Respiratory Management of the Newborn with an Omphalocele

Despite advances in neonatal care, infants with omphalocele have a mortality rate ranging between 5% and 25%. Respiratory insufficiency is a common clinical challenge and an independent predictor of mortality in these infants. The causes of respiratory failure are diverse and are not well understood. This chapter discusses the unique aspects of respiratory management in omphalocele infants. The authors have chosen references in this chapter with appropriate sample size, variable comparisons, regression analyses, and documented median follow-up times. Omphalocele is rare; therefore, the case reports of chapter references have important information

Congenital Diaphragmatic Hernia

Despite advances in neonatal and surgical care, the management of congenital diaphragmatic hernia (CDH) remains challenging with no definitive standard treatment guidelines. Several centers report mortality rates as low as 20%, but if extracorporeal membrane oxygenation (ECMO) support is required, the mortality rate rises to 50%. The disease severity is related to the degree of pulmonary hypoplasia and pulmonary hypertension that occurs with CDH. Both conditions decrease the infant’s ability to ventilate and oxygenate adequately at delivery. These physiologic conditions that impair gas exchange are the important determinants of morbidity and mortality in CDH infants. Presently, delivery of infants with CDH is recommended close to term gestation. The focus of care includes gentle ventilation, hemodynamic monitoring, and treatment of pulmonary hypertension followed by surgery for the defect. Extracorporeal membrane oxygenation (ECMO) is considered after failure of conventional medical management for infants ≥  34 weeks’ gestation or with weight >2 kg and no associated major lethal anomalies. This chapter discusses long‐term follow‐up recommendations for survivors, which should involve a multidisciplinary approach, as there are many surgical and nonsurgical consequences to the disease process. Clinical strategies that address these multifaceted aspects of care, from prenatal to long‐term follow‐up, may further reduce the high mortality rate for these infants

Understanding of Abdominal Compartment Syndrome among Pediatric Healthcare Providers

Background. The sparse reporting of abdominal compartment syndrome (ACS) in the pediatric literature may reflect inadequate awareness and recognition among pediatric healthcare providers (HCP). Purpose. To assess awareness of ACS, knowledge of the definition and intraabdominal pressure (IAP) measurement techniques used among pediatric HCP. Method. A written survey distributed at two pediatric critical care conferences. Results. Forty-seven percent of 1107 questionnaires were completed. Participants included pediatric intensivists, pediatric nurses, and others. Seventy-seven percent (n = 513) of participants had heard of ACS. Only 46.8% defined ACS correctly. The threshold IAP value used to define ACS was variable among participants. About one-quarter of participants (83/343), had never measured IAP. Conclusion. Twenty-three percent of HCP surveyed were unaware of ACS. Criteria used to define ACS were variable. Focused education on recognition of ACS and measuring IAP should be promoted among pediatric HCP

Paediatric Investigators Collaborative Network on Infections in Canada (PICNIC) study of aseptic meningitis

BACKGROUND: The seasonality, clinical and radiographic features and outcome of aseptic meningitis have been described for regional outbreaks but data from a wider geographic area is necessary to delineate the epidemiology of this condition. METHODS: A retrospective chart review was completed of children presenting with aseptic meningitis to eight Canadian pediatric hospitals over a two-year period. RESULTS: There were 233 cases of proven enteroviral (EV) meningitis, 495 cases of clinical aseptic meningitis and 74 cases of possible aseptic meningitis with most cases occurring July to October. Headache, vomiting, meningismus and photophobia were more common in children ≥ 5 years of age, while rash, diarrhea and cough were more common in children < 5 years of age. Pleocytosis was absent in 22.3% of children < 30 days of age with proven EV meningitis. Enterovirus was isolated in cerebrospinal fluid (CSF) from 154 of 389 patients (39.6%) who had viral culture performed, and a nucleic acid amplification test for enterovirus was positive in CSF from 81 of 149 patients (54.3%). Imaging of the head by computerized tomography or magnetic resonance imaging was completed in 96 cases (19.7%) and 24 had abnormal findings that were possibly related to meningitis while none had changes that were definitely related to meningitis. There was minimal morbidity and there were no deaths. CONCLUSION: The clinical presentation of aseptic meningitis varies with the age of the child. Absence of CSF pleocytosis is common in infants < 30 days of age. Enterovirus is the predominant isolate, but no etiologic agent is identified in the majority of cases of aseptic meningitis in Canadian children

Pediatric and Neonatal Surgery

Neonatal and Pediatric Surgery is a broad field with many challenges. The aim of this short book is to provide the reader with several informative chapters in the field of neonatal and pediatric surgery. Each chapter provides details on a specific area of this changing field. The scope of this book focuses on a few areas that are rare and challenging. For example, it covers preoperative and postoperative care of neonates. Important anesthesia considerations, including anesthesia for neonates and regional anesthesia, are discussed. A unique chapter on neonatal tumors is presented. The book provides an overview of the recent recommendations for care of infants and children that undergo cardiac surgery. The challenging aspects of caustic ingestion are explained. Each chapter stands alone as a detailed source of information for the reader. This book brings updated information with structured headings that will allow the reader to remain focused as the material is reviewed

