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Objective: In infants with gastroschisis, outcomes were compared between those where operative reduction and fascial closure were attempted ≤24 hours of age (PC), and those who underwent planned closure of their defect >24 hours of age following reduction with a pre-formed silo (SR). Summary of Background Data: Inadequate evidence exists to determine how best to treat infants with gastroschisis. Methods: A secondary analysis was conducted of data collected 2006–2008 using the British Association of Pediatric Surgeons Congenital Anomalies Surveillance System, and 2005–2016 using the Canadian Pediatric Surgery Network. 28-day outcomes were compared between infants undergoing PC and SR. Primary outcome was number of gastrointestinal complications. Interactions were investigated between infant characteristics and treatment to determine whether intervention effect varied in sub-groups of infants. Results: Data from 341 British and Irish infants (27%) and 927 Canadian infants (73%) were used. 671 infants (42%) underwent PC and 597 (37%) underwent SR. The effect of SR on outcome varied according to the presence/absence of intestinal perforation, intestinal matting and intestinal necrosis. In infants without these features, SR was associated with fewer gastrointestinal complications [aIRR 0.25 (95% CI 0.09–0.67, P = 0.006)], more operations [aIRR 1.40 (95% CI 1.22–1.60, P < 0.001)], more days PN [aIRR 1.08 (95% CI 1.03–1.13, P < 0.001)], and a higher infection risk [aOR 2.06 (95% CI 1.10–3.87, P = 0.025)]. In infants with these features, SR was associated with a greater number of operations [aIRR 1.30 (95% CI 1.17–1.45, P < 0.001)], and more days PN [aIRR 1.06 (95% CI 1.02–1.10, P = 0.003)]. Conclusions: In infants without intestinal perforation, matting, or necrosis, the benefits of SR outweigh its drawbacks. In infants with these features, the opposite is true. Treatment choice should be based upon these features.

KEY POINTS Congenital diaphragmatic hernia (CDH), which occurs in about 1 in 3300 live births, is a congenital defect in the diaphragm that allows herniation of abdominal viscera into the thorax.[1][1] The resulting abnormal lung development leads to pulmonary hypoplasia and pulmonary hypertension

The Canadian Pediatric Surgery Network (CAPSNet) has been collecting population-based data regarding congenital diaphragmatic hernia (CDH) across its 17 perinatal sites since 2005. With500 infants registered to date, CAPSNet has addressed many critical knowledge gaps pertaining to CDH care. Most importantly, it has identified variability in both CDH practice and outcome across Canada. Using the successful Evidence-based Practice for Improving Quality (EPIQ) method, CAPSNet is undertaking a national, multidisciplinary effort to standardize best practices for CDH, from prenatal diagnosis to hospital discharge, based on the best available evidence. The present article outlines the value of clinical research networks and the process CAPSNet will undertake to produce national consensus guidelines for CDH care.Le Réseau canadien de chirurgie pédiatrique recueille des données en population sur la hernie diaphragmatique congénitale (HDC) dans 17 sites périnatals depuis 2005. Puisque plus de 500 nourrissons y sont inscrits jusqu’à présent, le Réseau a corrigé de nombreuses lacunes liées aux soins de la HDC. Qui plus est, il a décelé la variabilité dans la pratique et les résultats de la HDC au Canada. Selon la méthode EPIC (un acronyme anglais qui signifie pratique fondée sur des données probantes pour améliorer la qualité), le Réseau déploie des efforts nationaux et multidisciplinaires pour normaliser les pratiques exemplaires en matière de soins de la HDC, du diagnostic prénatal au congé de l’hôpital, d’après les meilleures données probantes. Le présent article souligne la valeur des réseaux de recherche clinique et le processus que le Réseau entreprendra pour produire des lignes directrices consensuelles nationales sur les soins de la HDC.

