bluuebunny/crossref_metadata_2025 huggingface dataset:
Polyethylene Glycol Powder Solution Versus Senna for Bowel Preparation for Colonoscopy in Children
Authors: Terry Natalie A. , Chen‐Lim Mei Lin , Ely Elizabeth , Jatla Muralidhar , Ciavardone Denise , Esch Salina , Farace Lisa , Jannelli Frances , Puma Anita , Carlow Dean , Mamula Petar
Published: November 2012

Objectives:

Safety and effectiveness of large‐volume polyethylene glycol‐based solution (PEG‐ES) have been documented, but the taste and volume can be barriers to successful colonoscopy preparation. Efficacy and safety of small‐volume electrolyte‐free (PEG‐P) preparation (Miralax) for colonoscopy preparation have been rarely studied, although presently used at many pediatric centers. The primary objective of the present study was to determine whether PEG‐P results in a more efficacious and safe colonoscopy preparation as compared with senna.

Methods:

The study design was prospective, randomized, and single‐blinded. Patients ages 6 to 21 years were randomized to a 2‐day clean‐out regimen of PEG‐P at a dose of 1.5 g/kg divided twice per day for 2 days versus senna 15 mL daily (ages 6–12) or 30 mL daily (ages 12–21) for 2 days. Both preparations required 1 day of clear liquids whereas senna preparation required an additional day of full liquid diet. A blinded endoscopist graded the quality of preparation with a standardized cleanliness tool (Aronchick scale). Serum chemistry panels were obtained. Patients or parents rated symptoms and ease of preparation. The anticipated number of subjects was 166; however, the interim analysis demonstrated inferiority of senna preparation.

Results:

Thirty patients were evaluated in the present study. Of the patients in the PEG‐P arm, 88% (14/16) received an excellent/good score compared with 29% (4/14), with the senna preparation (P = 0.0022). Both preparations were well‐tolerated by patient‐graded ease of preparation. Demographics and laboratory values did not differ significantly across the 2 groups. No serious adverse events were noted.

Conclusions:

PEG‐P is an effective colonoscopy preparation whereas senna preparation was insufficient. Both were well‐tolerated and appear safe in a pediatric population.
Assessment of Nutrition Education Among Pediatric Gastroenterologists
Authors: Lin Henry C. , Kahana Doron , Vos Miriam B. , Black Dennis , Port Zack , Shulman Robert , Scheimann Ann , Mascarenhas Maria R.
Published: November 2012

Background and Aim:

Pediatric gastroenterology is the only pediatric subspecialty with nutrition as part of its official curriculum and objective; however, pediatric gastroenterology fellows believe that their baseline knowledge in nutrition is suboptimal. The purpose of the present study was to assess the perceived effectiveness of nutrition training among pediatric gastroenterologists, identify areas of need for additional education, and determine the perceived role of the gastroenterologist in obesity management.

Methods:

A survey was sent to members and fellows of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition to assess general nutrition education as well as obesity management and educational needs.

Results:

A total of 272 responses were received, for an overall response rate of 15.2% (272/1784). Most responders reported having average or above‐average knowledge base in all nutritional topics. There was strong interest in additional resources and a continuing medical education (CME) module on several nutrition topics including nutritional requirements in specific gastrointestinal (GI) disease, failure to thrive/growth failure, and parenteral nutrition support, with the format of CME dependent on the topic. There was also a strong interest in additional CME on the management of pediatric obesity (67%), as most responders believed that the management of obesity in children requires subspecialty care. The perceived role of the pediatric gastroenterologist was, however, one of support to treat the GI and hepatic comorbidities of obesity rather than serve as the main provider of comprehensive obesity care.

Conclusions:

Pediatric gastroenterologists identified gaps in their nutrition knowledge base that may be attributed to the present nutrition education training during fellowship. Multiple topics were identified for additional nutrition education, including obesity management. The nutrition management challenges of today necessitate improved baseline nutrition knowledge and this focus on nutrition should begin at the fellowship level.
Continuous 13C‐Methacetin Breath Test Differentiates Biliary Atresia From Other Causes of Neonatal Cholestasis
Authors: Shteyer Eyal , Lalazar Gadi , Hemed Nilla , Pappo Orit , Granot Esther , Yerushalmi Baruch , Gross Eitan
Published: November 2012

Background and Aim:

Distinguishing biliary atresia (BA) from other causes of neonatal cholestasis (NC) is challenging. Continuous BreathID 13C‐methacetin breath test (MBT) is a novel method that determines liver function. Methacetin is metabolized uniquely by the liver and 13CO2 is measured passively, through a nasal cannula in the exhaled breath. The aim of this study was to assess the ability of MBT to differentiate BA from other causes of NC.

Methods:

MBT was performed in infants with NC before any invasive procedure. Percent dose recovered (PDR) peak and time to peak (TTPP) of 13C recovered were correlated with blood test results and degree of fibrosis on liver biopsy.

Results:

Fifteen infants were enrolled in the study. Eight were eventually diagnosed as having BA. MBT showed that infants with NC from various causes reached the PDR peak after 44.5 ± 6.7 minutes, whereas infants with BA reached the PDR peak value after 54.7 ± 4.3 minutes (P < 0.005). This suggested low cytochrome P450 1A2 activity in the BA group. The area under the curve (AUC) was 0.95 (95% confidence interval [CI] 0.83–1), sensitivity of 88%, and specificity of 100%.

