Troy Gibbons

Management of Ingested Foreign Bodies in Children: A Clinical Report of the NASPGHAN Endoscopy Committee

Foreign body ingestions in children are some of the most challenging clinical scenarios facing pediatric gastroenterologists. Determining the indications and timing for intervention requires assessment of patient size, type of object ingested, location, clinical symptoms, time since ingestion, and myriad other factors. Often the easiest and least anxiety-producing decision is the one to proceed to endoscopic removal, instead of observation alone. Because of variability in pediatric patient size, there are less firm guidelines available to determine which type of object will safely pass, as opposed to the clearer guidelines in the adult population. In addition, the imprecise nature of the histories often leaves the clinician to question the timing and nature of the ingestion. Furthermore, changes in the types of ingestions encountered, specifically button batteries and high-powered magnet ingestions, create an even greater potential for severe morbidity and mortality among children. As a result, clinical guidelines regarding management of these ingestions in children remain varied and sporadic, with little in the way of prospective data to guide their development. An expert panel of pediatric endoscopists was convened and produced the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body ingestions. This guideline is intended as an educational tool that may help inform pediatric endoscopists in managing foreign body ingestions in children. Medical decision making, however, remains a complex process requiring integration of clinical data beyond the scope of these guidelines. These guidelines should therefore not be considered to be a rule or to be establishing a legal standard of care. Caregivers may well choose a course of action outside of those represented in these guidelines because of specific patient circumstances. Furthermore, additional clinical studies may be necessary to clarify aspects based on expert opinion instead of published data. Thus, these guidelines may be revised as needed to account for new data, changes in clinical practice, or availability of new technology.

Antireflux Surgery Outcomes in Pediatric Gastroesophageal Reflux Disease

OBJECTIVES:Antireflux surgery is performed frequently in children with gastroesophageal reflux disease (GERD). Few comparative studies exist which assess the indications for and short- or long-term outcome of open Nissen fundoplication (ONF) and laparoscopic Nissen fundoplication (LNF) for pediatric GERD. We investigated the frequency of reoperation and factors that might influence its occurrence.METHODS:We performed a retrospective, follow up cohort study of all children ≤5 years, who underwent LNF or ONF at our institution from January 1, 1997 to December 31, 2002, where five pediatric surgeons perform fundoplication. Mean follow up time was 36.2 months. The following information was obtained: surgical indications, hospital course data, and long-term surgical outcomes. Data were analyzed using univariate and multiple logistic regressions.RESULTS:Overall, 456 (150 [32.9%] ONF vs. 306 [67.1%] LNF) cases were analyzed. Reoperation was performed in 55 (12.06%), LNF 43 (14.05%), and ONF 12 (8%). The mean interim to reoperation for LNF was 11 months compared to 17 months for ONF (P = 0.007). The reoperation rate at 12 and 24 months were 10.5%, 13.4% and 4%, 6.7% respectively, when LNF was compared to ONF (P = 0.01). The multivariate analysis showed that initial LNF and prematurity were the main predictors for reoperation.CONCLUSIONS:The majority of reoperations for both LNF and ONF occurred in the first year after initial operation; LNF had a significantly higher reoperation rate than ONF. The probability of reoperation for LNF and ONF increases with the presence of comorbidities, especially prematurity and chronic respiratory conditions.

Bowel Preparation for Pediatric Colonoscopy: Report of the NASPGHAN Endoscopy and Procedures Committee

ABSTRACT Pediatric bowel preparation protocols used before colonoscopy vary greatly, with no identified standard practice. The present clinical report reviews the evidence for several bowel preparations in children and reports on their use among North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition members. Publications in the pediatric literature for bowel preparation regimens are described, including mechanisms of action, efficacy and ease of use, and pediatric studies. A survey distributed to pediatric gastroenterology programs across the country reviews present national practice, and cleanout recommendations are provided. Finally, further areas for research are identified.

Food Hypersensitivity and Otolaryngologic Conditions in Young Children

Objectives/Hypothesis To explore the relationship between food hypersensitivity and common upper aerodigestive disorders found in children younger than 2 years. Study Design Case control study. Setting Tertiary pediatric gastroenterology/otolaryngology clinics. Methods Two-year retrospective chart review of a common cohort of children younger than 2 years with suspected cow’s milk protein allergy (CMPA). Patients were managed in both a tertiary pediatric gastroenterology and otolaryngology clinic and compared with a control study group. Results One hundred ninety-one children with CMPA were reviewed. One hundred forty-one had aerodigestive complaints, with 101 having sufficient follow-up to participate in the study. Ninety-one percent of this final patient group demonstrated improved symptoms following dairy elimination. Twenty-five patients (27%) had associated otolaryngologic (ear, nose, and throat [ENT]) issues that had been refractory to maximal gastroesophageal reflux therapy. The most common associated upper aerodigestive conditions were persistent upper airway congestion (72%) and oropharyngeal dysphagia (80%). Sixty percent of ENT disease improved with elimination diet. Eosinophilic esophagitis was noted in 36% of the cohort who had mucosal biopsies performed. Otolaryngology intervention was much more common in the cohort of children with CMPA compared with controls (odds ratio, 33.78; 95% confidence interval, 7.55, 151.03). Conclusions CMPA is difficult to diagnose because of limited accurate diagnostic tools, especially in young children. This study suggests a relationship between CMPA and otolaryngologic conditions in children younger than 2 years. Some patients in this study showed symptom improvement via an elimination diet. Early recognition of otolaryngologic manifestations of CMPA may help manage this condition in young children.

