- Email: [email protected]
Essential fatty acid status in children with cholestasis, in relation to serum bilirubin concentration
ttty acid status in children with in relation t o serum bilirubin m
Piotr Socba, MD, Bertbold Koletzko, ~ID, Joanna Pawlowska, ~rD, and Jerzy Socha, ~gD
The liver plays a central role in the metabolism of polyunsaturated fatty acids. We studied the relationship between essential fatty acid (EFA) status and indicators of liver function in 15 children with chronic cholestasis aged 9 months to 3.4 years (median, 1.3 years). Compared with 13 control children, the patients studied had low percentage values of phospholipid EFAs, particularly of the 03-6 fatty acids linoleic acid (18:203-6) and arachidonic acid (20:403-6). Fatty acid values exhibited an inverse relationship to serum bile acids, as well as to serum bilirubin. Bilirubin values were unrelated to the EFA precursors linoleic acid and o~-linolenic acid but correlated inversely with the long-chain metabolites arachidonic acid (r = -0.75; p = 0.001), docosapentaenoic acid (22:503-3; r = -0.63; p = 0.01), and docosahexaenoic acid (22:603-3; r = 0.72; p = 0.002). We conclude that children with chronic cholestasis are at a high risk for EFA deficiency, which increases with progressive elevation of serum bilirubin. Hepatic conversion of essential precursor fatty acids into their long-chain metabolites may be increasingly impaired with advancing severity of liver disease. (J Pediatr 1997; 131:700-6).
Polyunsaturated fatty acids are essential components of structural lipids in all tissues and modulate cell membrane fluidity and function. The availability of long-chain PUFA (>18 carbon atoms), such as arachidonic and docosahexaenoic acids, is important for early human growth and development of membrane-rich tissues such as brain and retina. 1 Moreover, 0)-6 and 03-3
PUFA serve as precursors of icosanoids with important biologic roles as mediators of immune and vascular functions, as well as platelet aggregation. 2 We hypothesized that children with cholestatic disease have a poor PUFA status, because bile acids contribute to efficient PUFA absorption from the gut and because LCP are synthesized from their precursors, mainly in the liver. PUFA deple-
From the Kinderpoliklinik, Ludwig-Maximilians-Universil~, AJilncben, Germany, the Centrum Zdroveia Dziecka-lnstitute eor Child Health, Warsaw, Poland. Supported by Deutsche Forschuugsgemelnschaft, Bonn, Germany (Ko 912/4-3), and by the Polish Research Council (Komitet Badan Nankowych), Warsaw, Poland (No 4-S-405-00-405). Dr. Piotr Socha was the recipient of a scholarship (No. S.85/93) granted by Nestec Ltd., Vevey, Switzerland. Presented in part as a poster at the 28th annum meeting of the European Society of Paediatric Gastroenterology and Nutrition (ESPGAN); awarded the John Harries Prize in 1995. Submitted for publication Feb. 7, 1996; accepted Nov. 21, 1996. " Reprint requests: Berthold Koletzko, MD, Professor of Pediatrics, Kinderpoli!dinik, Ludwig-MaximiliansUniversity of Munich, Pettenkoferstr. 8a, D-80336 Miinchen, Germany. J Pediatr 1997; 131:258-64 Copyright © 1997 by Mosby-Year Book, Inc. 0022-3476/97/$5.00 + 0 9/21/79488
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fion of plasma lipid fractions was reported in adult patients with cirrhosis, 3 in whom it was associated with protein energy malnutrition 4'5 and the occurrence of encephalopathy. 6 In contrast, there is only limited information on the essential fatty acid status of children with cholestasis. Linoleic acid (18:203-6) depletion of total plasma f a t t y acids was found in children with a paucity of intralobular bile ducts. 7 Linoleic acid and arachidonic acid (20:403-6) deficiency was reported both in a group of children with Alagille syndrome and in four children with biliary atresia. 8 A serum phospholipid fatty acid pattern, reported in four infants with hepatobiliary disease who were receiving a formula with high-content medium-chain triglycerides and in whom a poor 03-6 EFA status was observed, was attributed to a high intake of medium-chain triglycerides and a low intake of lin01eic acid. 9 We studied the effects of chronic liver disease on PUFA status in children without supplementation with medium-chain triglycerides in their diets.
METHODS We investigated 15 children with chronic cholestasis (11 with surgically repaired bilia W atresia, 3 with intrahepatic cholestasis of unknown origin, 1 with Byler disease) treated as outpatients at the
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THE JOURNALOF PEDIATRICS Volume 13 I, Number 5
Centrum Zdrowia Dziecka in Poland; ages were 9 months to 3.4 years (median, 1.3 years). As a reference group, we studied la children aged 11 months to a.6 years (median, 1.6 years) in good general health who attended the same hospital and had no liver disease. The study protocol was approved by the local ethical committee, and parental informed consent was obtained. Three-day dicta W protocols were recorded in all patients with cholestasis, and the daily intakes of energy, protein, carbohydrates, fat, linoleic acid, 0~linolenic acid, and total PUFA were calculated. A venous blood sample was obtained from the fasted liver patients to determine, with standard methods, the serum bilirubin concentration; activities of alanine aminotransferase, alkaline phosphatase, and T-glutamyl transpeptidase; prothrombin time; total concentrations of bile acids; and serum total lipid, triglyceride, cholesterol, and phospholipid concentrations. Retinol and Ix-tocopherol serum concentrations were measured by high-performance liquid chromatography, ]° and the 0~-tocopherol/total lipid ratio was ca]culated. 11 Fatty acid composition of plasma phospholipids was determined in both groups from venous plasma obtained, with sodium etliylenediaminetetraacetate (1 rag/ ml) as the anticoagulant, and stored at -20 ° C for a maximum duration of 6 months until analysis. Lipids were extracted from 0.5 ml plasma with chloroform/methanol, and lipid classes were separated by thin-layer chromatography as previously described. 12 Fatty acids were transesterified with methanol and hydrochloric acid and analyzed by highresolution capilla W gas-liquid chromatography with the use of a Hewlett-Packard series II 5890 gas chromatograph, with on-column injection and flame-ionization detection (SGE column 50QC2/BPX70, column diameter 0.22 mm, column head pressure 1.5 bar; oven temperature initially 150 ° C, then temperature rise with 3 ° C/min to 180 ° C, then with 4 ° C/min to 200 ° C, and then with 1° C/min to 210 ° C [isotliermic period for 20 minutes]). Peak identification was verified by comparison
with authentic standards (Nu Check Prep. Inc., Elysian, Minn.) and by mass spectrometry (Hewlett-Packard series 5971 MSD). Results are expressed as a percentage (of weight/weight) of all fatty acids detected with a chain length between 12 and 22 carbon atoms, la Plasma lipid peroxides were determined immediately after sample collection with the spectrofluorometric method of Yagi I4,ls and expressed as thiobarbiturate reactive substance (measured in nanomoles per milliliter) in the patients with cliolestasis and in control subjects. Results were evaluated with Minitab for Windows release 9.2 (Nlinitab Inc., State College, Pa.). We present the data as medians with lower and upper quartiles (Q1 to Qs). For comparison of fatty acid profiles in children with eholestasis and the reference group, the MannWhitney two-sided rank test was used. Possible correlations were tested by the Spearman rank correlations and plotted as linear regressions. Differences and regressions were regarded as statistically significant atp less than 0.05.