Conclusions:

This pilot study shows that MBT can differentiate between BA and other causes of NC by time to peak of methacetin metabolism. The results suggest that MBT may be used as part of the diagnostic algorithm in infants with liver disease. Larger‐scale studies should be conducted to confirm these initial observations.
Newborn Lamb as a New Model for Studying Gastroesophageal Reflux
Authors: Djeddi Djamal , Samson Nathalie , Boudaa Nadia , Praud Jean‐Paul
Published: November 2012

We aimed to determine whether the newborn lamb at term is a valid model for studying gastroesophageal reflux. Seven bottle‐fed lambs, ages 2 to 3 days, underwent esophageal multichannel intraluminal impedance‐pH monitoring (MII‐pH). A total of 196 reflux episodes were recorded, including 73% alkaline and 27% weakly acidic. No acid refluxes were observed. Median bolus clearance time was 4 seconds (3; 5.5), and proximal reflux extent was 35% (26). This first report of MII‐pH in the newborn mammal sets the foundations for future studies with physiological and clinical relevance to human neonates.
Amoxicillin‐Clavulanic Acid Hepatotoxicity in Children
Authors: Hita Esther Ocete , García Jose Antonio Martín , Gonzalez Jose Carlos Flores , Molina Ana Abril , Cordero MJosé Aguilar , Escobar Javier Salmerón , Ruiz‐Extremera Angela
Published: November 2012

Objectives:

The objectives of the present study were to determine the importance of amoxicillin‐clavulanic acid (AC) hepatotoxicity in the paediatric population and to characterise the episodes identified and potential host‐specific factors. This was addressed via a prospective observational study in which 8 Spanish hospitals participated.

Methods:

A total of 11 cases were examined. For each patient included in the study, a structured and codified data‐collection protocol was complied with, taking note of patient demographics, characteristics of the treatment assumed to provoke the reaction, concomitant medication, course and outcome of the episode, and laboratory variables during the reaction. The latter were determined every 6 months from the outset to the eventual resolution of the case.

Results:

A total of 11 cases of AC hepatotoxicity were detected, affecting 9 boys and 2 girls, ages 1 to 11 years. Causality criteria were assessed using the Council for International Organizations of Medical Sciences scale.

Conclusions:

We conclude that the introduction of hepatotoxicity record systems in paediatric care, together with the continuing study and development of existing systems, would contribute to improving our epidemiological knowledge about the harmful effects of drugs on the liver.
Antibodies Against Deamidated Gliadin Peptides and Tissue Transglutaminase for Diagnosis of Pediatric Celiac Disease
Authors: Olen Ola , Gudjónsdóttir Audur H. , Browaldh Lars , Hessami Mozaffar , Elvin Kerstin , Liedberg Ann‐Sofie , Neovius Martin , Grahnquist Lena
Published: November 2012

Objectives:

The aim of the present study was to evaluate diagnostic performance and actual costs in clinical practice of immumoglobulin (Ig)G/IgA deamidated gliadin peptide antibodies (DGP) as a complement to IgA antibodies against tissue transglutaminase (tTG) for the diagnosis of pediatric celiac disease (CD).

Methods:

All of the consecutive patients younger than 18 years tested for tTG and/or DGP, who underwent duodenal biopsy because of suspected CD in Stockholm and Gothenburg, Sweden, from 2008 to 2010, were included. Medical records were reviewed.

Results:

Of 537 children who underwent duodenal biopsy, 278 (52%) had CD. A total of 71 (13%) were younger than 2 years and 16 (4%) had IgA deficiency. Sensitivity and specificity for tTG were 94% and 86%, respectively. Corresponding values for DGP were 91% and 26%. Positive predictive values (PPV) were 88% for tTG and 51% for DGP. There were 148 children who were tTG‐negative and DGP‐positive, of which only 5% (8/148) had villous atrophy. Among children younger than 2 years with normal IgA, PPV was 96% (25/26) for tTG and 48% (24/50) for DGP. In 16 IgA‐deficient children, 11 were DGP positive, of which 5 had CD (PPV 45%). Eight of 278 cases of CD would possibly have been missed without DGP. The cost of adding DGP and consequently more biopsies to be able to detect 8 extra cases of CD was €399,520 or €49,940 per case.

Conclusions:

For diagnosing CD, tTG is superior to DGP, even in children younger than 2 years. Combining tTG and DGP does not provide a better tradeoff between number of missed cases of CD, number of unnecessary duodenal biopsies, and cost than tTG alone.
Abnormal Gut Integrity Is Associated With Reduced Linear Growth in Rural Malawian Children
Authors: Weisz Ariana J. , Manary Micah J. , Stephenson Kevin , Agapova Sophia , Manary Faith G. , Thakwalakwa Chrissie , Shulman Robert J. , Manary Mark J.
Published: November 2012

The aim of the present study was to investigate the relation of environmental enteropathy, as measured by the dual sugar absorption test, to linear growth faltering in 2‐ to 5‐year‐old Malawian children. Dietary quality, food insecurity, anthropometry, and site‐specific sugar testing were measured in 418 children, and anthropometry was reassessed 3 months later. A linear regression model predicting linear growth was created. Better growth was associated with less urinary lactulose excretion, more clean water usage, not sleeping with animals, and no previous history of malnutrition. Eighty‐seven percent of children studied demonstrated evidence of environmental enteropathy. In conclusion, abnormal gut integrity is associated with reduced linear growth in a population of rural African preschool‐age children.
ESPGHAN Guidance on Coeliac Disease 2012
Authors: Egner William , Shrimpton Anna , Sargur Ravishankar , Patel Dina , Swallow Kirsty
Published: November 2012

