Effects of Sucrose and Nonnutritive Sucking on Pain Behavior in Neonates and Infants undergoing Wound Dressing after Surgery: A Randomized Controlled Trial.

INTRODUCTION: Wound dressing, a procedure that pediatric patients are commonly exposed to postoperatively, can cause strong physiological and pain behavioral responses despite being brief. This study evaluated the effects of using 24% sucrose plus a pacifier versus a pacifier alone to reduce the pain response from dressing wounds in neonates and infants. MATERIALS AND METHODS: Thirty-two neonates and infants who underwent surgery and required postoperative wound dressing were randomized to a pacifier group (n = 16) and a 24% sucrose plus pacifier group ("sucrose group"; n = 16). Demographic data, crying time, and pain behaviors were recorded using a video recorder. The pain behaviors were assessed independently using the neonatal infant pain scale (NIPS) by three assessors, who were expert in pediatric pain assessment and blinded to the subject allocations. RESULTS: Participants in the sucrose group were older than those in the pacifier group (6.19 ± 2.95 vs. 3.88 ± 3.2 months). While there were no differences in the NIPS scores of the two groups at 30, 120, and 240 seconds, the incidence of moderate-to-severe pain was lower in the sucrose group than the pacifier group at 120 seconds (37.5 vs. 50%). The crying time was lower in the sucrose group, but without statistical significance. CONCLUSION: The 24% sucrose plus pacifier was not superior to the pacifier alone in decreasing pain behavioral responses. Dressing wound pain produced a high-intensity pain behavioral response. A pain management strategy should be developed to lessen the postoperative procedural pain in pediatric patients.

Hepatic Histology and Morphometric Measurements in Idiopathic Extrahepatic Portal Vein Thrombosis in Children, Correlated to Clinical Outcome of Meso-Rex Bypass.

OBJECTIVE: The aim of this study was to correlate clinical, histologic, and morphometric features of the liver in children with extrahepatic portal vein thrombosis (EHPVT), with surgical outcome after Meso-Rex bypass (MRB). BACKGROUND: Idiopathic EHPVT, a significant cause of portal hypertension, is surgically corrected by MRB. Correlation of histologic and morphometric features of the liver with outcome has not been reported in children. METHODS: We retrospectively reviewed clinical and intraoperative data of 45 children with idiopathic EHPVT. Liver samples were obtained at the time of MRB. Morphometric measurements of portal tract structures were performed and correlated with surgical outcome. Median follow-up was 3.65 years after surgery (range 1.5 to 10 years). RESULTS: Thirty-seven (82.2%) children had successful MRB. There was no association between age, sex, and suture material with surgical outcome. Average patient age was higher in patients with postoperative complications (P = NS). Portal fibrosis, bridging, parenchymal nodules, portal inflammation, hepatocellular swelling, steatosis, dilatation of portal lymphatics, and periductal fibrosis did not show a significant difference between the 2 groups. Portal vein and bile duct area index were significantly smaller in the unsuccessful group (P = 0.004 and 0.003, respectively). A portal vein area index <0.08 had a lower chance of successful surgical outcome. Hepatic artery area index was not significantly different. Measured intraoperative portal blood inflow was the only significant clinical factor affecting surgical outcome (P = 0.0003). CONCLUSIONS: Low portal vein area index and intraoperative portal blood inflow may be negative prognostic factors for MRB outcome in children with idiopathic EHPVT. Average patient age was higher, although not statistically significant, in patients with postoperative complications.

Impact of muscle biopsy on diagnosis and management of children with neuromuscular diseases: A 10-year retrospective critical review.

BACKGROUND: Muscle biopsy facilitates morphologic, biochemical, and ultrastructural analysis of muscle for the purpose of making definitive neuromuscular diagnosis. However, muscle biopsy is an expensive, invasive, time-consuming, and resource-dependent procedure. The need for general anesthesia in children also increases the risks associated with this procedure. The aim of this study was to investigate the benefits of muscle biopsies performed over a 10-year period, with a focus on indications, suspected and histopathologic diagnosis, and impact on diagnosis and management decisions. METHODS: We retrospectively reviewed results of muscle biopsies performed in children at our center during the 2004 to 2014 study period. Clinical presentations, biopsy complications, pathologic results, and changes in management decision were reviewed and analyzed. RESULTS: Biopsies from 92 patients were included. Mean age of patients was 7.1years, and 66.3% were male. There were no perioperative complications, and definitive diagnosis was made in 74 patients. Regardless of whether pathologic changes were found or not, information gained from muscle biopsy significantly impacted prognosis and subsequent genetic counseling. CONCLUSIONS: Muscle biopsy is a safe and useful diagnostic tool in children suspected of having neuromuscular diseases, especially in those with muscle diseases. Definitive pathologic diagnosis helps to optimize treatment, counseling, and surveillance. THE TYPE OF STUDY AND LEVEL OF EVIDENCE: Study of diagnostic test: level 1.

Efficacy of surgical transversus abdominis plane block for postoperative pain relief following abdominal surgery in pediatric patients.

