Child physical abuse and COVID-19: Trends from nine pediatric trauma centers.

BACKGROUND: Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period. METHODS: We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data. RESULTS: There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality. CONCLUSIONS: Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.

Adrenocortical tumors in children.

Adrenocortical neoplasms are rare in childhood. Unlike their adult counterparts, they are often hormonally active and malignant. Despite being uncommon, adrenocortical neoplasms in children have significant associated morbidity and require complete surgical resection for effective management. Furthermore, the clinical overlap between adrenocortical neoplasms, adrenal medullary neoplasms, and functional disorders of the adrenal cortex requires that the practicing pediatric surgeon have a solid working knowledge of the presentation, diagnostic workup, and management of these anatomically related yet disparate pathologies.

Report of 52nd annual meeting of the pacific association of pediatric surgeons.

This is the report of the 52nd Annual Association of Pediatric Surgeons held in Christchurch, New Zealand, March 10-March 14, 2019.

Use of ECMO support in pediatric patients with severe thoracic trauma.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been used in the non-trauma setting for over 30 years. However, the use of ECMO in trauma remains a difficult question, as the risk of bleeding must be weighed against the benefits of cardiopulmonary support. METHODS: Retrospective review of children who sustained severe thoracic trauma (chest abbreviated injury score ≥3) and required ECMO support between 2009 and 2016. RESULTS: Of the 425 children who experienced severe thoracic trauma, 6 (1.4%) underwent ECMO support: 67% male, median age 4.8 years, median ISS 36, median GCS 3, and overall survival 83%. The median hospital day of ECMO initiation was 2 with a median ECMO duration of 7 days. All cannulations occurred through the right neck regardless of the size of the child. Five initially had veno-venous support with 1 requiring conversion to veno-arterial (VA) support. Both children on VA support suffered devastating cerebrovascular accidents, one of which ultimately led to withdrawal of care and death. Complications in the cohort included: paraplegia (1), neurocognitive defects/dysphonia (1), infected neck hematoma (1), deep femoral venous thrombosis (1), bilateral lower extremity spasticity (1). CONCLUSION: This small cohort supports the use of ECMO in children with severe thoracic injuries as a potentially lifesaving intervention, however, not without significant complication. LEVEL OF EVIDENCE: IV.

Reduction of resource utilization in children with blunt solid organ injury.

BACKGROUND/PURPOSE: Nonoperative management of blunt solid organ injuries continues to progress and improve cost-effective utilization of resources while maximizing patient safety. The purpose of this study is to compare resource utilization and patient outcomes after changing admission criteria from a grade-based protocol to one based on hemodynamic stability. METHODS: A retrospective review of isolated liver and spleen injuries was done using prospectively collected trauma registry data from 2013 to 2017. The 2 years preceding the change were compared to the 2 years after protocol change. All analyses were performed using SAS 9.4. RESULTS: There were 121 patients in the preprotocol cohort and 125 patients in the postprotocol cohort. Baseline demographics were similar along with injury mechanisms and severity. The ICU admission rate decreased from 40% to 22% (p = 0.002). There were no adverse events on the floor and no patient needed to be transferred to the ICU. CONCLUSIONS: A protocol for ICU admission based on physiologic derangement versus solely on radiologic grade significantly reduced admission rates to the ICU in children with solid organ injury. The protocol was safe and effectively reduced resource utilization. LEVEL OF EVIDENCE: Level II, prospective comparison study.

Longboard injuries treated at a level 1 pediatric trauma center.

INTRODUCTION: Recreation on longboards is gaining in popularity. The purpose of this study is to detail the injury patterns, treatment and management of children with longboarding injuries seen at a level 1 pediatric trauma center. METHODS: A retrospective review using our trauma registry from 2006 to 2016 of pediatric patients who sustained injuries while riding a longboard. RESULTS: Of 12,920 injured children, 64 (0.5%) were treated for injuries that occurred while riding a longboard. Median age was 14.5 years (IQR 13.6, 15.4) and 84% were male. Fifty-one (80%) suffered a traumatic brain injury (TBI) including 32 intracranial hemorrhages (ICH), 17 concussions, and 31 skull fractures. Seven (11%) were wearing helmets. Three patients required neurosurgical intervention. Extremity fractures were the most common reason for surgery. Ninety-six percent of patients were admitted to the hospital with a median length of stay of 1 day (IQR 1, 3). All children survived to discharge. Compared with skateboard injuries during the same period, TBI, ICH, concussion, and skull fractures were all greater. CONCLUSIONS: TBI ranging from concussion to ICH requiring craniotomy is common in children injured while riding a longboard, and greater than rates after skateboarding injuries. Extremity fracture was the most common reason for operative intervention. LEVEL OF EVIDENCE: III.

