The Cellie Coping Kit for children with Eosinophilic Esophagitis: Feasibility, acceptability, and preliminary outcomes.

Children with eosinophilic esophagitis (EoE) are faced with ongoing treatments that can impact their wellbeing. There are no evidence-based resources that families can implement independently to cope with EoE-related stressors. This study aimed to examine acceptability, feasibility, and preliminary outcomes of the newly developed Cellie Coping Kit for Children with EoE intervention. Forty child-caregiver dyads completed a baseline assessment (T1) and initiated the intervention; 30 (75%) child participants and 33 (82.5%) caregivers were retained to follow-up (T2). Of those who completed the T2 assessment, most reported that the intervention was easy to use (>90%) and would recommend the intervention to others (>90%). The intervention was feasible: >70% used the kit, and most indicated they would use it again (>75%). More than half of families reported learning new information and/or coping strategies. No statistically significant changes were identified in comparing T1 and T2 coping and health-related quality of life. These findings suggest that the Cellie Coping Kit for Children with EoE is a promising intervention in that it was well accepted, feasible, and helped many families learn novel strategies on how to manage EoE challenges. Future research should examine how to strengthen the intervention to achieve longer-term targeted outcomes.

Customized Postoperative Therapy Improves Bile Drainage in Biliary Atresia: A Single Center Preliminary Report.

BACKGROUND: Controversies in management of biliary atresia (BA) after hepatoportoenterostomy (HPE) lead to variable treatment protocols. We implemented standardized medical management after HPE, customizing the use of antibiotics and corticosteroids based on patient-specific factors. METHODS: In this retrospective analysis, 20 consecutive infants underwent HPE for BA and were compared to a historical cohort. Analysis of successful biliary drainage 3 months after HPE (defined as serum total bilirubin <2 mg/dL) was the primary endpoint; survival with native liver at 2 years was the secondary endpoint. RESULTS: Sixteen of 20 (80%) infants had successful bile drainage, compared to 8 of 20 (40%) infants in the historical cohort (P = 0.0225). Sixteen of 20 patients in the new protocol have reached 2 years of age or required liver transplantation. Among the sixteen, 11 (68.8%) are alive with native livers versus 10 of 20 (50%) in the historical cohort (P = 0.0970). CONCLUSION: This preliminary report suggests the potential benefit of tailored use of postoperative antibiotics and corticosteroids in improving biliary drainage after HPE. LEVEL OF EVIDENCE: III.

Telemedicine in Pediatric Gastroenterology: An Overview of Utility.

BACKGROUND: The availability of pediatric subspecialty services is a problem evident throughout the United States. Access to pediatric gastroenterology services, especially in rural areas, can be scarce. Telemedicine has been proposed as a tool capable of decreasing healthcare costs while extending medical care. OBJECTIVE: The purpose of this article is to review available literature regarding the utility of telemedicine as it applies to pediatric gastroenterology, specifically its role in eliminating healthcare disparities. METHODS: Research articles were identified through a PubMed search with key words focusing on telemedicine initiatives in pediatric gastroenterology, pediatric subspecialty, rural pediatric care, and adult gastroenterology. Studies were categorized based on the following areas of application: financial, time management, communication/community, and patient health and satisfaction. RESULTS: We reached the conclusion that evidence-supported trends in available literature provide a framework for pediatric gastroenterology telemedicine initiatives that can provide resource-sparing, community-enriching, and physician-improving services that ultimately serve to better patient health.

Effects of allergen sensitization on response to therapy in children with eosinophilic esophagitis.

