Today, I have the honor and the pleasure of introducing James Peter Keating, the recipient of the 2004 NASP-GHAN Distinguished Service Award. Dr. Keating and I have worked together since 1976.
Dr. Keating appeared disarmingly peaceful in the early 1970s, but the world around him was tumultuous. Some crises were serious, like the gasoline crisis. Other conflicts held great significance but developed along lighter lines, like the symbolic tennis match in which Billie Jean King crushed the boisterous Bobbie Riggs in a theatrical step forward in womens' sports. The tumult forced men to reconsider and redefine themselves, and Dr. Keating faced this crisis along with many of us. He did not have sufficient hair to emulate Tony from Saturday Night Fever. He had too much class to sink to the pranks of Bluto in Animal House. But he clearly struggled with his self-image. He began as a bearded Mephistopheles but settled on a Midwestern father.
Dr. Keating made more definitive progress in his professional life and established a paradigm that he would follow over the next decades. In the midst of caring for the myriad children with the familiar problems of constipation, encopresis, abdominal pain and diarrhea, he astutely recognized several unique problems. He was not a basic investigator in the sense of bench or laboratory science, but he was an investigator who used the basic tools of meticulous observation, insightful pattern recognition, original thinking, careful delineation of connections and effective intervention. With these skills, he provided guideposts in diagnosis and therapy for a generation of pediatric gastroenterologists.
In 1971, infants with intractable diarrhea populated most inpatient GI services. As Director of the Division of Pediatric Gastroenterology and Nutrition in the Department of Pediatrics at Washington University School of Medicine, Dr. Keating introduced parenteral nutrition therapy to St. Louis Children's Hospital. He published one of the first three articles describing the rationale and success of this therapy and then expanded the series to over 100 infants and children (1,2). The safety and efficacy of parenteral nutrition were clearly established.
In 1974, adult gastroenterologists introduced upper gastrointestinal endoscopy. Pediatric endoscopes did not exist. Dr. Keating and his colleagues published the first series of reports regarding pediatric patients undergoing upper gastrointestinal endoscopy for investigation of bleeding, pain or abnormal radiographs (3). In 1976, in a co-operative study with Cardinal Glennon Hospital, Dr. Keating described the successful use of conscious sedation to accomplish endoscopy (4). The principles of upper GI endoscopy in pediatric patients were solidly founded. Next, he provided the first description of pseudomembranous colitis following ampicillin therapy, elucidating the connection between common antibiotic therapy and this serious complication (5).
Throughout the 1970s, Reye Syndrome devastated previously healthy children, often after influenza or varicella infection. Along with John Partin, Bill Schubert and Peter Huttenlocher, Dr. Keating and his St. Louis colleagues contributed the seminal clinical descriptions of this illness. Dr. Keating clearly demonstrated that early recognition, intensive supportive care, careful attention to metabolic balance and early endotracheal intubation reversed the pattern of high mortality for Reye Syndrome. This approach became the model of care for multiple centers (6).
In the early 1980s, Dr. Keating published a paper in the New England Journal of Medicine describing the progressive neurologic syndrome afflicting children with chronic cholestasis, the first report to connect neurologic disabilities to chronic vitamin E deficiency (7). Fifteen years of clinical care, repeated examinations, determinations of vitamin E status and neuropathologic studies preceded this report. He correctly hypothesized the connection to vitamin E deficiency through a review of available literature describing animal models and the few clinical reports of abetalipoproteinemia. His observations provided the foundation for future investigations and the impetus to find effective vitamin E therapy for cholestatic patients.
