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Transnasal endoscopy (TNE) with virtual reality (VR) distraction allows for unsedated pediatric upper endoscopy. Understanding the pediatric population that is successful with TNE is imperative for patient selection and experience. We developed a “TNEase Score” to assess patient tolerance from the physician's assessment. The aim of this study was to identify factors that influence patient's acceptance and tolerability of sedation‐free TNE in pediatric patients undergoing the procedure. From March 2020 to April 2021, 110 TNEs were performed on subjects 5–22 years of age. The overall completion rate was 98.1%. Of these subjects, 66 subjects (60%) were graded by the gastroenterologist as TNEase Score 1 (with ease); 27 subjects (25%) were graded as TNEase Score 2 (minimal complaints); nine subjects (8%) were graded as TNEase score 3 (moderate complaints, required frequent reassurance); six subjects were graded as TNEase Score 4 (significant complaints and resistance); two subjects (2%) were graded as TNEase Score 5 (procedure terminated). Feasibility of TNE was significantly related to age, height, and whether the patient had undergone previous TNE. Thus, young age, shorter height, and first time TNE were significant predictors of higher TNEase score or difficulty tolerating TNE. Factors examined that did not predict higher TNEase score included gender, junior versus senior endoscopist, past medical history of anxiety, autism, attention‐deficit/hyperactivity disorder (ADHD), or history of using a nasal spray at home. “TNEase score” allowed grading of the subject's experience and the majority of patients tolerated TNE with minimal complaints. “TNEase Score” to evaluate patient tolerance of unsedated transnasal endoscopy There is growing interest in the technique of unsedated TNE with virtual reality distraction in pediatrics.Different from adult centers, pediatric centers face unique challenges with sedation‐free TNE including patient size and developmentally appropriate preparation for different ages which may affect patient tolerance and success.Centers performing TNE are frequently asked who the ideal patient is; many newer centers perform TNE in children 10 years and up, hypothesizing that older children may tolerate TNE better due to their age, size, and maturity. There is growing interest in the technique of unsedated TNE with virtual reality distraction in pediatrics. Different from adult centers, pediatric centers face unique challenges with sedation‐free TNE including patient size and developmentally appropriate preparation for different ages which may affect patient tolerance and success. Centers performing TNE are frequently asked who the ideal patient is; many newer centers perform TNE in children 10 years and up, hypothesizing that older children may tolerate TNE better due to their age, size, and maturity. We developed a “TNEase score” to assess patient tolerance from the physician's perspective.Feasibility of transnasal endoscopy (TNE) was significantly related to age, height and whether the patient had previous TNE. Thus, young age, shorter height, and first time TNE were significant predictors of higher TNEase score or more difficulty tolerating TNE.Factors examined that did not predict higher TNEase score included gender, junior versus senior endoscopist, past medical history of anxiety, autism, ADHD or history of using a nasal spray at home. We developed a “TNEase score” to assess patient tolerance from the physician's perspective. Feasibility of transnasal endoscopy (TNE) was significantly related to age, height and whether the patient had previous TNE. Thus, young age, shorter height, and first time TNE were significant predictors of higher TNEase score or more difficulty tolerating TNE. Factors examined that did not predict higher TNEase score included gender, junior versus senior endoscopist, past medical history of anxiety, autism, ADHD or history of using a nasal spray at home.

Although swallowed topical steroids are effective in inducing histological remission in eosinophilic esophagitis (EoE), their efficacy is limited by treatment nonadherence. In this study, we objectively measured adherence rates to swallowed topical steroids in adolescents with EoE over the course of 8 weeks and analyzed the association between adherence rate, disease and demographic features, symptom severity, and medication‐taking habit strength. We found that approximately 20% of adolescents with EoE were over‐dosing on their medications. After excluding these patients, mean adherence rate was 67.0% (±19.4%) and median adherence rate was 63% (interquartile range 53%–88%). Adherence was not associated with demographic features, disease history, symptom severity, or quality of life but was associated with habit strength (Pearson r= 0.48, P= 0.04). These findings suggest that habit strength may serve as a potential target for interventions aimed at improving adherence in adolescents with EoE.

