Comparison of Tolerance and Complication Rates Between Early and Delayed Feeding After Percutaneous Endoscopic Gastrostomy Placement in Children.

BACKGROUND: Enteral nutrition is commonly initiated 24 hours after percutaneous endoscopic gastrostomy (PEG) in children. Adult studies report safe refeeding within 1 to 6 hours of PEG, and these findings have been cautiously applied to children. Comparative studies assessing early versus next-day refeeding in children are currently lacking. This study evaluates feeding tolerance and complications following early versus next-day refeeding in children. METHODS: This is a single-center, pre-post study. In June 2015 our clinical practice changed to begin refeeding within 6 hours of PEG. Children receiving early refeeding from December 2015 to August 2017 were included. A retrospective cohort from February 2013 to April 2015 was used for comparison. RESULTS: Forty-six children received early refeeding after PEG and 37 received next-day refeeding. Gender distribution was similar in the 2 groups. Early refeeding patients were slightly older (3.5 vs 2.2 years) and heavier (15.5 vs 11.5 kg) at PEG placement compared to next-day refeeding patients. Early refeeding patients experienced greater postprocedural nausea and/or vomiting (19% vs 8%, P < 0.001) and leakage, irritation, and infection around the stoma (19% vs 0.0%, P < 0.001). Compared to early refeeders, next-day refeeding patients experienced higher occurrence of fever (35% vs 13%, P = 0.021), longer nutritional disruption (24.6 vs 3.7 hours, P < 0.001), and longer length of stay (51 vs 27 hours; P < 0.001). One next-day refeeding patient experienced peritonitis. One early refeeding patient experienced cellulitis requiring hospitalization and a second experienced gastrostomy tube migration into the peritoneal cavity requiring removal. CONCLUSION: Early refeeders experienced higher rates of postprocedural nausea or vomiting and irritation, leakage, or infection around the stoma; but experienced lower rates of postoperative fever. Early refeeding resulted in reduced nutritional interruption and hospital length of stay.

Quality Improvement Initiative: The Administration of Early Nutrition Following Percutaneous Endoscopic Gastrostomy Tube Placement in Children.

It is common practice for providers to wait up to 24 hours to begin enteral feedings using a newly placed gastrostomy tube in children. As a quality improvement initiative, guidelines were developed to begin early enteral nutrition 4 hours following gastrostomy tube placement. These patient care guidelines standardized electronic ordering, dosing, and feeding administration instructions. Healthcare professionals from the departments of gastroenterology, case management, and nutrition were asked to evaluate the new process by completing a questionnaire. Changes were made to the quality improvement initiative on the basis of the feedback received from the questionnaires. The early feeding initiative aimed to improve patient outcomes and enhance the quality of care received following the child's gastrostomy procedure. These guidelines will then be used in a prospective clinical trial to evaluate the validity of the quality improvement initiative.

Toxins and Biliary Atresia: Is Karenia Brevis (Red Tide) The Culprit?

OBJECTIVE: The study objective was to evaluate the association between Karenia brevis (K. brevis) exposure during pregnancy and the prevalence of biliary atresia (BA) in offspring. STUDY DESIGN: This was a hospital-based, case-control study in which cases were infants diagnosed with BA at Johns Hopkins All Children's Hospital from October 2001 to December 2019. Cases were matched 1:4 by age to controls who were randomly selected from a pool of healthy infants hospitalized during the study period for common pediatric diagnoses. Infants were excluded if they had congenital anomalies and/or were non-Florida residents. Gestational K. brevis exposure levels (cells/liter) were determined from Florida Fish and Wildlife Conservation Commission exposure data at 10- and 50 mile radii from the mother's zip code of residence. Multivariable conditional logistic regression determined odds of BA in offspring in relation to maternal gestational K. brevis exposure adjusted for infant sex, race/ethnicity, coastal residence, and seasonality. RESULTS: Of 38 cases and 152 controls, no significant inter-group differences were observed for infant race/ethnicity, season of birth, or coastal residence. Median gestational exposure at the 10 mile radius was 0 cells/liter in both groups. A greater proportion of cases had no gestational K. brevis exposure (63.2 %, n = 24) in comparison to controls (37.5 %, n = 57; p = .04) at a 10 mile radius. At a 50 mile radius, cases had a peak median exposure at 6 months of gestation compared to controls' peak at 9 months. After adjustment for sex, seasonality, race/ethnicity, and coastal residence, there was no significant association between BA and maximum K. brevis exposure per trimester of pregnancy observed at a 10- or 50 mile radius. CONCLUSION: In this matched case-control study, we observed no association between gestational K. brevis (cells/liter) exposure at a 10- or 50 mile radius from maternal zip code of residence and BA in offspring.

