Parents' experiences of sham feeding their child with esophageal atresia at home while awaiting reconstructive surgery. A qualitative interview study.

PURPOSE: This study aimed to explore parents' experience of sham feeding their baby born with esophageal atresia at home, waiting for reconstructive surgery. METHOD: Semi-structured interviews were conducted with parents of six children born with esophageal atresia waiting for delayed reconstruction. The interviews were analyzed using qualitative content analysis. RESULTS: Parents experienced that sham feed reinforced the healthy abilities in their baby. They had faith in their own ability as parents to care for their child as well as to see to their baby's strength to cope with difficulties. Parents expressed that the health care system can hinder as well as be a major support on their way to a more normal life at home while waiting for reconstructive surgery. CONCLUSION: The experience of sham feeding at home while waiting for reconstructive surgery is characterized by positive aspects both for children born with esophageal atresia and their parents.

Incidence and antiviral treatment of cytomegalovirus infection in infants with biliary atresia.

PURPOSE: Patients with biliary atresia (BA) and cytomegalovirus (CMV) infection may have poorer outcomes after Kasai portoenterostomy (KPE) than uninfected patients, suggesting a rationale for antiviral treatment (AVT). We aimed to describe the incidence of CMV infection and of AVT in BA patients, and to detect any differences between infected and uninfected patients to conclude if AVT is of use. METHODS: Data on BA patients who underwent KPE 2004-2020 were retrospectively collected, and the outcome was analyzed with regard to CMV status. RESULTS: Fifteen out of forty-six (33%) BA patients had signs of ongoing CMV infection. They did not differ significantly from the CMV-negative patients regarding rate of prematurity, birth weight, or biochemical markers but were slightly older at KPE. All patients received steroids postoperatively and all patients with ongoing CMV infection received AVT with very good effect on viremia and without major side effects. The AVT consisted of oral valganciclovir (10-40 (- 58) mg/kg/d) or intravenous ganciclovir (5.3-11 mg/kg/d). CONCLUSION: Ongoing CMV infection is common in this group of patients. The viremia can effectively be treated with AVT without any major side effects. Larger, randomized studies are needed to clarify the possible effect on clinical outcome.

International Core Outcome Set for Acute Simple Appendicitis in Children: Results of a Systematic Review, Delphi Study, and Focus Croups With Young People.

OBJECTIVE: To develop an international core outcome set (COS), a minimal collection of outcomes that should be measured and reported in all future clinical trials evaluating treatments of acute simple appendicitis in children. SUMMARY OF BACKGROUND DATA: A previous systematic review identified 115 outcomes in 60 trials and systematic reviews evaluating treatments for children with appendicitis, suggesting the need for a COS. METHODS: The development process consisted of 4 phases: (1) an updated systematic review identifying all previously reported outcomes, (2) a 2-stage international Delphi study in which parents with their children and surgeons rated these outcomes for inclusion in the COS, (3) focus groups with young people to identify missing outcomes, and (4) international expert meetings to ratify the final COS. RESULTS: The systematic review identified 129 outcomes which were mapped to 43 unique outcome terms for the Delphi survey. The first-round included 137 parents (8 countries) and 245 surgeons (10 countries), the second-round response rates were 61% and 85% respectively, with 10 outcomes emerging with consensus. After 2 young peoples' focus groups, 2 additional outcomes were added to the final COS (12): mortality, bowel obstruction, intraabdominal abscess, recurrent appendicitis, complicated appendicitis, return to baseline health, readmission, reoperation, unplanned appendectomy, adverse events related to treatment, major and minor complications. CONCLUSION: An evidence-informed COS based on international consensus, including patients and parents has been developed. This COS is recommended for all future studies evaluating treatment ofsimple appendicitis in children, to reduce heterogeneity between studies and facilitate data synthesis and evidence-based decision-making.

Thoracoscopy or Thoracotomy for Esophageal Atresia: A Systematic Review and Meta-analysis.

