Newborn circumcision outcomes: are parents satisfied with the results?

BACKGROUND/PURPOSE: Although physician-reported complications following circumcision are very low, parental satisfaction is not well documented. This study examined parental opinions and compared these with those of the medical professional. METHODS: Physicians independently assessed complications and cosmetic outcome following the circumcision. Six weeks post-circumcision, parental report of complications, cosmetic outcome, and overall satisfaction were assessed. RESULTS: Newborn infants (n = 710) were prospectively recruited and underwent either a Gomco [n = 552 (78 %)] or Plastibell(®) [n = 158 (22 %)] circumcision. Physician assessed complication rates were equivalent (Gomco 4.3 % versus Plastibell 5.1 %; p = 0.67), however, parental assessment found a much lower complication rate for Gomco 5.6 % versus Plastibell 12.0 % (p < 0.001). There was no difference between who performed the procedure nor between the techniques in regards to parental rating of overall satisfaction (excellent/good: Gomco 96.9 % versus Plastibell 95.6 %, p = 0.45). However, perceived post-operative pain as scored by parents was significantly higher in patients undergoing Plastibell procedure (6.4 % too much pain) versus Gomco (2.7 %; p = 0.05). Gomco accounted for 72.7 % of parental cosmetically unsatisfactory cases. CONCLUSIONS: Clinicians and parents differed considerably in terms of opinion of cosmetic outcome and occurrence of post-operative complications. This study emphasizes the need for clinicians to better understand and address parental concerns before and after circumcision.

Fetal lung lesions: can we start to breathe easier?

OBJECTIVE: The purpose of this study was to develop a simple and accurate approach for risk stratification of fetal lung lesions that are associated with respiratory compromise at birth. STUDY DESIGN: We conducted a retrospective review of 64 prenatal lung lesions that were managed at a single fetal care referral center (2001-2011). Sonographic data were analyzed and correlated with perinatal outcomes. RESULTS: Hydrops occurred in only 4 cases (6.3%). Among fetuses without hydrops, the congenital pulmonary airway malformation volume ratio (CVR) was the only variable that was associated significantly with respiratory compromise and the need for lung resection at birth (P < .01). Based on a maximum CVR >1.0, the sensitivity, specificity, positive predictive value, and negative predictive value for respiratory morbidity were 90%, 93%, 75%, and 98%, respectively. CONCLUSION: Nonhydropic fetuses with a maximum CVR >1.0 are a subgroup of patients who are at increased risk for respiratory morbidity and the need for surgical intervention. These patients should be delivered at a tertiary care center with pediatric surgery expertise to ensure optimal clinical outcomes.

Alcohol interventions for trauma patients are not just for adults: justification for brief interventions for the injured adolescent at a pediatric trauma center.

BACKGROUND: Research on the rates of alcohol and drug misuse as well as developmentally appropriate screening and intervention approaches in a hospitalized pediatric trauma population are lacking. The purpose of this study was to identify the rate of alcohol misuse in an admitted trauma population of adolescents aged 11 years to 17 years and to identify key correlates of alcohol misuse in this population including age, gender, and injury severity. METHODS: A prospective clinical study of 230 injured youth (aged 11-17 years) comprising both hospitalized and emergency department (ED) population was performed, and the patients were screened for the Alcohol Use Disorders Identification Test (AUDIT), blood alcohol levels (BALs), and drinking and driving index. The main outcome measures were rates of alcohol misuse characterized by a positive BAL or a positive AUDIT. RESULTS: Thirty percent hospitalized trauma patients screened positive for alcohol misuse. Five patients had a positive BAL without a positive AUDIT score. Binge drinking was the most commonly positive domain of the AUDIT tool. In hospitalized trauma patients who are older than 14 years (p = 0.005), it was significantly associated with a positive AUDIT score, but the injury severity score, gender, mechanism of injury, or positive BAL were not significant predictors. In the ED sample, 15.8% of patients had a positive AUDIT score. One-way analysis of variance among the ED group showed that age >or=14 was the single predictor of a positive AUDIT score. Twenty-three percent of hospitalized patients had been in a car, where the driver had been drinking. The average AUDIT scores in this group was 5.3 versus 1.0 (p < 0.001), compared with those who had not ridden in a car with a driver who had been drinking. CONCLUSIONS: Injured youth admitted to a pediatric trauma center are a high-risk population. Alcohol misuse is a significant cofactor for trauma for these patients, and effective developmentally appropriate interventions are justified and needed.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma.

