Introduction:Discharging patients with new nasogastric tubes (NGTs) for enteral nutrition at home is complex and requires intricate care coordination and education from a multidisciplinary team. We designed a quality improvement (QI) initiative to improve efficiency and decrease variation in care coordination for patients discharged with a new NGT. Our objective was to reduce mean modified hospital length of stay (mLOS) by 10% from baseline within 6 months and sustain improvement for 12 months. Methods:Applying the Model for Improvement, we used plan-do-study-act cycles to improve NGT discharge care coordination using a multidisciplinary team. Primary interventions rooted in Lean methodology included creating a standardized discharge algorithm, utilizing nurse practitioners as care coordination champions, routine consultation of an enteral tube service (ETS), and implementing a formula substitution guide. The primary outcome measure was mean mLOS. The process measure was the time from NGT placement to ETS consult. Balancing measures were ETS consult volume and 30-day healthcare reutilization. Statistical process control charts measured the impact of interventions. Results:Baseline mLOS decreased from 8.2 to 7.4 days with a sustained reduction in process variability over time. Time from NGT placement to ETS consult decreased from 4.1 to 3.0 days. There were no changes in 30-day healthcare reutilization or ETS consult volume over time. Conclusions:A multidisciplinary quality improvement initiative effectively improved complex NGT transitional care planning and was sustained over time.

ObjectivesThe objective of this study was to assess if enrollment in a pediatric multidisciplinary aerodigestive program significantly impacted families' experiences with care integration.MethodsA previously validated 48-question Pediatric Integrated Care Survey (PICS) was administered in a cross-sectional manner to both new (new-ADC) and established (est-ADC) patients presenting for an outpatient Aerodigestive Center visit at Boston Children's Hospital. Survey results were grouped into the following five care coordination domains: (1) access to care, (2) care goal creation/planning, (3) family impact, (4) communication with health care providers, and (5) team functioning. Families were asked to rate their care integration experiences in the prior 12 months using yes/no and Likert-based questions. Comparisons were analyzed using logistic regression. Factor analysis was also performed.ResultsNinety patient families were surveyed: 54 (60%) est-ADC patients and 36 (40%) new-ADC patients. Est-ADC patients reported higher levels of experience with team functioning, provider awareness of prior testing, provider communication, and access to alternative methods of communication. Self-identified non-White patients reported lower satisfaction in team functioning and provider understanding of their child's long-term care plan. No significant differences in care integration experiences before and after the onset of the coronavirus pandemic were seen.ConclusionsPatients enrolled in aerodigestive centers experienced improved care integration, most significantly in provider communication and team functioning. Despite these improvements, self-identified non-White families reported a lower care integration experience. What is Known Patients with aerodigestive conditions are often medically complex and require significant coordination of care between community and hospital based services. Care integration has been defined as providing patient-focused care coordination for patients and families across the healthcare spectrum.What is New Families of patients established within an aerodigestive program reported higher levels of satisfaction with care integration across the health care spectrum. Family satisfaction of care integration in an aerodigestive program was not negatively impacted by the coronavirus pandemic. Families self-identifying as non-White experienced lower satisfaction with care integration as compared to self-identifying white families.

OBJECTIVES:Aerodigestive disorders encompass various pathological conditions affecting the lungs, upper airway, and gastrointestinal tract in children. While advanced care has primarily occurred in specialty centers, many children first present to general pediatric gastroenterologists with aerodigestive symptoms necessitating awareness of these conditions. At the 2021 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the aerodigestive Special Interest Group held a full-day symposium entitled, Pediatric Aerodigestive Medicine: Advancing Collaborative Care of Children with Aerodigestive Disorders. The symposium aimed to underline the significance of a multidisciplinary approach to achieve better outcomes for these complex patients.METHODS:The symposium brought together leading experts to highlight the growing aerodigestive field, promote new scientific and therapeutic strategies, share the structure and benefits of a multidisciplinary approach in diagnosing common and rare aerodigestive disorders, and foster multidisciplinary discussion of complex cases while highlighting the range of therapeutic and diagnostic options. In this article, we showcase the diagnostic and therapeutic approach to oropharyngeal dysphagia (OPD), one of the most common aerodigestive conditions, emphasizing the role of a collaborative model.CONCLUSIONS:The aerodigestive field has made significant progress and continues to grow due to a unique multidisciplinary, collaborative model of care for these conditions. Despite diagnostic and therapeutic challenges, the multidisciplinary approach has enabled and greatly improved efficient, high-quality, and evidence-based care for patients, including those with OPD.

