R. Todd Maxson

Delayed gastric emptying in neurologically impaired children with gastroesophageal reflux: The role of pyloroplasty

The presence of delayed gastric emptying in neurologically impaired children with gastroesophageal reflux has led to controversy regarding appropriate surgical management. The authors reviewed the charts of neurologically impaired children requiring fundoplication to answer two questions: (1) is pyloroplasty needed in addition to fundoplication for delayed gastric emptying? and (2) Does delayed gastric emptying influence the morbidity associated with fundoplication? To answer the first question, 40 neurologically impaired children with delayed gastric emptying undergoing fundoplication were divided into two groups: Nissen and pyloroplasty (n = 21) and Nissen only (n = 19). The Nissen and pyloroplasty group had significantly more postoperative complications (23.8% v 5.0%) and took longer to reach full feeding (14.6 v 3.9) days. There were no differences in the incidence of recurrent symptoms, readmissions, or reoperations. To answer the second question, 58 neurologically impaired children undergoing fundoplication were grouped based on gastric emptying scan results: normal gastric emptying (> 32% in 1 hour) (n = 29) and delayed gastric emptying (n = 29). There were no differences in postoperative feeding tolerance, postoperative complications, recurrent symptoms, readmissions, or reoperations between the two groups. Delayed gastric emptying in neurologically impaired children with gastroesophageal reflux did not increase postoperative morbidity after fundoplication, and the addition of a pyloroplasty to fundoplication provided no additional benefit. The authors conclude that the procedure of choice for neurologically impaired children with gastroesophageal reflux is a fundoplication without pyloroplasty, regardless of the degree of delay in gastric emptying.

The protective role of enteral IgA supplementation in neonatal gut origin sepsis

Preterm infants and infants unable to breast feed are particularly susceptible to gut origin sepsis. Many studies have shown the benefits of breast milk in decreasing the incidence of bacterial infections in neonates. Little in vivo work has focused on prevention of neonatal gut origin sepsis with breast milk components. The aim of this study was to determine whether supplementation of a standard neonatal formula with exogenous, luminally administered, human secretory IgA protects against gut origin sepsis in a newborn rabbit model. Sixty New Zealand white rabbit pups were delivered by cesarean section 1 day preterm and divided into two groups--the IgA group (n = 26) and the non-IgA group (n = 34). Animals were gavage-fed a standard artificial formula (KMR) twice daily. The IgA group was supplemented on days 3 and 4 with 6.25 mg/kg of human secretory IgA. The non-IgA group received an equal volume of saline. On the evening of day 3, the animals were orally challenged with Escherichia coli K100. The quantity of bacteria that colonized the cecum was similar in the two groups. The quantity of bacteria that translocated to the mesenteric lymph node, liver, and spleen was significantly lower in the IgA group (P < .05). The incidence of translocation to the organs was also significantly lower in the IgA group (P < .05). The exogenous secretory IgA showed specificity to E coli K100 by ELISA. These data show that neonatal formula supplemented with human secretory IgA decreases the incidence and quantity of bacterial translocation of E coli K100 in a neonatal rabbit model.(ABSTRACT TRUNCATED AT 250 WORDS)

Screening for attention-deficit/hyperactivity disorder in a select sample of injured and uninjured pediatric patients

PURPOSE Injury is the leading cause of morbidity and mortality to children. The purpose of this study is to compare attention-deficit/hyperactivity disorder (ADHD) screening results in a select group of injured pediatric patients to noninjured patients. METHODS Parents of patients 6 to 12 years of age were enrolled in the study. Patients were either admitted for specific injury mechanisms (n = 133) or appendicitis (n = 157). Demographic and medical data were collected, and an ADHD screening tool was administered. Logistic regression models were used to compare screening results between groups. RESULTS The injured patient group was 3.25 times more likely to screen positive for ADHD (odds ratio, 3.25; 95% confidence interval, 1.57-6.72; P = .002) than the appendicitis group. Among the injured patients who screened positive for ADHD, only 34.0% reported currently receiving treatment. CONCLUSIONS Our results suggest that pediatric patients with certain injury mechanisms may warrant screening and referral for ADHD. Appropriate identification and treatment of undiagnosed ADHD may reduce the burden of injury recidivism. Screening and referral for ADHD within a trauma service should be evaluated for effectiveness as an injury prevention initiative.

