Simon S. Rabinowitz

Early Medical and Behavioral Characteristics of NICU Infants Later Classified With ASD

OBJECTIVES: Recent evidence suggests higher prevalence of autism spectrum disorder (ASD) in NICU graduates. This aim of this study was to identify retrospectively early behaviors found more frequently in NICU infants who went on to develop ASD. METHODS: Twenty-eight NICU graduates who later received a diagnosis of ASD were compared with 2169 other NICU graduates recruited from 1994 to 2005. They differed in gender, gestational age, and birth cohort. These characteristics were used to draw a matched control sample (n = 112) to determine which, if any, early behaviors discriminated subsequent ASD diagnosis. Behavioral testing at targeted ages (adjusted for gestation) included the Rapid Neonatal Neurobehavioral Assessment (hospital discharge, 1 month), Arousal-Modulated Attention (hospital discharge, 1 and 4 months), and Bayley Scales of Infant Development (multiple times, 4–25 months). RESULTS: At 1 month, children with ASD but not control children had persistent neurobehavioral abnormalities and higher incidences of asymmetric visual tracking and arm tone deficits. At 4 months, children with ASD had continued visual preference for higher amounts of stimulation than did control children, behaving more like newborns. Unlike control children, children with ASD had declining mental and motor performance by 7 to 10 months, resembling infants with severe central nervous system involvement. CONCLUSIONS: Differences in specific behavior domains between NICU graduates who later receive a diagnosis of ASD and matched NICU control children may be identified in early infancy. Studies with this cohort may provide insights to help understand and detect early disabilities, including ASD.

The seroprevalence of Helicobacter pylori in a referral population of children in the United States

OBJECTIVES:The purpose of this study was to determine the prevalence of serum antibodies directed against Helicobacter pylori (H. pylori) in children referred to childrens hospitals or medical centers throughout the United States.METHODS:This multisite cross-sectional prospective study involved 992 children from 12 states using a validated anti–H. pylori IgG enzyme immunoassay. The children were recruited into two groups: those without any GI complaints (non–GI referral, n = 619) and those who were referred for endoscopy because of abdominal pain (GI referral, n = 373).RESULTS:GI referral children had a higher rate of seropositivity (22.5%) than non–GI referral children (14.1%) from the same geographic regions. In both groups, older children were more likely to be seropositive for H. pylori, as were nonwhite children and those with lower socioeconomic status. H. pylori seropositivity rates were higher in GI referral children with four or more household members (relative risk [RR] = 1.47; CI 1.01–2.14). Multivariate analysis controlling for age, ethnicity, and household income, showed that presence of GI symptoms were associated with a nearly 2-fold risk for H. pylori seropositivity (odds ratio = 1.77, CI 1.27–2.47). Epigastric pain (RR = 2.21; CI = 1.33–3.66) and having three or more episodes of abdominal pain in the last 3 months (RR = 0.59, CI = 0.35–0.99) were the only specific symptoms significantly associated with H. pylori seropositivity.CONCLUSIONS:The H. pylori seropositivity rate of GI referral children with symptoms of abdominal pain was significantly higher. H. pylori infection in early childhood was found to be associated primarily with the childs household size and socioeconomic status.

The Use of an Oral Fluid Immunoglobulin G ELISA for the Detection of Helicobacter pylori Infection in Children

Background. Enzyme linked immunosorbent assay (ELISA) evaluation of oral fluid immunoglobulin G (IgG) antibodies to Helicobacter pylori is a unique approach for both epidemiological studies and the diagnosis of infection, especially in children. The use of oral fluid sampling to evaluate specific H. pylori IgG antibodies has advantages over serum, including reduced biohazard risk and noninvasive collection. Oral fluid sampling is fast and involves minimal patient discomfort. Since children facilitate transmission of H. pylori infection, a simple, accurate, noninvasive diagnostic test is necessary for large epidemiologic studies. The aim of our study was to evaluate a new oral fluid ELISA for detection of IgG antibodies to H. pylori in children.

