The Safety and Efficacy of Early Enteral Nutrition After Paediatric Enterostomy Closure - The EPOC Study.

INTRODUCTION: Keeping children nil by mouth until return of bowel function after intestinal anastomosis surgery is said to reduce complications. Fasting may extend up to five days, risking malnourishment and usage of parenteral nutrition. This study aims to establish the efficacy and safety of early enteral nutrition in children undergoing intestinal stoma closure. METHODOLOGY: A retrospective cohort study of children aged three months to 16 years who underwent an intestinal stoma closure between 1/1/2019 and 31/12/2021 at two tertiary paediatric hospitals was undertaken. Children fed clear fluids within 24 h (EEN) were compared to those commencing feeds later (LEN). The primary outcome was length of post-operative stay (LOS) and secondary outcomes included: time to feeds; time to stool; and complications. RESULTS: Of the 129 children that underwent a stoma closure, 69 met inclusion criteria: 35 (51 %) in the LEN group and 34 (49 %) in the EEN group. Children in the EEN group had a significantly shorter LOS (92.6 h vs 121.7 h, p = 0.0045). Early feeding was also associated with a significantly decreased time to free fluids (p < 0.001) and full enteral intake (p = 0.007). There was no significant intergroup difference in complications. CONCLUSION: Commencing feeding within 24 h of stoma closure is efficacious and safe, with clear reductions in LOS, time to full feeds and time to stool, and no increase in complications. Further research is required to extrapolate these findings to other populations. LEVEL OF EVIDENCE: III.

Neonatologist-performed point-of-care abdominal ultrasound: What have we learned so far?

This review describes the sonographic appearances of the neonatal bowel in Necrotising enterocolitis. It compares these findings to those seen in midgut-Volvulus, obstructive intestinal conditions such as milk-curd obstruction, and slow gut motility in preterm infants on continuous positive airway pressure (CPAP)-CPAP belly syndrome. Point-of-care bowel ultrasound is also helpful in ruling out severe and active intestinal conditions, reassuring clinicians when the diagnosis is unclear in a non-specific clinical presentation where NEC cannot be excluded. As NEC is a severe disease, it is often over-diagnosed, mainly due to a lack of reliable biomarkers and clinical presentation similar to sepsis in neonates. Thus, the assessment of the bowel in real-time would allow clinicians to determine the timing of re-initiation of feeds and would also be reassuring based on specific typical bowel characteristics visualised on the ultrasound.

Comparative analysis of off-road vehicle crashes in children: motorcycles versus quad bikes.

OBJECTIVE: To characterise and compare off-road motorcycle and quad bike crashes in children in New South Wales (NSW), Australia. METHODS: A retrospective, cross-sectional study was performed of children aged 0-16 years, admitted to hospitals in NSW, from 2001 to 2018 following an injury sustained in an off-road motorcycle or quad bike crash, using linked hospital admissions, mortality and census data.Motorcycle and quad bike injuries were compared regarding: demographics; incidence; body region injured and type of injury; injury severity based on the survival risk ratio; length of stay and mortality. RESULTS: There were 6624 crashes resulting in hospitalisation; 5156 involving motorcycles (77.8%) and 1468 involving quad bikes (22.2%). There were 10 fatalities (6 from motorcycles and 4 from quad bikes). The rates of injury declined over the study period for motorcycles, but not for quad bikes.Motorcycle riders were more likely than quad bike riders to have lower limb injuries (OR 1.49, p<0.001) but less likely to have head/neck (OR 0.616, p<0.001), abdominal (OR 0.778, p=0.007) and thoracic (OR 0.745, p=0.003) injuries. Quad bike crashes resulted in higher injury severity (mean International Classification Injury Severity Score 0.975 vs 0.977, p=0.03) and longer hospital stay (mean 2.42 days vs 2.09 days, p=0.01). CONCLUSIONS: There are significant differences between quad bike and motorcycle crashes in injury type and affected body region. While quad bike injuries in children were more severe, there were almost four times more hospitalisations from motorcycles overall. The overall larger burden of motorcycle crashes suggests a greater focus of injury prevention countermeasures for two-wheeled riders is needed.

Paediatric off-road vehicle injury in rural and regional Australia.

