Clinical use of the long acting somatostatin analogue octreotide in pediatrics

Paediatric acute respiratory distress syndrome: consider the role of lymphatics

We present a case of a 7-day-old male infant with severe respiratory disease requiring venoarterial extracorporeal membrane oxygenation therapy with evidence of lymphangiectasia on lung biopsy. Differentiating primary versus secondary lymphangiectasis in this patient remains a riddle despite extensive investigations including an infective screen, lung biopsy and whole-genome sequencing. In addition to the standard therapies used in paediatric acute respiratory distress syndrome, such as lung-protective ventilation, permissive hypoxaemia and hypercarbia, nursing in the prone position, early use of muscle relaxants, rescue intravenous corticosteroids and broad-spectrum antibiotics, the patient was also given octreotide despite the absence of a chylothorax based on the theoretical benefit of altering the lymphatic flow. His case raises an interesting discussion around the role of lymphatics in the pathophysiology of paediatric and adult respiratory distress syndrome and prompts the exploration of novel agents which may affect lymphatic vessels used as an adjunctive therapy.

Somatostatin analogues for the treatment of hyperinsulinaemic hypoglycaemia

Hyperinsulinaemic hypoglycaemia (HH) is a biochemical finding of low blood glucose levels due to the dysregulation of insulin secretion from pancreatic β-cells. Under normal physiological conditions, glucose metabolism is coupled to β-cell insulin secretion so that blood glucose levels are maintained within the physiological range of 3.5-5.5 mmol/L. However, in HH this coupling of glucose metabolism to insulin secretion is perturbed so that insulin secretion becomes unregulated. HH typically occurs in the neonatal, infancy and childhood periods and can be due to many different causes. Adults can also present with HH but the causes in adults tend to be different. Somatostatin (SST) is a peptide hormone that is released by the delta cells (δ-cells) in the pancreas. It binds to G protein-coupled SST receptors to regulate a variety of location-specific and selective functions such as hormone inhibition, neurotransmission and cell proliferation. SST plays a potent role in the regulation of both insulin and glucagon secretion in response to changes in glucose levels by negative feedback mechanism. The half-life of SST is only 1-3 min due to quick degradation by peptidases in plasma and tissues. Thus, a direct continuous intravenous or subcutaneous infusion is required to achieve the therapeutic effect. These limitations prompted the discovery of SST analogues such as octreotide and lanreotide, which have longer half-lives and therefore can be administered as injections. SST analogues are used to treat different forms of HH in children and adults and therapeutic effect is achieved by suppressing insulin secretion from pancreatic β-cells by complex mechanisms. These treatments are associated with several side effects, especially in the newborn period, with necrotizing enterocolitis being the most serious side effect and hence SS analogues should be used with extreme caution in this age group.

Octreotide and enterocutaneous fistula closure in neonates and children

Enterocutaneous fistula and its conservative management still pose a challenge for the surgeon. The use of octreotide and somatostatin in neonates and children as adjunctive therapy in the conservative management of this condition, leads to major controversy regarding its efficacy. Therefore, we conducted an extensive literature review of published articles regarding the use of somatostatin and its analogues in the treatment of enterocutaneous fistula in neonates and children. Our review is then presented together with a case vignette and discusses the different practical aspects of the treatment with these drugs.

CONCLUSION

The major diversity in treatment regimens among published studies makes outcomes difficult to compare. However, given the results of the different cases reported in the literature and of our own experience, we suggest a possible beneficial effect of octreotide and somatostatin on closure of enterocutaneous fistula in these patients.

Use of octeriotide in the management of neonatal chylothorax secondary to repair of congenital diaphragmatic hernia: a report of two cases and review of literature

Chylothorax, a known complication of surgery for Congenital Diaphragmatic hernia, can sometimes be resistant to treat. Octeriotide (Somatostatin analogue) can be useful in this situation. However, the dose and schedule of Octeriotide therapy in neonates is not well established. We report two cases of resistant chylothorax following surgery for congenital diaphragmatic hernia which were successfully managed by using an escalating infusion of octeriotide. The literature on the subject is also reviewed.