RESULTS The children with cholestasis had a wide range of clinical disease severity at presentation, as reflected by the range of bilirubin concentrations, from 17.1 to 376 ~tmol/L (4.7 to 17. 1 mgldl; median, 14.0 mg/dl), and the range of their ratios of body weight to normal body weight for age, from 0.4 to 1.0 (median, 0.86). Daily dietary intakes per kilogram of actual body weight (median, [Q1, Q3]) were 107.2 kcal (88.4, 144.5 kcal), a.7 gm protein (2.6, 4.7 gm), and a.4 gm fat (2.9, 4.3 gm). In relation to estimated normal body weights (50th percentile for age), intakes per kilogram of ideal body weight were 9a.5 kc~l (75.9, 108.6 kcal), 3.3 gm prorein (2.5, 3.9 gm), and 2.7 gm fat (2.5, 3.9 gm). Intakes of linoleic acid were 0.3 gm/100 kcal (0.2, 0.4 gm) and of c~linolenic acid 0.06 gin/100 kcal (0.03, 0.09 gm), with linoleic acid and total PUFA contributing 2.7% and 3.6%, respectively, of energy intake.
Median 0t-tocopherol concentrations and 0~-tocopherol/total lipid ratios were far below the lower limit of the normal range (Table I), 11 with subnormal 0~-tocopherol concentrations (<3.8 rag/L) in 12 and reduced 0t-tocopherol/total lipid ratios (<0.6 mg/gm) in 11 patients. Plasma TBARS values were significantly higher in patients with eholestasis (2.8 [1.5 to 3.3], median [Q1 to Q3]) than in control subjects (1.2 [1.1 to 1.3];p = 0.0006), with a trend to higher levels in patients with increased bilirubin concentrations (Spearman rank correlation coefficient: r = 0.48; /, = 0 . 0 7 ) .
The fatty acid p r o n e in plasma phospholipids of our reference group was similar to the results in a large group of German children of equal age studied by the same method in this laboratory. 15 Children with cholestasis had significan@ lower linoleic and AA values than did control subjects. The c0-3 precursor o~-linolenic acid (C18:3m-5) was significantly higher in patients with cholestasis, but there were no differences in its metabolites eicosapentaenoic (C20:5m5) and docosahexaenoic (C22:6m-3) acids (Table II). Total PUFA and LCP concentrations were lower in the patients with liver disease, whereas there were high levels of the nonessential fatty acids oleic acid (18:1m-9), Mead acid (20:3(0-9), and palmitoleic acid (16:1m7) (Table II). In four patients the 20:3m9/20:4m-6 ratio exceeded the 0.2 level, considered an indicator of EFA deficiency in subjects with undisturbed liver and desaturation function. 16 Dicta W intake of total PUFA (measured in grams per 100 kcal) was significantly correlated with plasma phospholipid contents of total P U F A (/- = 0.66; p < 0.01), total LCP (/- = 0.65; p = 0.02), c0-6 PUFA (r = 0.62; p = 0.02), and m-6 LCP (r = 0.68; p = 0.007) but not with c0-3 fatty acids. Total plasma phospholipid fatty acid concentrations did not correlate with results of clinical chemistry studies (alanine aminotransferase, alkaline phosphatase, T-glutamyl transferase, total lipids, triglycerides, phospholipids, cholesterol, prothrombin index, retinol, 0ttoeopherol, 0~-tocopherol/total lipids
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TFIE JOURNAL OF PEDIATRICS
NOVEMBER1997
fatty acid C16:0
P=0,05
C18:0 C20:0
P=0,005
C18:1e-9
=0,05
C20:3e-9
=0,03
C16:1o~-7
P=O,002
C18:2e-6 C20:3co6
C20:4o~-6
P=0,001
C22:4e-6
P=0,06
C18:3¢o-3
P=0,5
C20:5e-3
P=0,9
C22:5e-3
P=0,001
C22:6c0-3
P=0,002
PUFA
P=0,01
DISCUSSION
LCP surr -0,5 0,0 0,5 Spearman R value F~.
1. Spearmanrank order correlations between bilirubin concentration (measured in micromoles per liter) and contributions of fatty acids (percentage of weight/weight) to plasmaphospholipids in 15 children with cholestasis
TableI. Results of laboratory tests in 15 children with chronic cholestasis
702
ratio) and TBARS values, except for an inverse relation of bile acids and linoleic acid (r =-0.67; p = 0.01). Concentrations of several fatty acids correlated significantly with bilirubin concentrations (Fig. 1). Bilirubin concentrations were unrelated to values for the EFA precursors linoleic acid and ff-linolenic acid but correlated inversely with values for the long-chain metabolites dihomo- 7linolenic acid (20:50)-6), AA (20:40)-6) (Fig. 2), docosapentaenoic acid (22:50)5), and docosahexaenoic (22:60)-5) acid (Fig. 5). Both AA and docosahexaenoic acid reached very low levels in children with high bilirubin concentrations (> 100 gmol/L. Bilirubin values correlated positively with those for the nonessential fatty acids palmitoleie acid, oleic acid, and Mead acid (Fig. 1), whereas values for Mead acid and oleic acid correlated with stearic acid values (C18:0) (r = -0.85 and p = 0.0001, and r = -0.59 and g = 0.02, respectively).
In our study, children with severe liver disease had evidence of PUFA and particularly 0)-6 fatty acid deficiency, reflected by increased values of palmitoleic and Mead acids. 16 Only four children had an elevated 20:5ol-9/20:4o)-6 ratio, which is considered to indicate EFA deficiency in subjects with normal hepatic function and desaturation activity. However, it is not known whether an elevation of the 20:30)-9/20:401-6 ratio is a sensitive and specific indicator of EFA deficiency in disease. Desaturation activity is required for the synthesis of Mead acid (20:501-9) from oleic acid (18:101-9)16; therefore, in cases with impaired hepatic desaturation activity, intracellular EFA depletion might not be accompanied by an increase of Mead acid. Indeed, we did not fred a clear elevation in the Mead acid concentration or in the 20:50)-9/20:40)-6 ratio in children with severe primary protein energy malnutrition and EFA deficiency whose plasma fatty acid profiles were compatible with impaired desaturation activity. 17
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THE JOURNAL OF PEDIATRICS Volume 13 I, Number 5
Table II. Fatty acid composition of plasma phospholipids of 15 patients with cholestasis and 13 age-matched control subjects (median
[ql to Q3]' %wtlwt)
Even though the number of subjects in the reference group used for comparison was limited, their fatty acid values did not differ from a large group of German children investigated with the same methods, 13 which is in line with similar dicta W
habits in this age group in Poland and Germany, In addition to the effects of dicta W P U F A intake and a potential increase of P U F A oxidation in malnutrition, fat malabsorption in patients with liver disease appears to be a major causal factor
for the progressive decline of linoleie acid levels with increasing serum bile acid concentrations. This is similar to the reported progressive reduction of c~-tocopherol levels with increasing severity of cholestasis. 18 However, these factors do not pro-
703
SOCHA ET AL.
