NUTRITIONAL IMPACT OF GASTROSCHISIS
Emily Garabedian, Roman Sydorak, Andrew Fine, Diana Farmer, Joseph A Kitterman, John D Snyder, Pediatrics, UCSF, SF, CA; Surgery, UCSF, SF, CA; Pediatrics, UCSF, SF, CA; Surgery, UCSF, SF, CA; Pediatrics, UCSF, SF, CA; Pediatrics, UCSF, SF, CA
Gastroschisis is an abdominal wall defect that causes prolonged exposure of the fetal intestine to amniotic fluid. Prenatal ultrasound can now often diagnose the defect in utero, permitting interventional surgery to be performed immediately after birth. Despite these elements of improved care, prolonged feeding difficulties are often encountered. No recent studies have documented the nature and duration of nutritional difficulties of children with this defect.
We performed a retrospective review of all infants who were diagnosed with gastroschisis in the UCSF intensive care nursery (ICN) from 1/1/95 through 12/31/2000. Data were collected on the perinatal and neonatal course, type and number of surgeries, the nature and impact of complications, and the timing and outcome of enteral and parenteral nutrition, including the development of cholestasis. Cholestasis was defined as a conjugated bilirubin > 2.0 mg/dl. TPN cholestasis (TPNC) was defined as cholestasis with no other known cause for jaundice.
39 patients with gastroschisis were identified; prenatal diagnosis had been made in 32 (82%). 20 were females and the mean gestational age was 35.6 wk (± SD 3.0); 23/39 (59%) infants were born prematurely (<37 week gestation). The incidence of gastroschisis during this period was 0.7% of all infants admitted to the ICN. 38 infants received TPN; in the remaining infant, almost the entire bowel was non-viable and support was withdrawn. The initial surgery was either primary closure (PC) or placement of a silo to permit gradual replacement of the intestines. Nutritional outcomes are summarized in the Table for infants with PC and silo:
Table. No caption av...Image Tools
Risk factors for the development of TPNC included bowel resection, very prolonged TPN (>45d), and sepsis but no combination of these risk factors could account for all of the patients who developed cholestasis.
Despite continued advances in neonatal intensive care and pediatric surgical techniques, gastroschisis is associated with prolonged TPN use and with development of TPNC. Although infants with primary closure had significantly shorter hospital stays, the rate of prolonged TPN use (>14d) and the development of TPNC was similar in the 2 groups.
LAPAROSCOPIC ASSISTED PERCUTANEOUS ENDOSCOPIC JEJUNOSTOMY (LAPEJ): A NEW ENTERIC ACCESS TECHNIQUE IN CHILDREN
Koorosh Kooros, Alex F Flores, Marc S Lessin, Brian F Gilchrist, Pediatric Gastroenterology and Nutrition; Pediatric Surgery, Floating Hospital for Children, TUFTS-New England Medical Center, Boston, MA
Neurologically impaired children who have undergone gastrostomy tube placement alone, or fundoplication with gastrostomy tube placement are at high risk for gastroesophageal reflux. There is also a subset of neurologically impaired children who are not appropriate surgical candidates; it is for these reasons that several techniques for direct enteric feeding have been described. Each has been associated with unique problems. We describe a procedure in children that combines enteroscopy with laparoscopy to facilitate insertion of a jejunostomy tube.
Materials and Methods:
LAPEJ is performed under endotracheal anesthesia. The indications for the procedure were gastroesophageal reflux after previous fundoplication or gastrostomy tube placement. A 5mm laparoscope is placed through the umbilicus. A second trocar is placed in the left lower quadrant. Enteroscopy is carried out until the endoscopic light source is identified in the proximal jejunum. The jejunum is stabilized with a grasper placed through the second trocar. An Angiocath™ is introduced under direct vision into the intestinal lumen. A standard pull technique is used with a Bard™ gastrostomy tube.
