NewYork-Presbyterian’s Innovative Pediatric Motility Programs
The relationship between the brain and gut, or the brain-gut axis, begins in utero and persists throughout life. When this complex system dysfunctions, motility disorders can result that significantly impact a child’s health, development and well-being. NewYork-Presbyterian addresses the complex needs of children with motility disorders at its two dedicated centers: The Pediatric Motility Center at NewYork-Presbyterian Komansky Children's Hospital and The Pediatric Gastrointestinal Motility Center at NewYork-Presbyterian Morgan Stanley Children's Hospital. These centers are among the few pediatric motility programs in the country, and the only ones in the New York metropolitan region providing comprehensive testing, consultation, and treatment of motility disorders in infants, children, adolescents, and young adults to help parents understand the reasons for their child's symptoms and improve quality of life.
“Motility disorders are quite common in children and can range from benign conditions such as chronic constipation, abdominal pain, reflux and vomiting to more serious disorders such as gastroparesis, esophageal achalasia and Hirschsprung disease, a rare birth defect characterized by missing nerve cells in all or part of the large intestine,” says Thomas Ciecierega, MD, Associate Attending Pediatrician at NewYork-Presbyterian Weill Cornell Medical Center and Director of the Pediatric Motility Center at NewYork-Presbyterian Komansky Children’s Hospital. “These are usually chronic conditions that require sophisticated diagnostic testing. Most children respond to a combination of treatments, not just one, which is why a multidisciplinary yet individualized team approach that addresses the whole child is critical for success.”
Dr. Ciecierega specializes in in the diagnosis and treatment of children with complex inborn or acquired anorectal and esophageal defects including imperforated anus, esophageal atresia, trachea-esophageal fistula, as well as children with complex underlying conditions and genetic abnormalities such as Marfan syndrome, a disorder of the connective tissue that can result in constipation and irritable bowel syndrome (IBS).
At NewYork-Presbyterian Komansky, Dr. Ciecierega leads the oldest pediatric motility program in tri-state area and one of the oldest in the country. “Our program is distinguished by our multidisciplinary team approach in which pediatric gastroenterologists, behavioral psychologists, dieticians, pulmonologists, ENT specialists, speech and swallow specialists and surgery specialists collaborate to manage the medical and social needs of patients with motility problems,” says Dr. Ciecierega, who is also Director of the Pediatric Endoscopy Unit at NewYork-Presbyterian Komansky. “We offer specialized focused clinics for constipation, aerodigestive and specialized foregut problems.”
“We are proud to be a leading pediatric motility center in the metropolitan region when it comes to second opinions,” he adds. “We see many local referrals from other specialists, as well as patients who travel from other parts of the U.S. and the world, offering them the benefits of comprehensive motility testing and treatment.”
In his unwavering effort to bring the latest advances in diagnosis and treatment to pediatric patients, Dr. Ciecierega and his team frequently collaborate with other motility centers in the U.S. and abroad on research initiatives and the development of new techniques. He is currently serving as Chair of the Pediatric, Adolescent and Adult Foregut Interdisciplinary Society (PAAFIS), a consortium of leading international experts of foregut disorders that include surgeons, gastroenterologists and supporting specialists from the US, Europe and other parts of the world. For the past five years, Dr. Ciecierega and his colleagues have been hosting patient-based, hands-on foregut disorders conferences in the US and Germany.
The NewYork-Presbyterian Komansky Motility Center is one of few in the nation that offers antroduodenal manometry to assess the neuromuscular function of the stomach and small bowel for the evaluation of children with feeding intolerance, vomiting and bloating, and colonic manometry to measure the neuromuscular function of the colon for children who suffer from chronic constipation and encopresis.
“Constipation is a persistent problem in most children, with 50% of whom will remain constipated one year after diagnosis and treatment, and 30-35% of whom will remain constipated two years later after seeing a physician,” says Dr. Ciecierega. “We offer patients state-of-the-art, motility testing that is specifically tailored to children and infants, including EndoFLIP and IB-stim, among others, to help with complex conditions.”
“In addition to high-tech approaches, we also offer our patients integrative medicine modalities such as acupressure, acupuncture and hypnosis, which have been shown to be very effective in children with motility disorders,” he adds. “We give many patients a second chance at getting better and improving quality of their life.”
