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Percutaneous endoscopic gastrostomy (PEG) has gained great popularity for children with malnutrition and eating disorders secondary to chronic illness. However, the procedure is not without risks. We report on 62 infants and children, median age 4 years (1 month-20 years), who underwent PEG placement. Cerebral palsy with or without mental retardation was the most common diagnosis (50%). No complications related to the PEG procedure itself occurred, but postoperative pneumonia was seen in 10%. Late complications were few: intraperitoneal migration of the button in one child and prolapse of the stoma in another. At the time of button placement, after median 14 weeks, mean weight had increased from a standard deviation score of -2.7 to -2.2 (P < 0.001). We consider PEG to be a safe procedure for children with malnutrition requiring enteral feeding. Due to potential risks and complications related to this method, a multidisciplinary approach, as found in a "nutritional support team", is recommended.

Background: The efficacy of a 1-week "triple therapy" in children with Helicobacter pylori gastritis and recurrent abdominal pain was studied. The effect of treatment was also studied in correlation to recurrent abdominal pain., Methods: Thirty-two children with recurrent abdominal pain were investigated with H. pylori serology, 13C-urea breath test, and endoscopy. Gastric biopsy specimens were analyzed with a rapid urease test and histopathology. H. pylori-positive children were treated with omeprazole, clarithromycin, and metronidazole for 7 days. The same treatment was repeated for 2 weeks if a urea breath test produced positive results 1 month after the treatment period. If the test results were still positive after treatment, a second endoscopy was performed with culture., Results: Twenty-eight (87.5%) children were urea breath test-negative at follow-up 4 weeks (range, 4-15) after treatment. Another child became H. pylori-negative after a second treatment course. Two of the three children who were still positive after the two treatment periods, showed resistance to metronidazole and clarithromycin., Conclusions: One-week therapy with omeprazole, clarithromycin and metronidazole is an effective treatment in children with H. pylori infection. Bacterial resistance to clarithromycin and metronidazole must be monitored if treatment fails.

Total and free carnitine and acylcarnitine concentrations were analyzed in whole blood and plasma in 12 children with a mean age of 68.4 +/- 42.9 months who had received carnitine-free total parenteral nutrition (TPN) for an average of 4 years. The purpose of the study was to see if the children had become carnitine deficient and, if so, whether this correlated with poor lipid clearance. Compared to controls, the TPN-dependent children had significantly decreased concentrations of total and free carnitine in blood (26.6 +/- 9.4 (SD) mumols/L vs. 43.3 +/- 9.1 mumols/L, p less than 0.001, and 17.1 +/- 7.7 mumols/L vs. 35.2 +/- 8.1 mumols/L, p less than 0.001, respectively). Similar results were found in plasma (total carnitine of 19.0 +/- 8.0 mumols/L vs. 41.9 +/- 5.2 mumols/L, p less than 0.001, and free carnitine of 15.7 +/- 7.3 mumols/L vs. 36.1 +/- 5.2 mumols/L, p less than 0.001, respectively). The acylcarnitine concentration in plasma was decreased in the TPN children (3.3 +/- 1.5 mumols/L vs. 5.8 +/- 3.0 mumols/L, p less than 0.01) compared to controls. Despite the low carnitine concentrations, serum triglyceride levels and serum free fatty acid levels were within the normal range. There was no correlation between carnitine concentrations in plasma and serum triglyceride and free fatty acid levels. Our data show that children receiving carnitine-free TPN for many years developed markedly decreased concentrations of carnitine in blood and plasma. However, no adverse effects of the low carnitine levels were found on triglyceride and free fatty acid metabolism under stable conditions.

Long term parenteral nutrition is lifesaving in a few patients with severe gastrointestinal failure. Such therapy is often carried out at home (Home parenteral nutrition, HPN) and based on a high degree of self-care. The risk of complications is high, and it requires a considerable skill and experience from the hospital staff to manage HPN and educate patients. The prevalence of such patients in the Nordic countries is 3-4 per million. In some Nordic countries it is impossible to centralize this treatment only to one or two hospitals. With such a small number of patients scattered all over the country it is therefore important to establish a national co-operation and registration regarding HPN-patients. This will increase experience with HPN and make it possible to standardize the therapy with regards to indications, catheter technique, nutritional supply, management of complications, education etc. Furthermore it is a wish to expand this co-operation and registration to include all Nordic countries. Such multinational co-operation might be of value in cases of rare and difficult patients on HPN and in children and will further increase our experience with HPN. Results from a meeting on Nordic co-operation concerning HPN is presented.

Plasma amino acid concentrations were measured in 15 children aged 4-65 months who received home parenteral nutrition (PN) and in 10 normal controls. In seven patients (Group I), PN was the only source of nutrition. Eight patients (Group II) ingested 30%-70% of their total energy requirements and received the remainder intravenously. Group I and Group II patients received PN for 25.6 +/- 14.4 (SD) and 25.7 +/- 19.1 months, respectively. In comparison to controls, Group I had significantly decreased plasma concentrations of total essential amino acids, the three branched chain amino acids, cystine, tyrosine, and the three major urea cycle amino acids. Group II children displayed decreased plasma concentrations of two branched chain amino acids, leucine and valine, as well as cystine and tyrosine. Taurine was decreased in both groups. The presence of liver disease did not have a major effect on amino acid levels. These data indicate that children receiving long-term parenteral nutrition will develop abnormalities in their plasma amino acid concentrations even though they appear to receive adequate amounts of amino acids in their intravenous solutions. Further studies will be necessary to assess whether modifying the intravenous intake of amino acids will normalize plasma amino acid concentrations in these children.

The effect of intravenously administered lipids (intralipid) on immunologic function, complement, and coagulation was prospectively studied over 1 year in 15 children. The mean age of the children was 52.4 +/- 37.9 months; they had received total parenteral nutrition for an average of 3 years. Immunoglobulins (IgA, IgM, IgG), coagulation studies (platelets, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrinogen degradation products, factor V) and components of complement (C3, C4, and CH100) were analyzed. Activation of monocytes by opsonized zymosan was measured by chemiluminescence and compared with that of normal control subjects. The clinically stable children had normal monocyte activation and normal complement levels. The PT and PTT values were significantly increased but improved with increased intralipid dose; other coagulation factors were normal. Acutely sick children, however, had decreased fat tolerance with significantly increased serum triglyceride levels and PT and PTT values; their monocyte activation and complement factors remained normal. These data indicate that the dose of intralipid should be lowered during acute illnesses; we suggest close monitoring of PT and PTT values and of serum triglyceride and cholesterol levels to avoid the fat overload syndrome.

Fifteen children who fulfilled the criteria of chronic non-specific diarrhea of infancy were evaluated for intestinal bacterial overgrowth. In 10 of 11 successfully investigated children we found bacterial overgrowth of the small intestine by upper respiratory tract microflora. In 9 of 10 children (group I) treated with trimethoprim-sulfamethoxazole the diarrhea ceased immediately, whereas in all children in group II (n = 5; 3 children excluded because of growth of Yersinia enterocolitica) treated with low-lactose diet the diarrhea persisted (p = 0.004). The results indicate that bacterial overgrowth of the small intestine by upper respiratory tract microflora may be a cause of chronic non-specific diarrhea and that this diarrhea may be successfully treated with trimethoprim-sulfamethoxazole.