William J. Byrne

Correlation of esophageal lengths in children with height: Application to the Tuttle test without prior esophageal manometry

The complications that occurred during acid reflux testing were minimal. However, the potential for aspiration of instilled acid exists and HC1 should be removed from those infants found to have gross GER or from those whose symptoms have been apnea or recurrent pneumonia. In spite of the potential difficulties in the acid reflux test, it still is the most sensitive indicator for GER. Until other methods are devised, this test should be considered in any patient thought to have significant GER.

Effect of Individual L-Amino Acids on Gastric Acid Secretion and Serum Gastrin and Pancreatic Polypeptide Release in Humans

Individual l-amino acids were instilled intragastrically to determine possible differences in stimulation of gastric acid secretion and gastrin and pancreatic polypeptide release. Phenylalanine and tryptophan were significantly more potent stimulants of gastric acid secretion and of pancreatic polypeptide and gastrin release than any of the other amino acids tested. Smaller, but significant, responses were obtained with threonine for pancreatic polypeptide and with serine for acid secretion. We conclude that a major part of the acid-stimulating action of mixed amino acid solution can be explained by the aromatic amino acids, phenylalanine and tryptophan, which are also the most potent stimulants of gastrin and pancreatic polypeptide release. These studies suggest that the specific composition of amino acid mixtures determines the net effects of such mixtures on gastric secretion, and on release of both the antral hormone gastrin and the pancreatic hormone, pancreatic polypeptide.

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.

Increased Serum Gastrin Concentrations and Gastric Acid Hyposecretion in the Immediate Newborn Period

Thirty-two infants and their mothers were studied to determine the source of elevated serum gastrin concentrations in umbilical blood and to learn whether neonates hypersecreted acid in response to hypergastrinemia. Gastrin concentrations in the umbilical artery and vein were similar. Both were significantly higher than maternal gastrin concentrations. No significant amount of gastrin could be measured in placental extracts. These results suggest that the increased neonatal gastrin concentrations were fetal in origin. Continuous basal acid secretory studies done for 4 hr in 32 infants and for 8 hr in 9 infants demonstrated hyposecretion of gastric acid for the first 5 hr of life. Acid secretion from hour 6 to 8 was similar to that in older children. Increased gastrin levels were still present at hour 8 and were associated with normal gastric acid secretion.

Gastroesophageal fundoplication for the management of chronic pulmonary disease in children

Gastroesophageal reflux is a common cause of chronic pulmonary disease in children. Forty-two children with recurrent pneumonia or severe asthma were evaluated and shown to have signicant reflux. Esophagography and esophageal pH testing proved the best diagnostic tests for determining reflux. Although the pulmonary symptoms were often due to repeated aspiration, they appeared in several cases to be related to bronchospasm caused by acid in the upper esophagus. All of the children underwent Nissen fundoplication and gastrostomy an average of 30 months after the onset of pulmonary symptoms. Of the children who had preoperative pneumonia, 87 percent had no recurrence after operation. In 13 of the 14 asthmatic children who underwent operation, symptoms improved and less bronchodilator medication was required. Morbidity and mortality were closely related to the duration and severity of pulmonary disease.

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.

Home parenteral nutrition: results in 34 pediatric patients.

Although home parenteral nutrition (HPN) has been used successfully for adult patients, no extensive experience with children has been reported. During the past three years, we have managed 34 patients, ages 11/2 months to 201/2 years, on a HPN program for periods ranging from 23 to 786 days. Silastic Broviac catheters were inserted into the superior vena cava through the jugular or cephalic veins or into the inferior vena cava through the saphenous vein. The catheters were brought out onto the chest or lower abdominal wall through a subcutaneous tunnel. Solutions were infused over a 10–14-hour period each day, using a volumetric pump system. All patients improved their nutritional status. Twenty-three of 29 on the program for more than two months showed an increase in height. All patients evidenced a significant decrease in symptomatology. All resumed peer group activities while on HPN and were able to continue their education or work. At present 24 patients including 15 with Crohns disease no longer receive HPN. Administration of HPN through a Broviac catheter is a safe, successful technique for maintaining an optimal nutritional status in children with severe digestive disorders, and permits resumption of a more normal daily lifestyle. Following HPN, bowel adaptation and initiation of full oral alimentation become possible in many patients.

Home parenteral nutrition in infants.

The effects of prolonged home total parenteral nutrition on growth and psychomotor development were studied in eight infants during a two-year period. Each patient was begun on HTPN in the first 60 days of life, using a Broviac silastic catheter for venous access. Normalization of somatic growth has been observed in all patients during the study period. Six of eight patients have normal psychomotor development following discharge from the hospital into the home environment. Catheter-related complications in this group have been infrequent; one episode of sepsis was documented during 121 patient-months. The major metabolic complication observed was the development of rickets despite provision of recommended doses of vitamin D. HTPN appears to be useful in providing nutritional support for selected infants during the first two years of life.

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.

Effect of Enteral Feeding on the Maintenance of Gastric Acid Secretory Function

The effects of enteral feeding on the maintenance of gastrointestinal function in human infants are unknown. The effects of enteral feeding on gastric acid secretory function were studied by investigating three groups of infants: infants fed normally, infants with gastrointestinal disease fed by a combination of enteral and parenteral means, and infants fed by total parenteral nutrition. In 14 infants with gastrointestinal disease fed with total parenteral nutrition for a mean of 7 mo (range 1.5-24 mo), basal gastric acid secretion and pentagastrin-stimulated maximal gastric acid secretion were significantly less than in 26 normal infants (p less than 0.01) and in 11 infants with gastrointestinal disease nourished with a combination of enteral and parenteral feeding (p less than 0.01). In each of seven infants fed with total parenteral nutrition for a mean of 5 mo (range 1.5-10 mo), basal and maximal gastric acid secretion increased after a 6-8-wk trial of enteral feeding, a highly significant difference. In one infant, the ability to secrete normal amounts of acid in response to pentagastrin (achieved after an initial trial of enteral feeding) was lost after a 4-mo enteral fast, but returned after a second trial of enteral feeding. These results demonstrate that, in human infants, enteral feedings are necessary for normal oxyntic mucosal secretory function.