Myth: necrotizing enterocolitis: probiotics will end the disease, and surgical intervention improves the outcome

Necrotizing enterocolitis remains an important contributor to neonatal morbidity and mortality. Recent studies suggest that probiotic supplementation may reduce the risk of the disease in premature infants, and some authors recommend that this approach is ready to be utilized as standard-of-care. Once necrotizing enterocolitis is diagnosed and progresses toward peritonitis or perforation, surgical intervention is thought to improve the outcome, and investigators have suggested that peritoneal drainage is as effective as an exploratory laparotomy. In this chapter, we review the current state of knowledge, and suggest that additional studies are necessary to confirm that probiotics will end this disease, and that surgical intervention may not significantly improve the outcome after diagnosis in these compromised patients.     

儿童过敏性疾病特应性进程研究进展

儿童过敏性疾病患病率日益增高,不容忽视.儿童过敏性疾病存在特应性进程的假说早在1985年即得到证实,具体是指婴儿或儿童早期出现的某种过敏反应症状常预示未来其他过敏性疾病的发生,众多纵向流行病学研究支持这一假说,其中以来自欧洲和北美的研究居多,亦有研究对此假说提出质疑.儿童过敏进程受诸多因素影响,如早年喘息、性别、父母过敏史等.该文就相关研究展开综述,以对高危患儿的识别和及时干预提供线索.     

益生菌在儿童变态反应性疾病中的防治作用

变态反应性疾病逐年升高的发病率已引起全球的关注,严重危害儿童健康,其共同发病机制是机体对常见的吸入性或食物性过敏原产生以特异性IgE介导的或者细胞介导的免疫反应。流行病学调查、粪便菌群分析和临床研究均提示,变态反应性疾病的发生、发展与早期肠道菌群的紊乱密切相关。益生菌可调节肠道免疫反应、增加上皮细胞屏障功能和抑制病原菌的粘附定植,恢复或重建肠道正常微生物群。随着人们对变态反应性疾病认识的加深,益生菌对其防治作用将越来越受到人们的重视。     

Use of nasal filters in naso-bronchial allergy

In atopic individuals, inhalants may lead to a variety of clinical syndromes such as allergic rhinitis, asthma, urticaria and atopic dermatitis. Nasal filters consisting of a stainless steel wire gauze (33 μ pores) have proved useful in providing relief in these individuals.     

Mortality in micro-premature infants with necrotizing enterocolitis treated by primary laparotomy is independent of gestational age and birth weight

Previous reports indicate that mortality in micro-premature infants with surgical necrotizing enterocolitis (NEC) is inversely proportional to gestational age and birth weight. We have observed that patterns of survival in micro-premature infants with NEC appear to be changing and may be influenced by the use of primary laparotomy (PL). Thirty-one infants <1,500 g who underwent surgery for NEC were classified into two subgroups: extremely low birth weight infants <1,000 g (ELBW, N = 17) and very low birth weight infants 1,000–1,500 g (VLBW, N = 14) and the groups were compared. Data were retrospectively collected and analyzed using Chi-square or Fisher’s exact tests for categorical variables and Wilcoxon rank sum test for continuous variables. All 31 patients (100%) had radiographic evidence of pneumatosis intestinalis and all had operative findings of intestinal necrosis while 20/31 (67%) had intestinal perforation. Surgical mortality was 25% (7/28). Three additional patients died greater than 3 months after surgery of causes unrelated to NEC or surgery yielding an overall mortality of 32% (10/31). There were no significant differences in mortality between ELBW and VLBW patients (P = 0.42). The only variables associated with increased mortality were pannecrosis and longer segment of necrotic bowel (P = 0.005). In our neonatal unit, the mortality of micro-premature infants less than 1,500 g with surgical NEC appears to be independent of gestational age and birth weight. Although the small sample size may mitigate the validity of this study, we found that the most important determinants of mortality were pannecrosis and longer length of necrotic bowel.     

