Development of the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC) using a modified Delphi technique

One in three hospitalized children have disease-related malnutrition (DRM) upon admission to hospital, and all children are at risk for further nutritional deterioration during hospital stay; however, systematic approaches to detect DRM in Canada are lacking. To standardise and improve hospital care, the multidisciplinary pediatric working group of the Canadian Malnutrition Taskforce aimed to develop a pediatric, inpatient nutritional care pathway based on available evidence, feasibility of resources, and expert consensus. The working group (n = 13) undertook a total of four meetings: an in-person meeting to draft the pathway based on existing literature and modelled after the Integrated Nutrition Pathway for Acute Care (INPAC) in adults, followed by three online surveys and three rounds of online Delphi consensus meetings to achieve agreement on the draft pathway. In the first Delphi survey, 32 questions were asked, whereas in the second and third rounds 27 and 8 questions were asked, respectively. Consensus was defined as any question/issue in which at least 80% agreed. The modified Delphi process allowed the development of an evidence-informed, consensus-based pathway for inpatients, the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC). It includes screening <24 h of admission, assessment with use of Subjective Global Nutritional Assessment (SGNA) <48 h of admission, as well as prevention, and treatment of DRM divided into standard, advanced, and specialized nutrition care plans. Research is necessary to explore feasibility of implementation and evaluate the effectiveness by integrating P-INPAC into clinical practice.

Malnutrition care in hospitalized pediatric inpatients: comparison of perceptions and experiences across two pediatric academic health sciences centres

Malnutrition affects up to one in three Canadian children admitted to hospital. Awareness among pediatric healthcare providers (HCPs) of the prevalence and impacts of hospitalized malnutrition is critical for optimal management. The purpose of this study was to determine perceptions of malnutrition among pediatric HCP across two major academic health sciences centres, and to determine how the use of a standardized pediatric nutritional screening tool at one institution affects responses. Between 2020 and 2022, 192 HCPs representing nursing, dietetics, medicine, and other allied health were surveyed across McMaster Children's Hospital and The Hospital for Sick Children. 38% of respondents from both centres perceived rates of malnutrition between approximately one in three patients. Perceptions of the need for nutritional screening, assessment, and management were similar between centres. All respondents identified the need for better communication of hospitalized malnutrition status to community providers at discharge, and resource limitations affecting nutritional management of pediatric inpatients. This study represents the largest and most diverse survey of inpatient pediatric HCPs to date. We demonstrate high rates of baseline knowledge of hospital malnutrition, ongoing resource challenges, and the need for a systematic approach to pediatric nutritional management.

Functional contribution of the intestinal microbiome in autism spectrum disorder, attention deficit hyperactivity disorder, and Rett syndrome: a systematic review of pediatric and adult studies

Introduction

Critical phases of neurodevelopment and gut microbiota diversification occur in early life and both processes are impacted by genetic and environmental factors. Recent studies have shown the presence of gut microbiota alterations in neurodevelopmental disorders. Here we performed a systematic review of alterations of the intestinal microbiota composition and function in pediatric and adult patients affected by autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and Rett syndrome (RETT).

Methods

We searched selected keywords in the online databases of PubMed, Cochrane, and OVID (January 1980 to December 2021) with secondary review of references of eligible articles. Two reviewers independently performed critical appraisals on the included articles using the Critical Appraisal Skills Program for each study design.

Results

Our systematic review identified 18, 7, and 3 original articles describing intestinal microbiota profiles in ASD, ADHD, and RETT, respectively. Decreased Firmicutes and increased Bacteroidetes were observed in the gut microbiota of individuals affected by ASD and ADHD. Proinflammatory cytokines, short-chain fatty acids and neurotransmitter levels were altered in ASD and RETT. Constipation and visceral pain were related to changes in the gut microbiota in patients affected by ASD and RETT. Hyperactivity and impulsivity were negatively correlated with Faecalibacterium (phylum Firmicutes) and positively correlated with Bacteroides sp. (phylum Bacteroidetes) in ADHD subjects. Five studies explored microbiota-or diet-targeted interventions in ASD and ADHD. Probiotic treatments with Lactobacillus sp. and fecal microbiota transplantation from healthy donors reduced constipation and ameliorated ASD symptoms in affected children. Perinatal administration of Lactobacillus sp. prevented the onset of Asperger and ADHD symptoms in adolescence. Micronutrient supplementation improved disease symptomatology in ADHD without causing significant changes in microbiota communities' composition.

Discussion

Several discrepancies were found among the included studies, primarily due to sample size, variations in dietary practices, and a high prevalence of functional gastrointestinal symptoms. Further studies employing longitudinal study designs, larger sample sizes and multi-omics technologies are warranted to identify the functional contribution of the intestinal microbiota in developmental trajectories of the human brain and neurobehavior.

Systematic review registration

https://clinicaltrials.gov/, CRD42020158734.

Physical Activity in Pediatric Inflammatory Bowel Disease: A Scoping Review

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, systemic condition affecting the gastrointestinal tract. IBD can be severe and are associated with impairment in growth, school absences, abdominal pain, and fatigue. Physical activity (PA) could have an anti-inflammatory effect in addition to other benefits. It is important to address the possible risks, physiological effects of PA, and potential barriers, and facilitators for PA participation in pediatric IBD. However, potential barriers and facilitators to PA have yet to be adequately described.

METHODS

We conducted a scoping review to map and describe the current literature on PA in pediatric IBD populations between 1980 and April 2022 using Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines for Scoping reviews.

RESULTS

Nineteen articles were identified including 10 descriptive, 6 interventional, and 3 physiological responses to PA studies. Patients and healthy controls demonstrated similar responses to exercise. Barriers to participation were low self-esteem, body image, and active IBD symptoms. Facilitators included personal interest, activity with friends, and support from family.

CONCLUSION

This review highlighted that PA participation may reduce in children with IBD-related symptoms. Short- and medium-term impacts of PA on immune modulation require further study; it is possible that regular PA does not negatively affect biomarkers of disease activity.

Intestinal microbiome in short bowel syndrome: diagnostic and therapeutic opportunities

PURPOSE OF REVIEW

The intestinal microbiome plays a strong, complementary role in the development and integrity of the intestinal epithelium. This biology is crucial for intestinal adaptation, particularly after the mucosal insults that lead to short bowel syndrome (SBS). The purpose of this review is to discuss relationships between the intestinal microbiota and the physiology of intestinal adaptation.

