Molybdenum in infancy: balance studies in patients with intestinal stomata

This study investigated the supply of the essential trace element molybdenum (Mo) in infants with preternatural anus. It was divided into two separate investigations: (A) the complete fecal excretion of nine patients was collected in fractions over 24 h; and (B) 72 h balance studies and parallel plasma analysis were conducted in five infants and complemented by the longitudinal comparison of one of these patients with his (otherwise healthy) premature sister. Atomic absorption spectroscopy (balance studies) and high-resolution inductively coupled plasma mass spectrometry (HR-ICP-MS, plasma) were used for analysis. The following results were obtained. (A) The fecal Mo concentration ranged from 1.98 to 42.02 nmol Mo g(-1) dry fecal weight. (B) The daily intake in the balance studies was 43.2 (11.33-100.5) nmol Mo kg(-1) and the median retention was -2.91 (-32.45 to 48.6) nmol Mo kg(-1). In the premature twins the boy with an intestinal stoma had a negative balance and lost -3.32 micromol within 32 d, while his sister retained +0.45 micromol Mo in the same period. Plasma Mo ranged between 9.4 and 46.7 nmol l(-1).

CONCLUSION

The negative Mo balance results may indicate an increased risk of Mo deficiency in infants requiring a long-term preternatural anus.

Molybdenum balance studies in premature male infants

Despite the fact that the trace element molybdenum (Mo) is essential, there is insufficient knowledge about the demands in infancy. Mo balances were therefore assessed under consideration of formula Mo concentrations ranging from 0.125 to 2.704 micromol/l. Sixteen premature male infants participated in the investigation. Their birth weights were between 1,500 and 1,990 g, the median (range) gestational age was 34 (32-36) weeks and the post-conceptual age at the time of study 37.4 (34.1-40.6) weeks. Twenty-four balance studies were performed and the materials analysed by atomic absorption spectroscopy. Infants with a "low" Mo intake received 0.024 (0.020-0.035) micromol/ kg per day, had a urinary excretion of 0.02 (0.008-0.045) and a retention of 0.0006 (-0.03 to 0.008) micromol/kg per day. Infants with a "high" intake received 0.284 (0.227-0.487) micromol/kg per day, had a urinary excretion of 0.243 (0.118-0.378) and a retention of 0.022 (-71.1 to 141.44) micromol/kg per day. Since the median urinary excretion exceeded 60% of the Mo intake at low and high intakes, sufficient resorption but minimal retention was assessed at low intakes of Mo.

CONCLUSION

In view of the limited knowledge of long-term exposure to an elevated molybdenum intake and the substantial retention observed at higher intakes, upper limits should be set for molybdenum concentrations in preterm infant formulas.

Hereditary fructose intolerance and alpha(1) antitrypsin deficiency

A patient with coexisting hereditary fructose intolerance (HFI) and alpha(1) antitrypsin deficiency (alpha(1)ATD) is described. Protease inhibitor typing was not conclusive, presumably because of impaired N-glycosylation secondary to HFI. The case underlines the diagnostic role of molecular genetic techniques in inborn errors of metabolism.

[Atrial ectopic tachycardia in infancy caused by tumor of the interatrial septum]

A case of atrial ectopic tachycardia in an infant probably caused by a small tumor in the interatrial septum is presented. The arrhythmia was successfully treated with amiodarone. Several histologic abnormalities are known to cause AET, but an intracardiac tumor detectable by two-dimensional echocardiography is extremely rare. AET -especially in childhood-as well as cardiac tumors show a tendency to regression, so that even in this case medical treatment should be the first therapeutic choice. Interventional or surgical treatment is required just for those patients with AET this is resistant to medical treatment or reoccurs after finishing the medical treatment.

