Spontaneous pneumomediastinum: is a chest X-ray sufficient?

Spontaneous pneumomediastinum (SPM) is an uncommon disease defined as a non-traumatic presence of free air in the mediastinum, without underlying disease. We present a 13-year- old boy who was previously in a perfect health, who was presented with subcutaneous cervical emphysema, dysphagia, chest and neck pain. The chest roentgenogram revealed the presence of subcutaneous emphysema without any other abnormal findings. A computer tomography (CT) scan was obtained, and this confirmed the existence of subcutaneous cervical emphysema and also the presence of pneumomediastinum. The child's progress was uneventful and after 6 days he was discharged from the hospital in excellent clinical condition. We propose that chest CT is useful, in less obvious cases of SPM, to detect the free air in the mediastinum and probably SPM is underdiagnosed in clinical practice in the young people.     

Laparoscopic pyloromyotomy: is a knife really necessary?

Background  

Laparoscopic pyloromyotomy (LP) is currently accepted as a suitable treatment modality for infantile hypertrophic pyloric stenosis (IHPS). In this report, we describe some technical modifications of LP using a 3- or 5-mm hook with electrocautery as a substitute for a knife for incising the pylorus. The outcomes of LP using a standard retractable pyloromyotomy knife are compared with those of LP using a hook electrocautery.     

Asthma prevention: Breast is best?

Whilst breastfeeding has been considered to exert a preventative effect on the development of allergic disease, several recent publications have challenged this view, particularly with respect to the long-term outcomes for asthma. There are many other beneficial effects of breastfeeding apart from the possibility of allergy prevention. The suggestion that breastfeeding may increase the development of allergic disease raises concerns about the appropriate steps to take for primary prevention of allergy. It is concluded that breastfeeding can still be recommended for the beneficial effects in reducing atopic disease in childhood in addition to the other demonstrated benefits, and that there are unresolved questions concerning the few studies that suggest the possibility of increased allergic disease in later life.     

Typical halo nevi in childhood: is a biopsy necessary?

We sent questionnaires to pediatric dermatologists inquiring whether anyone had seen a child with halo nevi that developed into melanoma. None of the respondents reported having seen such a development. We conclude that typical halo nevi in children are usually benign and a skin biopsy is probably not necessary.     

Scatter radiation from chest radiographs: is there a risk to infants in a typical NICU?

Objective  

To evaluate the dose of scatter radiation to infants in a NICU in order to determine the minimal safe distance between isolettes.     

Asthma and hemoglobinopathy: When is supplemental oxygen required?

Asthma is the most common reason for referral to the emergency department in childhood. In severe attacks, supplemental O₂ is given when oxygen saturation level is <90%. Described herein is the case of a child with persistent low oxygen saturation as measured on pulse oximetry (S_pO₂) after full clinical recovery from an asthma attack. Simultaneously, P_aO₂ was normal. A diagnosis of abnormal hemoglobin with decreased oxygen affinity (hemoglobin Seattle) was made on hemoglobin electrophoresis and genetic analysis. To ascertain when supplemental oxygen was needed, an oxygen dissociation curve was plotted using the tonometer technique, and it was found that an S_pO₂ of 70% is parallel to a P_aO₂ of 60 mmHg. Plotting an oxygen dissociation curve is a simple reproducible method to determine when supplemental oxygen is required for a child with a hemoglobinopathy.     

Immediate posttraumatic seizures: is routine hospitalization necessary?

OBJECTIVE: A recent Internet survey of pediatric neurosurgeons showed that 86% routinely admitted children with immediate posttraumatic seizures (PTS) for a brief period of observation. We wished to determine whether certain children meeting predefined criteria could instead be safely discharged from the emergency room. METHODS: We reviewed the records of children admitted during the past 5 years with a diagnosis of seizure and head injury. Children with a minor head injury, a PTS occurring within 24 h of injury and no intracranial abnormalities on admission CT scan were included. Children with previous neurological conditions, a history of prior seizures (other than PTS or febrile seizures), a prior history of anticonvulsant use, or intracranial abnormalities on the admission CT scan were excluded. Records were abstracted for child's age, gender, length of admission, previous history of PTS or febrile seizures, mechanism of injury, location of impact, time between impact and PTS, the number, length and type of PTS, Glasgow Coma Score (GCS) on admission, subsequent complications and hospital costs. RESULTS: Seventy-one children met the inclusion criteria. Eleven children presented to the emergency room with prolonged seizures, transient apnea or persistently low GCS and required admission to the intensive care unit (ICU). Among the 60 remaining children with simple PTS, none had further seizures during the follow-up period, and none had significant complications. The average cost of hospitalization was known for 58 children; after excluding the costs for 5 patients who were admitted to the ICU, the average hospital cost amounted to USD 1,615 per patient. CONCLUSIONS: Our data suggest that children with isolated minor head injuries and simple PTS who recover fully in the emergency room, whose CT scans show no intracranial abnormalities and who have no prior history of neurological disease, epilepsy or anticonvulsant use are at low risk for recurrent seizures or neurological complications, and could potentially be sent home to a reliable caretaker and a stable home situation. However, because of the limited sample size in this study, the statistical risk of a bad outcome may be as high as 9%; we therefore suggest that much larger studies are potentially needed before this becomes a standard policy.     