NASPGHAN Capsule Endoscopy Clinical Report

Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.

Non-IgE-Mediated Cow Milk Allergy Is Linked to Early Childhood Clusters of Commonly Seen Illnesses: A Pilot Study

Objective. There are few established diagnostic tools to define non-IgE-mediated food hypersensitivity reactions. Cow milk protein allergy (CMPA) is a multisystem disorder affecting the gastrointestinal, skin, and lower and upper airway systems. This link is frequently missed because of subspecialty evaluation of the multisystem effects individually. The authors hypothesize that a more global evaluation based on a simple scored questionnaire will reveal this link. Methods. Over an 18-month period, children younger than 2 years with non-IgE-mediated CMPA were identified. A symptom questionnaire was developed and scored and also applied to a control population. The prevalence of symptoms in each group was compared and a cumulative score was determined. Symptoms evaluated included gastrointestinal, aerodigestive, lower airway, and skin symptoms. A positive response was scored 1 and a negative response scored 0. Results. Significant differences in prevalence rates between CMPA and control populations were noted, particularly in aerodigestive symptoms. There were marked differences in cumulative score between populations (P < .001). The authors identified a cut-off score at which there was close to 80% sensitivity and 90% specificity for distinguishing CMPA from a control population. Conclusion. A global evaluation of multiple systems can be an important diagnostic tool in determining CMPA in infants.

Malnutrition: A Hidden Problem in Hospitalized Children

Childhood undernutrition remains one of the greatest causes of morbidity and mortality. The World Health Organization (WHO) estimates that malnutrition contributes to 55% of childhood mortality worldwide. Children with severe malnutrition, also known as protein energy malnutrition (PEM), typically are also deficient in various micronutrients, including zinc, copper, selenium, iron, vitamin A, vitamin C, and vitamin E, which can result in immune dysfunction and increased risk of infection, particularly persistent diarrheal disease and lower respiratory tract infection. The vicious cycle of pediatric malnutrition, immunodeficiency, and infection has long been recognized as a major cause of childhood morbidity and mortality. Malnutrition can be categorized as primary or secondary malnutrition. In primary malnutrition, the main underlying cause is food insecurity, and this is the predominant form of malnutrition in developing countries. Although less common in economically developed nations, primary malnutrition occurs but usually in circumstances of extreme social neglect or poor nutritional intake arising from ignorance of proper infant feeding practices. In developed countries, the great majority of malnutrition is secondary and in association with an underlying disease process or disorder that predisposes the child to undernourishment. Survey data indicate the presence of severe malnutrition in a variety of settings, including the newborn and pediatric intensive care units and subspecialty wards of tertiary hospital centers, and is associated with adverse outcomes of morbidity, length of hospital stay, and mortality. Indeed, as advances in medicine have contributed to the extended life span of chronically ill children, systematic nutrition surveillance and appropriate management to ensure adequate protein, energy, and micronutrient intakes have taken on an added importance. Unfortunately, this is often underappreciated, with subsequent development and underrecognition of malnutrition.

Food Hypersensitivity and Ear, Nose, and Throat Pathology in Children Less than 2 Years of Age

Objective: Explore the relationship between food hypersensitivity associated with cows milk protein allergy (CMPA) and common gastrointestinal and upper aerodigestive disorders found in children less than two years of age. Method: Two-year retrospective chart review of a common cohort of children less than 2 years of age, managed in both a tertiary pediatric gastroenterology and otolaryngology clinic. Comparison with a control pediatric population was performed. Results: Of 191 children reviewed with CMPA, 141 demonstrated upper gastrointestinal (GI) complaints. Twenty-five (18%) of these children had otolaryngologic (ENT) conditions refractory to standard therapy with the majority being chronic otitis media (70%) and oropharyngeal dysphagia (80%). In contrast, only 2% of patients in a GI control group demonstrated ENT disease. Dairy elimination improved GI symptoms in 92 patients, and ENT disease improved in 60%. ENT conditions improved in the control group via standard therapy. Conclusion: This study suggests a relationship between CMPA and ENT concerns in children less than 2 years old, whereby food hypersensitivity can be associated with recalcitrant otits media and oropharyngeal dysphagia. Elimination diets can improve both GI and ENT conditions refractory to GERD therapy in patients with CMPA.