Qualitative Point-of-Care Ultrasound Enema Management for Constipation.

ABSTRACT: We discuss 10 cases where the qualitative evaluation of hard stool in the rectum with point-of-care ultrasound helped guide enema administration in a pediatric emergency department. Point-of-care ultrasound findings were especially valuable in cases where the presenting symptoms were undifferentiated, a language barrier was present, or the guardian and child denied that constipation was an active problem. When sodium phosphate enema administration was done in the pediatric emergency department, evacuation of the rectal stool burden was observed in most cases before final disposition.

Identifying Gender and Racial Bias in Pediatric Fellowship Letters of Recommendation: Do Word Choices Influence Interview Decisions?

OBJECTIVES: To describe linguistic differences in letters of recommendation (LORs) for pediatric fellowship candidates based on applicant and letter writer demographics and to examine if these differences influenced the decision to interview a candidate for a fellowship position. STUDY DESIGN: LORs for applicants to 8 pediatric subspecialty fellowships at a single academic center from the 2020 Match were analyzed in this cross-sectional study. Frequency of validated agentic and communal terms in each letter were determined by a language processing web application. Bias was determined as having a >5% surplus of agentic or communal terms. RESULTS: We analyzed 1521 LORs from 409 applicants: 69% were women, 28% were under-represented minorities in medicine (URM), and 50% were invited to interview. Overall, 66% of LORs were agentic biased, 16% communal biased, and 19% neutral. There was no difference in bias in LORs by an applicant's gender (woman 67% agentic vs man 62% agentic; P = .058), race, or ethnicity (non-URM 65% agentic vs URM 67% agentic; P = .660). Despite a lower frequency of agentic terms in LORs for applicants invited for interviews, when accounting for other components of an application and applicant demographics, no significant association was made between language bias in LORs and fellowship interview status. CONCLUSIONS: The frequency of agentic and communal terms in LORs for pediatric subspecialty fellowship candidates were not found to influence the decision to invite a candidate to interview. However, raising awareness of potential areas of bias within the pediatric fellowship selection process might lead to a more equitable and holistic approach to application review.

Vulvovaginal Complaints as the First Manifestation of Crohn's Disease in Children: Case Report.

BACKGROUND: Crohn's disease, a chronic gastrointestinal inflammatory condition, can involve gynecological structures. Rectovaginal or rectovestibular involvement may be the first sign in the pediatric population and may result in delayed diagnosis and treatment. CASE: A 9-year-old premenarchal female with chronic constipation and poor growth presented to the pediatric gynecologist for evaluation of persistent vulvovaginal discharge and vulvar irritation. Examination under anesthesia revealed a rectolabial fistula; colonoscopy was diagnostic of Crohn's disease. Immunotherapy resulted in improvement of symptoms and anatomical changes. SUMMARY AND CONCLUSION: In cases of persistent vulvar complaints in a child without clear diagnosis, a high index of suspicion for a non-gynecologic diagnosis is necessary. Collaboration between pediatric gynecologists, gastroenterologists, and surgeons can result in prompt diagnosis and treatment of genital Crohn's disease.

Words Used in Letters of Recommendation for Pediatric Residency Applicants: Demographic Differences and Impact on Interviews.

OBJECTIVE: To describe differences in agentic (achievement) and communal (relationship) terms in letters of recommendation (LORs) for pediatric residency candidates by applicant and letter writer demographics and to examine if LOR language is associated with interview status. METHODS: A random sample of applicant profiles and LORs submitted to one institution were analyzed from the 2020-21 Match. Letters of recommendation text was inputted into a customized natural language processing application which determined the frequency of agentic and communal words in each LOR. Neutral LORs were defined as having< 5% surplus of agentic or communal terms. RESULTS: We analyzed 2094 LORs from 573 applicants: 78% were women, 24% were under-represented in medicine (URiM), and 39% were invited to interview. Most letter writers were women (55%) and of senior academic rank (49%). Overall, 53% of LORs were agency biased, 25% communal biased, and 23% neutral. There was no difference in agency and communally biased LORs by an applicant's gender (men 53% agentic vs women 53% agentic, P = .424), race or ethnicity (non-URiM 53% agentic vs URiM 51% agentic, P = .631). Male letter writers used significantly more agentic terms (8.5%) compared to women (6.7% agentic) or writers of both genders (3.1% communal) (P = .008). Applicants invited to interview were more likely to have a neutral LOR; however, no significant association existed between language and interview status. CONCLUSIONS: No significant differences in language were found by applicant gender or race among pediatric residency candidates. Identifying potential biases within pediatric residency selection processes is important in creating an equitable approach to application review.

