Gastroenterology & GI Surgery

Drs. Kane and Petrosyan

POEM procedure is safe and effective for children with esophageal achalasia

Drs. Kane and Petrosyan

Drs. Petrosyan and Kane combined perform more POEM procedures for children than any other pediatric surgeons in the United States.

Peroral endoscopic myotomy (POEM) is a safe and effective procedure to treat pediatric achalasia according to a single-center outcomes study in the Journal of Pediatric Surgery.

Authors Timothy Kane, M.D., chief of General and Thoracic Surgery at Children’s National Hospital, and Mikael Petrosyan, M.D., MBA, associate chief of that division, together perform more of these procedures than any other pediatric surgeons in the United States.

Their experience with POEM shows that it is as safe and effective as the current standard of care for pediatric achalasia, which is a procedure called the laparoscopic Heller myotomy (LHM). Even better, previous research in adults and now in pediatric patients, has shown that those who undergo POEM as an alternative to LHM report less pain and often require shorter hospital stays after surgery.

Why it matters

POEM has been an option for adults with achalasia for many years, but not for children because it requires technical skill and expertise not readily available everywhere. More studies of young patients with successful outcomes following POEM procedures can help make the case for training more pediatric surgeons to learn this approach, and help this alternative method become an additional surgical option for children with achalasia.

The hold-up in the field

Achalasia is a rare condition in adults (1/100,000) and even less common in children, occurring in only 0.1 per 100,000 patients with an estimated prevalence of 10 per 100,000. The rarity of achalasia in children compared with adults makes collecting enough statistically significant evidence about how best to treat them difficult, more so than for other more common pediatric surgical conditions.

Children’s National Hospital leads the way

Children’s National Hospital is one of the only children’s hospitals in the country to offer the option of POEM for treatment of these conditions in children — and Drs. Kane and Petrosyan combined perform more of these procedures than any other pediatric surgeons in the United States.

The surgeons at Children’s National offer POEM as a primary intervention for children with esophageal achalasia and are also applying the same approach for pediatric gastroparesis as well.

Children’s National Hospital is one of only 12 children’s hospitals in the country, and the only hospital in the Washington, D.C., region, to be verified as a Level 1 Children’s Surgery Center by the American College of Surgeons (ACS) Children’s Surgery Verification Quality Improvement Program. This distinction recognizes surgery centers whose quality improvement programs have measurably improved pediatric surgical quality, prevented complications, reduced costs and saved lives.

Bottom line

Given their reported outcomes so far, the authors believe that in the long term this approach may replace the current pediatric standard of care, the LHM. More research is needed to make this case, however, including long-term follow-up studies of the patients who have undergone the procedure so far.

You can read the full study, “Per Oral Endoscopic Myotomy (POEM) for Pediatric Achalasia: Institutional Experience and Outcomes,” in the Journal of Pediatric Surgery.

hand holding blocks that spell out IBD

Q&A with Carmelo Cuffari, M.D., on inflammatory bowel disease

hand holding blocks that spell out IBDCarmelo Cuffari, M.D., the new director of Inflammatory Bowel Disease (IBD) Program at Children’s National Hospital is a pediatric gastroenterologist with over 25 years of expertise in managing children and adolescents with Crohn’s disease and ulcerative colitis. His areas of research include drug development and the pharmacology and genomics of immunomodulatory drugs in inflammatory bowel disease and in transplantation.

Here, Dr. Cuffari tells us more about the program he is leading and what it means for the future of pediatric IBD patients at Children’s National.

Q: What are some of the most valuable changes or advancements for the program you hope to see in the next couple of years?

A: In my position as director of IBD, Children’s National supports my goals for the program which include:

  • Expanded regional accessibility to an IBD specialist
  • Potential to develop international services
  • Potential to develop a multidisciplinary pediatric IBD program that would include surgery, psychology and genetics
  • Expanding staff to include another IBD specialist to increase our reach

Q: What makes the IBD at Children’s National unique from other programs in the country?

A: We have the unique possibility of developing a colorectal team with our surgical colleagues. This level of collaboration is unique and is a function of our division being under the department of pediatric surgery.

Q: Where do you see research in IBD going in the next few years?

A: There are many areas of exciting growth in research. The areas I am most excited about include:

  • Developing a tailored therapeutic approach to disease management that is disease phenotype specific
  • Developing biomarkers that may help identify which part of the immune system is dysregulated
  • Very early onset IBD (<6yrs) will be better defined genetically and immunologically
medical symbol on a map of the world

Observership program builds worldwide expertise to treat colorectal issues

medical symbol on a map of the worldPediatric colorectal specialists are in short supply, and this is particularly true in many areas of the developing world. When Marc Levitt, M.D., travels abroad, he consistently finds eager surgeons and nurses who wish to obtain advanced colorectal skills to help their patients. To meet this need Dr. Levitt has established an international observership program that brings leading physicians and nurses from around the globe to participate in one- to three-month-long observerships.

During 2022, the program will welcome participants from 13 different countries including Spain, Belgium, Vietnam, Indonesia, Chile, Pakistan, Uganda, Iraq, Mexico, Brazil, Saudi Arabia and Singapore.

Under the colorectal team’s instruction, participating physicians and nurses will learn how to diagnose and care for children with complex colorectal conditions. They will learn about the wide range of malformations and successful treatment options so they can bring these skills to patients in their home countries. Those selected for these observerships are among the most promising providers in their communities who currently work to improve treatment for children with colorectal issues.  The patients they care for are those who would otherwise have no or limited access to this specialty care.

For information about applying for the observership program, please contact the colorectal department at ColorectalVisitors@childrensnational.org.

Human Digestive System Anatomy

Intestinal rehabilitation program demonstrates high survival rates

Human Digestive System AnatomyIn a new study, researchers at Children’s National Hospital analyzed outcomes in children with short-bowel syndrome (SBS), parenteral nutrition dependence (PND) and intestinal failure-associated liver disease (IFALD) who were treated in the Children’s National Intestinal Rehabilitation Program (IRP) from 2007 to 2018.

The study, led by Clarivet Torres, M.D., director of the IRP at Children’s National, reviewed charts of 135 patients with SBS-PND at the time of their enrollment in the IRP. Of these, 89 patients had IFALD, defined as sustained (>2 months) conjugated bilirubin (CB) of ≥2 mg/dl at enrollment and/or abnormal liver biopsy, showing stage two through four fibrosis.

Historically, IFALD was a major cause of mortality among patients with intestinal failure and accounted for the high percentage of pediatric small-bowel transplants. Over the last two decades, outcomes of patients with SBS, PND and IFALD have been improving with creation of intestinal rehabilitation programs.