To evaluate the impact of type and dose of swallowed topical steroids (STS) and concurrent steroid therapy on the development and resolution of adrenal insufficiency (AI) in pediatric eosinophilic esophagitis (EoE). We performed a retrospective case-control study of pediatric EoE subjects in a single tertiary care center, who were treated with STS for at least 3 months and diagnosed with AI based on a peak stimulated cortisol level of <18 µg/dL (500 nmol/L). Steroid forms and doses, and endoscopy data were collected at the time of AI diagnosis and AI resolution or the last known evaluation. Steroid formulations were converted to a fluticasone-equivalent dose for analysis. Thirty-two EoE subjects with AI were identified, and 20 had AI resolution, including 12 who remained on lower dose STS. Eight of the 32 patients were also treated with extended-release budesonide (ER budesonide), which resulted in a 7-fold higher total daily steroid dose, and thus were analyzed separately. When the 24 cases that were not on ER budesonide were compared to the 81 controls, no difference was found in the STS dose nor total daily steroid dose, although the inhaled steroid dose had marginal significance. Peak eosinophil counts tended to increase when STS doses were decreased, except in subjects on ER budesonide at AI diagnosis. Altering the total daily steroid regimen can lead to resolution of AI in patients with EoE, though this may come at the expense of disease control.

Celiac disease (CeD) autoimmunity and coexisting inflammatory bowel disease (IBD) present a diagnostic dilemma. Our aims were to describe the phenotype of children with IBD and CeD seropositivity and evaluate provider confidence for diagnosing CeD in this population. We performed a single-center retrospective cohort study of subjects =18 years old with IBD and CeD seropositivity between 2006 and 2020. Subjects were considered to have IBD-CeD if they met CeD diagnosis by serology and histology per North American Society For Pediatric Gastroenterology, Hepatology and Nutrition guidelines and if providers suspected CeD as evaluated by a survey. The IBD-only cohort included seropositive participants that did not meet criteria for CeD. Demographic, histologic, gross endoscopic, and laboratory features were compared using Fisher exact test. Of 475 children with IBD, 8 had concomitant CeD, 5 had tissue transglutaminase (tTG) immunoglobulin A (IgA) > 10x upper limit of normal (ULN, P = 0.006), and 8 had villous atrophy (VA, P= 0.003) when compared with 17 seropositive participants with IBD-only. No children with IBD-CeD had esophageal eosinophilia, duodenal cryptitis, duodenal ulceration, or fecal calprotectin >250 µg/g. Factors that contributed to provider uncertainty for diagnosing CeD in IBD included the absence of VA and intraepithelial lymphocytes, the presence of neutrophilic and eosinophilic duodenitis, diffuse ulceration, elevated inflammatory markers, and immunosuppression therapy. Diagnosing CeD in children with IBD continues to be challenging. Although high titers of tTG IgA and VA increased provider confidence for diagnosing CeD in IBD, development of evidence-based guidelines are needed. They should better assess the importance of features atypical of concomitant CeD that contribute to uncertainty.

While dietary changes are recommended to treat pediatric non-alcoholic fatty liver disease (NAFLD), the role of specific nutrients in disease progression is unclear. The objective of this study is to (1) assess the macronutrient and micronutrient intake in adolescents with liver biopsy proven NAFLD [with and without non-alcoholic steatohepatitis (NASH)] and lean controls; (2) determine nutritional predictors of disease severity amongst these groups. Adolescents with biopsy-proven NAFLD and lean controls completed the Harvard Food Frequency Questionnaire. Twenty-eight NAFLD and 15 lean controls were studied. NAFLD with (n = 20) and without NASH (n = 8) had similar total calorie, protein, fat, and carbohydrate intake. Subjects with NASH had higher total sugar (122.3?±?48.3 vs 83.1?±?38.8?g), glucose (24.3?±?9.3 vs 15.2?±?7.5?g), sucrose (42.3?±?16.9 vs 28.8?±?11.7?g), and fructose (29.4?±?12.5 vs 18.1?±?8.0?g) intake than those with NAFLD but without NASH (P< 0.05). Both NAFLD groups had similar micronutrient intake. Alanine aminotransferase (ALT) correlated with total caloric intake (?= 0.4; P= 0.04). Total carbohydrate calories correlated with a higher NAS summary score (?= 0.38; P= 0.04) and lobular inflammation (?= 0.50; P= 0.007). Percent calories from added sugar and glucose correlated with worsening NAS summary score (?= 0.44, P= 0.02; ?= 0.48, P= 0.009) and lobular inflammation (?= 0.51, P= 0.006; ?= 0.53, P= 0.004). Percent calories from fructose correlated with lobular inflammation (?= 0.56; P= 0.002). Total daily calories, protein, fat, carbohydrate, and micronutrient intake were similar between NAFLD and lean controls. NASH patients consume similar total calories, protein, and fat as those without NASH, but have significantly higher sugar intake. NAFLD and lean children, however, have similar macro/micronutrient intake. Histologic disease severity correlates with total carbohydrate and added sugar intake, supporting a role for simple sugar intake in NAFLD progression.