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Risk stratification in gastroschisis: can prenatal evaluation or early postnatal factors predict outcome?

PURPOSE: The prenatal or postnatal factors that predict complex gastroschisis in patients (atresia, volvulus, necrotic bowel and bowel perforation) remain controversial. We evaluated the prognostic value of prenatal ultrasonographic parameters and early postnatal factors in predicting clinical outcomes. METHODS: We analyzed maternal and neonatal records of 46 gastroschisis patients treated from 1998 to 2007. Information regarding demographics, prenatal ultrasound data when available, intrapartum and postnatal course was abstracted from medical records. Outcome variables included survival, ventilator days, TPN days, time to full enteral feeds, complications and length of stay. Univariate or multivariate analysis was used, with P < 0.05 considered as significant. RESULT: A total of 75% of complex patients were categorized within 1 week of life. Interestingly, prenatal bowel dilation (>17 mm) and thickness (>3 mm) did not correlate with outcome or risk stratification into simple versus complex (P < 0.05). Complex patients had increased morbidity compared to simple patients (sepsis 58 versus 18%; P = 0.021, NEC 42 versus 9%; P = 0.020, short bowel syndrome 58 versus 3%; P = 0.0001, ventilator days 24 versus 10; P = 0.021; TPN days 178 versus 38; P = 0.0001 and days to full feeds 171 versus 31; P = 0.0001; and length of stay 90 versus 39 days, P = 0.0001). CONCLUSIONS: Prenatal bowel wall dilation and/or thickness did not predict complex patients or adverse outcome. Complex gastroschisis patients can be identified postnatally and have substantial morbidity.

Pushing the boundaries of ECLS: Outcomes in <34 week EGA neonates.

PURPOSE: Extracorporeal life support (ECLS) is usually reserved for infants ≥34weeks estimated gestational age (EGA) owing to concerns about increased mortality and incidence of intracranial hemorrhage (ICH). We sought to characterize survival, rates of ICH, and complications in <34week EGA neonates placed on ECLS. METHODS: 752 neonates of EGA 29-34weeks were identified in the Extracorporeal Life Support Organization (ELSO) Registry (1976-2008). Data analyzed included birthweight, survival, pre-ECLS conditions, ventilatory parameters and complications (including ICH and other neurological outcomes). Data were compared using t-test, Chi-square and logistic regression analyses. RESULTS: When compared to survival rates of 34week EGA neonates (58%), survival was statistically different for 29-33week EGA (48%, p=0.05). No significant difference in ICH incidence was seen between the 29-33week and 34week groups (21% vs. 17%, respectively), but a significant difference was seen in the incidence of cerebral infarct between groups (22% for 29-33weeks vs. 16% for 34weeks; p=0.03). ICH and survival did not correlate with EGA during logistic regression analysis. CONCLUSIONS: Though rates of survival and cerebral infarction were worse at 29-33weeks EGA compared with 34weeks, these differences were modest and may be clinically acceptable. This suggests that EGA<34weeks may not be an absolute contraindication to use of ECLS. LEVEL OF EVIDENCE: III.

Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy.

BACKGROUND: Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP). METHODS: Multicenter study of all pyloromyotomies (May 2007-December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers. RESULTS: Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006-4.083]; P=0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI -0.096 to 3.365]; P=0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P=0.2) and grade of primary operator did not affect the rate of either complication. CONCLUSIONS: This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.

Probiotic prophylaxis after pullthrough for Hirschsprung disease to reduce incidence of enterocolitis: a prospective, randomized, double-blind, placebo-controlled, multicenter trial.

