How Gastrostomy Tube Placement Influences Gastroesophageal Reflux

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A recent prospective observational study (M Aumar et al. J Pediatr 2018; 197: 116-20) examined the effect of percutaneous gastrostomy (PEG) tube placement on gastroesophageal reflux disease (GERD) over a 13 year period. This study included 326 patients, 56% who had neurologic impairment and had a median follow-up of 3.5 years (and in some cases follow-up to 15 years). GERD was defined as gastroesophageal reflux causing troublesome symptoms and/or complications. Routine pH studies or impedance were not performed.

Key findings:

  • GERD was present in 242 of 326 patients at baseline (74%).  GERD appeared in 11% of patients after PEG and was aggravated in 25% with preexisting GERD.
  • Factors associated with worsening GERD were neurologic impairment and preexisting GERD.
  • 53 patients (16%) required anti-reflux surgery with 22 (6%) in the year following PEG. The only factor identified with the need for surgery was neurologic impairment.
  • At last followup, PEG remained in place in 133 children (41%), and had been removed in 99 (30%).  94 children (29%) were deceased, including 2 from an early procedure-related complication.  In those who were deceased, the vast majority occurred related to evolution or complication of their underlying disease.

The authors note that studies have shown that PEG increases GERD, but “the majority of these studies were of low methodologic quality.”

My take: Routine antireflux surgery at the time of PEG placement is NOT needed in the majority of patients, even in those with baseline GERD.  Less than 20% of patients with GERD required antireflux surgery.

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How Often Should an Endoscopy Be Normal?

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An interesting retrospective study (S Wang et al. JPGN 2018; 66: 876-81) looks at a total of 218 endoscopies in 164 children and examines findings in relation to gastrointestinal symptoms.  The results focus mainly on upper endoscopy as there were only 20 who had isolated colonoscopy.

Key findings.

  • 164 of 612 (26.8%) of all new patients had an endoscopy
  • Among upper endoscopy, 72% were histologically normal, and 56% were macroscopically normal.  The authors suspect those with abnormal macroscopic appearance and normal histology were mainly errors in interpretation.
  • In those with isolated colonoscopy, 25% were histologically and macroscopically abnormal; thus, complete concordance among the 20 cases.
  • In those with combined procedures, the likelihood of abnormalities was higher at 53% for both histology and macroscopically being abnormal.  This higher rate was driven mainly by the increased suspicion and diagnosis of inflammatory bowel disease in this subset of 74 patients.
  • Overall, 49% of all first diagnostic endoscopies were completely normal, though 65% were histologically normal.
  • For upper endoscopy, in those who had performance for isolated abdominal pain, the histologic yield was 11%.  It was also 11% for reflux.  The symptom with highest yield was vomiting, yet even for this, the findings were normal in about 80%.
  • For colonoscopy, rectal bleeding had the highest yield, but 72% were normal in this small cohort, indicating that a trial of conservative management may be appropriate.

An important point in the discussion.  The authors take an exception to the idea that normal findings are reassuring.  “When procedures are performed despite the expectation of normality this has not been shown to lead to better clinical outcomes of patients…abdominal pain was unaffected by whether or not the patient had undergone endoscopy>”

My take: I agree with the authors that the histologic findings are more likely significant than macroscopic findings in the majority of patients.  However, it is worth noting that mild histologic findings are of dubious importance in many cases.  Ultimately, identifying strategies to maximize diagnostic yield is needed to provide more cost-effective care and minimize the risks of unnecessary procedures.

 

The Impact of Maternal Antibiotics on Necrotizing Enterocolitis and Death in Neonates

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A recent study (BD Reed et al. J Pediatr 2018; 197: 97-103) showed that prenatal antibiotic exposure was associated with lower rates of necrotizing enterocolitis (NEC) or death.

In this secondary analysis of a progressive study with 580 infants (<32 weeks) that were cared for in Level III neonatal intensive care units, the authors examined the outcomes of the neonates in relation to whether their mothers had prenatal antibiotics within 72 hours of delivery.

