Pediatric Year in Review

PEDIATRIC YEAR IN REVIEW 6 UPDATE IN THE MANAGEMENT OF AERODIGESTIVE PROBLEMS IN THE PULMONARY CLINIC Efficiency. Int J Pediatr Otorhinolaryngol. 2018; 113: 119- 123. Summary Aerodigestive patients have complex and interrelated disorders that affect the airway, breathing, swallowing and growth. The care of an aerodigestive patient is similarly complex and costly. This is a retrospective review of aerodigestive patients who were evaluated and treated before and after the inception of a multidisciplinary aerodigestive program. The electronic medical record was reviewed to determine elements of patient care and evaluation, and the cost of care was assessed using the Mayo Clinic Cost Data Warehouse methodology. There were 38 patients enrolled in this study. Patients enrolled in a multidisciplinary aerodigestive program had decreased time to diagnosis (6 vs 150 days), fewer radiation exposures (2 vs 4), and fewer anesthetic episodes (1 vs 2). There was a 41% reduction in the cost of medical care after development of a multidisciplinary aerodigestive program ($6,055 vs $10,374). Comments 1. This study highlights that multidisciplinary aerodigestive clinics can improve healthcare efficiency, decrease risk, and decrease cost. 2. The cost of care and patient outcomes following the initial diagno- sis is not described. 3. While the study is a natural experiment, the primary limitation is the lack of a control group and single-center design. TREATMENT OF TRACHEOMALACIA Shieh HF, Smither CJ, Hamilton TE, Zurakowski D, Visner GA, Manfredi MA, Baird CW, Jennings RW. Posterior Tracheopexy for Severe Tracheomalacia Associated with Esophageal Atresia (EA): Primary Treatment at the Time of Initial EA Repair vs Secondary Treatment. Front Surg. 2018; 4(80): 1-7. Summary Tracheomalacia is often associated with esophageal atresia and is characterized by dynamic collapse of the trachea. Posterior tracheopexy can prevent intrusion of the trachealis and has shown promise as a treatment of tracheomalacia in small, short-term trials. This was a retrospective series of patients with esophageal atresia who had a posterior tracheopexy for severe tracheomalacia- either at the time of the initial esophageal atresia repair (primary treatment) or after the initial repair for chronic respiratory symptoms (secondary treatment). Tracheomalacia was scored based on standardized endoscopic evaluation, and respiratory symptoms were identified from clinic visits. A total of 118 subjects underwent posterior tracheopexy, with 100 (85%) being secondary treatment. Posterior tracheopexy resulted in improvement in tracheomalacia score based on bronchoscopy for both the primary and secondary treatment. Similarly, both groups had improvement in clinical symptoms such as cough, respiratory distress, cyanotic spells, and brief unexplained events. Subsequent surgical interventions were necessary in 15 (13%) of patients. TREATMENT OF DYSPHAGIA Duncan DR, Mitchell PD, Larson K, McSweeney ME, Rosen RL. Association of Proton Pump Inhibitors with Hospitalization Risk in Children with Oropharyngeal Dysphagia. JAMA Otolaryngol Head Neck Surg. 2018; 144(12): 1116-1124. Summary There is growing concern that proton pump inhibitors (PPIs) may increase the risk of pulmonary and gastrointestinal infections in children and adults; however, PPIs are frequently prescribed for children with dysphagia due to concern of acid-related lung injury. This was a retrospective cohort study of children under 2 years of age with a diagnosis of dysphagia based on aspiration or penetration during videofluoroscopic swallow study. PPI exposure was based on medication prescription and physician notes. Hospitalizations were stratified by total, urgent pulmonary, and urgent gastrointestinal hospitalizations. Propensity score analysis was used to insure robustness of the analysis. There were 293 subjects enrolled in this study. Aspiration was identified in 156 (53%), and laryngeal penetration in 137 (47%). Nearly half of the subjects had at least one hospitalization. Children treated with PPIs were more likely to be admitted to the hospital (HR= 1.25) and had a nearly 2-fold increase in hospitalization frequency (IRR=1.77) even after adjusting for comorbidities and propensity weight for severity of dysphagia. Similarly, there was a more than 2-fold increase in hospital admission nights (IRR=2.51). Comments 1. These results highlight that PPIs are commonly used in children with dysphagia and may result in increased morbidity characterize by increased hospitalizations and hospital length of stay. 2. The use of propensity score analysis and adjustment for multiple potential confounder increases the robustness of the findings. 3. This study is limited by its retrospective nature and by only includ- ing children under 2 years of age. OTHER ARTICLES OF INTEREST Fracchia MS, Diercks G, Cook A, Hersh C, Hardy S, Hartnick M, Hartnick C. The Diagnostic Role of Triple Endoscopy in Pediatric Patients with Chronic Cough. Int J Pediatr Otorhinolaryngol. 2019; 116: 58-61.