Journal of Pediatric Gastroenterology and Nutrition最新文献

Objective: Acute pancreatitis (AP) is a common paediatric condition, yet there is little data to support optimal analgesic practice. The aim of this scoping review was to report analgesic practice, investigate trends in analgesic strategy and evaluate the impact of analgesic modality on outcomes.

Methods: A systematic search of Medline, Embase, CENTRAL, Pubmed Central and Google Scholar was performed by two independent investigators. This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

Results: Three retrospective cohort studies, all conducted in North America, reported on analgesic practice in paediatric AP. The studies included 658 patients (median age, 12 years; female sex, 57%; non-biliary aetiology, 85.9%). Overall, analgesia was administered in 67% of patients, including opioids in 59.5% (43.8%-71.4%). Rates of acetaminophen (17.9% and 77.7%) and non-steroidal anti-inflammatory drugs (7.7% and 40.2%) were reported in two studies. Two studies reported reducing rates of opioid administration or reduced duration of opioid administration since 2017 and 2014, respectively. One study did not find any correlation between opioid administration and sociodemographic factors, length of stay or admission to intensive care units. No studies reported on complications or quality of life. No studies investigated non-medical modalities. There were no long-term data on analgesic use post-discharge.

Conclusions: Opioids are the mainstay of pain treatment in paediatric AP in North America. However, factors that influence the analgesic type, the impact of analgesic modality on the post-pancreatitis outcome and long-term analgesic use constitute a knowledge gap. Future studies are needed to inform analgesic use in paediatric AP.

Mutations in doublecortin domain-containing protein 2 (DCDC2) lead to neonatal sclerosing cholangitis (NSC), and portal hypertension (PHTN). The objective of the study was to systematically evaluate PHTN, variceal bleeding, and outcomes of patients with DCDC2-related NSC. The study included children with homozygous or compound heterozygous variants in DCDC2. All 14 children with DCDC2-related NSC had PHTN. Eight (57.1%) developed variceal bleed at a median age of 3 years (range: 1.9-5 years). Eleven (78.6%) children with high-risk varices underwent endotherapy. Varices were completely eradicated in three, downstaged to low-risk in five, and there was no response with endotherapy in three. All three children with failure to eradicate/downstage varices had rebleed, and required listing for liver transplantation (LT). The study shows that children with variants in DCDC2 have a high incidence of variceal bleed at a very young age. Variceal eradication may often be difficult and rebleed rates are high; often necessitating LT.

Portal hypertension, a common sequela of chronic liver disease, is complicated by variceal hemorrhage, one of its most serious complications. Evidence-based approaches to managing variceal hemorrhage are limited by the scarcity of data related to this rare entity. Multicenter international registries are increasingly utilized to garner critical information about rare diseases. The International Multicenter Pediatric Portal Hypertension Registry (IMPPHR) was developed to acquire pediatric data about the mortality of first variceal hemorrhage and approaches to primary and second prophylaxis of variceal hemorrhage with a goal of improving outcomes in children with portal hypertension. IMPPHR evolved from pediatric portal hypertension symposia at the Baveno V and VI meetings in 2010 and 2015, with a formal executive committee initiating the development of IMPPHR in 2019. The registry opened in 2020, with data closure in 2024, including information from 44 centers and >700 subjects. The complexities and approaches to developing IMPPHR are described.

Objectives: We aimed to analyze the episodes of esophageal food bolus impaction (EFI) occurred over a time of 15 years in children admitted to a large pediatric emergency department (PED), documenting their clinical presentation, underlying pathology, management, biopsy rate, and follow-up visits. Additionally, to combine our institutional experience with the existing literature, a comprehensive review was conducted.

Methods: We reviewed the medical records of all children presenting to our PED with EFI from 2010 to 2024. The comprehensive review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement for systematic reviews. Electronic databases including PubMed/Medline and EMBASE were screened. The data obtained was synthesized to map out the actual status and current literature on pediatric EFI.

Results: We identified 54 cases of EFI. Overall, 22 patients (41%) had underlying pathology. Previous episodes were reported in 14 cases (26%). Urgent endoscopy was performed in 31 cases (57%). The presence of underlying pathology was associated with the need for endoscopic removal (p = 0.013), as well as the history of previous episodes (p = 0.016). Biopsies were performed in 14 cases (26%). Pediatric gastroenterologists showed a higher rate of performed biopsies compared to surgeons, as well as higher rate of follow-up visits. An underlying disease was found during later clinical follow-up in 5 out of 54 cases of EFI (9%). A comprehensive review of 16 studies revealed high rates of underlying pathology and low rates of biopsies and follow-up visits among children with EFI.

Conclusion: Increased vigilance in identifying underlying pathologies in children with EFI is crucial. The importance of performing biopsies, regardless of prior anatomical conditions, and the need for ongoing follow-up to ensure timely and accurate diagnoses should be addressed through shared protocols.

The Nancy Histological Index (NHI) is used to score histologic disease activity in patients with ulcerative colitis (UC). Our goal was to assess the utility of NHI at diagnosis in predicting clinical outcomes in pediatric patients with UC, in comparison to clinical and endoscopic scores. We retrospectively reviewed data at diagnosis of 106 children with UC (59 [55.7%] females; median age 14.4 [11.2-15.9] years, median Pediatric Ulcerative Colitis Activity Index [PUCAI] 35 [25-55]). During a follow-up of 116 (55-171) weeks, 33 patients (31.1%) required azathioprine therapy, and 32 (30.2%) were escalated to anti-tumor necrosis factor alpha (anti-TNFa). The PUCAI and Mayo endoscopic scores at diagnosis were significantly associated with escalation to anti-TNFa (p = 0.036 and p = 0.02, respectively), but not with initiation of azathioprine or subsequent acute severe colitis (ASC) events. However, the NHI was not associated with subsequent immunomodulators or anti-TNFa therapy (p = 0.42 and p = 0.78, respectively), nor with future ASC events (p = 0.70). In conclusion, the NHI failed to predict clinical outcomes in newly diagnosed pediatric patients with UC.

