William J Cochran

Overweight Children and Adolescents: A Clinical Report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Childhood overweight and obesity are major health problems with immediate and long-term consequences of staggering magnitude. Despite this, there are few preventive and therapeutic strategies of proven effectiveness available to public health and clinical practitioners. Accruing such evidence is currently and appropriately a health policy priority, but there is an urgent need to intervene even before comprehensive solutions are fully established. The aim of this Clinical Report on Overweight Children and Adolescents is to present information on current understanding of pathogenesis and treatment of overweight and obesity. We report on the epidemiology, molecular biology and medical conditions associated with overweight; on dietary, exercise, behavioral, pharmacological and surgical treatments; and on the primary prevention of overweight in children and adolescents.

Knowledge, attitudes and practice styles of north american pediatricians regarding gastroesophageal reflux disease

Background: The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition launched a provider and public education campaign in 2002 to raise awareness of gastroesophageal reflux disease (GERD). To determine the effectiveness of campaign messages, we conducted a knowledge, attitudes, and practice styles (KAPS) survey of pediatric providers. Understanding the spectrum of management styles of GERD in children is critical to achieve better health outcomes and reduce health care costs. Materials and Methods: The KAPS questionnaire was administered to 6000 randomly selected members of the American Academy of Pediatrics. Results: A total of 1245 members responded; 82% worked in a primary care setting and 18% in subspecialty practices. Overall, 66% of the members order diagnostic testing in routine practice, 54% start testing for GERD in neonates, and 38% start testing after 1 month of age. The most common tests ordered were barium esophagram (45%) and esophageal pH monitoring (37%). GERD treatment with acid suppression before ordering diagnostic testing was a choice of 82% of the respondents. However, 19% believed acid suppression was best achieved by H2 blockers. If acid suppression was indicated, then only 36% followed guideline recommendations for therapy duration and 52% followed guideline recommendations for dosing. Antireflux surgery was recommended only as a last resort by 92%. Overall, 69% of providers believed the amount of GERD-related information available was not enough. Respondents who were not aware of available GERD practice guidelines ranged from 74% to 92%. Conclusions: Pediatric providers appear to frequently order diagnostic testing and treatment for GERD, yet knowledge about evidence-based GERD management among this random sample appeared limited. Moreover, a significant number of providers were not aware of different guideline publications.

Total Body Electrical Conductivity Used to Determine Body Composition in Infants

ABSTRACT. Total body electrical conductivity (TOBEC) has been introduced as a rapid, safe, and noninvasive method suitable for the estimation of fat-free mass. The instrument (EMME or TOBEC) operates on the principle that organisms placed in an electromagnetic field perturb the field to a degree that depends on the amount and volume of distribution of electrolytes present. A study was designed to measure body composition in infants by the TOBEC method and to compare the results with those obtained using the isotope dilution technique. Sixteen infants (age range, 2 days to 9.7 months; weight range, 2 to 8.7 kg) were enrolled. Total body water (TBW) was determined by the isotope dilution technique using H218O. There was a good correlation between the natural logarithm of the TOBEC number and TBW, with a linear correlation coefficient of 0.949. The fat-free body mass of the infants was calculated by TBW (fat-free body mass=/0.082) and by the TOBEC method using the standard previously derived from mature rabbits. TBW measurements by H218O dilution appeared to overestimate fat-free mass which was greater than TBW in five of the 16 infants. Measured by the TOBEC method, fat-free mass ranged from 51 to 91% of total body weight. The TOBEC method is highly suitable for use with human infants and appears to determine body composition as accurately as other available methods.

Fat-Free Mass and Total Body Water of Infants Estimated from Total Body Electrical Conductivity Measurements

ABSTRACT. Total body electrical conductivity measurements can be used in conjunction with suitable calibration curves to quantitate fat-free mass and total body water. A study was designed to evaluate whether calibration curves, derived from miniature piglets, can be used to translate total body electrical conductivity measurements of human infants into estimates of total body water and fat-free mass. Thirty-four, healthy 2-, 4-, 8-, and 12-wk-old infants were studied. A comparison of the physical dimensions of infants and piglets indicated no large discrepancies in their body geometries that would invalidate the calibration from this standpoint. Estimates of fat-free mass, fat, and total body water were evaluated by comparison with the body composition of reference infants of comparable description. There was excellent agreement between the total body electrical conductivity-derived estimates and reference body composition values, suggesting that the calibration procedure is adequate. Thus, the total body electrical conductivity technique can be used to estimate the body composition of normal young infants without subjecting them to risk or discomfort.

The uncut Collis-Nissen fundoplication: Results for 79 consecutively treated high-risk children

PURPOSE The Nissen fundoplication fails to control gastroesophageal reflux (GER) in up to 25% of children with neurological impairment or chronic lung disease. The uncut Collis modification lengthens the intraabdominal esophagus, improving the antireflux function without opening the stomach. This study reviews the results of the uncut Collis-Nissen fundoplication in a pediatric series. METHODS Seventy-nine children had an uncut Collis-Nissen fundoplication performed over a 5-year period. The median age was 1.4 years. Associated problems included neurological impairment (77%), chronic lung disease (38%), and esophageal atresia (3%). Surgery was undertaken only in children with objective documentation of pathological GER, who had GER complications unresponsive to medical treatment. The usual complications that led to surgery were pulmonary (73%), esophagitis (67%), or failure to thrive (35%). Liquid gastric emptying was assessed routinely preoperatively, and was delayed in 42% patients who then had concomitant pyloroplasty. RESULTS GER was controlled in 97% of patients after a median follow-up of 1.8 years. All children with recurrent symptoms were restudied, and only two children had documented recurrent GER. One of these required a repeat fundoplication. Thirty-three percent were on promotility medication for feeding difficulties, gagging, or retching. There were postoperative complications in 26% (minor 23%, major 3%) and one postoperative mortality. Eleven late deaths were unrelated to surgery or GER. CONCLUSION The uncut Collis-Nissen fundoplication provides excellent control of GER in children and is associated with acceptable morbidity and low mortality. It should be particularly considered in children with neurological impairment or chronic lung disease.