Next, Dr. Keating and Kathleen Schwarz identified a group of children who had undergone colectomy for Hirschprungs disease with subsequent ileo-anal pull through surgery. These children suffered intervals of poor growth and slow weight gain along with periodic dehydration and sodium depletion. Dr. Keating and Dr. Schwarz documented that the usual dietary intake of sodium was insufficient to match fecal sodium losses and suggested that chronic sodium depletion was the probable mechanism for the growth disturbance and susceptibility to dehydration (8). Subsequently, Dr. Keating and Dr. Schwarz verified similar findings in infant ileostomates. They suggested that a spot urine sodium concentration provided a simple tool for evaluating the sodium status of such patients. Their recommendations for sodium supplementation proved effective in preventing periods of poor growth and dehydration (9).
In the 1990s, Dr. Keating energetically continued his clinical investigations. During his long tenure as Director of the Pediatric Intensive Care Unit, he noted an alarming increase in the number of infants admitted with hyponatremia due to water intoxication. He characterized the cardinal features of the epidemic. WIC-supported infants ages 4 to 6 months were identified as the most vulnerable group. It was discovered that there was insufficient formula provided to these infants for total nutritional support. Well-intentioned, caring mothers gave water in an effort to satisfy their hungry infants. This recognition led to effective educational intervention with a resultant marked reduction in the frequency of water intoxication and hyponatremia (10).
The 21st century dawned, and Dr. Keating considered a change in profession, but his drive for excellence and investigation led instead to additional salient observations and investigations such as his description of macrolipasemia in an adolescent (11). Identification of this phenomenon underscores his inquisitive nature. The usual explanation for hyperlipasemia, pancreatic disease, did not match the child's other clinical findings. The solution was to investigate and discover the true etiology.
Dr. Keating has worked assiduously at one task more than any other. He was and is a devoted mentor and teacher. He has had a profound and lasting impact on the current generation of pediatric gastroenterologists. Drs. Kathy Schwarz, Rob Squires, David Perlmutter, Jean Molleston and Mark Lowe, current leaders in pediatric gastroenterology, were all his students. They can recount how he taught by direct instruction but, more importantly, how he inspired by example. He demonstrated the power of astute observation, critical analysis and focused determination. Dr. Keating is not comfortable with lists of his achievements. He receives greater satisfaction from reviewing the accomplishments of his colleagues and trainees. Energized by the optimistic belief that we work hard, think clearly and support the best interests of children and families, he has convinced us that we can make a difference, provide a contribution and solve a medical dilemmas with warmth, compassion and insight. Presenting this award provides a delightful opportunity for us to thank him.
1. Keating JP, Ternberg JL. Amino acid-hypertonic glucose treatment for intractable diarrhea in infants. Am J Dis Child
2. Keating JP, Ternberg JL, Gleason WA. Parenteral hyperalimentation at St. Louis Children's Hospital. Clin Diag
3. Gleason WA, Tedesco FJ, Keating JP, Goldstein PD. Fiberoptic gastrointestinal endoscopy in infants and children. J Pediatr
4. Tedesco FJ, Goldstein PD, Gleason, WA, Keating JP. Upper gastrointestinal endoscopy in the pediatric patient. Gastroenterology
5. Keating JP, Frank AL, Barton LL, Tedesco FJ. Pseudomembranous colitis associated with ampicillin therapy. Am J Dis Child
6. DeVivo DC, Keating JP, Haymond MW. Reye Syndrome: Results of intenstive supportive care. J Pediatr
7. Rosenblum JL, Keating JP, Presnky AL, Nelson JS. A progressive neurologic syndrome in children with chronic liver disease. N Eng J Med
8. Schwarz KB, Keating JP, Ternbery JL, Bell MG, Howald MA. Sodium balance following Soave endo-rectal pull-through. J Pediatr Surg
9. Schwarz KB, Ternberg JL, Bell MJ, Keating JP. Sodium needs of infants and children with ileostomy. J Pediatr
10. Keating JP, Shears GJ, Dodge PR. Oral water intoxication in infants: An American epidemic. Am J Dis Child
11. Lowe ME, Keating JP. Persistent hyperlipasemia caused by macrolipase in an adolescent. J Pediatr