Concurrent cecal lipoma and Crohn's disease in a pediatric patient: A conservative approach.

We report the case of a 14-year-old patient with a known history of Crohn's disease who was incidentally diagnosed with an asymptomatic cecal lipoma. A routine surveillance colonoscopy as part of the management of the patient's Crohn's Disease revealed a well-defined, submucosal, yellowish mass in the patient's cecum. Histopathological examination of a biopsy specimen revealed submucosal adipose tissue, consistent with the endoscopic images showing the characteristic appearance of the lipoma. A computed tomography examination further confirmed the diagnosis. While colonic lipomas are infrequent and typically manifest later in life, few cases report the coexistence of a cecal lipoma with Crohn's disease, particularly in the pediatric population. In this case, managing this dual condition posed a notable challenge. Here, we present the conservative approach to managing a pediatric patient with cecal lipoma and Crohn's disease. The decision to leave the lipoma in situ was based on the absence of symptoms and potential risks associated with surgical removal.

Appendiceal mucinous neoplasm in adolescence: Diagnosis, management, and surveillance.

This case report describes a 17-year-old patient with a low-grade appendiceal mucinous neoplasm. The patient presented with non-bloody diarrhea, abdominal pain, and weight loss. A colonoscopy revealed a cecal polypoid mass that required laparoscopic surgery. The residual appendix was dilated with myxoglobulosis and histopathology confirmed the diagnosis of a low-grade appendiceal mucinous neoplasm staged pT3Nx. The potential risk of pseudomyxoma peritonei is a serious complication of these tumors. Surveillance plans include computed tomography abdomen and pelvis, and tumor markers every 6 months for the next 2 years. This case highlights the importance of considering appendiceal malignancy in patients with abdominal pain and weight loss, despite the rarity of the disease. It also emphasizes the need for careful monitoring due to the possible complications associated with these tumors. Treatment and prognosis for appendiceal neoplasms depend on the histopathologic characteristics, tumor-nodes-metastasis stage, tumor grade, and presence of peritoneal disease.

Extrahepatic cholangiocyte cilia are abnormal in biliary atresia.

OBJECTIVES: Biliary atresia (BA) is a rapidly progressive form of biliary fibrosis affecting neonates. We previously reported that primary cilia on the intrahepatic cholangiocytes of patients with both syndromic and nonsyndromic BA were structurally abnormal. Our objective was to determine whether extrahepatic cholangiocytes in human biliary atresia, intrahepatic and extrahepatic cholangiocytes of rhesus rotavirus (RRV)-infected neonatal mice, and RRV-infected primary neonatal extrahepatic cholangiocytes also demonstrate ciliary abnormalities. METHODS: The livers of neonatal BALB/c mice injected with RRV that developed jaundice, human extrahepatic bile duct samples obtained at time of hepatoportoenterostomy, and RRV-infected primary neonatal cholangiocytes were stained with antibodies against acetylated α tubulin to identify primary cilia. RESULTS: Extrahepatic cholangiocytes from RRV-treated mice demonstrated minimal loss of primary cilia at day 3 but almost complete loss at day 8 and partial loss at day 12. No changes were seen in mouse intrahepatic bile ducts at any of the time points. In the human BA samples, primary cilia were almost completely absent from extrahepatic duct cholangiocytes. There were, however, abundant cilia in the peribiliary glands adjacent to extrahepatic ducts in the BA sample. Cilia in RRV-infected primary neonatal cholangiocytes were significantly decreased compared with controls. CONCLUSIONS: Primary cilia are selectively lost from neonatal extrahepatic but not intrahepatic cholangiocytes after RRV infection in BALB/c mice. The cilia are also decreased in RRV-infected primary cholangiocytes and the extrahepatic ducts from human patients with BA. This suggests that ciliary abnormalities are part of the pathophysiology of BA.

