[Use of ranitidine in children's before and after an educative intervention with resident's in a third level pediatric hospital]. / Uso de ranitidina en niños antes y despuésde una intervención educativa en residentes de un hospital pediátrico de tercer nivel.

BACKGROUND: The H2-receptor blockers are often prescribed, but its good tolerance and accessibility have contributed to the abuse of these drugs. The lack of medical knowledge of the precise use of ranitidine involves a higher cost of care and possible errors. OBJECTIVE: To evaluate the use of ranitidine in a pediatric hospital of third level before and after an educational intervention for medical residents. MATERIALS AND METHODS: We reviewed 240 clinical files, taken at random from hospital wards, excluding emergency room and intensive care unit. The correct indications and the precise dose of the drug were verified. Ninety-three medical residents of each grade of the Pediatric residency were evaluated with an initial survey (IS). Each resident was handed a document with the indications,dosage of medicine and pharmacology. A month later, a second survey (SS) to the medial resident and clinical file was performed. RESULTS: The justified indication of ranitidine increased from 52.1 to 66.6% and not justified fell from 47.8 to 33.3%, the error in the prescription increased from 10.8 to 19.0% in the (SS) despite the educational intervention. CONCLUSION: The educational intervention on residents decreased prescribing of the drug when it is not justified; however more training and assistance to doctors and nurses is needed to avoid errors in prescribing and to prevent adverse effects.

An outbreak of Cryptosporidium diarrhea in a pediatric hospital.

PIP: Physicians investigated a nosocomial diarrhea outbreak among 11 2 year old undernourished children in the nutrition service of the pediatric teaching hospital, Hospital Infantile, in Mexico City, Mexico in April 1988. Health practitioners took at least 2 stool samples from each ill child to be analyzed for Cryptosporidium oocysts. The attack rate stood st 82%. The hospital admitted a malnourished child with chronic diarrhea and pneumonia on March 22. Laboratory tests revealed that he had many Cryptosporidium oocysts and was positive for HIV. Hospital staff did not isolate him. He died on May 9 of Escherichia coli and Candida septicemia. The outbreak ended 1 week later. Laboratory tests detected Cryptosporidium oocysts in 9 cases all of whom were 3-13 months old. Further the symptoms (mean duration 14 days, fever [mean peak 38.6 degrees Celsius, and vomiting] matched those of other reported Cryptosporidium diarrhea outbreaks. The epidemic curve suggested a common source of the outbreak. Since the infants received intravenous feedings or sterilized formula, food and water could not have been the source. The physicians believed the AIDS case was that source. Direct person to person transmission was probably not responsible since each infant had his/her own separate crib. Even though the physicians could not conclusively identify the vehicle of transmission, it was most likely the hands of hospitals staff either directly by touching the infants or by contaminating the nasogastric tubes. After the outbreak, the physicians observed that only 30% of medical personnel indeed washed their hands before caring for an infant. 4 previous studies on nosocomial Cryptosporidium diarrhea outbreaks also reported the source case as immunodeficient, but these studies only included adults.^ieng

[Supplementation of DL-alpha-tocopherol acetate in children with chronic cholestasis and vitamin E deficiency]. / Suplementación de DL-alpha-tocoferol acetato oral en niños con colestasis crónica y déficit de vitamina E.

OBJECTIVE: To determine the oral supplement doses of dl-alpha-tocopheryl-acetate to maintain normal serum alpha-tocopherol concentrations in children with chronic cholestasis and vitamin-E deficient. BACKGROUND: Malabsorption and deficiency of vitamin E in children with chronic cholestasis causes a progressive, neuromuscular degeneration at approximately 18-24 months of life, if left untreated. Using prompt treatment, it can be completely prevented and reversed to normal. METHOD: Longitudinal, prospective and comparative study was performed on consecutive sixty vitamin E deficient children with chronic cholestasis divided in three groups. After initial evaluation, therapy was started for 15 days in each group with 100 IU, 200 IU and 400 IU/day of oral dl-alpha-tocopheryl-acetate, respectively; alpha-tocopherol-status, neurological function and biochemical parameters were monitored during therapy. RESULTS: Any oral supplement does administrated for 15 days of dl-alpha-tocopheryl-acetate were enough to maintain the normalization of alpha-tocopherol status (p > 0.06). Neurological function, which had not deteriorated before entry in the trial, stabilized in all after 15 days of therapy. No adverse effects were observed. CONCLUSIONS: Oral supplement of dl-alpha-tocopheryl-acetate for 15 days with 100 IU, 200 IU, and 400 IU, in spite of safety, weren't enough to maintain the alpha-tocopherol serum concentration in children with chronic cholestasis and vitamin-E deficient.

