Improved Neurodevelopmental Outcomes Associated with Bovine Milk Fat Globule Membrane and Lactoferrin in Infant Formula: A Randomized, Controlled Trial.

OBJECTIVE: To evaluate neurodevelopment, growth, and health outcomes in infants receiving bovine milk fat globule membrane (MFGM) and lactoferrin in infant formula. STUDY DESIGN: Healthy term infants were randomized to a cow's milk-based infant formula or MFGM + LF (a similar infant formula, with an added source of bovine milk fat globule membrane [bMFGM; whey protein-lipid concentrate, 5 g/L] and bovine lactoferrin [0.6 g/L]) through 365 days of age. The Bayley Scales of Infant Development, 3rd edition cognitive composite score at day 365 was the primary outcome. Secondary outcomes included tolerance measures through day 365, additional neurodevelopmental and language outcomes, growth, and medically confirmed adverse events through day 545. RESULTS: Of 451 infants enrolled (control, 228; MFGM + LF, 223), 291 completed study feeding and Bayley-III testing at day 365 (control, 148; MFGM + LF, 143). The mean cognitive (+8.7), language (+12.3), and motor (+12.6) scores were higher (P < .001) for the MFGM + LF group; no differences were observed at day 545. Global development scores from day 120 to day 275 and attention at day 365 were significantly improved. Few group differences in day 545 neurodevelopmental outcomes were detected, however scores of some subcategories of the MacArthur-Bates Communicative Development Inventories were higher (P < .05) in the MFGM + LF group. The overall incidence of respiratory-associated adverse events and diarrhea were significantly lower for the MFGM + LF group through day 545. CONCLUSIONS: Infants receiving formula with added bovine MFGM and bovine lactoferrin had an accelerated neurodevelopmental profile at day 365 and improved language subcategories at day 545. Formulas were associated with age-appropriate growth and significantly fewer diarrhea and respiratory-associated adverse events through 545 days of age. TRIAL REGISTRATION CLINICALTRIALS.GOV:: NCT02274883.

Lactose-Free Milk or Soy-Based Formulas Do Not Improve Caregivers' Distress or Perceptions of Difficult Infant Behavior.

OBJECTIVES: The aim of the study was to test the hypothesis that caregiver-reported difficulties in infant behavior and caregivers' distress will significantly improve on lactose-free (LF) milk-based or LF soy-based formulas compared with a milk-based, lactose-containing formula. METHODS: In this double-blind randomized controlled trial, infants (mean age: 4.97 weeks) with caregiver-reported feeding problems on a milk-based lactose-containing formula were randomized to receive either LF milk-based (n = 96), LF soy-based (n = 97), or milk-based, lactose-containing (n = 103) formula. Study formula was infants' sole item of diet for 14 days. Infants' caregivers completed measures of infant behavior and caregivers' distress for the week preceding baseline and again for the week preceding the 14-day follow-up. RESULTS: Infants who received LF milk or LF soy-based formulas did not significantly differ from those who received milk-based, lactose-containing formula on follow-up caregiver-reported measures of infant difficultness from the Infant Characteristics Questionnaire, F(2, 277) = 0.83, nor on measures of caregivers' distress, assessed with measures of caregivers' mental health and parenting efficacy, F(2, 285) = 0.73-1.07. Across the 3 formula groups, scores on outcome measures significantly improved from baseline to follow-up (P < 0.001). CONCLUSIONS: Our study does not support LF milk or LF soy-based formulas to alleviate common infant behaviors such as fussiness, crying, or need for attention. Moreover, the data suggest that some difficulties in infant behaviors, as well as caregivers' distress and perceived efficacy in parenting difficult infants, may improve within a couple weeks of reporting difficulties to the pediatrician.

Nutritional and psychosocial outcomes of gastrostomy tube-dependent children completing an intensive inpatient behavioral treatment program.