Objective: Upadacitinib, an oral Janus kinase inhibitor (JAKi), is approved for inflammatory bowel disease (IBD) in adults. As on-label use will face significant delay in pediatrics, a real-world understanding of safety and efficacy in children is critical.

Methods: This is a single-center retrospective cohort of pediatric subjects (ages 9-20 years) with a diagnosis of IBD initiated on upadacitinib. The primary outcome was clinical response following induction (decrease of ≥20 points in the Pediatric Ulcerative Colitis Activity Index [PUCAI] or ≥12.5 points for the Pediatric Crohn's Disease Activity Index [PCDAI]). Secondary outcomes included steroid-free clinical remission (SF-CR) following induction and at Week 24 (PUCAI or PCDAI ≤10), post-induction mucosal response and remission (Mayo for ulcerative colitis [UC]/IBD-unclassified [IBD-U] and simple-endoscopic scoring for CD), and improvement in calprotectin and C-reactive protein (CRP) post-induction. Monitoring for adverse events was recorded.

Results: Twenty subjects (40% female with a median age of 16.3 years; 3 CD, 13 UC, 4 IBD-U) were initiated on upadacitinib. Clinical response at Week 8 (UC/IBD-U) and Week 12 (CD), was achieved in 90% (18/20). SF-CR was seen in 75% (16/20) following induction and maintained in 65% (11/17) reaching Week 24 of therapy. In subjects with UC/IBD-U (17), PUCAI was significantly improved at Weeks 8 and 24. Calprotectin post-induction showed a significant downtrend, whereas CRP did not. Endoscopic response was noted in seven of the eight cases, with three achieving endoscopic remission. One patient underwent subtotal colectomy after 2 weeks of upadacitinib induction. Another patient stopped therapy following the creation of a diverting ileostomy secondary to rectal perforation experienced following manual dilation of a rectal stricture. No new safety signals were reported.

Conclusion: Therapeutic options for children with IBD remain limited. In cases refractory to approved agents, our experience suggests that upadacitinib is effective with no new safety signals in a small subset of patients with IBD (ages 9-20 years) treated at a children's hospital.

Objectives: We aimed to evaluate the prevalence of food insecurity (FI) in the community pediatric gastroenterology (GI) subspecialty clinic at Texas Children's Hospital (TCH) West Campus and to assess the utilization of services through our partnership with a local food bank.

Methods: From July 1, 2023, to February 29, 2024, all patients seen in the pediatric GI clinic at TCH West Campus were screened for FI using the validated Hunger Vital Sign tool and given the opportunity to consult with a local food bank representative. A retrospective chart review was then performed on patients who completed the implemented FI screening process.

Results: 13.4% of the total patients screened positive for FI. Hispanic patients (p < 0.0001), patients with the preferred language of Spanish (p < 0.0001), those enrolled in Medicaid or Children's Health Insurance Program (p < 0.0001), and patients with obesity (body mass index ≥ 30.0, p = 0.0003) were more likely to screen positive for FI. Poor weight gain/failure to thrive and steatotic liver disease were significantly more common in those with FI (p < 0.0001 and p = 0.0003, respectively), while celiac disease, abdominal pain, and blood in stool were more common in those without FI (p = 0.0003, 0.0475, and 0.0404, respectively). As a result of our implemented FI screening process, 68.4% of those screening positive opted for resource referral, with 50.7% successfully receiving assistance in combating FI.

Conclusions: Identifying the potential impact of FI in common pediatric GI conditions calls for proactive screening and more holistic, patient-centered approaches in clinical practice.

Pediatric obesity, characterized by a body mass index (BMI) at or above the 95th percentile for age, affects a substantial number of children and adolescents worldwide. Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease, represents a prominent hepatic manifestation of obesity and metabolic syndrome, emerging as the most prevalent hepatic disorder among pediatric patients and a significant contributor to liver transplantation in adults. The escalating prevalence of pediatric MASLD mirrors the alarming rise in childhood obesity rates over recent decades. While lifestyle modifications focusing on dietary changes and increased physical activity constitute the cornerstone of MASLD management, achieving and maintaining significant weight reduction remains challenging. Moreover, disease progression often persists despite standard-of-care interventions, warranting exploration into alternative therapeutic strategies. Pharmacological interventions, particularly, glucagon-like peptide-1 receptor agonists (GLP-1RA), have shown promise in addressing pediatric obesity and its associated comorbidities, including MASLD. Recent studies have demonstrated the efficacy of GLP-1RA in inducing weight loss and improving liver enzyme levels, suggesting a potential role in halting disease progression, and reducing the risk of major adverse liver outcomes. This review provides a comprehensive overview of the current pharmacotherapy landscape for pediatric MASLD, with a focus on novel agents such as GLP-1RA. Furthermore, the manuscript proposes a practical algorithm to assist in integrating GLP-1RA into the clinical management of pediatric patients with obesity and MASLD. Despite promising results, further research is warranted to elucidate the long-term efficacy and safety of GLP-1RA in pediatric populations.