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This prospective study aimed to establish the effect of recombinant human growth hormone (rhGH) on intestinal function in children with short bowel syndrome (SBS). Eight children with neonatal SBS were included. All were dependent on parenteral nutrition (PN) for3 years (range, 3.8-11.6 years), with PN providing50% of recommended dietary allowance for age (range, 50%-65%). The subjects received rhGH (Humatrope) 0.13 mg/kg/d subcutaneously over a 12-week period. The follow-up was continued over a 12-month period after rhGH discontinuation. Clinical and biological assessments were performed at baseline, at the end of the treatment period, and 12 months after the end of treatment. No side effects related to rhGH were observed. PN requirements were decreased in all children during the course of rhGH treatment. Between baseline and the end of treatment, significant increases were observed in concentrations (mean ± standard deviation) of serum insulin-like growth factor 1 (103.1 ± 49.9 µg/L vs 153.5 ± 82.2 µg/L; P.01), serum insulin-like growth factor-binding protein 3 (1.7 ± 0.6 mg/L vs 2.5 ± 0.9 mg/L; P.001), and plasma citrulline (16.5 ± 14.8 µmol/L vs 25.2 ± 18.3 µmol/L; P.05). A median 54% increase in enteral intake (range, 10%-244%) was observed (P.001) and net energy balance improved significantly (P.002). It was necessary for 6 children to be maintained on PN or restarted after discontinuation of rhGH treatment, and they remained on PN until the end of the follow-up period. A 12-week high-dose rhGH treatment allowed patients to decrease PN, but only 2 patients could be definitively weaned from PN. Indications and cost-effectiveness of rhGH treatment for SBS pediatric patients need further evaluation.

We examined the relationship between body fat and body mass index (BMI) in a multiethnic population of obese children. BMI z-scores were compared to DEXA measures of whole body composition and regional fat distribution. Fat mass index (FMI) was best predicted by the equation: 1/[(0.159- 0.013 x percentile of total abdominal fat)- (0.01 x BMI z-score)], where percentile of abdominal fat ranges from 1 to 5. Predicted FMI had high agreement with FMI measured by DEXA. There were no detectable differences in this relation between different ethnic groups. Both BMI and abdominal fat should be used as a proxy to determine adiposity.

Multiple skinfold anthropometry (MSA) and bioelectrical impedance analysis (BIA) are useful as clinically non-invasive, inexpensive and portable techniques, although it is not clear if they can be used interchangeably in the same patient to routinely assess her/his body composition. In order to compare BIA, MSA and DXA in the estimation of lean body mass (LBM) of a pediatric obese population, 103 obese [body mass index (BMI)97th percentile] children (median age: 11 years; range: 5.4-16.7 years) underwent nutritional evaluation. After an overnight fast, the subjects' anthropometric measurements were performed by the same investigator: body weight (BW), height, skinfold thickness (four sites); fat body mass (FBM) using Brook or Durnin equations and dual X-ray absorptiometry (DXA). BIA was performed using a bioelectrical impedance analyzer (Analicor-Eugedia, 50 kHz) and Houtkooper's equation to calculate LBM. Linear regression analysis was performed to evaluate the relationship between the prediction of LBM by MSA, DXA and BIA. The differences between the three techniques were analysed using Student's t-test for paired observations and the Bland and Altmann method. A considerable lack of agreement was observed between DXA- and BIA-LBM (delta = -4.37 kg LBM; delta-2sigma = -11.6 kg LBM; delta+2sigma = +2.8 kg LBM); between DXA- and MSA-LBM (delta = -1.72 kg LBM; delta-2sigma = -8.2 kg LBM; delta+2sigma = +4.8 kg LBM) and between BIA- and MSA-LBM (delta = -2.65 kg LBM; delta-2sigma = -10.5 kg LBM; delta+2sigma = +5.2 kg LBM).In obese children, DXA, BIA and MSA should not be used interchangeably in the assessment of LBM because of an unacceptable lack of agreement between them. The discrepancies between methods increase with the degree of obesity.

BACKGROUND: Bacterial infections in infants constitute a risk factor for parenteral nutrition (PN)-related cholestasis. The possible role of infections in the development of liver fibrosis, the most severe long-term complication, has yet to be documented. This study retrospectively compares the incidence of sepsis in children with and without severe liver fibrosis. PATIENTS AND METHODS: Medical reports of 30 children in prolonged PN programs between March 1985 and March 2000 were reviewed. Starting at birth, the mean PN duration was 65 months (range, 8-150 months). According to the results of liver biopsy (LB), patients were split into 2 groups: group A (n = 16) with severe liver fibrosis (ie, septal fibrosis involving >50% of portal fields or cirrhosis) and group B (n = 14) with normal hepatic architecture or mild fibrosis (

Resume Les comites de liaison alimentation nutrition (CLAN) sont destines a ameliorer l'etat de sante des patients des etablissements de sante (ES). Afin de realiser l'etat des lieux des CLAN en 2004, une grille d'enquete proposee par le comite national de l'alimentation et de la nutrition dans les ES (CNANES) a ete envoyee par la direction de l'hospitalisation et de l'organisation des soins du Ministere de la sante aux structures departementales et aux ES. Trente pour cent des 779 ES qui ont repondu avaient un CLAN, dont la presence etait positivement liee a l'existence dans l'ES d'orientations alimentation nutrition, d'activites de formation, d'une activite de nutrition clinique, et a la taille de l'ES. Les CLAN existaient depuis 2,3 ans en moyenne, tenaient 2,3 reunions par an, etaient composes de neuf personnes, representant les diverses professions hospitalieres et les patients. Ils avaient comme premiers objectifs des actions d'evaluation, de redaction de documents, de formation, de structuration. Il existait un programme d'action des CLAN dans 70 % des cas, un rapport d'activite dans 33 % des cas, mais seulement 5 % des ES avaient un budget devolu au CLAN. Le manque de temps, de moyens ou de personnels, l'existence de commissions alimentation, ou la trop petite taille des ES etaient invoques pour ne pas creer de CLAN. Concernant l'ensemble des ES, 58 % avaient developpe une strategie alimentation nutrition, ils etaient dans 73 % des cas en autogestion de l'alimentation, produisaient une mediane de 400 repas/jour, et disposaient de 0,8 poste de dieteticiens (mediane). Seuls 35 % des ES avaient un programme de formation en alimentation nutrition, 35 % depistaient la denutrition et 24 % l'obesite, 28 % avaient une activite de nutrition clinique, et l'existence de reseaux ville–hopital lies a l'alimentation nutrition n'existait que dans 10 a 11 % des cas. Au total, les CLAN sont plus nombreux en 2004 qu'auparavant et semblent avoir un role favorable en alimentation nutrition dans les ES. La mise en place de plus de formations ou de structures de type interCLAN, ainsi que le partage de moyens entre divers ES peuvent etre preconises. L'evaluation de l'etat nutritionnel des patients doit etre plus frequente et des moyens humains et materiels plus importants dedies a l'alimentation nutrition seraient des facteurs favorables.

