Alain J. Benitez

Pediatric gastroparesis is a debilitating disease requiring more diverse and effective treatment options. Intrapyloric botulinum toxin (IPBT) injection has emerged as a therapeutic option, although evidence supporting its use in children remains limited. The aim of this review is to summarize the current literature on IPBT injection for pediatric gastroparesis, focusing on symptomatic outcomes and potential predictors of response. Overall, most studies report some degree of symptomatic improvement following the injection; however, these findings are derived from small, retrospective cohorts without control groups. Objective predictors of response evaluated include gastric emptying scintigraphy, which did not show correlation with treatment response. Similarly, antroduodenal manometry general impressions and endoscopic functional luminal probe parameters did not reliably predict symptomatic response to the injection. Several studies describe repeated injections, although protocols for repeat are unclear, and the response is varied. Body surface gastric mapping represents a novel modality that may provide gastric physiological data allowing its use as a biomarker guiding IPBT injection, although pediatric data is still limited. Other emerging modalities, including gastric emptying breath test and gastric magnetic resonance imaging, may further enhance assessment of gastroparesis and treatment response. The current pediatric evidence on IPBT injection for gastroparesis is limited by suboptimal study designs and lack of objective assessments of treatment response. Future prospective, controlled studies are needed to strengthen conclusions on IPBT injection efficacy for pediatric gastroparesis and to clarify its role in clinical practice.

Purpose of Review The health benefits of food are being increasingly recognized. Exposing children and parents to culinary medicine enables them to make healthy food choices with potential for long term health improvement. Here we review pediatric literature on culinary medicine, share results of a recent practice survey, and review strategies for program development and implementation including training opportunities. Recent Findings There is growing evidence of interest in culinary medicine in pediatrics. A pediatric culinary medicine practice survey directed to current practitioners in the USA showed great variability. Common challenges associated with the practice included sustained funding, program management needs and getting the message out to the right audience. Based on survey responses and current literature, we generated educational resources and practice recommendations to further knowledge on pediatric culinary medicine practice. Summary Several opportunities exist for practitioners to further the field of pediatric culinary medicine by engaging in additional clinical practices, research, education, and advocacy.

INTRODUCTION: Functional lumen imaging probe (FLIP) can assess the esophageal contractile response (CR). Anesthetic agents used during endoscopy affect esophageal contractility, however, the time or dose-dependent effect of specific medications on the esophageal CR in children is unknown. METHODS: Charts of patients aged 3–22 years undergoing endoscopy with FLIP for evaluation of dysphagia at 2 tertiary pediatric hospitals were reviewed. Anesthetic dose and timing were collected. FLIP data were exported to Wklytics to generate Panometry plots, and the CR was classified as normal, borderline, spastic, impaired, or absent based on established definitions. Binary logistic regression was performed to assess whether anesthetic administration was associated with absent CR. End-tidal sevoflurane concentration was compared across groups with normal, borderline, and absent/impaired CR. RESULTS: Three hundred-three pediatric patients with a mean (SD) age of 13 years (4), 65% adolescent boys, were included. Totally, 80 (26%) had abnormal esophageal CR, where 16 (5%) were impaired, 63 (21%) were absent, and 1 was spastic. Two hundred twenty-eight (75%) were diagnosed with eosinophilic esophagitis, and 215 (71%) received sevoflurane. The odds ratio for absent CR if sevoflurane was administered was 8.4 ( P < 0.001). Sevoflurane was used significantly more often for both induction and maintenance in patients with abnormal CR compared with normal CR (70% vs 38%, P < 0.001). During the maintenance phase of anesthesia, end-tidal sevoflurane concentration was higher in patients with abnormal CR compared with normal CR independent of propofol infusion, recruitment site, and distensibility. DISCUSSION: The timing and dose of sevoflurane is strongly associated with esophageal CR impairment during FLIP.

The Little Brain Big Brain meeting was established more than 30 years ago as an opportunity for early career researchers to meet, present and discuss exciting new developments in the field of enteric neuroscience and neurogastroenterology. Crucially, the meeting is organized by young investigators, for young investigators. In this Viewpoint, past attendees and organizers of the Little Brain Big Brain meeting discuss their research interests, share their experience with this unique meeting and provide insights into progress in the field of enteric neuroscience and neurogastroenterology and its future outlook.

