John N. Schullinger

An experimental study of acute neonatal enterocolitis—the importance of breast milk☆

Abstract Formula feeding in conjunction with hypoxia produces enterocolitis in newborn rats. Breast feeding under the same circumstances is completely protective. Enteric overgrowth of potentially pathogenic bacteria in only the formula-fed rats indicates that the gut flora plays an important role in the pathogenesis of enterocolitis. Breast milk through induction of passive enteric immunity and control of intestinal flora protects the rat and may protect at-risk premature infants from acute enterocolitis.

Hyperammonemia resulting from intravenous alimentation using a mixture of synthetic L-amino acids: A preliminary report

Hyperammonemia has been observed in three infants receiving total parenteral alimentation in which the nitrogen source was a mixture of synthetic L -amino acids (FreAmine). Two of the three infants developed lethargy, unresponsiveness, and twitching movements of the eyes and extremities followed by grand mal seizures. The hyperammonemia and associated clinical signs could be corrected by administration of 2 mmoles per kilogram of arginine-glutamate or 3 mmoles per kilogram of arginine-HCl and could be prevented by addition of as little as 0.5 to 1.0 mmoles per kilogram of arginine-HCl to the daily infusate. These observations make it mandatory to monitor blood ammonia levels in any infant receiving total parenteral alimentation.

Total intravenous alimentation in low-birth-weight infants: A preliminary report

Nine infants with birth weights less than 1,200 Gm. received total intravenous alimentation for 5 to 24 days. In six infants, alimentation was started within 48 hours of birth; in three others, the procedure was started at 12 to 14 days of age. When a caloric intake of more than 100 Cal. per kilogram per day was achieved, weight gain averaged 15.3 Gm. per day and nitrogen balance averaged 0.23 Gm. per day. No significant deviations were observed of plasma sodium, potassium, calcium, phosphorus, and acid-base values. The time required to regain the initial body weight after institution of intravenous nutrition was significantly improved over that expected in conventionally managed infants of similar weights. The results demonstrate that the technique, when properly used, warrants further controlled investigation in premature infants.

Imperforate anus: A survey from the members of the Surgical Section of the American Academy of Pediatrics+

T ttlS REPORT is based on a survey of the experience of members of the Surgical Section of the American Academy of Pediatrics with imperforate anus for the 5-yr period 1965 through 1969. The authors are the committee appointed to compile d~tta from answers to a questionnaire circulated to 301 members, including honorary overseas members. Many of the members reported as groups from the same institution. The survey represents the experience of pediatric surgeons reporting on 1166 patients from 51 institutions, including childrens hospitals and general hospitals.

Selective management of iatrogenic esophageal perforation in the newborn

Since 1974 nine neonates have been treated for iatrogenic esophageal perforation. They ranged in weight from 480 to 3900 g. Four of them had been resuscitated for meconium aspiration, four were being treated for respiratory distress syndrome (RDS), and one had received only routine postpartum suctioning and gastric aspiration. In five infants, esophageal perforation was suspected following traumatic intubation of difficulty in the passage of a catheter or tube. Three neonates passed formula from chest tubes placed for pneumothorax and one child presented with persistent pneumothorax. Esophageal perforation was documented in each case by direct visualization and/or radiographic studies. Three infants were treated with antibiotics and placement of a silastic nasogastric feeding tube. An additional two infants were treated with a silastic tube, antibiotics and chest tube drainage. Four children underwent operation: gastrostomy and drainage (2), gastrostomy and closure of perforation (1), gastrostomy only (1). There were no complications of deaths. Management of iatrogenic perforation of the esophagus depends upon the extent and location of the injury. A nonoperative approach can be successful in those infants with limited injury of short duration. Operation is required in cases with extensive extravasation or delay in diagnosis.

Antepartum Diagnosis and Management of in Utero Intestinal Volvulus with Perforation

IN recent years ultrasonography has contributed substantially to the prenatal diagnosis of various congenital malformations1 2 3 and thus revolutionized management in obstetric patients. The presen...

Neuroblastoma with intraspinal (dumbbell) extension

Twenty-three patients with neurogenic tumors having extradural extension (dumbbell tumors) were treated over a 30-year period. Three had ganglioneuroma, 6 had ganglioneuroblastoma, and 14 had neuroblastoma. Nineteen patients with malignant tumors had symptoms of spinal-cord compression; three patients with ganglioneuroma and one with a malignant tumor had no neurologic symptoms. Delays in diagnosis were frequent ranging from 6 weeks to 3 years in 10 patients. Sixteen patients had abnormal x-rays of the spine. All patients with malignant tumors had positive myelograms. Three patients with ganglioneuroma and 13 with malignant tumors are alive and free of disease. Seven patients with malignant tumors died: five with stage IV and 1 with stage III tumors from disease, and 1 with stage II tumor during laminectomy. Age and stage were important prognostic factors; location was not. Treatment consisted of excision and radiation or radiation only. Patients receiving lower-dose (less than 2000 rad) radiation did as well as those receiving much larger doses. Morbidity in patients with malignant tumors was high; 4 have spinal deformity (3 severe) and 8 of 13 surviving patients have residual neurologic deficits. Earlier diagnosis, a surgical approach which does not introduce morbidity, and low-dose radiation in younger patients are important factors in reducing morbidity.

