Kate B. Savoie

Improving gastroschisis outcomes: Does birth place matter?

PURPOSE Babies born in the hospital where they obtain definitive surgical care do not require transportation between institutions and may have shorter time to surgical intervention. Whether these differences result in meaningful improvement in outcomes has been debated. A multi-institutional retrospective study was performed comparing outcomes based on birthplace. METHODS Six institutions within the PedSRC reviewed infants born with gastroschisis from 2008 to 2013. Birthplace, perinatal, and postoperative data were collected. Based on the P-NSQIP definition, inborn was defined as birth at the pediatric hospital where repair occurred. The primary outcome was days to full enteral nutrition (FEN; 120kcal/kg/day). RESULTS 528 patients with gastroschisis were identified: 286 inborn, 242 outborn. Days to FEN, time to bowel coverage and abdominal wall closure, primary closure rate, and length of stay significantly favored inborn patients. In multivariable analysis, birthplace was not a significant predictor of time to FEN. Gestational age, presence of atresia or necrosis, primary closure rate, and time to abdominal wall closure were significant predictors. CONCLUSIONS Inborn patients had bowel coverage and definitive closure sooner with fewer days to full feeds and shorter length of stay. Birthplace appears to be important and should be considered in efforts to improve outcomes in patients with gastroschisis.

Age at presentation and management of pediatric intussusception: A Pediatric Health Information System database study

Background. Intussusception is uncommon in children older than 3 years, and use of enema reduction in older children is controversial. We sought to determine whether older children are at greater risk of requiring operative intervention and/or having pathology causing lead points, such that enema reduction should not be attempted. Methods. The Pediatric Health Information System database was reviewed from January 1, 2009–June 30, 2014. Patients were followed for 6 months from initial presentation or until bowel resection occurred. Successful enema reduction was defined as having radiologic reduction without additional procedures. Results. A total of 7,412 patients were identified: 6,681 were <3 years old, 731 patients were >3 years old. In those >3 years old, 450 (62%) were treated successfully with enema reduction; the rate of patients with a tumor diagnosis was similar in patients <3 years old and patients >3 years old (5% vs 6%, P = .07). The rate of a Meckels diagnosis was greater in patients >3 years old (2% vs 14%, P < .0001). In patients >3 years old, duration of stay between patients who underwent primary operative therapy versus those who underwent operative therapy after enema reduction was similar (4 days vs 4 days, P = .06). Older age was not associated with increased risk of recurrent admission for intussusception (P = .45). Conclusion. Pediatric Health Information System data suggest that enema reduction may be safe and effective for a majority of children even if older than 3 years.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis

Introduction The utility of focused assessment with sonography for trauma (FAST) in children is poorly defined with considerable practice variation. Our purpose was to investigate the role of FAST for intra-abdominal injury (IAI) and IAI requiring acute intervention (IAI-I) in children after blunt abdominal trauma (BAT). Methods We prospectively enrolled children younger than 16 years after BAT at 14 Level I pediatric trauma centers over a 1-year period. Patients who underwent FAST were compared with those that did not, using descriptive statistics and univariate analysis; p value less than 0.05 was considered significant. FAST test characteristics were performed using computed tomography (CT) and/or intraoperative findings as the gold standard. Results Two thousand one hundred eighty-eight children (age, 7.8 ± 4.6 years) were included. Eight hundred twenty-nine (37.9%) received a FAST, 340 of whom underwent an abdominal CT. Ninety-seven (29%) of these 340 patients had an IAI and 27 (7.9%) received an acute intervention. CT scan utilization after FAST was 41% versus 46% among those who did not receive FAST. The frequency of FAST among centers ranged from 0.84% to 94.1%. There was low correlation between FAST and CT utilization (r = −0.050, p < 0.001). Centers that performed FAST at a higher frequency did not have improved accuracy. The test performance of FAST for IAI was sensitivity, 27.8%; specificity, 91.4%; positive predictive value, 56.2%; negative predictive value, 76.0%; and accuracy, 73.2%. There were 81 injuries among the 70 false-negative FAST. The test performance of FAST for IAI-I was sensitivity, 44.4%; specificity, 88.5%; positive predictive value, 25.0%; negative predictive value, 94.9%; and accuracy, 85.0%. Fifteen children with a negative FAST received acute interventions. Among the 27 patients with true positive FAST examinations, 12 received intervention. All had an abnormal abdominal physical examination. No patient underwent intervention before CT scan. Conclusion As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level II; diagnostic tests or criteria study, level II; therapeutic/care management study, level III.

Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely

BACKGROUND Computed tomography is commonly used to rule out intra-abdominal injury (IAI) in children, despite associated cost and radiation exposure. Our purpose was to derive a prediction rule to identify children at very low risk for IAI after blunt abdominal trauma (BAT) for whom a CT scan of the abdomen would be unnecessary. STUDY DESIGN We prospectively enrolled children younger than 16 years of age who presented after BAT at 14 Level I pediatric trauma centers during 1 year. We excluded patients who presented more than 6 hours after injury or underwent abdominal CT before transfer. We used binary recursive partitioning to derive a prediction rule identifying children at very low risk of IAI and IAI requiring acute intervention (IAI-I) using clinical information available in the trauma bay. RESULTS We included 2,188 children with a median age of 8 years. There were 261 patients with IAI (11.9%) and 62 patients with IAI-I (2.8%). The prediction rule consisted of (in descending order of significance): aspartate aminotransferase >200 U/L, abnormal abdominal examination, abnormal chest x-ray, report of abdominal pain, and abnormal pancreatic enzymes. The rule had a negative predictive value of 99.4% for IAI and 100.0% for IAI-I in patients with none of the prediction rule variables present. The very-low-risk population consisted of 34% of the patients and 23% received a CT scan. Computed tomography frequency ranged from 4% to 96% by center. CONCLUSIONS A prediction rule using history and physical examination, chest x-ray, and laboratory evaluation at the time of presentation after BAT identifies children at very low risk for IAI for whom CT can be avoided.

Standardization of Feeding Advancement after Neonatal Gastrointestinal Surgery: Does It Improve Outcomes?

BACKGROUND Postabdominal intestinal surgery (PAIS) infants pose many complex management issues. Utilization of feeding guidelines has been shown to improve outcomes in preterm and low-birth-weight infants. We propose that standardization of feeding for PAIS infants is safe. METHODS We identified 163 PAIS infants: 93 prior to and 70 after implementation of a feeding guideline. The primary outcome was time to full enteral nutrition (EN). A propensity score-matched analysis was performed. RESULTS The preimplementation and postimplementation PAIS infants were similar at baseline. No significant differences were seen in matched groups for time to full EN, parenteral nutrition days, or time to discharge, but cholestasis was less severe in the postimplementation group and breast milk use increased. Good compliance (67%) to daily guideline use was achieved during the initial 2 years. CONCLUSIONS Utilization of a feeding guideline is safe and standardizes care within an institution, improving compliance to evidence-based practices and outcomes.

Health Disparities in the Appropriate Management of Cryptorchidism

Objective To assess regional practices in management of cryptorchidism with regard to timely fixation by the current recommended age of 18 months. Study design A retrospective study was performed. Charts of all patients who underwent surgical correction for cryptorchidism by a pediatric general surgeon or urologist within a tertiary pediatric hospital in an urban setting were systematically reviewed. Results We identified 1209 patients with cryptorchidism. The median age of surgical correction was 3.7 years (IQR: 1.4, 7.7); only 27% of patients had surgical correction before 18 months of age. Forty‐six percent of our patients were white, 40% were African American, and 8% were Hispanic. African American and Hispanic patients were less likely to undergo timely repair (P = .01), as were those with public or no insurance (P < .0001). A majority (72%) of patients had no diagnostic imaging prior to surgery. A majority of patients had palpable testes at operation (85%) and underwent inguinal orchiopexy (76%); 82% were operated on by a pediatric urologist. Only 35 patients (3%) experienced a complication; those repaired late were significantly less likely to develop a complication (P = .03). There were no differences in age at time of surgery by surgeon type. Conclusions A majority of our patients were not referred for surgical intervention in a timely manner, which may reflect poor access to care in our region. Public and self‐pay insurance status was associated with delayed repair. Education of community physicians and families could be potentially beneficial.