BACKGROUND: In children with eosinophilic esophagitis (EoE) foods are the most common disease triggers, but environmental allergens are also suspected culprits. OBJECTIVE: To determine the effects of environmental allergen sensitization on response to treatment in children with EoE in the southeastern United States. METHODS: Patients 2 to 18 years old who were referred to the Arkansas Children's Hospital Eosinophilic Gastrointestinal Disorders Clinic from January 2012 to January 2016 were enrolled in a prospective, longitudinal cohort study with collection of demographics, clinical symptoms, medical history, allergy sensitization profiles, and response to treatment over time. Comparisons were made between complete responders (peak esophageal eosinophil count <15 per high-power field [HPF]) and nonresponders (>25 eosinophils per HPF) after treatment with diet elimination alone, swallowed corticosteroids alone, or diet elimination and swallowed corticosteroids. Sensitization patterns to environmental allergens found in the southeastern United States were analyzed for the effect on treatment response. RESULTS: A total of 223 individuals were enrolled. Of these, 182 had environmental allergy profiling and at least one endoscopy while receiving proton pump inhibitor (PPI) therapy. Twenty-nine individuals had PPI-responsive EoE and were excluded from further analysis, leaving 123 individuals with non-PPI-responsive EoE who were further analyzed; 72 (58.5%) were complete responders and 33 (26.8%) were nonresponders. Seventeen individuals (13.8%) were partial responders (≥1 but ≤25 eosinophils per HPF) and excluded from further analysis. Nonresponders were more likely to be sensitized to perennial allergens (P = .02). There was no significant difference in response based on seasonal allergen sensitization. Individuals with mold or cockroach sensitization were more likely to fail combination diet and swallowed corticosteroid treatment (P = .02 and P = .002). CONCLUSION: Perennial allergen and mold sensitization may lead to nonresponse to EoE treatment in some patients. Additional studies are needed to further understand the effect of environmental allergens on EoE. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01779154.

NASPGHAN Capsule Endoscopy Clinical Report.

Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.

Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee.

Foreign body ingestions in children are some of the most challenging clinical scenarios facing pediatric gastroenterologists. Determining the indications and timing for intervention requires assessment of patient size, type of object ingested, location, clinical symptoms, time since ingestion, and myriad other factors. Often the easiest and least anxiety-producing decision is the one to proceed to endoscopic removal, instead of observation alone. Because of variability in pediatric patient size, there are less firm guidelines available to determine which type of object will safely pass, as opposed to the clearer guidelines in the adult population. In addition, the imprecise nature of the histories often leaves the clinician to question the timing and nature of the ingestion. Furthermore, changes in the types of ingestions encountered, specifically button batteries and high-powered magnet ingestions, create an even greater potential for severe morbidity and mortality among children. As a result, clinical guidelines regarding management of these ingestions in children remain varied and sporadic, with little in the way of prospective data to guide their development. An expert panel of pediatric endoscopists was convened and produced the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body ingestions. This guideline is intended as an educational tool that may help inform pediatric endoscopists in managing foreign body ingestions in children. Medical decision making, however, remains a complex process requiring integration of clinical data beyond the scope of these guidelines. These guidelines should therefore not be considered to be a rule or to be establishing a legal standard of care. Caregivers may well choose a course of action outside of those represented in these guidelines because of specific patient circumstances. Furthermore, additional clinical studies may be necessary to clarify aspects based on expert opinion instead of published data. Thus, these guidelines may be revised as needed to account for new data, changes in clinical practice, or availability of new technology.

Bowel preparation for pediatric colonoscopy: report of the NASPGHAN endoscopy and procedures committee.

Pediatric bowel preparation protocols used before colonoscopy vary greatly, with no identified standard practice. The present clinical report reviews the evidence for several bowel preparations in children and reports on their use among North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition members. Publications in the pediatric literature for bowel preparation regimens are described, including mechanisms of action, efficacy and ease of use, and pediatric studies. A survey distributed to pediatric gastroenterology programs across the country reviews present national practice, and cleanout recommendations are provided. Finally, further areas for research are identified.

Staple line ulcers: a cause of chronic GI bleeding following STEP procedure.

Intestinal failure (IF) results from a critical reduction in the functional intestinal mass resulting in dependence on total parenteral nutrition (TPN) for growth and survival. Short bowel syndrome (SBS) is the most common cause of intestinal failure in pediatrics. Following resection, the small bowel undergoes adaptation, a process wherein the bowel elongates and dilates in order to increase intestinal absorptive capacity. Small bowel dilatation can lead to dysmotility and small bowel bacterial overgrowth which may further enhance feeding intolerance. Bowel lengthening procedures are beneficial when there is significant dilatation of the small bowel and subsequent inability to advance enteral feeds. We describe a patient with intestine failure and short bowel syndrome due to gastroschisis who, presented with anemia and occult gastrointestinal bleeding, following Serial Transverse Enteroplasty procedure (STEP). Video capsule endoscopy (VCE) revealed multiple ulcerations at surgical staple sites throughout the distal 2/3 of the remaining small intestine which were the likely source of intestinal blood loss.

