Sequential analysis of child pain behavior and maternal responses: an observational study.

This laboratory-based study examined lagged associations between child pain behavior and maternal responses as a function of maternal catastrophizing (CAT). Mothers completed the parent version of the Pain Catastrophizing Scale. Children participated in a validated water ingestion procedure to induce abdominal discomfort with mothers present. Video recordings of their interactions were edited into 30-second segments and coded by 2 raters for presence of child pain behavior, maternal solicitousness, and nontask conversation. Kappa reliabilities ranged from 0.83 to 0.95. Maternal CAT was positively associated with child pain behavior and maternal solicitousness, P values <0.05. In lagged analyses, child pain behavior during a given segment (T) was positively associated with child pain behavior during the subsequent segment (T + 1), P <0.05. Maternal CAT moderated the association between (1) child pain behavior at T and maternal solicitousness at T + 1, and (2) solicitousness at T and child pain behavior at T + 1, P values <0.05. Mothers higher in CAT responded solicitously at T + 1 irrespective of their child's preceding pain behavior, and their children exhibited pain behavior at T + 1 irrespective of the mother's preceding solicitousness. Mothers lower in CAT were more likely to respond solicitously at T + 1 after child pain behavior, and their children were more likely to exhibit pain behavior at T + 1 after maternal solicitousness. These findings indicate that high CAT mothers and their children exhibit inflexible patterns of maternal solicitousness and child pain behavior, and that such families may benefit from interventions to decrease CAT and develop more adaptive responses.

Pain catastrophizing predicts verbal expression among children with chronic pain and their mothers.

This study examined intra- and inter-personal associations between pain catastrophizing and verbal expression in 70 children with recurrent abdominal pain and their mothers. Participants independently completed the Pain Catastrophizing Scale. Mothers and children then talked about the child's pain. Speech was categorized using a linguistic analysis program. Catastrophizing was positively associated with the use of negative emotion words by both mothers and children. In addition, mothers' catastrophizing was positively associated with both mothers' and children's anger word usage, whereas children's catastrophizing was inversely associated with mothers' anger word usage. Findings extend the literature on behavioral and interpersonal aspects of catastrophizing.

Specific carbohydrate diet for pediatric inflammatory bowel disease in clinical practice within an academic IBD center.

OBJECTIVE: Despite dietary factors being implicated in the pathogenesis of inflammatory bowel disease (IBD), nutritional therapy, outside of exclusive enteral nutrition (EEN), has not had a defined role within the treatment paradigm of pediatric IBD within IBD centers. Based on emerging data, Seattle Children's Hospital IBD Center has developed an integrated dietary program incorporating the specific carbohydrate diet (SCD) into its treatment paradigm. This treatment paradigm uses the SCD as primary therapy as well as adjunctive therapy for the treatment of IBD. The aim of this study was to evaluate the potential effects of the SCD on clinical outcomes and laboratory studies of pediatric patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS: In this retrospective study, we reviewed the medical records of patients with IBD on SCD. RESULTS: We analyzed 26 children on the SCD: 20 with CD and 6 with UC. Duration of the dietary therapy ranged from 3 to 48 mo. In patients with active CD (Pediatric Crohn's Disease activity index [PCDAI] >10), PCDAI dropped from 32.8 ± 13.2 at baseline to 20.8 ± 16.6 by 4 ± 2 wk, and to 8.8 ± 8.5 by 6 mo. The mean Pediatric Ulcerative Colitis Activity Index for patients with active UC decreased from a baseline of 28.3 ± 10.3 to 20.0 ± 17.3 at 4 ± 2 wk, to 18.3 ± 31.7 at 6 mo. CONCLUSION: This retrospective review provides evidence that the SCD can be integrated into a tertiary care center and may improve clinical and laboratory parameters for pediatric patients with nonstructuring, nonpenetrating CD as well as UC. Further prospective studies are needed to fully assess the safety and efficacy of the SCD in pediatric patients with IBD.

Fecal microbial transplant effect on clinical outcomes and fecal microbiome in active Crohn's disease.

