Journal of Pediatric Gastroenterology and Nutrition最新文献

Objectives: Practice variability exists regarding the timing of gastrostomy tube (GT) placement in patients unable to maintain adequate oral nutrition. We sought to assess patient factors predictive of longer surgical GT use to inform patient selection.

Methods: We conducted a single-center, retrospective cohort study including children ≤18 years who underwent surgical GT placement from June 1, 2018 to June 1, 2021 at a children's hospital. Bivariate and logistic regression analyses were performed to assess the impact of referral patterns, operative indications, and patient comorbidities on the length of GT use.

Results: Four hundred fifty-eight children underwent GT placement. Median age at placement was 5 months (interquartile range [IQR]: 2-12) and 52% were male. Fifty-six percent were referred from a neonatal intensive care unit;/cardiovascular intensive care unit provider before initial hospital discharge and 19% were outpatient referrals. Forty-six percent were premature and 50% exhibited oropharyngeal dysphagia. The median duration of nasogastric (NGT) feeding before GT placement was 36.5 days (IQR: 16-64). In those with GT removal (n = 140), the median duration of use was 269 days (IQR: 144-474), with 23% of the cohort no longer utilizing the GT within 12 months of placement. Patients with congenital lung disease (odds ratio [OR]: 3.03, p = 0.002) and genetic anomalies excluding isolated Trisomy 21 (OR: 3.57, p = 0.003) were more likely to require prolonged GT use.

Conclusions: Nearly a quarter of children attain full oral feeding within a year of GT placement. The identified factors predictive of prolonged GT use suggest early placement in these patients. Continuing NGT feeds in other patients may decrease the morbidity of unnecessary GT placement.

Objectives: Graft-versus-host disease (GVHD) commonly affects the gastrointestinal (GI) tract among children who undergo hematopoietic stem cell transplantation (HSCT). Studies concerning GI-acute GVHD (aGVHD) in developing countries are limited. Therefore, our aims were (1) to demonstrate clinical characteristics, endoscopic and histopathological findings in children with GI-aGVHD post-HSCT and (2) to compare features, risk factors, and clinical outcomes of children with GI-aGVHD versus non GI-aGVHD.

Methods: A retrospective single-center study was conducted on patients receiving the first successful HSCT aged <20 years old between January 2011 and December 2020. The patients were divided into groups with GI-aGVHD (clinically or endoscopy-histopathologically diagnosed) and without GI-aGVHD. Various aforementioned data were recorded to compare the risk factors and clinical outcomes of children with and without GI-aGVHD.

Results: Among 246 children post-HSCT, we identified 42 cases (17%) with GI-aGVHD (32 cases with the clinical diagnosis and 10 cases with endoscopy-histopathology confirmed diagnosis) and 204 patients without GI-aGVHD. When compared with children without GI-aGVHD, the GI-aGVHD group had higher rates of hypovolemic shock, renal failure, more extended hospital stays, and deaths (all p < 0.05). The GI-aGVHD group also had a higher proportion of cases with nonhematologic malignancy (odds ratio [OR] = 2.34, 95% confidence interval [CI] = 1.01-5.41, p = 0.047) and cytomegalovirus (CMV) reactivation before the GI-aGVHD episode (OR = 2.22, 95% CI = 1.09-4.51, p = 0.027).

Conclusions: GI-aGVHD after HSCT leads to increased morbidity and death. Underlying nonhematologic malignancy and history of CMV reactivation are associated with GI-aGVHD. Direct links between the aforementioned factors and the development of GI-aGVHD merit future studies.

Objectives: Colonic manometry catheter placement can be performed by colonoscopy or fluoroscopy. Our objective was to compare outcomes of colonoscopic to fluoroscopic catheter placement in children based on the extent of colon study and the likelihood of catheter displacement.

Methods: Colonic manometry studies performed between May 2015 and May 2022 were reviewed. All studies with catheter placement per rectum were included. Data on patient demographics, medical and surgical history, and information on catheter placement (type of catheter, placement technique, position, and displacement) were recorded.