Key findings:

  • Two-thirds of mothers received antibiotics w/in 72 hrs of birth, mainly ampicillin (37%) and azithormycin (26.4%).  Most (~60%) of the mothers who received antibiotics received more than 1 antibiotic.
  • In this cohort, NEC occurred in 7.5%, late onset sepsis (LOS) in 11.1%, and death in 9.6%.  The combined outcome of any of these events occurred in 21.3% of study infants.
  • Prenatal antibiotics were associated with a reduced risk of NEC (OR 0.28, CI 0.14-0.56), reduced risk of death (OR 0.29, CI 0.14-0.60) but not LOS (OR 1.59, CI 0.84-2.99).  Thus, the first two outcomes were within the confidence limits but not LOS.

The authors indicate that their initial hypothesis was that maternal antimicrobials (w/in 72 hours of birth) would increase the risk of NEC but in fact provided a 3-fold protection and reduced the risk of death.  The effects presumably would be mediated by changes in the infant microbiome related to infant’s exposure to microbial environment at birth and/or transplacental passage of antibiotics.  The authors note that their study did not consider mothers to be in the exposure to antibiotics group if their only exposure was antibiotics at the time of cesarean section due to limited time to effect neonate.  They did review this group and noted that if they were included in the exposure group that it would not have significantly changed the findings.

My take: This  intriguing finding that NEC and death occurred less often in infant’s whose mothers received antibiotics prior to delivery needs further study as does the long-term effect.

 

Digital Media Exposure and Well-Being

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Two studies show that increased digital media exposure (DME) is inversely related to a child’s well-being.

In the first study (S Ruest et al. J Pediatr 2018; 197: 268-74), the authors analyzed more than 64,000 U.S. children (2011-2012). ages 6-17 years.  Only 31% reported <2 hours per day of DME.  2-4 hrs/day of DME was noted in 36%, 4-6 hrs/day in 17%, and >6 hrs in 17%.  There was an inverse relationship between DME and 5 markers of well-being: completing homework, caring about academics, finishing tasks, staying calm when challenged, and showing interest in learning.

In the second study (P-Y Pin et al. J Pediatr 2018; 197: 262-7), the authors conducted a 1 year prospective trial with 1861 adolescents.  They found that 23% had internet addiction at baseline, with internet addiction based on the Chen Internet Addiction Scale. 59 students (3.9%) developed new self-harm/suicidal behaviors.  Internet addiction risk conferred a 2.41 relative risk of emerging self-harm/suicidal behaviors.

My take: These studies document a strong association between digital media exposure/internet addiction and worrisome behaviors/worsened well-being.

Pine Mountain Trail

How Does Splenda Affect the Gut Microbiota?

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“You should never assume. You know what happens when you assume. You make an ass out of you and me because that’s how it’s spelled.”

–Attributed to multiple individuals (but I heard this first when I watched Bad News Bears as a kid)

The increasing frequency of many conditions like inflammatory bowel disease cannot be explained by our genetics.  The search for environmental triggers are ongoing.  Broadly, the main suspects are dietary, antimicrobials, and pollutants. (Related blog post: Nutrition Week (Day 7) Connecting Epidemiology and Diet in Inflammatory Bowel Disease)

The latest concern is now Splenda:

“The Artificial Sweetener Splenda Promotes Gut Proteobacteria, Dysbiosis, and Myeloperoxidasse Reactivity in Crohn’s Disease-Like Ileitis” A Rodriguez-Palacios et al. Inflamm Bowel Dis 2018; 24: 1005-20.  Editorial 1055-6 by B Chassaing and AT Gewirtz.

This highly technical study involved research in ileitis-prone SAMP mice and includes a huge amount of data and cool figures.

The authors note in their discussion: “The term ‘Western diets’ implies a proven shift of the microbiota that enhances the susceptibility to adherent-invasive E coli infections and intestinal inflammation in mice.  In this study, we report similar findings due solely to the administration of a minor component of the diet.”