At the Pediatric Gastrointestinal Motility Center at NewYork-Presbyterian Morgan Stanley Children's Hospital, children with complex motility disorders receive evidence based, state-of-the-art care to enhance their quality of life.
“Many children have chronic motility disorders that significantly impact their wellbeing,” says Julie Khlevner, MD, Associate Professor of Pediatrics at Columbia University Medical Center and Director of the Pediatric Gastrointestinal Motility Center at NewYork-Presbyterian Morgan Stanley Children's Hospital. “Motility disorders are remarkably common in children and are often debilitating. As in adults, they are among the most challenging diagnoses to make and effectively treat and are often under recognized in the community. These disorders occur within a still-developing bowel, often exhibit different pathophysiology than in adult patients, and require distinct diagnostic and management approaches that must take developmental age and caregivers into consideration.”
At the NewYork-Presbyterian Morgan Stanley, Dr. Khlevner and her team offer a highly individualized approach to motility disorders and tailor treatment to patients’ unique needs. Comprehensive diagnostic and treatment modalities for a wide range of neurogastrointestinal and motility disorders include esophageal motor disorders, gastroesophageal reflux disease (GERD), gastroparesis, functional abdominal pain, irritable bowel syndrome (IBS), chronic refractory constipation and fecal incontinence, pediatric intestinal pseudo-obstruction, Hirschsprung’ s disease and other congenital gut anomalies.
“Our program offers many multidisciplinary clinics including Aerodigestive Clinic, Esophageal Atresia clinic and a Congenial Diaphragmatic Hernia Clinic that are unique in the tristate area,” says Dr. Khlevner. “Our multidisciplinary team is comprised of pediatric surgeons, pulmonologists, ENT specialists, speech-language pathologists, behavioral medicine specialists, and dieticians who collaborate to provide the most evidence-based and comprehensive care to children with complex neurogastrointestinal and motility disorders.”
Dr. Khlevner has long focused her clinical and research work on brain-gut axis (BGA) dysfunction. “It is widely recognized that neurogastrointestinal and motility disorders are a consequence of BGA dysfunction,” she explains. “BGA is a bidirectional relationship between the central nervous system and the digestive tract that regulates homeostatic functions. These concepts apply to IBS, the most researched BGA condition in neurogastroenterology. Historically, patients with chronic abdominal pain often underwent unnecessary testing, which delays the diagnosis of IBS. In recent years, specialists have been diagnosing IBS based on ROME 4 criteria, which relies on symptom-based guidelines. This allows specialists to perform selective or no testing to support a positive diagnosis of a functional GI disorder, leading to quicker and more effective treatment.”
In addition to performing 3D high resolution esophageal manometry, anorectal manometry and anorectal biofeedback therapy, Dr. Khlevner and her team offer advanced antroduodenal and colonic motility testing as well as innovative endoluminal functional luminal imaging probe (EndoFLIP) technology that measures the distensibility of the esophagus to aide patients with achalasia, esophageal strictures and post-operative esophageal disorders. The team also offer cutting-edge non-pharmacologic therapeutic options including IB-stim to help patients with chronic abdominal pain, nausea and IBS.
For Dr. Khlevner, the field of pediatric motility is especially rewarding because it enables her to provide specialized treatment options that allow children to improve and thrive. “When patients are correctly diagnosed and appropriately treated, they tend to do very well and appreciate our help,” she says. “Pediatric motility is an established field within gastroenterology that is quickly evolving. I’m passionate about moving this field forward, and through dynamic research and a busy clinic practice, I will continue to push the envelope to provide better understanding of the underlying mechanisms and more successful treatment options for these often debilitating conditions.”
“I’m grateful to have the strong support of the Chair of Pediatrics, Dr. Jordan Orange, my colleagues and the institution, as we work hard to build a nationally recognized, premier pediatric motility center in the US,” she adds.
Khlevner J, Park Y, Margolis KG. Brain-Gut Axis: Clinical Implications. Gastroenterol Clin North Am. 2018;47(4):727–739. doi:10.1016/j.gtc.2018.07.002