Once, almost 30 years ago, a resident on our pediatric staff at New York Hospital was discussing with me his future hopes in the field of infant and child care. He desired to specialize in a new field - pediatrie gastroenterology. What did I think of it? I discouraged him, believing the body system was too generalized at this young age level, and that, with few exceptions, well-trained pediatricians should be capable of treating the gastrointestinal problems of their patients. I could see the specialties of hematology, cardiology, endocrinology, neonatology and nephrology, but could not see gastroenterology as a specialty by itself.
We pediatricians, I argued, should certainly be able to diagnose pyloric stenosis, Meckel's diveniculum, ceh'ac syndrome and cystic fib ros is. And we should be able to treat diarrhea, vomiting and cow's milk sensitivities successfully. The cause and treatment of celiac disease had been reported by Dicke and his associates in Holland in 1950. There were already specialists in certain specific gastroenterological entities; Dorothy Anderson and Paul di Sant'Agnese of New York for cystic fibrosis, and Oscar Swenson of Boston who had treated several hundred cases of Hirschsprung's disease, were well known.
The resident, Dr. Murray Davidson, did not follow my advice, and soon was doing studies on colonie motility. He was, to my knowledge, the first pediatrie gastroenterologist in the United States, and within a few years, became a national authority. A new specialty had been born. Remembering my discussion with Dr. Davidson and reviewing my years in pediatrie practice, I am amazed at my lack of foresight. The field has grown rapidly since those days, and today there are already Í 20 gastroenterologvsts in this country. New entities have been described as well as new methods of diagnosis. It was discovered, for example, that many cases of abdominal pain in children were due to lactase deficiency - others to gastroesophageal reflux. In the area of diagnosis we have seen the advent of sonography and radioactive scanning, and methods of accurate diagnosis of biliary atresia or absence of the bile duct by laparoscopy or duodenal intubation with collection of duodenal fluid for bile pigments.
The present issue of Pediatrie Annals will bring the reader up to date in many of the areas relating to gastrointestinal disturbances in infancy and childhood. It is under the guest editorship of Dr. Marvin Ament, Professor of Pediatrics and Chief of the Division of Pediatrie Gastroenterology at the UCLA Medical Center. Dr. Ament is, today, one of the foremost specialists in the field and is well known not only from his articles, but also from his numerous seminars and round tables conducted at meetings of the Academy of Pediatrics and elsewhere.
In organizing the present symposium, Dr. Ament has enlisted, as contributors and coauthors, members of his Department of Pediatrie Gastroenterology at UCLA. Together, they divided the subject into five specific areas, all of which are of great interest and importance to the pediatrie practitioner. These subjects deal with cow's milk and soy protein intolerance, chronic diarrhea, gastroesophageal reflux, acute infectious gastroenteritis, and functional complaints.
All of the articles bring us the most recent concepts on these frequent problems of everyday practice. I remember so often shifting an infant's formula from cow's milk to a soybean preparation and then to a meat-base formula or Nutramigen. We did not know what caused these intolerances or why the gastrointestinal tract reacted so negatively; many of us tried skin tests without success. In the first article, Dr. Ament and Dr. Kibort emphasize that, even today, there is no in vitro test for this sensitivity. They then proceed to reveal their findings from biopsies of the small bowel as well as proctosigmoidoscopic observations of the colon. This is an excellent scientific approach to the study of basic pathology responsible for these gastrointestinal difficulties in children. (I am sure, however, that most practicing pediatricians will continue to use the therapeutic test of shifting to Nutramigen or Pregistimil before suggesting an infant undergo biopsy of the small bowel or even proctosigmoidoscopic examination of the colon.) The second subject discussed is chronic diarrhea, which frequently presents a difficult problem for the pediatrician - a problem not only of etiology but also one of treatment. The authors elucidate the many possible causes for this condition - causes that differ with age levels. Inaclearandsystematic fashion, they present methods to determine the etiology throughout periods of infancy and childhood. At an early age level, entities such as protein and disaccharide problems, infectious agents or cystic fibrosis may be involved. Later, there could be allergies, milk and protein sensitivities, celiac disease or giardiasis; and, later still, Crohn's disease and ulcerative colitis.