THE JOURNAL OF PEDIATRICS NOVEMBER 1997
i]" 4
""-.~
3
:
•
•
2 0
I
I
100
200
'
I
'
300
I
400
bilirubin concentration (i~mol/I) F~@. 2. Linear regression of serum bilirubin concentration (measured in micromoles per liter) and AA content (percentage weight/weight) in plasma phospholipids of 15 children with cholestasis(r = -0,75; p = 0.ool), 5-
I 4-
0 0
i 100
i 200
i 300
i 400
bilirubin concentration (~mol/I) FI.~. 3. Linear regression of serum bilirubin concentration (measured in micromoles per liter) and docosahexaenoic acid (DHA) content (percentage weight/weight) in plasma phospholipids of 15 children with cholestasis (r = -0.72; p = 0,002).
vide an explanation for the relatively greater depletion of LCP products than E F A precursors (Table II). One might consider that the low c~-tocopherol levels observed in the children with cholestasis 704
may have contributed to the poor P U F A status because of increased P U F A susceptibility to peroxiclative degradation. However, some unsaturated fatty acid concentrations were increased, ancl there was no
correlation of vitamin E concentrations or the vitamin E/total lipid ratio to values for TBARS, PUFA, 03-6, CO-S,and total LCE nor to serum bilirubin concentrations. Thus the observed marked LCP deficiency in the patients with liver disease appears to reflect primarily an impairment of formation rather than peroxidative degradation. In addition, the observed inverse correlation of the serum bilirubin concentration to EFA metabolite concentrations, but not to concentrations of their precursors, points to increasing impairment of hepatic P U F A conversion to LCP with advancing severity of liver disease. The serum bilirubin concentration is a powerful indicator of disease severity in cholestasis and predicts outcome of childhood autoimmune hepatitis 19 and survival of children with biliary atresia and hypoplasia after liver transplantation. 20 However, there is no indication of a direct relationship between hyperbilirubinemia and the activity of the hepatic mierosomal desaturase/elongase system used for LCP synthesis. 16 Microsomal membrane lipid peroxidation might contribute to the disturbed LCP formation, and children with cholestasis Seem to be more vulnerable to oxidative damage, as indicated b y high plasma TBARS concentrations in our patients, as well as in others 21 and in an experimental model. 22 Lemonnier et al. 21 found a significant correlation of plasma TBARS concentration with bilirubin concentration in children with biliary atresia and with a paucity of interlobular bile ducts,21 whereas there was only a nonsignificant trend to a higher TBARS concentration with an increasing bilirubin concentration in our study. One might suspect that the observed inverse correlation of LCP to bilirubin concentration reflects suppression of enzyme activity, observed with increasing severity of protein energN malnutrition, 17'23 as has been reported in adult patients with advanced liver disease. 4'5 However, the degree of malnutrition in chronic liver disease of childhood, as assessed by total body potassium determination and anthropometric measurements, was not related to the results of liver function tests. 24 It is tempting to speculate on the possible contribution of various hepatic en-
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THE JOURNAL OF PEDIATRICS Volume 13 I, Number 5
zymes to the observed disturbances of fatty acid metabolism in children with cholestasis. M a j o r enzymes involved in elongation and desaturation are zXg-desaturase, A6-desamrase, A5-desaturase, and elongases. 1'16 A9-Desaturase activity does not seem to be impaired, as indicated by high levels of oleic acid and palmitoleic acid. k 9 - D e s a t u r a s e was p r o v e d to be more resistant to liver damage, and recove W kinetics after carbon tetrachloride poisoning in rats are fast for A9-desaturase and slower for zX6-desaturase. 25 In contrast, kS-desaturase activity may be low, because A A is decreased whereas C20: 3~-6 levels are normal. Elongase activity might also be considered reduced, because some product/substrate ratios are low in patients vAth cholestasis (ratios: C24:l m-9/C20:Ro-9, C22:5m~3/C20:Sm-3, and C20:0/C18:0), but other product/substrate ratios are tmchanged (ratios: C22: 4m-6/C20:4o~-6, and C22:0/C20:0). The presence of normal M e a d acid/AA ratios (<0.2) in most patients, despite other signs of P U F A deficiency, may also be caused by low activities of AS desaturation and elongation, which, are involved in the synthesis of M e a d acid. 16 These hypotheses of possible mechanisms of metabolic changes should be tested b y stable-isotope studies of E F A metabolism, which recently have become feasible. 26 Reduced A A availability may contribute to a disturbed icosanoid balance in cholestasis 2'8 and may be one factor in the pathogenesis of altered coagulation, immunologic response, and renal function. 27 A positive correlation between A A status and g r o w t h was found in p r e t e r m infants 28'29 and in animal models, 30 and it is conceivable that poor A A status might also contribute to the growth disturbances observed in children with cholestasis. 31 Poor L C P status is associated with a p p a r e n t poor visual and psychomotor development in young, healthy infants 52'53 and, in addition to vitamin E deficiency, 34 might be a further factor that contributes to neurologic impairment in ,children with cholestasls.
lgZe than/: DI: H~and Demmdmair for his nzethodologfc aao£taaee, and Eva BehreJTdt, Petra Helm, and E,,a Skompa for excellent tedinca/a~siatanee.
