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The risk of developing treatment-warranted Type 1 retinopathy of prematurity (ROP) might be reduced in preterm infants by modifying certain systemic factors. There are steps that can be taken both early and late in the course of retinal vascular maturation that may potentially reduce an infant's risk of developing Type 1 ROP. In prethreshold stage 2-3 ROP without plus disease, a combination of supplemental oxygen, correction of severe anemia, and light adaptation to reduce rod photoreceptor oxygen consumption helped us to reduce ROP severity, and encouraged a return to a more physiologic retinal vascular maturation pattern. Thus, it may be possible to reduce the risk of developing Type 1 ROP by making adjustments in certain systemic parameters aimed at reducing retinal hypoxia, thereby gently lowering pathologically elevated levels of vascular endothelial growth factor (VEGF) within the eye.

Although there has been a marked reduction in perinatal morbidity and mortality rates over the past four decades, asphyxia in the perinatal period, leading to major motor and cognitive disabilities, continues to be a significant health problem worldwide. With a great deal of emphasis being placed on fetal monitoring, the rapid institution of appropriate resuscitative measures in depressed infants, as well as having more precision in the diagnosis and documentation of asphyxia, the mortality rate due to intrauterine hypoxia and birth asphyxia (ICD-9 code 768) has decreased by over 70% since 1979 in the USA. This trend has been noticed in Sweden and in the UK as well. Despite these advances, a large number of infants with neurological abnormalities manifested by cerebral palsy, hearing or visual impairment, and mental retardation are born each year, many due to problems encountered during the birthing process. For many years, since W. J. Little's initial report linking neurological and mental handicaps in infants and children to abnormalities of labor and delivery, premature birth and asphyxia neonatorum, physicians in general and the lay public in particular have considered that birth trauma and “perinatal asphyxia” were the primary causes of handicaps in children. They also felt that had appropriate obstetrical and neonatal care been provided, the majority of such handicaps could have been prevented.

Introduction Despite the fact that recent studies suggest that postpartum events account for only a fraction of untoward outcomes such as cerebral palsy, mental retardation, and chronic seizure disorders, management of the newborn during the immediate postpartum period is often subject to rigorous scrutiny by malpractice attorneys and their medical consultants. Because the potential for cerebral injury during the intrapartum period is real, it is critical that evidence-based principles of neonatal resuscitation as described in the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP) be applied in an effort to attenuate or even reverse pathologic processes originating in utero. Adequate maternal cardiac output and arterial oxygen content, in addition to a functioning placenta, serve to support the metabolic needs of the fetus. Disruption of oxygen supply to the fetus may have consequences after birth depending on the severity and duration of decreased oxygen delivery. Anything that impacts the health of the pregnant woman may also have adverse effects on the fetus. Fetal oxygen delivery may be impaired by poor maternal cardiopulmonary function such as that seen in cystic fibrosis and cardiomyopathy; altered uterine blood flow as in maternal hemorrhage; chronically or acutely diminished placental perfusion due to pregnancy-induced hypertension and uterine hyperstimulation; or umbilical cord dysfunction as in umbilical cord prolapse. Detection of fetal stress during the intrapartum period relies mainly on monitoring of the fetal heart rate. When a non-reassuring fetal heart rate is present, maneuvers to restore adequate oxygen delivery to the fetus are indicated.

Hypoxic-ischemic encephalopathy continues to be a major problem in perinatal medicine because of the high mortality rate and neurological and intellectual impairment in the surviving infants. In addition to the acute necrotic damage that occurs in the neurons initially, reperfusion injury and secondary neuronal damage continue for 6 to 72 hours after the initial insult. Secondary cellular energy failure, membrane breakdown, cellular influx of calcium ions, elaboration of cytokines, and oxidation of excitory amino acids all contribute to enhanced apoptosis of the neurons. Newer forms of therapy including the use of oxygen-free radical inhibitors and mild to moderate cerebral or systemic hypothermia for 72 hours following the asphyxial period are promising adjuncts as follow-up approaches to the affected newborns.