Food hypersensitivity and otolaryngologic conditions in young children.

OBJECTIVES/HYPOTHESIS: To explore the relationship between food hypersensitivity and common upper aerodigestive disorders found in children younger than 2 years. STUDY DESIGN: Case control study. SETTING: Tertiary pediatric gastroenterology/otolaryngology clinics. METHODS: Two-year retrospective chart review of a common cohort of children younger than 2 years with suspected cow's milk protein allergy (CMPA). Patients were managed in both a tertiary pediatric gastroenterology and otolaryngology clinic and compared with a control study group. RESULTS: One hundred ninety-one children with CMPA were reviewed. One hundred forty-one had aerodigestive complaints, with 101 having sufficient follow-up to participate in the study. Ninety-one percent of this final patient group demonstrated improved symptoms following dairy elimination. Twenty-five patients (27%) had associated otolaryngologic (ear, nose, and throat [ENT]) issues that had been refractory to maximal gastroesophageal reflux therapy. The most common associated upper aerodigestive conditions were persistent upper airway congestion (72%) and oropharyngeal dysphagia (80%). Sixty percent of ENT disease improved with elimination diet. Eosinophilic esophagitis was noted in 36% of the cohort who had mucosal biopsies performed. Otolaryngology intervention was much more common in the cohort of children with CMPA compared with controls (odds ratio, 33.78; 95% confidence interval, 7.55, 151.03). CONCLUSIONS: CMPA is difficult to diagnose because of limited accurate diagnostic tools, especially in young children. This study suggests a relationship between CMPA and otolaryngologic conditions in children younger than 2 years. Some patients in this study showed symptom improvement via an elimination diet. Early recognition of otolaryngologic manifestations of CMPA may help manage this condition in young children.

Non-IgE-mediated cow milk allergy is linked to early childhood clusters of commonly seen illnesses: a pilot study.

OBJECTIVE: There are few established diagnostic tools to define non-IgE-mediated food hypersensitivity reactions. Cow milk protein allergy (CMPA) is a multisystem disorder affecting the gastrointestinal, skin, and lower and upper airway systems. This link is frequently missed because of subspecialty evaluation of the multisystem effects individually. The authors hypothesize that a more global evaluation based on a simple scored questionnaire will reveal this link. METHODS: Over an 18-month period, children younger than 2 years with non-IgE-mediated CMPA were identified. A symptom questionnaire was developed and scored and also applied to a control population. The prevalence of symptoms in each group was compared and a cumulative score was determined. Symptoms evaluated included gastrointestinal, aerodigestive, lower airway, and skin symptoms. A positive response was scored 1 and a negative response scored 0. RESULTS: Significant differences in prevalence rates between CMPA and control populations were noted, particularly in aerodigestive symptoms. There were marked differences in cumulative score between populations (P < .001). The authors identified a cut-off score at which there was close to 80% sensitivity and 90% specificity for distinguishing CMPA from a control population. CONCLUSION: A global evaluation of multiple systems can be an important diagnostic tool in determining CMPA in infants.

Massive pan-gastrointestinal bleeding following cocaine use.

BACKGROUND: An 18-year-old adolescent with cystic fibrosis developed massive gastrointestinal bleeding. METHODS: History, physical examination, upper and lower endoscopy and wireless capsule endoscopy were performed. RESULTS: Upper and lower endoscopy did not reveal cause of persistent bleeding. Wireless capsule endoscopy revealed pan-gastrointestinal ischemic injury. Further discussion with the patient revealed recent cocaine ingestion. CONCLUSION: Most reported cases of gut injury following cocaine abuse describe juxtapyloric and colonic injury; this case demonstrates that ischemic gut injury after cocaine use can be extensive and may be the reason for the associated high mortality.

Placement of pH probes during upper endoscopy: direct visualization is accurate.

BACKGROUND: Accurate catheter placement in children for esophageal pH monitoring is performed following an endoscopy using a mathematical formula followed by confirmatory radiograph. AIM: To determine if endoscopic visualization of the gastroesophageal junction can be used for sensor placement without the need for confirmatory radiograph. METHODS: Sixty-four catheters were placed using the Strobel formula method and 57 catheters were placed by visualization. RESULTS: With the formula method, 66% of children required probe adjustment compared with 7% when the probe was placed by direct visualization (p < .005). CONCLUSION: Placing pH sensors under direct visualization is accurate and reduces radiation exposure.

