Abusive head trauma and crying infant-Public awareness of newborn and infant trauma.

AIM: Crying seems to be a common trigger for abusive head trauma (AHT), which is the leading cause of fatalities from physical abuse in infants. Our objective was to evaluate knowledge of AHT, crying infants and correct behavioural measures in a general population. METHODS: An online questionnaire (LimeSurvey) was created to assess the risk of shaking. The online survey contained a total of 41 questions, including a demonstration of a previously recorded video in which an infant doll is shaken. RESULTS: A total of 319 people, 245 of them (76.8%) with own children, participated in the study. Almost all respondents (98.4%) were aware of serious injuries due to shaking, even to the point of death (98.1%). Most participants (97.5%) had heard the term 'shaking trauma' prior but did not receive any professional information, neither before nor after birth (85.2% or 86%), or during follow-up examinations (88.5%). The majority of the participants (95%) considered that useful coping strategies in infant crying were inappropriate. CONCLUSION: The consequences of shaking an infant were common knowledge in a normal population, whereas there was a knowledge gap regarding the management of excessive crying infants. Prevention programmes should mainly focus on male caregivers during postnatal care.

Distribution and pattern of hand fractures in children and adolescents.

Hand fractures represent commonly encountered injuries in pediatric patients. However, due to modern means of mobility and product safety, the occurrence and distribution of these fractures have changed during the last decades. Therefore, it was the aim of this study to present an update of the epidemiology, pattern, and treatment of hand fractures in a large pediatric cohort. All patients aged between 0 and 17 years treated in our Department in 2019 with fractures of the phalanges, metacarpus, or carpus were included. The medical records were reviewed for age, gender, injury mechanism, fracture localization, season, and treatment. Patients were divided into three different age groups (0-5, 6-12, and 13-17 years). A total of 731 patients with 761 hand fractures were treated during the 1-year study period. The mean age was 11.1 ± 3.5 years, and the majority was male (65%). Male patients were significantly older compared to female patients (p = 0.008). Also, 78.7% of the fractures affected the phalanges, 17.6% the metacarpals, and 3.7% the carpal bones. The proximal phalanges were the most commonly fractured bones (41.5%). Patients with fractures of the carpus were significantly older compared to children sustaining fractures of the metacarpus or phalangeal bones (p < 0.001). Sixteen percent of our patients were treated surgically; these patients were significantly older compared to conservatively treated patients (p = 0.011).  Conclusion: The epidemiology, mechanisms of injury, distribution, and treatment of hand fractures significantly varies among different age groups. This knowledge is of importance for educational purposes of younger colleagues entrusted with care of children and adolescents as well as development of effective prevention strategies. What is Known: • Pediatric hand fractures represent the second most common fractures in children. • The epidemiology of pediatric hand fractures has changed during the last decades and therefore there is a need for an update regarding distribution and epidemiology of pediatric hand fractures. What is New: • In this retrospective cohort study, 761 pediatric hand fractures of 731 patients were analyzed in detail. • The main mechanisms of younger patients were entrapment injuries, older children most commonly sustained their fractures due to ball sport injuries. There was an increasing rate of metacarpal and carpal fractures with increasing age, and these fractures had to be treated operatively more often than phalangeal fractures.

Outcome after surgical treatment of venous malformations of the hand in childhood.

