Polyethylene glycol powder solution versus senna for bowel preparation for colonoscopy in children.

OBJECTIVES: Safety and effectiveness of large-volume polyethylene glycol-based solution (PEG-ES) have been documented, but the taste and volume can be barriers to successful colonoscopy preparation. Efficacy and safety of small-volume electrolyte-free (PEG-P) preparation (Miralax) for colonoscopy preparation have been rarely studied, although presently used at many pediatric centers. The primary objective of the present study was to determine whether PEG-P results in a more efficacious and safe colonoscopy preparation as compared with senna. METHODS: The study design was prospective, randomized, and single-blinded. Patients ages 6 to 21 years were randomized to a 2-day clean-out regimen of PEG-P at a dose of 1.5 g/kg divided twice per day for 2 days versus senna 15 mL daily (ages 6-12) or 30 mL daily (ages 12-21) for 2 days. Both preparations required 1 day of clear liquids whereas senna preparation required an additional day of full liquid diet. A blinded endoscopist graded the quality of preparation with a standardized cleanliness tool (Aronchick scale). Serum chemistry panels were obtained. Patients or parents rated symptoms and ease of preparation. The anticipated number of subjects was 166; however, the interim analysis demonstrated inferiority of senna preparation. RESULTS: Thirty patients were evaluated in the present study. Of the patients in the PEG-P arm, 88% (14/16) received an excellent/good score compared with 29% (4/14), with the senna preparation (P = 0.0022). Both preparations were well-tolerated by patient-graded ease of preparation. Demographics and laboratory values did not differ significantly across the 2 groups. No serious adverse events were noted. CONCLUSIONS: PEG-P is an effective colonoscopy preparation whereas senna preparation was insufficient. Both were well-tolerated and appear safe in a pediatric population.

Anthropometric, serologic, and laboratory correlation with villous blunting in pediatric celiac disease: diabetics are different.

OBJECTIVES: We evaluated the correlation between level of tissue transglutaminase (TTG) and endomysial antibodies (EMAs) to different degrees of intestinal damage in celiac disease (CD) children with [presence of diabetes mellitus (DM)+] and without [absence of diabetes mellitus (DM-)] type I diabetes. We also assessed the correlation between albumin, hemoglobin (hgb), transaminases, symptom presence, age of cereal introduction, and body mass index (BMI) to different degrees of intestinal damage. METHODS: Retrospective review of patients seen at the Children's Hospital of Philadelphia between January 2002 and June 2006 revealed 60 children (mean age 9.8 y) who had TTG, EMA, and other laboratory tests performed at time of histologic CD diagnosis from duodenal biopsies. Twenty-one of 60 children had DM. All children were stratified for histologic damage according to Marsh classification. RESULTS: Overall, Marsh (M) I lesions were seen in 2 (3.3%), MII in 2 (3.3%), IIIa in 14 (23.3%), IIIb in 15 (25%), and IIIc in 27 (45%); no differences in DM- versus DM+ groups. TTG was positive in all and EMA was positive in all but 1 child. Among DM- and DM+ children, median TTG and EMA values were higher with MIIIa-c, respectively. For DM-, BMI percentile, hgb, and mean corpuscular volume were lower with advancing histology. However, in DM+, no significant correlation of BMI percentile, hgb, or mean corpuscular volume with grade was observed. Cereal introduction age, hypoalbuminemia, and hepatitis did not differ between MIIIa-c in any group. CONCLUSIONS: TTG and EMA mean serum values are higher in CD children with severe enteropathy (MIIIc) than in those with mild enteropathy (MIIIa). CD in DM is accompanied by serologic and histologic findings identical to that of a non-DM CD population. As CD is identified through screening in DM, it is often silent and not associated with symptoms, growth abnormalities, or anemia. Clinical parameters (height, weight, hgb, symptoms) are not helpful in identifying silent CD in DM.

Bone mineral content deficits of the spine and whole body in children at time of diagnosis with celiac disease.

