Dinesh S. Pashankar

A Randomized, Prospective, Comparison Study of Polyethylene Glycol 3350 Without Electrolytes and Milk of Magnesia for Children With Constipation and Fecal Incontinence

OBJECTIVE. Our aim was to compare 2 laxatives, namely, polyethylene glycol 3350 without electrolytes and milk of magnesia, evaluating the efficacy, safety, acceptance, and 1-year outcomes. METHODS. Seventy-nine children with chronic constipation and fecal incontinence were assigned randomly to receive polyethylene glycol or milk of magnesia and were treated for 12 months in tertiary care pediatric clinics. Children were counted as improved or recovered depending on resolution of constipation, fecal incontinence, and abdominal pain after 1, 3, 6, and 12 months. An intent-to-treat analysis was used. Safety was assessed with evaluation of clinical adverse effects and blood tests. RESULTS. Thirty-nine children were assigned randomly to receive polyethylene glycol and 40 to receive milk of magnesia. At each follow-up visit, significant improvement was seen in both groups, with significant increases in the frequency of bowel movements, decreases in the frequency of incontinence episodes, and resolution of abdominal pain. Compliance rates were 95% for polyethylene glycol and 65% for milk of magnesia. After 12 months, 62% of polyethylene glycol-treated children and 43% of milk of magnesia-treated children exhibited improvement, and 33% of polyethylene glycol-treated children and 23% of milk of magnesia-treated children had recovered. Polyethylene glycol and milk of magnesia did not cause clinically significant side effects or blood abnormalities, except that 1 child was allergic to polyethylene glycol. CONCLUSIONS. In this randomized study, polyethylene glycol and milk of magnesia were equally effective in the long-term treatment of children with constipation and fecal incontinence. Polyethylene glycol was safe for the long-term treatment of these children and was better accepted by the children than milk of magnesia.

Increased Prevalence of Obesity in Children With Functional Constipation Evaluated in an Academic Medical Center

Objective. The rapidly increasing prevalence of obesity in children is the most important problem facing pediatricians today. A recent study suggested an association of obesity and constipation in children but lacked a control group for comparison. The objectives of this study were to evaluate the prevalence of obesity in a large cohort of children with functional constipation and to compare it with a control group representative of the general population. Methods. Retrospective chart review was performed on 719 children, between the ages of 4 and <18 years, with chronic functional constipation seen in the general pediatric and pediatric gastroenterology clinics between July 2002 and June 2004. Data collected included age, gender, BMI, and signs and symptoms of constipation including fecal incontinence. Obesity was classified as a BMI of >95th percentile and severe obesity as a BMI of ≥5 kg/m2 above the 95th percentile for age and gender. The control group consisted of all 930 children (4 to <18 years of age) presenting to the pediatric clinic for a well-child visit between January and June 2004. The χ2 and t tests were used for analysis. Results. Overall prevalence of obesity was significantly higher in constipated children (22.4%) compared with control children (11.7%), and this higher prevalence was also seen for severe obesity. The prevalence rates of obesity were significantly higher in constipated males (25%) than in constipated females (19%) and were significantly higher compared with the control males (13.5%) and control females (9.8%). Constipated boys in all 3 age groups had significantly higher rates of obesity than the control boys; the constipated girls had significantly higher obesity rates for the age groups between 8 and <18 years. Fecal incontinence (encopresis) was present in 334 of 719 (46%) constipated children. The prevalence of obesity was similar in constipated children with and without fecal incontinence. Conclusions. There is a significantly higher prevalence of obesity in children with constipation compared with age- and gender-matched controls. This higher prevalence is present in both boys (4 to <18 years of age) and girls (8 to <18 years of age) with constipation and is not related to the presence of fecal incontinence among constipated children. The higher prevalence of obesity may be a result of dietary factors, activity level, or hormonal influences and needs additional evaluation.

Polyethylene glycol 3350 without electrolytes for the treatment of functional constipation in infants and toddlers.

Objectives: We have recently reported the safety and efficacy of polyethylene glycol 3350 without electrolytes (PEG) for the daily treatment of constipation in older children. Because there are very few data available on the use of PEG in infants and toddlers, we evaluated the efficacy and safety of PEG for the treatment of constipation in children <2 years of age. Methods: This is a retrospective chart review of 75 constipated children <2 years of age at start of PEG therapy. PEG was started at an average dose of 1 g/kg body weight/d and parents were asked to adjust the dose to yield 1 to 2 soft painless stools/d. Data from the history and physical examination were collected initially and at short-term (≤4 months) and long-term (≥6 months) follow-up. Results: 75 otherwise healthy children received PEG for functional constipation. The mean age was 17 months (range, 1 to 24 months) and the mean duration of constipation was 10 months (range, 0.5 to 23 months). The mean duration of short-term follow-up was 2 months and mean duration of long-term follow-up was 11 months. The mean effective short-term PEG dose was 1.1 g/kg body weight/d and the mean long-term dose was 0.8 g/kg body weight/d. Constipation was relieved in 85% with short-term and in 91% with long-term PEG therapy. Adverse effects were mild and included diarrhea, which disappeared with lowering the dose. No subjects stopped PEG because of adverse effects. Conclusion: PEG is effective, well tolerated and appeared safe for the treatment of functional constipation in children <2 years of age.