OBJECTIVE: Surgical treatment of venous malformations (VMs) of the hand is challenging. The hand's small functional units, dense innervation, and terminal vasculature can be easily compromised during invasive interventions like surgery or sclerotherapy, leading to an increased risk of functional impairment, cosmetic consequences, and negative psychological effects. METHODS: We have conducted a retrospective review of all surgically treated patients diagnosed with VMs of the hand between 2000 and 2019 and evaluated their symptoms, diagnostic investigations, complications, and recurrences. RESULTS: Twenty-nine patients (females, n = 15) with a median age of 9.9 years (range, 0.6-18 years) were included. Eleven patients presented with VMs involving at least one of the fingers. In 16 patients, the palm and/or dorsum of the hand was affected. Two children presented with multifocal lesions. All patients presented with swelling. Preoperative imaging was done in 26 patients and consisted of magnetic resonance imaging in nine patients, ultrasound in eight patients, and both modalities in nine patients. Three patients underwent surgical resection of the lesions without any imaging. Indications for surgery were pain and restriction of function (n = 16), and when lesions were preoperatively evaluated as completely resectable (n = 11). In 17 patients, a complete surgical resection of the VMs was performed, whereas in 12 children, an incomplete resection of VM was deemed due to nerve sheath infiltration. At a median follow-up of 135 months (interquartile range, 136.5 months; range, 36-253 months), recurrence occurred in 11 patients (37.9%) after a median time of 22 months (range, 2-36 months). Eight patients (27.6%) were reoperated because of pain, whereas three patients were treated conservatively. The rate of recurrences did not significantly differ between patients presenting with (n = 7 of 12) or without (n = 4 of 17) local nerve infiltration (P = .119). All surgically treated patients who were diagnosed without preoperative imaging developed a relapse. CONCLUSIONS: VMs in the region of the hand are difficult to treat, and surgery is associated with a high recurrence rate. Accurate diagnostic imaging and meticulous surgery may contribute to improve the outcome of the patients.

Therapy preference of 131 parents confronted with a pediatric femoral fracture.

Background: The management of femoral fractures in children between 3 and 5 years of age is still vividly debated. Therefore, we aimed to assess the basic attitude of parents if confronted with a hypothetical femoral fracture of their toddler. Materials and methods: Parents of children aged between 12 and 36 months were asked for their preference after receiving detailed information on conservative and surgical treatment of femoral shaft fractures. Furthermore, we obtained information regarding the parents' gender, marital status, medical background, highest level of education and profession in a leading or non-leading position and if any of their children already had undergone any operations. The Freiburg Personality Inventory (FPI-R) questionnaire was used to assess parents' personality traits. Results: In total, 131 participants were included in this study. The vast majority (n = 116, 88.5%) preferred surgical treatment. The most frequently mentioned reasons for this decision were lack of acceptance, followed by faster reconvalescence, shorter hospital stay, less deformity or growth disorders and less stress on the child. The only reason stated against surgical treatment was the need of general anesthesia. A significantly higher rate of conservative procedures was noticed in self-employed participants and stress was found to significantly influence the treatment decision of the parents toward conservative treatment. Conclusion: The majority of parents confronted with a hypothetical femoral fracture of their child questioned in this study opted for a surgical approach with elastic stable intramedullary nailing (ESIN). This corresponds with trends toward surgery in these cases in major trauma centers in Europe.

Reliability of radiological measurements and treatment recommendations of displaced paediatric humeral medial epicondyle fractures.

There are conflicting recommendations regarding the amount of displacement necessitating stabilization of paediatric humeral medial epicondyle fractures. Our aim was to assess the reliability of the measurements of the displacement and the treatment recommendations of these fractures. The maximum displacement of 57 children with displaced humeral medial epicondyle fractures was analyzed on radiographs by six raters (4 paediatric surgeons, 2 paediatric radiologists) at two time points. In addition, the four surgeons recorded their treatment recommendation. Intraobserver and interobserver reliability were calculated with intraclass correlation coefficients (ICC) and Kappa values. The ICC for the intraobserver reliability ranged between 0.67 and 0.93. The raters disagreed with their own measurements between 8.8% and 28.1%. The ICC for the interobserver reliability of all six raters was 0.90 for measurement 1 and 0.93 for measurement 2. All six raters disagreed (difference > 2mm) in 93% of the cases in measurement 1 and in 91.2% in measurement 2. Treatment recommendations of the four paediatric surgeons between the two time points differed in 5.3% to 28.1% of the cases. Furthermore, the treatment recommendations were concordant in 24 cases (42%) at time point 1 and 32 cases (56.1%) at time point 2. In displaced paediatric medial epicondyle fractures, disagreement regarding measurement of displacement and recommendation for treatment is high. Validated and standardized measurement tools and a clear threshold for operative fixation of displaced medial epicondyle fractures are needed.