Intestinal absorption of manganese in experimental malnutrition.

We investigated possible changes in mechanisms of the intestinal absorption of Mn in rats malnourished with a low protein-low energy diet (M) for 4 weeks against controls fed a complete diet (C) during the same period. The absorption of Mn in the absence or in the presence of two small molecular weight ligands, citrate and L-histidine, was studied by an in vivo procedure. In both M and C rats, jejunal Mn absorption decreased linearly with time and was enhanced by the presence of the low molecular weight ligands. The initial rate of absorption, for Mn alone, was higher in M than in C rats, but it was indistinguishable between both groups in the presence of either citrate or L-histidine. Total Mn absorption, in midperfusion, was greater in M than in C animals with no ligands in the solutions (means +/- SEM, M = 2,969 +/- 923 vs. C = 654 +/- 218 pmol/cm, p less than 0.05). However, in the presence of citrate or L-histidine, the well-nourished rats absorbed more Mn than M rats. Also, water fluxes across the mucosa had a positive correlation with Mn transport when the ligands were present. This solvent drag of the trace element was not operant in the absence of citrate or L-histidine. These data indicate that the jejunal mucosa of M rats absorbs Mn more effectively than C animals, independently from water fluxes and the presence of small molecular weight chelators. These substances do not alter the uptake of Mn in growth-retarded rats, while they enhance the absorption of the trace metal in well-fed animals.

In vivo intestinal absorption of manganese in the rat.

The mechanisms of intestinal absorption of Mn in rats and the effects of low-molecular-weight ligands in this process were investigated using an in vivo perfusion system. Segments of either jejunum or ileum were perfused with isotonic solutions containing 0.0125 to 0.1 mM MnSO4 X 7H2O, in the presence or absence of double its concentration of either L-histidine (His) or citrate (Cit). In all cases the absorption of Mn declined with time; for example, in the absence of ligand Mn absorption fell from (means +/- SEM) 16.0 +/- 2.2 at 30 minutes to 2.3 +/- 4.1 pmol/(minute X cm) after 90 minutes of perfusion. Comparable declines occurred both in the jejunum and in the ileum in the presence of His or Cit. The initial absorption rates of Mn, obtained by extrapolation, were higher in the jejunum when His or Cit were present than when no ligands were included in the perfusate [means +/- SD, with His, 66.4 +/- 11.9; with Cit, 79.5 +/- 6.2; none = 17.8 +/- 3.3 pmol/(minute X cm)]. In the ileum, optimum absorption with His was observed between pH 7 and 8. The kinetics of in vivo Mn ileal absorption in the presence of His yielded a Kt of 0.056 mM and an estimated Vmax of 158 pmol/(minute X cm). The coefficient of diffusion was calculated to be 1.5 X 10(-3) cm2/minute. These data are compatible with a high affinity, low capacity, active transport mechanism for Mn in the rat intestine and suggest a limited role for small-molecular-weight ligands associated with both diffusional or active translocation processes.

[Manganese determination in blood from malnourished children]. / Determinación de manganeso en suero en niños desnutridos.

We investigated the serum manganese (Mn) concentration of 52 children less than two years old. 22 of them were healthy controls (C), 13 had marasmatic (M) malnutrition and 17 kwashiorkor (K). The measurements of Mn were done in an atomic absorption spectrophotometer with a graft furnace oven. The serum was diluted with 1% triton X-100. For the quantification of Mn we used the addition method. There was a significant difference between the levels of Mn measured in the M group (1,582 +/- 0.673 micrograms/L), and the K group (1,811 +/- 0.700 micrograms/L) and levels obtained in the controls (3,212 +/- 1,247 micrograms/L). When we compared the concentration of Mn by sex or age in each group, we didn't find any significant difference. We conclude that the severe malnourished children in our study present lower concentrations of Mn as compared with controls.

