Purpose: Cow’s milk protein allergy (CMPA) is a common condition in infants, but little is known about healthcare providers’ clinical experience treating infants with CMPA. To address this gap, we analyzed prospectively collected data from healthcare providers (HCPs) who treated infants under six months old with suspected CMPA using hypoallergenic formulas.The study focused on a commercial extensively hydrolyzed formula containing Lactobacillus rhamnosus GG (ATCC53103) (eHF-LGG) or a commercial amino acid formula (AAF). Methods: In this secondary analysis of prospectively collected survey data, 52 HCPs treated 329 infants under six months old with suspected CMPA using hypoallergenic formulas. A series of two de-identified surveys per patient were collected by HCPs to assess short-term symptom relief in the patients and HCP’s satisfaction with the management strategies. The initial survey was completed at the initiation of treatment of CMPA, and the second survey was completed at a follow-up visit. Results: The majority of HCPs (87%) in the study were general pediatricians, and most saw 2 to 10 CMPA patients weekly. Results showed that clinicians reported satisfaction with treatment in 95% of patients in the EHF cohort and 97% of patients in the AAF cohort and achieved expected clinical results in 93% and 97% of patients using eHF and AAF, respectively.Furthermore, few patients were switched from the hypoallergenic formula once initiated. Conclusion The study provides new insights into HCP perspectives on treating infants with CMPA and supports using hypoallergenic formulas to manage this condition. However, additional prospective controlled studies are needed to confirm these initial findings.

Purpose: Malnutrition is a significant issue for pediatric patients with cancer. We sought to evaluate the effectiveness and complication rate of percutaneous endoscopic gastrostomy (PEG) placement in pediatric oncology patients. Methods: A retrospective chart review was performed on 49 pediatric oncology patients undergoing PEG placement at Johns Hopkins All Children's Hospital between 2000 and 2016.Demographic and clinical characteristics, complications, absolute neutrophil count at time of PEG placement and at time of complications, length of stay, and mortality were identified.Weight-for-age Z-scores were evaluated at time of- and six months post-PEG placement. Results: The overall mean weight-for-age Z-score improved by 0.73 (p<0.0001) from pre-(–1.11) to post- (–0.38) PEG placement. Improvement in Z-score was seen in patients who were malnourished at time of PEG placement (1.14, p<0.0001), but not in those who were not malnourished (0.32, p=0.197). Site infections were seen in 12 (24%), buried bumper syndrome in five (10%), and tube dislodgement in one (2%) patient. One patient (2%) with fever was treated for possible peritonitis. There were no cases of other major complications, including gastric perforation, gastrocolic fistula, clinically significant bleeding, or PEGrelated death documented. Conclusion Consistent with previous studies, our data suggests a relationship between site complications (superficial wound infection, buried bumper syndrome) and neutropenia.Additionally, PEG placement appears to be an effective modality for improving nutritional status in malnourished pediatric oncology patients. However, larger prospective studies with appropriate controls and adjustment for potential confounders are warranted to confirm these findings.

Purpose: Percutaneous endoscopic gastrostomy (PEG) tube placements are commonly performed pediatric endoscopic procedures. Because of underlying disease, these patients are at increased risk for airway-related complications. This study compares patient characteristics and complications following initial PEG insertion with general endotracheal anesthesia (GETA) vs. anesthesia-directed deep sedation with a natural airway (ADDS). Methods: All patients 6 months to 18 years undergoing initial PEG insertion within the endoscopy suite were considered for inclusion in this retrospective cohort study. Selection of GETA vs. ADDS was made by the anesthesia attending after discussion with the gastroenterologist. Results: This study included 168 patients (GETA n=38, ADDS n=130). Cohorts had similar characteristics with respect to sex, race, and weight. Compared to ADDS, GETA patients were younger (1.5 years vs. 2.9 years, p=0.04), had higher rates of severe American Society of Anesthesiologists (ASA) disease severity scores (ASA 4–5) (21% vs. 3%, p<0.001), and higher rates of cardiac comorbidities (39.5% vs. 18.5%, p=0.02). Significant associations were not observed between GETA/ADDS status and airway support, 30-day readmission, fever, or pain medication in unadjusted or adjusted models. GETA patients had significantly increased length of stay (eβ =1.55, 95% confidence interval [CI]=1.11–2.18) after adjusting for ASA class, room time, anesthesia time, fever, and cardiac diagnosis. GETA patients also had increased room time (e β =1.20, 95% CI=1.08–1.33) and anesthesia time (eβ =1.50, 95% CI=1.30–1.74) in adjusted models. Conclusion Study results indicate that younger and higher risk patients are more likely to undergo GETA. Children selected for GETA experienced longer room times, anesthesia times, and hospital length of stay.