Objective To evaluate the type and frequency of psychiatric disorders in obese children and adolescents; to assess the correlation between psychopathology and severity of obesity; to explore the relationship between psychiatric disorders in obese children and obesity and psychopathology in their parents. Methods One hundred fifty-five children referred and followed for obesity were evaluated (98 girls and 57 boys; age, 5 to 17 years). Psychiatric disorders were assessed through a standardized diagnostic interview schedule (K-SADS R) and self-report questionnaires completed by the child (STAIC Trait-anxiety and CDI for depression) or his (her) parents (CBCL or GHQ). These obese children were compared with insulin-dependent diabetic (IDDM) outpatient children (N = 171) on questionnaire data. Results Eighty-eight obese children obtained a DSM-IV diagnosis, most often an anxiety disorder (N = 63). Psychological disorders were particularly pronounced in those obese children whose parents were disturbed. There was no correlation between severity of obesity in the child or his (her) parents and frequency of psychiatric disorders. Compared with diabetic children, they displayed significantly higher internalized and externalized questionnaire scores and poorer social skills. Conclusion These results highlight the importance of including a child psychiatric component in the treatment of obesity, which must engage the whole family.

Resume Objectif. – L’impact de la nutrition parenterale (NP) a long terme sur la fonction renale a ete peu etudie. Cette information est pourtant essentielle chez les enfants en insuffisance intestinale devenus de jeunes adultes ou candidats potentiels a la transplantation intestinale. L’objectif de cette etude etait donc d’evaluer la fonction renale d’enfants en NP cyclique prolongee et de patients en NP prolongee ayant debute dans l’enfance. Patients et methodes. – Vingt-huit patients ont ete etudies (18 garcons), sans uropathie associee, âge moyen 7,5 ans (10 mois–23 ans), avec une duree moyenne de NP de 5,9 ans (10 mois–16 ans). Les pathologies etaient : grele court (21 cas), anomalies fonctionnelles du tube digestif (6 cas) et un cas particulier. Ont ete etudies : la creatinine plasmatique, la renine et l’aldosterone plasmatiques, la clairance de la creatinine (ClCr) sur des urines de 24 heures, la clairance de l’inuline (ClIn), la clairance du PAH (ClPAH), la microalbuminurie, et la β2 microglobulinurie. Une echographie renale etait realisee. Resultats. – La creatininemie etait normale chez tous les patients. ClIn etait normale chez 75 % des patients. ClPAH etait normale chez les 16 patients etudies. La microalbuminurie et la β2 microglobulinurie etaient normales chez 17/19 patients. L’echographie renale etait normale dans tous les cas. Il n’existait pas de correlation entre la ClIn et la ClCr, ni entre la duree de NP et la fonction glomerulaire. Conclusion. – La fonction renale etant normale chez 75 % des patients, la responsabilite de la NP et de sa duree ne peuvent etre etablies pour les cinq patients ayant des anomalies de la fonction renale. La methode de choix de la mesure de la fonction renale glomerulaire chez ces patients est la ClIn.

Large intestinal fermentation and nutrient metabolism in colonocytes were investigated in a rat model of enteral feeding. Male Wistar rats (240–280 g) were submitted to 7 or 14 days of treatment: intragastric feeding (elemental formula) versus oral feeding (isocaloric and isonitrogenous diet, containing 5% purified cellulose) in the control group. Fermentation products and bacterial populations were analyzed in cecal contents. Colonic cells were isolated and tested for their capacities to metabolize [1-14C] butyrate and [U-14C]glutamine. After 7 days of enteral nutrition, short-chain fatty acid concentrations represented 52% of those measured in the control group, but colonocyte metabolism remained unchanged. After 14 days of enteral nutrition, short-chain fatty acid concentrations were still decreasing, although bacterial counts remained unchanged. In parallel, ammonia and lactate concentrations were significantly increased. The capacities to utilize butyrate and glutamine in colonocytes were only slightly affected. However, there was a dramatic increase in the ratio of β-OH-butyrate to acetoacetate fluxes, suggesting a more reduced redox mitochondrial state associated with enteral feeding.

Dans le but d'etudier le mode de presentation et l'evolution de la maladie de Crohn (CD) avec un debut avant l'âge de 10 ans et d'apprecier les indications et les effets de la chirurgie, une etude retrospective a ete realisee chez 18 enfants. Cent vingt-deux enfants avec CD ont ete traites pendant une periode de 22 ans dans notre institution. Trente ont eu le premier signe de la maladie avant l'âge de 10 ans. Dix-huit parmi les trente ont eu une resection intestinale (IR). L'âge moyen au debut de CD etait de 6.4 ans et la duree moyenne du suivi etait de 11.1 ans. Les symptomes les plus communs etaient de douleurs abdominales (72%), des diarrhees (72%) et des retards de croissance (50%). Le colon et l'ileon etaient le plus frequemment concernes. La plupart de ces enfants (94,5%) recevaient un traitement medical intensif et/ou un traitement nutritionnel avant la chirurgie. Nous avons realise 26 resections intestinales et 14 autres operations chez ces 18 patients. L'indication pour IR etait l'obstruction intestinale chronique (13 cas) ou un non fonctionnement intestinal chronique (13 cas). Une amelioration de l'etat clinique etait obtenue chez 17 des 10 cas. IR est benefique chez les enfants pour lesquels le traitement medical est inefficace. Un intervalle libre apres la chirurgie peut entrainer un moment important pour ameliorer la croissance, le developpement de la puberte et pour retourner a une vie presque normale pour un long moment.