Objective To decrease the percentage of patients undergoing an abdominal radiograph for evaluation of constipation within 24 hours of their initial gastroenterology visit. Study design In January 2015, we implemented a quality improvement, evidence-based guideline (EBG) aimed at standardizing the initial assessment of patients presenting for a new outpatient gastroenterology visit with a primary complaint of constipation. Over the subsequent 5 years, we followed the clinical impact of this guideline initiation with the goal of decreasing unnecessary abdominal radiograph use by 10% within 1 year of EBG launch. Patients older than 6 months and younger than 19 years were included. Results In total, 6723 patients completed new patient gastroenterology visits for a primary diagnosis of constipation between 2013 and 2019. Of these, 993 (14.8%) patients had abdominal radiographs taken within 24 hours of their initial visit. Over the 7 years of this project, a mean frequency of abdominal radiograph use decreased from 24% to less than 11%. In addition, a 57% decrease in hospital charges related to decreased radiograph use for constipation was found. No increases in subsequent emergency department visits or hospitalization for constipation within 30 days of patients' initial visits were seen. Conclusions Through local adoption of an EBG, routine use of abdominal radiographs taken during a patient's initial outpatient gastroenterology visit for constipation decreased by more than 50%. This reduction was maintained over a subsequent 5-year period without any detrimental side effects. (J Pediatr 2022;251:127-33).

ABSTRACT Objectives: The laparoscopic-assisted gastrostomy tube placement (LAP) has increasingly become the preferred method for placing gastrostomy tubes in infants and children. The goal of this retrospective review was to examine our institutional experiences with our transition from the percutaneous endoscopic gastrostomy (PEG) procedure to LAP technique. Methods: All patients undergoing primary PEG or LAP gastrostomy at Boston Children's Hospital between January 2010 and June 2015 were identified. The primary aim was to compare complication rates within the first 6 months after tube placement; differences in total hospital procedural costs, hospital resource utilization, and postoperative gastroesophageal reflux disease were examined. Results: Nine hundred and eighty-seven patients (442 PEG and 545 LAP gastrostomy tubes) were included. No differences in total complications within 6 months were seen. Patients undergoing PEG placement had more gastrostomy-related complications (PEG 30 [6.7%] vs LAP 13 [2.4%], P = 0.0007) and cellulitis (PEG 23 [5.1%] vs LAP 2 [0.4%], P = 0.03) within the first week of placement. Patients undergoing LAP procedures had more granulation tissue episodes (PEG 19 [4.4%] vs LAP 107 [19.8%], P = 0.005). No differences in emergency room visits, hospital readmissions, or postoperative gastroesophageal reflux disease were seen, although transition to a gastrojejunal tube was higher in patients undergoing LAP procedure (PEG 20 patients [4.6%] vs LAP 51 patients [9.5%], P = 0.0008). Conclusions: Total complications were similar between patients undergoing PEG versus LAP gastrostomy tube placement. Patients with the PEG procedure had more complications within the first week of placement versus patients with the LAP procedure had more granulation skin complications.

