Retropharyngeal abscesses in infants

Four children, between 6 days and 10 months old, presenting with varying manifestations of retropharyngeal abscess, are reported. A careful clinical examination and X-ray evaluation of neck is paramount in diagnosis and treatment. All four patients recovered without sequelae following surgical evacuation of pus.     

Non-traumatic colon perforation in children: a 10-year review

Colon perforation is an abdominal surgical emergency in the pediatric population, but is seldom reported when occurring from non-traumatic causes in children beyond the neonate. The goal of this study was to identify the clinical characteristics, management, and outcomes of non-traumatic colon perforation in children. Medical records for the 10-year period from September 1994 to September 2004 were reviewed for children beyond the neonate with non-traumatic colon perforation. Data gathered included age, gender, symptoms, duration of symptoms, physical findings, and length of postoperative hospital stay. Diagnostic information included laboratory data, radiographic imaging, and operative findings. Forty-four patients with non-traumatic colon perforation were recruited into this study. The mean age was 2.22 ± 1.87 years; 91.4% of cases were younger than 5 years old. The most common presenting symptom was fever (97.7%); the most common sign was abdominal distention (93.1%). The mean duration of symptoms prior to admission was 6.19 days. Pneumoperitoneum was presented in 86.3% of patients by plain abdominal radiograph. Ascending and transverse colon were the most common perforation sites. Non-typhoid salmonella was the leading pathogen isolated, causing 20.4% of episodes. One case died due to Clostridium speticum infection. Non-traumatic colon perforation most commonly affects children younger than 5 years of age. It may be secondary to infection, especially non-typhoid salmonella. Plain abdominal radiograph can be an adjuvant tool for the high index of suspicion for colon perforation in children with abdominal distention and history of fever or diarrhea for more than 5 days.     

The radiological spectrum of invasive aspergillosis in children: a 10-year review

BACKGROUND: Invasive aspergillosis is an uncommon but life-threatening event in the immunocompromised child. Attempts at fungal isolation are often unrewarding and a high index of radiological suspicion is essential in the early diagnosis of infected children. OBJECTIVE: To document the radiological spectrum of disease in invasive aspergillosis in the paediatric population. MATERIALS AND METHODS: A retrospective review of the imaging performed in 27 consecutive patients (age 7 months to 18 years) with documented invasive Aspergillosis encountered over a 10-year period at a single institution. RESULTS: Radiographic findings of pulmonary disease (20 patients) included segmental and multilobar consolidation, perihilar infiltrates, multiple small nodules, peripheral nodular masses and pleural effusions. No cavitating lesions were seen on CXR. Small cavitating nodules were present on CT in two of eight children. Chest wall disease was particularly associated with underlying chronic granulomatous disease. Disseminated disease manifested as osteomyelitis (n=5), cerebral (n=3), oesophageal (n=1), hepatic (n=2), renal (n=2) and cutaneous (n=5) involvement. Imaging findings are discussed. Twelve patients (44%) subsequently died from Aspergillus-related complications. CONCLUSIONS: Invasive aspergillosis presents with a wide variety of radiographic findings involving multiple organ systems. Respiratory findings are varied but often non-specific, and a high index of suspicion is necessary in immunocompromised patients. In contrast to adult disease, the incidence of cavitation of pulmonary lesions appears low.     

Hypospadias surgery: a 10-year review

Hypospadias surgery is one of the most difficult areas in pediatric urology and has been characterized by constant evolution. Some of the surgical techniques proposed in the past are now considered inadequate because of an unacceptable complication rate or poor functional and aesthetic results. The key for assessing a surgical technique (or a particular aspect of it) is continuous evaluation through long-term patient follow-up. We present the medical records of 693 patients over 10 years, all operated on by the same surgeon (the first author), with a minimum of 12 months of follow-up. The overall complication rate was 6.49% (45 cases). The most frequent complication was urethral fistula, occurring in 28 patients (62%). Other complications were redo for penile deformity or meatal retraction (eight cases, 17%), megalourethra (five cases, 11%), meatal stenosis (two cases, 4%), and urethral stenosis (two cases, 4%). We have noticed an increased rate of complications in patients older than 12 months (18.7% vs. 3.4% in patients younger than 12 months) and in patients operated on at puberty or later (15%). We have seen no difference in the complication rate related to the type of hospitalisation (day surgery vs. traditional hospitalisation). Regarding the relationship between the type of complication and the type of defect, except for the constant presence of fistulae, a high incidence of megalourethra was seen in proximal defects treated with preputial graft. The sexual outcomes of 32 subjects are presented. Multiple factors influence the final result, but the most important factor is the surgeons own experience. Knowledge of different techniques and delicate tissue handling are essential. Our experience shows that the ideal age for surgery is 8–12 months. Owing to a minimal emotional impact on the child and to a reasonable use of economical resources, we consider day surgery the ideal way to treat these patients whenever possible. Even in the absence of complications, follow-up must be continued at least until the end of puberty and, when possible, up to the patients sexual debut. Adequate interviews with the patients (principally teenagers and young adults) are the best way to evaluate their need for psychological support.     