The influence of mode of delivery on hematologic values in the umbilical vein

A variable white blood cell count without clinical signs of sepsis or hematological disorders is often observed in newborns. The intention of this study was to investigate the effect of mode of delivery on hematologic measurements, especially white blood cell count in the umbilical vein. 121 term newborns were investigated prospectively. They were subdivided into three groups: spontaneous births (n = 83), vacuum extraction (n = 19) and cesarean sections (n = 19). The mode of delivery influenced the leukocyte count and the precursor cells. The mean leukocyte counts after spontaneous birth (14.6 +/- 4.0 leukocytes/nl) and after vacuum extraction (16.6 +/- 7.4 leukocytes/nl) were significantly higher than after cesarean section (12.1 +/- 4.4 leukocytes/nl; p < 0.05). The precursors of leukocytes were also significantly higher in infants with vacuum extraction (1.06 +/- 0.83 cells/nl) than in spontaneously delivered infants (0.54 +/- 0.47 cells/nl). An inverse relationship between the number of leukocytes and the arterial cord blood pH was observed (p < 0.05). No significant differences were observed in the effect of mode of delivery on erythrocyte and platelet counts.

[Tuberculous spondylitis--a forgotten differential diagnosis in backache]

A four-year-old boy had been complaining for one year of backache when sitting or bending. Radiological changes in the lumbar spine were at first interpreted as due to an old vertebral fracture. Half a year after the onset of the symptoms his sister was found to have open pulmonary tuberculosis, but a positive Tine test (he had not received BCG vaccination) was without any consequences. He was finally hospitalized five months later because the backache persisted and he now also had impaired movement of the left hip-joint. Physical examination revealed a 10 x 15 cm firm mass in the abdomen. Imaging demonstrated destruction of the 4th and 5th lumbar vertebrae and a large abscess. Acid-fast bacteria were found in gastric juice. Tuberculostatic treatment was started with isoniazid (10 mg/kg), rifampicin (10 mg/kg) and pyrazinamide (30 mg/kg). Two weeks later spondylectomy was performed, the defect being bridged with bone chips from the iliac crest. Four months after the operation, tuberculostatic treatment now being only isoniazid and rifampicin, he was able to partake fully in all activities of his age group.

Comparison of umbilical arterial versus umbilical venous blood pH correlated with arterio-venous glucose difference and cardiotocographic score

The value of clinical parameters and umbilical arterial blood pH as indicator of prenatal hypoxia is disputed. In a prospective study of 86 vaginally delivered full-term infants, cardiotocographic (CTG) findings obtained 0-30 min and 30-60 min before birth were compared to pH values, O2 and CO2 partial pressures and glucose difference in umbilical arterial and venous blood. CTG findings were expressed as a score, higher values indicating fetal hypoxia. The venous but not the arterial blood pH was significantly related to the later (0-30 min) CTG score. The arterio-venous glucose difference was significantly related to both CTG scores. There was a significant statistical relationship between glucose difference and venous but not arterial blood pH. The later CTG score (0-30 min) also correlated significantly with O2 and CO2 partial pressures and base excess in the umbilical vein of all vaginally born infants. If CTG is accepted as an objective indicator of fetal hypoxia before birth, the arterio-venous glucose difference, and in the investigated range of pH-values, umbilical venous blood pH are more suitable than the arterial blood pH to ascertain the peripartal situation of the newborn.

Hirsutism-skeletal dysplasia-mental retardation syndrome with abnormal face and a uric acid metabolism disorder

We report on a German boy, born to nonconsanguineous parents, with an apparently new combination of multiple congenital anomalies including extraordinary hirsutism, marked brachycephaly, abnormal position of thumbs, pedes excavati with claw-toes, an abnormal face, and mental retardation. Additionally the boy manifests a disorder of uric acid metabolism. This sporadic case may represent a new syndrome due to a fresh autosomal or X-linked mutation, or chance-isolated case due to segregation of an autosomal recessive gene.

Faecal excretion in infants

Data on normal defaecation patterns in relation to diet during the first months of infancy are very limited. We therefore investigated in a prospective study faecal weight and gastro-intestinal passage time of breast fed (n = 12) and formula fed (n = 14) male infants. These were studied in 72 h collecting periods at the age of 17, 35, 57, 87 and 113 (+/- 4) days. Breast fed infants had a significantly lower daily dry faecal weight than formula fed infants in all periods investigated (median at the age of 113 days: 0.28 (0.17-0.75) g/kg and 0.81 (0.22-1.2) g/kg, respectively). Breast fed infants showed a large variation of gastro-intestinal passage time (6.79 h [range: 1.79-13.38 h] at the age of 17 days, 21.84 h [range: 5.41-75 h] at the age of 113 days). Comparable values of formula red infants were 13.75 h (range: 7.13-35.25 h) and 17.42 h (range: 5.38-36.5 h). Despite the efforts of approximation of infant formula to breast milk, differences of defaecation patterns in relation to diet are still relevant at this age and have to be considered in clinical practice.

