Effect of a laxative with and without tegaserod in adolescents with constipation predominant irritable bowel syndrome.

AIM: To determine the effect of a laxative alone and in combination with tegaserod in alleviating pain and improving stool frequency in adolescents with constipation predominant irritable bowel syndrome. PATIENTS: Forty-eight postpubertal adolescents of both sexes with constipation predominant irritable bowel syndrome, as defined by Rome II criteria, were randomly allocated to Group A (n = 27) for treatment with a laxative (polyethylene glycol 3350 oral solution) only or Group B (n = 21) for combination therapy with the laxative and tegaserod. Symptoms of abdominal pain (scale 0-10) and frequency of bowel movements were recorded daily in the pre-treatment phase and the post-treatment phase after a 7-day 'washout' period. Patients served as their own controls. RESULTS: Treatment with the laxative alone (Group A) resulted in significant increase in frequency of bowel movements (P < 0.05), but not significant improvement in pain (P > 0.05). Treatment with the combination of the laxative and tegaserod (Group B) led to significant increase in the frequency of bowel movements and also significant reduction in pain (P < 0.05). CONCLUSIONS: The laxative alone improved stooling but not pain in adolescents with constipation predominant irritable bowel syndrome. Addition of tegaserod resulted in alleviation of pain as well.

Use of energy-dense formula for treating infants with non-organic failure to thrive.

OBJECTIVE: To evaluate if simply increasing the energy density of the formula will lead to increased energy intake and weight gain in infants with non-organic failure to thrive. DESIGN: In this hospital-based trial, 15 infants (mean age, 7.6+/-1.4 months) with non-organic failure to thrive were fed a regular strength formula (2.8 kJ/ml) for 3 days and then switched to the same formula with a higher energy density (4.18 kJ/ml) for 3 days after a 2 day 'wash-out' period. Daily nude weights and energy intakes were recorded for the two 3 day periods. RESULTS: During feeding with the higher density formula, nine (60%) infants had a significant increase in their energy intake and weight gain (both P<0.02); four (27%) showed no change in energy intake and self-regulated their intake by decreasing the volume of feeds consumed to maintain energy intake; and two (13%) infants consumed a significantly reduced amount of energy (P<0.02). CONCLUSION: Increasing the energy density of the formula may provide a useful intervention to increase the weight gain and energy intake of most infants with non-organic failure to thrive.

Gastric emptying of two whey-based formulas of different energy density and its clinical implication in children with volume intolerance.

OBJECTIVE: Whey-based formulas have faster gastric emptying than casein-based formulas. Isoenergetic, isovolumic, whey-based formulas of different osmolarity and fat content empty in a similar manner. Will the gastric emptying of high and low energy density whey-based formulas be similar? DESIGN: We studied the gastric emptying rate of equal volumes of two whey-based formulas of different energy density (4.18 kJ/ml and 6.27 kJ/ml) and osmolality (270 and 450 mOsm/kg, respectively) in 10 children (4.5-12 y) with volume intolerance and resultant inability to gain weight. RESULTS: The two formulas had comparable gastric emptying rates at 30, 60, 90 and 120 min. Over a one month clinical trial, substitution of the lower energy density whey-based formula (no weight gain over 2 months) with an equal volume of the high energy density formula produced a mean weight gain of 1.17+/-0.5 kg per patient without change in tolerance. CONCLUSION: The higher density whey-based formula can safely substitute an equal volume of a lower energy density formula to produce weight gain without affecting tolerance. IMPLICATION: This provides an important intervention for increasing energy intake in children with volume intolerance or fluid restriction.

Benefits of thickened feeds in previously healthy infants with respiratory syncytial viral bronchiolitis.

Infants with respiratory syncytial virus (RSV) bronchiolitis have an increased risk of aspiration. The optimal feeding strategy for these patients has not been described. Fifteen previously healthy and clinically stable infants with RSV bronchiolitis underwent video-fluoroscopy studies to assess swallowing using thin barium. Those with abnormal studies underwent a repeat study, using barium that was thickened with rice cereal. Nine of 15 infants had abnormal studies with thin barium. Laryngeal or tracheal penetration with thin barium was seen in 3 and 2 infants, respectively, but not with thickened barium. Aspiration of thin barium was seen in 4 infants, but it corrected in 3 of these 4 infants with thickened barium. Thickened feeds provide a simple, safe, and cost-effective intervention to improve swallowing dysfunction and prevent aspiration in infants with RSV bronchiolitis.

Effect of cisapride on the QT interval in infants with gastroesophageal reflux.