Lawnmower injuries in children: a 10-year experience

Approximately 77,800 annual lawnmower-related injuries are treated in the USA, with 9,300 involving children. This work reviews the literature and reports our 10-year experience with lawnmower injuries. We retrospectively reviewed patients with lawnmower injuries admitted to the Women and Children’s Hospital of Buffalo from 1995 to 2005 and reviewed the literature. Sixteen patients with mower-related injuries were admitted to our institution, with three due to walk-behind mowers and 13 due to riding mowers. The mean age was 7.5 years. Riding mower injuries had a higher average injury severity score (14.3 vs. 9) and a longer average length of hospital stay (15 vs. 2 days). All of the walk-behind mower injuries were extremity injuries, with two requiring amputations. Eleven of the riding mower injuries had extremity injuries alone, one had isolated torso injuries, and one had both extremity and torso injuries. Three required amputations, and the two patients with torso injuries required extensive surgical reconstructions. Pediatric lawnmower injuries, particularly due to riding mowers, are a highly preventable cause of morbidity and mortality. Increased public safety awareness and further manufacturer safety modifications should be strongly encouraged in order to limit this cause of pediatric trauma.     

Injuries to children who had preinjury cognitive impairment: a 10-year retrospective review

OBJECTIVE: To determine differences between hospitalized injured children who had preinjury cognitive impairments (IMPs) and children who had no preinjury cognitive conditions (NO). DESIGN: Comparative analysis, excluding fatalities, of patients with IMP (n = 371) with patients with NO (n = 58 745), aged from 0 to 19 years. MAIN OUTCOME MEASURES: Demographics, injury characteristics, injury nature and severity, use of resources, disability, and disposition at discharge from acute care. DATA SOURCE: Medical records of children injured between January 1, 1989, and December 31, 1998, submitted to the National Pediatric Trauma Registry, Boston, Mass. RESULTS: Compared with children with NO, children with IMPs were more likely to be boys (72.5% vs 64.3%), to be older (53.1% vs 40.0%, aged 10-19 years), to be victims of child abuse (5.9% vs 1.6%), and to be individuals with self-inflicted injuries (2.2% vs 0.1%). They were more likely to be injured as pedestrians (19.9% vs 13.8%), less likely to be injured in sport activities (2.7% vs 6.9%), and less likely to sustain a penetrating injury (3.8% vs 8.3%). They were more likely to sustain injuries to multiple body regions (57.4% vs 43.7%) and the head (62.0% vs 45.1%), and to be severely injured. They were more likely to be admitted to the intensive care unit (52.6% vs 25.2), and their mean length of stay was twice as long (9.9 vs 4.8 days). They were also more likely to develop impairments from the current injury (46.6% vs 41.0%) and more likely to be discharged to a rehabilitation facility (11.1% vs 2.3%). The IMPs became worse in 75 children. CONCLUSIONS: Preinjury cognitive impairments in a pediatric population had a significant effect on the causes, nature, severity of injury, and outcomes. Targeted prevention programs should consider the characteristics of this population.     

Empyema thoracis: a 10-year comparative review of hospitalised children from south Asia