Some of the key points in the editorial:

  • IBD has multigenic influences and “results from a general breakdown in the normally mutually-beneficial relationship between the intestine and the complex microbial community it harbors.”
  • “New findings …that Splenda promotes microbiota dysbiosis in mice and exacerbates a hallmark of inflammation in ileitis-prone SAMP mice suggest that consumption of this synthetic sweetener may be a specific factor that contributes to development of IBD in persons genetically prone to this disorder.”
  • Splenda has two main components: sucralose (sweetener) and maltodextrin (filler)
  • Splenda did not “impact inflammatory markers in control mice, but rather increased such parameters in SAMP mice.”
  • Splenda changed the microbiota in both control mice and SAMP mice, “particularly enrichment of gamma Proteobacteria, which are broadly associated with gut inflammatory diseases.”
  • “Splenda may be relatively safe for the majority of the population but still represents a serious risk factor for those prone to developing IBD or other chronic inflammatory diseases.”
  • Substances like sucralose which are primarily excreted in the feces (nonabsorbed) have generally been viewed as harmless.  “Appreciation of the pivotal role of the microbiota in health questions the latter assumption.”

My take: I think the influences on the microbiota are difficult to tease out.  Thus, this study (in mice) indicates —don’t assume that nonabsorbed agents are harmless

Why Did the Young Woman’s Heartburn Keep Getting Worse?

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Mystery NY Times Case: Why Did the Young Woman’s Heartburn Keep Getting Worse?

An excerpt:

The radiologist who read the scan made an interesting observation. In each of the three visits to the E.R., the patient’s blood had been tested. All three tests showed an elevated white-blood-cell count. That could suggest an infection — but in her tests a quarter of those white blood cells were a cell type known as eosinophils, which normally make up only a tiny fraction of the white blood cells in the circulation. ..

When the radiologist saw the elevated level of eosinophils, however, he recalled an unusual and relatively new disorder known as eosinophilic gastroenteritis (EGE). He added this rarity to the list of possible causes of the patient’s abnormal CT findings on his report…

EGE is thought to be an unusual type of allergic reaction to foods. Food exposure triggers the recruitment of eosinophils to the gut, but once they have a toehold, repeated exposure isn’t necessary to keep them there. The disorder was first described in a series of patients in the United States in 1993 but since then has been found to occur throughout the developed world. Because it’s a relatively new disease, and because our understanding of allergy is still emerging, it’s not well understood. As recognition of the disorder expands, so, too, do the number of cases. Patients are usually started on an elimination diet and given steroids to further suppress the immune system. An elimination diet — one in which the foods most frequently linked to allergic reactions, like milk, eggs and wheat, are not consumed — has been shown to be helpful up to 90 percent of the time.

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Not Preparing for the Next Pandemic

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A terrific commentary (Bill Gates, NEJM 2018; 378: 2057-60) explains how we are NOT preparing for the next pandemic and what we should be doing and why.

Key points:

  • There has been incredible progress in many areas of global health and infectious diseases.  In fact, “child mortality has decreased by more than 50% since 1990.”  HIV is no longer “a certain death sentence” and there has been progress with malaria.
  • Yet, “there is a significant probability that a large and lethal modern-day pandemic will occur in our lifetime.”  Some recent events have alerted us to this risk, including swine flu in 2009, Ebola in 2014 as well as recent MERS (Middle East respiratory syndrome) and SARS (severe acute respiratory syndrome).
  • “We need better tools, an early detection system, and a global response system.”
  • “A simulation by the Institute for Disease Modeling shows what would happen if a highly contagious and lethal airborne pathogen, like the 1918 influenza, were to appear today.  Nearly 33 million people worldwide would die in just 6 months.” (see below)
  • Vaccine development holds some promise to protect against many pathogens.  One step to help with vaccines has been a public-private venture, Coalition for Epidemic Preparedness Innovations (CEPI).
  • Vaccines alone are not enough as they take time to stimulate immunity and often not enough people receive them.  “So we need to invest in other approaches, such as antiviral drugs and antibody therapies that can be stockpiled.”

My take (borrowed): “”If it were a military weapon [threat], the response would be to de everything possible to develop countermeasures.  In the case of biologic threats, that sense of urgency is lacking.  But the world needs to prepare for pandemics in the same serious way.”