Jay A. Perman

Eosinophilic esophagitis attributed to gastroesophageal reflux: Improvement with an amino acid-based formula☆☆☆

BACKGROUND & AIMSnTreatment for gastroesophageal reflux may be ineffective in patients with an eosinophilic infiltration of the esophagus. The aim of this study was to investigate whether unremitting symptoms of gastroesophageal reflux and biopsy abnormalities of the esophagus may be associated with the ingestion of certain foods.nnnMETHODSnTen children previously diagnosed with gastroesophageal reflux by standard testing with long-standing symptoms (median, 34.3 months; range, 6-78 months) despite standard antireflux therapies, including Nissen fundoplication in 6 patients, were fed the elemental formulas Neocate or Neocate-1-Plus (Scientific Hospital Supplies Inc., Gaithersburg, MD) for a minimum of 6 weeks. Each child had repeat endoscopy followed by open food challenges.nnnRESULTSnWhile receiving the formulas, patients had either resolution (n = 8) or improvement (n = 2) of symptoms. On follow-up esophageal biopsy, the maximal intraepithelial eosinophil counts decreased significantly before (median, 41; range, 15-100) to after (median, 0.5; range, 0-22) the formula trial (P = 0.005). Other reactive epithelial changes of the esophageal mucosa also improved significantly. All patients redeveloped their previous symptoms on open food challenges.nnnCONCLUSIONSnChronic gastrointestinal symptoms and histological changes of the esophagus unresponsive to standard treatments for gastroesophageal reflux were improved by the use of elemental formulas. Symptoms recurred when specific dietary proteins were reintroduced during open food challenges. The mechanism of these observations is unknown.

Behavioral Assessment and Treatment of Pediatric Feeding Disorders

Pediatric feeding disorders are estimated to occur in as many as one in every four infants and children, and when serious can require numerous, costly and sustained interventions. For over a decade research has cumulated evidence on the contributions of Behavior Analysis in understanding and remediating some types of pediatric feeding disorders. The systematic use of this body of evidence in conjunction with other approaches (medical, nutrition, occupational therapy, physical therapy, and so forth) is being carried out on an inpatient treatment unit at the Kennedy Krieger Institute. Key aspects are described here, including direct observation behavior assessment, approaches for increasing and decreasing feeding behavior, skill acquisition, transfer of treatment gains, and parent training. The results based on case studies and overall program evaluation indicate that medically complicated, severe feeding disorders can be treated successfully in a few months with a multidisciplinary approach which incorporates behavioral procedures. J Dev Behav Pediatr 15:278–291, 1994. Index terms: pediatric feeding disorders, food refusal, failure to thrive, tube dependence.

Effect of breastfeeding support from different sources on mothers' decisions to breastfeed.

A cross-sectional study compared 100 breastfeeding and 100 non-breastfeeding new mothers in order to investigate the relationship between mothers choice of breastfeeding and support from health professionals and lay people, taking into account potentially confounding sociodemographic influences. The importance of the male partners opinion about breastfeeding was also examined. A favorable attitude of partners towards breastfeeding was the most important factor associated with breastfeeding (odds ratio=32.8). Prenatal class attendance and breastfeeding support from lay people increased the odds of breastfeeding 2.7 and 3.3 times, respectively. Breastfeeding orientation provided by doctors, nurses, and nutritionists was not associated with the maternal decision to breastfeed. The results point toward the need for reevaluation of prenatal care interventions, inclusion of fathers in breastfeeding educational programs, and emphasis on community-based programs.

Are fathers prepared to encourage their partners to breast feed? A study about fathers' knowledge of breast feeding

In order to study fathers knowledge of breast feeding and its relationship with paternal factors, fathers of 92 breast feeding and 89 non‐breast feeding newborns were compared. Paternal factors included previous children and the way they were fed, participation in prenatal care, attendance at prenatal classes, breast feeding information provided by health professionals, use of reading materials and interest in learning more about the subject. The results indicated that fathers had poor knowledge about breast feeding, especially those whose children were being bottle fed. After adjustments for confounders, fathers who had previous breast‐fed child(ren), had attended prenatal classes and who received information about breast feeding from medical personnel had a significantly higher chance of having a better knowledge of breast feeding. It seems that fathers need to be better prepared to assume their new role as breast feeding supporters. Prenatal care was shown to be a good opportunity to improve fathers knowledge of breast feeding.

Gastrointestinal dysfunction and disaccharide intolerance in children infected with human immunodeficiency virus

Because gastrointestinal dysfunction is a major problem in children with human immunodeficiency virus (HIV) infection, we utilized breath hydrogen measurements to determine the relationship between disaccharide malabsorption and gastrointestinal dysfunction in HIV-infected children. We found a strong association between lactose intolerance and persistent diarrheal disease in this population (p less than 0.007, Mann-Whitney U test). We also found evidence of sucrose malabsorption and persistent diarrheal disease in three of the children. Extensive microbiologic evaluations failed to reveal an etiologic agent related to the occurrence of gastrointestinal symptoms. Our findings indicate that disaccharide intolerance is a common occurrence in HIV-infected children with persistent diarrheal disease. Careful attention to dietary intake may be required to ameliorate clinical symptoms and to maintain adequate nutrition.

