BACKGROUND: Cell salvage (CS) techniques are used to reduce exposure to allogeneic packed red blood cell (pRBC) transfusion in patients undergoing cardiac surgery. However, some studies suggest that inappropriate use of these techniques is associated with increased incidences of thrombocytopenia, excessive bleeding, and transfusion of non-red blood cell blood products, including fresh frozen plasma (FFP), cryoprecipitate, and platelets. Pediatric patients undergoing cardiac surgery are at higher risk for increased perioperative bleeding and blood product transfusion requirement. To date, limited evidence supports the use of CS to reduce pRBC transfusion in neonates and children undergoing cardiac surgery. OBJECTIVES: This study analyzed the efficacy of systematic use of CS in neonates and children undergoing cardiac surgery with cardiopulmonary bypass (CPB) compared to a historic cohort of children in whom CS was not used. Our primary endpoints included the incidences of pRBC, cryoprecipitate, and platelets transfusion occurring within 48 hours after CPB. METHODS: We performed a retrospective medical chart review to study all neonates and children who underwent cardiac surgery with CPB between January 2013 and December 2014 at Boston Children’s Hospital (BCH). Considering that CS has been systematically applied at BCH since January 2014, children were separated into a control group (before January 2014) and a CS group (after January 2014). Children treated with CS before January 2014 were excluded. We used uni- and multivariable logistic regression analysis to assess the effect of CS on the odds of blood products transfusion. RESULTS: Among 1228 patients included in the analysis, 730 were included in the CS group and 498 in the control group. The results of our multivariate logistic regression analysis showed that age < 12 months (odds ratio (OR): 2.95, 95% confidence interval (CI): 2.26-3.84), American Society of Anesthesiologists Physical Status Classification (ASA) > 3 (OR: 2.95, 95% CI: 2.26-3.84), Risk Adjustment for Congenital Heart Surgery score (RACHS) > 3 (OR: 1.78, 95% CI: 1.28-2.49), and the use of CS (OR: 0.57, 95% CI: 0.44-0.73) were good predictors for perioperative transfusion. Using univariable analysis, the use of CS was associated with a significant reduction in pRBC transfusion (OR: 0.76, 95% CI: 0.61-0.96, p = 0.021), but a significant increase in cryoprecipitate (OR: 1.37, 95% CI: 1.08-1.76, p = 0.009) and platelets transfusions (OR: 1.37 95% CI: 1.08- 1.76, p = 0.004). However, after adjustment for age < 12 months, ASA > 3, and RACHS > 3, the use of CS significantly reduced pRBC transfusion (OR: 0.57, 95% CI: 0.44-0.73, p < 0.001), with no effect on cryoprecipitate (OR: 1.08, 95% CI: 0.83-1.41, p = 0.543) and platelets transfusions (OR: 1.05, 95% CI: 0.81-1.36, p = 0.694). CONCLUSION: The use of CS in neonates and children undergoing cardiac surgery with CPB significantly reduced the incidence of pRBC transfusion. Although the systematic use of CS in adults has been associated with an increased incidence of non-pRBC transfusions, the use of CS in a high risk pediatric population (age < 12 months, ASA > 3, RACHS > 3) was associated with a 43% reduction of pRBC transfusion without any increases in cryoprecipitate and platelets transfusions.

