14
Training in Pediatric Endoscopy

Michael A. Manfredi¹ and Jenifer R. Lightdale²

¹ Medical Director, Esophageal and Airway Treatment Center, Associate Director, Gastrointestinal Procedure Unit, Division of Gastroenterology and Nutrition, Children’s Hospital Boston, Assistant Professor in Pediatrics, Harvard Medical School, Boston, MA, USA

² Division Chief, Pediatric Gastroenterology and Nutrition, UMass Memorial Children’s Medical Center, Professor of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA

Introduction

The history of pediatric endoscopy dates back to the 1970s, when the diameter of endoscopes became small enough to allow investigation in children [1]. In the 1980s, endoscopes were designed specifically for pediatric use, thereby cementing their role in clinical practice. Today, the diagnosis of gastrointestinal diseases in children often requires direct visualization of tissue and targeted tissue biopsies. In addition, therapeutic endoscopy has allowed for safe minimally invasive treatments of various gastrointestinal, hepatic, and pancreaticobiliary conditions that were once only performed by open surgical techniques with longer recovery periods.

Achieving competence in endoscopy is a fundamental component of fellowship training in pediatric gastroenterology, and requires the acquisition of related technical, cognitive, and integrative competencies. Typically, training in pediatric endoscopy generally takes place during formalized programs of at least 2 years duration.

As with endoscopy in adults, pediatric endoscopy requires both cognitive and technical expertise to diagnose and treat disorders of the gastrointestinal tract. There are many similarities in endoscopy training for adults and children. However, there are also fundamental differences that must be respected if endoscopic procedures are to be successfully performed safely, effectively, and efficiently in children. In this chapter, we will highlight those aspects unique to endoscopic training in pediatric gastroenterology.

Training program requirements

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) has stipulated that training programs in endoscopy have the following educational components [2]:

Exposure to clinical care and problem‐solving in pediatric patients with gastrointestinal disorders, including the provision of didactic sessions regarding endoscopic procedures.
The opportunity to learn appropriate technical and cognitive endoscopy skills from competent instructors.
A proper training environment for endoscopy and related procedures. This includes appropriately trained ancillary personnel (e.g., endoscopy nurses or technicians), functioning and well‐maintained age‐specific equipment, and trained personnel to perform cardiopulmonary resuscitation in pediatric patients.
Access to services provided by certified specialists in pediatric intensive care, pediatric surgery, pediatric anesthesia, pediatric radiology (including experts in interventional radiology), pathology (with expertise in pediatric gastrointestinal histology), and subspecialists to provide interactive exposure and teaching in these disciplines. These services must be available as a backup for pediatric patients who experience complications during or after procedures.
Availability of endoscopic teaching materials (e.g., books, atlases, DVDs, digital or online libraries) to enhance training and exposure.
Opportunities for trainees to work with “hands‐on models” or endoscopic simulators to learn and practice endoscopic techniques.
Procedures in place to periodically and formally review the progress of trainees.
Periodic reviews and updates of training methods, as well as the ability to monitor the quality of training in an endoscopy unit.

Esophagogastroduodenoscopy and colonoscopy

Developing diagnostic and therapeutic competency in pediatric endoscopic procedures requires both technical and nontechnical skills [3]. Trainees should perform endoscopic procedures with pediatric gastroenterologists primarily. They must also learn the indications for and the technique of performing each procedure, optimal means for documenting the results, and understand the clinical significance of endoscopic findings. It is vital that all pediatric endoscopists respect the potential for complications associated with the procedure, including risks of bleeding, infection, and bowel perforation. Trainees must be able to weigh those risks and determine if the procedure is warranted.

Patient assessment

To optimally prepare for pediatric gastrointestinal procedures, trainees in pediatric endoscopy should learn to obtain a careful medical history, perform a complete physical exam and review appropriate laboratory tests before sedation is administered. Patient risk factors that may affect pediatric endoscopy are myriad, and include the presence of sepsis, shock, or dehydration and electrolyte imbalance; acute and chronic respiratory conditions; underlying cardiovascular diseases, especially cyanotic congenital heart disease; acute and chronic neurological conditions, including seizure disorders; and liver or renal dysfunction [4]. A pre‐procedural physical exam should focus on the heart, circulation, lungs, head, neck, and airway. Laboratory tests are not required in the pre‐procedure assessment. However, trainees should recognize clinical indications where obtaining blood work would be useful for either pre‐procedure or pre‐anesthesia planning.