In intensive care nurseries it has become common practice to use microwave thawing of frozen human milk for more rapid accessibility. Twenty-two freshly frozen human milk samples were tested for lysozyme activity, total IgA, and specific secretory IgA to Escherichia coli serotypes 01, 04, and 06. The samples were heated by microwave for 30 seconds at a low- or high-power setting and then reanalyzed. One-mL aliquots of 10 additional human milk samples were microwaved at low (20 degrees C to 25 degrees C), medium (60 degrees C to 70 degrees C), and high (greater than or equal to 98 degrees C) setting before the addition to each of 1 mL of diluted E coli suspension. E coli growth was determined after 3 1/2 hours of incubation at 37 degrees C. Microwaving at high temperatures (72 degrees C to 98 degrees C) caused a marked decrease in activity of all the tested antiinfective factors. E coli growth at greater than or equal to 98 degrees C was 18 times that of control human milk. Microwaving at low temperatures (20 degrees C to 53 degrees C) had no significant effect on total IgA, specific IgA to E coli serotypes 01 and 04, but did significantly decrease lysozyme and specific IgA to E coli serotype 06. Even at 20 degrees C to 25 degrees C, E coli growth was five times that of control human milk. Microwaving appears to be contraindicated at high temperatures, and questions regarding its safety exist even at low temperatures.

The maturational decline in lactase-phlorizin hydrolase (LPH) activity was studied in groups of young rats ranging from suckling to early post-weaned states. Associated maturational increases in sucrase-isomaltase (SI) and maltase-glucoamylase (MG) activities were also examined as a comparison. Over this time period changes in cellular concentrations of the three enzymes were observed, reflecting corresponding changes in enzyme activities. Synthesis patterns accompanying these maturational changes in concentration were examined using labelled leucine as a marker. Synthesis of LPH was found to be maintained at constant rates independent of the maturation-associated decline in its concentration, whereas the increases in cellular concentrations of SI and MG were due to accelerated synthesis of the enzyme. Turnover of LPH, based on both the fractional synthesis rate and the disappearance rate of labelled leucine from prelabelled LPH pools, was increased in a quantitatively similar way to the decline in LPH concentration. These findings are consistent with our earlier proposal that the maturational decline of LPH occurs because of accelerated turnover, without a decrease in its rate of synthesis.

A prospective study was carried out to identify the immediate and long-range advantages and disadvantages of a walking-donor transfusion program for an intensive care newborn nursery. The effect of heparin on coagulation of blood was evaluated and found to be minimal. There was no evidence of transmission of HB 8 Ag. The prevalence of CMV infection at the time of follow-up was higher in infants who had received blood from donors seropositive for CMV than in infnats who had been transfused from seronegative donors. In our experience, a walking-donor program has been a safe and effective method for the provision of small transfusions of blood to sick neonates.

The rates of colonization and infection of newborns with coagulase-positive staphylococci were studied during five sequential periods using various modes of skin care in the nursery. Colonization and infection were low during the baseline period when total body bathing with 3% hexachlorophene was employed (period 1), but increased dramatically (80% colonization, 9.5% infection) when hexachlorophene was discontinued and replaced by Ivory Soap baths (period 2). Reinstitution of hexachlorophene (period 3) reduced both colonization and infection, but not to the low levels seen during period 1. A second Ivory Soap period (period 4) resulted in a return to high colonization (77%) and infection (11.5%) rates. During period 5, daily Ivory Soap baths were continued and bacitracin ointment was applied to the umbilical area at least three times daily. Colonization was reduced to 10% and infection to 3.0%. Bacitracin could not be detected in serum in 15 infants studied. Colonization with gram-negative enteric bacilli was highest while using hexachlorophene or Ivory-bacitracin, but no increase in gram-negative infections was seen. Colonization of newborns with non-group A β-hemolytic streptococci was not influenced predictably with various modes of skin care. The local application of bacitracin is a safe and effective method of controlling staphylococcal colonization and disease for infants in nurseries.

The intractable diarrhoea syndrome of infancy continues to be a major diagnostic and therapeutic challenge to the paediatrician and paediatric gastroenterologist. A carefully organized, staged approach to diagnosis will provide the best method of identifying those infants in whom a specific aetiology exists and for whom specific therapy is often available. Regardless of aetiology, however, the early use of appropriate nutritional support will not only reduce morbidity and mortality in these infants, but will prevent the development of many of the secondary consequences of malnutrition. The physician must compulsively pay attention to the details of daily management and provide an organized approach to diagnosis and treatment in order to improve the outcome of infants with intractable diarrhoea.