Differential absorption of zinc and low-molecular-weight ligands in the rat gut in protein-energy malnutrition.

The differences in zinc absorption in the presence of four low-molecular-weight ligands in the jejunum, ileum and colon of protein-energy malnourished juvenile rats (M), and their controls (C) were investigated. An in vivo perfusion procedure was applied to vascularly intact segments of the three areas of the gut. The absorption of L-proline and L-histidine, and a hydrolysis-resistant dipeptide, glycylsarcosine, were also determined. In certain instances, the M rats absorbed zinc at a lower rate than the C animals. This effect was especially consistent throughout the gut when glycylsarcosine was present in the perfusates. In the colon, zinc, but not the amino acids, was taken up. Glycylsarcosine was well absorbed by the colon in both the M and C rats. The data indicate that protein-energy deficiency may impair the absorption of zinc by the rat intestinal mucosa in the presence of low-molecular-weight substances of high affinity for zinc, without altering the absorption of amino acids, or of zinc organometallic complexes in which the metal is tightly bound. The two contrasting situations may be relevant to alleviating zinc deficiency in nutritionally compromised conditions.

Successful use of a chicken-based diet for the treatment of severely malnourished children with persistent diarrhea: a prospective, randomized study.

OBJECTIVE: To evaluate the efficacy of a chicken-based diet for the treatment of persistent diarrhea in severely malnourished children. STUDY DESIGN: Prospective, randomized, double-blind study that compared a chicken-based diet with elemental (Vivonex) and soy (Nursoy) diets. Hospitalized children with third-degree malnutrition and persistent diarrhea, aged 3 to 36 months, were included. Diets were isocaloric and given nasogastrically at 150 ml/kg per day in progressively increasing concentrations. RESULTS: Fifty-six children were included (18 received Vivonex, 19 Nursoy, 19 chicken). They had a mean age of 6.4 +/- 4.4 months, a mean weight of 3604 +/- 1232 gm, and a mean weight-for-age percentage of 51.4% +/- 7.2%. Sixty-four percent had associated conditions on admission to the hospital. Forty-one children (73.2%) were successfully treated (13 Vivonex, 13 Nursoy, 15 chicken). There were no differences in diarrheal outcomes, and all groups had significant weight gain. Failure was independent of the diet and was associated with the presence of infection on admission. There was a significantly higher nitrogen balance in the children from the chicken group (358.2 +/- 13 mg/kg per day) than in those receiving Vivonex (226.6 +/- 61) or Nursoy (291-4 +/- 111.6; p < 0.05) groups. CONCLUSIONS: The chicken-based diet was as effective as Vivonex or Nursoy. It is well tolerated, inexpensive, and widely available and thus represents an effective and inexpensive alternative to the treatment of severely malnourished children with persistent diarrhea.

[Intraesophageal pH in children with suspected reflux]. / pH intraesofágico en niños con sospecha de reflujo.

We study 22 children with clinical symptoms of gastroesophageal reflux. The main manifestations were: frequent vomiting, failure to thrive and repetitive pneumonia. In all of them we perform barium esophagogram (SEGD) with fluoroscopy, esophageal manometry (EM) and a four hours intraesophageal pH measurement. Thirteen of the twenty two children present a pathologic reflux (ERGE); in 16 we found SEGD that show reflux; three of them had an abnormal EM, the other 13 were normal. Seven patients showed alteration of the intraesophageal pH measurement. In conclusion the intraesophageal pH measurement in short period of time (4 hours) is a good method in the diagnosis of patients with ERGE.

Treatment of intractable constipation in children: experience with cisapride.

