Selecting appropriate gastroenteric contrast media for diagnostic fluoroscopic imaging in infants and children: a practical approach.

In our experience, questions about the appropriate use of enteric contrast media for pediatric fluoroscopic studies are common. The purpose of this article is to provide a comprehensive review of enteric contrast media used for pediatric fluoroscopy, highlighting the routine use of these media at a large tertiary care pediatric teaching hospital.

The Use of Enteric Contrast Media for Diagnostic CT, MRI, and Ultrasound in Infants and Children: A Practical Approach.

OBJECTIVE: Enteric contrast media are commonly administered for diagnostic cross-sectional imaging studies in the pediatric population. The purpose of this manuscript is to review the use of enteric contrast media for CT, MRI, and ultrasound in infants, children, and adolescents and to share our experiences at a large tertiary care pediatric teaching hospital. CONCLUSION: The use of enteric contrast material for diagnostic imaging in infants and children continues to evolve with advances in imaging technology and available enteric contrast media. Many principles of enteric contrast use in pediatric imaging are similar to those in adult imaging, but important differences must be kept in mind when imaging the gastrointestinal tract in infants and children, and practical ways to optimize the imaging examination and the patient experience should be employed where possible.

Healing patterns of clavicular birth injuries as a guide to fracture dating in cases of possible infant abuse.

BACKGROUND: Dating fractures is critical in cases of suspected infant abuse. There are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom. OBJECTIVE: Since birth-related clavicular fractures are not immobilized and their age is known, we propose that an assessment of these injuries may serve as a guide for dating inflicted fractures in young infants, acknowledging that patterns observed in the clavicle may not be entirely generalizable to other bones injured in the setting of abuse. MATERIALS AND METHODS: One hundred thirty-one radiographs of presumed birth-related clavicular fractures in infants between 0 and 3 months of age were reviewed by two pediatric radiologists with 30 and 15 years' experience. Readers were asked to evaluate images based on several parameters of fracture healing, with a focus on subperiosteal new bone formation (SPNBF) and callus formation. SPNBF and callus were each evaluated with regard to presence, thickness and character. Responses were correlated with known fracture ages. RESULTS: SPNBF was rarely seen in fractures less than 7 days old and was most often present by 10 days. Callus formation was rarely seen in fractures less than 9 days old and was most often present by 15 days. SPNBF thickness increased with fracture age and the character of SPNBF evolved from single-layered to solid/multilayered. Callus thickness decreased with fracture age and callus matrix evolved from soft to intermediate to hard in character. CONCLUSION: There is an evolution in clavicular fracture healing in young infants that follows a predictable pattern. These findings afford the prospect that predictable patterns of infant clavicular fracture healing can provide an evidence base that may be applicable in cases of suspected infant abuse.

Imaging of long gap esophageal atresia and the Foker process: expected findings and complications.

Long gap esophageal atresia (EA) is characterized by esophageal segments that are too far apart for primary anastomosis. Surgical repair utilizing interposition grafts or gastric transposition are often employed. The Foker staged lengthening procedure is an alternative surgical method that utilizes continuous traction on the esophagus to induce esophageal growth and allow for primary esophageal anastomosis. This pictorial review presents the step-by-step radiographic evaluation of the Foker procedure and illustrates the radiographic findings in the most commonly encountered complications in our cohort of 38 patients managed with this procedure from January 2000 to June 2012.

Preterm infant swallowing of thin and nectar-thick liquids: changes in lingual-palatal coordination and relation to bolus transit.

Tongue-soft palate coordination and bolus head pharyngeal transit were studied by means of postacquisition kinematic analysis of videofluoroscopic swallowing images of ten preterm infants referred from hospital NICUs due to poor oral feeding and suspicion of aspiration. Sequences of coordinated tongue-soft palate movements and bolus transits during swallows of thin-consistency and nectar-thick-consistency barium were digitized, and time series data were used to calculate continuous relative phase, a measure of coordination. During swallows of nectar-thick compared to thin barium, tongue-soft palate coordination was more likely to be antiphase, bolus head pharyngeal transit time was longer, and coordination was significantly correlated with bolus head pharyngeal transit. Analysis of successive swallows indicated that tongue-soft palate coordination variability decreased with nectar-thick but not with thin-consistency barium. Together, the results suggest that slower-moving bolus transits may promote greater opportunity for available sensory information to be used to modulate timing of tongue-soft palate movements so that they are more effective for pumping liquids.