LAPEJ was attempted in 13 patients, successfully in 11. The ages ranged from 2–20 years. All but one of the successful placements had a previous fundoplication and / or gastrostomy tube. The mean length of the procedure was 76 minutes. Feedings were successfully initiated in all patients 24 hours postoperatively. There were two instances of bolster migration into the abdominal wall, both of which were replaced nonsurgically under fluoroscopy. One patient required conversion to a Roux-en-Y jejunostomy 6 months later for persistent leakage. Two patients have died from causes unrelated to the tube placement. The remaining 8 patients have been followed from 1–16 months and all are tolerating full feeds through their tubes.
LAPEJ is a safe method of jejunostomy tube placement in high-risk patients. It is recommended for patients who have either failed fundoplication or are unable to tolerate gastrostomy feeds. The procedure provides both enteric and laparoscopic visualization allowing for exact placement in the proximal jejunum.
NUTRITIONAL MANAGEMENT OF INFANTS WITH CHRONIC DIARRHEA FED A FREE AMINO ACID-BASED MEDICAL FOOD
Dean L Antonson, Nancy D Murray, Maria M Oliva-Hemker, Lynn E Mattis, Vasundhara Tolia, Anne Wuerth, Marlene W Borschel, Pediatrics, University of Nebraska Medical Center, Omaha, NE; Pediatrics, Johns Hopkins University, Baltimore, MD; Pediatrics, Children's Hospital of Michigan, Detroit, MI; Clinical Nutrition Research, Ross Products Div. Abbott Laboratories, Columbus, OH
Elemental and semi-elemental feedings are recognized and prescribed as an appropriate nutritional regimen for chronic diarrhea (CD). Purpose: The purpose of this study was to assess the growth of infants fed EleCare® (Ross Products Div, Abbott Laboratories, Columbus, OH) as a primary feeding for 80 d in the nutritional management of CD from multiple etiologies. Methods: A non-randomized feeding study was conducted in infants ≤12 mo of age with CD, (duration >2 wk and ≥4 stools/d) and considered candidates for an elemental feeding. Following a 3-d baseline period on their current formula, infants received ≥50% of their total energy from EleCare fed at a similar dilution for 80 d. The primary efficacy measure was maintenance of weight for age z-score (zs) during the study. Mean rank stool consistency (MRSC) was the secondary variable. Intake, stool patterns, blood chemistries, a physician assessment of perceived abdominal complaints and targeted outcomes for each subject were assessed. The primary analysis was intent to treat (ITT). Results: 27 infants comprised the ITT group and 22 completed with accepted variations. The mean age at entry was 3.3±0.3 mo. 87% and 77% of the subjects maintained or improved their wt for age zs and MRSC during the study, respectively. Mean wt for age improved significantly from −0.47±0.21 at study day 1 (SD1) compared to −0.19± 0.19 at SD84. MRSC were 2.07±0.13 during baseline and 2.72±0.16 at SD84. The mean number of stools/d was 3.5±0.5 during baseline and 1.5±0.2 at SD84. Mean Hgb, Hct, serum albumin, SUN, and total protein increased and alkaline phosphatase decreased from SD1 to SD84. 95% of targeted outcomes were achieved at exit and an addditional 18 outcomes not targeted at SD1 were achieved at exit. At SD1, 63% of subjects had mild to severe complaints of nausea, abdominal pain or decreased physical activity compared to only 4% of subjects at SD84. At SD1, 81% of subjects had mild to severe complaints of emesis or diarrhea compared to 0% at SD84. Conclusion: The results demonstrated that EleCare was suitable for use in the nutritional management of infants with CD of various etiologies.
EXAMINING POSSIBLE PREDICTORS OF BODY MASS INDEX IN CHILDREN WITH AUTISM
Douglas G Field, Angela Smith, Kimberly Schreck, Keith Williams, Department of Pediatrics, Penn State Children's Hospital/Penn State College of Medicine, Hershey, PA; Department of Psychology, Penn State Harrisburg, Harrisburg, PA
To examine the relation between measures of autism severity, feeding problems, and number of foods eaten and body mass index(BMI) for-age-percentile among children with autism.
