Category Archives: Pediatric Gastroenterology Intestinal Disorder

Most Popular Posts of 2019

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The following are the most viewed posts from the past year:

Wishing friends, family and colleagues a healthy and happy New Year.

Morning in Sandy Springs, GA

 

Primary Prevention of Cow’s Milk Allergy

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A recent randomized clinical study (M Urashima et al. JAMA Pediatr. 2019;173(12):1137-1145) indicates that avoiding cow’s milk formula in the first 3 days of life may prevent the development of cow’s milk allergy. Thanks to Ben Gold for this reference.

Link to full Abstract (article behind paywall): Primary Prevention of Cow’s Milk Sensitization and Food Allergy by Avoiding Supplementation With Cow’s Milk Formula at Birth

The Atopy Induced by Breastfeeding or Cow’s Milk Formula (ABC) trial, a randomized, nonblinded clinical trial, began enrollment October 1, 2013, and completed follow-up May 31, 2018, at a single university hospital in Japan. The primary outcome was sensitization to cow’s milk (IgE level, ≥0.35 allergen units [UA]/mL) at the infant’s second birthday.

Immediately after birth, newborns were randomized (1:1 ratio) to BF with or without amino acid–based elemental formula (EF) for at least the first 3 days of life (BF/EF group) or BF supplemented with CMF (≥5 mL/d) from the first day of life to 5 months of age (BF plus CMF group).

If the mother, allocated to the BF/EF group, added more than 150 mL/d of EF to BF for 3 consecutive days, EF was switched to CMF after the fourth day. Thus, offspring allocated to BF/EF could avoid CMF for at least the first 3 days of life.

Key Finding:

  • “In this randomized clinical trial involving 312 newborns, risks of sensitization to cow’s milk and immediate-type food allergy, including cow’s milk allergy and anaphylaxis, were decreased by avoiding supplementation with cow’s milk formula for at least the first 3 days of life.”
  • “The primary outcome occurred in 24 infants (16.8%) in the BF/EF group, which was significantly fewer than the 46 infants (32.2%) in the BF plus CMF group (relative risk [RR], 0.52; 95% CI, 0.34-0.81).”
  • “The prevalence of food allergy at the second birthday was significantly lower in the BF/EF than in the BF plus CMF groups for immediate (4 [2.6%] vs 20 [13.2%]; RR, 0.20; 95% CI, 0.07-0.57) and anaphylactic (1 [0.7%] vs 13 [8.6%]; RR, 0.08; 95% CI, 0.01-0.58) types.”

This study is interesting in that it suggests that exposure to cow’s milk in the first three days of life potentially increases the risk of CMA, whereas a previous study (*see below) showed showed that early exposure to CMF within 14 days after birth reduces the risk of CMA.  In this previous study, exposure to small quantities of CMF for the first 3 days of life was not monitored. “Thus, the results of that observational study are not necessarily in contrast to those of the present trial.”

My take: This type of study is difficult to complete.  It is difficult to understand why exposure to cow’s milk in the first two weeks of life is helpful and why exposure in the first three days of life is detrimental with regard to the development of cow’s milk allergy.

*Katz Y, Rajuan N, Goldberg MR, et al. Early exposure to cow’s milk protein is protective against IgE-mediated cow’s milk protein allergy. J Allergy Clin Immunol. 2010;126(1):77-82.e1. doi:10.1016/j.jaci.2010.04.020)

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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.

Briefly noted: Mortality in Acute Severe Ulcerative Colitis

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C Dong et al. AP&T 2019 https://doi.org/10.1111/apt.15592

Link: Systematic review with meta‐analysis: mortality in acute severe ulcerative colitis

Key point:

  • “Six population‐based studies with 741,743 patients and 47 referral centre‐based studies with 2556 patients were included. The pooled 3‐month and 12‐month mortalities were respectively 0.84% and 1.01%”

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Do Button Battery Guidelines Need To Be Revised?

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A recent abstract presented at DDW (R Khalaf et al. abstract Sa2046) with 68 patients identified mucosal findings in the stomach and questioned whether the current guidelines are sufficient.  Generally, guidelines call for the immediate removal of button batteries in the esophagus but in asymptomatic children older than 5 years, most gastric batteries can be observed (see links to previous blog posts below which highlight expert recommendations).

Link: Sa2046 GASTRIC INJURY SECONDARY TO BUTTON BATTERY INGESTIONS IN CHILDREN: A RETROSPECTIVE MULTICENTER REVIEW

This study was reviewed in Gastroenterology & Endoscopy News: Retrieving Swallowed Batteries in Children: Don’t Watch and Wait  This link also highlights an abstract from the Emory pediatric GI group, NASPGHAN 2019 (#24), which found that only 5% of esophageal button batteries were removed within two hours.

An excerpt:

According to the National Poison Data System, between 1985 and 2017, roughly 3,500 button batteries were swallowed in the United States each year (www.poison.org/ battery/ stats). ..

The researchers reviewed 68 cases of children who underwent endoscopy after having swallowed button batteries, which are used in a variety of devices, such as cameras and watches. Eighteen of the patients (26%) were asymptomatic, but 41 (60%) had visible mucosal damage…

Some injuries were more severe. A 9-year-old child with a battery lodged in the antrum experienced a gastric perforation that led to pneumoperitoneum, Dr. Khalaf reported. Although only one other injury was as serious, the researchers identified no risk factors that predicted significant complications.

