Intravenous atropine treatment in infantile hypertrophic pyloric stenosis

Hypertrophic pyloric stenosis of infancy is a disorder of early infancy with typical clinical features and well-established radiological appearance of the pyloric canal. Many studies with surgical and medical treatment have been reported over the past fifty years. Pylorotomy has tended to become the favoured method of treatment as with expert paediatric, surgical, anaesthetic, and nursing services and specialised accommodation for infants, the outcome is good with low mortality, short stay in hospital and few complications. However, a variety of studies of medical treatment with anticholinergic drugs and successful outcomes in some large series of cases have also been reported from Sweden, United States of America and the United Kingdom. Since 1996 this group of workers from Osaka, Japan, has revived an interest in medical treatment with reports of a new regime using methyl atropine nitrate intravenously. To achieve satisfactory short term outcomes considerable variation in drug dosage and modified feeding regimes were necessary which involved much medical supervision and careful monitoring for toxic effects of the drug, which were minimal. The treatment was successful in the relatively small number of infants in the trial (19) with two infants being referred for pylorotomy, no mortality and no serious complications. An interesting part of this paper is the long term clinical follow up of the successfully treated infants over two years and ultrasonography of the pyloric canal which demonstrated the changes in muscle thickness and length of the canal. The disadvantages of the treatment mentioned by the authors are length of stay in hospital and the necessity to continue atropine medication orally after discharge home. Comparing the use of this anticholinergic drug intravenously with oral treatment using methyl scopolamine nitrate and similar restricted feeding regime, oral methyl scopolamine nitrate suppressed vomiting more quickly and reliably, was also available for subcutaneous injection if vomiting recurred as size of feeds was increased, and no toxic effects were seen in any dosage used. It would be interesting if these workers would be prepared to try the use of methyl scopolamine nitrate intravenously as pharmalogically this compound was reported to have a spasmolytic effect on gut two to three times greater than methyl atropine nitrate with lesser central nervous effects. This paper serves to emphasise once more that these infants should always be treated in paediatric centres where there is a high level of experienced paediatric care and nurses trained for neonatal special care.