Bowel re-dilation following serial transverse enteroplasty (STEP).

PURPOSE: The serial transverse enteroplasty (STEP) operation tapers and lengthens dilated small bowel. Some patients demonstrate bowel re-dilation following STEP. Factors associated with bowel re-dilation and its effect upon clinical outcome were evaluated. METHODS: Twenty STEP operations were reviewed. Sixteen cases were operated for failure to advance enteral feeding and were further analyzed. Available pre- and post-STEP radiographs were independently assessed for bowel re-dilation by two experienced pediatric radiologists. Potential factors of re-dilation were evaluated. Full enteral autonomy was defined as no longer requiring parenteral nutrition (PN) and remaining off PN for at least 12 months after STEP. RESULTS: There was complete concordance between the radiologists. 9 of 16 patients demonstrated radiographic bowel re-dilation following STEP. Age, follow-up duration, time interval between STEP and last imaging reviewed, gender, diagnoses, pre- and post-STEP bowel length and width were not significantly associated with re-dilation. However, median post-STEP duration of PN was significantly longer in the re-dilated group than in the non-dilated group (41 vs. 3 months, p = 0.006). In addition, only 1 of 9 re-dilated patients achieved enteral autonomy as compared with 6 of 7 non-dilated patients (p = 0.009). CONCLUSION: Longer PN duration after STEP increases probability of bowel re-dilation. Patients who re-dilated following STEP are significantly less likely to achieve enteral autonomy. Larger prospective data collections are warranted to further explore these relationships.

Lack of utility of abdominal x-rays in the evaluation of children with constipation: comparison of different scoring methods.

BACKGROUND AND AIM: Abdominal x-rays are used diagnostically in the evaluation of children with constipation. However, their clinical utility has not been established. The aim of the study was to assess the accuracy of different methods in identifying children with functional constipation (FC) or nonretentive fecal incontinence (NRFI). PATIENTS AND METHODS: Retrospective review of abdominal x-rays in which colonic transit (CT), Barr, Leech, and fecal loading (FL) scores were blindly measured by blinded pediatric gastroenterologists and a radiologist. Children were classified a priori as FC or NRFI. RESULTS: One hundred sixty patients (125 FC, 35 NRFI) were studied. There were significant differences (P < 0.05) when comparing those with FC and those with NRFI: CT: 51 +/- 18 vs 40 +/- 21 hours; Barr: 14 +/- 5 vs 11 +/- 4; Leech: 10 +/- 2 vs 8 +/- 2; FL: 2 +/- 0.5 vs 1.7 +/- 0.4. More than 20% of FC had normal Barr and Leech scores, whereas >50% of NRFI had abnormal scores. CT discriminated better between FC and NRFI. There was a significant correlation (P < 0.05) between CT and Barr (0.45), Leech (0.41) and FL scores (0.36), and between Barr and Leech scores (r = 0.94). There was good intraobserver correlation between Barr, Leech, and FL scores but poor interobserver reproducibility. CONCLUSIONS: Although significant differences in overall FC and NRFI scores exist, the discriminative value is low for all scores. There is poor interobserver reproducibility of the Barr, Leech, and FL scores. These findings confirm the limited value of the plain abdominal x-ray in the evaluation of children with constipation.

The presentation and management of vascular rings: an otolaryngology perspective.