Insights into the Composition of a Co-Culture of 10 Probiotic Strains (OMNi BiOTiC® AAD10) and Effects of Its Postbiotic Culture Supernatant.

BACKGROUND: We aimed to gain insights in a co-culture of 10 bacteria and their postbiotic supernatant. METHODS: Abundances and gene expression were monitored by shotgun analysis. The supernatant was characterized by liquid chromatography mass spectroscopy (LC-MS) and gas chromatography mass spectroscopy (GC-MS). Supernatant was harvested after 48 h (S48) and 196 h (S196). Susceptibility testing included nine bacteria and C. albicans. Bagg albino (BALBc) mice were fed with supernatant or culture medium. Fecal samples were obtained for 16S analysis. RESULTS: A time-dependent decrease of the relative abundances and gene expression of L. salivarius, L. paracasei, E. faecium and B. longum/lactis and an increase of L. plantarum were observed. Substances in LC-MS were predominantly allocated to groups amino acids/peptides/metabolites and nucleotides/metabolites, relating to gene expression. Fumaric, panthotenic, 9,3-methyl-2-oxovaleric, malic and aspartic acid, cytidine monophosphate, orotidine, phosphoserine, creatine, tryptophan correlated to culture time. Supernatant had no effect against anaerobic bacteria. S48 was reactive against S. epidermidis, L. monocytogenes, P. aeruginosae, E. faecium and C. albicans. S196 against S. epidermidis and Str. agalactiae. In vivo S48/S196 had no effect on alpha/beta diversity. Linear discriminant analysis effect size (LEfSe) and analysis of composition of microbiomes (ANCOM) revealed an increase of Anaeroplasma and Faecalibacterium prausnitzii. CONCLUSIONS: The postbiotic supernatant had positive antibacterial and antifungal effects in vitro and promoted the growth of distinct bacteria in vivo.

Chylous content might determine the optimal surgical approach for mesenteric lymphatic malformations in childhood.

BACKGROUND: Mesenteric lymphatic malformations (LMs) represent rare congenital anomalies that can include chylous or nonchylous content. The pathologic mechanisms explaining this phenomenon are poorly understood and not yet described. Furthermore, the current management approach does not consider the contents of the mesenteric LMs. In the present study, we have defined the relationship between the lymphatic mesenteric cyst content and the histologic evidence of LMs within the bowel wall. METHODS: We retrospectively investigated all patients with mesenteric LMs treated surgically at our department from 1999 to 2018. RESULTS: A total of 11 patients (6 girls and 5 boys) were included in our analysis. Seven patients had presented with LMs located in the jejunal mesentery, three in the ileocecal region, and only one in the mesocolon transversum and omentum. Of the 11 children, 7 had had LMs with nonchylous content and 4 had presented with chylous content LMs. Intestinal resection was performed in all 4 patients with chylous content LMs and 4 patients with nonchylous content LMs. Histopathologic evaluation of the surgical specimens determined that only the LMs with chylous content displayed malformed lymphatic channels throughout the bowel wall. The resected small bowel of four patients with nonchylous content showed no LM extension throughout the intestinal wall. CONCLUSIONS: LMs with chylous content seem to develop from malformed lymphatic channels within the bowel wall. In such cases, segmental intestinal resection is mandatory. In contrast, mesenteric LMs with nonchylous content can potentially be treated without bowel resection if the blood supply can be preserved. This finding is, to the best of our knowledge, reported in the present study for the first time.

Child safety programs for primary school children decrease the injury severity of dog bites.