REFERENCES 1. Decsi T, Koletzko B. Polyunsaturated fatty acids in infant nutrition. Acta Paediatr 1994;395:51-7. 2. Smith WL, Borgeat P, Fitzpatrick FA. The eicosanoids: cyclooxygenase, lipoxygenase, and epoxygenase pathways. In: Vance DE, Vance J, editors. Biochemistry of lipids, lipoproteins and membranes. Amsterdam: Elsevier Science Publishers; 1991. p. 297325. 3. Cabre E, Periago JL, Abad-Lacruz A, Gonzalez-Huix F,, Gonzalez J, EsteveComas M, et al. Plasma fatty acid prof'de in advanced cirrhosis: unsaturation deficit of lipid fractions. Am J Gastroenterol 1990;85:1597-604. 4. Cabre E, Periago JL, Abad-Laeruz A, et d. Polyunsaturated fatty acid deficiency in liver cirrhosis: its relationship to associated protein-energy malnutrition [preliminaW report]. Am J Gastroentero11988;83:712-7. 5. Gonzales J, Periago JL, Gil A, et al. Malnutrition-related polyunsaturated fatty acid changes in plasma lipid fractions of cirrhotic patients. Metabolism 1992;41:95460. 6. Cabre E, Periago JL, Gonzalez J, et al. Plasma polyunsaturated fatty acids in liver cirrhosis with or without chronic hepatic encephalopathy: a preliminary study. JPEN J Parenter Enteral Nutr 1992;16: 359-63. 7. Babin F, Lemonnier E Goguelin A, Ala~lle D, Lemonnier A. Plasma fatty acid composition and lipid peroxide levels in children with paucity of intedobular bile ducts. Ann Nutr Metab 1988;32:220-30. 8. Dupont J, Amedee-Manesme O, Pepin D, Chambaz J. Eicosanoid synthesis in children with cholestatic disease. J Inherit Metab Dis 1990;13:212-8. 9. Pettei M J, Daftary S, Levine JJ. Essential fatty acid deficiency associated with the use of a medium-chaln-triglyceride infant formula in pediatric hepatobiliary disease. Am J Clin Nutr 1991;53:1217-21. 10. De Leenheer AP, De Bevere VORC, De Ruyter MGM, Claeys AE. Simultaneous determination of retinol and 0~-tocopherol in human serum by high-performance liquid chromatography. J Chromatogr 1979; 162:408-13. 11. Sokol RJ, Heubi JE, Iannaccone ST, Bore KE, Balistreri WE Vitamin E deficiency with normal serum vitamin E concentrations in children with chronic chnlestasis. N Engl d Med 1984;310:1209-12. 12. Koletzko B, Schmidt E, Bremer HJ, Haug M, Harzer G. Effects of dietary long-chain polyunsaturated fatty acids on the essential
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
fatty acid status of premature infants. Fur J Pediatr 1989;148:669-75. Decsi T, Koletzko B. Fatty acid composition of plasma lipid classes in healthy subject from birth to young adulthood. Eur J Pediatr 1994;153:520-5. Yagi K. A simple fluorometric assay for lipoperoxide in blood plasma. Biochem Med 1976;15:212-6. Yagi K. Assay for serum lipid peroxide level and its clinical significance. In: Yag4 K (editor). Lipid peroxides in biology and medicine. New York: Academic Press; 1982. p. 223-41. Cook H\V. Fatty acid desaturatinn and chain elongation in eucaryotes. In: Vance DE, Vance J (editors). Biochemistry of lipids, lipoproteins and membranes. Amsterdam: Elsevier Science Publishers; 1991. p. 141-68. Koletzko B, Abiodun PO, Laryea MD, Bremer HJ. Fatty acid composition of plasma lipids in Nigerian children with proteinenergj¢ malnun'ition. Fur J Pediatr 1986; 145:109-15. Sokol R J, Heubi JE, Iannaccone S, Bove KE, Balistreri WF. Mechanism causing vitamin E deficiency during chronic childhood cholestasis, Gastroenterology 1983;85: 1172-82. Gregorin GV,, Vergani D, Mowat AP, Mieli-Vergani G. Outcome of autoimmune hepatitis (AIH) in childhood: prognostic value of serum bilirubin [Abstract]. J Pediatr Gastroenterol Nutr 1995;20: 451. Rodeck B, Melter M, KardoffR, Hoyer PE Burdelski M, Brodehl J. Liver transplantation in biliary atresia/hypoplasia: pretransplant factors influencing survival after transplantation [Abstract]. a Pediatr Gastroenterol Nutr 1996;22:442. Lemonnier F, Crestell D, Fenaunt M, Couturier M, Bernard O, Alagille D. Plasma lipid peroxides in cholestatic chili drem Acta Paediatr Scand 1987;76:92834. Sokol R J, Devecreaux M, Khandawala RA. Effect of dietary lipid and vitamin E on mitochondrial lipid peroxidation and hepatic injury in the bile duct-ligated rat. a Lipid Res 199l;32:1349-57. Decsi T, Zaknun D, Zaknuu J, Sped W, Koletzko B. Long-chain polyunsaturated fatty acids in children with severe proteinenergy without and with human immunodeficiency virus-1 infection. Am J Clin Nutr 1995;62:1283-8. Chin dE, Shepherd RW, Thomas BJ, et al. The nature of malnutrition in children with end-stage liver disease awaiting orthotopie liver transplantation. Am J Clin Nutr 1992;56:164-8. Carrean JP, Frommel D, Nguyen TT,
705
SOCHA ETAL.
Mazliak R Hepatic A9 and zX6desaturase activities during the recovery period following carbon tetrachloride poisoning. Lipids 1980;15:631-6. 26. Demmelmair H, Schenck U, Behrendt E, Sauerwald T, Koletzko B. Estimation of arachidonic acid synthesis in full-term neonates using natural variation of 13Ccontent. J Pediatr Gastroenterol Nutr 1995;21: 31-6. 27. Rimola A, Gines P, Cuso E, et al. Prostaglandin precursor fatty acids in cirrhosis with ascites: effect of linoleic acid infusion in functional renal failure. Clln Sci 1988;74: 613-9. 28. Koletzko B, Braun iV[.Arachidonic acid in
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early human growth: is there a relation? Ann Nutr Metab 1991;35:128-31. 29. Carlson SE, Werkman SH, Peeples JNI, Cooke RJ, Tolley EA. Arachidonic acid status correlates with first-year growth in preterm infants. Proc Natl Acad Sci 1993;90:1073-7. 30. Hart MH, Grandjean CJ, Park JHY, Erdmau SH, Vanderhoof JA. Essential fatty acid deficiency and postresection mucosal adaptation in the rat. Gastroenterology 1988;94:682-7. 31. Martinez-Ibanez ~v;,BoLx-OchoaJ, Lloret J, Broto J. Pediatric liver transplantation: life after portoenterostomy in biliary atresia. J Pediatr Surg 1992;27:830-2.
32. Makrides M, Neumann M, Simmer K, Pater J, Gibson R. Are long-chain polyunsaturated fatty acids essential nutrients in infancy? Lancet 1995;345:1463-8. 33. Agostoni C, Trojan S, Bellu R, Pdva E, Giovannini M. Neurodevelopmental quotient of healthy term infants at 4 mbnths and feeding practice: the role of long-chain polyunsaturated fatty acids. Pediatr Res 1995;38:262-6. 34. Sokol RJ, Butler-Simon N, Bettis D, Smith D, Silverman A. Tocopheryl polyethylene glycol 1000 succinate therapy for vitamin E deficiency during chronic childhood cholestasis: neurologic outcome. J Pediatr 1987;111:830-6.
Livingston S, Bridge EM,, Kaj?i L. J Pediatr 1947,'31:509-12 i: This study focused on the prognosis of children whose first seizure was "associated with an acute febrile illness." Ninety-four patients were included in the study. The outcome variable was at least 2 years of freedom from seizures at study contusion, which the authors called "recovery." All patients (18/18) with a history of only febrile convulsions recovered, compared with 37% (28/76) of the children with subsequent febrile and afebrile seizures. Fewer children with focal febrile convulsions recovered (10/58, 26%) in contrast with those who had generalized convulsions (36/56, 64%). Eighty-five percent (23/27) of children with a family history of childhood convulsions recovered, compared with 40% (20/50) of children with no family history of seizures and 29% (5/17) of children with a family history of epilepsy. Age at first seizure, race, sex, or use of anticonvulsant therapy did not affect prognosis. Comment: During the past 50 years, one of the most vexing questions facing pediatricians is the prognosis of children who present with their first febrile seizure. The methodolo~¢ used in this study includes significant selection bias because the patients were culled from a tertiary care pediatric epilepsy clinic at the Johns Hopkins hospital. However, subsequent studies, which utilized prospectively followed cohorts, confirm the conclusions of this article. This was a landmark article from one of the leading pediatric epileptologists of this century. This article reinforces the notion that with simple febrile seizures, it is better to educate the parents than to medicate the child.