L'assistance nutritionnelle a, des son origine, induit une reflexion ethique approfondie. Ce questionnement s'est enrichi au cours des trois dernieres decennies face aux problemes poses par le concept d'insuffisance intestinale et de dependance de la nutrition parenterale, la qualite de vie de ces enfants et les tentatives de sevrage de cette nutrition artificielle au prix d'innovations therapeutiques majeures. Trente ans plus tard, les programmes « regles » d'assistance nutritionnelle a domicile et de transplantation intestinale ou hepato-intestinale suscitent de nouvelles interrogations ethiques. C'est de la responsabilite du centre expert d'en tenir compte lors des choix strategiques qu'il sera amene a discuter avec les familles.

Resumen La fibrosis quistica del pancreas (cystic fibrosis [CF] para los anglohablantes, tambien llamada mucoviscidosis) es la mas frecuente de las enfermedades autosomicas recesivas graves de las poblaciones de Europa septentrional. En los ultimos anos la supervivencia ha mejorado considerablemente al pasar de una media de 5 anos, establecida hace 20 anos, a la media actual de 30 anos. Entre 1990 y el ano 2000 la supervivencia estimada aumento el 30 %. Es probable que en los proximos anos una mejor comprension de la fisiopatologia permita realizar progresos terapeuticos importantes, tanto desde el punto de vista de la sintomatologia como del tratamiento etiologico de la enfermedad.

Although hospitalized children are at risk of malnutrition, routine screening of nutritional status has been hindered by lack of a validated nutritional assessment tool.Our aim was to develop a simple pediatric nutritional risk score that could be used at hospital admission to identify patients at risk of acute malnutrition during hospitalization.Nutritional risk was assessed prospectively in 296 children. Anthropometric measurements, food intake, ability to eat and retain food, medical condition, and symptoms interfering with feeding (pain, dyspnea, and depression) were evaluated within 48 h of admission. Pathology was classified as mild (grade 1), moderate (grade 2), or severe (grade 3). The risk of weight loss was investigated with stepwise logistic regression.Weight loss during hospitalization occurred in 65% of the children and was2% of admission weight in 45% of patients. Multivariate analysis indicated that food intake50%, pain, and grade 2 and 3 pathologic conditions (P = 0.0001 for all) were associated with weight losses of2%. The nutritional risk score ranged from 0 to 5 and was calculated by adding the values for the significant risk factors as follows: 1 for food intake50%, 1 for pain, 1 for grade 2 pathologic condition, and 3 for grade 3 pathologic condition. A score of 1 or 2 indicated moderate risk and a score/=3 indicated high risk of malnutrition.This simple score is suitable for routine use to identify patients at risk of malnutrition during hospitalization. Implementation may prevent hospital-acquired malnutrition.

Resume L'iode est present en tres faible quantite dans le corps humain (15–20 mg chez l'adulte), et joue un role indispensable dans la synthese des hormones thyroidiennes. La thyroide est beaucoup plus sensible a la carence iodee chez le nouveau-ne et le nourrisson, en raison de son contenu en iode tres faible a cet âge. Les apports quotidiens recommandes en iode varient de 40 μg chez le nouveaune a 150 μg chez l'adulte. Le deficit en iode represente la premiere cause de retard mental evitable dans les pays en developpement; il n'a pas encore disparu en Europe, en particulier a l'Est, et s'accompagne d'une prevalence elevee de goitre. Un deficit en iode au cours de la grossesse augmente le risque d'hypothyroidie transitoire en periode neonatale, avec un taux eleve de ≪rappels≫ au cours du depistage de l'hypothyroidie congenitale. Les enquetes realisees en France suggerent l'interet d'un depistage du deficit en iode chez la femme enceinte et d'une augmentation du contenu minimal en iode a 10 μg/100 kcal dans les laits pour nourrissons et 20 μg/100 kcal dans les laits pour prematures. La prevention du deficit est idealement assuree par l'enrichissement en iode des sels destines a la consommation humaine, dont l'utilisation devrait etre encouragee. Le risque d'intoxication par l'iode et d'hypothyroidie secondaire justifie de proscrire formellement l'utilisation de desinfectants iodes chez le premature et le nouveau-ne, ainsi que chez la femme enceinte et allaitante. La lutte contre le deficit chronique en iode, associee a l'administration orale preventive d'iode, reduit considerablement le risque ulterieur d'un cancer de la thyroide en cas d'accident nucleaire, en diminuant la fixation thyroidienne des radio-isotopes.

Resume Les etats d'agression aigue ou chronique sont caracterises par une proteolyse importante entrainant une reduction, voire une negativation du bilan azote, et retentissant sur la croissance. Cet article propose des recommandations concernant les apports proteiques et energetiques dans ces etats chez l'enfant.

Purpose: The aim of the authors was to report an up-to-date review of their experience with 26 intestinal transplantations in children since 1987. Methods: A retrospective study was conducted of 26 patients with a mean age of 5 years (range, 0.3 to 14 years). Three groups were isolated. In group A (1987 to 1990), seven patients received nine isolated intestinal transplants for short bowel syndrome. Immunosuppression therapy consisted of cyclosporine, aziathioprine, and corticosteroids. In group B (1994-current), nine patients received nine isolated intestinal transplants for short bowel syndrom (n = 2), intestinal pseudoobstruction (n = 2), neonatal intractable diarrhea (n = 3), and Hirschsprung' disease (n = 1); hepatic biopsy results showed weak cholestasis or fibrosis. In group C (1994-current), 10 patients received 10 combined liver-small bowel transplants for short bowel syndrome (n = 3), neonatal intractable diarrhea (n = 4), and Hirschsprung' disease (n = 3); hepatic cirrhosis related to total parenteral nutrition (TPN) was shown in all cases. Groups B and C received immunosupressive treatment consisting of tacrolimus, aziathioprine, and corticosteroids. Posttransplant follow-up included intestinal biopsies of the small bowel twice a week and more frequently or combined with liver biopsy if rejection was suspected. Results: Overall patient survival (PS) and graft survival (GS) are 61% (16 of 26) and 50% (13 of 26), respectively. In group A, severe intestinal allograft rejection occurred in six patients leading to graft removal (GS, 11%). Five patients died of TPN complications after graft removal (PS, 28%). One survivor is off TPN, and one currently is waiting for a second graft. In group B, six patients survived (PS, 66%). Causes of death include hepatic failure (n = 1), renal and liver failure (n = 1), and systemic infection (n = 1). Severe intestinal allograft rejection occurred in five patients, which neccessitated aggressive immunosuppression (antilymphocyte serum) leading to an incomplete functional recovery of the graft. Only two patients currently are off TPN. In group C, eight patients survived (PS, 80%) all of which are currently off TPN. One patient died during the procedure, and one died of severe systemic infection. Intestinal graft rejection occurred in six patients; rejection of the liver allograft occurred in five patients, yet all rejections were weak and successfully treated by corticosteroids (GS, 80%). Conclusions: Intestinal transplantation is a valid therapeutic option for children with definitive intestinal failure and not only for short bowel syndrome. Tacrolimus improves graft and patient survival (group A v group B). The lower severity of graft rejection in combined liver-small bowel transplantation improves functional results of intestinal transplantation in children without additional mortality or morbidity (group B v group C).