Isolated defect of peroxisomal beta-oxidation in a 16-year-old patient

We describe a 16-year-old boy suffering from psychomotor retardation, sensorineuronal hearing impairment, peripheral neuropathy, hepatosplenomegaly, short stature and delayed puberty. Postnatally, muscular hypotonia, mild facial dysmorphism and delayed fontanelle closure had been noticed. At the time of our examination, adrenal cortical function was normal. Biochemical analysis revealed accumulation of very long (> C22) chain fatty acids in plasma and fibroblasts. Furthermore, elevated levels of intermediates of bile acid synthesis and phytanic acid were detectable. These findings are consistent with a defect in the peroxisomal beta-oxidation system. A generalised defect of peroxisomal function was excluded by normal plasmalogen levels in erythrocytes and normal plasmalogen de novo synthesis in fibroblasts. Immunoblotting of the peroxisomal beta-oxidation enzymes gave normal results suggesting retained immunoreactivity but catalytic inactivity of one of the enzymes involved, probably either the trifunctional protein or the peroxisomal ketothiolase. This case markedly differs clinically from the few published reports on isolated deficiencies of peroxisomal beta-oxidation. Among the patients with comparable biochemical findings, this is the first report of survival into adolescence.

[Craniometaphyseal dysplasia--characteristic roentgen findings]

Craniometaphyseal dysplasia is a rare disorder of bone remodeling, which is characterized by hyperostosis or sclerosis of the skull combined with metaphyseal flaring of the long tubular bones. Diagnosis is only possible on the basis of the characteristic radiographic findings, these are shown in a case report of a 2 1/2 year old boy. There is no therapy of craniometaphyseal dysplasia.

[Sodium and potassium metabolism in infancy]

BACKGROUND

Recommendations for the concentration of most nutrients in infant formulas are based on their concentration in human milk. Industry succeeded in adapting sodium and potassium content in infant formulas to concentration found in human milk. Whether this adaptation affects on infants' mineral balances was studied in breast-fed and artificially-fed infants.

METHODS

Sodium and potassium balances were performed in 16 term male infants from their 3rd until their 17th week of life. The balances were performed at home and comprised up to five periods in intervals of three to four weeks. Each balance period consisted of subsequent three 24 h collections of milk, stool and urine samples. Ten infants were breast-fed, six received an adapted infant formula supplemented with copper, zinc and iron.

RESULTS

The breast-fed infants got a mean intake of 1 mmol Na/kg b w x day and a mean intake of 1.8 mmol K/kg b w x day. Man retention was 0.4 mmol Na and 0.7 mmol K/kg b w x day. The formula-fed infants received 1.9 mmol Na/kg b w x day and 2.1 mmol K/kg b w x day. Na- and K-retention in this group was 0.5 and 0.6 mmol/kg b w x day respectively. Although sodium intake in the formula-fed infants was nearly twice as much as in the breast-fed infants the difference in sodium retention was only small (0.4 vs 0.5 mmol/kg b w x day). The formula-fed infants got more potassium than the breast-fed infants, but potassium retention was the same in both groups.

CONCLUSIONS

With the adapted infant formula of this study the artificially fed infant was as well supplied with sodium and potassium as the breast-fed infant. A further reduction of the sodium concentration seems not to be useful.

Longitudinal zinc balances in breast-fed and formula-fed infants

Longitudinal zinc (Zn) balance studies were performed under domestic conditions in term breast-fed (n = 10), term formula-fed (n = 5; Zn concentration in the formula: 4 mg/l) and preterm formula-fed (n = 3) infants during the first 17 weeks of life. Samples of milk, urine and feces were analyzed by atomic absorption spectrometry. The median daily Zn intake in breast-fed infants decreased from 0.592 (0.457-0.829) mg Zn/kg body weight to 0.151 (0.095-0.304) mg Zn/kg body weight in the first 17 weeks of life; comparable values for bottle-fed term infants were 0.58 (0.511-0.701) and 0.674 (0.529-0.731) mg Zn/kg body weight. The median percent retention of Zn intake was 27 (-60 to 81.4)% in breast-fed infants and 21.5 (-42 to 64)% in formula-fed infants. In view of the urinary and fecal Zn losses measured, a daily intake of 0.3-0.5 mg Zn/kg body weight is considered to be sufficient to ensure a Zn retention equivalent to breast-fed infants. This requires a Zn concentration of 2-3 mg/l of Zn depending on milk volume intake.