Traz~A. Glauser,MD Division of Neurology
706
!/
'
i
"
!i
Piotr Socba, MD, Bertbold Koletzko, ~ID, Joanna Pawlowska, ~rD, and Jerzy Socha, ~gD
The liver plays a central role in the metabolism of polyunsaturated fatty acids. We studied the relationship between essential fatty acid (EFA) status and indicators of liver function in 15 children with chronic cholestasis aged 9 months to 3.4 years (median, 1.3 years). Compared with 13 control children, the patients studied had low percentage values of phospholipid EFAs, particularly of the 03-6 fatty acids linoleic acid (18:203-6) and arachidonic acid (20:403-6). Fatty acid values exhibited an inverse relationship to serum bile acids, as well as to serum bilirubin. Bilirubin values were unrelated to the EFA precursors linoleic acid and o~-linolenic acid but correlated inversely with the long-chain metabolites arachidonic acid (r = -0.75; p = 0.001), docosapentaenoic acid (22:503-3; r = -0.63; p = 0.01), and docosahexaenoic acid (22:603-3; r = 0.72; p = 0.002). We conclude that children with chronic cholestasis are at a high risk for EFA deficiency, which increases with progressive elevation of serum bilirubin. Hepatic conversion of essential precursor fatty acids into their long-chain metabolites may be increasingly impaired with advancing severity of liver disease. (J Pediatr 1997; 131:700-6).
Polyunsaturated fatty acids are essential components of structural lipids in all tissues and modulate cell membrane fluidity and function. The availability of long-chain PUFA (>18 carbon atoms), such as arachidonic and docosahexaenoic acids, is important for early human growth and development of membrane-rich tissues such as brain and retina. 1 Moreover, 0)-6 and 03-3
PUFA serve as precursors of icosanoids with important biologic roles as mediators of immune and vascular functions, as well as platelet aggregation. 2 We hypothesized that children with cholestatic disease have a poor PUFA status, because bile acids contribute to efficient PUFA absorption from the gut and because LCP are synthesized from their precursors, mainly in the liver. PUFA deple-
From the Kinderpoliklinik, Ludwig-Maximilians-Universil~, AJilncben, Germany, the Centrum Zdroveia Dziecka-lnstitute eor Child Health, Warsaw, Poland. Supported by Deutsche Forschuugsgemelnschaft, Bonn, Germany (Ko 912/4-3), and by the Polish Research Council (Komitet Badan Nankowych), Warsaw, Poland (No 4-S-405-00-405). Dr. Piotr Socha was the recipient of a scholarship (No. S.85/93) granted by Nestec Ltd., Vevey, Switzerland. Presented in part as a poster at the 28th annum meeting of the European Society of Paediatric Gastroenterology and Nutrition (ESPGAN); awarded the John Harries Prize in 1995. Submitted for publication Feb. 7, 1996; accepted Nov. 21, 1996. " Reprint requests: Berthold Koletzko, MD, Professor of Pediatrics, Kinderpoli!dinik, Ludwig-MaximiliansUniversity of Munich, Pettenkoferstr. 8a, D-80336 Miinchen, Germany. J Pediatr 1997; 131:258-64 Copyright © 1997 by Mosby-Year Book, Inc. 0022-3476/97/$5.00 + 0 9/21/79488
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fion of plasma lipid fractions was reported in adult patients with cirrhosis, 3 in whom it was associated with protein energy malnutrition 4'5 and the occurrence of encephalopathy. 6 In contrast, there is only limited information on the essential fatty acid status of children with cholestasis. Linoleic acid (18:203-6) depletion of total plasma f a t t y acids was found in children with a paucity of intralobular bile ducts. 7 Linoleic acid and arachidonic acid (20:403-6) deficiency was reported both in a group of children with Alagille syndrome and in four children with biliary atresia. 8 A serum phospholipid fatty acid pattern, reported in four infants with hepatobiliary disease who were receiving a formula with high-content medium-chain triglycerides and in whom a poor 03-6 EFA status was observed, was attributed to a high intake of medium-chain triglycerides and a low intake of lin01eic acid. 9 We studied the effects of chronic liver disease on PUFA status in children without supplementation with medium-chain triglycerides in their diets.
METHODS We investigated 15 children with chronic cholestasis (11 with surgically repaired bilia W atresia, 3 with intrahepatic cholestasis of unknown origin, 1 with Byler disease) treated as outpatients at the
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THE JOURNALOF PEDIATRICS Volume 13 I, Number 5
Centrum Zdrowia Dziecka in Poland; ages were 9 months to 3.4 years (median, 1.3 years). As a reference group, we studied la children aged 11 months to a.6 years (median, 1.6 years) in good general health who attended the same hospital and had no liver disease. The study protocol was approved by the local ethical committee, and parental informed consent was obtained. Three-day dicta W protocols were recorded in all patients with cholestasis, and the daily intakes of energy, protein, carbohydrates, fat, linoleic acid, 0~linolenic acid, and total PUFA were calculated. A venous blood sample was obtained from the fasted liver patients to determine, with standard methods, the serum bilirubin concentration; activities of alanine aminotransferase, alkaline phosphatase, and T-glutamyl transpeptidase; prothrombin time; total concentrations of bile acids; and serum total lipid, triglyceride, cholesterol, and phospholipid concentrations. Retinol and Ix-tocopherol serum concentrations were measured by high-performance liquid chromatography, ]° and the 0~-tocopherol/total lipid ratio was ca]culated. 11 Fatty acid composition of plasma phospholipids was determined in both groups from venous plasma obtained, with sodium etliylenediaminetetraacetate (1 rag/ ml) as the anticoagulant, and stored at -20 ° C for a maximum duration of 6 months until analysis. Lipids were extracted from 0.5 ml plasma with chloroform/methanol, and lipid classes were separated by thin-layer chromatography as previously described. 12 Fatty acids were transesterified with methanol and hydrochloric acid and analyzed by highresolution capilla W gas-liquid chromatography with the use of a Hewlett-Packard series II 5890 gas chromatograph, with on-column injection and flame-ionization detection (SGE column 50QC2/BPX70, column diameter 0.22 mm, column head pressure 1.5 bar; oven temperature initially 150 ° C, then temperature rise with 3 ° C/min to 180 ° C, then with 4 ° C/min to 200 ° C, and then with 1° C/min to 210 ° C [isotliermic period for 20 minutes]). Peak identification was verified by comparison
with authentic standards (Nu Check Prep. Inc., Elysian, Minn.) and by mass spectrometry (Hewlett-Packard series 5971 MSD). Results are expressed as a percentage (of weight/weight) of all fatty acids detected with a chain length between 12 and 22 carbon atoms, la Plasma lipid peroxides were determined immediately after sample collection with the spectrofluorometric method of Yagi I4,ls and expressed as thiobarbiturate reactive substance (measured in nanomoles per milliliter) in the patients with cliolestasis and in control subjects. Results were evaluated with Minitab for Windows release 9.2 (Nlinitab Inc., State College, Pa.). We present the data as medians with lower and upper quartiles (Q1 to Qs). For comparison of fatty acid profiles in children with eholestasis and the reference group, the MannWhitney two-sided rank test was used. Possible correlations were tested by the Spearman rank correlations and plotted as linear regressions. Differences and regressions were regarded as statistically significant atp less than 0.05.