RECENT FINDINGS

We will address interactions between the intestinal microbiome and nutritional metabolism, factors leading to dysbiosis in SBS, and common compositional differences of the gut microbiome in SBS patients as compared to healthy controls. We will also discuss novel opportunities to expand diagnostic and therapeutic interventions in this population, by using our knowledge of the microbiome to manipulate luminal bacteria and study their resultant metabolites. As microbial therapeutics advance across so many fields of medicine, this review is timely in its advocacy for ongoing research that focuses on the SBS population.Our review will discuss 4 key areas: 1) physiology of the intestinal microbiome in SBS, 2) clinical and therapeutic insults that lead to a state of dysbiosis, 3) currently available evidence on microbiome-based approaches to SBS management, and 4) opportunities and innovations to inspire future research.

SUMMARY

The clinical implications of this review are both current, and potential. Understanding how the microbiome impacts intestinal adaptation and host physiology may enhance our understanding of why we experience such clinical variability in SBS patients' outcomes. This review may also expand clinicians' understanding of what 'personalized medicine' can mean for this patient population, and how we may someday consider our nutritional, therapeutic, and prognostic recommendations based on our patients' host, and microbial physiology.

Significant vomiting and weight loss in a pediatric epilepsy patient secondary to vagus nerve stimulation: A case report and review of the literature

Vagus nerve stimulation is a neuromodulatory treatment option for individuals with drug resistant epilepsy who are not resective surgical candidates. As the vagus nerve has widespread neural connections, stimulation can lead to an array of adverse effects. While vomiting and weight loss are known side effects of vagus nerve stimulation, these are typically transient, mild, and do not limit the ability to continue treatment. We describe a 17-year-old female with drug resistant focal epilepsy secondary to tuberous sclerosis complex, who began to experience daily emesis and significant weight loss approximately 2.5 years after VNS device insertion. Her body mass index progressively fell from between the 75th-85th percentiles to less than the first percentile. She underwent extensive workup by neurology, gastroenterology, and adolescent medicine services with no obvious cause identified. Prior to the insertion of an enteral tube for feeding support and urgent weight restoration, her vagus nerve stimulator was switched off, resulting in immediate cessation of her vomiting and a dramatically rapid recovery of weight over the ensuing few months. This case emphasizes the need to consider adverse effects of vagus nerve stimulation in the differential diagnosis of patients with otherwise unexplained new medical sequelae, and provides evidence potentially linking vagal stimulation to significant malnutrition-related complications. Outside of GI-related effects, few studies have shown late-onset adverse effects from VNS, including laryngeal and facial pain as well as bradyarrhythmia. Further research is needed to elucidate the exact mechanisms of vagus nerve stimulation to better anticipate and mitigate adverse effects, and to understand the pathophysiology of late-onset adverse effects in previously tolerant VNS patients.

Generic Health-Related Quality of Life Utility Measure for Preschool Children (Health Utilities Preschool): Design, Development, and Properties

OBJECTIVES

Health Utilities Preschool (HuPS) was developed to fill the need for a generic preference-based measure (GPM) applicable in early childhood. A GPM has all the properties for higher-order summary measures, such as quality-adjusted life-years, required to inform important policy decisions regarding health and healthcare services.

METHODS

Development was in accordance with published standards for a GPM, statistical procedures, and modeling. HuPS incorporates key components of 2 existing measurement systems: Health Status Classification System for Preschool Children and Health Utilities Index Mark 3 (HUI3). The study included a series of 4 measurement surveys: definitional, adaptational, quantificational, and evaluational health-related quality of life (HRQL). HuPS measurements were evaluated for reliability, validity, interpretability, and acceptability.

RESULTS

Definitional measurements identified 8 Health Status Classification System for Preschool Children attributes in common with HUI3 (vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain and discomfort), making the HUI3 scoring equation commensurate with HuPS health states. Adaptational measurements informed the content of attribute-level descriptions (n = 35). Quantificational measurements determined level scoring coefficients. HRQL scoring inter-rater reliability (intraclass correlation coefficient = 0.79) was excellent. Continuity of HRQL scoring with HUI3 was reliable (intraclass correlation coefficient = 0.80, P < .001) and valid (mean absolute difference = 0.016, P = .396).

CONCLUSIONS

HuPS is an acceptable, reliable, and valid GPM. HRQL scoring is continuous with HUI3. Continuity expands the applicability of GPM (HUI3) scoring to include subjects as young as 2 years of age. Widespread applications of HuPS would inform important health policy and management decisions as HUI3 does for older subjects.

Evaluation of Hepatitis in Pediatric Patients With Presumed Nonalcoholic Fatty Liver Disease

In 2017, the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition published clinical practice guidelines for the assessment and diagnosis of nonalcoholic fatty liver disease (NAFLD). We determined how frequently these investigations suggest an alternate etiology for chronic hepatitis in 8- to 17-year-old patients with body mass index >85%, elevated alanine aminotransferase and radiographic steatosis, and rates of adherence to 2017 guidelines.

Methods

We conducted a retrospective chart review of patients presenting to McMaster Children's Hospital from 2017-2020 for evaluation of suspected NAFLD. Bloodwork was reviewed.

Results

Ninety-five patients met inclusion criteria. Abnormal bloodwork that required further testing was found in 28.4%; a different chronic liver disease was ultimately diagnosed in 11.6%. Only 9.5% received comprehensive, additional bloodwork for other causes of liver disease.

Conclusion

A high proportion of patients evaluated for suspected NAFLD had bloodwork possibly suggesting an alternate diagnosis. Comprehensive testing was infrequently performed. These results reinforce the importance of maintaining a differential diagnosis among children presumed to have NAFLD.

A66 THE IMPACT OF A MULTIDISCIPLINARY ADOLESCENT AND YOUNG ADULT (AYA) INFLAMMATORY BOWEL DISEASE (IBD) ON CLINIC NO SHOW RATES

Background

Transitioning from pediatric to adult health care is associated with significant psychosocial and clinical morbidity. Adolescents not only transition their medical care, but also experience vast changes in the physical, social, and psychological spheres of their lives. The medical team must help navigate these changes to provide optimal care.

IBD in adolescence is associated with increased hospitalizations and surgery. This is due to several factors, including medication non-adherence and a failure to attend medical appointments. There has been a greater focus on improving care for this unique population.

McMaster Children’s Hospital has integrated the AYA IBD clinic for patients between the ages of 16 and 22. The goal is to transition patients using a developmentally appropriate framework to facilitate self-efficacy and help identify comorbid mental health conditions while building resilience.

