Parental perspectives on pediatric inflammatory bowel disease: Unraveling concerns, and study participation willingness.

OBJECTIVES: The impact of disease burden extends beyond pediatric inflammatory bowel disease (IBD) patients to include their parents. Previous studies, predating the biologic era, have highlighted parental concerns about potential side effects associated with IBD medications. However, there is a notable gap in the literature regarding parents' perceptions of clinical studies involving pediatric IBD patients. This study aims to explore the specific concerns troubling parents of children with IBD, identifying factors influencing these concerns, and assesses parental willingness to allow their child's participation in clinical studies. METHODS: Utilizing social media, we disseminated an anonymous questionnaire to parents of pediatric IBD patients. The questionnaire encompassed queries about parental willingness for their child to partake in clinical studies, aspects of the disease deemed bothersome, and the sense of coherence scale (SOC). RESULTS: Responses were obtained from 101 parents, with a mean age of 46.4, of whom 82.2% were female. Concerns about potential future side effects of their child's medications surpassed worries about disease symptoms (80.04% vs. 73.47%). Linear regression analysis revealed that parents with lower SOC scores, limited medical care accessibility, and a higher age of the child at diagnosis, exhibited heightened concerns about the future impact of the disease on their child (p = 0.016, 0.003, and 0.045, respectively). While a majority rejected participation in studies involving new medications (54.5%), there was greater agreement for studies on nutritional therapies (84.2%) and complementary medicine (91.1%). Classification tree analysis indicated that women were more inclined to permit their child's participation in studies focusing on complementary medicine (adjusted p = 0.002). CONCLUSION: Parents of IBD patients express greater apprehension about potential side effects from IBD medications and display reluctance toward their child participating in clinical studies related to medications.

Proton pump inhibitors in eosinophilic esophagitis (EoE) related to oral immunotherapy: is it as effective as in other EoE?

Oral immunotherapy (OIT) may induce eosinophilic esophagitis (EoE). Proton pump inhibitors (PPIs) are an effective treatment for EoE. However, the effect of PPI treatment is not well established in patients with EoE induced by OIT. Our primary aim was to compare the clinical, endoscopic, and histological response rates to PPIs in children with EoE induced by OIT (EoE+OIT) versus EoE patients without OIT (EoE-OIT). The secondary aims are to describe the clinical and histological features of EoE+OIT. Demographic, clinical, endoscopic, and histological findings of patients with EoE in the gastroenterology clinic at Shamir Medical Center between March 2015 and December 2022 were collected. Comparisons were performed between EoE+OIT and EoE-OIT patients. The study included 42 children (74% male, mean age 11.2), of whom 31 had EoE-OIT and 11 had EoE+OIT. There were no significant differences between groups regarding sex, comorbidities, symptoms, or endoscopic and histological characteristics at diagnosis. All 42 children were treated with PPIs after diagnosis with or without diet changes. The rates of any clinical response were 83.9% and 90.1% in the EoE-OIT group and EoE+OIT group, respectively (p = 1.0). The rate of any endoscopic response was 74.2% for EoE-OIT and 81.8% for EoE+OIT (p = 0.54). Histologically, PPIs were even more effective in the EoE+OIT group, where only 18.2% had no histological response at all compared to 51.6% in the EoE-OIT group (p = 0.1). CONCLUSION: PPI treatment is as effective in EoE with OIT as it is in EoE due to other etiologies. WHAT IS KNOWN: • Proton pump inhibitor (PPI) treatment is effective for achieving clinical response and histologic remission in some patients with eosinophilic esophagitis (EoE). • EoE has also been reported to be triggered by oral immunotherapy (OIT). WHAT IS NEW: • PPI treatment in EoE with OIT is as effective as treatment for EoE due to other etiologies.

Factors Associated With Adherence to a Gluten-Free Diet in Celiac Patients Diagnosed in Childhood as Compared to Adulthood.