Background: Myofascial release (MFR) is a form of massage therapy that involves identifying and releasing restrictions in the fascia and muscles. MFR-like techniques have shown improvement in abdominal pain, distention, constipation, and quality of life (QoL) in adults. Therefore, MFR may be helpful in patients with irritable bowel syndrome (IBS), a disorder of gut-brain interaction or functional gastrointestinal disorder, mainly presenting with prolonged abdominal pain, bloating, and altered defecation patterns, leading to impairment in QoL. Treatments for IBS are limited and do not always completely relieve pain. To date, no studies have evaluated the feasibility and acceptability of MFR for children with IBS as a potential therapy. Purpose: The aim of the study is to assess the feasibility and acceptability of administering abdominal wall-targeted MFR in children with IBS. Setting: This study was approved and conducted at Children’s Hospital of Philadelphia. Participants: Males and females aged 13–18 years meeting Rome IV criteria for IBS were included in the study. Research design: Participants underwent six 1-h weekly sessions of abdominal wall-targeted MFR with a licensed massage therapist (LMT) and performed self-MFR at home between sessions. Feasibility and acceptability data were collected via REDCap (Research Electronic Data Capture) by the study team and LMTs. Symptoms and QoL were assessed before and after the intervention period using child and parent versions of validated pediatric questionnaires. Results: Of 10 participants aged 14–18 years, 60% females underwent the MFR intervention and completed the 6-week protocol. The median visit compliance with questionnaire completion was 90%. All participants received self-MFR education and performed self-MFR between sessions. Fascia restrictions were identified and released in all participants, as reported by the LMTs. Most participants voluntarily provided positive feedback on MFR. All participants reported no or minimal soreness during or after MFR, and no adverse events were reported. Conclusions: Abdominal wall-targeted MFR is feasible to administer and well accepted in pediatric IBS patients.

Importance: Persistent upper gastroduodenal symptoms, such as nausea, vomiting, bloating, and abdominal pain, are widespread among pediatric patients. Multiple overlapping symptoms complicate the diagnostic process, necessitating the development of novel gastric function tests with actionable biomarkers. Body Surface Gastric Mapping (BSGM) has emerged as a promising diagnostic tool for gastroduodenal disorders, and this is the first detailed evaluation in adolescents. Objective: This study aimed to assess the utility of BSGM in delineating specific patient phenotypes among adolescents with functional dyspepsia (FD) and gastroparesis in order to guide clinical decision-making. Design: A prospective cross-sectional study recruited adolescents aged 12 to 21 between 2022 and 2024. Setting: Controls were recruited from New Zealand (controls) and Patients from the Children’s Hospital of Philadelphia, USA. Participants: Prospectively recruited participants included controls without gastroduodenal symptoms or motility-related medication usage and patients diagnosed with either gastroparesis (delayed gastric emptying test (GET)) or FD according to ROME IV criteria and a normal GET. Procedures: BSGM was performed using a standardized protocol, including simultaneous symptom reporting and the completion of validated symptom, psychometric and physical health questionnaires. Main Outcome: The primary outcome was to evaluate if BSGM could delineate specific patient phenotypes and provide clinically meaningful distinctions between gastroparesis and FD diagnoses, utilizing BSGM spectral outcome data. Results: Fifty-six subjects were recruited (31 controls, 25 patients); median age 16; 96% of patients were female. Control data showed that adult reference intervals provided an acceptable interpretation framework. Patients with FD (n=10) and gastroparesis (n=15) had common symptoms, mental health, quality of life and functional disability (all p>0.05). Three distinct BSGM phenotypes were identified: BSGM Normal (n=10), BSGM Delay (n=8), and Low Stability/Low Amplitude (n=7), having spectral differences in BMI-Adjusted Amplitude 34.6 vs 39.1 vs 19.9 ( p =.01) and Gastric Alimetry Rhythm Index: 0.45 vs 0.45 vs 0.19 ( p =.003). BSGM phenotypes demonstrated differences in symptoms (nausea p =0.04), physical health ( p =.04) and psychometrics (anxiety p =.03). Conclusion and Relevance: Adolescent patients with FD and gastroparesis have overlapping clinical profiles, making individualized treatment challenging. Conversely, employing BSGM to categorize patients into distinct phenotypes revealed clinically relevant differences, offering potential avenues for individualized therapeutic pathways.

