#NASPGHAN18 Highlights and Tweets (part 1)

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I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.

Here are a couple of highlights for me:

Slides from postgraduate course on CVS from Dr. Katja Kovacic

The slide from Dr. Lightdale (pg 22 in Syllabus) below suggests it is OK for scope if platelets >20K and OK for biopsies if platelets >50K. It is worth noting that some adult data indicate that even lower biospy thresholds are reasonable for biopsies (Post: Lower Endoscopic Thresholds for Thrombocytopenia). As always, one needs to consider carefully the risks compared with the benefits.

From Postgraduate Course

 

 

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.

New Button Battery Guidelines –with Honey and Vinegar

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Button batteries –definitely more scary than Halloween.  Here is a link to new guidelines from Poison Control: New Button Battery Guidelines 2018

A recent report from Nationwide Childrens, How Sweet It Is: Honey Attenuates Button Battery-Induced Esophageal Damage, highlights two important advances in button battery management that are now incorporated into the new button battery guidelines:

  1. At time of endoscopy,  “a weak acetic acid rinse (sterile vinegar) can help neutralize tissue pH and protect the esophagus from continued tissue breakdown after battery removal. This irrigation concept has now been successfully used in children around the world with good clinical outcomes.”
  2. Prior to endoscopy, “both honey and sucralfate (Carafate®) were able to effectively neutralize the tissue pH and reduce visible injury.”

“More than 3,000 cases occur per year, mostly among children younger than age 6, and severe cases are on the rise. Lodged button batteries can cause rapid injury, including permanent bilateral vocal cord paralysis and even death.”

Guideline recommendations with regard to acetic acid:

After a battery is removed from the esophagus, inspect the area endoscopically for evidence of perforation. If none is evident, irrigate the injured areas with 50 mL to 150 mL of 0.25% sterile acetic acid (obtained from the hospital pharmacy). Irrigate in increments and suction away excess fluid and debris through the endoscope. For decades toxicologists have advised against neutralization for fear of causing a thermal injury. However, a recent study (Jatana, 2016) using piglet esophagus preparations after button battery removal, showed only a minimal increase in temperature (0-3 oC), effective tissue surface pH neutralization, and decrease in the visible injury using this neutralization strategy. The tissue surface pH neutralization may reduce the development of progressive, delayed-onset esophageal injury after battery removal.

From guideline with regard to honey:

Administer honey immediately and while en route to the ER, if:

  1. A lithium coin cell may have been ingested (if you don’t know what kind of button battery was swallowed, assume it is a lithium coin cell unless it is a hearing aid battery);
  2. The child is 12 months of age or older (because honey is not safe in children younger than one year);
  3. The battery was swallowed within the prior 12 hours (because the risk that esophageal perforation is already present increases after 12 hours);
  4. The child is able to swallow; and
  5. Honey is immediately available.

How to dose honey:

      1. Give 10 mL (2 teaspoons) of honey by mouth every 10 minutes for up to 6 doses. Do not worry about the exact dose or timing.
      2. Use commercial honey if available, rather than specialized or artisanal honey (to avoid inadvertent use of large amounts of honey produced from potentially toxic flowers).
      3. Honey is NOT a substitute for immediate removal of a battery lodged in the esophagus. Honey slows the development of battery injury but won’t stop it from occurring. Do not delay going to an ER.

Why give honey?

Honey is administered to coat the battery and prevent local generation of hydroxide, thereby delaying alkaline burns to adjacent tissue. Efficacy is based on a 2018 study (Anfang et al) assessing the in vitro protective effects of various liquids in the cadaveric porcine esophagus and in vivoprotective effects of honey and sucralfate (Carafate®) compared to saline irrigations of batteries placed in the esophagus of live piglets. Both honey and sucralfate (Carafate®) effectively prevented the expected battery-induced pH increase and decreased the depth of the resulting esophageal injury.