Aims: To study the clinical and microbial profile of childhood empyema in South Asia and to identify the changes over the past three decades. Methods: A total of 265 children (aged 1 month to 12 years) with empyema admitted to the Advanced Pediatric Center, PGIMER, Chandigarh, India in 1989–98, were reviewed retrospectively. Results and Conclusions: One third of children were under 5. Culture positivity had decreased significantly (48% v 75%) over the years. Staphylococcus aureus continues to be the commonest (77%) aetiological agent; clustering was seen during hot and humid months (46%). Culture positive Streptococcus pneumoniae cases also decreased (9% v 27%); all were seen during the winter and spring season. Gram negative rods grew in more patients (11% v 7%). Community acquired methicillin resistant S aureus (MRSA) was isolated in three patients. Most children (93%) were treated with parenteral cloxacillin and an aminoglycoside. Tube drainage (TD) was used in 92% of fibropurulent cases, and was successful in 79%. Of 48 patients with failed TD, 12 needed decortication; limited thoracotomy was sufficient in the remaining 36. Surgery was mainly required by children with persistent pleural sepsis after 10 days of TD. Delaying surgery until 14 days had a significantly higher potential of requiring decortication. Early change to oral antibiotics (after 1–2 weeks of parenteral therapy) reduced the hospital stay significantly (17+7 v 23+7 days) without compromising long term outcome. Twenty two patients presenting late in the chronic stage underwent decortication at admission.     

Bone and gallium scintigraphy in children with rhabdomyosarcoma: A 10-year review

Technetium-99m bone and Gallium-67 scintigraphy has been widely used in the management of children with solid tumors. A retrospective review of all patients with rhabdomyosarcoma (RMS) from January 1980 to December 1989 was undertaken in order to determine the sensitivity and specificity of scintigraphy in detection of metastatic disease and to determine optimum frequency of serial scans in follow up. Over the 10-year period, 40 patients were diagnosed and treated for RMS: 22 were newly diagnosed from 1980-1984 and of these 16 had a minmum 5-year disease-free period whilst 6 died of the disease, giving a cure rate of 73%. A total of 271 bone and 236 Gallium-67 scans were performed. With respect to detection of metastatic disease in all tissues, Gallium-67 scans had a sensitivity of 84%, specificity 95% and bone scans had a sensitivity of 70% and specificity 95%. Bone scan sensitivity and specificity for skeletal metastases were 100% and 95%, respectively. Considering only patients with Gallium avid primary tumors, the Gallium-67 scan sensitivity was 94%. Ten patients developed new metastatic disease or primary recurrence after starting therapy, 8/10 within 12 months of diagnosis. Frequent surveillance scanning in the treatment phase, 2 years post-diagnosis, is of value in the early detection of metastases and monitoring disease response to therapy. Surveillance scanning after completion of treatment is more difficult to justify.     

汕头地区10年间儿童风湿病临床分析

目的　了解汕头地区儿童风湿病 (JRD)的流行情况及临床特点 ,提高诊断治疗水平。方法　收集1991～ 2 0 0 0年 10年间诊治的病历完整的JRD临床资料 ,进行回顾分析。结果　 10年间共诊治JRD 380例 ,以过敏性紫癜 (HSP)、儿童强直性脊柱炎 (JAS)、风湿热 (RF)、幼年特发性关节炎 (JIA)、儿童系统性红斑狼疮 (SLE)和皮肤粘膜淋巴结综合征 (MCLS)较为多见 ;HSP和SLE病例数有上升趋势 ,而RF则呈下降趋势。抗核抗体(ANA)、抗双链DNA抗体 (dsDNA)对SLE的诊断有较高特异性 ;而抗链球菌溶血素O抗体 (ASO)、类风湿因子可在多种疾病出现。JAS、JIA和SLE确诊时平均病程长达 1～ 8年。结论　HSP、JAS、RF、JIA、SLE和MCLS为汕头地区常见JRD。 10年来JRD病谱处于变化之中。儿童类风湿性关节炎 (JRA)一词应予摒弃。JAS、JIA和SLE等疾病尚未得到儿科临床医生的充分重视 ,应提高认识 ,加强早期诊断研究。     

Empyema thoracis: a 10-year comparative review of hospitalised children from south Asia.

AIMS: To study the clinical and microbial profile of childhood empyema in South Asia and to identify the changes over the past three decades. METHODS: A total of 265 children (aged 1 month to 12 years) with empyema admitted to the Advanced Pediatric Center, PGIMER, Chandigarh, India in 1989-98, were reviewed retrospectively. RESULTS AND CONCLUSIONS: One third of children were under 5. Culture positivity had decreased significantly (48% v 75%) over the years. Staphylococcus aureus continues to be the commonest (77%) aetiological agent; clustering was seen during hot and humid months (46%). Culture positive Streptococcus pneumoniae cases also decreased (9% v 27%); all were seen during the winter and spring season. Gram negative rods grew in more patients (11% v 7%). Community acquired methicillin resistant S aureus (MRSA) was isolated in three patients. Most children (93%) were treated with parenteral cloxacillin and an aminoglycoside. Tube drainage (TD) was used in 92% of fibropurulent cases, and was successful in 79%. Of 48 patients with failed TD, 12 needed decortication; limited thoracotomy was sufficient in the remaining 36. Surgery was mainly required by children with persistent pleural sepsis after 10 days of TD. Delaying surgery until 14 days had a significantly higher potential of requiring decortication. Early change to oral antibiotics (after 1-2 weeks of parenteral therapy) reduced the hospital stay significantly (17+7 v 23+7 days) without compromising long term outcome. Twenty two patients presenting late in the chronic stage underwent decortication at admission.     

