Hongyu Jiang

Energy imbalance and the risk of overfeeding in critically ill children

Objective: To examine the role of targeted indirect calorimetry in detecting the adequacy of energy intake and the risk of cumulative energy imbalance in a subgroup of critically ill children suspected to have alterations in resting energy expenditure. We examined the accuracy of standard equations used for estimating resting energy expenditure in relation to measured resting energy expenditure in relation to measured resting energy expenditure and cumulative energy balance over 1 week in this cohort. Design: A prospective cohort study. Setting: Pediatric intensive care unit in a tertiary academic center. Interventions: A subgroup of critically ill children in the pediatric intensive care unit was selected using a set of criteria for targeted indirect calorimetry. Measurements: Measured resting energy expenditure from indirect calorimetry and estimated resting energy expenditure from standard equations were obtained. The metabolic state of each patient was assigned as hypermetabolic (measured resting energy expenditure/estimated resting energy expenditure >110%), hypometabolic (measured resting energy expenditure/estimated resting energy expenditure <90%), or normal (measured resting energy expenditure/estimated resting energy expenditure = 90–110%). Clinical variables associated with metabolic state and factors influencing the adequacy of energy intake were examined. Main Results: Children identified by criteria for targeted indirect calorimetry, had a median length of stay of 44 days, a high incidence (72%) of metabolic instability and alterations in resting energy expenditure with a predominance of hypometabolism in those admitted to the medical service. Physicians failed to accurately predict the true metabolic state in a majority (62%) of patients. Standard equations overestimated the energy expenditure and a high incidence of overfeeding (83%) with cumulative energy excess of up to 8000 kcal/week was observed, especially in children <1 yr of age. We did not find a correlation between energy balance and respiratory quotient (RQ) in our study. Conclusions: We detected a high incidence of overfeeding in a subgroup of critically ill children using targeted indirect calorimetry The predominance of hypometabolism, failure of physicians to correctly predict metabolic state, use of stress factors, and inaccuracy of standard equations all contributed to overfeeding in this cohort. Critically ill children, especially those with a longer stay in the PICU, are at a risk of unintended overfeeding with cumulative energy excess.

Treatment of Vitamin D Insufficiency in Children and Adolescents with Inflammatory Bowel Disease: A Randomized Clinical Trial Comparing Three Regimens

CONTEXTnVitamin D insufficiency [serum 25-hydroxyvitamin D (25OHD) concentration less than 20 ng/ml] is prevalent among children with inflammatory bowel disease (IBD), and its treatment has not been studied.nnnOBJECTIVEnThe aim of this study was to compare the efficacy and safety of three vitamin D repletion regimens.nnnDESIGN AND SETTINGnWe conducted a randomized, controlled clinical trial from November 2007 to June 2010 at the Clinical and Translational Study Unit of Childrens Hospital Boston. The study was not blinded to participants and investigators.nnnPATIENTSnEligibility criteria included diagnosis of IBD, age 5-21, and serum 25OHD concentration below 20 ng/ml. Seventy-one patients enrolled, 61 completed the trial, and two withdrew due to adverse events.nnnINTERVENTIONnPatients received orally for 6 wk: vitamin D(2), 2,000 IU daily (arm A, control); vitamin D(3), 2,000 IU daily (arm B); vitamin D(2), 50,000 IU weekly (arm C); and an age-appropriate calcium supplement.nnnMAIN OUTCOME MEASUREnWe measured the change in serum 25OHD concentration (Δ25OHD) (ng/ml). Secondary outcomes included change in serum intact PTH concentration (ΔPTH) (pg/ml) and the adverse event occurrence rate.nnnRESULTSnAfter 6 wk, Δ25OHD ± se was: 9.3 ± 1.8 (arm A); 16.4 ± 2.0 (arm B); 25.4 ± 2.5 (arm C); P (A vs. C) = 0.0004; P (A vs. B) = 0.03. ΔPTH ± SE was -5.6 ± 5.5 (arm A); -0.1 ± 4.2 (arm B); -4.4 ± 3.9 (arm C); P = 0.57. No participant experienced hypercalcemia or hyperphosphatemia, and the prevalence of hypercalciuria did not differ among arms at follow-up.nnnCONCLUSIONSnOral doses of 2,000 IU vitamin D(3) daily and 50,000 IU vitamin D(2) weekly for 6 wk are superior to 2,000 IU vitamin D(2) daily for 6 wk in raising serum 25OHD concentration and are well-tolerated among children and adolescents with IBD. The change in serum PTH concentration did not differ among arms.