Report of PAPS meeting.

This is a report of the Pacific Association of Pediatric Surgeons Fifty-First Scientific Meeting held in Sapporo, Japan, from May 13to May 17, 2018.

Surgical outcomes of pancreaticoduodenal injuries in children.

PURPOSE: To examine surgical outcomes of children with pancreaticoduodenal injuries at a Quaternary Level I pediatric trauma center. METHODS: We queried a prospectively maintained trauma database of a level one pediatric trauma center for all cases of pancreatic and/or duodenal injury from 2002 to 2017. Analysis was conducted using JMP 13.1.0. RESULTS: 170 children presented with pancreatic and/or duodenal injury. 13 (7.7%) suffered a combined injury and this group forms the basis for this report with mean ISS of 22.8 (± 15.1), RTS2 of 6.4(± 2.1), and median age of 6.6 (1.3-13.5) years. Child abuse (31%) and bicycle injuries (23%) were the most common mechanisms. 8/13 (61.5%) required operative intervention. Higher AAST pancreatic and duodenal injury grade (2.9 vs. 1.2, p = 0.05 and 3.6 vs. 1.4, p = < 0.01), lower RTS2 (7.84 vs. 5.49, p < 0.01), and lower GCS (9.6 vs. 15, p = 0.03) predicted operative intervention. 6/8 (75%) undergoing surgery survived to discharge with only (2/6) survivors suffering postoperative complications. Both mortalities were secondary to severe traumatic brain injury. CONCLUSION: Surgical management of complex pancreaticoduodenal injury is an uncommon traumatic event that is associated with high injury severity, but survival occurs in most scenarios.

Longitudinal analysis of hospital charges following injury in a level 1 pediatric trauma system.

BACKGROUND: The treatment of injured children contributes substantially to the financial burden of a health care system. The purpose of this study was to characterize these charges at a level-1 pediatric trauma center. METHODS: Financial data for children (<14 years) admitted for traumatic injury from 1/2009 to 12/2014 were analyzed. The charges of the index admission and first two years following discharge were evaluated. RESULTS: 5853 trauma patients were included with average annual charges of $11,128,730. The most common mechanisms of injury were fall (44%), sports (12%), and bike (9%). The median ISS was 6 (IQR 4-10) with a mortality rate of 1.8% and Z-score of 13.04 (p<0.001). The overall total charges per patient during the index admission were $9513. Spinal cord and major abdominal injuries had the greatest charges per patient ($55,560 and $23,618 respectively) primarily owing to hospital LOS. During the first year after discharge, the total charges per patient were $1733, of which spinal cord injury resulted in highest overall ($19,426), owing to inpatient rehabilitation. For all other injury patterns, mean total charges per patient were $2376 (range $791-$3573). CONCLUSIONS: The value proposition in health care requires us to define outcomes relative to costs. Injury severity, major injury location, and hospital length of stay are the highest contributors for the financial burden of pediatric traumatic injury, while inpatient readmissions and inpatient rehabilitation drove higher charges in the years following discharge. TYPE OF STUDY: Clinical Research Paper. LEVEL OF EVIDENCE: II - Cohort Study.

Clearance of tunneled central venous catheter associated blood stream infections in children.

BACKGROUND: The optimal time to reinsert central venous catheters (tCVC) after a documented central line associated blood stream infection (CLABSI) is unclear. The goal of this study is to identify risk factors for children who develop persistent bacteremia after tCVC removal due to CLABSI. METHODS: We performed a retrospective cohort study from a tertiary children's hospital. Children who underwent removal of a tCVC due to CLABSI were included in our analysis. Our primary outcome was persistent bacteremia after tCVC removal defined by a persistently positive blood culture. Salient patient demographic and clinical factors were extracted from the medical record. RESULTS: A total of 140 patients met inclusion criteria and 27 (19%) had a persistent CLABSI after removal of the tCVC. There were no significant differences between the patients who cleared their bacteremia and those who develop persistent bacteremia. The median (IQR) time to positive blood culture after tCVC removal was 2.7 days (1.7- 4.0). CONCLUSIONS: We did not identify any patient risk factors distinguishing between a child who will clear a CLABSI versus develop a persistent CLABSI after tCVC removal. Blood stream infection clearance was rapid after tCVC removal, supporting a brief line holiday prior to tCVC reinsertion. LEVEL OF EVIDENCE: Level III Retrospective Case-Control Study.