OBJECTIVE: We prospectively studied the effect of cisapride per se on QT interval in young infants (3-6 months) with gastroesophageal reflux (GER) in a controlled setting. STUDY DESIGN: The infants diagnosed with GER and deemed to require therapy with cisapride were divided into 2 groups. Group A comprised infants with GER who underwent an electrocardiogram (ECG) before initiation of therapy with cisapride in the dose of 1 mg per kg per 24 hours, divided into 3 doses. They were reweighed after 7 to 10 days, and the dose was adjusted for their new weight. A repeat ECG was performed after approximately 2 weeks (12-18 days) of therapy. The QT interval was measured in each ECG and then the corrected QT interval was calculated by Bazett's formula. Group B comprised infants with GER who had already been on therapy with cisapride for over 1 month. All infants in group B received cisapride in an approximate dose of 1 mg per kg per 24 hours (.8-1.1 mg/kg/24 hours) given in 3 divided doses. They underwent only 1 ECG, ie, at 1 to 4 months after initiation of therapy. The measurement of the actual dose of cisapride was demonstrated to every parent and a marked measuring syringe was provided. The following categories of infants were not included: those with any underlying cardiopulmonary, renal, or hepatic problem; those with a history of apnea; those using a macrolide antibiotic or azole antifungal at any stage during the study; and infants hospitalized for any reason during the course of the study. RESULTS: Cisapride therapy in the dose of 1 mg/kg/day frequently resulted in a slight increase in the QT interval (pretreatment: 390 +/- 18 milliseconds; posttreatment: 400 +/- 20 milliseconds) but the increase was still below the accepted upper limit of 440 milliseconds and not statistically significant. Even with prolonged therapy, the pattern of change in QT interval was similar to that with therapy for 2 weeks. Overall, 2 of 100 (2%) infants developed a prolongation of corrected QT interval beyond the normal range (456 and 486 milliseconds). Neither infant had evidence of any arrhythmia or conduction defect on ECG. No additional factor could be identified in either infant to explain prolongation of the QT interval. CONCLUSION: Our experience suggests that cautious cisapride therapy in young infants in a modest dose does not result in arrhythmias or conduction defects. We recommend that: 1) the dose of cisapride in infants be <1.2 mg/kg/day and preferably between.8 and 1 mg/kg/day; 2) the right measure of the dose be actually demonstrated to the parents; and 3) parents be provided a list of drug interactions with cisapride. One should think twice before denying the use of an effective drug simply because of the need for closer monitoring and extra time spent for parent education.

Smaller volume, thickened formulas in the management of gastroesophageal reflux in thriving infants.

BACKGROUND: The effect of smaller volume, thickened formulas on gastroesophageal reflux is not clear. METHODS: The frequency of gastroesophageal reflux and duration of acid pH in the esophagus were determined in six thriving infants using extended esophageal pH monitoring. RESULTS: There was a significant reduction in frequency of emesis and gastroesophageal reflux but not the duration of acid pH in the esophagus with the use of infant formula thickened with rice cereal to provide a nutritionally appropriate intake in a smaller volume. CONCLUSIONS: Thickening of formula with rice cereal in a nutritionally balanced form and smaller volume may be an appropriate strategy for reducing frequency of emesis and gastroesophageal reflux in thriving infants.

Previously healthy infants may have increased risk of aspiration during respiratory syncytial viral bronchiolitis.

OBJECTIVE: Respiratory illnesses may cause feeding difficulties in infants. We studied the safety of oral feeding during respiratory syncytial viral (RSV) bronchiolitis in previously healthy infants. METHODS: Twelve previously healthy infants (3-12 months) with RSV bronchiolitis underwent barium swallow studies during the acute phase of illness. Those with abnormal studies underwent repeat studies 2 to 4 weeks later. RESULTS: The initial barium studies revealed aspiration in 3 infants. All repeat studies, performed 2 to 4 weeks later, were normal. CONCLUSIONS: Even previously healthy infants may be at risk of aspiration during RSV bronchiolitis.

Effect of parenteral nutrition on oral intake.

Oral intake following a high density oral supplement (preload) is lower than that after a low density preload. We studied a similar effect of parenteral nutrition on oral intake. Twelve neurologically intact children (8-16 yr) with orthopedic problems and no concurrent illness were included in the study. As part of the inclusion criteria, all patients had documented energy intake for breakfast of +/- 10% on 3 consecutive days. On the fourth day parenteral nutrition equal to 50% of the mean energy intake for breakfast was provided for 4 hours before breakfast and energy intake measured. The composition of the parenteral energy was matched with that of the oral intake. The mean oral energy intake without (470 +/- 90 kcal) and with (458 +/- 64 kcal) parenteral nutrition preload was comparable (p > 0.05). Our conclusion is that parenteral nutrition does not affect oral intake in patients without underlying gastrointestinal disease.

Nutrition and swallowing in pediatric neuromuscular patients.

The management of the patient with neuromuscular disease is complex. Every child should be seen as a distinct individual and therefore merits patient-specific assessment and intervention. This article reviews nutritional management using spinal muscular atrophy and Duchenne's muscular dystrophy as representative models. The history of nutritional intake, nutritional needs, and underlying medical problems with physical examination, anthropometric, body composition, and biochemical markers are all important parts of the assessment and should be done at regular intervals. Intervention may include calorie restriction or calorie supplementation. Treatment strategies that follow diagnosis of dysphagia include positioning, increased sensory input, or direct maneuvers, such as volume changes or thickening liquid. Percutaneous endoscopic gastrostomy can be safely placed in almost all situations with minimal risk. Patients benefit most from a multidisciplinary and systematic management program.