OBJECTIVE: Hirschsprung-associated enterocolitis (HAEC) is one of the most troublesome problems encountered after a pullthrough. We hypothesized that prophylactic administration of probiotics after a pullthrough procedure would decrease the incidence of HAEC. STUDY DESIGN: A prospective, double-blind, placebo-controlled, randomized trial was conducted at 2 children's hospitals. Infants undergoing pullthrough were randomized to probiotic or placebo for a period of 3 months post-pullthrough. Primary outcome was incidence of post-operative HAEC. Other outcomes included severity of HAEC by clinical grade, number of HAEC episodes and extent of aganglionosis. Pearson Chi Square analysis, as well as logistic regression, was used for statistical analysis. RESULTS: Sixty-two patients were recruited (Sites: A=40; B=22). One was lost to follow up and one immediate post-op death was not included in final analysis. Probiotics were administered to 32 patients. Distribution of placebo/probiotics was equal between sites (P=0.858). Mean age at pullthrough was 6.5 ± 8.1(± SD) months. The incidence of HAEC was 28.3%. The incidence of HAEC was not statistically different between probiotic and placebo study groups. CONCLUSIONS: Incidence of HAEC was not reduced with prophylactic probiotics. Future studies are needed to better determine the etiology and possible ways of preventing this complex condition.

Neonatal circumcision: is feeding behavior altered?

BACKGROUND: The effect of circumcision on feeding behavior in the newborn period is unknown. We hypothesized that circumcision would not have a significant effect on newborn feeding. METHODS: This prospective study analyzed the effect of circumcision on neonatal feeding behavior. Inclusion criteria were healthy male infants WHO were exclusively bottle-fed and underwent a circumcision before discharge from the newborn nursery. We collected data (N = 42) on gestational age, birth weight, Apgar scores, maternal age, gravid status, anesthesia used during delivery, analgesia used after circumcision, time of circumcision, and volume and frequency of feeding before and after circumcision. Data were analyzed by using paired t tests, multivariable regression analysis, and analysis of variance (with SPSS version 18). Significance was P < .05 (2-tailed α). RESULTS: Descriptive statistics for the entire group (N = 42) are as follows: mean ± SD gestational age: 38.7 ± 1.2 weeks; mean birth weight: 3.3 ± 0.4 kg; maternal age: 26.7 ± 6.3 years; baseline feeding (mean of first 2 feedings before circumcision): 24.5 ± 9.9 mL; mean first feeding after circumcision: 21.7 ± 11.9 mL; and mean second feeding: 26.7 ± 13.5 mL. Forty-eight percent of patients increased their feeding volume after circumcision compared with baseline, and 52% of patients decreased their feeding volume, which persisted with the second feeding. There was no statistical difference between the baseline and first feeding (P = .11) or second feeding (P = .22). CONCLUSIONS: Our data suggest that circumcision does not alter feeding after circumcision. This information will be useful in counseling families regarding circumcision in the newborn period.

Contemporary outcomes in infants with congenital heart disease and bochdalek diaphragmatic hernia.

BACKGROUND: Fifteen percent of infants with congenital diaphragmatic hernia (CDH) are born with a coexisting cardiac anomaly. The purpose of this study was to evaluate contemporary outcomes in this patient population and to identify potential risk factors for in-hospital mortality. METHODS: Data from all CDH neonates with congenital heart disease managed at a single pediatric tertiary care referral center between 1997 and 2011 were retrospectively analyzed. RESULTS: Forty (18%) of 216 CDH patients had a cardiac anomaly. This group was associated with a significant decrease in overall survival when compared with patients without cardiac anomaly (55% versus 81%; p = 0.001). There was no association between type of cardiac anomaly and mortality based on risk stratification according to the Risk Adjustment for Congenital Heart Surgery and The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery scoring systems (p = 0.86 and p = 0.87, respectively). Birth weight was similarly no different between survivors and nonsurvivors (2.8 ± 0.6 kg versus 2.8 ± 0.9 kg, respectively; p = 0.98). There was a trend toward increased extracorporeal membrane oxygenation use among nonsurvivors (p = 0.13). Infants with hemodynamic stability enabling subsequent cardiac repair were associated with lower mortality (p = 0.04). Survivors had a wide spectrum of long-term morbidity, but most had some evidence of neurodevelopmental impairment. CONCLUSIONS: This large single-institution series suggests that the overall prognosis of infants with concomitant CDH and congenital heart disease can be quite variable, regardless of the type of heart anomaly. Hemodynamic instability and need for extracorporeal membrane oxygenation correlate with higher mortality. Although some long-term survivors have excellent outcomes, most suffer from chronic, long-term morbidities.

