Sumatriptan in the treatment of cyclic vomiting.

OBJECTIVE: To describe a patient with cyclic vomiting who was treated successfully with sumatriptan, a serotonin, agonist. CASE SUMMARY: A patient with a 4-year history of cyclic vomiting was treated for an episode of nausea, vomiting, and abdominal pain. This patient had been hospitalized numerous times for cyclic vomiting over the previous 4 years, each hospitalization lasting from 3 to 11 days. Following a single subcutaneous injection of sumatriptan 6 mg, the patient ceased vomiting and was discharged 40 hours from the time of admission. DISCUSSION: The efficacy of sumatriptan in migraine headache appears to be mediated through its agonist activity at the serotonin1D receptor, resulting in constriction of dural blood vessels. According to published reports, therapeutic attempts at controlling cyclic vomiting often have included antimigraine therapies. Consistent with these reports, sumatriptan also appears effective in the treatment of cyclic vomiting. CONCLUSION: The pathogenesis of cyclic vomiting appears to share similarities with classic migraine, both of which may respond to sumatriptan therapy according to this report and previous work. Further study of the use of sumatriptan in the treatment of cyclic vomiting appears warranted.

Effects of soy formulas on mineral metabolism in term infants.

We studied 40 healthy term infants who received a soy-based formula containing either a single carbohydrate (glucose polymers) or dual carbohydrates (glucose polymers and sucrose). Ten exclusively breast-fed infants served as controls for the first four months of the study. All infants were studied at 2 weeks, 2 months, and 4 months of age for anthropometric development, biochemical values, and bone mineral content. There were no differences among the three groups in weight, length, or head circumference gains. Serum levels of calcium, phosphorus, magnesium, copper, 25-hydroxycholecalciferol, and alkaline phosphatase were also similar. However, at 4 months of age, the breast-fed group had a higher plasma zinc level than both formula-fed groups, and at 2 and 4 months of age, it had higher bone mineral content and bone density.

Comparison of macronutrient concentration of preterm human milk between two milk expression techniques and two techniques for quantitation of energy.

Generally, when newborns in intensive care units receive human milk, we do not know the quantity of nutrients in that milk because such analysis is time-consuming and expensive. In our study, however, we sought to compare fat, protein, lactose, and energy concentration of a three-times-a-day sampling with a 24-h expression and to measure the difference between the calculated energy yield from protein, fat, and carbohydrate measurements and bomb calorimetry. At 14-18 days postpartum, 20 mothers of premature infants (30-34 weeks' gestation) expressed milk three times a day: 8 a.m., 12 p.m., and 8 p.m. At these three times, each mother expressed 3-5 ml of fore-milk and 3-5 ml of hind-milk for the sampling; the result was pooled for a 24-h expression. Only fat concentration differed significantly between fore- and hind-milk samples. Protein, fat, lactose, and energy concentration did not differ significantly between the two collection methods, 24-h expression and sampling. Moreover, we found no significant difference between the calculated number for energy content and the bomb calorimetry method of energy determination. The average fore- and hind-milk samples at 12 p.m. matched the 24-h milk expression. For clinical use, a milk sample obtained around 12 p.m. can predict macronutrient concentration, therefore allowing us to calculate an infant's approximate nutrient consumption.

Vomiting and diarrhea.

Vomiting and diarrhea are frequently encountered in pediatric patients. Dehydration, a serious consequence of both vomiting and diarrhea, results in the deaths of more than 700 children annually in the United States. With appropriate parent education, both morbidity and mortality can be reduced, and much of the anxiety about these problems can be alleviated. Parents must be educated to recognize the associated signs and symptoms that indicate serious disease and warrant notifying the physician. Fluid therapy should be individualized, and parents should be informed of the appropriate steps to take. Parents must make quantitative observations and keep records not only to enable the physician to assess adequate fluid balance but also to be able to demonstrate to themselves the effectiveness of the treatment. It is just as important for the physician to reassure parents, who will have concerns about long-term nutritional or growth consequences.

Bone mineral status in childhood accidental fractures.

We studied the bone mineral and calcium (Ca) status of 17 children who suffered an accidental fracture in 1980. These children were matched by age and sex to a nonfractured control group. Blood was drawn for serum Ca, phosphorus, magnesium, 25-hydroxycholecalciferol ( calcidiol ), alkaline phosphatase, and albumin. Bone mineral content (BMC) was evaluated by photon absorptiometry. There were no differences in serum values between the two groups. Twelve (71%) of the 17 children in the fracture group had a lower BMC than their matched controls. The BMC of the fracture group was lower than their controls, 0.423 +/- 0.042 v 0.461 +/- 0.037 g/cm. Four of the 15 in the fracture group ingested less than 60% of the recommended dietary allowance (RDA) for Ca and P (800 mg/day), while all the controls were ingesting at least 60% of the RDA. Four children of the fracture group who were ingesting less Ca and P than those of the control group also had low BMC.

