Biologics Delay Progression of Crohn's Disease, but Not Early Surgery, in Children.

BACKGROUND & AIMS: Up to 30% of patients with Crohn's disease (CD) require surgery within the first 5 years from diagnosis. We investigated the recent risk of bowel surgery in an inception cohort of pediatric patients with CD and whether early use of biologics (tumor necrosis factor antagonists) alters later disease course. METHODS: We collected data from the Pediatric Inflammatory Bowel Disease Collaborative Research Group registry on 1442 children (age, ≤16 y) diagnosed with CD from January 2002 through December 2014. Data were collected at diagnosis, 30 days following diagnosis, and then quarterly and during hospitalizations for up to 12 years. Our primary aim was to determine the 10-year risk for surgery in children with CD. Our secondary aim was to determine whether early use of biologics (<3 mo of diagnosis) affected risk of disease progression. RESULTS: The 10-year risk of first bowel surgery was 26%. The 5-year risk of bowel surgery did not change from 2002 through 2014, and remained between 13% and 14%. Most surgeries occurred within 3 years from diagnosis. The only predictor of surgery was disease behavior at diagnosis. CD with inflammatory behavior had the lowest risk of surgery compared to stricturing disease, penetrating disease, or both. We associated slowing of disease progression to stricturing or penetrating disease (but not surgery) with early use of biologics, but this effect only became evident after 5 years of disease. Our results indicate that biologics slow disease progression over time (hazard ratio, 0.85; 95% CI, 0.76-0.95). CONCLUSIONS: In an analysis of data from a registry of pediatric patients with CD, we found that among those with significant and progressing disease at or shortly after presentation, early surgery is difficult to prevent, even with early use of biologics. Early use of biologics (<3 mo of diagnosis) can delay later disease progression to stricturing and/or penetrating disease, but this affect could become evident only years after initial management decisions are made.

Retrospective Comparison of Fluticasone Propionate and Oral Viscous Budesonide in Children With Eosinophilic Esophagitis.

BACKGROUND: Eosinophilic esophagitis (EoE) is treated with dietary modification and/or pharmacologic management with swallowed topical steroids. Swallowed fluticasone propionate (FP) and oral viscous budesonide (OVB) have proven to be effective in resolving symptoms and reversing histologic changes in children and adults with EoE. There are minimal comparative studies between the 2 agents. OBJECTIVE: The aim of the study was to retrospectively compare endoscopic and histologic outcomes after FP versus OVB therapy in children with EoE in our center. METHODS: We performed a retrospective chart review of subjects diagnosed with EoE at a tertiary care center between 2010 and 2015. Inclusion criteria were FP or OVB therapy for ≥8 weeks along with pre- and post-treatment endoscopic evaluation. Demographic and clinical features and endoscopic and histologic assessment were recorded for comparative analysis. Histologic response was defined as <15 eos/hpf and remission as <5 eos/hpf. RESULTS: The study included 68 EoE patients (20 FP and 48 OVB) with a mean age of 10.6 ±â€Š5.2 years (range 1-20 years); 81% were boys and 68% were Caucasian. No significant demographic or clinical differences were noted between the 2 study groups. Overall histologic response to topical steroids was seen in 44 of 68 (65%) patients. A significantly greater number of patients achieved histologic response with OVB (36/48, 75%) than with FP (8/20, 40%) (P = 0.0059). Mean pretreatment peak eos/hpf was 46 ±â€Š19 in the FP group versus 45 ±â€Š23 in the OVB group. Mean post-treatment peak eos/hpf was 20 ±â€Š29 in the FP group versus 12 ±â€Š16 in the OVB group (P = 0.002). There was also a significantly greater difference in the change of absolute eos/hpf from pre- to post-treatment in the OVB group (-33) versus FP (18) (P = 0.047). A greater number of OVB-treated patients without asthma had a histologic response compared to those with asthma (P = 0.031). The response to OVB was not affected by the delivery vehicle, namely sucralose (Splenda) versus Neocate Duocal. CONCLUSIONS: Our data suggest that treatment with OVB leads to better endoscopic and histologic outcomes than FP. Adherence to treatment and history of asthma are major determining factors in the response to treatments. Using Neocate Duocal as the OVB delivery vehicle is just as effective as sucralose.

Dose-response Relationship Between Donor Human Milk, Mother's Own Milk, Preterm Formula, and Neonatal Growth Outcomes.

