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This chapter is based on the memories of those who shaped the relationship between the European and the North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition. The first joint meeting of the 2 Societies took place in Paris in 1978, followed by 1 in New York in 1985, 1 in Amsterdam in 1990, 1 in Houston in 1994, and the last one in Toulouse in 1998. The formation of the Federation of the International Societies for Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) preceded the First World Congress of all Societies, which took place in Boston in 2000. The success of this meeting was followed by world congresses in Paris in 2004, Iguassu in 2008, Taiwan in 2012, and Montreal in 2016. NASPGHAN and ESPGHAN jointly took on the direction of the Journal of Pediatric Gastroenterology and Nutrition in 1991. Communication between the 2 Societies is extremely active, with members participating in many joint projects.

Academic health centers (AHCs) have a unique opportunity and corresponding moral obligation to improve the quality and equity of care for the communities they serve. AHCs must recognize and address the stark reality that social determinants of health (SDH) significantly influence the health and well-being of populations. SDH include genetics, social circumstances, environment, behavioral choices, and access to medical care. Because SDH are linked to health disparities, addressing SDH enhances AHCs ability to promote health equity. To address SDH, AHCs must: (1) assure that all health professions work together toward a common goal of health for the populations served; (2) provide high-quality, affordable patient care to all with a goal of achieving health care equity across health care settings, delivery systems, and populations; and (3) include the voice of the patient in health care research and decision-making.

The medical and psychosocial complexities involved in cases of Munchausen Syndrome by Proxy typically necessitate carefully organized interdisciplinary responses. The role of social work in the effectiveness of such responses is both crucial and historically under-considered in the existing literature. This article presents the historical and specific diagnostic components of this complex and perplexing condition, along with practice guidelines for clinical responses, with information relevant to child protection issues across multiple settings.

Objective:This paper reports on the status of lactose digestion during early and late pregnancy and at 8 weeks postpartum in an African-American population. The hypothesis is that lactose digestion and milk tolerance do not change throughout pregnancy anddo not differ from those of non-pregnant African-American women.Design and subjects:This longitudinal study determined lactose digestion after ingesting 240 ml of 1% fat milk containing 12g of lactose at: (1) early pregnancy, prior to 16 weeks (n = 148); (2) late pregnancy, 30–35 weeks (n = 77); and (3) 8 weeks postpartum (n = 93). One hundred and one comparably matched non-pregnant African-American women served as controls.Results:Prevalence of lactose digestion, as measured by breath hydrogen, was 80.2% in the control women, 66.2% in early pregnancy, 68.8% in late pregnancy and 75.3% postpartum. The prevalence of women reporting symptoms was approximately 20% regardless of lactose absorption status. However, the control women reported significantly more symptoms than did the pregnant women.Conclusions:This study indicates that there is no significant change in lactose digestion during pregnancy. The prevalence of lactose intolerance for the pregnant African-American women studied is similar to that for non-pregnant African-American women and similar to previous prevalence reports in adult African-Americans. There was no change in the tolerance of lactose noted during pregnancy in these women. There were, however, fewer symptoms reported by the lactose-maldigesting pregnant women.

Pediatric feeding disorders are common: 25% of children are reported to present with some form of feeding disorder. This number increases to 80% in developmentally delayed children. Consequences of feeding disorders can be severe, including growth failure, susceptibility to chronic illness, and even death. Feeding disorders occur in children who are healthy, who have gastrointestinal disorders, and in those with special needs. Most feeding disorders have underlying organic causes. However, overwhelming evidence indicates that abnormal feeding patterns are not solely due to organic impairment. As such, feeding disorders should be conceptualized on a continuum between psycho-social and organic factors. Disordered feeding in a child is seldom limited to the child alone; it also is a family problem. Assessment and treatment are best conducted by an interdisciplinary team of professionals. At minimum, the team should include a gastroenterologist, nutritionist, behavioral psychologist, and occupational and/or speech therapist. Intervention should be comprehensive and include treatment of the medical condition, behavioral modification to alter the child's inappropriate learned feeding patterns, and parent education and training in appropriate parenting and feeding skills. A majority of feeding problems can be resolved or greatly improved through medical, oromotor, and behavioral therapy. Behavioral feeding strategies have been applied successfully even in organically mediated feeding disorders. To avoid iatrogenic feeding problems, initial attempts to achieve nutritional goals in malnourished children should be via the oral route. The need for exclusive tube feedings should be minimized.

As consumption of dietary fructose and sorbitol increases, the association between consumption of these sugars and gastrointestinal symptoms has been recognized. As a result, studies of fructose and sorbitol absorption and malabsorption have emerged with investigations relying largely on the use of breath hydrogen (H2) measurements. Since these sugars are prevalent in fruit juices, a major dietary staple in the first 5 years of life, an understanding of fructose and sorbitol absorption is particularly important to pediatric health care providers. This review examines fructose and sorbitol absorption in humans, reviewing as well the breath H2 method upon which studies of fructose and sorbitol absorption largely depend.

