Quality improvement dissemination in pediatric surgery: The APSA quality and safety toolkit

Shared experiential learning is critical in the field of pediatric surgery to support the translation of evidence into practice. Surgeons who develop QI interventions in their own institutions based on the best available evidence create work products that can accelerate similar projects in other institutions, rather than continuously reinventing the wheel. The American Pediatric Surgical Association (APSA) Quality and Safety Committee (QSC) toolkit was created to facilitate knowledge-sharing and thereby hasten the development and implementation of QI. The toolkit is an expanding open-access web-based repository of curated QI projects that includes evidence-based pathways and protocols, stakeholder presentations, parent/patient educational materials, clinical decision support (CDS) tools, and other components of successful QI interventions in addition to contact information for the surgeons who developed and implemented them. This resource catalyzes local QI endeavors by showcasing a range of projects that can be adapted to fit the needs of a given institution, and it also serves as a network to connect interested surgeons with successful implementers. As healthcare shifts towards value-based care models, quality improvement becomes increasingly important, and the APSA QSC toolkit will continue to adapt to the evolving needs of the pediatric surgery community.     

Social determinants of health as drivers of inequities in pediatric injury

A child's social determinants of health (SDH), including their neighborhood environment, insurance status, race and ethnicity, English language proficiency and geographic location, all significantly impact their risk of injury and outcomes after injury. Children from socioeconomically disadvantaged neighborhoods experience overall higher rates of injury and different types of injuries, including higher rates of motor vehicle-, firearm-, and violence-related injuries. Similarly, children with public insurance or no insurance, as a proxy for lower socioeconomic status, experience higher rates of injuries including firearm-related injuries and non-accidental trauma, with overall worse outcomes. Race and associated racism also impact a child's risk of injury and care received after injury. Black children, Hispanic children, and those from other minority groups disproportionately experience socioeconomic disadvantage with sequelae of injury risk as described above. Even after controlling for socioeconomic status, there are still notable disparities with further evidence of racial inequities and bias in pediatric trauma care after injury. Finally, where a child lives geographically also significantly impacts their risk of injury and available care after injury, with differences based on whether a child lives in a rural or urban area and the degree of state laws regarding injury prevention. There are clear inequities based on a child's SDH, most predominantly in a child's risk of injury and the types of injuries they experience. These injuries are preventable and the SDH provide potential upstream targets in injury prevention efforts.     

Impact of neonatal nutrition on necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the leading cause of morbidity and mortality in preterm infants. NEC is multifactorial and the result of a complex interaction of feeding, dysbiosis, and exaggerated inflammatory response. Feeding practices in the neonatal intensive care units (NICUs) can vary among institutions and have significant impact on the vulnerable gastointestinal tract of preterm infants. . These practices encompass factors such as the type of feeding and fortification, duration of feeding, and rate of advancement, among others. The purpose of this article is to review the data on some of the most common feeding practices in the NICU and their impact on the development of NEC in preterm infants. Data on the human milk bioactive component glycosaminoglycans, specifically hyaluronan, will also be discussed in the context of postnatal intestinal development and NEC prevention.     

Evaluation of catch-up growth in severe pediatric Hashimoto's hypothyroidism

BackgroundWe aimed to evaluate catch-up growth in children with severe Hashimoto's hypothyroidism (HH) after thyroid hormone replacement therapy (HRT).MethodsA multicenter retrospective study was conducted including children referred for growth slowdown that led to the diagnosis of HH between 1998 and 2017.ResultsA total of 29 patients were included, with a median age of 9.7 years (13–172 months). Median height at diagnosis was -2.7 [-4.6; -0.1] standard deviation score (SDS), with a height loss of 2.5 [0.7; 5.4] SDS compared to height before growth deflection (p<0.0001). At diagnosis, the median TSH level was 819.5 mIU/L [100; 1844], the median FT4 level was 0 pmol/L [undetectable; 5.4], and the median anti-thyroperoxidase antibody level was 1601 UI/L [47; 25,500].In the 20 patients treated only with HRT, there were significant differences between height at diagnosis and height at 1 year (n = 19, p<0.0001), 2 years (n = 13, p = 0.0005), 3 years (n = 9, p = 0.0039), 4 years (n = 10, p = 0.0078), and 5 years (n = 10, p = 0.0018) of treatment but not in the case of final height (n = 6, p = 0.0625). Median final height was -1.4 [-2.7; 1,5] SDS (n = 6), with a significant difference between height loss at diagnosis and total catch-up growth (p = 0.003).The other nine patients were also given growth hormone (GH). They were smaller at diagnosis (p = 0.01); however, there was no difference in final height between those two groups (p = 0.68).ConclusionSevere HH can lead to a major height deficit, and catch-up growth seems to be insufficient after treatment with HRT alone. In the most severe cases, administration of GH may enhance this catch-up.     