Chronic enteropathy: clinical aspects.

Diarrheal disease is a major cause of childhood morbidity and mortality worldwide. Chronic enteropathy with subsequent persistent diarrhea and associated vicious cycles of malnutrition, increased gut permeability and secondary immunodeficiency are particularly devastating in the childhood population. The major causes of chronic enteropathy differ significantly between developed countries and developing countries. In developed countries, infectious and postinfectious diarrhea as well as abnormalities in immune response including celiac disease, food-induced allergic enteropathy and idiopathic inflammatory bowel disease account for most cases of chronic enteropathy. In developing countries, syndromic persistent diarrhea associated with malnutrition and secondary immunodeficiency due to human immunodeficiency virus (HIV) infection predominate as the major causes of chronic enteropathy. These latter two causes account for a disproportionate share of the more than 2.5 million deaths of children under 5 years of age due to diarrhea each year worldwide. From a practical perspective, diagnostic evaluation of chronic enteropathy in developing countries is often limited to identifying potential causative enteropathogens and antimicrobial treatment. Proper management with an emphasis on fluid homeostasis and protocolized nutritional therapy and rehabilitation is essential to successful treatment of syndromic persistent diarrhea.

Antireflux surgery outcomes in pediatric gastroesophageal reflux disease.

OBJECTIVES: Antireflux surgery is performed frequently in children with gastroesophageal reflux disease (GERD). Few comparative studies exist which assess the indications for and short- or long-term outcome of open Nissen fundoplication (ONF) and laparoscopic Nissen fundoplication (LNF) for pediatric GERD. We investigated the frequency of reoperation and factors that might influence its occurrence. METHODS: We performed a retrospective, follow up cohort study of all children

The use of proton pump inhibitors in children: a comprehensive review.

Proton pump inhibitors (PPIs) belong to a group of chemically related compounds whose primary function is the inhibition of acid production in the final common metabolic pathway of gastric parietal cells. PPIs are highly selective and effective in their action and have few short- or long-term adverse effects. These pharmacologic features have made the development of PPIs the most significant advancement in the management of acid peptic related disorders in the last two decades. There are numerous published adult studies that describe the pharmacology, efficacy and safety of these anti-secretory agents; however, in the pediatric population, there are very few comparable studies, particularly multicenter studies with significant patient enrollment. In preparing this article, our aim was to perform a comprehensive review of the literature on the clinical pharmacology and use of PPIs in the pediatric population, and to briefly review some recent articles. Relevant literature was identified by performing MEDLINE/Pubmed searches from January 1990 to December 2001. Combinations of the following search terms were use to analyze these databases: proton pump inhibitor, children, pediatrics, gastroesophageal reflux disease (GERD), esophagitis, intestinal metaplasia, Helicobacter pylori, omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole, and safety. Abstracts from the 14th annual conference of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) 2001, and the Disease and Digestive Week 2001, were also included in the review. All pediatric studies reviewed were limited to either omeprazole or lansoprazole. The dosage range used for the management of GERD and related disorders with lansoprazole was 0.73-1.66 mg/kg/day (maximum 30 mg/day). The dosage range for GERD management using omeprazole was 0.3-3.5 mg/kg (maximum 80 mg/day). The dosage range for omeprazole used for H. pylori was 0.5-1.5 mg/kg/day, with a maximum dosage of 40 mg/day, and lansoprazole-containing regimens for H. pylori eradication used dosages ranging from 0.6-1.2 mg/kg/day, with a maximum dosage of 30 mg/day. Few severe adverse events were reported with the use of either drug. Eradication rates for H. pylori were 56-87% for lansoprazole-based triple therapy, and 75-94% for omeprazole-based eradication regimens. To date, there are no published controlled trials of sufficient power comparing the efficacy of the five commercially available PPIs in children, for a variety of acid peptic diseases. Studies suggest that PPIs are highly effective for the management of GERD and related disorders, and are a critically needed component of triple therapy to eradicate H. pylori. PPIs have a very good tolerability profile in adults and children, but long-term tolerability studies are needed, particularly in the pediatric population. Multicenter studies are critically needed to evaluate the second-generation PPIs, to compare PPI efficacy to each other, and to assess the importance of developmental and genetic pharmacology of these drugs in children with acid-peptic disease.