Informed consent

The process of obtaining informed consent to perform procedures in children mandates the endoscopist to interact not only with the patient, but also with the parents or guardians, who in the majority of the cases will be providing informed consent [5]. If the patient is an adolescent, it may be appropriate to obtain informed assent. Trainees must learn to recognize that the pre‐procedure period is a stressful time for both patients and families. In turn, they must develop interpersonal and communication skills that reflect both professionalism and compassion.

Sedation

To achieve optimal sedation for endoscopy in their young patients, pediatric gastroenterologists must be trained to consider many factors, including patient age, medical history, clinical status, anxiety level, as well as the optimal sedation level to target, in order to select the appropriate methods and agents [6]. The two primary types of sedation are endoscopist‐administered intravenous (IV) sedation and anesthesiologist‐administered general anesthesia. General anesthesia involves the depression of a child’s respiratory drive and requires the presence and expertise of an anesthesiologist. IV sedation maintains the child’s ability to breathe spontaneously and protect his/her own airway. In mastering procedural sedation skills, trainees in pediatric gastroenterology must learn to perform simultaneous tasks of administering sedation while performing the procedure.

Trainees must also learn the wisdom of carefully assessing children as to their level of cooperation both prior to scheduling and again on the day of the procedure [7]. Personality and psychosocial development stages may vary widely and greatly impact children’s reactions to sedative medications in both the rapidity and the depth of sedation achieved. Infants under 6 months of age have little anxiety and sedate easily. Infants greater than 6 months who have developed “stranger anxiety” may sedate more easily if parents remain next to them during induction. School‐aged children may be surprisingly difficult to sedate, belying higher anxiety levels than may be appreciated. Adolescents may be composed during pre‐procedure preparations, and then become disinhibited and exhibit strong anxiety with initial doses of sedatives.

Sedation for pediatric endoscopy procedures: when not to use it

Trainees must learn that certain pediatric gastrointestinal procedures may not require sedation. In particular, flexible sigmoidoscopy, percutaneous liver biopsy, changes or removals of percutaneous endoscopically placed gastrostomy (PEG) tubes, and placement of pH or impedance probes can generally be performed without sedation. Children may even be candidates for unsedated transnasal endoscopy [8]. The use of no sedation also allows children an almost immediate return to normal functioning after a procedure, including the ability to eat, and return to school. However, by not sedating patients, endoscopists incur the risk of not completing procedures in a satisfactory way for both the doctor and the child.

Cognitive aspects of training in sedation

Once the decision to employ sedation during a procedure has been made, trainees must learn to judge the best sedation option targeted to the appropriate level. If IV sedation is used, pediatric endoscopists must be prepared for children to become agitated, adding to stress for both patients and clinical staff. General anesthesia provides the advantage of complete patient immobility, but also carries a very specific risk profile. Providing sedation for endoscopic procedures in children by working with anesthesiologists also increases procedural costs and utilization of hospital resources.

It is our opinion that trainees in pediatric endoscopy should master skills involved in both working with anesthesiologists, in addition to skills in administering IV sedation without anesthesiology assistance, as part of their standard training program. Indeed, there may be vast institutional differences regarding access to anesthesiologists, as well as operating room time, that may impact the ease with which general anesthesia can be scheduled for pediatric gastrointestinal procedures. Graduates of programs which do not use endoscopist‐administered sedation may find themselves learning a completely new skill upon starting a new position in an institution with limited access to anesthesiology support.

Within institutions that work with anesthesiologists to provide sedation for pediatric endoscopy, there may be tremendous variation in care at the anesthesiologist level in terms of which inhalational and IV agents are utilized [9]. Not all anesthesiologists may be trained to provide sedation for pediatric endoscopic procedures, or understand the goals of those procedures. Pediatric endoscopists should be trained to understand the various risks and side effects of various anesthesia regimens so as to best advocate for their patients.

Technical aspects of training in sedation

The choice of which type of sedation and which specific medications to employ in sedating pediatric and adolescent patients for gastrointestinal procedures should be tailored to the procedure and the patient. The two most common classes of sedatives used in pediatric endoscopy units are benzodiazepines and narcotics. However, trainees should gain an understanding of all classes of drugs which may be used for pediatric procedures. Table 14.1 lists different sedation agents and recommended doses.