Helmet under-utilization by children during equestrian events is associated with increased traumatic brain injury.

PURPOSE: Awareness of equestrian related injury remains limited. Studies evaluating children after equestrian injury report under-utilization of safety equipment and rates of operative intervention as high as 33%. METHODS: We hypothesized that helmets are underutilized during equestrian activity and lack of use is associated with increased traumatic brain injury. We queried the trauma database of a level one pediatric trauma center for all cases of equestrian and rodeo related injury from 2005 to 2015. Analysis was conducted using SAS 9.4. RESULTS: Of 312 children identified, 142 were assessed for use of a helmet. Only 28 children (19.7%) had documented use of a helmet. Most injuries occurred while riding a horse (83%) or bull (13%) with traumatic brain injury being the most common injury (51%). Helmet use was associated with decreased ISS (7.1 vs. 11.3, p<0.01), TBI (32.4% vs. 55.3%, p=0.03), and ICU admission (10.7% vs. 29%, p=0.05). Multivariable analysis reveals lack of helmet use to be an independent predictor of TBI (OR 2.5, 95% CI 1.1-6.3). CONCLUSION: Helmets are underutilized by children during equestrian related activity. Increased awareness of TBI and education encouraging helmet use may decrease morbidity associated with equestrian activities. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

A case of Cushing ulcer in an 8-month-old patient with medulloblastoma.

The authors present the first case of a Cushing ulcer in an infant with medulloblastoma who, despite being administered stress ulcer prophylaxis, worsened after corticosteroids were initiated. An 8-month-old boy presented with progressive vomiting, lethargy, and decreased oral intake. Imaging revealed a heterogeneous fourth ventricular mass. Preoperatively, the patient was started on dexamethasone. The patient underwent an uncomplicated external ventricular drain placement and suboccipital craniotomy for resection of the lesion. The results of the pathological analysis were consistent with medulloblastoma. Postoperatively, the patient had melanotic stools, which were reported to be occurring for months prior to presentation. Two proximal duodenal bulb ulcers were found and required definitive surgical repair. The patient recovered from the acute postsurgical course after continued stress ulcer prophylaxis and is currently undergoing chemotherapy.

The use of angiography in pediatric blunt abdominal trauma patients.

BACKGROUND: Angiography is a common treatment used in adults with blunt abdominal trauma and/or severe pelvic fractures. The Committee on Trauma of the American College of Surgeons has recently advocated for this resource to be urgently available at pediatric trauma centers; however, its usefulness in the pediatric setting is unclear. The purpose of this study was to determine the incidence of angiography in the treatment of blunt abdominal trauma among injured children. METHODS: An analysis was performed using an established public use data set of children (younger than 18 years) treated at 20 participating trauma centers for blunt torso trauma through the Pediatric Emergency Care Applied Research Network. Patients who underwent angiography of the abdomen or pelvis were identified and analyzed. RESULTS: Of the 12,044 children evaluated for blunt abdominal trauma included within the data set, 973 sustained abdominopelvic injuries. Of these, only 26 (3%) underwent angiography. The median age was 14 years, 65% were males, with a mortality rate of 19%. Overall, 29 angiographic procedures were performed: 21 abdominal, 8 pelvic, with 3 patients undergoing both abdominal and pelvic. Eleven patients underwent embolization of a bleeding vessel, all of which were related to the spleen. No hepatic, renal, or pelvic vessels required embolization. The median time to angiography from emergency department evaluation was 7.3 hours. In addition to angiography, 50% also required surgical intervention, of which 31% underwent a laparotomy. Thirty-five percent of these patients required blood product transfusion, and 42% were admitted to the intensive care unit. CONCLUSION: The emergent use of angiography with embolization is uncommon in pediatric patients with blunt abdominal injuries. The requirement that pediatric trauma centers have access to interventional radiology within 30 minutes may be unnecessary. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level IV.

Paravertebral regional blocks decrease length of stay following surgery for pectus excavatum in children.

