Christopher D. Jolley

Failure to thrive

I nadequate growth, which may be accompanied by a delay in psychosocial development, has been termed failure to thrive (FTT). This is a rather broad if not somewhat vague concept. Specificity and consensus in defining FTT has been lacking. Although the differential diagnosis for medical diseases responsible for FTT has expanded, the exact mechanisms connecting growth failure, parental behavior, and undernutrition are still unknown. The clinical picture has not changed much if at all, but study of the etiopathogenesis in FTT has evolved considerably. Much of this study has been limited by its retrospective nature. The weakened and listlessappearing FTT infant is the ultimate end result of a multitude of potential influences and requires intervention long before this picture eventually presents. The death rate for institutionalized infants in the United States during the early 1900s was exceedingly high. These infants had growth failure that progressed until their inevitable death despite appropriate medical intervention. The growth failure described was almost minor compared with the infants’ loss of spirit. These asylum infants exhibited a complete apathy for life. The exact causes were unknown, and this syndrome was appropriately termed “hospitalism.” Many infants who were boarded out in private homes had much better outcomes. Although the institutions eventually were closed, the condition of isolation and growth failure continued both in hospitalized infants and in infants raised in homes. Attention shifted from the hospital to the home care giver, and the term “hospitalism” gradually changed to “maternal deprivation syndrome.” This suggested a new source of the problem of FTT and initiated a great deal of interest in the psychosocial aspects that contributed to a mother depriving her baby of critical care. Much of this research suggested that behind every undernourished infant was a psychotic or depriving mother. However, later studies focused on more objective parameters in the study of FTT. Currently, the poorly descriptive term “failure to thrive” is used to describe this infantile withering. The label of FTT is frequently tagged to an infant or child with apparent growth faltering. However, weight changes that appear abnormal may be entirely appropriate. These normal variations easily can confuse the picture. Thus, it is important to qualify FTT with more specific descriptors. The lack of consensus regarding these specifics has hindered meaningful research. Approaching FTT in the clinical setting depends on how we characterize and determine growth failure. A thorough history and physical examination are critical in recognizing normal variation, navigating the differential diagnosis, and avoiding unnecessary intervention. A multidisciplinary or team approach offers a thoroughness that a practitioner may not be able to achieve working alone. Inclusion of the family into the team can be useful in both the evaluation and management of FTT. Establishing rapport and maintaining trust is vital to communication with the family during the assessment of growth failure. This generally requires several visits and is highly time-consuming. Family involvement facilitates the assessment of compliance and identification of issues regarding social dysfunction. Pediatric undernutrition caused by inadequate intake is increasingly seen within the context of feeding disorders. Further development of the concept of the mother-child relationship, the role of the infant, and the overall effect on feeding has offered more specific targets of interest in understanding nonorganic growth failure. Maternal psychopathology is no longer acceptable as the sole cause of FTT. The framework of the mother-child relationship has provided new perspecFrom the Department of Pediatrics, University of Florida, Gainesville, Florida, USA. Curr Probl Pediatr Adolesc Health Care 2003;33:183-206.

Brief Report: The Association Between Peer Victimization, Prosocial Support, and Treatment Adherence in Children and Adolescents with Inflammatory Bowel Disease

OBJECTIVE To examine the relationship between peer victimization, prosocial support, and treatment adherence in children and adolescents with Inflammatory Bowel Disease (IBD). METHOD Thirty-eight children diagnosed with IBD, between the ages of 7-19 years, and their parents were recruited from an outpatient Gastroenterology Clinic. Each child completed the Social Experience Questionnaire. The child, parent, and treating physician completed a one-item measure of child medication adherence. RESULTS Child reported positive social interactions moderated the relationship between child reported peer victimization and self-reported medication adherence (t = -2.09; p = .045). These relationships held when parent report of child adherence was substituted for child reported adherence in this model (t = -2.37; p = .024). CONCLUSIONS The findings from this pilot study suggest that prosocial support may buffer children with IBD from experiencing the more negative effects of peer victimization on treatment adherence and highlight the importance of social interactions in youth with IBD. Implications for treatment are discussed.

Antibodies to Escherichia coli outer membrane porin C in the absence of anti-Saccharomyces cerevisiae antibodies and anti-neutrophil cytoplasmic antibodies are an unreliable marker of Crohn disease and ulcerative colitis.