References:

  1. Anfang RR, Jatana KR, Linn RL, Rhoades K, Fry J, Jacobs IN. pH-neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury. The Laryngoscope. 2018 Jun 11. [Epub ahead of print]
  2. Jatana KR, Rhoades K, Milkovich S, Jacobs IN. Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal. The Laryngoscope. 2017 Jun;127(6):1276-1282.

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.

 

#NASPGHAN18 Abstract: LR for Pancreatitis & Pumpkin Shot

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At NASPGHAN18, an abstract provided more information that indicates that lactated ringer’s is probably the best intravenous fluid for most children with acute pancreatitis

Related blog posts:

 

2018 Pumpkin for our House

Endoscopic Experts Needed In Pediatrics

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A recent study (A Schmidt et al. Gastroenterol 2018; 155: 674-86) shows how a new endoscopic technique, over-the-scope clips (OTSC), are more effective than standard endoscopic therapy for patients with recurrent bleeding of peptic ulcers.

Key finding: A multicenter prospective randomized unblinded study with 66 patients (33 in each arm) with found that hemostasis with OTSC had a failure rate (further bleeding) of 15.2% compared with 57.6% in those with standard therapy.

The authors note that standard endoscopic techniques are effective in more than 90% with rebleeding rates of 2-10%.  In those with rebleeding, followup endoscopy has a much lower success rate.

My take:

  • This study highlights a problem in pediatric endoscopy –the lack of expertise in these rare cases.  To learn even ‘standard’ endoscopic therapy, most pediatric GI fellows will need to collaborate with adult gastroenterologists in order to have exposure to a sufficient number of cases.
  • The development of alternatives like hemospray (Hemospray for GI Bleeding) which is technically-easy should be helpful for pediatric endoscopists with less endoscopic training.

Related article: 

P Tran et al. JPGN 2018; 67: 458-63.  This retrospective analysis of 11 pediatric cases (median age 14.7 yrs) reported technical success in all cases, though 2 patients with anastomotic ulcers requred additional medical intervention. The article has some pretty cool pictures.

Related blog posts:

 

Lake Agnes, Banff

Lake Agnes Teahouse Menu

 

Briefly Noted: Progression of Fatty Liver Disease on MRI

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M Mouzaki  et al. J Pediatr 2018; 201: 86-92. This study with 65 patients evaluated nonalcoholic fatty liver disease (NAFLD) progression between two MRI studies, with a median time span of 27 months.

Key findings:

  • There was no correlation between change in liver stiffness and change in ALT; there was a weak correlation between ALT change and fat fraction.
  • MRI fat fraction and stiffness decreased in 29% and 20% of patients respectively and increase in 25% and 22% respectively.

My take: When we find effective therapies, we will need better non-invasive markers to follow NAFLD progression.

Related blog posts

Tea House Trail, near Lake Louise, Banff

Briefly noted: Selective Serotonin Reuptake Inhibitors (SSRIs) and Linear Growth

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CA Calarge et al. J Pediatr 2018; 201: 245-51. This study analyzed data from 4 separate trials with a total of 267 boys treated with risperidone.  In this cohort, 71% had taken an SSRI.

Key finding: The duration and cumulative dose of SSRI was inversely associated with height z score, especially during Tanner 3 and 4 stages.  The effect was approximately 1 cm for every year of treatment.

The authors speculate that SSRIs could “alter serotonin signaling, which is known to control GH secretion.”

My take:

  1. This study shows an association between SSRIs and linear growth but it remains unclear if this affects adult height (could postpone growth).
  2. This potential adverse effect needs to be considered in the clinical picture of the severe impairment and distress that can occur due to untreated depression and anxiety.

Related blog post: Brave New World: Psychotropic Manipulation and Pediatric Functional GI Disorders

Lake Louise, Banff

Why I Don’t Check Vitamin D Levels During IBD Flare-ups

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A recent study (C Striscuiglio et al. JPGN 2018; 67: 501-6) helps explain the role of inflammation on vitamin D levels in pediatric patients (n=51) with inflammatory bowel disease (IBD).

