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Anafy A, Mirkin Y, Galai T, Ben-Tov A, Moran-Lev H, Yerushalmy-Feler A, Cohen S, Amir AZ. Acute pancreatitis in children with inflammatory bowel disease: Risk factors, clinical course, and prognosis. J Pediatr Gastroenterol Nutr 2024; 79:325-334. [PMID: 38837432 DOI: 10.1002/jpn3.12279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/17/2024] [Accepted: 05/25/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVES To characterize the clinical course of acute pancreatitis (AP) in pediatric inflammatory bowel disease (IBD) patients compared to children with AP without IBD and to identify risk factors associated with AP among IBD patients. METHODS This retrospective, single-center study compared clinical characteristics of children (<19 years) with AP with and without concomitant IBD who were hospitalized 2005-2019. We also conducted a risk factor analysis of AP development in pediatric IBD. RESULTS Sixty-eight (54% males) patients with 120 episodes of AP were admitted at a median age of 15.3 years. Thirteen patients (14 episodes) had a co-diagnosis of IBD, representing 4% of our IBD patient population. The AP-IBD patients presented with lower amylase levels compared to the non-IBD patients (160 [interquartile range, IQR: 83-231] vs. 418 [IQR: 176-874] U/L, p > 0.01), all had a mild pancreatitis, and none required invasive intervention. The presumed etiology for AP in all IBD patients was IBD-related: IBD flare-up in five, side effects of medications in two, and undetermined in seven. The only risk factor for AP development among IBD patients was IBD-associated arthritis (23% vs. 3% for IBD-non-AP, p = 0.04), while extracolonic Crohn's disease and induction therapy with nutrition were negative risk factors (15% vs. 51%, p = 0.05, and 8% vs. 44%, p = 0.04, respectively). Other parameters, including disease type and medications, were nonsignificant. CONCLUSION The clinical course of AP in pediatric IBD patients is mild. Only IBD-associated arthritis emerged as a risk factor for the development of AP, while, unexpectedly, IBD medication did not.
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Affiliation(s)
- Adi Anafy
- The Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, The Faculty of Medical & Health Sciences, Tel-Aviv, Israel
| | - Yehoshua Mirkin
- Tel Aviv University, The Faculty of Medical & Health Sciences, Tel-Aviv, Israel
| | - Tut Galai
- The Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, The Faculty of Medical & Health Sciences, Tel-Aviv, Israel
| | - Amir Ben-Tov
- The Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, The Faculty of Medical & Health Sciences, Tel-Aviv, Israel
| | - Hadar Moran-Lev
- The Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, The Faculty of Medical & Health Sciences, Tel-Aviv, Israel
| | - Anat Yerushalmy-Feler
- The Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, The Faculty of Medical & Health Sciences, Tel-Aviv, Israel
| | - Shlomi Cohen
- The Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, The Faculty of Medical & Health Sciences, Tel-Aviv, Israel
| | - Achiya Z Amir
- The Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, The Faculty of Medical & Health Sciences, Tel-Aviv, Israel
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Fathema K, Karim B, Al-Azad S, Rukunuzzaman M, Ahmed M, Rifah TJ, Saha D, Benzamin M. Computed Tomography Assessment of Severity of Acute Pancreatitis in Bangladeshi Children. Pediatr Gastroenterol Hepatol Nutr 2024; 27:176-185. [PMID: 38818279 PMCID: PMC11134178 DOI: 10.5223/pghn.2024.27.3.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/10/2023] [Accepted: 10/30/2023] [Indexed: 06/01/2024] Open
Abstract
Purpose Acute pancreatitis (AP) is common among children in Bangladesh. Its management depends mainly on risk stratification. This study aimed to assess the severity of pediatric AP using computed tomography (CT). Methods This cross-sectional, descriptive study was conducted in pediatric patients with AP at the Department of Pediatric Gastroenterology and Nutrition, BSMMU, Dhaka, Bangladesh. Results Altogether, 25 patients with AP were included, of whom 18 (mean age, 10.27±4.0 years) were diagnosed with mild AP, and 7 (mean age, 10.54±4.0 years) with severe AP. Abdominal pain was present in all the patients, and vomiting was present in 88% of the patients. Etiology was not determined. No significant differences in serum lipase, serum amylase, BUN, and CRP levels were observed between the mild and severe AP groups. Total and platelet counts as well as hemoglobin, hematocrit, serum creatinine, random blood sugar, and serum alanine aminotransferase levels (p>0.05) were significantly higher in the mild AP group than in the severe AP group (p=0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of CT severity index (CTSI) were 71.4%, 72.2%, 50%, and 86.7%, respectively. In addition, significant differences in pancreatic appearance and necrosis were observed between the two groups on CT. Conclusion CT can be used to assess the severity of AP. In the present study, the CTSI effectively assessed the severity of AP in pediatric patients.