OBJECTIVE: This systematic review with meta-analysis compares health- and provider-based outcomes of thoracoscopic to thoracotomy repair of esophageal atresia. SUMMARY OF BACKGROUND DATA: Thoracoscopic surgery has become a routine operation for esophageal atresia repair. However, large studies comparing the safety and efficacy of thoracoscopy to thoracotomy are scarce. Current reviews are obscured with institutional experiences or pool small samples. METHODS: PRISMA-compliant search in Medline/PubMed, EMBASE, Web of Science, and Cochrane Library (PROSPERO #CRD42019121862) for original studies comparing thoracoscopy to thoracotomy for esophageal atresia. Quality assessments were performed using the Joanna Briggs Institute Critical Appraisal Tool. Meta-analyses were presented as odds ratios and standardized mean differences. RESULTS: This is the largest published meta-analysis, including 17 studies and 1043 patients. Thoracoscopy produce shorter hospital stay [standardized mean differences (SMD) -11.91; 95% confidence interval (CI) 23.49-6.10; P = 0.0440], time until extubation (SMD -3.22; 95% CI 5.93-0.51; P = 0.0198), time until first oral feeding (SMD -2.84; 95% CI 4.62-1.07; P = 0.0017), and fewer musculoskeletal complications [odds ratio (OR) 0.08; 95% CI 0.01-0.58; P = 0.0133). Thoracoscopy is as safe as thoracotomy regarding leakage (OR -1.92; 95% CI 0.97-3.80; P = 0.0622), stricture formation (OR 2.66; 95% CI 0.86-3.23; P = 0.1339), stricture dilatation (OR 1.90; 95% CI 0.16-3.88; P = 0.0767), and mortality (OR 1.18; 95% CI 0.34-4.16; P = 0.7934). However, thoracoscopy take longer (SMD +27.69; 95% CI 12.06-43.32; P = 0.0005) and necessitate more antireflux surgery (OR 2.12; 95% CI 1.06-4.24; P = 0.0343). CONCLUSION: Thoracoscopy is effective and safe, with similar or better outcomes than thoracotomy for patients and providers. The only significant drawback is the need for antireflux surgery in the first years of life. Comparative randomized long-term studies are needed.

Long-term Follow-up for Missed Cases of Eosinophilic Esophagitis in Children With Previous Foreign Body in the Esophagus.

OBJECTIVES: A foreign body impacted in the esophagus could be a sign of eosinophilic esophagitis (EoE). Our aim was to investigate if children previously diagnosed with a foreign body in the esophagus had a missed diagnosis of EoE. METHODS: In this population-based longitudinal study, all children (0-18 years) diagnosed with a foreign body in the esophagus in Stockholm, Sweden 2006 to 2016, were identified. In addition to a review of medical files, each family was contacted (n = 325) and asked standardized questions. Children with symptoms indicating EoE were offered esophagogastroduodenoscopy (EGD). RESULTS: We found 325 pediatric cases of foreign body. Two hundred and seven (64%) underwent an endoscopy at the event, 3 of these had biopsies taken, whereby 2 were diagnosed with EoE. Six additional patients were diagnosed with EoE between the initial event and the study follow-up. Children with persisting symptoms suggestive of EoE at the follow-up (n = 21), were offered EGD whereof 7 accepted. Four new cases of EoE were found. Hence, 12 (3.7%) of the children with a previous foreign body, either spontaneously released or endoscopically removed, were diagnosed with EoE. In the structured interview, dysphagia, food impactions and drinking excessively with meals, as well as food allergies, were significantly more common in EoE patients. CONCLUSIONS: Children with a foreign body in the esophagus are at risk of having EoE. Biopsies should be taken during foreign body removal and questions about swallowing problems and allergic diseases should be carefully explored also in children who do not need EGD because of spontaneous release.

Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial.

OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of nonoperative treatment of acute nonperforated appendicitis in children during 5 years of follow-up. METHODS: A 4-year follow-up of a previous randomized controlled pilot trial, including 50 children with acute nonperforated appendicitis, was performed. The patients were initially randomized to nonoperative treatment with antibiotics or appendectomy with 1-year follow-up previously reported. Data were extracted from the computerized notes and telephone interviews.The primary outcome was treatment failure, defined as need for a secondary intervention under general anesthesia, related to the previous diagnosis of acute nonperforated appendicitis. RESULTS: The children were followed up for at least 5 years [median 5.3 (range 5.0-5.6)] after inclusion. There were no failures in the appendectomy group (0/26) and 11 failures in the nonoperative group (11/24). Nine failures had occurred during the first year after inclusion, 2 of whom had histologically confirmed appendicitis. There were 2 further patients with recurrent acute appendicitis 1 to 5 years after inclusion. Both these patients had uncomplicated laparoscopic appendectomies for histologically confirmed acute appendicitis. There were no losses to follow-up. CONCLUSIONS: At 5 years of follow-up 46% of children treated with antibiotics for acute nonperforated appendicitis had undergone an appendectomy, although acute appendicitis was only histologically confirmed in 4/24 (17%). Treatment with antibiotics seems to be safe in the intermediate-term; none of the children previously treated nonoperatively re-presented with complicated appendicitis.

Nonoperative treatment for nonperforated appendicitis in children: a systematic review and meta-analysis.