Obesity and malnutrition in children and adults: A clinical review.

Background: In the U.S., children and adults are consuming more low-nutrient foods with added sugar and excess fats as compared to healthy, high-quality calories and micronutrients. This diet is increasing the prevalence of malnutrition and nutritional deficiencies, despite high calorie intake. This is a review of the common micronutrient deficiencies, the risk factors for malnutrition, dietary plans, and the health consequences in children and adults with obesity in the U.S. Methods: This clinical review of literature was performed on the MEDLINE (PubMed) search engine. A total of 1391 articles were identified and after review, a total of 130 were found to be most pertinent. Discussion: The most common micronutrient deficiencies found in patients with obesity were vitamin A, thiamine (B1), folate (B9), cobalamin (B12), vitamin D, iron, calcium, and magnesium, especially prior and after bariatric surgery. Diets that produced the most weight reduction also further puts these individuals at risk for worsening malnutrition. Malnutrition and micronutrient deficiencies can worsen health outcomes if not properly managed. Conclusion: Adequate screening and awareness of malnutrition can improve the health outcomes in patients with obesity. Physiologic changes in response to increased adiposity and inadequate intake increase this population's risk of adverse health effects. Malnutrition affects the individual and contributes to worse public health outcomes. The recommendations for screening for malnutrition are not exclusive to individuals undergoing bariatric procedures and can improve the health outcomes of any patient with obesity. However, clearly, improved nutritional status can assist with metabolism and prevent adverse nutritional outcomes post-bariatric surgery. Clinicians should advise on proper nutrition and be aware of diets that worsen deficiencies.

Endoscopic Assessment and Serial Balloon Dilatation in a Toddler With Dyskeratosis Congenita-Hoyeraal-Hreidarsson Syndrome Following Bone Marrow Transplant: A Case Report.

We report a 3-year-old patient with suspected oropharyngeal graft-versus-host disease (GVHD) who developed progressive dysphagia to solids and liquids. The patient has a history of Dyskeratosis Congenita-Hoyeraal-Hreidarsson Syndrome with associated bone marrow failure requiring a nonmyeloablative matched sibling hematopoietic stem cell transplant. Esophagram revealed significant narrowing in the cricopharyngeal region. Subsequent esophagoscopy showed a proximal, high-grade pinhole esophageal stricture that was very difficult to visualize and cannulate. High-grade esophageal strictures are uncommon in very young children with GVHD. We believe the patient's underlying Dyskeratosis Congenita-Hoyeraal-Hreidarsson Syndrome in the setting of inflammatory changes seen in GVHD following hematopoietic stem cell transplant set the stage for a high-grade esophageal obstruction. The patient's symptoms improved with serial endoscopic balloon dilation.

Peeling Back the Layers: Sloughing Esophagitis in a Teenager with Chronic Vomiting.

Esophagitis dissecans superficialis (EsoDS) is a rare condition characterized by the shedding of superficial esophageal epithelium. Limited data exists on EsoDS in the pediatric population. We present a case of a 17-year-old female with chronic nausea and vomiting diagnosed with EsoDS. Endoscopy revealed esophageal mucosal sloughing, and histology confirmed esophagitis with mucosal necrosis. EsoDS is underrecognized, and its association with psychoactive medications remains unclear. Fortunately, EsoDS cases tend to resolve spontaneously without complications. Awareness of EsoDS is essential, and further research is needed to understand its prevalence and outcomes in pediatric patients.

Avoiding Surgery: Endoscopic Treatment of Congenital Duodenal Stenosis.

Duodenal stenosis is a rare congenital anomaly that is typically treated surgically, although endoscopic incisional therapy (EIT) and balloon dilation are minimally invasive alternatives. We present a case of a 15-month-old male with vomiting and difficulty tolerating solid food due to severe congenital duodenal stenosis. The patient underwent EIT and serial duodenal dilation to a diameter of 20 mm, which resulted in significant symptom improvement. Intralesional corticosteroid injection (ISI) was administered to help prevent the duodenal septum from restricturing. The combination of EIT, balloon dilation, and ISI was successful in treating the patient's congenital duodenal stenosis and avoided the need for surgery. However, further studies are required to confirm the efficacy of this treatment approach in this patient population. This report highlights the potential of this minimally invasive approach as an alternative to surgical intervention in the management of congenital duodenal stenosis.