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Affiliation(s)
- Kaniz Fathema
- Department of Pediatric Gastroenterology and Nutrition, Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh
| | - Bazlul Karim
- Department of Pediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Salahuddin Al-Azad
- Department of Radiology and Imaging, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Md. Rukunuzzaman
- Department of Pediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Mizu Ahmed
- Department of Dermatology, Shahid Syed Nazrul Islam Medical College Hospital, Kishoregonj, Bangladesh
| | - Tasfia Jannat Rifah
- Department of Pediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Dipanwita Saha
- Department of Pediatric Gastroenterology and Nutrition, Comilla Medical College, Comilla, Bangladesh
| | - Md. Benzamin
- Department of Pediatric Gastroenterology and Nutrition, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh
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Devecí U, Ünsal SK, Dogan Y. A Retrospective Review of Children followed up with the Diagnosis of Acute Pancreatitis. Niger J Clin Pract 2023; 26:1876-1885. [PMID: 38158356 DOI: 10.4103/njcp.njcp_441_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/23/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Acute pancreatitis (AP) is an inflammatory disease of the pancreas, the frequency of which increases in childhood. AIM To investigate the demographic, etiological, clinical, laboratory, and radiological characteristics of children followed up with the diagnosis of AP. The study also included genetic studies of recurrent cases. MATERIALS AND METHODS This retrospective cohort study included pediatric patients <18 years of age with AP who were followed up with recurrent pancreatitis in the Pediatrics Department of a University Hospital between January 2010 and April 2021. Patients who met at least 2 of the 3 criteria defined by the International Pediatric Pancreatitis Study Group (INSPPIRE) were accepted as AP. Demographic, etiological, and clinical data of the patients, developing complications, pathological evaluation of the samples, and genetic analysis results were obtained from the patient files. The obtained data were statistically analyzed using the SPSS version 26.0 program. Descriptive statistics of the data were expressed as mean ± standard deviation, median, minimum and maximum values, number (n), and percentage (%). Kolmogorov-Smirnov test, Mann Whitney U test, Chi-square test and Fischer test were used. RESULTS Fifty-four (50%) female and 54 (50%) male patients with a mean age of 9.96 ± 4.8 years who met the study criteria were included in the study. In the follow-up, it was reported that acute recurrent pancreatitis developed in 23 (21%) patients and chronic pancreatitis developed in 8 (7%) patients. The most common complaints were abdominal pain (94.4%), and vomiting (60.2%), followed by malnutrition (36.1%), nausea (17.6%), diarrhea (13%), and fever (13%). Etiology could not be determined in 19.4% of the patients. It was noted that the genetic predisposition of the patients played a role in the development of recurrent and chronic pancreatitis. Amylase, lipase, and CRP values, which are among the laboratory parameters showing the severity and prognosis of AP, were found to be significant. CONCLUSIONS Sociocultural and demographic data of the patients should also be taken into account. Gene sequences that cause to genetic predisposition should be determined in recurrent and chronic pancreatitis cases. Acute pancreatitis should be considered in the differential diagnosis of patients with frequent abdominal pain and vomiting.
