A recent retrospective study (D Orsagh-Yentis) Pediatrics 2019; 143: pii:320181988) examined children <6 years of age (n=759,054) and presentation to an emergency department in the U.S. for a foreign body ingestion (FBI) from 1995-2015. This study was reviewed at our recent national meeting by David Brumbaugh -related blog post: #NASPGHAN19 Postgraduate Course (Part 1) (Slides below).
- FBI rates increased from 9.5 to 18 per 10,000 during the 20 year study period
- Coins accounted for 61.7% of FBI
- Most children (89.7%) were able to be discharged after their suspected ingestion
- Battery ingestion represented 0.14% of all ingestions in 1995 to 8.4% in 2015
Related blog posts:
- Foreign Bodies in Children -Expert Guidance
- New Button Battery Guidelines -with honey and vinegar
- Button battery -Update For Families
- Foreign Bodies in Children: Expert Recommendations
- Magnetic Foreign Bodies -Still a Problem | gutsandgrowth
- More on magnet ingestions | gutsandgrowth
- Cheap Technology for Button Battery Ingestions | gutsandgrowth
- Watch for change in the stools” | gutsandgrowth
A recent analysis (MG Warren et al J Pediatr 2019; 214: 41-6) examined gastrostomy tube (GT) placement among 4569 extremely low birthweight (ELBW) infants (birth wt <1000 gm) who were enrolled in the National Instittue of Child Health and Human Development Neonatal Research Network (25 centers).
- 333 (7.3%) underwent GT placement; 76% had GT placed postdischarge from NICU
- Among patients with GT placement, 56% had weight <10th percentile, 61% had neurodevelopmental impairment (NDI), and 55% had chronic breathing problems
- At last follow-up, 32% of infants who required GT placement were taking full oral feeds.
- Rates of fundoplication varied widely between centers, ranging from 0% to 6.4% among the centers.
In the discussion, the authors note the well-recognized associations between feeding difficulties and language delays in ELBW infants. In addition, “behavioral and emotional problems have …been described in children with feeding problems.”
The authors also state, without evidence, that the high rate of GT placement after discharge suggests that “a large proportion of ELBW infants were first discharged from the NICU orally feeding but could not maintain these skills.” Alternative explanations include the following:
- Many infants were sent home with NG (nasogastric) supplementation and after not making progress with oral feedings, elective GT placement was done when the infant was a more suitable candidate (eg. improved respiratory status, better nourished, etc.)
- Problems with oral feeding became apparent after discharge including poor growth and aspiration. In fact, the authors note that “orormotor dysfunction and avoidant feeding behaviors at 3 and 12 months corrected age” were nearly twice as likely in infants born <34 weeks
- While this study did not fully capture data regarding home NG feedings, 14% of patients sent home with NG feedings eventually received a GT
My take: This study indicates that 7% of ELBW infants undergo GT placement and that about one-third out-grow the need for GT supplementation after ~2 years.
Related blog posts:
A recent retrospective study (N Nguyen et al. Clin Gastroenterol Hepatol 2019; 17: 2455-2462) describe the feasibility of unsedated transnasal endoscopy (TNE) for monitoring eosinophilic esophagitis (EoE) in children (n=190, subject ages 3-22 years).
TNE was facilitated by distraction with either video google or virtual reality (starting 2016). NPO time was 2 hours before the TNE.
- Over 294 TNEs were completed from 300 attempts (98% success)
- Cost of TNE was halved: $4393 compared to $9444 for EGD (does not count pathology costs)
- Adverse events: 8 (2.7%) with vomiting, 9 (3.1%) spit up, 11 (3.7%) with epistaxis
- By 2017, TNE accounted for 31.8% of upper endoscopies in 2017
The authors recommend that TNE be offered starting at age 5 years in those without a known stricture.
My take: I am looking forward to less invasive/less costly ways of monitoring treatment response in EoE. I think TNE can lower costs –though I am a little surprised that the cost of TNE in their institution was still more than $4000. In our outpatient endoscopy center, costs for an upper endoscopy/biopsy with anesthesia are typically about one-third the cost of an EGD in their study and about three-fourths the cost of a study TNE.