Acute appendicitis is the most common surgical emergency in children. Nonoperative treatment of nonperforated acute appendicitis in children is an alternative to appendectomy. The purpose of this systematic review and meta-analysis was to determine the outcomes of nonoperative treatment of nonperforated acute appendicitis in children in the literature. Databases were searched to identify abstracts, using predefined search terms. The abstracts were reviewed by two independent reviewers and articles were selected according to inclusion and exclusion criteria. Data were extracted by the two reviewers and analyzed. The literature search yielded 2743 abstracts. Twenty-one articles were selected for analysis. The study design was heterogenous, with only one randomized controlled study. The symptoms resolved in 92% [95% CI (88; 96)] of the nonoperatively treated patients. Meta-analysis showed that an additional 16% (95% CI 10; 22) of patients underwent appendectomy after discharge from initial hospital stay. Complications and length of hospital stay was not different among patients treated with antibiotics compared with those who underwent appendectomy. Nonoperative treatment of nonperforated acute appendicitis children is safe and efficient. There is a lack of large randomized controlled trials to compare outcomes of nonoperative treatment with appendectomy.

Management strategies and treatment results of pediatric choledochal malformations in the Nordic countries.

BACKGROUND: Incidence and long-term outcomes of choledochal malformations (CMs) in children remain unclear. METHODS: Clinical characteristics, operative details, complications, and follow-up data were collected from eight pediatric surgical centers in Sweden, Norway, Denmark, and Finland, which also answered a questionnaire addressing management practices. RESULTS: During 2000-2017, 126 pediatric CMs were diagnosed, corresponding an incidence of 1:37,400. Diagnostic, treatment, and follow-up practices varied markedly. Of patients with complete clinical data (n = 119), 85% and 11% had type I and IV CMs and were managed by open hepaticojejunostomy at median age of 2.5 (interquartile range 0.46-5.8) years. Associated malformations were more common in fusiform and type IV (23%) than cystic CMs (8%, p = 0.043). Pancreaticobiliary maljunction was more frequently confirmed in patients presenting with pancreatitis (26% vs. 7%, p = 0.005) and with fusiform CMs (56% vs. 25%, p = 0.001). Cholangitis/pancreatitis episodes, occurring in 12% during postoperative follow-up of 4.0 (2.0-7.9) years, associated with longer surveillance (OR 1.32, 95% CI 1.13-1.54, p < 0.001). However, only two thirds of centers continued follow-up until adulthood. No malignancies were reported. CONCLUSIONS: CM incidence was higher than traditionally reported among Western populations. Although open hepaticojejunostomy carries good short-term outcomes, long-term morbidity is noteworthy. Standardized evidence-based management strategies and long-term follow-up are encouraged.

Clinical presentation of intussusception in Swedish children under 3 years of age and the validity of diagnostic coding.

PURPOSE: Intussusception has been associated with rotavirus vaccine. The rotavirus vaccine will soon be introduced in the Swedish national immunization program. A validation of the diagnosis of intussusception among Swedish children in the Swedish National Patient Register is needed, as a basis for future vaccine safety surveillance by Swedish registers. METHODS: This diagnostic study reviewed the medical admission records of 392 Swedish children with intussusception from 1987 to 2013. The records were randomly selected by The National Board of Health and Welfare from all Sweden and from both pediatric and pediatric surgery care. Positive predictive values (PPV) were calculated to study the concordance between the diagnosis coded in the Swedish Patient Register and the accepted international criteria of case definitions. RESULTS: The PPV for a definitive diagnosis, based on certain radiology findings or surgery, was 84%. When clinically probable cases were added the PPV was 87%. When cases of possible intussusception were added the PPV was 89%. The PPV for the 240 children under 1 year was 88%. CONCLUSION: Swedish health care registers can be used in the evaluation of incidences of intussusception when rotavirus vaccine will be introduced, due to a high validity of the diagnosis of intussusception in the registers.

Intraoperative cultures during appendectomy in children are poor predictors of pathogens and resistance patterns in cultures from postoperative abscesses.

