Category Archives: Pediatric Gastroenterology Intestinal Disorder

Another Day in the US: School Deaths Related to Firearms

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Between 2001-2013, gun related deaths exceeded the total number of deaths from AIDS, terrorism, war, and illegal drug overdoses combined (according to Vox -see Firearm Mortality in U.S).  Here are some tweets in reaction to yesterday’s tragic events.

Link to The Onion commentary: ‘No Way To Prevent This’

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Acute Pancreatitis: Clinical Report from NASPGHAN

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There are no surprises in a recent clinical report on acute pancreatitis (M Abu-El-Haija et al. JPGN 2018: 66: 159-76) from NASPGHAN.

Here are a few of the points:

  • The authors recommend ultrasound for initial imaging and checking liver enzymes, GGT, calcium and triglycerides.
  • For fluids, they indicate that in adults there is evidence suggesting that lactated ringer’s (LR) is likely preferable to normal saline.  In children, on presentation, “if evidence of hemodynamic compromise, a bolus of 10 to 20 mL/kg” of crystalloid is recommended followed by “1.5 to 2 times maintenance IV fluids.”
  • For pain management not responding to acetaminophen or NSAIDs, “IV morphine or other opioids should be used.”
  • They recommend early oral/enteral nutrition (within 48 to 72 hours of presentation).
  • They recommend against prophylactic antibiotics in severe acute pancreatitis.
  • They recommend against probiotics, anti-proteases, and antioxidant therapy.
  • For fluid collections that need drainage or necrosectomy, nonsurgical approaches are favored.
  • Acute biliary pancreatitis, “Cholecystectomy safely can and should be performed before discharge in cases of mild uncomplicated acute biliary pancreatitis.”

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American Ingenuity!!

Cancer due to Overweight/Obesity

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The increasing risk of cancer due to overweight and obesity has been reported by the Centers for Disease Control and Prevention in recent MMWR report (CB Steele et al. MMWR 2017; 66: 1052-8)  Vital Signs: Trends in Incidence of Cancers Associated with Overweight and Obesity — United States, 2005–2014

Key points:

  • Overweight and obesity are associated with increased risk of at least 13 different types of cancer.
  • Overweight- and obesity-related cancers accounted for 40% of all cancers diagnosed in 2014.
  • The incidence of overweight- and obesity-related cancers (excluding colorectal cancer) increased significantly among persons aged 20–74 years during 2005–2014, mirroring increases of obesity observed since 1960.
  • The findings emphasize the importance of intensifying nationwide efforts to prevent and treat overweight and obesity.

My take: While the medical risks related to overweight/obesity generally are attributed to worsened cardiovascular disease, this study adds information regarding the increased risks of some types of cancer as well.

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Iron Metabolism Improves after Anti-TNF Therapy for Crohn’s Disease

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A previous study has shown that low vitamin D levels improved with anti-TNF therapy for Crohn’s disease in the absence of supplemental vitamin D.  Similarly, a recent study (MA Atkinson, MB Leonare, R Herskovitz, RN Baldassano, MR Denburg. JPGN 2018; 66: 90-4) showed improvement in iron metabolism with anti-TNF therapy.

In 40 children and adolescents with Crohn’s disease, the authors measured serum hepcidin-25 and hemoglobin at baseline and then 10 weeks after anti-TNF therapy.

Key findings:

  • Median hepcidin concentrations decreased (27.9–>23.2 ng/mL) and mean hemoglobin increased (10.6–>10.9).
  • Disease activity and markers of inflammation also decreased.

My take: This study shows that improvement in inflammation is associated with meaningful improvement in anemia.  However, most patients will need additional treatment for anemia, particularly as anemia may be related to blood loss in addition to anemia of chronic disease/inflammation.

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Opioid Epidemic Affecting HCV Infection in Adolescents (as well as adults)

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SA Barritt et al. J Pediatr 2018; 192: 159-64. Increasing Prevalence of Hepatitis C among Hospitalized Children Is Associated with an Increase in Substance Abuse

Background:  “After a sustained decline in new HCV cases, in recent years there has been a significant increase in HCV incidence in adults in many areas, primarily associated with the use and abuse of intravenous heroin and prescription opioids.” This study examines this trend in adolescents.

From abstract:

Study design

We examined hospitalizations in children using the Kids’ Inpatient Database, a part of the Healthcare Cost and Utilization Project. We identified cases using the International Classification of Diseases, 9th edition, codes for HCV infection during 2006, 2009, and 2012. Nonparametric tests for trend were used to calculate trend statistics.

Results

From 2006 to 2012 nationally, the number of hospitalizations of children with HCV increased 37% (2.69 to 3.69 per 10 000 admissions; P < .001). The mean age of children hospitalized was 17.6 years (95% CI, 17.4-17.8). HCV cases among those 19-20 years of age represented 68% of the total HCV diagnoses, with a 54% increase over the years sampled (P < .001 for trend). The burden of HCV in children was highest in whites, those in the lowest income quartile, and in the Northeast and Southern regions of the US (all P < .0001). The prevalence of substance use among children with HCV increased from 25% in 2006 to 41% in 2012 (P < .001).

Conclusion

The increases of HCV in hospitalized children are largely in teenagers, highly associated with substance abuse, and concentrated in Northeast and Southern states. These results strongly suggest that public health efforts to prevent and treat HCV will also need to include adolescents.

My take: Despite the availability of highly effective therapy for hepatitis C, the opioid epidemic undermines any prospect for eliminating hepatitis C infections.