The updated ESPGHAN guidance on coeliac disease recommends the use of common multiples of the upper limit of normal (ULN) for IgA tissue transglutaminase antibodies (TG2) when deciding which diagnostic pathway to follow. The current lack of standardisation between assays makes it difficult to harmonise results between centres as different performance characteristics are observed with each assay. This variability is shown in data from external quality assessment distributions. As a result, the updated guidance is too generalised for use with all the commercial TG2 kits and is therefore not translatable for use in all centres.
Navigating the Gluten‐free Diet in College
Authors: Panzer Rebecca M. , Dennis Melinda , Kelly Ciaran P. , Weir Dascha , Leichtner Alan , Leffler Daniel A.
Published: November 2012

Factors that affect adherence to the gluten‐free diet (GFD) are reported in children and adults; however, there is little data regarding young adults. The objective of the present study is to explore adherence challenges experienced by young adults in college. Responses from the online survey (N = 50), interview (N = 21), and focus group (N = 7) indicate students were motivated to adhere but experience challenges related to dining services and social situations. Dining services from 6 colleges reported a variety of accommodations for students with celiac disease, but request increased student involvement. Tools and strategies that facilitate communication between students and dining services may improve adherence.
Aminotransferase Upper Reference Limits and the Prevalence of Elevated Aminotransferases in the Korean Adolescent Population
Authors: Park Seung Ha , Park Ha Young , Kang Jong Woo , Park Jinse , Shin Kyong Jin
Published: November 2012

Objectives:

For the pediatric population, upper reference limits (URLs) for aminotransferase levels have not been established. The prevalence of high aminotransferase levels provides important information regarding the burden of liver disease in the current childhood obesity endemic.

Methods:

We set the URL of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) for participants ages 10 to 19 years (n = 2746) from the 2007 to 2009 Korea National Health and Nutrition Examination Survey at the 97.5th percentile of that population who were determined to be at low risk for liver disease (n = 1717; low risk was defined as testing negative for hepatitis B virus surface antigens, the absence of alcohol use disorder, having normal body mass index, and having normal lipid or carbohydrate metabolism).

Results:

The URLs for ALT were 33 IU/L for boys and 25 IU/L for girls, and the corresponding limits for AST were 33 IU/L for boys and 28 IU/L for girls. The weighted prevalence of elevated ALT levels was 6.5% in the sample, 8.2% in boys and 4.5% in girls. The prevalence of elevated AST levels was 3.9% and had no sex differences. We also found that elevated ALT levels are associated with male sex, older age, obesity, and presence of abnormal lipid levels. Having elevated AST levels is associated with obesity, younger age, and exhibiting laboratory indicators of abnormal lipid metabolism.

Conclusions:

Aminotransferase URLs are being established for the first time, and our results may be useful in determining a baseline level for monitoring the secular trends of liver disease in future studies of adolescent populations.
Role of Sex in the Treatment and Clinical Outcomes of Pediatric Patients With Inflammatory Bowel Disease
Authors: Lee Grace J. , Kappelman Michael D. , Boyle Brendan , Colletti Richard B. , King Eileen , Pratt Jesse M. , Crandall Wallace V.
Published: November 2012

Objective:

To examine sex differences in medical therapy and clinical outcomes in pediatric patients with inflammatory bowel disease (IBD).

Methods:

We performed a cross‐sectional analysis of children with Crohn disease (CD) and ulcerative colitis (UC) using data from the ImproveCareNow Network collected between May 2007 and May 2010. Clinical remission, disease severity, body mass index (BMI) z scores, normal height velocity, and medication use were analyzed by sex and age.

Results:

One thousand four hundred nine patients were included (993 had CD and 416 had UC). No significant sex differences were found in disease severity, BMI, height velocity, or use of medications. Further analysis of combination therapy with infliximab + 6‐mercaptopurine/azathioprine and infliximab + methotrexate also did not reveal any differences. No sex differences were found after mediation use was stratified by age (those younger than 13 years and those 13 years old or older).

Conclusions:

In this sample of CD and UC pediatric patients, no significant sex differences were found in disease severity, BMI, height velocity, or medication use. Our data do not support the use of sex as a major factor in patient risk stratification for children with IBD. In addition, despite concerns for sex‐specific complications of some medications, our analysis did not suggest any sex differences in medication use.
Ultrashort Bowel Syndrome in Children
Authors: Sanchez Sabrina E. , Javid Patrick J. , Healey Patrick J. , Reyes Jorge , Horslen Simon P.
Published: November 2012

Objective:

Recent data have demonstrated improved survival in children with intestinal failure. We hypothesized that this trend would also be observed in children with ultrashort bowel syndrome.

Methods:

A prospective database from Seattle Children's Intestinal Failure Program was used to evaluate outcomes and morbidities of consecutive patients with 10 cm or less of small bowel enrolled in the program since 2005. Data are listed as median (range).

Results:

Five patients were identified with a bowel length of 6 (1–10) cm and follow‐up of 54 (43–61) months. All children have survived and are currently between 3.5 and 5.5 years of age. One patient underwent isolated intestinal transplantation and one patient is currently listed for intestinal transplantation. The transplanted child is fully enterally fed. The other patients remain at least partially dependent on parenteral nutrition. None of these patients have current evidence of parenteral nutrition‐associated liver disease. Patients have required extensive care after referral to our program, including 18 (15–32) visits to the emergency room, 152 (114–273) days of inpatient care, and 6 (5–9) central line–associated blood stream infections.