Several roentgenologists in Britain for the past 20 years have annually seen more cases of hiatal herniae in children than have roentgenologists in the United States. The authors decided to determine whether or not the adoption of the criteria employed by some of these British roentgenologists, if used at our hospital in children under the age of 10 years, would result in our finding more cases of hiatal hernia.A retrospective study of 1 year was done using "British" diagnostic criteria, the results of which were compared to the previous 2 years’ experience in our hospital. We found 10 times more cases of hiatal hernia when these criteria, new to the United States, were employed. Most of the patients were less than a year old, and all patients had severe symptoms attributable to hiatal herniae.Our findings show that roentgenologists need to be more aware of the roentgen features of hiatal hernia in infants and young children. They should appreciate that the roentgen features differ in the young from older...

The prevalence of primary adult lactose malabsorption and the pattern of milk use were studied among 109 Indians from various tribes of the American Great Basin and Southwest. Included were 100 persons who reported being full-blooded Indians as well as three with Mexican admixture and 6 with some European ancestry. Lactose malabsorption was found in 92% of the full-blooded Indians but in only 50% Indians who acknowledged European admixture. These results agree with those of studies of native Americans done elsewhere which show very high prevalences of such lactose malabsorption among adults reported as fullblooded and lower prevalences among individuals with admitted European ancestors. The suggestion made is that in pre-Colombian times, before interbreeding with Europeans began on any scale, such lactose malabsorption may have been nearly universal among native American adults. Most of the Indians studied consumed abundant milk since childhood but were nevertheless predominantly malabsorbers as adults. This argues against the induction hypothesis advanced by some to explain the striking ethnic differences that occur around the world in primary adult lactose malabsorption.

We have examined the nature of the decline of lactase (EC 3.2.1.23) activity in the maturing rat intestine. It was established in an initial study that the activity decline reflected a proportional reduction in the concentration of the enzyme protein. Accumulation patterns into lactase, total intestinal proteins and sucrase (Ec 3.2.1.48)-isomaltase (EC 3.2.1.10) were compared, 4 h following administration of a tracer dose of [ 3 H]leucine to weanling rats exhibiting a wide range of lactase decline. Accumulation of increasing amounts of label in total intestinal proteins and sucrase-isomaltase pools was found to accompany the lactase decline, in contrast to accumulation of a constant amount of label in the declining lactase pools. The pattern of increased label accumulation in total intestinal proteins was shown in a corollary study to reflect a corresponding acceleration of total protein synthesis. On this basis, the finding of a constant amount of label in the declining lactase pools suggested a constant synthesis of lactase. We proposed earlier that associated reductions in enterocyte life-span (leading to correspondingly less lactase accumulation) rather than suppressed synthesis may provide the primary causal basis of lactase decline in the postweaned mammal.

This study was initiated to evaluate the effect of early expression on the bacterial colony count of human milk. Significant bacterial contamination (greater than or equal to 10,000 colony-forming units/ml milk) was more common in 11 mothers who delayed the onset of expression of their milk compared with mothers who began to express their milk in the immediate postpartum period (n = 15) or who began to nurse their own full-term infants soon after delivery (n = 9). These data suggest that mothers who are separated from their prematurely born or sick infants should begin to express milk for their own infants as soon after birth as possible to provide milk with low bacterial contamination for frozen storage and later use.

The authors gratefully acknowledge the contributions of case histories by Michael D. Amy Ion, M.D., of Children’s Hospital, Palo Alto, Ca. and Robert E. Sinai, M.D., of Fremont Pediatric Medical Group, Fremont, Ca., which form the basis of this discussion of human milk usage.

Intrapartum records of mothers delivering babies with perinatal aspiration syndrome (PAS) at Stanford University Medical Center over a 22 month period were compared to those of control groups. In this series, 50 babies, or 1.5 per cent of live-born babies, developed PAS. Intrapartum complications, fetal distress, use of mid forceps, and breech presentations were found with significantly increased frequency (p

Ontogenic development continues after birth in mammalian enteric epithelium as an adaptive mechanism to extrauterine life. In the rat, particularly significant developmental changes in enteric structure, function, and cytokinetic properties occur over a short critical period (usually between 16 and 20 days of age), preparatory to dietary change with weaning. Surgical bypass of ileal segments was performed on suckling rats of 12–14 days of age, and the effect on subsequent intestinal development was studied in both the bypassed and the shortened segment remaining in continuity. The bypassed segment, although achieving normal maturational patterns of active sucrase appearance and maltase accumulation, continued to maintain coincident immature patterns of high lactase activity and low cell turnover times. The intestine in continuity showed precocious appearance of active sucrase and accumulation along with maltase to greater than control levels, accompanied by a normal coincident decline in lactase activity and enterocyte life-span. Involvement of intraluminal influences on various parameters of enteric ontogenic development is thus indicated with the effects expressed by a delay in the excluded (bypassed) segment and by stimulation in the shortened segment in continuity. Data are presented in further support of the hypothesis that the life-span of the enterocyte serves postnatally as a primary determinant of enteric lactase levels.

