The impact of a lipid injectable emulsion (SMOF) on conjugated bilirubin levels in children receiving prolonged parenteral nutrition: A large single center experience.

BACKGROUND: The SMOFlipid is a composite emulsion that has showed benefits, but limited data is available on children receiving prolonged parenteral nutrition (PN). This study aimed to compare conjugated bilirubin (CB) levels at the end of ILE administration in this population. METHODS: Medical charts of all infants treated with Intralipid (Jan 2012-Sep 2013) or SMOFlipid (Oct 2013-Dec 2016) were reviewed. Only infants that received PN for ≥28 consecutive days were included. Laboratory data were extracted from the closest day of initiation and discontinuation of the ILE (±7 days). For the primary objective, an analysis of covariance was employed, adjusting for initial CB values and total days of ILE administration. CB values were log-transformed to normalize distribution. Statistical tests were two-sided and performed at the significance level <0.05. RESULTS: A total of 150 infants were included: 72 used Intralipid for 82 times and 88 received SMOFlipid in 92 occasions. The incidence of cholestasis was 20% (Intralipid) and 4.5% (SMOFlipid). Infants treated with SMOFlipid had significantly lower CB levels at the end of ILE administration with geometric mean ratio between groups of 1.7 (95% CI:1.0, 2.8; p < 0.05). CONCLUSION: In a large and heterogenous group of infants receiving PN for ≥28 consecutive days the final levels of CB were significantly lower with SMOFlipid when compared to Intralipid suggesting a protective role of this type of ILE in this high-risk population. CLINICAL RELEVANCY STATEMENT: SMOFlipid is an emulsion that has showed benefits, but limited data is available on children receiving prolonged parenteral nutrition (PN). This study compared conjugated bilirubin (CB) levels at the end of ILE administration in infants that received PN for ≥28 consecutive days with either SMOFlipid or Intralipid. In a large number of patients with several gastrointestinal diseases lower CB levels were observed with the use of SMOFlipid with geometric mean ratio between groups of 1.7 (95% CI:1.0, 2.8; p < 0.05). Our results demonstrate a protective role of this type of ILE in this high-risk population.

Vulvar swelling and the timely diagnosis of Crohn's disease: A case report.

Children with vulvar swelling often present to multiple physicians and face a prolonged period of ambiguity and extraneous treatments. Here, we report a case of an 8-year-old girl who presented to the dermatology clinic with a 2-month history of vulvar swelling and was ultimately diagnosed with Crohn's disease. Although extra-intestinal manifestations are common in inflammatory bowel diseases, they rarely present before an existing diagnosis. This report highlights this potential early manifestation and demonstrates how timely diagnosis leads to improved outcomes for patients, their families, and healthcare systems.

A Cross-Sectional Study on Malnutrition in Inflammatory Bowel Disease: Is There a Difference Based on Pediatric or Adult Age Grouping?

BACKGROUND: Malnutrition, commonly observed in inflammatory bowel disease (IBD), is associated with increased morbidity and mortality and is attributed to multiple causes. The added energy costs of growth in the child and adolescent with IBD are an additional risk factor. METHODS: The aim of the study was to perform a cross-sectional comparison of nutritional parameters in IBD between pediatric and adult cases. RESULTS: We found that prevalence of undernutrition (low body mass index) and hypoalbuminemia was not different in pediatric, compared with adult patients. Anemia and iron deficiency were more often observed in pediatric subjects, compared with adults (59.1% vs 36.9%, respectively, P < 0.0001; and 37.9% vs 25.3%, P < 0.002). Vitamin B12 deficiency was significantly less common in the pediatric than in the adult group (5.4% vs 19.4%, P < 0.0001). Elevated C-reactive protein was more frequent in pediatric compared with adult cases (49.8% vs 38.4%, P < 0.01). CONCLUSIONS: Patients with active Crohn's disease were more likely to be undernourished in both pediatric and adult populations. In both groups, predicators of undernutrition included low albumin levels (odds ratio [OR], 2.53; P < 0.006) and active disease (OR, 1.99; P < 0.03). Our results call for close surveillance of nutritional status for IBD patients, regardless of age.