OBJECTIVE: Off-road riding of quad bikes and motorcycles is common among children across rural and remote Australia, but is a significant source of injury and hospitalisation. An in-depth analysis of paediatric off-road vehicle crashes was undertaken to inform injury prevention countermeasures by characterising injury patterns and sources of injury. DESIGN: This is a prospective in-depth case series. PARTICIPANTS: Participants are children aged 16 and under who have been hospitalised due to injury sustained from the use of an off-road motorcycle or quad bike in New South Wales, Australia. INTERVENTIONS: Crash investigation techniques (medical data, structured interview, vehicle and crash site inspection) were used to ascertain details of the crash event, protective gear, injury information and contributory factors. RESULTS: Thirty children were recruited, 27 boys and 3 girls, ranging in age from 4 to 16 years, having crashed on off-road motorcycles (n = 27) or quads (n = 3). Most (73.3%) were participating in unstructured social riding. A total of 67 separate injuries were observed, with overall Injury Severity Scores between 1 and 35. There were high rates of wearing helmets and motorcycle-specific garments. The most commonly injured areas were the upper and lower extremities. The most common sources of injury were from impacting the ground, obstacles/other riders or the vehicle. CONCLUSION: This study demonstrates the patterns of riding and injury in rural paediatric off-road vehicle riders, occurring despite high rates of helmet/protective gear use. This underscores the need for investigation into the injury mitigation and fit properties of protective gear and the inherent risks for physically and developmentally maturing children.

Traumatic duodenal injuries in children: a single-centre study.

BACKGROUND: Traumatic duodenal injuries in children are rare, and few studies have documented duodenal injuries in children, especially in Australasia. This study assessed the mechanism, investigations, management and outcomes of children (aged <16 years) with duodenal injuries. METHODS: Retrospective review was conducted over a 16-year period from a single paediatric trauma centre. RESULTS: Sixteen cases of duodenal injuries were identified: 15 cases of blunt duodenal injury and only one case of penetrating injury. Motor vehicular accidents were the most common cause of injury, followed by auto-pedestrian injuries and handlebar injuries. Only grade I and II injuries were identified. Computed tomography aided diagnosis in all cases of blunt duodenal injuries, especially given the variable nature of symptoms. Eight patients underwent laparotomy, of whom five required duodenal repair. Three patients underwent primary repair with omental patch, one patient underwent primary repair with gastrostomy and one patient underwent two-layered repair with t-tube duodenostomy. There were no delays in operative management within 24 h and no complications identified. CONCLUSION: In comparison to other paediatric trauma centres worldwide, the majority of duodenal injuries were low grade and attributed to blunt trauma. Computed tomography aided diagnosis in all cases of blunt duodenal injury. Primary repair of duodenal injuries was possible in the majority of cases requiring operative repair.

Open Versus Ultrasound Guided Tunneled Central Venous Access in children: A Randomized Controlled Study.

BACKGROUND: The purpose of this study was to compare open insertion to ultrasound guided percutaneous insertion of central access catheters performed in a tertiary pediatric hospital in terms of its safety and complication rates. METHODS: This was an ethics approved prospective randomized trial of children under 16 y of age. Procedure was performed by surgeons with varying experience with percutaneous and open insertion. Primary outcome studied was complications-immediate and late. Secondary outcomes were time taken to complete procedure, conversion rates, duration of line use. RESULTS: A total of 108 patients were analyzed. Sixty-four were male. Right internal jugular vein was accessed in 97. Eighty-one lines were double lumen, 23 implantable access devices, and the rest were single lumen catheters. More than one needle puncture was needed in 22% of the cases but there were no conversions in the ultrasound group. Twelve patients needed more than one insertion to achieve optimal position of the tip. Eleven patients had immediate and late complications. Percutaneous lines lasted 45 d longer though this was not statistically significant. Operating time was 20.6% shorter with percutaneous access. Post-removal measurement of vein size by ultrasound demonstrated significant decrease in size in the open group. CONCLUSIONS: Ultrasound guided percutaneous insertion was safe. The study also demonstrated a decrease in operating times, preservation of vein size, and no increase in complication rates in the US group when performed by operators of varying expertise.

Observational study of falls in children from windows and balconies: What has changed?

