Diaphragmatic plication in the extremely low birth weight infant.

A case of acquired diaphragmatic paralysis in an extremely low birth weight infant complicated by respiratory failure, recurrent atelectasis, and pneumonia is described. Diaphragmatic plication led to a rapid improvement in pulmonary function and allowed for discontinuation of mechanical ventilation in less than 1 week. Therapeutic options for acquired diaphragmatic paralysis, including the rationale for early operative intervention, in this patient population are discussed.

Percutaneous needle aspiration of small interloop abscesses in children.

Treatment of small postoperative interloop abscesses (ILA) can be challenging. In children, these collections have usually been drained surgically at a second operation. This article describes three children with small postoperative ILAs who were treated by percutaneous needle aspiration and parenteral antibiotics, with good outcomes. The advantages of this technique and its utilization in the management of children with ILAs are discussed.

Minimal head trauma in children revisited: is routine hospitalization required?

OBJECTIVE: Children with a question of occult head injury are routinely hospitalized despite having both normal central nervous system (CNS) and computed tomographic (CT) scan examinations. We determined the incidence of significant CNS morbidity after occult head injury to determine whether or not hospital admission was necessary in children after minimal head trauma. METHODS: We reviewed the records of children admitted to a level I trauma center with a question of closed head injury, an initial Glasgow Coma Scale equal to 15, a normal neurologic exam, and a normal head CT scan. Children with associated injuries requiring admission were excluded. The endpoints were deterioration in CNS exam, new CT findings, and the need for a prolonged hospital stay. RESULTS: Sixty-two patients were studied with a mean age of 7 years (range, 1 month to 15 years), and 65% were male. The primary mechanisms of injury were fall (45%) and vehicular crash (23%). The mean injury severity score was 4 +/- 2. The mean length of stay was 1.2 days (range, 1 to 3 days). Prolonged hospitalization occurred in 9 patients (15%). No child developed significant CNS sequelae warranting hospital admission. Total charges for these hospitalizations were $177 874. CONCLUSIONS: Children undergoing emergency department work-up of occult head injury, who have a normal CNS exam and a normal head CT scan, do not seem to be at risk for significant CNS sequelae. These patients can be discharged home with parental supervision and avoid unnecessary and costly hospitalization.

Midgut volvulus. An ever-present threat.

OBJECTIVE: To identify risk factors for midgut volvulus (MGV) and to seek clues to early diagnosis of MGV in children with malrotation. DESIGN: Retrospective patient series. SETTING: Academic medical center. PATIENTS: Sixty-eight consecutive children who had a Ladd operation performed between January 1970 and December 1991. Excluded were three patients whose records were unavailable and patients who had a Ladd operation during the course of repair of an abdominal wall defect or congenital diaphragmatic hernia. RESULTS: Forty of 68 patients had MGV at operation. There was an inverse correlation between age at onset of symptoms and the probability of MGV: 85% (29/34) of patients less than 1 month of age had MGV compared with 43% (10/23) of older children. Patients who had symptoms for less than 4 days were more likely to have MGV (88%; 30/34) than patients who had more chronic symptoms (43%; 10/23). Bilious (green) vomiting was more highly associated with MGV (80%; 35/44) than nonbilious vomiting (38%; 3/8) or pain (50%; 6/12). Roentgenograms of the upper gastrointestinal tract were very accurate for the diagnosis of malrotation but frequently failed to identify MGV (sensitivity, 54%; 13/24). Despite the high proportion of MGV, only three patients had gangrenous bowel. Of these three patients, one died and two have short-gut syndrome. CONCLUSION: Neonates with a short history of bilious vomiting are most likely to have MGV-complicating malrotation, but older children who have chronic intermittent symptoms are also at risk. Since there is no way to predict which patients will develop catastrophic bowel necrosis, early diagnosis and operation are necessary to prevent mortality and short-gut syndrome.

Predictors of postoperative respiratory complications in premature infants after inguinal herniorrhaphy.