The BMI was calculated for 95 children with autism spectrum disorders. The children's caregivers completed three measures: the Gilliam Autism Rating Scale, a measure of autism severity, the Children's Eating Behavior Inventory, a meaure of mealtime and eating behaviors, and the Food Preference Inventory, a list of 145 common foods. Using the CDC Growth Charts, the children were categorized into four groups based upon their BMI for-age-percentile ( 95th percentile). The group means for the measures completed by caregivers were calculated.
There were no significant differences between the four groups on the severity of autism as measured by the Gilliam Autism Rating Scale, feeding problems as measured by the Children's Eating Behavior Inventory, and number of foods eaten (Table 1).
The hypothesis that autism severity and feeding problems would predict the body mass index was not confirmed. While we did not expect the number of foods eaten to be related to body mass index, this relation did approach significance (p= .068). With a larger sample, this relation may have been significant. Future plans include increasing our sample size and examining the effects of sensory specific satiety on eating behavior in children with autism. Mean scores per group
PENTANUCLEOTIDE REPEAT (TTTTA)n POLYMORPHISM IN THE 5` CONTROL REGION OF THE APOLIPOPROTEIN (a) GENE AND ATHEROTHROMBOTIC SERUM LIPOPROTEIN (a) CONCENTRATION, IN A PORTUGUESE PEDIATRIC POPULATION
Helena Ferreira, Elísio Costa, Emilia Vieira, Anabela Leão, Rui Magalhãaes, Lourenço Gomes, José Barbot, Rosário dos Santos, Serviço de Pediatria, Hospital Maria Pia; Serviço de Hematologia, Hospital Maria Pia; Unidade de Genetica Molecular, Instituto de Genética Médica Dr Jacinto de Magalhães;, Instituto de Ciências Biomédicas Abel Salazar; Serviço de Patologia Clínica, Hospital Maria pia, Porto, Portugal
Lipoprotein (a) [Lp(a)] is a complex of apolipoprotein (a) [apo(a)] and low density lipoprotein, which is associated with atherothrombotic disease. Most of the interindividual variations in plasma levels of Lp(a) can be attributed to sequence differences linked to the apo(a) locus. The apo(a) gene contains a pentanucleotide repeat (TTTTA)n polymorphism, 1.4 Kb upstream from the apo(a) gene reading frame. This polymorphism has been suggested to be important in control of apo(a) gene expression. Alleles containing more repeats were generally associated with lower plasma Lp(a) concentration.
The aim of this study was to investigate a possible link between the number of TTTTA repeats and atherothrombotic serum Lp(a) concentrations [Lp(a) > 30 mg/dl].
We studied 96 pediatric patients, 51 with serum Lp(a) concentrations above and 45 with concentrations below 30 mg/dl. Genotyping of the polymorphism in the 5`control region of the apo(a) gene was performed by fluorescence labeled polymerase chain reaction and subsequent analysis by automated capillary electrophoresis.
In this population, the apo(a) allele with (TTTTA)8 was the most common with a frequency of 76.04%. Alleles with 9, 10, 11, and 7 TTTTA repeats accounted for 13.02, 8.33, 1.56 and 1.04% respectively. No statistically significant difference was found in the genotype distribution between the two groups, with Lp(a) < and > 30 mg/dl (χ 2=2.527; p>0.05). Homozygosity for the (TTTTA)8 allele was found in 51,1 % of children with Lp(a) levels below and in 64,7% with Lp(a) levels above the cut-off point, although this was not statistically significant (χ 2= 1.302; p>0.05).
Our results suggest that the pentanucleotide repeat polymorphism in the 5`control region of the apolipoprotein (a) gene is not directly associated with atherothrombotic serum lipoprotein (a) concentration in our population.
FOUR YEARS OF FEEDING: OUTCOMES OF INTENSIVE BEHAVIORAL TREATMENT FOR SEVERE FEEDING PROBLEMS
Douglas G Field, Melissa Garland, Keith Williams, Katherine Riegel, Department of Pediatrics, Penn State Children's Hospital/Penn State College of Medicine, Hershey, PA
To determine the effectiveness of an intensive day treatment feeding program in treating severe feeding problems in children.