Another dimension to survival: predicting outcomes with fetal MRI versus prenatal ultrasound in patients with congenital diaphragmatic hernia.

PURPOSE: A major determinant of survival in patients with congenital diaphragmatic hernia (CDH) is severity of pulmonary hypoplasia. This study addresses the comparative effectiveness of prenatal methods of lung assessment in predicting mortality, extracorporeal membrane oxygenation (ECMO), and ventilator dependency. METHODS: We retrospectively reviewed all patients born with isolated CDH between 2004 and 2008. Lung-to-head ratio (LHR) and observed-to-expected LHR (OELHR) were obtained from prenatal ultrasounds. Percent-predicted lung volume (PPLV) was obtained from fetal MRI (fMRI). Postnatal data included in-hospital mortality, need for ECMO, and ventilator dependency at day-of-life 30. RESULTS: Thirty-seven patients underwent 81 prenatal ultrasounds, while 26 of this sub-cohort underwent fMRI. Gestational age during imaging study was associated with LHR (p=0.02), but not OELHR (p=0.12) or PPLV (p=0.72). PPLV, min-LHR, and min-OELHR were each associated with mortality (p=0.03, p=0.02, p=0.01), ECMO (p<0.01, p<0.01, p=0.03), and ventilator dependency (p<0.01, p<0.01, p=0.02). For each outcome, PPLV was a more discriminative measure, based on Akaike's information criterion. Using longitudinal analysis techniques for patients with multiple ultrasounds, OELHR remained associated with mortality (p=0.04), ECMO (p=0.03), and ventilator dependency (p=0.02), while LHR was associated with ECMO (p=0.01) and ventilator dependency (p=0.02) but not mortality (p=0.06). CONCLUSION: When assessing fetuses with CDH, OELHR and PPLV may be most helpful for counseling regarding postnatal outcomes.

Restorative proctocolectomy without diverting ileostomy in children with ulcerative colitis.

PURPOSE: The safety of performing a restorative proctocolectomy (RP) and J-pouch ileoanal anastomosis (IPAA) without diverting ileostomy for children with ulcerative colitis (UC) is a subject of extensive debate. Our goal was to examine pediatric outcomes of RP and IPAA without ileostomy. METHODS: We performed a single-institution review of UC patients who had RP and IPAA with (+Ostomy) or without (-Ostomy) diverting ileostomy from 2002 to 2010. Surgeon and patient preference determined ileostomy decision. The study included 50 patients (28 +Ostomy, 22 -Ostomy). RESULTS: Preoperative demographics were similar between 2 groups in age (13.5 ± 3.5 years -Ostomy, 14.3 ± 3 years +Ostomy), serum albumin (3.6 ± 0.7 -Ostomy, 3.6 ± 0.7 +Ostomy), body mass index (20.8 ± 6.9 -Ostomy, 21.3 ± 8.6 +Ostomy), and daily corticosteroid dose (22.4 ± 17.7 mg -Ostomy, 23.5 ± 13.7 mg +Ostomy). Operating time was less in -Ostomy with mean times of 6:22 ± 2:04 vs 9:07 ± 2:57. The -Ostomy group required fewer ileoanal anastomotic dilations per patient (0.4 ± 0.8 vs 1.4 ± 1.9). Functional outcomes were not significantly different regarding pouchitis episodes per patient (0.6 ± 1.1 -Ostomy, 0.6 ± 1.1 +Ostomy), daily bowel movements (5.5 ± 1.9 -Ostomy, 6.7 ± 4.0 +Ostomy), and daily postoperative loperamide dose (8.4 ± 4.3 mg -Ostomy, 6.8 ± 4.0 mg +Ostomy). CONCLUSION: Short- and long-term outcomes can be equivalent in patients with and without diverting ileostomy, but questions remain regarding patient selection and quality of life impact.