The aim of this study was to report the presentation and outcome of 22 consecutive children (13 female) who presented with a syndrome of chronic intestinal pseudo-obstruction with or without urinary tract involvement. We analyse the main clinical and histopathological features and discuss therapeutic management. Ten patients had signs of intestinal obstruction at birth, in which 6 presented antenatally with megacystis on ultrasound. Six children presented with constipation and/or obstruction between 1 and 6 months of age and in 6 other patients diagnosis was made between the ages of 1 and 12 years. There was a family history in 4 patients. Investigations showed diffusely dilated gut on x-ray with slow transit on small bowel follow through. Absent or abnormal motor migrating complex with low amplitude contractions were demonstrated on duodeno-jejunal manometry in 12/13. Megacystis occurred in 15/21 and megaureter in 2/21. Full thickness biopsies (n = 22) revealed involvement of muscle layers in 8, and abnormal myenteric plexus on histochemistry in 13. In 1, the biopsies were inconclusive. Recurrent urinary tract infections occurred in all with structural urinary tract abnormality and most had bacterial overgrowth. Severe recurrent episodes of obstruction which required parenteral nutrition (PN) occurred in all patients. Drugs were unhelpful and decompression ileostomies or colostomies were performed in 20/22. Five children died from sepsis (n = 3) or sudden death. Eleven patients remain partially or totally dependent on PN despite decompression ileostomy in 10/11. Six patients underwent colectomy and ileorectal pull-through, 2 of which remain on long-term PN, while the others are totally orally fed. Despite careful histological study pointing to 2 main forms, myopathy and neuropathy, the etiology of primary intestinal pseudoobstruction syndromes remains unknown. It may present antenatally while most of the time the gut and the urinary tract are diffusely involved. The condition has a high morbidity with a percentage requiring long-term PN. Although the mortality rate is high (23%), careful treatment of urinary tract infections and bacterial overgrowth, decompression surgery and judicious use of PN allows survival to adult life.

The prevalence of home enteral and parenteral nutrition programmes is rising rapidly all over the world, in children as in adults. Home artificial nutrition, especially parenteral nutrition, is an expensive technology but is life-saving for many patients. The only possible alternative to home treatment is keeping patients in hospital, and cost-benefit studies have demonstrated that home nutrition is about 70% more cost-effective than hospital-based therapy. Although home nutrition is usually considered by children and families to lead to an improvement in their quality of life, the complications of these techniques, including psychological consequences, have to be carefully assessed and prevented.

Severe malnutrition is defined by a weight for height below 70% of international standards or by presence of oedema in a clinically undernourished child. Severe malnutrition associated with oedema is called kwashiorkor. The origin of oedemas of kwashiorkor is still debated, but its relation with protein deficiency is strongly questioned. The same dietary management is now recommended for malnutrition with or without oedema. Present recommendations are based, as for well nourished children, on the separate estimation of nutritional requirements for maintenance and growth. Total requirements vary between 0.7 g/kg/day in the first few days of treatment to 5 g/kg/day or more when weight gain is maximum. As a result of high energy requirement during catch-up growth, protein requirements never exceed 10 to 12% of total energy needs.

We describe an immunocompetent 8-year-old boy with a serological profile indicating chronic infection by Epstein-Barr virus (EBV) who developed subcutaneous and pulmonary lesions related to a peripheral T-cell proliferation. No clonal rearrangement of T-cell receptor or immunoglobulin genes was seen. However, the finding of a t(3;17)(q21;q25) in 44 metaphases from one skin lesion demonstrated a clonal origin. We also showed that the proliferative T cells contained EBV genome leading to the diagnosis of EBV-associated peripheral T-cell lymphoma. Further cytogenetic and molecular studies are needed to identify genes implicated in the pathogenesis of this haematological malignancy.

L-Arginine and L-glutamine are highly metabolized by intestinal cells, leading to various metabolites, including L-citrulline, which is required for optimal growth. Elemental diets, used in clinical practice to treat growth failure and malnutrition, are very different from complex diets normally consumed. The aim of the present study was to assess the effects of an elemental diet compared with a complex diet on L-arginine metabolism in rat isolated enterocytes and its modulation by L-glutamine.Rats were fed the elemental diet (group ED) or the control diet (group C) for 14 days. Villus enterocytes then were isolated, and metabolic capacities or enzyme activities were assessed.The incubation of enterocytes isolated from group C with 0.1 mmol/L L-[U-14C]-arginine led to the production of 125 +/- 25 pmol L-citrulline/10(6) cells per 30 minutes. This production showed a twofold increase in the presence of 2 mmol/L L-glutamine. In group ED, L-citrulline synthesis from L-arginine was markedly lower in the absence or in the presence of L-glutamine. This coincided with lower carbamoylphosphate synthase I activity and carbamoylphosphate (CP) content of enterocytes. Other L-arginine and L-glutamine metabolic pathways were not affected. Similar results were obtained when the elemental diet was administered continuously through a gastric catheter or fed by mouth.L-Glutamine favors the synthesis of L-citrulline from L-arginine in isolated enterocytes, probably via an increase in CP production. Changing the diet composition, from a complex to an elemental diet, results in an alteration of the enterocyte capacity to synthesize L-citrulline from L-arginine, irrespective of the rhythm of delivery.

Resume Effectue dans le cadre du CLAN, l'objectif de ce travail etait d'evaluer dans 7 unites d'hospitalisation d'enfants et d'adultes le risque de denutrition des patients et les modalites de leur prise en charge nutritionnelle. Le risque nutritionnel a ete evalue en utilisant un score clinique. Le taux de couverture des besoins energetiques a ete calcule par le rapport entre apports recus et apports theoriques recommandes pour l'âge et le poids. Cent trente-six patients, dont 94 enfants, ont ete etudies. Il existait une forte prevalence de sujets a risque de denutrition : 52% a risque moyen et 17% a risque eleve. Une nutrition parenterale avait ete mise en œuvre dans 30% des cas, une nutrition enterale dans 15%; 54% etaient suivis par une dieteticienne; 28% n'avaient aucune prescription nutritionnelle. Une inadequation marquee entre besoins «theoriques et apports effectifs etait objectivee. Ainsi, 40%, des patients pris en charge recevaient moins de 75% des apports recommandes. Cette etude montre que les facteurs de « risques nutritionnelssont particulierement eleves au niveau de notre site hospitalier et que le « soutien nutritionneldans ce contexte demeure encore insuffisant. La mobilisation de tous les professionnels qu'a enclenchee le CLAN devrait permettre d'apporter des solutions a ces difficultes.