Association of food allergy with asthma severity and atopic diseases in Jewish and Arab adolescents

Aim: To investigate the prevalence of reported food allergy and its association with atopic diseases and asthma severity among Jewish and Arab adolescents. Subjects and methods: The self‐report questionnaire of the International Study of Asthma and Allergies in Childhood (ISAAC) was administered to adolescents aged 13–14 years from randomly selected junior high schools in Israel. Questions regarding food allergy were added. Results: A total of 11 171 questionnaires were available for analysis. Food allergy was reported by 3.6% of participants: 1.9% milk, 0.6% egg, 0.6% peanut and 0.4% sesame. On multivariate analysis, food allergy was strongly associated with current asthma (OR, 2.5; 95% CI, 1.8–3.3), atopic eczema (OR, 3.2; 95% CI, 2.4–4.3) and allergic rhinitis (OR, 2.4; 95% CI, 1.8–3.1). Arabs were significantly more allergic to peanut (OR, 2.5; 95% CI, 1.5–4.1), egg (OR, 3.5; 95% CI, 2.1–5.9) and sesame (OR, 2.3; 95% CI, 1.2–4.5) than Jews, and less allergic to milk (OR, 0.6; 95% CI, 0.4–0.9). Asthmatic subjects with food allergy had significantly more parameters of severe asthma than those without food allergy (p < 0.001). Conclusions: The prevalence of allergy to specific foods differs between Jews and Arabs. Asthmatic adolescents with food allergy report more severe asthma than those without food allergy.     

Effect of probiotics on gastrointestinal symptoms and small intestinal permeability in children with atopic dermatitis

OBJECTIVE: To determine whether probiotic lactobacilli may alleviate small intestinal inflammation and strengthen the intestinal barrier function in children with atopic dermatitis. STUDY DESIGN: In a double-blinded, placebo-controlled, cross-over study, probiotic lactobacilli (Lactobacillus rhamnosus 19070-2 and L reuteri DSM 12246) were administered for 6 weeks to 41 children with moderate and severe atopic dermatitis. Gastrointestinal symptoms were registered before and during treatment and small intestinal permeability was measured by the lactulose-mannitol test. RESULTS: During Lactobacillus supplementation, there was a significant decrease in the frequency of gastrointestinal symptoms (39% during the placebo period versus 10% during active treatment, P=.002). There was a positive association between the lactulose to mannitol ratio and the severity of the eczema (r=0.61, P=.02 after placebo and r=0.53, P=.05 after active treatment). After probiotic treatment, the lactulose to mannitol ratio was lower (0.073) than after placebo (0.110, P=.001). CONCLUSIONS: Impairment of the intestinal mucosal barrier appears to be involved in the pathogenesis of atopic dermatitis. The study suggests that probiotic supplementation may stabilize the intestinal barrier function and decrease gastrointestinal symptoms in children with atopic dermatitis.     

Prenatal Diagnosis and Management of Fetal Long QT Syndrome

This report describes a fetus presenting with second-degree atrioventricular block, sinus bradycardia, and transient ventricular tachycardia with ventriculoatrial dissociation. Long QT syndrome (LQTS) was suspected due to the association of heart rhythm disturbances and very short transmitral early deceleration time. This impaired relaxation of the left ventricle was explained by the extreme prolongation of the refractory period caused by the prolonged relaxation time. The infant was treated successfully with beta-blockers and implantation of a pacemaker. The prognosis is poor when LQTS presents utero or during the first week of life. To date, only a few case reports of a fetus with LQTS have been published.     

Effect of interleukin 2 on intractable herpes virus infection and chronic eczematoid dermatitis in a patient with Wiskott-Aldrich syndrome

Recombinant interleukin 2 (rIL2) was administered to a patient with Wiskott-Aldrich syndrome for the treatment of an intractabel facial herpetiforme lesion. This treatment appeared to be effective in suppressing the virus activity. At the same time, a transient improvement of the chronic eczematoid dermatitis was observed. During rIL2 administration, the CD3+ and CD4+ subsets of peripheral blood lymphocytes increased in number. These changes might play an important role in the induction of anti-viral immunity and in the improvement of dermatits.     