Aims

To explore the impact of the implementation of a dedicated transition clinic on attendance at medical visits for AYA patients with IBD.

Methods

The total numbers of patients booked in the AYA IBD Clinic was compared to an age matched subset of the patients in the adult McMaster Complex IBD (CIBD) Clinic. These visits were assessed based on whether the visit was: attended, cancelled, or no showed. Visits were then stratified between in-person and virtual visits. Unpaired t tests was performed to compare the AYA IBD clinic and the CIBD clinic. Findings were deemed significant based on p-values <0.05.

Results

The percentages of patients that attended visits (in-person or virtually) was similar between both clinics at 86% versus 79% Year 1 (Y1) and 76% versus 81% Year 2 (Y2). The number of patients seen in the AYA clinic increased from Y1 (n=92) to Y2 (n=131). The CIBD clinic saw fewer patients between Y1 (n=202) and Y2 (n=79). There were a higher number of patients who cancelled or no showed in Y2 versus Y1 for the AYA virtual visits (13 versus 8) compared to the CIBD clinic (Y2,1 versus Y1,1).

Conclusions

Our results highlight the challenges of transitioning adolescent patients with IBD. Our retrospective study was not powered to show significance. Given the increase in cancellation and no-show rates in Y2, the AYA clinic has incorporated a patient navigator to issue reminder phone calls and facilitate communication with patients between clinics. Future studies will re-assess how the presence of a patient navigator impacts attendance and cancellation rates. Future studies will also assess how the AYA clinic impacts transition readiness and self-efficacy, which is being measured through validated questionnaires in our clinic.

Funding Agencies

Grants-In-Aid

Nutritional Therapies and Their Influence on the Intestinal Microbiome in Pediatric Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic, autoimmune disorder of the gastrointestinal tract with numerous genetic and environmental risk factors. Patients with Crohn’s disease (CD) or ulcerative colitis (UC) often demonstrate marked disruptions of their gut microbiome. The intestinal microbiota is strongly influenced by diet. The association between the increasing incidence of IBD worldwide and increased consumption of a westernized diet suggests host nutrition may influence the progression or treatment of IBD via the microbiome. Several nutritional therapies have been studied for the treatment of CD and UC. While their mechanisms of action are only partially understood, existing studies do suggest that diet-driven changes in microbial composition and function underlie the diverse mechanisms of nutritional therapy. Despite existing therapies for IBD focusing heavily on immune suppression, nutrition is an important treatment option due to its superior safety profile, potentially low cost, and benefits for growth and development. These benefits are increasingly important to patients. In this review, we will describe the clinical efficacy of the different nutritional therapies that have been described for the treatment of CD and UC. We will also describe the effects of each nutritional therapy on the gut microbiome and summarize the strength of the literature with recommendations for the practicing clinician.

Pediatric Patient and Parent Perceptions of Fecal Microbiota Transplantation for the Treatment of Ulcerative Colitis

BACKGROUND

Fecal microbiota transplantation (FMT) has gained attention for its role in the treatment of ulcerative colitis (UC). Acceptance of this treatment, particularly among children and their parents, is an important aspect of assessing its feasibility for pediatric inflammatory bowel disease care. To date, no studies have assessed FMT acceptance among pediatric patients who underwent FMT treatment. Here, we explored the perceptions and experiences of FMT in a population of pediatric UC patients who participated in a recent FMT pilot randomized controlled trial.

METHODS

Children who received bi-weekly FMT treatments for 6 weeks through a clinical trial (NCT02606032) and their parents participated in face-to-face, semi-structured interviews led by study investigators. Interviews were audiotaped, transcribed, and analyzed using validated qualitative research methods.

RESULTS

Eight patients and eight parents were interviewed, with qualitative data summarized across four themes and 11 subthemes. The majority of participants perceived FMT as a "natural treatment" and cited lack of response to conventional medications and fear of medication side-effects as motivators for pursuing FMT. Pre-treatment, patients and parents expressed concerns regarding physical discomfort with FMT administration; post-treatment, most patients reported feeling "completely normal." Both patients and parents uniformly expressed interest in pursuing FMT again in the future if available. Convenience of medication therapies, and perceived naturality and efficacy of FMT were all endorsed.

CONCLUSIONS

This is the first study to describe pediatric and parent experiences receiving FMT. This information is valuable to develop and encourage future FMT trials involving children. Pre-treatment, concerns about FMT were common. Post-treatment, patients reported tolerance to FMT and a desire to continue receiving this therapy if available. Further trials of FMT in UC are needed. Investigators should include pediatric patients without concern of acceptance.

The neonatal microbiome in utero and beyond: perinatal influences and long-term impacts

The neonatal microbiome offers a valuable model for studying the origins of human health and disease. As the field of metagenomics expands, we also increase our understanding of early life influences on its development. In this review we will describe common techniques used to define and measure the microbiome. We will review in utero influences, normal perinatal development, and known risk factors for abnormal neonatal microbiome development. Finally, we will summarize current evidence that links early life microbial impacts on the development of chronic inflammatory diseases, obesity, and atopy.

Microbiota-Immune Interactions in Ulcerative Colitis and Colitis Associated Cancer and Emerging Microbiota-Based Therapies

Ulcerative colitis (UC) is a chronic autoimmune disorder affecting the colonic mucosa. UC is a subtype of inflammatory bowel disease along with Crohn's disease and presents with varying extraintestinal manifestations. No single etiology for UC has been found, but a combination of genetic and environmental factors is suspected. Research has focused on the role of intestinal dysbiosis in the pathogenesis of UC, including the effects of dysbiosis on the integrity of the colonic mucosal barrier, priming and regulation of the host immune system, chronic inflammation, and progression to tumorigenesis. Characterization of key microbial taxa and their implications in the pathogenesis of UC and colitis-associated cancer (CAC) may present opportunities for modulating intestinal inflammation through microbial-targeted therapies. In this review, we discuss the microbiota-immune crosstalk in UC and CAC, as well as the evolution of microbiota-based therapies.