Adverse events related to ibuprofen treatment for patent ductus arteriosus in premature neonates

ObjectiveOur study aimed to review adverse drug reactions (ADRs) associated with ibuprofen treatment of patent ductus arteriosus (PDA) in premature neonates.MethodWe retrospectively evaluated electronic patient records from neonates treated with ibuprofen for PDA during 5 years in a French neonatal intensive care unit. Full chart review and targeted triggers were used to detect ADRs. The causality between suspected ADRs and medication was evaluated using the WHO causality assessment method by pharmacovigilance experts. Categorical variables were compared using chi-square tests or Fisher's test. Quantitative variables were compared using the Student t test. We explored the risk factors associated with ADR using univariate model analysis.ResultOf 227 infants with a mean gestational age (GA) of 27 weeks (24–33), 12 (5%) developed intestinal perforation and seven, necrotizing enterocolitis (3%). The perforation occurred less frequently in infants older than 27 weeks GA (OR = 0.14; 95% CI = 0.03–0.66, P = 0.01). Other observed ADRs were acute renal failure (25 infants, 11%) and thrombocytopenia (five infants, 2%).ConclusionGastrointestinal complications observed in infants treated with ibuprofen for PDA including gastrointestinal perforations occur in less mature infants. Active chart review of the patient's medical file with a trigger tool should be evaluated for routine ADR monitoring.     

Clinical complications in children with false-negative results in cystic fibrosis newborn screening

ObjectiveTo present signs and symptoms and clinical course in cystic fibrosis patients with false-negative newborn screening (CF NBS).Materials and methodsAll children presented in this paper were covered by CF NBS. The group of 1.869.246 newborns was screened in the Institute of Mother and Child in Warsaw within a period of 01.01.1999 – 31.05.2019. Screening protocols evolved over time from IRT/IRT to IRT/DNA/EGA.ResultsThe authors identified 11 patients with false-negative NBS, in whom CF was diagnosed based on clinical symptoms or the examination of siblings with positive CF NBS. In the study group, the diagnosis was made significantly later in comparison to positive CF NBS patients ranging from 2 months to 15 years of age. CF NBS strategy does not significantly affect the sensitivity of the screening.ConclusionIn the presence of clinical symptoms, additional diagnostics must be implemented, in spite of the negative screening results. At first, the sweat test should be conducted, followed by a DNA analysis of the most common mutations in the given population. The diagnostic process requires searching for CFTR mutations not typically associated with a high chloride concentration in sweat. Repetition of sweat chloride concentration enables the diagnosis in children whose initial chloride values in sweat are borderline, and no CF-causing mutations are detected. In strong clinical indications, the extension of DNA analysis (EGA) is recommended in order to identify rare CF variants. In children with meconium ileus, genetic analysis is mandatory.     

Bariatric procedures including Roux-en-Y gastric bypass in French adolescents

IntroductionIn France, approximately 100 obese adolescents undergo a bariatric procedure every year. To date, only data from laparoscopic adjustable gastric banding (LAGB) or sleeve gastrectomy (SG) have been published. Our objective was to report the outcomes of a series of French obese adolescents who underwent a Roux-en-Y gastric bypass (RYGB).MethodsWe included all obese adolescents aged 13–19 years who underwent RYGB in our department from 2008 with at least 2 years of follow-up after surgery. We analyzed the course of the anthropometric data, comorbidities, and subsequent adverse events.ResultsStarting in September 2008, out of 93 obese adolescents who requested bariatric surgery, 39 (35%) underwent a bariatric procedure. From these adolescents, 2-year follow-up data were available for 26 patients who had a RYGB. At the time of surgery, the mean patient age was 17.4 years (standard deviation [SD]=1.4) and the body mass index (BMI) was 52.0 kg/m² (SD=7.8). One patient was lost to follow-up. At 2 years after surgery,  the mean BMI was 35.7 kg/m² (SD=9.4) with a mean decrease in BMI of 31.9% (SD=11.6). Comorbidities improved for most of the patients: high blood pressure (2/2) and pseudotumor cerebri (1/1) were cured after surgery, and dyslipidemia improved globally. The complications observed were anemia, abdominal pain requiring celioscopy (n = 2), and oxalic nephrolithiasis.ConclusionOnly one third of the obese adolescents requesting bariatric surgery were operated on. Our series including exclusively obese adolescents who underwent an RYGB presents the results of this technique on weight loss and comorbidities; mechanical and nutritional complications remain uncommon. These results are similar to those obtained in studies of adult patients.