Utility of Enteral Contrast Protocols in Pediatric Adhesive Small Bowel Obstruction: A Prospective Multicenter Observational Study.

OBJECTIVE: Our objective was to determine the utility of enteral contrast-based protocols in the diagnosis and management of adhesive small bowel obstruction (ASBO) for children. BACKGROUND: Enteral contrast-based protocols for adults with ASBO are associated with decreased need for surgery and shorter hospitalization. Pediatric-specific data are limited. METHODS: We conducted a prospective observational study between October 2020 and December 2022 at nine children's hospitals who are members of the Western Pediatric Surgery Research Consortium. Inclusion criteria were children aged 1-20 years diagnosed with ASBO who underwent a trial of nonoperative management (NOM) at hospital admission. Comparisons were made between those children who received an enteral contrast challenge and those who did not. The primary outcome was need for surgery. RESULTS: We enrolled 136 children (71% male; median age: 12 y); 84 (62%) received an enteral contrast challenge. There was no difference in rate of operative intervention between the no contrast (34.6%) and contrast groups (36.9%; P=0.93). Eighty-seven (64%) were successfully managed nonoperatively with no difference in median length of stay (P=0.10) or rate of unplanned readmission (P=0.14). Among the 49 children who required an operation, there was no significant difference in time from admission to surgery or rate of small bowel resection based on prior contrast administration. CONCLUSIONS: The addition of enteral contrast-based protocols for management of pediatric ASBO does not decrease the likelihood of surgery or shorten hospitalization. Larger randomized studies may be needed to further define the role of radiologic contrast in the management of ASBO in children.

Maternal allergy-preventive diet index, offspring infant diet diversity, and childhood allergic diseases.

BACKGROUND: Studies of childhood diet diversity and allergic disease have not examined additional associations with an offspring allergy-linked maternal diet index during pregnancy. We studied both associations in a pre-birth cohort. METHODS: Offspring allergic disease diagnoses were obtained from electronic medical records. Maternal and infant diet were self-reported. Adjusted parametric Weibull time-to-event models assessed associations between maternal diet index, infant diet diversity and time to development of allergic rhinitis, atopic dermatitis, asthma, wheeze, IgE-mediated food allergy, and a combined outcome of any allergic disease except for wheeze. RESULTS: Infant diet diversity at 1 year was associated with the risk of the combined outcome between 1 and 4 years of age (p = .002). While both maternal diet index and infant diet diversity at 1 year were associated with the risk of the combined outcome between 1 and 4 years of age (both p < .05), infant diet diversity at 1 year did not modify the association between maternal diet index and the risk of the combined outcome between 1 and 4 years of age (p = .5). The group with the lowest risk of the combined allergy outcome had higher maternal diet index and higher infant diet diversity. CONCLUSIONS: The novel finding that both maternal diet index during pregnancy and infant diet diversity at 12 months are associated with the risk of a combined allergic disease outcome points to two targets for preventive interventions: maternal diet index scores during pregnancy and offspring diet diversity during infancy.

Comparison of best landmarks for calculating fetal jaw measurements by ultrasound and MRI in micrognathia.

BACKGROUND: Micrognathia can be diagnosed in utero with ultrasound by measuring the jaw index and/or inferior facial angle, though it can be challenging due to fetal positioning. The jaw index can be measured with magnetic resonance imaging (MRI) using the masseter muscle, but indistinct margins can lead to inaccuracy; the easily visualized posterior teeth buds may be a better landmark. OBJECTIVE: We aimed to evaluate inter-reader variability, agreement with ultrasound, and association with postnatal outcomes using MRI to measure the inferior facial angle, jaw index by masseter muscle, and jaw index by posterior teeth buds. MATERIALS AND METHODS: A single-institution retrospective review was performed of singleton pregnancies with prenatally diagnosed micrognathia by ultrasound or MRI from September 2013-June 2022. Ultrasound measurements were obtained by a maternal-fetal medicine specialist and MRI measurements by two radiologists to evaluate inter-reader variability. Intraclass correlation coefficients (ICC) and Bland-Altman analysis were used to assess agreement between imaging methods and logistic regressions and ROC curves to assess associations with postnatal outcomes. RESULTS: Forty-three fetuses (median gestational age 26 weeks (IQR 22-31); 47% male (20/43)) were included. Ultrasound measurements could not be obtained for jaw index in 15/43 (35%) fetuses and inferior facial angle in 11/43 (26%); MRI measurements were obtained by at least one reader in all cases. Jaw index by teeth buds demonstrated lowest inter-reader variability (ICC = 0.82, P < 0.001) and highest agreement with ultrasound (bias -0.23, 95% CI -2.8-2.2). All MRI measurements, but not ultrasound, predicted need for mandibular distraction (inferior facial angle P = 0.02, jaw index by masseter muscle P = 0.04, jaw index by teeth buds P = 0.01). CONCLUSION: Fetal MRI measurements, particularly jaw index measured by posterior teeth buds, demonstrate low inter-reader variability and high agreement with ultrasound, and may predict need for mandibular distraction postnatally.