Characterization of central venous catheter-associated deep venous thrombosis in infants.

PURPOSE: Deep venous thrombosis (DVT) is a frequent complication in infants with central venous catheters (CVCs). We performed this study to identify risk factors and risk-reduction strategies of CVC-associated DVT in infants. METHODS: Infants younger than 1 year who had a CVC placed at our center from 2005 to 2009 were reviewed. Patients with ultrasonically diagnosed DVT were compared to those without radiographic evidence. RESULTS: Of 333 patients, 47% (155/333) had femoral, 33% (111/333) had jugular, and 19% (64/333) had subclavian CVCs. Deep venous thromboses occurred in 18% (60/333) of patients. Sixty percent (36/60) of DVTs were in femoral veins. Femoral CVCs were associated with greater DVT rates (27%; 42/155) than jugular (11%; 12/111) or subclavian CVCs (9%; 6/64; P < .01). There was a 16% DVT rate in those with saphenofemoral Broviac CVCs vs 83% (20/24) in those with percutaneous femoral lines (P < .01). Multilumen CVCs had higher DVT rates than did single-lumen CVCs (54% vs 6%, P < .01), and mean catheter days before DVT diagnosis was shorter for percutaneous lines than Broviacs (13 ± 17 days vs 30 ± 37 days, P = .02). Patients with +DVT had longer length of stay (86 ± 88 days vs 48 ± 48 days, P < .01) and higher percentage of intensive care unit admission (82% vs 70%, P = .02). CONCLUSIONS: Deep venous thrombosis reduction strategies in infants with CVCs include avoiding percutaneous femoral and multilumen CVCs, screening percutaneous lines, and early catheter removal.

Acute kidney injury in congenital diaphragmatic hernia requiring extracorporeal life support: an insidious problem.

PURPOSE: Patients with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS) are at increased risk for acute kidney injury (AKI). We hypothesized that AKI would be associated with increased mortality. We further hypothesized that vasopressor requirement, nephrotoxic medications, and infections would be associated with AKI. METHODS: We performed a retrospective chart review in all patients with CDH requiring ECLS from 1999 to 2009 (n = 68). Patient variables that could potentiate renal failure were collected. We used a rise in creatinine from baseline by the RIFLE (risk, 1.5×; injury, 2×; failure, 3×; loss; and end-stage renal disease) criteria to define AKI. Statistical analysis was performed via SPSS (SPSS, Chicago, IL) using Student t test and χ(2) analysis, with P < .05 being considered significant. RESULTS: Survival to hospital discharge was 37 (54.4%) of 68. Acute kidney injury was identified in 48 (71%) of 68 patients, with 15 (22% of all patients) qualifying as injury and 33 (49% of all patients) qualifying as failure by the RIFLE criteria. Patients who qualified as failure by the RIFLE criteria had a significant decrease in survival (27.3% with failure vs 80% without failure; P = .001). Patients who qualified as failure also had increased length of ECLS (314 ± 145 vs 197 ± 115 hours; P = .001) and decreased ventilator-free days in the first 60 days (1.39 ± 5.3 vs 20.17 ± 17.4 days; P = .001). There was no significant difference in survival when patients qualified as risk or injury. CONCLUSIONS: This is the first report using a systematic definition of AKI in patients with CDH on ECLS. There is a high incidence of AKI in these patients, and when it progresses to failure, it is associated with higher mortality, increased ECLS duration, and increased ventilator days. This highlights the importance of recognizing AKI in patients with CDH requiring ECLS and the potential benefit of preventing progression of AKI or early intervention.

Vertical expandable prosthetic titanium rib device insertion: does it improve pulmonary function?

