Jean Badoual

Procalcitonin as a marker for the early diagnosis of neonatal infection

Serum procalcitonin was determined in newborn infants at the time of admission to the pediatrics or obstetrics unit. Increased levels were found in all neonates with bacterial sepsis. Neonates with viral infection, bacterial colonization, or neonatal distress had normal or slightly increased levels. These data suggest that procalcitonin might be of value in diagnosing neonatal sepsis.

Small-bowel bacterial overgrowth in children with chronic diarrhea, abdominal pain, or both☆☆☆★

OBJECTIVE To evaluate the frequency of small-bowel bacterial overgrowth (SBBO) as a cause of chronic digestive symptoms in a large cohort of children, using the glucose breath hydrogen test (BHT). DESIGN Patients were 53 children (aged 2 months to 12 years) with chronic diarrhea, abdominal pain, or both. Diagnosis of SBBO was defined with a BHT by a change in H2 concentration of 10 ppm H2 or more in expired air after an oral glucose load. Patients with a positive BHT result were included in group 1 and treated with a combination of colistin and metronidazole for 10 days; a second BHT was performed 1 month later. Group 2 comprised patients with a negative BHT result. Group 3 (n = 15) was a control group of healthy subjects, and group 4 (n = 6) a comparison group of subjects with bacteriologically documented SBBO. RESULTS Eighteen patients (34%) had a positive BHT result and 35 a negative result. The BHT results were comparable in groups 1 and 4 and in groups 2 and 3, respectively. Fasting H2 levels were higher in group 1 than in groups 2 (p < 0.001) and 3 (p < 0.01). In group 1, children were younger than in group 2 (1 +/- 1 year vs 3.9 +/- 3 years; p < 0.001) and diarrhea was frequent (83%), but 17% of patients had abdominal pain alone. Fetid stools (p < 0.01), mucus in stools (p < 0.01), and flatulence (p < 0.05) were more frequent in group 1 than in group 2. Antibiotic treatment of children in group 1 led to a rapid disappearance of symptoms and normalization of BHT results. CONCLUSION SBBO appears to be a frequent cause of chronic digestive symptoms in children, especially before the age of 2 years. The BHT provides a simple and noninvasive method of detecting it. The recognition of SBBO in children leads to effective treatment.

Impairment of lung diffusion capacity in Schönlein-Henoch purpura.

Twenty-nine children with typical Schönlein-Henoch purpura (SHP) were tested at the initial phase of the disease for respiratory function. Of the 29 patients, 28 had a decrease of lung transfer for carbon monoxide (TLCO) as measured by a steady-state method. Lung volumes and blood gas values were normal; slight radiologic signs of interstitial lung involvement were observed in 18 of 26 patients. There was a decrease in TLCO to 56.8% of normal values for height and gender and to 58.5% when normal values were volume-adjusted to functional residual capacity. In 19 of 25 patients, TLCO measurements were performed at 3-month intervals during follow-up. In all cases, normalization of TLCO values was observed only after complete clinical recovery from SHP. All children with persisting symptoms, even limited to microscopic hematuria or slight proteinuria, had low TLCO values. In one patient low TLCO during follow-up preceded a late relapse of SHP in the form of acute nephritic disease with characteristic IgA deposits on renal biopsy. We conclude that low TLCO in SHP is probably related to alteration of the alveolar-capillary membrane by circulating immune complexes. This noninvasive technique may be useful in diagnosis, and during the follow-up of the disease as an early indicator of reactivation.

Isoniazid acetylation metabolic ratio during maturation in children

Isoniazid acetylation metabolic ratio (MR) was studied in 61 children with tuberculosis after administration of isoniazid. MR was calculated as the molar acetylisoniazid to isoniazid concentration ratio. MR was used as a probe for N‐acetyltransferase activity and to determine the acetylation phenotype. MR had a bimodal distribution with an antimode between 0.48 and 0.77. MR and the percentage of fast acetylators increased significantly with age. The cumulative frequency of fast acetylators increased with age, with a plateau reached around 4 years. MR value was checked during treatment in 44 children. All children but one who initially appeared as fast acetylators remained in this group after repeated testing. Among the 30 slow acetylators, 12 became fast acetylators, and 10 showed a variable phenotyping at different ages. A bimodal distribution of the isoniazid acetylation MR was shown in children, with an antimode close to that described in the literature and a maturation of isoniazid acetylation during the first 4 years.

Distinct features of upper gastrointestinal endoscopy in the newborn.

Between January 1987 and December 1990, 293 upper GI endoscopic procedures were performed in 219 neonates <1 month of age. No lesion was found in 57 cases (26%; group 1), whereas esophagitis was present in 158 cases, alone in 45 cases (20.6%; group 2) and associated with gastritis in 113 cases (51.8%; group 3). The association of esophagitis with gastritis seems to be a specific feature of neonates and not older children. The presence of gastritis with esophagitis suggests that a primary peptic mechanism is unlikely to explain all endoscopic findings, although the presence of such a mechanism secondary to esophagitis could contribute to the esophageal lesions. Acute fetal distress was more frequent in group 3 than in the other groups. Symptoms associated with endoscopic lesions in groups 2 and 3 were, respectively, malaise (38 and 42%), hematemesis (4 and 35%), frequent regurgitation (45 and 26%), and difficult feeding and/or failure to thrive (26 and 24%). In Group 3, minor symptoms often led to the diagnosis of severe mucosal lesions, and antireflux therapy elicited prompt relief of clinical symptoms. The causes of neonatal esophagogastritis remain unknown. Wide use of en-doscopy in the presence of discrete clinical abnormalities is likely to considerably improve the clinical condition of some children in their first days of life.

