Feasibility of enhancing well-child visits with family nutrition and physical activity risk assessment on body mass index.

OBJECTIVE: Integration of behavioural risk assessment into well-child visits is recommended by clinical guidelines, but its feasibility and impact is unknown. METHODS: A quasi-experimental study evaluated the feasibility and effectiveness of risk assessment on body mass index (BMI) at 1-year follow-up. Children with assessments (intervention) were compared with those who did not complete assessments (non-respondent) and those who received standard care (non-exposed). RESULTS: Analyses included 10,647 children aged 2-9 years (2,724 intervention, 3,324 non-respondent and 4,599 non-exposed). Forty-five per cent of parents completed the assessments. Intervention and non-respondent groups differed in change in BMI z-score at 1 year by -0.05 (confidence interval [CI]: -0.08, -0.02; P = 0.0013); no difference was observed with non-exposed children. The intervention group had a smaller increase in BMI z-score (0.07 ± 0.63) than non-respondent group (0.13 ± 0.63). For children with normal weight at baseline, intervention versus non-respondent groups differed in BMI z-score change by -0.06 (CI: -0.10, -0.02; P = 0.0025). However, children with overweight at baseline in the intervention versus the non-exposed group differed in BMI z-score change (0.07 [CI: 0.02, 0.14]; P = 0.016). When analysed by age, results were similar for 2- to 5-year-olds, but no differences were found for 6- to 9-year-olds. CONCLUSION: Automating risk assessment in paediatric care is feasible and effective in promoting healthy weight among preschool but not older children.

Gastroesophageal reflux contributing to chronic sinus disease in children: a prospective analysis.

OBJECTIVE: To explore the possible role of gastroesophageal reflux (GER) in children with chronic sinus disease (CSD). DESIGN: A descriptive prevalence study of the frequency of GER and nasopharyngeal reflux in children with CSD. SETTING: Pediatric otolaryngology and gastroenterology outpatient clinics of a regional medical center. PATIENTS AND OTHER PARTICIPANTS: Consecutive children aged 2 to 18 years referred for evaluation of CSD from December 1, 1996, through April 30, 1998. INTERVENTIONS: Participants underwent 24-hour monitoring with dual pH probes, and participants (or their parents) completed questionnaires before treatment and at specific intervals after treatment. MAIN OUTCOME MEASURES: Prevalence of GER and nasopharyngeal reflux in children with CSD, and the response of sinusitis to treatment in those diagnosed with GER. RESULTS: Nineteen (63%) of 30 patients demonstrated esophageal reflux, which is well above the expected prevalence of GER in the healthy general population. Six (32%) of these 19 patients demonstrated nasopharyngeal reflux. Fifteen (79%) of 19 patients improved after treatment for GER. CONCLUSIONS: The children in this population had a prevalence of GER that was significantly higher than expected. Furthermore, most children with GER demonstrated improvement of sinus disease after treatment of GER. We recommend that children with CSD refractory to aggressive medical management be evaluated for GER and, if GER is present, be treated accordingly, before sinus surgery is considered.

American Academy of Pediatrics. Committee on Nutrition. Calcium requirements of infants, children, and adolescents.

This statement is intended to provide pediatric caregivers with advice about the nutritional needs of calcium of infants, children, and adolescents. It will review the physiology of calcium metabolism and provide a review of the data about the relationship between calcium intake and bone growth and metabolism. In particular, it will focus on the large number of recent studies that have identified a relationship between childhood calcium intake and bone mineralization and the potential relationship of these data to fractures in adolescents and the development of osteoporosis in adulthood. The specific needs of children and adolescents with eating disorders are not considered.

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.

Reliability of fat-free mass estimates derived from total-body electrical conductivity measurements as influenced by changes in extracellular fluid volume.

Our study addresses the concern that the relationship between total-body electrical conductivity (TOBEC) measurements and the fat-free mass (FFM) or total-body water (TBW) of an individual is altered if significant fluid and electrolyte changes occur. Body composition and TOBEC measurements were obtained from 11 healthy miniature piglets before and after an intraperitoneal injection of physiological saline. The procedure expanded the extracellular fluid (ECF) volume by 11.8-34.1%, which represented an average increase in TBW of 7.9%. The linear regressions that related the preinjection and postinjection estimates of TBW or FFM to the corresponding transformed TOBEC signals were the same. Thus, the prediction equations derived for the untreated piglets accurately predicted both TBW and FFM in the piglets whose volume was expanded. These data suggest that prediction equations derived from healthy subjects should be equally valid for subjects with altered fluid status.

Total body water estimated by measuring total-body electrical conductivity.

A second-generation total-body electrical conductivity (TOBEC) instrument for adults (HA-2) was evaluated against isotope dilution of 2H and 18O for its ability to estimate total body water (TBW) in 20 healthy adults. The highest correlation coefficient (0.997) and the lowest standard error of the estimate (0.68 kg) were obtained using the first (FC0) and third (FC2) Fourier coefficients of the transformed TOBEC signals and the variables height (m) times average lean circumference (m) and age (y) in the prediction equation of TBW as follows: TBW (H218O) in kg = 10.8 + (0.0724.FC0) - (0.221.FC2) + (0.0398.age) + (9.2.height.average lean circumference) where average lean circumference is the average of the lean chest, abdomen, and thigh circumferences. The TOBEC instrument for adults provides a suitable alternative for the estimation of TBW.

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.

Body fat in normal adults estimated by oxygen-18- and deuterium-dilution and by anthropometry: a comparison.

