Beate C. Beinvogl

Risk of Serious Infections Associated with Biologic Agents in Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analyses

Objective To assess whether treatment with biologic response modifying agents during clinical trial study periods increases the risk of serious infections in children with juvenile idiopathic arthritis (JIA). Study design A systematic literature review using Medline, Embase, Cochrane library, and the clinical trial registry was performed up to July 2017. Random effects meta‐analyses were used to compare rates of serious infections in children with JIA given biologic agents compared with controls, and the pooled relative risk calculated. Subanalyses were performed for different biologic agent classes. Results In total, 19 trials accounting for 21 individual studies were included (11 for tumor necrosis factor‐alpha inhibitors [n = 814 patients], 3 for interleukin‐6 inhibitors [n = 318], 6 for interleukin‐1 inhibitors [n = 353], and 1 for selective T‐lymphocyte costimulation modulators [n = 122]). Patients (68% female) had a mean age of 10.8 years. Seventeen serious infections were reported among 810 children receiving biologic agents and 15 among 797 controls. The most frequent infections were bronchopulmonary and varicella. No statistically significant difference in risk of serious infections was found between children receiving biologic agents compared with control groups (pooled relative risk = 1.13; 95% CI [0.63, 2.03]) during the trial study periods. The risk remained nonsignificant when evaluating the different classes of biologic agents separately. However, the analyses were underpowered to detect differences in the risk of serious infections overall or differences between classes of biologic agents. Conclusions In this systematic review and meta‐analyses, serious infections were uncommon and not significantly increased among patients with JIA receiving biologic agents compared with controls. However, the analyses were underpowered and study periods were relatively short. Ongoing careful monitoring for serious infections remains necessary for all patients with JIA, and particularly those receiving biologic agents.

Multidisciplinary treatment of pediatric functional gastrointestinal disorders results in improved pain and functioning

&NA; Functional gastrointestinal disorders (FGIDs) are common in children and adolescents, frequently resulting in extensive testing, school absenteeism, disability, and poor quality of life.1–3 FGIDs result from a complex interplay between genetic predisposition, biological triggers, and psychosocial triggers, and are best explained by the biopsychosocial model.1 Although this implies the necessity of multidisciplinary treatment, studies showing the efficacy of such an intervention are lacking. We describe the outcome of children with severe FGIDs treated in a multidisciplinary program.

Are We Using Abdominal Radiographs Appropriately in the Management of Pediatric Constipation

Objective To identify the reasons why pediatric gastroenterologists obtain abdominal radiographs in the management of pediatric constipation. Study design This was a prospective study surveying providers regarding their rationale, interpretation, resultant change, and confidence in their management before and after obtaining KUBs in patients seen for suspected constipation. Demographics and clinical findings were obtained from medical records. Results A total of 24 providers were surveyed after 72 patient encounters. Reasons for obtaining an abdominal radiograph included evaluation of stool burden (70%), need for a clean out (35%), fecal impaction (27%), cause of abdominal pain (24%), demonstration of stool burden to families (14%), assessment of response to therapy (13%), or encopresis (10%). The plan was changed in 47.6% of cases based on radiographic findings. In cases in which a plan was outlined before obtaining the radiograph (69%), the initial plan was implemented on average in 52.5%. In cases with no plans before obtaining the radiograph, previously unconsidered plans were implemented in 8.7%. Provider confidence in the management plan increased from 2.4 ± 2.7 to 4.1 ± 1.8 (P < .05) after the abdominal radiograph. Conclusion Abdominal radiographs commonly are obtained by pediatric gastroenterologists in the evaluation and management of constipation. The majority used it to make a diagnosis, and nearly one‐half changed their management based on the imaging findings. Overall, they reported an improved confidence in their management plan, despite evidence that radiographic findings poorly correlate with clinical severity. This study highlights the need for further provider education regarding the recommendations delineated in existing constipation guidelines.