There is a significant incidence of inguinal hernia in premature infants and the optimal timing of repair is controversial. A high rate of postoperative respiratory complications has been reported in this group. In this study, the records of 47 premature infants (mean gestational age, 30.3 weeks) who underwent herniorrhaphy while still in the neonatal intensive care unit were reviewed in an effort to define those conditions that are independent risk factors for complications. Forty-three percent of infants had complications, including postoperative assisted ventilation (34%), episodes of apnea and/or bradycardia (23%), emesis and cyanosis with first feeding (6%), and requirement for postoperative reintubation (4%). Although low gestational age and postconceptual age at operation, low birth weight for gestational age, and preoperative ventilatory assistance were significantly associated with postoperative complications, only a history of respiratory distress syndrome/bronchopulmonary dysplasia (odds ratio 2.3), a history of patent ductus arteriosus (odds ratio 2.5), and low absolute weight at operation (odds ratio 3.5 for 1,000-g decrease) were independent risk factors for postoperative complication. Despite previous reports citing postconceptual age as the factor having the greatest impact on postoperative complications, these results indicate that a history of respiratory dysfunction and size at operation may be more important predictors of postoperative respiratory dysfunction in preterm infants.

Outcome of nonoperative management of splenic injury with nuclear scanning. Clinical significance of persistent abnormalities.

Uncertainties remain about the frequency and need for diagnostic imaging following recovery from splenic injury with nonoperative management. To gain further understanding, the final appearance of the splenic roentgenographic image was evaluated in 20 consecutive children (mean age, 10.1 years) undergoing serial studies up to 70 weeks following injury. A total of 65 technetium 99m sulfur colloid scans, including 45 follow-up studies, were obtained and evaluated. By 20 weeks following injury, six patients (30%) were normal, four (20%) demonstrated minimal residual effects, and 10 (50%) had significantly improved, leaving some persistent abnormality. None of the patients in the last group showed any clinical problem. No distinctions could be made by comparing the severity of the initial injury with a persisting imaging defect. We conclude that clinical considerations alone should determine whether any follow-up imaging be performed in children recovering from splenic injury.

Coincidence of congenital toxoplasmosis and biliary atresia in an infant.

A 4-week-old infant presenting with neonatal cholestasis was found to have congenital toxoplasmosis and biliary atresia. This is the first patient in which their coincidence is reported. Because biliary atresia can coexist with either congenital infection or inborn errors of metabolism, evaluation for an obstructive etiology of jaundice in infants with a recognized cause of intrahepatic cholestasis is necessary.

Evaluation of Nissen fundoplication in neurologically impaired children.

The value of performing Nissen fundoplication in neurologically impaired children is a controversial issue. To evaluate the benefit of fundoplication in these children, hospital records were reviewed for 77 children who underwent fundoplication for gastroesophageal reflux (GER). Fifty-two children were neurologically impaired; 25 children had no neurological impairment. Impaired children had significantly fewer hospital admissions (1.8 v 0.7; P less than .005) and total days of hospitalization (36 v 14; P less than .005) during the first postoperative 6 months, compared with the immediate preoperative 6-month period. Normal children had fewer hospital admissions and days postoperatively, but the difference was not significant. Impaired children with preoperative failure to thrive (FTT had significantly increased average monthly weight gain over the first 6-month period postoperatively, compared with preoperative growth rate (3.0% v 0.9% of total body weight; P less than .05). Average monthly weight gain at 1 and 2 years postoperatively was not significantly different from preoperative values for impaired children. Growth rate of normal children with FTT did not change significantly postoperatively. Symptomatic relief was comparable in the normal and impaired children. Perioperative mortality was 0% in the normal children and 6% in the impaired children. This study demonstrates that Nissen fundoplication in neurologically impaired children with GER can be performed safely, reduces the frequency of hospitalization, and improves short-term weight gain.

The effect of right atrial catheters on infectious complications of chemotherapy in children.

Rates of infections and catheter complications in children with right atrial catheters (RACs) receiving chemotherapy were compared with those without RACs in a retrospective cohort study. One hundred sixty-five children presenting to Yale-New Haven Hospital with a malignancy diagnosed between January 1, 1981 and December 31, 1985 were followed through June 30, 1986 for the number of treatment-related complications resulting in hospitalization. The time on therapy totaled 80,089 person-days that were divided into 510 periods of observation defined by the presence or absence of a RAC, disease status (remission, partial remission, or relapse), intensity of chemotherapy (using a 0 to 4 scale), and use of radiation therapy. Children with RACs experienced markedly higher rates of sepsis (14-fold higher, P less than .0001) and catheter-site infection or other catheter complications requiring hospitalization (both greater than 30-fold higher, P less than .0001). These effects persisted after controlling for other risk factors, ie, disease status, chemotherapy intensity, and age. Children with RACs also had higher rates of fever and neutropenia and other infections requiring hospitalization that were more strongly influenced by the other risk factors. The association of RACs with sepsis, fever and neutropenia, and days hospitalized for treatment-related complications was assessed using multivariable analysis methods to control for disease status, intensity of chemotherapy, radiation therapy, type of cancer, age, and sex. The presence of a RAC (rate ratio [RR], 6.39; P less than .0001) and the disease status (RR, 2.45; P = .0004) were the only factors that predicted sepsis. Fever and neutropenia rates were most influenced by chemotherapy intensity (RR, 2.31; P = .0001) and age (RR, 0.94; P = .013 per year of age) and less by the presence of a RAC (RR, 1.56; P = .053). Controlling for other risk factors, children with RACs experienced a 6.4-times higher rate of sepsis and spent an average of 15.4 more days per year in the hospital for treatment-related complications.