Objectives: Antibodies to Escherichia coli outer membrane porin C (anti-OmpC), Saccharomyces cerevisiae, and neutrophil-specific nuclear antigens are associated with inflammatory bowel disease (IBD) in children and young adults. We hypothesized that anti-OmpC, in the absence of anti–S cerevisiae antibodies (ASCA) and antineutrophil cytoplasmic antibodies (ANCA), is an assay that overestimates the presence of Crohn disease (CD) and ulcerative colitis (UC). Patients and Methods: A retrospective review of patients evaluated at our institution between January 2002 and June 2006 revealed that 170 had serodiagnostic immunological assays performed as part of an evaluation for possible IBD. The assays were screened for a pattern in which anti-OmpC was present in the absence of ASCA and ANCA. Results: Seven patients between 3 and 20 years of age were discovered to be positive for anti-OmpC but negative for ASCA and ANCA. These patients were determined to have significant medical conditions without combined radiographic, endoscopic, or histological evidence of IBD. Despite the reported 85% positive predictive value of anti-OmpC for IBD, none of the 7 patients with isolated anti-OmpC had a diagnosis of CD or UC. Conclusions: Anti-OmpC, in the absence of ASCA and ANCA, is a serological pattern noted in a subset of medically complex cases in children and young adults without CD or UC.

Long-term outcomes of gastric electrical stimulation in children with gastroparesis

BACKGROUND Gastric electrical stimulation (GES) has been used in adults with gastroparesis. However its use has been limited in children. We describe the largest experience with GES in children with long-term outcomes. METHODS Data were collected on children who underwent GES over a 10-year period. Data regarding demographics, medical history, hospital course, and outcomes were collected and analyzed. Symptom scores (validated Likert scores) were compared using a paired Students t test. RESULTS Overall, 97 patients underwent GES, and a majority were teenage Caucasian girls. Ninety-six had temporary GES (tGES), and 66 had improvement in their symptoms. A total of 67 underwent permanent implantation (pGES), and there was significant reduction in all individual symptoms (p<0.001) as well as the total symptom score (TSS) (p<0.0001) at 1, 6, 12, and >12 months. Recurrence of symptoms leading to device removal occurred in 7 cases. Forty-one patients had continued improvement in symptoms for over 12 months, with a mean follow-up of 3.5 years (range 1-9 years). CONCLUSIONS This study represents the largest experience of systematic application of GES in children. GES is a safe and effective therapy for selected children with intractable GP with continued symptomatic improvement at 1 year and beyond.

Health-related quality of life in youth with Crohn disease: role of disease activity and parenting stress.

Objectives: Health-related quality of life (HRQOL) is an important, but understudied construct in pediatric inflammatory bowel disease. Family level predictors of HRQOL have been understudied as are the mechanisms through which disease activity affects HRQOL. The present study examines the relation between a family level factor (parenting stress) and HRQOL in youth with Crohn disease. Parenting stress is examined as a mechanism through which disease activity affects HRQOL. Methods: A total of 99 adolescents with Crohn disease and their parents were recruited across 3 sites. Adolescents completed the IMPACT-III (inflammatory bowel disease–specific HRQOL). Parents completed the Pediatric Inventory for Parents, a measure of medically related parenting stress that assesses stress because of the occurrence of medical stressors and stress because of the perceived difficulty of stressors. Disease activity was obtained from medical records. Results: Parenting stress because of the occurrence of medical stressors partially mediated the disease severity–HRQOL relation, reducing the relation between these variables from 49.67% to 31.58% (B = −0.56, P < 0.0001). Bootstrapping analysis confirmed that the indirect effect of disease severity on HRQOL via parenting stress significantly differed from zero. Parenting stress because of the perceived difficulty of medical stressors partially mediated the disease severity–HRQOL relation, reducing the relation from 49.67% to 30.29% (B = −0.55, P < 0.0001). The indirect effect was confirmed via bootstrapping procedures. Conclusions: As disease severity increased, parenting stress also increased, and adolescent HRQOL decreased. Parenting stress should be considered and assessed for along with medical factors as part of a comprehensive approach to improve HRQOL in adolescents with Crohn disease.

Comparison of the 13C-urea blood test to histology and rapid urease testing in the diagnosis of Helicobacter pylori infection in children.

