Comparison of preparation and narcotic-sedative premedication in children undergoing surgery.

A psychological preparation program was developed for use prior to emergency surgery in children. The purpose of this study was to test the hypothesis that provision of specific information prior to an emergency operation would reduce the need for premedication to control anxiety and stress. Children were randomly assigned to either a verbally prepared group given narcotic-sedative premedication (control) or to a psychologically prepared group given only atropine as premedication. The child and parent rated their own anxiety on a Visual Analogue Scale (VAS). The children and parents were also assessed by a nurse preoperatively and postoperatively using a similar scale. The children's pulse, blood pressure, and cortisol were also measured. The results showed no significant difference between the psychologically prepared group and the premedicated group, suggesting that psychological preparation compares favorably with narcotic-sedative premedication.

Chronic inflammatory bowel disease in children and adolescents in Sweden.

The incidence and prevalence of chronic inflammatory bowel disease (IBD) in children was established during 1984 and 1985 in a prospective study in Sweden. The patients with IBD were classified as having ulcerative colitis (UC), Crohn's disease (CD), probable Crohn's disease (PCD), and indeterminate colitis (IC) according to defined histopathologic, endoscopic, and radiologic criteria. The study covered 1.51 million children less than 16 years of age (93% of all children in Sweden). The incidence of IBD was 5.0 and 4.5 and the prevalence was 17.6 and 18.2 per 100,000 children during the 2 years, respectively. The mean prevalence of UC was 7.5 per 100,000 and of CD + PCD was 6.2 per 100,000. The prevalence of IC was 4.2 per 100,000, which corresponds to 23% of the children with IBD.

Gliadin-specific serum immunoglobulins A, E, G, and M in childhood: relation to small intestine mucosal morphology.

An enzyme-linked immunosorbent assay technique was developed to determine serum antigliadin antibodies of the IgA, IgE, IgG, and IgM classes. The antibody level of each serum specimen was expressed as an index value, i.e., optical density of test serum/optical density of cutoff, where cutoff was calculated for each immunoglobulin class as the mean + 3 SD for six healthy controls. Indices for each immunoglobulin class were determined in 69 children who were admitted for their first small intestinal mucosal biopsy due to either symptoms of malabsorption compatible with celiac disease, or short stature without other symptoms. Especially raised levels of antigliadin IgA antibodies in serum correlated strongly with villous atrophy and in infants less than or equal to 3 years of age were invariably elevated above controls, provided they were on a gluten-containing diet. Raised levels of IgG and IgE antibodies to gluten were often seen in children with normal mucosal morphology, i.e., when symptoms were due to other gastrointestinal disorders than celiac disease. It is concluded that determination of antigliadin IgA antibodies in children less than or equal to 3 years is a useful screening test before small intestinal biopsy, especially in children where the indication for biopsy is not otherwise obvious. The method can also be used to assess the results of therapy and, conceivably, compliance.

Surface ultrastructure of the small intestine mucosa in children with celiac disease. I. Untreated disease and effects of long-term gluten elimination and challenge.

Forty-eight gut mucosa specimens from 27 children with celiac disease, diagnosed by means of conventional serial biopsies taken at different dietary conditions, were studied by means of scanning electron microscopy (SEM). The observations were correlated with those made by concomitant dissection microscope (DM), light microscope (LM), and transmission electron microscope (TEM) examinations. Five children with constitutional short stature served as controls. The results of the SEM analyses were in good conformity with the observations made by DM, LM, and TEM. In addition, SEM was found to offer further structural variables to be analyzed. In active celiac disease and after challenge with dietary gluten, which is necessary to establish the diagnosis of children, the lesions specifically observed by SEM were (1) a strikingly uniform destruction of the villi and a distortion of the enterocytes but with preserved extrusion zones, and (2) a decrease and disruption of the glycocalyx of the enterocytes with marked irregularity of the microvilli. After successful dietary treatment and despite a normalization of the gut mucosa by routine LM, SEM often disclosed persisting lesions of the enterocytes. It was concluded that by inclusion of SEM in the routine assessments of gut biopsy specimens in children with celiac disease, the diagnostic precision becomes increased.

Surface ultrastructure of the small intestine mucosa in healthy children and adults: a scanning electron microscopic study with some methodological aspects.

Biopsy specimens of light microscopically (LM) normal small intestine mucosa from eight healthy, constitutionally short-statured children without signs of gastrointestinal disease and six healthy adults were studied by scanning electron microscopy (SEM) supplemented by transmission electron microscopy (TEM). The effects on surface morphology of various preparative procedures were also investigated, using small intestine mucosa from cats and rats. Fixation with OsO4--either alone, or following glutaraldehyde fixation--markedly changed the surface ultrastructure compared to that after glutaraldehyde fixation only. By low power SEM, some differences were observed in the appearance of the small gut mucosa between adults and young children. In adults and in children above 3 years of age, the villi were usually shaped like fingers or leaves, but in infants, ridge-shaped villi predominated. The villi showed, however, a smooth surface in both infants and adults, and medium and high power SEM displayed similar pictures, irrespective of age; here the typical structural features of the normal small gut mucosa in humans were (1) distinct extrusion zones at the crests of the villi and almost no signs of enterocyte extrusion along the sides of the villi, and (2) regular enterocytes with polygonal, flat, apical surfaces covered by a thick glycocalyx that obscured the underlying microvilli.

Oral health in coeliac disease and cow's milk protein intolerance.