Ventilator-bound very low birth weight (VLBW) infants represent an increasing proportion of our nursery population. We reviewed the hospital course of 38 VLBW infants who required more than 1 month of intermittent mandatory ventilation (IMV) between 1976 and 1978. Twenty-eight infants survived; 10 died. There were no significant differences between survivors and nonsurvivors in estimated gestational age (EGA), Apgar scores, first pH, first mean arterial pressure (MAP), h of IMV required, or birth weight; nor did the incidence of patent ductus arteriosus (PDA), respiratory distress syndrome (RDS), or transport differ. Pneumothorax was significantly more common among those infants who died. When ventilator settings were reviewed, significant differences were found consistently between the 2 groups of 3, 5, and 7 days of age, but not at 1, 14, 21, or 28 days of age. A predictive model for estimating the probability of survival of such infants was developed based upon these data, employing birth weight, mean airway pressure (MAWP) at 7 days of age, and occurrence of pneumothorax, and was applied prospectively to a group of 29 such infants born in 1979 and 1980. Prediction of outcome was significantly more accurate than chance alone. We conclude that prolonged ventilator dependence is largely confined to VLBW infants; that it is the rule among infants less than 750 g; and that accurate, objective assessment of an individual infant's prognosis may lead to improved care.

Hydrocortisone administration to infant rats enhanced cellobiase and maltase activities and induced precocious expression of sucrase and trehalase activities along the length of the small intestine. These activity changes reflected proportional concentration increases in the enzymes lactase (EC 3.2.1.23), maltase/glucoamylase (EC 3.2.1.20) and sucrase-isomaltase (EC 3.2.1.48/10). Administration of an equivalent tracer dose of [3H]leucine (by body weight) to control and hydrocortisone-treated infant rats resulted in greater accumulation of label in the carbohydrase pools of the treated rats, suggesting their increased de novo synthesis. The increased concentrations of lactase and maltase/glucoamylase induced by exogenous hydrocortisone were matched by the presence of corresponding greater amounts of label in their brush border pools. Accumulation of label in each of the lactase, maltase/glucoamylase and sucrase-isomaltase pools was generally similar in the hydrocortisone-treated rats, suggesting equivalent stimulation of their synthesis as a group by the humoral agent. The turnover rates of the carbohydrases as a group were found to be similar and did not appear to differ in control and hydrocortisone-treated rats. Total protein synthesis rates were slightly greater in the intestine of the hydrocortisone-treated group of rats.

Lactose loading tests and other means were used to determine the pattern of primary "adult" lactose malabsorption (LM) and milk use among 171 subjects, including 122 children and 49 adults, almost all of them Pima Indians of Arizona. LM develops at quite young ages in full-blooded Pima children: already in the 3- to 4-year age group, 40% had LM. Of 62 full-blooded Indians (greater than or equal to 4 years of age), 59 (95%) had LM. Of 41 Indians (greater than or equal to 4 years) who were of mixed Indian-northern European ancestry, however, only 25 (61%) had LM, and, among them, prevalence of LM correlated with degree of northern European admixture. Whereas only 21% of Pima lactose absorbers reported symptoms after the loading test, 72% of malabsorbers did so, with older malabsorbers more likely to experience symptoms. In their everyday lives, only 23% of malabsorbers recognized symptoms brought on by milk consumption, but the percentage of malabsorbers making such an association increased with age. Nevertheless the Pima, adults as well as children, continue to drink reasonable quantities of milk. Family pedigrees are consistent with the hypothesis that adult lactose absorption is inherited as an autosomal dominant trait. Over-all results of this study, moreover, support the geographic hypothesis advanced to explain ethnic or racial differences in prevalence of LM, rather than the induction hypothesis.