Evaluate trends in method of access (percutaneous cannulation vs open cannulation) for pediatric extracorporeal membrane oxygenation and determine the effects of cannulation method on morbidity and mortality.Retrospective cohort study.The Extracorporeal Life Support Organization's registry was queried for pediatric patients on extracorporeal membrane oxygenation for respiratory failure from 2007 to 2015.None.Of 3,501 patients identified, 77.2% underwent open cannulation, with the frequency of open cannulation decreasing over the study period from approximately 80% to 70% (p0.001). Percutaneous cannulation patients were more commonly male (24.2% vs 21.5%; p = 0.01), older (average 7.6 vs 4.5 yr; p0.001), and heavier (average 33.0 vs 20.2 kg; p0.001). Subset analysis of patients on venovenous extracorporeal membrane oxygenation revealed higher rates of mechanical complications due to blood clots (28.9% vs 22.6%; p = 0.003) or cannula problems (18.9% vs 12.7%; p0.001), cannula site bleeding (25.3% vs 20.2%; p = 0.01) and increased rates of cannula site repair in the open cannulation cohort. Limb related complications were not significantly different on subset analysis for venovenous extracorporeal membrane oxygenation patients stratified by access site. Logistic regression analysis revealed that method of access was not associated with a difference in mortality.The proportion of pediatric patients undergoing percutaneous extracorporeal membrane oxygenation cannulation is increasing. Mechanical and physiologic complications occur with both methods of cannulation, but percutaneous cannulation appears safe in this cohort. Further analysis is needed to evaluate long-term outcomes with this technique.

A previously healthy 2-year-old boy presented to the emergency department with a decreased level of consciousness. A physical examination was unremarkable except for miosis and atypical limb movements. The patient underwent an extensive workup, including the search for metabolic, infectious, neurologic, and toxicologic etiologies. An abdominal ultrasound was performed because the child continued to remain neurologically impaired with no cause identified on other investigations. The ultrasound revealed a persistent uncomplicated ileoileal intussusception. The patient was taken to the operating room for surgical reduction. The child recovered fully postoperatively. This case illustrates the rare presentation of intussusception encephalopathy, which can be a diagnostic dilemma, especially when none of the symptoms of intussusception are present. Endogenous opioid poisoning is hypothesized to be the cause of the miosis and may hint at the diagnosis and aid in early management.

Postoperative abscesses after perforated appendicitis have no clear risk factors or indications for percutaneous drainage. Our study addressed these two issues.A logistic regression model was used to delineate risk factors for postoperative abscess in children with perforated appendicitis treated during a recent 5-year period. Drainage of abscess was compared to antibiotic treatment.Postoperative abscess occurred in 42 (14.8%) of 284 patients. Higher WBC count, presence of bowel obstruction at presentation, diffuse peritonitis with a dominant abscess at surgery, and one specific surgeon were significantly associated with postoperative abscess, while fever or pain requiring narcotics at the time of abscess diagnosis was significantly associated with drainage. Compared to non-drainage, those drained had longer hospital stay including readmissions (15.9 ± 5.3 vs. 12.2 ± 4.6 days, p0.005) and less readmissions (9.5 vs. 33.3%, p = 0.06). Over the 5-year period, there was no increased trend in abscess occurrence (p = 0.56), but there was an increased trend in the use of percutaneous drainage (p = 0.02).The risk of a postoperative abscess can be predicted by specific clinical characteristics, surgical findings, and treatment-related factors. Percutaneous drainage was associated with longer hospital stays, but less readmissions.

Neonates with gastroschisis make up an increasing proportion of prolonged surgical NICU admissions. While infectious complications are known to increase patient morbidity, it is unclear whether they vary according to abdominal closure method, or can be predicted by initial patient assessment. A national, prospective, disease-specific database was evaluated for episodes of wound infection (WI) and catheter-related infection (CRI). Antibiotic use and timing, as well as method and location of abdominal closure were studied. The gastroschisis prognostic score (GPS) was calculated and evaluated as a predictor of infectious complications. Of 395 patients, 48 (12.6%) had a documented abdominal WI, and 59 patients (14.9%) had at least one episode of CRI-most commonly coagulase negative staphylococcus. Most abdominal closures took place within 6 h of admission (194 = 51.3%), while 132 (34.9%) were delayed greater than 24 h. The WI rate was greater in the delayed group (21.2 vs. 8.2%, p = 0.0006). The GPS was found to predict development of an infectious complication (WI + CRI, p = 0.04). Infectious complications remain an important consideration in the management of gastroschisis. GPS correlates with the development of infectious complications. Prophylaxis for skin flora and early closure, when feasible, may reduce WI rates.

The efficacy of exogenous surfactant administration is influenced by numerous factors, which has resulted in variable outcomes of clinical trials evaluating this treatment for the acute respiratory distress syndrome (ARDS). We investigated several of these factors in an animal model of acid aspiration including different surfactant preparations, and different delivery methods. In addition, high-frequency oscillation (HFO), a mode of mechanical ventilation known to recruit severely damaged lungs, was utilized. Lung injury was induced in adult rabbits via intratracheal instillation of 0.2 N HCl followed by conventional mechanical ventilation (CMV) until Pa(O2)/FI(O2) values ranged from 220 to 270 mm Hg. Subsequently, animals were given one of three surfactants administered via three different methods and physiological responses were assessed over a 1-h period. Regardless of the surfactant treatment strategy utilized, oxygenation responses were not sustained. In contrast, HFO resulted in a superior response compared with all surfactant treatment strategies involving CMV. The deterioration in physiological parameters after surfactant treatment was likely due to overwhelming protein inhibition of the surfactant. In conclusion, various surfactant treatment strategies were not effective in this model of lung injury, although the lungs of these animals were recruitable with HFO, as reflected by the acute and sustained oxygenation improvements.