Recent data from the International Intestinal Failure Registry Pilot Phase showed improved outcomes, with 8% mortality. However, IFALD was the cause of death in 7% and almost 50% of patients were still PN dependent at 12 months of follow-up.

The study at Children’s National reveals normalization of the conjugate hyperbilirubinemia in 99% of the patients with IFALD, over a median time of 9.5 weeks after enrollment, with nontransplant treatment. It also demonstrates a transplant-free survival in 97% of these patients. Although the median percentage of expected bowel length in the study population was only 23% and over half had no ileocecal valve, 81% of patients were successfully weaned from PN over a median time of 5 months of being enrolled in the IRP.

Dr. Torres and her team demonstrate high rates of transplant-free survival and enteral autonomy among SBS children with IFALD who do not have underlying primary motility/genetic disorders.

Despite a high acuity of symptoms and pathology (for example, ultrashort bowel, initially high PND, initial CB >4 mg/dl, significant fibrosis/cirrhosis), they reduced their PN needs relatively quickly and improved IFALD. As one of the larger IRPs in the United States, Children’s National demonstrates high survival rates of patients without the need for liver or intestinal transplantation.

Other Children’s National authors include Vahe Badalyan, M.D., and Parvathi Mohan, M.D.

Torres C, Badalyan V, Mohan P. Twelve-year outcomes of intestinal failure associated liver disease in children with short bowel syndrome: 97% transplant -free survival and 81% enteral autonomy.  Journal of Parenteral and Enteral Nutrition. 2021;1–10. https://doi.org/10.1002/jpen.2112

surgeon doing laparoscopic surgery

Autonomous robotic laparoscopic surgery for intestinal anastomosis

surgeon doing laparoscopic surgery

Children’s National Hospital in collaboration with the University of North Carolina Wilmington and Johns Hopkins University developed an enhanced autonomous strategy for laparoscopic soft tissue surgery.

A new approach to soft tissue surgery could simplify autonomous surgical planning and enable collaborative surgery between an autonomous robot and human, a new study published in Science Robotics finds. This is the first time a robot can complete an autonomous soft tissue surgical task under laparoscopic conditions, forming the foundation for future soft tissue surgeries.

Children’s National Hospital in collaboration with the University of North Carolina Wilmington and Johns Hopkins University developed an enhanced autonomous strategy for laparoscopic soft tissue surgery. The multi-institutional effort made it possible to perform a robotic laparoscopic small bowel anastomosis in phantom and in vivo intestinal tissues. The findings further suggest that autonomous robot-assisted surgery has the potential to provide more efficacy, safety and consistency independent of an individual surgeon’s skill and experience.

The hold-up in the field

Autonomous anastomosis is known to be a challenging soft tissue surgery task. And in the laparoscopic setting, surgeries like these prove to be more challenging because of the need for high maneuverability and repeatability under motion and vision constraints – especially in pediatric patients.

“This work represents the first time autonomous soft tissue surgery has been performed using a laparoscopic technique and is the first step in bridging the gap between human and machine towards completing autonomous surgical tasks in soft tissue surgeries,” says Hamed Saeidi, Ph.D., assistant professor at University of North Carolina Wilmington and lead author of the study.

To overcome the unpredictable motions of the tissue, the experts used machine learning based techniques to track the dynamic motions of the soft tissue during the surgery. These methods also pave the way for markerless methods for tracking the tissue motion in future surgeries.

“Until now, laparoscopic autonomous surgeries were not possible in soft tissue due to the unpredictable motions of the tissue and limitations on the size and capabilities of surgical tools,” says Justin Opfermann, M.S., Ph.D., student and Johns Hopkins University and co-author.

What’s unique

Performing autonomous surgery would require the development of novel suturing tools, imaging systems and robotic controls to visualize a surgical scene, generate an optimized surgical plan and then execute that surgical plan with the highest precision.

The autonomous robot takes its skill one step further when performing surgical tasks on soft tissues by enabling a robot-human collaboration to complete more complicated surgical tasks where preoperative planning is not possible.

Additionally, the robot used in this work uses a novel shared control scheme called “conditional autonomy,” whereby the robot performs the majority of the surgical task, which the surgeon oversees.

Bottom line

“Combining all of these features into a single system is non-trivial,” Opfermann adds. “In 2016, we were the first group to demonstrate feasibility of semi-autonomous small bowel anastomosis with a robot in soft tissue, and now we can perform autonomous laparoscopic anastomosis.”

The resulting anastomosis had more consistency and achieved higher burst strength than surgeons suturing with manual technique, resulting in less anastomotic leak.

In laparoscopic surgeries – and pediatric patients especially – these challenges are even more difficult due to the small size of the patient. Robotic anastomosis is one way to ensure that surgical tasks that require high precision and repeatability can be performed with more accuracy and precision in every patient independent of surgeon skill.

“As a surgeon, I can attest to the potential benefits of improving how we perform surgery on our patients,” says Michael Hsieh, M.D., Ph.D., director of Transitional Urology at Children’s National Hospital. “Working with my engineering colleagues at Johns Hopkins, we’ve been able to develop prototypes of supervised, autonomous suturing robots that may be a step towards such improvements.”

gluten free cupcakes

Grant funds behavioral intervention study of teens with celiac disease

Shayna Coburn

Shayna Coburn, Ph.D. was awarded a National Institute of Health (NIH) K23 Career Development Grant from the National Institute of Diabetes and Digestive and Kidney Diseases.

Shayna Coburn, Ph.D., was awarded a National Institute of Health (NIH) K23 Career Development Grant from the National Institute of Diabetes and Digestive and Kidney Diseases. This is the first NIH funded behavioral intervention study focused on children and teens with celiac disease.

The award will allow Dr. Coburn to refine and test a behavioral intervention for teens with celiac disease and their parents. Using feedback from teen and parent stakeholders, the goal of Dr. Coburn’s research is to improve a telehealth-based coping skills group for teens and parents in the Children’s National Celiac Program and then test whether it improves their quality of life and self-management of the gluten-free diet. Dr. Coburn will also conduct a randomized controlled trial to compare outcomes to those patients who receive current standard of care with the Celiac Program.

Dr. Coburn is a licensed psychologist in the Division of Gastroenterology, Hepatology and Nutrition at Children’s National Hospital and is in charge of psychosocial services in the Celiac Disease Program, which offers consultations and empirically supported interventions to help families navigate the challenges of diagnosis and management of the gluten-free diet. She also contributes to the local and national celiac disease community through her development of support and coping skills groups, educational programming, advocacy and research.