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Affiliation(s)
- U Devecí
- Departments of Pediatric Gastroenterology, Hepatology and Nutrition, Elazig/Türkiye
| | - S K Ünsal
- Pediatrics, Firat University School of Medicine, Elazig/Türkiye
| | - Y Dogan
- Departments of Pediatric Gastroenterology, Hepatology and Nutrition, Elazig/Türkiye
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Ikeda M, Kikuta K, Hamada S, Takikawa T, Matsumoto R, Sano T, Sasaki A, Sakano M, Tarasawa K, Fujimori K, Fushimi K, Masamune A. Trends and clinical characteristics of pediatric acute pancreatitis patients in Japan: A comparison with adult cases based on a national administrative inpatient database. Pancreatology 2023; 23:797-804. [PMID: 37827972 DOI: 10.1016/j.pan.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/12/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND /Objectives: Pediatric acute pancreatitis (AP) is not as rare as previously thought, and an increased incidence thereof has been reported. We aimed to clarify the trends and clinical characteristics of pediatric AP in Japan. METHODS We utilized the Japanese Diagnosis Procedure Combination inpatient database for patients admitted between April 2012 and March 2021, and extracted the data of patients whose principal diagnosis was AP (ICD-10 code K85) or in whom AP accounted for most of the medical expenses. Patients were classified into pediatric (≤18 years) and adult (age >18 years) groups. RESULTS We included 3941 AP cases in pediatrics and 212,776 in adults. AP cases accounted for 0.08 % of all admissions in pediatrics and 0.33 % in adults, with upward trends during the study period. The proportion of AP patients among all admissions was increased with advancing age in pediatrics. Compared to adults, pediatric AP patients had a smaller proportion of severe cases (22.9 % vs. 28.7 %; P < 0.001), fewer interventions for late complications (0.2 % vs. 1.3 %; P < 0.001), shorter hospital stays (mean 16.6 days vs. 18.0 days; P = 0.001), lower overall mortality (0.7 % vs. 2.9 %; P < 0.001), and lower mortality in severe cases (1.3 % vs. 5.6 %; P < 0.001). Pediatric cases were more frequently transferred from other institutions and treated at academic hospitals than adults (both P < 0.001). CONCLUSIONS There was an upward trend in the proportion of AP among all admissions in pediatrics, with a lower risk of complications and mortality than adult cases.
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Affiliation(s)
- Mio Ikeda
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kazuhiro Kikuta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Shin Hamada
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Tetsuya Takikawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Ryotaro Matsumoto
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Takanori Sano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Akira Sasaki
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Misako Sakano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kunio Tarasawa
- Division of Health Administration and Policy, Tohoku University Graduate School of Medicine, Japan
| | - Kenji Fujimori
- Division of Health Administration and Policy, Tohoku University Graduate School of Medicine, Japan
| | - Kiyohide Fushimi
- Division of Health Policy and Informatics, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan.
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Juhász MF, Sipos Z, Ocskay K, Hegyi P, Nagy A, Párniczky A. Admission risk factors and predictors of moderate or severe pediatric acute pancreatitis: A systematic review and meta-analysis. Front Pediatr 2022; 10:947545. [PMID: 36245710 PMCID: PMC9561825 DOI: 10.3389/fped.2022.947545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Pediatric acute pancreatitis (PAP) has an increasing incidence and is now estimated to be almost as common as in adults. Up to 30% of patients with PAP will develop moderate or severe disease course (M/SPAP), characterized by organ failure, local or systemic complications. There is still no consensus regarding on-admission severity prediction in these patients. Our aim was to conduct a systematic review and meta-analysis of available predictive score systems and parameters, and differences between on-admission parameters in mild and M/SPAP. Methods We conducted a systematic search on the 14th February, 2022 in MEDLINE, Embase and CENTRAL. We performed random-effects meta-analysis of on-admission differences between mild and M/SPAP in laboratory parameters, etiology, demographic factors, etc. calculating risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) and created forest plots. For the meta-analysis of predictive score systems, we generated hierarchical summary receiver operating characteristic curves using a bivariate model. Chi-squared tests were performed and I2 values calculated to assess statistical heterogeneity. Results We included 44 studies - mostly retrospective cohorts - in our review. Among predictive score systems examined by at least 5 studies, the modified Glasgow scale had the highest specificity (91.5% for values ≥3), and the Pediatric Acute Pancreatitis Severity score the highest sensitivity (63.1% for values ≥3). The performance of other proposed score systems and values were summarized. Traumatic (RR: 1.70 95% CI: 1.09-2.67) and drug-induced (RR: 1.33 95% CI: 0.98-1.87) etiologies were associated with a higher rate of M/SPAP, while anatomical (RR: 0.6195% CI: 0.38-0.96) and biliary (RR: 0.72 95% CI: 0.53-0.99) PAP tended to be less severe. Discussion Many predictive score systems were proposed to assess the possibility of M/SPAP course. The most commonly used ones exhibit good specificity, but subpar sensitivity. Our systematic review provides a rigorous overview of predictive options assessed thus far, that can serve as a basis for future improvement of scores via the addition of parameters with a better observed sensitivity: e.g., lipase exceeding 7-times the upper threshold, hemoglobin, etc. The addition of etiological factors is another possibility, as they can herald a more severe disease course. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307271, PROSPERO, identifier: CRD42022307271.