Conclusions:

Long‐term survival in children with ultrashort bowel length is possible after referral to an intestinal failure program, although extensive medical management is required. These children may be reasonable candidates for long‐standing intestinal rehabilitation as a bridge to intestinal transplantation.
Prospective Evaluation of 1‐Day Polyethylene Glycol‐3350 Bowel Preparation Regimen in Children
Authors: Abbas Mazen I. , Nylund Cade M. , Bruch Carol J. , Nazareno Luzviminda G. , Rogers Philip L.
Published: November 2012

Objectives:

The aim of the present study was to evaluate efficacy, safety, and tolerability of a pediatric colonoscopy bowel preparation regimen composed of polyethylene glycol‐3350 (PEG‐3350) and a sports drink completed in a few hours.

Methods:

A prospective, open‐label trial of a colonoscopy bowel preparation in children ages 8 to 18 years that included 238 g of PEG‐3350 mixed with 1.9 L of Gatorade completed in a few hours. Efficacy was determined using the Boston Bowel Preparation Scale. Basic metabolic profiles and questionnaires were obtained that assessed for safety, adverse effects, tolerability, and patient acceptability.

Results:

Forty‐six patients completed the study. Patients were predominately boys (56.5%) with a mean age of 14.50 years (SD ±2.9 years). Forty‐three (93.5%) were able to complete the regimen. All of the colonoscopies were completed to the cecum and 84% had terminal ileum visualization. Seventy‐seven percent were found to be effective preparations. Nausea/vomiting were the most common reported adverse effect (60%) followed by abdominal pain/cramping (44%) and fatigue/weakness (40%). Overall, the regimen was acceptable with 1 exception being the large volume to drink. There were no clinically significant changes in basic metabolic profiles, although there was a statistically significant decrease in the mean potassium (0.16 mEq/L; P = 0.016), blood urea nitrogen (2.68 mg/dL; P < 0.0001), and carbon dioxide (1.89 mmol/L; P < 0.0001).

Conclusions:

This study demonstrated that PEG‐3350 + Gatorade administered in a few hours is an effective, safe, and moderately tolerable bowel preparation regimen for colonoscopy in children.
Endoscopic Ultrasound–guided Drainage of Pancreatic Fluid Collections in Children
Authors: Ramesh Jayapal , Bang Ji Y. , Trevino Jessica , Varadarajulu Shyam
Published: November 2012

Background and Objective:

Although endoscopic ultrasound (EUS)–guided drainage of pancreatic fluid collections (PFCs) has evolved as the standard of care in adults, its role as a single‐step drainage modality in children is unclear. The aim of the present study was to evaluate the efficacy and safety of single‐step EUS‐guided drainage of PFCs in children.

Methods:

This is a retrospective study of all of the children who underwent single‐step EUS‐guided drainage of PFCs during a 4‐year period at 1 institution. An endoscopic retrograde cholangiopancreatography was attempted before EUS‐guided drainage to evaluate the pancreatic duct and bridge any ductal disruption.

Results:

A total of 7 children (4 boys; mean age 8.4 years [standard deviation 2.1]) underwent EUS‐guided drainage of PFCs. The etiology was blunt abdominal trauma in 5, hereditary pancreatitis in 1, and idiopathic pancreatitis in 1. Both technical and treatment success rates were 100% with median procedural duration of 12 minutes (interquartile range 12–20 minutes). Two patients underwent repeat EUS‐guided drainage due to lack of adequate resolution of PFC on follow‐up computed tomography. There were no immediate or delayed complications. At a median follow‐up of 1033 days (interquartile range 193–1167 days), all of the children were doing well with no PFC recurrence.

Conclusions:

Single‐step EUS‐guided drainage of PFC in children is technically feasible, safe, clinically effective, and when available, should be the first‐line treatment modality.
Antireflux Surgery in Children With Neurological Impairment
Authors: O'Loughlin Edward V. , Somerville Helen , Shun Albert , Gangemi Rachel , La Hei Erik , Desphande Aniruddh , O'Loughlin Timothy F.
Published: November 2012

Objectives:

The aim of the present study was to report caregiver perceptions to antireflux surgery and gastrostomy in children with severe neurological impairment and to report the complications of the surgery.

Methods:

Children were identified from a clinic database and clinical information and surgical complications were extracted from the database and hospital medical records. A cross‐sectional questionnaire addressing severity of symptoms was administered to parents/caregivers and scored with a 5‐point Likert scale (1 is much better to 5, much worse).

Results:

A total of 122 children, median age 74 months (interquartile range 29–124), 63% spastic quadriplegic cerebral palsy, had antireflux surgery. Laparoscopic surgery was performed in 77 of 122 (63%) and 117 of 122 (96%) had gastrostomy insertion. Questionnaire was completed by 89 of 122 (73%) children; median duration of time from fundoplication to questionnaire was 77 months (43–89). The majority of caregivers indicated that surgery improved or greatly improved weight gain, chest infections, vomiting, and feeding tolerance. Only 2 caregivers reported that they regretted consenting to surgery. Serious surgical complications occurred in 10%.

