Contribution of the 13C-urea breath test to the detection of Helicobacter pylori gastritis in children.

Serology, 13C-urea breath test, histology, Campylobacter-like organism testing, and culture were performed in 95 consecutive children to evaluate the contribution of these tests to the detection of Helicobacter pylori infection. In analyses considering any combination of three positive tests as "gold standard" for diagnosing H pylori infection, 26 children were Helicobacter positive (27%), which is only one patient more than the number of children with only a positive culture. The accuracy of culture was excellent when "any combination of three positive tests" was used as the gold standard (sensitivity 96%, specificity 100%, positive predictive value 100% [false positivity 0%], negative predictive value 99% [false-negative results 1%]). The results of invasive and noninvasive tests were comparable. When culture was considered as "gold standard," the sensitivity of serology and 13C-urea breath test was 96%; the specificity was 96% and 93%, respectively; the positive predictive value was 89% and 83% (false-positive results in 11% and 17%); and the negative predictive value for both was 99% (false-negative results in 1%). It is concluded that culture can be used as gold standard, but that non-invasive tests such as serology and/or 13C-urea breath test can be used to diagnose H pylori infection in children, since each has at least 95% sensitivity and 92% specificity.

The prevalence of Helicobacter pylori positivity in a symptom-free population, aged 1 to 40 years.

Epidemiologic data about the prevalence of Helicobacter pylori positivity as determined by serology are presented in a large series of asymptomatic subjects (n = 1046). Serology is nowadays generally accepted as a valid non-invasive screening method for the detection of a Helicobacter pylori infection. Blood samples were taken from apparently healthy children (n = 480; aged 1-17 years) and pregnant women (n = 566; age 18-40 years) who were admitted for routine pre-surgery or pre-natal blood analysis. 162 (15.5%) had a positive titer for Helicobacter pylori. There was a significant increase in the number of positive patients with increasing age (ranging from 6.2% in the age group of the 1-5 years old to 31.0% in the age group of the 36-40 years old (p < 0.01). The meaning of this relatively high prevalence of "asymptomatic carriers" remains to be evaluated. A long-term follow-up of these patients should be considered to evaluate if they will develop clinical manifestations suggestive for Helicobacter pylori infection.

The contribution of specific immunoglobulin M antibodies to the diagnosis of Helicobacter pylori infection in children.

OBJECTIVE: To evaluate the diagnostic value of specific immunoglobulins G and M in the detection of Helicobacter pylori infection. METHODS: Sera from 68 H. pylori-infected children and 35 H. pylori-negative children (aged 1-15 years) were examined using recent-generation serum enzyme-linked immunosorbent assay (ELISA) tests (Malakit Helicobacter pylori series; Biolab, Limal, Belgium). RESULTS: All of the investigated children had positive values for immunoglobulin G antibodies. However, anti-H. pylori-specific immunoglobulin M could be detected only in 19 (27.9%) of the 68 children. When compared with the 13C-urea breath test, these findings represent sensitivity, specificity and positive and negative predictive values of 27.9, 100, 100 and 41.7%, respectively, for the serum ELISA test for the detection of H. pylori-specific immunoglobulin M compared with 100.0, 97.2, 98.5 and 100.0%, respectively, for the Malakit for the detection of specific immunoglobulin G antibodies. CONCLUSION: Although H. pylori-specific immunoglobulin G has been established as a reliable indicator of active H. pylori infection, using the Malakit for the detection of H. pylori-specific immunoglobulin M does not seem to be of major value in the diagnosis of H. pylori infection in children.

Impact of significant weight loss on maximal oxygen uptake in obese children and adolescents.