A previously healthy, fully immunized, 14 kg four-year-old girl presented to the local emergency department with a seven-day history of upper respiratory tract symptoms and 24 h of fever, irritability and decreased oral intake. Her temperature on presentation was 38.9°C, heart rate 120 beats/min, respiratory rate 25 breaths/min, and blood pressure 90/60 mmHg. She was alert but irritable on physical examination, mildly volume-depleted and had evidence of meningismus. Her electrolytes were normal, notably a serum sodium concentration of 138 mmol/L, and there was pleocytosis of the cerebrospinal fluid. The patient was admitted with a working diagnosis of bacterial meningitis, given a 20 mL/kg normal saline bolus and commenced on intravenous (IV) vancomycin and ceftriaxone. She was started on maintenance IV fluids, consisting of dextrose 3.3% in NaCl 0.3% (‘2/3 – 1/3’) with KCl 20 mmol/L at 50 mL/h. She was also permitted to drink oral fluids as tolerated. Twenty-four hours later, the child’s irritability improved; however, she was noted to have headache and nausea. She was assessed by the paediatrician who reassured the family that these symptoms were consistent with meningitis. Her urine output was noted to be adequate, though it was not specifically quantified. Electrolytes were not repeated. That evening (36 h following admission), the patient was noted to be increasingly lethargic and subsequently had a generalized seizure. She was managed with IV lorazepam, followed by a phenobarbital load of 20 mg/kg. Stat electrolytes requested at the onset of the seizure revealed hyponatremia ([Na+]: 122 mmol/L). Hypertonic saline (3% NaCl) was administered, and arrangements were made for transfer to a tertiary care centre. En route she suffered a respiratory arrest, requiring intubation and ventilation. The child progressed to cardiac arrest, with unsuccessful resuscitation. In addition to evidence of meningitis (pathology and cultures were positive for Neisseria meningitidis, serotype B), the autopsy revealed severe cerebral edema with secondary brainstem herniation believed to be caused by the acute hyponatremia. Note: For privacy reasons, elements from published cases were used to construct this vignette (1,2). LEARNING POINTS Paediatric hyponatremia cases have been reported in the literature, the majority of which documented the use of hypotonic IV fluids (1).Though severe cases are infrequent, their devastating outcomes have prompted the emergence of recent research and evidence for safe IV fluid practices in children. Acute hyponatremia is defined as a fall in serum sodium concentration from normal to

Several factors have been shown to influence the efficacy of exogenous surfactant therapy in the acute respiratory distress syndrome. We investigated the effects of four different alveolar environments (control, saline-lavaged, N-nitroso- N-methylurethane, and hydrochloric acid) on the metabolic and functional properties of two exogenous surfactant preparations: bovine lipid extract surfactant and recombinant surfactant-associated protein (SP) C drug product (rSPC) administered to each of these groups. The main difference between these preparations was the lack of SP-B in the rSPC. Our results demonstrated differences in the large aggregate pool sizes recovered from each of the experimental groups. We also observed differences in SP-A content, surface area cycling characteristics, and biophysical activities of these large aggregate forms after the administration of the two exogenous surfactant preparations. We conclude that the alveolar environment plays a critical role, influencing the overall efficacy of exogenous surfactant therapy. Thus further preclinical studies are warranted to investigate the specific factors within the alveolar environment that lead to the differences observed in this study.

We report a case of a mesenchymal hamartoma of the liver in a twenty-month-old girl. The patient initially consulted her pediatrician, and was then referred to the emergency room for evaluation of a palpable upper midline abdominal mass. The initial referral questioned splenomegaly. Radiologic workup consisted of an abdominal ultrasound, followed by a magnetic resonance imaging (MRI) which showed a left hepatic lobe mass measuring 10 × 7 × 12 cm. The patient eventually underwent a left hepatectomy for excision of the mass. Postoperative course was complicated by a biliary leak secondary to an anatomic variant. The goal of this case report is to review the main features of liver hamartomas, and to discuss the possible anatomical variants of the biliary system that can be encountered in children.