Colin D. Rudolph

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition.

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

EPIDEMIOLOGIC AND CLINICAL CHARACTERISTICS OF CHILDREN WITH NEWLY DIAGNOSED INFLAMMATORY BOWEL DISEASE IN WISCONSIN: A STATEWIDE POPULATION-BASED STUDY

OBJECTIVE To define epidemiologic and clinical characteristics of newly diagnosed pediatric inflammatory bowel disease (IBD) in a large population-based model. STUDY DESIGN All pediatric gastroenterologists providing care for Wisconsin children voluntarily identified all new cases of IBD during a 2-year period. Demographic and clinical data were sent to a central registry prospectively for analysis. RESULTS The incidence of IBD in Wisconsin children was 7.05 per 100,000, whereas the incidence for Crohns disease was 4.56, more than twice the rate of ulcerative colitis (2.14). An equal IBD incidence occurred among all ethnic groups, and children from sparsely and densely populated counties were equally affected. The majority (89%) of new IBD diagnoses were nonfamilial. CONCLUSIONS This study provides novel, prospective, and comprehensive information on pediatric IBD incidence within the United States. The surprisingly high incidence of pediatric IBD, the predominance of Crohns disease over ulcerative colitis, the low frequency of patients with a family history, the equal distribution of IBD among all racial and ethnic groups, and the lack of a modulatory effect of urbanization on IBD incidence collectively suggest that the clinical spectrum of IBD is still evolving and point to environmental factors contributing to the pathogenesis.

A Global, Evidence-Based Consensus on the Definition of Gastroesophageal Reflux Disease in the Pediatric Population

OBJECTIVES:To develop an international consensus on the definition of gastroesophageal reflux disease (GERD) in the pediatric population.METHODS:Using the Delphi process, a set of statements was developed and voted on by an international panel of eight pediatric gastroenterologists. Statements were based on systematic literature searches using Medline, EMBASE, and CINAHL. Voting was conducted using a six-point scale, with consensus defined, a priori, as agreed by 75% of the group. The strength of each statement was assessed using the GRADE system.RESULTS:There were four rounds of voting. In the final vote, consensus was reached on 98% of the 59 statements. In this vote, 95% of the statements were accepted by seven of eight voters. Consensus items of particular note were: (i) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of ∼8 years; (ii) histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other conditions; (iii) Barretts esophagus should be defined as esophageal metaplasia that is intestinal metaplasia positive or negative; and (iv) extraesophageal conditions may be associated with GERD, but for most of these conditions causality remains to be established.CONCLUSIONS:The consensus statements that comprise the Definition of GERD in the Pediatric Population were developed through a rigorous process. These statements are intended to be used for the development of future clinical practice guidelines and as a basis for clinical trials.

Classifying complex pediatric feeding disorders.

BACKGROUND This study defines the multiple characteristics associated with complex pediatric feeding problems and determines the relative frequency of each classification in a population referred to an interdisciplinary feeding team. METHODS The written reports from team evaluations on 103 children (64 males, 39 females; age range 4 months to 17 years) were reviewed. Prematurity and/or presence of developmental delay was coded. Identified factors related to current feeding problems were coded according to five categories: structural abnormalities, neurological conditions, behavioral issues, cardiorespiratory problems, metabolic dysfunction. RESULTS Interrater reliability for the classification coding was 88%. Thirty-eight percent of the children had a history of pre- maturity and 74% were reported to have evidence of developmental delay. The following five categories or combinations were coded most frequently: structural-neurological-behavioral (30%), neurological-behavioral (27%), behavioral (12%), structural-behavioral (9%), and structural-neurological (8%). Overall, behavioral issues were coded more often (85%) than neurological conditions (73%), structural abnormalities (57%), cardiorespiratory problems (7%), or metabolic dysfunction (5%). CONCLUSIONS Data analysis using this classification system revealed that the majority of children in this sample had a behavioral component to their complex feeding problem, regardless of concurrent physical factors. These findings suggest that complex pediatric feeding problems are biobehavioral conditions in which biological and behavioral aspects mutually interact, and both need to be addressed to achieve normal feeding.

Cyclic vomiting syndrome in adults

Abstract  Cyclic vomiting syndrome (CVS) was initially described in children but can occur in all age groups. Cyclic vomiting syndrome is increasingly recognized in adults. However, the lack of awareness of CVS in adults has led to small numbers of diagnosed patients and a paucity of published data on the causes, diagnosis and management of CVS in adults. This article is a state‐of‐knowledge overview on CVS in adults and is intended to provide a framework for management and further investigations into CVS in adults.

Feeding disorders in infants and children.

Feeding disorders are common in infants and children. Multiple interacting behavioral, anatomic, and functional factors all can impact on the feeding process, making the evaluation and treatment of pediatric disorders complex and challenging. Knowledge of the normal process of feeding and swallowing, a careful history, observation of the patient during a feeding session, and selected tests usually provide an understanding of the underlying cause of feeding difficulties. Treatment of underlying pathology and careful balancing of the risks and benefits of oral feeding underlie the selection of an optimal management strategy.