Key findings:

  • The free/total 25-OH D ratio was higher in patients with newly-diagnosed IBD compared to healthy controls (P< .001)
  • A significant direct correlation was found between free/total 25-O D ratio and the activity index of disease (P= .01)
  • While there was frequent deficiency in total vitamin D levels,  the free 25-OH D which is the active form of vitamin D was normal or elevated in patients with newly-diagnosed IBD; this, in turn, was due to a decrease in vitamin-D binding protein which is related to inflammation. The authors hypothesized that at the cellular level in the intestine, there may be peripheral resistance due to inflammation and even supratherapeutic levels of free vitamin D could be needed to produce the active form (1,25-OH D).

My take: This study shows that 25-OH D levels (total) have almost no value at the onset of IBD.  Even normal or elevated free levels of 25-OH D which were found in this study does not preclude the potential need to supplement with vitamin D according to the study authors. In addition, as noted in previous posts, Vitamin D levels can normalize without supplementation when the patient’s IBD responds to therapy.

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.

Dangerous animal –seen on our hike to the tea house, Banff

#NASPGHAN18 -Our Poster on Antibiotic Stewardship and PEG Placement

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Thanks to Chelly Dykes for presenting poster later today and to co-authors for collaborating on this project: Jeffery Lewis, Bonney Reed-Knight and Cate Crenson.

Full abstract below.

ABSTRACT:

 Background: While there is general agreement that antibiotic prophylaxis for percutaneous gastrostomy (PEG) tube insertion reduces the risk of infection at the site of placement (Lipp A, Cochrane Review 2013), optimal antibiotic selection and regimen remain unclear; as a result, there is widespread practice variation.  In addition, in order to limit the development of bacterial resistance and complications from antibiotic use (eg. Clostridium difficile infection), antibiotic stewardship programs have aimed to limit antibiotic usage, particularly broad-spectrum antibiotics.

Methods: From December 1, 2016 through May 1, 2018, the charts of all patients who underwent PEG tube placement in our children’s hospital were reviewed.  This period coincided with an optional practice change in antibiotic prophylaxis.  Prior to the study period, the typical patient received prophylaxis with a three-dose regimen of cefoxitin.  During the study period, at the discretion of the gastroenterologist, patients received either a three-dose regimen of cefoxitin (n=38) or treatment with cefazolin (n=109); 73 patients received a single dose of cefazolin prior to PEG placement and 36 received multiple doses.  The initial dose of either regimen was given within thirty minutes of placement.  All patients were observed for at least 24 hours.  In patients with PEG tube site infections based on clinical assessment, rescue antibiotic treatment was prescribed.

Results: In total, 144 subjects had PEG placement. The main indications for PEG placement were swallow dysfunction (56.2%), poor growth (17.6%), feeding aversions (18.9%) and malignancy (6%).  In the cefoxitin group, clinical infection occurred in 3 of 35 (8.6%).  In the cefazolin group, clinical infection occurred in 20 of 109 (18.3%). In the subset of patients who received multiple doses of cefazolin, the clinical infection rate was 6 of 36 (16.7%). Patients in the cefazolin group had a 2.39 times higher odds (95% CI  0.667-8.612) of infection compared to the cefoxitin group. Although rates of infection were more than twice as high in the cefazolin group compared to the cefoxitin group, this association did not differ statistically using a chi square test (x^2 = 1.89, p = 0.20).

Conclusion: This study highlights the ongoing uncertainty regarding optimal antibiotic prophylaxis for PEG tube placement.  The difference in the clinical infection rate between cefazolin and cefoxitin was not statistically significant; however, the absolute rate of infection in the cefazolin group was more than twice as high as the cefoxitin group and this may influence selection of antibiotic prophylaxis for PEG tube insertion.