OBJECTIVES Infants frequently present with feeding difficulties and respiratory symptoms, which are often attributed to gastroesophageal reflux but may be due to oropharyngeal dysphagia with aspiration. The Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) is a clinical measure of gastroesophageal reflux disease but now there is greater understanding of dysphagia as a reflux mimic. We aimed to determine the degree of overlap between I-GERQ-R and evidence of dysphagia, measured by Pediatric Eating Assessment Tool-10 (Pedi-EAT-10) and videofluoroscopic swallow study (VFSS). METHODS We performed a prospective study of subjects <18 months old with feeding difficulties. All parents completed Pedi-EAT-10 and I-GERQ-R as a quality initiative to address parental feeding concerns. I-GERQ-R results were compared to Pedi-EAT-10 and, when available, results of prior VFSS. Pearson correlation coefficients were calculated to determine the relationship between scores. Groups were compared with one-way ANOVA and Fisher's exact test. ROC analysis was completed to compare scores with VFSS results. RESULTS 108 subjects with mean age 7.1 ± 0.5 months were included. Pedi-EAT-10 and I-GERQ-R were correlated (r = 0.218, p = 0.023) in all subjects and highly correlated in the 77 subjects who had prior VFSS (r = 0.369, p = 0.001). The blue spell questions on I-GERQ-R had relative risk 1.148 (95% CI 1.043-1.264, p = 0.142) for predicting aspiration/penetration on VFSS, with 100% specificity. Scores on the question regarding crying during/after feedings were also higher in subjects with abnormal VFSS (1.1 ± 0.15 vs 0.53 ± 0.22, p = 0.04). CONCLUSIONS I-GERQ-R and the Pedi-EAT-10 are highly correlated. I-GERQ-R results may actually reflect oropharyngeal dysphagia and not just gastroesophageal reflux disease in infants.

OBJECTIVES:Oropharyngeal dysphagia and aspiration may occur in infants and children. Currently, there is wide practice variation regarding when to feed children orally or place more permanent gastrostomy tube placement. Through implementation of an evidence-based guideline (EBG), we aimed to standardize the approach to these patients and reduce the rates of gastrostomy tube placement.METHODS:Between January 2014 and December 2018, we designed and implemented a quality improvement intervention creating an EBG to be used by gastroenterologists evaluating patients ≤2 years of age with respiratory symptoms who were found to aspirate on videofluoroscopic swallow study (VFSS). Our primary aim was to encourage oral feeding and decrease the use of gastrostomy tube placement by 10% within 1 year of EBG initiation; balancing measures included total hospital readmissions or emergency department (ED) visits within 6 months of the abnormal VFSS.RESULTS:A total of 1668 patients (27.2%) were found to have aspiration or penetration noted on an initial VFSS during our initiative. Mean gastrostomy tube placement in these patients was 10.9% at the start of our EBG implementation and fell to 5.2% approximately 1 year after EBG initiation; this improvement was sustained throughout the next 3 years. Our balancing measures of ED visits and hospital readmissions also did not change during this time period.CONCLUSIONS:Through implementation of this EBG, we reduced gastrostomy tube placement by 50% in patients presenting with oropharyngeal dysphagia and aspiration, without increasing subsequent hospital admissions or ED visits.

Objectives: Limited literature exists as to whether preoperative gastrostomy (GT) evaluation may predict which patients will go onto require gastrojejunostomy (GJ) tube feeding. The goal of this study was to compare the preoperative evaluations between patients maintained on GT feeds versus patients who required conversion to GJ feeds. Methods: We identified patients at Boston Children's Hospital who underwent GT tube placement and required GJ feeding between 2006 and 2012. GT patients were matched according to age, neurologic, and cardiac status with GJ-converted patients. Preoperative characteristics, rates of total hospitalizations, and respiratory-related admissions were reviewed. Results: A total of 79 GJ patients (median interquartile range (IQR): age 15 (4.3, 55.7) months; weight 8.8 (4.6, 14.5) kg) were matched with 79 GT patients (median (IQR): age 14.6 (4.7, 55.7) months; weight 8.5 (5, 13.6) kg). Median time from GT to GJ conversion was 8 (IQR 3, 16) months. Both groups had similar rates of successful preoperative nasogastric feeding trials (GT (84.5%) versus GJ (83.1%), P = 1.0), upper gastrointestinal series (GT (89.1%) versus GJ (93.2%), P = 0.73), abnormal videofluoroscopic swallow studies (GT (53.8%) versus GJ (62.2%), P = 0.4), and completion of gastric emptying studies (GT (10.1%) versus GJ (5.1%), P = 0.22). No differences were seen in preoperative hospitalization rates (P = 0.25), respiratory admissions (P = 0.36), although GJ patients had a mean reduction in the number of hospitalization of 1.5 +/- 0.5 days, P < 0.001, after conversion. Conclusions: No differences in preoperative patient characteristics or diagnostic evaluations were seen in GT fed versus GJ converted patients. GJ patients did experience an overall decrease in total admissions after GJ conversion.