Topical agents

In children undergoing upper endoscopy, there may be some benefit derived from applying a topical anesthetic spray to the posterior pharynx, such as cetacaine or lidocaine. Mastering the skill of topical drug delivery for children requires depression of the tongue and elicitation of a gag reflex with a tongue blade during spraying. This may be highly unpleasant for children, and trainees may be taught to perform this after some light sedation has been administered. Trainees should also learn about specific drug risks associated with the use of topical anesthetics, including systemic absorption and methemoglobinemia, which is treated with methylene blue [10].

Table 14.1 Recommendations for dosages of drugs commonly used for IV sedation for pediatric gastrointestinal procedures.

Drug	Route	Maximum dose (mg/kg)	Time to onset (min)	Duration of action (min)
Benzodiazepines
Diazepam	IV	0.1–0.3	1–3	15–30
	Rectal	0.2–0.3	2–10	15–30
Midazolam	oral	0.5–0.75	15–30	60–90
	IV	0.05–0.15	2–3	45–60
	Rectal	0.5–0.75	10–30	60–90
Opioids
Meperidine	IV	1–3	<5	2–4
	IM	1–3	10–15	2–3
Fentanyl	IV	0.001–0.005 (1–5 μgm/kg in 0.5–1.0 μgm/kg increments)	2–3	30–60
Ketamine	IV	1–3	1	15–60
	IM	2–10	3–5	15–150

Benzodiazepines

As a class of sedatives, benzodiazepines are generally safe and fast‐acting, with high therapeutic indexes. They are well known for their anxiolytic and amnestic effects, and may be combined with narcotics for added analgesia and sedation. In turn, respiratory depression is unusual when benzodiazepines are used alone, but quite common when used in conjunction with narcotics. To date, it is recommended that all benzodiazepines be administered to children in small serial increments, with close clinical monitoring to determine the level of sedation achieved with each dose. It is not recommended that benzodiazepines be given as bolus doses during pediatric endoscopy.

Narcotics

Narcotics are primarily analgesics, but have enhanced sedative effects when used in combination with benzodiazepines. Common side effects of narcotics include pruritus and nausea. Many children may be anecdotally noted to scratch their noses after a narcotic is infused, and trainees must learn to avoid oversedating in response. Indeed, trainees must learn to appreciate that respiratory depression is very commonly seen with the use of narcotics alone, and especially in combination with benzodiazepines.

Ketamine

Trainees will also gain from learning about the pros and cons of ketamine, a derivative of phencyclidine that binds to opiate receptors, and rapidly induces a trancelike cataleptic condition with significant analgesia [11]. The resulting dissociative state largely spares upper airway muscular tone and laryngeal reflexes. Thus, unlike most sedatives, ketamine can be used with high reliability to significantly immobilize children with minimal cardiac or respiratory risks. The main disadvantages to using ketamine include its association with hallucinogenic emergence reactions in some children, increased airway secretions, as well as an increased potential for laryngospasm [12].

Propofol

Use of anesthesiologist‐administered propofol in pediatric endoscopy units has become very common in recent years, and trainees should gain an understanding of its properties [9]. Propofol is an ultra‐short‐acting anesthetic that features a rapid onset of action and a short recovery time. It can be used to induce and maintain a spectrum of sedation levels, ranging from moderate to deep anesthesia. Propofol also confers excellent amnesia for the procedure in children. Nevertheless, a main disadvantage of propofol is its relatively narrow therapeutic range. In children, lower propofol dosages may be required to achieve adequate sedation when it is given in combination with midazolam and fentanyl.

Reversal agents for pediatric sedation

Trainees in pediatric endoscopy should become familiar with reversal agents for oversedation in children. In particular, they should understand that reversal effects are nearly always shorter than the effects of the drugs being reversed. As such, patients who receive a dose of a reversal agent should be monitored for an extended period, and should be administered repeat doses if necessary. Reversal agents are available for benzodiazpines and narcotics, and are listed in Table 14.2 with recommended dosages for children. Currently, there are no reversal agents for ketamine or propofol.