Results: We reviewed 555 studies and included 482 studies performed on 453 children (51% female, median age 10 years, interquartile range: 7-14 years). The catheter was placed during colonoscopy in 274 studies and using fluoroscopy in 208 studies. Children with colonoscopic placement were significantly older (median age 11 vs. 8 years, p < 0.001), more commonly male (55% vs. 41%, p = 0.003), and more commonly had functional constipation (85% vs. 69%, p < 0.001). Children with fluoroscopic placement more often had pediatric intestinal pseudo-obstruction (10% vs. 1%, p < 0.001), a diverting ostomy (21% vs. 7%, p < 0.001), and a cecostomy (10% vs. 4%, p = 0.023). A successful catheter placement (reaching ascending colon) was significantly more common using colonoscopy (49% vs. 23%, p < 0.001). There were no differences in frequency or extent of catheter displacement between colonoscopic and fluoroscopic placement.

Conclusions: Colonoscopic placement was superior to fluoroscopic placement in terms of the extent of the colon studied with no differences in frequency of catheter displacement. Colonoscopic placement should be the preferred method in most children with refractory constipation.

Objective: To compare faecal calprotectin, plasma amino acids and clinical outcomes in preterm infants receiving powdered human milk-based fortifier (PHMF) compared to powdered bovine milk-based fortifier (PBMF) in preterm infants on an otherwise exclusive human milk diet.

Methods: A randomised controlled trial in infants <32 weeks of gestation or <1500 g who only received human milk and had reached full enteral feeds (150 mL/kg/day), without pre-existing gastrointestinal morbidity. Primary outcome was faecal calprotectin within 21 days of starting fortification; secondary outcomes were calprotectin at discharge, plasma amino acids and clinical outcomes, including growth and neonatal morbidities.

Results: The trial stopped early after the manufacturer's withdrawal of PHMF. Thirty-one infants were enroled, three without informative sampling, leaving 14 per group. No statistical differences were seen in faecal calprotectin on Day 7 (236 mcg/g PHMF vs. 303 mcg/g PBMF, p = 0.90) or 21 (135 mcg/g PHMF vs. 315 mcg/g PBMF, p = 0.21). Adjusting for gestation and day of life, and including all time points after enrolment to discharge, fortifier type did not impact faecal calprotectin (coefficient estimate -7.13, 95% confidence interval = -172 to 158, p = 0.93). Rates of key neonatal morbidities did not differ. PHMF infants grew more slowly reaching statistical significance in change in weight standard deviation score at discharge compared to PBMF infants (mean (standard deviation) -0.94 (0.7) PHMF vs. -0.24 (0.8) PBMF, p = 0.02).

Conclusions: We did not detect reduced gut inflammation as measured by faecal calprotectin in PHMF compared to PBMF but weight gain was slower, of potential clinical importance.

Objectives: Children with short bowel syndrome (SBS) are at increased risk of micronutrient deficiencies. We aimed to study weaning off parenteral nutrition (PN) as a risk factor for vitamin and trace element deficiencies and growth deficit.

Methods: Children born between 2010 and 2019, treated for SBS in Helsinki University Hospital, were followed for their nutrition, growth, and vitamin and trace element biochemical status. Information on these as well as patient characteristics and intestinal anatomy were collected from electronic patient records.

Results: A total of 59 patients with SBS were identified. The weaning period was found to be a risk factor for micronutrient deficiencies and growth. Most frequent deficiencies were detected for vitamin K as suggested by prothrombin time (PT) (91% of patients), vitamin D (70%), and vitamin A (67%). Other deficiencies were less common with 44% for vitamin B12, 25% for selenium, 19% for copper, 24% for zinc, and 11% for vitamin E. For all the studied micronutrients, 3 months before to 1 month postweaning had the highest rate of micronutrient deficiencies, except for vitamin B12, for which the highest proportion of deficiencies presented at 1-6 months postweaning.