BACKGROUND: The prevalence of pediatric obesity has increased over the past few decades in all ethnic, gender, and age groups. The treatment of obesity, especially in children with moderate to severe conditions, is difficult. In this study, we examined the impact of significant weight loss as a result of participation in a multi-disciplinary weight management program on maximal oxygen uptake (VO2max) in obese children and adolescents. METHODS: Eleven obese children and adolescents (7 to 14 years of age; mean age, 12.3 +/- 1.9 years) were enrolled in a weight management program at the Children's Hospital of New Orleans. The treatment program included a high-protein, very low-calorie diet (VLCD; protein intake, 1.5 to 2.0 g/kg of ideal body weight per day; and 800 kcal/d). Diets were supplemented with extra fluid, minerals, and vitamins. All subjects attended weekly 2-hour clinic sessions. During these sessions, they received nutrition instruction, participated in a moderate-intensity, progressive exercise program, and learned behavior-modification techniques. Weight, height, body mass index ([BMI]; wt/ht2), and VO2max by indirect calorimetry were obtained at enrollment and at the end of 10 weeks of treatment. RESULTS: There was a significant decrease in body weight after 10 weeks. The BMI decreased significantly from 34.1 +/- 4.8 on entry to 29.4 +/- 3.5 (mean +/- SD; P < 0.0001). Despite the significant weight loss, VO2max increased significantly (P < 0.001) from entry (19.2 +/- 3.0 mL/kg/min) to completion of 10 weeks (22.4 +/- 5.8 mL/kg/min). However, absolute VO2max L/min was unchanged. CONCLUSIONS: We conclude that relative VO2max mL/kg/min is significantly improved in obese youth after significant weight loss with a VLCD and moderate-intensity, progressive exercise. However, because absolute VO2max L/min was unchanged, this improvement seems to result from the reduction in total body weight as opposed to the effect of the moderate-intensity exercise intervention.

The impact of significant weight loss on resting energy expenditure in obese youth.

BACKGROUND: The prevalence of obesity in American youth is increasing and treating the condition is difficult. METHODS: We have developed a multidisciplinary weight-reduction program that includes a very low calorie diet followed by a hypocaloric diet, exercise, and behavior modification. Based on data collected at baseline and at the end of the acute intervention phase (10 weeks), we assessed the impact of the weight loss that resulted from participation in this weight reduction program on the resting energy expenditure and body composition of obese children and adolescents. RESULTS: There was a significant decrease in body weight and body fat as assessed by weight determinations and skin-fold measurements after 10 weeks. The body mass index decreased significantly from 33.8 on entry to 29.6 (P < 0.0001). Despite the significant weight loss, resting energy expenditure and lean body mass remained constant from entry until the completion of the acute phase. CONCLUSION: We conclude that a multidisciplinary weight-reduction program that combines a very low calorie diet followed by a balanced hypocaloric diet, with a moderate-intensity progressive exercise program and behavior modification is an effective means for weight-reduction in obese children and adolescents. Furthermore, fat mass is significantly reduced while lean body mass and resting energy expenditure are unaltered.

Plasma amino acid concentrations in term-born infants fed a whey predominant or a whey hydrolysate formula.

BACKGROUND: Hydrolysates are used in the treatment and prevention of cows milk protein allergy. Hydrolysis might alter the plasma level of amino acids. METHODS: Forty-five infants were included in a double-blind prospective study and were randomized in two groups: one receiving a whey predominant formula (n = 20) and the second group receiving a whey hydrolysate formula (n = 25). Weight and length gain was evaluated up to the age of 13 weeks, when blood was sampled for determination of fasting plasma amino acids. RESULTS: Four infants of the hydrolysate group dropped out because refusal to ingest the formula. Weight and length gain at 13 weeks of age were extremely comparable. Significant differences in plasma concentrations were observed for a number of nonessential and essential amino acids (p = .035 to .0001). Threonine and lysine were both higher in the hydrolysate group, and aspartic acid, cystine, methionine, tyrosine, phenylalanine, histidine, and arginine were lower in the hydrolysate group. CONCLUSIONS: These differences in plasma amino acid levels have to be regarded with care because all concentrations were within normal ranges, with the exception of threonine. Weight and length gain of the hydrolysate and the whey predominant formula were identical.

Hepatic insulin clearance increases after weight loss in obese children and adolescents.

BACKGROUND: Obesity is a rapidly increasing health problem among US youth. Hyperinsulinemia is associated with obesity and has been found to be a contributory factor for the development of cardiovascular disease in the obese. It has been suggested that hyperinsulinemia of obesity is a result of increased insulin secretion caused by insulin resistance. However, it has been shown in adults that decreased hepatic insulin clearance (HIC) is the primary cause of hyperinsulinemia in this population. METHODS: We studied 15 obese children and adolescents (11 F, 4 M; 8.6 to 18.1 years) before and 10 weeks after their enrollment in a multidisciplinary weight reduction program, which included a protein-sparing modified fast, a moderate intensity progressive exercise program, and a behavior-modification intervention. RESULTS: All patients lost weight (P < 0.05). Measurements of immunoreactive insulin (IRI) and C-peptide reactivity (CPR) were performed before the program and at 10 weeks. IRI levels dropped significantly, whereas CPR levels did not change. CPR/IRI molar ratios, considered an indirect estimation of HIC, rose significantly after weight loss. CONCLUSIONS: Our data suggest that hyperinsulinemia seen in obese children and adolescents is caused by decreased HIC. The cause for this decrease remains unknown, but it is reversible upon weight loss.