Infants and young children with HIV infection commonly suffer from gastrointestinal manifestations of their disease. Many HIV infected children have evidence of persistent diarrhoea, malabsorption, malnutrition or growth failure. The aetiology and pathogenesis of gastrointestinal dysfunction in HIV infected children have not been well defined. We performed immunocytochemical analyses on intestinal tissue from 19 HIV-infected children with gastrointestinal dysfunction or growth failure. None of these 19 children had microbial pathogens identified in faecal samples using standard microbiological methods. Intestinal tissues were obtained from the children by biopsy and were examined for antigens from Pneumocystis carinii, cytomegalovirus (CMV) and herpes simplex virus (HSV) using the avidin-biotin-complex immunohistochemical technique and monoclonal or monospecific antibodies. We detected at least one of these pathogens in samples from eight (42%) of 19 HIV infected children. P. carinii was the most prevalent pathogen, found in five of the eight HIV infected children. All of the children with intestinal pneumocystis infection were receiving prophylaxis directed at the prevention of pulmonary disease with this organism and none of them were undergoing active pulmonary infection. We also identified CMV antigens in intestinal tissues from four children and HSV antigens in intestinal tissues from one child. Two children were infected with more than one pathogen. On the other hand, none of these pathogens were found in the tissues obtained from 10 HIV-uninfected patients who had intestinal tissues obtained for chronic non-infectious diarrheal and inflammatory diseases (P < 0.01, Fisher's exact test). Our findings indicate that some children with HIV infection and gastrointestinal dysfunction may be infected with opportunistic pathogens despite negative analyses employing standard microbiological methods. Our study also indicates that HIV infected children can undergo intestinal infection with P. carinii despite the administration of standard immunoprophylactic regimens directed at the prevention of infection with this organism.

Malnutrition and growth failure are frequent clinical consequences of human immunodeficiency virus (HIV) infection in children. Tube feeding is a means by which to increase the enteral intake of nutrients. We examined the effect of tube feeding in 18 children, median age 6 months (range, 3-159). Tube feedings were initiated due to growth failure in all, which was also associated with dysfunctional swallowing or aspiration in seven children and gastroesophageal reflux in two. Tube feedings were infused via nasogastric tube (n = 4) or gastrostomy tube (n = 14) and were continued for a median of 8.5 months (range, 2-24). Stoma complications developed in three children with gastrostomy tubes; these were the only tube-related side effect. Tube feedings were discontinued due to noncompliance (n = 3), gastrostomy leakage (n = 2), intolerance (n = 2), and death (n = 3). Anthropometric changes were evaluated comparing mean standard deviation scores (Z) before and after tube feeding. Tube feeding resulted in significantly increased weight for age (Z, -2.13 +/- 0.7 vs. -1.46 +/- 1.4; p = 0.04), weight for height (Z, -1.07 +/- 1.0 vs. -0.13 +/- 1.0; p = 0.004), and arm fat area (Z, -1.75 +/- 1.3 vs. -0.62 +/- 1.2; p = 0.01). However, tube feeding did not result in significant changes in height for age (Z, -1.93 +/- 0.8 vs. -1.74 +/- 1.6) or arm muscle area (Z, -1.24 +/- 0.9 vs. -0.57 +/- 1.2). Tube feedings effectively increased the weight of HIV-infected children in this study, but they were not sufficient to correct linear growth deficits.

Microvillus inclusion disease is a rare congenital disorder that presents with severe diarrhea in the newborn period. Multiple therapeutic attempts to control the diarrhea have failed, leading to a chronic dependence on parenteral nutrition and a high infant mortality. This report presents the first child with microvillus inclusion disease in whom small bowel transplantation has been successful, allowing for the administration of total caloric requirements via the enteral route.

The safety and efficacy of olsalazine sodium was compared to sulfasalazine over 3 months in a multicenter, randomized, double-blind study of 56 children with mild to moderate ulcerative colitis. Twenty-eight children received 30 mg/kg/day of olsalazine (maximum, 2 g/day) and 28 received 60 mg/kg/day of sulfasalazine (maximum, 4 g/day). Side effects were frequent in both groups. Eleven of 28 patients (39%) on olsalazine reported headache, nausea, vomiting, rash, pruritus, increased diarrhea, and/or fever. Thirteen of 28 on sulfasalazine (46%) reported similar side effects and/or neutropenia, and four patients had the drug stopped because of an adverse reaction. After 3 months, 11 of 28 (39%) on olsalazine were asymptomatic or clinically improved, compared to 22 of 28 (79%) on sulfasalazine (p = 0.006). In addition, 10 of 28 patients on olsalazine versus one on sulfasalazine required prednisone because of lack of response or worsening of colitis (p = 0.005). The dose of olsalazine used in this clinical trial was thought to be equivalent to a standard dose of sulfasalazine, but fewer patients on olsalazine improved and a greater number had progression of symptoms when compared to sulfasalazine. Although side effects were slightly less frequent for olsalazine, the number of patients was too small to detect a clinically significant difference.