Parental presence at induction of anesthesia: perceptions of a pediatric surgical department before and after program implementation.

INTRODUCTION: Parental presence at induction of general anesthesia (PPI) is highly desired by children and parents. However, it often faces resistance from medical personnel. We conducted a survey evaluating the perceptions of surgeons before and after establishment of a PPI program. METHODS: Internal web-based surveys using Likert Scale questions were administered to all members of a pediatric surgical department before and after the introduction of PPI at a freestanding children's hospital. Pre and post results were compared by Wilcoxon rank-sum tests. A p-value ≤0.0026 was considered significant due to the Bonferroni correction. RESULTS: The survey was sent to 59 surgeons 1year before and 5years after gradual implementation of PPI. Response rates were 46% and 54%, pre and post implementation, respectively. After implementation, there was a statistically significant increased level of agreement with the statement: "PPI improves the parents' level of satisfaction" (p=0.0025) and a statistically significant decreased level of agreement with the statement "PPI lengthens the duration of induction" (p=0.0001). Before initiation, 56% wanted to see PPI implemented, while after implementation, 97% wanted PPI to remain. CONCLUSIONS: A majority of pediatric surgeons favored maintaining PPI after implementation. Resistance to initiation of PPI should not hinder implementation. TYPE OF STUDY: Survey LEVEL OF EVIDENCE: Not applicable.

Wireless capsule endoscopy for obscure small-bowel disorders: final results of the first pediatric controlled trial.

BACKGROUND AND AIMS: Obscure small-bowel disorders are jejunal and ileal lesions undiagnosed by traditional imaging techniques (endoscopic, radiologic). We evaluated the diagnostic usefulness and safety of capsule endoscopy for obscure small-bowel disorders in children and adolescents. METHODS: Comparative, prospective, self-controlled trials in patients (age, 10-18 y) suspected to have either small-bowel Crohn's disease, polyps, or obscure gastrointestinal (GI) bleeding. Capsule results were compared with the diagnostic imaging studies normally used in this age group. RESULTS: Among 20 patients suspected of Crohn's disease, multiple lesions consistent with this diagnosis were observed by capsule endoscopy in 50%. Small-bowel Crohn's disease was ruled out in 8 patients. Eosinophilic enteropathy was found in 2 others. For polyp detection (n = 6), capsule endoscopy yielded 100% concordance with the control studies when analyzed per patient. However, capsule endoscopy revealed a greater number (50%) of polyps. Among patients with obscure bleeding (n = 4), the capsule examination confirmed a diagnosis of vascular malformations in 3. Capsule endoscopy more accurately identified the precise source of bleeding compared with angiography. All 30 capsule studies were well tolerated, although 1 capsule was retained owing to an inflammatory stenosis. The capsule eventually was expelled after corticosteroid therapy. CONCLUSIONS: Capsule endoscopy correctly diagnosed or excluded a bleeding source, small-bowel polyps, or Crohn's disease of the small bowel in 29 of 30 patients. Capsule endoscopy permits an accurate, noninvasive approach for diagnosing obscure small bowel lesions in children over the age of 10.

Neonatal cholestasis associated with fetal arrhythmia.

We evaluated the consequence of different types of fetal arrhythmia in the development of neonatal cholestasis. The charts of 38 children born at St. Justine Hospital between 1993 and 2001 with sustained and hemodynamically significant fetal arrhythmias were studied: 19 with supraventricular tachycardia, 14 with atrial flutter, and 5 with atrio-ventricular (AV) block. Six of these 38 children presented with cholestasis. The average duration of arrhythmia was 15.7 days in the noncholestatic group, compared with 40.3 days in the cholestatic group ( P <.05). The three infants with supraventricular tachycardia who developed cholestasis survived and resolved their cholestasis, whereas 2 of 3 infants with AV block died. No infant with atrial flutter developed cholestasis. We conclude that newborns who developed tachyarrhythmia during their fetal life can show transient neonatal cholestasis. In patients with AV block, severe and irreversible liver failure could be observed. In addition, extensive collapse of the stroma and the absence of hepatocytes (foie vide) also were observed in a patient with anti-Ro antibodies.