Safety, feasibility, and efficacy of a resistance training program in preadolescent obese children.

BACKGROUND: Safe and effective exercise programs are needed to prevent and treat chronic diseases in childhood. In particular, preadolescent obese children should participate in activities that are specific to their special needs. Resistance or strength training has been prescribed for adult obese persons. Research is limited concerning the use of resistance training in programs that treat obese preadolescents. METHODS: Nineteen treatment subjects (7-12 years of age) were enrolled in a 10-week weight management program which included diet, behavior modification, and aerobic and flexibility exercises. Forty-eight control subjects (7-12 years of age) participated in the diet, behavior modification program, and a thrice-a-week walking program. The efficacy of the overall weight management program was examined by anthropometry at 10 weeks and 1 year. RESULTS: Fifteen treatment subjects completed the 10-week program (retention rate, 78.9%). Thereafter compliance decreased by approximately 33% for the long-term study. Seventeen control subjects completed the program (retention rate, 35%). Weight, percent of ideal body weight, and body mass index were reduced significantly at 10 weeks (P<0.0001) and did not increase significantly at 1-year follow-up in both treatment and control groups. Height increased significantly at 1 year in both treatment and control subjects. In the treatment subjects, percent fat decreased significantly (P<0.001), whereas fat-free mass did not change significantly (P>0.05). CONCLUSIONS: A resistance-training program may be included safely in a multidisciplinary weight management program for obese preadolescent male and female children. The addition of specific exercise regimes such as resistance training may improve program retention especially in severely obese youth.

Serology as a valid screening test for Helicobacter pylori infection in asymptomatic subjects.

Serologic testing is generally accepted as a valid noninvasive screening method for the detection of a Helicobacter pylori infection. To validate serology as an appropriate screening test for H pylori infection in symptom-free subjects, a recent-generation enzyme-linked immunosorbent assay for the detection of H pylori-specific IgG was performed in a large series of asymptomatic women. Blood samples for H pylori serology were taken from 542 apparently healthy women (aged 20 to 40 years) during prenatal screening. In this group, 120 (22.1%) had a positive titer for H pylori. We observed a significantly higher overall prevalence of H pylori seropositivity in nonwhites (62.3%) when compared with Belgian-born whites (17.8%). In both groups there was a significant increase in seropositivity with increasing age. To investigate the correlation between a positive enzyme-linked immunosorbent assay and the actual presence of an active H pylori infection, carbon 13-labeled urea breath tests were performed in 85 seropositive and in 65 randomly selected seronegative subjects. These breath tests were positive in 82 (96.5%) of 85 seropositive and in none of the seronegative subjects, reflecting an actual presence of H pylori in the gastric mucosa of the seropositive women. We conclude that in our population of H pylori-seropositive subjects positive serologic findings correlates extremely well with an active infection with this bacterium. However, because all subjects who were investigated were actually symptom-free, it still should be determined whether these patients should undergo upper gastrointestinal endoscopy and/or be treated with an eradication therapy against H pylori. Further long-term follow-up studies will be required to answer this question.

Helicobacter pylori disease in childhood.

Helicobacter pylori (H. pylori) is responsible for one of the most frequently encountered infectious diseases worldwide. H. pylori infection can lead to the development of gastritis and peptic ulcer disease. The presence of H. pylori in the human stomach also represents an increased risk for gastric cancer and gastric lymphoma. Epidemiologic data obtained in adults suggest that the actual colonization with H. pylori is in fact determined by childhood factors. Therefore, the pediatric age group represents the ideal target population for studies concerning the pathogenesis and epidemiology of H. pylori infection.

A comparative evaluation of whey hydrolysate and whey-predominant formulas. How well do infants accept and tolerate them?