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Affiliation(s)
- Márk Félix Juhász
- Heim Pál National Pediatric Institute, Budapest, Hungary
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Zoltán Sipos
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Klementina Ocskay
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary
- Centre for Translational Medicine, Department of Medicine, University of Szeged, Szeged, Hungary
- Division of Translational Medicine, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Anikó Nagy
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Andrea Párniczky
- Heim Pál National Pediatric Institute, Budapest, Hungary
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
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Tian G, Zhu L, Chen S, Zhao Q, Jiang T. Etiology, case fatality, recurrence, and severity in pediatric acute pancreatitis: a meta-analysis of 48 studies. Pediatr Res 2022; 91:56-63. [PMID: 33742133 DOI: 10.1038/s41390-021-01454-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/24/2020] [Accepted: 02/17/2021] [Indexed: 01/31/2023]
Abstract
For children, there are very few published reviews focusing on severe acute pancreatitis (AP). PubMed, EMBASE, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Wanfang data, EBSCO, and Cochrane Library were searched from inception until March 2020. Meta-regression analyses were used to estimate the etiology, case fatality, recurrence, and severity of pediatric AP in different regions (North America, Asia, South America, Europe, and Oceania). Pooled data from 47 papers (48 studies) found that main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate (CFR) of pediatric AP is 4.7% (North America), 6.2% (Europe), 2.4% (Asia), 3.1% (South America), and 7.4% (Oceania). The incidence rates of recurrent acute pancreatitis (RAP) in children who have had an episode of acute pancreatitis in North American, Asia, and Europe were 15.3, 13.1, and 13.8%, respectively. The incidence of severe acute pancreatitis (SAP) in different regions was 30.3% (Oceania), 29.2% (South America), 20.8% (Europe), 15.8% (Asia), and 13.7% (North America). It suggests that physicians should notice the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage. IMPACT: It indicates the etiology of pediatric acute pancreatitis for the initial assessment, diagnosis, and prediction of relapse. Main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate of pediatric AP is diverse worldwide. It suggests that physicians noticed the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage.
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Affiliation(s)
- Guo Tian
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pulsed Electric Field Technology Medical Transformation, Hangzhou, Zhejiang, China
| | - Lu Zhu
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shuochun Chen
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qiyu Zhao
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pulsed Electric Field Technology Medical Transformation, Hangzhou, Zhejiang, China
| | - Tian'an Jiang
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China. .,Zhejiang Provincial Key Laboratory of Pulsed Electric Field Technology Medical Transformation, Hangzhou, Zhejiang, China.
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Trout AT, Anupindi SA, Freeman AJ, Macias-Flores JA, Martinez JA, Parashette KR, Shah U, Squires JH, Morinville VD, Husain SZ, Abu-El-Haija M. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the Society for Pediatric Radiology Joint Position Paper on Noninvasive Imaging of Pediatric Pancreatitis: Literature Summary and Recommendations. J Pediatr Gastroenterol Nutr 2021; 72:151-167. [PMID: 33003171 DOI: 10.1097/mpg.0000000000002964] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT The reported incidence of pediatric pancreatitis is increasing. Noninvasive imaging, including ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), play important roles in the diagnosis, staging, follow-up, and management of pancreatitis in children. In this position paper, generated by members of the Pancreas Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the Abdominal Imaging Committee of The Society for Pediatric Radiology (SPR), we review the roles of noninvasive imaging in pediatric acute, acute recurrent, and chronic pancreatitis. We discuss available evidence related to noninvasive imaging, highlighting evidence specific to pediatric populations, and we make joint recommendations for use of noninvasive imaging. Further, we highlight the need for research to define the performance and role of noninvasive imaging in pediatric pancreatitis.
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Affiliation(s)
- Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center
- Department of Radiology
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sudha A Anupindi
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - A Jay Freeman
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | | | - J Andres Martinez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Kalyan R Parashette
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA
| | - Uzma Shah
- Pediatric Gastroenterology, Hepatology and Nutrition, Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA
| | - Judy H Squires
- Department of Radiology, University of Pittsburgh Medical Center, Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Veronique D Morinville
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Sohail Z Husain
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford School of Medicine, Stanford, CA
| | - Maisam Abu-El-Haija
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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