Prenatal exposure to poly- and perfluoroalkyl substances and the incidence of asthma in early childhood.

EXPOSURE TO POLY: and perfluoroalkyl substances (PFAS) in early life may increase the risk of childhood asthma, but evidence has been inconsistent. We estimated associations between maternal serum concentrations of PFAS during pregnancy and clinician-diagnosed asthma incidence in offspring through age eight. We included 597 mother-child pairs with PFAS quantified in mid-pregnancy serum and childhood medical records reviewed for asthma diagnoses. We used separate Cox proportional hazards models to assess the relationship between log-transformed concentrations of five PFAS and the incidence of asthma. We estimated associations between the PFAS mixture and clinician-diagnosed asthma incidence using quantile-based g-computation. PFAS concentrations were similar to those among females in the US general population. Seventeen percent of children (N = 104) were diagnosed with asthma during follow-up. Median (interquartile range) duration of follow-up was 4.7 (4.0, 6.2) years, and median age at asthma diagnosis was 1.7 (0.9, 2.8) years. All adjusted hazard ratios (HRs) were elevated, but all 95% confidence intervals (CI) included the null. The HR (95% CI) of asthma for a one-quartile increase in the PFAS mixture was 1.17 (0.86, 1.61). In this cohort of children followed to eight years of age, prenatal PFAS concentrations were not significantly associated with incidence of clinician-diagnosed asthma.

Longitudinal Success of Tonsillectomy for Obstructive Sleep Apnea in Children with Down Syndrome.

OBJECTIVE: Obstructive sleep apnea is common in children with Down syndrome (DS). Tonsillectomy is recommended as the first-line approach in treating children with obstructive sleep apnea (OSA), however, there is limited data on the long-term outcomes in children with DS who undergo tonsillectomy. In this retrospective study, we examined the long-term polysomnographic and symptomatic outcomes in children with DS who underwent tonsillectomy with or without an adenoidectomy (T&A). We hypothesize that the success of T&A to treat OSA in children with DS will diminish with time. STUDY DESIGN: A retrospective chart review of children with DS who underwent T&A between 2009 and 2015 was conducted. Inclusion criteria were children with at least 1 postoperative polysomnogram (PSG) within 6 months of T&A with an obstructive apnea/hypopnea index (OAHI) < 5. Outcomes were determined by subsequent clinic visits and postoperative polysomnograms: OAHI ≥ 5, snoring reported during clinic visit and time to reoccurrence. SETTING: Childrens Hospital Colorado. RESULTS: Of the 57 children with mild OSA at 1st (initial) PSG, 13/40 (33%) children had OAHI ≥ 5 at the 2nd postoperative PSG. Of the 18 patients who underwent a 3rd PSG, 4 (22%) progressed to moderate/severe OSA. A total of 17 patients out of the original 57 (30%) progressed to moderate/severe OSA with the median time for the additional post-op PSG's being 2.3 years. CONCLUSION: Children with DS who have at most mild OSA (OAHI < 5) following a T&A are at risk for progressing to at least moderate OSA within 2 years after their T&A. A surveillance PSG 2 years following surgery will identify these children.

The Effect of Social Vulnerability on Perioperative Tonsillectomy Outcomes in Children.

OBJECTIVE: To determine if children with greater social vulnerability are more likely to experience a prolonged oxygen requirement (POR) following adenotonsillectomy to inform the need for overnight monitoring prior to discharge. METHODS: A previously published prospective study assessing children observed overnight following adenotonsillectomy for obstructive sleep-disordered breathing was reanalyzed including social vulnerability index (SVI). The outcome was POR beyond 3 h following extubation. Logistic regression was used to assess the association of SVI components with POR. SVI components were assessed as quartiles of cohort values. Final adjusted models included race, asthma, Down syndrome, and pre-operative SpO2. RESULTS: A total of 462 children had SVI data available and were included. 354 (76.6%) were > = 3 years of age. Overall, 351 (76%) did not have a POR. The median overall SVI percentile was 26.5 (Q1 10.4, Q3 60.1). When categorized by SVI quartiles, there was a statistically significant difference with POR for overall SVI percentile (p = 0.007), SVI household composition percentile (p = 0.033), and median SVI housing/transportation percentile (p = 0.005). Individuals with an overall SVI in the 4th quartile (greatest vulnerability) were 2.63 times more likely to experience a POR than those in the 1st quartile (lowest social vulnerability) in adjusted logistic regression (95% OR CI 1.23-5.62; p = 0.01). CONCLUSIONS: There is a significant association between greater neighborhood-level social vulnerability and a POR following adenotonsillectomy. We propose that a child's SVI be considered when planning for the perioperative course following adenotonsillectomy. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2449-2454, 2024.