Long-term outcomes of infants and children undergoing percutaneous endoscopy gastrostomy tube placement.

Objectives: Little is known about long-term outcomes of patients undergoing percutaneous endoscopic gastrostomy (PEG) placement. The purpose of this study was to examine tube-related major complications in pediatric patients undergoing PEG placement during a 10-year follow-up period. Methods: A retrospective chart review of patients undergoing PEG placement from April 1999 through December 2000 at Boston Childrens Hospital was performed. Cumulative incident rates of major complications (defined by additional hospitalization, surgical or interventional radiology procedures) as well as time between PEG placement and major complications were evaluated using Kaplan-Meier survival analysis. Time to elective tube removal and patient mortality was also assessed. Results: One hundred thirty-eight patients (59% [nu200a=u200a82] boys [median age 22.5 months] [interquartile range, IQR 9–72.5], weight 9.2 kg [IQR 6.1–15.8]), underwent PEG placement during the study period and were followed at our hospital for a median of 4.98 years (IQR 1.5–8.7) years. Median time to elective tube removal was 10.2 years, with approximately half of the patients estimated to still have an indwelling enteral tube 10 years after placement. Fifteen patients (11%) had at least 1 major complication related to their gastrostomy tubes during the examined time period. The cumulative incidence of patients having a major complication was 15% (95% confidence interval 8.9–24.5) by 5.4 years. Conclusions: Children undergoing PEG placement have a long-term high risk of morbidity related to enteral tubes. Major complications can occur many years after PEG placement. Larger prospective studies may be useful to assess risk factors for PEG-related complications in pediatrics.

Effects of heavy prenatal alcohol exposure and iron deficiency anemia on child growth and body composition through age 9 years

BACKGROUNDnPrenatal alcohol exposure has been associated with pre- and postnatal growth restriction, but little is known about the natural history of this restriction throughout childhood or the effects of prenatal alcohol on body composition. The objective of this study was to examine the effects of heavy prenatal alcohol exposure on longitudinal growth and body composition.nnnMETHODSnEighty-five heavy drinking pregnant women (≥2xa0drinks/d or ≥4xa0drinks/occasion) and 63 abstaining and light-drinking controls (<1xa0drink/d, no binging) were recruited at initiation of prenatal care in an urban obstetrical clinic in Cape Town, South Africa and prospectively interviewed during pregnancy about alcohol, smoking, drug use, and demographics. Among their children, length/height, weight, and head circumference were measured at 6.5 and 12xa0months and at 5 and 9xa0years. Percent body fat (BF) was estimated at age 9xa0years using bioelectric impedance analysis.nnnRESULTSnIn multiple regression models with repeated measures (adjusted for confounders), heavy alcohol exposure was associated with reductions in weight (0.6xa0SD), length/height (0.5xa0SD), and head circumference (0.9xa0cm) from 6.5xa0months to 9xa0years that were largely determined at birth. These effects were exacerbated by iron deficiency in infancy but were not modified by iron deficiency or measures of food security at 5xa0years. An alcohol-related postnatal delay in weight gain was seen at 12xa0months. Effects on head circumference were greater at age 9 than at other age points. Although heavy alcohol exposure was not associated with changes in body composition, children with fetal alcohol syndrome (FAS) and partial fetal alcohol syndrome (PFAS) had lower percent BF than heavy exposed nonsyndromal and control children.nnnCONCLUSIONSnHeavy prenatal alcohol exposure is related to prenatal growth restriction that persists through age 9xa0years and an additional delay in weight gain during infancy. FAS and PFAS diagnoses are associated with leaner body composition in later childhood.

Diagnosis of supra-esophageal gastric reflux: correlation of oropharyngeal pH with esophageal impedance monitoring for gastro-esophageal reflux

Backgroundu2002 Oropharyngeal (OP) pH monitoring has been developed as a new way to diagnose supra‐esophageal gastric reflux (SEGR), but has not been well validated. Our aim was to determine the correlation between OP pH and gastro‐esophageal reflux (GER) events detected by multichannel intraluminal impedance‐pH (MII‐pH).

Maintenance of optimal vitamin D status in children and adolescents with inflammatory bowel disease: a randomized clinical trial comparing two regimens.