Conclusions:

Serious complications were uncommon in this series of antireflux surgery in neurologically impaired children. Although gagging and retching were common following surgery, a high percentage of caregivers reported improved nutrition, reflux‐related symptoms, and high levels of satisfaction.
Endoscopic and Pharmacological Secondary Prophylaxis in Children and Adolescents With Esophageal Varices
Authors: dos Santos Juliana Magalhães Reis , Ferreira Alexandre Rodrigues , Fagundes Eleonora Druve Tavares , Ferreira Amanda Pifano Soares , Ferreira Letícia Sauma , Magalhães Maria Carolina Ribeiro , Bittencourt Paulo Fernando Souto , Carvalho Simone Diniz , Filho Paulo Pimenta Figueiredo , Penna Francisco José
Published: November 2012

Objective:

The aim of this study was to describe the results of endoscopic secondary prophylaxis, alone or in combination with propranolol, used to prevent upper gastrointestinal bleeding (UGIB) in children and adolescents with esophageal varices.

Methods:

This observational study followed 43 patients younger than 18 years who received secondary prophylaxis between August 2001 and December 2009. Sclerotherapy and/or band ligation were performed, and propranolol was used when no contraindications were present. The rebleeding rate, number of endoscopic sessions required for variceal eradication, rate of varix recurrence, the occurrence of varices at the gastric fundus, and the occurrence of portal hypertensive gastropathy were evaluated.

Results:

Endoscopic prophylaxis in combination with propranolol was performed in 25 patients (58.1%) and endoscopic prophylaxis alone was performed in 18 patients (41.9%). Esophageal varices were eradicated in all of the patients after a median of 3 sessions. Varices recurred in 22 patients (51.2%). Rebleeding occurred in 13 patients (30.2%). Fundal varices and portal hypertensive gastropathy developed in 31% and 61.9% of patients, respectively. No deaths related to the endoscopic procedure or UGIB occurred. No statistically significant differences in any of the studied variables were observed when comparing endoscopic prophylaxis with propranolol and endoscopic prophylaxis alone.

Conclusions:

No significant differences were observed between sclerotherapy and band ligation. Secondary prophylaxis was effective in eradicating esophageal varices. The use of propranolol did not affect the results of the endoscopic prophylaxis. Furthermore, randomized studies will be necessary to assess the best form of prevention during childhood.
Duodenal Intraepithelial Lymphocytosis With Normal Villous Architecture in Pediatric Patients
Authors: Shmidt Eugenia , Smyrk Thomas C. , Faubion William A. , Oxentenko Amy S.
Published: November 2012

Objectives:

Small bowel intraepithelial lymphocytosis (IELs) with normal villous architecture is a relatively common finding, often of uncertain significance. The aims of our study were to determine the prevalence of this finding, its clinical associations, its specificity for celiac disease (CD), and whether histologic clues exist that increase the specificity for CD in this setting, all in the pediatric population.

Methods:

The Mayo Clinic electronic pathology database was searched between January 1, 2000 and December 31, 2009 for patients younger than 18 years who had the terms “normal villi” and “increased intraepithelial lymphocytes” in their small bowel biopsy reports. All of the slides were reviewed to confirm the histologic findings. Demographic, serologic, pathologic, and clinical informations were obtained.

Results:

Among 1290 duodenal biopsies obtained from children during the years 2000 and 2009, 56 (4.3%) were noted to have “normal villous architecture with increased intraepithelial lymphocytes.” In the 54 patients not known to have CD before biopsy, 48 (89%) had serologic testing for CD. Of these 48 patients, 9 were labeled with CD, although only 5 of 9 met the definite criteria for the diagnosis, based on a combination of serologic markers, human leukocyte antigen haplotyping, and response to gluten‐free diet. No clinical features pointed to a diagnosis of CD. There was no correlation between CD and number of IELs, but patients with newly diagnosed CD were more likely to have a tip‐heavy lymphocyte distribution. Other diagnoses made during the study period and in follow‐up were inflammatory bowel disease (5), Helicobacter pylori infection (3), medication‐related injury (10), and systemic autoimmune disorders (2).

Conclusions:

Increased IELs with normal villous architecture in small bowel biopsies are clinically important in children, and are associated with a new definite diagnosis of CD in 9% of pediatric patients. Even at this low sensitivity, clinical work‐up for CD is mandated in all of the patients with this finding.
Time‐ and Segment‐related Changes of Postresected Intestine
Authors: Buccigrossi Vittoria , Armellino Carla , Tozzi Arturo , Nicastro Emanuele , Esposito Ciro , Alicchio Francesca , Cozzolino Santolo , Guarino Alfredo
Published: November 2012

Objectives:

The aim of the present study was to investigate the segment‐ and time‐related changes in rat short bowel syndrome and construct a 4‐dimensional (4D) geometrical model of intestinal adaptation.

Methods:

Sprague‐Dawley rats were divided into 3 groups: 2‐day, 7‐day, and 15‐day postresection groups in which 75% of the jejunoileum was removed. Histological and morphometrical parameters in the remaining proximal to distal intestinal segments, from the jejunum to the distal colon, were comparatively evaluated in the groups. The data were used to construct a 4D geometric model in which villi were considered as cylinders, and their surface area was expressed as cylinder lateral area.

Results:

Major adaptive changes were observed in the ileum consisting of an increase in both the diameter of base and the height of villi. A parallel reduction in their number/mm2 was observed. The resulting ileal architecture was characterized by a limited number of large villi. An opposite pattern was observed in the jejunum whose postresection structure consisted of an increased number of villi. No changes were observed in the colon. Postresection restructuring was early and faster in the ileum than in the jejunum resulting in an increase in absorptive area of 81.5% and 22.5% in the ileum and jejunum, respectively.