Octreotide in Hennekam syndrome-associated intestinal lymphangiectasia

A number of disorders have been described to cause protein losing enteropathy (PLE) in children. Primary intestinal lymphangiectasia (PIL) is one mechanism leading to PLE. Few syndromes are associated with PIL; Hennekam syndrome (HS) is one of them. The principal treatment for PIL is a high protein, low fat diet with medium chain triglycerides supplementation. Supportive therapy includes albumin infusion. Few publications have supported the use of octreotide to diminish protein loss and minimize hypoalbuminemia seen in PIL. There are no publications on the treatment of PIL with octreotide in patients with HS. We report two children with HS and PLE in which we used octreotide to decrease intestinal protein loss. In one patient, octreotide increased serum albumin to an acceptable level without further need for albumin infusions. The other patient responded more dramatically with near normal serum albumin levels and cessation of albumin infusions. In achieving a good response to octreotide in both patients, we add to the publications supporting the use of octreotide in PIL and suggest that octreotide should be tried in patients with PIL secondary to HS. To the best of our knowledge, this is the first case report on the use of octreotide in HS-associated PIL.

Therapeutic applications of octreotide in pediatric patients

BACKGROUND/AIM

We report our experience with the use of octreotide as primary or adjunctive therapy in children with various gastrointestinal disorders.

PATIENTS AND METHODS

A pharmacy database identified patients who received octreotide for gastrointestinal diseases. Indications for octreotide use, dosing, effectiveness, and adverse events were evaluated by chart review.

RESULTS

A total of 21 patients (12 males), aged 1 month to 13 years, were evaluated. Eleven received octreotide for massive gastrointestinal bleeding caused by portal hypertension-induced lesions (n=7), typhlitis (1), Meckel's diverticulum (1), and indefinite source (2). Blood transfusion requirements were reduced from 23 ± 9 mL/kg (mean ± SD) to 8 ± 15 mL/kg (P<0.01). Four patients with pancreatic pseudocyst and/or ascites received octreotide over 14.0 ± 5.7 days in 2 patients. In 3 children, pancreatic pseudocyst resolved in 12 ± 2 days and pancreatic ascites resolved in 7 days in 2. Three patients with chylothorax received octreotide for 14 ± 7 days with complete resolution in each. Two infants with chronic diarrhea received octreotide over 11 ± 4.2 months. Stool output decreased from 85 ± 21 mL/kg/day to 28 ± 18 mL/kg/day, 3 months after initiation of octreotide. The child with dumping syndrome responded to octreotide in a week. Adverse events developed in 4 patients: Q-T interval prolongation and ventricular fibrillation, hyperglycemia, growth hormone deficiency, and hypertension.

CONCLUSION

Octreotide provides a valuable addition to the therapeutic armamentum of the pediatric gastroenterologist for a wide variety of disorders. Serious adverse events may occur and patients must be closely monitored.

Prevention and management of asparaginase/pegasparaginase-associated toxicities in adults and older adolescents: recommendations of an expert panel

The rapidly increasing use of pegasparaginase (pegASNase) in adults, after a half century of use of asparaginase (ASNase) in children, has prompted a need for guidelines in the management and prevention of toxicities of asparagine depletion in adults. Accordingly, an initial set of recommendations are provided herein. Major advantages of pegASNase are its 2-3-week duration of action, in contrast to less than 3 days with native ASNase, and the flexibility of intravenous or intramuscular administration of pegASNase and associated patient and physician convenience. The most frequent toxicities of both types of ASNase are hepatic and pancreatic, with pancreatitis being the most serious. Other toxicities are hypersensitivity reactions, thrombosis, nausea/vomiting, and fatigue. Whether or not the replacement of one dose of pegASNase for 6-9 doses of native ASNase can be achieved in adults with similar efficacy and acceptable toxicities to those achieved in children remains to be established.