CONTEXTnVitamin D promotes bone health and regulates the immune system, both important actions for pediatric patients with inflammatory bowel disease (IBD). The supplementation dose that would maintain optimal serum 25-hydroxyvitamin D concentration (25OHD ≥ 32 ng/mL) is unknown.nnnOBJECTIVEnThe objective of the study was to compare two supplementation regimens efficacy and safety in maintaining optimal 25OHD in children with IBD.nnnDESIGNnThis was a randomized, not blinded, controlled trial.nnnSETTINGnThe trial was conducted in the Boston Childrens Hospital Clinical and Translational Study Unit.nnnPARTICIPANTSnSixty-three patients, aged 8-18 years with IBD and baseline 25OHD greater than 20 ng/mL were enrolled; 48 completed the study, and one withdrew for adverse events.nnnINTERVENTIONnArm A received 400 IU of oral vitamin D2 daily (n = 32). Arm B received 1000 IU daily in the summer/fall and 2000 IU in the winter/spring (n = 31).nnnMAIN OUTCOMEnThe main outcome was the probability of maintaining 25OHD of 32 ng/mL or greater in all trimonthly visits for 12 months.nnnRESULTSnThree participants in arm A (9.4%) and three in arm B (9.7%) achieved the primary outcome (P = .97). The incidence of adverse events, all minor, did not differ. More participants in arm A developed C-reactive protein level of 1 mg/dL or greater (31% vs 10%, P = .04) and IL-6 greater than 3 pg/mL (54% vs 27%, P = .05).nnnCONCLUSIONSnDaily oral vitamin D2 doses up to 2000 IU were inadequate to maintain optimal 25OHD but were well tolerated. The finding of lower incidence of elevated inflammatory markers and cytokines among participants receiving higher vitamin D2 doses merits further study.

Risk Factors for Complications in Infants and Children with Percutaneous Endoscopic Gastrostomy Tubes

OBJECTIVEnTo identify risk factors associated with percutaneous endoscopic gastrostomy (PEG) tube complications in a large cohort of infants and children.nnnSTUDY DESIGNnWe performed a chart review of 591 pediatric patients undergoing PEG tube placement between 2006 and 2010 at Boston Childrens Hospital. Frequency and type of major and minor complications associated with PEG tubes in children were identified. Univariate and multivariate analyses were then conducted to determine potential risk factors for complications.nnnRESULTSnA total of 198 PEG-related complications (72 major and 126 minor) were noted in our cohort of 591 patients. Approximately 10.5% of patients experienced at least one major complication and 16.4% experienced at least one minor complication, with the great majority of complications occurring after discharge postplacement. Age <6 months (P = .003), American Society of Anesthesiologists class III (P = .02), and presence of a neurologic disorder (P = .05) were found to be protective against experiencing a major complication, whereas the presence of a ventriculoperitoneal shunt was confirmed to be a risk factor (P = .01) for major complications.nnnCONCLUSIONnBoth minor and major complications are common in children after PEG tube placement, with most complications occurring several months postoperatively. Certain patient factors, including age, neurologic status, and American Society of Anesthesiologists class, may be protective, and the presence of a ventriculoperitoneal shunt may be associate with an increased risk of complications after PEG tube placement.

Juvenile polyps: recurrence in patients with multiple and solitary polyps.

BACKGROUND & AIMSnJuvenile polyps are benign hamartomas with neoplastic potential that are the most frequent gastrointestinal polyp of childhood. Most information about juvenile polyps in childhood comes from small published series that lack detailed outcome data. We sought to identify a large cohort of children with one or more polyps and analyze clinical characteristics, including polyp recurrence, which might contribute to the development of management guidelines.nnnMETHODSnA retrospective chart review study of patients with juvenile polyps of the colon was performed. Cases were identified by searching a single hospital pathology database from 1990 to 2009 for the diagnosis of juvenile polyps. Recorded information included basic demographics, family history, genetic testing, and colonoscopy and pathology reports.nnnRESULTSnA total of 257 children (median age, 5.6 y; 61.5% male) with juvenile polyps were identified. Among 192 patients who underwent complete colonoscopy at initial diagnosis, 117 (60.9%) had a single polyp, 75 (39.1%) had multiple polyps, 8 (4.2%) had polyps restricted to the right colon, and a total of 1653 polyps were found during 350 colonoscopy examinations. Polyps recurred in 21 of 47 (44.7%) patients after initial eradication, including 3 (16.7%) of 18 presenting with a single polyp. Neoplasia was found in 10 of 257 (3.9%) patients (right colon in 7 patients). Germline DNA abnormalities in mothers against decapentaplegic Drosophila (SMAD4), bone morphogenetic protein receptor 1A (BMPR1A), and phosphatase and tensin homolog (PTEN) were detected in 10 of 23 (43.5%) patients with multiple polyps.nnnCONCLUSIONSnRecurrent polyp formation is common in children with juvenile polyps and occurs in patients with multiple and solitary polyps. Standardized protocols for detecting polyp recurrence, associated gene mutations, and neoplasia should be developed for children with juvenile polyps.