Past studies have reported differences between pediatric and adult celiac disease patients. We aimed to compare factors associated with adherence to a gluten-free diet between these groups. An anonymous online questionnaire was sent via the Israeli Celiac Association and social networks to celiac patients. The Biagi questionnaire was used to assess dietary adherence. A total of 445 subjects participated. Mean age was 25.7 ± 17.5 years and 71.9% were female. Subjects were divided into six groups according to age at diagnosis: younger than 6 years (134 patients, 30.7%), 6-12 (79 patients, 18.1%), 12-18 (41 patients, 9.4%), 18-30 (81 patients, 18.5%), 30-45 (79 patients, 18.1%), and 45 years and above (23 patients, 5.3%). There were several significant differences between childhood- and adulthood-diagnosed patients. Pediatric patients were less likely to be noncompliant with a gluten-free diet (3.7% vs. 9.4%, p < .001). They were also more frequently followed by a gastroenterologist ( p < .001), a dietitian ( p < .001), and participated in a celiac support group ( p = .002). In logistic regression analyses, longer duration of disease was associated with poor compliance. In conclusion, pediatric-diagnosed celiac patients are more adherent to a gluten-free diet than those diagnosed in adulthood, with better social support and nutritional follow-up possibly contributing.

Caustic Ingestion in Children: The Otolaryngologist Perspective.

OBJECTIVES: Caustic ingestion in children is a significant cause of morbidity despite preventive measures. Upon arrival to the emergency department, these children are often initially seen by the otolaryngologist and later on by the gastroenterologist. This study aimed to determine which otolaryngological and gastrointestinal signs and symptoms can better predict abnormal findings on imaging, esophagogastroduodenoscopy (EGD), and complications development. METHODS: We performed a retrospective chart review of children 18 years or younger admitted because of caustic ingestion between January 2007 and November 2019. RESULTS: Forty-one children with a median age of 4.2 years (interquartile range, 1.7-16.7 years) were included; of them, 22 (53.6%) were males. Nineteen children (46.3%) underwent EGD, which revealed no pathology in 13 cases (68.4%). Most ingested substances were in the form of liquid (82.9%), accidentally ingested (82.9%), and with an alkaline pH (57.5%). Stridor, dyspnea, drooling, abnormal oral cavity findings, dysphagia, and vomiting were significantly associated with pathological findings on imaging and/or EGD and/or complications development ( P = 0.028, P = 0.028, P = 0.022, P = 0.02, P < 0.001, and P = 0.01 respectively). Laryngopharyngeal group of findings (dyspnea, stridor, hoarseness, sore throat, and/or drooling) predicted a higher risk for complications development than the gastrointestinal group (dysphagia, abdominal pain, vomiting, or abdominal swelling and/or tenderness) ( P = 0.011, P = 0.31 respectively). CONCLUSIONS: In children, after caustics ingestion, laryngopharyngeal signs and symptoms may predict a higher risk for complications development in comparison with gastrointestinal signs and symptoms. We therefore stress the importance of otolaryngological examination upon arrival to the emergency department.

The Knowledge and Attitudes of Pediatricians in Israel Towards Vegetarianism.

OBJECTIVES: Pediatricians have an important role in the dietary education of children, and in the nutritional health of their patients. We aimed to assess nutritional knowledge, familiarity with guidelines, and attitudes of pediatricians regarding vegetarian diets. METHODS: A cross-sectional study using a previously implemented questionnaire, distributed amongst a convenience sample of pediatricians in Israel. For each participant, scores of knowledge and of attitudes towards vegetarian diets were calculated. Scores were analyzed and compared between various categorizations of the respondents. RESULTS: Of 270 respondents (60.4% female individuals), 14.1% were following a vegetarian or semi-vegetarian diet. The overall mean scores for knowledge and attitude were 37.9 ±â€Š16.0% and 38.1 ±â€Š20.7%, respectively. Among pediatricians currently following a vegetarian or semi-vegetarian diet, mean knowledge and attitude scores were higher by 12.2% (95% confidence interval [CI] 6.8-17.6, P < 0.001) and 17.4% (95% CI 10.5-24.2, P < 0.001), respectively, compared with nonvegetarians. Knowledge scores were found to be positively correlated with attitude scores. Only 13.4% of pediatricians felt that their medical degree studies prepared them well to deal with vegetarian patients. A higher knowledge score was correlated with inquiring of patients eating habits, and counseling on vegetarian diets. CONCLUSIONS: Pediatricians possess a low average knowledge base in vegetarian nutrition. The majority of pediatricians do not hold positive attitudes concerning vegetarian diets. We show a positive correlation between overall knowledge and overall attitude for individual participants. Increasing the knowledge base of pediatricians regarding vegetarian diets may lead them to conceive meatless diets in a more positive light and better counsel their patients.

The Safety and Feasibility of a New Through-the-scope Balloon-assisted Enteroscopy in Children.