Are chest radiographs routinely necessary following thoracostomy tube removal?

OBJECTIVE: Chest radiographs (CXRs) are routinely obtained at many institutions in all pediatric patients following thoracostomy tube removal to search for pneumothorax (PTX). To aid in evaluating the necessity of this practice, this study investigates whether clinical signs and symptoms may be a sensitive predictor of PTX in such patients. MATERIALS AND METHODS: Reports from CXRs obtained following chest tube removal in all pediatric patients (374 patients) who underwent cardiac surgery with chest tube placement over 1 year were reviewed. For cases with reported PTX, the PTX was quantified and chart review was performed to assess whether signs and symptoms of PTX preceded the CXR result. RESULTS: Fifty-one of 374 children (13.6%) had a radiographically defined PTX within 6 h after thoracostomy tube removal. The PTX was large (>40%) in 2 children, moderate (20-40%) in 5 children, and small (<20%) in 44 children. Symptoms (dyspnea, tachypnea, respiratory distress) or signs (increased oxygen requirement, worsening arterial blood gas and/or hypotension) of respiratory distress were present at the time of the initial CXR in six of seven patients, who later underwent a major clinical intervention, and in one patient who did not. Major clinical interventions were performed in all patients with a large PTX, four of five patients with a moderate PTX, and one patient with a small PTX that later enlarged. CONCLUSIONS: Clinical signs and symptoms identified nearly all patients with significant pneumothoraces. Future prospective investigations may examine reserving chest radiography following chest tube removal for select groups, such as symptomatic patients or those with tenuous cardiovascular status.     

Acute esophageal coin ingestions: is immediate removal necessary?

Aims Coins are the most commonly encountered foreign body ingestions presenting to the emergency department (ED). The purpose of our study was to retrospectively evaluate a new institutional protocol implemented in 1998, in which healthy patients with acute (less than 24 h) coin ingestions located below the thoracic inlet, were observed at home with next-day follow-up. If repeat radiographs revealed a persistent esophageal foreign body, then the coin was removed.Methods The charts of all patients who presented to the ED with a complaint of esophageal foreign body were reviewed from 1 January 1998 until 31 December 2001. Patients were excluded if they had non-acute ingestions, known esophageal pathology, severe symptoms such as stridor or inability to tolerate oral fluids, or incomplete records.Results Of 31 patients with esophageal coin ingestions, 16 had coins above the thoracic inlet. Three of these patients were asymptomatic and all experienced spontaneous coin passage into the stomach within 2 h of ED presentation while awaiting coin removal. There were eight eligible patients with coins located below the thoracic inlet. Three of five patients with mid-esophageal coins experienced spontaneous coin passage while the remaining two required coin removal on next-day follow-up for persistent esophageal coins. Three of three patients with distal-esophageal coin ingestions experienced spontaneous coin passage. There were no complications in any of the patients who underwent delayed coin removal either due to the procedure itself or to a delay in therapy.Conclusions Patients with acute esophageal coin ingestions may experience spontaneous coin passage and therefore, patients with coins located below the thoracic inlet with minor symptoms may be candidates for next-day follow-up. If repeat radiographs reveal a persistent esophageal coin, then the coin should be immediately removed. Furthermore, asymptomatic patients with coins above the thoracic inlet should undergo repeat radiographs in 2–5 h, as spontaneous coin passage may occur. Our protocol may also be more convenient and cost-effective as patients can be observed at home.     

Diagnostic techniques for obstructive sleep apnoea: is polysomnography necessary?

Obstructive sleep apnoea (OSA) is a common condition of childhood with significant associated morbidity. The comprehensive evaluation of children who present with suggestive symptoms involves the overnight recording and assessment of both sleep and respiration by polysomnography in a sleep laboratory. These studies require resources and facilities that are not widely available and thus simpler, more available and less expensive alternatives have been sought. This review discusses the available alternatives to polysomnography for the evaluation of the child with suspected obstructive sleep apnoea.     

Contralateral inguinal exploration in premature neonates: is it necessary?

Purpose  

The purpose of this study was to review our management of neonatal inguinal hernias in premature infants over a 5-year period to ascertain any change in practice.     

Paediatric MRI under sedation: is it necessary? What is the evidence for the alternatives?

To achieve diagnostic images during MRI examinations, small children need to lie still to avoid movement artefact. To reduce patient motion, obviate the need for voluntary immobilisation or breath-holding and therefore obtain high-quality images, MRI of infants is frequently carried out under sedation or general anaesthesia, but this is not without risk and expense. However, many other techniques are available for preparing children for MRI, which have not been fully evaluated. Here, we evaluate the advantages and disadvantage of sedation and anaesthesia for MRI. We then evaluate the alternatives, which include neonatal comforting techniques, sleep manipulation, and appropriate adaptation of the physical environment. We summarize the evidence for their use according to an established hierarchy. Lastly, we discuss several factors that will influence the choice of imaging preparation, including patient factors, imaging factors and service provision. The choice of approach to paediatric MRI is multi-factorial, with limited scientific evidence for many of the current approaches. These considerations may enable others to image children using MRI under different circumstances.