Conclusions:

Postresection adaptation is intestinal segment–specific because all of the major changes occur in the ileum rather than in the jejunum. Sparing ileal segments during resection may improve the outcome of patients undergoing extensive intestinal resection. Our 4D model can be used to test interventions aimed at optimizing postresection intestinal adaptation.
Detection of Low‐concentration Host mRNA Transcripts in Malawian Children at Risk for Environmental Enteropathy
Authors: Agapova Sophia , Stephenson Kevin , Manary Micah , Weisz Ariana , Tarr Phillip I. , Mkakosya Rahjab , Maleta Ken , Shulman Robert J. , Manary Mark , Shaikh Nurmohammad
Published: November 2012

Background and Objective:

Transcriptomic analysis of fecal samples is an emerging method for the diagnosis of gastrointestinal pathology because it is noninvasive and requires minute volumes of analyte; however, detection of mRNA in low copy numbers in human stool is challenging. Our objective was to develop a method for detecting human mRNA suggestive of environmental enteropathy (EE) in feces.

Methods:

Stool samples from 70 Malawian children, 34 without EE and 36 with EE, as defined by dual sugar absorption, were used to develop the methodology for mRNA detection. Multiple RNA isolation techniques and polymerase chain reaction formats were tested to detect 38 potential mRNA biomarkers suggestive of EE, and the results compared.

Results:

RNA isolation using magnetic bead extraction best recovered host mRNA in stool, and digital droplet polymerase chain reaction was the most sensitive format to detect low copy numbers of mRNA. In all of the 70 samples, >20 copies of glyceraldehyde‐3‐phosphate dehydrogenase/200 mg of stool were detected. Copy numbers of potential biomarkers were normalized to glyceraldehyde‐3‐phosphate dehydrogenase, to account for interspecimen differences in concentration of human mRNA. Of the 38 transcripts chosen for initial evaluation, 24 had copy numbers >10 in all of the samples tested. Of the 6 potential markers measured in all of the 70 samples, REG4 best differentiated children with and without EE.

Conclusions:

A reproducible and reliable method to quantify human mRNA in stool present in low copy numbers has been developed, and may prove useful in investigations of EE and possibly other inflammatory gut conditions.
Should Intussusception in Children Prompt Screening for Celiac Disease?
Authors: Reilly Norelle R. , Aguilar Kathleen M. , Green Peter H.
Published: November 2012

Objectives:

An association between adult celiac disease (CD) and intussusceptions (ISs) has been described. Although more common among children, intussusception has not been linked with childhood CD aside from isolated case reports. Our aim was to investigate the frequency of IS among children with CD.

Methods:

A patient database containing children with biopsy‐proven CD was reviewed, in addition to radiology records contained in a hospital‐maintained clinical data repository.

Results:

Of 254 children with biopsy‐proven CD and complete records available for review, abdominal imaging was performed in 21%, mainly because of abdominal pain. Among children with CD, 1.2% experienced an IS <9 months before their diagnosis with CD. Among children seen at our institution in the same time period, 0.07% experienced an IS. The majority of those children with CD who were found to have IS had no evidence of nutritional deficit at the time of IS. IS was not identified in any children with CD who had been treated with a gluten‐free diet.

Conclusions:

IS was far more common among children in our cohort with untreated CD than in the general pediatric population simultaneously seen at our center. The diagnosis of CD should be considered in children with IS, even in the absence of signs of nutritional compromise.
Balloon Expulsion Test as a Screen for Outlet Obstruction in Children With Chronic Constipation
Authors: Belkind‐Gerson Jaime , Goldstein Allan M. , Kuo Braden
Published: November 2012

Objective:

Chronic constipation (CC) is a common problem in pediatrics and is often the result of obstructed defecation. The aim of the present study was to study the feasibility and efficacy of the balloon expulsion test (BET) in the diagnosis and management of children with CC.

Methods:

Retrospective study comparing BET and high‐resolution anorectal manometry (ARM). The BET was done together with ARM in 29 children, ages 8 to 19 years, with CC. For BET, a 60‐mL balloon was used. Passage of balloon in 1 minute or less was considered normal.

Results:

Fifteen of the 29 children had a normal BET. Of these, 14 also had an ARM, all of which were normal (except for 2 cases with a hypertonic baseline anal sphincter). Thus 12 of 14 with BET and ARM were normal on both (correlation between the tests 86%). Of the 14 children that failed BET, 10 had distal abnormalities by ARM, contrast studies, EMG, or assessment by a pelvic physical therapist. All of the patients with a nonrelaxing sphincter or outlet obstruction were treated with laxatives, anal sphicter Botox, and/or pelvic physical therapy and biofeedback. In follow‐up of at least 3 months, all of the patients with a failed BET were improved.