Drs. Katie Donnelly, Panagiotis Kratimenos, Rana Hamdy, Shayna Coburn and Brynn Marks

Five Children’s National Hospital faculty named to Society for Pediatric Research

Drs. Katie Donnelly, Panagiotis Kratimenos, Rana Hamdy, Shayna Coburn and Brynn Marks

The Society for Pediatric Research (SPR) announced five new members from Children’s National Hospital: Drs. Rana Hamdy, Panagiotis Kratimenos, Brynn Marks, Shayna Coburn and Katie Donnelly.

The Society for Pediatric Research (SPR) announced five new members from Children’s National Hospital. Established in 1929, SPR’s mission is to create a multi-disciplinary network of diverse researchers to improve child health.

Membership in SPR is a recognized honor in academic pediatrics. It requires nomination by academic peers and leaders as well as recognition of one’s role as an independent, productive child health researcher.

“I am so proud of our faculty and all that they have accomplished. I am thrilled that they have been recognized for their achievements,” said Beth A. Tarini, M.D., M.S., SPR president and associate director for the Center for Translational Research at Children’s National Hospital.

SPR 2021 active new members from Children’s National are:

    • Katie Donnelly, M.D., M.P.H., attending physician in the Emergency Department at Children’s National Hospital. She is the medical director for Safe Kids DC, an organization dedicated to preventing accidental injuries in children in Washington DC. Her personal research interest is in preventing firearm injuries in children and she is a member of Safer through Advocacy, Firearm Education and Research (SAFER), a multidisciplinary team dedicated to firearm injury prevention at Children’s National. She is also the medical director of the newly founded hospital-based violence intervention program at Children’s National and an associate professor of pediatrics and emergency medicine at The George Washington University.“To be recognized by my peers as a researcher with a significant contribution to our field is very validating. It also opens a world of potential collaborations with excellent scientists, which is very exciting!” said Dr. Donnelly. “I am grateful for the immense support offered to me by the Division of Emergency Medicine to complete the research I am passionate about, especially my mentor Monika Goyal.”
    • Panagiotis Kratimenos, M.D., Ph.D., newborn intensivist and neuroscientist at Children’s National. He studies mechanisms of brain injury in the neonate, intending to prevent its sequelae later in life. Dr. Kratimenos’ interest lies in identifying therapies to prevent or improve neurodevelopmental disabilities of sick newborns caused by prematurity and perinatal insults.“Being a member of SPR is a deep honor for me. SPR has always been a ‘mentorship home’ for me since I was a trainee and a member of the SPR junior section,” said Dr. Kratimenos. “A membership in the SPR allows us to access a very diverse, outstanding team of pediatric academicians and researchers who support the development of physician-scientists, honors excellence through prestigious grants and awards, and advocates for children at any level either locally, nationally, or internationally.”
    • Rana Hamdy, M.D., M.P.H., M.S.C.E., pediatric infectious diseases physician at Children’s National and Director of the Antimicrobial Stewardship Program. She is an assistant professor of pediatrics at George Washington University School of Medicine and Health Sciences. Her area of expertise focuses on the prevention and treatment of antimicrobial resistant infections and the promotion of good antimicrobial stewardship in inpatient and outpatient settings.“It’s an honor to be joining the Society for Pediatric Research and becoming part of this distinguished multidisciplinary network of pediatric researchers,” said Dr. Hamdy. “I look forward to the opportunity to meet and work with SPR members, make connections for future collaborations, as well as encourage trainees to pursue pediatric research through the opportunities that SPR offers.”
    • Shayna Coburn, Ph.D., director of Psychosocial Services in the Celiac Disease Program at Children’s National. She is a licensed psychologist specializing in coping and interpersonal relationships in chronic illness treatment, particularly for conditions involving specialized diets. She holds an appointment as assistant professor of psychiatry and behavioral sciences at The George Washington University School of Medicine and Health Sciences. Her work has focused on promoting effective doctor-patient communication, reducing healthcare disparities and supporting successful adherence across the developmental span of childhood and adolescence. She currently has a Career Development Award from National Institute of Diabetes and Digestive and Kidney Diseases to refine and test a group intervention designed to improve self-management and quality of life in teens with celiac disease.
      “I hope that my background as a psychologist researcher will help diversify SPR. As an SPR member, I hope to encourage more opportunities for training, awards, and other programs that would be inclusive of clinician researchers who may not hold a traditional medical degree,” said Dr. Coburn.
    • Brynn Marks, M.D., M.S.-H.P.Ed., endocrinologist at Children’s National. As a clinical and translational scientist her goal is to use unique personal experiences and training to optimize both patient and provider knowledge of and behaviors surrounding diabetes technologies thereby realizing the potential of diabetes technologies improve the lives and clinical outcomes of all people living with diabetes. Her experiences as a person living with Type 1 diabetes have undoubtedly shaped her clinical and research interests in diabetes management and medical education.
      “It is an honor to be accepted for membership in the Society for Pediatric Research,” said Dr. Marks.  “Being nominated and recognized by peers in this interprofessional pediatric research community will allow me networking and growth opportunities as I continue to advance my research career.”
two doctors perform surgery

Can complex pediatric surgery interventions be standardized to facilitate telementoring?

two doctors perform surgery

The study’s authors write, “These discussions are particularly relevant to surgeons in small or rural practices who provide much-needed care to underserved populations and have decreased exposure to these index cases. Conversely, in some developing countries where prevalence of rare congenital surgical conditions is higher, there is a shortage of adequately trained pediatric surgeons. Each of these scenarios involves a mismatch in experience and exposure, which can result in poor patient outcomes and inadequate healthcare delivery.”

How does a surgeon-in-training get enough exposure to rare or complex cases to serve the patients who need them? How does a practicing surgeon perform enough cases each year to maintain proficiency at such index cases?

The authors of a study in the Journal of Pediatric Surgery, including Marc Levitt, M.D., chief of the Division of Colorectal and Pelvic Reconstruction at Children’s National Hospital, write that, “These discussions are particularly relevant to surgeons in small or rural practices who provide much-needed care to underserved populations and have decreased exposure to these index cases. Conversely, in some developing countries where prevalence of rare congenital surgical conditions is higher, there is a shortage of adequately trained pediatric surgeons. Each of these scenarios involves a mismatch in experience and exposure, which can result in poor patient outcomes and inadequate healthcare delivery.”

