Post Frenotomy Massage for Ankyloglossia in Infants-Does It Improve Breastfeeding and Reduce Recurrence?

OBJECTIVES: Frenotomy is performed in breast fed infants who experience difficulty in latching after failed conservative management for ankyloglossia or tongue-tie. Though parents sometimes enquire about massage after frenotomy, neither published evidence nor clinical consensus supports this. The aim of our study was to assess if there was significant difference in breast feeding or recurrence rate between those infants who had post frenotomy massage and those who did not. METHODS: A retrospective study was conducted in a tertiary Children's hospital from January 2018 to December 2018. The tongue-tie service consisted of five pediatric surgical consultants, three of whom routinely advice post frenotomy massage. As a result, we had two groups to compare -massage and non-massage group. Total sample size (n = 599) consisted of those who were advised massage (n = 282) and those who were not advised massage (n = 317). RESULTS: Overall recurrence rate was 4/599 (0.66%) and this did not achieve statistical significance between the two groups. Breast feeding rates were also similar in both the groups. However, it is interesting to note that only 43.5% of those advised massage adhered to the massage regimen. CONCLUSIONS: Improvement in breast feeding and recurrence after frenotomy were similar between massage and non-massage groups. This confirms the lack of any additional benefit of post frenotomy massage. This study assists clinicians with decision making not to advise massage as it is unlikely to benefit infants with tongue-tie.

Stoma recycling in a surgical neonatal unit: Prevalence, challenges, and review of nursing attitudes.

AIM: Recycling has been shown to improve growth, nutrition and facilitate early stoma closure. We aim to review current practice and nursing experience at a tertiary paediatric surgical unit and to evaluate possible areas for improvement. METHOD: Retrospective study of all neonates who underwent a stoma closure between January 2018 and October 2020, alongside a nursing staff survey on experience and barriers to effective recycling. Data presented as median (range) and number (percentage). P value <0.05 was regarded as significant. RESULTS: A total of 71 neonates were included; median birthweight 869.5 (500-3600)g and gestation 26 (23-40) for a median of 15.5 (1-51) days. Rates of early stoma closure were similar in both the recycling (RG) and non recycling groups (NRG); 15/29 vs. 21/42, p > 0.999. Thirty-nine neonatal nurses responded to the survey with 36/39 (92%) having prior experience of recycling. Time constraints were the main reason nurses felt it was difficult to achieve effective recycling, with some also being worried about causing damage. Increased training and parental involvement were two potential solutions suggested by nurses to overcome these issues. CONCLUSION: Despite the known benefits, less than half of our cohort had successful recycling prior to stoma closure. Increased training, development of a uniform policy and involvement of the parents may help to improve the rates of stoma recycling. LEVEL OF EVIDENCE: Level III (Retrospective Comparative Study).

Nurse-led service for children with gastrostomies: a 2-year review.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) feeding can provide long-term nutritional support for patients with a functional gastrointestinal system but insufficient oral intake. Some patients, however, may require jejunal feeding, which can be achieved using a PEG tube with jejunal extension (PEG-J). A previous review at a tertiary paediatric hospital revealed poor documentation and a high incidence of buried bumper syndrome (BBS) in children with gastrostomies. Subsequently, a nurse-led service for gastrostomy care was introduced. AIM: To determine the impact of the nurse-led service. METHODS: Prospective review, at 1 year and 2 years, following either a PEG or PEG-J insertion. Patient records were reviewed and a telephone survey was conducted. Statistical analysis was performed using Fisher's exact test. FINDINGS: 32 PEG and 6 PEG-J patients were included in this study. There was 100% documentation of provision of care instructions. Average satisfaction with the service was over 8/10. Incidence of BBS was 0% in the PEG group and 17% in the PEG-J group. Of those parents/carers surveyed, 74% wanted additional tube care support via SMS text message. CONCLUSION: Introduction of a nurse-led service resulted in complete documentation of provision of care and sustained high levels of parental satisfaction. Future care should focus on utilising technological platforms.

Open Primary Button Versus Laparoscopic Percutaneous Endoscopic Gastrostomy: Results From a Case-control Study.

