Use of endolumenal functional lumen imaging probe in investigating paediatric gastrointestinal motility disorders.

Investigating gastrointestinal (GI) motility disorders relies on diagnostic tools to assess muscular contractions, peristalsis propagation and the integrity and coordination of various sphincters. Manometries are the gold standard to study the GI motor function but it is increasingly acknowledged that manometries do not provide a complete picture in relation to sphincters competencies and muscle fibrosis. Endolumenal functional lumen imaging probe (EndoFLIP) an emerging technology, uses impedance planimetry to measure hollow organs cross sectional area, distensibility and compliance. It has been successfully used as a complementary tool in the assessment of the upper and lower oesophageal sphincters, oesophageal body, the pylorus and the anal canal. In this article, we aim to review the uses of EndoFLIP as a tool to investigate GI motility disorders with a special focus on paediatric practice. The majority of EndoFLIP studies were conducted in adult patients but the uptake of the technology in paediatrics is increasing. EndoFLIP can provide a useful complementary data to the existing GI motility investigation in both children and adults.

Rate of paediatric gastrostomy insertion in England and relationship to epidemiology of cerebral palsy.

Background and objectives: Gastrostomy tubes are commonly used to provide an alternative route for enteral nutrition. Most of the gastrostomies are inserted in children with cerebral palsy. Previous studies have shown an increase in insertion rate, however, epidemiological studies reveal a stasis in prevalence of cerebral palsy. We aimed to provide an up-to-date rate of gastrostomy insertion in children in England over a 20-year period and systematically review the prevalence of cerebral palsy to ascertain an epidemiological explanation for insertion trends. Methods: Retrospective search of Hospital Episode Statistic, a database held diagnosis and procedural code from all England National Health Service hospitals from 2000 to 2021 using International Classification of Disease-10 and Office of Population Censuses and Survey's Classification-4. England Office for National Statistics data were used for population census. MEDLINE and EMBASE were systematically searched for epidemiology of cerebral palsy. Results: There were 23 079 gastrostomies inserted in children <15 years in England (2000-2021) leading to a frequency of 12.4 insertions per 100 000 children per year and 1383 gastrostomy insertions in 15-18 years age group (6 per 100 000). The overall gastrostomy insertion rate in children <15 years has increased from 3.7 procedures per 100 000 in 2000 to 18.3 per 100 000 in 2017. Prevalence of cerebral palsy remained stable (1.5-3.3 per 1000 birth) since 1985. Conclusions: There was a significant increase in the rate of gastrostomy insertion in children in England during most of the last 20 years not explained by a stable prevalence of cerebral palsy.

EndoFLIP assessment of pyloric sphincter in children: a single-center experience.

Background: Gastrointestinal complaints are common in children with neurodisabilities, vomiting, retching and poor feed tolerance are frequently reported. Endolumenal functional lumen imaging probe (EndoFLIP) is used to assess compliance and distensibility of the pylorus and can predict response to Botulinum Toxin in adult with gastroparesis. We aimed to review pyloric muscle measurements using EndoFLIP in children with neuromuscular disabilities and significant foregut symptoms and to assess the clinical response to intrapyloric Botulinum Toxin. Methods: Retrospective review of clinical notes of all children who underwent pyloric EndoFLIP assessment in Evelina London Children's Hospital from March 2019 to January 2022. EndoFLIP catheter was inserted at the time of endoscopy via existing gastrostomy tract. Results: A total of 335 measurement from 12 children were obtained, mean age 10.7±4.2 years. Measurements (pre and post Botox) were obtained with 20, 30 and 40 mL balloon volume. Diameter (6.5, 6.6), (7.8, 9.4) and (10.1, 11.2), compliance (92.3, 147.9), (89.7, 142.9) and (77, 85.4) mm3/mmHg, distensibility (2.6, 3.8), (2.7, 4.4) and (2.1, 3) mm2/mmHg and balloon pressure was (13.6, 9.6), (20.9, 16.2) and (42.3, 35) mmHg. Eleven children reported clinical symptom improvement after Botulinum Toxin injection. Balloon pressure was positively correlated to diameter (r=0.63, P<0.001). Conclusions: Children with neurodisabilities who present with symptoms suggestive of poor gastric emptying do have a low pyloric distensibility and poor compliance. EndoFLIP via existing gastrostomy tract is quick and easy to perform. Intrapyloric Botulinum Toxin appears to be safe and effective in this cohort of children leading to clinical and measurements improvement.