CASE REPORT--A 15-year 6-month-old boy suffered from isolated recurrent rectal bleeding. Rectoscopy and colonoscopy allowed to identify and to excise one large size villous polyp, which was the site of dysplasia and liberkuhn adenocarcinoma. Transrectal ultrasonography showed thickened mucosa and submucosa and suspect adenopathy. Proctectomy, ganglionic curage and coloanal anastomosis were then performed; one of the excised adenopathies was metastatic. The patient died twelve hours after surgery from an unexplained cardiovascular collapse. CONCLUSIONS--Unspecific symptoms of colorectal cancer explain that its diagnosis is often delayed. Prognosis is poor related to the advanced stages at diagnosis and mucinous adenocarcinomas. Better knowledge of the clinical presentations and of high risk situations as polyposis, ulcerative colitis, hereditary non polyposis colorectal cancer could improve the prognosis.

We describe a form of intractable diarrhea in six children (four girls) with similar clinical histories and identical histopathologic features. The children had watery diarrhea of neonatal onset requiring total parenteral nutrition. Two had siblings who had died of diarrhea in the first year of life; two others are sisters. Repeated duodenal or jejunal biopsies revealed villous atrophy with normal or hyperplastic and regenerative cryptae, normal cellularity of the lamina mesenterii propria, and no signs of T-cell activation. The main histologic features are epithelial dysplasia with focal crowding and disorganization of the surface enterocytes, pseudocystic formation of the glands, and abnormal regenerative cryptae. The basement membrane components were studied with polyclonal antibodies on frozen specimens, and were compared with biopsy specimens from patients with celiac disease or autoimmune enteropathy. Relative to the control subjects, there was faint and irregular deposition of laminin at the epithelium–lamina mesenterii propria interface, whereas deposits of heparan sulfate proteoglycan were large and lamellar. The primary or secondary nature of these modifications of the basement membrane remains to be determined, but the modifications might be related to epithelial abnormalities and to the severity of this neonatal diarrhea, which resisted all treatment and necessitated permanent total parenteral nutrition. (J P EDIATR 1995;127:212-9)

Resume Le developpement de la nutrition — parenterale et enterale — a bouleverse le pronostic de l'amputation du grele chez l'enfant. L'importance des relations mises en evidence depuis 20 ans entre nutrition et intestin en rend compte. La surface d'absorption assure le transfert des nutriments et regule les flux d'eau et d'electrolytes, son renouvellement epithelial etant controle par des facteurs de croissance intrinseques, luminaux et systemiques. Ses besoins metaboliques sont couverts par une selection de carburants specifiques — glutamine et acides gras a chaines courtes. Ainsi le grele, en modulant les echanges inter-organes de substrats, participe a la regulation du metabolisme energetique et proteique. Apres resection etendue, le grele residuel est, chez l'enfant, l'objet d'une remarquable adaptation avec hyperplasie de sa muqueuse ; il ressort des travaux experimentaux que la nutrition « locale— luminale et vasculaire — est fondamentale dans le developpement de ce processus. Basee sur ce concept, est proposee une prise en charge couplee de nutrition enterale et parenterale, avec adjonction de nutriments specifiques et de facteurs de croissance. Les resultats de ce programme nutritionnel sont remarquables, la survvie atteint 97 % et l'autonomie digestive est atteinte dans pres de 80 % des cas. Par contre, lorsqu'il s'avere que l'enfant est «definitivementdependant de la nutrition parenterale, l'alternative logique est la transplantation intestinale, confrontee jusqu'a present a d'importantes difficultes. Ses modalites reposent sur un protocole regle de conditionnement du greffon, de prophylaxie des translocations bacteriennes et de prevention du rejet avec les nouveaux immunosuppresseurs, tels que le FK 506. Plus de 50 transplantations du grele isole ou combine au foie ont ete effectuees chez l'enfant depuis 5 ans ; la moitie d'entre eux ont pu etre sevres de la nutrition parenterale. Le role joue par la nutrition dans l'encadrement de cette greffe est essentiel concourant a en ameliorer encore les resultats.

Resume Les donnees sur l'utilisation de l'absorptiometrie biphotonique (ABP) sont rares chez l'enfant. Aucune ne concerne l'enfant en nutrition parenterale (NP) prolongee. L'objectif de cette etude est de comparer les resultats de la masse grasse (MG) mesuree par anthropometrie a ceux obtenus par ABP. Elle concerne 20 enfants (15 garcons) de 2 ans et demi a 16 ans en NP cyclique depuis en moyenne 62 mois (13 mois-12 ans). L'anthropometrie et l'ABP ont ete effectuees le meme jour, 6 a 8 heures apres l'arret de la NP. Le poids mesure et celui « construitpar ABP sont positivement correles (r = 0,998, p

ObjectivesTo compare the pubertal development, the hormonal profiles and the prevalence of hirsutism and menstrual disorders in obese adolescent girls and adolescent girls with type 1 diabetes mellitus (T1DM).MethodsData were collected from 96 obese adolescent girls and 78 adolescent girls with T1DM at Tanner stage IV or V, whose ages ranged between 11.9 and 17.9 years.ResultsHigh prevalence of hirsutism and menstrual disorder was found in the obese adolescent girls (36.5 and 42% respectively) and the adolescent girls with T1DM (21 and 44% respectively). The obese girls were significantly younger at pubarche, thelarche and menarche than the girls with T1DM. Hirsutism in the obese girls and those with T1DM was associated with hyperandrogenaemia and a raised free androgen index (FAI). When the cause of the raised FAI was investigated in both the groups of girls with hirsutism, the raised FAI in the obese girls was due to low serum sex hormone-binding globulin (SHBG) levels. In contrast, the raised FAI of the girls with T1DM and hirsutism was due to hyperandrogenaemia. Menstrual disorders in the T1DM girls were associated also with hyperandrogenaemia unlike obese girls.ConclusionsHirsutism and menstrual disorders are common in obese adolescent girls and adolescent girls with T1DM. Although hyperandrogenaemia is present in both groups of girls, the androgenic profiles of the two groups differ. The hyperandrogenaemia in the obese girls is primarily due to their decreased serum SHBG levels, whereas the hyperandrogenaemia in the girls with T1DM is due to their increased androgen production.

