Pancreatitis: etiology, diagnosis, and management.

Inflammation of the pancreas (pancreatitis) has many presentations in children and adolescents, ranging from intrauterine congenital onset with sequelae of early exocrine pancreatic insufficiency as in the diseases of cystic fibrosis and Shwachman-Diamond syndrome to postnatal onset as a consequence of embryologic anomalies affecting pancreatic drainage postulated to exist in pancreas divisum, or of traumatic, obstructive, hemodynamic, metabolic or biochemical insults. The etiology is often elusive with up to 30% of cases being idiopathic. Modern imaging modalities of endoscopic ultrasonography and magnetic resonance cholangiopancreatography extend the diagnostic power of conventional abdominal ultrasonography and computed tomography. In addition, there is increasing pediatric experience with endoscopic retrograde cholangiopancreatography. Medical management remains supportive, with optimal timing and indications for surgery in cases of pancreatic necrosis and pseudocyst assessed. Three temporal patterns of pancreatitis appear in children: acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis. Acute pancreatitis is of abrupt onset, often attributable to a specific cause, and of variable severity and duration but self-limited with eventual resolution. Acute attacks of pancreatitis recurring after periods of remission characterize acute recurrent pancreatitis and indicate an intrinsic problem or susceptibility. Chronic pancreatitis is present in most of these cases in which pancreatic inflammation and destruction never completely remits.     

Childhood hypertension: etiology, diagnosis, and treatment

The introduction of blood pressure measurements as an integral part of the routine care of children and adolescents has increased awareness of a significant incidence of hypertension in the pediatric age group. The concepts and principles discussed in this article provide a basis for the diagnosis and management of childhood hypertension.     

Central precocious puberty: epidemiology, etiology, diagnosis and treatment

Central precocious puberty (CPP) is a rare disease with female predominance and a higher incidence among adopted children. Of idiopathic aetiology in most cases, in the past few years the first mutations in patients with CPP have been described. The prevalence of organic disease is notably lower among girls with CPP. However, no predictors have been described to select which kind of girls should undergo an imaging tests. Although the sensitivity of the determination of basal LH as a marker of CPP has improved with the new techniques, to date, the LH peak after LHRH stimulation test remains the gold standard for the diagnosis of CPP. Finally, the use of GnRH analogues has shown to be particularly effective in the treatment of CPP patients less than 6 years-old.     

Cerebral palsy-definition, classification, etiology and early diagnosis

Cerebral palsy is a common neurodevelopmental condition encountered by pediatricians. The condition may present itself in many diferent clinical spectra. The etiological and risk factors are many and an awareness of the interplay of multiple factors in the causation of CP is crucial. In many cases, the cause of Cerebral palsy may not be apparent. Cerebral palsy is invariably associated with many deficits such as mental retardation, speech and language and oromotor problems. A thorough neurodevelopmental assessment of the child with Cerebral Palsy should include evaluation of associated deficits so that a comprehensive early intervention program an be planned and executed.     

Specific and nonspecific lymphadenitis in childhood: etiology, diagnosis, and therapy

Over a period of 4 years, 39 children with lymphadenitis were treated surgically; in 31 cases cervical lymph nodes were the main location. In 9 cases the lymphadenitis was caused by mycobacterial infection.Staphylococcus aureus was the most frequent causative organism of unspecific lymphadenitis (11 cases). The therapy of choice appears to be surgical treatment and medical care after operation. Especially in mycobacterial lymphadenitis, complete surgical excision of the lymph node is decisive for definitive healing. There was only 1 case of therapy-resistant, relapsing cervical lymphadenitis that needed a second operation. Causative organisms in this case wereMycobacterium avium andMycobacterium intracellulare. All other patients showed an uneventful postoperative clinical course. We believe that a consequent diagnostic process and cooperation between the pediatric surgeon and pediatrician are necessary for effective therapy.     