Recent studies have shown reduced breath hydrogen (H2) excretion in methane (CH4)-producing healthy individuals following ingestion of lactulose. This questions the reliability of the breath hydrogen test (BHT) in CH4 excretors, but the relationship between CH4 and H2 excretion in other clinical applications of the BHT is not known. We reviewed BHT results in two groups of subjects: (1) 385 children tested for lactose malabsorption in a hospital setting, and (2) 109 lactose-malabsorbing patients tested with a home kit. The percentage of lactose malabsorbers in group 1 (51%) was the same regardless of CH4-producing status (P = 0.97). The BHT data from group 2 showed a positive correlation (r = 0.6, P0.000001) between the magnitude of the rise in CH4 and H2 concentrations, and the H2 excretion curves were significantly higher in the CH4-producing individuals. We conclude that attention to CH4-producing status is not necessary in the interpretation of the lactose BHT.

Increased intestinal permeability to lactulose has been reported in patients with cystic fibrosis (CF). To determine whether this finding is unique to CF or whether it is related to accompanying exocrine pancreatic dysfunction, we evaluated 31 patients with CF and 10 with Shwachman syndrome who had variable degrees of pancreatic dysfunction, together with 17 healthy control subjects. There was no significant difference in the mean urinary lactulose excretion, expressed as the percentage of dose recovered, between CF and non-CF patients with pancreatic insufficiency (2.1% +/- 1.2% and 1.9% +/- 0.8, respectively) or between CF and non-CF patients with pancreatic sufficiency (0.6% +/- 0.5% and 0.6% +/- 0.3%, respectively). However, there was a significant difference in mean lactulose excretion between the pancreatic-insufficient and the pancreatic-sufficient patients (both CF and non-CF groups; p less than 0.001 and p less than 0.013, respectively). We further analyzed the results from 26 of the 41 patients (16 patients with CF and 10 non-CF patients) with pancreatic dysfunction who had previously undergone quantitative pancreatic function testing. A nonlinear, inverse relationship was found between urinary lactulose excretion and exocrine pancreatic function determined by duodenal trypsin output. These data confirm a direct relationship between intestinal lactulose permeability and the degree of exocrine pancreatic dysfunction, unrelated to the cause of the pancreatic disease.

Breath hydrogen (H2) measurements are applied in clinical medicine for the detection of carbohydrate malabsorption. H2 in expired air results when dietary sugars escape absorption in the small intestine, thereby becoming available for bacterial fermentation. H2 produced by bacterial metabolism of the carbohydrate is absorbed into the portal circulation and excreted in breath. Relatively simple collection, storage, and analysis methodologies have been developed in recent years. They permit convenient and noninvasive testing of patients in most age groups for common clinical disorders of digestion and absorption, including lactase deficiency and other disorders of di- and mono-saccharide malabsorption, starch malabsorption, and small bowel bacterial overgrowth. Limitations of breath hydrogen testing are few. Developmental considerations constrain the ease of interpretation of breath H2 measurements in early infancy, and factors affecting intraluminal H2 production by the intestinal flora may occasionally affect the H2 signal. Despite these factors, breath H2 testing has repeatedly been demonstrated to be the most accurate indirect indicator of lactase deficiency, and breath H2 measurments have been widely applied in studying digestion of the entire spectrum of dietary carbohydrates.Key words: breath test, hydrogen, carbohydrate, lactose, bacterial overgrowth.

As medical schools across the nation consider the recent call made by the Association of American Medical Colleges to increase numbers of medical school students by 30% by 2015, it is important to explore the characteristics of the applicant pool. Understanding the make-up of the pool of recent applicants to the University of Kentucky College of Medicine can assist us in defining areas where the pool could be expanded in the future. Reviewing data from 2002-2006, we will examine the Kentucky county of origin of our applicants and matriculants. We will describe demographic characteristics of our applicants and matriculants with regard to gender, race and ethnicity, and international backgrounds. We will also look at factors that may discourage or dissuade prospective applicants from seeking admission to medical school including undergraduate grades, denial of the initial application to medical school, and cost considerations.

Numbers of articles have recently appeared in the lay press regarding the need for physicians to improve their rapport with patients, enhance their caring behaviors, and demonstrate actions that could be described as nice. Nice physicians are patient-centered, demonstrating skills that enable them to understand the patient's perspective, share information, and develop a partnership with patients. In fact, various medical associations have called for students, residents, and practicing physicians to demonstrate professional behaviors that might be indicative of nice, such as honesty, respectfulness, compassion, integrity, sensitivity, responsiveness, and altruism. Unfortunately, however, nice behaviors are not always modeled in academic medical centers. Medical staff members may, on occasion, demonstrate lack of patience, insensitivity, or rudeness that suggests that the coarseness of society has crept too much into our profession. Can the culture of an institution be moved toward embracing nice behaviors? We believe that a culture of nice can be nurtured in our setting by expecting civility, and exhibiting it in all interactions; reinforcing the message of being nice in all forms of verbal and written communication; recognizing Master Clinicians distinguished by their manner and their quality of care; developing methods to measure and reward physicians based on the way they "doctor;" devising innovative ways to integrate training on how to be nice into the educational curricula for both medical students and residents; and recruiting students, residents, faculty, and staff who are most likely to fit into our institutional environment and contribute to our mission in a positive manner.