Acute infectious gastroenteritis is a different, problem - especially dangerous in infancy- and primarily found in undeveloped countries where hygiene is poor, infection is frequent and treatment is inadequate. A recent article in the magazine Pediatrics estimated that in 1 976, there were 500 million cases of diarrhea in babies in Asia, Africa and Latin America, killing between 5 million and 18 million infants. In the United States, the death rate has been cut to a minimum by modern methods of diet care, fluid and electrolyte replacement and the prevention of dehydration. The article on this subject in this symposium opens with an account of the etiology of acute diarrhea. It is emphasized that, in this country, most cases are of viral origin. The underlying pathology which prevents absorption is described, and the authors note that acute viral gastroenteritis is not associated with colitis.
On the other hand, bacterial pathogens causing gastroenteritis, while not as frequently encountered, are more severe in their effects. The pathology is well described, and severe symptoms such as colitis or blood and pus in the stool are not uncommon. The remainder of the article presents a model to evaluate the child with diarrhea and discusses diagnostic tests and treatment. This is an excellent reference for the practicing pediatrician.
The diagnosis, gastroesophageal reflux, is comparatively new in pediatrie terminology. (There is no such entity mentioned in the 1969 edition ofNelson's Textbook of Pediatrics. Chalasta is described as a cardioesophageal relaxation occurring in infants and clearing in a few months.)
But within the past ten years, the term gastroesophageal reflux, as differentiated from hiatus hernia, has come into medical usage. The article contributed to this symposium by Dr. William E. Berquist clarifies this subject. Dr. Berquist notes that the term gastroesophageal reflux is nonspecific and may or may not represent a pathological condition. Older children have the usual classic signs - heartburn, retrosternal discomfort and a bitter taste of regurgitated water. Methods of diagnosis for this condition are described, including radiographie studies, scintigraphic studies, esophageal manometry, and intraesophageal pH monitoring. The uses of endoscopy and esophageal biopsy are also presented. In his discussion of diagnosis, the author brings up the subject of hiatal hernia which, as differentiated from gastroesophageal reflux, has been a source of considerable controversy among pediatricians as well as radiologists. Regarding treatment of the reflux, Dr. Berquist suggests upright posturing after each meal. However, if there are marked sequellae, the Nissan fundoplication is advised. The possible use of cimetidine is also discussed.
The final paper in the symposium, entitled "Functional Complaints and the Pediatrìe Gastroenterologist," has been written by Dr. Glen Barclay, Assistant Professor of Pediatrics at the UCLA Medical Center. The gastrointestinal disorders of infants and children due to emotional causes are recognized by many practicing pediatricians. We all have seen tense, crying, regurgitative infants held by tense, jittery mothers or nurses quiet down, relax and retain their feedings when held by persons who are calm and reassuring. We have seen many cases of constipation in children, induced by mothers who looked upon the infants' stools as filthy and nasty, and so, forced toilet training. We have seen a great many cases of poor appetite caused by parental efforts to force children to finish their meals. We have seen numerous "stomach aches" when, for example, children are left in school by their parents for the first time.
Dr. Barclay discusses certain gastroenterological symptoms which so often are found ?? be basically emotional - régurgitation, vomiting, constipation, diarrhea, encopresis and recurrent abdominal pain.
But, although the relationship of mind and body is emphasized, we are constantly being reminded of the old medical adage: "Rule out the organic first before considering a condition to be emotional." As a guide to pediatricians, Dr. Barclay includes six tables listing the organic causes of régurgitation, chronic diarrhea, fecal retention, and abdominal pain. This is an excellent article, directing the pediatrician to work with both the parents and the child, when efforts are being made to overcome emotional problems.