Toward Better Understanding of Pediatric Feeding Disorder: A Proposed Framework for Patient Characterization.

To establish a foundation for methodologically sound research on the epidemiology, assessment, and treatment of pediatric feeding disorder (PFD), a 28-member multidisciplinary panel with equal representation from medicine, nutrition, feeding skill, and psychology from seven national feeding programs convened to develop a case report form (CRF). This process relied upon recent advances in defining PFD, a review of the extant literature, expert consensus regarding best practices, and review of current patient characterization templates at participating institutions. The resultant PFD CRF involves patient characterization in four domains (ie, medical, nutrition, feeding skill, and psychosocial) and identifies the primary features of a feeding disorder based on PFD diagnostic criteria. A corresponding protocol provides guidance for completing the assessment process across the four domains. The PFD CRF promotes a standard procedure to support patient characterization, enhance methodological rigor, and provide a useful clinical tool for providers and researchers working with these disorders.

Mucous Fistula Refeeding Promotes Earlier Enteral Autonomy in Infants With Small Bowel Resection.

OBJECTIVE: Infants requiring intestinal resection because of necrotizing enterocolitis (NEC) or small bowel atresia (SBA) may benefit from mucous fistula refeeding (MFR) of enterostomy output to improve nutrition and bowel adaptation before reanastomosis. Previous series demonstrated improved outcomes with MFR but did not account for varied patient characteristics as potential sources of bias. We performed a cohort analysis using multivariable adjusted models to compare outcomes of patients with and without MFR. METHODS: Retrospective chart review was performed for patients with NEC or SBA and small bowel resection with enterostomy and MF. Demographic and outcome data was compared between MFR and non-MFR groups using adjusted multivariable analysis for potential confounding variables. RESULTS: MFR was performed in 65 of 101 patients (64%), including 45 of 75 patients with NEC and 20 of 26 patients with SBA. Reasons for not receiving MFR included bowel stricture, technical limitation, or not otherwise specified. NEC patients receiving MFR had 14 fewer days to achieve full enteral feeds after intestinal reconnection, 22 fewer days of parenteral nutrition, lower peak direct bilirubin by 2.4 mg/dL, and 77% less odds of ursodiol use (all P < 0.01). SBA patients had similar trends not reaching statistical significance. Growth parameters were improved in MFR groups. There were no complications or increased infections from MFR. CONCLUSIONS: This study suggests that MFR safely improves nutritional outcomes in infants with intestinal resection, related to decreased total parenteral nutrition (TPN) dependence and earlier enteral autonomy.

Adherence to Masking Requirement During the COVID-19 Pandemic by Early Elementary School Children.

BACKGROUND: Top public health experts and organizations strongly recommend universal masking for children older than 2 years old during the COVID-19 pandemic, but speculate it may be difficult for young children. This study sought to assess the usage of cloth face masks in grades pre-K-2 and identify associated characteristics and adverse events. It is the first data to assess mask wearing by young children in school. METHODS: This online, prospective, observational, survey in multiple schools within a single school district in a major metropolitan area measured adherence to face covering mandates by students in grades pre-K-2 as measured by percentage of day with appropriate face mask wearing per report via daily teacher surveys for the first 4 weeks of school. RESULTS: The primary outcome was percent of the day that the entire class was wearing their masks appropriately. Of the estimated almost 1000 students and 1048 classroom days reported, the mean percentage of the school day with appropriate mask usage was 76.9%. CONCLUSIONS: For a majority of the day while conducting in-person instruction, children in grades pre-K-2 are able to adhere to mask wearing as a key mitigation strategy for limiting SARS-CoV2 infection spread and possible future use.

Development and repair of aorto-esophageal fistula following esophageal button battery impaction: A case report.