Impact of COVID-19 on Pediatric Gastroenterology Fellow Training in North America.

BACKGROUND: The COVID-19 pandemic has drastically changed healthcare systems and training around the world. The Training Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition sought to understand how COVID-19 has affected pediatric gastroenterology fellowship training. METHODS: A 21 question survey was distributed to all 77 pediatric gastroenterology fellowship program directors (PDs) in the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition program director database via email on April 7. Responses collected through April 19, 2020 were analyzed using descriptive statistics. RESULTS: Fifty-one of 77 (66%) PDs from the United States, Canada, and Mexico responded to the survey. Forty-six of 51 (90%) PDs reported that they were under a "stay-at-home" order for a median of 4 weeks at the time of the survey. Two of the 51 (4%) programs had fellows participating in outpatient telehealth before COVID-19 and 39 of 51 (76%) at the time of the survey. Fellows stopped participating in outpatient clinics in 22 of 51 (43%) programs and endoscopy in 26 of 51 (52%) programs. Changes to inpatient care included reduced fellow staffing, limiting who entered patient rooms, and rounding remotely. Fellows in 3 New York programs were deployed to adult medicine units. Didactics were moved to virtual conferences in 47 of 51 (94%) programs, and fellows used various online resources. Clinical research and, disproportionately, bench research were restricted. CONCLUSIONS: This report provides early information of the impact of COVID-19 on pediatric fellowship training. Rapid adoption of telehealth and reduced clinical and research experiences were important changes. Survey information may spur communication and innovation to help educators adapt.

Complementary and Alternative Medicine Use in Children With Inflammatory Bowel Disease.

Complementary and alternative medicine (CAM) consists of products and practices that are not considered to be a part of conventional medicine. This article reviews pediatric studies on CAM in inflammatory bowel disease (IBD) along with relevant adult studies. Prevalence of CAM use ranges from 22% to 84% in children with IBD all over the world. CAM use in IBD includes diet changes, supplements, herbals, botanicals, and mind-body therapies. Common reasons for using CAM include severe disease and concern for adverse effects of conventional medicines. Despite widespread use, there are limited studies on efficacy and safety of CAM in children. Small studies suggest a favorable evidence for use of probiotics, fish oil, marijuana, and mind-body therapy in IBD. Adverse effects of CAM are reported but are rare. The article provides current state of knowledge on the topic and provides guidance to physicians to address CAM use in pediatric patients with IBD.

Prevalence and Patterns of Marijuana Use in Young Adults With Inflammatory Bowel Disease.

OBJECTIVES: Recent studies in adults report symptom relief with marijuana use in patients with inflammatory bowel disease (IBD). We assessed the prevalence, pattern, effects, and adverse effects of marijuana use in young adults with IBD. METHODS: We conducted a prospective questionnaire survey study at a pediatric IBD clinic. All patients (18-21 years of age) answered anonymous questionnaires about demographics, IBD, medications, and marijuana use. RESULTS: Fifty-three patients (mean age 18.7 years, 32 boys) were enrolled. Thirty-seven patients (70%) reported using marijuana currently or in the past. There was no statistically significant difference between the users and nonusers of marijuana regarding demographics, disease activity, or medications. Despite prolonged use of marijuana, 70% of patients did not discuss it with their gastroenterologists. Twenty-four patients used marijuana medicinally for IBD symptoms in addition to medical therapy. Although majority found marijuana to be moderately/very helpful, complete relief of symptoms such as abdominal pain, poor appetite, nausea, and diarrhea was seen in 29%, 37%, 14%, and 10% of patients, respectively. Only half of patients reported knowledge of possible adverse effects of marijuana and 19% of patients reported mild neuropsychiatric adverse effects. Overall, 98% of patients supported legalization of marijuana and 85% were interested in using medical marijuana if it became legally available. CONCLUSIONS: We found a high rate of marijuana use in our cohort of young adults with IBD. Majority of users report symptom improvement but do not inform physicians. Future well-controlled studies are necessary to assess role of marijuana in IBD therapy.