Importance:Proton pump inhibitors (PPI) are commonly prescribed to children with oropharyngeal dysphagia and resultant aspiration based on the assumption that these patients are at greater risk for reflux-related lung disease. There is little data to support this approach and the potential risk for increased infections in children treated with PPI may outweigh any potential benefit. Objective:The aim of this study was to determine if there is an association between hospitalization risk in pediatric patients with oropharyngeal dysphagia and treatment with PPI. Design, Setting, and Participants:We performed a retrospective cohort study to compare the frequency and length of hospitalizations for children who had abnormal results on videofluoroscopic swallow studies that were performed between January 1, 2015, and December 31, 2015, and who were or were not treated with PPI, with follow-up through December 31, 2016. Records were reviewed for children who presented for care at Boston Children's Hospital, a tertiary referral center. Participants included 293 children 2 years and younger with evidence of aspiration or penetration on videofluoroscopic swallow study. Exposures:Groups were compared based on their exposure to PPI treatment. Main Outcomes and Measures:The primary outcomes were hospital admission rate and hospital admission nights and these were measured as incident rates. Multivariable analyses were performed to determine predictors of hospitalization risk after adjusting for comorbidities. Kaplan-Meier curves were created to determine the association of PPI prescribing with time until first hospitalization. Results:A total of 293 patients with a mean (SD) age of 8.8 (0.4) months and a mean (SD) follow-up time of 18.15 (0.20) months were included in the analysis. Patients treated with PPI had higher admission rates (Incidence rate ratio [IRR], 1.77; 95% CI, 1.16-2.68) and admission nights (IRR, 2.51; 95% CI, 1.36-4.62) even after adjustment for comorbidities. Patients with enteral tubes who were prescribed PPIs were at the highest risk for admission (hazard ratio [HR], 2.31; 95% CI, 1.24-4.31). Conclusions and Relevance:Children with aspiration who are treated with PPI have increased risk of hospitalization compared with untreated patients. These results support growing concern about the risks of PPI use in children.

Purpose: Outcomes associated with primary laparoscopic gastrojejunal (GJ) tube placement in the pediatric population were evaluated.Methods: A single-institution, retrospective review examined patients undergoing laparoscopic GJ tube placement between June 2011 and December 2014. Outcomes included gastric feeding tolerance, subsequent fundoplication, complications, and mortality.Results: Ninety laparoscopic GJ tubes were placed. Median follow-up was 342 days (interquartile range [IQR]=141-561 days). Median patient age was 5months (IQR=3-11 months) and weight was 5.2 kg (IQR=4-8.4 kg). The most common indications for placement were gastroesophageal reflux (n = 85, 94.4%) and/or aspiration (n = 40, 44.4%). Most common comorbidities included cardiac (n = 34, 37.8%) and respiratory (n = 29, 32.2%) diseases. The complication rate was 17.8%, including one case of intestinal perforation. Thirty-four (37.7%) patients transitioned to gastric feeding within 1 year; time to conversion was 156 days (IQR = 117-210 days); of those, 18.9% patients transitioned to oral feedings. A fundoplication was later performed in 4 children for persistent reflux. Mortality was 23.3% with no procedural-related deaths.Conclusion: Primary laparoscopically placed GJ tubes are a reliable means of enteral access for pediatric patients with gastric feeding intolerance. Many of these children are successfully transitioned to gastric and/or oral feedings over time. Further studies are needed to characterize which patients are best served with a GJ tube versus alternatives such as fundoplication. (C) 2017 Elsevier Inc. All rights reserved.

