Martin J. Bell

Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging.

A method of clinical staging for infants with necrotizing enterocolitis (NEC) is proposed. On the basis of assigned stage at the time of diagnosis, 48 infants were treated with graded intervention. For Stage I infants, vigorous diagnostic and supportive measures are appropriate. Stage II infants are treated medically, including parenteral and gavage aminoglycoside antibiotic, and Stage III patients require operation. All Stage I patients survived, and 32 of 38 Stage II and III patients (85%) survived the acute episode of NEC. Bacteriologic evaluation of the gastrointestinal microflora in these neonates has revealed a wide range of enteric organisms including anaerobes. Enteric organisms were cultured from the blood of four infants dying of NEC. Sequential cultures of enteric organisms reveal an alteration of flora during gavage antibiotic therapy. These studies support the use of combination antimicrobial therapy in the treatment of infants with NEC.

Epidemiologic and bacteriologic evaluation of neonatal necrotizing enterocolitis

The incidence of necrotizing enterocolitis (NEC) in our neonatal unit has varied from 4.7% to zero to 4.4% during three time periods. Simultaneously, significant changes have occurred in the spectrum of bacterial species in the gastrointestinal tract of unaffected infants in the same unit. During the first period of increased attack rate, 82% of gastric and 88% of fecal Enterobacteriaceae were E. coli and K. pneumoniae. When the attack rate decreased the frequencies were 11% (gastric) and 47% (fecal), and P. mirabilis was retrieved with increased frequency. The return of E. coli and K. pneumoniae as the dominant organisms was associated with an increase in NEC. Infants with NEC, compared with controls, had a statistically significant increased frequency of retrieval of E. coli and K. pneumoniae from gastric and fecal samplings. The data suggest an active role for certain enteric bacteria in the pathogenesis of NEC.

Antral diaphragm—a cause of gastric outlet obstruction in infants and children

Gastric outlet obstruction in infants and children may be due to a partial, prepyloric antral diaphragm. Twelve new patients are added to the 32 described previously. Onset of symptoms varied from shortly after birth to five years. Nonbilious vomiting was the most common presenting symptom. Radiographic evaluation requires specific technique for demonstration of the web and to differentiate this from pylorospasm and pyloric stenosis. Gastroscopy was employed in three patients. Repair usually consisted of incision of the web and construction of a patulous gastric outlet. All patients remained asymptomatic after operation. The etiology of the webs remains unknown, but they may result from an excessive local endodermal proliferation early in gastric development.

Management of breast lesions in children and adolescents.

The records of 207 patients evaluated and treated for breast abnormalities during a 10-yr period were reviewed. Patients ranged in age from 1 wk through 16 yr. Seventy-eight per cent were female. Operative procedures were performed in 134 patients (64%). Most common diagnoses were fibroadenoma, premature thelarche, and precocious puberty in the females, and pubertal gynecomastia in the males. Age and sex separate patients into natural subgroups. In females beyond the neonatal period, premature thelarche and precocious puberty are the most likely cause of breast enlargement. Breast biopsy is only rarely indicated for a distinct mass lesion in the prepubertal breast. Mass lesions in the breast of adolescent females require excisional biopsy. In the male, pubertal gynecomastia is the most common form of breast enlargement and only occasionally requires subcutaneous mastectomy for cosmetic and psychologic reasons. Careful evaluation of all children with breast enlargement is indicated to uncover underlying causes and to avoid unnecessary operative procedures.

Prepyloric gastric antral web: a puzzling epidemic.

Antral webs and diaphragms are considered a rare cause of gastric outlet obstruction in infants and children. A radiographic diagnosis of antral web was made in 28 children during a 26-mo period. Nonbilious, often projectile vomiting was the predominant presenting symptom in 24 infants who were less than 6 mo of age. The older children complained of pain, vomiting, fullness after eating, and eructation. The characteristic radiologic finging was a wirelike transverse septum 1--2 cm proximal to the pylorus. Poor antral filling was an important early clue in the radiographic search for the webs. Pyloroplasty was performed in 20 patients, frequently after failure of medical management of symptoms. Coexistent congenital abnormalities were present in 28% of patients. A search for environmental and familial factors has failed to elucidate any teratogenic influences in this population.

Perforated stress ulcers in infants

During a 5-yr period, 10 infants less than 1 yr of age developed gastroduodenal perforation during treatment for severe underlying illness. Brisk gastrointestinal hemorrhage preceded perforation in most patients. In contrast to stress ulceration in adults, infants appear to have a higher frequency of single ulcers, perforation, and duodenal (rather than gastric) location. The mortality of 40% in this group, and in those patients reported in the literature who have been treated since 1960, implies that effective preventive and therapeutic measures are not yet available and also emphasizes the serious nature of the underlying disorder.

Appendectomy in childhood: Analysis of 105 negative explorations

Laparotomy with a preoperative diagnosis of acute appendicitis disclosed a normal appendix in 105 children (22.1 percent). In less than half of these, another condition was found or later identified, which explained the symptoms leading to operation. Ovarian lesions, acute ileocolitis, and serositis were the most frequently identified abnormalities. Twelve patients (11 percent) underwent definitive procedures in addition to appendectomy. Among patients in whom no abnormality was identified at laparotomy, peritoneal cultures yielded a broad range of organisms in 42 percent of those who had cultures. This may represent a mild form of acute primary peritonitis and may explain the symptoms which were confused with acute appendicitis.

Alternate-day single-dose prednisone therapy: A method of reducing steroid toxicity

Abstract Of 20 children who received renal allografts, 14 were treated for prolonged periods with alternate-day single-dose prednisone therapy as part of their immunosuppressive regimen. Long-term graft survival and function are maintained and steroid toxicity is minimized. Growth and sexual maturation are permitted with this form of steroid therapy. Of the other six patients, one required no prednisone, three require low-daily-dose prednisone therapy to prevent rejection, and two patients have expired.

The microbial flora and antimicrobial therapy of neonatal peritonitis

Data from 31 infants with gastrointestinal perforation were analyzed to determine the microorganisms usually present in the peritoneum and blood, and the antibiotic susceptibility of those organisms. Multimicrobial contamination of the peritoneal cavity was present in over one-half of the patients and 23% were found to have mixed aerobic-anaerobic peritoneal flora. Most common organisms were E. coli and Bacteroides species. Blood cultures were positive in 32% of patients, most frequently growing E. coli. Among numerous antibiotics tested, only gentamicin was effective against all Enterobacteriaceae isolated. Clindamycin was 99% effective against Bacteroides species isolated and 90% against other anaerobes. Group D streptococcus was the most frequently isolated gram positive aerobe. Based on these findings, empiric therapy with ampicillin, gentamicin and clindamycin is recommended for neonates with gastrointestinal perforation. Adjustments in therapy for individual patients should be based upon culture and sensitivity data.

Staging laparotomy for Hodgkin's disease in children

Experience with staging laparotomy in twenty-one children has produced minimal immediate postoperative morbidity. Sepsis in two patients after discharge has prompted the long-term use of penicillin. Confirmation or revision of clinical staging by laparotomy has proved to be an accurate means of determining therapy and prognosis in children.