Conclusions:

We found a high correlation between a normal ARM and BET. If the BET is abnormal and the ARM does not identify a cause for the distal obstruction, additional studies may be needed, including contrast enema, defecography, or electromyography. BET appears to be a safe, reliable, and useful test in the evaluation and management of CC in children.
Childhood Obesity for Pediatric Gastroenterologists
Authors: Huang Jeannie S. , Barlow Sarah E. , Quiros‐Tejeira Ruben E. , Scheimann Ann , Skelton Joseph , Suskind David , Tsai Patrika , Uko Victor , Warolin Joshua P. , Xanthakos Stavra A. ,   NASPGHAN Obesity Task Force
Published: November 2012

Obesity in childhood is one of the major health issues in pediatric health care today. As expected, the prevalence of obesity‐related comorbidities has risen in parallel with that of obesity. Consultation regarding these concomitant diseases and subsequent management by subspecialists, including pediatric gastroenterologists, is now common and has resulted in obesity being recognized as a chronic disease requiring coordination of care. Although medications and even surgery may provide effective, though often temporary, treatments for obesity and its comorbidities, behavioral interventions addressing healthy dietary and physical activity habits remain a mainstay in the obesity treatment paradigm. Therefore, the issue of weight management must be addressed by both general practitioner and subspecialist alike. In this report, we review select aspects of pediatric obesity and obesity‐related management issues because it relates in particular to the field of pediatric gastroenterology and hepatology.
Consanguinity and Inflammatory Bowel Diseases
Authors: Mouzan Mohammad El , Al‐Mofarreh Mohammad , Assiri Asaad , Hamid Yassin , Saeed Anjum
Published: November 2012

Objective:

The aim of the present study was to investigate the relation between consanguinity and inflammatory bowel diseases (IBD).

Methods:

Review of the medical records of children with a final diagnosis of IBD to determine age, sex, and type of IBD, supplemented by information on consanguinity and family history (FH) of IBD in relatives. There were 138 children, ages 1.4 to 19.3 years, and 50% were girls.

Results:

The prevalence of consanguinity was 50%, 53%, 39% and 60% in IBD, Crohn disease (CD), ulcerative colitis (UC), and controls, respectively. There was a significantly higher prevalence of consanguinity in controls than in patients with IBD and UC (P = 0.02 and 0.026, respectively), whereas the difference between CD patients and controls was not significant (P = 0.20). The prevalence of first cousin consanguinity was 71%, 73.2%, 61.5% and 70.5% in patients with IBD, CD, UC, and controls, respectively, indicating no significant difference between these conditions and controls (P = 0.95, P = 0.78, P = 0.33, respectively). There was no significant difference in the prevalence of consanguinity in the parents of children with or without a FH of either CD (P = 0.89) or UC (P = 0.32).

Conclusions:

There is no significant relation between parental consanguinity and IBD in this population, especially when there is no FH of disease, suggesting reduced genetic susceptibility; however, further studies including larger sample size and details of FH of consanguinity and IBD in multiple generations are needed for further definitions of the role of consanguinity.
Transient Elastography Is a Useful Noninvasive Tool for the Evaluation of Fibrosis in Paediatric Chronic Liver Disease
Authors: Fitzpatrick Emer , Quaglia Alberto , Vimalesvaran Sunitha , Basso Maria Sole , Dhawan Anil
Published: November 2012

Background:

Outcome of liver disease in children is mainly determined by severity and progression of liver fibrosis. Liver biopsy is the accepted standard for evaluating fibrosis but is limited by the need for sedation in children, sampling error, and risks including bleeding. The aim of the present study was to compare tools for noninvasive assessment of liver fibrosis in a paediatric cohort.

Methods:

Children undergoing liver biopsy for chronic liver disease were recruited and underwent transient elastography (TE). Liver biopsies were scored by a hepatohistopathologist from F0 (no fibrosis) to F4 (cirrhosis). TE was compared with biopsy score.

Results:

During the study period, 104 children (62 boys) were enrolled (median age 13.6 years). Diagnosis was autoimmune liver disease in 27; nonalcoholic fatty liver disease in 37; posttransplant in 16; hepatitis B/C in 8; Wilson disease in 5; and the remainder, miscellaneous. TE was successful in all but 7 patients and was a good discriminator of significant fibrosis (≥F2) (P < 0.001), severe fibrosis (≥F3) (P < 0.001), and cirrhosis (F4) (P = 0.003). The area under the receiver operating characteristic curve for the prediction of ≥F2, ≥F3, and F4 using TE was 0.78, 0.79, and 0.96, respectively. TE performed best in children with autoimmune liver disease and in those posttransplant.

Conclusions:

The present study demonstrates that TE is a reliable tool in distinguishing different stages of liver fibrosis in paediatric patients. Thus, TE may serve as a useful adjunct to liver biopsy for diagnostic purposes providing a reliable method of noninvasively monitoring liver disease progression in children.
Comparison of Diagnostic Methods for Pancreatic Insufficiency in Infants With Cystic Fibrosis
Authors: Tardelli Amanda C.S. , Camargos Paulo A.M. , Penna Francisco J. , Sarkis Pauliane F.B. , Guimarães Elizabet V.
Published: November 2012

Objective:

The objective of the present study is to compare daily weight gain and laboratory analysis (72‐hour fecal fat and steatocrit) with fecal elastase‐1 (EL‐1) when diagnosing pancreatic insufficiency (PI) in infants with cystic fibrosis (CF).

Methods:

A total of 39 infants with CF, diagnosed consecutively by newborn screening at 2 referral centers, were included in the study. Daily weight gain and results of laboratory analysis of stool samples were compared using the κ coefficient and the receiver operator characteristic (ROC) curve.

Results:

Using the criterion of low daily weight gain, the frequency of PI was 92.3%; using the 72‐hour fecal fat, steatocrit, and fecal EL‐1 tests, the frequency was 42.3%, 86.2%, and 84.6%, respectively. EL‐1 was used as the reference test. It was observed that the criteria of low daily weight gain (<50th percentile) and abnormal steatocrit, used together, showed the highest sensitivity (91.3%) and specificity (83.3%) for the diagnosis of PI.