Purpose: Percutaneous endoscopic gastrostomy (PEG) tube placements are commonly performed pediatric endoscopic procedures. Because of underlying disease, these patients are at increased risk for airway-related complications. This study compares patient characteristics and complications following initial PEG insertion with general endotracheal anesthesia (GETA) vs. anesthesia-directed deep sedation with a natural airway (ADDS). Methods: All patients 6 months to 18 years undergoing initial PEG insertion within the endoscopy suite were considered for inclusion in this retrospective cohort study. Selection of GETA vs. ADDS was made by the anesthesia attending after discussion with the gastroenterologist. Results: This study included 168 patients (GETA n=38, ADDS n=130). Cohorts had similar characteristics with respect to sex, race, and weight. Compared to ADDS, GETA patients were younger (1.5 years vs. 2.9 years, p=0.04), had higher rates of severe American Society of Anesthesiologists (ASA) disease severity scores (ASA 4–5) (21% vs. 3%, p<0.001), and higher rates of cardiac comorbidities (39.5% vs. 18.5%, p=0.02). Significant associations were not observed between GETA/ADDS status and airway support, 30-day readmission, fever, or pain medication in unadjusted or adjusted models. GETA patients had significantly increased length of stay (eβ =1.55, 95% confidence interval [CI]=1.11–2.18) after adjusting for ASA class, room time, anesthesia time, fever, and cardiac diagnosis. GETA patients also had increased room time (e β =1.20, 95% CI=1.08–1.33) and anesthesia time (eβ =1.50, 95% CI=1.30–1.74) in adjusted models. Conclusion Study results indicate that younger and higher risk patients are more likely to undergo GETA. Children selected for GETA experienced longer room times, anesthesia times, and hospital length of stay.

Abdominal Pain ; Adult ; Appetite ; Child ; Deglutition Disorders ; Diagnosis ; Endoscopy ; Gastritis ; Helicobacter pylori ; Histiocytes ; Humans ; Incidental Findings ; Male ; Nausea ; Pediatrics ; Stomach Neoplasms ; Vomiting ; Xanthomatosis

PURPOSE: Percutaneous liver biopsy (PLB), a diagnostic procedure to identify several hepatobiliary disorders, is considered safe with low incidence of associated complications. While postoperative monitoring guidelines are suggested for adults, selection of procedural recovery time for children remains at the discretion of individual operators. We aim to determine if differences exist in frequency of surgical complications, unplanned admissions, and healthcare cost for children undergoing outpatient PLB for cohorts with same-day vs. overnight observation. METHODS: We performed a retrospective cohort study in children 1 month to 17 years of age undergoing ultrasound-guided PLB from January 2009 to August 2017 at a tertiary care, pediatric referral center. Cohorts were defined by postprocedural observation duration: same-day (≤8 hours) vs. overnight observation. Outcomes included surgical complications, medical interventions, unscheduled hospitalization within 7 days, and total encounter costs. RESULTS: One hundred and twelve children met study criteria of which 18 (16.1%) were assigned to same-day observation. No differences were noted in demographics, anthropometrics, comorbidities, biopsy indications, or preoperative coagulation profiles. No major complications or acute hospitalizations after PLB were observed. Administration of analgesia and fluid boluses were isolated and given within 8 hours. Compared to overnight monitoring, same-day observation accrued less total costs (US $992 less per encounter). CONCLUSION: Same-day observation after PLB in children appears well-tolerated with only minor interventions and complications observed within 8 hours of procedure. We recommend a targeted risk assessment prior to selection of observation duration. Same-day observation appears an appropriate recovery strategy in otherwise low-risk children undergoing outpatient PLB.
Adult ; Analgesia ; Biopsy ; Child ; Cohort Studies ; Comorbidity ; Cost-Benefit Analysis ; Demography ; Health Care Costs ; Hospitalization ; Humans ; Incidence ; Liver ; Outpatients ; Referral and Consultation ; Retrospective Studies ; Risk Assessment ; Tertiary Healthcare