Changing Referral Trends of Acute Pancreatitis in Children: A 12-year Single-center Analysis

Background:Acute pancreatitis is a painful inflammatory disorder known to occur in children. Recent reports, primarily on the basis of adult data, have suggested an increasing incidence. However, pediatric studies are limited. Objective:The study was performed to examine the frequency of acute pancreatitis in a pediatric population from 1994 to 2007 and to characterize etiologies by age subsets. Patients and Methods:In this retrospective study, cases of pancreatitis were identified by ICD-9 codes and subjected to inclusion criteria. Results:Two hundred and seventy-one cases of pancreatitis met inclusion criteria. Mean age of the subjects was 13.1 ± 5.6 years. The recurrence rate was 15.3%. Biliary disease was the most common etiology (32.6%). Acute pancreatitis cases evaluated at a single tertiary care center increased 53% between 1995 to 2000 and 2001 to 2006 (P < 0.02). However, when cases were normalized by all annual pediatric emergency department visits for all medical reasons, the increase was reduced to 22% and lost statistical significance (P = 0.16). The rise was not associated with a change in etiologies or body mass index (BMI). Conclusions:This is the first report demonstrating that an increase in pediatric pancreatitis may in part be due to growing referrals to tertiary care centers. The data on etiologies, particularly with regard to differing ages, may be helpful in managing children who present with acute pancreatitis.

Gastric polyps and nodules in children receiving long-term omeprazole therapy.

Objective Multiple gastric polyps have been reported to occur in adults receiving omeprazole therapy. There are little published data in children. We report our experience in monitoring the gross and histologic appearance of the stomach in children receiving long-term omeprazole therapy. Methods This was a retrospective review of the charts of children who received omeprazole for more than 6 months for reflux esophagitis between 1989 and 1998. All patients had repeated endoscopic examinations until healing of the esophagitis was confirmed and then annually thereafter. At endoscopy, gastric mucosal swellings were classified as polyps or nodules based on histology. Results Thirty-one children had long-term endoscopic follow-up while receiving omeprazole. Seven of 31 children had gastric polyps and/or nodules, noted between 10 and 48 months (mean = 28 months) of omeprazole therapy. Four had nodules only, one had a sessile hyperplastic polyp, and two had both a polyp (one hyperplastic and one fundic gland polyp) and nodules. All lesions were found in the gastric body. Nodules in four of the six children disappeared spontaneously while the children continued to receive omeprazole. The polyps persisted. There were no dysplastic changes in the gastric mucosa or polyps in any of the patients. There were no significant differences between the 7 children with and the 24 without polyps/nodules with respect to age, gastrin concentrations, or dose and duration of omeprazole therapy. Conclusions Gastric polyps and nodules may be found in children receiving long-term omeprazole therapy. The gastric changes in our patients were benign during the mean observation period of 31 months.

Increased prevalence of gastroesophageal reflux symptoms in obese children evaluated in an academic medical center.

Goals To test the hypothesis that obese children are at higher risk of having gastroesophageal reflux symptoms compared with nonobese children. Study In this prospective study, 236 obese children (age: 7 to 16u2009y) were interviewed using a standard questionnaire for reflux symptoms and a reflux symptom score was calculated. Obesity was defined as body mass index (BMI) greater than 95th percentile for age and sex. One hundred and one age-matched and sex-matched children with BMI between 5th and 95th percentile served as controls. Demographic data were collected in all children. We compared prevalence rates of a reflux symptom score and other symptoms between the 2 groups. Results A prevalence rate of a positive reflux symptom score (13.1%) was significantly higher in obese children than in the control group (2%) (odds ratio: 7.3, 95% CI: 1.7-31). Obesity remained as the only significant predictor for a positive reflux symptom score after controlling for other variables such as age, sex, race, and caffeine exposure (adjusted odds ratio: 7.4, 95% CI: 1.7-32.5). A positive reflux symptom score increased significantly from 2% in the control group to 11.7% in 196 obese children to 20% in 40 severely obese children (with BMI z-score >2.7). Conclusions Obese children (age: 7 to 16u2009y) are at higher risk of having reflux symptoms compared with the control group. This risk is independent of age, sex, or race and increases with higher BMI.

Two-day bowel preparation with polyethylene glycol 3350 and bisacodyl: a new, safe, and effective regimen for colonoscopy in children.