Prevention, diagnosis, and treatment of influenza: current and future options

Because influenza significantly affects the health of children, this review describes the current and future options for preventing, diagnosing, and treating influenza infections. Currently, the inactivated influenza vaccine is recommended for prevention of influenza; however, the live, attenuated, intranasal influenza vaccine is a potential future option. For diagnosis, viral culture is the gold standard, although four rapid diagnostic tests are available for more immediate results. The impetus for rapid results is the availability of effective antiviral agents indicated for early influenza infection. The four currently approved antiviral agents are amantadine, rimantadine, zanamivir [Relenza, Glaxo Wellcome, Inc., Research Triangle Park, NC] and oseltamivir [Tamiflu, Roche Pharmaceuticals, Nutley, NJ]. The indications, benefits, side effects and ages for which each drug is approved are reviewed.     

Gastroschisis: an update

Gastroschisis (GS) continues to increase in frequency, with several studies now reported an incidence of between 4 and 5 per 10,000 live births. The main risk factor would seem to be young maternal age, and it is in this group that the greatest increase has occurred. Whilst various geographical regions confer a higher risk, the impact of several other putative risk factors, including smoking and illicit drug use, may be less important than when first identified in early epidemiological studies. Over 90% of cases of GS will now be diagnosed on antenatal ultrasound, but its value in determining the need for early delivery remains unclear. There would appear no clear evidence for either routine early delivery or elective caesarean section for infants with antenatally diagnosed GS. Delivery at a centre with paediatric surgical facilities reduces the risk of subsequent morbidity and should represent the standard of care. The relative roles of primary closure, staged closure and ward reduction, with or without general anaesthesia, appear less clear with considerable variation between centres in both the use of these techniques and subsequent surgical outcomes. Survival rates continue to improve, with rates well in excess of 90% now routine. The limited long-term developmental data available would suggest that normal or near-normal outcomes may be expected although there remains a need for further studies.     

Gastroschisis: a 15-year,single-center experience

70 cases of gastroschisis (GS) were surgically treated at the Pediatric Surgical University Clinic, Münster, from 1984 through 1998. The defect occurred more frequently in males (44) than females (26). The average birth weight was 2,383 g and mean gestational age 36.8 weeks. 9 infants (12.9%) were delivered vaginally and the rest (87.1%) by cesarean section; 34 of the 61 (55.7%) cesarean sections were done solely for prenatal ultrasonic identification of the abdominal-wall defect. 10 infants (14.3%) underwent primary closure; in 19 (27.1%) primary closure of the skin was possible, however, a single solvent-dried dura (SDD) graft was required for fascial enlargement. The remaining 41 infants (58.6%) had extensive defects and required two grafts for optimal closure. 22 patients (31.4%) had associated anomalies, the most common being bowel atresias and undescended testis. 14 (20%) required secondary laparotomies because of bowel-associated complications and 1 (1.4%) for a urinary-bladder perforation. 11 patients (15.7%) had non-bowel-associated complications. The average postoperative tracheal intubation time was 3.9 days and the average hospital stay was 75.6 days. The overall mortality was 2.8%. No major complications associated with SDD implants were encountered; only 4 patients (5.7%) had minor complications such as local inflamation and infection and were managed conservatively. The present data support the employment of SDD implants as acceptable biomaterial for the repair of large GS defects.     

Rhabdomyolysis: a review of clinical presentation, etiology, diagnosis, and management

Rhabdomyolysis is a condition that results from many underlying etiologies and can present in a myriad of ways to the emergency physician. However, some clinical and laboratory features are almost always present and, if noted, can help in making the diagnosis. This review article will focus on the presenting symptoms, the various etiologies, the underlying mechanisms, and the current management of pediatric rhabdomyolysis.     

Gastroschisis and omphalocele

The survival rate of patients with abdominal wall defects has gradually improved with the advances in the investigation and treatment modalities. The present paper reviews the results of various treatment modalities and also analyses the long term results in these patients. A meta-analysis was performed via a medline search of English written clinical studies containing the text words “abdominal wall defects”, gastroschisis and “omphalocele or exomphalos” from 1953 to 1998. The present consensus on operative management of abdominal wall defect is to provide primary closure, if it can be achieved without haemodynamic or respiratory compromise. Patients with primary closure on analysis were found to have better survival rates, reduced risk of sepsis and overall, a shorter hospital stay. However, resumptions of oral feeds, duration of total parenteral nutrition (usually lasting 10–15 days) and ventilatory sgpport required postoperatively did not significantly differ in the primary and silo technique. Long term outcome of these patients is generally good, but they have high incidence of GER (40–50%) for which they should be on regular follow up.     