In partnership with community agencies and organizations, University of Kentucky College of Medicine (UKCOM) launched an after-school program focusing on creating healthy, active lifestyles for students at a Lexington elementary school. Chosen for the underserved population of children it cares for, the school exhibits all of the national risk factors for obesity: low-income families (57% of annual household incomes less than $10,000); minority population (80% of the children African-American or Hispanic); and located in an unsafe neighborhood for outdoor physical activity. These demographics resulted in a school population that had body mass index (BMI) demographics of 48.8% overweight (BMI85%), including 30.7% obese (BMI95%), in contrast with the national average of 16% obese.Targeting the school's children with a BMI85th percentile, an after-school program was created. The students met twice a week for 90-minute sessions of fun physical activities, proper nutritional information, as well as small group sessions with pediatric psychiatry residents focusing on good choices and proper motivations in life. Universal school interventions were also instituted in an attempt to reach the entire school population.Initial findings after the first year of the program indicated a slowing in the average rate of weight gain by the targeted population. While the results, compared to accessible data in a school population with similar demographics, did not reach statistical significance, the trends were in the desired direction. A statistically significant difference (p=0.027) was observed in mean BMI percentile for the universal school population versus the comparison school.School-based prevention and intervention conducted by a coalition of community agencies and organizations is a promising and cost-effective approach to curtailing childhood obesity.

The North American Society for Pediatric Gastroenterology and Nutrition published guidelines for the evaluation of children suspected of being infected with Helicobacter pylori. The stool antigen test for H. pylori, which was recently commercialized in the United States, was evaluated in two high-risk pediatric populations. The results are encouraging but should be interpreted with caution. A number of studies suggest that delayed gastric emptying may accompany a variety of disorders, or may be a cause of vomiting. The outcome of children with dyspeptic symptoms is described, and the results will be helpful in reassuring anxious parents. Studies examining the development of H, K-adenosine triphosphatase in infants and the role of enteric glial cells in infantile hypertrophic pyloric stenosis are discussed. A study of neonates with allergic gastroenteropathy suggests that this disorder may be more common in this age group than generally thought.

The effect of diet, usual (44 +/- 4% energy as fat), high-fat (49 +/- 4% energy as fat), and moderate-fat (33 +/- 2% energy as fat), on gastric function (lipase and pepsin activities, pH, emptying rate) and intragastric digestion of fat were assessed in six children with cystic fibrosis. Fasting and postprandial activity of digestive enzymes, gastric pH, and gastric volume measured before, during, and after 120 min of feeding did not differ significantly as a function of fat intake. Postprandial gastric lipase output (units per kilogram of body weight) during usual, moderate-fat, and high-fat diets was close to or higher than (38.8 +/- 7.2, 44.9 +/- 8.6, and 54.8 +/- 5.5 U/kg per 20 min) gastric lipase output of premature infants (22.5 +/- 6.4 to 28.3 +/- 6.6 U/kg per 20 min) or of healthy adults (5.4 +/- 0.4 U/kg per 15 min) fed a high-fat diet. Postprandial pepsin output was higher (4749 +/- 797, 6117 +/- 925, and 5444 +/- 819 U/kg per 20 min) than in premature infants (597 +/- 77 to 743 +/- 97 U/kg per 20 min) or healthy adults (781 +/- 56 U/kg per 15 min). Eighty minutes after feeding gastric lipolysis reached 20 to 36%. This study shows that gastric lipase activity is high in cystic fibrosis patients maintained on diets providing 32% to 49% energy as fat, and that gastric lipase level did not increase over the ranges of dietary fat intake tested.

Autistic disorder is a pervasive developmental disorder manifested in the first 3 years of life by dysfunction in social interaction and communication. Many efforts have been made to explore the biologic basis of this disorder, but the etiology remains unknown. Recent publications describing upper gastrointestinal abnormalities and ileocolitis have focused attention on gastrointestinal function and morphology in these children. High prevalence of histologic abnormalities in the esophagus, stomach, small intestine and colon, and dysfunction of liver conjugation capacity and intestinal permeability were reported. Three surveys conducted in the United States described high prevalence of gastrointestinal symptoms in children with autistic disorder. Treatment of the digestive problems may have positive effects on their behavior.