Whey hydrolysate formulas are a recent and important innovation in infant feeding. This study compared clinical tolerance and acceptability of a whey hydrolysate formula (WH) with those of a whey-predominant formula (WF) in 45 infants. Four infants (16%) who refused to drink WH formula were eliminated from the study. Mean volume intake was significantly lower for WH (120 mL/kg/day) than for WF (147 mL/kg/day; P < .001). Consequently, mean caloric intake was also significantly different: 80 kcal/kg/day (WF) vs 97 kcal/kg/day (WF; P < .001). Nevertheless, weight gain from birth to 13 weeks of age was nearly identical in both groups (171% for WH vs 178% for WF). No significant differences were noted in duration of feeding, number of pauses during feeding, number of stools per day, or number of regurgitations per day. The lower rate of caloric intake and the dropout rate of 16% for WH raise questions about the use of WH formula in normal infants, as has become the case in some Western European regions.

Diagnosis of Helicobacter pylori.

In view of its potential risk for the development of gastrointestinal disease or even gastric cancer at a later age, the study of Helicobacter pylori infection in childhood is gaining increasing importance and H. pylori infection is being considered a major issue of public health. H. pylori infection can be detected by a variety of methods. Because of its easy use, affordability, and overall availability, serology is the preferred diagnostic test, especially for large epidemiological studies. Based on our results, one might consider treating a child with recurrent abdominal pain and positive serology for H. pylori without further work-up, and only perform additional investigations when an anti-H. pylori therapy fails to resolve the complaints. According to this proposition, endoscopy of the upper gastrointestinal tract remains indicated in children if the noninvasive tests for Helicobacter pylori are negative in the absence of a diagnosis, or if symptomatology persists despite treatment.

Pediatric gastritis and peptic ulcer disease.

Inflammation of the gastric and duodenal mucosa is the end result of an imbalance between mucosal defensive and aggressive factors. The degree of inflammation and imbalance between defensive and aggressive factors can then result in varying degrees of gastritis and/or mucosal ulceration. Gastritis and ulcers of the duodenum or stomach can be classified as primary or secondary. The majority of children with chronic gastritis and ulcers in the stomach or duodenum have secondary inflammation or mucosal ulceration. These secondary ulcers generally occur due to a systemic condition like head trauma or overwhelming sepsis, or as sequelae to drug ingestion (i.e. non-steroidal anti-inflammatory agents), but secondary gastroduodenal ulcers can also occur in specific disease conditions such as Zollinger-Ellison syndrome or Crohn's disease. In almost all children with primary duodenal or gastric ulcers mucosal inflammation and, less frequently, ulceration is caused by a spiral shaped, gram-negative, microaerobic rod Helicobacter pylori. Recent epidemiological evidence has linked chronic H. pylori infection with the development of gastric carcinomas.

Presentation and management of Helicobacter pylori infection in childhood.

Helicobacter pylori is responsible for one of the most frequently encountered infectious diseases worldwide. Helicobacter pylori infection can lead to the development of gastritis and peptic ulcer disease. The presence of Helicobacter pylori in the human stomach also represents an increased risk of gastric cancer and gastric lymphoma. Epidemiological data obtained in adults suggest that the actual colonization with Helicobacter pylori is in fact determined by childhood factors. Therefore, the pediatric age group represents the ideal target population for studies concerning the pathogenesis and epidemiology of Helicobacter pylori infection. The present work reflects our experience with regard to the diagnosis, epidemiology and pathogenesis of Helicobacter pylori infection in childhood.

Chronic diarrhea: causes, presentation, and management.

Important inroads are being made into understanding the pathophysiology of diarrhea. Clear understanding of key mechanisms should suggest new approaches to combat disease. Exciting developments are occurring in terms of super-ORS solutions, particularly with the promise of short chained glucose polymers and glutamine. Perhaps the most important development is the prospect of a good rotavirus vaccine being available before the end of the decade. Chronic diarrhea seems to be on the increase globally, probably because of the success of ORS. The mechanisms that lead to mucosal injury are elusive, and therapy still largely supportive and empiric. Celiac disease continues to be a puzzle, because of the uncomfortable feeling that a majority of cases may be missed because of atypical presentations. The successful use of long term parenteral nutrition has allowed survival and better characterization of cases that otherwise would have perished as 'lethal protracted diarrhea'. Microvillus inclusion disease may be the commonest congenital secretory diarrhea. The role of the recently reported high prevalence of glucoamlase deficiency may be important. Lastly, attention to micronutrients, particularly low vitamin A and probably zinc may prove to be important in prevention and amelioration of diarrhea and growth failure.