Nonalcoholic fatty liver disease and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022.

Background: This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides clinicians an overview of nonalcoholic fatty liver disease (NAFLD), potential progression to nonalcoholic steatohepatitis (NASH), and their application to obesity. Methods: The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership. Results: Topics of this CPS include the prevalence of NAFLD and NASH, the prevalence of NAFLD and NASH among patients with obesity, as well as NAFLD and NASH definitions, diagnosis, imaging, pathophysiology, differential diagnosis, role of high fructose corn syrup and other simple sugars, and treatment (e.g., nutrition, physical activity, medications). Conclusions: This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding NAFLD and obesity is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Patients with obesity are at increased risk for NAFLD and NASH. Patients may benefit when clinicians who manage obesity understand the etiology, diagnosis, and optimal treatment of NAFLD with a goal to prevent NASH.

"Jingle All the Way!": Sharp Foreign Bodies Embedded Within the Esophageal Mucosa During the Holiday Season.

Sharp pointed objects in the esophagus are extremely hazardous and can lead to complications such as mucosal ulcerations, perforations, obstruction, abscess, and fistula formation. Patients exhibit symptomatology based on the location within the proximal or distal esophagus. Ingestion of a sharp foreign object warrants emergent endoscopic removal, particularly when lodged in the esophagus. We present two young children, a 30-month-old male and a 10-month-old male, who underwent emergent endoscopic evaluation following the ingestion of a jingle bell and a Christmas ornament hanger, respectively. Types of ingested sharp foreign bodies may vary during the holiday season and present unique diagnostic and therapeutic challenges for pediatric physicians. Additionally, foreign body ingestions are not limited to children including teenagers and should also be considered in infants. Here, we report two young patients who ingested unique holiday ornaments and describe the management of these impacted esophageal foreign bodies.

Heterotopic Gastric Mucosa Causing Rectal Bleeding in a Young Child.

Heterotopic gastric mucosa (HGM) in the colon and small bowel is a very rare finding. We report a case of HGM in the rectum of an 8-year-old child with a history of eosinophilic esophagitis after having a colonoscopy to evaluate for inflammatory bowel disease. The colonoscopy was normal except for rectal tissue erythema and edema. Inflammatory bowel disease has been reported in some cases of children with eosinophilic changes of the esophagus. The child had intermittent rectal bleeding thought to be due to constipation. Interestingly, when the patient was placed on a proton pump inhibitor for the treatment of eosinophilic esophagitis, the rectal bleeding decreased. After our patient ceased proton pump inhibitor therapy, he experienced a large amount of rectal bleeding. Histological findings revealed HGM in the colon/rectum. An extensive review of the incidence, diagnosis, and treatment is discussed.

Esophageal polyp in a teenage boy with eosinophilic esophagitis.

The association of eosinophilic esophagitis and esophageal polyps has been reported in the literature but remains a rare finding in both adults and children. The patient in this case report presented with progressively worsening dysphagia secondary to eosinophilic esophagitis and an esophageal polyp. Dysphagia is always abnormal, and endoscopic evaluation is essential. Dysphagia is a well-known symptom in patients with eosinophilic esophagitis. While esophageal polyps as a whole are less common in the pediatric population, they should not be overlooked as a possible cause of dysphagia and esophageal obstruction.

Corrigendum to "Social consequences and genetics for the child with overweight and obesity: An obesity medicine association (OMA) clinical practice statement 2022" [Obes. Pillars 3 (2022) 100032].

[This corrects the article DOI: 10.1016/j.obpill.2022.100032.].

Metabolic, behavioral health, and disordered eating comorbidities associated with obesity in pediatric patients: An Obesity Medical Association (OMA) Clinical Practice Statement 2022.