Autism is a collection of behavioral symptoms characterized by dysfunction in social interaction and communication in affected children. It is typically associated with restrictive, repetitive, and stereotypic behavior and manifests within the first 3 years of life. The cause of this disorder is not known. Over the past decade, a significant upswing in research has occurred to examine the biologic basis of autism. Recent clinical studies have revealed a high prevalence of gastrointestinal symptoms, inflammation, and dysfunction in children with autism. Mild to moderate degrees of inflammation were found in both the upper and lower intestinal tract. In addition, decreased sulfation capacity of the liver, pathologic intestinal permeability, increased secretory response to intravenous secretin injection, and decreased digestive enzyme activities were reported in many children with autism. Treatment of digestive problems appears to have positive effects on autistic behavior. These new observations represent only a piece of the unsolved autism "puzzle" and should stimulate more research into the brain-gut connection.

Macroamylasemia is considered to be rarely associated with celiac disease (CD). We have evaluated patients in whom macroamylasemia or elevated total amylase (TA) led to the diagnosis of CD. These cases served as a catalyst for examining the prevalence of elevated TA and macroamylase (MA) in patients with active CD.Total amylase and MA measurements were performed in the sera of 124 celiac patients with positive antiendomysium and tissue transglutaminase tests, in 100 patients on gluten-free diet (GFD) with negative serology test results, and in the sera of 89 healthy controls. Macroamylasemia was measured by using the PEG precipitation method.Twenty-three newly diagnosed celiac patients had elevated serum amylase levels (2 SD above the controls). The average TA and MA levels were significantly elevated in both celiac groups. The nonprecipitated amylase levels (pancreatic and salivary amylase fractions) were not different from those of the controls. Three controls (3.4%), 21 newly diagnosed celiac (16.8%), and seven patients on GFD (7%) had significantly elevated MA activity in their sera.A significant percentage of the newly diagnosed patients with CD have macroamylasemia. Serum MA remained elevated in some patients on strict GFD. In addition, in the presence of an elevated amylase or MA the possibility of CD should be considered.

Lactase-deficient adults demonstrate improved lactose absorption and fewer symptoms when consuming yogurt than when consuming milk containing equivalent amounts of lactose. To examine this effect and its mechanisms in children, we compared symptoms and hydrogen production as an index of lactose malabsorption after typical servings of milk, pasteurized yogurt, and yogurt containing active live culture in 14 lactose- malabsorbing children (mean age 9.5 y). Symptoms and interval breath-hydrogen concentrations were recorded for 8 h after inges- tion of 12 g lactose served as milk and yogurts. Lactose-malab- sorbing children experienced significantly fewer symptoms after consuming yogurt containing active cultures than after consuming milk (P < 0.005). Pasteurized yogurt showed an intermediate effect. Lactose from yogurt was not better absorbed than was lactose from milk, as indicated by similar areas under the hydrogen curve; however, yogurt was associated with a delayed time to rise and lower rate of rise of the hydrogen curve. The rate of hydrogen rise correlated with the degree of symptoms. In children, mecha- nisms other than enhanced lactose absorption from yogurt may bead to changes in the kinetics of hydrogen production, which in turn are associated with improved tolerance. Am J C/in Nutr

Background & Aims Treatment for gastroesophageal reflux may be ineffective in patients with an eosinophilic infiltration of the esophagus. The aim of this study was to investigate whether unremitting symptoms of gastroesophageal reflux and biopsy abnormalities of the esophagus may be associated with the ingestion of certain foods. Methods Ten children previously diagnosed with gastroesophageal reflux by standard testing with long-standing symptoms (median, 34.3 months; range, 6–78 months) despite standard antireflux therapies, including Nissen fundoplication in 6 patients, were fed the elemental formulas Neocate or Neocate-1-Plus (Scientific Hospital Supplies Inc., Gaithersburg, MD) for a minimum of 6 weeks. Each child had repeat endoscopy followed by open food challenges. Results While receiving the formulas, patients had either resolution (n = 8) or improvement (n = 2) of symptoms. On follow-up esophageal biopsy, the maximal intraepithelial eosinophil counts decreased significantly before (median, 41; range, 15–100) to after (median, 0.5; range, 0–22) the formula trial ( P = 0.005). Other reactive epithelial changes of the esophageal mucosa also improved significantly. All patients redeveloped their previous symptoms on open food challenges. Conclusions Chronic gastrointestinal symptoms and histological changes of the esophagus unresponsive to standard treatments for gastroesophageal reflux were improved by the use of elemental formulas. Symptoms recurred when specific dietary proteins were reintroduced during open food challenges. The mechanism of these observations is unknown.

Dairy products containing live bacteria that possess lactase activity are used for dietary management of lactose maldigestion. The efficacy of acidophilus milk and the effect of consuming unfermented milk that had been inoculated with yogurt bacteria have not been examined in children. We compared scores for breath H2 excretion and symptoms of 20 lactose-maldigesting children following ingestion of 250 ml of uninoculated milk with two identical milks inoculated with 10(10) cells of Lactobacillus acidophilus or with a commercial yogurt starter culture containing 10(8) cells of Lactobacillus lactis and 10(10) cells of Streptococcus thermophilus. Nine of 10 subjects who were symptomatic following ingestion of uninoculated milk experienced a reduction in symptoms following ingestion of milk inoculated with L. acidophilus, without a decline in H2 excretion. Five of 6 subjects who were symptomatic following uninoculated milk had decreased symptoms and a significant reduction in H2 excretion following milk inoculated with the yogurt culture. For lactose-maldigesting children, milks inoculated with L. acidophilus or with a yogurt culture were associated with decreased symptoms compared with those with uninoculated milk.