Cisapride improves enteral tolerance in pediatric short-bowel syndrome with dysmotility.

Background and Objectives:Gastrointestinal dysmotility is common in pediatric short-bowel syndrome, leading to prolonged parenteral nutrition dependence. There is limited literature regarding the safety and efficacy of cisapride for this indication. The aim of the study was to describe the safety and efficacy of cisapride for enteral intolerance in pediatric short-bowel syndrome. Methods:Open-labeled pilot study in a limited access program for cisapride. Indications were short-bowel syndrome with underlying dysmotility and difficulty advancing enteral feeds despite standard therapies and without evidence of anatomic obstruction. Patients received cisapride 0.1 to 0.2 mg/kg per dose for 3 to 4 doses per day. We collected electrocardiogram, nutrition, and anthropometric data prospectively at study visits. Results:Ten patients with mean (SD) age of 30.3 (30.5) months were enrolled in our multidisciplinary pediatric intestinal rehabilitation program. Median (interquartile range [IQR]) duration of follow-up was 8.7 (3.1–14.3) months. Median (IQR) residual bowel length was 102 (85–130) cm. Median (IQR) citrulline level was 14.5 (10.5–31.3) μmol/L. Diagnoses included isolated gastroschisis (n = 3), gastroschisis with intestinal atresia (n = 4), necrotizing enterocolitis (n = 2), and long-segment Hirschsprung disease (n = 1). Six subjects had at least 1 prior bowel-lengthening procedure. Median (IQR) change in percentage enteral energy intake was 19.9% (15.4%–29.8%) during follow-up (P = 0.01). Seven patients improved in enteral tolerance during treatment and 2 were weaned completely from parenteral nutrition. Complications during therapy were prolonged corrected QT interval (n = 2), gastrointestinal bleeding (n = 2), D-lactic acidosis (n = 1), and death due to presumed sepsis (n = 1). Longitudinal analysis (general estimating equation model) showed a strong positive association between cisapride duration and improved enteral tolerance. Mean percentage of enteral intake increased by 2.9% for every month of cisapride treatment (P < 0.0001). Conclusions:Cisapride is a potentially useful therapy in patients with pediatric short-bowel syndrome with gastrointestinal dysmotility. We observed modest improvement in feeding tolerance where prior treatments failed; however, patients treated with cisapride require careful cardiac monitoring because corrected QT prolongation occurred in 20% of our cohort.

Assessment of hemoglobin threshold for packed RBC transfusion in a medical-surgical PICU.

Objective: Results of a large multicenter randomized clinical trial published in 2007 demonstrated no benefit in using a liberal versus conservative RBC transfusion threshold in stable critically ill children. Using the conservative threshold decreased the number of RBC transfusions without increasing adverse outcomes. We aimed to determine if wide dissemination of this evidence altered the hemoglobin threshold used for RBC transfusions in our pediatric medical-surgical ICU. Design: Before-after retrospective cohort study using multiple administrative databases and chart review. Setting: PICU serving medical and surgical patients. Patients: All potentially stable children receiving a RBC transfusion in the PICU in 2006 (prepublication) and in 2009–2010 (postpublication). Children were considered unstable and excluded if they were severely hypoxic, receiving renal replacement therapy, hemodynamically unstable, or bleeding. Interventions: Physician education on evidence supporting hemoglobin transfusion thresholds in teaching conferences, staff meetings, and via e-mail. Measurements and Main Results: In 2006, 14.6% of patients (n = 285/1,940) received a RBC transfusion. In 2009–2010, 12.1% of patients (n = 551/4,542) received a RBC transfusion. We evaluated patients transfused when they were potentially clinically stable, including 145 children in 2006 (191 transfusion days) and 266 children in 2009–2010 (369 transfusion days). We found no significant differences in age, sex, race, diagnoses, postoperative status, illness severity scores, mortality, or length of stay between these two groups. The median hemoglobin transfusion threshold decreased significantly from 8.0 g/dL (interquartile range 7.3, 8.6 g/dL) in 2006 to 7.5 g/dL (interquartile range 6.9, 8.1 g/dL) in 2009–2010 (p = 0.001). The percentage of transfusion days using a hemoglobin threshold more than 7 g/dL decreased from 81% (n = 154) in 2006 to 71% (n = 261) in 2009–2010. Conclusion: Although transfusion thresholds in potentially stable critically ill children in our PICU significantly decreased after dissemination of best available evidence, 71% of patients were transfused at a hemoglobin threshold more than 7 g/dL.