OBJECTIVES: Small bowel involvement in Crohn disease (CD) is clinically important for diagnosis and treatment. Single and double-balloon enteroscopy have already become important diagnostic tools in such cases. The on-demand NaviAid AB device enables deep advancement into the small bowel, using an anterograde or retrograde approach. In adults, this procedure is feasible, safe, and rapid. This work aimed to assess the safety and feasibility of NaviAid AB enteroscopy in pediatric patients. METHODS: Single-center, prospective study using the through-the-scope balloon-assisted-enteroscopy (TTS-BAE) NaviAid AB device for the evaluation of the small bowel in children with suspected or known inflammatory bowel disease (IBD). The system consists of a single-use balloon catheter inserted through the instrument channel of a standard colonoscope. It consists of an inflation/deflation system (NaviAid SPARK), which is inflated to anchoring pressure. The repetitive push-pull technique enables the advancement of the colonoscope along the small intestine. RESULTS: Fifty analyzed endoscopic procedures (30 retrograde, 20 anterograde) were performed in 34 children (52.9% boys, mean age 13.7 years). Average maximal depth of insertion (MDI), advancement depth using the NaviAid AB and average total procedure time were 138 cm (range 100-190 cm), 81 cm (range 40-120 cm), and 12.8 minutes (range 7.3-19.0 minutes), respectively, for the anterograde approach and 143 cm (range 100-170 cm), 64 cm (range 20-95 cm), and 21.9 minutes (range 13.9-32.0 minutes), respectively, for the retrograde approach. No serious or device-related adverse events were reported. CONCLUSIONS: NaviAid AB enteroscopy in children is safe, feasible, and enables assessment of the small intestine in a short period of time.

Early Surgery Versus Biologic Therapy in Limited Nonstricturing Ileocecal Crohn's Disease-A Decision-making Analysis.

BACKGROUND: Surgery is the preferred option for patients with symptomatic localized fibrostenotic ileocecal Crohn's disease (CD) but not for those with predominantly active inflammation without obstruction. The benefit of early surgery in patients with a limited nonstricturing ileocecal CD over biologic treatment is still a debate. OBJECTIVE: Our objective is to formulate a decision analysis model based on recently published data to explore whether early surgery in patients with limited nonstricturing CD is preferred over biologic treatment. METHODS: We constructed a Markov model comparing 2 strategies of treatment: (1) early surgery vs (2) biologic treatment. To estimate the quality-adjusted life years (QALYs) and the costs in each strategy, we simulated 10,000 virtual patients with the Markov model using a Monte Carlo simulation 100 times. Sensitivity analyses were performed to evaluate the robustness of the model and address uncertainties in the estimation of model parameters. RESULTS: The costs were $29,457 ± $407 and $50,382 ± $525 (mean ± SD) for early surgery strategy and biologic treatment strategy, respectively. The QALY was 6.24 ± 0.01 and 5.81 ± 0.01 for early surgery strategy and biologic treatment strategy, respectively. CONCLUSION: The strategy of early surgery dominates (higher QALY value [efficacy] and less cost) compared with the strategy of biologic treatment in patients with limited ileocecal CD.

Lymphoid follicles in children with Helicobacter pylori-negative gastritis.

PURPOSE: The prevalence of Helicobacter pylori gastritis has been declining, whereas H. pylori-negative gastritis has become more common. We evaluated chronic gastritis in children with regard to H. pylori status and celiac disease (CD). PATIENTS AND METHODS: Demographic, clinical, endoscopic, and histologic features of children who underwent elective esophagogastroduodenoscopy were reviewed retrospectively. Gastric biopsies from the antrum and corpus of the stomach were graded using the Updated Sydney System. H. pylori presence was defined by hematoxylin and eosin, Giemsa, or immunohistochemical staining and urease testing. RESULTS: A total of 184 children (61.9% female) met the study criteria with a mean age of 10 years. A total of 122 (66.3%) patients had chronic gastritis; 74 (60.7%) were H. pylori-negative. Children with H. pylori-negative gastritis were younger (p=0.003), were less likely to present with abdominal pain (p=0.02), and were mostly of non-Arabic origin (p=0.011). Nodular gastritis was found to be less prevalent in H. pylori-negative gastritis (6.8%) compared with H. pylori-positive gastritis (35.4%, p<0.001). The grade of mononuclear infiltrates and neutrophil density was more severe in the H. pylori-positive group (p<0.001). Pan-gastritis and lymphoid follicles were associated most commonly with H. pylori. Although less typical, lymphoid follicles were demonstrated in 51.3% of H. pylori-negative patients. The presence or absence of CD was not associated with histologic findings in H. pylori-negative gastritis. CONCLUSION: Our findings suggest that lymphoid follicles are a feature of H. pylori-negative gastritis in children independent of their CD status.