We report the case of a seven-year-old boy with an ingested foreign body, which was retained within the appendix for a known duration of ten months, ultimately requiring appendectomy. The ingested foreign body was incidentally discovered by abdominal x-ray at an emergency room visit for constipation. Despite four bowel cleanouts, subsequent x-rays showed persistence of the foreign body in the right lower quadrant. While the patient did not have signs or symptoms of acute appendicitis, laparoscopic appendectomy was performed due to the risk of this foreign body causing appendicitis in the future. A small metallic object was found within the appendix upon removal. This case highlights the unique challenge presented by foreign body ingestions in non-verbal or developmentally challenged children and the importance of further diagnostic workup when concerns arise for potential retained foreign bodies.
Appendectomy ; Appendicitis ; Appendix ; Autism Spectrum Disorder ; Child ; Constipation ; Emergency Service, Hospital ; Endoscopy ; Foreign Bodies ; Gastroenterology ; Humans ; Male ; Pediatrics

Buried bumper syndrome is a rare but potentially severe complication of percutaneous endoscopic gastrostomy tube insertion. Though this complication is uncommon, it may lead to pressure necrosis, bleeding, perforation, peritonitis, sepsis, or death. Each case of buried bumper syndrome is unique in terms of patient comorbidities and anatomic positioning of the buried bumper. For this reason, many approaches have been described in the management of buried bumper syndrome. In this case report, we describe the case of an adolescent Caucasian female who developed buried bumper syndrome three years after undergoing percutaneous endoscopic gastrostomy insertion. We review diagnosis and management of buried bumper syndrome and describe a novel technique for bumper removal in which we use a guide wire in combination with external traction to maintain a patent gastrostomy lumen while removing the internal percutaneous endoscopic gastrostomy bumper.
Adolescent ; Catheterization* ; Comorbidity ; Diagnosis ; Endoscopy ; Female ; Gastroenterology ; Gastrostomy ; Hemorrhage ; Humans ; Necrosis ; Pediatrics ; Peritonitis ; Sepsis ; Traction

Congenital antral webs are a rare but relevant cause of gastric outlet obstruction in infants and children. The condition may lead to feeding refusal, vomiting, and poor growth. Due to the relative rarity of the disease, cases of congenital antral web are frequently misdiagnosed or diagnosed with significant delay as physicians favorably pursue diagnoses of pyloric stenosis and gastric ulcer disease, which are more prevalent. We report a case of an eight-month-old female who presented with persistent non-bilious emesis, feeding difficulties, and failure to thrive and was discovered to have an antral web. The web was successfully treated with endoscopic balloon dilation, which resolved her symptoms. Two years later, the patient remains asymptomatic and is thriving with weight at the 75th percentile for her age.
Child ; Diagnosis ; Endoscopy ; Failure to Thrive ; Female ; Gastric Outlet Obstruction ; Humans ; Infant ; Pediatrics ; Pyloric Stenosis ; Stomach Ulcer ; Vomiting

Foreign body ingestions pose a significant health risk in children. Neodymium magnets are high-powered, rare-earth magnets that is a serious issue in the pediatric population due to their strong magnetic force and high rate of complications. When multiple magnets are ingested, there is potential for morbidity and mortality, including gastrointestinal fistula formation, obstruction, bleeding, perforation, and death. Many cases require surgical intervention for removal of the magnets and management of subsequent complications. However, we report a case of multiple magnet ingestion in a 19-month-old child complicated by gastroduodenal fistula that was successfully treated by endoscopic removal and supportive care avoiding the need for surgical intervention. At two-week follow-up, the child was asymptomatic and upper gastrointestinal series obtained six months later demonstrated resolution of the fistula.
Child ; Eating ; Endoscopy ; Fistula* ; Follow-Up Studies ; Foreign Bodies ; Gastric Fistula ; Hemorrhage ; Humans ; Infant ; Intestinal Fistula ; Mortality ; Neodymium*