A retrospective review of all children admitted to our intensive day treatment feeding program for a period of 48 months was conducted. The children were divided into three groups; children dependent on tube feedings, children who had failure to thrive, but not yet on tube feedings, and children with extreme food selectivity, but who did not have failure to thrive. The effectiveness of treatment was examined by evaluating the outcome at the end of the program and long-term outcome.
The outcomes of each patient was categorized as either a success, partial success or failure. These categories were defined as follows:
Success - 100% oral feedings (children with tube dependence), oral intake enough to promote weight gain (children with failure to thrive), and eating at least five foods per food group (children with extreme food selectivity).
Partial success - tube feedings decreased by at least 50% (children with tube dependence).
Failure - tube feedings decreased by less than 50% (children with tube dependence), oral intake not enough to promote weight gain (children with failure to thrive), eating five or less foods per food group (children with extreme food selectivity).
Efficacy outcomes are shown in Table 1.
This study shows that an intensive day treatment program for severe feeding behaviors can produce both immedcate and long-lasting positive outcomes for many children who have severe feeding problems. Future research will focus on identifying factors related to maintenance of treatment over time and when intervention should begin in some children.
FAILURE TO ADVANCE TEXTURES-MEDICAL, BEHAVIORAL AND DEVELOPMENTAL ETIOLOGIES IN A FEEDING DISORDERS PROGRAM
Diane L Barsky, Pediatric Feeding & Swallowing Ctr, Div of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
Feeding disorders defined as the inability to consume by mouth in quantity and/or quality nutrition which is developmentally appropriate for a child, occur in 20–25% of all children. The Pediatric Feeding and Swallowing Center is a multidisciplinary team of professionals representing disciplines from pediatrics, speech, occupational therapy, behavioral psychology, nutrition and physical therapy working together to evaluate and treat children with feeding disorders.
Children present to the Feeding Center with a variety of complaints including food refusal, selectivity and failure to progress textures. A common complaint is failure to advance texture; these children often present with gagging on a variety of foods, accepting only baby food. Their limited intake often places them at risk for nutritional deficiencies and serves as a significant source of parental stress.
A retrospective chart review was performed of 38 children presenting with a chief complaint of failure to advance textures. These children would not accept any texture beyond baby food or naturally occuring smooth purees. They all gagged and/or vomited when any higher texture was presented. The charts were reviewed for developmental status and medical diagnoses
Of the 38 children reviewed the mean age at presentation was 22 months (14–2 mos). Modified barium swallow studies performed on 16 children were all normal. Gastroesophageal reflux was diagnosed in 65% (25 pts), 22 had esophagitis diagnosed by endoscopy. Of the 22 with esophagitis, 6 had eosinophils and were diagnosed with food allergies. Developmental delay was diagnosed in 30%, including autism, PDD, Down's syndrome and sensory integration disorder. Treatment of gastroesophageal reflux did not result in advancement of textures. In 1/3 of the children out-patient therapy with the team was beneficial; the other 2/3 of the children required an intensive day treatment program. The program included behavioral modification in collaboration with oral motor and sensory therapy, average length of stay was 3 weeks. The children with developmental delay were more likely to be enrolled directly into the day treatment program.
Gastroesophageal reflux should be considered in children presenting with an inability to advance textures, but treatment will be most effective in collaboration with a multidisciplinary feeding team.
ALBUMIN AND HEMOGLOBIN LEVELS IN INFANTS WITH SEVERE MALNUTRITION
Carlos A Velasco, Gretel T Ramirez, Olga L Segovia, Elsa M Latorre, Gastroenterologia y Nutricion Pediatrica, Universidad del Valle, Cali, Valle, Colombia; Facultad de Salud, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
In Colombia, 2% of the pediatric population has severe malnutrition (SM). Such children can show deficits of albumin (Alb) and hemoglobin (Hb).
To determine the Alb and Hb levels in children with SM.
Patients and methods:
Retrospective and comparative studies were carried out. 125 chldren < 2months old each, were included. Those children, from the HURGV in Bucaramanga, Colombia, had a SM diagnosis, on a six-year period. 72 children from 1 to 21 months old took part as a control group without malnutrition. Age, gender, and Alb and Hb levels were included. It was considered hipoalbuminemia (<3.5gr/dl) and anemia (<11gr%). The statistical analysis was based yon the t of student distribution, it been significative a p<0.05.