To establish whether cisapride is beneficial in children with intractable constipation, an open trial was performed. Chronically constipated children who had failed at least 12 weeks of medical therapy received cisapride at a dose of 0.2 mg/kg/dose TID for 12 weeks. Children with pelvic floor dyssynergia were excluded. Patients were followed prospectively for at least 12 months. Thirty children were initially enrolled, and 27 (14 boys, 13 girls) completed the study. At the end of 12 weeks of cisapride treatment, there was a significant increase in the number of bowel movements per week (1.43 +/- 0.52 to 6.48 +/- 4.16; p < 0.05) and significant decreases in the number of accidents per day (2.86 +/- 2.71 to 0.52 +/- 1.23; p < 0.05) and doses of laxatives used per week (14.33 +/- 5.84 to 3.37 +/- 7.10; p < 0.05). Encopresis disappeared in 65.2% of cases (p < 0.0001) and improved in 26%. Sixty-nine percent of the patients stopped using laxatives (p < 0.001). After 12 weeks 18 patients (66.6%) were asymptomatic, seven (25.9%) showed some improvement in bowel movement frequency and number of accidents, and two (7.4%) showed no improvement. The cisapride was well tolerated. After long-term follow-up (20 +/- 9.8 months), 37% of patients had recovered (asymptomatic and off laxatives and cisapride) and 29.6% were still asymptomatic but were using laxatives or cisapride. There were no differences in baseline characteristics between recovered and nonrecovered patients. We conclude that cisapride is effective in the treatment of some children with intractable constipation without pelvic floor dyssynergia.

[Selective IgA deficiency and malabsorption. Review of the literature apropos of a case]. / Deficiencia selectiva de IgA y malabsorción. Revisión de la literatura a propósito de un caso.

One of the most common primary immunodeficiencies is the selective deficiency of IgA, which is present in very variable clinical conditions. This situation had conducted to different criteria with respect to the clinical meaning in a particular patient. The association of immunodeficiency of IgA and intestinal malabsorption is reported as statistically significant in the international literature. Nevertheless, the precise pathogenic connection between them is unknown. The relationship between bowel and immune system is reviewed here, and illustrated with the clinical case of a six-year old girl who presented with malabsorption and selective deficiency of IgA.

Cisapride for the treatment of constipation in children: A double-blind study.

OBJECTIVE: To determine whether cisapride is effective in the treatment of children with constipation. STUDY DESIGN: Double-blind, placebo-controlled study in which children with chronic constipation were randomly assigned to treatment with cisapride or placebo for 12 weeks. RESULTS: Forty children were enrolled, and 36 completed the therapy. Treatment successes occurred in 13 of 17 (76%) subjects in the cisapride group and 8 of 19 (37%) subjects in the placebo group (P <.03). The odds ratio for response after cisapride administration was 8.2 times higher (95% CI 1.3 to 49.4). During cisapride therapy, there was a significant improvement in number of spontaneous bowel movements per week (from 0.9 +/- 0.1 to 4.1 +/- 1.1), and there was a significant decrease in number of fecal soiling episodes per day (1.8 +/- 0.5 to 0.08 +/- 0.4), percent with encopresis (82% vs 23%), number of laxative doses per week (from 10.3 +/- 2.6 to 0.8 +/- 0.6), percent using laxatives (77% to 24%), and total gastrointestinal transit time (from 115.0 +/- 3.7 hours to 77.0 +/- 11.1 hours). With placebo, there were no significant changes in the number of spontaneous bowel movements (from 1.0 +/- 0.8 to 2.2 +/- 0.6), percent with encopresis (74% vs 47%), or total gastrointestinal transit time (from 112.5 +/- 4.9 hours to 95.4 +/- 9.8 hours); but there was a significant decrease in number of fecal soiling episodes per day (from 1.3 +/- 0.4 to 0.4 +/- 0.2) and number of laxative doses used per week (from 11.5 +/- 2.9 to 2.05 +/- 0.7). The final number of spontaneous bowel movements, fecal soiling episodes, laxatives used, or percent patients with encopresis was not different when patients receiving cisapride were compared with those receiving placebo. CONCLUSION: Cisapride was effective in the treatment of children with constipation.

Nutritional management of regurgitation in infants.

Infantile regurgitation is a frequently occurring problem. Throughout the world, anxious parents are imploring physicians to eliminate their infant's regurgitation. General practitioners, pediatricians and pediatric gastroenterologists strive to alleviate infantile regurgitation and its related parental stress. In this paper we define the scope of the problem and analyze the optimal, cost-efficient management approach to simple regurgitation in infants. The intent of this paper is to disseminate this information to practicing physicians and other health care professionals in an attempt to minimize the impact of this annoying problem of infancy and to eliminate confusion and expensive diagnostic tests and use of sub-optimal treatment modalities. Parental reassurance and dietary management by feeding thickened formula are important components in managing regurgitation in infants while maintaining optimal nutritional intake for adequate growth and development.