Value of the 24 hour intraoesophageal pH monitoring in children.

Twenty four hour oesophageal intraluminal pH probe studies were performed in 114 children (range age: one month-12 years) referred for symptoms or signs compatible with gastroesophageal reflux. Forty five patients had reflux disease alone, 69 had evidence of oesophagitis which was assessed endoscopically and histologically. Recordings were also performed in 63 control patients. The occurrence of reflux was analysed for the total study period and particularly while awake, asleep, fasting, and during postcibal periods. Oesophageal acid exposure time and the number of reflux episodes lasting greater than five minutes during the total study period provided the best discrimination between patients and controls; however, 20% and 30% of all reflux patients had both normal (with 2 SD of control) acid exposure time and number of long lasting reflux episodes, respectively. Patients with oesophagitis had significantly more acid reflux than those with simple uncomplicated disease during postcibal, fasting, awake periods, but not during sleep; however, increasing severity of oesophagitis was not associated with increasing acid exposure. The ability of the intraluminal oesophageal pH test to discriminate patients with various degrees of reflux disease decreased if only postprandial pH variables were taken into account. We conclude that: (1) the 24 hour intraoesophageal pH monitoring may present false negative results that limit overall sensitivity of the test; (2) the presence of oesophagitis does not seem to be associated with increased oesophageal acid exposure during sleep; (3) limiting the pH recording to postprandial periods reduces the discriminatory power of the test.

Bowel frequency in healthy children.

Bowel frequency was recorded, on a diary sheet basis, in 662 children from six Italian cities. There is a wide interindividual variability, showing a sharp decrease with age; we report the distribution of the percentiles in the different age groups. Among infants, the breast-fed ones pass significantly more stools than the formula-fed.

Heat stable enterotoxin produced by Escherichia coli in acute diarrhoea.

We screened 569 children with acute onset diarrhoea from five Italian towns for heat stable enterotoxin produced by Escherichia coli. We compared an enzyme linked immunoabsorbent assay (ELISA) with the standard suckling mouse assay for detection of the enterotoxin. A total of 31 (5.4%) children were found who had strains of E coli that produced heat stable enterotoxin: 26 strains were positive in both tests, four only in the suckling mouse assay, and one only in the ELISA. Compared with the suckling mouse assay the sensitivity of the ELISA was 87% and the specificity was 99.8%. The mean age of the children with E coli that produced heat stable enterotoxin was 22 months. Fifteen (48%) of the children had ingested potentially contaminated food and five (17%) had a previous contact with someone with diarrhoea. The clinical picture was milder than that described in developing countries. Faecal osmolality and the osmolal gap were consistent with a secretory diarrhoea in 12 out of 15 (80%) of these children. The mean duration of the diarrhoea was five days. Heat stable enterotoxin produced by E coli is a common cause of mild diarrhoeal illness in Italian children.

Cimetidine treatment of reflux esophagitis in children: an Italian multicentric study.

The effectiveness of cimetidine (30-40 mg/kg/day) was evaluated in 32 children with gastroesophageal reflux disease complicated by esophagitis who entered a random double-blind trial for 12 weeks. Esophagitis was diagnosed in all patients by endoscopy with biopsy. Seventeen patients (age, mean +/- SD: 21.7 +/- 37.65 months) received cimetidine (c-pts), and 15 (age, mean +/- SD: 29.03 +/- 39.73 months) received a placebo (p-pts). All patients received intensive postural therapy. Based on clinical and endoscopic (and histologic) data, 12 c-pts and three p-pts were healed (p less than 0.01), the condition of four c-pts and three p-pts had improved (not statistically significant), and the condition of one c-pt and nine p-pts had worsened (p less than 0.01). Both clinical and esophagitis scores significantly decreased only in the c-pt group, as compared with p-pts. Improvement of esophagitis was seen in all (100%) of c-pts with mild or moderate esophagitis versus 57.14% of p-pts (p less than 0.01) and in 87.5% of c-pts with severe esophagitis as compared with 25% of the p-pt group (p less than 0.01). We conclude that cimetidine is an effective agent for treatment of reflux esophagitis in children. Although gastroesophageal reflux disease in infancy has a naturally self-limited course with conservative care (thickened feedings and posture adjustment), extensive pharmacologic therapy is needed in the presence of esophagitis.

[Jejunal biopsy]. / La biopsia digiunale.

Considering many years' experience in various centres, the authors evidence indications, contraindications, and possible technical inconveniences relative to jejunum biopsy. They analyze various aspects concerning the rightest methods of performance particularly concerning the patient's sedation and immobilization, the local anaesthesia of the back pharynx, techniques facilitating the placement of the capsule the sampling of the mucosa (mucous membrane) and the recovery of the capsule. Then the authors examine the criteria of evaluation of the biopsy sample through both stereomicroscopical and traditional microscopical examinations. They analyze the main parameters in the histological evaluation of biopsy and the basic conditions to observe in order to evaluate histological aspects correctly. Finally they propose a score of histological evaluation, for quick, easy routine use; its results can be reproduced in accordance with traditional histological reading which allows examiners from different centres to confirm their judgements about the atrophy of the mucosa and enables more significant comparisons in case of biopsy repeated on the same subject.

Effects of the composition and caloric value of infant formulas on intake and hormone levels.