Objectives: To assess the safety, efficacy, and acceptance of a 2-day bowel preparation with polyethylene glycol (PEG) 3350 without electrolytes and bisacodyl for colonoscopy in children. Patients and Methods: In a prospective study, 111 children of mean age 11.9 years were given 2 g/kg of PEG and a 5-mg tablet of bisacodyl daily for 2 days before colonoscopy. Stool frequency, consistency, and adverse effects were monitored for the duration of the bowel preparation. Compliance and quality of colonic preparation were assessed on the day of the colonoscopy. Results: The average daily stool frequency increased from a baseline of 2, to 4* on day 1, and 6.5* on day 2 of the bowel preparation (*P < 0.001 for difference vs baseline). The colonic preparations were rated as excellent or good in 92% and 93% of the patients in the right and left colon, respectively. Adverse effects were mild nausea (19%), abdominal pain (11%), and vomiting (4%). The compliance was rated as excellent in 95% of the patients. Conclusions: A 2-day bowel preparation with PEG and bisacodyl is safe, effective, and well accepted for colonoscopy in children without any major adverse effects.

Recurrent acute pancreatitis associated with propionic acidemia.

Propionic acidemia (PA) is a severe metabolic disorder of infants and children (1), resulting from a defect in the mitochondrial enzyme propionyl-coenzyme A carboxylase (PCC). PA is inherited in an autosomal recessive manner. Patients experience metabolic acidosis, ketosis, seizures, and mental retardation. Acute pancreatitis is a potentially life-threatening inflammatory disorder that has many known inciting factors, including metabolic derangements (2,3). However, although acute pancreatited with PA (4,5), recurrent acute

Prevalence of functional gastrointestinal disorders in obese and overweight children

Objective:To compare the prevalence of functional gastrointestinal disorders such as functional constipation (FC), functional abdominal pain (FAP), functional abdominal pain syndrome (FAPS) and irritable bowel syndrome (IBS) between a large cohort of healthy obese/overweight children and normal-weight children.Methods:Healthy children between the ages of 4 and 18 years were eligible for recruitment from the Yale Pediatric Primary Care clinic, Yale Adolescent clinic and a local private practice in Orange, CT, USA. Study subjects or their parents were interviewed using a questionnaire based on the ROME III standardized criteria for diagnosing functional gastrointestinal disorders. Medical records were reviewed to collect information about age, gender, height, weight, body mass index (BMI), ethnicity and chronic medical conditions. Children were classified into obese, overweight and normal-weight based on their BMI for age and gender. Data were analyzed to compare the prevalence of FC, FAP, FAPS and IBS between obese/overweight children and normal-weight children.Results:A total of 450 children (45% males) were recruited. There were 191 (42%) obese/overweight children and 259 (58%) normal-weight children. FAPS (odds ratio (OR) =2.1, 95% confidence interval (CI): 1.21–3.64, P=0.007), FC (OR=1.83, 95% CI: 1.12–2.98, P=0.01), and IBS (OR=2.59, 95% CI: 1.40–4.79, P=0.003) were significantly more prevalent in the obese/overweight children than in the normal-weight children. Of the obese/overweight children, 47% had at least one functional gastrointestinal disorder compared with 27% of the normal-weight children (P⩽0.001). Only 36% of the children with functional gastrointestinal disorders sought medical attention for their symptoms.Conclusions:Obese/overweight children have a higher prevalence of functional gastrointestinal disorders than normal-weight children. Almost half of the obese/overweight children had at least one functional gastrointestinal disorder.

Risk Factors Associated with Biliary Pancreatitis in Children

Objectives: Little is known about risk factors for biliary pancreatitis in children. We characterized cases of pediatric biliary pancreatitis, compared biliary with nonbiliary cases, examined differences in presentation between younger and older children, and studied features distinguishing gallstone- from sludge-induced pancreatitis. Methods: We evaluated 76 episodes of biliary pancreatitis from 271 cases of acute pancreatitis in children admitted to a tertiary care hospital from 1994 to 2007. Results: Of the 76 cases, 55% had gallstones, 21% had sludge, and 24% had structural defects. Hispanic children had 2.85 (Pu200a=u200a0.01) and 5.59 (Pu200a=u200a0.003) times higher probability for biliary pancreatitis than white and black children, respectively. Median serum amylase and lipase in children with biliary pancreatitis were 64% and 49% higher, respectively, compared with other causes (Pu200a<u200a0.05). In multiple logistic regression, aspartate aminotransferase was an independent predictor of biliary pancreatitis (odds ratio 6.69, Pu200a=u200a0.001). When comparing gallstone- with sludge-induced causes, obesity was an independent predictor (38% more prevalent, Pu200a<u200a0.01) of gallstone cases. Conclusions: Hispanic ethnicity is a risk factor and aspartate aminotransferase is a biomarker for biliary pancreatitis over other causes. Furthermore, obesity can distinguish gallstone- from sludge-induced pancreatitis. These findings may spur prospective studies to determine the optimal evaluation and management of children with biliary pancreatitis.