Surgical consultation in neonates with congenital syphilis

Objective: The aim was to review the incidence and clinical presentation of neonates with congenital syphilis requiring surgical consultation at a single tertiary neonatal intensive care unit (NICU). Methods: Between 2014 and 2016, all records incorporating congenital syphilis and syphilis during pregnancy were obtained to establish disease incidence. During this time, neonates with congenital syphilis and a pediatric surgery consultation were reviewed. Demographic data, details of surgical consultation, operations and clinical outcomes were recorded. Results: Between 2014 and 2016, cases of maternal syphilis increased from one to five, and congenital syphilis cases ranged from two to ten. In 2016, four (40%) required surgical consultation. Indications for surgical consultation included: (1) obstructive jaundice, (2) abdominal distension with bilious emesis, (3) distension and hematochezia, and (4) possible anorectal malformation. All were diagnosed by rapid plasma reagin test (RPR) and completed a 10-day course of Penicillin G. One neonate with obstructive jaundice underwent surgery to rule out biliary atresia. Three neonates did not require surgical intervention. Conclusion: An understanding of congenital syphilis is imperative for pediatric surgeons. Hepatic and gastrointestinal manifestations may mimic surgical diagnoses in neonates. Keywords: Congenital syphilis, Surgical consults, Neonates, Syphilis in pregnanc

Atropine: A Cure for Persistent Post Laparoscopic Pyloromyotomy Emesis?

Background: Atropine has been used as a successful primary medical treatment for hypertrophic pyloric stenosis. Several authors have reported a higher rate of incomplete pyloromyotomy with the laparoscopic approach compared to open. In this study, we evaluated the use of atropine as a medical treatment for infants with emesis persisting greater than 48 hours after a laparoscopic pyloromyotomy. Materials and Methods: We performed a retrospective chart review of infants receiving a laparoscopic pyloromyotomy between November 1998 and November 2012. Infants with emesis that persisted beyond 48 hours postoperatively were given 0.01mg/kg of oral atropine 10 minutes prior to feeding. Infants remained inpatient until they tolerated two consecutive feedings without emesis. Results: 965 patients underwent laparoscopic pyloromyotomy; 816 (84.6%) male and 149 (15.4%) female. Twenty-four (2.5%) received oral atropine. The mean length of stay for patients who received atropine was 5.6 ± 2.6 days, an average of 3 additional days. They were discharged home with a one-month supply of oral atropine. Follow up evaluation did not reveal any complications from receiving atropine. The median follow up was 21 days. None returned to the operating room for incomplete pyloromyotomy. There were 17 (1.8%) operative complications in our series; 9 mucosal perforations, 2 duodenal perforations, and 6 conversions to open for equipment failure or poor exposure. There were 4 (0.4%) post-operative complications: 2 episodes of apnea requiring reintubation and 2 incisional hernias that required a second operation. There were no deaths. Conclusion: Oral atropine is a viable treatment for persistent emesis after a pyloromyotomy and reduces the need for a second operation due to incomplete pyloromyotomy

Outcomes in omphalocele correlate with size of defect

Background: Omphaloceles can be some of the more challenging cases managed by pediatric surgeons. Single center studies have not been meaningful in delineating outcomes due to the length of time required to accumulate a large enough series with historical changes in management negating the results. The purpose of this study was to evaluate factors impacting the morbidity and mortality of neonates with omphaloceles.Methods: A multicenter, retrospective observational study was performed for live born neonates with omphalocele between 2005 and 2013 at nine centers in the United States. Maternal and neonatal data were collected for each case. In-hospital management and outcomes were also reported and compared between neonates with small and large omphaloceles.Results: Two hundred seventy-four neonates with omphalocele were identified. The majority were delivered by cesarean section with a median gestational age of 37 weeks. Overall survival to hospital discharge was 81%. The presence of an associated anomaly was common, with cardiac abnormalities being the most frequent. Large omphaloceles had a significantly longer hospital and ICU length of stay, time on ventilator, number of tracheostomies, time on total parenteral nutrition, and time to full feeds, compared to small omphaloceles. Birth weight and defect size were independent predictors of survival.Conclusion: This is the largest contemporary study of neonates with omphalocele. Increased defect size is an independent predictor of neonatal morbidity and mortality.Level of evidence: Level II

Paediatric Investigators Collaborative Network on Infections in Canada (PICNIC) study of aseptic meningitis

Abstract Background The seasonality, clinical and radiographic features and outcome of aseptic meningitis have been described for regional outbreaks but data from a wider geographic area is necessary to delineate the epidemiology of this condition. Methods A retrospective chart review was completed of children presenting with aseptic meningitis to eight Canadian pediatric hospitals over a two-year period. Results There were 233 cases of proven enteroviral (EV) meningitis, 495 cases of clinical aseptic meningitis and 74 cases of possible aseptic meningitis with most cases occurring July to October. Headache, vomiting, meningismus and photophobia were more common in children ≥ 5 years of age, while rash, diarrhea and cough were more common in children < 5 years of age. Pleocytosis was absent in 22.3% of children < 30 days of age with proven EV meningitis. Enterovirus was isolated in cerebrospinal fluid (CSF) from 154 of 389 patients (39.6%) who had viral culture performed, and a nucleic acid amplification test for enterovirus was positive in CSF from 81 of 149 patients (54.3%). Imaging of the head by computerized tomography or magnetic resonance imaging was completed in 96 cases (19.7%) and 24 had abnormal findings that were possibly related to meningitis while none had changes that were definitely related to meningitis. There was minimal morbidity and there were no deaths. Conclusion The clinical presentation of aseptic meningitis varies with the age of the child. Absence of CSF pleocytosis is common in infants < 30 days of age. Enterovirus is the predominant isolate, but no etiologic agent is identified in the majority of cases of aseptic meningitis in Canadian children