Gastrostomy Tube Weaning and Treatment of Severe Selective Eating in Childhood: Experience in Israel Using an Intensive Three Week Program.

BACKGROUND: Children dependent on gastrostomy tube feeding and those with extremely selective eating comprise the most challenging groups of early childhood eating disorders. We established, for the first time in Israel, a 3 week intensive weaning and treatment program for these patients based on the "Graz model." OBJECTIVES: To investigate the Graz model for tube weaning and for treating severe selective eating disorders in one center in Israel. METHODS: Pre-program assessment of patients' suitability to participate was performed 3 months prior to the study, and a treatment goal was set for each patient. The program included a multidisciplinary outpatient or inpatient 3 week treatment course. The major outcome measures were achievement of the target goal of complete or partial tube weaning for those with tube dependency, and expansion of the child's nutritional diversity for those with selective eating. RESULTS: Thirty-four children, 28 with tube dependency and 6 with selective eating, participated in four programs conducted over 24 months. Their mean age was 4.3 ± 0.37 years. Of all patients, 29 (85%) achieved the target goal (24 who were tube-dependent and 5 selective eaters). One patient was excluded due to aspiration pneumonia. After 6 months follow-up, 24 of 26 available patients (92%) maintained their target or improved. CONCLUSIONS: This intensive 3 week program was highly effective in weaning children with gastrostomy tube dependency and ameliorating severe selective eating. Preliminary evaluation of the family is necessary for completion of the program and achieving the child's personal goal, as are an experienced multidisciplinary team and the appropriate hospital setup, i.e., inpatient or outpatient.

Congenital protein losing enteropathy: an inborn error of lipid metabolism due to DGAT1 mutations.

Protein-losing enteropathy (PLE) is a clinical disorder of protein loss from the gastrointestinal system that results in hypoproteinemia and malnutrition. This condition is associated with a wide range of gastrointestinal disorders. Recently, a unique syndrome of congenital PLE associated with biallelic mutations in the DGAT1 gene has been reported in a single family. We hypothesize that mutations in this gene are responsible for undiagnosed cases of PLE in infancy. Here we investigated three children in two families presenting with severe diarrhea, hypoalbuminemia and PLE, using clinical studies, homozygosity mapping, and exome sequencing. In one family, homozygosity mapping using SNP arrays revealed the DGAT1 gene as the best candidate gene for the proband. Sequencing of all the exons including flanking regions and promoter regions of the gene identified a novel homozygous missense variant, p.(Leu295Pro), in the highly conserved membrane-bound O-acyl transferase (MBOAT) domain of the DGAT1 protein. Expression studies verified reduced amounts of DGAT1 in patient fibroblasts. In a second family, exome sequencing identified a previously reported splice site mutation in intron 8. These cases of DGAT1 deficiency extend the molecular and phenotypic spectrum of PLE, suggesting a re-evaluation of the use of DGAT1 inhibitors for metabolic disorders including obesity and diabetes.

Orthostatic hypotension in children with acute febrile illness.

BACKGROUND: Children presenting to the Pediatric Emergency Department (PED) with fever often describe symptoms such as lightheadedness, dizziness, fatigue, and weakness, and may appear pale. They may also present with a chief complaint of syncope. Such symptoms may result from orthostatic hypotension. OBJECTIVE: To determine whether children with an acute febrile illness have a higher incidence of orthostatic hypotension compared to afebrile children. METHODS: A prospective cohort study was conducted at the PED at Assaf Harofeh Medical Center, a university-affiliated hospital in Israel. Eighty children aged 4-18 years were recruited. Thirty-nine had fever (>38°C for 6-48 h) and 41 were afebrile. All subjects had their blood pressure measured in the supine position (after 5 min of rest) and again after standing for 3 min. The main outcome measure was orthostatic hypotension, that is, a reduction of systolic blood pressure of at least 20 mm Hg, or a fall in diastolic blood pressure of at least 10 mm Hg within 3 min of standing. RESULTS: There were no differences between the groups in gender, age, height, or weight. Orthostatic hypotension was found in 10/39 (25.6%) of febrile children and in 2/41 (5%) of afebrile children (p=0.012). CONCLUSIONS: The incidence of orthostatic hypotension among febrile children in the PED is high, and may explain common symptoms such as dizziness or syncope. Such patients should be instructed to drink properly and to avoid rapid changes in body posture.