This study was carried out to evaluate the iron status of 30 children aged 1 to 18 years who had been receiving total parenteral nutrition (TPN) for an average of 43 months with iron intakes of 100 micrograms/kg per day. Iron status was assessed by assaying the serum iron and ferritin levels and the transferrin saturation coefficient as a function of iron intake. Liver biopsy specimens were taken from 13 children. Twelve children had serum ferritin levels greater than 300 ng/ml, and 8 had levels greater than 800 ng/ml. The serum ferritin level and the transferrin saturation coefficient were positively correlated (r = 0.81; p0.01). The serum ferritin level was positively correlated with TPN duration and with the total iron intake (r = 0.68; p0.01). Of the 13 liver biopsy specimens, six showed signs of iron deposition. We conclude that there is a risk of iron overload in children receiving 100 micrograms iron per kilogram of body weight per day by TPN, indicating that intake should be reduced.

Resume Les emulsions lipidiques intraveincuses (ELI) constituent une source d'energie privilegiee permettant de reduire les effets d'apports excessifs en glucose (lipogenese, thermogenese, production de CO 2 ). Les ELI constituent en outre une source d'acides gras essentiels meme lorsqu'elles comportent 50 % de triglycerides a chaine moyenne. L'utilisation metabolique (oxydation) ou le stockage dans le tissu adipeux sont les destinees des ELI. L'etude de la clairance plasmatique d'une ELI ne renseigne ni sur leur utilisation, ni sur leur eventuelle captation par le systeme reticuloendothelial. Cette eventualite est a l'origine de complications hematologiques qui peuvent etre prevenues par une utilisation d'ELI chez l'enfant, a des doses n'excedant pas 3,5 g/kg/j et a des debits inferieurs a 0,2 g/kg/h. Des etudes recentes chez l'enfant ont montre que la capacite maximale d'oxydation des lipides exogenes etait de l'ordre de 3 g/kg/24 h.

Hypercalciuria and bone disease are frequently associated with total parenteral nutrition (TPN) in children and adults. The aim of this study was to assess the influence of calcium, phosphorus, and vitamin D intakes on hypercalciuria. We observed seven children aged 4-13 years receiving home cyclic TPN for 4 consecutive years. Calcium and phosphorus intakes, constant during the 1st year, were reduced during the last 3 years to 50 and 30% of the initial intakes, and vitamin D was stopped during the 3rd and the 4th years. All children had hypercalciuria and one of them had acute painful osteopenia and nephrocalcinosis at the beginning of the study. Hypercalciuria was corrected and painful bone disease did not occur during the three following years, with TPN daily intakes of calcium, 0.35 mmol/kg, and phosphorus, 0.70 mmol/kg. Cessation of vitamin D administration during 48 months led to no further decrease in calciuria nor to the occurrence of clinical or biological signs of vitamin D deficiency. However, we hypothesize that excessive vitamin D intake may have facilitated the occurrence of the TPN-related bone disease in one patient and should be avoided. The possible role of parenteral aluminum loading is also discussed.

The relative effect of glucose and lipids on whole-body protein-metabolism kinetics was assessed in seven infants undergoing parenteral feeding. Protein intake was kept constant and nonprotein energy was either provided as glucose alone or as an isoenergetic glucose-lipid mixture according to a randomized crossover trial. Protein metabolism and energy-substrate utilization were assessed by a primed, constant L-[13C]leucine infusion, combined with indirect calorimetry. There was a significant difference in the pattern of energy-substrate utilization according to regime. Protein turnover (11.3 +/- 0.7 vs 9.8 +/- 0.4 g.kg-1.d-1; P less than 0.05), protein breakdown (8.4 +/- 0.6 vs 7.1 +/- 0.4 g.kg-1.d-1; P less than 0.05), and amino acid oxidation rates (2.7 +/- 0.4 vs 1.4 +/- 0.5 g.kg-1.d-1; P less than 0.05) were higher for the glucose than the glucose-lipid treatment, whereas protein-synthesis rates did not significantly differ. These results suggest that the nature of energy substrates delivered to parenterally fed infants may affect protein metabolism.

Using a quantitative in vitro model simulating clinical conditions, we studied the efficacy of conventional and nonconventional 3-day therapies involving vancomycin for treating the internal surface of catheters colonized with a slime-producing strain of Staphylococcus epidermidis. When infused for 1 hr every 8 hr through the catheter at the daily dose recommended for a 10-kg child (450 mg), vancomycin alone reduced bacterial colonization but failed to sterilize the inserts. Vancomycin was more active in combination with netilmicin (25 mg for 1 hr every 8 hr), rifampin (150 mg for 90 min every 12 hr), or fosfomycin (500 mg for 4 hr every 6 hr), but the catheters were inconsistently decontaminated after 3 days of treatment. Two nonconventional modes of antibiotic administration were tested for their capacity to ensure high levels of vancomycin in the catheter lumen over a prolonged time. Vancomycin infused continuously through the catheter at a daily dose of 450 mg had the same poor sterilizing effect as vancomycin administered intermittently. On the contrary, catheters were totally decontaminated when 2.5 mg of vancomycin in a volume of 0.5 ml were injected twice daily into noninfused catheters, confirming that the antibiotic-lock technique is an approach of great interest to sterilize the internal surface of catheters colonized with staphylococci.

It is essential that children on prolonged parenteral nutrition for anatomical or functional loss of small bowel should enjoy a quality of life which is as normal as possible. Their return home is a major factor in this. Over the past 8 years, 112 children were able to remain at home on cyclic parenteral nutrition. Forty-nine of them are no longer on home parenteral nutrition (HPN), 45 are still on HPN, and 18 have died. Growth and quality of life were good in most cases. Most of the complications were from infection, 1 septicaemia per 594 days on HPN. In the light of these results, HPN seems to be the best option for children requiring prolonged parenteral nutrition, although it can only be considered within the framework of a specialized centre, which ensures patient follow-up, and provides the logistical support required for this high-technology treatment.