Seventy-six normal full-term infants have been observed from birth to the fourth month of life. Thirty-six were breast-fed; the others were fed four different feeds (conventional or adapted formulas) containing different amounts of calories, protein, fat, and carbohydrate. The control mechanism of volume intake appears to be well functioning in infants fed human milk and adapted formulas providing conventional calorie concentrations. The other formulas were associated with either a high BUN or high base insulin concentrations. It is concluded that uncontrolled amounts of milk should be fed only to breast-fed infants and those receiving adapted formulas but not to those fed formulas that provide high calorie or protein concentrations.

[Constant flow enteral feeding with an elemental diet in the treatment of severe protracted diarrhea in early childhood]. / La nutrizione enterale a flusso costante con dieta elementare nel trattamento delle diarree gravi protratte della prima infanzia.

The enteric nutrition with constant flow (ENCF) with elemental and semielemental diets is a very useful therapeutic approach in the management of severe and protracted diarrhoea in young infants. It can be proceeded or not by a period of total parenteral nutrition according to age of the patient, the entity and duration of the diarrhoea and the degree of the malnutrition and the presence or not of an infection. The indication of the enteric alimentation with a constant flow has been done in cases of severe diarrhea prolonged more than 14 days without response to the traditional dietetic treatment and/or a state of malnutrition with weight - 2 SD with respect to the average of the age/height ratio and/or a plasma proteins less than or equal to 4.5 g% and an albuminemia less than 2.8 g%. The casuistry is made up of 19 cases, from the age of 1 month to 20 month. The duration of the treatment was between 13 and 123 days. The enteric alimentation was done with elemental or semielemental diet with an osmolarity of 320 m OSM/C. freshly preparated; each of the ingredients could be modified independently one from the other. The decision to modify qualitatively and quantitatively the diet is always the consequence of a daily evaluation of the nutritional needs of the child and at the same time of the digestive tolerance valued according to precise clinical and biological criteria. The results obtained were: arrest of diarrhoea in 90% of the cases (17/19), continuation of diarrhoea in 10% (2/19) and death in 1 case. The weight increase was obtained in 90% of the cases (M = 13.2 gr./die). The Authors discuss the criteria to decide 1) if a period of TPN had to proceed the ENCF, 2) the more adapt components to utilize for elemental and semielemental diet, 3) the modality of practial realization, 4) the criteria of clinical and biological supervision, 5) the possible mechanical and metabolical complications. The Authors conclude that the ENCF with elemental and semielemental diets is an important progress in the therapeutic approach in serious and protracted diarrhoea in young infants. The knowledge of the problem, a careful clinical and biological supervision are the best methods to obtain the maximum and the minimum risks of mechanical and metabolical complications.

[Exclusive parenteral nutrition via a peripheral vein in the treatment of severe protracted diarrhea in early childhood. Personal experience and clinical contribution]. / La nutrizione parenterale esclusiva per vena periferica nel trattamento della diarrea grave protratta nella prima infanzia. Esperienza personale e cotributo clinico.

Total peripheral parenteral nutrition (T.P.P.N.) in the treatment of prolonged serious diarrhea in infancy is discussed. T.P.P.N. was employed for a period from 7 to 38 days in 18 particular diarrhoic infants with a good result in the 89%. Authors stress out conditions to obtain the best tolerance to glucidic, protidic and lipidic components. Limits of this therapy are related, overall, to the impossibility to deal with it for more than 3 weeks. When hyperbilirubinemie, respiratory failure and sepsis are present T.P.P.N. isn't prudentially to be used.

[Protocol of treatment of acute diarrhea in infancy]. / Protocollo della terapia delle diarree acute nella prima infanzia.

We suggest some guidelines for symptomatic treatment of acute diarrhea in infants under two, as it has been tested both in several hospital departments. Considering some well-known employed clinical and metabolic evaluations, cases (uncommon) needing sudden parenteral treatment are distinguished from those less serious ones (more common) when previous feeding is quickly re-established using oral rehydratation.

Diet and antibody response to vaccinations in healthy infants.

Antibody responses to poliovirus, diphtheria, pertussis, or tetanus vaccine were compared in five groups of infants. The 62 infants had been brought up on breast milk or on one of four types of artificial feed in the first five months of life. The types of artificial feed varied in quality and quantity of protein; they were high or low protein cow's milk, an adapted formula (with a casein/albumin ratio of 40/60), and a formula based on soy flour. After the age of 5 months, all infants were put on the same diet. The general pattern of antibody responses as determined by antibody levels when the infants were 5 and 8 months old was that those fed on breast milk or high-protein cow's milk had adequate and sustained antibody responses; those fed on the adapted formula had a high but temporary response; and those fed on low-protein cow's milk or the soy-based formula had poor responses.

Potential complications in the use of wheat bran for constipation in infancy.

A commercially available wheat bran preparation has been given to six infants between the ages of 6 and 16 months suffering from constipation not due to metabolic or anatomic causes. In all infants, normal bowel movements reappeared after a month of a diet containing bran. After a month on this diet, we observed the following: a decrease in blood levels of calcium, phosphate, and trace elements; an increase in fecal excretion of biliary salts and cholesterol; and an appearance of predominantly proteolytic fecal flora over the saccharolitic flora. These findings, especially the first one, indicate that bran preparations should be used in infancy with extreme caution because of possible side effect on the patient's nutritional status and growth. If bran is used, blood levels of minerals should be repeatedly checked in order to prevent the appearance of vitamin D-dependent rickets and the depletion of trace elements.