Telementoring is one strategy being explored by the American College of Surgeons’ Telementoring Task Force initiative. Pediatric anorectal malformations (ARM), pediatric colorectal surgical procedure, posterior sagittal anorectoplasty (PSARP) were the “index” areas for the pilot study. Once the expert established the areas of great need, they will test the feasibility of a curriculum and training program using telementoring in pediatric surgery. The ACS Task Force notes that these conditions are relatively rare and require a particular skill level to manage appropriately, making them good candidates for the study.

The Journal of Pediatric Surgery study presents a process for mapping out a standardized curriculum for these procedures. First, the authors sought expert consensus on three interoperative checklists that form a de facto curriculum for teaching, learning and performing ARM and PSARP procedures. Second, a multidisciplinary team of medical educators and pediatric surgery experts drafted the checklists. The authors then sought review and input from pediatric colorectal surgery experts at 10 institutions worldwide, who comprised the study’s colorectal pediatric surgery subject matter expert panel. To be considered “expert,” participants had to meet or exceed several strict inclusion criteria related to years in practice and experience with these case types.

Institutions of the colorectal pediatric surgery subject matter expert panel.

Institutions of the colorectal pediatric surgery subject matter expert panel.

The process led to a successful set of consensus documents. “To our knowledge, this is the first study to establish and standardize key intraoperative objectives using a modified-Delphi method in pediatric surgery,” the authors write. “Although this process can be quite time consuming, it provides an incredible opportunity to standardize intraoperative teaching and expectations of trainees. Future studies will expand these checklists into developing a competency assessment tool involving assessment for validity and reliability in a clinical setting to ultimately improve patient safety through standardization.”

Dr. Levitt says the overarching goal of this work is “to improve the surgical technique everywhere [to] thereby help as many kids as we can, even those we will never meet.”

Vahe Badalyan

Q & A with Celiac Disease Program Director Vahe Badalyan, M.D.

Vahe Badalyan

Vahe Badalyan, M.D., Celiac Disease Program Director

Children’s National Hospital is helping to improve the way pediatric celiac disease is diagnosed and treated. We are proud to announce that Vahe Badalyan, M.D., is the new director of our Celiac Disease Program. Here, Dr. Badalyan tells us more about his work and what makes the Children’s National Celiac Disease Program unique.

Why did you decide to work in this field?

I developed my interest in gastroenterology (GI) from the first months of being a pediatric intern at Inova Fairfax Children’s Hospital. As a resident, I was fortunate to work with and learn from the pediatric GI group led by Ian Leibowitz, M.D., whose mentorship and example inspired me to choose a career in pediatric GI. This field is ripe with so many opportunities to improve the lives of children with very diverse medical conditions, such as celiac disease, inflammatory bowel disease, liver disease and short bowel syndrome, while achieving professional fulfillment and satisfaction. Later, as a pediatric GI fellow at Children’s National, I was fortunate to work with the late John Snyder, M.D., who was in the foundation of developing our celiac program and was so passionate about helping children and families cope with celiac disease. Part of the reason I joined the celiac program is to continue Dr. Snyder’s legacy and to build on his vision to provide excellent care, education and advocacy for our celiac patients.

What is the importance of the multidisciplinary clinic approach for celiac care?

The advantage of the multidisciplinary clinic approach is that patients receive comprehensive care that is tailored to their specific needs. In this setting, medical, nutrition and mental health professionals come together to share the care priorities from their unique perspectives and build a roadmap for the patient that incorporates details of care that may otherwise have been missed. Patient questions pertaining to multiple specialties can be discussed and answered right then and there.

What are some of the most valuable changes or advancements for the program you hope to see in the next couple of years?

We hope to expand the screening and diagnosis of celiac disease in our communities, as many patients with celiac have minimal or no symptoms and go undiagnosed for years. Early detection will allow us to get involved sooner in patients’ lives and make a bigger difference for them. We also hope to be a part of clinical research on celiac disease, including drug therapy trials.

What makes the Celiac Program at Children’s National unique from other programs in the country?

We place a big emphasis on mental health and have a dedicated psychologist working with the children and their families. We also have an excellent celiac educator, dietician, coordinator and nurse practitioner who empower our patients to cope with celiac, lead normal lives and achieve their dreams and aspirations.

Dr. Matthew Bramble, Vincent Kambale, and Neerja Vashist

Gut microbiome may impact susceptibility to konzo

Dr. Matthew Bramble, Vincent Kambale, and Neerja Vashist

From left to right: Dr. Matthew Bramble, Vincent Kambale, and Neerja Vashist. Here, the team is processing samples in the field collected from the study cohort prior to storage in liquid nitrogen. Bramble et al. Nature Communications (2021).

Differences between gut flora and genes from konzo-prone regions of the Democratic Republic of Congo (DRC) may affect the release of cyanide after poorly processed cassava is consumed, according to a study with 180 children. Cassava is a food security crop for over half a billion people in the developing world. Children living in high-risk konzo areas have high glucosidase (linamarase) microbes and low rhodanese microbes in their gut, which could mean more susceptibility and less protection against the disease, suggest Children’s National Hospital researchers who led the study published in Nature Communications.

Konzo is a severe, irreversible neurologic disease that results in paralysis. It occurs after consuming poorly processed cassava — a manioc root and essential crop for DRC and other low-income nations. Poorly processed cassava contains linamarin, a cyanogenic compound. While enzymes with glucosidase activity convert starch to simple sugars, they also break down linamarin, which then releases cyanide into the body.

Neerja Vashist learning how to make fufu

Neerja Vashist is learning how to make fufu. Fufu is a traditional food made from cassava flour, and the cassava flour used in the making of the fufu here has gone through the wetting method to further remove toxins from the cassava flour prior to consumption. Bramble et al. Nature Communications (2021).

“Knowing who is more at risk could result in targeted interventions to process cassava better or try to diversify the diet,” said Eric Vilain, M.D., Ph.D., director of the Center for Genetic Medicine Research at Children’s National. “An alternative intervention is to modify the microbiome to increase the level of protection. This is, however, a difficult task which may have unintended consequences and other side effects.”

The exact biological mechanisms underlying konzo disease susceptibility and severity remained poorly understood until now. This is the first study to shed light on the gut microbiome of populations that rely on toxic cassava as their primary food source.

“While the gut microbiome is not the sole cause of disease given that environment and malnourishment play a role, it is a required modulator,” said Matthew S. Bramble, Ph.D., staff scientist at Children’s National. “Simply stated, without gut microbes, linamarin and other cyanogenic glucosides would pose little to no risk to humans.”