Effect of Enteral Tube Feeding on Growth of Children with Symptomatic Human Immunodeficiency Virus Infection

Summary Malnutrition and growth failure are frequent clinical consequences of human immunodeficiency virus (HIV) infection in children. Tube feeding is a means by which to increase the enteral intake of nutrients. We examined the effect of tube feeding in 18 children, median age 6 months (range, 3–159). Tube feedings were initiated due to growth failure in all, which was also associated with dysfunctional swallowing or aspiration in seven children and gastroesophageal reflux in two. Tube feedings were infused via nasogastric tube (n = 4) or gastrostomy tube (n = 14) and were continued for a median of 8.5 months (range, 2–24). Stoma complications developed in three children with gastrostomy tubes; these were the only tube-related side effect. Tube feedings were discontinued due to noncompliance (n = 3), gastrostomy leakage (n = 2), intolerance (n = 2), and death (n = 3). Anthropometric changes were evaluated comparing mean standard deviation scores (Z) before and after tube feeding. Tube feeding resulted in significantly increased weight for age (Z, −2.13 + 0.7 vs. −1.46 + 1.4; p = 0.04), weight for height (Z, −1.07 + 1.0 vs. −0.13 + 1.0; p = 0.004), and arm fat area (Z, −1.75 + 1.3 vs. −0.62 + 1.2; p = 0.01). However, tube feeding did not result in significant changes in height for age (Z, −1.93 + 0.8 vs. −1.74 + 1.6) or arm muscle area (Z, −1.24 + 0.9 vs. −0.57 + 1.2). Tube feedings effectively increased the weight of HIV-infected children in this study, but they were not sufficient to correct linear growth deficits.

Nutritional Consequences of Bowel Segments in the Lower Urinary Tract

To assess for altered fat absorption in a group of 26 patients who underwent bladder replacement or augmentation between 1975 and 1988 serum samples were assayed for levels of B12 and carotene. Reconstruction was done with ileum and/or cecum in 22 patients, and 4 who had undergone sigmoid cystoplasty and were not expected to be at risk for fat malabsorption were included as controls. Followup ranged from 4 months to more than 8 years. No patient demonstrated low values of B12 or carotene regardless of postoperative duration, bowel segment location or length of segment. Use of ileal segments less than 45 cm. long even with associated incorporation of the ileocecal valve and adjacent cecum does not appear to compromise fat absorption or the enterohepatic circulation.

Utility of Breath Ethane as a Noninvasive Biomarker of Vitamin E Status in Children

ABSTRACT: The purpose of our study was to determine if the ethane content of expired air could be a useful index of vitamin E status in children. Eight children with vitamin E deficiency secondary to chronic severe liver disease were studied: six of these children were treated with parenteral vitamin E (2–5 mg/kg/dose every 4–7 d). Measures of vitamin E status pre- and posttherapy were: serum vitamin E, 2 ± 1 versus 7 ± 1 μg/mL (p < 0.001); serum vitamin E:total lipids, 0.3 ± 0.1 versus 1.0 ± 0.1 mg/g (p < 0.001); and erythrocyte peroxide hemolysis test, 80 ± 10 versus 6 ± 12% (p < 0.001). Fasting breath ethane in the patients pre- and posttherapy was 78 ± 10 versus 31 ± 11 pmol/kg/min (p < 0.001). Breath ethane correlated negatively with serum vitamin E (p < 0.042) and serum E:total lipids (p < 0.004) and positively with the erythrocyte peroxide hemolysis test (p < 0.003). Values for treated patients did not differ from those for fasted sibling controls (34 ± 12 pmol/kg/min), postprandial sibling controls (31 ± 12 pmol/kg/min), and healthy children sampled randomly, in the nonfasted state (21 ± 14 pmol/kg/min). Breath ethane production in one patient (up to 168 pmol/kg/min) did not normalize after treatment of vitamin E deficiency until her selenium deficiency was corrected as well. We conclude that this noninvasive test can be useful as a screen for vitamin E deficiency in children and for ascertaining response to therapy. The presence of high concentrations of ethane in expired air in vitamin E-sufficient subjects may indicate deficiencies of other antioxidants such as selenium.

The Rett syndrome: Progress report on studies at the Kennedy institute

Clinical, biochemical and pathological studies in patients with the Rett syndrome (RS) are presented. The neuropathological changes and alterations in neurotransmitter markers are particularly interesting and provide valuable information that may be helpful in understanding the behavior and neurological phenotype of RS.

Gastric Function in Children with Cystic Fibrosis: Effect of Diet on Gastric Lipase Levels and Fat Digestion

The effect of diet, usual (44 ± 4% energy as fat), high-fat (49 ± 4% energy as fat), and moderate-fat (33 ± 2% energy as fat), on gastric function (lipase and pepsin activities, pH, emptying rate) and intragastric digestion of fat were assessed in six children with cystic fibrosis. Fasting and postprandial activity of digestive enzymes, gastric pH, and gastric volume measured before, during, and after 120 min of feeding did not differ significantly as a function of fat intake. Postprandial gastric lipase output (units per kilogram of body weight) during usual, moderate-fat, and high-fat diets was close to or higher than (38.8 ± 7.2, 44.9 ± 8.6, and 54.8 ± 5.5 U/kg per 20 min) gastric lipase output of premature infants (22.5 ± 6.4 to 28.3 ± 6.6 U/kg per 20 min) or of healthy adults (5.4 ± 0.4 U/kg per 15 min) fed a high-fat diet. Postprandial pepsin output was higher (4749 ± 797, 6117 ± 925, and 5444 ± 819 U/kg per 20 min) than in premature infants (597 ± 77 to 743 ± 97 U/kg per 20 min) or healthy adults (781 ± 56 U/kg per 15 min). Eighty minutes after feeding gastric lipolysis reached 20 to 36%. This study shows that gastric lipase activity is high in cystic fibrosis patients maintained on diets providing 32% to 49% energy as fat, and that gastric lipase level did not increase over the ranges of dietary fat intake tested.