OBJECTIVE: To review the presentation and natural history of children with vascular rings and present management guidelines. METHODS: Retrospective study of tertiary care pediatric medical center charts from 1991 to 2002. RESULTS: There were 37 males and 27 females with a diagnosis of vascular rings. At presentation, 91% of patients had airway symptoms and 47% had esophageal symptoms. Airway symptoms included stridor (63%), recurrent respiratory infections (47%), respiratory distress (19%), and cough (17%). The most common esophageal symptom was dysphagia (27%). Pre-operative studies included: echocardiography (96%), chest X-ray (93%), barium swallow (75%), magnetic resonance imaging (MRI) (60%), and computerized tomography (CT) scan of the chest (59%). Surgical management included open (n=25) and thoracoscopic (n=39) approach. Complications included recurrent laryngeal nerve injury in five patients (8%). CONCLUSION: Children with vascular rings present with respiratory and/or feeding difficulty. The evaluation should include chest X-ray, echocardiography, and barium swallow. Direct laryngoscopy and bronchoscopy are recommended to assess the degree of compression of the airway and/or esophagus, tracheomalacia, and vocal fold motion prior to intervention. Indication for surgical release is given when the diagnosis is made and can be assisted by advanced radiology studies. Surgical options include minimally invasive techniques involving either thoracoscopic or robotic-assisted repairs, as well as open procedures involving thoracotomy.

Risk stratification of children being evaluated for intussusception.

CONTEXT: Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to bowel perforation. OBJECTIVE: To determine predictive clinical criteria and develop a decision tree to risk-stratify children with possible intussusception. DESIGN/METHODS: This is a prospective observational cohort study of children aged 1 month to 6 years who presented with possible intussusception. A data-collection form was completed before knowledge of any advanced imaging. Univariate analysis was performed, and decision trees were developed using recursive partitioning. RESULTS: In the study, 310 patients were enrolled, including 38 (12.3%) with intussusception. The median age was 21.1 months and 61% were male. Univariate predictors of intussusception included age older than 6 months (P = 0.04), male gender (P = .007), history of lethargy (P = .001), and abnormal plain x-ray (P = .0001). Multivariate analysis through recursive partitioning identified decision trees (with and without the result of a plain abdominal x-ray) and allowed identification of patients at low risk. The decision tree based on the results of an abdominal x-ray (negative or positive), age (≤ 5 or >5 months), diarrhea (present or absent), and bilious emesis (present or absent) had the best test performance (sensitivity: 97% [95% confidence interval (CI): 86-100]; negative predictive value: 99% [95% CI: 93-100]; negative likelihood ratio: 0.08 [95% CI: 0.01-0.6]). CONCLUSIONS: Among children who were being evaluated for intussusception, we prospectively determined clinical criteria and developed a decision tree to risk-stratify children with possible intussusception.

Chest radiographic and CT evaluation of lung abnormalities in pediatric patients with laryngeal cleft.

BACKGROUND: The purpose of this study was to (1) evaluate chest radiography (CR) and computed tomography (CT) findings in pediatric patients with laryngoscopically confirmed laryngeal cleft and (2) determine whether CT provided additional information over CR in evaluating lung abnormalities in pediatric patients with laryngeal cleft. METHODS: Two pediatric radiologists performed a retrospective review of CRs and CTs in pediatric patients with laryngoscopically confirmed laryngeal cleft from January, 2002 to January, 2010. Lungs were evaluated for pattern (airspace or interstitial), distribution (upper, middle, or lower lung zones), and extent (<25% or >25%) of abnormalities on CRs and CTs. In patients who had both CR and CT, CT findings were compared with concurrent CRs to determine whether CT provided additional information and resulted in alterations in patient management. RESULTS: The final study cohort consisted of 67 pediatric patients (37 males and 30 females; mean age 3.0 years ± 3.5 years; range 25 days to 17.5 years) who had CR. Sixteen (24%) of these 67 patients had both CR and CT. Chest radiographs were abnormal in 47 patients (70%) which included consolidation (n = 35; 74%) and reticular opacities in 12 patients (26%). Lung parenchymal abnormalities were observed in the upper (n = 10; 21%), middle (n = 2; 4%), or lower (n = 35; 75%) lung zones on CR. The extent of lung parenchymal abnormalities was >25% in 30 patients (64%) and <25% in 17 patients (36%). Chest CT examinations were abnormal in all 16 patients (100%) who had available chest CT examinations, which included consolidation (n = 9; 56%) and reticular opacities (n = 7; 44%). Lung parenchymal abnormalities were observed in the upper (n = 2; 12.5%) or lower (n = 14; 87.5%) lung zones on CT. The extent of lung abnormalities was >25% in 10 patients (60%) and <25% in six patients (40%). CT provided major additional findings in 12 patients (75%) and minor findings in four patients (25%). Additionally, CT improved the evaluation of the distribution and extent of lung abnormalities in 11 patients (69%). The additional information provided by CT resulted in alteration of patient management in seven patients (43.8%). CONCLUSIONS: Among pediatric patients with laryngeal cleft, CR and CT often show lung abnormalities such as consolidation and reticular opacities. CT frequently provides additional information, which may change patient management.