In order to study fathers' knowledge of breast feeding and its relationship with paternal factors, fathers of 92 breast feeding and 89 non-breast feeding newborns were compared. Paternal factors included previous children and the way they were fed, participation in prenatal care, attendance at prenatal classes, breast feeding information provided by health professionals, use of reading materials and interest in learning more about the subject. The results indicated that fathers had poor knowledge about breast feeding, especially those whose children were being bottle fed. After adjustments for confounders, fathers who had previous breast-fed child(ren), had attended prenatal classes and who received information about breast feeding from medical personnel had a significantly higher chance of having a better knowledge of breast feeding. It seems that fathers need to be better prepared to assume their new role as breast feeding supporters. Prenatal care was shown to be a good opportunity to improve fathers' knowledge of breast feeding.

A cross-sectional study compared 100 breastfeeding and 100 non-breastfeeding new mothers in order to investigate the relationship between mothers' choice of breastfeeding and support from health professionals and lay people, taking into account potentially confounding sociodemographic influences. The importance of the male partners' opinion about breastfeeding was also examined. A favorable attitude of partners towards breastfeeding was the most important factor associated with breastfeeding (odds ratio=32.8). Prenatal class attendance and breastfeeding support from lay people increased the odds of breastfeeding 2.7 and 3.3 times, respectively. Breastfeeding orientation provided by doctors, nurses, and nutritionists was not associated with the maternal decision to breastfeed. The results point toward the need for reevaluation of prenatal care interventions, inclusion of fathers in breastfeeding educational programs, and emphasis on community-based programs.

Breath hydrogen testing (BHT) is a simple and reliable method for identifying impaired carbohydrate absorption. We describe a laboratory exercise in physiology for medical students using BHT as the teaching tool. The students collect fasting samples of expired air from each other using a simple nasal prong technique. They then drink one of several different aqueous carbohydrate solutions. Additional samples of expired air are collected by the students at 90 and 120 min after substrate ingestion and are analyzed by gas chromatography. Between sampling periods, discussions of digestive physiology are provided by the faculty. Students tabulate their BHT results as well as recording any symptoms using a standard scoring system. A total of 460 students have participated. We found that the percentage of students who malabsorbed a given substrate was similar each year. The results obtained in these student exercises closely parallel those reported in the literature. We conclude that BHT is an excellent teaching tool for illustrating carbohydrate digestion and absorption, even when performed by minimally trained subjects.

The purpose of our study was to determine if the ethane content of expired air could be a useful index of vitamin E status in children. Eight children with vitamin E deficiency secondary to chronic severe liver disease were studied: six of these children were treated with parenteral vitamin E (2–5 mg/kg/dose every 4–7 d). Measures of vitamin E status pre- and posttherapy were: serum vitamin E, 2 ± 1 versus 7 ± 1 μg/mL (p < 0.001); serum vitamin E:total lipids, 0.3 ± 0.1 versus 1.0 ± 0.1 mg/g (p < 0.001); and erythrocyte peroxide hemolysis test, 80 ± 10 versus 6 ± 12% (p < 0.001). Fasting breath ethane in the patients pre- and posttherapy was 78 ± 10 versus 31 ± 11 pmol/kg/min (p < 0.001). Breath ethane correlated negatively with serum vitamin E (p < 0.042) and serum E:total lipids (p < 0.004) and positively with the erythrocyte peroxide hemolysis test (p < 0.003). Values for treated patients did not differ from those for fasted sibling controls (34 ± 12 pmol/kg/min), postprandial sibling controls (31 ± 12 pmol/kg/min), and healthy children sampled randomly, in the nonfasted state (21 ± 14 pmol/kg/min). Breath ethane production in one patient (up to 168 pmol/kg/min) did not normalize after treatment of vitamin E deficiency until her selenium deficiency was corrected as well. We conclude that this noninvasive test can be useful as a screen for vitamin E deficiency in children and for ascertaining response to therapy. The presence of high concentrations of ethane in expired air in vitamin E-sufficient subjects may indicate deficiencies of other antioxidants such as selenium.

Gastrointestinal dysfunction is a serious problem in many children infected with human immunodeficiency virus (HIV), the etiology of which has not been clearly defined. Quantitative nucleic acid amplification was used to study the correlation between shedding of HIV nucleic acids and gastrointestinal symptoms in HIV-infected infants and children. Many with HIV infection and persistent diarrheal disease shed HIV nucleic acids in their feces, as did an HIV-infected patient without apparent diarrheal disease. HIV nucleic acids were not found in feces of non-HIV-infected individuals. Intestinal infection with HIV appears to be important in the pathophysiology of gastrointestinal dysfunction in infants and children with HIV infection. Furthermore, the fecal shedding of HIV may play a role in HIV transmission in environments prone to high levels of fecal-oral contamination.