Objective: Helicobacter pylori infection is commonly investigated in children with abdominal pain. The definitive means of diagnosing infection, histology, requires endoscopy and sedation, making it invasive and expensive. Our objective was to compare histology against a less invasive and safer method, the 13C-urea blood test. Patients and Methods: Forty children with abdominal pain undergoing upper endoscopy were randomized into either of 2 dosages of 13C-urea. Several biopsies were taken for histology and rapid urease testing. After endoscopy, each child ingested a randomly assigned dosage of either 75 mg or 125 mg 13C-urea, and blood was withdrawn 30 min later. Results: Irrespective of the dosage of 13C-urea, the 13C-urea blood test performed with high accuracy (89%) when compared against either histology or rapid urease testing. The sensitivity and specificity of the blood test was 83% and 91%, respectively. When the smaller dosage of 13C-urea was used, the accuracy of the blood test was 100% compared with histology. There were no adverse events related to using either dosage of 13C-urea. Conclusions: The 13C-urea blood test may be comparable with histology in diagnosing H pylori infection in children, and the smaller dosage of 13C-urea does not adversely affect blood test performance. The 13C-urea blood test is well tolerated in children.

Neurostimulation of the gastrointestinal tract: review of recent developments.

Neurostimulation is one manifestation of neuromodulation of the gastrointestinal (GI) tract. This manuscript reviews the history of neurostimulation of the GI tract with emphasis on current methods of stimulation.

Elevated Alkaline Phosphatase in Children: An Algorithm to Determine When a "Wait and See" Approach is Optimal.

Due to the possibility of underlying hepatobiliaryor bone diseases, the diagnostic work up of a child with elevated alkaline phosphatase (AP) levels can be quite costly. In a significant proportion of these patients, elevated AP is benign, requiring no intervention: hence, known as transient hyperphosphatasemia (THP) of infants and children. A 27-month old previously healthy Caucasian female was found to have isolated elevation of AP four weeks after the initial symptoms of acute gastroenteritis. One month later, when seen in hepatobiliary clinic, signs and symptoms of gastrointestinal, hepatobiliary, or bone disease were absent and physical examination was normal. The diagnosis of THP was made, and, as anticipated, AP levels normalized after four months. Using this case as an example, we suggest an algorithm that can be utilized as a guide in a primary care setting to arrive at the diagnosis of THP and avoid further tests or referrals.

Extracellular Calcium Dictates Onset, Severity, and Recovery of Diarrhea in a Child with Immune-Mediated Enteropathy

Diarrhea causes monovalent and divalent ion losses that can influence clinical outcome. Unlike the losses of monovalent ions, such as Na+, K+, Cl−, and HCO3−, which are generally large in quantity (osmoles) and therefore determine the severity of diarrhea, the losses of divalent ions are relatively small in osmoles and are often overlooked during diarrheal treatment. Studies now suggest that despite divalent ions being small in osmoles, their effects are large due to the presence of divalent ion-sensing receptors and their amplifying effects in the gut. As a result, losses of these divalent ions without prompt replacement could also significantly affect the onset, severity, and/or recovery of diarrheal disease. Herein, we report a case of a malnourished child with an immune-mediated enteropathy who developed episodes of “breakthrough” diarrhea with concurrent hypocalcemia while on appropriate immunotherapy. Interestingly, during these periods of diarrhea, stool volume fluctuated with levels of blood Ca2+. When Ca2+ was low, diarrhea occurred; when Ca2+ levels normalized with replacement, diarrhea stopped. Based on this and other observations, a broader question arises as to whether the Ca2+ lost in diarrhea should be replaced promptly in these patients.

Pancreatic Disease in Children and Adolescents

Many childhood pancreatic disorders are rare, although they can represent significant and potentially severe disease. The spectrum of disease is very broad, ranging from the complex and bizarre congenital anomalies to the more typical acquired causes (eg, drug-induced pancreatitis or trauma injury). Genetics appears to play a major role in many childhood pancreas diseases, unlike adults where alcohol is a major factor. Nevertheless, there are similarities, and most of the disorders discussed here can be found in both the pediatric and adult age groups. Some of these disorders may be evolving and may be seen in both young and older patients. Newer imaging modalities and therapeutic endoscopy continue to be studied, although their ultimate role and utility in children has yet to be fully elucidated.