Premature infant swallowing: patterns of tongue-soft palate coordination based upon videofluoroscopy.

Coordination between movements of individual tongue points, and between soft palate elevation and tongue movements, were examined in 12 prematurely born infants referred from hospital NICUs for videofluoroscopic swallow study (VFSS) due to poor oral feeding and suspicion of aspiration. Detailed post-evaluation kinematic analysis was conducted by digitizing images of a lateral view of digitally superimposed points on the tongue and soft palate. The primary measure of coordination was continuous relative phase of the time series created by movements of points on the tongue and soft palate over successive frames. Three points on the tongue (anterior, medial, and posterior) were organized around a stable in-phase pattern, with a phase lag that implied an anterior to posterior direction of motion. Coordination between a tongue point and a point on the soft palate during lowering and elevation was close to anti-phase at initiation of the pharyngeal swallow. These findings suggest that anti-phase coordination between tongue and soft palate may reflect the process by which the tongue is timed to pump liquid by moving it into an enclosed space, compressing it, and allowing it to leave by a specific route through the pharynx.

Endoscopic repair of laryngeal cleft type I and type II: when and why?

OBJECTIVES/HYPOTHESIS: To evaluate the clinical features of children with type I and type II laryngeal cleft and the role of conservative monitoring versus endoscopic repair in their management. METHODS: Clinical presentation and evaluation; findings at the time of laryngoscopy, bronchoscopy, and esophagoscopy; and efficacy and outcome of conservative monitoring and endoscopic CO(2) laser repair. RESULTS: Eighty-one patients were evaluated for aspiration. Seventy-four patients were diagnosed as having a clinically significant laryngeal cleft. Thirty-two patients (14 males, 18 females) were monitored conservatively. Forty-nine patients (26 males, 23 females) required surgical intervention due to failed medical and feeding therapy of aspiration related to their laryngeal clefts (28 type I, 21 type II). Endoscopic CO(2) laser repair was used in all these patients. CONCLUSIONS: Medical and feeding therapy should be the first modality of treatment in patients with laryngeal cleft type I and type II. Factors supporting surgical repair include: 1) clinically apparent aspiration with feeding, 2) severity of pulmonary status, 3) findings on modified barium swallow and chest x-ray, 4) absence of significant comorbid conditions predisposing to aspiration, 5) findings on upper aerodigestive endoscopy, and 6) poor response to medical management and feeding therapy.

Neonatal intestinal obstruction simulating meconium ileus in infants with long-segment intestinal aganglionosis: radiographic findings that prompt the need for rectal biopsy.

BACKGROUND: The initial clinical presentation and radiographic finding of microcolon in children with long-segment intestinal aganglionosis involving the entire colon, ileum and sometimes the jejunum can mimic meconium ileus. This makes the diagnosis difficult for the radiologist and surgeon. OBJECTIVE: To document and describe the clinical and radiographic findings in children with long-segment intestinal aganglionosis who are initially thought to have meconium ileus. MATERIALS AND METHODS: We reviewed the cases of six neonates with long-segment intestinal aganglionosis presenting as meconium ileus at our institutions between 1978 and 2002. We examined the clinical presentation and the radiographic, surgical, and pathologic findings. In addition, 17 cases from the literature were identified and are included in the discussion. RESULTS: A total of 23 cases were reviewed. Right lower quadrant intraluminal calcifications were noted on abdominal radiographs in all six neonates of our series and were described in 13 of the 17 neonates reported in the literature. Similarly, a microcolon was present in five of the six neonates of our series and in 14 of 16 historical neonates (one not reported). CONCLUSION: In a neonate with small-bowel obstruction and a microcolon, the presence of right lower quadrant intraluminal calcifications should raise the suspicion of long-segment intestinal aganglionosis even if the operative findings are typical of meconium ileus and a biopsy should be performed.