Gastroesophageal reflux disease in children: What's new right now?

Gastroesophageal reflux (GER) in children is very common and refers to the involuntary passage of gastric contents into the esophagus. This is often physiological and managed conservatively. In contrast, GER disease (GERD) is a less common pathologic process causing troublesome symptoms, which may need medical management. Apart from abnormal transient relaxations of the lower esophageal sphincter, other factors that play a role in the pathogenesis of GERD include defects in esophageal mucosal defense, impaired esophageal and gastric motility and clearance, as well as anatomical defects of the lower esophageal reflux barrier such as hiatal hernia. The clinical manifestations of GERD in young children are varied and nonspecific prompting the necessity for careful diagnostic evaluation. Management should be targeted to the underlying aetiopathogenesis and to limit complications of GERD. The following review focuses on up-to-date information regarding of the pathogenesis, diagnostic evaluation and management of GERD in children.

Parenteral Nutrition in Pediatric Patients with Neurodisability: Current Perspectives.

Pediatric neurodisability describes functional limitations in children with varied severity and complexity often attributed to brain or neuromuscular abnormalities. The life expectancy of children with neurodisability is improving, but many will require significant medical support. The gastrointestinal tract is usually affected in children with neurodisability and can lead to a wide range of symptoms. In gastrointestinal (GI) dystonia, a newly coined term, feeding will trigger a distressing dystonia and symptoms can improve with cessation of feed. Parenteral nutrition (PN) is often viewed as a viable option in severe GI dystonia or when enteral feeding does not support sufficient nutrition. The use of PN in children with severe neurodisability is complex. It involves an intricate interplay between medical, psychological and ethical factors. In the absence of a universally agreed guidance on the use of PN in this cohort, paediatricians should maintain the individual need of the child at the centre of the decision-making process and work closely with families and other healthcare professionals before initiating or withholding PN in children with severe neurodisability. In this article, we discuss the complex and multifaceted approach to the use of PN in children with severe neurodisability and aimed to explore the medical, psychological and ethical aspect dilemmas facing clinicians looking after children with declining gut function who may require PN support.

Ultrasonic-Assisted Extraction of Toxic Acidic Components from Acidic Oil Using 1,8-Diazobicyclo[5.4.0]undec-7-ene-Based Ionic Liquids.

Ionic liquids (ILs) show remarkable performance in enhancing the naphthenic acid extraction efficiency and decreasing the extraction time. However, the ultrasonic-assisted IL-based extraction of naphthenic acid is merely addressed previously. Therefore, this study investigated the impact of essential ultrasonic parameters, including amplitude and time, on naphthenic acid extraction using different ILs, and the system was optimized for maximum extraction. The IL 1,8-diazobicyclo[5.4.0]-undec-7-ene (DBU) with thiocyanate anions revealed the highest efficiency in extracting naphthenic acid from a model oil (dodecane) at optimized conditions, and the experimental liquid-liquid equilibrium data were obtained at atmospheric pressure for the mixture of dodecane, [DBU], thiocyanate, and naphthenic acid. In addition, the influence of the chain length of the cation (hexyl, octyl, or decyl) on the extraction efficiency was also evaluated by determining the distribution coefficients, and the conductor-like screening model for real solvents (COSMO-RS) study was carried out at infinite dilution. It was found that [DBU-Dec] [SCN] gives the best extraction efficiency and has a distribution coefficient of 9.2707 and a performance index of 49.48. Based on these values, ILs can be ordered as follows: [DBU-Dec] [SCN] > [DBU-Oct][SCN] > [DBU-Hex][SCN] in the decreasing order of performance index 49.48, 41.58, and 28.13. Moreover, non-random two liquid and Margules thermodynamic models were employed to investigate the interaction parameters between the components. Both models showed excellent agreement with the experimental results and could successfully be used for ultrasonic-assisted IL extraction of naphthenic acid.