To understand the influence of a detrimental subsistence on the gut flora and its relationship to this debilitating multifactorial neurological disease, the researchers compared the gut microbiome profiles in 180 children from the DRC using shotgun metagenomic sequencing. This approach evaluates bacterial diversity and detects the abundance of microbes and microbial genes in various environments.

The samples were collected in Kinshasa, an urban area with diversified diet and without konzo; Masi-Manimba, a rural area with predominant cassava diet and low prevalence of konzo; and Kahemba, a region with predominant cassava diet and high prevalence of konzo.

Dr. Nicole Mashukano and Dr. Matthew Bramble wetting cassava flour

From left to right: Dr. Nicole Mashukano and Dr. Matthew Bramble. Dr. Mashukano leads the efforts in Kahemba to teach the wetting method to individuals in different health zones. The wetting method is used as an additional step to further detoxify toxins from cassava flour prior to consumption. Here, Dr. Mashukano and Dr. Bramble are spreading out the wet mixture of cassava flour and water into a thin layer on a tarp for drying in the sun, which allows cyanogen breakdown and release in the form of hydrogen cyanide gas. Bramble et al. Nature Communications (2021).

“This study overcame many challenges of doing research in low-resource settings,” said Desire Tshala-Katumbay, M.D., M.P.H., Ph.D., FANA, co-senior author and expert scientist at Institut National de Recherche Biomédicale in Kinshasa, DRC, and professor of neurology at Oregon Health & Science University. “It will open novel avenues to prevent konzo, a devastating disease for many children in Sub-Saharan Africa.”

For next steps, the researchers will study sibling pairs from konzo-prone regions of Kahemba where only one sibling is affected with the disease.

“Studying siblings will help us control for factors that cannot be controlled otherwise, such as the cassava preparation in the household,” said Neerja Vashist, Ph.D. candidate and research trainee at Children’s National. “In this work, each sample had approximately 5 million DNA reads each, so for our follow-up, we plan to increase that to greater than 40 million reads per sample and the overall study cohort size. This study design will allow us to confirm that the trends we observed hold on a larger scale, while enhancing our ability to comprehensively characterize the gut microbiome.”

multimodal imaging images

Real-time surgical guidance system enables multimodal tissue monitoring

For the first time, researchers at Children’s National Hospital successfully demonstrated a label-free tissue perfusion imaging in a pre-clinical model, according to a study published in IEEE Transactions on Biomedical Engineering.

Richard Jaepyeong Cha, Ph.D., research faculty associate professor at Children’s National, and colleagues combined visible, near-infrared laser speckle contrast imaging (LSCI) and snapshot hyperspectral (HSI) cameras into a single clinical multimodal imaging device suitable for real-time intraoperative visualization and demonstrated such a device in a surgical model for the first time, to the best knowledge of the authors. This system provides instant microcirculation information about the ischemic regions, normal tissue and transitional ischemic zones with quantitative values that are reproducible.

“Our pre-clinical work demonstrated a novel, dye-free imaging platform for quantitatively assessing bowel perfusion. The ability to identify optimal surgical resection margins can improve surgical performance and patient outcome in terms of more targeted bowel resection and bowel preservation without anastomotic leakage,” Cha said. “This new optical imaging and quantitative assessment technology holds great promise to solving the long-standing issue of suboptimal assessment of intestinal viability.”

Intraoperative imaging techniques for the precise monitoring of blood flow, hemorrhage and oxygen saturation are needed to minimize errors caused by blood vessel ligation to reduce surgical blood loss and successfully isolate and resect ischemic regions.

When the blood flow, hemorrhage and oxygen are not monitored properly, anastomotic leak (AL) is a serious complication of intestinal surgery that can occur due to a technical error, and most frequently because of poorly vascularized intestine.

This complication of intestinal surgery carries with it a reported mortality ranging from 6 to 39%. The best time to prevent a possible AL is during its creation in the operating room.

Creating a healthy and safe intestinal anastomosis requires a good blood supply to the two ends of bowel to be joined. The tools for diagnosing well-perfused bowel intraoperatively are limited and often rely on the subjective evaluation of the surgeon.

“We are hoping that the use and application of multimodal LSCI/HSI imaging, capable of both non-invasive and quantitative gross tissue perfusion assessment, will provide colorectal/general surgeons with a convenient and objective method for assessment of bowel perfusion characteristics and facilitate surgical transection in tissues requiring colorectal anastomosis,” Cha said.

Recently, indocyanine green fluorescence angiography (ICG-FA) was introduced for intraoperative assessment of anastomotic perfusion. Preliminary evidence suggests that ICG-FA may reduce the rate of anastomotic leakage in gastrointestinal surgery.

Perfusion assessment at the site of anastomosis may alter surgical strategy and possibly reduce anastomotic leakage rates. However, ICG-FA evaluation requires an exogenous fluorophore and the surgeon must subjectively assess the quality of perfusion. For an ideal intestinal viability test, it is essential that the technique is easily performed by the surgeon, minimally invasive, objective and reproducible—which is what Lee et al. demonstrate with their new approach.

multimodal imaging system

US News badges

For fifth year in a row, Children’s National Hospital nationally ranked a top 10 children’s hospital

US News badges

Children’s National Hospital in Washington, D.C., was ranked in the top 10 nationally in the U.S. News & World Report 2021-22 Best Children’s Hospitals annual rankings. This marks the fifth straight year Children’s National has made the Honor Roll list, which ranks the top 10 children’s hospitals nationwide. In addition, its neonatology program, which provides newborn intensive care, ranked No.1 among all children’s hospitals for the fifth year in a row.

For the eleventh straight year, Children’s National also ranked in all 10 specialty services, with seven specialties ranked in the top 10.

“It is always spectacular to be named one of the nation’s best children’s hospitals, but this year more than ever,” says Kurt Newman, M.D., president and CEO of Children’s National. “Every member of our organization helped us achieve this level of excellence, and they did it while sacrificing so much in order to help our country respond to and recover from the COVID-19 pandemic.”

“When choosing a hospital for a sick child, many parents want specialized expertise, convenience and caring medical professionals,” said Ben Harder, chief of health analysis and managing editor at U.S. News. “The Best Children’s Hospitals rankings have always highlighted hospitals that excel in specialized care. As the pandemic continues to affect travel, finding high-quality care close to home has never been more important.”

The annual rankings are the most comprehensive source of quality-related information on U.S. pediatric hospitals. The rankings recognize the nation’s top 50 pediatric hospitals based on a scoring system developed by U.S. News. The top 10 scorers are awarded a distinction called the Honor Roll.

The bulk of the score for each specialty service is based on quality and outcomes data. The process includes a survey of relevant specialists across the country, who are asked to list hospitals they believe provide the best care for patients with the most complex conditions.