Elective splenopexy for wandering spleen.

The diagnosis of wandering spleen is usually made at the time of operation owing to symptoms caused by torsion of the spleen. Splenectomy has been performed in almost all of the reported cases. A 6-year-old girl presented with intermittent abdominal pain and a mobile abdominal mass. The diagnosis of wandering spleen was confirmed by computerized tomography. Elective splenopexy was performed by securing the spleen in an extraperitoneal pocket.

Congenital umbilical arteriovenous malformation: a rare cause of congestive heart failure in the newborn.

A newborn presented in congestive heart failure on the second day of life. Cardiac catheterization was normal, but aortic injection showed a congenital umbilical artery to umbilical vein arteriovenous malformation. Three similar cases have been reported. All four patients were successfully treated by complete excision of the malformation.

Nutrition and inflammatory bowel disease.

Nutritional support, whether enteral or parenteral, is an important part of the treatment of IBD. Inadequate oral intake, malabsorption, and increased gastrointestinal losses all contribute to malnutrition. Weight loss, cachexia, abnormal body composition, and multiple micronutrient deficiencies are common. Acute repletion of body weight and correction of specific nutrient deficiencies improve the patients' sense of well-being and decrease morbidity, especially in the perioperative period. If a short period of bowel rest (10 to 14 days) is part of the medical therapy of acute exacerbations of IBD, TPN should be administered to prevent further nutritional deficiencies. Chronic undernutrition, and growth failure in children, usually are best treated by intensive enteral supplementation. Prolonged bowel rest and TPN (4 to 6 weeks) have not been shown to improve outcome but may be appropriate in carefully selected patients. Long-term home TPN may be necessary for patients who have short gut syndrome. The mainstay of treatment for IBD is medical therapy including corticosteroids. Timely and appropriate surgery is equally important and should not be considered a last resort. Careful nutritional management is essential but is adjunctive rather than primary therapy.

Thrombus associated with central venous catheters in infants and children.

From 1978 to 1987, 350 infants and children had silicone central catheters placed for long-term venous access. Real time echocardiography showed a catheter tip thrombus in 16 patients, including 12 premature infants and four children. Catheters had been in place for eight to 560 days. Thirteen patients were receiving total parenteral nutrition (TPN) at the time thrombus was identified, and one patient had received TPN 2 weeks previously. Indications for echocardiography included sepsis (7), respiratory insufficiency (6), evaluation of heart disease (3), and catheter malfunction (1); several patients had multiple indications. Treatment was individualized and included atriotomy (2), systemic heparin and thrombolytic agents with or without catheter removal (8), catheter removal only (3), and observation (3). Four of eight patients treated with thrombolysis had complete clot lysis and four had partial dissolution. Two patients managed expectantly had resolution of the thrombus. None of the patients suffered further complications or died as a result of the thrombus, but ten of the 16 died 1 to 12 weeks later from their underlying disease. Forty-seven asymptomatic patients were studied by echocardiography to assess the incidence of unsuspected right atrial thrombus. Their catheters had been in place for a mean of 200 days and only 11 had been used for TPN. None of these patients had identifiable thrombus at the catheter tip. The incidence of catheter tip thrombus, which is higher than previously suspected, is related to prematurity, TPN, and continuous catheter use, but not duration of catheterization. The incidence is low in asymptomatic patients. Treatment regimen must be individualized and this series reflects a trend toward more conservative management.

Bilateral hydrothorax complicating central venous catheterization in a child: case report.