RESULTS The children with cholestasis had a wide range of clinical disease severity at presentation, as reflected by the range of bilirubin concentrations, from 17.1 to 376 ~tmol/L (4.7 to 17. 1 mgldl; median, 14.0 mg/dl), and the range of their ratios of body weight to normal body weight for age, from 0.4 to 1.0 (median, 0.86). Daily dietary intakes per kilogram of actual body weight (median, [Q1, Q3]) were 107.2 kcal (88.4, 144.5 kcal), a.7 gm protein (2.6, 4.7 gm), and a.4 gm fat (2.9, 4.3 gm). In relation to estimated normal body weights (50th percentile for age), intakes per kilogram of ideal body weight were 9a.5 kc~l (75.9, 108.6 kcal), 3.3 gm prorein (2.5, 3.9 gm), and 2.7 gm fat (2.5, 3.9 gm). Intakes of linoleic acid were 0.3 gm/100 kcal (0.2, 0.4 gm) and of c~linolenic acid 0.06 gin/100 kcal (0.03, 0.09 gm), with linoleic acid and total PUFA contributing 2.7% and 3.6%, respectively, of energy intake.
Median 0t-tocopherol concentrations and 0~-tocopherol/total lipid ratios were far below the lower limit of the normal range (Table I), 11 with subnormal 0~-tocopherol concentrations (<3.8 rag/L) in 12 and reduced 0t-tocopherol/total lipid ratios (<0.6 mg/gm) in 11 patients. Plasma TBARS values were significantly higher in patients with eholestasis (2.8 [1.5 to 3.3], median [Q1 to Q3]) than in control subjects (1.2 [1.1 to 1.3];p = 0.0006), with a trend to higher levels in patients with increased bilirubin concentrations (Spearman rank correlation coefficient: r = 0.48; /, = 0 . 0 7 ) .
The fatty acid p r o n e in plasma phospholipids of our reference group was similar to the results in a large group of German children of equal age studied by the same method in this laboratory. 15 Children with cholestasis had significan@ lower linoleic and AA values than did control subjects. The c0-3 precursor o~-linolenic acid (C18:3m-5) was significantly higher in patients with cholestasis, but there were no differences in its metabolites eicosapentaenoic (C20:5m5) and docosahexaenoic (C22:6m-3) acids (Table II). Total PUFA and LCP concentrations were lower in the patients with liver disease, whereas there were high levels of the nonessential fatty acids oleic acid (18:1m-9), Mead acid (20:3(0-9), and palmitoleic acid (16:1m7) (Table II). In four patients the 20:3m9/20:4m-6 ratio exceeded the 0.2 level, considered an indicator of EFA deficiency in subjects with undisturbed liver and desaturation function. 16 Dicta W intake of total PUFA (measured in grams per 100 kcal) was significantly correlated with plasma phospholipid contents of total P U F A (/- = 0.66; p < 0.01), total LCP (/- = 0.65; p = 0.02), c0-6 PUFA (r = 0.62; p = 0.02), and m-6 LCP (r = 0.68; p = 0.007) but not with c0-3 fatty acids. Total plasma phospholipid fatty acid concentrations did not correlate with results of clinical chemistry studies (alanine aminotransferase, alkaline phosphatase, T-glutamyl transferase, total lipids, triglycerides, phospholipids, cholesterol, prothrombin index, retinol, 0ttoeopherol, 0~-tocopherol/total lipids
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TFIE JOURNAL OF PEDIATRICS
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fatty acid C16:0
P=0,05
C18:0 C20:0
P=0,005
C18:1e-9
=0,05
C20:3e-9
=0,03
C16:1o~-7
P=O,002
C18:2e-6 C20:3co6
C20:4o~-6
P=0,001
C22:4e-6
P=0,06
C18:3¢o-3
P=0,5
C20:5e-3
P=0,9
C22:5e-3
P=0,001
C22:6c0-3
P=0,002
PUFA
P=0,01
DISCUSSION
LCP surr -0,5 0,0 0,5 Spearman R value F~.
1. Spearmanrank order correlations between bilirubin concentration (measured in micromoles per liter) and contributions of fatty acids (percentage of weight/weight) to plasmaphospholipids in 15 children with cholestasis
TableI. Results of laboratory tests in 15 children with chronic cholestasis
702
ratio) and TBARS values, except for an inverse relation of bile acids and linoleic acid (r =-0.67; p = 0.01). Concentrations of several fatty acids correlated significantly with bilirubin concentrations (Fig. 1). Bilirubin concentrations were unrelated to values for the EFA precursors linoleic acid and ff-linolenic acid but correlated inversely with values for the long-chain metabolites dihomo- 7linolenic acid (20:50)-6), AA (20:40)-6) (Fig. 2), docosapentaenoic acid (22:50)5), and docosahexaenoic (22:60)-5) acid (Fig. 5). Both AA and docosahexaenoic acid reached very low levels in children with high bilirubin concentrations (> 100 gmol/L. Bilirubin values correlated positively with those for the nonessential fatty acids palmitoleie acid, oleic acid, and Mead acid (Fig. 1), whereas values for Mead acid and oleic acid correlated with stearic acid values (C18:0) (r = -0.85 and p = 0.0001, and r = -0.59 and g = 0.02, respectively).
In our study, children with severe liver disease had evidence of PUFA and particularly 0)-6 fatty acid deficiency, reflected by increased values of palmitoleic and Mead acids. 16 Only four children had an elevated 20:5ol-9/20:4o)-6 ratio, which is considered to indicate EFA deficiency in subjects with normal hepatic function and desaturation activity. However, it is not known whether an elevation of the 20:30)-9/20:401-6 ratio is a sensitive and specific indicator of EFA deficiency in disease. Desaturation activity is required for the synthesis of Mead acid (20:501-9) from oleic acid (18:101-9)16; therefore, in cases with impaired hepatic desaturation activity, intracellular EFA depletion might not be accompanied by an increase of Mead acid. Indeed, we did not fred a clear elevation in the Mead acid concentration or in the 20:50)-9/20:40)-6 ratio in children with severe primary protein energy malnutrition and EFA deficiency whose plasma fatty acid profiles were compatible with impaired desaturation activity. 17
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THE JOURNAL OF PEDIATRICS Volume 13 I, Number 5
Table II. Fatty acid composition of plasma phospholipids of 15 patients with cholestasis and 13 age-matched control subjects (median
[ql to Q3]' %wtlwt)
Even though the number of subjects in the reference group used for comparison was limited, their fatty acid values did not differ from a large group of German children investigated with the same methods, 13 which is in line with similar dicta W
habits in this age group in Poland and Germany, In addition to the effects of dicta W P U F A intake and a potential increase of P U F A oxidation in malnutrition, fat malabsorption in patients with liver disease appears to be a major causal factor
for the progressive decline of linoleie acid levels with increasing serum bile acid concentrations. This is similar to the reported progressive reduction of c~-tocopherol levels with increasing severity of cholestasis. 18 However, these factors do not pro-
703
SOCHA ET AL.