Related study: A Krigel et al. Clin Gastroenterol Hepatol 2019; 17: 2489-96. This study showed increasing use of anesthesia assistance (AA) for colonoscopy in adults from 16.7% in 2006 to 58.1% in 2015. This data was derived from the Premier Perspective database with more than 4.6 million patients who had an outpatient colonoscopy. AA was associated with a median increase in cost of $182 for patients with commercial insurance.
Related blog post: Waiting for the String Test for EoE
“80 percent of success is just showing up” —Woody Allen
Reading a recent (brief) study (BA Blansky et al. Clin Gastroenterol Hepatol 2019; 17: 2503-4) reminded me of the quote from Woody Allen. This study of children with Celiac disease (CD) demonstrates a high rate of children who were lost to follow-up at a leading Children’s hospital.
- From a randomly selected retrospective cohort (2010-2014) with 241 eligible subjects, one-fourth of children were lost to follow-up within a year of diagnosis. 22 (9%) had NO GI visits after their diagnostic procedure.
- Risk factors for loss of follow-up: sibling with CD (HR 1.90), Medicaid insurance (HR 2.19), and older age at diagnosis; those with adherence had median age at diagnosis of 8.7 years compared with 11.4 years for those lost to follow-up.
- Median time to tissue transglutaminase (TTG) IgA normalization was 17 months. Of 141 who had recommended follow-up, 25% had elevated TTG IgA at last GI visit.
My take: These numbers should not be surprising to most clinicians. If clinicians want to improve follow-up and outcomes, then families will need more nudging; EMRs can be configured to help in this task.
Related blog posts:
- Closer Followup for Celiac Disease & Pediatric Guidelines This post highlights poor followup in a 2012 study.
- Will Asymptomatic Patients with Potential Celiac Disease Benefit from a Gluten Free Diet?
- Ultra-short Celiac Disease
- 99% Accuracy in Non-Biopsy Celiac Disease
- Followup Biopsies in Pediatric Celiac Disease?
- How Slow Do Objective Markers of Celiac Change After Treatment? | gutsandgrowth
- Are followup biopsies necessary in celiac disease? Look beyond the headlines
- To biopsy or not to biopsy -that is the question (for Celiac disease)
- Celiac Titers and Likelihood of Celiac Disease | gutsandgrowth
- Taking One ‘Bite’ At A Time -For Celiac Diagnosis | gutsandgrowth
- Expert review: Celiac disease
- False-positive serology for Celiac disease | gutsandgrowth
- Nuance in Celiac Serology Interpretation | gutsandgrowth
- Elevated Celiac Serology Associated with Reduced… | gutsandgrowth
- Is functional pain more common in children… | gutsandgrowth
- How Accurate is Serology at Predicting Mucosal Healing in …
SR Gupta et al. JPGN 2019; 69: 544-50. This article reports on preliminary experience in 54 children who received external (non-hospital) infliximab infusions. The average age was 17.6 years. The authors noted no serious safety concerns. Prior to arranging these infusions, the authors insisted on the following:
- Infusion services had to guarantee pediatric trained nurses with PALS certification
- Emergency medications had to be available
- A plan for emergency communication was arranged
- Postinfusion communication would occur with each infusion
BN Limketkai et al. Inflamm Bowel Dis 2019; 25: 1828-37. This study, using Truven Health MarketScan database (2007-16) reviewed proactive or reactive mucosal monitoring after biologic initiation in IBD. Early (< 6 months) proactive monitoring (88% endoscopy-based) was performed in 11% (n=2195/19,899) of patients with Crohn’s and 12.8% (925/7247) of patients with ulcerative colitis.
- “Early proactive monitoring was associated with a reduction in disease-related complications for CD (aHR 0.90) and UC (aHR 0.87) and predominantly driven by a reduction in corticosteroid use.”