Gastroschisis: neonatal features and somatic development

Thirty-nine newborns were treated for gastroschisis at the Children's Hospital, Helsinki University Central Hospital from 1964 to 1980. Sixteen infants died during the first hospital admission. Of the 23 survivors, 11 were two years or older, and these 11 children were subjected to a follow-up examination. The incidence of the lesion increased markedly during the period of observation. Dysmaturity (birth weight at or below the 10th percentile of normal intrauterine growth) accompanied gastroschisis in 17 cases, and a low birth weight (below 2,500 g) in 23 cases. The mortality of gastroschisis was clearly and constantly decreasing, being 54% for the first decade, 23% for the last 5 years, and 41% for the total series. The age of the mothers at parturition, 20.9 years, was significantly (p less than 0.001) lower than the Finnish average. The extensive clinical and laboratory analysis of the 11 oldest children with completed reconstruction of the abdominal wall indicated good physical condition and, specifically, normal absorptive function of the intestine.     

Gastroschisis: a radiological and clinical review

A retrospective clinico-radiological review was undertaken of 66 consecutive cases of gastroschisis managed at our institution between August 1982 and February 1993. The condition's morbidity and mortality were reviewed, as were its radiological features and their impact upon management. All patients underwent surgery in the first 24 h of life, and the overall survival rate was 92 %. The finding of bowel atresia at operation was associated with a particularly poor outcome, with only two out of five infants surviving. A minority of infants developed serious complications including necrotizing enterocolitis, short-bowel syndrome, persistent small-bowel dysfunction and cholestatic jaundice. Investigation by plain films, contrast studies and ultrasound examinations was necessary and helpful in these patients. Plain film radiography commonly revealed bowel-wall thickening and luminal dilatation, frequently accompanied by generalised abdominal distension. Small-bowel enema was considered to be superior to the conventional follow-through in distinguishing mechanical from functional obstruction in infants with persistent bowel dilatation. Received: 29 April 1996 Accepted: 20 May 1996     

Gastroschisis and omphalocele: treatments and long-term outcomes

Between February 1994 and April 2004, we treated 40 children with gastroschisis and 26 children with omphalocele. We recorded the course of pregnancy, pre- and post-natal complications, delivery, operation, post-operative therapy, and long-term outcomes. Additionally, we conducted follow-up examinations of 37 of these 66 children (56%). We analysed their abdominal musculature, development, cosmetic result and quality of life. The median duration of follow-up was 6.3 years (range 1–10). In 35/40 children (88%) with gastroschisis and in 18/26 children (69%) with omphalocele, there had been prenatal diagnosis. The average maternal age of 23.9 years in the gastroschisis group was lower than in the omphalocele group (29.9 years). Delivery was by caesarean section in 93% of the gastroschisis group and 65% of the omphalocele group. Outcomes following vaginal delivery were no worse than those after caesarean section. Further, congenital abnormalities were shown in 28% of gastroschisis cases, and were limited to the gastrointestinal tract. Of the omphalocele cases 81% showed further abnormalities. Direct closure of the abdominal wall defect was possible in 31/40 (78%) of the gastroschisis cases and 15/26 (58%) of the omphalocele cases. Mortality in gastroschisis was nil; two children with omphalocele died (8%). Outcomes were better after primary closure than in stepwise reconstruction. Follow-up showed good results in all categories. Developmental delays were rapidly made up after treatment, and 75% of the children had no gastrointestinal problems, or suffered from these rarely. Almost all the children were of normal weight and height, and physical and intellectual development were delayed in only one third of the children. The surgical scar was rated as good or very good in about 80% of the cases. Except for those with severe defects, the children had good ratings for quality of life. Improvements in short-term results of gastroschisis and omphalocele treatment can be attributed to recent developments in prenatal diagnosis and the advancements of centralised perinatal care. Our long-term results clearly demonstrate that initial gastrointestinal problems and developmental delays were made up during the first two years of life. Prenatal counselling can now be more optimistic.