The oral health of 24 children and adolescents, 19 with coeliac disease (CD) and 5 with cow's milk protein intolerance (CMPI) were compared with that of 24 randomly selected paired controls. Mineralisation disorders in the form of hypoplasias and/or opacities occurred in 74% of the cases of CD and 68% of their controls. All 5 cases with CMPI had mineralisation disorders, as did 2 of their controls. The disorders usually took the form of opacities, and both these and the hypoplasias were of a mild nature in all the groups. Serious hypoplasias did not occur at all. The caries status was, on average, better in the CD and CMPI groups than in the controls. Recurrent oral lesions occurred with almost the same frequency in the intolerance groups and in the controls. The study, therefore, gave no clear evidence that CD or CMPI involves a significant risk of poorer oral health, provided adequate paediatric and dental care is given.

Lingual lipase. Its role in lipid digestion in infants with low birthweight and/or pancreatic insufficiency.

At birth both pancreatic lipase and carboxylic ester hydrolase, two important lipolytic enzymes secreted by the pancreas, are present in duodenal contents but the activities of these enzymes are low. Another enzyme of possible importance in lipolysis is the lingual lipase which is secreted from serous glands present at the posterior part of the tongue. The enzyme is present already at birth and has been found in gastric contents from preterm infants in the 34th gestational week. The secretion of lingual lipase is stimulated by feeding and it is resistent against acid inactivation. The activity in gastric contents increases after feeding. This lipase hydrolyzes dietary triglycerides to mainly diglycerides and free fatty acids and may serve as a complement to the poorly developed pancreatic lipase activity. Furthermore, by the formation of polar lipolytic products the digestibility of dietary lipids in the duodenum may increase. Human milk lipase contributes to the lipolysis. It is inactive in the milk but becomes activated by the bile acids in the duodenum. Balance studies in preterm infants have shown that by pasteurization of human milk fat absorption decreases by one third.

Lingual lipase: an important lipase in the digestion of dietary lipids in cystic fibrosis?

A convenient lipase assay that discriminates between pancreatic and lingual lipase activities was developed to describe some properties of the triglyceride-hydrolyzing activities of lingual lipase (from von Ebners glands) and pancreatic lipase. Secretion of lingual lipase is stimulated by feeding. Gastric contents collected postyprandially from patients with cystic fibrosis (CF) contained lipase activity which is probably secreted from pharyngeal tissues. Also, duodenal contents from CF patients contained lipase activity with properties very close to those found in gastric contents from CF patients and controls. Apparently, the serous glands responsible for the secretion of lingual lipase is less affected than the exocrine pancrease in this disease. During fat balance experiments, CF patients utilized around 40% of the dietary lipids and more than 50% of milk lipids given as a test meal were hydrolyzed in the duodenum within 2 hr. In these patients with severe pancreatic insufficiency, we suggest that the lingual lipase is responsible for a considerable proportion of triglyceride hydrolysis. This hydrolysis starts in the stomach and continues in duodenum.

Collecting and banking human milk: to heat or not to heat?

Data on human breast milk and its handling when fed to babies who cannot be breast-fed were reviewed to determine whether the method of processing and storage affected the properties of the milk. Breast milk is normally contaminated by potential pathogens, which seem to produce no ill effects, but it also contains antimicrobial properties which protect against infection. The evidence suggests that pasteurisation not only eliminates pathogenic bacteria but also damages bacteriostatic mechanisms, so making the milk more susceptible to later contamination. Pasteurisation also affects the nutritional properties of milk. Freezing has little effect on milk proteins, while a study on the effect of refrigeration showed that there was little bacterial growth at temperatures below 8 degrees C. Several years' experience of feeding donated raw milk to newborn infants has confirmed that it produces no ill effects. These findings suggest that pasteurisation of donated breastmilk is unnecessary, and it is not recommended, while the decision whether or not to freeze the milk may be made on practical grounds. Raw breast milk can be safely stored at 4-6 degrees C for 72 hours.

Decrease of lipase and esterase activities in intestinal contents of newborn infants during test meals.

Both lipase and esterase activities were present in intestinal contents of all newborns studied, from the first day of life. In adults given a test meal lipase activity increased and esterase activity remained unchanged. In contrast, both activities decreased markedly in infants on feeding. During the digestion of the test meal the lipase activity in intestinal contents of the infants was much lower than in adults (ratio of median values 1:27) and the esterase activity was also several fold lower (ratio of median values 1:1.3). Speculation Newborn infants often absorb lipids less efficiently than adults. One contributing factor may be that their incompletely developed pancreas responds to feedings with comparatively low outputs of lipolytic enzymes. The newborn may be more dependent than adults on auxiliary sources of lipase activity such as the pharyngeal lipase and/or the bile-stimulated lipase in human milk.

On the source of lipase activity in gastric contents.

--A convenient assay procedure for determination of the activity of pharyngeal lipase (gastric content lipase), using a long chain triglyceride as substrate, is described. Lipase activity in extracts of rat tongue, salivas collected from the upper esophageal pouch from two human newborns with congenital esophageal atresia and in gastric content obtained from an infant with pyloric stenosis were studied. Optimal lipase activities of the three enzyme sources were found in the same pH-range. During hydrolysis the composition of the products formed were also similar. The data presented indicate that at least some of the lipase activity which is responsible for lipolysis in the stomach of the newborn, originates in pregastric tissues.

Role of feeding on lipase activity in gastric contents.

Lipase activity was recorded in gastric contents collected from healthy term and preterm neonates. In contrast to pancreatic lipase activity this lipase activity was higher at pH 5.5 than at pH 8.0 and it was more resistent to acid inactivation. Lipase activity was found in gastric contents from all infants who were regularly fed, but was not present in gastric contents from some infants when collected before regular feeding was established. During test meals lipase activity in gastric contents increased considerably in all infants studied. During such a test meal there was a progressive relative decrease in triglycerides whilst diglycerides showed a relative increase suggesting an active lipolytic process in the stomach. An assay procedure for determination of lipase activity in gastric contents is also described.