Urinary Metabolites Enable Differential Diagnosis and Therapeutic Monitoring of Pediatric Inflammatory Bowel Disease

Rates of pediatric Crohn's disease (CD) and ulcerative colitis (UC) are increasing globally. Differentiation of these inflammatory bowel disease (IBD) subtypes however can be challenging when relying on invasive endoscopic approaches. We sought to identify urinary metabolic signatures of pediatric IBD at diagnosis, and during induction treatment. Nontargeted metabolite profiling of urine samples from CD (n = 18) and UC (n = 8) in a pediatric retrospective cohort study was performed using multisegment injection-capillary electrophoresis-mass spectrometry. Over 122 urinary metabolites were reliably measured from pediatric IBD patients, and unknown metabolites were identified by tandem mass spectrometry. Dynamic changes in sum-normalized urinary metabolites were also monitored following exclusive enteral nutrition (EEN) or corticosteroid therapy (CS) in repeat urine samples collected over 8 weeks. Higher urinary excretion of indoxyl sulfate, hydroxyindoxyl sulfate, phenylacetylglutamine, and sialic acid were measured in CD as compared to UC patients, but lower threonine, serine, kynurenine, and hypoxanthine (p < 0.05). Excellent discrimination of CD from UC was achieved based on the urinary serine:indoxylsulfate ratio (AUC = 0.972; p = 3.21 × 10^-5). Urinary octanoyl glucuronide, pantothenic acid, and pyridoxic acid were also identified as specific dietary biomarkers of EEN in pediatric IBD patients who achieved clinical remission. This work may complement or replace existing strategies in the diagnosis and early management of children with IBD.

Influence of bacterial components on the developmental programming of enteric neurons

BACKGROUND

Intestinal bacteria have been increasingly shown to be involved in early postnatal development. Previous work has shown that intestinal bacteria are necessary for the structural development and intrinsic function of the enteric nervous system in early postnatal life. Furthermore, colonization with a limited number of bacteria appears to be sufficient for the formation of a normal enteric nervous system. We tested the hypothesis that common bacterial components could influence the programming of developing enteric neurons.

METHODS

The developmental programming of enteric neurons was studied by isolating enteric neural crest-derived cells from the fetal gut of C57Bl/6 mice at embryonic day 15.5. After the establishment of the cell line, cultured enteric neuronal precursors were exposed to increasing concentrations of a panel of bacterial components including lipopolysaccharide, flagellin, and components of peptidoglycan.

KEY RESULT

Exposure to bacterial components consistently affected proportions of enteric neuronal precursors that developed into nitrergic neurons. Furthermore, flagellin and D-gamma-Glu-mDAP were found to promote the development of serotonergic neurons. Proportions of dopaminergic neurons remained unchanged. Proliferation of neuronal precursor cells was significantly increased upon exposure to lipopolysaccharide and flagellin, while no significant changes were observed in the proportion of apoptotic neuronal precursors compared to baseline with exposure to any bacterial component.

CONCLUSIONS AND INTERFACES

These findings suggest that bacterial components may influence the development of enteric neurons.

Lyophilized fecal short-chain fatty acid and electrolyte determination by capillary electrophoresis with indirect UV detection for assessment of pediatric inflammatory bowel disease

Short-chain fatty acids (SCFAs) and electrolytes are major constituents of human feces involved in maintaining gastrointestinal homeostasis that underlie complex diet, host and microbiome interactions. Reliable quantification of SCFAs and electrolytes is challenging given the heterogeneity of stool specimens from pediatric patients with diarrhea-predominate inflammatory bowel disease (IBD). Herein, we introduce two validated methods for determination of 3 SCFAs and 5 electrolytes consistently quantified from fecal extracts when using capillary electrophoresis with indirect UV detection (CE-iUV), where concentrations are normalized to total dried weight (mmol/kg d.w.). Lyophilization facilitates sample handling and extraction of heterogeneous stool specimens (∼ 15 mg) from a cohort of children with Crohn's disease (CD, n = 12) and ulcerative colitis (UC, n = 10) treated with exclusive enteral nutrition (EEN) or corticosteroid (CS) therapy to induce remission, respectively. Good technical precision (mean CV = 13 %, n = 14) and accuracy (recovery from 84 to 116%) is demonstrated for SCFAs and electrolytes from freeze dried stool extracts using a modified Bligh-Dyer protocol with low micromolar detection limits (∼ 2-15 μM). Fecal butyrate is 2.6-fold higher in CD as compared to UC patients (effect size = 1.51; p = 0.00291), and there is a strong co-linearity between fecal butyrate and acetate (r = 0.835) unlike propionate, which is correlated with fecal calprotectin (r = 0.517), a protein biomarker of intestinal inflammation. Also, a longitudinal study of matching stool samples collected from a sub-set of IBD patients revealed about a 7-fold enrichment in magnesium and calcium following 4 weeks of EEN as compared to baseline (F > 4.1 ; p < 0.05) unlike the CS treatment arm with no changes in other fecal SCFAs and electrolytes, including sodium, potassium, and ammonium. CE-iUV enables rapid fecal SCFA and electrolyte determination as required for new insights into the role of gut dysbiosis in IBD, as well as treatment monitoring of nutritional interventions that stabilize the disease course in affected children.

A retrospective three-year analysis using real-world data on uptake of broad-based NextGen sequencing panels in community oncology practices

e13668

Background: There are over 100 FDA approved targeted therapies across 15 cancer types, offering improved outcomes over existing therapies. However, many of these require genetic testing, for example, advanced non-small cell lung cancer (aNSCLC) patients have over 15 targeted therapies requiring a DNA-based test. Doing multiple tests can exhaust sample, while increasing cost and turn-around time. NGS panels, often with hundreds of genes, can address some of these issues. Here we asked across aNSCLC patients if the use of NGS panels has increased over the last 3 years in community oncology practices. Methods: The Integra Connect database, which includes electronic medical record (EMR) and claims data on over 1,000,000 US cancer patients, was queried across five community oncology practices to identify aNSCLC patients (stage IIIB or IV) treated between January 2017 and January 2020. Manual chart review abstracted tumor type, stage, treatment, and testing. Patients tested for all 7 NCCN recommended genes (EGFR, ALK, ROS1, BRAF, MET, RET, ERBB2) were grouped as “NGS Panel”, patients with less genes as “Single Gene/Small Panel”, and patients with no evidence of testing as “No Test”. A Chi-Square test was used to compare actionable results between patients with NGS panels versus small panels. Results: 1,007 aNSCLC patients were analyzed and showed a doubling of the use of broad-based NGS testing from 13% in 2017 to 26% in 2019 across over 100 oncologists (table). 23% of patients had actionable results when tested on broad-based panels versus 17% using single gene or small panels (p = .048). Targeted therapies were used in 17% of broad-based tested patients, versus 15% in patients tested for single genes or small panels. Conclusions: We see an uptake of broad-based NGS testing in community oncology, which can lead to more actionable results and better utilization of targeted therapies for those patients. However, this seems to be caused by providers shifting from small panels to large panels, rather than an overall increase in testing, as we do not see the percentage of untested patients decrease. [Table: see text]

A226 CHILD AND PARENT PERCEPTIONS OF FAECAL MICROBIOTA TRANSPLANT (FMT): QUALITATIVE PERSPECTIVES FROM PARTICIPANTS IN A TRIAL OF FMT FOR PEDIATRIC ULCERATIVE COLITIS

Background

Fecal microbiota transplant (FMT) is being increasingly studied across a range of therapeutic indications, including ulcerative colitis (UC). Pediatric patients may have unique responses to microbiome-based therapeutics, given their younger age, fewer comorbidities, and greater susceptibility to medication-related side effects.