Upper endoscopy

Diagnostic esophagogastroduodenoscopy (EGD) is the most common procedure performed in pediatric gastroenterology. Even before a trainee holds the endoscope, they must develop an understanding the basic upper gastrointestinal tract anatomy, as well as the indications and contraindications of performing endoscopy. For a description of landmarks and anatomy for EGD, see Chapter 4.

The majority of EGDs in children are performed for diagnostic purposes. Indications for diagnostic and therapeutic upper endoscopy are listed in Table 14.3. There are relatively few contraindications to upper endoscopy in children. Size of the patient is rarely a contraindication and the procedure can be performed safely in neonates as small as 1.5–2 kg [13]. The only near‐absolute contraindication for endoscopy is when bowel perforation is suspected.

Most other conditions that might give an endoscopist pause before obtaining consent for EGD in children represent relative contraindications, and should be weighed in terms of whether the benefits of performing the procedure outweigh its risks [4]. For example, coagulopathy is a relative contraindication for diagnostic endoscopy, although extra care is certainly required and biopsies would be contraindicated until the coagulopathy is corrected. Neutropenia is another relative contraindication. Cardiopulmonary issues may also preclude the performance of upper endoscopy, with the exceptional indication of therapeutic endoscopy for gastrointestinal hemorrhage. Even in these situations, the patient should be stabilized with initial resuscitation measures (i.e., administration of crystalloid and blood products) prior to performing the procedure.

Table 14.2 Reversal agents for benzodiazepines and opioids and recommended dosages.

Drug	(Class antagonist)	Route	Dose	Time to onset (min)	Duration of action (min)
Flumazenil	(Benzodia‐zepines)	IV	0.01 mg/kg (max 3 mg/hr)	1–2	<60
Naloxone	(Narcotics)	IV/IM	0.1 mg/kg	2–5	20–60

Table 14.3 Indications for upper endoscopy.

Procedure type	Clinical indication
Diagnostic	Abdominal pain with significant morbidity or signs of organic disease (weight loss, anemia, vomiting, fevers)
	Anemia (unexplained)
	Anorexia
	Caustic ingestion
	Diarrhea/malabsorption (chronic)
	Dysphagia
	Hematochezia
	Intractable or chronic GERD (including surveillance for Barrett’s esophagus)
	Odynophagia
	Vomiting/hematemesis
	Weight loss/failure to thrive
Therapeutic	Dilation of esophageal and upper‐GI strictures
	Esophageal varices eradication
	Foreign‐body removal
	Upper‐GI bleeding control

Technical skills

The technical aspects of performing upper endoscopy are essentially the same in adults and in children. The main difference between the two lies in the choice of equipment. It is important to have an understanding and general knowledge of smaller endoscopy equipment required to scope the smaller anatomy of infants and young children (See also Chapter 5 for more in‐depth description.).

Instruments

Pediatric endoscopes are commercially produced by Olympus USA (Center Valley, PA), Pentax USA (Montvale, NJ), and Fujinon Inc. (Wayne, NJ) and, in general, are similar in design to adult endoscopes, with only subtle differences. Today’s modern pediatric gastroscopes have a fiber‐optic light source, an instrument/suction channel, and an air/water nozzle. They have four‐way directional tip control that ranges from 180° to 210°in the up direction, 90–120° in the down direction, and with 100–120° deflection in both the left and right direction. The technical aspects of these scopes can be found in Table 14.4. Most new modes of pediatric gastroscopes by all three major companies have comparable tip deflection when compared to standard adult scopes. Older model gastroscopes have less tip deflection which can limit visibility slightly.

Pediatric gastroscopes range from 5.4 to 5.8 mm in diameter. The main limiting factor with all pediatric endoscopes is the 2.0 mm working channel, which is considerably smaller than the working channel in adult endoscopes. The small working channel makes suctioning more difficult and limits the ability to use pediatric endoscopes for therapeutic maneuvers, as less equipment is available in small enough sizes to pass through. Some of the newer slim pediatric gastroscopes have slightly enlarged the working channel to either 2.2 mm or 2.4 mm. Although the larger working channel may improve suctioning slightly, limitations regarding which therapeutic equipment is compatible still remain. The pediatric endoscopy trainee should have full working knowledge of the size of the endoscope being used as well as what equipment can be used to perform their procedure. Table 14.5 lists equipment that can be used in small pediatric endoscopes with a 2.0–2.4 mm working channel.