BACKGROUND: Transversus abdominis plane (TAP) block is a promising effective method for postoperative pain control after major abdominal surgery. Using a landmark technique, it is easily performed, but its popularity has decreased because of less efficacy due to inaccurate injection and the potential for intraperitoneal organ damage. Ultrasound-guided TAP block provides better results and less complications, but it requires experienced operators. Surgically administered TAP (sTAP) block is a simple technique and may cause less complications. This study was aimed to determine the efficacy of sTAP on postoperative pain control in pediatric patients following a major abdominal surgery, compared with local anesthetic infiltration and no block. METHODS: This stratified, randomized controlled trial was conducted in pediatric patients, below the age of 15 years, who underwent non-laparoscopic major abdominal surgery. Patients were allocated into three groups. The control group received no block; the LA group received 0.25% bupivacaine for local wound infiltration; and the sTAP group received 0.25% bupivacaine for TAP block performed by a surgeon before abdominal wall closure. Parameter records included the incidence of inadequate pain control, time to first analgesic, opioid requirement within 24 h, and complications of these techniques. RESULTS: Fifty-four patients were recruited. There was no significant difference in the incidence of inadequate pain control (P = 0.589). The median time to first analgesic was 380 min in the sTAP group compared with 370 and 420 min in the LA and control groups, respectively (95%CI = 193-567, 121-619, and 0-1012; P = 0.632). The median dose of total opioid requirement (calculated as fentanyl-equivalent dose) was 1.95, 2.05, and 2.04 µg·kg(-1) ·24 h(-1) in the sTAP, LA, and control groups, respectively (IQR = 0.65, 2.20; 0.59, 3.32; 0.38, 2.60; P = 0.723). No complications of sTAP block were detected. CONCLUSIONS: There was no significant advantage of the sTAP block over local infiltration or no intervention for postoperative pain control in pediatric patients undergoing non-laparoscopic major abdominal surgeries.

Effects of a restrictive fluid regimen in pediatric patients undergoing major abdominal surgery.

OBJECTIVE: To investigate the effects of restrictive fluid regimen during major abdominal surgery in pediatric patients. BACKGROUND: In adults, a restrictive and goal-directed regimen as opposed to a liberal-fluid regimen results in better outcomes after various major surgical procedures. The different ratio of body fluid distribution in pediatric patients from those of adults may influence different needs of fluid. METHODS: This stratified, randomized, controlled trial was conducted in 25 pediatric patients (mean age <3 years) undergoing major abdominal surgery. Patients were allocated to two groups based on their perioperative fluid management. 'control group' received maintenance plus deficit plus interstitial space replacement plus ongoing loss, whereas 'restrictive group' had a similar treatment, but were given no interstitial space replacement. Intraoperative fluid resuscitation was guided by hemodynamics and base excess. Parameters recorded included hemodynamic variables, the volume and type of intravenous fluid, blood chemistry (including lactate, base excess, and electrolyte), chest X-ray, body weight, complications, and return of bowel function. RESULTS: Patients in control group needed significantly less additional fluid for resuscitation compared to restrictive group (0.62 ± 3.51 ml · kg(-1) · h(-1) vs 5.04 ± 4.16 ml · kg(-1) · h(-1) ; P = 0.012). In restrictive group, heart rates were higher (P = 0.012) and base excess showed more negative results (P = 0.049). There were no differences between the groups in terms of the total volume requirement, postoperative kidney function, chest X-ray, variation of body weight and the postoperative outcomes. CONCLUSIONS: Volume preload corresponding with an estimated interstitial space replacement was suitable for application to pediatric patients undergoing major abdominal surgery.

Successful nontransplant resection of POST-TEXT III and IV hepatoblastoma.

BACKGROUND: Liver transplantation is increasingly advocated as primary surgical therapy for children with hepatoblastoma involving 3 or 4 sectors of the liver after neoadjuvant chemotherapy. This study evaluated the results of nontransplant hepatectomy in children who might otherwise have been considered for liver transplantation. METHODS: All children who underwent resection at a single institution from 1998 to 2009 for POST-TEXT IV or centrally located POST-TEXT III hepatoblastoma after neoadjuvant chemotherapy were reviewed. RESULTS: Fourteen children (7 boys) with a median age of 8 months at diagnosis met study criteria. Pulmonary metastases in 3 patients were resected in 2 and resolved with chemotherapy in 1 patient. Preoperative grouping after neoadjuvant chemotherapy was POST-TEXT IV in 3 patients and POST-TEXT III in 11 patients. Thirteen of 14 (93%) children who underwent aggressive resection despite being potential candidates for primary transplantation were alive and tumor-free with a median follow-up of 57 months. Observed survival rates at 1, 2, and 5 years were 93%, 91%, and 88% respectively. Event-free survival rates at 1, 2, and 5 years were 93%, 91%, and 75%, respectively. CONCLUSIONS: Excellent survival (93%) was obtained with aggressive resection in children with POST-TEXT III and IV hepatoblastoma meeting criteria for transplant referral. The 1 death occurred in a patient with unfavorable small cell histology. These children should be managed at institutions experienced in both advanced pediatric hepatobiliary surgery and transplantation. Operative exploration was frequently required to ultimately determine which tumors can be resected and which require transplantation.

