Journal of Pediatric Gastroenterology and Nutrition最新文献

Objectives: Children with intestinal failure (IF) require central venous catheters for parenteral nutrition and are at risk for central line associated blood stream infections (CLABSI). Prophylactic ethanol lock therapy has historically been used for CLABSI prevention. A recent national shortage of ethanol necessitated exploring an alternative lock strategy using sodium bicarbonate. This study sought to assess the impact of ethanol and sodium bicarbonate locks on CLABSI rates in children with IF.

Methods: A retrospective cohort study was conducted in pediatric patients with IF 0-21 years of age followed by the Intestinal Rehabilitation Program at Seattle Children's Hospital who received ethanol or sodium bicarbonate locks from 2018 to 2023. Rates of CLABSI, line repair, line replacement and line occlusion were calculated per 1000 catheter days. Variables were compared between the two lock groups using the Mann-Whitney U or Fisher's exact tests.

Results: Fifty-five patients were identified including 19 children who received ethanol locks and 36 with sodium bicarbonate locks. Rates of CLABSI were similar between the ethanol and sodium bicarbonate lock cohorts (2.03 [3.46], 1.59 [2.83]; p = 0.617(mean [standard deviation]). The sodium bicarbonate group had a lower rate of line replacement (2.21 [1.17-3.84], 0.00 [0.00-1.73]; p = 0.01, median [interquartile range]) and trended toward a lower rate of line repair, (1.94 [0.00-4.15], 1.07 [0.00-1.61]; p = 0.23).

Conclusions: This study demonstrates that sodium bicarbonate locks are a safe and effective alternative to ethanol locks for pediatric patients with IF with equivalent rates of CLABSI and decreased rates of line replacements and repairs.

Objectives: Dietary therapy is often used in the management of children with inflammatory bowel diseases (IBD). Nevertheless, appropriate dietetic support and resources are not universally available, potentially leading to variable practices. This survey aimed to describe contemporary dietary practices and resourcing across IBD member centers of European Society of Paediatric Gastroenterology Hepatology & Nutrition (ESPGHAN).

Methods: An anonymous 33-item questionnaire survey on nutritional care and dietetic resources was circulated to the Porto Group and IBD Interest Group of ESPGHAN in November 2023.

Results: We obtained responses from 63/145 (43%) physicians from 31 countries. Fifty-four (86%) physicians, routinely use exclusive enteral nutrition (EEN) for induction of remission, 26/63 (41%) partial enteral nutrition (PEN) for maintenance of remission and 28 (44%) implement food-based dietary therapies, the most popular being Crohn's Disease (CD) exclusion Diet coupled with PEN 36 (61%). Notably, 41 (65%) reported offering dietary counseling for active CD compared to 20 (32%) for ulcerative colitis (UC, p = 0.005). Availability of a dietitian varied between centers, with 13 (21%) rarely or never having a dietitian available. Among sites where a dietitian was always or mostly available, 93% used EEN compared to 70% of sites where a dietitian was less available (p = 0.028). Access to dietitians was reported for 31% of CD patients in lower-income countries versus 66% in high-income countries (p = 0.015). Over 50% of CD patients sought dietary advice, compared to 41% of UC patients (p < 0.001).

Conclusions: We identified variable practices in nutritional therapy and dietetic resources among pediatric IBD centers. Addressing these challenges will improve IBD therapy and integrate nutritional therapies in the multi-disciplinary care of these patients.

Objectives: Few approved treatments exist for children with Crohn's disease (CD). The REALITI study retrospectively assessed the effectiveness and safety of ustekinumab in real-world clinical settings for children with CD.

Methods: Data were collected from the prospective ImproveCareNow (ICN) registry for pediatric patients (≥ 2 to <18 years old) and young adult patients (≥ 18 to <26 years old), regardless of baseline CD severity. Additional analyses were conducted for a subset of patients who had moderately-to-severely active CD (short pediatric CD activity index [sPCDAI] ≥30). Key Week-52 endpoints included clinical remission (sPCDAI ≤10) and corticosteroid-free (CF) clinical remission. Safety events of interest were assessed at Week 52.

Results: Overall, 479 patients with CD were treated with ustekinumab, 348 pediatric patients and 131 young adults; most were biologic-exposed (pediatric, 98.9%; young adult, 95.4%). At Week 52 (observed case; excluding patients without Week 52 data), clinical remission was achieved by 47.3% (125/264) of pediatric patients and 44.8% (39/87) of young adults, and CF clinical remission by 41.3% (109/264) and 39.1% (34/87), respectively. At Week 52 (observed case), among patients with moderately-to-severely active CD, clinical remission was achieved by 36.9% (41/111) of pediatric patients and 34.3% (12/35) of young adults, and CF clinical remission by 31.5% (35/111) and 28.6% (10/35), respectively. Ustekinumab was well tolerated, with no new safety signals identified.