Mental health is a growing concern in pediatric celiac disease (CD). This study utilized the Revised Children’s Anxiety and Depression Scale (RCADS) to investigate anxiety and depression symptom rates. Participants were children ages 8 to 17 years (M = 11.7, SD = 2.7; N = 175) with biopsy-proven CD (Median = 1.1 years post-diagnosis, IQR = 0–4) categorized into groups based on the child’s age, caregiver or child respondent, presence or absence of comorbidities, and gluten-free diet duration. Self-reported RCADS scores showed 39% of children having clinically significant concerns for anxiety or depression (P< 0.0001) but only 7% of caregiver-proxy RCADS scores indicated significant concerns for the child’s anxiety and 14% for the child’s depression. Rates of child-reported anxiety and depression symptoms were significantly higher for those without medical comorbidities than those with (P= 0.04). Therefore, screening for mental health concerns, particularly anxiety and depression, should be routinely performed in pediatric patients with CD.

Mental health is a growing concern in pediatric celiac disease (CD). This study utilized the Revised Children's Anxiety and Depression Scale (RCADS) to investigate anxiety and depression symptom rates. Participants were children ages 8 to 17 years (M = 11.7, SD = 2.7; N = 175) with biopsy‐proven CD (Median = 1.1 years post‐diagnosis, IQR = 0–4) categorized into groups based on the child's age, caregiver or child respondent, presence or absence of comorbidities, and gluten‐free diet duration. Self‐reported RCADS scores showed 39% of children having clinically significant concerns for anxiety or depression (P< 0.0001) but only 7% of caregiver‐proxy RCADS scores indicated significant concerns for the child's anxiety and 14% for the child's depression. Rates of child‐reported anxiety and depression symptoms were significantly higher for those without medical comorbidities than those with (P= 0.04). Therefore, screening for mental health concerns, particularly anxiety and depression, should be routinely performed in pediatric patients with CD.

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Exclusive enteral nutrition (EEN) is infrequently used in the United States but is an effective treatment for pediatric Crohn disease (CD). Limited data exists regarding patient and parent perspectives on this treatment modality. The aim of this study was to determine parent and provider perspectives regarding EEN and understand parent-cited barriers to its use. We surveyed the parents/guardians of children ages 1 through 17 with CD in our institution regarding EEN. Healthcare provider perspectives regarding reason for stopping EEN and those cited by survey respondents were compared using retrospective chart review. One hundred fifteen (62.5%) out of 184 recipients responded to the survey. Ninety percentage of respondents had heard of EEN but of these, 26% had not discussed it with their gastroenterologist. Thirty-eight patients (33%) were treated in the past and 15 (13%) were currently on EEN. Common barriers cited by current EEN users were cost/finances and difficult social situations. Of the children who stopped EEN, most did so as parents felt it was not working (n?=?14, 37%). In these cases, their primary gastroenterologist cited treatment failure for 4 cases and nonadherence for 6. Despite the efficacy of EEN and interest in dietary treatments by patients with CD, there are many barriers surrounding effective communication and successful implementation of dietary therapies. Future research is needed regarding patient-physician communication, cost mitigation, and coping with the social limitations of dietary therapies.