Intestinal strictures presenting with gastrointestinal blood loss

The typical manifestations of intestinal strictures include abdominal distention, bilious vomiting, hematochezia, diarrhea, disaccharide intolerance, and occasional growth failure. However, chronic gastrointestinal (GI) blood loss from ulcers at the site of the stricture has not been noted as a major feature. We report three patients in whom an intestinal stricture presented with minimal evidence of obstruction, but with GI bleeding and anemia. Our experience indicates that intestinal strictures with ulcers must be considered in the differential diagnosis of blood loss, and that surgical intervention may be required if GI blood loss is chronic and laboratory results are negative.

Graft-versus-host disease: gastrointestinal involvement with a rectovaginal fistula.

Bone marrow transplantation is an accepted form of treatment for aplastic anemia and end-stage hematological malignancies. Despite a satisfactory outcome in selected patients, more than one-half develop acute graft-versus-host disease (GVHD), characterized typically by involvement of the skin, liver, and gastrointestinal tract. We describe an unusual case in which a 10-year-old girl developed gastrointestinal symptoms as the only manifestation of GVHD. The patient presented with a rectovaginal fistula and had clinical, radiological, and histological features of gastrointestinal GVHD without evidence of liver or skin involvement.

631 THE USE OF TOTAL BODY IMPEDANCE TO DETERMINE BODY COMPOSITION IN INFANTS

Total body impedance (EMME or TOBEC instrument) has been introduced as a rapid, noninvasive device for the determination of fat-free mass (FFM) (J. Pediatr. Gastroenterol. Nutr. 3:199, 1984). The instrument operates on the principle that organisms placed in an electromagnetic field perturb it to a degree that depends upon the amount and volume of distribution of electrolytes. The body composition of infants was studied by this method. Compositional changes occur during growth; therefore an infant animal standard using this method was required. (The infant miniature pig was selected, because its size and composition approximate those of the human infant.) Fifteen infants (age, 2 d to 13 mo; wt, 2 to 9 kg) were analyzed by the impedance method. Total body water (TBW) was determined by the isotope dilution technique using deuterated water. There was a good linear correlation between TBW and the ln of the impedance signal (r = .954). FFM of the infants was calculated by TBW (FFM = TBW/.82) and by the impedance method using a standard previously derived from mature rabbits. TBW appeared to overestimate FFM which was greater than total body wt in 4 of 15 infants. FFM by the impedance method ranged from 54 to 91% of total body wt. Five pigs (wt, 2.3 to 4.7 kg) have been studied by impedance and chemical analysis. There was good linear correlation between the ln of the impedance signal and TBW by desiccation (r = .995).Conclusions: 1) an infant miniature pig growth standard is expected to improve the predictive accuracy of the impedance method, and 2) the impedance method is highly suitable for use with human infants and determines body composition more accurately than other available methods.

PROXIMAL MUSCLE WEAKNESS RESPONDING TO SELENIUM THERAPY: A CASE REPORT

Van Rij reported proximal muscle weakness in a case of selenium (Se) deficiency in New Zealand in 1979. Since then cardiomyopathy, but not proximal muscle weakness, has been reported in the USA. A 33 y.o. white female was on home parenteral nutrition for 4½ years due to a duodenocecostomy secondary to a traumatic jejunoilectomy. During the first year she noted proximal muscle weakness which did not improve over the next 3½ years. She noted weakness with arm lifting and inability to rise from a squatting position. During a study of Se function, glutathione peroxidase levels were found to be profoundly low in plasma and blood cells.Plasma Se level initially was 32.5 ng.ml (nl=60-120). After 3-4 weeks of treatment with Se (400 μg/d IV) as selenous acid, the patients muscle strength testing markedly improved as the GSHPx activities in plasma, platelets, granulocytes, & mononuclear cells became normal. Red cell GSHPx activity approached normal levels much more slowly, and may not be a sensitive reflection of whole body selenium status.

USE OF 13C-GLUCOSE BREATH TESTS IN THE CHARACTERIZATION OF ABSORPTION OF CARBOHYDRATE IN FORMULA BY INFANTS WITH DIARRHEA

The appearance time (AT) of the first detectable levels of 13CO2 (> .01% dose/min) in breath following the oral administration of UL-13C-glucose (13C-G, 5 mg/kg) provides an estimate of the time required for orally administered 13C-G to reach the primary site of absorption and utilization. The AT for 13C-G will increase as the absorption of glucose occurs at more distal sites, until a maximum is reached when the glucose enters the colon where it is rapidly oxidized to CO2. The AT of 13C-G administered alone and with formula (60-240 ml) has been used to characterize glucose absorption and utilization in 6 infants (16-93 d) with diarrhea and malnutrition (arm/FOC < 0.28). A maximum value of 27 min for the AT of 13C-G from formula was determined in an infant with congenital glucose-galactose malabsorption, in whom colonic utilization of CHO was demonstrated by breath H2 production and partial recovery of 13C in stool. AT for 13C-G in formula, obtained for the 6 infants measured, were 5,7,15,20,30,30 min, respectively, providing indirect evidence for the colonic utilization of dietary glucose in at least 2 of the infants. In the absence of formula, AT for 13C-G decreased to 10,15,10,10,2,10 min, respectively. This suggests that the CHO load in the formula may have contributed to the small bowel malabsorption of glucose in those infants with near maximal formula AT values.