BACKGROUND: A dose-response relationship between proportions of donor human milk (DHM) intake and in-neonatal intensive care unit (in-NICU) growth rates, if any, remains poorly defined. Objective was to evaluate interrelationships between percentages of DHM, mother's own milk (MOM), and preterm formula (PF) intake and neonatal growth parameters at 36 weeks postmenstrual age or NICU discharge. METHODS: Infants eligible for this single-center retrospective study were inborn at ≤32 weeks gestation or ≤1800 g, stayed in the NICU for ≥7 days, and received enteral nutrition consisting of human milk fortified with Enfamil human milk fortifier acidified liquid. Study exposures were defined as 10% increments in the total volumetric proportions of infant diet provided as MOM, DHM, or PF. Outcomes were growth parameters at 36 weeks postmenstrual age or NICU discharge. Multivariable linear regression modeled the adjusted additive effect of infant diet on individual growth parameters. RESULTS: A total of 314 infants records were eligible for analysis. Using MOM as reference, the adjusted mean growth velocity for weight significantly decreased by 0.17 g ·â€Škg ·â€Šday for every 10% increase in DHM intake, but did not vary with PF intake. The adjusted mean change in weight z score significantly decreased with increasing proportion of DHM intake but significantly improved with increasing PF intake. The adjusted mean head circumference velocity was significantly decreased by 0.01 cm/wk for every 10% increase in DHM intake, in reference to MOM, but did not vary with PF intake. Neither proportion of DHM nor PF intake was associated with length velocity. CONCLUSIONS: When DHM and MOM are fortified interchangeably, preterm infants receiving incremental amounts of DHM are at increased risk of postnatal growth restriction. The dose-response relationship between DHM, MOM, and PF and long-term growth and neurodevelopmental outcomes warrants further research.

Back Pain in a Pediatric Emergency Department: Etiology and Evaluation.

OBJECTIVES: Back pain is an uncommon chief complaint in the pediatric emergency department (ED). However, there are serious underlying conditions requiring prompt diagnosis and treatment. While the etiology is usually benign, variation exists in the evaluation. The study purpose was to describe pediatric patients who presented to the ED with back pain and evaluate for associations with laboratory and radiologic abnormalities indicative of underlying musculoskeletal pathology. METHODS: A retrospective review was conducted of patients aged birth to 18 years who presented to a pediatric ED with a chief complaint of back pain during a 1-year period. Primary outcome was discharge diagnosis, categorized as nonpathologic back pain, pathologic back pain, and other etiologies. Descriptive statistics were used. RESULTS: Two-hundred thirty-two patient encounters were reviewed, with 177 included in data analysis. A nonpathologic diagnosis of back pain was found in 76.8% of visits. Back pain and back or muscle strain were the most common diagnoses. Pathologic back pain diagnoses represented 2.3% of visits. Radiologic imaging was performed in 37.9%. Positive findings were noted in 16.9% of radiographs; no abnormalities were noted on computed tomography scan or magnetic resonance imaging. Laboratory studies were conducted in 35%. Abnormal plain radiographs were associated with a pathologic diagnosis of back pain (P < 0.001). CONCLUSIONS: Most pediatric patients presenting to the ED with back pain were found to have a nonpathologic etiology and were discharged. Among those with a pathologic back pain diagnosis, abnormal radiograph findings were the only statistically significant factor, whereas laboratory studies, computed tomography scans, and magnetic resonance imaging scans were less indicative.

Symptom-Guided Emergency Department Discharge Instructions for Children With Concussion.

OBJECTIVES: The objective was to evaluate the use and utility of a novel set of emergency department discharge instructions (DIs) for concussion based on a child's ongoing symptoms: symptom-guided DIs (symptom DIs). Differences in clinical outcomes were also assessed. METHODS: A convenience sample of 114 children aged 7 to 17 years presenting to an urban pediatric emergency department with a complaint of concussion was assembled. Children were randomized to standard DIs or symptom DIs. Children completed a graded symptom checklist (GSC) and completed daily the GSC for 1 week. Telephone follow-up was performed at 7 days after enrollment using a standardized survey. RESULTS: Fifty-eight children received the symptom DIs, and 56 received the standard DIs. Rates of use were similar with reported rates of 92% for symptom DIs and 84% for standard DIs. Caregivers with symptom DIs reported that the DIs were more helpful in determining when their child could return to school and physical activity (P < 0.05) than caregivers with standard DIs. Children continued to have postconcussive symptoms days and weeks after their injury with 44% of children with symptom DIs and 51% of children with standard DIs reporting symptoms on the GSC at 1 week. CONCLUSIONS: Both study groups reported frequent use of the DIs. Caregivers with symptom DIs found them particularly helpful in determining when their child could return to school and physical activity. Larger-scale investigations are needed to further develop instructions that are easy to use and that may decrease the postconcussive period.