10年住院新生儿死因分析

目的：分析１０年住院新生儿死亡原因。方法：回顾分析１０年住院新生儿病死原因及与成熟度、死亡时间的关系。结果：２２１例死亡病例中呼吸道病症占４５．７８％,严重感染占２０．３６％,颅内出血占１４．９３％,先天畸形占１２．６７％。其中早产儿占５４．３０％。生后７ｄ内死亡占８０．９９％。加强早产儿管理和呼吸管理后,新生儿病死率由１９８９年的９．００％下降至１９９８年的０．９６％。结论：预防早产,完善早产儿管理尤其呼吸管理是降低新生儿病死率的关键。     

Staphylococcus aureus bacteraemia in children: a 5-year retrospective review

OBJECTIVE: The clinical presentation of Staphyloccocus aureus bacteraemia has been well described in adults, but there is a paucity of published data on the presentation of S. aureus bacteraemia in children. This review sought to compare the presentation of S. aureus in children with that of adults. METHODS: We conducted a 5-year retrospective chart review of S. aureus bacteraemia at the Royal Alexandra Hospital for Children between 1994 and 1998. RESULTS: Of the 140 episodes of S. aureus bacteraemia, 53% were community acquired and 47% nosocomially acquired. The clinical presentation of S. aureus bacteraemia in the children in the present study differed significantly from published studies of adult patients. Of children with community-acquired bacteraemia without pre-existing medical conditions, 59% had a bone or joint infection, which is higher than adult series. Endocarditis has been associated with up to 30% of community-acquired bacteraemia in adults but was much less frequent (1.4%) in the present study. Despite the infrequent use of empiric antibiotic therapy (34% of episodes), the case fatality rate (1.4%) was significantly lower than the published literature relating to adults (11-32%). CONCLUSION: The present study highlights the differences between S. aureus bacteraemia in adults and children.     

Tetanus in children: an 11-year review

One hundred and three cases of tetanus in children 1-12 years of age were reviewed. Sixty-six per cent had severe disease, half of whom required management with total muscle paralysis and intermittent positive pressure ventilation (IPPV), and 70% in this group developed signs of sympathetic overactivity (SOA). Control of SOA with morphia 0.5-1 mg/kg/dose given 1-4 times a day appears to have decreased the mortality rate from this complication of severe tetanus. There was a relative resistance to drug control of SOA in the youngest children. High output renal failure developed in two children, an incidence much the same as reported in severely affected adults. The overall mortality rate of this series was 14.5%: all the deaths were amongst those severely affected. The cause of death could be attributed to tetanus in half, while in the remainder it resulted from complications of intensive therapy. Tetanus in children resembles the disease in adults.     

Neonatal outcome of gastroschisis and exomphalos: a 10-year review

OBJECTIVE: To study neonatal outcomes associated with gastroschisis and exomphalos in a regional neonatal unit. METHODS: A retrospective (1988-97) data analysis to study the effect of the type of defect/surgery, mode/place of delivery and associated anomalies on time to start and reach full feeds, duration of total parental nutrition (TPN) support and total hospital stay. Exact bivariate test procedures were used for data analysis. RESULTS: Twenty-one cases of gastroschisis (17 inborn) and five cases (four inborn) of exomphalos were identified. Of these, 23.8% cases of gastroschisis and 60% of cases of exomphalos had associated gut anomalies. The survival rates for gastroschisis and exomphalos were 91 and 100%, respectively. The median time to start and reach full enteral feeds in outborn neonates was longer than in inborn neonates (9 vs 25 days, respectively, P = 0.01; and 16 vs 49 days, respectively, P = 0.01), as was the duration of TPN support (14 vs 42 days, respectively; P = 0.02). Neonates with gastroschisis had significant delays in starting and reaching full feeds compared with neonates with exomphalos (median 13 vs 4.5 days, respectively, P = 0.03; and 24 vs 8, respectively, P = 0.02) and they required prolonged support with TPN (median 23 vs 6 days, respectively; P= 0.01). Antenatal detection was significantly more frequent in inborn compared with outborn neonates (100 vs 67%, respectively; P = 0.03). The severity of associated gut anomalies and the delivery to surgery interval did not differ significantly to explain the increased morbidity in outborn neonates. Outcome was not significantly different after analysis by type of surgery and mode of delivery. CONCLUSIONS: Increased morbidity in outborn neonates may be related to factors such as temperature, care, hydration status, care of the defect and vascular compromise of prolapsed gut during prolonged transportation.     