Conclusions: In the REALITI study of real-world data from the ICN registry, the effectiveness and safety of ustekinumab treatment through 52 weeks were similar in pediatric and young adult patients with CD.

Trial registration: ClinicalTrials.gov identifier: NCT05242458; https://clinicaltrials.gov/study/NCT05242458.

Objectives: Complete blood count (CBC) is a simple and cost-effective test performed during routine examination. We investigated whether CBC could assist in the assessment of disease phenotype and disease activity at diagnosis in pediatric inflammatory bowel disease (IBD).

Methods: We included 120 pediatric patients (73 ulcerative colitis [UC] and 47 Crohn's disease [CD]) and 120 age-matched healthy controls (6-18 years). CBC indices, including neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR) and neutrophil-to-monocyte ratio (NMR) measured at onset, were compared between the patient and control groups. Optimal cut-off values for absolute lymphocyte count (ALC) and LMR were determined using the ROC curve analysis and the Youden Index to predict disease behavior in patients with CD. Multivariate logistic regression analysis was used to evaluate the independent relationship between these parameters and to predict disease behavior in CD.

Results: UC and CD patients demonstrated significantly higher leukocyte, platelet, neutrophil, monocyte counts and NLR compared to controls (p < 0.05). CD patients had significantly lower ALC than UC and control groups (p = 0.008 and p = 0.039, respectively). Patients with moderate- severe UC and pancolitis exhibited significantly decreased Hgb levels, MCV and increased PLT counts (p < 0.05). After adjusting for age and sex at diagnosis, multivariate logistic regression analysis revealed that decreased ALC (< 1.65 ×109/L) and LMR (< 2.54) were significant predictors of CD with stricturing, penetrating disease and perianal involvement (p = 0.049 and p = 0.004, respectively).

Conclusions: In pediatric IBD, the severity of UC and disease behavior of CD can be assessed using CBC indices at diagnosis. These results demonstrate the potential role of CBC indices in predicting disease phenotype.

Objective: A tracheoesophageal fistula (TEF) is an abnormal communication between the esophagus and trachea, most often associated with esophageal atresia (EA), a rare congenital malformation affecting 1 in 2400-4500 live births. While surgical repair of EA/TEF is typically completed in infancy, recurrent or missed TEF can be diagnosed later. Open repair can be technically challenging, often requiring re-do thoracotomy or neck dissection. We describe our center's experience, using endoscopic electrocautery in combination with esophageal clips for closure of TEF.

Methods: We conducted a retrospective review of all patients who underwent an endoscopic TEF repair with esophageal clip application at our institution (IRB# 20-021016). All patients underwent triple endoscopy (flexible bronchoscopy, esophagogastroduodenoscopy, and rigid bronchoscopy) with pulmonary, gastroenterology (GI), and otolaryngology (ENT). Electrocautery was performed on the tracheal side by ENT or pulmonary and esophageal clip placement by GI.

Results: Between November 2019 and February 2025, 14 patients underwent successful endoscopic closure of 15 TEF. One patient failed endoscopic closure of a proximal missed congenital TEF but had successful endoscopic closure of their recurrent TEF. Ten TEF were closed with electrocautery and esophageal clip placement while five were closed with cautery alone. No significant complications occurred, and all closures were confirmed with follow-up endoscopy.

Conclusion: Endoscopic electrocautery with esophageal clip application, by a skilled multidisciplinary team, offers a minimally invasive alternative to open repair for missed congenital, recurrent, and acquired TEFs. It may be considered as a first line approach, especially in patients with high surgical risk.

Objective: Constipation is a common gastrointestinal concern in children, often prompting screening for celiac disease (CeD), particularly in refractory cases. However, limited data exist on the clinical course of constipation in children with CeD following treatment with a gluten-free diet.

Methods: We reviewed electronic health records from the Mayo Clinic between 1994 and 2024 for children (<18 years) who presented with constipation and then diagnosed with CeD. Children were classified into groups based on the symptoms at the time of presentation. Constipation outcome was considered resolved by the documentation of improvement on a gluten-free diet without ongoing laxative use, while unresolved cases required continued laxative therapy. A sub-analysis was performed for children with encopresis.

Results: We identified 248 children with CeD, 177 (71%) had biopsy-confirmed CeD, and 56 (23%) were diagnosed with serology-only criteria. The mean age at diagnosis was 7.8 years (±4.98), with most being White (99%) and female (68%). Constipation was the main presenting symptom, but most children also exhibited additional symptoms at the time of diagnosis. Over an average of 5.3 years (±2.1) of follow-up, constipation was resolved in 32% of children, while 68% required ongoing laxatives, in the subgroup of children with encopresis, only 29% had documented resolution. Tissue transglutaminase antibody normalization was slower in children with unresolved constipation. Trends were observed toward a higher prevalence of anxiety, depression (42% vs. 30%) and thyroid disorders (13% vs. 9%) in the unresolved group. We also noticed a trend to a higher likelihood of constipation resolution in children with type 1 diabetes mellitus (14% vs. 4%), but none reached statistical significance.