Reduced long-term respiratory morbidity after treatment of respiratory syncytial virus bronchiolitis with ribavirin in previously healthy infants: a preliminary report.

Previously healthy infants less than 6 months of age with severe respiratory syncytial virus bronchiolitis who required hospitalization were identified from hospital records. Infants had been treated either conservatively (control group, n = 19) or with ribavirin added to conservative management (study group, n = 22). All infants underwent a 1-year follow-up after the initial illness. There was a significant reduction in the prevalence of reactive airway disease in the group treated with ribavirin (P < 0.05) compared with the control group, both in terms of the proportion of patients developing airway reactivity (59% vs. 89%) and the number of episodes of reactive airway disease (31 vs. 70). Our data suggest that ribavirin reduces the prevalence of airway reactivity.

Nutritional assessment in children and adolescents.

Accurate nutritional assessment of a child is a complex task involving simultaneous evaluation of several parameters, e.g., nutrient intake and requirement and physical and anthropometric examination, including body composition and biochemical markers. Several of these tests are not readily available in all settings and one may have to rely on simpler tools like thorough clinical assessment, which has a surprisingly high degree of sensitivity.

Effect of low- and high-fat, peptide-based diets on body composition and disease activity in adolescents with active Crohn's disease.

BACKGROUND: The effect of nasogastric feeding with high- and low-fat, peptide-based diets on body composition and disease activity was studied in adolescents with active Crohn's disease. METHODS: Fourteen patients with active Crohn's disease (12 to 17 years) were fed exclusively through nasogastric feedings with two isocaloric, isonitrogenous, peptide-based diets, either with low- or high-fat content, for 3 weeks each in a randomized manner then were "crossed over" to the other diet for another 3 weeks of feeding. At the end of each 3-week period, urine and stools were collected for 72 hours for measuring energy absorption and nitrogen utilization (n = 6). Weight, height, triceps skin folds, fat free body mass, and disease activity were also monitored (n = 14). RESULTS: There was no difference in any parameter of energy absorption or nitrogen utilization between the two formulas irrespective of the order in which they were administered. The changes in nutritional parameters were also comparable with both formulas. There was a significant increase in weight, fat free body mass and triceps skinfold thickness during both the 3-week periods of feeding (p < .05). This was accompanied by a significant reduction in the pediatric Crohn's disease activity index (p < .05). CONCLUSIONS: Peptide-based diets may be useful in restoring the fat free body mass and improving the disease activity in patients with Crohn's disease. A high fat (high medium-chain triglycerides) diet did not offer any nutritional advantage over a similar but low-fat diet. The improvement in disease activity during feeding with a low-fat diet was comparable to that with a high-fat diet. The improvement in disease activity seems to be associated with improvement in lean body mass irrespective of the type of diet used to achieve it.

Incidence of gastroesophageal reflux with whey- and casein-based formulas in infants and in children with severe neurological impairment.

Ten exclusively gastrostomy-fed, neurologically impaired children (4.5-14.5 years old) with gastroesophageal reflux were randomly assigned to receive feedings with either a casein- or a whey-based formula for 48 h each and then crossed over to the other formula. One 24-h pH probe study each was performed while being fed casein- and whey-based formula, respectively. There was a significant reduction in episodes and duration of gastroesophageal reflux while consuming the whey-based formula (p < 0.05). Whey-based feedings should be considered an additional tool in conjunction with other antireflux measures to treat gastroesophageal reflux more effectively in children with severe neurological impairment. A similar study was also conducted involving 14 infants (3-12 months old) with documented gastroesophageal reflux using 24-h pH probe monitoring while consuming a casein-based formula. The formula was changed to a whey-based formula and the pH probe study repeated within 3-5 days. Four infants showed improvement and the rest showed either deterioration (1/14) or comparable results (9/14). The reduction in the mean number of episodes or duration of gastroesophageal reflux with the whey-formula was not significantly different from that with the casein-based formula (p > 0.05). Based on these findings, generalized recommendations for the use of whey-based formula in infants with gastroesophageal reflux cannot be made.

Nutritional management of dumping syndrome associated with antireflux surgery.

Eight children were identified as having dumping syndrome by a glucose tolerance test and evidence of rapid gastric emptying. All had undergone a fundoplication with concomitant feeding gastrostomy placement at 18.4 +/- 17.4 months of age (range, 3 to 54 months). Symptoms suggestive of dumping syndrome occurred 1 to 4 months after surgery. There was considerable delay in diagnosis (3 to 8 months). These children were successfully managed with nutritional manipulation alone, using a combination of a complex carbohydrate and a fat emulsion. Complete resolution of symptoms and normoglycemia was achieved in all the children, without any complications.