Assaults with a sharp object in small children: a 16-year review

Injuries as a result of assaults with sharp object in small children are rare and data on them are scarce. The Red Cross War Memorial Children's Hospital is presently the only Children's Hospital in South Africa with a dedicated Level 1 trauma unit for children under the age of 13 years, and we have an annual trauma load of over 10,000 patients. A retrospective review was performed using the Data Base of the Child Accident Prevention Foundation of Southern Africa at the Red Cross War Memorial Children's Hospital in Cape Town. All children who were coded as an 'assault with sharp object' were included in this study. Five-hundred-and-fifty-one (551) patients were retrospectively reviewed, of which 373 (68%) were boys and 177 (32%) girls. The mean age of the children was 7 years. The majority of children (51%) sustained injuries at the head or neck region, 26% sustained an injury at the trunk and 26% at the extremities. The majority of children sustained minor injuries (62%), thirty-three (33%) moderate and 5% severe injuries. Three children died. The most commonly recorded object used in the assault was glass or (broken) bottles (33%) and knives (18%). Other objects recorded included sticks, stones, pens, pencils, scissors, machetes and nails. The majority of perpetrators were known to the child. Assaults with a sharp object in small children are relatively rare and represent only 0.328% of all paediatric trauma patients. Although rare, these injuries carry a significant morbidity and even mortality. The majority of injuries occurred at home. Prevention programmes, specifically targeting the caretakers, should be implemented to prevent these tragic injuries.     

Retropharyngeal neuroblastoma in a neonate: case report and literature review

Primary cervical neuroblastoma (NB) in neonates is extremely rare. We treated a 1-day-old male neonate who presented with stridor and feeding difficulty and was subsequently diagnosed with NB of the retropharynx. The tumor was excised in toto transorally, and no metastatic lesions were confirmed. Histopathology and molecular genetic analysis showed poorly differentiated NB with no N-myc amplification, stage I NB. He has had no signs of recurrence or adverse sequelae during 18 months of follow-up. We report our experience and review the literature.     

Patterns of recurrence of intussusception in children: a 17-year review

Purpose. Patterns of recurrence of intussusception (INT) were reviewed to determine whether changes in management have affected the rate and patterns of recurrence as well as long-term outcome in children with multiple (i. e., 2 or more) recurrences. Materials and methods. Review was done of 763 children with 876 intussusceptions, including (1) recurrence rate, (2) patterns of recurrence (number of and interval between recurrences), (3) reducibility, (4) pathologic lead points (PLP), (5) operative findings and (6) long-term follow-up in those with multiple recurrences. Results. Above features (1)–(6) were the same in those managed with barium enema (1979–1985) and those managed with air enema (1985–1996). Overall recurrence rate was 9 %; 11 % with barium enema and 8 % with air enema. Sixty-nine patients had 113 recurrences: 47/69 (68 %) and 1 recurrence and 22/69 (32 %) had multiple recurrences. Multiple recurrences presented as isolated episodes or in clusters up to 8 years. Reducibility was 100 % for initial INT and 95 % for recurrent episodes; there were no perforations. Surgery, in 4 with irreducible recurrence, revealed no PLP. PLP were present in 5 (8 %): 2 (4 %) with 1 recurrence and 3 (14 %) with multiple recurrences. No pattern of recurrence was predictive for PLP. Long-term follow-up (up to 15 years) available in 11 with multiple recurrences revealed a favourable outcome. Conclusions. Rates and patterns of recurrence did not change with altered management. Because of the high reduction rate of recurrences, lack of perforation and favourable long-term follow-up, we recommend radiological reduction for recurrent INT. Multiple recurrences are not a contraindication. A careful search for PLP is mandatory. Surgery should be reserved for irreducible recurrences or for demonstrated PLP. Received: 30 December 1997 Accepted: 1 May 1998