PURPOSE: Management of postoperative pain following repair of pectus excavatum has traditionally included thoracic epidural analgesia, narcotics, and benzodiazepines. We hypothesized that the use of intercostal or paravertebral regional blocks could result in decreased inpatient length of stay (LOS). METHODS: We conducted a retrospective cohort study of 137 patients (118 Nuss and 19 Ravitch - Nuss and Ravitch patients were analyzed separately) who underwent surgical repair of pectus excavatum with pain management via epidural, intercostal, or paravertebral analgesia from January 2009-December 2012. Measured outcomes included LOS, pain scores, benzodiazepine/narcotic requirements, emesis, professional fees, hospital cost, and total cost. RESULTS: In the Nuss patients, LOS was significantly reduced in the paravertebral group (p<0.005) and the intercostal group (p<0.005) compared to the epidural group, but was paradoxically countered by a nonsignificant increase in total cost (p=0.09). While benzodiazepine doses/day was not increased in the paravertebral group (p=0.08), an increase was seen in narcotic use (p<0.005). Despite increased narcotic use, no differences were seen in emesis between epidural and paravertebral use. Compared to epidural, pain scores were higher for both intercostal and paravertebral on day one (p<0.005), but equivalent for paravertebral on day three (p=0.62). The Ravitch group was too small for detailed independent statistical analysis but followed the same overall trend seen in the Nuss patients. CONCLUSION: Our use of paravertebral continuous infusion pain catheters for pectus excavatum repair was an effective alternative to epidural analgesia resulting in shorter LOS but not a decrease in overall cost.

Preventable transfers in pediatric trauma: A 10-year experience at a level I pediatric trauma center.

BACKGROUND: Injured children are often treated at one facility then transferred to another that specializes in pediatric trauma care. The purpose of this study was to identify and characterize potentially preventable transfers (PT) to a freestanding level-I pediatric trauma center. METHODS: Children with traumatic injuries transferred between 2003 and 2013 were retrospectively analyzed. A PT was defined as a child who was discharged within 36hours of arrival without surgical intervention or advanced imaging studies. RESULTS: During this period, 6380 children were transferred, with head injury being the most common injury. 61% had CT imaging performed before transfer. The mean age was 6.9years, mean injury severity score (ISS) 10.4, and median transfer distance 37miles. 27% of these transfers were classified as PT. Air transport was used in 15% at mean charge of $18,574. 29% were discharged from the emergency department. When compared, PTs were younger (6.0 vs. 7.2years, p<0.001), with lower median ISS (5 vs. 9, p<0.001), shorter median LOS (15 vs. 43.6hours, p<0.001), and less PICU admissions (6% vs. 34%, p<0.001). CONCLUSION: A significant number of pediatric trauma transfers can be classified as preventable. Reducing preventable transfers could offer opportunities for improving value in a trauma care system.

One hospital, one appendectomy: The cost effectiveness of a standardized doctor's preference card.

PURPOSE: Appendicitis in children provides a unique opportunity to explore changes that reduce variation, reduce cost, and improve value. In this study we sought to evaluate the effectiveness of standardization of surgical technique and intraoperative disposable device utilization for laparoscopic appendectomy among all surgeons at a tertiary children's hospital. METHODS: All 6 surgeons at our tertiary children's hospital agreed to standardize to a single technique of performing a laparoscopic appendectomy. We collected data on all pediatric patients who had a laparoscopic appendectomy following implementation of the uniform doctor's preference card (DPC) (March 1, 2013 to February 28, 2014) and compared them to a historical control group. RESULTS: Implementation of the uniform DPC decreased the device cost per appendectomy from $844.11 to $305.32. Operative times (skin incision to skin closure) were 34.8 minutes prior to the uniform DPC and 37.0 minutes using the uniform DPC. There were no significant differences in postappendectomy outcomes. CONCLUSION: We have demonstrated that implementation of a uniform DPC and technical standardization for laparoscopic appendectomy can significantly reduce cost. Furthermore, this can occur without dramatically increasing operative times, length of stay, or postoperative complications.

Effectiveness of an organized bowel management program in the management of severe chronic constipation in children.

BACKGROUND: Chronic constipation is a common problem in children. The cause of constipation is often idiopathic, when no anatomic or physiologic etiology can be identified. In severe cases, low dose laxatives, stool softeners and small volume enemas are ineffective. The purpose of this study was to assess the effectiveness of a structured bowel management program in these children. METHODS: We retrospectively reviewed children with chronic constipation without a history of anorectal malformation, Hirschsprung's disease or other anatomical lesions seen in our pediatric colorectal center. Our bowel management program consists of an intensive week where treatment is assessed and tailored based on clinical response and daily radiographs. Once a successful treatment plan is established, children are followed longitudinally. The number of patients requiring hospital admission during the year prior to and year after initiation of bowel management was compared using Fisher's exact test. RESULTS: Forty-four children with refractory constipation have been followed in our colorectal center for greater than a year. Fifty percent had at least one hospitalization the year prior to treatment for obstructive symptoms. Children were treated with either high-dose laxatives starting at 2mg/kg of senna or enemas starting at 20ml/kg of normal saline. Treatment regimens were adjusted based on response to therapy. The admission rate one-year after enrollment was 9% including both adherent and nonadherent patients. This represents an 82% reduction in hospital admissions (p<0.001). CONCLUSIONS: Implementation of a structured bowel management program similar to that used for children with anorectal malformations, is effective and reduces hospital admissions in children with severe chronic constipation.