BACKGROUND: The aim of this study was to determine whether children with celiac disease (CD) have deficits in spine (SP) and whole body (WB) bone mineral content (BMC) at time of diagnosis, and whether the deficits are related to altered growth and body composition. The secondary aim was to examine the effect of histological grade on BMC. PATIENTS AND METHODS: A retrospective study of children who had undergone a dual energy x-ray absorptiometry scan at the time of diagnosis with CD between October 1, 2003, and June 15, 2006, were compared with a healthy reference sample of similar age and race from the same geographic region in the United States. SP and WB BMC were expressed as sex-specific z scores relative to age and relative to height to assess differences in the CD group versus controls. Pearson correlation, t tests, and analysis of variance were performed to determine predictors of BMC. RESULTS: Forty-four children (mean age 10.6 +/- 3.4 years; 77% female, 96% white) with CD were evaluated and compared with 338 healthy children. Children with CD were shorter than children of similar age and sex. SP and WB BMC for age z scores were significantly lower in the CD group compared with controls. When adjusted for height, significant deficits in WB BMC persisted in patients with CD. Low SP and WB BMC correlated with advanced histological grade in CD. Low body mass index correlated with low WB BMC in CD. CONCLUSIONS: Newly diagnosed children with CD may benefit from screening for low bone mineral content. Patients with low body mass index and those with advanced histological damage (Marsh grade IIIc) particularly may be at risk for osteopenia.

Use of laparoscopic cholecystectomy for biliary dyskinesia in the child.

BACKGROUND: Biliary dyskinesia (BD) is a consideration as a cause of chronic abdominal pain in the pediatric population. We sought to correlate the results of cholecystokinin-diisopropyl iminodiacetic acid (CCK-DISIDA) scanning, the basis for diagnosis of BD, with outcome after laparoscopic cholecystectomy. METHODS: A retrospective review was performed of all patients who underwent a laparoscopic cholecystectomy from May 2000 through March 2007. The diagnosis of BD was based on CCK-DISIDA scan demonstrating a gallbladder ejection fraction (GBEF) of less than 35% and/or reproduction of pain on CCK administration or no filling of the gall bladder with a normal ultrasound examination. Hospital, General Surgery office, and Gastroenterology Office charts were reviewed for demographic and management data points. We used chi(2) and Mann-Whitney tests for statistical analysis. RESULTS: For the period of review, 430 patients underwent a laparoscopic cholecystectomy including 75 patients with a preoperative diagnosis of BD. The mean age of the BD population was 14 (range, 9-19) years. Female to male ratio was 2.4:1. The mean body mass index was 24.4 kg/m(2). On average, patients had abdominal symptoms for 15.5 (range, 0.25-72) months. Each patient underwent nearly 2.5 studies (computed tomography, ultrasound, esophagogastroduodenoscopy, or upper gastrointestinal series) before diagnosis by CCK-DISIDA. The mean GBEF was 17.4%. When commented on (n = 41), pain on CCK administration was noted in 25 (61%) patients. Pathology revealed chronic cholecystitis in 44%. After laparoscopic cholecystectomy, 58 (77.33%) patients reported resolution of their abdominal pain (mean follow-up 4 months). Of the 17 patients without improvement, 7 were later diagnosed with other underlying pathology (Crohn's, hiatal hernia, cyclic vomiting). There was no difference in GBEF, age, histopathology, or sex between the two groups. There were no complications. CONCLUSION: Laparoscopic cholecystectomy is a safe and effective treatment for the majority of children diagnosed with BD. Although CCK-DISIDA was used to identify biliary dysfunction, it did not correlate with outcome.

Hydroxyapatite cement reconstruction in the growing craniofacial skeleton: an experimental model.

Hydroxyapatite cement (HAC) has been shown to osseoconduct and may even osseoconvert. These properties render it suitable for repairing cranial defects in growing children. The objective of this pilot study was to determine if growth is restricted after HAC reconstruction in a growing, nonprimate, animal model. Frontoparietal craniotomies were performed on 10 4-week-old Yorkshire piglets. In 3 control piglets, the bone flap was resutured; in 7 experimental piglets, the defect was reconstructed with HAC. Analysis 6 months after surgery included craniometric measurements, biomechanical testing, and histological sectioning. Nine craniofacial measurements did not differ between controls and experimental animals. The mean midline-to-temporal line distance contralateral to the defect was 20% larger in the experimental group (P = 0.006), however, and experimental animals had a larger difference between right and left orbital breadths (+3% difference versus -1% difference; P = 0.003). The mean stiffness of the HAC-repaired defect was not different from the contralateral side in contrast to the resutured bone flap in controls, which was significantly less stiff than unoperated bone (162 N/mm compared with 358 N/mm; P < 0.05). Based on our animal model, HAC seems to be a sound alternative method of craniotomy reconstruction in the growing skull.