Characterization of obstructive sleep apnea before and after tongue-lip adhesion in children with micrognathia.

OBJECTIVES: To characterize airway obstruction before and after tongue-lip adhesion in children with micrognathia using polysomnography. DESIGN: Retrospective pilot case series. PARTICIPANTS AND METHODS: Evaluation of all children with micrognathia who underwent tongue-lip adhesion and polysomnography before and after surgery from 2002 to 2007 (N  =  8). RESULTS: Eight children met inclusion criteria; six were girls. The mean interval between polysomnography and tongue-lip adhesion was 6 days (range, 2 to 13 days) preoperatively and 17 days (range, 5 to 32 days) postoperatively. Severe obstructive sleep apnea was identified in seven of eight (88%) children, with a mean preoperative obstructive apnea hypopnea index of 52.6 events per hour (range, 7.1 to 85.7 events per hour). None had significant central sleep apneas (>5 per hour). Tongue-lip adhesion resulted in a mean decrease of 34.5 events per hour (range, -65.8 to 71.6 events per hour). After tongue-lip adhesion, seven of eight (87.5%) patients had an improved obstructive apnea hypopnea index, with resolution of obstructive sleep apnea in one child and improvement to mild (two) and moderate (two) obstructive sleep apnea in four others. Only one child had an obstructive apnea hypopnea index that increased after tongue-lip adhesion. Peak end-tidal pCO(2) measurements were elevated in all eight children before surgery at a mean of 60 mm Hg (range, 52 to 76 mm Hg) that improved to 51 mm Hg (range, 45 to 59 mm Hg), with normal peak levels in four children. Oxygen saturation nadir improved from 73% (range, 58% to 81%) to 82% (range, 65% to 94%). CONCLUSIONS: Tongue-lip adhesion may be performed in micrognathic infants to alleviate airway obstruction. Polysomnographic evaluation in this pilot study before and after surgery suggests that tongue-lip adhesion usually improves obstructive sleep apnea, but only 38% had complete resolution. Future studies of tongue-lip adhesion efficacy should include polysomnographic evaluation.

Splenectomy in hereditary spherocytosis: Review of 1,657 patients and application of the pediatric quality indicators.

OBJECTIVE: The objective of the present study is to profile the outcome and safety of pediatric patients undergoing splenectomy with hereditary spherocytosis (HS) using a nationwide sample and the Agency for Healthcare Research and Quality (AHRQ) Pediatric Quality Indicators (PDIs). PATIENTS AND METHODS: A retrospective cross-sectional descriptive analysis of a non-overlapping combination of the National Inpatient Sample (NIS), and Kids' Inpatient Database (KID) databases (1988-2004) were performed. These combined databases contain information from nearly 93 million discharges in the United States. Children with an age at admission of <18 years of age and HS (ICD-9 diagnosis code of 282.0) who underwent total splenectomy (ICD-9 procedure code of 41.5) were identified. Variables of gender, race, co-existing diagnoses, hospital type, and charges adjusted to 2006 dollars, length of stay, inpatient mortality, and complications were collected. PDIs were identified for each patient by linking the data obtained from the NIS and KID databases with the PDIs using the AHRQ Quality Indicators Wizard. RESULTS: Splenectomy for HS was associated with low morbidity and mortality. Accompanying cholecystectomy and/or appendectomy appeared to be safely performed at the same operation. Of the 13 PDIs identified by AHRQ as potentially avoidable adverse events, none were observed to occur in more than 1% of the patients. CONCLUSIONS: Based on the results of this study, splenectomy in patients with HS appears safe and to result in a minimal number of potentially preventable complications as identified by the AHRQ PDIs. We have successfully demonstrated use of the indicators to aid in the analysis of a specific surgical procedure within a subset of the pediatric population.

Prehospital predictors of risk for pelvic fractures in pediatric trauma patients.

Pelvic fractures are uncommon in children, but can occur as a result of high-energy impact injuries to the lower torso in association with blunt trauma. Pelvic fractures can be associated with significant morbidity while the work-up and treatment for these injuries is costly. The aim was to identify risk factors that help determine which pediatric trauma patients are at highest risk of sustaining a pelvic fracture to aid in the development of criteria for the targeted use of pelvic radiographic imaging. A retrospective analysis was conducted using the only pediatric trauma registry in the state of Maryland, located at The Johns Hopkins Children's Center. All blunt trauma patients who were younger than 15 years of age from 1990 to 2005 were included in the analysis (n = 13,360) with a final diagnosis of pelvic fracture as the primary outcome of interest. Comparisons were made using Pearson's chi-square for categorical and the Mann-Whitney rank sum test for non-normally distributed variables. Pelvic fractures following blunt trauma in children are associated with age, race, place and mechanism of injury. Compared to children 4 years and younger, pelvic fractures were more likely to occur in children aged 5-9 years (OR = 3; P = 0.000), as well as 10-14 years (OR = 5; P = 0.000). Compared to blunt trauma injuries from falls, children who were struck by vehicles or who were occupants in motor vehicle crashes (MVC) were six times (P = 0.000) and twice (P = 0.02) as likely to sustain a pelvic fracture, respectively. Four factors were demonstrated by this study to be significantly associated with pediatric pelvic fractures: being Caucasian, age between 5 and 14 years, being struck as a pedestrian or a motor vehicle crash occupant. Identification of these factors may aid clinicians in selecting patients who are at highest risk for pelvic fracture and may benefit most from pelvic radiography.