Management and classification of type II congenital portosystemic shunts.

BACKGROUND: Congenital portosystemic shunts (PSS) with preserved intrahepatic portal flow (type II) present with a range of clinical signs. The indications for and benefits of repair of PSS remain incompletely understood. A more comprehensive classification may also benefit comparative analyses from different institutions. METHODS: All children treated at our institution for type II congenital PSS from 1999 through 2009 were reviewed for presentation, treatment, and outcome. RESULTS: Ten children (7 boys) with type II PSS were identified at a median age of 5.5 years. Hyperammonemia with varying degrees of neurocognitive dysfunction occurred in 80%. The shunt arose from a branch of the portal vein (type IIa; n = 2), from the main portal vein (type IIb; n = 7), or from a splenic or mesenteric vein (type IIc; n = 1). Management included operative ligation (n = 6), endovascular occlusion (n = 3), or a combined approach (n = 1). Shunt occlusion was successful in all cases. Serum ammonia decreased from 130 ± 115 µmol/L preoperatively to 31 ± 15 µmol/L postoperatively (P = .03). Additional benefits included resolution of neurocognitive dysfunction (n = 3), liver nodules (n = 1), and vaginal bleeding (n = 1). CONCLUSION: Correction of type II PSS relieves a wide array of symptoms. Surgery is indicated for patients with clinically significant shunting. A refined classification system will permit future comparison of patients with similar physiology.

Focal nodular hyperplasia in children: clinical features and current management practice.

BACKGROUND: Although nonoperative management is an accepted practice for most adults with focal nodular hyperplasia (FNH), questions remain about the safety and feasibility of this strategy in children. Our aim was to review the clinical features of children with FNH and determine current management patterns. METHODS: We reviewed records of all children and adolescents with FNH managed at our institution from 1999 to 2009 and performed a MEDLINE search to identify all published cases of FNH in the pediatric population. RESULTS: A total of 172 patients with FNH were identified, including 11 at our institution. The median age at diagnosis was 8.7 years and 66% were female. Median tumor size was 6 cm, and 25% had multiple lesions. Thirty-six percent were symptomatic at presentation. Twenty-four percent had a history of malignancy. Management included resection (61%), biopsy followed by observation (21%), and observation alone (18%). Indications for resection included symptoms (48%), inability to rule out malignancy (24%), tumor growth (15%), and biopsy-proven concurrent malignancy (9%). CONCLUSIONS: Although FNH is a benign lesion that is typically managed nonoperatively in adults, most children with FNH currently undergo resection because of symptoms, increasing size, or inability to confidently rule out malignancy.

Choledochal cyst in two pediatric heart transplant patients.

Choledochal cyst is a relatively uncommon entity in Western countries. No reports of choledochal cyst in heart transplant patients have been reported to date. We report two cases of choledochal cyst in pediatric heart transplant recipients, one with post-transplant lymphoproliferative disorder (PTLD) within the cyst. The first patient had abdominal pain, increased liver enzymes and was seropositve for Epstein-Barr virus. A choledochal cyst with PTLD was removed 4 years after heart transplantation. The second patient presented 14 years after heart transplantation with a choledochal cyst that was excised for severe abdominal pain. This previously unreported association between choledochal cysts in conjunction with PTLD and heart transplantation is interesting and a possible common pathogenesis is proposed. The management and alternative treatments were briefly noted. We recommend an aggressive treatment for patients with suspected choledochal cyst after heart transplantation because of the increased potential for malignant transformation.

Body composition and metabolic changes associated with massive intestinal resection in mice.

BACKGROUND: The specific changes in body composition and metabolism during the adaptation response to massive intestinal loss are presently unclear. The present study was designed to determine alterations in these parameters using an established mouse model. METHODS: Male C57/Bl6 mice underwent either 50% small bowel resection (SBR) or transection with reanastomosis (Sham) operation. Oxygen consumption per unit time, carbon dioxide production per unit time, respiratory quotient, and energy expenditure were measured by indirect calorimetry along with body composition determination by nuclear magnetic resonance at postoperative days 1, 3, 7, 14, 21, and 28. RESULTS: The mice that underwent SBR had lower rates of metabolism as measured by decreased energy expenditure, carbon dioxide production per unit time and oxygen consumption per unit time when compared with the Sham group throughout the study period. During adaptation, SBR mice had restoration of body fat at two weeks after the operation while the lean mass and body weight remained lower throughout. CONCLUSION: Without supplemental parenteral nutrition, the adaptation response to massive SBR is characterized by reduced energy metabolism and an inappropriate replenishment of fat stores over lean mass. Futures studies will be needed to determine the metabolic effects of various growth factors designed to enhance structural features of adaptation.