BACKGROUND: Complications from esophageal button battery impactions remain a real fear for practicing pediatric gastroenterologists and surgeons. This case describes a child who developed an aorto-esophageal fistula 25 days after initial battery ingestion and survived due to prompt placement of an aortic stent via minimally invasive surgery, avoiding an open procedure. CASE PRESENTATION: A 6-year-old female presented acutely with a mid-esophageal button battery impaction witnessed by her parents. Presenting symptoms included chest pain and emesis. Button battery location and size were confirmed on X-ray. She underwent removal with flexible esophagogastroduodenoscopy (EGD) and rigid esophagoscopy. She was admitted to the hospital and received conservative medical management, with serial cross-sectional imaging via chest MRIs to assess the evolution of her injury according to available national guidelines, and was discharged after 12 days of close inpatient monitoring. Despite these measures the patient represented 25 days post-ingestion with hematemesis from a new aorto-esophageal fistula, requiring emergent cardiac catheterization with successful, life-saving aortic stent placement. She remained admitted for an additional 12 days of monitoring as her diet was advanced slowly post-catheterization. Since this second hospitalization she continues to do well, with outpatient follow-up by multiple subspecialists. CONCLUSIONS: This case highlights the continued uncertainty regarding the risk of developing this complication, as well as gaps in the current literature and guidelines for managing these patients following ingestion and esophageal injury. It also details the unique course following development of this complication and its surgical repair.

Intensive Multidisciplinary Intervention for Young Children with Feeding Tube Dependence and Chronic Food Refusal: An Electronic Health Record Review.

OBJECTIVE: To assess characteristics and outcomes of young children receiving intensive multidisciplinary intervention for chronic food refusal and feeding tube dependence. STUDY DESIGN: We conducted a retrospective study of consecutive patients (birth to age 21 years) admitted to an intensive multidisciplinary intervention program over a 5-year period (June 2014-June 2019). Inclusion criteria required dependence on enteral feeding, inadequate oral intake, and medical stability to permit tube weaning. Treatment combined behavioral intervention and parent training with nutrition therapy, oral-motor therapy, and medical oversight. Data extraction followed a systematic protocol; outcomes included anthropometric measures, changes in oral intake, and percentage of patients fully weaned from tube feeding. RESULTS: Of 229 patients admitted during the 5-year period, 83 met the entry criteria; 81 completed intervention (98%) and provided outcome data (46 males, 35 females; age range, 10-230 months). All patients had complex medical, behavioral, and/or developmental histories with longstanding feeding problems (median duration, 33 months). At discharge, oral intake improved by 70.5%, and 27 patients (33%) completely weaned from tube feeding. Weight gain (mean, 0.39 ± 1 kg) was observed. Treatment gains continued following discharge, with 58 patients (72%) weaned from tube feeding at follow-up. CONCLUSIONS: Our findings support the effectiveness of our intensive multidisciplinary intervention model in promoting oral intake and reducing dependence on tube feeding in young children with chronic food refusal. Further research on the generalizability of this intensive multidisciplinary intervention approach to other specialized treatment settings and/or feeding/eating disorder subtypes is warranted.

Scurvy as a Sequela of Avoidant-Restrictive Food Intake Disorder in Autism: A Systematic Review.

OBJECTIVE: To document the clinical presentation of scurvy in children with autism spectrum disorder (ASD) and summarize the contemporary approaches to assessment and management in this population. Scurvy is a disease caused by vitamin C deficiency most often detected in populations at high risk for nutrition insufficiency (e.g., extreme poverty). Children with ASD and severe food selectivity consistent with avoidant-restrictive food intake disorder may also be at risk for scurvy. METHOD: We searched MEDLINE, CINAHL, and PsycINFO databases (1990-2018) in peer-reviewed journals for studies of children with ASD and scurvy. Inclusion criteria required confirmed diagnosis of ASD and scurvy in children (birth to 18 years) with a clear description of restrictive dietary patterns. Cases of scurvy due to other causes were excluded. We used a standardized protocol to independently code information; agreement between coders was high. RESULTS: The systematic search identified 20 case reports involving 24 children (mean age = 9 ± 3.5; 22 boys/2 girls). The eventual diagnosis of scurvy followed a wide range of negative diagnostic testing; treatment with ascorbic acid and/or a multivitamin resulted in rapid improvement. CONCLUSIONS: Symptoms of scurvy mimic other pediatric conditions (e.g., cancer). The range of diagnostic testing increased costs and healthcare risks (radiation, sedation) and delayed the diagnosis of scurvy. In children with ASD and severe food selectivity, a nutrition evaluation and laboratory testing are warranted before a more elaborate testing.