OBJECTIVES: Limited published data describe the long-term effects of behavioral strategies to wean children from gastrostomy tube (GT) feeding dependence. This study presents data relating to nutritional and psychosocial outcomes observed during a 1-year period in medically complex GT feeding-dependent patients who completed an inpatient behavioral-based tube weaning protocol. METHODS: This was a retrospective study of prospectively and retrospectively collected data associated with a clinical cohort of 77 children diagnosed as having a feeding disorder, GT feeding dependence (>1 year), and an inability to maintain acceptable growth via oral feeding completing an inpatient tube weaning protocol. Nutritional data (percentage of ideal body weight, and oral energy intake as percent ofenergy goal) and psychosocial data (mealtime behavior problems, quality of caregiver and child interactions, and parenting stress) were assessed pre- and post-hospitalization. Nutritional data were also monitored longitudinally at 1, 3, 6, and 12 months postreatment. Data were grouped for retrospective analysis. RESULTS: Mealtime environment and feeding behaviors significantly improved, and all of the patients demonstrated reductions in tube dependence aside from 1 treatment failure. Fifty-one percent of patients were fully weaned from tube feeding after 2 weeks and an additional 12% completed weaning in the outpatient follow-up clinic within 1 year. Patients maintained nutritional stability at the 1-year posttreatment follow-up appointment. CONCLUSIONS: Inpatient behavioral interventions are highly effective and safe for transitioning long-term tube feeding children to oral feeding.

Do oro-anal transit markers predict which children would benefit from colonic manometry studies?

OBJECTIVES: The aim of the study was to compare oro-anal transit time (OTT) measured by radio-opaque markers with colon motility (CM) findings in children with chronic constipation and to assess clinical outcomes in children with chronic constipation evaluated by OTT and CM studies. METHODS: Twenty-four children with chronic constipation (12 girls; median age 12 years [3-18 years]; median symptoms 87 months [6-186 months]) who underwent OTT and CM studies were reviewed. The OTT was determined using commercially available Sitzmarks. Patients were studied for a median of 23 months (4-60 months) and outcomes reviewed. RESULTS: All 5 children with normal OTT had normal CM; however, only 47% (9/19) of children with slow OTT had an abnormal CM. The abnormal CM findings were total colonic pseudo-obstruction in 3 and left colonic pseudo-obstruction in 6 children. Of the 9 children with abnormal CM, 5 were managed surgically, 1 with medicine escalation, and 3 were lost to follow-up; all 6 children with known follow-up have more bowel movements and less soiling. Of the 15 children with normal CM, 10 were managed with medication escalation, 3 with behavioral intervention, and 2 surgically. Of these 15 children, 8 improved, 1 did not change, 2 worsened, and 4 were lost to follow-up. CONCLUSIONS: OTT studies may be helpful to predict which children should be referred for CM studies. Normal OTT studies may predict normal colon manometry; however, abnormal OTT studies may not predict abnormalities in colonic manometry in children with chronic constipation. Therefore, patients with slow transit marker studies should be assessed by colon manometry to evaluate colon neuromuscular integrity.

Assessing family-based feeding strategies, strengths, and mealtime structure with the Feeding Strategies Questionnaire.

OBJECTIVE: Develop a questionnaire to assess family-based feeding strategies, strengths, and mealtime structure for use with children with feeding problems; validate this new instrument with caregivers of young children from the community and a specialty feeding-clinic; and examine preliminary evidence for reliability and validity. METHODS: Community caregivers (n = 702) and caregivers seeking services at a pediatric feeding specialty clinic (n = 288) completed the Feeding Strategies Questionnaire (FSQ). A smaller portion of these families also completed an established feeding measure. RESULTS: Exploratory and confirmatory factor analyses were conducted to develop and validate the FSQ factor structure that resulted in six scales: Mealtime Structure, Consistent Mealtime Schedule, Child Control of Intake, Parent Control of Intake, Between Meal Grazing and Encourages Clean Plate. Evidence of reliability and validity was obtained. CONCLUSION: It appears the FSQ can aid the assessment of feeding strategies relevant to the prevention or treatment of pediatric feeding difficulties.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).

OBJECTIVE: To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. METHODS: An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices. RESULTS: More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. CONCLUSIONS: This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Colonic volvulus in children with intestinal motility disorders.

