The Effect of the Flint Water Crisis Secondary to Increased Lead Levels in Drinking Water on Constipation in Children in the City of Flint, Michigan, USA.

Introduction  Constipation is a common condition in children, affecting almost one-third of the population at some point in childhood across the world. Functional constipation is the most common cause, with no clear etiology. From April 25, 2014, through October 16, 2015, the water source for the city of Flint residents was untreated Flint River water, which resulted in lead-contaminated drinking water. Lead poisoning has been associated with constipation and has multisystem sequelae, including neurological, muscular, and hematological impacts. Children may be especially vulnerable to this with their higher water intake-to-body weight ratio. There has been no previous study examining the possible relationship between the Flint water crisis and constipation in children. In our study, we aimed to see if the increased lead level in the water had any effect on constipation in children in Flint. Methods We included all children seen and diagnosed with constipation at Hurley Medical Center's Pediatric Gastrointestinal (GI) Clinic. We included only children seen in 2013 (pre-water crisis) and 2017 (post-water crisis). Children with chronic neurologic disorders, celiac disease, hypothyroidism, diabetes, Hirschsprung's disease, short bowel syndrome, and gastrointestinal surgeries were excluded. We looked at the age of presentation, associated symptoms, medications used, need for hospital admission or emergency department (ED) visits, and improvements at follow-up. Results  A total of 79 patients were included in the study. There were 29 patients from 2013 and 50 patients from 2017 (post-lead exposure period). The rate of constipation referrals to the GI clinic for the Flint population of children was significantly higher in 2017 (p=0.001). The most common associated symptom was abdominal pain in both groups. Straining was more prominent in the 2017 group (60%) compared to the 2013 group (34.5%, p=0.029). There was no clinical or statistically significant difference between the groups noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history of urinary tract infection (UTI), abdominal distention, or stool impaction. Conclusions The number of patients referred to Hurley's Pediatric GI Clinic for constipation increased after the lead water crisis in Flint. Moreover, straining has significantly increased in post-lead exposure compared to pre-lead exposure. There was no clinical or statistically significant difference noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history of UTI, abdominal distention, or stool impaction between both groups. A larger study would need to be done to confirm these findings, rule out other cofactors, and look into minerals in water and their effect on intestine innervations.

COVID-19 pandemic and challenges in pediatric gastroenterology practice.

The current coronavirus pandemic is imposing unpreceded challenges to the practice of pediatric gastroenterology. These are highlighted in their impact on performing aerosol-generating endoscopy procedures and the need to accommodate longer room turnaround time for disinfection, ensuring appropriate and consistent safety measures for patients, staff and providers, and emphasizing the importance for screening patients for active coronavirus disease (COVID) infection before endoscopy when possible. Pediatric patients are less likely to exhibit severe COVID-related symptoms so survey-based screening would not be a sensitive measure to identify patients with active infections. To address the restrictions of patients coming for face to face clinic encounters, there has been rapid expansion of telehealth services in a very short time period with several difficulties encountered. To survive these challenges, pediatric gastroenterology practices need to adapt and accept flexibility in clinical operations with ongoing commitment to safety for patients and healthcare workers.

Safety and Efficacy of the Push Endoscopic Technique in the Management of Esophageal Food Bolus Impactions in Children.

OBJECTIVES: Adult-based guidelines support the use of the pull (extraction) endoscopic technique in managing esophageal food bolus impactions (FBIs) but allow the consideration of the push (advancement) technique with caution based on available published literature. The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines mention the use of gentle endoscopic pushing for disimpaction but elaborate that this technique has not been studied in children. Our study aimed at assessing the safety and efficacy of the push technique in managing pediatric esophageal FBIs. METHODS: This was a retrospective cohort study of all pediatric patients presenting with esophageal FBIs to a pediatric tertiary care center from 2003 to 2016. RESULTS: Two hundred forty-two procedures for esophageal foreign body removal were reviewed. Thirty-nine procedures for managing esophageal FBIs were included in a total of 23 patients (1-4 procedures per patient). The most common underlying diagnoses were eosinophilic esophagitis and repaired tracheoesophageal fistula. The cohort had a median age of 8 years and median weight of 34.4 kg. Initial endoscopic disimpaction methods included 20 push and 19 pull technique attempts with success rates of 65% and 68%, respectively (P = 1.0). Unsuccessful attempts using 1 technique were successfully accomplished using the other technique. Patients initially managed by either of the 2 disimpaction techniques did not differ in age, weight, sex, or underlying diagnoses. No procedure-related complications were reported at our center. CONCLUSION: The present study shows that the push technique is as safe and effective as the pull technique in managing esophageal FBIs in pediatric patients.