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Probiotics for Prevention of Nosocomial Diarrhea in Children

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A recent review (I Hojsak et al. JPGN 2018; 66: 3-9) examined published trials regarding the role of probiotics in the prevention of nosocomial diarrhea. The review was conducted by a working group on behalf of ESPGHAN.

Key findings:

  • “Recommendation: If probiotics for preventing nosocomial diarrhea in children are considered, the WG [working group] recommends using L rhamnosus GG (at least 10 to the 9th CFU/day, for the duration of hospital stay).
  • Quality of evidence: Moderate
  • Strength of recommendation: Strong
  • Number needed to treat (in order for beneficial effect in one): 12 patients

The authors do not recommend L reuteri DSM17938 due to lack of efficacy; other probiotics did not receive a recommendation either due to lack of data or lack of efficacy.

It is possible that there have been unpublished negative probiotic studies which would alter the calculation of a beneficial effect.

My take: While the working group recommends L rhamnosus GG if probiotics are used to prevent diarrhea, the absolute benefit is low.

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Probiotics for Colic –2018 Update

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There is some debate about whether colic is truly a GI disorder.  A recent commentary (V Sung, MD Cabana. J Pediatr 2017; 191: 6-8) provides some insight.

Key points:

  • “‘Colic’ is a term coined by the ancient Greeks…derived from ‘kolikos,’ meaning crampy pain, sharing its root with the the word colon.”
  • “Since 1994, there have been at least a dozen case-control studies that have indicated differences in the gut microbiota between infants with and without colic.”
  • Studies have had conflicting results with whether calprotectin levels are increased in infants with colic compared with controls.
  • Among probiotics, L reuteri DSM17938 “is the best studied strain.” Despite several studies suggesting efficacy, “the largest and only double-blind randomized trial that included both breastfed and formula-fed infants with colic (n=167) in Australia was ineffective.
  • The commentary reviews a recent study (Fatheree NY et al. J Pediatr 2017; 191: 170-8) “although very small in comparison, adds to this literature, being the second double-blind randomized, placebo-controlled trial of L reuteri DSM17938 shown to be ineffective in breastfed infants with colic.” Sample size =20. “It is the first to document increased fecal calprotectin levels that decrease with reduced crying” …though this “may be reflections of normal levels in healthy young infants, which change over time.”  In addition, this study did not find evidence of systemic inflammation.  The authors speculate that the frequent use of antireflux medications could dampen the effects of probiotics.

My take: We still do not know whether efforts at changing an infant’s microbiome improve clinical outcomes in colic.

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Crohn’s Disease Diagnosis Identified After Colectomy in Presumed Ulcerative Colitis

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A recent retrospective single-center study (I Jones et al. JPGN 2018; 66: 69-72) identified a high rate of inflammatory bowel disease (IBD) reclassification.  From 2003-2014, 570 children were diagnosed with IBD, including 190 with ulcerative colitis.  29 of these patients underwent colectomy.  Among this select group, 24% (7/29) were subsequently reclassified as having Crohn’s disease, sometimes several years later.  Only two of the seven reclassified patients were younger than 10 years of age at the time of colectomy.

My take: This rate of Crohn’s disease following colectomy is higher than in previous reports (generally 5-10%).  The larger point is that the diagnosis of ulcerative colitis is more uncertain in the pediatric population, particularly in those in the first decade of life.

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Pancreatitis -Feedings and Genetics

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KM Ellery et al. J Pediatr 2017; 191: 164-9.  This prospective pediatric study examined 30 patients with mild acute pancreatitis in a “patient-directed nutrition” (PDN) pathway using a low fat diet and compared to a historical control of 92 patients in a “treatment team-directed nutrition” (TTDN) pathway. In the PDN group, patients were allowed a low-fat oral diet (<5 g fat per entrée, <1 g fat per snack, and only 1 entrée or snack at a time) at the time of admission.

Key findings:

  • PDN group had median length of stay of 48.5 hours compared with 93 hours for the TTDN group
  • PDN group was NPO for median of 14 hours compared to 34 hours for TTDN group
  • No patients in the PDN group had complications within 30 days of discharge

Y Xiao et al. J Pediatr 2017; 191: 158-63.  Among 55 pediatric patients with chronic pancreatitis and 14 with acute recurrent pancreatitis, there were 45 and 10 patients respectively who harbored 1 or more mutations in pancreatitis-associated genetic disorders: PRSS1, SPINK1, CFTR, CASR, CTSB, CTRC, KRT8

My take: These two studies indicate that oral feeding in mild acute pancreatitis leads to shorter hospital stays and that pediatric patients with chronic pancreatitis and acute recurrent pancreatitis frequently have predisposing genetic mutations.

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The Half Empty Glass: Rumination Outcomes

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Briefly noted:

A Alioto, C DiLorenzo. JPGN 2018; 66: 21-25.  In this study based on patient follow-up questionnaires, among 47 adolescents with rumination syndome who received inpatient treatment, Key findings:

  • ~20% reported complete cessation of rumination for at least 6 months; though, even in this group, 73% had at least some recurrent symptoms.
  • 40% reported a reduction in rumination intensity following discharge and ~80% reported having at least one day with no rumination.
  • Triggers for recurrence of rumination symptoms included stress (51.4%), illness (27%), menstruation (10.8%), and certain foods (18.9%).
  • Treatment of rumination syndrome helped eliminate the need for supplemental tube feedings in the “vast majority of patients.”

One important limitation of this study is the patient selection; this group of inpatients with rumination syndrome at a specialized center likely had more severe rumination syndrome.

My take: Like many GI conditions, the expectation for rumination syndrome should probably be improvement/management rather than resolution/cure.

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