50 SM children kwashiorkor type (KW) belong to the group I, 10±5 months old, 34 male, and the group II, 72 SM children marasmus type (MAR), of 9±6 months old (p>0.05). The Alb level were: group I=1.9±0.6 gr/dl (o.5 to 3.7 gr/dl), group II=3.4±0.6 gr/dl (1.9 to 4.9 gr/dl) and control group=4.1±0.5 gr/dl (3.1 to 5 gr/dl). There were important differences among I and II groups (p=0.000, 95% CI, 1.15 to 1.61); between I and control groups (p=0.000, 95% CI, 1.92 to 2.36) and between II and control groups (p=0.000, 95% CI, −0.96 to −0.56). The Hb levels were: group I=9.4±2.4 gr% (4.1 to 14.7 gr%), group II=10.6±1.9 gr% (5.8 to 14.3 gr%) and control group=11.0±1.3 gr% (8.5 to 13.6 gr%). There were important differences between I and II groups (p=0.004, 95% CI, 0.40 to 1.98) and between I and control groups (p=0.000, 95% CI, 0.91 to 2.33).
Children with KW showed a higher commitment in Alb and Hb, than children with MAR, such MAR showed Alb lower than control group; those data were available in the worldwide literature about the field, although in our media were not described.
INFLUENCE OF MATERNAL BEHAVIOR AND KNOWLEDGE ON FOOD CHOICES FOR THEIR CHILDREN. DO MOTHER'S REALLY KNOW BEST?
Roberto Gugig, Angelica Rendon, Carol Porter, Melvin B Heyman, Department of Pediatrics, University of California, San Francisco, CA
Health education interventions aimed at children's diets typically target mothers. Little is known about factors influencing each mother's food choices for children. The purpose of this study was to characterize how mothers of newborns make these choices.
A nutrition questionnaire was developed to assess three domains: demographics, knowledge of applied nutrition, and motivation about food choices for children. A pilot study was done to determine reliability (test-retest) and construct validity. The final instrument consisted of 34 questions and took ∼15 minutes to complete. Format of the questions included open and closed structures (demographics), multiple choice (applied knowledge), and a 5-point Likert scale (motivation) ranging from “Never” (1) to “Very often” (5). Informed consent was obtained from all participants.
146 mothers on the obstetrical ward were approached; 115 answered the questionnaire. Mothers ranged from 23 to 34 years of age, and were of White (58), African American (26), Hispanic (17), or Others (14) origin. The test-retest reliability was 0.85, well above the minimum required of 0.7. Nutrition experts scored significantly better than the subjects, suggesting good construct validity. A majority of mothers, 76/115 (66%), provided food to children based on its health and nutrient value. However, 56 (49%) were also motivated to provide food based on convenience (fast food) and TV advertising. Additionally, only 25 (22%) correctly answered at least 50% of the questions in the knowledge part of the questionnaire. These findings were not influenced by age, race, income, education level, or marital status.
Most mothers appeared to be motivated to provide healthful foods, but were also influenced by convenience and advertising. Mothers lacked knowledge regarding age-appropriate foods and the nutrient values of foods. While mothers intend to provide a healthful diet, it is important that their knowledge be improved to make better food choices, particularly if convenience and advertising are strong influences of food choices for their children.
IS PRIMARY RADIOGRAPHIC GUIDED PLACEMENT OF LOW PROFILE GASTROSTOMY DEVICE (MICKEY ) FEASIBLE IN ICN INFANTS?