Mediastinal ganglioneuroblastoma-secreting vasoactive intestinal peptide causing secretory diarrhoea

In this case report we describe a case of mediastinal ganglioneuroblastoma-secreting vasoactive intestinal peptide (VIP), causing secretory diarrhoea in an 18-month-old child. An 18-month-old girl presented with a 2-month history of diarrhoea, abdominal distension and weight loss. Investigations revealed secretory diarrhoea with hypokalaemia, hyponatraemia and hypochloraemia and metabolic acidosis. Her stool output was 2.5-3.lday(-1) with increased stool sodium. VIP levels were strikingly high with normal glucagon and gastrin levels. X-ray of the chest revealed a well-defined mass in the right upper zone with tracheal shift, which was confirmed with computed tomography (CT) of the chest. The mass was resected and the patient became asymptomatic. This case shows that secretory diarrhoea caused by VIP and produced by ganglioneuroblastoma indicates a favourable prognosis, provided it is resectable.

Management of portal hypertension in children

Management of portal hypertension in children has evolved over the past several decades. Portal hypertension can result from intrahepatic or extrahepatic causes. Management should be tailored to the child based on the etiology of the portal hypertension and on the functionality of the liver. The most serious complication of portal hypertension is gastroesophageal variceal bleeding, which has a mortality of up to 30%. Initial treatment of bleeding focuses on stabilizing the patient. Further treatment measures may include endoscopic, medical, or surgical interventions as appropriate for the child, depending on the cause of the portal hypertension. β-Blockers have not been proven to effectively prevent primary or secondary variceal bleeding in children. Sclerotherapy and variceal band ligation can be used to stop active bleeding and can prevent bleeding from occurring. Transjugular intrahepatic portosystemic shunts and surgical shunts may be reserved for those who are not candidates for transplant or have refractory bleeding despite medical or endoscopic treatment.

[Octreotide therapy for persistent hyperinsulinemic hypoglycemia of infancy]

This paper presents a clinical case of persistent hyperinsulinemic hypoglycemia of infancy (PHHI) and a literature review on this subject. We report on a newborn who presented with hypoglycemic episodes in her first 24 hs of life and was treated successfully with octreotide until the moment. PHHI is the most common cause of persistent hyperinsulinism in infancy and can be hazardous for the development of the central nervous system. There are few current options for clinical treatment, with variable efficacy, and octreotide seems to be the best option before surgical treatment, the only way to control the disease. Preoperative evaluation allows one to adequately distinguish between focal or diffuse processes and suggests the extension of pancreatic resection, improving surgical results and reducing the incidence of postoperative sequelae. Partial pancreatectomy is the procedure of choice in focal disease.

Somatostatin or octreotide as treatment options for chylothorax in young children: a systematic review

OBJECTIVE

Chylothorax is a rare but life-threatening condition in children. To date, there is no commonly accepted treatment protocol. Somatostatin and octreotide have recently been used for treating chylothorax in children. We set out to summarise the evidence on the efficacy and safety of somatostatin and octreotide in treating young children with chylothorax.

DESIGN

Systematic review: literature search (Cochrane Library, EMBASE and PubMed databases) and literature hand search of peer reviewed articles on the use of somatostatin and octreotide in childhood chylothorax.

PATIENTS

Thirty-five children treated for primary or secondary chylothorax (10/somatostatin, 25/octreotide) were found.

RESULTS

Ten of the 35 children had been given somatostatin, as i.v. infusion at a median dose of 204 microg/kg/day, for a median duration of 9.5 days. The remaining 25 children had received octreotide, either as an i.v. infusion at a median dose of 68 microg/kg/day over a median 7 days, or s.c. at a median dose of 40 microg/kg/day and a median duration of 17 days. Side effects such as cutaneous flush, nausea, loose stools, transient hypothyroidism, elevated liver function tests and strangulation-ileus (in a child with asplenia syndrome) were reported for somatostatin; transient abdominal distension, temporary hyperglycaemia and necrotising enterocolitis (in a child with aortic coarctation) for octreotide.

CONCLUSIONS

A positive treatment effect was evident for both somatostatin and octreotide in the majority of reports. Minor side effects have been reported, however caution should be exercised in patients with an increased risk of vascular compromise as to avoid serious side effects. Systematic clinical research is needed to establish treatment efficacy and to develop a safe treatment protocol.