Conclusions: The weaning period from PN is a risk for micronutrient deficiencies. Regular monitoring and sufficient supplementation are essential for preventing malnutrition.

Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is traditionally done in the prone position. In pediatrics, patient anatomy and anesthesia practices are considerations that affect procedural success and anesthesia time. The aim of our study was to evaluate the safety, procedural success, and efficiency of pediatric ERCP in the prone versus supine positions.

Methods: ERCPs from September 2016 to August 2023 were reviewed at our center. Demographic and procedure variables were collected. Multivariate linear regression was performed to determine the effect of patient position on total anesthesia time.

Results: Two hundred and eighty-three patients (378 ERCPs) were included. There were significant differences in fellow involvement, proportion of native papillae, procedural indication, and total anesthesia time by ERCP position. Multivariate linear regression found that supine position was associated with 9.3-min decrease in anesthesia time and American Society of Anesthesiologists Class 1 or 2 was associated with 10.6-min decrease in anesthesia time. Factors that were associated with increased anesthesia time were additional procedure, increased procedure time, and native papilla. Finally, we found a learning curve for transitioning from prone to supine position was between 10 and 40 cases. After the learning curve, we found 11-min decrease in mean procedure time and 16-min decrease in total anesthesia time in the supine position.

Conclusions: This is the first pediatric study to evaluate the role of patient positioning on ERCP outcomes and total anesthesia time. Given similar procedural outcomes, the impact of increased anesthesia time on neurodevelopment in children, and the cost to the patient, the supine position may be preferred to a prone position.

Objectives: To study the health-related quality of life (HRQoL) and its possible determinant factors in Spanish children with eosinophilic esophagitis (EoE) and their parents.

Methods: Multicenter observational cross-sectional study. The Spanish version of the Pediatric Quality of Life Eosinophilic Esophagitis Module was filled out by EoE patients aged 8-18 and their parents. Demographic, psychosocial, and clinical variables were studied. Multiple linear regression was performed to identify related factors of HRQoL.

Results: A total of 279 children and their parents participated (72.7% males). 39.1% received swallowed corticosteroids, 35.5% proton pump inhibitors and 16.8% diet. 1.1% received other treatments and 7.5% received no treatment. Poor compliance to treatment was observed in 11.5% and 6.5% of patients were referred to mental health. The Total Scale Scores were 72.71 ± 17.50 and 75.62 ± 16.73 for children and parents, respectively. "Communication" was the dimension with the highest scores (82.14 ± 21.65 and 81.59 ± 24.13) while "Food and Eating" (48.92 ± 32.94 and 62.85 ± 28.78), and "Food Feelings" (53.55 ± 29.96 and 53.95 ± 27.78) had the lower scores. Patients and parents under dietary treatment showed lower scores than those under pharmacological treatment, 65.77 ± 16.96 versus 74.28 ± 16.96, p = 0.001 and 68.33 ± 17.32 versus 77.24 ± 15.97, p = 0.001, respectively. Factors associated with worse HRQoL scores were symptom frequency, diet, food allergies, and the need for mental health assistance.

Conclusions: The HRQoL of children and their parents was "good." However, diet, frequency of symptoms, food allergies, and the need for mental health care were the factors that had a negative impact on HRQoL of children with EoE.

Objective: Paediatric autoimmune liver disease (pAILD) is a rare condition with serious health implications. Notwithstanding treatment advancements, areas of uncertainty and knowledge gaps still exist. We here investigated the real-life approach to pAILD management in Europe.

Methods: A survey was distributed to members of the European Rare Liver Disease Reference Network (ERN RARE-LIVER) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Hepatology Interest Group. Information was gathered regarding clinical activity, medications used, and access to paediatric drug formulations at each site.