Lactose intolerance is a common condition that can cause nonspecific gastrointestinal symptoms. A reliable diagnosis cannot be made on the basis of the patient's history. The breath hydrogen test is simple, noninvasive, accurate, and inexpensive and is the diagnostic method of choice. In addition to traditional dietary restriction of lactose, treatment may consist of alterations in dietary fat content or caloric density to reduce symptoms and use of dairy products or additives that provide lactase activity.

Because gastrointestinal dysfunction is a major problem in children with human immunodeficiency virus (HIV) infection, we utilized breath hydrogen measurements to determine the relationship between disaccharide malabsorption and gastrointestinal dysfunction in HIV-infected children. We found a strong association between lactose intolerance and persistent diarrheal disease in this population (p less than 0.007, Mann-Whitney U test). We also found evidence of sucrose malabsorption and persistent diarrheal disease in three of the children. Extensive microbiologic evaluations failed to reveal an etiologic agent related to the occurrence of gastrointestinal symptoms. Our findings indicate that disaccharide intolerance is a common occurrence in HIV-infected children with persistent diarrheal disease. Careful attention to dietary intake may be required to ameliorate clinical symptoms and to maintain adequate nutrition.

To examine the association between methane (CH4) excretion and experimental colonic carcinogenesis, we measured CH4 excretion in rats treated with the colonic carcinogen azoxymethane (AOM, 7 mg/kg weekly for 10 weeks) and paired controls. CH4 excretion was not initially detected in either experimental or control groups, but all animals acquired positive CH4 excretion status by time of sacrifice (week 26). There was no difference between groups or among AOM-treated animals with and without tumors in the median time to onset of detectable CH4 excretion or in the amount of CH4 excreted. Our results fail to provide support for a link between CH4 excretion and experimental colonic dysplasia or adenocarcinoma.

Clinical, biochemical and pathological studies in patients with the Rett syndrome (RS) are presented. The neuropatho-logical changes and alterations in neurotransmitter markers are particularly interesting and provide valuable information that may be helpful in understanding the behavior and neurological phenotype of RS.

Osteoporosis in postmenopausal women may be reduced in both incidence and severity by a calcium intake of 1500 mg/d (1). Dairy products represent the richest natural food source for calcium, but a major impediment to the intake of dairy products is the desire to avoid symptoms attributable to lactose intolerance. These symptoms include excessive flatus, bloating, abdominal pain, nausea, and feelings of fullness. At least 30% of the US population maldigests lactose (2). In this issue of the Journal, Suarez et al (3) compared symptoms in women consuming diets containing 1300 mg Ca, but either unmodified in lactose content or with the lactose content extensively reduced through enzymatic hydrolysis. In each diet, the amount of lactose or reduced lactose ranged from 34 to 2 g. Women were divided equally between those who digested lactose and those who did not as determined by breath-hydrogen testing. Women with lactose maldigestion reported no significant differences in bloating, abdominal pain, diarrhea, or their perception of overall symptom severity whether ingesting the conventional dairy-rich diet or the lactose-hydrolyzed diet. Women with lactose maldigestion did, however, report increased flatus frequency and subjective impression of rectal gas during the period of high lactose intake. Not surprisingly, women who digested lactose reported no significant differences for any symptom during ingestion of conventional or lactose-hydrolyzed dairy products. Because on balance the women with lactose maldigestion tolerated the “high” lactose diet, the authors concluded that “the symptoms resulting from lactose maldigestion are not a major impediment to the ingestion of a dairy-rich diet supplying

LEARNING OUTCOME: To state the prevalence and effects of lactose intolerance in pregnant African-American women Objective: To determine the prevalence of lactose intolerance in pregnant African-American women, any change in tolerance that may occur and reported symptoms after consuming 240 ml of 1% milk. Design: This longitudinal study compared lactose status: 1) prior to 16 weeks gestation, 2) between the 30th and 35th week and 3) at 8 weeks post-partum. Similar non-pregnant control women were independently studied at one point. Subjects: 148 pregnant and 101 non-pregnant African-American women were randomly selected from 4 clinics. Subjects were free of metabolic disease, intestinal disease, eligible for the WIC program and free of obstetric complications. Control women met all study criteria. Main outcome measures: Breath hydrogen was collected hourly for 8 hours following ingestion of 240 ml of 1% milk. A breath hydrogen rise of > 20 ppm indicated lactose intolerance. Symptoms of flatulence, diarrhea, abdominal pain and bloating were continuously monitored and reported during the 8 hours. Statistical analysis: Results were analyzed using two-tailed t tests and x 2 test. Results: Prevalence of lactose intolerance was 80.2% in the control women, 66.4% in early pregnancy, 68.8% during late pregnancy and 75.3% at post-partum. There was no statistically significant change in lactose digestion during pregnancy. Control women reported significantly more symptoms than the pregnant women. An increase in intestinal transit time was evidenced by breath hydrogen peak at 5 hours during early and late pregnancy and at 4 hours post-partum and for controls. Conclusions: Prevalence of lactose intolerance in pregnant African-American women is similar to non-pregnant African-American women. There appears to be no physiologic adaptation to lactose during pregnancy; as previously reported in the literature. Symptoms caused by milk may be lessened during pregnancy due to increased intestinal transit time. Pregnant African-American women need nutrition counseling which considers this information and informs their decision regarding milk or alternative sources of protein and calcium.