Hirschsprung disease presenting as sigmoid volvulus: a case report and review of the literature

While sigmoid volvulus is commonly seen in older patients, it is rarely encountered in children and younger adults. Consequently, heightened awareness of this entity is required to avoid a delay in diagnosis. Among the pediatric and adult cases of colonic volvulus previously reported in the English literature, 23 of the affected individuals have also been diagnosed with Hirschsprung disease (HD). This report describes a 12-year-old male with a history of chronic constipation who presented with vomiting and abdominal distension and was found to have sigmoid volvulus with previously unrecognized HD. The case presentation is followed by a review of the literature describing colonic volvulus secondary to HD in children.

Prevalence and characteristics of eosinophilic esophagitis in 2 ethnically distinct pediatric populations

To the Editor: Eosinophilic esophagitis (EoE) is an immune/antigenmediated disease characterized by symptoms related to esophageal dysfunction and by eosinophil-predominant mucosal inflammation. Age-dependent symptom variability is well recognized in children. A recent study in adult patients reported significant racial/ethnic EoE phenotypic differences; however, ethnic variations in the clinical/histopathologic properties of pediatric EoE have not been examined. Published data describe findings in predominantly white pediatric subjects. This report investigates EoE characteristics in a black, inner-city pediatric cohort, and compares findings with those in a rural white population. This study was approved by the respective institutional review boards at SUNY-Downstate Medical Center and at Marshall University. Children with EoE were identified from all pediatric diagnostic upper endoscopies performed at SUNY-Downstate Medical Center, Brooklyn, New York, and at Marshall University, Huntington, West Virginia, between January 1, 2003, and April 30, 2010. Subjects were excluded if symptoms resolved following acid suppressive treatment. Information obtained from patient records and reflecting standard practice for evaluating EoE at both sites included patient age, ethnicity, symptoms, personal and family history of atopy, peripheral eosinophilia, total IgE, radioallergosorbent test results (cow milk protein, soy protein, wheat, eggs, peanuts/tree nuts, seafood), and endoscopic and histopathologic findings. Endoscopic findings at diagnosis were identified by reviewing procedure photographs and written reports. Consistent with consensus recommendations and with routine protocols at both sites, at least 1 biopsy each was obtained from the distal and the midesophagus in all subjects. EoE (>_15 eosinophils in a single hpf) was confirmed on reexamination by a single pathologist (R.G.). Two-tailed, independent-samples mean tests (for continuous variables) and x analyses (for noncontinuous variables) were used (SPSS, version 17.0; IBM Corp, Armonk, NY). Ninety-six patients were eligible for this retrospective study: 44 from SUNY-Downstate and 52 from Marshall University. These numbers represent 3.1% and 3.3%, respectively, of all diagnostic (ie, initial) pediatric upper endoscopies performed at these centers during the study period. All 52 eligible subjects in theWVa cohort werewhite, and all were included. At SUNY-Downstate, 37 of the 44 eligible children were studied. Five black subjects had incomplete clinical data, and the only 2 white subjects with EoE were excluded to maintain group homogeneity. Males were more commonly affected than females in both groups (M:F [black vs white], 2.7:1 vs 3.0:1; P 5 not significant [ns]). Age ranges were similar (black 5 8 months to 17 years; white 5 6 months to 18 years); however, the mean age at diagnosis was significantly younger in black subjects (black vs white 5 4.5 vs 9.5 years, P < .001, 95% CI, 2.5-6.2). Fig 1 indicates presenting symptoms in both groups. Feeding difficulties, not including vomiting or regurgitation, were

Hepatitis C infection in children and adolescents with end-stage renal disease

Abstract The prevalence of hepatitis C virus (HCV) infection and the risk factors associated with its transmission are described in a contemporary cohort of 55 children and adolescents with end-stage renal disease (ESRD). Thirty-seven patients were on dialysis or had been transplanted (ESRD) and 18 had chronic renal failure (CRF) but had not yet received dialysis. Seven (19%) tested positive for HCV by enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR), or both. None of the children with CRF were infected. HCV infection was associated with length of time on dialysis, but not with age, gender, race, or units of blood transfused. These data corroborate earlier reports and confirm that children with ESRD continue to have a high prevalence of HCV. It is also shown for the first time that elevated transaminases should not be employed to predict HCV infection in this cohort, as all affected children had normal serum levels. Because of unique characteristics in this cohort, both ELISA and PCR are required to maximize HCV diagnostic sensitivity. Although HCV remains an important consideration in pediatric ESRD, the present study shows that recent advances in clinical practice have eliminated one of the major ways in which it was previously being transmitted.