This study focuses on the impact of a prevention program regarding dog bites in children. As a consequence of our previous investigation in 2005, we have initiated a child safety program for primary school children starting January 2008 until present to teach children how to avoid dog attacks and how to behave in case of an attack. In our retrospective study, we analyzed all patients younger than 15 years presenting with dog-related injuries between 2014 and 2018. As the main indicator for success of the prevention measures taken, we have defined the severity of injury in comparison to our previous study. Out of 296 children with dog-related injuries, 212 (71.6%) had sustained a dog bite. In the vast majority (n = 195; 92%), these patients presented with minor injuries; the extremities were most commonly affected (n = 100; 47%). Injuries to the head (n = 95; 45%) and trunk (n = 18; 8%) were less frequent. The proportion of severe injuries (8%) was significantly lower compared to our previous study, where 26% of children presented with severe injuries necessitating surgical intervention, while the number of patients requiring in-hospital treatment declined from 27.5% in the period 1994-2003 to 9.0% in the period between 2014 and 2018 (p < 0.05).Conclusion: Teaching of primary school children may effectively reduce the injury severity of dog bites. What is Known: • Dog bites are a substantial healthcare problem especially in children. What is New: • This study shows that a broad-based prevention program for primary school children can effectively decrease the severity but not the frequency of dog bite injuries in children.

The Financial Burden of Surgery for Congenital Malformations-The Austrian Perspective.

Neonatal "surgical" malformations are associated with higher costs than major "non-surgical" birth defects. We aimed to analyze the financial burden on the Austrian health system of five congenital malformations requiring timely postnatal surgery. The database of the Austrian National Public Health Institute for the period from 2002 to 2014 was reviewed. Diagnosis-related group (DRG) points assigned to hospital admissions containing five congenital malformations coded as principal diagnosis (esophageal atresia, duodenal atresia, congenital diaphragmatic hernia, gastroschisis, and omphalocele) were collected and compared to all hospitalizations for other reasons. Out of 3,518,625 total hospitalizations, there were 1664 admissions of patients with the selected malformations. The annual mean number was 128 (SD 17, range 110-175). The mean cost of the congenital malformations per hospital admission expressed in DRG points was 26,588 (range 0-465,772, SD 40,702) and was significantly higher compared to the other hospitalizations (n = 3,516,961; mean DRG 2194, range 0-834,997; SD 6161; p < 0.05). Surgical conditions requiring timely postnatal surgery place a significant financial burden on the healthcare system. The creation of a dedicated national register could allow for better planning of resource allocation, for improving the outcome of affected children, and for optimizing costs.

Cardiorespiratory performance and locomotor function of patients with anorectal malformations.

The aim of this study was to assess whether adolescents following anorectal malformation repair have a decreased cardiorespiratory performance capacity and impaired motor skills. All eligible children treated for ARMs between 2000 and 2014 were invited to participate in a prospective study consisting of a clinical examination, evaluation of Bowel function and Quality of Life, spirometry, spiroergometry and assessment of the motor activity. The results were compared to a healthy age- and sex-matched control group. There was no statistically significant difference in height, weight, BMI, muscle mass or body fat percentage between the study and the control group. Nine out of 18 patients (50%) had an excellent functional outcome with a normal Bowel Function Score. Spirometry revealed no significant differences between ARM patients and controls, four patients showed a ventilation disorder. Spiroergometry revealed a significantly lower relative performance capacity and the overall rating of the motor activity test showed significantly decreased grades in ARM patients. ARM patients were affected by an impaired cardiopulmonary function and decreased motor abilities. Long-term examinations consisting of routine locomotor function evaluation and spiroergometry are advisable to detect impaired cardiopulmonary function and to prevent a progression of associated complications and related impaired quality of life.

Trauma in pediatric urology.

In pediatric trauma, the kidney is the most commonly injured organ of the urinary tract. Renal trauma occurs in 10% to 20% of all pediatric blunt abdominal trauma cases. The vast majority of renal injuries can be treated conservatively. However, cases associated with hemodynamic instability require operative interventions. Injuries to the ureter, bladder or urethra are almost exclusively encountered in polytraumatized children. The aim of this article is to give an overview on traumatic injuries to the pediatric urinary system.

Laparoscopic Treatment of Gastroesophageal Reflux Disease in Children: How We Do It.

