Pediatric endoscopy: how can we improve patient outcomes and ensure best practices?

Introduction: Strategies to promote high-quality endoscopy in children require consensus around pediatric-specific quality standards and indicators. Using a rigorous guideline development process, the international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) was developed to support continuous quality improvement efforts within and across pediatric endoscopy services.

Areas Covered: This review presents a framework, informed by the PEnQuIN guidelines, for assessing endoscopist competence, granting procedural privileges, audit and feedback, and for skill remediation, when required.

Promoting Research that Supports High-Quality Gastrointestinal Endoscopy in Children.

Purpose Of Review: Defining and measuring the quality of endoscopic care is a key component of performing gastrointestinal endoscopy in children. The purpose of this review is to discuss quality metrics for pediatric gastrointestinal endoscopy and identify where additional research is needed.

Recent Findings: Pediatric-specific standards and indicators were recently defined by the international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) working group through a rigorous guideline consensus process.

The Evolution of Sedation for Pediatric Gastrointestinal Endoscopy.

Sedation for pediatric endoscopy has evolved from an endoscopist-administered component of procedures to an almost entirely anesthesiologist-supported endeavor. Nevertheless, there are no ideal endoscopist or anesthesiologist-administered sedation protocols, and wide practice variation exists in both models. Furthermore, sedation for pediatric endoscopy, whether administered by endoscopists or anesthesiologists, remains the highest risk to patient safety.

Metabolomic profiling of extraesophageal reflux disease in children.

Although respiratory symptoms in children are often attributed to gastroesophageal reflux disease, establishing a clear diagnosis of extraesophageal reflux disease (EERD) can be challenging, as there are no sensitive or specific EERD biomarkers. The aim of this study was to evaluate the metabolite profile in bronchoalveolar (BAL) fluid from children with suspected EERD and assess the impact of reflux treatment on these metabolites. In this prospective pilot study, we performed nontargeted global metabolomic profiling on BAL fluid from 43 children undergoing testing with bronchoscopy, upper endoscopy, and multichannel intraluminal impedance with pH (pH-MII) for evaluation of chronic respiratory symptoms.

The Spectrum of Reflux Phenotypes.

The focus on a symptom-based definition for gastroesophageal reflux disease (GERD) in adults and children has contributed to widespread use of acid suppression medications in patients with so-called typical reflux symptoms to treat the possibility of acid-mediated disease. Diagnostic testing with upper endoscopy, esophageal biopsies, ambulatory reflux monitoring, and/or esophageal manometry is often pursued when patients do not respond optimally to these medications. By using information from this diagnostic testing, GERD has shifted from a single diagnosis to a phenotypic spectrum, and each phenotype has unique pathophysiologic mechanisms driving symptom perception.

Abnormal 24-hour pH-impedance Testing Does Not Predict Reduced Quality of Life in Children With Reflux Symptoms.

Objectives: Symptoms of gastroesophageal reflux (GER) have been associated with reduced health-related quality of life (QOL) in children, though it is unclear whether reflux burden on objective diagnostic testing, such as 24-hour multichannel intraluminal impedance with pH (pH-MII) is associated with impaired QOL in children. Our aim was to identify predictors of QOL impairment based on the results of esophageal reflux testing.

Methods: In this prospective, cross-sectional study of children undergoing pH-MII and esophagogastroduodenoscopy (EGD) for evaluation of suspected gastroesophageal reflux disease, we collected validated questionnaires (Pediatric Gastroesophageal Symptom and Quality of Life Questionnaire [PGSQ], Pediatric Quality of Life Inventory 4.

Continuous Feedings Are Not Associated With Lower Rates of Gastroesophageal Reflux When Compared With Bolus Feedings.

Gastroesophageal reflux disease is common in children with gastrostomy tubes. Clinicians often transition to continuous feedings in an attempt to reduce reflux burden, though there is limited data to support this practice. In this retrospective study, we analyzed 24-hour multichannel intraluminal impedance with pH studies in 18 children with gastrostomy tubes receiving exclusive enteral nutrition with a combination of daytime bolus and overnight continuous feedings.

The Prevalence of Rome IV Nonerosive Esophageal Phenotypes in Children.

Objectives: To assess the prevalence of Rome IV nonerosive esophageal phenotypes in children using multichannel intraluminal impedance testing and to describe the rates of proton pump inhibitor (PPI) responsiveness and the frequency of microscopic esophagitis in these patients.