Reduction of excessive height in boys by bilateral percutaneous epiphysiodesis around the knee

In this study, the results of percutaneous epiphysiodesis as a surgical method to decrease final height is described in 15 boys with a predicted final height of more than 205 cm. A total of 17 boys with a height prediction between 195 and 209 cm without treatment were included as controls. The study period was from 1995-2002 and patients were followed for a mean period of 3.9 years (range 2.3-6.5 years) after surgery; controls were followed for 8.3 years (range 2.0-12.1 years). Final height in the treated boys was 203.6 cm (range 195.5-214.5 cm) compared to the predicted height of 210.6 cm (range 205.7-222.7 cm). The reduction in final height versus the predicted height was 7 cm and ranged between 1.2 and 13.8 cm. Final height in the control boys was 199.9 cm (range 191.3-206.7 cm). No significant side-effects of epiphysiodesis were observed. Besides final height reduction, epiphysiodesis resulted in normalisation of body proportions, expressed as the subischial leg length/sitting height ratio. This ratio in the operated patients at final height was 0.96 (range 0.90-1.01) and in the controls 0.94 (range 0.88-1.03).

CONCLUSION

Epiphysiodesis can be advised as a method to decrease final height in boys with predicted tall stature. An additional advantage of this method is a normalisation of body proportions.

Congenital chylothorax treated with octreotide

Congenital chylothorax is the accumulation of lymphatic fluid within the pleural space. Cases unresponsive to conservative management usually require surgery. Octreotide has been used successfully to treat post-traumatic chylothoraces in the pediatric and adult population. Its exact mode of action is uncertain but it is believed to reduce lymphatic drainage by a direct action on splanchnic lymph flow. We report a case of congenital chylothorax where surgery was avoided with the compassionate trial of the somatostatin analogue, octreotide. A 33 week gestation female infant, born with the presence of large bilateral pleural effusion, was unresponsive to conservative management. Octreotide was commenced on day 15, with 10 days of an octreotide infusion, initially 0.5 microg/kg per hour and increased daily by 1 microg/kg per hour to 10 microg/kg per hour. Treatment was associated with prompt respiratory improvement prior to cessation of pleural drainage over the 10 day. She remains well at 6 months of age. Further studies are required to ascertain its true value in congenital chylothorax.

L-asparaginase-induced severe necrotizing pancreatitis successfully treated with percutaneous drainage

L-asparaginase is a key component of the antileukemic therapy in children with acute lymphoblastic leukemia (ALL). Pancreatitis has been noted to be a complication in 2-16% of patients undergoing treatment with L-asparaginase for a variety of pediatric neoplasms. Most cases of pancreatitis associated with L-asparaginase toxicity are self-limiting and respond favorably to nasogastric decompression and intravenous hyperalimentation. However, in rare instances, hemorrhagic pancreatitis or necrosis may occur. L-asparaginase-induced pancreatitis is an uncommon but potential lethal complication of the treatment of leukemia. We present a pediatric patient with leukemia and a severe, L-asparaginase-induced necrotizing pancreatitis, treated successfully with percutaneous drainage used to flush the infected necrotic parts.

Successful use of somatostatin in a case of neonatal chylothorax

A 2-week-old infant status postrepair of gastroschisis had spontaneous bilateral chylothoraces necessitating thoracostomy drainage. Voluminous chylous drainage persisted despite cessation of enteral feedings. On administration of the somatostatin analogue octreotide, pleural drainage diminished markedly and ceased entirely within 4 days. These results, along with reported successes in treatment of chylothorax after thoracic surgery, support the prospective investigation of somatostatin use in problematic chylothorax.

[Octreotide treatment of post surgical chylothorax]

Chylothorax is an infrequent complication of cardiac surgery in children. Most patients respond to a low-fat diet or to parenteral nutrition, but pleuroperitoneal drainage or thoracic duct ligature is sometimes required. We present the case of a 3-year-old girl with Down syndrome and complex atrioventricular canal defect who presented chylothorax 22 days after the Glenn procedure with bidirectional pulmonary-cava fistula. Low-fat diet and parenteral nutrition produced no improvement and the patient was treated with octreotide 1-2 mcg/kg/min in intravenous continuous perfusion, which produced remission of chylothorax. Subsequently, 20 mcg/kg/day of octreotide was subcutaneously administered in three doses, allowing progressive dietary normalization, without recurrence of chylothorax or adverse effects. In conclusion, octreotide is well tolerated and produces few adverse effects. It could be used as a therapeutic alternative in chylothorax refractory to conservative treatment.