Results: Thirty-six centres from 22 European countries responded to the survey. The majority are exclusively paediatric units (86%). Among participants, 80% follow <50 children with pAILD, of which 25%-50% are <10 years old in 44% of centres. All centres use predniso(lo)ne as first-line therapy, alone (15/36) or with azathioprine (21/36). Azathioprine and mycophenolate are the preferred second-line options in centres using first-line steroid monotherapy (11/15) or combined steroid-azathioprine (19/21), respectively. Tacrolimus is used as third-line agent in 15/36 centres. Proactive measurement of drug metabolites and target levels vary widely among centres. Paediatric predniso(lo)ne formulations are commercially available in 7/22 European countries, azathioprine in 3, mycophenolate in 14, tacrolimus in 15 and ursodeoxycholic acid in 14. When paediatric formulations are unavailable, children are treated with magisterial preparations or 'solid' formulations (crushed or intact).

Conclusions: Treatment of pAILD in Europe varies widely in terms of medications used and treatment monitoring. Availability of paediatric drug formulations across Europe is limited. Collaborative initiatives are needed to define evidence-based strategies for management of pAILD and to promote an equal, age-appropriate treatment for affected children.

Objective: We aimed to provide an evidence-supported approach to diagnose, monitor, and treat children with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC).

Methods: The core group formulated seven PICO-structured clinical questions. A systematic literature search from inception to December 2022 was conducted by a medical librarian using MEDLINE and EMBASE. Core messages from the literature were phrased as position statements and then circulated to a sounding board composed of international experts in pediatric gastroenterology and hepatology, histopathology, adult gastroenterology and hepatology, radiology, and surgery. Statements reaching at least 80% agreement were considered as final. The other statements were refined and then subjected to a second online vote or rejection.

Results: Regular screening for gamma-glutamyltransferase (GGT) is essential for detecting possible biliary disease in children with IBD. MR cholangiopancreatography is the radiological modality of choice for establishing the diagnosis of PSC. Liver biopsy is relevant in the evaluation of small duct PSC or autoimmune hepatitis. Children who do not have known IBD at the time of PSC diagnosis should undergo initial screening with fecal calprotectin for asymptomatic colitis, and then at least once yearly thereafter. Children with a cholestatic liver enzyme profile can be considered for treatment with ursodeoxycholic acid and can continue if there is a meaningful reduction or normalization in GGT. Oral vancomycin may have a beneficial effect on GGT and intestinal inflammation, but judicious use is recommended due to the lack of long-term studies. Children with PSC-IBD combined with convincing features of autoimmune hepatitis may benefit from corticosteroids and antimetabolites.

Conclusions: We present state-of-the-art guidance on the diagnostic criteria, follow-up strategies, and therapeutic strategies and point out research gaps in children and adolescents with PSC-IBD.

Objectives: The aim of our study was to assess the effectiveness and side-effect profile of a combination of azithromycin and metronidazole (CD AZCRO) as alternative induction therapy for 8 weeks in mild to moderately active paediatric Crohn's disease (CD).

Methods: We performed a retrospective cohort study (November 2012 to July 2023) of a regional paediatric inflammatory bowel disease service. Disease activity, faecal calprotectin (FC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), haematological parameters and albumin were collected at baseline, 8 and 16 weeks. At Week 8, patients were divided based on (paediatric Crohn's disease activity index) score and inflammatory markers (blood and stool) into: Group 1 clinical remission and Group 2 non-remission.

Results: A total of 48 patients were initially identified of whom 44 were included in the intention-to-treat analysis. After 8 weeks, the overall remission rate was 64%. Of the 38 patients who completed the CD AZCRO course, 28 patients (74%) entered remission (Group 1) and 10 (26%) did not (Group 2). At baseline a shorter disease duration, low weight z score and higher inflammatory burden (ESR, platelets and FC levels) were observed in Group 2. After 8 weeks, Group 1 showed improved CRP levels and higher albumin and haemoglobin levels than Group 2. Median FC declined significantly from 650 mcg/g at baseline to 190 mcg/g at Week 8 in Group 1 (p < 0.001). At 16 weeks, 23/28 patients (82%) continued in clinical remission. Nausea and vomiting were reported in 4/44 patients.

Conclusions: Our real-world data demonstrate that CD AZCRO represents an alternative induction therapy for mild to moderate paediatric CD.