It is necessary to consider catheter-related events when a previously stable patient has an acute change in cardiopulmonary status, regardless of the duration of catheter use; and to recognize that hydrothorax from vein perforation may be bilateral, necessitating bilateral drainage procedures.

Cesarean section does not improve outcome in gastroschisis.

Elective cesarean section (CS) following prenatal diagnosis of gastroschisis has been advocated to decrease morbidity and mortality. To examine this hypothesis, we reviewed the records of 28 consecutive patients with gastroschisis treated between 1975 and 1987. Fourteen infants were delivered vaginally (V) and fourteen by CS, of which seven were elective, five were for fetal distress, and two were for breech presentation. Prenatal diagnosis was made in nine infants in the CS group and none in the vaginal group. The two groups were comparable in gestational age (V = 37.6 weeks, CS = 35.8 weeks, P = .05), birth weight (V = 2,508 g, CS = 2,444 g, P = NS), and five-minute Apgar score (V = 7.8, CS = 6.8, P = NS). Outcome was similar as measured by hospital mortality (V = 0/14, CS = 1/14, P = NS), complications (V = 4/14, CS = 5/14, P = NS), days to enteral feeding (V = 14, CS = 19, P = NS), and days in the hospital (V = 27, CS = 34, P = NS). The only complication related to mode of delivery was preventable; an infant delivered vaginally had avulsion of a short segment of mesentery requiring bowel resection. Infants born by CS were slightly more likely to have primary closure (5/14) than babies delivered vaginally (3/14, P = NS), but this may reflect independent trends in the last 5 years. Elective CS following prenatal diagnosis in seven patients did not improve outcome; primary closure was achieved in only one infant, and three had a complication. Since these data show no significant difference in morbidity and mortality between vaginal and CS delivery, we suggest that CS should not be recommended simply because a prenatal diagnosis of gastroschisis is made.

Appendicitis in children. Accuracy of the barium enema.

The barium enema (BE) may be useful in the diagnosis of atypical appendicitis in children. We analyzed our experience with 18 children in whom appendicitis was suspected and BE was performed. All of the children underwent surgical exploration. Nonfilling of the appendix with cecal indentation, extravasation of barium from the appendix, or both, were considered positive signs of an inflamed appendix on BE. Using these criteria, 12 of 14 cases of proved appendicitis were true positive and two were equivocal. Four children were proved not to have appendicitis; one of these patients had a true-negative BE, two had equivocal BEs, and there was one false-positive BE (Schönlein-Henoch purpura). Extravasation of barium into the peritoneal cavity was noted in one patient; this was a rare complication.

Familial apple peel jejunal atresia: surgical, genetic, and radiographic aspects.

Fifty-seven cases of apple peel jejunal atresia have been reported in the English literature. Patients with this anomaly have a high incidence of prematurity (70%), malrotation (54%), short gut syndrome (74%), multiple atresias (15%), complications (63%), and mortality (54%). Mortality has decreased from 63% to 47% since 1970. We report three new cases of apple peel jejunal atresia, including two from one family. Radiographic evidence of high small bowel obstruction and a malrotated microcolon on preoperative roentgenogram with barium enema should suggest this diagnosis. Five families, including ours, have been reported in which more than one child was affected, and it has been suggested that this disorder is transmitted by an autosomal recessive gene. However, the occurrence of conventional intestinal atresia in other siblings, the association with multiple atresias, and discordance in a set of apparently monozygotic twins indicate that there may be a more complex spectrum of genetic transmission. Subsequent siblings are at increased risk for apple peel atresia or related malformations. Prenatal ultrasound can facilitate early diagnosis and treatment.

Laparoscopy in the management of the nonpalpable testis.

Laparoscopy was performed at operation in 32 patients between 7 and 63 months old (average age 31 months), who had 33 nonpalpable testes. Of the testes 7 (21.2 per cent) were in the inguinal region or just proximal to the internal ring, 5 (15.2 per cent) were in a high intra-abdominal position and 21 (63.6 per cent) were absent. In every instance of a nonpalpable gonad in which a testis was found to be absent at operation the vas and gonadal vessels were observed laparoscopically to exit the inguinal ring or to end blindly just proximal to the internal inguinal ring. A hernia or patent processus vaginalis was not observed in these 21 cases. In every case of an absent testis the contralateral testis was located normally in the scrotum. Furthermore, when a hernia was observed laparoscopically a testis was found on the ipsilateral side at the level of the internal ring or more distally.