BACKGROUND: Crohn's disease (CD) is a chronic idiopathic inflammatory intestinal disorder associated with fecal dysbiosis. Fecal microbial transplant (FMT) is a potential therapeutic option for individuals with CD based on the hypothesis that changing the fecal dysbiosis could promote less intestinal inflammation. METHODS: Nine patients, aged 12 to 19 years, with mild-to-moderate symptoms defined by Pediatric Crohn's Disease Activity Index (PCDAI of 10-29) were enrolled into a prospective open-label study of FMT in CD (FDA IND 14942). Patients received FMT by nasogastric tube with follow-up evaluations at 2, 6, and 12 weeks. PCDAI, C-reactive protein, and fecal calprotectin were evaluated at each study visit. RESULTS: All reported adverse events were graded as mild except for 1 individual who reported moderate abdominal pain after FMT. All adverse events were self-limiting. Metagenomic evaluation of stool microbiome indicated evidence of FMT engraftment in 7 of 9 patients. The mean PCDAI score improved with patients having a baseline of 19.7 ± 7.2, with improvement at 2 weeks to 6.4 ± 6.6 and at 6 weeks to 8.6 ± 4.9. Based on PCDAI, 7 of 9 patients were in remission at 2 weeks and 5 of 9 patients who did not receive additional medical therapy were in remission at 6 and 12 weeks. No or modest improvement was seen in patients who did not engraft or whose microbiome was most similar to their donor. CONCLUSIONS: This is the first study to demonstrate that FMT for CD may be a possible therapeutic option for CD. Further prospective studies are required to fully assess the safety and efficacy of the FMT in patients with CD.

Fecal microbiota transplantation via nasogastric tube for recurrent clostridium difficile infection in pediatric patients.

Fecal microbiota transplantation (FMT) is a safe and effective therapy for adults with recurrent Clostridium difficile colitis, but data regarding FMT in children are limited and focus on colonoscopic administration of FMT. We present 10 consecutive children who received FMT via nasogastric tube for treatment of recurrent C difficile infection. Median age was 5.4 years, and 30% were receiving simultaneous immunosuppression. Median follow-up was 44 days, and 90% of patients resolved their C difficile infection; one patient relapsed 2 months later after receiving antibiotics. FMT via nasogastric tube appears safe, well tolerated, and effective in treating pediatric recurrent C difficile colitis.

Fecal microbial transplant via nasogastric tube for active pediatric ulcerative colitis.

BACKGROUND: Ulcerative colitis (UC), a chronic inflammatory disease of the large intestine, is characterized by a dysregulated immune reaction. UC is associated with fecal dysbiosis. Human and animal studies support the fact that the gastrointestinal microbiome may trigger the intestinal immune response, resulting in UC. Fecal microbial transplantation (FMT), by changing the gastrointestinal microbiome of patients with UC, may be a therapeutic option. METHODS: Four patients with moderate symptoms defined by the Pediatric Ulcerative Colitis Activity Index were enrolled in a prospective, open-label study of FMT via nasogastric tube in pediatric UC (US Food and Drug Administration IND 14942). After the donor and patient evaluation, patients received FMT with follow-up evaluations at 2, 6, and 12 weeks after transplantation. Study subjects were maintained on their pretransplant medications. The Pediatric Ulcerative Colitis Activity Index score, C-reactive protein, and stool calprotectin were completed during each study visit. RESULTS: Four patients with UC were enrolled (all boys). Ages ranged from 13 to 16 years. Patients tolerated FMT without adverse effects. None of the patients clinically improved with FMT, nor were there any significant changes in stool calprotectin or laboratory values, including C-reactive protein, albumin, and hematocrit. Three individuals received additional standard medical therapies before the end of the study. CONCLUSIONS: This study, although showing that single-dose FMT via nasogastric tube is well tolerated in active pediatric UC, did not show any clinical or laboratory benefit.

Evidence based practice: decreasing psychiatric revisits to the emergency department.

Inpatient psychiatric settings anticipate changes in reimbursement that will link payment rates to objective quality measures. Readmission rates are expected to be one of the quality measures. Inpatient areas are undertaking initiatives to decrease readmission rates in preparation for this change. The emphasis on avoiding readmission could cause an increase in emergency room revisit rates by psychiatric patients. In preparation for this potential impact, the mental health emergency service within the Emergency Department of a not-for-profit community based hospital implemented a proactive process improvement plan. The plan's goal was to insure that all patients' care was provided according to a defined standardize best practice process. Steps of the plan focused on (1) improving treatment providers' communications across the continuum of care, (2) enhancing communication between the mental health emergency department nurses and the on-call psychiatrists, (3) developing on-line decisional support to enhance communication, and (4) providing providers with feedback on the impact of changes. Implementation of the improvement process decreased the mean psychiatric emergency revisit rate from 5.7% to 4.3% and decreased the variability in monthly rates from a range of 1.83%-9.53% to a range of 3.53%-5.56%.