A Pilot Randomized Clinical Trial of a Multidisciplinary Intervention for Encopresis in Children with Autism Spectrum Disorder.

Children with autism spectrum disorder (ASD) are often delayed in achieving bowel continence, resulting in negative outcomes. In this pilot trial, 20 children with ASD and encopresis were randomly assigned to multidisciplinary intervention for encopresis (MIE; n = 10) or a waitlist control group (n = 10). The MIE group was treated for constipation and received a 10-day behavioral intervention that utilized suppositories to produce predictable bowel movements that were reinforced. Caregivers were trained to implement the intervention. Results support the feasibility of clinical trials of MIE, with high enrolment, competition, attendance, and caregiver acceptability. Preliminary outcomes were positive, with six of 10 in the MIE group achieving continence by the end of treatment compared to 0 in the control group (p = 0.005).Registered at clinicaltrials.gov (https://clinicaltrials.gov); ID: NCT02383732.

Image-guided placement of percutaneous de novo low-profile gastrojejunostomy tubes in the pediatric population: a study of feasibility and efficacy.

BACKGROUND: De novo low-profile gastrojejunostomy tubes in pediatric patients offer less external catheter bulk and decreased propensity for dislodgement as children become more mobile. While small cohort studies have evaluated de novo placement of coaxial, adjustable-length, percutaneous gastrojejunostomy (GJ) tubes in children, placement of de novo low-profile GJ tubes in pediatric patients has not been analyzed. OBJECTIVE: This study evaluates technical feasibility, safety and clinical efficacy of percutaneous, retrograde placement of de novo low-profile GJ tubes in infants and children. MATERIALS AND METHODS: Following institutional review board approval, all de novo low-profile GJ tube placements in patients were retrospectively reviewed between May 2014 and May 2017. Technical parameters of fluoroscopy time, tube size, T-fasteners and complications were recorded. Clinical data, including age, indication, weight gain and complications, were analyzed. RESULTS: Thirty-four de novo low-profile GJ tubes were placed in 34 patients (median age: 9.4 months, range: 2 months-11.8 years; median pre-procedural weight: 7.5 kg, range: 2.9-31.6 kg). Twenty-one 14-Fr and 13 16-Fr GJ tubes were placed with technical success rate of 100%. Average weight gain 3 months' post procedure was 1.1 kg (range: 0.3-4.8 kg) and average weight percentile for age increase was 9.6% (range: -48.9% to 53.5%). One major complication occurred following balloon inflation within the tract causing pain requiring urgent replacement of the GJ tube. Minor complications occurred in 11 patients (32%): accidental dislodgement (n=9), skin irritation (n=4), tube dysfunction (n=2), leakage (n=2) and tube migration into the esophagus (n=1). CONCLUSION: Percutaneous, antegrade, image-guided placement of de novo low-profile GJ tubes is technically feasible, safe and clinically efficacious in appropriately selected pediatric patients.

A multidisciplinary treatment for encopresis in children with developmental disabilities.

Achieving continence of one's bowel movements is a key step in development and failure to do so leads to many negative consequences. Treatments for encopresis appearing in the literature have employed behavioral strategies; medications such as suppositories, laxatives, or enemas; and in some studies a combination of these approaches. To date, attempts to extend successful treatments for encopresis in typically developing children to those with developmental disabilities have been limited. The current study included three participants diagnosed with developmental disabilities who had a history of encopresis. None of the participants had a continent bowel movement under baseline conditions. Continent bowel movements increased during treatment that included the addition of suppositories to elicit continent bowel movements. Two participants began having independent continent bowel movements (i.e., without requiring suppositories) and medication was successfully faded out for the remaining participant. Treatment took between 13 and 21 days.

