Technetium-99m hexamethylpropyleneamine-oxime-labeled leukocyte scintigraphy in inflammatory bowel disease in children.

Technetium Tc 99m-labeled hexamethylpropyleneamine-oxime (Tc-HMPAO) scintigraphy has been evaluated in adults with inflammatory bowel diseases and has shown promising ability to define intensity and extent of disease. To evaluate the method's utility in children, we studied 27 pediatric patients-23 with inflammatory bowel diseases and 4 control subjects without abdominal inflammation. Autologous leukocytes labeled with Tc-HMPAO were reinjected into each patient and serial scans were obtained up to 4 hours later. None of the control subjects had any uptake of Tc-HMPAO by the bowel. Disease localization as defined by the scan correlated well with that visualized in surgical specimens from five patients, at endoscopy in three patients, with barium studies of two patients, and with computed tomography scanning of the abdomen in one patient. A "scan score" was calculated by comparing uptake of tracer in five bowel segments with iliac crest bone marrow activity. Scan score correlated much better with clinical disease activity (correlation coefficient = 0.62) than did the erythrocyte sedimentation rate (correlation coefficient = 0.24). Scintigraphy with Tc-HMPAO appears to be useful in evaluation of disease localization and intensity in children with inflammatory bowel disease.

Thickened feedings as a cause of increased coughing when used as therapy for gastroesophageal reflux in infants.

To determine whether thickening of infant formula feedings with rice cereal increases coughing, we studied 25 infants from birth to 6 months of age, referred for evaluation of gastroesophageal reflux. Coughing was blindly quantified after each of a pair of isocaloric meals (one thickened and one unthickened). Coughing was more frequent after thickened feedings than after unthickened feedings.

Tardive dyskinesia associated with use of metoclopramide in a child.

Tardive dyskinesia is a chronic, often permanent, movement disorder that has been reported in elderly patients receiving metoclopramide. We describe an 8-year-old boy with tardive dyskinesia that developed when he received metoclopramide as part of therapy for gastroesophageal reflux and erosive esophagitis.

Pancreatitis in young children with cystic fibrosis.

Five young children with cystic fibrosis and abdominal pain were found to have pancreatitis. Diagnosis was delayed in four patients because of the belief that pancreatitis occurs only in older patients with cystic fibrosis. In one patient pancreatitis was diagnosed before cystic fibrosis and diagnosis of cystic fibrosis was delayed. Pancreatitis should be considered as a possible cause of abdominal pain in pancreatic-sufficient children with cystic fibrosis and cystic fibrosis should be considered as a possible cause of pancreatitis, even in the young child.

Fatal aortoesophageal fistula due to double aortic arch: an unusual complication of prolonged nasogastric intubation.

Fatal hematemesis occurred in a 3-month-old boy due to erosion by a nasogastric tube into the right component of an unrecognized double aortic arch. This is the youngest of six reported patients with arterioesophageal fistula in the literature. Including this patient, five of six had nasogastric tubes in place. The tube may have led to fistula formation by compression of the esophageal wall against an anomalous vessel. When a vascular ring is suspected, indwelling esophageal tubes such as nasogastric tubes should not be used.

Prone positioning in infant gastroesophageal reflux: is elevation of the head worth the trouble?

To determine whether head-elevated prone positioning is better than flat prone positioning for infants with gastroesophageal reflux, we studied 100 babies less than 6 months of age who were being examined for reflux with an intraluminal esophageal pH probe while the babies were in each of the two positions, with the use of a crossover design protocol. During both a 2-hour postprandial period and a fasting period, pH probe measurements in each position included (1) minutes with pH less than 4, (2) number of episodes with pH less than 4, (3) mean duration of such episodes, (4) number of such episodes longer than 5 minutes, and (5) the duration of the longest episode. Significant reductions with head elevation were found for only two of these 10 values: the frequency of reflux episodes postprandially (7.5 +/- 0.7 vs 5.9 +/- 0.5 episodes per 2 hours; p less than 0.05) and the frequency of episodes longer than 5 minutes postprandially (1.4 +/- 0.1 vs 1.2 +/- 0.1 episodes per 2 hours; p less than 0.005). There was no significant reduction in the total duration of postprandial reflux nor in any measure of reflux during the fasting period. The 90 infants in whom an abnormal degree of gastroesophageal reflux was documented had no significant differences between flat prone and head-elevated prone position for any of the 10 pH probe measurements. Head-elevated prone positioning is probably not worth the extra effort required to maintain it.