We report the results of a prospective study of catheter-related sepsis (CRS) in 154 gastroenterology paediatric patients treated for medical (n = 102) or surgical (n = 52) disorders. Over 2 years, 185 central venous catheters (CVC) were placed, including 155 Broviac and 30 Jonathan Shaw CVC. CVC remained in place 13,331 days (6,539 days of cyclic parenteral nutrition), with a mean catheter life of 72 days. Forty-eight episodes of CRS occurred, most of them due to coagulase-negative staphylococci (n = 29) and Staphylococcus aureus (n = 17). CRS rate was 0.26, with an overall incidence of 1 infection per 278 days of parenteral nutrition (PN). Factors significantly associated with CRS were: age 1–5 years (p < 0.01), a medical indication for treatment (p < 0.001) and summer months of PN (p < 0.01). Interestingly, CRS occurred predominantly (65%) within the first 2 months following CVC placement and the risk of infection correlated with local haemorrhage at the time of insertion (p < 0.01). Appropriate systemic therapy, without removing the catheter, permitted resolution of 90.9% (4044) of all CRS and 100% (2828) of CRS due to coagulase-negative staphylococci.

Eight children on long-term, total parenteral nutrition (TPN) were found to have elevated aluminium (Al) levels in plasma (51 ± 11 μg 1 1 ), urine (223 ± 78 μg 24 h) and bone. The load of Al in TPN solution was 232 ± 89 μg/day, and, among the different parenteral solution components high Al concentrations were found in amino-acids, calcium gluconate, potassium lactate, and trace elements, representing respectively 40%, 30%, 15%, and 10% of the total Al intakes. The authors conclude that children receiving long-term TPN have excessive Al intakes and are exposed to Al toxicity. The prevention of Al contamination requires careful control of the TPN components.

Resume Il n'existe aucune donnee concernant l'utilisation prolongee des triglycerides a chaine moyenne (TCM) chez l'enfant en nutrition parenterale (NP). Cette etude a porte sur 12 enfants âges de 1,5 a 17 ans en NP a domicile avec des apports parenteraux quotidiens de 214 ± 92 mg/kg d'azote et de 47 ± 17 Kcal/kg d'energie non proteique (ENP). L'ENP comportait 10 a 32% de lipides a chaine longue (TCL) (Intralipide® 20%). Apres substitution dose pour dose et au meme rythme de l'Intralipide® 20% par une emulsion contenant 50% de TCM et 50% de TCL (Bruneau®), les sujets ont ete suivis a 1, 3 et 6 mois. Aucun signe d'intolerance clinique n'a ete note ; parmi les marqueurs biologiques etudies, les seules modifications significatives (p

Four children aged 6 months to 9 years received fully HLA-mismatched ABO identical small intestinal allografts. In order to monitor the rejection process and to study epithelial changes induced by intestinal T cells activated by an allogeneic reaction, iterative biopsies were performed through the ileal enterostomy and processed for histology and immunohistochemistry. Episodes of acute histological reaction were observed in all 4 patients between day 10 and 160. It was preceded by appearance of pericryptic CD3+CD4+ or CD8+ T cells of recipient origin, increasing numbers of which expressed CD25. Simultaneously, early epithelial changes were noted: increased HLA-DR expression by enterocytes and decreased mitotic rate as shown by decreased numbers of KI67+ cells in crypts. During acute histological rejection, massive infiltration of mucosa by CD25+CD3+ T-cells and activated macrophages (KIM6+CD25+), was associated with crypt necrosis and then, destruction of surface epithelium. Successful treatment of graft rejection episodes with antilymphocytic serum (2), anti-CD3 monoclonal antibody (2), anti-CD25 monoclonal antibody (1) resulted in a rapid decrease of CD3+ cells, a more progressive decrease of CD25+ and KIM6+ macrophages, reappearance of KI67+ cells in crypts followed after a variable delay by recovery of villous architecture. Chronic histological rejection was observed in 1 patient after 7 months. It was characterized by total villous atrophy, fibrosis, endarteritis, infiltration of lamina propria and epithelium by CD3+CD8+ cells, a small number of which CD25+, strong HLA-DR expression by crypt and surface epithelium, increased numbers of KI67 enterocytes. Altogether these data suggested that activated T cells can induce two types of villous atrophy.(ABSTRACT TRUNCATED AT 250 WORDS)

Resume Les modifications de biodisponibilite de certains acides amines et oligo-elements peuvent etre expliquees par la formation de complexes dans les solutions pour nutrition parenterale. Cet article a pour objet la mise en evidence d'un complexe cysteine-zinc et l'etude de sa stabilite dans les melanges nutritifs. La cysteine libre, la cysteine complexee et la cystine sont analysees par une technique de chromatographie liquide, respectant la structure des complexes. Dans notre modele experimental (solutions aqueuses de cysteine et de zinc), la cysteine complexee est en equilibre avec la cysteine libre. Dans les melanges pour nutrition parenterale, la cysteine libre disparait des J0. De plus, la concentration du complexe retrouvee experimentalement est superieure a la valeur theorique du complexe cysteine-zinc. D'autres oligo-elements et alcalino-terreux sont susceptibles de se complexer a la cysteine.

More information is needed regarding the prognosis of children receiving home parenteral nutrition (HPN). This article describes 20-year outcome data in children receiving HPN and provides separate profiles for the major pediatric diagnostic subgroups.This retrospective study included children who started receiving HPN between January 1, 1980, and December 31, 1999, in a single pediatric HPN center.A total of 302 children were recruited, 230 (76%) with primary digestive disorders and 72 (24%) with nonprimary digestive disorders. Median age at HPN onset was 1.5 years. Median duration of HPN was 1.3 years. By January 1, 2000, 54% had weaned from HPN, 26% were still receiving HPN, 16% had died, and 4% had undergone intestinal transplantation. The survival probabilities at 2, 5, 10, and 15 years were 97%, 89%, 81%, and 72%, respectively. The likelihood and cause of death depended on the underlying diagnosis. Nine percent of children with primary digestive disorders died, 24% from their primary disease and 48% from liver disease or sepsis. Children with intractable diarrhea of infancy had the highest mortality rate (25%) and the highest incidence of liver disease (48%; P = 0.0002). Thirty-eight percent of children with primary nondigestive diseases died, 94% from their primary disease and 6% from liver disease or sepsis.Outcome and survival of children receiving HPN are mainly determined by their underlying diagnosis. Nearly all children with primary digestive disease survive if referred early to an expert center.