Acute procedural interventions after pediatric blunt abdominal trauma: A prospective multicenter evaluation

BACKGROUND Pediatric intra-abdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS We prospectively enrolled children younger than 16 years after BAT at 14 Level I Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared with those who did not receive an intervention using descriptive statistics and univariate analysis; p less than 0.05 was considered significant. RESULTS Two hundred sixty-one (11.9%) of 2,188 patients had IAI. Forty-five (17.2%) IAI patients received an acute procedural intervention (38 operations, seven angiographic embolization). The mean age for patients requiring intervention was 7.1 ± 4.1 years and not different from the population. Most patients (88.9%) with IAI-I were normotensive. IAI-I patients were significantly more likely to have a mechanism of motor vehicle collision (66.7% vs. 38.9%), more likely to present as a Level I activation (44.4% vs. 26.9%), more likely to have a Glascow Coma Scale less than 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical examination (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent computed tomography scan before intervention. Operations consisted of laparotomy (n = 21), laparoscopy converted to open (n = 11), and laparoscopy alone (n = 6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury, including seven angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for solid organ injury (59.2% vs. 7.6%). Postoperative mortality from IAI was 2.6%. CONCLUSION Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course and have excellent clinical outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.BACKGROUND Pediatric intraabdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS We prospectively enrolled children <16 years following BAT at 14 Level-One Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared to those who did not receive an intervention using descriptive statistics and univariate analysis; p < 0.05 was considered significant. RESULTS 261 of 2188 patients (11.9%) had IAI. 45 IAI patients (17.2%) received an acute procedural intervention (38 operations, 7 angiographic embolization). The mean age for patients requiring intervention was 7.1+/-4.1 years and not different from the population. The majority of patients with IAI-I were normotensive (88.9%). IAI-I patients were significantly more likely to have a mechanism of MVC (66.7% vs. 38.9%), more likely to present as a level I activation (44.4% vs. 26.9%), more likely to have a GCS < 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical exam (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent CT scan before intervention. Operations consisted of laparotomy (n=21), laparoscopy converted to open (n=11), and laparoscopy alone (n=6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury (SOI), including 7 angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for SOI (59.2% vs. 7.6%). Post-operative mortality from IAI was 2.6%. CONCLUSIONS Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course, and have excellent clinical outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Use of a Gastroschisis Feeding Guideline to Improve Standardization of Care and Patient Outcomes at an Urban Children's Hospital

BACKGROUND This study examined clinical outcomes associated with the use of a gastroschisis-specific (GS) feeding advancement guideline. METHODS We performed a retrospective study of all simple gastroschisis babies (N = 65) treated between June 2009June 2015. We compared patients treated on a postintestinal surgery guideline using either a 1-day (1D) or 3-day (3D) feeding advancement from August 2009-August 2013 with infants treated on a GS guideline from September 2013-June 2015. RESULTS Patients in the 2 groups were similar in sex, race, gestational age, weight, and comorbidities. Median time to full enteral nutrition (EN) was 11 days for the 1D group, 22 days for the 3D group, and 18 days for the GS group (P < .01). However, lengths of stay and estimated weight gain per day were similar among the groups. A total of 3 infants (10%) in the 1D group developed necrotizing enterocolitis compared with none in the 3D or GS groups. Control chart analysis showed reduced variation in median time to full EN in the GS group when compared with the 1D and 3D groups. Guideline adherence was significantly better with the GS guideline when compared with the 1D or 3D guidelines (94% vs 72% vs 90%; P < .01). CONCLUSION A GS protocol yielded reduced variation in median time to full EN, significant improvement in percent adherence to the guideline, and zero cases of necrotizing enterocolitis. Weight gain and lengths of stay were not adversely affected by slower feeds.

Health disparities in infants with hypertrophic pyloric stenosis

BACKGROUND This study investigates whether health disparities exist in infants with hypertrophic pyloric stenosis (HPS), to identify factors affecting definitive treatment, and if more morbidity occurs. METHODS A 6-year retrospective analysis was performed on infants with HPS. Analysis of variance was used to evaluate the impact of socioeconomic factors on disease severity and hospitalization. General linear models were used to assess the impact of risk factors on the outcomes. RESULTS There were a total of 584 infants. African-Americans had lower serum chloride (P < .001), higher bicarbonate (P = .001), and sodium levels (P = .006), adding to longer hospitalization than whites (P = .03). Uninsured infants had lower sodium and chloride (P < .001) and higher bicarbonate (P < .001), resulting in a longer time to operation (P = .05) than privately insured infants. In multivariable analyses, African-Americans were associated with chloride (P = .002) and higher bicarbonate (P = .009), and uninsured status remained significantly associated with all electrolyte abnormalities. CONCLUSIONS African-American and poorly insured infants with HPS had greater risk of metabolic derangements. This required more time to correct dehydration and electrolytes, adding to longer hospitalizations.