- Another interesting finding was that ~40% of patients had biologic therapy initiated without assessment of mucosal disease activity within 6 months.
- The authors state that disease monitoring is typically more useful in CD than UC because with the latter, cessation of bleeding and diarrhea appear to be adequate surrogates.
- This study was not able to assess whether a biomarker like fecal calprotectin would be suitable due to its low utilization.
RZ Cohen, BT Schoen, S Kugathasan, CG Sauer. JPGN 2019; 69: 551-6. In this chart review, the authors identified anti-drug antibodies (ADA) in 24.8% (n=58) of patients undergoing therapeutic drug monitoring (n=234) with both infliximab and adalimumab. 54% of this group had antibody suppression with dose optimization. Of note, 37 patients had detectable ADA at time of initial drug monitoring. Dose optimization was 10 mg/kg every 4 weeks with infliximab or 40 mg weekly with adalimumab. Patients who were switched to a second anti-TNF agent (n=23) were not more likely to develop ADA to the second agent (small sample size). Also, the authors caution that in the five patients with ADA levels (>10 U/mL), dose optimization failed and patients required a therapeutic switch. My take: This study provides some useful information about the frequency of ADA. My view is that the actual drug level is more critical than the presence of ADA; though, the presence of high ADA often precludes the ability to deliver a therapeutic drug level.
Related blog posts:
- CCFA Updates 2019 -Proactive Therapeutic Drug Monitoring
- Proactive Therapeutic Drug Monitoring -Different Time Points
- Appropriate Proactive Therapeutic Drug Monitoring
- Briefly Noted: Induction Infliximab Levels Infliximab level ≥18 mcg/mL at week 6 was strongly associated with clinical and biologic response as well as achieving an infliximab level ≥5 mcg/mL at week 14 (AUC 0.85).
- Is Standard Infliximab Dose Too Low in Pediatrics?
- Combination Therapy Study Points to Central Role of Adequate Drug Levels
- Can Therapeutic Drug Monitoring with Monotherapy Achieve Similar Results as Combination Therapy for IBD? | gutsandgrowth The authors utilized TDM at week 10. If the IFX level was <20 mcg/mL, the dose and frequency of infliximab were both adjusted. If the level was between 20 & 25, either the frequency was adjusted or no adjustment, and if the level was >25, then no adjustment in dosing was performed.
Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
About two years ago, James Franciosi presented research at NASPGHAN meeting indicating that the main difference between children with eosiniophilic esophagitis (EoE) who respond to proton pump inhibitiors (PPIs) compared to those who do not was related to their metabolism of PPIs and not related to the nature of their underlying EoE.
Related blog: #NASPGHAN17 Eosionophilic Esophagitis Session
Now, more has been published on this topic: EB Mougey et al. JPGN 2019; 69: 581-7.
In this study with 92 patients, data was collected from participants in a prospective clinical trial of high-dose PPI for EoE.
- 57 (62%) were responsive to PPIs and 35 (38%) were not responsive to PPIs
- Carriage of STAT6 allele variant rs1059513 predicted responsiveness to PPIs with OR of 6.16
- Carriage of STAT6 rs324011 synergizes with CYP2C19*17 to predict PPI-nonresponsive EoE
- Carriers of CYP2C19*17 are more likely to fail PPIs for EoE. Children with CYP2C19*17 gain of function “have a 7.7 fold better odds of failing PPI therapy” than noncarriers.
- CYP2C19*17 effects “appears to be exerted within a specific range of PPI doses…and does not appear to exert influence at the low and high ends of this dose range.”
- STAT6, which in this study is a cofactor, “upregulates transcription of CCL26 (eostaxin-3) 53-fold in esophageal eosinophilia relative to levels in peptic esophagitis and 490-fold over levels found in normal esophageal biopsies.”
- PPIs effectiveness “does not correlate with esophageal” acid exposure; thus, its effects are mediated via an anti-inflammatory mechanism.
My take: This study indicates that genotype-guided dosing of PPIs for the treatment of EoE is likely to be worthwhile.