Below are links to the seven Children’s National specialty services that U.S. News ranked in the top 10 nationally:

The other three specialties ranked among the top 50 were cardiology and heart surgerygastroenterology and gastro-intestinal surgery, and urology.

sick child in palliative care hospital bed

How POEM may change the standard of care for pediatric achalasia

sick child in palliative care hospital bed

Today, Drs. Petrosyan and Kane have performed over 35 POEM procedures for children to resolve esophageal achalasia symptoms.

In 2016, pediatric surgeons Mikael Petrosyan, M.D., and Timothy Kane, M.D., published an article in the Journal of Pediatric Surgery reviewing their experience with the surgical treatment of achalasia and how peroral endoscopic myotomy (POEM) was a new technique being used at Children’s National Hospital to treat esophageal achalasia in children.

The procedure, first used in adults to treat esophageal achalasia, uses a different approach than the current minimally invasive standard of care for children, the Heller myotomy. At the time of the initial study, the team had performed only a few POEM procedures for children but was already starting to see the promise this procedure could offer if done correctly.

While esophageal achalasia affects only about one in every 1 million kids (versus one in 100,000 for adults), the condition, which occurs when the esophagus muscles fail to function properly and the lower sphincter of the esophagus doesn’t relax enough to allow food into the stomach, can have serious impacts on daily life. The tight sphincter may cause food backup, heartburn, chest pain, and many other painful symptoms. Unfortunately, medical interventions including balloon endoscopy or Botox injections, are only temporary fixes that don’t last longer than a month or so before further treatment is needed. For kids who have long lives ahead of them, a surgical solution is the best hope for permanent symptom relief.

At the time of the 2016 study, Dr. Kane said that, “Heller myotomy works very well for most kids — that’s why it’s the standard of care. Our study found that patients who underwent the POEM procedure experienced the same successful outcomes as Heller patients, and we already knew from adult data that POEM patients reported less pain following surgery — a win-win for children.”

Today, Drs. Petrosyan, the associate chief, and Kane, the chief, of General and Thoracic Surgery at Children’s National, have performed over 35 POEM procedures for children to resolve esophageal achalasia symptoms. Increasingly, they find themselves recommending the POEM for many reasons, including, of course, the faster recovery. Kids who have a POEM procedure also often go home in one to two days following surgery and report less pain — typically a sore throat from the endoscopy and the anesthesia, but very little pain at the surgical site.

The surgeons say that the while it takes a steep learning curve to perfect the technique of using POEM in children due to the size of the available instruments to perform the procedure coupled with the challenge of a child’s tiny esophagus, the benefits for patients are well worth it.

“There’s only a single incision in the esophagus, and no incision in the abdomen,” says Dr. Petrosyan. “Kids tolerate the surgery really well, report very little pain, and recover very quickly with minimal complications.”

Even better, he continues, unlike the Heller myotomy, POEM can be performed at any point in treatment, even if other therapies or surgical interventions (including a Heller myotomy) have been previously performed. It can also be repeated if needed — though so far, they haven’t needed to do any further revisions in the population at Children’s National.

Drs. Petrosyan and Kane have performed successful POEM procedures for children with esophageal achalasia between the ages of four and 12. Younger children, (under a year of age) with smaller anatomy, continue to be treated using the Heller procedure due to the limitations in size of the surgical instruments.

Children’s National Hospital is one of the only children’s hospitals in the country to offer the option of POEM for treatment of these conditions — and Drs. Kane and Petrosyan combined perform more of these procedures than any other pediatric surgeon in the United States.

A forthcoming peer-reviewed study will highlight the use of POEM for this population and weigh its success against the current standards of care for treating children with esophageal achalasia.

In the meantime, the surgeons at Children’s National continue to offer POEM as a primary intervention for children with esophageal achalasia and are also applying the same approach for pediatric gastroparesis as well.

Shikib Mostamand

Functional GI Disorders Clinic helps patients with complex GI conditions

Shikib Mostamand

Shikib Mostamand, M.D., pediatric gastroenterologist at Children’s National Hospital, shares what makes the FGID clinic model unique.

Children’s National Hospital has started a multi-disciplinary Functional GI Disorders (FGID) Clinic to treat patients with complex gastroenterology disorders and illnesses that are unique to children. Shikib Mostamand, M.D., pediatric gastroenterologist at Children’s National shares what makes this clinic model unique.

What is the purpose of this clinic?

The purpose of this clinic is to establish a multi-disciplinary clinic to diagnose and treat functional GI Disorders (FGIDs) using a comprehensive, multi-modal approach to chronic abdominal pain and sensory predominant FGIDs (functional abdominal pain/visceral hyperalgesia, irritable bowel syndrome, chronic nausea, etc.). These are complex patients with various biopsychosocial and pathophysiologic mechanisms underlying their abdominal pain.

The clinic endeavors to serve as a unified home for their care. It strives to be the ideal venue to utilize diverse primary care, subspecialty and therapeutic offerings for managing chronic abdominal pain and related FGIDs.

How will this work benefit patients?

We have adopted a multi-disciplinary approach where the pediatric gastroenterologist, GI psychologist, psychiatrist and a pain medicine specialist work together to comprehensively take care of patients and improve their quality of life. This clinic model will allow us to capture valuable data and generate research questions and data to help us better understand pediatric FGIDs and improve care. Additionally, this will minimize the number of visits patients will have to make, as they will see multiple specialties in the same visit at the same time.

How is Children’s National leading in this space? How unique is this work? 

There are only a few other institutions that provide a collaborative, multi-disciplinary approach like this. These programs focus only on functional abdominal pain and not other functional GI disorders.

This model and approach to FGID is unique to Children’s National and not offered at many leading pediatric institutions. Thus, we are working towards innovating the care and creating a future standard for taking care of children with FGIDs.

common food allergens

Psychotherapeutic treatment for psychosocial concerns related to food allergy

common food allergens

Pediatric food allergy is a growing public health concern, with 8 percent of children in the United States affected. Although new treatments for food allergies are being developed, the vast majority of cases are currently managed by daily evaluation of food safety and vigilance for accidental allergen exposure and allergic reactions. This often impacts patients’ and caregivers’ quality of life and overall psychosocial functioning.

In a recent article published in the Journal of Allergy and Clinical Immunology: In Practice, Linda Herbert, Ph.D., and Audrey DunnGalvin, Ph.D., provide a review of mental health concerns related to food allergy. The authors present two cases in which patients received psychological services for food allergy-related anxiety. For both cases, treatment resulted in decreased anxiety and improved food allergy management/oral immunotherapy treatment engagement.

