Which is Safer –Drip Feeds or Bolus Feeds in Healthy Preterm Infants?

Posted on January 28, 2015 by gutsandgrowth

A recent provocative study (J Pediatr 2014; 165: 1255-7) takes a look at the frequency of cardiorespiratory events in healthy neonates <33 weeks gestation who needed supplemental enteral tube feeds.

It is generally accepted that continuous or “drip” feedings are less likely to provoke reflux events (and reflux-induced cardiorespiratory events) by limiting the amount of formula in the stomach at any time point. If there is less formula, presumably there would be less stomach distention and a lower likelihood of reflux. In addition, a continuous amount of formula would serve to buffer stomach acid.

Despite the sound theoretical underpinnings, is this really true? In this study, the authors detected fewer cardiorespiratory events with polysomnographic monitoring in healthy premature neonates who were fed with bolus feedings rather than with drip feedings.

Study design: Each of 33 infants served as its own control. During a 6-hour monitoring period, noninvasive polysomnographic recordings were performed. Each infant was fed twice via an orogastric tube. The first meal was given as a 10-minute bolus (by gravity) and the second was delivered over 3 hours. It is noted that the tube was removed after the bolus feeding (this is not routinely done in clinical practice).

Demographics: Median gestational age was 31 weeks and median postnatal age was 16 days. Fortified human milk was given in 12, premature formula in 7, and 14 had mixed feeding.

Results (Table 2): “continuous feeding was associated with a greater number of prolonged apneas and apnea-related hypoxic episodes.”

Median Apnea Frequency: 4 in continuous versus 2 in bolus group (no obstructive apneas were noted)
Median hypoxic episodes: 3 in continuous versus 2 in bolus group.

The authors speculate that leaving the tube in place for continuous feeds could increase GER-related apnea or trigger ‘protective upper airway reflexes in response to the irritating stimulus.’

Bottomline: The assumption that continuous feedings will reduce cardiorespiratory events is not supported by this study. The findings warrant cautious interpretation; the small sample size and specific ages of the premature infants are significant limitations. In addition, leaving an enteral tube in place after a bolus feeding would be a better design as this is a routine practice.

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NASPGHAN Postgraduate Course 2014 -3rd Module | gutsandgrowth

Prucalopride -Not Better Than Placebo for Children with Constipation

Posted on January 27, 2015 by gutsandgrowth

Background: There were high expectations for prucalopride for the treatment of constipation based on previous small studies as well as a placebo-controlled trial in adults. In adults, after 12 weeks of treatment, between 19.5-29% were responders compared to 9.6-12.1% in placebo patients. Prucalopride is a 5-hydroxytryptamine receptor-4 (5HT4) agonist which has been shown to accelerate colonic motility and is similar structurally to agents like cisapride and tegaserod; these latter medications have shown effectiveness as prokinetics but were limited by life-threatening cardiovascular side effects.

Design: Large (n=213), multicenter, placebo-controlled trial (Mugie SM, et al. Gastroenterol 2014; 147: 1285-95, editorial 1214-16). Response to medication indicated by >3 spontaneous bowel movements per week and <1 episode of fecal incontinence every 2 weeks.

Findings:

17% of prucalopride subjects and 17.8% of placebo subjects were considered responders.
If based solely on bowel movement frequency, 29.2% of prucalopride achieved >3 BMs/week, whereas 35.5% of placebo-treated patients achieved this frequency.
Adverse effects were similar

Why did Prucalopride not work?

The authors and editorial make several speculations. In children, withholding behavior is much more important in the pathophysiology of functional constipation (FC) than in adults. In addition, slow transit constipation is much more common in adults than in children. In the adolescents (≥12 to <18) there was a mild response noted: 18.5% compared with 14.8% of placebo-treated patients (P=.38). The editorial notes that the short length of the trial (8 weeks) could explain the negative results, though this is unlikely.

The editorial, by Samuel Nurko and Miguel Saps, notes a much higher response to polyethylene glycol which “is the mainstay of treatment.” “PEG-based solutions achieved a successful outcome in 56% of participants compared with 29% in the lactulose group.”

Take-home message: “This study does not provide new data to justify a change in the indication of PEG as first line of treatment for FC in children.”

In followup to questions regarding Miralax safety, here is a link from NASPGHAN’s Neurogastroenterology and Motility Committee: Miralax FAQ

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A Sign in Our Office –Needs Clarification

AAP -Behind the Scenes (Part 2)

Posted on January 27, 2015 by gutsandgrowth

Besides the focus on legislation and access to care, the AAP meeting provided an infectious disease update from Dr. Harry Keyserling, membership update by Dr. Roma Klicius, the Pediatric Foundation Report by Dr. Bob Wiskind, an update on oral health care by Dr. Chevron Brooks, a brief update on AAP Friends of Children by Dr. Jay Berkelhammer, and discussion about transitional care.

