Abdominal plain film before gastrostomy tube placement to predict success of percutaneous endoscopic procedure.

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) tube feeding is a convenient method for children requiring long-term enteral nutrition. Preoperative fitness of the majority of pediatric PEG candidates is graded as American Society of Anesthesiologists physical status ≥ III, indicating increased risk for peri- and postoperative morbidity. The success rate of endoscopic insertion is high, but variations in the anatomy may lead to failure of PEG placement and repeated exposure to anesthesia for surgical gastrostomy. We evaluated the efficiency of using abdominal plain film with gastric insufflation in the preparatory phase to predict a successful PEG insertion and avoid rescheduling. METHODS: A single-center cohort of candidates for PEG underwent abdominal plain film with gastric insufflation in the preparatory phase before tube insertion. The x-ray film was considered normal when the stomach projected distal to the costal margin. Primary endpoint was the success rate of PEG insertion. Multivariate logistic regression analysis was used to identify factors associated with PEG insertion failure. RESULTS: A total of 303 candidates for PEG underwent abdominal plain film (age range 0.3-18.1 years). PEG tube insertion succeeded in 287 cases (95%). In case of an abnormal abdominal film, the probability of successful PEG insertion dropped to 67% (95% confidence interval 46%-87%). In a multivariate logistic regression model, significant predictors for PEG insertion failure were spinal deformities (odds ratio [OR] 12.1), previous abdominal surgery (OR 8.5), neurological impairment (OR 4.1), and abnormal plain abdominal film (OR 10.3). CONCLUSIONS: Assessment of the gastric anatomy by abdominal plain film in PEG candidates with spinal deformities, previous abdominal surgery, or neurological impairment may help to identify children with a high likelihood of PEG insertion failure. This strategy enables the endoscopist to notify the surgeon in advance for a potential conversion and avoids repeated exposure to anesthesia.

The duration of effect of infliximab maintenance treatment in paediatric Crohn's disease is limited.

BACKGROUND: Infliximab is effective for induction and maintenance of remission in children with moderately to severely active Crohn's disease (CD). AIM: To evaluate the long-term efficacy of infliximab treatment in paediatric CD. METHODS: In this observational, multicentre study, all paediatric CD patients in The Netherlands treated with infliximab from October 1992 to November 2009 and with minimal follow-up of 3 months since start of infliximab, were studied. RESULTS: One hundred and fifty-two CD patients [81M; median age at start of infliximab 15.0 years (IQR 13.1-16.4)] received a median number of 10.5 infliximab infusions (IQR 6-21). Median follow-up after start of infliximab was 25 months (IQR 13-40). Kaplan-Meier analysis showed that the cumulative probability of losing response to infliximab in patients who initially required repeated infusions was 13%, 40% and 50% after 1, 3 and 5 years, respectively. Seventy-four patients (49%) needed dose adjustments, with a median time to any adjustment of 6 months. CONCLUSIONS: Duration of effect of infliximab is limited as 50% of patients on infliximab maintenance treatment lose their therapeutic response after 5 years. Dose adjustments after start of infliximab are frequently needed to regain therapeutic benefit. These findings emphasise the need for effective, long-term treatment strategies for paediatric CD.

A cohort study of haemoglobin and zinc protoporphyrin levels in term Zambian infants: effects of iron stores at birth, complementary food and placental malaria.

OBJECTIVE: To examine zinc-protoporphyrin (ZPP) and haemoglobin levels, and to determine predictors of iron deficiency anaemia (IDA) in Zambian infants. SUBJECTS AND METHODS: Ninety-one women and their normal birth weight (NBW) infants were followed bi-monthly during the first 6 months of life, and iron status, food intake, malaria parasitaemia and growth were monitored. At 4 months, the infants were divided into two groups, and the data were analysed according to whether or not they were exclusively breastfed. RESULTS: Almost two-third of infants were born with low iron stores as defined by ZPP levels, and this proportion increased with age. Over 50% had developed IDA by 6 months. Exclusive breastfeeding at 4 months could be a protective factor for IDA (odds ratio (OR): 0.2; 95% confidence interval (CI): 0.0-1.1). Exclusively breastfed infants had higher haemoglobin values at 4 and 6 months (mean difference 0.6; 95% CI: 0.1-1.2 g/dl and mean difference 0.9; 95% CI: 0.2-1.7 g/dl, respectively), compared with infants with early complementary feeding. In univariate analysis, past or chronic placental malaria appeared to be a predictor of IDA at 4 and 6 months, but the significance was lost in multivariate analysis. CONCLUSIONS: Zambian NBW infants are born with low iron stores and have a high risk to develop IDA in the first 6 months of life. Continuation of exclusive breastfeeding after 4 months is associated with a reduction of anaemia. The effect of placental malaria infection on increased risk of infant IDA could not be proven.

Diagnostic accuracy of the haemoglobin colour scale in neonates and young infants in resource-poor countries.

Due to the insidious nature of infant anaemia, this disorder frequently remains undetected and untreated by health-care workers in resource-poor settings. We assessed the accuracy of a low-cost and simple diagnostic tool, the haemoglobin colour scale (HCS), in estimating haemoglobin (Hb) values in infants between zero and four months of age. In a rural hospital in Zambia, blood samples were analysed for Hb concentration by HCS and HemoCue method. Bland-Altman plots were used to express agreement between the two methods. The mean difference between HCS and HemoCue at birth (n = 94), two months (n = 87) and four months (n = 69) was 0.39, 0.20 and -0.11 g/dL, respectively. Limits of agreement were -2.39 to 1.51, -1.80 to 2.20 and -1.98 to 1.75 g/dL, respectively. Disagreement with HemoCue measurements of more than 2 g/dL was noted in only 4% of all blood samples. We conclude that the HCS provides Hb estimations in infants aged 0-4 months that are sufficiently accurate to improve timely recognition of anaemia in settings where there is no laboratory.