Is nasogastric tube decompression necessary after major abdominal surgery in children

Nasogastric (NG) decompression has traditionally been used after major abdominal surgery in pediatric patients. This study was designed to determine if NG tubes could be routinely omitted in pediatric patients undergoing major abdominal procedures. Between January 1993 and December 1995, 83 patients had follow-up prospectively without NG decompression after a variety of major abdominal surgeries. NG tubes were inserted for persistent vomiting or abdominal distension. Exclusion criteria included bowel obstruction, intestinal atresia, and perforation of the stomach or duodenum. Ages ranged from 13 days to 22 years. Seventy-four patients (89%) were treated successfully without postoperative NG decompression. There were no cases of pneumonia, wound dehiscence, anastomotic leak, or delay in return of gastrointestinal function. Nine patients required NG tubes for persistent vomiting or abdominal distension. An anastomotic leak developed in one patient after endorectal pull-through. NG decompression is unnecessary after most major abdominal operations in pediatric patients. The endorectal pull-through may represent a group of patients that benefit from routine decompression.

Prehospital cardiopulmonary resuscitation in the pediatric trauma patient

PURPOSE Children requiring prehospital cardiopulmonary resuscitation (CPR) after traumatic injury have been shown to have poor survival. However, outcome of children still receiving CPR on-arrival by emergency medical service to the emergency department (ED) has not been demonstrated in a published clinical series. METHODS An 11-year retrospective analysis from a level I pediatric trauma center of the outcomes of children requiring prehospital CPR after traumatic injury was undertaken. Outcome variables were stratified by survival, death, and CPR on-arrival. RESULTS Of 169 children requiring prehospital CPR, there were 28 survivors and 141 deaths. Of 69 children requiring CPR on-arrival to the ED, there were no survivors. There were 70 females and 99 males. Mean age of survivors was 3.4 years; nonsurvivors, 8.8 years; and 4.6 years for CPR on-arrival. Thirty-nine percent of all injuries were sustained in motor vehicle collisions; 20%, motor pedestrian collisions; 19%, assaults; 7%, falls; 4%, all terrain vehicle/motorcycle/bicycle; and 4%, gunshot wounds. Forty-two percent of all patients expired in the ED, whereas 34% expired in the intensive care unit. Eighty-seven percent of CPR on-arrival patients expired in the ED. Fifty-five percent of survivors had full neurologic recovery. CONCLUSION Although mortality was extremely high for children requiring CPR in the field After traumatic injury, it was absolute for those arriving at the ED still undergoing CPR.

Hemodynamic variables predict outcome of emergency thoracotomy in the pediatric trauma population.

BACKGROUND Limited data exist regarding indications for resuscitative emergency thoracotomy (ETR) in the pediatric population. We attempt to define the presenting hemodynamic parameters that predict survival for pediatric patients undergoing ETR. METHODS We reviewed all pediatric patients (age <18years), entered into the National Trauma Data Bank from 2007 to 2010, who underwent ETR within one hour of ED arrival. Mechanism of injury and hemodynamics were analyzed using Chi squared and Wilcoxon tests. RESULTS 316 children (70 blunt, 240 penetrating) underwent ETR, 31% (98/316) survived to discharge. Less than 5% of patients survived when presenting SBP was ≤50mmHg or heart rate was ≤70bpm. For blunt injuries there were no survivors with a pulse ≤80bpm or SBP ≤60mmHg. When survivors were compared to nonsurvivors, blood pressure, pulse, and injury type were statistically significant when treated as independent variables and in a logistic regression model. CONCLUSIONS When ETR was performed for SBP ≤50mmHg or for heart rate ≤70bpm less than 5% of patients survived. There were no survivors of blunt trauma when SBP was ≤60mmHg or pulse was ≤80bpm. This review suggests that ETR may have limited benefit in these patients.

Persistent gastrocutaneous fistula: factors affecting the need for closure.

PURPOSE The occurrence of gastrocutaneous fistula (GCF) is a well-known complication after gastrostomy tube placement. We explore multiple factors to ascertain their impact on the rate of persistent GCF formation. METHODS We retrospectively reviewed patient records for all gastrostomies (GT) constructed at our institution from 2007 to 2011. Association of GCF with method of placement, concomitant fundoplication, neurologic findings, duration of therapy, and demographics was evaluated using logistic regression. RESULTS Nine hundred fifty patients had GTs placed, of which 148 patients had GTs removed and 47 (32%) of 148 required surgical closure secondary to persistent GCF. Laparoscopic and open procedures comprised 79 (53%) of 148 and 69 (47%) of 148, respectively. Seventeen (22%) patients in the laparoscopic group developed persistent GCF, compared to 30 (43%) in the open group (P=0.035, OR=2.52). Seventy-one patients had concomitant Nissen fundoplication. Thirty-one (44%) developed GCF, compared to 16 (21%) without a Nissen (P=0.002, OR=4.94). Patients with button in place for 303 days had persistent GCF incidence of 23%, compared to 45% at 540 days (P<0.001, OR=3.51) and 50% at 850 days (P=0.011, OR=4.51). Patients with device placed at 1.8 months of age were more likely to develop GCF compared to those with device placed at 8.9 months of age (P=0.017, OR=2.35). CONCLUSION Open operations, concurrent Nissen and younger age at placement were all statistically significant factors causing persistent GCF.