Infliximab Optimization Based on Therapeutic Drug Monitoring in Pediatric Inflammatory Bowel Disease.

BACKGROUND: Infliximab (IFX) is an effective treatment for the management of moderate to severe inflammatory bowel disease (IBD). Low-serum IFX levels are associated with the development of antibodies to IFX (ATI), which subsequently associated with clinical relapse and increased morbidity. The primary purpose of this study is to examine the relation between dose and interval to IFX level. Secondary goal is to evaluate the relation between IFX level and ATI in a pediatric IBD population. METHODS: We performed a retrospective chart review of all children diagnosed with IBD and treated with IFX at a tertiary care pediatric IBD center. We performed our analysis based on prescribed dosing intervals and rounded dose up to 5 or 10 mg/kg as indicated in clinical practice. RESULTS: Our study included 278 samples from 129 children on IFX. ATI were detected in 37 samples (13.3%). Low IFX levels (<3 µg/mL) were detected in 37.2% of children receiving IFX. Samples with ATI present had significantly lower levels of IFX than samples in which ATI were not present. For the dose 5 mg/kg, Q6 dosing had significantly higher IFX levels than Q8 dosing (P = 0.009). Higher IFX levels were seen with interval shortening rather than dose escalation. CONCLUSIONS: We demonstrate that low IFX levels are associated with development of immunogenicity to IFX as measured by ATI. We demonstrate that interval shortening rather than dose escalation results in higher IFX levels. We suggest that given the high number of IFX levels below 3 µg/mL in patients, early IFX level evaluation or primary initiation of Q6 week dosing be considered.

A Systematic Review and Meta-Analysis of Intensive Multidisciplinary Intervention for Pediatric Feeding Disorders: How Standard Is the Standard of Care?

OBJECTIVE: To assess models of care and conduct a meta-analysis of program outcomes for children receiving intensive, multidisciplinary intervention for pediatric feeding disorders. STUDY DESIGN: We searched Medline, PsycINFO, and PubMed databases (2000-2015) in peer-reviewed journals for studies that examined the treatment of children with chronic food refusal receiving intervention at day treatment or inpatient hospital programs. Inclusion criteria required the presentation of quantitative data on food consumption, feeding behavior, and/or growth status before and after intervention. Effect size estimates were calculated based on a meta-analysis of proportions. RESULTS: The systematic search yielded 11 studies involving 593 patients. Nine articles presented outcomes based on retrospective (nonrandomized) chart reviews; 2 studies involved randomized controlled trials. All samples involved children with complex medical and/or developmental histories who displayed persistent feeding concerns requiring formula supplementation. Behavioral intervention and tube weaning represented the most common treatment approaches. Core disciplines overseeing care included psychology, nutrition, medicine, and speech-language pathology/occupational therapy. The overall effect size for percentage of patients successfully weaned from tube feeding was 71% (95% CI 54%-83%). Treatment gains endured following discharge, with 80% of patients (95% CI 66%-89%) weaned from tube feeding at last follow-up. Treatment also was associated with increased oral intake, improved mealtime behaviors, and reduced parenting stress. CONCLUSIONS: Results indicate intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties. Future research must address key methodological limitations to the extant literature, including improved measurement, more comprehensive case definitions, and standardization/examination of treatment approach.

Optimizing Transition to Home Enteral Nutrition for Pediatric Patients.

Enteral nutrition is delivered via the gastrointestinal tract when oral intake is not sufficient to maintain nutrition status. There is evidence that long-term home enteral nutrition (HEN) can be advantageous to pediatric patients by improving quality of life and function. Data from pediatric patients receiving either nasogastric tube or gastrostomy tube feeds indicate good outcomes in terms of maintaining and improving nutrition status as evidenced by anthropometric measurements. As the number of pediatric patients requiring HEN increases, development of an effective program to allow smooth transition to the home is necessary. The formation of a multidisciplinary HEN management team can achieve the important task of taking care of children requiring HEN who are technology dependent. Members of a multidisciplinary HEN team can include care coordinators, nurses, physicians, dietitians, and speech therapists. Planning for patient discharge to home should start well before the actual discharge, with timely identification of home caregivers, the family's learning style, and completion of other requirements for safe administration of HEN. Education should be provided in a continuum, starting at the identification of nutrition support while still in the hospital and continuing after discharge to address concerns and long-term complications of HEN.