The infant with chronic vomiting: the value of the upper GI series.

BACKGROUND: Vomiting is very common in infants. It is usually attributed to gastroesophageal reflux and no radiological evaluation is performed. Pediatric radiologists, however, still perform many upper GI series in these infants to exclude an underlying anatomic abnormality as a cause for vomiting. OBJECTIVE: To evaluate the yield of upper GI series in the evaluation of otherwise healthy infants 1 month to 1 year of age with vomiting for more than 30 consecutive days. MATERIALS AND METHODS: Clinical records and upper GI reports of 344 otherwise healthy infants that were referred for UGI by pediatric gastroenterologists because of chronic vomiting were analyzed. Patients with hematemesis, bilious vomiting, dysphagia, respiratory symptoms and patients that required hospitalization were excluded. RESULTS: Findings other than gastroesophageal reflux were seen in only 2 patients out of 344 (0.6%). In one patient duodenal stenosis was diagnosed. In another patient a small hiatal hernia was seen. CONCLUSIONS: The yield of upper GI in otherwise healthy infants 1 month to 1 year of age with chronic vomiting is extremely low, and the performance of the UGI in this specific group of patients may not be justified.

Incidence of spinal cord lesions in patients with intractable constipation.

Abstract Spinal magnetic resonance imaging of children with intractable constipation was reviewed. Nine percent of patients had spinal cord abnormalities. Tethered cord was the most common lesion in 75% of patients. Magnetic resonance imaging is a useful tool to evaluate children with intractable constipation.

Isolated neonatal swallowing dysfunction: a case series and review of the literature.

Our purpose was to describe the natural history of isolated neonatal swallowing dysfunction (INSD). Nine infants with INSD are described. Eight presented within two weeks of birth. Symptoms included choking and cyanotic spells with feeds, recurrent aspiration, apnea, stridor, and vomiting. Three had nonspecific neurological abnormalities and were diagnosed later in life with underlying disorders (myotonic dystrophy, CHARGE association, velocardiofacial syndrome). All required tube feeding. Six tolerated nasogastric feedings and received a gastrostomy tube. Three failed nasogastric feeds and required jejunal feedings. The gastrostomy tube was removed in 7/9 at a mean age of 37 +/- 9 months. In conclusion, INSD has a good long-term prognosis. The presence of minor neurological abnormalities at presentation suggests another underlying disorder. Nasogastric feeding followed by a gastrostomy is recommended in those without gastroesophageal reflux. Jejunal feedings are necessary in some. While most improve over time, they may need nutritional support for 3 years or more.

Association of Schatzki ring with eosinophilic esophagitis in children.

OBJECTIVE: To describe the clinicopathologic characteristics of children with Schatzki ring and to determine if Schatzki ring is associated with eosinophilic esophagitis. METHODS: The authors report 18 adolescents with radiographically diagnosed Schatzki ring (SR). Their clinical and histologic characteristics were reviewed in a blinded fashion. RESULTS: The mean age of the patients was 15.8 +/- 0.8 years and mean duration of symptoms was 2.6 +/- 0.4 years. By histologic criteria, two groups of patients were defined. Eight had clinical and histologic criteria of eosinophilic esophagitis (EE) and 10 of peptic esophagitis. There were no differences in the symptoms or radiographic findings in the two groups. The SR was not identified by endoscopy in any EE patient and was identified in 70% of peptic esophagitis patients. Grossly apparent mucosal features associated with EE were significantly more common in those with EE. Those with peptic esophagitis had a significantly higher acid exposure than did those with EE (12.6 +/- 2.9 v 2.0 +/- 1.1%; P < 0.01) by esophageal pH probe. Patients with peptic esophagitis responded to proton pump inhibitors and/or dilatation, whereas those with EE did not have good response and required specific therapy for EE. CONCLUSIONS: EE may play a role in the pathogenesis of some patients with SR.