Concomitant Use of Immunomodulators Affects the Durability of Infliximab Therapy in Children With Crohn's Disease.

BACKGROUND & AIMS: It is important to determine the effects of immunomodulators on the ability of children to remain on infliximab therapy for Crohn's disease (durability of therapy), given the potential benefits and risks of concomitant therapy-especially with thiopurines in male patients. We investigated how immunomodulatory treatment affects the durability of infliximab therapy. METHODS: We collected data from the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry, from January 2002 through August 2014, on 502 children with Crohn's disease who participated in a prospective multicenter study. Data were collected from patients who received at least a 3-dose induction regimen of infliximab, and their concomitant use of immunomodulators: no thiopurine or methotrexate treatment, treatment for 6 months or less during infliximab therapy, or treatment for more than 6 months during infliximab therapy. RESULTS: The probabilities (± standard error) that children remained on infliximab therapy for 1 year, 3 years, and 5 years after the treatment began were 0.84 ± 0.02, 0.69 ± 0.03, and 0.60 ± 0.03, respectively. Age, sex, and disease extent or location did not affect the durability of infliximab therapy. Greater length of concomitant use of immunomodulators was associated with increased time of infliximab therapy. The probability that patients with more than 6 months of immunomodulator use remained on infliximab therapy for 5 years was 0.70 ± 0.04, compared with 0.48 ± 0.08 for patients who did not receive immunomodulators and 0.55 ± 0.06 for patients who received immunomodulators for 6 months or less (P < .001). In boys who received immunomodulators for 6 months or more after starting infliximab, the overall durability of infliximab therapy was greater among patients receiving methotrexate than thiopurine (P < .01); the probabilities that they remained on infliximab therapy for 5 years were 0.97 ± 0.03 vs 0.58 ± 0.08, respectively. CONCLUSIONS: In children with Crohn's disease, concomitant treatment with an immunomodulator for more than 6 months after starting infliximab therapy increases the chances that patients will remain on infliximab. In boys, methotrexate appears to increase the durability of infliximab therapy compared with thiopurine.

Optimal periods of exclusive breastfeeding associated with any breastfeeding duration through one year.

OBJECTIVE: To quantify optimal minimum durations of exclusive breastfeeding associated with maintenance of any breastfeeding at 15 time points during the first year of life. STUDY DESIGN: Mothers (n = 1189) from the prospective Infant Feeding Practices Study II cohort who initiated exclusive breastfeeding with healthy term infants were included. In a 80:20 split-sample validation study, receiver operating characteristic curves estimated optimal minimum durations of exclusive breastfeeding needed to predict maintenance of any breastfeeding at 15 time points during the first year (n = 951). Logistic regression estimated the predictive performance of the identified thresholds adjusted for maternal age, race, education, parity, support system, and return-to-work status. Results were validated in the remaining 20% (n = 238). RESULTS: Optimal minimum durations ranged from 4.0-17.1 weeks of exclusive breastfeeding associated with maintenance of any breastfeeding at 15 time points. All estimated threshold durations were statistically significant after adjustment. CONCLUSIONS: Using a methodological approach unique to breastfeeding duration research, the authors report optimal durations of exclusive breastfeeding associated with duration of any breastfeeding at time points throughout the first year. Perinatal clinicians, pediatricians, lactation professionals, policymakers, researchers, and families might apply these findings to achieve desirable collective breastfeeding duration outcomes.

Clinical Presentation and Five-Year Therapeutic Management of Very Early-Onset Inflammatory Bowel Disease in a Large North American Cohort.