My take: There are a lot of button battery ingestions.  More data is needed to determine whether more button batteries from the stomach should be retrieved.

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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.

Our Study: Provider Level Variability in Colonoscopy Yield

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Most readers of this blog will recognize that one focus has been on delivering high value medical care.  In pediatric gastroenterology, there is a great deal of variability in the use of endoscopy as a tool.  When there are individuals with high-use/low-value endoscopy, some might question whether this is due to training, expediency, financial motivation, or a lack of clinical confidence.

There have been a number of studies looking at diagnostic yield with pediatric colonoscopy but none on individual provider variation.   To look into this issue, we examined our outpatient experience with colonoscopy among 16 providers.  This work has now been published:

Digestive Diseases (Full Text): Diagnostic Yield Variation with Colonoscopy among Pediatric Endoscopists

Key points:

  • This study found high variability in diagnostic yield among the 16 clinicians ranging from as low as 22% to as high as 86% (p = 0.11) with an overall diagnostic yield of 48% for colonoscopy; excluding follow-up colonoscopies, the diagnostic yield was 42%.
  • Abnormal calprotectin and abnormal blood tests were associated with higher diagnostic yields of 83 and 65%, respectively, compared with symptoms such as diarrhea, and rectal bleeding which had yields of 43, and 61%.
  • Ileal intubation rates averaged 90% (range ­63–100%, p = 0.06). Ileal intubation is important because, among our patients with a normal colon, there were 21 (6%) with a grossly abnormal ileum and an additional 16 (4%) with abnormal histology in the ileum.  Thus, about 10% of patients with a normal endoscopic and histologic evaluation of the colon had abnormalities in the terminal ileum. A NASPGHAN report (JPGN 2017; 65: 125-31) on quality improvement recommended an ileal intubation rate of 90% as a goal.

Comments:

  • Our group’s overall diagnostic yield is similar to previous studies which ranged from 33-64%.
  • Among physicians with the lowest and highest yield, there was not a specialized focus in IBD or functional GI disorders.  Thus, the driving factor for the variation in diagnostic yield is related to the threshold for performing an endoscopy in patients with probable functional disorders and the response to parental pressures.
  • A negative endoscopic study has not been shown to improve outcomes in patients with functional abdominal pain; though a normal colonoscopy would provide reassurance in some situations (eg. familial polyposis).

My take: Goals for pediatric endoscopy to provide high-value care could include ileal intubation rates of >90% and provider diagnostic yields of >40%.  High-value also includes the actual cost of the procedure; most of our outpatient endoscopies are performed in a pediatric ambulatory center with much lower costs than hospital-based endoscopy.

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Another Study Questions the Efficacy of Drip Feeds for Reflux

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Several years ago, a small study showed that bolus feeds were as well-tolerated in premature infants as drip feeds: Which is Safer -Drip Feeds of Bolus Feeds for Preterm Infants?

Now, a retrospective study (LB Mahoney, E Liu, R Rosen. JPGN 2019; 69: 678-81) found no difference in the rate of reflux in 18 children who were with gastrostomy-tube dependent.

In this study, 24-hour multichannel intraluminal impedance with pH monitoring (MII-pH) examine reflux events in children receiving exclusive enteral nutrition with a combination of daytime bolus feeds and overnight continuous feeds; each patient served as their own control.  this included 6 with prior fundoplication.

Key finding:

  • There was no difference in rate of reflux events when comparing bolus feedings and drip (aka continuous) feedings.

The limitations in this study include the small sample size and retrospective design.  The authors estimate that to achieve adequate power (80% power) to detect a risk ratio of 1.2 would require 211 patients.

My take: This study and other small studies challenge the assumption that drip feedings are safer. Though, until a larger prospective study is performed, we will not know.

Quebec City

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.

How Benign Are Juvenile Polyps?

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A recent retrospective study (N Ibrahimi et al. JPGN 2019; 69: 668-72) reviewed juvenile polyp characteristics over a 14 year period (2003-17) from 213 pediatric subjects who underwent 326 procedures.  The authors state their review was intended for nonsyndromic juvenile polyps, though 23 of the patients had ≥5 polyps (which is incongruous with their presented methods of including children with less than 5 polyps).

Key findings:

  • The authors state that polyp recurrence rates on repeat colonoscopy were 1.5% if one polyp, 19.2% if 2-4 polyps, and 82.6% if 5-10 polyps
  • Juvenile polyps harbored adenomatous changes in 26 (12%) of patients
  • The presence of adenomatous changes did not correlate with polyp number; however, a polyp on the right-sided was more likely to harbor adenomatous changes

It is possible that some of the ‘recurrent’ polyps were missed polyps, as polyps can be easily overlooked.  I had a recent experience of removing numerous polyps (14) from a child recently and some were identified in part due repeated visualization of several colonic segments.  The recent ESPGHAN position paper is useful in children with multiple polyps; their recommendations include: In a child with a single JP, a repeat colonoscopy is not routinely required. (Weak recommendation, very low quality of evidence).

My take: This report is notable for the following:

  1. a fairly high rate of adenomatous changes in juvenile polyps.
  2. a high recurrence rate for children with multiple polyps

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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.

More Frequent Foreign Body Ingestions

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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).

Key findings:

  • 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

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Gastrostomy Tube Placement in Extremely Low Birthweight Infants

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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).

Key findings:

  • 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.

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