Aims

We recently conducted the first pilot RCT of FMT in Canada for the treatment of pediatric ulcerative colitis (PediFETCh Trial) and conducted qualitative interviews post-study of participants and their parents. This study aims to describe the experience and perceptions of children who received FMT, and their parents.

Methods

Patients enrolled in the PediFETCh Trial (ClinicalTrials.gov: NCT02487238) and their parents were invited to participate in face-to-face, semi-structured interviews. Interviews were audiotaped, transcribed, and analyzed using open coding (NVivo 12 Pro).

Results

8 patients and 8 parents were interviewed. Our data has been summarized into 4 domains and 11 composite themes (Table 1). Most patients and parents saw FMT as a natural treatment. Pre-treatment, patients were concerned with receiving “someone else’s poo” and physical discomfort, while parents were concerned with transmission of enteric infections or psychiatric diseases. Both felt their decision to pursue FMT was influenced by frustration with previous lack of response to medications and a fear of medication side effects. Post-treatment, most patients and families expressed no concerns over potential future side effects as a result of the FMT, and all patients reported feeling “completely normal”. Patients were split between preferring FMT or medication, with convenience of medication being an important factor, while others favored FMT for its perceived naturality and symptomatic improvements. For most families, natural therapies and diet played an important role in influencing their decision to pursue FMT; however, several parents reported that alternative healthcare practitioners did not support their desire to pursue FMT.

Conclusions

The study offers valuable insights into pediatric patients’ and parents’ experiences receiving FMT across several themes. Our results suggest a high rate of acceptance and interest in FMT research by pediatric patients and their parents. These findings suggest strategies to improve future delivery of FMT in clinical trials, and should support inclusion of children in FMT-based studies.

Funding Agencies

Hamilton Health Sciences New Investigator Fund (2015, Spring); Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario (HAH-17-002)

A242 EXERCISE AND PHYSICAL ACTIVITY IN PEDIATRIC INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW AND RECOMMENDATIONS

Background

Inflammatory bowel disease (IBD) is a chronic life-long condition affecting 0.25% of the North American population. Childhood onset IBD is particularly aggressive, with disease often characterised by poor growth, severe unpredictable abdominal pain and frequent school absences. Treatment involves lifelong medications, which do not always resolve symptoms and carry increased cumulative risks of infections, malignancy, or other adverse effects. Exercise has been suggested as a method of ameliorating some of the symptoms associated with IBD. To date, few studies have investigated the role of exercise and physical activity in paediatric IBD patients.

Aims

We conducted a systematic review assessing the role of exercise and physical activity in paediatric IBD.

Methods

This Level III systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. An electronic database search of Pubmed, Google Scholar, and Cochrane used the search terms “(physical activity or exercise), (Inflammatory Bowel Disease), and (children or paediatric)”. Of the 1458 articles identified during the two rounds of review, only 21 articles met final inclusion criteria.

Results

Three main themes emerged from the review: 1) prescriptive exercise and physical activity ameliorated symptoms IBD and improved physical well-being, 2) patients who actively engage in exercise and physical activity show improved markers of inflammation and decreased future risk of disease, 3) exercise and physical activity improves the mental health and well-being of paediatric IBD patients. The results recommended 30–60 minutes, 6 times per week of mild to moderate aerobic exercise activity. It was noted that vigorous and high intensity exercise was well-tolerated by most IBD patients. Further, exercise prescription should be tailored to individual needs.

Conclusions

Exercise and physical activity improves mental and physical health and well-being of paediatric IBD patients, including decreasing the risk of future disease exacerbation in patients with mild to moderate disease activity. Clinicians and practitioners should consider actively prescribing exercise and physical activity to IBD patients as part of a standard treatment algorithm.

Funding Agencies

None

Protocol for a double-blind, randomised, placebo-controlled pilot study for assessing the feasibility and efficacy of faecal microbiota transplant in a paediatric Crohn's disease population: PediCRaFT Trial

INTRODUCTION

Crohn's disease (CD) is a chronic inflammatory condition with transmural involvement of the gastrointestinal tract. Extraintestinal manifestations are common, and the disease burden on patients and the healthcare system is significant. While treatment options have expanded in recent years, they have mainly focused on dampening the immune response, thus carrying notable risks associated with long-term immunosuppression. Faecal microbiota transplant (FMT) targets inflammatory bowel disease (IBD) by modifying intestinal dysbiosis. Limited adult and paediatric data have demonstrated a favourable response to FMT in IBD; however, no randomised controlled trial has yet been published in paediatrics. This double-blind, randomised, placebo-controlled pilot study will assess feasibility and efficacy outcomes of FMT in a paediatric CD population.

METHODS AND ANALYSIS

Forty-five patients between the ages of 3 and 17 years, with established CD or IBD unclassified, will be enrolled 2:1 to undergo FMT intervention or placebo control. Participants will undergo a colonoscopic infusion to the terminal ileum at baseline, followed by oral capsules two times per week for 6 weeks. Outcomes will be measured throughout the intervention period and 18 weeks of subsequent follow-up. Primary outcomes will assess feasibility, including patient recruitment, sample collection and rates of adverse events. Secondary outcomes will address clinical efficacy, including change in clinical response, change in urine metabolome and change in microbiome.

ETHICS AND DISSEMINATION

Ethics approval from the local hospital research ethics board was obtained at the primary site (McMaster Children's Hospital, Hamilton), with ethics pending at the secondary site (Centre Hospitalier Universitaire-Sainte-Justine, Montréal). RBX7455 and RBX2660 are human donor-sourced, microbiota-based therapeutic formulations. Both RBX7455 and RBX2660 are currently undergoing clinical trials to support potential US Food and Drug Administration approval. Approval to conduct this paediatric clinical trial was obtained from Health Canada's Biologics and Genetic Therapies Directorate. The results of this trial will be published in peer-reviewed journals and will help inform a large, multicentre trial in the future.