Melawati T Yuwono, Thomas M Rossi, Randolph K Otto, J Alan Paschall, Amin Y Tjota, Pediatric G.I. & Nutrition, Mary Bridge Children's Hospital, Tacoma, WA, USA; Pediatric GI & Nutrition, University of Rochester, Rochester, NY; Radiology, Mary Bridge Children's Hospital, Tacoma, WA; Critical Care, Mary Bridge Children's Hospital, Tacoma, WA; Pediatric GI & Nutrition, University of Rochester, Rochester, NY
Gastrostomy feedings are applied to pediatric patients for support of nutritional status and growth. Gastrostomy tubes may be placed either surgically, endoscopically or with radiographic guidance. Low profile devices are preferable to conventional gastrostomy tubes because they offer convenience of use and cosmetic acceptability. Low profile gastrostomy tubes are usually placed through an existing gastrocutaneous stoma. Radiographic placement involves creation of the gastrostomy and primary placement of the device under fluoroscopic guidance. No sudies have been reported assessing this method in children.
Data were prospectively collected during the last 24 months from January, 1999 through December, 2001. Indications for placement of the gastrostomy tube included: Pierre Robin (n= 3 ), hypoxic encephalopathy (n=4), congenital hydrocephalus (n=2), congenital heart disease (n=3), feeding difficulty ( n = 2), chronic lung disease (n= 2), recurrent aspiration pneumonia (n=1). The “ Mickey “ gastrostomy tube was placed radiographically under sedation with intravenous propofol after informed consent obtained. prophylactic intravenous antibiotics was given prior gastrostomy tube pacement.. The patients received either bolus or continues feeding.
The average age of the patients at time of tube placement was 27.5 days 8 were female and 9 were male. Mean follow up has been 18.2 months with a range of 6 to 28 months. No complications occurred during the placement and all the tubes have functioned well. Subsequent complications related to procedure were not encountered. 3 patients died from their underlying disease process not related to tube placement.
1. This study provides new evidence that “Mickey” low profile gastrostomy tube can be placed as an initial feeding tube in children with a diversity of medical conditions. 2. Complications related to tube placement are not significantly different than other methods of placement. 3. This method appears desirable for any non-sugical candidates needing gastrostomy feedings.
EXPERIENCE WITH NEW LOW PROFILE GASTROSTOMY TUBE ENTRI-STAR AS A LONG TERM FEEDING OPTION
Melawati T Yuwono, Thomas M Rossi, Amin Y Tjota, Pediatric GI & Nutrition, Mary Bridge Children's Hospital, Tacoma, WA; Pediatric GI & Nutrition, University of Rochester, Rochester, NY; Pediatric GI & Nutrition, University of Rochester, Rochester, NY
Gastrostomy tubes are useful in providing optimal nutrition support to patients with problems of nutrient delivery to the GI tract.
Skin level gastrostomy tubes are more convenient to use, eliminating protruding extra-abdominal tubing. Devices with fixed retention bolsters require forceful insertion inducing pain and potential trauma. We evaluated the “EntriStar” skin level gastrostomy system, which utilizes a sturdy obturator allowing for greater extension of the bolster for ease insertion and removal. Also we evaluated the outcome after two years of placement.
Indication for gastrostomy tube included: neurologic impairment (n=8), failure to thrive (n=1), dysphagia (n=1). The majority of patients had experience with skin level devices and had met with problems such as frequent tube replacement due to malfunction of the button valve; frequent weakened balloons and problems with obtaining insurance approval for frequent replacement. The patients received most of their nutrition need as well as medications via the tube on a daily basis. All patients were expected to use the tube for a long term. The “Entri Star” was placed under sedation after informed consent obtained.
Patient's mean age was 6.9 years. 60% were male and 40% were female. No complications occured during the placement of the tubes. The mean follow up has been 5.4% months with a range of 2 to 24 months.
Two patients were noted to have entrapment of the tube in the gastric mucosa. This occurred secondary to significant weight gain. The tube was removed by simple traction. Three other patients accidentally had the tube pulled out. Three patients experienced leakage around the tube. Despite the complications none of the patients required hospitalization or surgery.
This study provides new evidence that the new low profile gastrostomy tube Entri Star is safe and easy to insert. Placement is quick and well tolerated. Risk of perforating the stomach is not encountered with the new obturator designed to prevent the slippage of the obturator beyond the tube fraction upon placement. However, incidence of accidental removal are encountered in patients who are very active secondary to entanglement of the tubing during feeding. Close observation is recommended.
© 2002 Lippincott Williams & Wilkins, Inc.