The authors also discuss unmet food allergy-related psychosocial needs, including the lack of food allergy-specific anxiety measures, psychosocial domains that warrant investigation, development of supportive interventions for patients engaging in allergen immunotherapy and the lack of adequate mental health providers with food allergy expertise.

Read the full article in the Journal of Allergy and Clinical Immunology: In Practice.

foods that cause allergies

Patients’ perspectives and needs on novel food allergy treatments

foods that cause allergies

Food allergy is a major public health concern in many countries around the world. In the United States, studies suggest that it affects up to 8% of children and 10% of adults and is responsible for an emergency room admission every three minutes. Historically, the only treatment for food allergy has been complete allergen avoidance combined with rescue medications when accidental exposures occur. Fortunately, advances in food allergy research over the past decade have yielded new treatments, but with these new treatments come new stressors.

In a recent study published in the journal Current Treatment Options in Allergy, Linda Herbert, Ph.D., and colleagues provide an overview of the current state of the literature regarding patients’ and caregivers’ food allergy experiences and needs within the United States. The authors also put forth a set of recommendations regarding how best to proceed with patient-centered development and evaluation of new food allergy treatments.

Read the full study in Current Treatment Options in Allergy.

NASPGHAN meeting logo

Children’s National Gastroenterology team presents virtually at NASPGHAN conference

NASPGHAN meeting logo

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) conference provides experts with an advanced understanding of the normal pediatric development and physiology of diseases of the gastrointestinal tract and liver.

The Children’s National Hospital gastroenterology team was due to present in-person at the conference but were unable to as a result of the COVID-19 pandemic. Instead they presented educational sessions virtually to gastroenterology experts across the country. The presentations spanned a variety of topics and are listed below:

  • Trisomy 21: Not all duodenal abnormalities are Celiac Disease
  • Celiac Kids Research Consortium (CeliacKIDS)
  • Postoperative complications in pediatric IBD patients on biologic therapy undergoing intra-abdominal surgery
  • 6 week infliximab trough levels as predictor of therapeutic maintenance infliximab trough levels and patient outcomes
  • Inflammatory bowel disease characteristics in pediatric patients of South Asian origin in the United States
  • Investigating treatment response rates in pediatric inflammatory bowel disease patients after switching biologics
  • Severely elevated fecal calprotectin in a pediatric patient with persistent giardiasis
  • Persistent hypoglycemia after treatment of gestational alloimmune liver disease (GALD)

The 2021 annual conference will be held on November 4-6 in Nashville, Tennessee.

Lee Beers

Lee Beers, M.D., F.A.A.P, begins term as AAP president

Lee Beers

“The past year has been a stark reminder about the importance of partnership and working together toward common goals,” says Dr. Beers. “I am humbled and honored to be taking on this role at such a pivotal moment for the future health and safety of not only children, but the community at large.”

Lee Savio Beers, M.D., F.A.A.P., medical director of Community Health and Advocacy at the Child Health Advocacy Institute (CHAI) at Children’s National Hospital, has begun her term as president of the American Academy of Pediatrics (AAP). The AAP is an organization of 67,000 pediatricians committed to the optimal physical, mental and social health and well-being for all children – from infancy to adulthood.

“The past year has been a stark reminder about the importance of partnership and working together toward common goals,” says Dr. Beers. “I am humbled and honored to be taking on this role at such a pivotal moment for the future health and safety of not only children, but the community at large.”

Dr. Beers has pledged to continue AAP’s advocacy and public policy efforts and to further enhance membership diversity and inclusion. Among her signature issues:

  • Partnering with patients, families, communities, mental health providers and pediatricians to co-design systems to bolster children’s resiliency and to alleviate growing pediatric mental health concerns.
  • Continuing to support pediatricians during the COVID-19 pandemic with a focus on education, pediatric practice support, vaccine delivery systems and physician wellness.
  • Implementation of the AAP’s Equity Agenda and Year 1 Equity Workplan.

Dr. Beers is looking forward to continuing her work bringing together the diverse voices of pediatricians, children and families as well as other organizations to support improving the health of all children.

“Dr. Beers has devoted her career to helping children,” says Kurt Newman, M.D., president and chief executive officer of Children’s National. “She has developed a national advocacy platform for children and will be of tremendous service to children within AAP national leadership.”

Read more about Dr. Beer’s career and appointment as president of the AAP.

Cover of the December issue of Seminars on Pediatric Surger

Reflections on Seminars in Pediatric Surgery December 2020

Cover of the December issue of Seminars on Pediatric Surger

Marc Levitt, M.D., served as guest editor of a special December Seminars in Pediatric Surgery dedicated to the care and treatment of anorectal malformations.

By Marc Levitt, M.D., chief of the Division of Colorectal and Pelvic Reconstruction at Children’s National Hospital

I was honored to serve as the Guest Editor on the topic of “Anorectal Malformations” in the prestigious Seminars in Pediatric Surgery Volume 29, Issue 6, December 2020.

We had 64 contributing authors from 12 countries; Australia, Austria, Germany, Ghana, Italy, Israel, the Netherlands, Nigeria, Spain, South Africa, the United Kingdom and the United States, and 12 U.S. colorectal collaborating programs; Children’s National, Boston Children’s, Children’s Mercy, Children’s Wisconsin, C.S. Mott Children’s, Cincinnati Children’s, Nationwide Children’s, Nicklaus Children’s, Omaha Children’s, Primary Children’s, Seattle Children’s, and UC Davis Children’s.

There were eight authors from the Children’s National team; myself, Colorectal Director Andrea Badillo, M.D., Colorectal Program Manager Julie Choueiki, MSN, RN, Surgical Center Director Susan Callicott, Katie Worst, CPNP-AC, Grace Ma, M.D., Chief of Urology Hans Pohl, M.D., and Chief of Gynecology Veronica Gomez-Lobo, M.D.

The series of articles included in this collection illustrate new techniques and ideas that over time have made a dramatic and positive impact on the care and quality of life of children who suffer from colorectal problems. With an integrated approach to the care of this complex group of patients, great things can be achieved. As we endeavor to advance this field, we need to always remember that, as Alberto Pena, M.D., often said, “it is not the unanswered questions, but rather the unquestioned answers that one must pursue.”