BACKGROUND: Chronic intestinal pseudo-obstruction (CIP) is a condition characterized by symptoms of bowel obstruction in the absence of an anatomical cause. Patients with CIP and chronic intractable constipation (CIC) can also develop anatomical obstruction, and the presenting symptoms mimic those of underlying pseudo-obstruction. OBJECTIVES: Our objectives were to evaluate the incidence, clinical presentation, and diagnostic investigations of colonic volvulus in children with intestinal motility disorders and to differentiate these episodes of colonic volvulus from the underlying motility disorder based on clinical presentation and imaging techniques. MATERIALS AND METHODS: Patients records of children with colonic volvulus cared for at our institution over the previous 20 years were retrospectively reviewed. We identified 8 patients who were between 2 and 22 years of age at the time of diagnosis with colonic volvulus who also had CIP and CIC. RESULTS: The mean age +/- SD at presentation with colonic volvulus was 13.2 +/- 5.05 years. All patients presented with worsening of abdominal distension and pain. The mean duration of symptoms of colonic volvulus before seeking medical help was 4.2 days (range 1-7 days). Water-soluble contrast enema was the single most useful investigation for confirming the diagnosis. All patients required surgery. There was no mortality associated with colonic volvulus. CONCLUSIONS: Clinicians should be vigilant and include volvulus in the differential diagnosis of the acute onset of abdominal distension and pain in patients with CIP and CIC. Delay in diagnosis can result in bowel ischemia and perforation.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition consensus statement on the diagnosis and management of cyclic vomiting syndrome.

Cyclic vomiting syndrome (CVS) is a disorder noted for its unique intensity of vomiting, repeated emergency department visits and hospitalizations, and reduced quality of life. It is often misdiagnosed due to the unappreciated pattern of recurrence and lack of confirmatory testing. Because no accepted approach to management has been established, the task force was charged to develop a report on diagnosis and treatment of CVS based upon a review of the medical literature and expert opinion. The key issues addressed were the diagnostic criteria, the appropriate evaluation, the prophylactic therapy, and the therapy of acute attacks. The recommended diagnostic approach is to avoid "shotgun" testing and instead to use a strategy of targeted testing that varies with the presence of 4 red flags: abdominal signs (eg, bilious vomiting, tenderness), triggering events (eg, fasting, high protein meal), abnormal neurological examination (eg, altered mental status, papilledema), and progressive worsening or a changing pattern of vomiting episodes. Therapeutic recommendations include lifestyle changes, prophylactic therapy (eg, cyproheptadine in children 5 years or younger and amitriptyline for those older than 5), and acute therapy (eg, 5-hydroxytryptamine receptor agonists, termed triptans herein, as abortive therapy, and 10% dextrose and ondansetron for those requiring intravenous hydration). This document represents the official recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition for the diagnosis and treatment of CVS in children and adolescents.

Erythromycin lacks colon prokinetic effect in children with functional gastrointestinal disorders: a retrospective study.

BACKGROUND: Motilin, a peptide hormone has a direct excitatory effect on circular smooth muscle strips derived from the human colon. Reduced plasma motilin concentration has been reported in adults with chronic constipation. Erythromycin, a non-peptide motilin receptor agonist, induces phase 3 of the migrating motor complex (MMC) in the antro-duodenum and also reduces oro-cecal transit time. A pediatric study has reported an improvement in clinical symptoms of constipation following erythromycin administration, but the effect on colon motility in children has not been formally evaluated. We used colon manometry to study the effect of intravenous erythromycin lactobionate at 1 mg/kg on colon motility in ten children. METHODS: We selected patients with normal antroduodenal and colon manometry studies that were performed simultaneously. All studies were performed for clinically indicated reasons. We quantified the effect of erythromycin on colon contraction by calculating the area under the curve (AUC). RESULTS: The mean (SE of mean) AUC in the colon during the fasting, post-erythromycin and postprandial phases of the study was 2.1 mmHg/sec (0.35), 0.99 mmHg/sec (0.17) and 3.05 mmHg/sec (0.70) respectively. The AUC following erythromycin was significantly less compared to the fasting phase of the study (p < 0.01). CONCLUSION: Erythromycin lacks colon prokinetic effect in children with chronic constipation evaluated by colon manometry.

Neuromotor markers of esophageal motility in feeding intolerant infants with gastroschisis.