OBJECTIVE: To evaluate the presentation, therapeutic management, and long-term outcome of children with very early-onset (VEO) (≤ 5 years of age) inflammatory bowel disease (IBD). STUDY DESIGN: Data were obtained from an inception cohort of 1928 children with IBD enrolled in a prospective observational registry at multiple centers in North America. RESULTS: One hundred twelve children were ≤ 5 years of age with no child enrolled at <1 year of age. Of those, 42.9% had Crohn's disease (CD), 46.4% ulcerative colitis (UC), and 10.7% had IBD-unclassified. Among the children with CD, children 1-5 years of age had more isolated colonic disease (39.6%) compared with 6- to 10-year-olds (25.3%, P = .04), and 11- to 16-year-olds (22.3%, P < .01). The change from a presenting colon-only phenotype to ileocolonic began at 6-10 years. Children 1-5 years of age with CD had milder disease activity (45.8%) at diagnosis compared with the oldest group (28%, P = .01). Five years postdiagnosis, there was no difference in disease activity among the 3 groups. However, compared with the oldest group, a greater proportion of 1- to 5-year-olds with CD were receiving corticosteroids (P < .01) and methotrexate (P < .01), and a greater proportion of 1- to 5-year-olds with UC were receiving mesalamine (P < .0001) and thiopurine immunomodulators (P < .0002). CONCLUSIONS: Children with VEO-CD are more likely to have mild disease at diagnosis and present with a colonic phenotype with change to an ileocolonic phenotype noted at 6-10 years of age. Five years after diagnosis, children with VEO-CD and VEO-UC are more likely to have been administered corticosteroids and immunomodulators despite similar disease activity in all age groups. This may suggest development of a more aggressive disease phenotype over time.

Potassium hydroxide: an alternative reagent to perform the modified apt test.

We tested the performance of potassium hydroxide (KOH) in the modified Apt test under different experimental conditions using sodium hydroxide as a positive control. Like sodium hydroxide, KOH differentiated fresh fetal and adult blood stains on a cloth but not dried blood. KOH may be used to perform the Apt test at the bedside.

Liver enzyme elevations within 3 months of diagnosis of inflammatory bowel disease and likelihood of liver disease.

BACKGROUND: Inflammatory bowel disease-associated liver diseases (IBD-LDs) include autoimmune hepatitis (AIH), primary sclerosing cholangitis (PSC), and an overlap syndrome. Prospective unbiased multicenter data regarding the frequency of IBD-LD in patients with pediatric inflammatory bowel disease (IBD) are lacking. We examined early alanine aminotransferase (ALT) and γ-glutamyl transpeptidase (GGT) elevations in children diagnosed as having IBD and assessed the likelihood of IBD-LD. METHODS: Data collected from the prospective observational Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry enrolling children of age <16 years within 30 days of diagnosis. AIH, PSC, and overlap syndrome were diagnosed using local institutional criteria. RESULTS: A total of 1569 subjects had liver enzymes available. Of the total, 757 had both ALT and GGT, 800 had ALT only (no GGT), and 12 had GGT only (no ALT). Overall, 29 of 1569 patients (1.8%) had IBD-LD. IBD-LD was diagnosed in 1 of 661 (0.15%) of patients with both ALT and GGT ≤ 50 IU/L compared with 21 of 42 (50%) of patients with both ALT and GGT > 50 (odds ratio 660, P < 0.0001). Of the 29 patients with IBD-LD, 21 had PSC, 2 had AIH, and 6 had overlap syndrome. IBD-LD was more common in patients with ulcerative colitis and IBD-unclassified (indeterminate colitis) than in those with Crohn disease (4% vs 0.8%, respectively, P < 0.001). CONCLUSIONS: Elevation of both ALT and GGT within 90 days after the diagnosis of IBD is associated with a markedly increased likelihood of IBD-LD. Both ALT and GGT levels should be measured in all of the pediatric patients newly diagnosed as having IBD.

Effect of surgical subspecialty training on patent ductus arteriosus ligation outcomes.