Background: This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. This CPS will be followed by a companion CPS covering further comorbidities, including genetics and social consequences related to overweight and obesity. These CPSs are intended to provide clinicians with an overview of clinical practices applicable to children and adolescents with body mass indices greater than or equal to the 95th percentile for their ages, particularly those with adverse consequences resulting from increased body mass. The information in this CPS is based on scientific evidence, supported by the medical literature, and derived from the clinical experiences of members of the OMA. Methods: The scientific information and clinical guidance in this CPS is based upon referenced evidence and derived from the clinical perspectives of the authors. Results: This OMA statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. It provides clinical information regarding identifying and treating metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children over the 95th percentile of weight/height for age. Conclusions: This OMA clinical practice statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children and provides an overview of current recommendations. These recommendations lay out a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications.

Social consequences and genetics for the child with overweight and obesity: An obesity medicine association (OMA) clinical practice statement 2022.

Background: This Obesity Medicine Association (OMA) clinical practice statement (CPS) covers two topics: 1) genetics and 2) social consequences for the child with overweight and obesity. This CPS is intended to provide clinicians with an overview of clinical practices applicable to children and adolescents with body mass indices greater than or equal to the 85th percentile for their ages, particularly those with adverse consequences resulting from increased body mass. The information in this CPS is based on scientific evidence, supported by the medical literature, and derived from the clinical experiences of members of the OMA. Methods: The scientific information and clinical guidance in this CPS is based upon referenced evidence and derived from the clinical perspectives of the authors. Results: This OMA clinical practice statement details two topics: 1) genetics and 2) social consequences for the child with overweight and obesity. Conclusions: This OMA clinical practice statement on genetics and social consequences for the child with overweight and obesity is an overview of current literature. The literature provides a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications.

Nutrition and physical activity: An Obesity Medicine Association (OMA) Clinical Practice Statement 2022.

Background: This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on Nutrition and Physical Activity provides clinicians an overview of nutrition and physical activity principles applicable to the care of patients with increased body fat, especially those with adverse fat mass and adiposopathic metabolic consequences. Methods: The scientific information and clinical guidance is based upon referenced evidence and derived from the clinical perspectives of the authors. Results: This OMA CPS on Nutrition and Physical Activity provides basic clinical information regarding carbohydrates, proteins, fats (including trans fats, saturated fats, polyunsaturated fats, and monounsaturated fats), general principles of healthful nutrition, nutritional factors associated with improved health outcomes, and food labels. Included are the clinical implications of isocaloric substitution of refined carbohydrates with saturated fats and vice-versa, as well as definitions of low-calorie, very low-calorie, carbohydrate-restricted, and fat-restricted dietary intakes. Specific dietary plans discussed include carbohydrate-restricted diets, fat-restricted diets, very low-calorie diets, the Mediterranean diet, Therapeutic Lifestyle diet, Dietary Approaches to Stop Hypertension (DASH), ketogenic (modified Atkins) diet, Ornish diet, Paleo diet, vegetarian or vegan diet (whole food/plant-based), intermittent fasting/time restricted feeding, and commercial diet programs. This clinical practice statement also examines the health benefits of physical activity and provides practical pre-exercise medical evaluation guidance as well as suggestions regarding types and recommended amounts of dynamic (aerobic) training, resistance (anaerobic) training, leisure time physical activity, and non-exercise activity thermogenesis (NEAT). Additional guidance is provided regarding muscle physiology, exercise prescription, metabolic equivalent tasks (METS), and methods to track physical activity progress. Conclusion: This Obesity Medicine Association Clinical Practice Statement on Nutrition and Physical Activity provides clinicians an overview of nutrition and physical activity. Implementation of appropriate nutrition and physical activity in patients with pre-obesity and/or obesity may improve the health of patients, especially those with adverse fat mass and adiposopathic metabolic consequences.

Medication-induced weight gain and advanced therapies for the child with overweight and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement 2022.

Background: This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details medication-induced weight gain and advanced therapies for the child with overweight or obesity. Methods: The scientific information and clinical guidance in this CPS are based on scientific evidence, supported by the medical literature, and derived from the clinical perspectives of the authors. Results: This OMA Clinical Practice Statement addresses medication-induced weight gain and advanced therapies for the child with overweight or obesity. Conclusions: This OMA Clinical Practice Statement on medication induced-weight gain and advanced therapies for the child with overweight or obesity is an overview of current recommendations. These recommendations provide a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications. This CPS also addresses treatment recommendations. This section is designed to help the provider with clinical decision making.