The case of five pediatric patients who presented to the Royal Children's Hospital, Melbourne with newly diagnosed diabetes mellitus between January 2001 and September 2003 is reported. Each case was complicated by hyperosmolarity and hypernatremia and required intensive therapy. Fluid intake prior to admission in each case was documented and consisted of between 5 and 12 L of carbonated carbohydrate beverages and 'isotonic' sports drinks. At presentation, biochemical results of the four cases (four males and one female), mean age 13.6 yr (range 11.7-15.1 yr) included glucose (mean 1460 mg/dL; range 864-2106), adjusted sodium (mean 176.3 mmol/L; range 165-183), serum osmolarity (mean 399 mmol/kg; range 364-424), anion gap (mean 48 mEq/L; range 42-84), and pH (mean 7.15; range 7.01-7.27). All five cases had evidence of ketonuria on presentation. Treatment in all five cases consisted of replacement of fluids over a prolonged period of 72 h and careful monitoring of electrolyte response. Three of five cases required hemofiltration in the first 48 h postadmission. All five cases made a complete recovery without neurological sequelae. Carbonated carbohydrate fluid intake may precipitate a more severe presentation of type 1 diabetes mellitus (T1DM). Fluid composition and intake should be carefully estimated at admission to help identify and manage similar cases.

ABBREVIATION SQCP Spastic quadriplegic cerebral palsyAIM Gastrostomy feeding children with spastic quadriplegic cerebral palsy (SQCP) improves weight gain but may cause excess deposition of body fat. This study was designed to investigate whether weight gain could be achieved without an adverse effect on body composition by using a low-energy feed in gastrostomy-fed children with SQCP.METHOD Fourteen children (seven male; seven female; median age 2y; range 10mo-11y) with SQCP were studied, 13 of whom were classified as Gross Motor Function Classification Score (GMFCS) level V and one as GMFCS level IV. Children were eligible for the study if they weighed between 8 and 30kg with a diagnosis of severe SQCP and significant feeding difficulties in whom a clinical decision had been made to insert a gastrostomy feeding tube. The feed used in the study had an energy concentration of 0.75kcal ⁄ mL (Nutrini Low Energy Multi Fibre). Assessments were performed before gastrostomy insertion (baseline) and after 6 months, and included body composition, growth, nutritional intake, and gastrointestinal symptoms. RESULTSThere was a significant increase in weight (median difference 1.9kg; 95% confidence interval [CI] 0.85-3.03kg; p=0.012), mid-upper arm circumference (median difference 1.45cm; 95% CI )0.36cm to 3.47cm; p=0.043), and lower leg length (median difference 1.62cm; 95% CI 0.44-3.95cm; p=0.012) over the 6 months. There was no significant increase in fat mass index (median diff 1.21, 95% CI )1.15 to 2.94, p=0.345) or fat free mass index (median diff )1.43, 95% CI )1.15 to 2.94, p=0.249). Micronutrient levels remained within reference ranges with the exception of elevated chromium. The median percentage intake of the estimated average requirements for energy (kcal) was 43% at the beginning of the study and 48.8% after 6 months on the low-energy feed.INTERPRETATION Children with SQCP who are fed a low-energy, micronutrient-complete, high-fibre feed continue to grow even with energy intakes below 75% of the estimated average requirements. This was not associated with a disproportionate rise in fat mass or fat percentage, and the majority of micronutrient levels remained within the reference range.Epidemiological studies of the feeding and nutritional problems of children with spastic quadriplegic cerebral palsy (SQCP) have highlighted that feeding difficulties and their associated consequences are common and severe, thus causing parents concern. 1,2 However, the advent of the gastrostomy tube has provided a way of bypassing the effects of oral motor impairment and the gastrostomy allows for the safe and effective delivery of nutrition and medication directly into the gastrointestinal tract. Previous studies have also shown that gastrostomy tube feeding improves the growth and general health of children with SQCP 3-5 while also improving the quality of life of the parent or carer. 6,7 Although gastrostomy feeding improves overall weight gain, it has also been associated with an excess deposition of body fat compared with typ...

Experienced professionals often do not recognise stool colour associated with biliary obstruction. The authors propose that stool colour cards similar to those used in Japan and Taiwan may improve early detection of hepatobiliary disease at a minimal cost.

Objectives: To critically appraise ileocolonoscopy practice in a large tertiary center, where ileocolonoscopy is exclusively performed by experienced pediatric colonoscopists, particularly focusing on: indications for the procedure; bowel preparation efficacy; IC completion rates and timings; diagnostic yield; and complications. Patients and methods:We prospectively evaluated all patients referred to our clinic between July 2015 and June 2016. Data on age, height and weight, gender, surgical history, indications for colonoscopy, bowel preparation given, bowel cleansing efficacy were collected. The following were calculated: percentage of terminal ileal intubation; time to terminal ileum; total duration of each procedure. Additionally, we evaluated the number and the type of complications encountered and the number of patients readmitted within 30 days from the elective procedure. Endoscopic diagnostic yield, stratified for indication, was calculated.Results: A total of 1392 patients were referred; 181 required an endoscopic evaluation of the lower GI tract (Outpatient Department conversion rate: 13%). Main indications for IC were: recurrent abdominal pain 38.1%; unexplained chronic diarrhea 16%; suspected IBD 24.9%; isolated rectal bleeding 13.2%; occult GI bleeding 1.6%; unexplained faltering growth 1.6%; IBD restaging 2.6%; miscellaneous 1.6%. Terminal ileum was reached in all the patients (TI intubation rate = 100%). Median time to TI was 9.8 minutes (1 to 50 minutes). Time to TI was lower in younger patients compared to older ones (p = 0.005). Bowel-cleansing was judged as: Grade 1 in 49.2%; Grade 2 in 33.7%; Grade 3 in 13.3%; and Grade 4 in 3.9%. A significant statistical correlation was recorded between bowel-cleansing and time to TI. The positive diagnostic yield was: 11.6% in patients with abdominal pain; 37.9% in patients with chronic diarrhea; 51.1% in patients with suspected IBD; 29.2% in patients with isolated rectal bleeding; 33.3% in patients with occult GI bleeding; 0% in patients with faltering growth; and 33% in the miscellaneous group. Conclusions:In conclusion, appropriately targeted IC in the management of children with GI symptoms, is a safe, fast and useful investigation. TI intubation rates of 100% are achievable and desirable and can be conducted quickly. Poor bowel preparation impacts negatively on this and IC duration may be faster in younger children. High diagnostic yields have been recorded in patients with a clinical suspicion of IBD. Diagnostic yield in isolated recurrent abdominal pain is low. Training to excellence in pediatric IC should be a persistent goal.

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