Iron availability from an infant formula supplemented with bovine lactoferrin

Iron balance studies were performed in 16 term infants from their 3rd until their 17th week of life. The balance studies were performed at home and comprised five periods with an interval of 3 to 4 weeks, each consisting of three 24-hour collections of milk and stool samples. Seven infants were fed an adapted infant formula supplemented with bovine lactoferrin (100 mg/100 ml) and nine received the same formula without lactoferrin. The lactoferrin supplemented group received 169 micrograms iron/kg b.w. x day and retained 63 micrograms/kg b.w. x day. The mean iron intake of infants fed with the adapted formula without supplementation of lactoferrin was 118 micrograms/kg b.w. x day. The retention of iron was 43 micrograms/kg b.w. x day. Mean percentage retention of iron in the supplemented group was 36%, in the non-supplemented group 28%.

How necessary is a chromosomal analysis in growth-retarded girls?

In growth-retarded girls, shortness may be the only clinical sign of Turner syndrome. Therefore recommendations have been published that a chromosomal analysis should be carried out in every girl showing growth retardation. The present study was carried out to examine whether the head circumference of small girls can serve as a criterion and hence limit the need for expensive chromosomal analysis. The head circumferences of 45 girls with Turner syndrome were compared with those of 41 growth-retarded girls. It could be shown that the heads of the patients with Turner syndrome had a normal circumference, whereas the heads of the control group were significantly smaller. In view of this result, the risk of overlooking Turner syndrome in diagnosing growth retardation without a chromosomal analysis could be estimated to be 1:9000. The conclusion is drawn that a chromosomal analysis is not necessary in girls whose growth retardation is combined with a small head circumference and who do not show other malformations.

Urinary zinc excretion in infancy

In view of the conflicting data on urinary Zn excretion in infancy we investigated the possible influence of contamination, collecting methods, nutrition (human milk versus formula) and longitudinal changes during the first 16 weeks of life. Methodical investigation showed that special attention is necessary to avoid contamination due to the use of Zn-containing baby creams in the genital region. The sampling device for collection should include the smallest area of skin possible and the use of Zn-containing baby creams has to be avoided both during the collection and at least 24 hours prior to urine collection. Previous fractional urine sampling of the collecting method to be evaluated proves that erroneously high values are not obtained at the beginning of collection. Midstream urinary samples reduce the possibility of contamination. Increased urinary excretion was shown in pre-term infants under theophylline or coffeine medication. The median daily urinary Zn excretion in healthy breast-fed term infants declined significantly from 0.063 (0.027-0.111) mg per kg body weight at the age of 2 weeks to 0.018 (0.004-0.059) mg per kg body weight at the age of 16 weeks. Comparable values for formula-fed term infants were 0.029 (0.025-0.063) mg per kg body weight initially and 0.025 (0.007-0.059) mg per kg body weight at the end of the study. These values can be used as reference values for the urinary Zn excretion of healthy infants.

Selenium balances in young infants fed on breast milk and adapted cow's milk formula

Selenium intake, renal and fecal excretion, and retention were determined in 11 breast-fed term infants and in 9 term infants fed with an adapted cow's milk formula. In most cases three-day-balances were determined five times at the age of 2, 5, 8, 12, and 16 weeks. Analytical determination of selenium was by atomic absorption spectroscopy with a selenium hybrid system after wet ashing of samples. The mean breast milk concentrations of selenium show a significant decrease in the course of lactation from 31.0 micrograms/L in the first collecting period to 17.6 micrograms/L in the last one. The two formula milks contained 11.8 and 7.7 micrograms/L. Intake in the breast milk group was higher than in the formula group, whereas absolute renal and fecal excretion were essentially the same. This leads to a higher selenium retention in the breast-fed infants than in the formula-fed infants, where most of the balances are negative.

Trace element excess in PKU diets?