TRIAL REGISTRATION NUMBER

NCT03378167; pre-results.

Haemophilus parainfluenza bacteremia post-ERCP and cholecystectomy in a pediatric patient: A case report

Haemophilus parainfluenzae is a species that is commonly found in the human respiratory tract. It is an uncommon cause of gastrointestinal infection and bacteremia. Here, we present the case of a 17-year-old boy who developed H. parainfluenzae bacteremia and intraabdominal abscess after endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by elective cholecystectomy within 3 days. The patient was successfully treated with IV ceftriaxone with improvement in symptoms and progressive resolution of his abscess. We report a pediatric case of H. parainfluenzae infection occurring post-ERCP and cholecystectomy, and describe the convergence of two major risk factors for H. parainfluenzae bacteremia in the same pediatric patient.

Genomic testing and treatment landscape in patients with advanced non-small cell lung cancer (aNSCLC) using real-world data from community oncology practices

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Background: While aNSCLC is a leading cause of US cancer deaths, targeted therapies and immune checkpoint inhibitors (ICPi) have emerged as important new treatment options for these pts NCCN guidelines recommend testing of eight genes in aNSCLC patients at diagnosis. Targetable alterations (TA) in four genes, EGFR, ALK, ROS1, and BRAF, are associated with FDA-approved therapies. The labels for ICPis indicate that pts with TAs in EGFR and ALK are not candidates for first line treatment with ICPi. Methods: The Integra Connect database, which includes electronic medical record (EMR) and claims data on approximately 600,000 cancer patients, was queried across five community oncology practices (289 oncologists) to identify aNSCLC patients (stage 3B or 4) treated since January 2017. Manual review of charts was done to abstract tumor type/stage, drug regimens, and evidence of somatic genetic testing. A Wilcoxon rank sum test was used to test difference in time to results (TTR) for blood- vs tissue-based tests. Results: A total of 1,203 aNSCLC patients were identified. Testing rates varied from 54% for EGFR to 22% for all 4 genes (table). 163 patients had a TA in EGFR, ALK, ROS1 or BRAF, and 55% of these pts did not receive targeted therapy. 84 pts with TA’s in EGFR or ALK had no evidence of progression on targeted therapy, yet 31 (37%) received an ICPi; 24% had the TA test result prior to ICPi use and 13% received the TA result after starting ICPi. Median TTR for blood-based somatic tests was shorter than tissue-based tests (4 vs 14 days, p-value= 3.5-e07). Conclusions: Our analysis in the community oncology setting for aNSCLC pts finds evidence of underutilization of genomic testing, underutilization of targeted therapies, and ICPi use outside of label. Further research is needed to identify strategies to increase testing in aNSCLC pts to provide physicians with the information needed to make optimal treatment decisions. [Table: see text]

Development of the Pediatric Social Risk Instrument Using a Structured Panel Approach

BACKGROUND

Social determinants of health impact child illness. Currently, no instrument exists to identify social need during hospital admission.

METHODS

Using the UCLA (University of California Los Angeles)-RAND appropriateness method, consensus was reached for an instrument to identify social need in hospitalized children. A panel of 11 experts reviewed candidate indicators through 3 rounds to reach consensus. The instrument then underwent usability testing.

RESULTS

Three hundred and forty-seven indicators from the literature were sorted into 18 social risk themes. After 3 rounds, consensus was reached on 82 indicators. Six additional social risk themes were recommended by the panel, resulting in consensus for 18 additional indicators. Final refinement resulted in an instrument containing 86 indicators representing 11 social risk themes. Usability testing identified that the tool was well received by families. Final feedback was incorporated into a post-usability instrument.

CONCLUSIONS

Using the UCLA-RAND appropriateness method, a new pediatric social risk instrument was created to identify social need for hospitalized children.

Protocol for a randomised, placebo-controlled pilot study for assessing feasibility and efficacy of faecal microbiota transplantation in a paediatric ulcerative colitis population: PediFETCh trial

INTRODUCTION

Ulcerative colitis (UC) is a chronic, relapsing condition characterised by colonic inflammation. Increasing prevalence in early-age diagnosis provides opportunities for additional complications in later life as a result of prolonged exposure to inflammatory and therapeutic insults, necessitating novel avenues for therapeutics which may result in fewer side effects. Faecal microbiota transplantation (FMT) has previously demonstrated potential therapeutic benefit in an adult randomised-controlled trial and several recurrent Clostridium difficile infection studies. This phase Ib pilot will be the first randomised, single-blinded, placebo-controlled trial to assess feasibility and patient outcomes in a paediatric inflammatory bowel disease (IBD) population.

METHODS AND ANALYSIS

Fifty patients will be randomised 1:1 to receive normal saline control or active sample. Enema administrations will be performed two times per week for 6 weeks, followed at a 6-month follow-up period. Feasibility outcomes will include measures of patient eligibility, recruitment, willingness to participate, samples collections, hospitalizations and drop-out rate. Improvements in disease symptoms will determine the efficacy of treatment. Clinical disease scores will be taken throughout the study period using the Paediatric Ulcerative Colitis Activity Index (PUCAI). Monitoring of inflammatory markers in blood and stool will be performed at regular intervals. Microbiome analysis will be conducted on stool samples collected throughout the trials period. Imaging and endoscopic surveillance will be conducted if clinically necessary.

ETHICS AND DISSEMINATION

Ethics was obtained from local hospital research ethics boards across all three sites. Health Canada and FDA approval was obtained for the use of an Investigatory New Drug product. Results from this trial will be presented in international conferences and published in peer-review journals.

TRIAL REGISTRATION NUMBER

Trial registration number: NCT02487238; preresults.

Fecal microbial transplant for the treatment of pediatric inflammatory bowel disease

The role of fecal microbial transplant (FMT) in the treatment of pediatric gastrointestinal disease has become increasingly popular among pediatric practitioners, patients, and parents. The success of FMT for the treatment of recurrent Clostridium difficile infection (RCDI) has bolstered interest in its potential application to other disease states, such as inflammatory bowel disease (IBD). FMT has particular interest in pediatrics, given the concerns of patients and parents about rates of adverse events with existing therapeutic options, and the greater cumulative medication burden associated with childhood-onset disease. Published literature on the use of FMT in pediatrics is sparse. Only 45 pediatric patients treated for RCDI have been reported, and only 27 pediatric patients with pediatric IBD. The pediatric microbiome may uniquely respond to microbial-based therapies. This review will provide a comprehensive overview of fecal microbial transplant and its potential role in the treatment of pediatric inflammatory bowel disease. We will discuss the microbiome in pediatric inflammatory bowel disease, existing adult and pediatric literature on the use of FMT in IBD treatment, and pediatric FMT trials that are currently recruiting patients. This review will also discuss features of the microbiome that may be associated with host response in fecal transplant, and potential challenges and opportunities for the future of FMT in pediatric IBD treatment.