With regard to the infectious diseases update, Dr. Keyserling noted that despite the flu vaccine’s lower “match” this year and its reduced effectiveness, it is still quite important to receive the flu vaccine.

Each year, about 1/3rd ot the population gets the flu.
About 1 in 10,000 people die due to the flu.
In 2012-13, there were 171 pediatric deaths across the country due to influenza. 90% of these deaths occurred in children who were not immunized; in other words, for a child with the flu, the risk of death is more than 10 times higher in those who do not receive the immunization.

Here are a couple of slides (used with permission) regarding the flu:

Risk of Death from the Flu

Flu Data thru Jan 2015

Flu Vaccine Coverage

Bottomline: The AAP is working on preventing deaths from all vaccine-preventable deaths, including the flu.

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Since my job at the AAP is to work on nutrition-related issues, I would welcome suggestions for areas of concern. As there are separate areas devoted to obesity and breastfeeding, my goal is to work on other aspects of nutrition in children. Some ideas that have come up already include an update on gluten-related disorders and nutritional supplements. Any other advice?

Upcoming AAP Schedule

AAP -Behind the Scenes (Part 1)

Posted on January 26, 2015 by gutsandgrowth

Recently I was asked to become a board member for the Georgia Chapter of the American Academy of Pediatrics (AAP) in the role of chair of the section of nutrition. My role at this meeting was limited. I was impressed by the commitment of the participants and by the range of activities that the AAP chapter was working on –all in the efforts of improving the health of children in Georgia.

I only took a few notes but here are some of the details. Dr. Evelyn Johnson (President) provided the president’s report and an overview of the chapter activities.

Dr. Anu Sheth provided an update on the Medicaid Task Force. This issue was discussed in some detail. The issue at stake is the low reimbursement for office visits for children with Medicaid coverage; the rate has not changed in 13 years with one notable exception. In 2013-2014, the federal government provided a one-time boost in the rates of Medicaid reimbursement with the role out of the ACA (Obamacare) to encourage availability of primary care physicians to see the new enrollees. There is preliminary evidence that this boost did improve access to care.

According to a recent study (NEJM 2015; January 21, 2015DOI: 10.1056/NEJMsa1413299), “Our study provides early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times.”

Since 43.2% of all children in Georgia receive their health insurance through Medicaid this is a big issue. It is also directly related to another topic of provider access. 61 counties in Georgia have a deficit of needed pediatricians and 23 counties have no pediatrician at all. Currently, Medicaid rates to physician practices are only about 75% of Medicare rates and compared to commercial insurance plans, they pay only half.

Based on these considerations, the AAP is urging its members to contact their state legislators, particularly those more involved in the budget decision-making process. While bumping Medicaid rates in the face of other budget constraints may be difficult, default limiting of access results in higher costs through emergency room visits and complications.

Georgia Politicians with Greatest Impact on Healthcare Decisions

Rural communities are more affected by access issues than urban counties. Dr. Angela Highbaugh-Battle provided an update on the Governor’s Rural Hospital Task Force. There have been a number of hospital closures and more appear to be imminent. Communities that are losing hospitals are losing important jobs, access to timely care, and will have difficulty attracting new businesses.

Another related topic was the issue of ‘retail-clinic’ healthcare. While the ease of access is quite helpful for families, there are numerous concerns about the quality of care. Several clinicians described their efforts to provide alternatives including extended hours in their practices and weekend hours as well.

One fascinating aspect about the discussion of retail clinics was its juxtaposition with efforts to improve the process of remaining board-certified (See related blog: Resistance to Maintenance of Certification | gutsandgrowth). Given the increasing use of retail-clinics and midlevel providers, several clinicians emphasized that board-approval is not a strong consideration for families seeking healthcare. The fact that the board approval process is not tied to a broad effort to show its impact on patient care and/or to market the efforts of pediatricians has led to widespread dissatisfaction.

Take-home message: The issue of adequate access to primary care physicians along with high quality care is important for everyone. Make your voice heard!

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Helpful Position Paper: Percutaneous Endoscopic Gastrostomy in Children

Posted on January 25, 2015 by gutsandgrowth

A recent European Society for Pediatric Gastroenterology Hepatology and Nutrtition (ESPGHAN) position paper provides some useful advice regarding the management of percutaneous endoscopic gastrostomy (PEG) in children and adolescents (JPGN 2015; 60: 131-41).