PURPOSE: Surgical outcomes data for patent ductus arteriosus (PDA) ligation come primarily from single institution case series. The purpose of this study was to evaluate national PDA ligation trends, and to compare outcomes between pediatric general (GEN) and pediatric cardiothoracic (CT) surgeons. METHODS: The Pediatric Health Information System database was queried to identify neonates who underwent PDA ligation from 2006 through 2009. Outcomes evaluated included surgical morbidity, in-hospital mortality, length of stay, and total charges. Outcomes were compared between pediatric general and pediatric cardiothoracic surgeons. RESULTS: The records of 1,482 neonates who underwent PDA ligation were identified and analyzed. Overall mean gestational age was 26 ± 3 weeks and birth weight was 888 ± 428 g. The majority of patients among both surgeons had birth weights of ≤1,000 g (77.2%) and were born at ≤27-week gestation (81.5%). Most of the PDA ligations were performed by pediatric CT surgeons (n = 1,196, 80.7%). The mortality rate did not differ by surgeon subspecialty training (GEN = 5.2%, CT 7.9%, p = 0.16). Neonates in the cardiothoracic surgeon cohort showed lower length of stay (p < 0.001-0.05) and total hospital charges (p < 0.05) among patients with birth weight ≤1,200 g. Proxy measures of surgical morbidity-gastrostomy, fundoplication, and tracheostomy-showed no significant differences between the two surgical subspecialists overall or across birth weight subgroups (p > 0.05). CONCLUSION: These data provide a contemporary snapshot of PDA ligation outcomes at American children's hospitals. Pediatric general surgeons achieve comparable outcomes performing PDA ligation compared to pediatric cardiothoracic surgeons.

Outcome following aminosalicylate therapy in children newly diagnosed as having ulcerative colitis.

OBJECTIVES: Despite a paucity of published supporting data, 5-aminosalicylate (5-ASA) use in pediatric ulcerative colitis (UC) is common. The present study describes the use and outcome of a large multicenter inception cohort of children with UC treated with 5-ASA. METHODS: Data were obtained from the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry, a prospective North American observational study of children newly diagnosed as having inflammatory bowel disease ages 16 years or younger. Patient data are recorded at diagnosis, 30 days, and then quarterly. Patients are managed by physician dictate, not protocol. Disease activity is classified by physician global assessment. The primary outcome examined was corticosteroid (CS) free, inactive UC at 1 year following initiation of 5-ASA within 30 days of diagnosis (with or without concomitant CS use) without the need for rescue therapy (immunomodulators, biologics, or colectomy). RESULTS: Study subjects included 213 patients newly diagnosed as having UC who received oral 5-ASA compounds (115 of whom also received CS) during the first 30 days after diagnosis, and no other oral therapies for the treatment of UC. Of these 213 patients, 86 (40%) were CS free and physician global assessment inactive at 1 year without rescue. Outcome was not associated with disease severity at diagnosis, demographic or laboratory factors examined, or initial dose of 5-ASA used. CONCLUSIONS: Forty percent of children taking 5-ASA as primary maintenance therapy at diagnosis are in CS-free remission after 1 year of treatment. Further pediatric studies will be needed to address whether increased adherence and/or higher dosing schedules will improve outcomes.

Preoperative immunosuppression is not associated with increased postoperative complications following colectomy in children with colitis.

OBJECTIVES: The aim of the present study was to review postoperative complications of pediatric patients undergoing colectomy for ulcerative colitis (UC) or inflammatory bowel disease-unspecified (IBD-U) with a focus on preoperative immunosuppression including exposure to infliximab. METHODS: We performed a retrospective chart review of all of the children with UC or IBD-U undergoing colectomy at our institution from 1996 to 2010. Data collected included indication for colectomy, immunosuppressive medications taken within 30 to 90 days of colectomy, surgical techniques and staging, and early and late postoperative complications. RESULTS: A total of 51 patients underwent colectomy (45 UC, 6 IBD-U) (55% male, 63% pancolitis at diagnosis, mean age at diagnosis 10.8 ± 3.8 years, mean age at colectomy 13.1 ± 3.8 years). Indications for colectomy were fulminant colitis in 26% and medically refractory chronic disease in 74%. Patient exposure to immunosuppression in the 30 days before colectomy included corticosteroids (88%), thiopurines (51%), and calcineurin inhibitors (4%). Within 90 days before colectomy, 65% of patients were exposed to infliximab. Small bowel obstruction was the most common postoperative complication, occurring in 19% (treated surgically in 30%), followed by wound infection in 8% and intraabdominal abscess in 6%. One patient developed postoperative sepsis. There was no increased incidence of early or late infectious or noninfectious complications in those patients taking or not taking thiopurines or calcineurin inhibitors (within 30 days), or infliximab (within 90 days). CONCLUSIONS: Preoperative exposure to thiopurines or calcineurin inhibitors (within 30 days) or infliximab (within 90 days) was not associated with increased postoperative complications in our cohort undergoing colectomy for UC or IBD-U.

