In the critically ill, nothing-by-mouth infant, would enteral administration of simulated amniotic fluid improve feeding tolerance compared with the current practice of no therapy? An evidence-based review

Necrotizing enterocolitis (NEC ) can be a devastating disease in the NIC U population. The current standard of practice of not providing enteral nutrition to the critically ill and the premature infant is thought to result in pathophysiologic changes of the gastrointestinal (GI) tract that may result in the development of NEC. Various methods of preventing or reducing the incidence of NEC in the NIC U have been explored. One such method is the enteral administration of simulated amniotic fluid (SAF). This article compares, contrasts, and reviews the available evidence regarding the use of SAF feedings as a means of reducing GI tract changes associated with nothing-by-mouth (NPO) status.     

Gastrointestinal pathology in neonates: new imaging strategies

The mainstay of imaging of gastrointestinal (GI) pathology in infants has always been and still is the plain radiograph of the abdomen and conventional contrast studies. In this review emphasis is placed on the situations where there are new imaging strategies and alternative modalities of imaging, including US, CT, MRI and radionuclide studies. This review will deal with GI pathology in the newborn and in the older neonate. It will also refer to any new approaches to imaging GI pathology in the premature infant. Finally the review will address how antenatal diagnosis of gastrointestinal tract abnormalities has changed the imaging strategy and management of the neonate.     

Neonatal metrizamide gastrointestinal series in suspected necrotizing enterocolitis

The diagnosis of necrotizing enterocolitis (NEC) in neonates may be made by clinical presentation, roentgenographic findings, or a combination of both. Diagnosis leads to immediate treatment including nasogastric suction, parenteral antibiotics, plasma, and close monitoring of clinical, roentgenographic, and laboratory findings. Occasionally, neither the clinical nor plain roentgenographic appearance of an infant allows the diagnosis of NEC to be made or excluded with confidence. In such infants portable isotonic metrizamide gastrointestinal (GI) series were used to help make the decision of whether to begin treatment for NEC or to continue feeding the patient. Of 15 patients examined, two exhibited signs of NEC and were successfully treated medically without GI (tract) sequelae. Twelve neonates had normal results of metrizamide GI series and ten were immediately fed with no GI complication. One of these 12 infants had feedings withheld for several days as a result of a positive blood culture. One infant with severe cardiac and pulmonary disease had profound adynamic ileus and could not be fed. We have found the metrizamide GI series to be a useful study in neonates suspected of having NEC.     

Enteral administration of hematopoietic growth factors in the neonatal intensive care unit

GI trophic factors have been identified that influence the prenatal and postnatal growth and development of the GI tract. Systemically as well as enterally administered growth factors can stimulate GI growth and maturation, suggesting that trophic factors in the serum of neonates can modulate GI growth via receptors on the serosal membranes of enterocytes. GI trophic factors can be synthesized endogenously or provided prenatally in amniotic fluid and postnatally in human milk.
GI trophic factors in human milk play an important role in regulating the adaptive functional changes that accompany the transition to postnatal enteral feedings. Although human milk growth factors are not essential for infant survival, the elevated risk of GI-related illnesses in formula-fed compared with human milk-fed infants suggests that bioactive compounds in human milk contribute to the protective effects of human milk feedings (13).
GI trophic factors have the potential to be used therapeutically to enhance GI maturation and repair following injury. These applications may be particularly useful in the premature or postsurgical infant. Several issues require further research, including: (i) the efficacy of oral versus systemic administration; (ii) characterization of the complex interactions among the various growth factors; (iii) the effect of exogenously administered growth factors on endogenous production of that factor, its receptor or other growth factors; (iv) the effect of growth factors upon tissues not directly associated with the GI tract; and (v) the determination of safe and effective limits. Significant advances in feeding strategies to reduce feeding intolerance in the neonate are likely to occur with the application of these principles in clinical neonatology.     