PURPOSE: Vertical expandable prosthetic titanium rib (VEPTR) insertion and expansion has been advocated to increase thoracic volume and pulmonary function in patients with thoracic insufficiency syndrome. We reviewed our experience with VEPTR implantation to determine if lung function and growth is augmented, to determine the children's functional status, and if the scoliosis is controlled. METHODS: From 2006 to 2010, 29 insertions and 57 expansions were performed in 26 patients at our institution. Demographic data were reviewed in conjunction with complications, scoliosis angles, pulmonary function tests (PFTs), and computed tomography-guided 3D reconstructions to determine lung volumes; and quality of life scores were determined using a modified Scoliosis Research Society (SRS) questionnaire preoperatively and postoperatively. The groups were also stratified by age (because of lung growth potential), disease (congenital or infantile scoliosis, Jeune syndrome, neuromuscular, other structural thoracic disorders), and sex. Analyses using SPSS (SPSS, Chicago, Ill) were performed with P < .05 considered significant. RESULTS: Each patient underwent 3.03 ± 1.8 surgeries, spending 0.97 ± 1.8 days in the intensive care unit and 4.41 ± 6 days in the hospital for each procedure. Mean age was 90.7 ± 41 months. Of the 36 complications, most were because of infection (12), half requiring operative repair (hardware removal). The average PFT percent predicted values for forced expiratory volume in 1 second, forced vital capacity, and RV were 54.6 ± 22, 58.1 ± 24, and 145.3 ± 112, respectively, preoperatively and 51.8 ± 20, 55.9 ± 20, and 105.6 ± 31, respectively, postoperatively. The lung volumes measured by computed tomography when corrected for age do not increase significantly postoperatively. The mean Cobb measurement for the preoperative major curves was 64.7° and postoperatively was 46.1° for those curves measured preoperatively, for a 29% curve improvement. All postoperative curves had a mean of 56.4° and 58.1° at final follow-up, a 3% curve increase. The SRS scores for patients remained unchanged and no statistical difference was seen from preoperative to postoperative values. No statistically significant difference was seen in complications, PFT (forced expiratory volume in 1 second, forced vital capacity, RV), lung volumes, scoliosis angles, and SRS scores between sex, age, and disease categories. CONCLUSION: There was mild improvement in scoliosis angles but no improvement in lung function and volume. Scoliosis Research Society scores indicate that the children have near normal function both before and after VEPTR placement. Pulmonary function, lung volume, and patient subjective assessments did not increase dramatically after VEPTR placement, although scoliosis angles improved.

Assessment of termination of trauma resuscitation guidelines: are children small adults?

BACKGROUND: Guidelines for termination of resuscitation in prehospital traumatic cardiopulmonary arrest (TCPA) have recently been published for adults. Clinical criteria for termination of care include absent pulse, unorganized electrocardiogram (ECG), fixed pupils (all at the scene), and cardiopulmonary resuscitation (CPR) greater than 15 minutes. The goal of this study was to evaluate these guidelines in a pediatric trauma population. METHODS: Pediatric trauma patients with documented arrest were included in the study. Data assessed were duration of CPR, ECG rhythm, pulse assessment, pupil response, transport times, and standard injury criteria (eg, mechanism of injury). Survivors were compared to nonsurvivors using descriptive statistics, chi(2), and Pearson correlation. RESULTS: Between 2000 and 2009, 30 patients were identified as having had a TCPA. Of the 30 with a prehospital TCPA, there were 9 females and 21 males (0.2-18 years old). The average (SD) injury severity score was 35.4 (20.6). Twenty-four patients (80%) did not survive. Severe traumatic brain injury was associated with nonsurvivors in 78%. One-way analysis of variances demonstrated that CPR greater than 15 minutes (P = .011) and fixed pupils (P = .022) were significant variables to distinguish between survivors and nonsurvivors, whereas ECG rhythm (P = .34) and absent pulse (P = .056) did not, 42 +/- 28 minutes for nonsurvivors and 7 +/- 3 minutes for survivors. CONCLUSION: Criteria for termination of resuscitation correctly predicted 100% of those who died when all the criteria were met. More importantly, no survivors would have had resuscitation stopped. Duration of CPR seems to be a strong predictor of mortality in this study.

Gastrostomy tube placement in infants and children: is there a preferred technique?