Forty-eight infants, including 14 premature infants who were appropriate size for gestational age (AGA), 10 full-term AGA infants, 18 full-term infants who were large for gestational age (LGA), and six premature LGA infants of diabetic mothers (IDMs), had measurements of skinfold thickness (SFT) in the first 72 h of life. For the 24 LGA infants, there was a significant positive correlation between maternal glycohemoglobin (Hb AIc) in the post-partum period and SFT (r = 0.42, p less than 0.05). Our observations in this study support those of others, demonstrating that SFT increases with increasing gestational age. In addition, they support the hypothesis that, in diabetic pregnancies, or pregnancies associated with an elevated Hb AIc, a reflection of the time-integrated blood glucose level over the weeks preceding parturition, fetal hyperglycemia and hyperinsulinemia stimulate increased triglyceride synthesis in adipose cells and lead to an increase in fetal subcutaneous fat.

Of 22 survivors of gastroschisis and omphalocele, most had poor weight gain. Although one-third of gastroschisis babies were small-for-gestational age at birth, no other predisposing factors for poor growth could be demonstrated. No child had intrinsic gastrointestinal or metabolic sequelae at 3 years of age, as demonstrated by radiographic studies, fecal fat excretion, or serum chemistry screen. One-third of those tested had IQs less than 90; five had abnormal electroencephalograms; one had impaired hearing. Intellectual impairment was related to length of hospitalization due to a variety of nongastrointestinal factors. Neither growth nor intellectual development was related to the type of lesion present, even when IQ is corrected for prematurity. Impairment of growth and intellectual outcome may be related to prematurity, small-for-gestation birth weight, and nongastrointestinal neonatal complications.

Cells of the intestinal mucosa of the infant and adult rat maintain a pattern of continuous growth, accumulating structural and functional proteins and lipids while migrating the length of the villus column. Cells of jejunal and ileal segments were fractionated sequentially from villus tip to inner crypt and distribution patterns were determined for DNA, total protein, cholesterol, phospholipid, and disaccharidases. Patterns of increasing ratios of protein, lipids, and disaccharidases to DNA were maintained to villus tips, with only slight fall-off of enzymes observed. Distribution profiles of disaccharidases, when computed relative to protein (as seen in previous reports), show distortion of the true cellular distribution pattern of these enzymes as determined by the DNA content of the fractions. Wide variation in cell protein concentrations was evident between jejunal and ileal segments in pre- and postweaned rats. Ileal cells of the suckling rat contained particularly high protein concentrations, which appeared to be largely transitory in nature and related to food intake. Cholesterol and phospholipids were found to be concentrated in the microvillus membrane and account for a significantly large fraction of the cellular content of these lipids.

Fifty-five infants who survived respiratory failure in the neonatal period with the aid of assisted ventilation were studied in order to evaluate their long-term prognosis. Over 80 per cent of these infants had normal intelligence and either minimal or no neurologic abnormalities. Only four infants had I.Q. scores of less than 85. The incidence of neurologic and intellectual handicaps was highest in low-birth-weight infants (

The arrangement of the sugar hydrolases, sucrase-isomaltase, maltase, and lactase on the microvillus membrane of rat intestine was investigated by immunological technique. The enzymes were purified essentially free of each other to near homogeneity and antisera of high specificity were obtained against each. Microvillus membranes were prepared routinely in high purity from rat intestine and contained an average 61% protein, 20% lipid, and 19% carbohydrate, with the sugar hydrolases comprising an estimated 20--25% of the membrane protein. The immunoreactivity of membrane-bound sucrase-isomaltase, maltase, and lactase was investigated with antisera demostrating specific reactivity to each, when tested in the presence of other membrane extractives. The membrane-bound enzymes were found in each case to combine with antibody in amounts equivalent to that required to effect precipitation of comparable units of the free enzymes from solution. Preloading membrane vesicles with antibodies to any two of the enzymes did not affect either the immunoreactivity or extractability (by papain or Triton X-100) of the third. The antibody-binding studies indicated an arrangement of these enzymes independent of each other on the membrane surface, in a manner allowing each to maintain a high degree of molecular freedom.

Lactase and maltase, the predominant sugar hydrolases associated with the intestinal brush border membrane of the suckling rat, were purified essentially free of the other to near homogeneity (lactase at specific activity 23, maltase at specific activity 58), and their specific physicochemical properties determined. Antisera prepared to each showed by immunodiffusion a single common precipitin line with pure enzyme and solubilized proteins of the brush border membrane. Brush border membranes were purified 26–35-fold from infant rat intestine. Membranes prepared from 10-day-old rats contained 32% protein, 43% lipid and 25% carbohydrate with lactase and maltase estimated to comprise in excess of 10% and 2%, respectively, of the membrane protein. Immunotitration curves of lactase and maltase showed equivalent antibody binding by the membrane-bound and free enzyme forms. Furthermore, antibody binding to one enzyme did not affect the immunotitration curve or the extractability (by papain or Triton X-100) of the other membrane-bound enzyme. It was concluded that the lactase and maltase molecules are attached singly on the external membrane surface in a spatially independent manner with their antigenic sites as freely available to antibody binding as exhibited by their papain-solubilized counterparts.