L'objectif de cette etude retrospective est d'analyser les facteurs pronostiques et la croissance staturo-ponderale a long terme apres resection intestinale etendue en periode neonatale. Population et Methodes: 87 enfants, nes entre 1975 et 1991, porteurs d'un grele court, ont ete suivis avec un recul moyen de 15 ans. Les donnees anatomiques, longueur de grele, absence de valvule ileocaecale (VIC), influencant la duree de la NP initiale ont ete analysees. Les poids et taille ont ete reportes sur les courbes de croissance et analyses. Les tailles finales des patients ayant atteint la puberte ont ete etudiees et comparees a la taille predite par la formule de Tanner. Les patients ont ete analyses en fonction du sevrage de la nutrition parenterale (NP) et de la croissance. Ils ont ete classes en 3 groupes: A (n = 9) toujours dependants de la nutrition parenterale, B (n=12) initialement sevres puis a nouveau dependants d'une assistance nutritive, C (n = 57) autonomes sur le plan digestif. Resultats: Neuf enfants sont decedes avant d'avoir pu etre sevres de la NP. La survie globale est de 89,7% et depend de l'annee de naissance. La duree de la NP est influencee par la longueur de grele residuel et la presence ou non de la valvule ileo-caecale (VIC). Parmi les 78 survivants, les enfants du groupe A ont une longueur de grele < 40 cm et/ou l'absence de VIC. Ceux du groupe B ont un grele de 35 ′ 19 cm, une VIC dans 50% des cas et une duree de NP de 47,4′23,8 mois. Une cassure staturo-ponderale significative est observee en moyenne dans les 4 annees qui suivent le sevrage necessitant la reprise d'une NP ou d'une nutrition enterale. Ceux du groupe C ont un grele de 57 ′ 19 cm, une VIC dans 81% des cas et une duree de NP de 16,1 ′ 11,4 mois. Apres sevrage de la NP, leur croissance staturo-ponderale ulterieure se fait regulierement entre - 2 et + 2 DS, leur puberte survient normalement et leur taille adulte atteint une valeur proche de leur taille cible genetique. Conclusion: Les facteurs anatomiques longueur de grele residuel et l'absence de VIC conditionnent la duree de la NP et l'evolution initiale et permettent des les premieres annees de vie de prevoir l'evolution de la croissance a long terme. Celle-ci peut etre consideree comme normale apres sevrage de la NP chez 73% des enfants de cette serie. Au contraire, des facteurs anatomiques defavorables et une NP initiale de longue duree justifient une surveillance attentive de la croissance et une reprise eventuelle d'une assistance nutritive. Le groupe d'enfants restant definitivement dependant d'une NP est candidat a la transplantation intestinale.

International audience; A better knowledge of intestinal adaptation after resection is required to improve the nutritional support that is given to patients. The aim of this study was to understand the metabolic changes underlying early adaptation after massive intestinal resection. Rats were assigned to either 80% intestinal resection or transection. All animals received the same intragastric nutrition. On day 8, plasma glutamine turnover was measured. Substrate use was determined on isolated enterocytes that were incubated in the presence of D-[U-(14)C] glucose (2 mmol/L), L-[U-(14)C] glutamine (2 mmol/L), L-[U-(14)C] arginine (1 mmol/L), or L-[1-(14)C] ornithine (1 mmol/L). Plasma glutamine turnover was similar in both groups. The rate of enterocyte glutamine use was significantly increased in the resection group, although the maximal glutaminase activity was unchanged. Glutathione generation was enhanced 3-fold in remnant intestine as compared with transected intestine (P

Intravenous administration of nutrition mixtures induces endothelial damage and arterial wall remodeling in animal models. To study endothelial function and common carotid artery mechanical properties in children receiving parenteral nutrition, we used noninvasive ultrasonic measurements in 18 children on parenteral nutrition and 18 controls. No difference appeared in the geometry of the common carotid artery (intima media thickness, systolic and diastolic diameters) between the patients on parenteral nutrition and the controls. The incremental elastic modulus was significantly higher in the patients on parenteral nutrition (1.8 +/- 0.4 versus 1.4 +/- 0.5 4 mm Hg x 10(3), p < 0.05) reflecting alteration of the elastic properties of the arterial wall independent of the vessel geometry. The flow-mediated dilatation of the brachial artery was significantly lower in the patients on parenteral nutrition (6 +/- 3 versus 8 +/- 3%, p < 0.05), whereas the dilatation after glyceryl trinitrate administration was similar (22 +/- 9 versus 25 +/- 9%). Children on parenteral nutrition exhibit endothelial dysfunction and altered stiffness of the common carotid artery. The noninvasive methods used in this study may prove useful for objectively determining the effects of various preventive methods.

Over the past 30 years, long-term parenteral nutrition (PN) has became a well-established intervention for adults and children suffering from chronic intestinal failure. In North America and in Europe, the concept of paediatric home parenteral nutrition (HPN) programmes date from the late 1970s or early 1980s (1, 2). Over the past 20 years, major advances have benefited the nutritional efficacy and safety of long-term PN in children, and improved the quality of life provided to patients and families. That led to an increase in the number of indications for HPN in children, as well as an increase in the duration of HPN programmes. Therefore, new ethical and economic issues are currently emerging.

Children who are receiving parenteral nutrition are at risk of aluminum overload, which may contribute to such side effects as osteopenic bone disease. The aim of the present study is to determine the aluminum contamination of parenteral nutrition solutions and their components, and to assess the aluminum status of children on long-term parenteral nutrition.Aluminum concentrations were determined by graphite furnace absorption spectroscopy in components and in final parenteral nutrition solutions. The urinary aluminum excretion and plasma aluminum concentration were determined in 10 children on long-term parenteral nutrition.The mean aluminum concentration in the administered parenteral nutrition solutions was 1.6 +/- 0.9 micromol x l(-1)(mean +/- standard deviation (SD)). The resulting mean aluminum daily intake of the 10 patients was 0.08 +/- 0.03 micromol x kg(-1) x day(-1).Compared to two previous studies performed in 1990 and in 1995 in our hospital, the aluminum contamination of parenteral nutrition solutions and the daily aluminum intake of the children seemed to decrease. However, the plasma aluminum concentration and daily urinary aluminum excretion of the children still remain above normal standards. The children had no clinical symptoms of bone disease but aluminum accumulation in tissue can not be excluded. To prevent this iatrogenic toxicity, the aluminum contamination of parenteral nutrition should be assessed regularly.