BACKGROUND: Feeding problems in neonates with gastroschisis are commonly attributed to foregut dysmotility. However, the dysmotility mechanisms are not well understood. OBJECTIVE: Our aim was to differentiate the pharyngoesophageal motility characteristics in neonates with gastroschisis compared with the controls. Specifically, the characteristics of swallowing, upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES) were evaluated during basal state and upon provocation. PATIENTS AND METHODS: Surgically repaired and recovered study infants with persistent feeding difficulties (n = 8; 36 +/- 2 weeks gestational age) and controls (n = 8; 38 +/- 2 weeks gestational age) were evaluated at 40 +/- 2 weeks and 42 +/- 2.5 weeks postmenstrual age, respectively. The basal and adaptive pharyngoesophageal motility characteristics were evaluated using a specially designed esophageal motility catheter with UES and LES sleeves and pneumohydraulic micromanometric water perfusion system at the crib side. Analysis of variance, chi-square, and t tests were applied; data are shown as mean +/- standard deviation, and P < 0.05 was considered significant. RESULTS: Birth weight was less in gastroschisis (P < 0.03, vs controls) and length was less at motility study (P < 0.01, vs controls). The study group (vs controls) needed prolonged respiratory support (21 +/- 23 vs 1 +/- 2 days; P < 0.001) and prolonged gavage feeding (167 +/- 100 vs 9 +/- 16 days; P < 0.01). Compared with the controls, the gastroschisis group had lower frequency (P < 0.05) and poor propagation of spontaneous swallows (P < 0.001), UES relaxation time was shorter (P < 0.05), rate of relaxation was faster (P < 0.001), and esophageal peristaltic propagation velocity was slower (P < 0.05). Upon esophageal provocation with air and liquids, frequency occurrence of the esophageal reflexes was low (P < 0.05) with respect to primary peristalsis, secondary peristalsis, UES contractile reflex, and LES relaxation reflex. CONCLUSIONS: In gastroschisis feeding milestones and respiratory milestones were delayed, basal pharyngoesophageal peristaltic failure was common, adaptive peristaltic reflexes were less frequent and failed to occur, and frequency occurrences of UES and LES responses were impaired. These neuromotor markers may provide clues to define the esophageal motor function abnormalities in infants with an abnormality thought to be limited to the intestine.

Gastrointestinal motility disorders in adolescent patients: transitioning to adult care.

A wide spectrum of gastrointestinal motility disorders present in childhood. Some are unique to children, especially congenital disorders including certain pseudo-obstruction disorders or those associated with anatomic developmental defects, whereas others are common adult disorders, such as achalasia, that rarely manifest in children. This article reviews the pediatric presentations and sequelae of childhood gastrointestinal motility disorders and then discusses long-term management issues for these children as they progress into adulthood. The goal is to optimize medical care and ensure the adequate nutritional status essential for neurocognitive and psychosocial development of the child. Multidisciplinary care from specialists, including gastroenterologists, psychologists, and pain specialists, is often required to optimize the lives of these patients.

Treatment options in pediatric GERD.

Gastroesophageal reflux (GER) is a common physiologic phenomenon in infants and children. GER that results in symptoms or complications--hence the evolution to GER disease (GERD)--warrants targeted evaluation and appropriate treatment. Judicious use of acid-suppression therapy remains the mainstay of pharmacologic treatment of GERD. However, recognition of treatment goals and potentials risks of acid suppression must be considered prior to initiation of therapy. The role of surgical intervention for GERD remains limited.

Knowledge, attitudes and practice styles of North American pediatricians regarding gastroesophageal reflux disease.

BACKGROUND: The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition launched a provider and public education campaign in 2002 to raise awareness of gastroesophageal reflux disease (GERD). To determine the effectiveness of campaign messages, we conducted a knowledge, attitudes, and practice styles (KAPS) survey of pediatric providers. Understanding the spectrum of management styles of GERD in children is critical to achieve better health outcomes and reduce health care costs. MATERIALS AND METHODS: The KAPS questionnaire was administered to 6000 randomly selected members of the American Academy of Pediatrics. RESULTS: A total of 1245 members responded; 82% worked in a primary care setting and 18% in subspecialty practices. Overall, 66% of the members order diagnostic testing in routine practice, 54% start testing for GERD in neonates, and 38% start testing after 1 month of age. The most common tests ordered were barium esophagram (45%) and esophageal pH monitoring (37%). GERD treatment with acid suppression before ordering diagnostic testing was a choice of 82% of the respondents. However, 19% believed acid suppression was best achieved by H2 blockers. If acid suppression was indicated, then only 36% followed guideline recommendations for therapy duration and 52% followed guideline recommendations for dosing. Antireflux surgery was recommended only as a last resort by 92%. Overall, 69% of providers believed the amount of GERD-related information available was not enough. Respondents who were not aware of available GERD practice guidelines ranged from 74% to 92%. CONCLUSIONS: Pediatric providers appear to frequently order diagnostic testing and treatment for GERD, yet knowledge about evidence-based GERD management among this random sample appeared limited. Moreover, a significant number of providers were not aware of different guideline publications.