Budesonide use in pediatric Crohn disease.

BACKGROUND AND AIM: Budesonide (BUD) is being used in pediatric Crohn disease (CD) because it is believed to have the potential to reduce corticosteroid-related toxicity; however, few data are available describing its use. The aim of the present study was to describe BUD use in an inception cohort of pediatric patients with CD. METHODS: Data were derived from the prospective Pediatric IBD Collaborative Research Group Registry established in 2002 in North America. Use of BUD in children with CD was examined. RESULTS: BUD was used in 119 of 932 (13%) of children with newly diagnosed CD, with 56 of 119 (47%) starting BUD ≤ 30 days of diagnosis (26/56 with ileum and/or ascending colon [IAC] disease). BUD was used as monotherapy (9%), in combination with 5-aminosalicylates (77%), or in combination with immunomodulators (43%). Forty-three percent (24/56) went on to receive conventional corticosteroid at some point following their first BUD course. For the 63 of 119 (53%) who started BUD beyond the diagnosis period, 51 of 63 (81%) also received prednisone, with BUD used as a means of weaning from prednisone in 17 of 63 (27%). Patients with IAC disease who received BUD ≤ 30 days of diagnosis were just as likely to have received conventional corticosteroids by 1 year as were those who did not receive BUD ≤ 30 days of diagnosis. Two-thirds (77/119) of patients received BUD for ≤ 6 months. CONCLUSIONS: BUD is being used among pediatric patients newly diagnosed as having CD, although the majority does not have disease limited to the IAC. BUD monotherapy was rare, and further data are required to better define the role of BUD in the treatment of pediatric CD.

Outcome following thiopurine use in children with ulcerative colitis: a prospective multicenter registry study.

OBJECTIVES: Despite little supporting data, thiopurine use is common in pediatric ulcerative colitis (UC). Our aim was to determine outcome following thiopurine use in a multicenter inception cohort of children diagnosed with UC. METHODS: Data were obtained from a prospective observational study of newly diagnosed children <16 years of age. Data are recorded at diagnosis, 30 days, and quarterly. Patients are managed by physician dictates not protocol. Disease activity is classified by physician global assessment. The primary outcome was corticosteroid (CS)-free inactive UC at 1 year following thiopurine initiation without the need for rescue therapy (infliximab, calcineurin inhibitors, or colectomy). RESULTS: Of 1,490 patients in our registry, 394 have UC (mean age at diagnosis 11.3±3.7 years); 197 (50%) received thiopurine (49% ≤3 months from diagnosis). Also, 84% were receiving CSs and 60% 5-aminosalicylates at thiopurine start. Of the 197 patients, there was insufficient follow-up (41), previous or concomitant use of infliximab (16), or calcineurin inhibitor (7), leaving 133 patients evaluable at 1 year. Of these, 65 (49%) had CS-free inactive UC without rescue therapy. CS-free inactive disease at 1 year after initiating thiopurine was not affected by starting thiopurine ≤3 months vs. >3 months from diagnosis, gender, age, or concomitant treatment with 5-aminosalicylates. Kaplan-Meier analysis showed that the likelihood of remaining free of rescue therapy in the thiopurine-treated patients was 73% at 1 year. CONCLUSIONS: Approximately 50% of children with UC starting thiopurine without previous or concomitant biologic or calcineurin inhibitor therapy have CS-free inactive disease 1 year later without the need for rescue therapy.

Evaluation of pediatric sensorineural hearing loss: a survey of pediatric otolaryngologists.

OBJECTIVES: We sought to determine the trends in the evaluation of pediatric patients with sensorineural hearing loss (SNHL) and to determine evaluation patterns based on respondents' demographic data. METHODS: All members of the American Society of Pediatric Otolaryngology were invited to voluntarily and anonymously complete an online survey. The survey was available from September 2009 to January 2010 and addressed demographic data and tests obtained in evaluating new pediatric patients with SNHL at different age points and with different degrees of hearing loss. RESULTS: The response rate was 22.9% (79 of 345). For all ages and all types of SNHL, the most common consultations were genetics (26% to 76%) and ophthalmology (31% to 66%) consultations. Computed tomography of the temporal bones (49% to 66%), genetic testing (25% to 68%), and electrocardiography (13% to 43%) were the most commonly performed tests. Although there was no consistent difference in practice patterns by gender or years of practice, there were differences in the use of thyroid function tests, TORCH titers, and autoimmune studies by hospital affiliation. CONCLUSIONS: Type of SNHL and age are factors in the evaluation of pediatric patients with SNHL. Additionally, evaluation patterns differ according to region and hospital affiliation. The results of this study may provide guidance for otolaryngologists in making information-based and cost-effective evaluations.