Diagnosis and management of gastrointestinal perforations in childhood dermatomyositis with particular reference to perforations of the duodenum

Four children with dermatomyositis were recently seen with gastrointestinal perforations. The sites of perforation in the four cases were: (1) the duodenum, esophagus, and colon; (2) the duodenum; (3) the distal stomach; and (4) the traverse colon. The gastric and transverse colon perforations were intraperitoneal and easily diagnosed. The gastric perforation was treated successfully by partial gastrectomy. The patient with the colon perforation underwent exteriorization; death occurred from cerebral complications possibly related to vasculitis. Both duodenal perforations were posterior in the distal descending portion. Enzymatic dissection into the right lower quadrant produced confusing clinical and radiographic signs and extensive retroperitoneal necrosis. Successful treatment was obtained by partial gastrectomy, sump drainage of the perforation, and parenteral nutrition. Gastrointestinal perforation is a well-recognized complication of vasculitis in childhood dermatomyositis. In particular, perforations of the distal duodenum, as reported by others, are associated with delay in diagnosis and high mortality.

Hypothyroidism caused by topical povidone-iodine in a newborn with omphalocele

A case of physiologic hypothyroidism caused by the topical application of povidone-iodine (PVPI) in a newborn with an omphalocele is presented. The literature on systemic absorption and effects of PVPI is reviewed. A management strategy is offered.

Cholelithiasis in childhood

T HE incidence of choIeIithiasis in chiIdren is not the rare occurrence it was once considered to be. A review of the Iiterature discloses reports of a surprisingIy Iarge cohection of cases by Potter1 and others (SalIick,2 SeidIer and BrakeIy3). This report of a case and review of the Iiterature is made with a view toward adding to the weight of evidence that ChoIeIithiasis is a disease to be considered in the differential diagnosis of the acute or chronic surgica1 condition within the abdomen in chiIdren. Roentgenographic study shouId be encouraged in a11 obscure abdomina1 conditions in chiIdhood; ChoIecystography is we11 toIerated by chiIdren and its more frequent use undoubtedIy wouId uncover many more cases of ChoIeIithiasis. The simiIarity between the symptoms of acute appendicitis and ChoIeIithiasis is some\vhat confusing, and during the operation for appendicitis the gaIlbladder shouId be paIpated for caIcuIi if possibIe. Dr. SaIIick’s2 paper on the subject of choIeIithiasis suggests that the condition be cIassified into three varieties, namely, maIformations, inflammations and those of metabohc origin. In infancy and very earIy chiIdhood biIiary disease may be due to malformations of the biliary passages with atresia or absence of one or more components of the system. Stagnation of biIe due to mechanica factors pIays an important roIe in the formation of concretions which may form in the biIiary system. Inflammation of the gaIIbIadder in Iater chiIdhood with either suppuration or spontaneous recovery does not usuaIIy give rise to the formation of calculi. There is IinaIIy that type of ChoIecystitis and cholelithiasis simiIar to that which occurs in aduIt life and is usuaIIy regarded to be of a metaboIic nature. Congenital abnormaIities as a ruIe are not helped by surgery. The second type usuaIIy recovers without the necessity of an operation and the third or adult type is treated wit? cholecystectomy. The incidence of the dis se in chiIdren is more evenIy distributed between the sexes than it is in the aduIt form of cholelithiasis, the occurrence in femaIes being only slightI?; higher than it is in males. The cases reported further revea1 that the disease occurs more frequently in oIder than in younger chiIdren, the number of patients above eight years being more common than beIow this age. There are congenita1 bihary conditions not considered in this discussion of ChoIeIithiasis which uouIc1, however, make the frequency of biliary tract disease more common in the first few years of Iife, but these cannot be considered as true cases of ChoIeIithiasis as presented herein. The etioIogic factors in the formation of biIiary concretions are commonIy agreed upon by most surgeons who report these conditions. Acute exanthemas and respiratory infections probably pIay a roIe in the pathologic process. Typhoid fever, which was once considered a major etioIogic factor, has diminished in importance due to improvements in sanitation, and the infrequency of typhoid has not diminished the occurrence of ChoIeIithiasis. In Lowenburg and Mitchell’s” series five patients had an associated upper respiratory tract infection. LambIia infestation has been found by a number of surgeons; Smithies5 found this parasite in biIiary drainage (1928) and ZeIditch6 aIso reported tweIve cases of biIiary tract infestation. These, however, were not a11 cases with accompanying cholelithiasis. Extrahepatic biIiary obstruction due to compression by adjacent structures such as Lymph nodes detiniteIy pIays a part in the stagnation of bile and the formation of biIiary concretions. These nodes are usuaIIy situated atthe junction of the cystic and common bile ducts and were found in severa of the cases reported, as we11 as in the case herein presented.