Initial experience with octreotide in the pediatric population

Octreotide is a somatostatin analogue that has been suggested as a therapeutic agent in various diverse disease processes including gastrointestinal bleeding, pancreatitis, hypoglycemia related to hyperinsulin states, and chylous peritoneum/thorax. Despite successful use in the adult population, there is limited information concerning its use in pediatric patients. The authors retrospectively review their experience with octreotide in 10 infants and children ranging in age from 14 days to 17 years. Octreotide, administered by continuous intravenous infusion or intermittent bolus dosing, was used in the treatment of gastrointestinal bleeding in four patients, pancreatitis in three patients, chylous leaks in two patients, and hypoglycemia related to nesidioblastosis in one patient. The clinical course of these patients and the potential therapeutic impact of octreotide are evaluated. Additionally, previous experiences with octreotide in pediatric patients, dosing regimens, and the potential role of the drug in other disease processes are discussed.

Pancreatitis in the Pediatric ICU Patient

Several factors may be involved in the etiology of pancreatitis, including traumatic injury, drugs, toxins, infectious agents, and biliary disease. As opposed to the general pediatric population, the diagnosis in the pediatric intensive care unit (PICU) population may be masked by the inability of the patient to communicate due to associated disease processes, use of sedative/analgesic agents, or altered cognitive function. Due to these issues, a high index of suspicion is necessary to arrive at a timely diagnosis. This issue is of significant importance, as the compromised ICU patient may be unable to tolerate the added stress of a secondary illness such as pancreatitis. The authors present five cases, review the possible etiologies of pancreatitis in the PICU patient, and discuss its presentation in this unique patient population. The incidence in our PICU of five cases in approximately 1,200 admissions over an 18-month period suggests that this problem is of a greater magnitude than we would have previously thought.

Hypoglycemia in infants and children

Hypoglycemia is more common in the pediatric patient than in adults. This article discusses the many diagnoses that can be associated with hypoglycemia in infancy and childhood. A guide to help practitioners evaluate such patients and suggested treatments for many of these disorders are provided. As genetic diagnosis continues to develop, it is anticipated that the list of specific disorders associated with hypoglycemia in infancy and childhood will increase.

Growth hormone bioactivity and immunoactivity in tall children

In subjects with constitutional tall stature, both low and high GH response to stimulation tests have been observed when measured by commercial kits. To investigate the reason for these conflicting results, we evaluated growth hormone (GH) secretion using different assays as well as GH-binding protein and insulin-like growth factor-I (IGF-I) concentrations in tall children. Serum samples were collected from 22 prepubertal constitutionally tall children, aged 2.87-13.25 years, during two pharmacological tests to evaluate serum GH levels measured by both immunofluorometric assay (IFMA) and the Nb2 cell bioassay. Serum IGF-I values were evaluated by RIA. Circulating low affinity (LA) and high affinity (HA) GH-binding proteins (GHBPs) were evaluated by FPLC gel filtration. Considering the highest serum GH levels as measured by IFMA, the 22 tall subjects were divided into two groups: group A including 16 children with blunted serum GH peak levels (5.78+/-0.68 ng/ml) and group B including 6 subjects with normal serum GH peak values (15.73+/-1.56 ng/ml). No differences were observed in serum GH peak levels as measured by the Nb2 cell bioassay between group A (14.77+/-1.54 ng/ml) and group B (16.03+/-1.96 ng/ml), and between both groups and 11 age-and sex-matched controls (12.25+/-1.19 ng/ml). In group A, the Nb2 cell bioassay/IFMA ratio of serum GH peak levels (0.29+/-0.08) was significantly higher (p<0.05) than in group B (0.07+/-0.01). No differences were found in serum LA-GHBP and HA-GHBP as well as in IGF-I concentrations between the 16 patients of group A and the 6 of group B. Likewise, no difference in auxological parameters was found between the two groups. The biological activity of GH evaluated using the Nb2 cell bioassay is similar in tall children with a low GH response as measured by IFMA in comparison with those with a normal GH response, and is in agreement with both the auxological data and serum IGF-I concentrations.