Weak analgesics and nonsteroidal anti-inflammatory agents in the management of children with acute pain

The PSIs include acetaminophen, NSAIDs, and salicylates. They can be used alone for the treatment of mild pain or as an adjunct to opioid analgesia. In children, most experience is with acetaminophen and ibuprofen. For the treatment of mild to moderate pain, these agents can be administered as needed or at fixed intervals. The latter dosing scheme may provide a more consistent serum level, thereby improving analgesia. The major advantages of acetaminophen are its availability as a suppository for PR administration and its lack of effects on renal and GI function, adverse effects that may be seen with the NSAIDs. Many of the effects on platelet functioning, RBF, and the GI tract may be eliminated with the introduction of NSAIDs that selectively inhibit COX II without effects on COX I, the enzyme present in the GI tract, renal system, and platelets. Future evaluations with these agents in the pediatric population are needed. For more severe pain, the NSAID salicylate or acetaminophen can be combined with a weak opioid, such as codeine, oxycodone, or hydrocodone. When using oral analgesics, factors that may interfere with effective analgesia include a child's refusal to take the medication, ineffective doses and dosing regimens, decreased bioavailability following PO administration, inability to tolerate PO medications because of nausea or vomiting, altered GI motility, and a delayed onset caused by slow absorption. With such caveats in mind, the PO route provides an effective and cost-effective means for many patients. It should be considered as the primary route for pediatric patients in the treatment of mild to moderate pain, even in the hospital setting.     

Enteral administration of hematopoietic growth factors in the neonatal intensive care unit

By 20 wk of gestation, the human fetal gastrointestinal (GI) tract morphologically resembles that of the term infant, but functional development is limited before 26 wk. By 30 wk of gestation, the fetus has the capacity for limited digestion and enteral absorption. GI growth and development continue postnatally. Trophic factors, including nutrients, peptides, hormones and growth factors, are recognized as having important influences on the morphology and histology of the developing GI tract. Other trophic factors are important in adaptation and repair following injury. Many such factors are provided in utero via amniotic fluid swallowing and later by human colostrum and milk. CONCLUSION: This review discusses cytokines with known GI trophic effects, either in vitro or in vivo, and focuses on those cytokines that have been used in the neonatal intensive care unit.     

The impact of development of the gut on infant nutrition

We have described the developmental pattern of the GI tract, constituent tissues of which do not develop simultaneously, either functionally or morphologically. Dietary modifications to suit the stage of development have been described, and possible changes resulting from these modifications are also discussed. It is important to note that the newborn period is a time in which rapid development is taking place while the GI system is still not fully mature, hence the macro- and micronutrients given during this period should be adjusted both quantitatively and qualitatively to suit the needs of the infant, particularly so if he is premature or compromised.     

Intestinal obstruction caused by duplication of the caecum

Two cases of caecal duplication are presented, one in a neonate and one in an infant. The diagnosis was made at laparotomy, which had been undertaken for the presumptive diagnosis of intestinal atresia and torsion of an ovarian cyst respectively. Also the literature on alimentary tract duplications is reviewed, referring to the incidence, presenting symptoms, and location of the duplication, in particular that of the caecum.     

Effect of a hyperosmolar solution on the small intestine of newborn rats: irreversible damage and overgrowth of bacteria

The effect of a hyperosmolar solution (gastrografin, Schering, 1,750 mosm/l) on the gastrointestinal (GI) tract of newborn Wistar rats was studied. The rats received an inoculum of Klebsiella bacteria on the 1st day of life, following which gastrografin was given twice daily via an orogastric tube. All the rats receiving gastrografin showed GI symptoms from the 3rd day of life, and 80% died before completion of the experiment on the 7th day. Macroscopic and microscopic examination of the GI tract revealed gross changes confined to the small intestine. Specimens from stools and peritoneal cavity for culture of Klebsiella obtained immediately after killing were positive in the rats that had received gastrografin. Control rats had no GI symptoms and showed normal findings at autopsy; cultures obtained from stools and peritoneal cavity were all negative. This experiment indicates that in newborn rats a continuous hyperosmolar load in the GI tract causes irreversible damage to the small intestine; promoting the growth of pathogenic bacteria and providing a means for translocation of the micro-organisms to the abdominal cavity.     