Conclusions:

When fecal EL‐1 analysis is not immediately available, low daily weight gain associated with abnormal steatocrit can be adopted as a criterion for initiating pancreatic enzyme replacement therapy in infants with CF; however, EL‐1 testing should be performed later for confirmation of PI.
Oral Microbial Profile Discriminates Breast‐fed From Formula‐fed Infants
Authors: Holgerson Pernilla L. , Vestman Nelly R. , Claesson Rolf , Öhman Carina , Domellöf Magnus , Tanner Anne C.R. , Hernell Olle , Johansson Ingegerd
Published: November 2012

Objectives:

Little is known about the effect of diet on the oral microbiota of infants, although diet is known to affect the gut microbiota. The aims of the present study were to compare the oral microbiota in breast‐fed and formula‐fed infants, and investigate growth inhibition of streptococci by infant‐isolated lactobacilli.

Methods:

A total of 207 mothers consented to participation of their 3‐month‐old infants. A total of 146 (70.5%) infants were exclusively and 38 (18.4%) partially breast‐fed, and 23 (11.1%) were exclusively formula‐fed. Saliva from all of their infants was cultured for Lactobacillus species, with isolate identifications from 21 infants. Lactobacillus isolates were tested for their ability to suppress Streptococcus mutans and S sanguinis. Oral swabs from 73 infants were analysed by the Human Oral Microbe Identification Microarray (HOMIM) and by quantitative polymerase chain reaction for Lactobacillus gasseri.

Results:

Lactobacilli were cultured from 27.8% of exclusively and partially breast‐fed infants, but not from formula‐fed infants. The prevalence of 14 HOMIM‐detected taxa, and total salivary lactobacilli counts differed by feeding method. Multivariate modelling of HOMIM‐detected bacteria and possible confounders clustered samples from breast‐fed infants separately from formula‐fed infants. The microbiota of breast‐fed infants differed based on vaginal or C‐section delivery. Isolates of L plantarum, L gasseri, and L vaginalis inhibited growth of the cariogenic S mutans and the commensal S sanguinis: L plantarum >L gasseri >L vaginalis.

Conclusions:

The microbiota of the mouth differs between 3‐month‐old breast‐fed and formula‐fed infants. Possible mechanisms for microbial differences observed include species suppression by lactobacilli indigenous to breast milk.
Benign Hepatic Nodular Lesions After Treatment for Childhood Cancer
Authors: Masetti R. , Colecchia A. , Rondelli R. , Martoni A. , Vendemini F. , Biagi C. , Prete A. , Festi D. , Lima M. , Pession A.
Published: November 2012

Background:

Benign nodular hepatic regenerating lesions such as focal nodular hyperplasia (FNH) have been reported as rare complications of the antineoplastic therapy received during infancy. Little is known about the risk factors associated with the onset of these lesions and their diagnostic management.

Methods:

We have analyzed a series of benign hepatic nodular lesions occurring in children previously treated for malignant tumors in our institution in a period of 11 years. An extensive description of the imaging presentation of the lesions has been provided to facilitate the differential diagnosis, and a risk factor analysis has been conducted.

Results:

A total of 14 diagnoses (10 FNH and 4 hemangiomas) of benign nodular hepatic lesions have been found. Hematopoietic stem cell transplantation is the most important statistically independent risk factor associated with the development of these lesions, especially for FNH. No malignant transformation of nodules has been recorded during a median follow‐up time of 4 years.

Conclusions:

In our experience, FNH is the most frequent benign nodular hepatic lesions occurring after treatment for childhood cancer. Hematopoietic stem cell transplantation is the most important risk factor to be taken in account. After a secure diagnosis of these benign lesions, only a close imaging follow‐up is recommended.
Serum Retinol‐binding Protein 4 Is Independently Associated With Pediatric NAFLD and Fasting Triglyceride Level
Authors: Huang Shu‐Ching , Yang Yao‐Jong
Published: November 2012

Objectives:

Nonalcoholic fatty liver disease (NAFLD) is identified as a major liver disease in children. The present study aimed to identify the prevalence and predictors of pediatric NAFLD and the correlation between serum retinol‐binding protein 4 (RBP4) levels and metabolic characteristics in children.

Methods:

A total of 748 schoolchildren, ages 6 to 12 years, were enrolled in 2009. The body weight and height were measured in the morning before intake. Laboratory tests included overnight fasting serum lipids, insulin, liver enzymes, and RBP4 levels. Hepatic steatosis was determined by ultrasound in 219 volunteers.

Results:

The rates of NAFLD were 3% in the normal‐weight, 25% in the overweight, and 76% in the obese children. Twenty (22%) of obese children had abnormal alanine aminotransferase (ALT) levels. In children with NAFLD, younger age and higher body mass index (BMI), insulin/homeostasis model of assessment, and male sex rate were associated with abnormal liver function. Stepwise increments in BMI, insulin, homeostasis model of assessment, and ALT were found in children with normal livers to simple steatosis, and to steatosis with abnormal ALT. Multiple logistic regression analysis confirmed that serum RBP4 levels (P = 0.048), ALT (P = 0.048), and BMI (P < 0.001) were independently predictors of pediatric NAFLD. Moreover, multiple linear regression analysis revealed that only serum triglycerides levels were positively related to RBP4 levels (P < 0.001).

Conclusions:

Higher RBP4 and ALT levels as well as BMI are independently associated with pediatric NAFLD in Taiwan. In addition, an increment in RBP4 levels was positively correlated to hypertriglyceridemia in children.