OBJECTIVES: Open primary balloon gastrostomy (PBG) presents a potential alternative to percutaneous endoscopic gastrostomy (PEG) in children as it obviates the need for change under general anaesthetic; however, the complication profile of PBG compared to PEG is not well defined. Previous series comparing the two have been hampered by the groups not being equivalent. Our paediatric surgical centre has offered PBG as an alternative PEG since 2014. We used a matched case-control study to compare outcomes for PBG and PEG. METHODS: Patients undergoing PBG were used as "cases" and matched 1:3 by age and diagnosis to patients undergoing PEG, demographics, and clinical data as "controls." Primary outcome was rate of complications classified according to Clavien-Dindo (I-V). Secondary outcomes included time to feed and length of stay. Non-parametric, categorical and multivariate logistic regression analyses were performed. Data here presented as median with interquartile range (IQR). RESULTS: We included 140 patients (35 PBG:105 PEG). The 2 groups were comparable for sex, weight at surgery, and follow-up duration. Median operative time was longer for PBG (43 min [IQR 36.5-61.5] vs 27.5 min [18.25-47.75], P < 0.001). Multivariate analysis demonstrated a statistically significant, higher incidence of symptomatic granulation tissue in PBG (10 [29%] vs 6 [6%], P = 0.0008), this remained significant on multivariate analysis (OR 7.56 [2.33-23.5], P = 0.001), no other complication remained significant. The overall complication rate was not statistically different. CONCLUSIONS: PBG and PEG have similar overall complication rates; however, PBG appears to have a higher incidence of granulation tissue. This observation must be weighed against the need for further general anaesthetic which is not insignificant in medically complex children.

10 Years' Experience in Balanitis Xerotica Obliterans: A Single-Institution Study.

INTRODUCTION: Balanitis xerotica obliterans (BXO) is uncommon in children. Diagnosis of the condition is almost always clinical and supported by histology. Our aim was to evaluate the outcomes of children undergoing circumcision for BXO and explore the correlation between surgical and histological findings. MATERIALS AND METHODS: A 10-year retrospective review (2007-2017) of all children, aged 16 and less, undergoing circumcision at a tertiary teaching hospital was conducted. Statistical analysis was performed using Fisher's exact test. RESULTS: BXO occurred in 91/1025 (8.9%) children. The highest incidence of BXO was in the 5 to 10 age group (13.3%; p < 0.0001). The commonest symptom was foreskin scarring (62.6%). Intraoperatively, involvement of foreskin alone was seen in 26.4%, foreskin and meatus in 47.2%, and foreskin, meatus, and glans in 26.4%. Preoperatively, 24.2% of patients were prescribed steroid cream. Histologically, all patients showed microscopic changes confirming BXO. A total of 87.9% of patients only had a circumcision, and 11% required a meatal procedure along with the circumcision. Postoperatively, 19.8% of patients required a further procedure after an average duration of 5.8 months (range: 2-12 months); the majority of whom (83.3%) were prescribed postoperative steroid cream. CONCLUSION: Clinical correlation by surgeons has a high degree of accuracy (>90%). Meatal involvement is more common than previously reported. The use of pre- or postoperative steroids does not obviate the need for further surgical procedures. Patients can have recurrent symptoms 1 year following surgery, and prolonged follow-up is necessary.

Aborted Tracheo-esophageal Fistula in a Neonate.

Esophageal atresia (EA) is an uncommon congenital anomaly which is often associated with a tracheoesophageal fistula. An isolated EA is a rarer anomaly and its diagnosis has implications for the ongoing treatment and outcome of the infant. For the first time, we report a case of a premature newborn with a pure EA and a tracheal diverticulum, containing both respiratory and esophageal mucosa. We have termed this an aborted trachea-esophageal fistula. Recognition of these very rare variations of foregut anomalies may contribute to our understanding of their pathogenesis.

Bronchoscopy as a screening tool for symptomatic tracheomalacia in oesophageal atresia.

AIM: Oesophagealatresia/tracheo-oesophageal fistula (OA-TOF) is associated with tracheomalacia (TM). In our institution it is routine for OA-TOF patients to undergo dynamic flexible bronchoscopy (DFB) assessing both the site of the fistula and the presence or absence of TM. We aimed to determine the value of this investigation as a screening tool to predict subsequent symptomatic tracheomalacia in these patients. METHODS: All patients with OA-TOF who underwent DFB at the time of initial repair between June 2014 and November 2016 were included prospectively. The findings at DFB were recorded. Patients were grouped according to the presence or absence of TM and followed to determine which of them developed symptomatic airway problems. The sensitivity and specificity of TM at initial bronchoscopy as a screening tool for subsequent symptomatic TM were calculated. The study was given ethical approval by our institution. MAIN RESULTS: Twenty-three patients were included in the study. Median follow-up was for 7 (1-27) months. Fifteen (65%) were found to have TM at their first DFB; 13 (57%) subsequently developed airway symptoms, and of these 11 had TM at initial DFB. One patient with severe TM (>90% tracheal collapse) at initial DFB was completely asymptomatic following OA-TOF repair. The sensitivity was 85%, and specificity was 60%. The positive and negative predictive values were 73% and 75%, respectively. CONCLUSIONS: DFB is a useful tool in many aspects of the management of OA/TOF. However, it is not a good screening tool to predict symptomatic tracheomalacia with moderate sensitivity and a low specificity. LEVEL OF EVIDENCE: Level IIb, Retrospective cohort study.