The Santmyer swallow: a new and useful infant reflex.

A puff of air administered to the face of 102 subjects (from 33 week's gestation on the first day of life to age 42 years) elicited a reflex swallow identical to a normal primary peristaltic sequence in 88. Subjects who responded were younger than 24 months of age or severely disabled neurologically; those who did not respond were older than 11 months and free of neurological abnormality. Response was variable between 11 and 24 months. This swallow response appears to be a clinically useful but previously unrecognised infant reflex.

Thickening of infant feedings for therapy of gastroesophageal reflux.

To assess the effect of thickening of feedings on gastroesophageal reflux and gastric emptying, 20 infants were examined with technetium scintigraphy and detailed behavioral observation after each of a pair of feedings, one with radiolabeled infant formula alone and the other with radiolabeled formula thickened with dry rice cereal. The thickened and unthickened meals were followed by similar amounts of scintigraphically demonstrated gastroesophageal reflux. However, the number of episodes of emesis (1.2 +/- 0.7 vs 3.9 +/- 0.9 per 90 minutes postprandial), the percent of gastric emptying at 30 minutes (17.8% +/- 2.7% vs 22.4% +/- 2.4%), the time spent crying (11.7 +/- 3.1 minutes vs 17.6 +/- 3.8 minutes per 90 minutes), and the total time spent awake (45.2 +/- 5.9 minutes vs 53.1 +/- 4.9 minutes per 90 minutes) were significantly less after the thickened feedings. Because thickening of infant feedings increases the caloric density, decreases emesis, decreases crying time, and increases sleep time in the postprandial period, it is likely to be beneficial in the treatment of infants with gastroesophageal reflux associated with failure to thrive.

Enteral versus parenteral therapy for intractable diarrhea of infancy: a prospective, randomized trial.

Thirteen infants with intractable diarrhea were classified as having severe or moderate malabsorption on the basis of D-xylose absorption. Within each group (designated severe and moderate), patients were randomly assigned to continuous enteral nutrition (CEN) with an elemental formula or to an alternative therapy: total parenteral nutrition (TPN) for the severe patients or intermittent oral nutrition (ION) with the elemental formula for the moderate patients. Within the severe group, CEN and TPN produced similar correction of malnutrition (6.0 +/- 2.5 weeks vs 6.5 +/- 2.5 weeks for weight to reach the 5th percentile for age, P = 0.69), but CEN was associated with faster resolution of malabsorption and diarrhea (2.8 +/- 0.5 weeks vs 9.8 +/- 1.1 weeks, P = 0.02), fewer complications, and less expensive hospitalization than TPN. The moderate group was too small for clear distinctions between the two therapies. D-xylose absorption effectively distinguished between severe malabsorption (requiring 20.6 +/- 2.6 days of enteral therapy before tolerance of oral feeding) and moderate malabsorption (requiring 11.6 +/- 1.7 days), P less than 0.03. Enteral therapy is more widely applicable in severe intractable diarrhea of infancy than has been appreciated, and can produce superior results to TPN.

Positioning for prevention of infant gastroesophageal reflux.

A controlled, prospective comparison of the use of the infant seat versus prone, head-elevated positioning in a harness was undertaken in 15 infants with gastroesophageal reflux. pH monitoring of the distal esophagus demonstrated less reflux in the harness than in the seat (P less than 0.001) during 19 pairs of two-hour postprandial trials. This difference was the result of both fewer episodes (P less than 0.001) and briefer episodes (P less than 0.05). Prone-elevated positioning in the harness described is superior to positioning in an infant seat in the treatment of gastroesophageal reflux in infants younger than 6 months.