The aim of the study was to evaluate whether children with eosinophilic esophagitis (EoE) demonstrated an association between health-related quality of life (HRQoL) improvements and symptom reduction during 12 months of treatment; to examine age-related EoE discrete symptom presentation; and to describe residual symptom and HRQoL burden. Children ages 2 to 18 years with EoE were assessed at the onset of treatment and 12 months later at 4 tertiary care centers. Continuous measures of symptoms and symptom severity were based on 8 discrete EoE symptoms. HRQoL was measured with the Pediatric Quality of Life (PedsQL) parent-proxy (PR) report, child self-report (CR), and Family Impact Module. Mixed-effects modeling was used to test changes over time for symptom burden and child and family HRQoL. One hundred nine children were followed (ages 2–18 years, mean age 7.6 [4.6] years, 77% boys, 87% white). Baseline symptom number mean was 3.5 (standard deviation = 2.3, range 0–8) and symptom severity mean was 5.5 (standard deviation = 4.3, range 0–24). EoE symptom number and symptom severity decreased significantly over the 12 months (P= 0.013, P< 0.001, respectively). PedsQL PR Total, Physical, Psychosocial, and Family Impact scores all improved significantly (P= 0.001, 0.012, 0.012, 0.015, respectively) but PedsQL child self-report scores did not. Symptom reduction correlated with PR PedsQL improvement (P= 0.01). Few discrete symptoms completely remitted, but lowered severity ratings indicated clinically significant improvement. Year-long treatment in multidisciplinary tertiary centers reduced most symptoms and improved parent-reported HRQoL in children with EoE. The frequency of residual symptoms and persistently lower HRQoL, however, underscore the chronic nature of pediatric EoE.

Pneumatic balloon and bougie dilation are widely used methods for pediatric esophageal dilation. There are no studies directly comparing the safety of these techniques in pediatric patients. This study compared adverse events (AEs) of balloon and bougie dilation in children at a single institution. AEs were identified by means of a prospective clinical registry of all procedure related AEs from 2012 to 2015 at a single institution. Identified AEs underwent retrospective review of procedural and clinical details. The category of each AE was recorded and severity was assigned using a 5-point scoring system. AEs were compared between balloon and bougie dilation for different severities. There were 105 patients who underwent 246 dilation sessions. Balloon dilation was performed more commonly (n = 190, 77%) as compared to Maloney dilators (n = 56, 23%). Patients with balloon dilation were younger (3.0 vs 14.5 years, P= 0.0001) and more likely to have strictures from caustic ingestion (42% vs 2%, P< 0.0001) or surgical anastomoses (34% vs 5% P< 0.0001). Bougie dilation was used more commonly in patients with eosinophilic esophagitis (77% vs 7%, P< 0.0001)). In multivariate analysis, each year of increasing age was associated with a 12% increase in any AEs (P= 0.015), but no difference in clinically significant AEs (grade 2 or higher) was identified between dilation methods. Bougie and balloon dilation did not have significant differences in AE rates, but the patient populations differed between the 2 methods. The dilation method should depend on stricture characteristics and endoscopist expertise with each method.

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Pediatric colonic eosinophilia represents a confounding finding with a wide differential. It is often difficult to determine which children may progress to inflammatory bowel disease (IBD), which have an eosinophilic colitis (EC), and which may have no underlying pathology. There is little guidance for the practitioner on the approach to these patients. To define the clinical presentations of colonic eosinophilia and identify factors which may aid in diagnosis we reviewed patients with colonic eosinophilia and the clinicopathologic factors associated with their diagnoses. An 8-year retrospective chart review of children whose histopathology identified colonic eosinophilia (N = 72) compared to controls with normal biopsies (N = 35). Patients with colonic eosinophilia had increased eosinophils/high-power field compared to controls (P< 0.001) and had 3 clinical phenotypes. Thirty-six percent had an inflammatory phenotype with elevated erythrocyte sedimentation rate (P< .0001), chronic inflammation on colonic biopsies (P< 0.001), and were diagnosed as having IBD. Thirty-seven percent were diagnosed as having EC, associated with male sex (P< 0.005) and peripheral eosinophilia (P= 0.041). Twenty-one percent had no significant colonic pathology. Forty-three percent of patients had >1 colonoscopy and 68% of these had change from initial diagnoses. There are 3 main phenotypes of children with colonic eosinophilia. Signs of chronic systemic inflammation raise suspicion for IBD. Peripheral eosinophilia and male sex are associated with EC. A significant percent of children with colonic eosinophilia do not have colonic disease. Eosinophils/high-power field is not reliable to differentiate etiologies. Repeat colonoscopies may be required to reach final diagnoses.