Over decades now, laparoscopic Nissen fundoplication represents the treatment of choice for symptomatic children with gastroesophageal reflux disease (GERD) unresponsive to medication. Although the basic principles of Nissen's technique are still essential today, academic studies of long-term results, complications, and patients benefits have fostered distinct modifications. Identification of surgical factors for wrap migration, dysphagia, and recurrent GERD led to recommendations for "short and floppy" wraps with minimal dissection of the phrenoesophageal membranes. This report summarizes up-to-date information from experts in the field on "how to wrap it right" followed by a critical discussion about long-term benefits for children with GERD and future developments of laparoscopic Nissen fundoplication.

Rapidly involuting congenital hemangioma of the liver in a newborn with incomplete Pentalogy of Cantrell: description of a new association.

The perinatal management of newborns with giant omphaloceles requires careful suspicion concerning 'unexpected' associated malformations. We describe a newborn with a combination of incomplete Pentalogy of Cantrell consisting of giant omphalocele, anterior congenital diaphragmatic hernia (CDH) and pericardial absence complicated by a hepatic rapidly involuting congenital hemangioma (RICH). A giant omphalocele was detected prenatally. Postnatally, staged closure of the omphalocele was planned. A mass of the liver was noted and (mis-)taken for a hematoma. In the further course, the baby developed cardiorespiratory insufficiency due to a central CDH which was excised. Subsequently, staged closure of the omphalocele became impossible. Specific workup revealed a mass in the left liver lobe. The mass was resected and the abdominal wall defect repaired. Histology confirmed the diagnosis of an RICH. The surgical treatment of newborns with giant omphaloceles requires a multidisciplinary neonatal support and an elaborate pediatric surgical armamentarium to cope with additional malformations.

Cardiorespiratory performance capacity and airway microbiome in patients following primary repair of esophageal atresia.

BACKGROUND: Patients following repair of an esophageal atresia (EA) or tracheoesophageal fistula (TEF) carry an increased risk of long-term cardiopulmonary malaise. The role of the airway microbiome in EA/TEF patients remains unclear. METHODS: All EA/TEF patients treated between 1980 and 2010 were invited to a prospective clinical examination, spirometry, and spiroergometry. The airway microbiome was determined from deep induced sputum by 16 S rRNA gene sequencing. The results were compared to a healthy age- and sex-matched control group. RESULTS: Nineteen EA/TEF patients with a mean age of 24.7 ± 7 years and 19 age- and sex-matched controls were included. EA/TEF patients showed a significantly lower muscle mass, lower maximum vital capacity (VCmax), and higher rates of restrictive ventilation disorders. Spiroergometry revealed a significantly lower relative performance capacity and lower peak VO2 in EA/TEF patients. Alpha- and beta-diversity of the airway microbiome did not differ significantly between the two groups. Linear discriminant effect size analysis revealed significantly enriched species of Prevotella_uncultured, Streptococcus_anginosus, Prevotella_7_Prevotella_enoeca, and Mogibacterium_timidum. CONCLUSION: EA/TEF patients frequently suffer from restrictive ventilation disorders and impaired cardiopulmonary function associated with minor alterations of the airway microbiome. Long-term examinations of EA/TEF patients seem to be necessary in order to detect impaired cardiopulmonary function. IMPACT: The key messages of the present study are a significantly decreased VCmax and exercise performance, as well as airway microbiome differences in EA/TEF patients. This study is the first to present parameters of lung function and exercise performance in combination with airway microbiome analysis with a mean follow-up of 24 years in EA/TEF patients. Prospective, long-term studies are needed to unravel possible interactions between alterations of the airway microbiome and impaired pulmonary function in EA/TEF patients.

Feasibility of the ultrasound-guided supraclavicular cannulation of the brachiocephalic vein in very small weight infants: A case series.

