSup">3</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CRP, mg/L \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Albumin, g/dL \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Faecal calprotectin, μg/g \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Weight, kg \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Height, cm \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Day 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diverting ileostomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">890,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">136 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">570 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Day 74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74th day of diverting ileostomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">914,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">130 (ileostomy) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.800 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">104.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Day 74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1st FMT infusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Day 93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2nd FMT infusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Day 113 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Post-FMT outcome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">565,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">115 (ileostomy) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">105 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Day 113 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ileostomy closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Day 127 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 days post-ileostomy closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">995,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">650 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.600 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">105.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Day 163 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 days post-ileostomy closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">887,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">730 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">105.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1838782.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient progress.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diverting ileostomy for the treatment of severe, refractory. Pediatric inflammatory bowel disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.C. Maxwell" 1 => "N. Dawany" 2 => "R.N. Baldassano" 3 => "P. Mamula" 4 => "P. Mattei" 5 => "L. Albenberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MPG.0000000000001498" "Revista" => array:6 [ "tituloSerie" => "J Pediatr Gastroenterol Nutr" "fecha" => "2017" "volumen" => "65" "paginaInicial" => "299" "paginaFinal" => "305" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28045769" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An overview of fecal microbiota transplantation: techniques, indications, and outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L.J. Brandt" 1 => "O.C. Aroniadis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gie.2013.03.1329" "Revista" => array:6 [ "tituloSerie" => "Gastrointest Endosc" "fecha" => "2013" "volumen" => "78" "paginaInicial" => "240" "paginaFinal" => "249" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23642791" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety, tolerability, and clinical response after fecal transplantation in children and young adults with ulcerative colitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Kunde" 1 => "A. Pham" 2 => "S. Bonczyk" 3 => "T. Crumb" 4 => "M. Duba" 5 => "H.J. Conrad" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MPG.0b013e318292fa0d" "Revista" => array:6 [ "tituloSerie" => "J Pediatr Gastroenterol Nutr" "fecha" => "2013" "volumen" => "56" "paginaInicial" => "597" "paginaFinal" => "601" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23542823" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fecal microbial transplant via nasogastric tube for active pediatric ulcerative colitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.L. Suskind" 1 => "N. Singh" 2 => "H. Nielson" 3 => "G. 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Tanaka" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5223/pghn.2016.19.3.214" "Revista" => array:6 [ "tituloSerie" => "Pediatr Gastroenterol Hepatol Nutr" "fecha" => "2016" "volumen" => "19" "paginaInicial" => "214" "paginaFinal" => "220" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27738605" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008900000003/v1_201809020413/S2341287918301339/v1_201809020413/en/main.assets" "Apartado" => array:4 [ "identificador" => "38181" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008900000003/v1_201809020413/S2341287918301339/v1_201809020413/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287918301339?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 10 | 27 |
| 2024 October | 64 | 42 | 106 |
| 2024 September | 64 | 31 | 95 |
| 2024 August | 66 | 67 | 133 |
| 2024 July | 51 | 22 | 73 |
| 2024 June | 73 | 32 | 105 |
| 2024 May | 50 | 30 | 80 |
| 2024 April | 52 | 38 | 90 |
| 2024 March | 43 | 25 | 68 |
| 2024 February | 43 | 34 | 77 |
| 2024 January | 36 | 19 | 55 |
| 2023 December | 44 | 19 | 63 |
| 2023 November | 34 | 38 | 72 |
| 2023 October | 34 | 27 | 61 |
| 2023 September | 32 | 26 | 58 |
| 2023 August | 28 | 16 | 44 |
| 2023 July | 33 | 28 | 61 |
| 2023 June | 24 | 27 | 51 |
| 2023 May | 44 | 24 | 68 |
| 2023 April | 19 | 19 | 38 |
| 2023 March | 44 | 21 | 65 |
| 2023 February | 23 | 33 | 56 |
| 2023 January | 30 | 28 | 58 |
| 2022 December | 64 | 31 | 95 |
| 2022 November | 70 | 38 | 108 |
| 2022 October | 71 | 53 | 124 |
| 2022 September | 56 | 24 | 80 |
| 2022 August | 59 | 54 | 113 |
| 2022 July | 55 | 45 | 100 |
| 2022 June | 41 | 64 | 105 |
| 2022 May | 58 | 57 | 115 |
| 2022 April | 51 | 39 | 90 |
| 2022 March | 81 | 56 | 137 |
| 2022 February | 48 | 33 | 81 |
| 2022 January | 47 | 52 | 99 |
| 2021 December | 48 | 40 | 88 |
| 2021 November | 32 | 45 | 77 |
| 2021 October | 79 | 76 | 155 |
| 2021 September | 60 | 39 | 99 |
| 2021 August | 31 | 56 | 87 |
| 2021 July | 31 | 26 | 57 |
| 2021 June | 42 | 45 | 87 |
| 2021 May | 59 | 39 | 98 |
| 2021 April | 127 | 76 | 203 |
| 2021 March | 70 | 49 | 119 |
| 2021 February | 43 | 23 | 66 |
| 2021 January | 29 | 21 | 50 |
| 2020 December | 47 | 15 | 62 |
| 2020 November | 26 | 19 | 45 |
| 2020 October | 33 | 20 | 53 |
| 2020 September | 32 | 30 | 62 |
| 2020 August | 25 | 16 | 41 |
| 2020 July | 41 | 31 | 72 |
| 2020 June | 40 | 16 | 56 |
| 2020 May | 47 | 25 | 72 |
| 2020 April | 33 | 15 | 48 |
| 2020 March | 19 | 28 | 47 |
| 2020 February | 24 | 7 | 31 |
| 2020 January | 36 | 13 | 49 |
| 2019 December | 52 | 22 | 74 |
| 2019 November | 43 | 10 | 53 |
| 2019 October | 40 | 6 | 46 |
| 2019 September | 28 | 12 | 40 |
| 2019 August | 50 | 17 | 67 |
| 2019 July | 56 | 22 | 78 |
| 2019 June | 35 | 16 | 51 |
| 2019 May | 60 | 14 | 74 |
| 2019 April | 97 | 22 | 119 |
| 2019 March | 43 | 16 | 59 |
| 2019 February | 54 | 24 | 78 |
| 2019 January | 46 | 20 | 66 |
| 2018 December | 57 | 21 | 78 |
| 2018 November | 77 | 36 | 113 |
| 2018 October | 122 | 50 | 172 |
| 2018 September | 183 | 66 | 249 |
| 2018 August | 0 | 1 | 1 |
| 2018 July | 0 | 3 | 3 |
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