Study Design: We conducted a retrospective review of all children ≥5 years of age who underwent esophagogastroduodenoscopy and multichannel intraluminal impedance testing off PPI therapy for evaluation of typical gastroesophageal reflux symptoms. Only children with symptoms during the multichannel intraluminal impedance testing were included.

A Pilot Study of Ketamine versus Midazolam/Fentanyl Sedation in Children Undergoing GI Endoscopy.

Background. Ketamine sedation has been found superior by physician report to traditional sedation regimens for pediatric endoscopy. Goal.

Fellow perceptions of training using computer-based endoscopy simulators.

Background: Integrating procedural training by using computer-based endoscopic simulators (CBES) into gastroenterology fellowships may facilitate technical skill development, while posing no additional risk to patients.

Objective: The aim of our study was to survey pediatric gastroenterology fellows about their experiences with and perceptions of CBES as compared with actual procedures, prior to and after exposure to both types of endoscopic learning.

Design And Setting: All first-year trainees at Children's Hospital Boston (2003-2008) were invited to complete a written, pretraining questionnaire and then perform at least 10 each of CBES endoscopies and colonoscopies prior to performing actual procedures.

Nurse reports of adverse events during sedation procedures at a pediatric hospital.

The purpose of our study was to examine the reliability of nurse reports of adverse events related to procedural sedation in children. A descriptive, correlational design was used to analyze for inter-rater agreement between prospective adverse event reporting and that identified on independent review of the medical record. All sedation documentation at a pediatric hospital over one calendar year was reviewed, and inter-rater reliability of reporting was analyzed using K statistics.

Agitation during procedural sedation and analgesia in children.

Background: Agitation that occurs in children receiving standard procedural sedation regimens may indicate inadequate patient comfort and compromise procedural success. Although agitation in uninterrupted pediatric procedures is recognized to occur, it is not generally tracked as an adverse event, and there have been no formal studies to determine its rate of incidence.

Methods: We identified intraprocedural agitation in a large cohort of children undergoing standardized sedation regimens in a tertiary care pediatric hospital over a calendar year and compared it with rates of well-accepted quality measures of sedation using odds ratio analysis, with 95% confidence intervals (CIs).

Efficiency of propofol versus midazolam and fentanyl sedation at a pediatric teaching hospital: a prospective study.

Background: Many pediatric endoscopists are adopting propofol in their practices, with the expectation that propofol will increase their overall efficiency.

Objective And Setting: To compare the efficiency of propofol versus midazolam and fentanyl by measuring elapsed times between initial intravenous administration and patient discharge at a pediatric teaching hospital.

Design: Endoscopy times were prospectively collected for consecutive patients who were undergoing either anesthesiologist-administered propofol or endoscopist-administered midazolam and fentanyl.

Methods of sedation in pediatric endoscopy: a survey of NASPGHAN members.

The performance of endoscopy in children generally requires the concomitant administration of sedation to ensure the patient's safety, comfort, and cooperation throughout the procedures. New pharmacological agents, increased procedural volume, variable access to anesthesia support, and improvement in endoscopic technique have contributed to vast differences in sedation regimens for gastrointestinal procedures in patients of all ages. To better understand variation in practice patterns among pediatric gastroenterologists, the NASPGHAN Endoscopy and Procedures Committee surveyed 103 NASPGHAN members during a recent NASPGHAN national meeting.

Sedation of the pediatric and adolescent patient for GI procedures.

There remains no ideal sedative for pediatric and adolescent patients undergoing gastrointestinal procedures. Instead, pediatric gastroenterologists must consider many factors, including patient age, medical history, clinical status, anxiety level, as well as targeted sedation level, to select the appropriate methods and agents to achieve optimal sedation for endoscopy. The two primary types of sedation are endoscopist-administered intravenous (IV) sedation and anesthesiologist-administered general anesthesia.

Percutaneous liver biopsy practice patterns among pediatric gastroenterologists in North America.

Objectives: To document current percutaneous liver biopsy (PLB) practices among pediatric gastroenterologists.

Materials And Methods: A total of 699 practicing pediatric gastroenterologists received an e-mail invitation to participate in a Web-based survey. Our primary outcome was whether or not pediatric gastroenterologists reported currently performing PLB.

Caloric restriction in C57BL/6J mice mimics therapeutic fasting in humans.

Background: Caloric restriction (CR) has long been recognized as a dietary therapy that improves health and increases longevity. Little is known about the persistent effects of CR on plasma biomarkers (glucose, ketone bodies, and lipids) following re-feeding in mice. It is also unclear how these biomarker changes in calorically restricted mice relate to those observed previously in calorically restricted humans.