肠道共生细菌和肠上皮屏障间关系的研究进展

人类出生后,其胃肠道黏膜表面与肠道共生细菌和致病性病原体密切接触.肠道上皮屏障作为抵御细菌入侵的第一道防线,通过模式识别受体产生对致病性病原体杀伤性免疫应答,而对共生细菌产生保护性应答.肠上皮细胞在对共生细菌形成免疫耐受,维持肠道免疫稳态中发挥重要作用.共生细菌能协助肠道上皮抵御病原体侵袭,并调节肠道免疫发育和免疫功能.在共生细菌和宿主肠道之间形成免疫平衡,否则易引起肠道炎症疾病.该文从共生细菌对宿主肠道的作用、肠上皮屏障对共生细菌形成免疫耐受机制以及肠道上皮屏障对共生细菌识别平衡破坏引起的疾病等多方面对共生细菌和肠上皮屏障之间关系作一综述.     

Neurenteric cyst of the mediastinum--case report and review of the literature

A case of an infant with a mediastinal neurenteric cyst is used to review this rare entity. By definition a neurenteric cyst is the combination of an entodermal cyst with a vertebral dysplasia. Neurenteric cysts are located in the posterior mediastinum, preferentially on the right side. In a third of the patients these cysts are associated with malformations of CNS a./o. GI tract. They occur predominantly in males. The symptoms of a mediastinal mass usually become obvious during the first months of life. The therapy of choice is complete resection.     

Gastrointestinal malignancy in cystic fibrosis

Cystic fibrosis (CF) is a multisystem disease affecting the gastrointestinal (GI) tract as well as the lungs. As survival has increased significantly over the past few decades, complications not seen previously have become apparent. There is an overall increased rate of malignancy in CF, particularly from the GI tract and in the post-transplant population. The most common sites of malignancy are the pancreatico-biliary and digestive tract, as well as an increased rate of testicular cancer. Using an illustrative case of metastatic oesophageal malignancy which initially appeared to be hepatic in origin, we have reviewed the literature surrounding malignancy in CF with a particular focus on the GI tract.     

Cholelithiasis in infants with Down syndrome. Three cases and literature review.

Only four cases of cholelithiasis have been reported in patients with Down syndrome and none in Down syndrome infants. The cases of three Down syndrome infants (all males) with cholelithiasis are reported. Each exhibited different fetal complications, and in each, Down syndrome was diagnosed at birth. Gallstones apparently were congenital (a rarity) in one infant, since they were detected on the first day of life. Cholelithiasis was an incidental finding in another of the infants when, at 12 weeks old, he had renal ultrasonography because of a urinary tract infection. The third infant was 4 months old when sonographic studies revealed a gallstone. Despite the confirmation of cholelithiasis in all three infants, none has since had any signs or symptoms that suggest the need for intervention. Cholelithiasis is probably more common in Down syndrome infants than has been supposed, but whether Down syndrome infants with gastrointestinal (GI) malformations are more likely to have gallstones than are children with similar GI malformations but with normal karyotypes is unknown.     

博卡病毒感染与婴幼儿喘息性疾病

喘息性疾病是婴幼儿常见的呼吸系统疾病,发病率逐年上升.呼吸道病毒感染是诱发婴幼儿喘息的重要因素.近来研究发现,博卡病毒也与婴幼儿喘息性疾病有关,研究两者之间的关系将对婴幼儿喘息性疾病的防治具有重要意义.     

Massive lower gastrointestinal hemorrhage caused by CMV disease as a presentation of HIV in an infant

The gastrointestinal (GI) manifestations of acquired immunodeficiency syndrome in children are related to opportunistic infections like cytomegalovirus (CMV). CMV disease of the GI tract is a major cause of morbidity and mortality in immunocompromised patients: it typically produces mucosal ulcerations that can result in pain, bleeding, diarrhea, and GI perforation, often around the cecum. Preoperative diagnosis may be difficult, plain films and barium enema are often nonspecific, and endoscopic evaluation is impossible when there is massive bleeding. The patient usually needs surgery to establish the correct diagnosis and initiate appropriate treatment. The use of gancyclovir for CMV disease in the postoperative period has improved the prognosis. Accepted: 26 April 1999     

Atresias of the gastrointestinal tract in an inbred, previously unstudied population

 Retrospective analysis of the records of newborns with gastrointestinal (GI) atresias in a 16-year period revealed that more than 25% of patients had genetically-influenced atresias. Among these, an appreciable increase was observed in atresias confined to the antral region and in a syndrome of hereditary multiple GI atresias. In the absence of environmental and teratogenic factors, this increase could be due to the traditional social practice of endogamy in this population. However, this clinical finding remains to be supported by relevant prospective genetic studies. Accepted: 5 June 2000     