In my own article on advances in the field, a 2021 update, I reproduce a piece by my daughter, Jess Levitt, who wrote something applicable to the care of children with colorectal problems, with the message that helping to create order is vital to improve a somewhat chaotic medical process traditionally available for the care of complex care. Her essay is reproduced here:

“A” must come before “B,” which must come before “C,” everybody knows that. But what if the Millercamp’s of this world did not have to sit next to the Millerchip’s when it comes to seating arrangements? Can Pat Zawatsky be called before Jack Aaronson when the teacher is taking attendance? Do those 26 letters that make up all the dialogue, signs, thoughts, books, and titles in the English-speaking departments of the world need their specific spots in line? Everyone can sing you the well-known jingle from A to Z, but not many people can tell you why the alphabet is the way it is. For almost as long as humans have had the English language, they have had the alphabet. The good ole ABCs.

However, the alphabet represents the human need for order and stability. I believe that the same thinking that went into the construct of time and even government went into the alphabet. Justifiably, lack of order leads to chaos. Knife-throwing, gun-shooting chaos, in the case of lack of governmental order. Listen to me when I tell you that there is absolutely no reason that the alphabet is arranged the way that it is. Moreover, the alphabet is simply a product of human nature and how it leads people to establish order for things that do not require it. 

Now I know this sounds crazy but bear with me. Only if you really peel away the layers of the alphabet will you find the true weight it carries. People organized the letters of our speech into a specific order simply because there wasn’t already one. Questioning this order will enlighten you on the true meaning of it. Really dig deep into the meaning behind the social construct that is the alphabet. Short and sweet as it may be, the order of the ABCs is much less than meets the eye. There is no reason that “J” should fall before “K!” Understand this. Very important as order is, it is only a result of human nature.  What’s next? X-rays become independent of Xylophones in children’s books of ABCs? 

You know what the best part is? Zero chance you even noticed that each sentence in this essay is in alphabetical order.

Her literary contribution inspired me to do something similar. Take a look at the list of articles in this Seminars edition:

  1. Creating a collaborative program for the care of children with colorectal and pelvic problems. Alejandra Vilanova-Sánchez, Julie Choueiki, Caitlin A. Smith, Susan Callicot, Jason S. Frischer and Marc A. Levitt
  2. Optimal management of the newborn with an anorectal malformation and evaluation of their continence potential. Sebastian K. King, Wilfried Krois, Martin Lacher, Payam Saadai, Yaron Armon and Paola Midrio
  3. Lasting impact on children with an anorectal malformations with proper surgical preparation, respect for anatomic principles, and precise surgical management. Rebecca M. Rentea, Andrea T. Badillo, Stuart Hosie, Jonathan R. Sutcliffe and Belinda Dickie
  4. Long-term urologic and gynecologic follow-up and the importance of collaboration for patients with anorectal malformations. Clare Skerritt, Daniel G. Dajusta, Molly E. Fuchs, Hans Pohl, Veronica Gomez-Lobo and Geri Hewitt
  5. Assessing the previously repaired patient with an anorectal malformation who is not doing well. Victoria A. Lane, Juan Calisto, Ivo Deblaauw, Casey M. Calkins, Inbal Samuk and Jeffrey R. Avansino
  6. Bowel management for the treatment of fecal incontinence and constipation in patients with anorectal malformations. Onnalisa Nash, Sarah Zobell, Katherine Worst and Michael D. Rollins
  7. Organizing the care of a patient with a cloacal malformation: Key steps and decision making for pre-, intra-, and post-operative repair. Richard J. Wood, Carlos A. Reck-Burneo, Alejandra Vilanova-Sanchez and Marc A. Levitt
  8. Radiology of anorectal malformations: What does the surgeon need to know? Matthew Ralls, Benjamin P. Thompson, Brent Adler, Grace Ma, D. Gregory Bates, Steve Kraus and Marcus Jarboe
  9. Adjuncts to bowel management for fecal incontinence and constipation, the role of surgery; appendicostomy, cecostomy, neoappendicostomy, and colonic resection. Devin R. Halleran, Cornelius E.J. Sloots, Megan K. Fuller and Karen Diefenbach
  10. Treating pediatric colorectal patients in low and middle income settings: Creative adaptation to the resources available. Giulia Brisighelli, Victor Etwire, Taiwo Lawal, Marion Arnold and Chris Westgarth-Taylor
  11. Importance of education and the role of the patient and family in the care of anorectal malformations. Greg Ryan, Stephanie Vyrostek, Dalia Aminoff, Kristina Booth, Sarah Driesbach, Meghan Fisher, Julie Gerberick, Michel Haanen, Chelsea Mullins, Lori Parker and Nicole Schwarzer
  12. Ongoing care for the patient with an anorectal malfromation; transitioning to adulthood. Alessandra Gasior, Paola Midrio, Dalia Aminoff and Michael Stanton
  13. New and exciting advances in pediatric colorectal and pelvic reconstructive surgery – 2021 update. Marc A. Levitt

The first letter of each article forms an acrostic of the word “COLLABORATION” which is the secret sauce behind any success in the field of pediatric colorectal care.

feeding tubes

NIH grant funds development of pediatric feeding tube placement device

feeding tubes

A new grant will help to finalize development of the Pediatric PUMA-G System, the world’s first and only ultrasound-based procedure for placing feeding tubes into the stomach.

Researchers at Children’s National Hospital have received grant funding from the National Institute of Diabetes and Digestive and Kidney Diseases, within the National Institutes of Health (NIH), to finalize development of the Pediatric PUMA-G System, the world’s first and only ultrasound-based procedure for placing feeding tubes into the stomach. The funding will also support the first clinical trial of this technology in pediatric patients.

“Children’s National was chosen because we have a strong record of innovating pediatric devices and surgical procedures through the Sheikh Zayed Institute and we have a busy clinical interventional radiology service,” says Karun Sharma, M.D., Ph.D., director of Interventional Radiology and associate director of clinical translation at the Sheikh Zayed Institute for Pediatric Surgical Innovation (SZI) at Children’s National. “We are proud to be a part of this collaboration that will potentially help improve care of pediatric patients who cannot tolerate feeding by mouth.”

The feeding tubes are vital for children who cannot eat or swallow and require liquid nutrition (known as enteral feeding). Common feeding tube placement procedures for children may expose them to risks from invasive surgical tools or from ionizing radiation, which may lead to cancer in young patients at elevated rates. The PUMA-G System is less invasive and uses ultrasound to help physicians image the body during the procedure.

The grant, totaling $1.6M, will clinically evaluate the Pediatric PUMA-G System in collaboration with CoapTech, a biotechnology medical device company and two other premier pediatric medical centers — New York-Presbyterian Morgan Stanley Children’s Hospital and Children’s Hospital of Philadelphia.