We estimated body fat in 20 normal adults (10 males and 10 females) from 18O- and 2H-dilution spaces and from the equations of Durnin & Womersley and Pollock, Schmidt & Jackson based on skinfold thickness measurements. Differences between methods for body fat estimation were found to be sex-dependent: subsequent analyses indicated significant differences between methods within each sex. Regardless of sex, the highest fat estimates were obtained with the 18O-dilution method, followed by those obtained with the 2H-dilution method or the Durnin & Womersley equation. The lowest fat estimates were obtained using the Pollock, Schmidt & Jackson equation. The 18O-dilution method and the Durnin & Wormersley anthropometric method are both suitable and appropriate for body fat estimation in adults studied under field conditions.

In vivo isotope-fractionation factors and the measurement of deuterium- and oxygen-18-dilution spaces from plasma, urine, saliva, respiratory water vapor, and carbon dioxide.

In vivo isotope-fractionation factors were determined for hydrogen and oxygen between plasma water samples and samples of urine, saliva, respiratory water vapor, and carbon dioxide in 20 normal adults. The isotope-fractionation factors ranged from 0.944 to 1.039 for 2H in breath water vapor and for 18O in breath CO2, respectively. When corrected for isotope fractionation, the 2H- and 18O-dilution spaces determined from urine, saliva, respiratory water, and CO2 were within -0.10 +/- 1.09 kg (mean +/- SD, n = 60) and 0.04 +/- 0.68 kg (n = 80), respectively, of the values determined from plasma. In the absence of these corrections, we observed a 6% overestimation of 2H-dilution space and a 1% overestimation of 18O-dilution space from the use of respiratory water values. A 4% underestimation of the 18O-dilution space was observed for breath CO2 without correction for isotope fractionation.

Fat-free mass and total body water of infants estimated from total body electrical conductivity measurements.

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.

Total body electrical conductivity measurements: effects of body composition and geometry.

This study used an animal model to analyze the effect of body geometry and chemical composition on the calibration of a total body electrical conductivity (TOBEC) instrument developed to measure the body composition of human infants. The TOBEC signal (adjusted for length) of infant miniature pigs from 10 to 33 days of age correlated highly with their chemically analyzed fat-free mass (FFM; r = 0.998) and total body water contents (TBW; r = 0.998); 95% prediction intervals (approximately +/- 2 SEE) for individual measurements were +/- 0.16 kg FFM and +/- 0.12 liter water. These values were significantly improved (+/- 0.08 kg and +/- 0.06 liter, respectively) by accounting for individual variability in weight/length2. The effect of variations in the composition of FFM on the TOBEC measurements was evaluated by comparing the response of the infant piglets with that of adult rabbits of similar size. The differences in composition, primarily TBW and Na content, were insufficient to alter the electrical properties of FFM appreciably. Thus the TOBEC used under the conditions defined in this study accurately predicted the FFM and TBW content of infant miniature pigs. The calibration derived from the piglets will be applicable to the interpretation of the TOBEC measurements of human infants provided their FFM is of comparable shape to that of the piglets. Differences in composition are likely to be of consequence only if the proportion of fat within the FFM and the FFM density are widely divergent. This, however, does not appear to be the case.

Total body electrical conductivity used to determine body composition in infants.

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.

Proximal muscle weakness and selenium deficiency associated with long term parenteral nutrition.

A 33-yr-old white female with short bowel syndrome secondary to trauma was maintained on home parenteral nutrition for 4 yr when her plasma, red cell, white cell, and platelet glutathione peroxidase (GSHPx) activities were found to be extremely low, as were her plasma and red cell selenium levels. During her first year on parenteral nutrition she noted the onset of an inability to rise from a squatting position, rapid tiring when stair climbing, and weakness when attempting to lift large or moderately heavy objects. Treatment with 400 micrograms/d of selenious acid intravenously was associated with a disappearance of her symptoms and an increase in proximal muscle strength within 6 wk. The plasma and red cell selenium levels, and the plasma and white cell GSHPx activities rose to normal levels within 6 wk. Red cell GSHPx activity returned to normal by 3 mo.

Chylous ascites in infants and children: a case report and literature review.

Successful treatment of an infant with chylous ascites secondary to "congenital leaky lymphatics" is described, followed by a literature review of cases of pediatric chylous ascites. The infant was placed on home total parenteral nutrition for 10 weeks, during which time the chylous ascites resolved and did not recur with the introduction of a normal diet. Forty cases of pediatric chylous ascites have been reported since 1960, with an age range from birth to 18 years. The presenting signs and symptoms were secondary to abdominal distension in over 80% of cases. The chylous ascites was secondary to trauma, which included child abuse (19%), obstruction (27%), or lymphatic abnormalities (54%). Most studies described were not helpful in making the diagnosis, except for lymphangiography and exploratory laparotomy. Many patients were treated with a high-protein, low-fat diet, with or without medium-chain triglycerides, with variable success. Total parenteral nutrition (TPN) was the primary therapeutic modality in five patients, and in all but one of the cases there was complete resolution of the chylous ascites over 3 to 10 weeks with no significant side effects. Total parenteral nutrition, including home TPN, is a safe and effective therapeutic modality for some cases of chylous ascites.

New method for the estimation of lean body mass in infants (EMME instrument): validation in nonhuman models.

An innovative, safe, and rapid method suitable for the determination of lean body mass in infants is described. The machine (EMME) operates on the principle that a biologic specimen in an electromagnetic field perturbs the field proportional to its conductivity which is dependent on the amount of electrolyte present. The physical characteristics of the EMME signal are described. Experiments done with phantom infants composed of electrolyte solution and corn oil showed a very linear relationship between fat-free volume and the natural log of the EMME signal (r = 0.97). A similar relationship was noted for ground beef (r = 0.91) and live rabbits (r = 0.99). The EMME instrument appears to hold promise as a rapid noninvasive means of determining lean body mass in infants.