Background Studies have suggested that when intravenous (IV) soybean oil (SO) is replaced with fish oil (FO), direct hyperbilirubinemia is more likely to resolve. The necessary duration of FO has not been established. This study seeks to determine if 24 weeks of FO is an effective and safe therapy for intestinal failure associated liver disease (IFALD). Materials and Methods This is a clinical trial using patients with IFALD between the ages of 2 weeks and 18 years. SO was replaced with FO (1 g/kg/day) in 10 subjects who were receiving the majority of their calories from parenteral (PN). Subjects were compared to 20 historical controls receiving SO. SO for both groups was prescribed by the primary medical team at variable doses. The primary outcome was time to reversal of cholestasis. Secondary outcomes were death, transplant, and full enteral feeds. Safety measurements included growth, essential fatty acid deficiency, and laboratory markers to assess bleeding risk. Results The Kaplan-Meier method estimates that 75% in the FO group will experience resolution of cholestasis by 17 weeks vs. 6% in the SO group (p < 0.0001). When compared to the SO group, the FO group had decreased serum direct bilirubin concentrations at weeks 8 (p=0.03), 12, 16, 20 and 24 (p< 0.0001). While length Z-score at the end of the study increased in the FO group compared to baseline (p=0.03), there were no significant differences in other outcomes. Conclusions A limited duration of FO appears to be safe and effective in reversing IFALD.

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We sought to identify age group specific maternal risk factors for gastroschisis. Maternal characteristics and prenatal factors were compared for 1,279 live born infants with gastroschisis and 3,069,678 without. Data were obtained using the California database containing linked hospital discharge, birth certificate and death records from 1 year prior to the birth to 1 year after the birth. Backwards-stepwise logistic regression models were used with maternal factors where initial inclusion was determined by a threshold of p < 0.10 on initial crude analyses. Due to the strong association of gastroschisis with young maternal age, models were stratified by age groups and odds ratios were calculated. These final models identified maternal infection as the only risk factor common to all age groups and a protective effect of obesity and gestational hypertension. In addition, age specific risk factors were identified. Although gestation at the time of infection was not available, a sexually transmitted disease complicating pregnancy was associated with increased risk in the less than 20 years of age grouping whereas viral infection was associated with increased risk only in the 20-24 and more than 24 years of age groupings. Urinary tract infection remained in the final logistic model for women less than 20 years. Short interpregnancy interval was not found to be a risk factor for any age group. Our findings support the need to explore maternal infection by type and gestational timing.

BACKGROUND AND OBJECTIVES: Despite previous studies demonstrating no difference in mortality or morbidity, the various surgical approaches for necrotizing enterocolitis (NEC) in infants have not been evaluated economically. Our goal was to compare total in-hospital cost and mortality by using propensity score-matched infants treated with peritoneal drainage alone, peritoneal drainage followed by laparotomy, or laparotomy alone for surgical NEC. RESULTS: Successful propensity score matching was performed with 699 infants (peritoneal drainage, n = 101; peritoneal drainage followed by laparotomy, n = 172; and laparotomy, n = 426). Average adjusted cost for peritoneal drainage followed by laparotomy was $ CONCLUSIONS: Propensity score-matched analysis of surgical NEC treatment found that peritoneal drainage followed by laparotomy was associated with decreased mortality compared with peritoneal drainage alone but at significantly increased costs. WHAT'S KNOWN ON THIS SUBJECT:Mortality rates and health care expenditures are high among infants requiring surgery for necrotizing enterocolitis. The impact of different surgical managements on mortality remains equivocal. Adjusted economic differences for various surgical treatments may exist but have not been elucidated. WHAT THIS STUDY ADDS:After performing a relatively large-scale, adjusted analysis of cost and mortality for surgical managements currently used for treating necrotizing enterocolitis, a costbenefit for a particular surgical approach was demonstrated while accounting for comorbidities and group assignment bias.

Background Neonates with gastrointestinal disorders (GD) are at high risk for parenteral nutrition associated liver disease (PNALD). Soybean-based intravenous lipid emulsions (S-ILE) have been associated with PNALD. This study’s objective was to determine if a lower dose when compared to a higher dose of S-ILE prevents cholestasis without compromising growth. Material and Methods This multi-center randomized controlled pilot study enrolled subjects with GD who were ≤ 5 days of age to a low dose (approximately 1 g/kg/day) (LOW) or control dose of S-ILE (approximately 3 g/kg/day) (CON). The primary outcome was cholestasis (direct bilirubin (DB) > 2 mg/dL) after the first seven days of age. Secondary outcomes included growth, PN duration, and late onset sepsis. Results Baseline characteristics were similar between the LOW (n=20) and CON groups (n=16). When the LOW group was compared to the CON group, there was no difference in cholestasis (30% vs. 38%, p=0.7) or secondary outcomes. However, mean (±SE) DB rate of change over the first eight weeks (0.07±0.04 vs. 0.3±0.09 mg/dL/week, p=0.01) and entire study (0.008±0.03 vs. 0.2±0.07 mg/dL/week, p=0.02) was lower in the LOW group when compared to the CON group. Conclusion In neonates with GD who received a lower dose of S-ILE, DB increased at a slower rate in comparison to neonates who received a higher dose of S-ILE. Growth was comparable between the groups. This study demonstrates a need for a larger, randomized controlled trial comparing two different S-ILE doses for cholestasis prevention in neonates at risk for PNALD.

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WHAT'S KNOWN ON THIS SUBJECT:There has been a dramatic increase in the use of adolescent bariatric surgery. However, previous studies were unable to distinguish laparoscopic versus open procedures. Furthermore, the use of laparoscopic adjustable gastric banding (LAGB) has not been studied on a population level. WHAT THIS STUDY ADDS:The rate of LAGB increased sevenfold from 2005 to 2007 with a corresponding decrease in the rate of laparoscopic Roux-en-Y gastric bypass. Furthermore, white adolescents represented only 28% of those who were overweight but accounted for 65% of the procedures.abstract OBJECTIVE: The goal of this study was to evaluate trends, and outcomes of adolescents who undergo bariatric surgery. PATIENTS AND METHODS: RESULTS:Overall, 590 adolescents (aged 13-20 years) underwent bariatric surgery in 86 hospitals. White adolescents represented 28% of those who were overweight but accounted for 65% of the procedures. Rates of laparoscopic adjustable gastric banding (LAGB) increased 6.9-fold from 0.3 to 1.5 per 100 000 population (P Ͻ .01), whereas laparoscopic Roux-en-Y gastric bypass (LRYGB) rates decreased from 3.8 to 2.7 per 100 000 population (P Ͻ .01). Self-payers were more likely to undergo LAGB (relative risk [RR]: 3.51 [95% confidence interval: 2.11-5.32]) and less likely to undergo LRYGB (RR: 0.45 [95% confidence interval: 0.33-0.58]) compared with privately insured adolescents. The rate of major in-hospital complication was 1%, and no deaths were reported. Of the patients who received LAGB, 4.7% had band revision/removal. In contrast, 2.9% of those who received LRYGB required reoperations. CONCLUSIONS:White adolescent girls disproportionately underwent bariatric surgery. Although LAGB has not been approved by the US Food and Drug Administration for use in children, its use has increased dramatically. There was a complication rate and no deaths. Long-term studies are needed to fully assess the efficacy, safety, and health care costs of these procedures in adolescents.

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