Pilot Study Evaluating Efficacy of 2 Regimens for Hypovitaminosis D Repletion in Pediatric Inflammatory Bowel Disease.

OBJECTIVES: Vitamin D is critical for skeletal health; hypovitaminosis D is common in pediatric inflammatory bowel disease (IBD), yet optimal repletion therapy is not well studied. We aimed to conduct a pilot trial comparing the efficacy of 2 vitamin D regimens of weekly dosing for the repletion of hypovitaminosis D in pediatric IBD. METHODS: Subjects identified from our IBD clinic with 25-hydroxyvitamin D (25[OH]D) concentrations <30 ng/mL were randomized to 10,000 (n = 18) or 5000 (n = 14) IU of oral vitamin D3/10 kg body weight per week for 6 weeks. Serum 25(OH)D, Ca, and parathyroid hormone concentrations were measured at baseline, week 8, and week 12. RESULTS: In the higher dosing group, serum 25(OH)D increased from 23.7 ±â€Š8.5 ng/mL at baseline to 49.2 ±â€Š13.6 ng/mL at 8 weeks; P < 0.001. In the lower dosing group, serum 25(OH)D increased from 24.0 ±â€Š7.0 ng/mL at baseline to 41.5 ±â€Š9.6 ng/mL at 8 weeks; P < 0.001. At 12 weeks, serum 25(OH)D concentrations were 35.1 ±â€Š8.4 and 30.8 ±â€Š4.2 ng/mL for the higher and lower dose regimens, respectively. Mean serum Ca and parathyroid hormone concentrations did not significantly change during the study. No patient exhibited hypercalcemia, and no serious adverse events occurred. CONCLUSIONS: Both treatment arms were safe and effective at normalizing vitamin D nutriture in pediatric IBD. Although significant repletion of 25(OH)D concentration was achieved in both dosing groups at 8 weeks, this effect was lost by the 12-week follow-up. Maintenance vitamin D therapy following initial repletion is likely required to maintain long-term normalized vitamin D status.

Gastrointestinal symptoms in autism spectrum disorder: a meta-analysis.

BACKGROUND: In pediatric settings, parents often raise concerns about possible gastrointestinal (GI) symptoms in autism spectrum disorder (ASD), yet the specificity of these concerns are not well studied. OBJECTIVE: To conduct a meta-analysis of research investigating GI symptoms among children with ASD. METHODS: We searched Medline, PsycINFO, and PubMed databases (1980-2012) in peer-reviewed journals. Analysis involved studies with a comparison group presenting quantitative data on GI symptoms using combinations of terms for ASD and GI indicators. The systematic search yielded 15 studies. We calculated effect sizes and 95% confidence intervals (CIs) using a random-effects model. RESULTS: Children with ASD experience significantly more general GI symptoms than comparison groups, with a standardized mean difference of 0.82 (0.24) and a corresponding odds ratio (OR) of 4.42 (95% CI, 1.90-10.28). Analysis also indicated higher rates of diarrhea (OR, 3.63; 95% CI, 1.82-7.23), constipation (OR, 3.86; 95% CI, 2.23-6.71), and abdominal pain (OR, 2.45; 95% CI, 1.19-5.07). CONCLUSIONS: Results indicate greater prevalence of GI symptoms among children with ASD compared with control children. Identified studies involved high methodological variability and lack of comprehensive data prohibited analysis of GI pathophysiologies (eg, gastroesophageal reflux) typically associated with organic etiologies, limiting conclusions about the underpinnings of the observed association. Future research must address critical questions about the causes and long-term impact of GI symptoms in ASD. Such analyses will require more systematic research and clinical activities, including improved diagnostic screening, standardized assessment, and exploration of potential moderators (eg, dietary restrictions).