Thomas C. Halpin

Colitis, persistent diarrhea, and soy protein intolerance

Four infants with suspected soy protein intolerance were studied prospectively. All had vomiting, diarrhea, hematochezia, and weight loss of more than 10%. Laboratory abnormalities included anemia (3), acidosis (3), hypoalbuminemia (3), hypernatremia (1), hyponatremia (3), and mild eosinophilia (2). Symptoms developed between three hours and five days after systematic testing with increasing volumes of soy formula. After challenge with soy protein formula, proctosigmoidoscopy and rectal biopsy were performed within 24 hours of developing stools with gross blood. Proctosigmoidoscopy showed both spontaneous and induced friability and loss of vascular pattern in mucosa. Rectal biopsy showed acute colitis with crypt abscesses, depletion of mucus from rectal glands, and polymorphonuclear leukocytes within the lamina propria. Soy protein-induced colitis should be suspected in those infants who present with persistent and bloody diarrhea after being fed soy formula.

Chronic idiopathic intestinal pseudo-obstruction syndrome in children—clinical characteristics and prognosis

Eleven children with the diagnosis of chronic idiopathic intestinal pseudo-obstruction are presented. Four children, all siblings of a symptomatic patient, were asymptomatic and were diagnosed radiographically. The clinical course was characterized by intermittent episodes of abdominal distention, vomiting, abdominal pain, diarrhea, constipation, and malnutrition. Radiographic studies were most helpful in making the diagnosis. Findings on upper gastrointestinal series included abnormal esophageal motility, delayed gastric emptying, dilated loops of small bowel, and disorganized transit of barium. Half of the patients had abnormal evacuation patterns on barium enema. Manometric studies of esophageal motility were abnormal in seven of ten children. In those patients studied, small bowel and rectal biopsies contained ganglion cells. Treatment was directed at relieving symptoms, which in four patients became persistent and required total parenteral nutrition. CIIPS carries a poor long-term prognosis in children.

Lymphonodular hyperplasia of the colon as a pathologic finding in children with lower gastrointestinal bleeding

The serious implication of gastrointestinal blood loss in children is well recognized; however, the significance of lymphonodular hyperplasia of the colon (LNHC) as a pathologic finding in this group of children is unclear. We reviewed the records of 95 children, ages 2-48 months, who were referred to our clinic with a history of hematochezia. Proctosigmoidoscopy was performed on 65 of them. Twenty children (31%) examined proctosigmoidoscopically were found to have LNHC, with no other identified source of bleeding. Clinical histories, endoscopic findings, and colonic biopsy specimens from the LNHC group were examined. Clinical presentation of patients in this group was not distinctive. LNHC was most prominent in the distal colon and rectum and was endoscopically characterized by friability (13/20) and ulceration (3/20). Characteristics of biopsy specimens from children with LNHC were than compared with tissue obtained from an age-matched control population and children with colitis. Biopsy specimens from children with LNHC contained increased numbers of lymphoid follicles and larger follicles than those from the control group. Specimens also contained mucosal inflammation and epithelial thinning and ulceration overlying enlarged follicles. We conclude that LNHC is a frequent proctosigmoidoscopic finding in children evaluated for lower gastrointestinal bleeding. The endoscopic and histologic appearance of these lesions would suggest that LNHC is not a normal finding and represents a potential source of rectal bleeding in children.

Pathologic Childhood Aerophagia: A Recognizable Clinical Entity

Pathologic childhood aerophagia is a rarely recognized, often poorly treated entity that has remained almost undescribed in either the surgical or pediatric literature. In only 1 of 9 children the condition was recognized at presentation. The initial diagnosis of the others was Hirschsprungs disease (2), malabsorption syndrome (3), gastric outlet syndrome (1), constipation (1), and esophagitis (1). Five were hospitalized and two underwent surgical procedures. History disclosed a remarkably constant triad: previous normal stooling pattern, visible and often audible air swallowing and excessive flatus. Physical examination often demonstrated a markedly or intermittently distended and tympanitic abdomen. Abdominal musculature was thinned in children with chronic aerophagia. Roentgenographic evaluation showed massively distended loops of intestine throughout without associated air-fluid levels. There was marked compression of the diaphragm with limited excursion in some. Laboratory and malabsorption testing was normal. Treatment is limited to recognition of the problem, nasogastric decompression in severe cases and psychologic counseling when symptoms persist in the older child. The recognition of this condition may lead to a better understanding of its pathophysiology and will reduce the number of unnecessary admissions or surgical procedures.