Social Risk Screening for Pediatric Inpatients

This systematic review aims to identify existing social risk screening instruments applicable to hospitalized children (primary) and evaluate their content validity and methodological quality (secondary). Individual questions were abstracted and sorted by social risk theme. Content validity was evaluated by 13 hospital-based social workers. Methodological quality was assessed using the 108-item Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. A total of 1070 citations were evaluated and 146 articles were reviewed, which identified 44 unique instruments. No instrument was applicable to social risk in hospitalized children. Sixty-one percent of instruments focused on a single social risk theme and only 18% of instruments covered more than 5 themes. The 2 instruments with the highest combination of social worker endorsement and COSMIN scores each addressed only 1 social risk theme relevant to hospitalized children. A broad, content valid and methodologically strong social risk screening instrument for hospitalized children was not identified.

Clinical and Serologic Patterns in a Large Canadian Paediatric Cohort with Celiac Disease, At Presentation and Follow-Up

BACKGROUND: Celiac Disease (CD) is a chronic illness involving an autoimmune response to gluten, leading to small intestinal inflammation in genetically susceptible individuals. A weakness in the North American pediatric CD literature exists around serologic outcomes after initiation of a gluten free diet (GFD). Only one published North American pediatric study looks at normalization of TTG after initiation of a GFD and only assessed TTG normalization at 6 months post diagnosis. Data is also limited on other clinical patters such as levels of anemia and BMI over the course of treatment of CD.

OBJECTIVES: We sought to characterize serologic and clinical patterns in CD over an extended course using one of the largest databases of pediatric CD in North America.

DESIGN/METHODS: A retrospective review of all patients diagnosed with CD at our institution from 1996-2014 was completed. Patients required biopsy-proven CD according to the Marsh criteria. Data abstracted included age at diagnosis, gender, reason for referral, comorbidities, family history of CD and autoimmune conditions, BMI, hemoglobin, MVC, fer-ritin, IgA and anti-TTG levels. A Cochran-Armitage trend test was used to trend anti-TTG and hemoglobin normalization over time

RESULTS: 227 patients were identified who met study criteria. Visits with associated anti-TTG or hemoglobin analysis were categorized by time since diagnosis. At 6-12 months, 12-17 months, 18-23 months, 24-29 months, 30-35 months and 36-41 months from diagnosis 66.7% (n=144), 75% (n=40), 85.6% (n= 76), 86.9 (n= 23), 93.5 (n=62) and 95% (n= 20) of patients had normalized their anti-TTG levels respectively from a baseline of 100% abnormal TTG and 5.7% (n=140), 7.3% (n=41), 5.1% (n=77), 5.0% (n=20), 1.6% (n=60) and 5.0% (n=20) had anemia versus 18% at presentation.

CONCLUSION: The small p-value (p=&lt;0.0001) for the Cochran-Armitage test for anti-TTG normalization indicates the increased probability of a normalized anti-TTG as time from diagnosis increases. Knowledge of the slope of this trend could assist clinicians with better understanding the effectiveness of treatment for their patients. In this cohort, anti-TTG levels normalized over a broad time span, with increasing numbers of patients normalizing their anti-TTG through to the end of the study period. Further research goals aim to determine predictors of early anti-TTG normalization. In this cohort, the proportion of patient with anemia quickly decreased from a baseline of 18%, to general pediatric population levels between 6-12 months after treatment initiation and remained stable in this range through to the end of the study period with a non-significant p value (p=0.06) for trend over time.

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Assessment of Gluten Exposures in Children with Celiac Disease

BACKGROUND: Celiac Disease (CD) is one of the most common chronic diseases of childhood. A strict, lifelong gluten-free diet (GFD) remains the sole treatment for CD. Reports of accidental or intentional ingestion of gluten are common, but little is known about the sources or context of such exposures.

OBJECTIVES: We sought to ascertain the self-reported causes for gluten exposure for children with Celiac Disease.

DESIGN/METHODS: Parents of children with biopsy-proven CD followed at McMaster Children’s Hospital were asked to review a 22-item questionnaire listing sources, situations and causes of gluten exposure for their child. The questionnaire encompassed both intentional and unintentional gluten exposures and was developed through consultation with Registered Dietitians and Faculty in the Division of Pediatric Gastroenterology at McMaster Children’s Hospital. Children independently completed a similar 21-item questionnaire adapted for pediatric use. Participants were invited to describe any additional sources or circumstances leading to gluten consumption not captured in the questionnaire.

RESULTS: A total of 123 families participated in the study with a median of 32 months on a GFD. A minimum of one cause of gluten exposure was selected by 65% of parents and 60% of children. Restaurant dining was identified as a source of gluten consumption by 39% of parents, due to a lack of knowledge of the GFD by restaurant staff or poor labeling of menu items. Other commonly selected items on the parent questionnaire included: difficulty while traveling (13%), to avoid exclusion at social events (12%), and a lack of negative symptoms following gluten exposure (9%). Few parents identified cost (2%), or the availability of gluten-free food as a concern (5%). Children most commonly identified restaurant eating (32%), and the lack of any negative symptoms from eating gluten as the main causes of gluten exposure (14%). In this study population, 11% of children acknowledged consuming gluten because they felt left out at either home, school or with friends.

CONCLUSION: This study provides information about the common causes of gluten exposure for children with CD in Ontario, Canada. Restaurant dining and travel were the most commonly identified sources of gluten ingestion. Our study highlights the need for improved menu labeling and education of restaurant staff, requiring both policy changes and dialogue with food service industries. While availability of gluten-free products has greatly improved, exclusion from social activities remain a concern for both children and their parents. Further qualitative studies may build on these identified themes to better understand challenges families face with the GFD.

Role of the microbiome in energy regulation and metabolism

Intestinal microbes regulate metabolic function and energy balance; an altered microbial ecology is believed to contribute to the development of several metabolic diseases. Relative species abundance and metabolic characteristics of the intestinal microbiota change substantially in those who are obese or have other metabolic disorders and in response to ingested nutrients or therapeutic agents. The mechanisms through which the intestinal microbiota and its metabolites affect host homeostasis are just beginning to be understood. We review the relationships between the intestinal microbiota and host metabolism, including energy intake, use, and expenditure, in relation to glucose and lipid metabolism. These associations, along with interactions among the intestinal microbiota, mucus layer, bile acids, and mucosal immune responses, reveal potential mechanisms by which the microbiota affect metabolism. We discuss how controlled studies involving direct perturbations of microbial communities in human and animal models are required to identify effective therapeutic targets in the microbiota.