INTRODUCTION: Infants who have dysphagia (difficulty swallowing) are often recommended thickened oral liquids, which can be easier to swallow and allow infants to continue feeding orally. In the last decade, a xanthan gum thickener, SimplyThick®, was commonly used in preterm infants with dysphagia because of its ability to thicken breast milk. In 2011, the FDA cautioned against the use of SimplyThick in preterm infants, because of case reports of necrotizing enterocolitis (NEC), a condition where the bowel becomes inflamed and can lead to intestinal perforation or necrosis, systemic infection, the failure of multiple organs and death (Moore, 2016; Press Announcements, 2011). However, since the FDA warning, there have been no studies examining the prevalence of necrotizing enterocolitis in infants who consume SimplyThick. AIMS: Among infants at BCH who used SimplyThick and other thickeners at <1-year old between October 1st, 2012- December 31st, 2015 to 1) describe the patients’ clinical characteristics, including indications for SimplyThick and other thickeners and 2) determine the prevalence of necrotizing enterocolitis and adverse effects. METHODS: We performed a retrospective chart review in infants who had been seen at Boston Children’s Hospital, and prescribed or recommended SimplyThick thickener under the age of 1 (defined as from 0 up to and including 12 months) from October 1, 2012 to December 31, 2015. We collected information from electronic medical records and an existing quality improvement database of infants who had an abnormal modified barium swallow study. We collected information regarding clinical variables (e.g. patient age, patient sex, patient weight, gestational age at birth, clinical indications), nutritional information, and outcomes (presence of NEC or other adverse effects). These data were entered into a REDCap database and analyzed using SAS statistical software. RESULTS: We identified 20 cases of infants meeting our inclusion criteria. The duration of follow-up ranged from 6 months to 9.3 months. This follow up was either until the case turned 12 months of age or 6 months after the use of SimplyThick if the age started SimplyThick was greater than 6 months old. Mean corrected age at the time that SimplyThick was started was 6.2 months (range, 2.7 to 10.6 months), and 6 (30%) were born preterm at a gestational age ranging from 24.7 to 36.5 weeks. In cases that eventually stopped using SimplyThick (14 cases, 70%), SimplyThick was continued for a mean duration of 42.1 weeks (range 1.1 to 117.1 weeks). The most common indications for SimplyThick were aspiration documented on a modified barium swallow test, dysphagia and GERD. The most common reasons for discontinuation of SimplyThick were no longer requiring thickened feeds, or needing to stop oral feeding. No cases of necrotizing enterocolitis were reported among the 20 subjects. No adverse effects of SimplyThick were reported. CONCLUSION: Among 20 infants started on SimplyThick at 6.2 months and followed for up to 6 to 9.3 months, there were no cases of necrotizing enterocolitis. Further data collection is required to confirm these findings. / 2019-07-11T00:00:00Z

INTRODUCTION: Anemia is a frequent complication in patients with inflammatory bowel disease (IBD). The inflammation observed in IBD negatively impact absorption of iron. This could lead to increased hospitalizations, affect growth and development, and decrease overall quality of life. This is especially pronounced in the pediatric population. The screening and treatment of iron deficiency anemia (IDA) varies between centers, and as a result, roughly 40-60% of pediatric IBD patients are iron deficient. OBJECTIVES: The objective of this study is to assess the efficacy and safety profile of intravenous and enteral iron therapy in a population of iron deficient patients with IBD. The secondary aim of this study is to determine if oral or intravenous iron therapy can improve hematologic and iron parameters. We will also examine the longitudinal changes in gastrointestinal (GI) symptoms and quality of life in patients receiving oral and intravenous iron supplementation. METHODS: We conducted a prospective cohort study in pediatric patients with IBD admitted to the inpatient GI service at Boston Children’s Hospital from 09/05/2017 to 03/05/2018. Forty-six IBD patients were screened, and twenty-nine (63%) were identified as iron deficient and were consented for data collection through chart review and administration of the IMPACT-III quality of life questionnaire. RESULTS: Out of the twenty-nine IBD patients, eighteen (62%) received intravenous iron, seven (24%) received oral iron, and four (14%) were untreated and served as controls. The mean change in hemoglobin in patients receiving parenteral, oral, or no iron therapy was 1.6g/dl±0.5, 1.1g/dl±0.4, and 0.2g/dl±0.5, respectively. The change in hemoglobin was significant between the parenteral and oral iron group (P<0.05). The mean change in health-related quality of life scores in patients receiving parenteral or oral iron therapy was 11.6±11.4 and 3.8l±7.5, respectively. CONCLUSION: Our study demonstrates that intravenous iron therapy was more efficacious than oral iron in improving hematologic and iron parameters in IBD patients. This improvement was concomitant with higher scores on the IMPACT-III quality of life questionnaire, suggesting that iron supplementation improves health-related quality of life in IBD patients with iron deficiency anemia.

Thesis (Ed.M.)--Boston University