Table 1 provides a succinct description of the potential benefits of PEG compared with nasogastric tube including less dislodgement, reduces risk of aspiration, better appearance, safer/more reliable enteral access, optimizes development of oral skills, less blockage/clogging, cost-effective, less interference with daily activities, avoids nasal irritation/trauma, reduced anxiety at mealtimes, and shorter meal times.

Table 2 provides a good summary of clinical indications including optimizing nutritional status, maintaining hydration, supporting unpalatable diet, decompressing stomach, improving medication adherence, ensuring safe feedings/prevent aspiration, and improving quality of life.

The position paper reviews relative and absolute contraindications (uncorrectable coagulopathy, interposition of enlarged organs, frank peritonitis); I did not see any mention of high dose steroids as a relative contraindication. Given high dose steroids’ impact on healing, PEG needs to be avoided if possible in this setting (in my opinion).

The authors provide extensive information on potential complications (table 6 and table 7).

Other key points:

“In the United Kingdom, it is accepted by the National Institute of Clinical Effectiveness that expectation of continuous NGT use for a minimum of 4 weeks (www.nice.org.uk/CG032 –this reference provided by authors focuses on NGT in adults), or even 2 to 3 weeks, should prompt consideration of PEG insertion.”
“The use of a routine preoperative upper GI contrast study is NOT advised to rule out malrotation.”
“Asymptomatic children do not require investigation for GERD before PEG insertion.” However, the authors note that in the presence of significant symptomatic reflux, or reflux in the presence of an unsafe swallow/progressive neurologic disease, or chronic respiratory disease, this should prompt discussion around the need for a surgical antireflux procedure.
The authors suggest that PEG change to a button can occur “after a period of 2 months or more.” Our institution generally does not change prior to 3 months.
The authors state that formula (rather than clears) can be started within 4 to 6 hours of PEG insertion.
One aspect of their recommendations that I disagreed with was their advice on preventing a ‘buried bumper.’ “To prevent a ‘buried bumper,’ the PEG should be carefully pushed into the stomach by 1 to 2 cm and then rotated once a week from day 7 postinsertion.”
Perhaps this advice is offered as the guideline also suggests that patients do not need much follow-up: “The child will require follow-up, typically provided by nurse specialists 3 months after placement of the gastrostomy. Thereafter, annual review of the device is usually adequate…between routine appointments caregivers should have access to appropriately trained professionals.” In my view, if the tube is appropriately sized (checked early on) and patients are followed (for excessive weight gain), then pushing in the tube should be unnecessary.

Take-home message: Overall, this is a useful reference/summary for PEG tube management, though some recommendations are based on practice patterns rather than high-quality data.

Are there others who would like to relay their experience and advice?

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Walking May Lower Risk of Death

Posted on January 24, 2015 by gutsandgrowth

From NBC news: A walk a day may keep early death away

Here’s the “skinny:” (an excerpt)

The findings that a daily, stroll of 20 minutes may reduce a person’s risk of premature death by up to 30 percent are consistent… with the physical activity guidelines for Americans.

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Walking with a “Z” or an “X” | gutsandgrowth

Don’t Get Run Over When You Walk

EXCEPTIONal Outcomes and Liver Allocation

Posted on January 23, 2015 by gutsandgrowth

A recent study (Hepatology 2015; 61: 285 & editorial 28-31) takes a closer look at US liver organ allocation and outcomes.

The editorial notes that our allocation in the US is targeted towards “need.” Since February 2001, the MELD score was adopted with “the stated aim of reducing deaths on the waiting list.” Other potential aims:

Equity –so any one who might benefit from a graft has an equal chance and a first-come, first-served approach is adopted
Utility –organs are allocated to the recipient who is likely to have the best outcomes
Benefit –organs are allocated to the patient who has the greatest benefit, so taking into account the risks of dying with and without a transplant
Fairness — ‘an ill-defined combination of all the approaches’

The editorial notes that “despite the concerns the approach has been highly effective in achieving its goal in reducing waiting list mortality.”

“Like any system, it can be manipulated and, given the life-saving nature of transplantation, it is scarcely surprising that both legal and illegal methods have been adopted to artificially raise the MELD score and distort allocation.”

The study reviewed 78,595 adult liver transplant candidates (2005-2012). 27.3% of the waiting list was occupied by candidates with exceptions.

Candidates with exceptions fared much better on the waiting list compared to those without exceptions in mean days waiting (HCC 237 versus non-HCC 426), transplantation rates (HCC 79.1% versus non-HCC 40.6%), and waiting list death rate (HCC 4.5% versus non-HCC 24.6%).