Development of height and weight in children with diabetes mellitus: Report on two prospective multicentre studies,one cross-sectional,one longitudinal

Optimal regimen for insulin therapy should lead to normal longitudinal growth and weight gain in children with diabetes mellitus. However, reports published so far indicate that this goal of paediatric diabetology is currently not achieved in a considerable number of patients. In a cross-sectional sample of 89 children with insulin dependent diabetes mellitus (IDDM) for more than 3 years, we found the relation of height to weight to be significantly different compared to 102 healthy school children of similar age. Using bivariate analysis, body shape in these children with diabetes was shifted towards small and obese (P<0.05) compared to control children. We subsequently initiated a longitudinal study and followed children from the onset of diabetes for the following 3 years, recording height, weight and bone age as well as glycosylated haemoglobin and daily insulin requirement. At diagnosis, height SDS was identical in children with IDDM (+0.04±0.10) compared to control children (–0.07±0.10; M±SE), while weight SDS was –0.26±0.10 in children with diabetes (controls: +0.01±0.1). Bone age was identically retarded in newly diagnosed IDDM children (–0.73±0.12 SDS) and in our control group of children from the same regional background (–0.50±0.12; n.s.). In this group of children with diabetes mellitus followed prospectively, height to weight relationship differed from controls after 2 and after 3 years of the disease (P<0.05). At 2 years, body size in children with diabetes was shifted towards taller and heavier compared to controls, while at 3 years, the relation of height to weight was even more abnormal with increased obesity but a reduction of standardized height. This is the same relation encountered in the cross-sectional sample of children with a duration of diabetes beyond 3 years. These data demonstrate that even modern insulin therapy does not guarantee normal development of height and weight in children with IDDM.A preliminary report on these data was presented at the ESPE-Meeting at Copenhagen in 1988 (Abstract no. 171).     

Paucity of intrahepatic bile ducts,solitary kidney and atrophic pancreas with diabetes mellitus: Atypical Alagille syndrome?

Abstract A child with the tentative diagnosis of Alagille syndrome is reported. Additional renal abnormalities are unilateral kidney agenesis and a kidney with subcortical cysts with decreased function. At the age of 5 years, insulin-dependent diabetes mellitus developed, with the pancreas being atrophic and negative pancreatic islet cell antibodies.Conclusion This observation extends the picture of Alagille syndrome and suggests an overlap with renal-hepatic-pancreatic dysplasia (Iyemark syndrome).     

Pearson bone marrow-pancreas syndrome with insulin-dependent diabetes,progressive renal tubulopathy,organic aciduria and elevated fetal haemoglobin caused by deletion and duplication of mitochondrial DNA

We report a patient with a clinical picture consisting of small birth weight, connatal hypoplastic anaemia, vacuolised bone marrow precursors, failure to thrive, and, subsequently, by insulin-dependent diabetes, renal Fanconi syndrome, lactic acidosis, complex organic aciduria, and elevation of haemoglobin F and of adenosine deaminase activity. The clinical course was progressive and death occurred at age 19 months. A high proportion of mitochondrial (mt) DNA molecules with a deletion of nucleotides 9238 to 15575 were identified in several tissues; about half of the shortened mtDNA molecules were concatenated to form circular dimers. The clinical and laboratory findings support recent conclusions that Pearson syndrome is not confined to bone marrow and pancreas, as originally described, but is a multi-organ disorder associated with delctions in part of the mtDNA molecules. The tissue distribution and the relative proportions of the abnormal mtDNA molecules apparently determine the phenotype and clinical course.     

Wheezing illness and re-hospitalization in the first two years of life after neonatal respiratory distress syndrome

OBJECTIVES: To determine the impact of respiratory distress syndrome (RDS) on wheezing illnesses and re-hospitalizations in children as old as 2 years of age. STUDY DESIGN: We observed 2 geographically defined cohorts of children with RDS born after 26 weeks of gestation during 1990 to 1995 and 1996 to 1999 and gestationally paired control subjects. Recurrent wheezing illness and the re-hospitalizations caused by a respiratory condition were recorded. RESULTS: In the first year of life, 47 of 224 infants with RDS and 18 of 224 control subjects born in 1990 to 1995 had recurrent wheezing illness (P <.005) compared with 21 of 109 infants with RDS and 14 of 109 control subjects in the latter cohort (P=.27). A higher number of infants with RDS were readmitted to the hospital (25% versus 13%, P=.002) in the former period, and they spent more days in hospital during both periods. The frequencies of wheezing remained constant in the second year of life, but hospital admissions decreased. Siblings at home, male sex, and bronchopulmonary dysplasia were additional risk factors of wheezing illnesses. CONCLUSION: RDS increases the incidence of wheezing illnesses during the first 2 years of life. Changes in the management of RDS during the 1990s was associated with a decreased incidence of subsequent RDS-associated respiratory morbidity.     