Assessing disease activity using the pediatric Crohn's disease activity index: Can we use subjective or objective parameters alone?

BACKGROUND: The pediatric Crohn's disease activity index (PCDAI) is used as a standard tool to assess disease activity in clinical trials for pediatric Crohn's disease. AIM: To examine which items on the PCDAI drive assessment of disease activity, and how subgroups of subjective and objective items reflect change in disease state over time. METHODS: Selective raw data from three prospectively collected datasets were combined, including 703 children with full PCDAI data at baseline, at 3-mo (Q1, n = 670), and 1-year (Q4, n = 474). Change in individual PCDAI scores from baseline to Q1 and to Q4 were examined using the non-weighted PCDAI. RESULTS: Abdominal pain, well-being, weight, and stooling had the highest change scores over time. Objective indicators including albumin, abdominal exam, and height velocity followed. Change scores for well-being and abdominal exam did not explain significant variance at Q1 but were significant predictors at Q4 (P < 0.001 and P < 0.05). Subjective and objective subgroups of items predicted less variance (18% and 22%) on total PCDAI scores at Q1 and Q4 compared to the full PCDAI, or a composite scale (both 32%) containing significant predictors. CONCLUSION: Although subjective items on the PCDAI change the most over time, the full PCDAI or a smaller composite of items including a combination of subjective and objective components classifies disease activity better than a subgroup of either subjective or objective items alone. Reliance on subjective or objective items as stand-alone proxies for disease activity measurement could result in misclassification of disease state.

Outcome following infliximab therapy in children with ulcerative colitis.

OBJECTIVES: Infliximab is effective in treating moderate/severe ulcerative colitis (UC) in adults. The aim of this study was to determine the outcome after treatment with infliximab in pediatric UC. METHODS: We performed a multicenter cohort study of 332 pediatric patients with UC enrolled in the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry. Children12 months). Mean age at infliximab initiation was 13.3+/-2.6 (range 6-17) years; 87% of patients had pancolitis. Median follow-up was 30 months. Continuous maintenance (CM) therapy was given in 65%, episodic in 21%, episodic converted to CM in 6%, and insufficient data in 8% of patients. Sixty-three percent of patients were corticosteroid refractory, and 35% were corticosteroid dependent. Concomitant medications at first infliximab infusion included corticosteroids (87%), thiopurines (63%), and 5-aminosalicylates (51%). Corticosteroid-free inactive disease by physician global assessment was noted in 12/44 (27%), 15/39 (38%), and 6/28 (21%) patients at 6, 12, and 24 months, respectively. Kaplan-Meier analysis showed that the likelihood of remaining colectomy free after treatment with infliximab was 75% at 6 months, 72% at 12 months, and 61% at 2 years. CONCLUSIONS: In this cohort of children with UC receiving infliximab, corticosteroid-free inactive disease was observed in 38 and 21% of patients at 12 and 24 months, respectively. By 24 months, 61% of patients had avoided colectomy.

Effect of gluten-free diet on growth and glycemic control in children with type 1 diabetes and asymptomatic celiac disease.

We aimed to evaluate the effects of a gluten-free diet on growth and glycemic control in children with type 1 diabetes mellitus (DM) and asymptomatic, biopsy-proven celiac disease (CD). Each case of CD was compared to two children with DM and no CD. We studied weight, height, and hemoglobin A1c (HgbAlc) up to 12 months pre- and post- CD diagnosis in 29 cases and 58 controls. The change in body mass index (deltaBMI Z-score) over 2 years was significantly higher in CD cases vs. controls (mean +/- SD 0.33 +/- 0.74 vs. +/- 0.08 +/- 0.46; p = 0.023). However, BMI Z-score did not change in CD patients diagnosed with DM for > 1 year. Mean HgbA1c was similar between groups throughout the study. In conclusion, children with asymptomatic CD and DM do not have significant changes in BMI, height Z-score or metabolic control 1 year post-diagnosis.