The editorialists recommend that “we should consider diverting some of the resources used to develop and implement a perfect allocation scheme into increasing the number of donors and livers used for transplant and, in the longer term, finding treatments and interventions that will render liver transplantation a treatment of historic interest.” Now that’s a lofty goal.

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In the News …CRE due to ERCPs

Posted on January 22, 2015 by gutsandgrowth

Carbapenem-Resistant Enterobacteriaceae (CRE) are difficult to treat infections. A recent story in USA Today noted their association with endoscopic retrograde cholangiopancreatography (ERCP)/duodenoscopes. According to the article, the FDA is working with the manufacturers to eliminate this risk. Compared to other endoscopes, the side-viewing scopes are more technically-difficult to clean because of its “elevator” mechanisms. “The biggest cases involved dozens of patients and multiple deaths.” It is likely that more frequent and easier-to-treat infections may be transmitted as well; these types of infections generally do not result in full-fledged epidemiological investigations. Here’s the link: “Deadly bacteria on medical scopes trigger infections” This link has particularly good diagrams explaining resistant organisms. It is important to emphasize that these infections, to my knowledge, have not been reported with the more common endoscopic procedures. Because of technical differences in the scopes, the standard cleaning procedures are effective for upper endoscopies and colonoscopies. Related posts:

Not Happy With Functional GI Diseases

Posted on January 21, 2015 by gutsandgrowth

A recent study (J Pediatr 2015; 166: 85-90, editorial 11-14) finds that children with functional gastrointestinal diseases (FGID) had more impaired “quality of life” than children with organic gastrointestinal diseases. For those of us taking care of these children, this finding does not come as a surprise, but there is a lot to learn from this study nonetheless.

Using the Pediatric Quality of Life Inventory 4.0 Generic Core Scales, the authors completed a 9-site study with 689 families for patients with physician-diagnosed GI disorders including functional problems like irritable bowel syndrome and dyspepsia as well as organic diseases like Crohn’s disease and ulcerative colitis. These patients were compared with a healthy control sample of 1114 families.

In addition to obtaining health-related quality of life (HRQOL) data, the authors reported information on school days missed, days in bed, parent missed workdays, and healthcare utilization.

Key findings:

FGID and organic GI diseases demonstrated lower HRQOL than healthy controls across all measures (emotional, physical, social, and school; P<0.001 for all) with larger effect sizes for FGID.
FGID and organic GI diseases also had more school days missed, days in bed, parent missed workdays, and healthcare utilization, again with larger effect sizes for FGID.

The associated editorial tries to work through the reasons why the impact of FGID is greater than an organic disease.

The authors hypothesize that two factors play a big role:

1. Issue of control:

FGID -the cause is less evident
FGID -very few effective treatments
These factors may contribute to families feeling helpless and ‘out of control’

2. Issue of response shift:

The authors explain that response shift indicates a circumstance in which a “patient is compelled to adjust to this new reality.”
Response shift often involves a change in expectations
Response shift often involves a change in prioritization
Thus, response shift could explain why patients with organic GI disease have higher quality of life scores.

In addition, the authors note that with many FGID, that physicians often “suspect constipation is the cause…when laxative therapy is not helpful, this leads to more frustration.” They advocate shifting the focus for these families from “finding a cure to managing day-to-day symptoms.”

In my view, there are a lot of other factors at play that may help explain why HRQOL is lower in patients with FGIDs. This can include a high incidence of emotional disturbances (eg. anxiety, depression) and poor coping skills (eg. catastrophizing). This study also is another example showing that the physical severity of the medical disease does not correlate with the severity of the impact.

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Will I Have This Stomach Pain Forever? (Part 2)

Posted on January 20, 2015 by gutsandgrowth

The article reviewed earlier today on this blog (Clinical Gastroenterology and Hepatology 2014; 12: 2026-32) has been reviewed on the AGA blog as well (some of this information is redundant from earlier post):

Here’s a link to a summary of the article: AGA blog on RAP and here’s an excerpt: Sara Horst et al investigated whether pediatric functional abdominal pain leads to functional gastrointestinal disorders (FGIDs) such as irritable bowel syndrome (IBS) in adulthood. They performed a longitudinal analysis of 392 children (8−16 years old) initially seen at a subspecialty clinic for recurrent abdominal pain. Horst et al assessed the contribution of gastrointestinal symptoms, extra-intestinal somatic symptoms, and depressive symptoms to FGIDs 5−15 years later. They found that on average 9 years later, 41% met symptom criteria for FGID—mostly irritable bowel syndrome and functional dyspepsia. Levels of depressive symptoms in childhood correlated a greater likelihood of FGID later in life (see figure).