As both gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE) are associated with malnutrition and feeding dysfunction, this study compares growth, nutrition, and feeding behaviors in children with GERD and EoE. Subjects ages 1 to 7 years with GERD or EoE were enrolled in a prospective study. Assessments included length/height, weight, 3-day food diary, serum biomarkers of nutrition, and the Behavioral Pediatric Feeding Assessment Scale. Mean weight-for-length zscores in GERD and EoE children were -0.93 and -1.14 (p = NS) and mean body mass index zscores were 0.29 and -0.13 (P= NS). Vitamin D intake was below the daily recommended intake in GERD subjects. EoE subjects’ intake was below daily recommended intake of Vitamin D and calcium. GERD and EoE groups both had normal intake of calories, carbohydrates, proteins, fats, and iron, and normal serum ferritin (25 vs 34 ng/mL), prealbumin (21 vs 20 mg/dL), parathyroid hormone (42 vs 37 pg/mL), and Vitamin D (both 30 ng/mL). Behavioral Pediatric Feeding Assessment Scale problem and frequency scores were similar in GERD and EoE subjects but were higher than those of a historical cohort of healthy controls (Hedges’ g of 0.95 and 1.1, respectively). EoE subjects on food allergen restriction diets had significantly less feeding dysfunction than those on regular diets. As a selected group of children with uncomplicated GERD or EoE were without nutritional deficiencies but had maladaptive feeding, providing anticipatory guidance to minimize mealtime challenges, monitoring for improvement, or referring to a feeding therapist, may be beneficial. A trial of food allergen restriction may provide additional benefit for those with EoE.

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We aimed to determine whether tissue transglutaminase (tTG) autoantibody positivity was associated with dietitian-assessed adherence to a gluten-free diet in pediatric patients with celiac disease and identify areas where adherence falters. We reviewed the records of children with celiac disease who had a standardized evaluation of adherence by a registered dietitian. A negative tTG value was not associated with good adherence (P= NS). Adherent and nonadherent children differed with respect to purposeful and accidental gluten exposure (P< 0.0001), knowledge (P= 0.003), cross-contact (P= 0.003), potential exposure via medications and cosmetics (P= 0.004), and potential exposure while at restaurants (P< 0.0001), but not with respect to potential exposure at school (P= NS). Based on our findings, we suggest that negative tTG levels are not necessarily indicative of good adherence to a gluten-free diet in pediatric patients with celiac disease. A separate assessment of adherence is needed focusing on knowledge, behavior while dining out, and intent to adhere.

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Autoimmune hepatitis (AIH) is a common pediatric liver disease and long-term remission is usually maintained with azathioprine (AZA). There is no consensus on the target range for AZA active metabolite 6-thioguanine (6-TGN) levels in pediatric AIH. The aim of the present study was to characterize the outcomes of pediatric patients with AIH and determine correlations between AZA dosing or 6-TGN metabolite levels and biochemical remission. A retrospective chart review was performed and data on presentation, laboratories including AZA metabolite levels, medication use, and outcomes were collected. Between 2002 and 2013, 66 children with AIH were identified (mean age at diagnosis 9.6 ± 5.1 years) with a mean follow-up period of 2.9 ± 3.2 years. Common presenting symptoms included jaundice, fatigue, and abdominal pain. The majority of subjects received steroids for induction and AZA for maintenance of remission. Seventy-nine percent achieved biochemical remission (mean time to remission 6.2 ± 9.2 months), 14% were in the induction phase of therapy, 6% required liver transplantation, and 18% were weaned off immunosuppression and remained in remission. 6-TGN levels ranging from 50 to 250 pmol/8 × 108red blood cell count were associated with biochemical remission (alanine aminotransferase levels of ?50 U/L). The vast majority of children with AIH maintain a sustained remission with AZA monotherapy. Biochemical remission was maintained with 6-TGN levels much lower than that recommended for inflammatory bowel disease. These findings suggest that patients should be maintained at the lowest AZA dose possible that is associated with biochemical remission.