Lack of relationship of Clostridium difficile to antibiotic-associated diarrhea in children.

We studied prospectively the conversion rate to Clostridium difficile-positive stool cultures in 31 children receiving oral antibiotics for common infections and looked for a possible association of C. difficile colonization with diarrhea. The incidence of pretreatment positive stool cultures was 35% with the majority of positive findings in infants less than 1 year of age. After treatment with oral antibiotics C. difficile was cultured from the stool of 42% of the children. Eleven children developed diarrhea during antibiotic therapy. Seven of these children had at least one stool culture positive for C. difficile and four had persistently negative cultures. Oral antibiotic treatment of common infections in otherwise healthy children does not appear to predispose to stool colonization with C. difficile, nor is the presence of C. difficile in stools in these children significantly associated with the onset of antibiotic-associated diarrhea.

Growth and plasma amino acid concentrations in term infants fed either whey-predominant formula or human milk.

We found no significant differences in mean growth measurements or mean plasma amino acid concentrations in 14 healthy full-term infants fed a whey-predominant cow milk formula and 15 healthy full-term infants who were breast-fed. Plasma taurine concentrations did not differ despite a tenfold higher level of taurine in human milk versus that in the formula. Plasma amino acid concentrations were measured one hour after feeding when the infants were 3 days and 2, 8, and 16 weeks of age. Weight, length, head circumference, crown-rump length, and skinfold thickness were measured at 3 days, 2 weeks, and 1, 2, 4, and 6 months of age. This study indicates that a whey-predominant cow milk formula compares favorably with human milk as a primary feeding for full-term infants.

Postcibal gastroesophageal reflux in children.

The effect of eating on childhood gastroesophageal reflux (GER) is unclear. Twenty-eight asymptomatic children and 28 children with symptoms of GER were fed apple juice or milk-formula and observed for 3 hr postcibal. Distal esophageal pH was monitored continuously during this interval and used to quantitate the frequency and duration of GER. A period of frequent GER occurred for up to 2 hr after apple juice feedings in asymptomatic children, whereas symptomatic patients had frequent GER for longer periods. Compared to apple juice feedings, milk-formula feedings resulted in a decreased esophageal acidity for the first 2 hr. However, the type of feeding did not affect GER seen in asymptomatic children more than 2 hr postcibal. The frequency and duration of postcibal GER were not reduced by the upright position in either group. Effective medical treatment of symptomatic children did not eliminate the frequent GER within 2 hr of apple juice feedings, whereas the Nissen fundoplication usually eliminated all GER. The absence of GER episodes following apple juice correlated with the inability of most children to burp or vomit following antireflux surgery. Therefore, frequent GER for up to 2 hr after clear liquid meals is probably physiologic in children. The effective control of vomiting by medical or surgical therapy correlated best with a decrease in GER more than 2 hr postcibal.

Intra-arterial infusions and intestinal necrosis in the rabbit: potential hazards of umbilical artery injections of ampicillin, glucose, and sodium bicarbonate.

Umbilical artery catheters are frequently employed for administration of medications. When the catheter tip is positioned adjacent to major aortic tributaries or inadvertently in the mesenteric arteries, high concentrations of infused substances may perfuse the intestine. Injections of saline, 50% dextrose, 10% dextrose, 8.4% sodium bicarbonate, and 100 mg/ml ampicillin were made into a branch of the mesenteric artery supplying 10 to 15 cm of rabbit ileum. The intestine was then examined two to five days later. All segments of intestine perfused with saline and 10% dextrose were grossly and microscopically normal. In each of the eight sites perfused with 50% dextrose, intestinal necrosis was noted (P less than .001). Four of eight sites perfused with ampicillin had hemorrhage and villus atrophy (p less than .001). Of the eight sites perfused with sodium bicarbonate, three had necrosis with hemorrhage and five had villus edema. The data indicate that intraarterial infusions of high concentrations of sodium bicarbonate, glucose, and ampicillin produce serious lesions in an animal model. This suggests that appropriate precautions should be exercised when administering medications through the umbilical artery catheter.

Surgery in children with gastroesophageal reflux and respiratory symptoms.