THE JOURNAL OF PEDIATRICS NOVEMBER 1997
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3
:
•
•
2 0
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100
200
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300
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400
bilirubin concentration (i~mol/I) F~@. 2. Linear regression of serum bilirubin concentration (measured in micromoles per liter) and AA content (percentage weight/weight) in plasma phospholipids of 15 children with cholestasis(r = -0,75; p = 0.ool), 5-
I 4-
0 0
i 100
i 200
i 300
i 400
bilirubin concentration (~mol/I) FI.~. 3. Linear regression of serum bilirubin concentration (measured in micromoles per liter) and docosahexaenoic acid (DHA) content (percentage weight/weight) in plasma phospholipids of 15 children with cholestasis (r = -0.72; p = 0,002).
vide an explanation for the relatively greater depletion of LCP products than E F A precursors (Table II). One might consider that the low c~-tocopherol levels observed in the children with cholestasis 704
may have contributed to the poor P U F A status because of increased P U F A susceptibility to peroxiclative degradation. However, some unsaturated fatty acid concentrations were increased, ancl there was no
correlation of vitamin E concentrations or the vitamin E/total lipid ratio to values for TBARS, PUFA, 03-6, CO-S,and total LCE nor to serum bilirubin concentrations. Thus the observed marked LCP deficiency in the patients with liver disease appears to reflect primarily an impairment of formation rather than peroxidative degradation. In addition, the observed inverse correlation of the serum bilirubin concentration to EFA metabolite concentrations, but not to concentrations of their precursors, points to increasing impairment of hepatic P U F A conversion to LCP with advancing severity of liver disease. The serum bilirubin concentration is a powerful indicator of disease severity in cholestasis and predicts outcome of childhood autoimmune hepatitis 19 and survival of children with biliary atresia and hypoplasia after liver transplantation. 20 However, there is no indication of a direct relationship between hyperbilirubinemia and the activity of the hepatic mierosomal desaturase/elongase system used for LCP synthesis. 16 Microsomal membrane lipid peroxidation might contribute to the disturbed LCP formation, and children with cholestasis Seem to be more vulnerable to oxidative damage, as indicated b y high plasma TBARS concentrations in our patients, as well as in others 21 and in an experimental model. 22 Lemonnier et al. 21 found a significant correlation of plasma TBARS concentration with bilirubin concentration in children with biliary atresia and with a paucity of interlobular bile ducts,21 whereas there was only a nonsignificant trend to a higher TBARS concentration with an increasing bilirubin concentration in our study. One might suspect that the observed inverse correlation of LCP to bilirubin concentration reflects suppression of enzyme activity, observed with increasing severity of protein energN malnutrition, 17'23 as has been reported in adult patients with advanced liver disease. 4'5 However, the degree of malnutrition in chronic liver disease of childhood, as assessed by total body potassium determination and anthropometric measurements, was not related to the results of liver function tests. 24 It is tempting to speculate on the possible contribution of various hepatic en-
SOCHA El" AL,
THE JOURNAL OF PEDIATRICS Volume 13 I, Number 5
zymes to the observed disturbances of fatty acid metabolism in children with cholestasis. M a j o r enzymes involved in elongation and desaturation are zXg-desaturase, A6-desamrase, A5-desaturase, and elongases. 1'16 A9-Desaturase activity does not seem to be impaired, as indicated by high levels of oleic acid and palmitoleic acid. k 9 - D e s a t u r a s e was p r o v e d to be more resistant to liver damage, and recove W kinetics after carbon tetrachloride poisoning in rats are fast for A9-desaturase and slower for zX6-desaturase. 25 In contrast, kS-desaturase activity may be low, because A A is decreased whereas C20: 3~-6 levels are normal. Elongase activity might also be considered reduced, because some product/substrate ratios are low in patients vAth cholestasis (ratios: C24:l m-9/C20:Ro-9, C22:5m~3/C20:Sm-3, and C20:0/C18:0), but other product/substrate ratios are tmchanged (ratios: C22: 4m-6/C20:4o~-6, and C22:0/C20:0). The presence of normal M e a d acid/AA ratios (<0.2) in most patients, despite other signs of P U F A deficiency, may also be caused by low activities of AS desaturation and elongation, which, are involved in the synthesis of M e a d acid. 16 These hypotheses of possible mechanisms of metabolic changes should be tested b y stable-isotope studies of E F A metabolism, which recently have become feasible. 26 Reduced A A availability may contribute to a disturbed icosanoid balance in cholestasis 2'8 and may be one factor in the pathogenesis of altered coagulation, immunologic response, and renal function. 27 A positive correlation between A A status and g r o w t h was found in p r e t e r m infants 28'29 and in animal models, 30 and it is conceivable that poor A A status might also contribute to the growth disturbances observed in children with cholestasis. 31 Poor L C P status is associated with a p p a r e n t poor visual and psychomotor development in young, healthy infants 52'53 and, in addition to vitamin E deficiency, 34 might be a further factor that contributes to neurologic impairment in ,children with cholestasls.
lgZe than/: DI: H~and Demmdmair for his nzethodologfc aao£taaee, and Eva BehreJTdt, Petra Helm, and E,,a Skompa for excellent tedinca/a~siatanee.