Adult rats when fed a high carbohydrate diet of 70% sucrose or glucose for 24 h following a 4-day fast showed increased concentrations of intestinal sucrase-isomaltase (EC 3.2.1.48, EC 3.2.1.10) and maltase-glucoamylase (EC 3.2.1.20) but not lactase-phlorizin hydrolase (EC 3.2.1.23, EC 3.2.1.62). The concentration increases of these enzymes were accompanied by corresponding acceleration of their synthesis rates. Contrary to earlier studies by others, suggesting that upper villus cells in the fasted intestine are unresponsive to stimulation of sucrase activity by refeeding a high-sucrose diet, the concentration increases of both sucrase-isomaltase and maltase-glucoamylase were seen to occur in cells all along the length of the villus column. The earlier studies differed from the present study by basing enzyme assays relative to protein rather than the DNA content of villus cell fractions. We have shown that villus cells increase their protein content severalfold while migrating to villus tip, providing the basis for the difference between earlier and the present findings. Further evidence that stimulation of sucrase-isomaltase and maltase-glucoamylase by high carbohydrate is not restricted to the crypt and lower villus region was obtained by the finding that their synthesis rates appeared to be equally stimulated along the length of the villus column.

Forty-six neonates with hypoxemia were treated with tolazoline, a pulmonary vasodilator, within the first two days of life. Eight of ten (80%) infants without apparent lung disease responded with a mean increase in PaO2 of 116 torr within one hour of beginning tolazoline infusions. One of the responding infants and two nonresponders died. Thirty-six additional infants with a variety of pulmonary disorders had severe hypoxemia which was refractory to mechanical ventilation. Twenty-one (58%) responded with a mean increase in PaO2 of 130 torr within one hour after beginning tolazoline and 13 (62%) of these survived. Fifteen patients had little or no improvement in PaO2 following tolazoline and only three (20%) of these infants survived. Responders could not be distinguished from nonresponders by clinical or laboratory features prior to therapy with tolazoline. Fourteen infants experienced complications possibly related to tolazoline.

From 1961 to 1976, 229 infants with birth weights ranging from 751 to 1,000 gm were admitted to the Stanford University Hospital Intensive Care Nursery. The overall neonatal mortality for these infants was 63% (144/229), and there were ten late deaths. Before 1967, no infant in this group who required mechanical ventilation survived; therafter, 30% (34/114) of the ventilated patients survived. Of the 75 long-term survivors 60 participated in a high-risk infant follow-up program; these included 23 infants who had received mechanical ventilation. The mean birth weight of these infants was 928 ± 67 (SD) gm. Seventeen children (28%) had significant morbidity: seven (12%) with severe handicaps and ten (17%) with moderate handicaps. During this same period, seven infants weighing less than 750 gm at birth were also observed. The three infants who had not required ventilatory support thrived; the other four infants had required respirators and were significantly handicapped. More recently, neonatal mortality for infants with birth weights from 751 to 1,000 gm has improved: for 1977 to 1980, it was 28% (33/118). Furthermore, neonatal mortality for ventilated infants in this weight group was 27% (26/95). These data indicate an improved prognosis for very low-birth-weight infants, even with ventilatory support.

Nine children were evaluated two to three years after institution of either medical or surgical management of their hiatal herniae. Four children treated medically ranged from 6 to 16 months of age. Three were clinicalluy cured of symptoms and one clinically improved, indicating the efficacy of medical management in some young children. The firth medically treated child, age 10 years, was also clinically improved. Four children initially had surgical hiatal hernia repair: one (16 days old) because of pulmonary aspiration with associated cardiorespiratory arrest, two (age 3 and 6 years) because medical management failed, and one (age 7 years) who presented with an esophageal stricture. Surgery for hiatal herniae in children should be researved for patients in whom medical management has failed or for patients with serious complications.

Elevated concentrations of blood NH 3 were found in seven infants who were receivingcasein or fibrin hydrolysates intravenously. Hepatic enzymes and/or hepatic histology were abnormal in four of these seven infants. The high concentration of NH 3 in the protein hydrolysate preparation may contribute to the hyperammonemia.