AIM: To describe patterns of injury from window and balcony falls in children presenting to a tertiary paediatric trauma centre in New South Wales. METHODS: A retrospective review of cases of children <15 years who had sustained injuries in a fall from a building, identified from the trauma database between 1998 and 2019. RESULTS: A total of 381 falls from windows and balconies were recorded over the 22-year study period. There were 218 falls from windows (57%) and 163 from balconies. The majority (64%) were children under 4 years of age. The male to female ratio was 2:1. While many children sustained simple abrasions, contusions and lacerations, 17% sustained injuries with an injury severity scores of ≥12. There were four deaths. CONCLUSIONS: This study identified that children falling from buildings remains a problem in Australia. Although many injuries were minor, severe injuries and fatalities continue to occur.

Surgeon Performed Ultrasound for Diagnosis of Intussusception - A Pilot Study.

Aim: To study the diagnostic accuracy of surgeon performed ultrasound (SPU) in the diagnosis of children presenting with clinical suspicion of intussusception to a tertiary paediatric facility in NSW, Australia. Methods: Children under the age of 16 presenting to the emergency department with clinical features suggestive of intussusception were recruited. After obtaining consent SPU was performed by a Paediatric surgeon. All patients subsequently had an ultrasound performed in radiology department (RPU) on which management was based. Diagnosis and images of SPU were reviewed by an independent radiologist blinded to results of the formal study. Results: Of 7 children enrolled 5 were male. Age ranged from 3 months to 7 years (mean 2.64, SD 2.282), weight from 5.2kgs to 25.2kgs (mean 13.69, SD 6.721). Five out of the 7 children presented during day hours i.e. 8a.m.-5 p.m. (mean 12.72, SD 4.049). Mean time to SPU was 6.3 hours (SD7.1) and RPU was 8.3 hours (SD 7.6). SPU was earlier by 2 hours and correlation between SPU and RPU was 100 percent. Conclusion: SPU for intussusception can be performed early and accurately. Surgeons should train and use ultrasound as a reliable tool in evaluating the child with suspected intussusception.

Trends of traumatic spinal injury-related hospitalizations in Australian children over a 10-year period: a nationwide population-based cohort study.

BACKGROUND CONTEXT: Despite its potential to cause serious and life-long disability or death, population-based data on traumatic spinal injury in pediatric populations is scarce. PURPOSE: To quantify and describe the incidence and cost of hospitalizations for traumatic spinal injury among Australian children, and to examine the trend over a 10-year period. STUDY DESIGN: Population-based retrospective cohort study. PATIENT SAMPLE: Children aged ≤16 years who were hospitalized for traumatic spinal injury in Australia during 1 July 2002 to 30 June 2012. OUTCOME MEASURES: Age-standardized hospital admission rates. METHODS: This study used linked hospitalization and mortality data. Age-standardized hospitalization rates were calculated with 95% confidence intervals (CIs). Negative binomial regression was used to examine change in temporal trends in hospitalization rates. RESULTS: There were 4,360 hospitalizations for pediatric traumatic spinal injury during the 10-year study period. Males and older children were more frequently hospitalized, and falls and road trauma accounted for almost three-quarters of hospitalizations. The average overall annual hospitalization rate was 9.43 (95% CI: 9.15-9.72) per 100,000 population, with an annual percent change of 1.2% (95% CI: -0.1% to 2.4%). There was an increase in the annual hospitalization rate for spinal dislocations, sprains, and strains (3.0% [95% CI: 0.8%-5.3%]) and among female children (1.7% [95% CI: 0.0%-3.4%]). The estimated total hospital treatment costs were AUD$43 million over the 10-year study period, with an estimated mean cost per child of AUD$9,867. CONCLUSIONS: Pediatric traumatic spinal injury is associated with significant morbidity and mortality. The burden of hospitalized pediatric traumatic spinal injury in Australia is rising, in particular spinal dislocations, sprains, and strains among female children. Targeted prevention strategies are needed to reduce the burden of pediatric traumatic spinal injury. It is recommended that a coordinated national strategy for preventing childhood traumatic spinal injury is developed and implemented in Australia.

The Predictors for Positive Yield Abdominal Computed Tomography in Pediatric Abdominal Trauma.