CARD15 gene mutations and risk for early surgery in pediatric-onset Crohn’s disease

BACKGROUND & AIMS The risk for Crohns disease (CD) is determined in part by genetic factors. Three recently described mutations in the CARD15(NOD2) gene have been associated with adult-onset CD. We investigated the effect of CARD15 mutations on disease manifestation, disease progression, and the risk for early surgery in childhood-onset CD. METHODS Genotyping for 3 CARD15 mutations: R702W, G908R, and 3020insC, was performed in 186 children with CD from a prospective cohort. A transmission-disequilibrium test was used to test for association with CD. Genotype with disease location and behavior was tested with logistic regression analysis. The effect of mutations on surgical outcome was evaluated using a Cox proportional hazard analysis. RESULTS The mean age at CD diagnosis was 12.4 years. The frequency of allelic mutations observed was 6.6% for R702W, 6% for G908R, and 13.1% for 3020insC. Of Caucasian CD children, 42% had at least one CARD15 mutation. None of the non-Caucasian children with CD had any CARD15 mutation. A significant association was detected for 3020insC (P = .0045). Ileal location (odds ratio, 4.3; P = .003) and stricturing disease (odds ratio, 6.6; P = .0001) was more frequent and the risk for surgery was higher (hazard ratio, 5.8; P < .0001) and surgery occurred earlier (hazard ratio, 2.24) in those children with 3020insC mutation compared with those without 3020insC. CONCLUSIONS In children with pediatric-onset CD, early development of stricturing behavior leading to surgical resection is influenced by ileal location and 3020insC variant of the CARD15 mutation. Genetic testing may identify children with CD who are at risk for early surgery.

Pediatric laryngopharyngeal sensory testing during flexible endoscopic evaluation of swallowing: feasible and correlative.

Laryngopharyngeal sensory testing can predict aspiration risk in adult patients. Its feasibility and potential role in the evaluation of pediatric swallowing is undetermined. The goals of this study were to determine the feasibility of performing laryngopharyngeal sensory testing in awake pediatric patients and to assess whether the sensory testing results correlated with aspiration during a feeding assessment or correlated with a history of pneumonia. Fiberoptic endoscopic evaluation of swallowing with sensory testing was performed in 100 pediatric patients who were evaluated for feeding and swallowing disorders. The swallowing function parameters evaluated were pooled secretions, laryngeal penetration, and aspiration. The laryngopharyngeal sensory tests were performed by delivering a pressure-controlled and duration-controlled air pulse to the aryepiglottic fold through a flexible laryngoscope to induce the laryngeal adductor response (LAR). The air pulse stimulus ranged in intensity from 3 to 10 mm Hg. The patients tested ranged from 1 month to 24 years of age, with a median age of 2.7 years. Sensory testing was completed in 92% of patients. Patients who had an LAR at less than 4 mm Hg rarely if ever had episodes of laryngeal penetration or aspiration. Those with an LAR at 4 to 10 mm Hg had variable amounts of aspiration and laryngeal penetration. The LAR could not be elicited at the maximum level of intensity (10 mm Hg) in 22 patients, who demonstrated severe laryngeal penetration and/or aspiration. Elevated laryngopharyngeal sensory thresholds correlated positively with previous clinical diagnoses of recurrent pneumonia, neurologic disorders, and gastroesophageal reflux, and correlated positively with findings of pooled secretions, laryngeal penetration, and aspiration. Laryngopharyngeal sensory testing in children is feasible and correlative.

NASPGN guidelines for training in pediatric gastroenterology

G.G.C. has received com M.C. has served on th served on the board o and Enteral Nutrition; her institution has rec collaborative and Prov pensation from Child L.A.G. has received c received compensatio employment, expert t stocks/stock options; LLC, consulted to No received or has grants Institutes of Health, th holds equity interest in has received compens Fibrosis Foundation; M Abbott Laboratories, Foundation, the Natio Diseases/National Ins ticals; E.A.R. has rece sionalism & Ethical institution has receive as the medical editor has received compen Pharmaceuticals, and Nutrition; J.T. has rec Pediatrics, Prometheu conflicts of interest. Copyright # 2012 by E Hepatology, and Nut Gastroenterology, He DOI: 10.1097/MPG.0b01

Effect of Intraventricular Histamine on Hormone Secretion in Dogs

In pentobarbital-anesthetized dogs, infusion of a low dose of histamine directly into the third ventricle increased plasma ACTH concentration. The increase was unaffected by metiamide, a drug which blocks H2 receptors, but was abolished by mepyramine, a drug which blocks H1 receptors. Mepyramine alone did not produce a decrease in plasma ACTH concentration in stressed dogs. Infusion of the H1 agonist 2-methylhistamine increased plasma ACTH concentration, whereas infusion of the H2 agonist 4-methylhistamine decreased plasma ACTH concentration and blocked the response to surgical stress. Histamine, 2-methylhistamine and 4-methylhistamine had no statistically significant effect on plasma renin activity, blood pressure, or heart rate, and histamine had no effect on plasma prolactin concentration. There were no consistent, specific effects on growth hormone secretion. We conclude that activation of central H1 receptors increases ACTH secretion in dogs, and that activation of central H2 receptors decreases ACTH secretion. Some of the reported effects of cyproheptadine and other drugs on ACTH secretion may be due to their antihistamine activity.