Propofol is a safe, well-tolerated anesthetic that is labeled as contraindicated in patients with egg or soy allergy. This contraindication has become increasingly problematic given the rising incidence of food allergy and eosinophilic esophagitis (EoE). To address this issue, we studied practice patterns of propofol use for esophagogastroduodenoscopies in children with EoE and food allergies at our institution. A retrospective observational study of 1365 esophagogastroduodenoscopies from January 2013 to June 2014 was performed. Data were analyzed using Student ttests, chi square tests, Fisher exact tests, and multivariable logistic regression. We found that propofol was used significantly less in patients with egg or soy allergy, and in patients with EoE, even after adjusting for the presence of food allergy. There was no difference in complication rates relative to propofol use. Propofol was used safely in pediatric patients with EoE and food allergy in this limited single-center review.

Characterize the proportion of acid and nonacid esophageal reflux events in young infants with suspected gastroesophageal reflux (GER) using combined pH‐multichannel intraluminal impedance (MII) monitoring. Determine the symptom index correlation with nonacid reflux and acid reflux events. Prospective study of children, aged 2 weeks to 1 year, referred to The Children's Hospital of Denver Gastroenterology Clinic for evaluation of GER. Exclusion criteria were congenital anomalies or syndromes, cerebral palsy, mental retardation, and pulmonary or cardiac disease. The children were admitted to The Children's Hospital General Clinical Research Center for a 20 hour pH‐MII study. Acid suppression was either never used or discontinued 2 weeks before testing. Thirty‐four infants were enrolled from February 2004 to February 2005. Ages ranged from 2 months to 11 months, median = 7 (20 females/14 males). One thousand eight hundred ninety reflux events were detected by MII, and 588 reflux events were detected by pH probe alone. The percent of reflux that was acid was 47% (888 events) versus 53% of (1,002 events) nonacid reflux events. The proportion of nonacid reflux decreased with age (P< 0.0001 by Pearson χ2test) and with increasing time elapsed from last meal. There were 958 total symptoms evaluated. The most frequently reported symptom was fussiness/pain, which correlated with nonacid reflux events 24.6% and acid reflux 25.2%. The proximal height of a reflux was predictive for symptoms of fussiness/pain, arching, and burping. MII detects more reflux events than pH monitoring alone. The proportion of nonacid reflux to acid reflux events in infants is more similar to adults than previously reported. Combined pH‐MII esophageal monitoring identifies more reflux events and improves clinical correlation with symptoms.

Characterize the proportion of acid and nonacid esophageal reflux events in young infants with suspected gastroesophageal reflux (GER) using combined pH-multichannel intraluminal impedance (MII) monitoring. Determine the symptom index correlation with nonacid reflux and acid reflux events.

The purpose of the present study was to identify barriers to dietary adherence found in the treatment of children with eosinophilic gastrointestinal diseases (EGIDs) and food allergy. A prospective study using a self-administered survey to parents of children with EGIDs at a national advocacy meeting was completed. Responses from 45 participants describing children ages 1 to 18 years (69% boys) identified that 63% were adherent to food restrictions. Physicians provided dietary instructions more often than dietitians. Nonadherence was associated with lack of school support (P< 0.027). Access to a dietitian may improve the care of children with EGIDs.

The purpose of the present study was to identify barriers to dietary adherence found in the treatment of children with eosinophilic gastrointestinal diseases (EGIDs) and food allergy. A prospective study using a self-administered survey to parents of children with EGIDs at a national advocacy meeting was completed. Responses from 45 participants describing children ages 1 to 18 years (69 boys) identified that 63 were adherent to food restrictions. Physicians provided dietary instructions more often than dietitians. Nonadherence was associated with lack of school support (P<0.027). Access to a dietitian may improve the care of children with EGIDs.