OBJECTIVES: Abdominal computed tomography (ACT) use in the initial evaluation of pediatric abdominal trauma is liberal in most instances. The aim of this study was to identify the predictors for a positive yield ACT scan in this population. METHODS: A prospective, cohort, single-center observational study was conducted at Children's Hospital at Westmead, New South Wales, from January 2008 to June 2015 on 240 pediatric abdominal trauma patients who had abdominal computed tomography. Clinical, laboratory, imaging, and interventional variables were explored with univariate and multivariate analyses among children who sustained abdominal trauma. RESULTS: Of 240 patients, positive ACT scans were found in 161 patients (67%), 112 patients (47%) had intra-abdominal injury, and 20 patients (8%) required invasive therapeutic interventions. Mortality rate was 1.7% (4 patients) due to nonabdominal causes. Multivariate analyses revealed that increasing age (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.02-1.24; P = 0.024), high injury severity score (OR, 1.14; 95% CI, 1.07-1.21; P < 0.001), abnormal abdominal examination (OR, 5.95; 95% CI, 2.08-17.01; P = 0.001), elevated alanine aminotransferase greater than 125 IU/L (OR, 46.28; 95% CI, 2.81-762.49; P = 0.007), abnormal pelvic radiograph (OR, 14.03; 95% CI, 2.39-82.28; P = 0.003), presence of gross hematuria (OR, 4.14; 95% CI, 1.04-18.23; P = 0.044), low initial hematocrit level (less than 30%) (OR, 8.51; 95% CI, 1.14-63.70; P = 0.037), and positive focused assessment with sonography for trauma (OR, 2.61; 95% CI, 1.01-7.28; P = 0.048) remained significantly associated with abnormal ACT scan. In contrast, those who required scanning of other body region(s) were less likely to have abnormal ACT scan (OR, 0.34; 95% CI, 0.14-0.86; P =0.022). CONCLUSIONS: Integrating the abdominal examination findings, relevant laboratory values, and focused assessment with sonography for trauma results with the physicians' suspicion may aid in stratifying patients for ACT scan. Further efforts should be made to decrease number of normal ACT scans; yet not to increase the number of delayed or missed injures with its inherent morbidity and mortality.

Determining the priorities for change in paediatric trauma care delivery in NSW, Australia.

BACKGROUND: Injury remains the leading cause of death and disability for Australian children. There is known variability in the quality of care delivered to injured children in Australia. This study prioritises recommendations developed from an expert review of paediatric trauma cases, for implementation with the aim of improving health service delivery to children sustaining severe injury. METHODS: A modified-Delphi study was conducted between October 2018 and February 2019. Two rounds of an online survey to rank the suitability and importance of each of the 26 recommendations was conducted. Final decisions on the priorities for change in the paediatric trauma system was determined by a consensus of ≥80% for importance and/or suitability. RESULTS: One hundred and one participants completed Round 1, and 60 participants completed Round 2 of the modified-Delphi. In Round 1, 13 recommendations reached ≥80% and in round 2, 11 recommendations reached ≥80%. Those ranked highest focussed on pre-hospital airway management, streamlining retrieval and transfer processes, improving hospital nursing ratios and radiology reporting. CONCLUSION: This modified-Delphi study identified the priority areas for recommended change to the NSW paediatric trauma system. Work to address these areas has the potential to provide more coordinated and timely care to children sustaining severe injury.

Radiation exposure in infants with oesophageal atresia and tracheo-oesophageal fistula.

PURPOSE: Oesophageal atresia and tracheo-oesophageal atresia require surgical repair in early infancy. These children have significant disease-related morbidity requiring frequent radiological examinations resulting in an increased malignancy risk. METHODS: A single-centre, retrospective review was performed of radiation exposure in children with OA/TOF born 2011-2015. Medical records were reviewed to determine the number and type of imaging studies involving ionising radiation exposure enabling the calculation of the estimated effective dose per child over the first year of life. RESULTS: Forty-nine children were included. Each child underwent a median of 19 (IQR 11.5-35) imaging studies, which were primarily plain radiography (median = 14, IQR 7-26.5). The overall median estimated effective dose per patient was 4.7 (IQR 3.0-9.4) mSv, with the majority of radiation exposure resulting from fluoroscopic imaging (median 3.3 mSv, IQR 2.2-6.0). 'Routine' postoperative oesophagrams showed no leak in 35/36 (97%) with the remaining study showing an insignificant leak that did not alter management. CONCLUSIONS: Careful consideration should be given to the use of imaging in OA/TOF to minimise morbidity in these vulnerable infants. Oesophagrams in children without the symptoms of anastomotic leak or stricture should be discontinued. Standardisation of monitoring protocols with regard to radiation exposure should be considered.