The Maternal Diet Index and Offspring Microbiota at 1 Month of Life: Insights from the Mediterranean Birth Cohort MAMI.

Background: Maternal diet during pregnancy may play a role in infant health outcomes via the maternal microbiota. We assessed the association of the maternal diet index for the Mediterranean area (MDI-med) with infant gut microbiota at 1 month of life. Methods: The MAMI study is a longitudinal birth cohort in the Mediterranean area. In this work, a cross-sectional study, including 120 mother-infant dyads with available maternal diet and infant microbiota at 1-month-old data, was undertaken. The MDI developed in the US (MDI-US) was adapted for the MAMI cohort (MDI-med). Stratification based on extreme values resulted (22 in the "lower" MDI-med group and 23 in the "upper" group from the mean). Relative microbial abundances and alpha (microbial richness and diversity indexes) and beta diversity (Bray-Curtis distance matrix) were compared between the groups. Results: Higher maternal daily vegetable intake and lower red meat intake were the characteristics of the "upper" MDI-med group. Significantly lower microbial diversity (Shannon and InvSimpson index (p = 0.01)), but no changes in richness (Chao1 index) nor in beta-diversity, using Bray-Curtis distance, were observed in the "upper" group, compared to the "lower" MDI-med group. A higher relative abundance of the Bifidobacterium genus (Actinomycetota phylum) was associated with maternal daily vegetable and yogurt intake. Conclusion: Reduced infant microbial diversity at 1 month of age was associated with "upper" MDI-med scores. Higher maternal intakes of vegetables and yogurt were associated with higher relative abundances of the Bifidobacterium genus in the infant gut. Further studies are needed to understand the link between pregnancy diet, infant microbiota, and health outcomes.

Lack of Association of Pediatric Surgical Patient Outcomes With Increased Disposable Operating Room Supply Costs.

INTRODUCTION: There is wide variation in the cost of disposable operating room supplies between surgeons performing the same operation at the same institution. The general relationship between variation in disposable supply cost and patient outcomes is unknown. We aimed to evaluate the relationship between disposable supply cost and patient outcomes for sixteen common operations. METHODS: Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For procedure, the median disposable OR costs were calculated. Each operation performed was categorized as low cost (below the group median) or high cost (above the group median. We compared the rates of adverse events (clinic visit within 5 days, 30-day emergency department visit, unplanned reoperation, unplanned readmission, anesthesia complications, prolonged hospital length of stay, need for blood product transfusion, or death) between procedures with low and high disposable supply costs. RESULTS: 1139 operations performed by 48 unique surgeons from five specialties were included; 596 (52%) were low-cost and 543 (48%) high-cost. The low and high-cost groups did not differ regarding most demographic characteristics. Overall, 21.9% of children suffered any adverse outcome; this rate did not differ between the low and high-cost groups when evaluated individually or in aggregate (20.5% vs 23.6%, p = 0.23). CONCLUSION: Our data demonstrate that across a wide range of pediatric surgical procedures, the cost of disposable operating room supplies was not associated with the risk of adverse outcomes. LEVEL OF EVIDENCE: Level 3.

Age-Related Food Aversion and Anxiety Represent Primary Patient Barriers to Food Oral Immunotherapy.

BACKGROUND: Although oral immunotherapy (OIT) for food allergy is a reasonable treatment option, barriers to this procedure's implementation have not been extensively evaluated from a patient perspective. OBJECTIVE: We evaluated the barriers patients face during OIT administration, including anxiety and taste aversion, and the role of health care professionals, especially dietitians. METHODS: A survey in Canada and the United States involved families currently enrolled in food OIT programs. RESULTS: Of responses from 379 participants, fear of reaction was the most common barrier to OIT initiation, with 45.6% reporting it being a "very significant" barrier with other fears reported. However, taste aversion represented the prominent obstacle to continuation. Taste aversion was associated with a slower buildup (P = .02) and a reduction in dose (P = .002). Taste aversion was a strongly age-dependent barrier for initiation (P < .001) and continuation (P < .002), with older children over 6 years of age reporting it as a very significant barrier (P < .001). Boredom was reported as a concern for specific allergens such as peanut, egg, sesame, and hazelnuts (P < .05), emphasizing the need for diverse food options. Notably, 59.9% of respondents mixed OIT foods with sweet items. Despite these dietary concerns, dietitians were underutilized, with only 9.5% of respondents having seen a dietitian and the majority finding dietitian support helpful with greater certainty about the exact dose (P < .001). CONCLUSIONS: Taste aversion and anxiety represent primary patient-related barriers to OIT. Taste aversion was highly age dependent, with older patients being more affected. Dietitians and psychology support were underutilized, representing a critical target to improve adherence and OIT success.