The association between positive screen for future persistent posttraumatic stress symptoms and injury incident variables in the pediatric trauma care setting.

BACKGROUND Posttraumatic stress (PTS) disorder after injury is a significant yet underaddressed issue in the trauma care setting. Parental anxiety may impact a child’s risk of future, persistent PTS symptoms after injury. This study aimed to: (1) identify injury incident and demographic variables related to a positive screen for future, persistent PTS symptoms in children; and (2) examine the relationship between parental anxiety and a positive screen for future, persistent PTS symptoms in children. METHODS From November 2009 to August 2010, 124 patients were enrolled at a pediatric trauma center. Inclusion criteria were as follows: (1) age 7 years to 17 years; (2) hospitalized for at least 24 hours after physical trauma; and (3) English or Spanish speaking. State and trait anxiety were measured for both pediatric patients and their parents/guardians via the state trait anxiety inventory for children and state trait anxiety inventory, respectively. Risk for future, persistent PTS, among pediatric patients was assessed via the screening tool for early predictor of posttraumatic stress disorder (STEPP). RESULTS Of 116 participants assessed via the STEPP, 32 (28%) screened positive for risk of future, persistent PTS symptoms. Motor vehicle collision and parental presence at injury were associated with a positive STEPP screen. The effect of parental presence on positive STEPP screen was modified by parental trait anxiety. Children of anxious parents present at injury were over 14 times as likely to screen positive for risk of future, persistent PTS, as those without a parent present. CONCLUSION The risk of future, persistent PTS, after injury among the pediatric population is substantial. Parents with existing trait anxiety are shown to influence their child’s risk for future, persistent PTS, particularly if present at the injury event. Further study of PTS prevention and control strategies are needed among this population within the trauma care setting. (J Trauma Acute Care Surg. 2012;72: 1640–1646. Copyright

Prospective validation of the shock index pediatric-adjusted (SIPA) in blunt liver and spleen trauma: An ATOMAC + study☆

BACKGROUND Age-adjusted pediatric shock index (SIPA) does not require knowledge of age-adjusted blood pressure norms, yet correlates with mortality, serious injury, and need for transfusion in trauma. No prospective studies support its validity. METHODS A multicenter prospective observational study of patients 4-16years presenting April 2013-January 2016 with blunt liver and/or spleen injury (BLSI). SIPA (maximum heart rate/minimum systolic blood pressure) thresholds of >1.22, >1.0, and >0.9 in the emergency department were used for 4-6, 7-12 and 13-16year-olds, respectively. Patients with ISS ≤15 were excluded to conform to the original paper. Discrimination outcomes were compared between SIPA and shock index (SI). RESULTS Of 1008 patients, 386 met inclusion. SI was elevated in 321, and SIPA elevated in 282. The percentage of patients with elevated index (SI or SIPA) and blood transfusion within 24 hours (30% vs 34%), BLSI grade ≥3 requiring transfusion (28% vs 32%), operative intervention (14% vs 16%) and ICU admission (64% vs 67%) was higher in the SIPA group. CONCLUSION SIPA was validated in this multi-institutional prospective study and identified a higher percentage of children requiring additional resources than SI in BLSI patients. SIPA may be useful for determining necessary resources for injured patients with BLSI. LEVEL OF EVIDENCE Level II prognosis.

Screening for risky alcohol use among caregivers of pediatric trauma patients: a pilot study.

BACKGROUND Injury is the leading cause of death for children and has been linked to caregiver drinking. Screening and brief intervention for risky drinking has been successful in adult trauma centers but has not been evaluated in caregivers of pediatric trauma patients. The purpose of this study was to investigate a pilot screening process for risky drinking caregivers, to determine rates of risky alcohol use, and to assess potential relationships between risky drinking and child safety behaviors. METHODS Caregivers of pediatric trauma patients were screened by trained injury prevention educators. The screening assessed risky drinking, tobacco and illicit drug use, and child safety behaviors. Data were analyzed using descriptive analysis, frequency comparisons, and univariate logistic regression. RESULTS Over 7 months, 295 caregivers were screened; 32.5% (n = 96) screened positive for risky alcohol use. For 173 injured children, one caregiver was screened, and for 61 children, two caregivers were screened. In the one-caregiver group, 29% (n = 50) screened positive for risky drinking. For the two-caregiver group, in 18% (n = 11) of the cases, both caregivers screened positive, whereas in 39% (n = 24) only one caregiver screened positive. Males were more likely to screen positive (p < 0.01). Relationships between reported child safety behaviors and risky drinking were of interest, but not statistically significant. CONCLUSIONS The results of our study demonstrate that a substantial number of caregivers of pediatric trauma patients will self-report risky drinking behaviors, and therefore, an opportunity exists for these families to receive the benefits of screening and brief intervention programs in pediatric trauma care settings.