Gastrointestinal blood flow and oxygen consumption in the newborn lamb: effect of chronic anemia and acute hypoxia

The purpose of this study was to investigate the compensatory change in circulation and oxygenation of the newborn lamb gastrointestinal (GI) tract in response to anemic and hypoxic hypoxemia. Radiolabeled microspheres were used to measure blood flow. We subjected the newborn lamb to a 30-35% reduction in hematocrit 4 d before study and to a 10% oxygen environment for 30 min during the study to induce chronic anemic and acute hypoxic hypoxemia, respectively. The circulatory and oxygenation responses were measured 1 h after a standard milk feeding in all cases. During the experimental periods, no change in total GI blood flow was observed. Because of a failure to augment blood flow during hypoxemia, O2 delivery to the GI tract decreased significantly. Despite this, GI O2 consumption was not compromised because tissue O2 extraction by the GI tract rose significantly. The response of the newborn lamb GI tract to hypoxemia after feeding is augmentation of O2 extraction. The newborn's GI tract did not regulate local GI blood flow.     

Can we predict or prevent sudden unexpected deaths during infancy?

Mechanisms for sudden unexpected infant deaths remain unproven but the possibilities include cardiac arrhythmias, hypoglycaemia, prolonged apnoea from central respiratory control failure, seizure-induced apnoea, prolonged airway obstruction and alveolar atelectasis. Many of these mechanisms could be treated if the infant at risk could be identified. To date, identification programmes have not been sufficiently sensitive or specific. All the evidence presently available suggests that clinical and socioeconomic factors alone will not be sufficient and that as yet unidentified physiological or biochemical measurements must be included in a scoring system if such an approach is to be effective. Epidemiological studies have shown that a suboptimal intrauterine environment and respiratory tract infections during early infancy are present to excess in future victims. Improvements in antenatal and postnatal care, particularly to mothers from areas of socioeconomic deprivation, will almost certainly reduce the incidence of sudden infant deaths. Certain respiratory tract infections may induce episodes of severe hypoxaemia due to abnormal apnoea and therefore it is not only essential that the infection risk in young infants from pertussis is minimized by immunization of the childhood population but also that methods of preventing other infections, such as respiratory syncytial virus, are developed and applied as soon as possible. Re-organization of mother and baby clinics and mother and baby social groups in order to minimize contact between young infants and pre-school children may reduce cross-infection by respiratory tract pathogens.     

Intestinal IgA deposition in Henoch-schönlein purpura with severe gastro-intestinal manifestations

Abstract In patients with Henoch-Schönlein purpura (HSP) presenting with severe gastro-intestinal (GI) symptoms, IgA deposition was studied in endoscopically obtained mucosal biopsies. A total number of 11 patients (male, 7; female, 4) were enrolled in this study; 7 patients underwent upper GI endoscopy and biops 1 underwent sigmoidoscopy and 3 underwent both. Upper GI endoscopy in each patient showed various mucosal changes including redness, petechiae, erosions, and ulcerations, most predominant in the second part of the duodenum. Sigmoidoscopy demonstrated no abnormality in two of four patients. Intestinal deposition of IgA was positive in 7 of 11 patients with HSP. Histological examination showed non-specific inflammation of varying degrees in each patient, but no small vessel vasculitis was observed. IgA deposits were seen in only 2 of 23 control subjects with various GI diseases. Positive rate of IgA deposition per patient was significantly higher in patients with HSP than in controls (P<0.005).Conclusion IgA deposition in the GI tract, as in the skin kidneys, is characteristic of HSP. Intestinal IgA deposition complements the diagnostic criferia of HSP.Presented in part at the 4th Pan-Pacific Congress of Paediatric Gastroenterology and Nutrition, Tokyo, September 1994     

肠三叶因子的研究进展

肠三叶因子是三叶肽家族中最重要的小分子多肽,主要分布于肠道.近年研究发现,肠三叶因子还分布于脑、呼吸道、眼部等其他部位.研究基因重组肠三叶因子,将对胃肠道、呼吸道、眼科等疾病的治疗产生深远的影响.