Home total parenteral nutrition: An alternative approach to the management of children with severe chronic small bowel disease☆

A home program of total parenteral nutrition (HTPN) has been developed for managing patients with severe chronic small bowel disease who would otherwise be unable to leave the hospital. Six such children were treated by this program using a Broviac catheter to shorten hospitalization, to decrease the cost of care, and to normalize their lives as much as possible. They ranged in age from 2 1/4-17 yr and received HTPN for periods of from 1-11 mo. Criteria for instituting this therapy were the inability to maintain fluid and nutritional balance on therapeutic diet or oral formula, or a need for 30 or more days of conventional TPN. The 6 patients had a total of 1139 days on HTPN with 1 episode of catheter sepsis and 1 localized infection at the catheter site. None of the catheters clotted but 1 was accidentally dislodged. Small bowel adaptation occurred in 4 of the 6 patients. This allowed gradual discontinuous of HTPN and reinstitution of total oral alimentation.

Multifocal osteonecrosis in adolescents with Crohn's disease: a complication of therapy?

Three adolescents with severe Crohns ileocolitis developed osteonecrosis after receiving intravenous corticosteroids and parenteral nutrition, including 10% lipid infusion. Each had achieved clinical remission with therapy. However, several months following completion of therapy, each developed arthralgias and arthritis of weight-bearing and non-weight-bearing joints. Roentgenographic evaluation revealed osteonecrosis involving multiple joints. Osteonecrosis may result from the interference with blood flow to bone and has been produced in animals by infusion of lipid solutions and administration of corticosteroids. We report these cases of osteonecrosis as a probable complication of corticosteroid and lipid infusion in adolescents treated for severe Crohns disease.

Parietal cell function of full-term and premature infants: unstimulated gastric acid and intrinsic factor secretion

A 1-h basal collection of gastric secretions was taken from 14 healthy full-term infants (group I) and 10 premature infants (group II). Simultaneously, acid and intrinsic factor (IF) secretion was measured. In an additional group of 19 full-term infants (group III), 16 had IF detectable in their gastric secretions immediately at birth. Volumes of gastric juice (ml/kg/h) and IF secretion (ng/ kg/h) were similar for group I and group II infants. Acid secretion (mEq/kg/h) was significantly less in group II (p < 0.01). There was a linear correlation between acid secretion (mEq/kg/h) and IF secretion (ng/kg/h) for group I (r = 0.85, p < 0.001). There was no correlation between the values for the premature infants in group II. The study documents that the parietal cell of the premature infant has the same capacity to secrete IF as the cell of the more mature infant. It also demonstrates the presence at birth of IF in gastric secretions, which suggests in utero secretion and independence from enteral feeding for stimulation.

Iron-Deficiency Anemia in Childhood Inflammatory Bowel Disease: Treatment with Intravenous Iron-Dextran

A prospective protocol for iron replacement was used in six children with severe inflammatory bowel disease who had iron-deficiency anemia. All were given a single total-dose infusion of iron-dextran after a taper of the parenteral nutrition solution. Each had hematologic and biochemical correction of their iron-deficiency anemia. As outlined, intravenous iron-dextran appears to be a safe, efficacious, and practical method of iron repletion in children with inflammatory bowel disease who require prolonged parenteral nutrition and bowel rest.

Prophylaxis and Treatment of Childhood Rickets with Parenteral Cholecalciferol

The safety and efficacy of parenteral cholecalciferol was evaluated in the treatment and prevention of childhood rickets. Children with active disease, and those at high risk for developing rickets were treated either with intravenous or intramuscular cholecalciferol in dosages of 1000 to 1500 IU daily, for periods of 28 to 450 days. All children with rickets responded with radiographic evidence of healing. No child in the prophylaxis group developed bone disease. Side effects were minimal. Parenteral cholecalciferol is a safe and effective therapy for the treatment and prevention of childhood rickets.