Burden of Pediatric Functional Gastrointestinal Disorder in an Emergency Department-A Single-Center Experience.

OBJECTIVES: Functional gastrointestinal disorders (FGIDs) are recurrent or chronic gastrointestinal signs and symptoms in the absence of anatomical or biochemical alterations. They are commonly treated in outpatient setting but often present to emergency departments. We aimed to estimate the burden of pediatric FGID on a busy accident and emergency (A&E) department. METHODS: Electronic patient records were used to retrospectively analyze the A&E attendances of 3866 patients presenting with either constipation or abdominal pain. Those found not to have a surgical/organic cause were assessed in terms of various parameters, that is, arrival times, wait times, and investigations performed. RESULTS: A total of 91.31% of the attendances relating to constipation or nonsurgical, nonorganic causes of abdominal pain were self-referred with only 3.64% arriving via ambulance, an average wait time ranging between 138 and 156 minutes, and a total of 1008 investigations carried out on patients presenting with these symptoms. A total of 63.65% of the patients were discharged without follow-up. CONCLUSIONS: Functional gastrointestinal disorders place considerable burden on the A&E, in terms of resource usage, time of clinicians, and financial strain. More education should be provided to families of those experiencing FGID in an outpatient setting to minimize A&E resource utilization. More research is needed to ascertain the true burden of FGIDs, both financially and in terms of time and resource.

Bowel transit studies in children: evidence base, role and practicalities.

Constipation is common in children and adults with varied worldwide prevalence. The majority of children have functional constipation as defined by Rome clinical criteria and respond favourably to standard medical therapy; up to one-third can develop difficult-to-treat constipation requiring investigation and specialist treatment. Colon function tests aim to assess the neuromuscular integrity, the movement of faeces across the colon and evaluate/predict response to the therapy. The 'ideal' test should be practical, non-invasive, widely available and cost-effective. None of the available diagnostic tools is designed to provide a comprehensive assessment of colon function and clinicians often have to combine more than one test to answer different questions. In this review, we aim to assess the strengths and limitations of the commonly available diagnostic investigations (radiopaque marker studies, scintigraphy, wireless motility capsule and colonic manometry) used to assess colon transit in children and to provide guidance on the most appropriate test for particular clinical settings.

Review of a paediatric inflammatory bowel disease service during the pandemic and the impact of the CNS role.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic relapsing and remitting condition. The COVID-19 pandemic has severely disrupted provision of medical care across the world. IBD clinical nurse specialists (CNSs) played a pivotal role in the care of children with IBD during the pandemic national lockdown and in the recovery phase. This article aims to look at the impact of COVID-19 on the paediatric IBD service in one children's hospital and the effect on the IBD CNSs' workload. METHOD: A retrospective review of clinical notes and the service's IBD database from January 2019 to September 2020. RESULTS: There was a significant increase in the number of email and telephone contacts to the IBD CNS team during lockdown. There was an increase in virtual clinics, and an increase in new IBD patients coming to the service, but a reduction in the number of face-to-face consultant clinics. CONCLUSION: COVID-19 has disrupted medical services to children with IBD and led to a reduction in face-to-face activities but has also led to a significant increase in virtual activities. CNSs have taken up a wider role to cover patient care during a time of both medical and nursing redeployment.

Ultrasonic-Assisted Technique as a Novel Method for Removal of Naphthenic Acid from Model Oil Using Piperidinium-Based Ionic Liquids.