Management of pneumatosis intestinalis in children over the age of 6 months: a conservative approach.

BACKGROUND: Pneumatosis intestinalis (PI) is an uncommon and poorly understood condition. Although it can be an incidental finding in asymptomatic individuals, it can also be secondary to life-threatening bowel ischaemia and sepsis. In premature infants, it is a pathognomonic sign of necrotising enterocolitis. There is no consensus regarding management and long-term outcome of children with PI. AIM: Review of our experience of PI in children beyond the early infantile period. METHODS: Retrospective review of patient's records and radiological images from 2013 to 2015. RESULTS: Eighteen patients (three girls) had radiologically confirmed PI. The median age was 4.5 years (range 8 months-13 years). Background medical conditions (number): short bowel syndrome (one), congenital heart disease (two), sickle cell disease (one), epilepsy (three), cerebral palsy (six), myotonic dystrophy (four) and peroxisomal biogenesis defect (one).Six children (33%) presented with abdominal distension, four (22%) with abdominal pain, three (17%) with bilious vomiting, two (11%) with diarrhoea and one (6%) with rectal bleeding. Two (11%) were asymptomatic. One had air in portal vein and two had pneumoperitoneum.All patients with symptomatic PI were treated conservatively with successful outcome and complete resolution of PI. None required surgical intervention. CONCLUSION: PI in children who are not on chemotherapy or immunosuppressant appears to follow a benign course and is responsive to conservative management. In contrast to adults, portal venous gas and pneumoperitoneum do not predict the need for surgical intervention.

Long-term efficacy of a tongue tie service in improving breast feeding rates: A prospective study.

BACKGROUND: Breast feeding rates in England at 3months of age are approximately 17% for exclusive breast-feeding and 55% for breast-feeds supplemented with formula. Tongue-tie (TT) in infants is cited as a significant cause of difficulty with maintaining breast-feeding. Early treatment and support can improve breast-feeding and allow infants to benefit from the many long-term benefits of breast-feeding. Our aim was to determine BF rates in infants 3months after attending our tongue-tie clinic (TTC). METHODS: Institutional ethical approval and study approval were obtained. Patients attending the TTC from May to July 2016 were included. Telephone contact was made 3months postprocedure to establish current behaviour. Symptom resolution was recorded as complete resolution (CR), moderate resolution (MoR), or minimal resolution (MiR). Feeding pattern was either exclusively BF or combined breast and formula feeds or exclusively formula fed. RESULTS: 100 infants were included with complete follow-up data on 87 (87% response rate). Median age at release of TT was 17 (2-88) days without any recurrence. Status at 3months was CR (n=70, 80%); MoR (n=13, 15%), and MiR (n=4, 5%). 43 (49%) were exclusively BF, 36 (41%) were supplementing BF with some formula (2/3 by choice and 1/3 owing to insufficient milk production), and 8 (10%) were using only formula milk (7 by choice and 2 owing to ongoing feeding difficulties). Of the 17 mothers still experiencing symptoms, 5 were exclusively breast-feeding, and 8 were persisting with combined feeds. CONCLUSION: Infants attending our tongue-tie clinic achieved both higher exclusive breastfeeding and combined breast and bottle-feeding when compared to national breast-feeding data at 3months of age. This can facilitate the achievement of long-term breastfeeding, exposing infants and mothers to many of the associated benefits. LEVEL OF EVIDENCE: 4.

Short article: Buried bumper syndrome in children: incidence and risk factors.