Identifying areas for improvement in paediatric trauma care in NSW Australia using a clinical, system and human factors peer-review tool.

BACKGROUND: There is known variability in the quality of care delivered to injured children. Identifying where care improvement can be made is critical. This study aimed to review paediatric trauma cases across the most populous Australian State to identify factors contributing to clinical incidents. METHODS: Medical records from three New South Wales Paediatric Trauma Centres were reviewed for children <16 years requiring intensive care; with an injury severity score of ≥9, or who died following injury between July 2015 and September 2016. Records were peer-reviewed by nurse surveyors who identified cases that might not meet the expected standard of care or where the child died following the injury. A multidisciplinary panel conducted the peer-review using a major trauma peer-review tool. Records were reviewed independently, then discussed to establish consensus. RESULTS: A total 535 records were reviewed and 41 cases were peer-reviewed. The median (IQR) age was 7 (2-12) years, the median ISS was 25 (IQR 16-30). The peer-review identified a combination of clinical (85%), systems (51%) and communication (12%) problems that contributed to difficulties in care delivery. In 85% of records, staff actions were identified to contribute to events; with medical task failure the most frequently identified cause (89%). CONCLUSION: The peer-review of paediatric trauma cases assisted in the identification of contributing factors to clinical incidents in trauma care resulting in 26 recommendations for change. The prioritisation and implementation of these recommendations, alongside a uniform State-wide trauma case review process with consistent criteria (definitions), performance indicators, monitoring and reporting would facilitate improvement in health service delivery to children sustaining severe injury.

Complexity of gastroschisis predicts outcome: epidemiology and experience in an Australian tertiary centre.

BACKGROUND: Gastroschisis is a congenital anomaly of the fetal abdominal wall, usually to the right side of umbilical insertion. It is often detected by routine antenatal ultrasound. Significant maternal and pediatric resources are utilised in the care of women and infants with gastroschisis. Increasing rates of gastroschisis worldwide have led institutions to review local data and investigate outcomes. A collaborative project was developed to review local epidemiology and investigate antenatal and neonatal factors influencing hospital length of stay (LOS) and total parental nutrition (TPN) in infants born with gastroschisis. METHODS: We performed a five-year review of infants born with gastroschisis (2011-2015) at a major Australian centre. Complex gastroschisis was defined as involvement of stenosis, atresia, ischemia, volvulus or perforation and closed or vanishing gastroschisis. We extracted data from files and databases at the two participating hospitals, a major maternal fetal medicine centre and the affiliated children's hospital. RESULTS: There were 56 infants antenatally diagnosed with gastroschisis with no terminations, one stillbirth (2%) and one infant with 'vanishing' gastroschisis. The mean maternal age was 23.9 years (range, 15-39 years). The mean gestation at delivery was 36 weeks (range, 25-39+ 3 weeks). Of the 55 neonates who received surgical management, 62% had primary closure. The median LOS was 33 (IQR, 23-45) days and the median duration of TPN was 26 (IQR, 17-36) days. Longer days on TPN (median 35 vs 16 days, P = 0.03) was associated with antenatal finding of multiple dilated bowel loops. Postnatal diagnosis of complex gastroschisis was made in 16% of cases and was associated with both longer LOS (median 89 vs 30 days, P = 0.003) and days on TPN (median 46 vs 21 days, P = 0.009). CONCLUSION: Complex gastroschisis was associated with greater days on TPN and LOS. We found no late-gestation stillbirths and a low overall rate of 1.8%, suggesting the risk for stillbirth associated with gastroschisis is lower than previously documented. This information may assist counselling families. Improved data collection worldwide may reveal causative factors and enable antenatal outcome predictors.

Neurocognitive outcomes in children following immersion: a long-term study.