Modified food starches in baby foods.

Modified food starches were developed as a stabilizer, providing desirable consistency, texture, and storage ability. They are used primarily in strained and junior foods and, to a minor extent, in infant formulas. However, despite the fact that there is an increasing tendency to introduce solid foods to infants at a very early age, there is few long-term studies to delineate the effect of starch feeding on the growth of young infants. Modified food starches used by the food industry for infants and young children are of concern and there is an urgent need for additional data regarding their bioavailability, effect on nutrient absorption, intestinal changes, and toxic, mutagenic, and carcinogenic effects. Therefore, the inclusion of modified food starches should be used prudently and sparingly.

[Endoscopic closure of a recurrent tracheoesophageal fistula]. / Fermeture endoscopique d'une fistule trachéo-oesophagienne récidivante.

We report a successful endoscopic obliteration of a large recurrent tracheo-esophageal fistula (diameter 0.6 cm, length 2 cm) in a 12-year old girl, using a combination of N-butyl-2-cyanoacrylate followed by polidocanol injected through a polyethylene catheter. The severe pulmonary infection, that rendered surgery potentially life-threatening, resolved after endoscopic closure. The girl remained asymptomatic for 14 months after the first obliteration. Chronic coughing was the symptom of relapse. A follow-up endoscopy revealed that most of the N-butyl-2-cyanoacrylate had disappeared from the fistula, whose endoscopic appearance was unchanged. A second obliteration with the same products was performed. The girl has again been asymptomatic for 10 months. The endoscopic obliteration is a worth-while technique, to be considered as an alternative to surgery in patients presenting with a complicated recurrent tracheo-oesophageal fistula.

Chronic diarrhea in infancy and childhood.

Important inroads are being made into understanding the pathophysiology of acute diarrhea. Clear understanding of key mechanisms should suggest new approaches to combat disease. Exciting developments are occurring in terms of super-ORS solutions, particularly with the promise of short-chained glucose polymers and glutamine. Perhaps the most important development is the prospect of a good rotavirus vaccine being available before the end of the decade. Chronic diarrhea seems to be on the increase globally, probably because of the success of ORS. The mechanisms that lead to mucosal injury are elusive and therapy is still largely supportive and empiric. Celiac disease continues to be a puzzle, not least because of the uncomfortable feeling that a majority of cases may be being missed because of atypical presentations. The successful use of long-term parenteral nutrition has allowed survival and better characterization of cases that otherwise would have perished as "lethal protracted diarrhea". Microvillus inclusion disease may be the most common congenital secretory diarrhea. The role of the recently reported high prevalence of glucoamylase deficiency may be important. Lastly attention to micronutrients, particularly low vitamin A and probably zinc, may prove to be important in prevention and amelioration of diarrhea and growth failure.

The role of modified food starches in baby food.

Modified food starches were developed as a stabilizer, suspending the food particles and providing a desirable consistency, texture, and storage ability. They are used primarily in strained and junior foods and to a minor extent in infant formulas. This review discusses modified food starches because of four principal concerns. The first relates to the bioavailability of the starch itself. The second is the potential that indigestible starch may have for producing diarrheal symptoms, malabsorption, and changes in gastrointestinal flora. The third is the possibility that modified food starches might be implicated in gastrointestinal disease like Crohn's ileocolitis. The fourth is the toxicological effect of the chemicals used to modify the starch and their possible mutagenic and carcinogenic properties.

A multidisciplinary approach to the treatment of childhood obesity.

Childhood obesity is a chronic disease that is associated with significant co-morbidity. Successful treatment and prevention of childhood obesity requires a multidisciplinary approach, including diet, nutrition education, behavior modification, and exercise. We studied 87 children (39 males, 48 females; aged 7-17 years) enrolled in a one-year multidisciplinary weight reduction program. Subjects were placed on a very low calorie/high protein diet, a moderate-intensity progressive exercise program, and behavior modification sessions for 10 weeks. Measures were taken at baseline 10 weeks, and 1 year. Significant anthropometric changes in weight, percent of ideal body weight, and percent body-fat were observed in all patients. We conclude that a multidisciplinary weight reduction program including diet, behavior modification, and exercise is an effective instrument to achieve weight loss in obese children and adolescents.