Case Report: Endoscopic Features of Intestinal Smooth Muscle Tumor in a Child with AIDS

Intestinal leiomyosarcomas are exceedingly rare in immunologically intact children, except during infancy. While leiomyosarcomas account for less than 2% of all soft tissue tumors in childhood, they are the second most frequent malignancy in children with the acquired immunodeficiency syndrome (AIDS). In this cohort they are often located in unusual sites for primary soft tissue tumors. This report describes a young girl with advanced AIDS, referred for evaluation of abdominal pain, hematochezia, and wasting syndrome. Colonoscopy revealed two 1- to 2-cm submucosal nodules with central umbilication. Repeat colonoscopy 18 months later revealed no changes in these lesions. Biopsy revealed a submucosal spindle-cell lesion, with necrosis and cellular atypia. Initially it was characterized as a partially excised low-grade leiomyosarcoma. However, the final consensus diagnosis was smooth muscle tumor of uncertain malignant potential. Because of her advanced AIDS, there was no attempt at surgical resection or chemotherapy. Thirty-six months after initial referral, she remains alive without radiographic or clinical evidence of local extension or metastases. Additional data are required to determine the long-term outcome of these indolent submucosal tumors in the digestive tracts of children with AIDS.

Intestinal perforation 14 years after abdominal irradiation and chemotherapy for Wilms tumor

A 3-year-old girl underwent left nephrectomy and removal of a tumor thrombus from the inferior vena cava and right atrium in 1978 because of Wilms tumor. Her treatment consisted of tumor bed irradiation (4,000 cGy) and chemotherapy with actinomycin D, vincristine, and doxorubicin. The patient underwent laparo-tomy 2 months after completion of abdominal irradiation to relieve intestinal obstruction. Fourteen years later, she underwent another laparotomy because of an “acute abdomen” and was found to have perforation of the jejunum in the radiation field. Histopathological examination of resected intestine revealed evidence of severe chronic radiation enteritis. A diagnosis of chronic radiation enteritis should be considered in patients who had received abdominal irradiation and who manifest abdominal pain/vomiting even several years after irradiation.

Pediatric Helicobacter pylori gastropathy demonstrates a unique pattern of gastric foveolar hyperplasia

Helicobacter pylori (Hp) are the most common agents causing gastric mucosal injury worldwide. Foveolar hyperplasia is a key component of the stomachs reaction to injury. This study examines histopathologic characteristics associated with Helicobacter pylori and with non‐ Helicobacter pylori‐associated gastropathy in children and adolescents, and compares the prevalence of foveolar hyperplasia among these disease subgroups and normal control subjects.

Aripiprazole reversed gastroparesis in a child with 1q21.1–q21.2 microdeletion

An 11-year-old Caucasian boy, with a microdeletion in the 1q21.1–q21.2 region, had multiple medical conditions including gastroparesis documented initially at the age of 5. The patient had a history of poor feeding since infancy and had been treated for gastro-oesophageal reflux disease (GERD), constipation and multiple food allergies. As a consequence of the GERD and his concurrent immunoglobulin (IgG) subclass deficiency, the patient had multiple otolaryngologic (ENT) infections and required two sinus surgeries. The patient had poor weight gain (below the third percentile for weight-for-age) and required a short course of parenteral nutrition and eventually a gastrostomy tube. He was started on metoclopramide as treatment for gastroparesis with an increase in his appetite, oral intake and weight gain. However, severe headaches and worsening in his behaviour caused the agent to be discontinued. He had little weight gain and after a course of parenteral nutrition he was converted to a transpyloric feeding tube. Because of ongoing behavioural problems that interfered with his school performance, a psychiatrist started him on aripiprazole. After aripiprazole was prescribed at age 11, his appetite and oral intake dramatically increased and a repeat gastric emptying study was normal. The increased oral intake and weight gain continued, allowing removal of the feeding tube. More than 2 years later, on aripiprazole, he continues to gain weight without any supplemental feedings.