Helicopter versus ground emergency medical services for the transportation of traumatically injured children.

BACKGROUND: Helicopter emergency medical services (HEMS) are a common mode of transportation for pediatric trauma patients. We hypothesized that HEMS improve outcomes for traumatically injured children compared to ground emergency medical services (GEMS). METHODS: We queried trauma registries of two level 1 pediatric trauma centers for children 0-17 years, treated from 2003 to 2013, transported by HEMS or GEMS, with known transport starting location and outcome. A geocoding service estimated travel distance and time. Multivariate regression analyses were performed to adjust for injury severity variables and travel distance/time. RESULTS: We identified 14,405 traumatically injured children; 3870 (26.9%) transported by HEMS and 10,535 (73.1%) transported by GEMS. Transport type was not significantly associated with survival, ICU length of stay, or discharge disposition. Transport by GEMS was associated with a 68.6%-53.1% decrease in hospital length of stay, depending on adjustment for distance/time. Results were similar for children with severe injuries, and with propensity score matched cohorts. Of note, 862/3850 (22.3%) of HEMS transports had an ISS<10 and hospitalization<1 day. CONCLUSIONS: HEMS do not independently improve outcomes for traumatically injured children, and 22.3% of children transported by HEMS are not significantly injured. These factors should be considered when requesting HEMS for transport of traumatically injured children.

A dynamic postoperative protocol provides efficient care for pediatric patients with non-ruptured appendicitis.

PURPOSE: Postoperative management of pediatric patients with non-ruptured appendicitis is highly variable and often includes an overnight stay in the hospital. We implemented a criteria-based postoperative protocol designed to eliminate postoperative antibiotics and facilitate timely discharge by utilizing the bedside nurse to evaluate for readiness for discharge. METHODS: We collected data on all patients with non-ruptured appendicitis at our institution following protocol implementation (May 1, 2012 to April 30, 2013) and compared them to a control group. RESULTS: 580 patients were treated for non-ruptured appendicitis (285 prior protocol, 295 new protocol). Following implementation of our protocol, there was an overall reduction in length of stay from 40.1 (SD 27.5) to 23.5 (SD 20.8)h, and total cost of care per patient also decreased from $5783 (SD $2501) to $4499 (SD $1983) (p<0.001). There was no change in hospital readmission rate (1.1% prior protocol, 1.4% new protocol) or postoperative abscess rate (0.8% prior protocol, 0.3% new protocol). CONCLUSION: Our new protocol reveals the value of eliminating postoperative antibiotics and leveraging the continuous availability of the bedside nurse in the determination of readiness for discharge.

Charge Awareness Affects Treatment Choice: Prospective Randomized Trial in Pediatric Appendectomy.

OBJECTIVE: To determine whether charge awareness affects patient decisions. BACKGROUND: Pediatric uncomplicated appendicitis can be treated with open or laparoscopic techniques. These 2 operations are considered to have clinical equipoise. METHODS: In a prospective, randomized clinical trial, nonobese children admitted to a children's hospital with uncomplicated appendicitis were randomized to view 1 of 2 videos discussing open and laparoscopic appendectomy. Videos were identical except that only one presented the difference in surgical materials charges. Patients and parents then choose which operation they desired. Videos were available in English and Spanish. A postoperative survey was conducted to examine factors that influenced choice. The trial was registered at ClinicalTrials.gov (NCT 01738750). RESULTS: Of 275 consecutive cases, 100 met enrollment criteria. In the group exposed to charge data (n = 49), 63% chose open technique versus 35% not presented charge data (P = 0.005). Patients were 1.8 times more likely to choose the less expensive option when charge estimate was given (95% confidence interval, 1.17-2.75). The median total hospital charges were $1554 less for those who had open technique (P < 0.001) and $528 less for the group exposed to charge information (P = 0.033). Survey found that 90% of families valued having input in this decision and 31% of patients exposed to charge listed it as their primary reason for their choice in technique. CONCLUSIONS: Patients and parents tended to choose the less expensive but equally effective technique when given the opportunity. A discussion of treatment options, which includes charge information, may represent an unrealized opportunity to affect change in health care spending.