BACKGROUND: Intraoperative cultures are commonly sent in complicated appendicitis. Culture-guided antibiotics used to prevent postoperative infectious complications are debated. In this study, we describe the microbial overlap between intraoperative and abscess cultures, and antibiotic resistance patterns. METHOD: A local register of a children's hospital treating children 0-15 years old with appendicitis between 2006 and 2013 was used to find cases with intraoperative cultures, and cultures from drained or aspirated postoperative intraabdominal abscesses. Culture results, administered antibiotics, their nominal coverage of the identified microorganisms, and rationales given for changes in antibiotic regimens were collected from electronic medical records. RESULTS: In 25 of 35 patients who met inclusion criteria, there was no overlap between the intraoperative and abscess cultures. In 33 of 35 patients, all identified intraoperative organisms were covered with postoperative antibiotics. In 14 patients, organisms in the abscess culture were not covered by administered antibiotics. Enterococci not found in the intraoperative culture were found in 12 of 35 abscesses. We found no difference in the antibiotic coverage between rationales given for antibiotic changes. CONCLUSION: The overlap between intraoperative cultures and cultures from subsequent abscesses was small. Lack of antibiotic coverage of intraoperative cultures was not an important factor in abscess formation.

In-hospital Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children: A Single-center Retrospective Cohort Study.

OBJECTIVE: To investigate the correlation between in-hospital surgical delay before appendectomy for suspected appendicitis and the finding of perforated appendicitis in children. METHODS: All children undergoing acute appendectomy for suspected acute appendicitis at Karolinska University Hospital, Stockholm, Sweden from 2006 to 2013 were reviewed for the exposure of surgical delay. Primary endpoint was the histopathologic finding of perforated appendicitis. The main explanatory variable was in-hospital surgical delay, using surgery within 12 hours as reference. Secondary endpoints were postoperative wound infection, intra-abdominal abscess, reoperation, length of hospital stay, and readmission. To adjust for selection bias, a logistic regression model was created to estimate odds ratios for the main outcome measures. Missing data were replaced using multiple imputation. RESULTS: The study comprised 2756 children operated for acute appendicitis. Six hundred sixty-one (24.0%) had a histopathologic diagnosis of perforated appendicitis. In the multivariate logistic regression analysis, increased time to surgery was not associated with increased risk of histopathologic perforation. There was no association between the timing of surgery and postoperative wound infection, intra-abdominal abscess, reoperation, or readmission. CONCLUSIONS: In-hospital delay of acute appendectomy in children was not associated with an increased rate of histopathologic perforation. Timing of surgery was not an independent risk factor for postoperative complications. The results were not dependent on the magnitude of the surgical delay. The findings are analogous with previous findings in adults and may aid the utilization of available hospital- and operative resources.

Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial.

OBJECTIVE: The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children. METHODS: A pilot randomized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children. Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were randomized either to treatment with antibiotics or to surgery. Follow-up was for 1 year. RESULTS: Fifty patients were enrolled; 26 were randomized to surgery and 24 to nonoperative treatment with antibiotics. All children in the surgery group had histopathologically confirmed acute appendicitis, and there were no significant complications in this group. Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis. Another 6 patients have had an appendectomy due to recurrent abdominal pain (n = 5) or parental wish (n = 1) during the follow-up period; none of these 6 patients had evidence of appendicitis on histopathological examination. CONCLUSIONS: Twenty-two of 24 patients (92%) treated with antibiotics had initial resolution of symptoms. Of these 22, only 1 patient (5%) had recurrence of acute appendicitis during follow-up. Overall, 62% of patients have not had an appendectomy during the follow-up period. This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted.

Recurrence of acute appendicitis after non-operative treatment of appendiceal abscess in children: a single-centre experience.

BACKGROUND/PURPOSE: The aim of this study was to evaluate the incidence of recurrence of acute appendicitis after initial successful non-operative treatment of appendiceal abscess in children. METHODS: This study was an observational cohort study of children treated non-operatively for appendiceal abscess at a large tertiary referral centre from 2006 to 2010. The primary outcome was recurrence of acute appendicitis. Secondary outcome variables were re-admission and interval appendectomy. RESULTS: Eighty-nine patients were discharged after successful non-operative treatment of appendiceal abscess. The median age was 10.1 (1.3-16.3) years. Nine patients underwent surgery during the follow-up period. Five patients were re-admitted with ongoing symptoms leading to an appendectomy. They all returned shortly after discharge and are considered failures of initial treatment. Two of 82 patients returned with a new episode of acute appendicitis during the trial period. Hence, the recurrence rate was 2.4 % during 5.1 years of follow-up. CONCLUSION: Our data support the strategy of not performing an interval appendectomy after successful non-operative treatment with antibiotics of an appendiceal abscess in children.

Considerable differences in management of cytomegalovirus infection in patients with biliary atresia.