BACKGROUND: The aim of this retrospective analysis was to evaluate the clinical feasibility of the supraclavicular ultrasound-guided cannulation of the brachiocephalic vein in infants weighing less than 1500 g. METHODS: The ultrasound probe was placed in the supraclavicular region so as to obtain the optimum sonographic long-axis view of the brachiocephalic vein. By using an in-plane approach the brachiocephalic vein was cannulated by using a 24-gauge intravenous cannula under real-time ultrasound guidance into the vein followed by the insertion of a 2-French single lumen catheter using the Seldinger technique. RESULTS: Forty-six brachiocephalic vein cannulations in infants weighing between 0.55 and 1.5 kg (Median: 1.2; 95%-CI: 0.9-1.2) were included. Ultimate success rate was 89.1% (41 out of 46). One cannulation attempt was required in 30 (65.2%) patients, 2 in 6 (13%) and 3 in 5 (10.8%), respectively. Smaller weight babies did not require significantly more cannulation attempts. The probability of successful cannulation on the first attempt increased significantly from 40% (2010) to more than 80% (2019) over the time course of this series. Median catheter dwell time was 15 days (95%-CI: 9-20) with one catheter being removed prematurely after 8 days due to obstruction. CONCLUSION: Supracalvicular in-plane real-time ultrasound-guided cannulation of the brachiocephalic vein seems to be a convenient and feasible option to provide large-bore central venous access for very small and sick babies.

Diagnostic and Clinical Management of Skull Fractures in Children.

OBJECTIVE: The indications of routine skull X-rays after mild head trauma are still in discussion, and the clinical management of a child with a skull fracture remains controversial. The aim of our retrospective study was to evaluate our diagnostic and clinical management of children with skull fractures following minor head trauma. METHODS: We worked up the medical history of all consecutive patients with a skull fracture treated in our hospital from January 2009 to October 2014 and investigated all skull X-rays in our hospital during this period. RESULTS: In 5217 skull radiographies, 66 skull fractures (1.3%) were detected. The mean age of all our patients was 5.9 years (median age: 4.0 years); the mean age of patients with a diagnosed skull fracture was 2.3 years (median age: 0.8 years). A total of 1658 children (32%) were <2 years old. A typical boggy swelling was present in 61% of all skull fractures. The majority of injuries were caused by falls (77%). Nine patients (14%) required a computed tomography (CT) scan during their hospital stay due to neurological symptoms, and four patients had a brain magnetic resonance imaging. Nine patients (14%) showed an intracranial hemorrhage (ICH; mean age: 7.3 years); one patient had a neurosurgery because of a depressed skull fracture. Nine patients (14%) were observed at our pediatric intensive care unit for a mean time of 2.9 days. The mean hospital stay was 4.2 days. CONCLUSIONS: Our findings support previous evidence against the routine use of skull X-rays for evaluation of children with minor head injury. The rate of diagnosed skull fractures in radiographs following minor head trauma is low, and additional CT scans are not indicated in asymptomatic patient with a linear skull fracture. All detected ICHs could be treated conservatively. Children under the age of 2 years have the highest risk of skull fractures after minor head trauma, but do not have a higher incidence of intracranial bleeding. Neuroobservation without initial CT scans is safe in infants and children following minor head trauma and CT scans should be reserved for patients with neurological symptoms.

Foreskin reconstruction and preservation of a thin distal urethra: a challenge in tubularized incised plate urethroplasty.

PURPOSE: The aim of this retrospective study was to evaluate the functional and cosmetic outcome of tubularized incised plate urethroplasty (TIPU) with preputial reconstruction and preservation of a thin distal urethra when applicable. METHODS: The records of 64 boys with hypospadias, who underwent TIPU between 2000 and 2007 were analyzed. 33 (52%) underwent foreskin reconstruction and a thin distal urethra was preserved and incorporated in 19 (30%) patients. The Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), and uroflowmetry were evaluated in 55 boys (86%) after a mean of 4.8 years. RESULTS: All patients had a vertically oriented meatus. The overall rate of fistula occurrence was 9% and of wound dehiscence, 5%. Among 33 preputial reconstructions, two (6%) patients had dehiscence and three (9%) had a fistula. No cases of stricture or stenosis occurred. There were significantly more complications with reconstruction of the foreskin (p = 0.012) and preservation of a thin distal urethra (p = 0.021). Uroflowmetry was normal in 76% of patients. PPPS and HOSE revealed excellent results. CONCLUSION: TIPU produces excellent cosmetic and functional results with few complications; complications are more common after foreskin reconstruction and use of a thin distal urethra.