Prevalence and risk factors of metabolic syndrome in obese children and adolescents: the role of the severity of obesity

The present study was performed to determine the prevalence of metabolic syndrome (MS) and its risk factors in obese children and adolescents. The study included 352 obese children and adolescents (body mass index [BMI] ≥ 95th percentile) aged between 2 and 19 years. The diagnosis of MS was made according to the criteria adapted from the World Health Organization (WHO) and the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines. BMI z-scores were calculated to assess the degree of obesity. The prevalence of MS and risk factors were determined. Determinants of MS were examined using regression analysis. The prevalence of MS was 41.8%. The age at onset of obesity, sedentary life-span, fasting blood levels of glucose, insulin, triglyceride, very-low-density lipoprotein (VLDL) cholesterol, and alanine aminotransferase (ALT) were higher, while levels of high-density lipoprotein (HDL) cholesterol and the number of actively spent hours were lower in cases with MS (p < 0.05). The most important determinant of MS was BMI z-score (r = 0.31, p < 0.0001). A one-point increase in BMI z-score yielded a 2-fold increase in the prevalence of MS. The prevalence of MS increased from 27.6% to 60.7% when the BMI z-score increased from 2.3 to 3.3. The risk of developing MS was 2.6-fold higher in cases with BMI z-score > 3 when compared to those with z-scores between 2 and 3. The results from this study indicate that, although the correlation between MS and the BMI z-score was weak, the BMI z-score may be an effective parameter in identifying obese children and adolescents at risk for MS. Screening the cases with BMI z-scores ≥ 2 for MS is important for establishing an early diagnosis.     

Clinical determinants and utility of early postnatal maximum weight loss in fluid management of extremely low birth weight infants

Background

The early postnatal physiological body weight loss process is poorly understood in preterm infants. It is complicated by clinical conditions which adversely affect the body fluid balance during 1st two weeks of life. A lack of physiological weight loss potentially could result in significant morbidities. Body weight is utilized in determining daily fluid volume intakes. Extremely low birth weight infants (birth weight < 1000 g, ELBW) have the highest morbidity and mortality among all neonates.

Aim/objective

The objective was to evaluate the early postnatal weight changes and its clinical determinants in ELBW infants. We examined the maximum weight loss from birth weight (MWL) in ELBW infants and tested its association with clinical variables which could potentially implicate the body fluid balance during the first two weeks of life.

Study design

Prospectively entered data in the computerized radiology, biochemical and hematological records, and daily case notes were retrospectively extracted during a 3-year study period. The infants' and maternal demographic, clinical course and outcome variables relevant to body fluid balance during the first two weeks of life were correlated with MWL. Pearson's correlation coefficient and Pearson's partial correlation tests were utilized for data analysis.

Results

Data are presented as mean ± SD. MWL in the entire cohort (n = 102) was 14.2 ± 5.4%. Day of life of MWL was 5.5 ± 2.1 and that of birth weight regained 14.5 ± 4.2 days. MWL correlated negatively with gestational age, antenatal steroid receipt (ANS) and pregnancy associated hypertension and positively with total days on oxygen, fluid intake, urinary output and the day of life when birth weight was regained. All these correlations were lost after controlling for GA except for the day of life when birth weight was regained. MWL did not correlate with RDS or its severity, hypotension, PIE, IVH, PDA and length of stay. Over 91% infants had MWL within 3.1-25%. Male, Caucasian and ELBW infants unexposed to ANS tended to have weight loss in excess of 25%.

Conclusion

MWL is governed by maturation and is not affected by concurrent clinical factors including fluid intakes during the 1st two weeks of life in ELBW infants. MWL within the estimated range of 14.5 + 4.2% of birth weight does not promote morbidities. Male, Caucasian and ELBW infants unexposed to ANS are susceptible to excessively high weight losses in early postnatal period.