Objectives: Patients with biliary atresia (BA) and ongoing cytomegalovirus (CMV) infection may have poorer outcomes after Kasai portoenterostomy than uninfected patients. Still, there is no consensus on the usefulness of viral testing and antiviral treatment (AVT). This study aims to explore the need for future research on AVT for CMV infection by assessing how CMV infection in BA patients is managed in different centers. Methods: An online questionnaire with 10 questions was offered to participants at an international congress on BA, organized in collaboration with the European Reference Network for rare liver diseases in 2022. Answers to questions were either dichotomic or multiple choices of different numeric intervals. Ongoing CMV infection was defined by detecting cytomegalovirus-immunoglobulin M (CMV-IgM) in serum or cytomegalovirus-deoxyribonucleic acid (CMV-DNA) by polymerase chain reaction in blood or urine. Results: There were 43 respondents from 36 centers in 26 countries. The total number of BA patients per year was between 208 and 380 from centers with 0-5 to >20 BA patients yearly (median 6-10). CMV infection was tested in 27 centers (75%), of which 18 (67%) use AVT. The rate of CMV infection varied between 0%-5% and 40%-50% (median 5%-10%). Willingness to treat the infection did not differ between centers with low and high rates of CMV infection. Conclusions: Most centers test for CMV infection, and a considerable proportion use AVT despite the lack of evidence of its benefits. A future randomized study on treating CMV infection in BA patients is necessary and feasible.

Prevalence of Mental Health Problems, Associated Factors, and Health-Related Quality of Life in Children with Long-Gap Esophageal Atresia in Sweden.

BACKGROUND: Children with long-gap esophageal atresia (LGEA) face a high risk of digestive and respiratory morbidity, but their mental health outcomes have not been investigated. We aimed to identify the prevalence of mental health problems in children with LGEA, associated factors and health-related quality of life (HRQOL). METHODS: Twenty-six children with LGEA aged 3-17 were recruited nationwide in Sweden. One of their parents and adolescents aged 11-17 completed information on the child's mental health (Strength and Difficulties Questionnaire), generic (PedsQL 4.0) and condition-specific HRQOL (EA-QOL). Parents gave information on current child symptomatology. Mental health level was determined using validated norms; abnormal≥90 percentile/borderline≥80 percentile/normal. Elevated levels were considered borderline/abnormal. Data were analyzed using descriptives, correlation and Mann-Whitney-U test. Significance level was p < 0.05. RESULTS: Twelve children with LGEA aged 3-17 (46%) had elevated scores of ≥1 mental health domain in parent-reports, whereas 2 adolescents (15%) in self-reports. In parent-reports, 31% of the children had elevated levels of peer relationship problems, with associated factors being child sex male (p = 0.037), airway infections (p = 0.002) and disturbed night sleep (p = 0.025). Similarly, 31% showed elevated levels of hyperactivity/inattention, and associated factors were male sex (p = 0.005), asthma (p = 0.028) and disturbed night sleep (p = 0.036). Elevated levels of emotional symptoms, seen in 20%, were related to swallowing difficulties (p = 0.038) and vomiting problems (p = 0.045). Mental health problems correlated negatively with many HRQOL domains (p < 0.05). CONCLUSIONS: Children with LGEA risk mental health difficulties according to parent-reports, especially peer relationship problems and hyperactivity/inattention, with main risk factors being male sex, airway problems and sleep disturbances. This should be considered in follow-up care and research, particularly since their mental health problems may impair HRQOL. LEVELS OF EVIDENCE: Prognosis study, LEVEL II.

Decision making in the management of hydroceles in infants and children.

UNLABELLED: The aim of this article was to establish a ground for evidence-based decision making in dealing with hydroceles, according to the age of the child and the presenting signs and symptoms. This prospective cohort study was conducted at Al-Kademyia Teaching Hospital in Baghdad, Iraq, during the period from December 2001 to December 2005. There were two groups of patients: group 1 involved 121 patients that presented with hydroceles at less than 1 year of age that were followed up to their first birthday to monitor the fate of hydroceles. Group 2 involved 140 patients, 1-12 years of age, who presented with hydroceles and had surgery. Their age, the affected side, diurnal changes in size, and the findings at surgery were recorded. In group 1, 89% of patients with hydroceles had spontaneous resolution or showed marked improvement during the first year of life and only 11% required an operation. The indications for surgery were the presence of an associated inguinal hernia (7%) and development of a huge hydrocele (3%). In group 2, 83% of patients with hydroceles presented within the first 5 years of age. Diurnal changes in the size of hydroceles were encountered in 92% of cases. CONCLUSION: 89% of patients with infantile hydrocele will have a spontaneous resolution owing to the ongoing changes in the patent processus vaginalis. Surgical intervention in the first year of life is only required for those who have an associated inguinal hernia and for those with hydroceles that become huge in size.