PURPOSE: Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques, including LAP-assisted PEG, offer alternatives to the standard open gastrostomy technique. This study compares the outcomes of the PEG and LAP techniques. METHODS: All gastrostomy tube placements were reviewed at our institution from January 2004 to October 2008. Demographic, procedural, and outcome data were collected. Univariate and logistic regression statistical analysis was performed with SPSS (SPSS, Chicago, IL), and P < or = .05 considered significant. RESULTS: Of 238 gastrostomy tubes placed, 134 were PEG (56.3%) and 104 were LAP (43.7%). Most tubes were inserted for failure to thrive (74.4%) and feeding difficulties (52.1%). Patient weight and age were increased and operative time decreased for PEG compared with other methods. Percutaneous endoscopic gastrostomy patients also had a statistically higher number of postoperative complications, requiring a return trip to the operating room (P = .02). CONCLUSION: Minimally invasive PEG and LAP techniques have supplanted the open technique for most patients. Operative time for PEG placement is shorter than other methods, and patients chosen for the PEG method of placement are older and of greater weight. However, there were significant and more serious postoperative complications requiring a second operation in the PEG group when compared with the LAP group.

Long-term functional outcome and quality of life in patients with high imperforate anus.

PURPOSE: Anorectal malformations (ARMs) are associated with a large number of functional sequale that may affect a child's long-term quality of life (QOL). The purposes of this study were to better quantify patient functional stooling outcome and to identify how these outcomes related to the QOL in patients with high imperforate anus. METHODS: Forty-eight patients from 2 children's hospitals underwent scoring of stooling after 4 years of life. Scoring consisted of a 13-item questionnaire to assess long-term stooling habits (score range: 0-30, worst to best). These results were then correlated with a QOL survey as judged by a parent or guardian. RESULT: Mean (SD) age at survey was 6.5 (1.6) years. Comparison of QOL and clinical scoring showed no signficant difference between the 2 institutions (P > .05). There was a direct correlation between the QOL and stooling score (Pearson r(2) = 0.827; beta coefficient = 24.7, P < .001). Interestingly, functional stooling scores worsened with increasing age (Pearson r(2) = 0.318, P = .02). Patients with associated congenital anomalies had a high rate of poor QOL (44% in poor range; P = .001). Stooling scores decreased significantly with increasing severity/complexity of the ARM (P = .001). CONCLUSION: A large number of children experience functional stooling problems, and these were directly associated with poor QOL. In contrast to previous perceptions, our study showed that stooling patterns are perceived to worsen with age. This suggests that children with ARMs need long-term follow-up and counseling.

Traumatic cervical spine injuries: characteristics of missed injuries.

PURPOSE: Computed tomographic (CT) scanning has mostly replaced x-rays as an imaging modality, but concerns exist because of excess radiation, missed injuries, and whether it is the definitive procedure for intubated patients. The purpose of this study was to characterize missed cervical spine injuries (CSIs). METHODS: All pediatric (<18) trauma patients from 2004 to 2006 were analyzed. Age, sex, Injury Severity Score (ISS), mechanism, time, and missed injuries were reviewed. Flexion/extension views were used in patients with prolonged intubation. Descriptive statistics, chi(2), Student's t test, and bivariate correlation were used. RESULTS: There were 1307 pediatric trauma patients admitted with 318 imaged for potential CSI. Computed tomography was the sole imaging study in 200, x-rays in 64, and both in 54. Time to C-spine clearance was similar for all modalities (P > .05). For CT, 34 (10.7%) were initially positive for CSI with 7 false-positives (FPs) and no false-negative (FN). There were 18 patients with CSI identified by x-ray, with 5 FPs and 5 FNs (missed injuries). The 5 FNs missed by x-ray were all positive by CT scan and required no intervention. None of the flexion/extension views revealed an additional injury. Sex, intubated patients, ISS, age, type, and injury location were not predictive of a missed injury (P > .05).The sensitivity of CT scan was 1.0, specificity was 0.976, and the positive predictive value was 79.4%. The sensitivity of plain x-ray was 61.5%, the specificity was 1.6%, and the positive predictive value was 61.5%. CONCLUSIONS: Our data suggest that CT scans should be the primary modality to image a CSI. Flexion/extension views did not add to the decision making for C-spine clearance after CT evaluation.