Allergy to nondairy proteins in mother's milk as assessed by intestinal permeability tests.

The intestinal permeability test is a noninvasive method which, when done during a food provocation procedure, can detect the deleterious effect of food on the intestinal mucosa in allergic children. We report on a 1‐month‐old breast‐fed boy with a history of regurgitation, diarrhea, difficult feeding, and malaise suggesting food allergy. Intestinal permeability tests were done with the mothers milk and showed breast‐milk‐induced alterations of intestinal permeability. No improvement occurred in the childs clinical symptoms or in the results of the intestinal permeability test when the mother withdrew dairy products from her diet. Disappearance of the childs symptoms and normalization of intestinal permeability during provocation with the milk were obtained after elimination of egg and pork from the mothers diet. This observation suggests that dietary proteins different from cows milk antigens may be transferred to breast milk and induce adverse reactions in hypersensitive infants.

Isoniazid dose adjustment in a pediatric population.

This retrospective analysis was designed to evaluate the inactivation index (I3) method used to adjust the isoniazid dose during long-term administration in a pediatric population. Before starting on antituberculosis therapy, sixty-one children received one 10 mg.kg-1 isoniazid test-dose (D). The isoniazid and acetyl isoniazid concentrations were measured by high-performance liquid chromatography on a plasma sample collected 3 hours (C3h) after administration. The patients were separated into slow and fast acetylator groups according to the metabolic ratio. The dose adjustment method using the I3 is based on the assumption that there is a linear correlation between C3h and D [C3h = (I3 x D) - 0.6] in which the slope is I3 and the Y intercept is equal to -0.6 mg.l-1. I3 was determined from a single plasma concentration determination and used to calculate the dose recommended to obtain a desired C3h equal to 1.5 micrograms.ml-1: recommended dose (mg.kg-1) = (1.5 + 0.6)/I3.I3 was significantly higher in the slow acetylator group (0.55 +/- 0.16) than in the fast one (0.26 +/- 0.13), which leads us to recommend a significantly lower dose in the slow acetylator group (4.2 +/- 1.5 mg.kg-1) than in the fast one (10.3 +/- 4.6 mg.kg-1). The data obtained in a subgroup of 21 patients who had at least three consecutive determinations of C3h after different dosages allowed us to verify that there was a linear correlation between C3h and the dose. The mean slope of the correlation lines in that subgroup was 0.61 +/- 0.25 and the 95% confidence interval of the estimated Y-intercept include the theoretical value of -0.60, which shows that our data are consistent with those previously reported in adults. The percentage of patients with a C3h plasma concentration within the expected range (1.5 +/- 0.5 micrograms.ml-1) was significantly higher (69%) in those whose dose was derived from the calculation than in the others (25%). Within each acetylator group, the range of the recommended dose varied widely, and these results emphasize the usefulness of individual dose adjustment based on the inactivation index method.

Pefloxacin after Failure of Initial Antibiotic Therapy in Children with Severe Invasive Salmonellosis

Auoroquinolones are widely used for the treatment of enteric fever or invasive salmonellosis in adults (Asperilla et al. 1990). However, they are not licensed for use in children, in whom they are administered only for severe infections. Thus, for susceptible strains, the treatment of enteric fever and septicaemic salmonellosis in childhood is generally ampicillin, amoxicillin or cotrimoxazole (Hornick 1987). The persistence of severe clinical symptoms, despite therapy with antibiotics possessing good in vitro activity, raises the question of the real efficacy of the treatment. We report here 7 cases of severe salmonellosis in children with clinical failure of a commonly used initial antibiotic treatment that is active in vitro, followed by a dramatic improvement after short term therapy with pefloxacin. 1. Patients and Methods

Allergy to nondairy proteins in mother's milk as assessed by intestinal permeability tests

The intestinal permeability test is a noninvasive method which, when done during a food provocation procedure, can detect the deleterious effect of food on the intestinal mucosa in allergic children. We report on a 1-month-old breast-fed boy with a history of regurgitation, diarrhea, difficult feeding, and malaise suggesting food allergy. Intestinal permeability tests were done with the mothers milk and showed breast-milk-induced alterations of intestinal permeability. No improvement occurred in the childs clinical symptoms or in the results of the intestinal permeability test when the mother withdrew dairy products from her diet. Disappearance of the childs symptoms and normalization of intestinal permeability during provocation with the milk were obtained after elimination of egg and pork from the mothers diet. This observation suggests that dietary proteins different from cows milk antigens may be transferred to breast milk and induce adverse reactions in hypersensitive infants.