In this study, piperidinium-based ionic liquids (IL) containing trifluoromethanesulfonate, phenolate, and dicyanamide anions were synthesized. Using the ILs, extraction of naphthenic acid from highly acidic oil with a total acid number (TAN) of 1.44 was studied. Two agitation techniques have been implemented for the extraction process, which were mechanical stirring and ultrasonic-assisted irradiation. 1-Butyl-1-methylpiperidinium phenolate [BMPi][Phe] showed the best potential in extracting naphthenic acid from oil, with complete removal of naphthenic acid with IL-to-oil ratios of 0.010 and 0.0025 for the mechanical stirring method and the ultrasonic-assisted method, respectively. Ultrasonic-assisted extraction process shows very good potential in enhancing the extraction efficiency of naphthenic acid. Optimization and study on the effects of ultrasonic parameters, namely, IL-to-oil ratio, ultrasonic amplitude, and time, were studied through response surface methodology (RSM). Using [BMPi][Phe], the optimum conditions obtained are IL-to-oil ratio of 0.03, 53.91% of amplitude, and 4.29 min of extraction time. Under these optimum conditions, 100% removal of naphthenic acid was achieved.

Nurse-led service for children with gastrostomies: a 2-year review.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) feeding can provide long-term nutritional support for patients with a functional gastrointestinal system but insufficient oral intake. Some patients, however, may require jejunal feeding, which can be achieved using a PEG tube with jejunal extension (PEG-J). A previous review at a tertiary paediatric hospital revealed poor documentation and a high incidence of buried bumper syndrome (BBS) in children with gastrostomies. Subsequently, a nurse-led service for gastrostomy care was introduced. AIM: To determine the impact of the nurse-led service. METHODS: Prospective review, at 1 year and 2 years, following either a PEG or PEG-J insertion. Patient records were reviewed and a telephone survey was conducted. Statistical analysis was performed using Fisher's exact test. FINDINGS: 32 PEG and 6 PEG-J patients were included in this study. There was 100% documentation of provision of care instructions. Average satisfaction with the service was over 8/10. Incidence of BBS was 0% in the PEG group and 17% in the PEG-J group. Of those parents/carers surveyed, 74% wanted additional tube care support via SMS text message. CONCLUSION: Introduction of a nurse-led service resulted in complete documentation of provision of care and sustained high levels of parental satisfaction. Future care should focus on utilising technological platforms.

Nutrition Evaluation Screening Tool: An Easy to Use Screening Tool for Hospitalised Children.

PURPOSE: Nutrition screening is vital to ensure patients are appropriately managed in hospital. In paediatrics there is currently no universally accepted nutrition screening tool. The Nutrition Evaluation Screening Tool (NEST) was developed as an easy to use and practical screening tool for hospitalised children. We aim to evaluate compliance of the NEST and assess agreement of the NEST with the already validated nutrition screening tools, Screening Tool for Risk on Nutritional Status and Growth (STRONGkids), Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) and the Subjective Global Nutritional Assessment (SGNA) tool. METHODS: Retrospective review of 102 patient episodes at the Evelina London Children's Hospital. Electronic records were used to assess NEST compliance and to complete the nutrition tools for each patient episode. Cohen's kappa was used to determine the level of agreement between each nutrition tool. RESULTS: There was moderate agreement between the NEST and the two screening tools, STRONGkids (κ=0.472) and STAMP (κ=0.416) for patients on initial screening at admission. 87.2% of patient episodes were NEST compliant within 24 hours of admission to hospital. CONCLUSION: The moderate agreement between these two already validated screening tools enhances the NEST's validity as a paediatric screening tool. The NEST had the strongest correlation with the SGNA tool compared to other screening tools. The NEST is user friendly screening tool for hospitalised children.

Renal involvement in paediatric inflammatory bowel disease.

Inflammatory bowel disease (IBD), which includes Crohn's disease, ulcerative colitis and inflammatory bowel disease unclassified, is a chronic inflammatory disorder that predominantly affects the gastrointestinal (GI) tract and has a rising incidence in both children and adults. Symptoms are caused by inappropriate inflammatory response triggered by interaction between the environment, gut microbiome and host immune system in a genetically susceptible individual. Extranintestinal manifestations of IBD are common and can affect any body system outside the gut; they can precede or run parallel to GI inflammation. Renal involvement in IBD is uncommon and can be part of extraintestinal manifestation or metabolic complications of IBD. Many medications used to treat IBD can cause renal damage. Renal manifestation in children with IBD can range from asymptomatic biochemical abnormalities to variable stages of renal impairment with significant morbidity and even mortality burden.