Knowledge of trace element requirements of infants with phenylketonuria (PKU) fed a semisynthetic diet is limited. Three infants with PKU detected early were studied longitudinally in classical balance studies for 72 h, under domestic conditions, at the ages of 2, 5, 8, 12 and 16 weeks. Iron, copper and manganese concentrations in the diet and faeces were determined by atomic absorption spectroscopy. The median concentrations in the diet (4.8 mg Fe/L, 1.7 mg Cu/L, 0.43 mg Mn/L) exceed those in human milk. This is mainly due to supplementation of the amino acid preparation used. The increased intake led to a significantly higher daily retention of Cu and Mn from the PKU-diet fed, with a median of 0.17 mg Cu/kg and 6.4 micrograms Mn/kg body weight; the median retention of Fe was 0.24 mg Fe/kg. Our results confirmed the doubts about the suitability of the present trace element supplementation in formula for infants with PKU during the first four months of life.

Perinatal glucose metabolism as an indicator for stress and hypoxia during different forms of delivery

In 82 term newborns divided into three groups (spontaneous delivery, caesarean section and vacuum extraction) we investigated umbilical artery pH, artery and vein glucose levels and calculated the veno-arterial difference of glucose. The three groups showed significant differences of artery and vein glucose levels. The highest umbilical artery (UA) and umbilical vein (UV) glucose levels were found after vacuum extractions (n = 13, UA: 98 mg/dl, UV: 104 mg/dl), the lowest levels were present in the group of caesarean section (n = 16, UA: 52 mg/dl, UV: 65 mg/dl). After spontaneous deliveries the intermediate levels were observed (n = 55, UA: 70 mg/dl, UV: 84 mg/dl). The mean of UA-UV-glucose difference was low after vacuum extractions and statistically different from the values after caesarean section and spontaneous deliveries. The mean of UA-pH did not show statistically significant differences in the three groups. The regression analysis between UA-pH and UA-UV-glucose difference revealed a highly significant dependency in the group of caesarean section (p less than 0.01) but no dependency after vacuum extraction. Significant dependency was also found in the group of spontaneous delivery (p less than 0.05).

Longitudinal manganese and copper balances in young infants and preterm infants fed on breast-milk and adapted cow's milk formulas

1. Mn and Cu intake and retention in twenty full-term infants and six preterm infants were studied on the basis of 72 h balances. The age of the infants was 2-16 weeks and the gestational age of the preterm infants (triplets) 34 and 36 weeks. Three nutrition schemes were pursued: breast-fed, formula-fed with unsupplemented adapted formula and formula-fed with trace element supplementation. 2. The mean Mn concentration of all breast-milk samples (n 2339) was 6.2 micrograms/l. The two formulas had similar Mn concentrations (77 and 99 micrograms/l) but had different Fe, Cu (121 and 619 micrograms/l), Zn and I contents. The mean Cu concentration in mother's milk was 833 micrograms/l. 3. The following mean daily Mn intakes and retentions (micrograms/kg) respectively were measured: breast-fed full-term 1.06 (SD 0.43) and 0.43 (SD 0.65), formula-fed full-term 14.2 (SD 3.1) and 2.8 (SD 4.8), formula-fed preterm 15.0 (SD 2.2) and 0.06 (SD 5.87). The results for Cu were 114.5 (SD 22.3) and 88.0 (SD 46.5) micrograms/kg in breast-fed, 19.8 (SD 4.2) and 4.6 (-11.5-9.6) in the unsupplemented formula-fed and 106.4 (SD 18.9) and 55.5 (SD 20.3) in the supplemented formula full-term infant group. No significant influence of the trace element contents of the formulas on the relative retention of Mn or Cu was found. 4. Young preterm infants, and to some degree young full-term infants, often had negative Mn balances caused by a high faecal excretion. The formulas with a Mn concentration below 100 micrograms/l gave a sufficient supply of Mn. Preterm infants fed on the unsupplemented formula had a marginal Cu supply and their first balances were negative (-3.8 (SD 1.8) micrograms/kg). 5. In accordance with the estimated safe and adequate daily dietary intakes (recommended dietary allowances), formula-fed infants receive much more Mn than breast-fed infants and their absolute retention is higher. 6. Cu from breast-milk had a significantly better biological availability than that from cow's milk formula. If retentions similar to those in breast-fed infants are intended, we conclude, therefore, that cow's milk formula should be fortified with Cu up to a level of at least 600 micrograms/l.