We reviewed our seven-year experience in 63 children with an operation to control gastroesophageal reflux and respiratory symptoms. The age at operation, sex, major associated disorders, and control of vomiting in this group of children were compared with another group of 72 children without respiratory symptoms who also had an antireflux operation during the same period. Associated central nervous system, pharyngeal, or esophageal disorders were common in both groups. Vomiting was controlled in 96% of patients. Fifty-six of 61 (92%) children had at least partial relief of respiratory symptoms postoperatively. The complete relief of these symptoms was more likely in patients without major associated disorders (97% vs 59% P = 0.0009). Central nervous system disorders were present in most children with incomplete resolution of respiratory symptoms. It appears that a significant number of affected infants and children may have respiratory difficulties unrelated to the presence of GER.

Patterns of postcibal gastroesophageal reflux in symptomatic infants.

Symptomatic infants displayed three patterns of gastroesophageal reflux after drinking apple juice (20 ml/kg or 300 ml/m2 of body surface area). The type I pattern occurred in patients who had continuous postcibal gastroesophageal reflux, large hiatal hernias and frequently required an antireflux operation. A functional motility disorder suggesting delayed gastric emptying appeared to be important in infants with discontinuous reflux (type II pattern). These infants had frequent gastroesophageal reflux for only 2 3/4 hours postcibally, antral-pylorospasm, increased low esophageal sphincter pressures, and a high incidence of pulmonary symptoms and non-specific watery diarrhea. The mixed (type III) pattern of gastroesophageal reflux occurred in a small number of infants and exhibited features of both type I and II patterns.

Gastroesophageal reflux causing respiratory distress and apnea in newborn infants.

Respiratory distress, apnea, and chronic pulmonary disease since birth were identified in 14 infants who also had symptomatic gastroesophageal reflux. Birth weights varied from 760 to 4,540 gm. All infants had radiographic changes similar to those in bronchopulmonary dysplasia. Cessation of apnea and improvement of pulmonary disease occurred only after medical (8) or surgical (6) control of gastroesophageal reflux. Simultaneous tracings of esophageal pH, heart rate, impedance pneumography, and nasal air flow in five infants demonstrated that reflux preceded apnea. Apnea could be induced by instillation of dilute acid, but not water or formula, into the esophagus. Prolonged monitoring of esophageal pH more than two hours after feeding in 14 other infants less than 6 weeks of age (birth weight 780 to 3,350 gm) without a history of recent vomiting indicated that reflux was not greater than in normal older children.

The lower esophageal sphincter in gastroesophageal reflux in children.

Esophageal function was evaluated in 51 children less than 2 years of age with radiologic evidence of gastroesophageal reflux. Detection of an acid esophageal pH was a sensitive measure of gastroesophageal reflux. Lower esophageal sphincter pressures were greater in reflux patients with respiratory symptoms (18.0 +/- 1.4 mm Hg) than in reflux patients without respiratory symptoms (9.5 +/- 1.0 mm Hg). The intra-abdominal segment of the lower esophageal sphincter was shorter in patients with reflux than in controls (0.51 +/- 0.05 cm vs. 0.75 +/- 0.08 cm). It was also shorter in patients requiring surgical therapy (0.34 +/- 0.05 cm) than in those responding to medical therapy (0.63 +/- 0.07 cm).

Hazards of calcium gluconate therapy in the newborn infant: intra-arterial injection producing intestinal necrosis in rabbit ileum.

Five infants received 10% calcium gluconate via umbilical artery catheters, which resulted in intestinal bleeding and lesions of the buttock, anus, groin, and thigh. The effects of intra-arterial calcium gluconate in two animal models were investigated. Injection of calcium into the aorta in the region of the posterior mesenteric artery resulted in immediate hyperperfusion of the descending colon; this may be an early hemodynamic response to injury in the area of colon supplied by this vessel. Injections into the arterial arcade of the rabbit ileum resulted in intestinal necrosis and villous atrophy. The use of umbilical artery catheters for administration of calcium gluconate is potentially hazardous.

Defective neutrophil chemotactic responses in patients with recurrent episodes of otitis media and chronic diarrhea.

Fourteen patients who had repeated episodes of otitis media and diarrhea were evaluated to determine if a defect in the host defense mechanism could account for the unusual incidence of infection. Each of the patients with recurrent otitis media and diarrhea had a profound defect in neutrophil chemotactic responsiveness. The mean chemotactic index of the patients was 21 +/- 6, while that of 25 controls was 62 + 10. Other neutrophil functions, lymphocyte T-cell populations, immunoglobulins, and complement components were normal in the patients. Serum IgE levels were also normal. The presence of a defect in neutrophil chemotaxis in these patients with recurrent otitis media and chronic diarrhea suggests that the phagocyte may play an important role in protection of the mucosal surfaces of the respiratory and gastrointestinal tracts.