Successful management with octreotide of a child with L-asparaginase induced hemorrhagic pancreatitis

BACKGROUND

Octreotide is a synthetic somatostatin analogue which has been suggested for use in the management of acute pancreatitis. While studies have looked at octreotide use in the setting of pancreatitis due to chronic alcohol use or trauma, little is known of its role in management of drug induced acute pancreatitis; particularly in the pediatric setting.

PATIENTS AND METHODS

We present a case of a 5 1/2-year-old white female who developed severe, necrotizing, hemorrhagic pancreatitis with pseudocyst formation secondary to L-asparaginase use as a part of her therapy for acute lymphoblastic leukemia (ALL). She was managed initially with intravenous fluids, bowel rest, nasogastric suctioning, parenteral narcotices, and broad spectrum antibiotics. In addition, within 12 hours of admission to The Children's Hospital (TCH) in Denver, Colorado, she began therapy with octreotide (5 micrograms/kg/day IV divided b.i.d.). With this management, her pseudocyst decompressed without need for surgical intervention, her pancreatitis fully resolved, and she recovered full pancreatic function without any long-term sequelae.

CONCLUSION

Use of octreotide may have served a role in limiting the severity of the disease process in this case. Further studies need to be done to verify its usefulness in this setting.

Surgical management of gastrointestinal endocrine tumours

The surgical management of gastrointestinal endocrine tumours must involve a multidisciplinary approach. The importance of accurate diagnosis, rendering the patient safe, and, in our opinion, localizing the tumour(s) before embarking on surgery cannot be overemphasized. Surgery is the only available treatment for cure. Occult primary tumours are now rarely a problem with novel imaging techniques, which can also improve detection and hence clearance of local spread. Surgical management in extensive metastatic or multicentric disease is less rigidly defined, and is dependent on the endocrine syndrome. A better understanding of tumour pathology, for example in MEN 1, has not always simplified matters. An appreciation of the benefit of chemotherapy, use of somatostatin analogues and hepatic artery embolization are vital to target appropriate palliative surgery. Hepatic transplantation may have an increasing role in the future. Surgical strategies must adapt to new medical treatments. If therapeutically relevant, advances in tumour biology (for example somatostatin receptor subtypes and growth factors) will influence surgical strategies in the future.

Somatostatin in the treatment of a pancreatic pseudocyst in a child

Pancreatic pseudocyst is a know complication of acute pancreatitis and pancreatic trauma. The treatment of pancreatitis remains a challenge and the pancreatic pseudocyst is often approached surgically. Lately, the use of somatostatin and its long-acting analogue octreotide have proved useful in the treatment of pancreatitis and its complications in adults. This is the first report on the use of somatostatin in the treatment of a pancreatic pseudocyst in a child. We present the case of a posttraumatic pancreatic pseudocyst in a 10-year-old boy, regressing rapidly under somatostatin treatment, by which means surgical re-intervention could be avoided.

Surgical management and treatment of pancreatic fistulas

Pancreatic fistulas most commonly derive as complications of elective surgical procedures on the pancreas and as sequelae of pancreatitis or pancreatic trauma. The majority of external pancreatic fistulas can be managed nonoperatively, with an expected rate of closure exceeding 80%. Internal fistulas are somewhat less likely to close with conservative measures alone. Octreotide has been shown to significantly reduce fistula output and to hasten the closure of both internal and external pancreatic fistulas without affecting the overall rates of closure. Operative therapy is reserved for the treatment of fistulas that do not respond to conservative medical management. In randomized prospective trials, prophylactic octreotide has been shown to reduce the morbidity of elective pancreatic resections with respect to overall complication and fistula formation rates. Surgical experience and technique appear to be the most important factors in determining the overall complication rates following elective pancreatic surgery.