Iron balances in infant nutrition

Iron balance studies were performed in 17 full term male infants from their 3rd until their 17th week of life. The balance studies were made in the infant's home and comprised 5 periods with an interval of 3-4 weeks, each consisting of three 24-hour collections. Ten infants were breast-fed, 3 received an adapted infant formula (P1, iron content 1.1 mg/l) and 4 were given the same formula enriched with iron, copper and zinc (P2, iron content 10.35 mg/l). From the 3rd to the 17th week of life the breast-fed infants got a mean iron intake of 0.2 mg/kg body weight X 3 days and they retained 0.09 mg/kg b.w. X 3 days. The P1 group received 0.48 and 0.47 mg/kg b.w. X 3 days and retained -0.01 and -0.5 mg iron/kg b.w. X 3 days, while the P2 group had an intake from 5.04 to 6.38 mg b.w. X 3 days and retained between 1.13 and 3.66 mg iron/kg b.w. X 3 days. Comparing the 3 groups it can be concluded that the P1 group retained definitely less iron than the breast-fed group, whereas the P2 group retained 12 to 40 times more iron than the breast-fed babies.

Use of saliva in monitoring carbamazepine medication in epileptic children

In 17 children on carbamazepine medication alone and 15 children on combined drug regimens, carbamazepine levels were determined in paired samples of serum and mixed saliva by enzyme immunoassay. Carbamazepine levels in serum and saliva were highly correlated in within-patient and between patient series (r = 0.87--0.94). Salivary levels were altered to a minor and clinically insignificant degree by stimulation of saliva flow. Mean saliva/serum ratios, calculated from drug concentrations in saliva specimens collected without and with stimulation were 0.44--0.45 and 0.41--0.43, respectively. The saliva/serum ratio was independent of the serum carbamazepine level and was not affected by concomitant drug medication. The data indicate that measuring salivary levels by enzyme immunoassay is suitable for predicting serum carbamazepine levels. Thus, measurement of carbamazepine levels in mixed saliva samples obtained by a noninvasive technique is recommended for routine monitoring of carbamazepine medication in epileptic children.

Identification of the triploid genome by the C-banding method

We report on cytogenetic studies of a malformed fetus, whose clinical symptoms indicated the diagnosis of triploidy. This was confirmed by chromosome analysis of peripheral lymphocytes of cord blood. Using the C-banding method it was possible to identify the origin of the extra haploid set: marker chromosomes indicate, that nonreduction of the first meiotic division in the father's spermiogenesis most probably leads to triploidy. However, in our case fertilization of the zygote by two sperms cannot be excluded.

Histamine release, formation of prostaglandin-like activity (SRS-C) and mast cell degranulation by the direct lytic factor (DLF) and phospholipase A of cobra venom

Cobra venom, alone and in combination, on mast cell degranulation, histamine release and formation of prostaglandin-like activity (SRS-C) was studied in perfused guinea-pig lungs and in mast cell-containing rat peritoneal cell suspensions. For comparison, the effect of equivalent doses of whole cobra venom was investigated. 1. Cobra venom caused mast cell degranulation, histamine release and SRS-C formation in both systems. For comparable effects much higher doses had to be used in guine-pig lungs than in rat peritoneal cell suspensions. 2. Phase A showed little degranulation of mast cells in both systems, a limited histamine release in rat peritoneal cell suspensions and none in perfused guinea-pig lungs. It caused a considerable SRS-C formation in both, lung tissue and peritoneal cell suspensions. 3. DLF caused histamine release, SRS-C formation and mast cell degranulation in both systems; in rat peritoneal cell suspensions it acted almost as strong as equivalent doses of cobra venom, in guinea pig lungs it was much less active. 4. In rat peritoneal cell suspensions the effects of DLF and phase A in combination did not exceed the sum of their single effects. In guinea-pig lungs these two substances interacted in a potentiating synergism. It is concluded that DLF is the main cytotoxic principle of cobra venom, whereas ph-ase A alone is not cytotoxic. The difference in the synergism of DLF and ph-ase A between rat peritoneal cells and guinea-pig lungs may be due to two different actions of DLF and species differences as regards sensitivity against these actions.