OBJECTIVE: Buried bumper syndrome (BBS) is a serious complication in gastrostomy-dependent children. Many need surgical correction. On account of comorbidities, this becomes a high-risk procedure. Our aim was to review the incidence of BBS in children and to identify the risk factors. PATIENTS AND METHODS: Retrospective review of patients' records over 10 years, 2006-2015, was carried out. Types of tubes, operative interventions, comorbidities and records were noted. Two-tailed Fisher's exact test was used for statistical analysis. RESULTS: A total of 535 patients were reviewed. Overall, 475 had only percutaneous endoscopic gastrostomy (PEG) and 60 had a jejunal extension with percutaneous endoscopic gastrostomy (PEG-J). Twenty-nine patients (PEG-J - 16/26; PEG - 13/26) had a total of 31 BBS episodes. The overall incidence of BBS in our study was 5.4%. The age at presentation ranged from 1 to 18 years (median 8.6 years). All had significant comorbidities (neurodevelopmental 26/29, cardiorespiratory 14/29, genetic 16/29). Overall, 27/29 had two or more comorbidities. The mean time to development of BBS was 1025±634 days. BBS was found in the second or the subsequent tube in four patients with PEGs (P<0.0004) and in 10 PEG-Js (P<0.0001). Twenty-five patients needed laparotomy. There were no postoperative deaths. CONCLUSION: In BBS, the two significant risk factors identified were a having PEG-J and two or more previous gastrostomy insertions. Vigilance in documentation and prolonged follow-up to provide regular education to carers can reduce the incidence of this preventable complication.

Inflammatory duodenal necrosis complicating gastroschisis.

Babies with gastroschisis have an increased risk of necrotizing enterocolitis (NEC) that can lead to short bowel syndrome, a long-term parenteral nutrition requirement, and its associated complications. To our knowledge, this is the first case report of recurrent duodenal ischemia and necrosis associated with gastroschisis in the absence of NEC totalis.

Primary hepatic sarcomas in children--a single-center experience over 19 years.

BACKGROUND/PURPOSE: Primary hepatic sarcomas are rare and account for about 13% of primary hepatic neoplasms. There are few reported series of pediatric hepatic sarcomas, and the aim was to review our experience. METHODS: A retrospective analysis of cases managed from 1988 to 2007 by the pediatric liver unit in Birmingham, UK, was conducted. RESULTS: Nineteen children were identified. These presented with sudden abdominal pain (n = 6), obstructive jaundice (n = 3), incidental mass (n = 3), and chronic pain/distension (n = 3). Vascular involvement was identified in 3, and 6 had pulmonary metastases. Three patients had primary resection, and 3 only a biopsy. Thirteen had a biopsy followed by chemotherapy and resection. Surgery included extended hepatectomy (n = 11), hepatectomy (n = 3), and nonanatomical resections (n = 2). There was 1 major intraoperative complication. Median inpatient stay was 7 days. One biliary leak developed 4 weeks postoperatively. Five of the 16 patients who underwent resection of the primary tumor died. Eleven were alive at a median follow-up of 3 years. CONCLUSION: This is a challenging group of patients. Local control remains pivotal to successful treatment. Good results can be achieved in a specialist center with multidisciplinary approach.

Long-term results of central venous access devices in children with haemophilia.

AIMS: Central venous access devices (CVADs) are often used to provide reliable venous access for factor VIII administration in children with haemophilia. This study investigates their long-term outcome. METHODS: A retrospective cohort study of 44 CVADs inserted into 31 children with haemophilia at a single centre between 1991 and 2006. RESULTS: Eight (18%) CVADs are still in place and working well. Fourteen (31.8%) were removed when the child was able to return to peripheral vascular access. Twenty-two (50%) were removed because of complications, most of these children needing a replacement CVAD. The median duration that the first CVAD was in place was 51 months. There were no life-threatening complications. CONCLUSIONS: CVADs function well in children with haemophilia for a long time, with a relatively low complication rate, and can tide a child over a difficult period for vascular access.

Incorporation of Integra in tissue defects: a pilot study in the rat model.

Integra has been shown to be very useful in accelerating the growth of neodermis. It has found extensive use in case of burns as a primary dressing immediately after a burn, after release of contractures and following scar revision. It has been used to achieve cover after the debridement of extensive infective processes involving the skin. Encouraged by these results we have assessed the application of Integra to augment and/or patch defects of the urinary bladder, diaphragm and the abdominal wall in the rat model. This was a pilot study and involved the incorporation of Integra in the diaphragm, the urinary bladder (extramucosal) and the muscle layer of the abdominal wall. Eight adult Wistar rats were given general anaesthesia and Integra was implanted with absorbable sutures at the sites mentioned. The omentum was hitched to the collagen matrix surface to revascularise the graft. The silicone was left in situ. The operative period was covered with antibiotics. The anaesthesia was then reversed. Postoperatively the rats were given analgesia and feeds started immediately. The rats were sacrificed after 3 weeks. The abdominal cavity was examined for adhesions. The Integra implant along with adjacent tissue was harvested and examined histologically. There were no visible intra-abdominal adhesions. The histology revealed good degree of neovascularisation and fibrosis in and adjacent to the implant. This was comparable to the changes seen in the skin. This pilot study has shown that implanting Integra invokes a similar response in deeper tissues and it can develop neovascularisation from the omentum. Hence, this could find some application in treating congenital conditions such as diaphragmatic hernias, abdominal wall defects and for bladders requiring augmentation. Our initial results are quite encouraging and we feel that this field should be further explored.

