Bacterial contamination of the small intestine as an important cause of chronic diarrhea and abdominal pain: diagnosis by breath hydrogen test.

Unsuspected bacterial contamination of the small intestine was indicated by breath hydrogen testing in nine patients aged 2 to 34 months during physical examinations for chronic diarrhea and abdominal pain. Elevated bacterial counts of questionable significance were found in duodenal aspirates before and after antibiotic treatment. There was no evidence of bile salt deconjugation or structural changes in the small intestine by light or electron microscopy. This may indicate that the site of colonization is distal to the biopsy site. Breath testing indicated lactose malabsorption in all patients, and four of five patients tested also malabsorbed sucrose. Duodenal disaccharidase levels in all patients were within the normal ranges, but in eight patients the lactase-sucrase ratio was greatly elevated (0.80 +/- 0.36; normal less than 0.45). Dietary restriction alone did not cause complete cessation of symptoms, whereas all patients responded dramatically to oral antibiotic therapy. When patients were well, the lactase-sucrase ratio had returned to normal in those tested, and all nine had normal lactose and lactulose breath hydrogen tests. Unsuspected bacterial contamination of the small intestine, which is easily detected using the breath hydrogen test, may be more commonly associated with chronic diarrhea in children than has been previously realized. In such cases, therapy should be directed at removing the contamination.

Malignant otitis externa in an infant with selective IgA deficiency: a case report.

The occurrence of malignant otitis externa (MOE) in infancy is rare. We report a case of MOE in a neonate who was later identified to have selective IgA deficiency. She was successfully treated with oral ciprofloxacin, but developed external auditory canal stenosis, a deformed pinna, persistent facial nerve palsy, temporal bone erosion and hearing loss. No cases of MOE in selective IgA deficiency have been reported in literature. This is also the first report on the use of ciprofloxacin in infants with MOE.

Weight gain in exclusively breastfed preterm infants.

The weight gain of 355 preterm low birth weight infants, who were exclusively breastfed by their own mothers after discharge from the special care nursery, was analysed prospectively over the first 24 weeks of infancy. Preterm infants with birth weights of 1000-1500 g significantly doubled their birth weight by 10 weeks of age and tripled it by 18 weeks, with a growth velocity of 20-30 g/day up to 20 weeks of age. Preterm infants with birth weights of 1501-2000 g doubled their birth weight by 12 weeks of age and tripled it by 16 weeks, with a growth velocity of 30 g/day up to 11 weeks and 20 g/day after the 12th week. Preterm infants born at 32 weeks gestational age had a period of growth delay up to 3 weeks of age followed by a brisk catch-up phase, whereas infants born at 34 and 36 weeks gestational age had a shorter period of growth delay of 2 weeks followed by a similar catch up phase. The weights attained were comparable to intra-uterine growth rates.

Serum and intestinal immune response to rotavirus enteritis in children.

This study was designed to assess the serum and mucosal immune response to naturally acquired rotavirus enteritis in children. Serum and duodenal secretions were collected 1 week and again 4 to 5 weeks after the onset of illness from 10 children. In two of these children, the procedure was repeated 12 to 15 months later. Another 10 children with bacterial enteritis were studied as controls. The antibody response in serum included a significant elevation of rotavirus-specific immunoglobulin M (IgM) in acute-phase samples (P less than 0.05), but not in convalescent-phase samples, when compared with controls. Rotavirus-specific IgG and IgA levels were significantly elevated in convalescent-phase serum when compared with acute-phase serum (P less than 0.025), but not in control serum. Rotavirus-specific IgA levels in convalescent duodenal secretions were significantly raised when compared with both acute-phase and control samples (P less than 0.01). Rotavirus-specific IgM levels were elevated in acute-phase duodenal secretions (P less than 0.05), but not in convalescent-phase secretions. In two children, the secretory IgA response had disappeared by 12 months. These studies demonstrate the presence of rotavirus-specific antibody in duodenal secretions which may be important for protection against reinfection and may be capable of being stimulated by oral vaccination.

Pancreatic polypeptide secretion. A marker for disturbed pancreatic function in cystic fibrosis.

Pancreatic polypeptide, a 36-amino peptide, is released from the pancreas by a variety of stimuli, including intravenous Boots secretin. Studies in a generalized destructive and inflammatory process such as chronic pancreatitis have revealed a markedly diminished response to stimulation. To assess whether pancreatic polypeptide release in response to Boots secretin provides a useful measure of pancreatic destruction in cystic fibrosis, 41 patients with proven cystic fibrosis, aged 14 months-23 years, and seven control subjects, aged 18-24 years were studied. Serum pancreatic polypeptide, measured by radioimmunoassay, rose from a basal of 18.5 +/- 2.7 pmol/liter to a peak of 35.6 +/- 4.3 pmol/liter at 5 min in cystic fibrosis, and from a basal of 10.8 +/- 2.8 pmol/liter to a 5-min peak of 109 +/- 27.7 pmol/liter in control subjects. The basal levels of both groups were similar but the cystic fibrosis patients had a significantly lower peak response than controls (P less than 0.05). The peak over basal pancreatic polypeptide ratio was calculated and was less than five in 93% of cystic fibrosis patients, whereas all control subjects had a ratio greater than five. Pancreatic polypeptide measurements in response to secretin may be a convenient and useful means of following the course of pancreatic disease in a chronic illness such as cystic fibrosis.

Abnormal pancreatic electrolyte secretion in cystic fibrosis. Reliability as a diagnostic marker.

We performed pancreatic function tests on sixty-five cystic fibrosis (CF), and eleven control children. The technique used continuous IV infusion of cholecystokinin and secretin, with duodenal juice collection over a 90 min period, and was made quantitative by continuous duodenal infusion and distal collection of an unabsorbable marker (bromosulphthalein). Some CF patients had near normal pancreatic enzyme outputs, some had impaired but measurable levels, but most (79%) had almost absent trypsin secretion. CF children with better pancreatic function, were younger and more likely to be male. All controls showed a large increase in bicarbonate concentration and secretion rate per kilogram body weight during the test, but most children with CF (96.5%) did not. Because two of our CF patients had water and bicarbonate secretion within the control range, this finding does not exclude the diagnosis of CF. Sodium, potassium and chloride ion secretion in CF patients was lower than controls but overlap occurred. We found a linear correlation between acinar and tubular secretion in CF patients which indicates that there is probably not a primary genetic defect in pancreatic bicarbonate secretion in CF.