Conclusion: Many children with CeD continue to experience persistent unresolved constipation despite adherence to a gluten-free diet. Comorbidities are associated with a lower rate of constipation resolution.

Objectives: Despite the growing use of unsedated transnasal endoscopy (uTNE) in pediatrics, no validated tool exists to assess competence in performing uTNE, hindering effective training and consistent, high-quality performance. Video-based assessment offers a scalable and reliable method for assessing and enhancing procedural skills. Using Delphi methodology, we aimed to identify key competencies and establish content validity evidence for the TransNasal Endoscopy Skills Assessment Tool (TNE-SAT), a video-based tool designed to assess clinician competence in performing uTNE.

Methods: North American pediatric uTNE experts iteratively rated potential assessment items, on a 5-point scale, based on their importance as indicators of endoscopist competence in performing uTNE. After each voting round, items scoring ≤3/5 were eliminated, and the remaining items were re-sent to the panel for further rating until consensus was reached, defined as ≥80% of panelists rating all remaining items ≥4. Items meeting this threshold were included in the final TNE-SAT tool.

Results: Twenty-seven experts from 19 sites across North America participated. One hundred thirty items were generated through literature review, task deconstruction, and Delphi panelist input. Three rounds of surveys were completed before consensus was achieved, with response rates ranging from 85% to 9. Seven items reached consensus for inclusion in the final TNE-SAT.

Conclusions: This North American Delphi study identified core competencies required for effective uTNE performance and informed the development of the TNE-SAT, a structured, video-based tool to assess clinician competence. The TNE-SAT offers a promising tool to guide training and support quality improvement in pediatric uTNE.

Objectives: Acute kidney injury (AKI) is a complication commonly observed in adults with acute pancreatitis (AP) but remains poorly studied in pediatric patients. We investigated the utility of AKI biomarkers-kidney injury molecule-1 (KIM-1), lipocalin 2 (NGAL), cystatin-C (CYS-C), and renalase (RNLS) in acute and chronic pancreatitis (CP), and to assess AP severity, and evaluate kidney function.

Methods: Plasma and urine samples were collected from children with AP (n = 49), CP (n = 50), and healthy controls (HC; n = 20). AKI biomarkers levels were measured using enzyme-linked immunosorbent assays (ELISA). AP patients were categorized into two groups: mild AP (MAP) and moderate/severe AP (SAP). Kidney function was evaluated using plasma creatinine (pCre) and CYS-C-based enhanced glomerular filtration rate (eGFR) formulas.

Results: Plasma KIM-1 and pCYS-C were elevated in AP versus CP and HCs (p < 0.0001). Urinary NGAL (uNGAL) was elevated in AP subjects, with 14% of patients exceeding the value of 125 ng/mL. Plasma A-RNLS remained same between AP and HCs (p = 0.78) but was elevated in CP cohort (p < 0.0001). However, pF-RNLS levels declined in AP compared to HCs and CP (p < 0.0001). SAP subjects (20% of AP cohort) had elevated pKIM-1 and pCYS-C compared to MAP (p = 0.002, p = 0.003). eGFR declined in AP subjects with 84% of AP patients showing CYS-C eGFR <90 mL/min/1.73 m². Plasma CYS-C, pA-RNLS, and pF-RNLS predicted AP from CP with area under the receiving operating curve of 0.86 (95% CL).

Conclusion: Elevated pKIM-1, pCYS-C, and uNGAL, along with declining pF-RNLS, are helpful in distinguishing pediatric AP from CP. Quantifying the Levels of pKIM-1 and pCYS-C within the first 48 h can help predict development of SAP.

Little information exists about social risk among pediatric gastroenterology, hepatology, and nutrition (PGHN) patients. The goal of this study was to examine racial and ethnic differences in social risk among Medicaid-insured PGHN patients. Electronic health records from 1341 patients between May 2022 and February 2024 with responses to the Accountable Health Communities screening tool were included. The main outcome was presence of any social risk. To test the hypothesis that racial and ethnic differences in social risk exist, logistic regression adjusting for child age, sex, and preferred language was used. Overall, 29% of patients reported a social risk. Compared to non-Hispanic white patients, patients with Hispanic/Latino, Black, other, and missing race and ethnicity had higher odds of reporting social risks. To promote health equity, better understanding of effective, holistic strategies to integrate social care into PGHN care is warranted.