Primary sternal osteomyelitis: a case series and review of the literature.

PURPOSE: Primary sternal osteomyelitis is rare in the pediatric population. METHODS: We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review. RESULT: A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy. CONCLUSION: Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.

Life-threatening respiratory distress in a neonate with a pericardial cyst.

Our case report details the clinical course and management of a neonate with acute life-threatening respiratory distress presenting soon after birth. She needed intubation and ventilation. A pericardial cyst was diagnosed after a CT scan and 2D echo investigation. As a temporizing procedure the fluid was tapped and the child was electively operated. Postoperatively she made an uneventful and complete recovery. We have reviewed the literature for this rare and often asymptomatic lesion.

Management of traumatic urethral disruption in children: Oman experience, 1988-2000.

BACKGROUND: Traumatic urethral disruptions in children differ anatomically from those of adults. In children, the posterior urethra is not protected by the prostate and may be injured at any level. The management of traumatic rupture of the urethra still a matter of debate, and there is no agreement as to which is the best of 3 options. METHODS: This was a retrospective analysis. Over a 12-year period the authors dealt with 21 urethral disruptions. The authors had detailed follow-up of 20 patients (14 posterior and 6 anterior). Trans-symphyseal urethroplasty (6 early primary repairs and 3 delayed repairs) for complete posterior urethral disruptions was performed. The early repairs were carried out within 7 days of the injury. Primary alignment was performed for 3 of the 4 partial ruptures of the posterior urethra and for all 6 anterior urethral disruptions. Postoperatively, the patients were evaluated for incontinence, penile erectile dysfunction, and stricture formation. RESULTS: In one of the early repairs a stricture developed that responded to dilatations. A second patient with bladder neck injury had incontinence after the repair. She underwent a urethral lengthening procedure and still has stress incontinence. Erections were observed in all 4 boys. One of the delayed repairs developed a stricture postoperatively. Of the 9 partial ruptures (6 anterior and 3 posterior) that underwent primary alignment, 4 had strictures. Some of these strictures required up to 5 dilatations or internal urethrotomy for cure. One patient with complete rupture underwent primary alignment, which broke down, and a long stricture developed. This patient is still awaiting a delayed repair. One posterior partial rupture, repaired primarily at another hospital, had a stricture and an urethrocutaneous fistula that responded to curettage and dilatations. CONCLUSIONS: Primary repairs required less hospitalization and a shorter duration of indwelling catheters. In light of this experience the authors recommend a primary repair in patients with complete posterior urethral disruptions.

Achalasia of the cardia: experience with hydrostatic balloon dilatation in children.

BACKGROUND: Achalasia is a disorder of oesophageal motility and is rare in children. The mainstay of therapy has been surgery with its attendant complications and long postoperative stay. Treatment by hydrostatic balloon dilatation, a less morbid procedure, has not found much favour. OBJECTIVE: To review the overall efficacy of balloon dilatation for the treatment of achalasia in children and to highlight the high incidence of non-syndromic familial cases in Oman. MATERIALS AND METHODS: This is a retrospective study of all patients ( n=12) with achalasia treated with balloon dilatation at the Royal Hospital, Muscat, from 1991 to 1999. The diagnosis was established with a barium oesophagogram. Dilatation was performed under general anaesthesia. On follow-up, the weight and recurrence of symptoms were recorded. Investigations were done only if the patients were symptomatic on follow-up. Recurrence was treated with further dilatation. RESULTS: Of the 12 patients, 10 had excellent alleviation of symptoms. Two patients developed recurrence of symptoms which responded favourably to further dilatation. The average length of postoperative stay in the hospital was 2 days. Of these 12 patients, there were 3 sets of siblings who did not have any other syndromic associations. This group also showed very good prognosis. The mean follow-up period was 3.5 years for all patients. CONCLUSIONS: The results of balloon dilatation were very satisfactory. We also recommend this procedure when there is recurrence of symptoms. It has lower morbidity than surgery and hospital stay is shorter. Furthermore, we have a high rate of non-syndromic familial cases, all with a favourable outcome.