Obesity and gastrointestinal disorders in children.

Obesity in children has become a global pandemic during the last decade. Recent studies have reported an association between obesity and functional gastrointestinal (GI) disorders. In addition, obesity is also becoming increasingly recognized at diagnosis of organic GI diseases such as celiac disease and inflammatory bowel disease. An awareness of all possible complications and associations of obesity by the practicing physician is crucial to provide comprehensive care to obese children. This article reviews the present data on the association between obesity and various common GI disorders. The possible mechanisms and the clinical significance of this association are also discussed.

Celiac disease in a child with ulcerative colitis: a possible genetic association.

Celiac disease and inflammatory bowel disease including ulcerative colitis (UC) and Crohn's disease are both immune-mediated enteropathies. It is rare for both celiac disease and inflammatory bowel disease to occur together in an individual patient. This association has been reported in adults, however, very rarely in children. Here, we report an unusual case of an 8-year-old child with a history of anemia and failure to thrive who presented with bloody diarrhea. His evaluation showed anemia, elevated inflammatory markers, and positive celiac antibodies. Endoscopic evaluation revealed partial duodenal villous atrophy and pancolitis. He was diagnosed with celiac disease and UC and responded well to a gluten-free diet and steroid/mesalamine therapy. The patient's genetic testing revealed markers showing susceptibility for both celiac disease and UC. It is important to be aware of this association as both conditions can present with similar clinical features, however, require different therapeutic approaches.

Two-day bowel preparation with polyethylene glycol 3350 and bisacodyl: a new, safe, and effective regimen for colonoscopy in children.

OBJECTIVES: To assess the safety, efficacy, and acceptance of a 2-day bowel preparation with polyethylene glycol (PEG) 3350 without electrolytes and bisacodyl for colonoscopy in children. PATIENTS AND METHODS: In a prospective study, 111 children of mean age 11.9 years were given 2 g/kg of PEG and a 5-mg tablet of bisacodyl daily for 2 days before colonoscopy. Stool frequency, consistency, and adverse effects were monitored for the duration of the bowel preparation. Compliance and quality of colonic preparation were assessed on the day of the colonoscopy. RESULTS: The average daily stool frequency increased from a baseline of 2, to 4* on day 1, and 6.5* on day 2 of the bowel preparation (*P < 0.001 for difference vs baseline). The colonic preparations were rated as excellent or good in 92% and 93% of the patients in the right and left colon, respectively. Adverse effects were mild nausea (19%), abdominal pain (11%), and vomiting (4%). The compliance was rated as excellent in 95% of the patients. CONCLUSIONS: A 2-day bowel preparation with PEG and bisacodyl is safe, effective, and well accepted for colonoscopy in children without any major adverse effects.

Recurrent acute pancreatitis in a child with primary hyperparathyroidism.

Hypercalcemia is an important etiology to consider in the evaluation of acute pancreatitis. Not only is it a treatable cause, but understanding the basis for this etiology may provide new insight into the common biochemical mechanisms involved in the pathogenesis of pancreatitis. We report a case of an 11-year-old girl with hypercalcemia due to primary hyperparathyroidism who developed recurrent pancreatitis. We review clinical and experimental data that implicate hypercalcemia as the cause and discuss mechanisms for the association.