Pediatric feeding disorders are estimated to occur in as many as one in every four infants and children, and when serious can require numerous, costly and sustained interventions. For over a decade research has cumulated evidence on the contributions of Behavior Analysis in understanding and remediating some types of pediatric feeding disorders. The systematic use of this body of evidence in conjunction with other approaches (medical, nutrition, occupational therapy, physical therapy, and so forth) is being carried out on an inpatient treatment unit at the Kennedy Krieger Institute. Key aspects are described here, including direct observation behavior assessment, approaches for increasing and decreasing feeding behavior, skill acquisition, transfer of treatment gains, and parent training. The results based on case studies and overall program evaluation indicate that medically complicated, severe feeding disorders can be treated successfully in a few months with a multidisciplinary approach which incorporates behavioral procedures.

Our previous work suggested that increased intestinal permeability was related to the degree of exocrine pancreatic dysfunction in Cystic Fibrosis (CF). Others have suggested this finding represents a specific abnormality of CF. To further evaluate this question we studied CF (n=31) and non-CF (n=10) patients (Shwachman Syndrome) with variable degrees of exocrine pancreatic dysfunction They were categorized into pancreatic insufficient (PI) and pancreatic sufficient (PS) groups based on fecal fat balance studies. After an overnight fast, patients were fed 20 grams of lactulose and urine was collected for 8 hours. Urinary lactulose excretion (% intake) was determined by thin-layer chromatography. Mean urinary lactulose excretion was no different between CF and non-CF patients with either PI (2.10±1.21 and 1.92±0.76) or PS (0.63±0.49 and 0.61±0.34). There was a significant difference in lactulose excretion between PI and PS patients in CF and non-CF groups (p

The diagnosis of inflammatory bowel disease rests on radiologic, endoscopic, and histologic creteria. Five patients, 2 to 17 years of age, sought medical attention because of chronic abdominal pain, diarrhea, and heme-positive stools. Rectal biopsies, visual inspection of colonic mucosa through the colonoscope, and contrast radiographs of the large and small intestine yielded nonspecific results. Serial endoscopic biopsies demonstrated a gradient of inflammatory changes diminishing in severity distally from the ileocecal valve and cecum. The disease process was most evident in specimens from the cecum, whereas biopsies distal to the transverse colon had a normal histologic appearance in all five patients. Biopsies from the proximal colon may provide evidence of inflammatory bowel disease not detectable using standard techniques. The combination of chronic abdominal pain, diarrhea, and heme-positive stools associated with inflammatory changes in biopsy specimens obtained from the proximal colon, but normal findings on radiologic, colonoscopic, and rectal biopsy examinations, may represent an early stage in the evolution of chronic nonspecific inflammatory bowel disease, including ulcerative colitis or regional enteritis (Crohn disease).

Gynecomastia is generally a benign occurrence in 39% to 67% of the normal adolescent male population.1,2 Although the etiology of the breast development is not entirely clear, it may be due to a transient increase in serum estradiol leading to an increase in the estradiol to testosterone ratio. Gynecomastia in adolescent boys may also be associated with a variety of pathologic conditions in which there is an elevation in the estradiol to testosterone ratio. Examples of these conditions include Klinefelter syndrome, congenital anorchia, androgen resistance, orchitis, trauma, congenital adrenal hyperplasia, thyrotoxicosis, starvation, cirrhosis, testicular tumors, adrenal tumors, and primary liver carcinoma.3

Among physiological materials available for sampling by the pediatrician, breath has received the least attention. Important questions concerning breath collection methods and the sensitivity and specificity of breath tests remain to be answered. Nevertheless, the validation and the use of nonradioactive labels and simpler collection methods have established the safety, noninvasiveness, and simplicity of breath tests for use in the pediatric population. Because samples can be collected in the field, office, or hospital and are easily stored, the use of central laboratory facilities will permit pooling of resources and decreased cost. In the case of hydrogen excretion following carbohydrate loads, accurate measurements within the diagnostic range of 2 to 10 ppm are possible by gas chromatographs equipped with thermal conductivity detectors, and should be available in most hospital laboratories. For the application of stable isotopically labeled substrates, the development of regional mass spectrometry centers will permit easier accessibility to and reduced cost of the requisite technology for isotope measurement. Thus, breath tests hold considerable promise for extending our capacity to study and evaluate in vivo metabolic processes both in the clinic and in the laboratory.