Hospital-legal partnership at Toronto Hospital for Sick Children: the first Canadian experience

Operating a hospital-legal partnership on a pro bono basis positively impacts patients' families by providing legal assistance for non-medical issues that affect the health of their children and their ability to care for their children. This article describes a formative evaluation of the first hospital-legal partnership in Canada, established at The Hospital for Sick Children in Toronto in 2009, which was carried out through file reviews and interviews with staff, lawyers and family members. The early indications of success of this partnership suggest that its use as a template for similar programs at other Canadian healthcare institutions should be considered.

Prospective evaluation of residents on call: before and after duty-hour reduction

BACKGROUND

On July 1, 2009, in Ontario the maximum period of continuous duty that residents were permitted to work was reduced from 28 to 24 hours. We evaluated the effect of regulation on residents in 3 eras: 2 before (2005 and early 2009) and 1 after (late 2009) the duty-hour reduction.

METHODS

On-call pediatric residents on pediatric medicine rotations prospectively recorded the numbers of patients (assigned and admitted) and the durations of direct patient care, documentation, staff supervision, and education attended. Sleep was measured with actigraphy.

RESULTS

The 51 residents worked 180 duty periods, were assigned a median of 6 (interquartile range: 4 -12) daytime patients and 24 (interquartile range: 19-30) overnight patients. Residents reported spending means of 239 minutes providing direct patient care, 235 minutes documenting, and 243 minutes sleeping and receiving 73 minutes of staff supervision and 52 minutes of education. From early 2009 to after duty-hour reduction, residents provided 47 fewer (19.6%) minutes of direct patient care (P = .056) and received 44 fewer minutes (60.3%) of supervision (P = .0005) but spent similar times documenting, receiving education, and sleeping. In early 2009, residents provided 73 more minutes (30.5%) of direct patient care (P = .0016), spent 63 more minutes (26.8%) documenting, and slept 105 fewer minutes (43.0%) (P = .0062) than in 2005.

DISCUSSION

After duty-hour reduction in 2009, we found reduced supervision and direct patient care. Comparison of the 2 periods before duty-hour reduction showed less sleep and longer patient contact in early 2009, which suggests that changes occurred without regulation.

Probiotic supplementation in the first 6 months of life in at risk Asian infants--effects on eczema and atopic sensitization at the age of 1 year

BACKGROUND

The role of probiotics in allergy prevention remains uncertain but has been shown in some studies to have a possible protective effect on eczema.

OBJECTIVE

We aimed to assess the effect of probiotic supplementation in the first 6 months of life on eczema and allergic sensitization at 1 year of age in Asian infants at risk of allergic disease.

METHODS

A double-blind, placebo-controlled randomized clinical trial involving 253 infants with a family history of allergic disease was carried out. Infants received at least 60 mL of commercially available cow's milk formula with or without probiotic supplementation [Bifidobacterium longum (BL999) 1 x 10(7) colony forming unit (CFU)/g and Lactobacillus rhamnosus (LPR) 2 x 10(7) CFU/g] daily for the first 6 months. Clinical evaluation was performed at 1, 3, 6 and 12 months of age, with serum total IgE measurement and skin prick tests conducted at the 12-month visit. The primary and secondary end-points were eczema and allergen sensitization, respectively.

RESULTS

The incidence of eczema in the probiotic (22%) group was similar to that in the placebo group (25%) (P=0.53). The median Scoring Atopic Dermatitis score at 12 months was 17.10 (9.74) in the probiotic group and 11.60 (8.40) in the placebo group (P=0.17). The prevalence of allergen sensitization showed no difference (probiotic=24% vs. placebo=19%, P=0.26). The total IgE geometric mean (95% confidence interval) was 18.76 (12.54-24.98) kU/L in the probiotic group and 23.13 (16.01-30.24) kU/L in the placebo group (P=0.15). Atopic eczema (with sensitization) in the probiotic (7.3%) group was comparable to the placebo group (5.8%) (P=0.86).

CONCLUSION

Early life administration of a cow's milk formula supplemented with probiotics showed no effect on prevention of eczema or allergen sensitization in the first year of life in Asian infants at risk of allergic disease. Further work is needed to determine whether timing of supplementation, dose and probiotic strain are important considerations.

Epidemiology and clinical risk factors predisposing to thromboembolism in children with cancer

PURPOSE

The prevalence and risk factors for thromboembolism (TE) in children with cancer are largely unknown. This retrospective cohort study aims to determine the epidemiology of TE and to identify potential risk factors for TE in children with cancer.

METHODS

We used logistic regression to determine the association of age (<10 years vs. > or =10 years), gender, type of cancer, presence or absence of intra-thoracic disease (mediastinal mass or any primary or metastatic pulmonary disease), type of central venous line (CVL) and CVL-dysfunction (difficulty of blood draw, infusion or documented CVL infection) on the risk of developing TE.

RESULTS

Fifty-seven of 726 patients [7.9%; 95% confidence intervals (CI); 6.0,10.0] developed TE; children with brain tumors (n = 201) had significantly lower prevalence of TE (0.5%; P < 0.001). Older patients had increased risk of developing TE compared to younger patients [Odds ratios (OR) 1.8; 95% CI; 1.0,3.2; P = 0.036]. Children with acute lymphoblastic leukemia (ALL) (OR 4.6; 95% CI; 1.8, 12.3; P = 0.002), lymphoma (OR 3.8; 95% CI; 1.3, 11.1; P = 0.016), and sarcoma (OR 4.3; 95% CI; 1.4, 13.3; P = 0.012) had an increased risk of TE. Subgroup analyses showed that patients with CVL-dysfunction and intra-thoracic disease had a higher prevalence of TE compared to those without CVL-dysfunction (22.8% vs. 8.8%; 95% CI; 4.0, 24.3; P = 0.006) and intra-thoracic disease (18.0% vs. 6.1%; 95% CI; 2.4, 21.4; P = 0.02).

CONCLUSIONS

TE is common in children with cancer. Age and type of cancer are independent risk factors for TE in children with non-CNS cancers. CVL-dysfunction and intra-thoracic disease are significantly associated with the diagnosis of TE.