REFERENCES 1. Decsi T, Koletzko B. Polyunsaturated fatty acids in infant nutrition. Acta Paediatr 1994;395:51-7. 2. Smith WL, Borgeat P, Fitzpatrick FA. The eicosanoids: cyclooxygenase, lipoxygenase, and epoxygenase pathways. In: Vance DE, Vance J, editors. Biochemistry of lipids, lipoproteins and membranes. Amsterdam: Elsevier Science Publishers; 1991. p. 297325. 3. Cabre E, Periago JL, Abad-Lacruz A, Gonzalez-Huix F,, Gonzalez J, EsteveComas M, et al. Plasma fatty acid prof'de in advanced cirrhosis: unsaturation deficit of lipid fractions. Am J Gastroenterol 1990;85:1597-604. 4. Cabre E, Periago JL, Abad-Laeruz A, et d. Polyunsaturated fatty acid deficiency in liver cirrhosis: its relationship to associated protein-energy malnutrition [preliminaW report]. Am J Gastroentero11988;83:712-7. 5. Gonzales J, Periago JL, Gil A, et al. Malnutrition-related polyunsaturated fatty acid changes in plasma lipid fractions of cirrhotic patients. Metabolism 1992;41:95460. 6. Cabre E, Periago JL, Gonzalez J, et al. Plasma polyunsaturated fatty acids in liver cirrhosis with or without chronic hepatic encephalopathy: a preliminary study. JPEN J Parenter Enteral Nutr 1992;16: 359-63. 7. Babin F, Lemonnier E Goguelin A, Ala~lle D, Lemonnier A. Plasma fatty acid composition and lipid peroxide levels in children with paucity of intedobular bile ducts. Ann Nutr Metab 1988;32:220-30. 8. Dupont J, Amedee-Manesme O, Pepin D, Chambaz J. Eicosanoid synthesis in children with cholestatic disease. J Inherit Metab Dis 1990;13:212-8. 9. Pettei M J, Daftary S, Levine JJ. Essential fatty acid deficiency associated with the use of a medium-chaln-triglyceride infant formula in pediatric hepatobiliary disease. Am J Clin Nutr 1991;53:1217-21. 10. De Leenheer AP, De Bevere VORC, De Ruyter MGM, Claeys AE. Simultaneous determination of retinol and 0~-tocopherol in human serum by high-performance liquid chromatography. J Chromatogr 1979; 162:408-13. 11. Sokol RJ, Heubi JE, Iannaccone ST, Bore KE, Balistreri WE Vitamin E deficiency with normal serum vitamin E concentrations in children with chronic chnlestasis. N Engl d Med 1984;310:1209-12. 12. Koletzko B, Schmidt E, Bremer HJ, Haug M, Harzer G. Effects of dietary long-chain polyunsaturated fatty acids on the essential
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
fatty acid status of premature infants. Fur J Pediatr 1989;148:669-75. Decsi T, Koletzko B. Fatty acid composition of plasma lipid classes in healthy subject from birth to young adulthood. Eur J Pediatr 1994;153:520-5. Yagi K. A simple fluorometric assay for lipoperoxide in blood plasma. Biochem Med 1976;15:212-6. Yagi K. Assay for serum lipid peroxide level and its clinical significance. In: Yag4 K (editor). Lipid peroxides in biology and medicine. New York: Academic Press; 1982. p. 223-41. Cook H\V. Fatty acid desaturatinn and chain elongation in eucaryotes. In: Vance DE, Vance J (editors). Biochemistry of lipids, lipoproteins and membranes. Amsterdam: Elsevier Science Publishers; 1991. p. 141-68. Koletzko B, Abiodun PO, Laryea MD, Bremer HJ. Fatty acid composition of plasma lipids in Nigerian children with proteinenergj¢ malnun'ition. Fur J Pediatr 1986; 145:109-15. Sokol R J, Heubi JE, Iannaccone S, Bove KE, Balistreri WF. Mechanism causing vitamin E deficiency during chronic childhood cholestasis, Gastroenterology 1983;85: 1172-82. Gregorin GV,, Vergani D, Mowat AP, Mieli-Vergani G. Outcome of autoimmune hepatitis (AIH) in childhood: prognostic value of serum bilirubin [Abstract]. J Pediatr Gastroenterol Nutr 1995;20: 451. Rodeck B, Melter M, KardoffR, Hoyer PE Burdelski M, Brodehl J. Liver transplantation in biliary atresia/hypoplasia: pretransplant factors influencing survival after transplantation [Abstract]. a Pediatr Gastroenterol Nutr 1996;22:442. Lemonnier F, Crestell D, Fenaunt M, Couturier M, Bernard O, Alagille D. Plasma lipid peroxides in cholestatic chili drem Acta Paediatr Scand 1987;76:92834. Sokol R J, Devecreaux M, Khandawala RA. Effect of dietary lipid and vitamin E on mitochondrial lipid peroxidation and hepatic injury in the bile duct-ligated rat. a Lipid Res 199l;32:1349-57. Decsi T, Zaknun D, Zaknuu J, Sped W, Koletzko B. Long-chain polyunsaturated fatty acids in children with severe proteinenergy without and with human immunodeficiency virus-1 infection. Am J Clin Nutr 1995;62:1283-8. Chin dE, Shepherd RW, Thomas BJ, et al. The nature of malnutrition in children with end-stage liver disease awaiting orthotopie liver transplantation. Am J Clin Nutr 1992;56:164-8. Carrean JP, Frommel D, Nguyen TT,
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SOCHA ETAL.
Mazliak R Hepatic A9 and zX6desaturase activities during the recovery period following carbon tetrachloride poisoning. Lipids 1980;15:631-6. 26. Demmelmair H, Schenck U, Behrendt E, Sauerwald T, Koletzko B. Estimation of arachidonic acid synthesis in full-term neonates using natural variation of 13Ccontent. J Pediatr Gastroenterol Nutr 1995;21: 31-6. 27. Rimola A, Gines P, Cuso E, et al. Prostaglandin precursor fatty acids in cirrhosis with ascites: effect of linoleic acid infusion in functional renal failure. Clln Sci 1988;74: 613-9. 28. Koletzko B, Braun iV[.Arachidonic acid in
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early human growth: is there a relation? Ann Nutr Metab 1991;35:128-31. 29. Carlson SE, Werkman SH, Peeples JNI, Cooke RJ, Tolley EA. Arachidonic acid status correlates with first-year growth in preterm infants. Proc Natl Acad Sci 1993;90:1073-7. 30. Hart MH, Grandjean CJ, Park JHY, Erdmau SH, Vanderhoof JA. Essential fatty acid deficiency and postresection mucosal adaptation in the rat. Gastroenterology 1988;94:682-7. 31. Martinez-Ibanez ~v;,BoLx-OchoaJ, Lloret J, Broto J. Pediatric liver transplantation: life after portoenterostomy in biliary atresia. J Pediatr Surg 1992;27:830-2.
32. Makrides M, Neumann M, Simmer K, Pater J, Gibson R. Are long-chain polyunsaturated fatty acids essential nutrients in infancy? Lancet 1995;345:1463-8. 33. Agostoni C, Trojan S, Bellu R, Pdva E, Giovannini M. Neurodevelopmental quotient of healthy term infants at 4 mbnths and feeding practice: the role of long-chain polyunsaturated fatty acids. Pediatr Res 1995;38:262-6. 34. Sokol RJ, Butler-Simon N, Bettis D, Smith D, Silverman A. Tocopheryl polyethylene glycol 1000 succinate therapy for vitamin E deficiency during chronic childhood cholestasis: neurologic outcome. J Pediatr 1987;111:830-6.
Livingston S, Bridge EM,, Kaj?i L. J Pediatr 1947,'31:509-12 i: This study focused on the prognosis of children whose first seizure was "associated with an acute febrile illness." Ninety-four patients were included in the study. The outcome variable was at least 2 years of freedom from seizures at study contusion, which the authors called "recovery." All patients (18/18) with a history of only febrile convulsions recovered, compared with 37% (28/76) of the children with subsequent febrile and afebrile seizures. Fewer children with focal febrile convulsions recovered (10/58, 26%) in contrast with those who had generalized convulsions (36/56, 64%). Eighty-five percent (23/27) of children with a family history of childhood convulsions recovered, compared with 40% (20/50) of children with no family history of seizures and 29% (5/17) of children with a family history of epilepsy. Age at first seizure, race, sex, or use of anticonvulsant therapy did not affect prognosis. Comment: During the past 50 years, one of the most vexing questions facing pediatricians is the prognosis of children who present with their first febrile seizure. The methodolo~¢ used in this study includes significant selection bias because the patients were culled from a tertiary care pediatric epilepsy clinic at the Johns Hopkins hospital. However, subsequent studies, which utilized prospectively followed cohorts, confirm the conclusions of this article. This was a landmark article from one of the leading pediatric epileptologists of this century. This article reinforces the notion that with simple febrile seizures, it is better to educate the parents than to medicate the child.
Traz~A. Glauser,MD Division of Neurology
706
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