Objective To identify the reasons why pediatric gastroenterologists obtain abdominal radiographs in the management of pediatric constipation. Study design This was a prospective study surveying providers regarding their rationale, interpretation, resultant change, and confidence in their management before and after obtaining KUBs in patients seen for suspected constipation. Demographics and clinical findings were obtained from medical records. Results A total of 24 providers were surveyed after 72 patient encounters. Reasons for obtaining an abdominal radiograph included evaluation of stool burden (70%), need for a clean out (35%), fecal impaction (27%), cause of abdominal pain (24%), demonstration of stool burden to families (14%), assessment of response to therapy (13%), or encopresis (10%). The plan was changed in 47.6% of cases based on radiographic findings. In cases in which a plan was outlined before obtaining the radiograph (69%), the initial plan was implemented on average in 52.5%. In cases with no plans before obtaining the radiograph, previously unconsidered plans were implemented in 8.7%. Provider confidence in the management plan increased from 2.4 +/- 2.7 to 4.1 +/- 1.8 (P < .05) after the abdominal radiograph. Conclusion Abdominal radiographs commonly are obtained by pediatric gastroenterologists in the evaluation and management of constipation. The majority used it to make a diagnosis, and nearly one-half changed their management based on the imaging findings. Overall, they reported an improved confidence in their management plan, despite evidence that radiographic findings poorly correlate with clinical severity. This study highlights the need for further provider education regarding the recommendations delineated in existing constipation guidelines.

immunohistochemistry staining in TZ.Methods TZ of HD patients were analyzed on HPS specimen by studying the expression of the neuronal markers calretinin and PGP9.5.We determined the order of appearance of neurites in mucosa and ganglion cells in submucosal and myenteric plexuses in direction from aganlionic to ganglionic zone.We measured the distance between calretinin positive neurites in the mucosa and calretinin and/or PGP9.5 positive ganglion cells in the submucosal and myenteric plexuses.Results Tissue samples from intestinal pull-through surgery between 2006 and 2016 were reviewed in 29 HD patients, (23 males).The median age at pull-through surgery was 2.6 months (0.4-34.8).26 (90%) presented with a short form of HD (rectosigmoid).In 27 out of 29 TZ, Calretinin positive mucosal neurites appeared prior to submucosal plexus calretinin or PGP9.5 positive ganglion cells (median distance 4mm, range 2-12mm) and prior to calretinin or PGP9.5 positive myenteric plexus ganglion cells (median distance 10mm, range 10->30mm).In 2 specimens, Calretinin positive neurites, submucosal and myenteric ganglion cells were expressed at the same level.Calretinin positive ganglion cells in submucosal plexus appeared in 48% of TZ prior to ganglion cells in myenteric plexus (14 cases) with a median distance between calretinin positive ganglion cells in the submucosal and myenteric plexus of 6 mm (3-12mm) in 10 patients and a distance >25mm in 4 patients.In 5 cases calretinin positive ganglion cells of myenteric plexus were expressed prior to ganglion cells in submucosal plexus.In 8 cases, calretinin positive ganglion cells in myenteric plexus and submucosal plexus appeared at the same level 3 mm after the calretinin positive mucosal neurites (2-5mm).In all cases at 30 mm proximal to the zone of first appearance of calretinin positive cells, ganglionic cells were present in both plexuses.Conclusion There is a high heterogenicity in the order of appearance of ganglionic cells in the intestinal wall of TZ.Immunohistochemistry staining with Calretinin and PGP9.5 allows adequate determination of length of TZ.Within a 30mm length distance after the first appearance of calretinin positive neurites, the surgical resection could be performed in ganglionic healthy tissue in all individuals.

Placement of gastrostomy tubes in infants and children has become increasingly commonplace. A historical emphasis on use of open gastrostomy has been replaced by less invasive methods of placement, including percutaneous endoscopic gastrostomy and laparoscopically assisted gastrostomy procedures. Various complications, ranging from minor to the more severe, have been reported with all methods of placement. Many pediatric patients who undergo gastrostomy tube placement will require long-term enteral therapy. Given the prolonged time pediatric patients may remain enterally dependent, further quality improvement and education initiatives are needed to improve long-term care and outcomes of these patients.