Development, formulation and optimization of a novel biocompatible ionic liquids dispersant for the effective oil spill remediation.

The application of chemical dispersants in marine oil spill remediation is comprehensively reported across the globe. But, the augmented toxicity and poor biodegradability of reported chemical dispersants have created necessity for their replacement with the bio-based green dispersants. Therefore, in the present study, we have synthesized five ionic liquids (ILs) namely 1-butyl-3-methylimidazolium lauroylsarcosinate, 1,1'-(1,4-butanediyl)bis(1-H-pyrrolidinium) dodecylbenzenesulfonate, tetrabutylammonium citrate, tetrabutylammonium polyphosphate and tetrabutylammonium ethoxylate oleyl ether glycolate, and formulated a water based ILs dispersant combining the synthesized ILs at specified compositions. The effectiveness of formulated ILs dispersant was found between 70.75% and 94.71% for the dispersion of various crude oils ranging from light to heavy. Further, the acute toxicity tests against zebra fish and grouper fish have revealed the practically non-toxic behaviour of formulated ILs dispersant with LC50 value greater than 100 ppm after 96 h. In addition, the formulated ILs dispersant has provided excellent biodegradability throughout the test period. Overall, the formulated new ILs dispersant is deemed to facilitate environmentally benign oil spill remediation and could effectively substitute the use of hazardous chemical dispersants in immediate future.

Anorectal manometry in children with defecation disorders BSPGHAN Motility Working Group consensus statement.

Defecatory disorders in children, including chronic constipation (CC) and fecal incontinence (FI), are common conditions worldwide and have a significant impact on children, their families, and the healthcare system. Anorectal manometry (ARM) and high-resolution anorectal manometry (HRAM) are relatively novel tools for the assessment of anal sphincter function and rectal sensation and have contributed significantly to improving the understanding of the anorectum as a functional unit. ARM has been recognized as the investigation of choice for adults with symptoms of defecation disorders, including fecal incontinence (FI), evacuation difficulties, and constipation. Although it is the gold standard tool in adults, it has yet to be formally accepted as a standardized diagnostic tool in the pediatric age, with limited knowledge regarding indications, protocol, and normal values. ARM/HRAM is slowly becoming recognized among pediatricians, but given that there are currently no agreed guidelines there is a risk that will lead to diversity in practice. The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN)-Motility Working Group (MWG) therefore has taken the opportunity to provide guidance on the use of ARM/HRAM in children with CC and/or FI.

Distal oesophageal spasm secondary to eosinophilic oesophagitis in a child: response to diet therapy.

We report a case of a school-age child with symptomatic distal oesophageal spasm (DES), clinical dysphagia and typical feature in high-resolution oesophageal manometry secondary to eosinophilic oesophagitis (EoE). His symptoms resolved with normalisation of oesophageal manometry after standard treatment of EoE. DES is mainly an adult disorder and rarely affect children; to the best of our knowledge, this is the first reported case in a child that document full recovery after treating the underlying EoE.

Pediatric Esophageal Dilatations: A Cross-Specialty Experience.