Removal of impacted food in children with eosinophilic esophagitis using Saeed banding device.

Food impaction in patients with eosinophilic esophagitis is being recognized increasingly. Retrieval of impacted food may be necessary if it does not resolve spontaneously. The present report describes a new technique for removal of friable impacted food from the esophagus using a modified version of the Saeed banding device. With this technique, impacted food was safely removed in a single attempt in each of 3 patients.

Reconceptualizing feeding and feeding disorders in interpersonal context: the case for a relational disorder.

The feeding of young children is fundamentally a relational and multisystemic process. Successful treatment of clinically significant feeding problems involves careful assessment of the full range of influences on the feeding relationship and integrated treatment approaches. However, current diagnostic approaches to feeding disorders tend to be reductionistic, exclusively focused on the child as an individual, and overly concerned with exclusionary criteria. Criteria are proposed for "Feeding Disorder Between Parent and Child" that address these limitations and embrace the complexity of feeding problems. A multiaxial diagnosis that describes the child (including medical, developmental, and behavioral characteristics); the parent; the parent-child relationship; and the social and nutritional context of feeding will more accurately speak to treatment planning in this population. The proposed diagnostic criteria were developed and refined on the basis of the available literature and many years of treatment experience across the authors of this article. The proposed diagnosis will support the development and evaluation of treatment packages with components specifically targeted to issues of the child, parent, parent-child interaction, and the broader environment.

The KTP laser: an emerging tool in pediatric otolaryngology.

PURPOSE: To report the frequency and spectrum of use of the potassium titanyl phosphate (KTP) laser in a tertiary referral pediatric otolaryngology practice and to focus on a novel use for the KTP laser which has not previously been described in the literature. DESIGN: A retrospective chart review of the operative log database of a pediatric otolaryngologist in a tertiary referral setting over a seven year period. RESULTS: Out of 2886 cases, a total of 49 (1.7%) involved the use of the KTP laser. These included 7 otologic cases, 3 laryngeal cases, 31 subglottic/tracheal cases, 1 esophageal case and 7 nasal cases. One of these cases involved a previously unreported use of the KTP laser, closure of a tracheo-esophageal fistula (TEF). CONCLUSION: The KTP laser is an important operative tool in pediatric otolaryngology and new uses for this laser continue to emerge. One of these, KTP closure of a TEF offers pediatric otolaryngologists the potential for significant changes in management of this congenital problem with reduced surgical morbidity. Familiarity with the KTP laser and expertise in its use and applications is essential in providing state-of-the-art care to pediatric otolaryngology patients in a tertiary referral center.

Altered laryngeal sensation: a potential cause of apnea of infancy.

Delayed maturation of respiratory control of breathing and the laryngeal adductor reflex (LAR) are commonly implicated in infant apnea. A swallow response occurs to remove the stimulus from the pharynx to prevent aspiration once the glottis reopens. Induction of apnea by poorly cleared endogenous upper airway secretions has been postulated to be a potential cause of infant apnea. Our purpose was to determine whether alteration in the LAR, an indicator of laryngeal sensation, and the presence of secretions influenced the responsiveness of the LAR in infants with apnea. The LAR was induced in 20 infants with apnea (median gestational age, 36.5 weeks) by application of air pulses of controlled duration (50 ms) and intensity (2.5 to 10 mm Hg) to the aryepiglottic fold. Twenty infants evaluated for upper respiratory tract anomalies were used as a comparison group (median gestational age, 39 weeks). The infants with apnea required higher-intensity stimuli (p < .001) to induce the LAR (6.2 +/- 1.6 mm Hg) than did the comparison group (4.3 +/- 1.0 mm Hg) and demonstrated poorer clearance of secretions (p < .001). These findings were significant even when we adjusted for postconceptional age at the time of the test (p = .007). The findings of this study suggest that decreased laryngeal sensitivity results in poor endogenous secretion clearance and that it may induce a prolonged glottic closure event to prevent aspiration. This closure may play a role in infant apnea.