INTRODUCTION: There are limited data characterizing eating habits among pediatric patients with eosinophilic esophagitis (EoE). We compared eating behaviors in pediatric patients with EoE with healthy controls and assessed the degree of correlation with symptomatology, endoscopic and histologic findings, and esophageal distensibility. METHODS: We conducted a prospective, observational study where subjects consumed 4 food textures (puree, soft solid, chewable, and hard solid) and were scored for eating behaviors including number of chews per bite, sips of fluid per food, and consumption time. Symptomatic, endoscopic, histologic, and esophageal distensibility data were collected for case subjects. RESULTS: Twenty-seven case subjects and 25 healthy controls were enrolled in our study (mean age 11.0 years, 63.5% male). Compared with healthy controls, pediatric patients with EoE demonstrated more chews per bite with soft solid (13.6 vs 9.1, P = 0.031), chewable (14.7 vs 10.7, P = 0.047), and hard solid foods (19.0 vs 12.8, P = 0.037). Patients with EoE also demonstrated increased consumption time with soft solid (94.7 vs 58.3 seconds, P = 0.002), chewable (90.0 vs 65.1 seconds, P = 0.005), and hard solid foods (114.1 vs 76.4 seconds, P = 0.034) when compared with healthy controls. Subgroup analysis based on disease status showed no statistically significant differences in eating behaviors between active and inactive EoE. Total endoscopic reference score positively correlated with consumption time (r = 0.53, P = 0.008) and number of chews (r = 0.45, P = 0.027) for chewable foods and with number of chews (r = 0.44, P = 0.043) for hard solid foods. Increased consumption time correlated with increased eosinophil count (r = 0.42, P = 0.050) and decreased esophageal distensibility (r = −0.82, P < 0.0001). DISCUSSION: Altered eating behaviors including increased chewing and increased consumption time can be seen in pediatric patients with EoE, can persist despite histologic remission, and may be driven by changes in esophageal distensibility.

Objective: To develop and validate a set of static and animated pediatric gastroduodenal symptom pictograms. Methods: There were three study phases: 1: Co-creation used experience design methods resulting in ten pediatric gastroduodenal symptom pictograms (static and animation); 2: an online survey to assess acceptability, face and content validity; and 3: a preference study. Phases 2 and 3 compared the novel paediatric pictograms with existing pictograms used with adult patients. Results: Eight children aged 6-15 years (5 Female) participated in Phase 1, 69 children in Phase 2 (median age 13 years: IQR 9-15), and an additional 49 participants were included in Phase 3 (median age 15: IQR 12-17). Face and content validity were higher for the pediatric and animated pictogram sets compared to pre-existing adult pictograms (78% vs. 78% vs. 61%). Participants with worse gastric symptoms (lower PedsQL-GIS score) had superior comprehension of the pediatric pictograms (χ ² ₈ < .001). The pediatric pictogram set was preferred by all participants over animation and adult (χ ² ₂ < .001). Conclusion: The co-creation phase resulted in the symptom concept confirmation and design of ten acceptable static and animated gastroduodenal pictograms with high face and content validity when evaluated with children aged 6 to 18. Validity was superior when children reported more problematic symptoms. Therefore, these pictograms could be used in clinical and research practice to enable standardized symptom reporting for children with gastroduodenal disorders. Why is it important: ▪ Diagnosis of gastroduodenal disorders of the gut-brain interaction (DGBI) in pediatrics is difficult as symptoms often overlap. ▪ Pediatric patients find identifying and distinguishing symptoms difficult. ▪ Validated gastroduodenal symptom pictograms have been found to help adults accurately report their symptoms and have been used effectively to standardize symptom monitoring, including continuous symptom reporting during investigations. ▪ There are no validated pediatric gastroduodenal symptom pictograms. What we did: ▪ Co-created a set of ten pediatric gastroduodenal symptom pictograms. ▪ Undertook a face and content validity study to assess the novel pictograms with 118 pediatric participants with a median PedsQL-GIS score of 86.1 (IQR 68.1-90.0). The Outcome: ▪ Designed a novel set of pictograms with face and content validity that were preferred over other sets, enabling acceptable, simple and validated pediatric patient reporting of their gastroduodenal symptoms.

INTRODUCTION: Inflammation in eosinophilic esophagitis (EoE) often leads to esophageal strictures. Evaluating esophageal narrowing is clinically challenging. We evaluated esophageal distensibility as related to disease activity, fibrosis, and dysphagia. METHODS: Adult patients with and without EoE underwent endoscopy and distensibility measurements. Histology, distensibility, and symptoms were analyzed. RESULTS: Patients with EoE had significantly lower distensibilities than controls. We found a cohort with esophageal diameter under 15 mm despite lack of dysphagia. DISCUSSION: This study raises concern that current assessments of fibrostenosis are suboptimal. We describe a cohort with unrecognized slender esophagus that were identified through impedance planimetry measurements. This tool provides additional information beyond symptomatic, histologic, and endoscopic assessments.