Aim of the Study: Esophageal dilatations are commonly performed in pediatric patients who have undergone an esophageal atresia/tracheoesophageal fistula (EA/TEF) repair or following caustic injury. We sought to compare the practice of esophageal dilatation across different specialties. Methods: We analyzed all patients who had an esophageal dilatation at our center between April 2014 and December 2018. Patients were identified via prospectively maintained databases and clinical coding records. Patients had a combination of dilatations under each specialty: interventional radiology (IR), surgery, and gastroenterology. Results: Thirty-five individual patients underwent 226 dilatations, median dilatations per patient was 3 (1-40). The median age at first dilatation was 18 months (1-194 months). Sixty-eight percent of patients had a previous EA/TEF repair. IR performed 59% of dilatations, surgeons 26%, and 15% by gastroenterologists. Surgeons more frequently were performing initial dilatations (P < .05) and performed more dilatations in EA/TEF patients (P < .0001). There was a significant difference between the time from a surgical dilatation until the next dilatation, 3.7 months, compared with an IR dilatation, 1.8 months (ANOVA, P < .05). Surgeons more frequently increased the size of balloon used (57% versus 33% versus 39%, P < .01). There was no significant difference in balloon size between specialties or in the incremental increase in size between subsequent dilatations. There was one postprocedure perforation, managed conservatively (complication rate = 0.4%). Conclusion: We have demonstrated that on average, patients wait longer after a surgical dilatation until their next procedure, and surgical teams are more likely to increase the size of the dilating balloon. Surgeons tend to be more involved in their postoperative patients in the initial phases of stricture management. Our results suggest the feasibility and safety of a multispecialty approach for these patients.

Azathioprine dosing and metabolite measurement in pediatric inflammatory bowel disease: does one size fit all?

BACKGROUND: Azathioprine is widely used for the maintenance of remission in children with inflammatory bowel disease (IBD). Measuring thiopurine metabolites 6-thioguanine (6-TGN) and 6-methyl-mercaptopurine (6-MMP) can aid in optimizing treatment and preventing toxicity. We report a proactive approach combining early metabolite measurements with IBD activity index to achieve optimal azathioprine dosing. METHODS: The reporting of azathioprine dosing, IBD activity indexes and thiopurine metabolites was evaluated retrospectively in 40 children with IBD. Additional treatments and the effect of azathioprine on blood counts were also examined. RESULTS: Forty children (40% female) with IBD (26 Crohn's disease, 12 ulcerative colitis, and 2 unclassified IBD), mean age 12.2±3.4 years, were included in the study. The mean azathioprine dose was 1.3±0.4 mg/kg; mean 6-TGN level was 280±151 pmol/8 × 108 red blood cells (RBC) and mean 6-MMP level 1022±1007 pmol/8 × 108 RBC. Disease activity index (Crohn's and ulcerative colitis, pediatric specific) at the time of metabolite measurement was 6.5±8. Twenty-eight children did not require azathioprine dose adjustment, while it was increased in 12. Data from children with azathioprine monotherapy were analyzed separately and the results were similar. CONCLUSION: Timely measurement of thiopurine metabolites and clinical assessment can provide a powerful tool to optimize azathioprine dosing and reduce serious adverse effects in children with IBD.

Synthesis, characterization, ecotoxicity and biodegradability evaluations of novel biocompatible surface active lauroyl sarcosinate ionic liquids.

Ionic liquids (ILs) based surfactants have been emerged as attractive alternatives to the conventional surfactants owing to their tailor-made and eco-friendly properties. Therefore, present study described the synthesis of nine new fatty amino acids based IL surfactants utilizing lauroyl sarcosinate anion and pyrrolidinium, imidazolium, pyridinium, piperidinium, morpholinium and cholinium cations for the first time. The synthesized surface active lauroyl sarcosinate ionic liquids (SALSILs) were characterized by 1H NMR, 13C NMR and TGA. Next, the surface tension and critical micellar concentrations were determined and compared with the surface properties of ILs based surfactants. Further, the toxicity and biodegradability of the synthesized SALSIILs were evaluated to confirm their safe and efficient process applications. The studies revealed that three out of nine synthesized SALSILs containing pyridinium cation have showed strong activity towards the tested microbial growth. The remaining six SALSILs met the biocompatible measures demonstrating moderate to low activity depends on the tested microbes. The alicyclic SALSILs containing morpholinium and piperidinium cations have demonstrated 100% biodegradation after 28 days of the test period. Overall, it is believed that the synthesized SALSILs could effectively replace the conventional surfactants in a wide variety of applications.