OBJECTIVE: To investigate long-term neurocognitive outcomes after a near-drowning incident in children who were deemed neurologically intact on discharge from hospital. DESIGN: A prospective cohort study of near-drowning children. SETTING: 95 drowning and near-drowning admissions, 0-16 years of age, from January 2009 to December 2013, to The Children's Hospital at Westmead, Sydney, NSW, Australia. PARTICIPANTS: 23 children both met the criteria and had parental consent for the study. MAIN OUTCOME MEASURES: Identification of the long-term deficits in behaviour, executive function, motor skills, communicative skills and well-being over a 5-year period. Assessment was undertaken at 3-6 months, 1 year, 3 years and 5 years after near-drowning at clinic visits. Physical developmental screening and executive function screening were done using Behavior Rating Inventory of Executive Function-Preschool version (BRIEF-P) and BRIEF. RESULT: 95 drowning and near-drowning episodes occurred during the study period. 10 (11%) children died, 28 were admitted to the paediatric intensive care unit and 64 directly to a ward. 3 children died in emergency department, 7 children had severe neurological deficit on discharge from the hospital. 23 were subsequently recruited into the study; 5 (22%) of these children had abnormalities in behaviour and/or executive function at some during their follow-up. CONCLUSION: Children admitted to hospital following a near-drowning event warrant long-term follow-up to identify any subtle sequelae which might be amenable to intervention to ensure optimal patient outcome.

Transition zone pull-through in Hirschsprung's disease: a tertiary hospital experience.

BACKGROUND: Pull-through of ganglionic bowel is essential for successful treatment of Hirschsprung's disease. We studied the incidence of transition zone pull-through in our institution and compared its outcome with ganglionic bowel pull-through. METHODS: Children who underwent Soave's pull-through for Hirschsprung's disease from January 2005 to November 2012 were studied. Patients were divided into two groups: ganglionic bowel pull-throughs (Group 1) and transition zone pull-throughs (Group 2). Demographics, presentations, surgical procedure, post-operative results and complications including redo procedures were recorded and reviewed along with histopathology reports. RESULTS: Fifty patients underwent Soave's pull-through for Hirschsprung's disease in our group. The median age at surgery was 13.5 days in Group 1 and 22.5 days in Group 2. Transition zone pull-through occurred in eight children (16%). Transition zone pull-through was attributed to errors in histologic interpretation (n = 5), sampling (n = 2) and surgical technique (n = 1). The transition zone was significantly longer in Group 2 (P = 0.002). Constipation and enterocolitis were the main complications needing therapy. One child in Group 2 required surgery for adhesive intestinal obstruction. CONCLUSIONS: The length of the transition zone in children with transition zone pull-through was significantly longer. Though our children with transition zone pull-through did not require redo surgery the possibility of redo surgery remains. Transition zone pull-through should still be considered an error and should be prevented.

Aganglionosis with the absence of hypertrophied nerve fibres predicts disease proximal to rectosigmoid colon.

PURPOSE: The gold standard for the diagnosis of Hirschsprung's disease (HSCR) is the pathologic evaluation of a rectal biopsy that demonstrates the absence of ganglion cells and nerve fibre hypertrophy. However, it has been frequently reported that hypertrophic nerves may not be present in some variants like long-segment HSCR, total colonic aganglionosis, premature and very young infants. The aim of this study was to determine this association. METHODS: We performed a retrospective review of the HSCR database at our tertiary care children's hospital from 2000 to 2013. In order to analyse the relationship between the diameter of the nerve fibres and the level of aganglionosis, we classified the patient sample into two groups-fibres ≤40 and >40 µm. The groups were statistically compared with P < 0.05 being significant. RESULTS: Rectal biopsies of 92 patients confirmed as HSCR with definitive operation performed at the same institution were reviewed. The mean nerve diameter was 50.1 µm (range 20-87.5 µm). Nerve fibre diameter ≤40 µm was predictive of transition zone above the sigmoid colon. A specificity of 77.3 % and a likelihood ratio of 2.03 supported this perception. No correlation was noted between nerve fibre diameter and gestational age at birth, birth weight or age at biopsy. CONCLUSION: The absence of nerve fibre hypertrophy in the presence of aganglionosis on rectal biopsy specimens is predictive of long-segment HSCR.