Safety and Durability of Accelerated Infliximab Dosing Strategies in Pediatric IBD: A Single Center, Retrospective Study.

OBJECTIVES: Infliximab (IFX) is commonly used to treat children with inflammatory bowel disease (IBD). We previously reported that patients with extensive disease started on IFX at a dose of 10 mg/kg had greater treatment durability at year one. The aim of this follow-up study is to assess the long-term safety and durability of this dosing strategy in pediatric IBD. METHODS: We performed a retrospective single-center study of pediatric IBD patients started on IFX over a 10-year period. RESULTS: Two hundred ninety-one patients were included (mean age = 12.61, 38% female) with a follow-up range of 0.1-9.7 years from IFX induction. One hundred fifty-five (53%) were started at a dose of 10 mg/kg. Only 35 patients (12%) discontinued IFX. The median duration of treatment was 2.9 years. Patients with ulcerative colitis ( P ≤ 0.01) and patients with extensive disease ( P = 0.01) had lower durability, despite a higher starting dose of IFX ( P = 0.03). Adverse events (AEs) were observed to occur at a rate of 234 per 1000 patient-years. Patients with a higher serum IFX trough level (≥20 µg/mL) had a higher rate of AEs ( P = 0.01). Use of combination therapy had no impact on risk of AEs ( P = 0.78). CONCLUSIONS: We observed an excellent IFX treatment durability, with only 12% of patients discontinuing therapy over the observed timeframe. The overall rate of AEs was low, the majority being infusion reactions and dermatologic conditions. Higher IFX dose and serum trough level> 20 µg/mL were associated with higher risk of AEs, the majority being mild and not resulting in cessation of therapy.

Postpyloric Feeding Access in Infants and Children: A State of the Art Review.

Achieving postpyloric feeding access is a clinical challenge faced by the pediatric gastroenterologist in everyday practice. Currently, there is limited literature published on the topic. This article provides a practical summary of the literature on the different methods utilized to achieve postpyloric feeding access including bedside, fluoroscopic, endoscopic and surgical options. Indications and complications of these methods are discussed as well as a general approach to infants and children that require intestinal feeding.

Durability of Infliximab Is Associated With Disease Extent in Children With Inflammatory Bowel Disease.

OBJECTIVES: The aim of the study was to evaluate infliximab (IFX) dosing and treatment durability relative to luminal disease burden in patients with inflammatory bowel disease. METHODS: Records from 98 pediatric patients treated with IFX between 2012 and 2014 were reviewed. Disease extent was classified as "limited," "moderate," or "extensive" based on cumulative assessment of mucosal involvement. Patients started taking standard 5 mg/kg dosing were compared with those initiated taking 10 mg/kg with regard to treatment durability. RESULTS: Overall, 26.4%, 58.3%, and 70% with limited, moderate, or extensive disease, respectively, started taking a standard IFX dose of 5 mg/kg required therapy escalation. Patients with moderate and extensive disease, started taking the 5 mg/kg per dose, showed statistically significant shorter times to escalation than those with limited disease. The percentage of patients remaining on their initial 5 mg/kg per dose at 12 months was 80.1%, 56.9%, and 40.0% for limited, moderate, and extensive disease, respectively. Among patients started taking 10 mg/kg, 100% remained on this dose. All the patients with limited disease who required dose escalation continued on the higher dose at the time of analysis; however, among those with the most extensive disease, 43% failed escalation because of nonresponse or infusion reaction. CONCLUSIONS: Patients with extensive disease started taking 5 mg/kg of IFX were more likely to require dose escalation compared to those with limited or moderate disease. All of the patients with moderate and extensive disease started taking 10 mg/kg of IFX remained on this dose. These results suggest that patients with more extensive disease may benefit from higher initial IFX dosing as it relates to durability of the treatment.

An unusual case of pediatric granulomatosis with polyangiitis complicated by splenic infarction presenting as inflammatory bowel disease.

We describe a case of granulomatosis with polyangiitis (GPA) in a 7-year-old-male who initially presented with symptoms concerning for Inflammatory bowel disease. GPA is a rare, multisystemic necrotizing vasculitis involving small arteries and veins. The clinical presentation can be variable given its multisystemic involvement but more commonly involves the upper and lower airways and kidneys. This case highlights rare gastrointestinal symptoms of GPA, further complicated by an additional unique finding of splenic infarction. We hope to raise awareness for this rare illness to assist in diagnosis and treatment, as timely induction of remission can reduce significant morbidity and mortality in the pediatric population.

Knowledge, Attitudes, and Behaviors of Pediatric Primary Care Providers on Management of Cholestasis.

Biliary atresia is a common cause of cholestasis in infants and is a time-sensitive diagnosis. A survey was distributed to pediatric primary care providers in order to assess variations in diagnosis and management of cholestasis. Participants were identified from physician parent groups on social media and regional pediatric residency programs. Information on knowledge and interpretation of screening tests, past experience/behavior, confidence, and comfort level managing cholestasis, as well as demographic information was collected. Out of 116 eligible respondents, 94.8% were confident in diagnosing hyperbilirubinemia but only 10.3% knew the biochemical definition of direct hyperbilirubinemia. Of the 56% of providers who had some knowledge of the guidelines, 18.5% stated the guidelines changed the way they evaluate cholestasis. These results demonstrate a gap in knowledge of diagnosing and evaluating cholestasis, which could provide the framework for standardized screening, leading to earlier identification of biliary atresia.