Newly postulated neurodevelopmental risks of pediatric anesthesia: theories that could rock our world

Multiple General Anesthesia in Children: A Systematic Review of Its Effect on Neurodevelopment

The effect of multiple general anesthesia (mGA) procedures administered in early life is a critical theme and has led the Food and Drug Administration (FDA) to issue an alert. This systematic review seeks to explore the potential effects on neurodevelopment of mGA on patients under 4 years. The Medline, Embase and Web of Science databases were searched for publications up to 31 March 2021. The databases were searched for publications regarding "children multiple general anesthesia OR pediatric multiple general anesthesia". Case reports, animal studies and expert opinions were excluded. Systematic reviews were not included, but they were screened to identify any possible additional information. A total of 3156 studies were identified. After removing the duplicates, screening the remaining records and analyzing the systematic reviews' bibliography, 10 studies were considered suitable for inclusion. Comprehensively, a total cohort of 264.759 unexposed children and 11.027 exposed children were assessed for neurodevelopmental outcomes. Only one paper did not find any statistically significant difference between exposed and unexposed children in terms of neurodevelopmental alterations. Controlled studies on mGA administered before 4 years of age support that there might be a greater risk of neurodevelopmental delay in children receiving mGA, warranting the need for careful risk/benefit considerations.

"Systematic Review and Guidelines for Perioperative Management of Pediatric Patients Undergoing Major Plastic Surgery Procedures, With a Focus on Free Tissue Transfer."

BACKGROUND

Microsurgical free tissue transfer has been successfully implemented for various reconstructive applications in children. The goal of this study was to identify the best available evidence on perioperative management of pediatric patients undergoing free tissue transfer, and use it to develop evidence-based care guidelines.

METHODS

A systematic review was conducted in Pubmed, Embase, Scopus, and Cochrane Library databases. Since a preliminary search of the pediatric microsurgical literature yielded scant data with low level of evidence (LOE), pediatric anesthesia guidelines for healthy children undergoing major surgeries were also included. Exclusion criteria included: vague descriptions of perioperative care, case reports, and studies of syndromic or chronically ill children.

RESULTS

204 articles were identified, and 53 met inclusion criteria. Management approaches specific to the pediatric population were used to formulate recommendations. High quality data was found for anesthesia, analgesia, fluid administration / blood transfusion, and anticoagulation (LOE 1). Lower quality evidence was identified for patient temperature (LOE 3) and vasodilator use (LOE 4). Key recommendations include: administering sevoflurane for general anesthesia, implementing a multimodal analgesia strategy, limiting preoperative fasting, restricting blood transfusions until hemoglobin < 7 g/dl unless patient is symptomatic, and reserving chemical venous thromboembolism prophylaxis for high risk patients.

CONCLUSIONS

Pediatric-specific guidelines are important as they acknowledge physiologic differences in children, which may be overlooked when extrapolating from adult studies. These evidence-based recommendations are a key first step toward standardization of perioperative care of pediatric patients undergoing plastic surgical procedures, including free tissue transfer, to improve outcomes and minimize complications.

Case Report: Traumatic Stress and Developmental Regression: An Unintended Consequence of Complex Cardiac Care

This brief case report outlines a novel approach to supporting the development of a pediatric complex cardiac care patient. Patient X is a 19-month old patient who spent 5.5 months in hospital and underwent multiple surgeries including heart transplantation. This case report explores the impacts of his condition and care on his development and family functioning within the framework of an integrated care model. This case report is uniquely complimented by outpatient neurodevelopmental follow up, dyadic trauma-informed intervention and use of telemedicine allowing for a deeper understanding of the family adaptation that provide novel insight into long-term trajectory beyond discharge. Throughout care Patient X met criteria for both a traumatic stress disorder and global developmental delay. This case study highlights the threat complex care poses to neurodevelopment, pediatric mental health and family dynamics as well as opportunities for intervention.

Frontal electroencephalogram based drug, sex, and age independent sedation level prediction using non-linear machine learning algorithms

Brain monitors which track quantitative electroencephalogram (EEG) signatures to monitor sedation levels are drug and patient specific. There is a need for robust sedation level monitoring systems to accurately track sedation levels across all drug classes, sex and age groups. Forty-four quantitative features estimated from a pooled dataset of 204 EEG recordings from 66 healthy adult volunteers who received either propofol, dexmedetomidine, or sevoflurane (all with and without remifentanil) were used in a machine learning based automated system to estimate the depth of sedation. Model training and evaluation were performed using leave-one-out cross validation methodology. We trained four machine learning models to predict sedation levels and evaluated the influence of remifentanil, age, and sex on the prediction performance. The area under the receiver-operator characteristic curve (AUC) was used to assess the performance of the prediction model. The ensemble tree with bagging outperformed other machine learning models and predicted sedation levels with an AUC = 0.88 (0.81–0.90). There were significant differences in the prediction probability of the automated systems when trained and tested across different age groups and sex. The performance of the EEG based sedation level prediction system is drug, sex, and age specific. Nonlinear machine-learning models using quantitative EEG features can accurately predict sedation levels. The results obtained in this study may provide a useful reference for developing next generation EEG based sedation level prediction systems using advanced machine learning algorithms.

Clinical trial registration: NCT 02043938 and NCT 03143972.

Effect of ketamine combined with lidocaine in pediatric anesthesia

Background

We conducted a randomized clinical trial to determine whether adjunctive lidocaine diminishes the incidence of adverse effects in pediatric patients sedated with ketamine.

Methods

This case‐control study involved 586 consecutive pediatric patients necessitating anesthesia. Then systolic blood pressure, heart rate, respiratory rate, and blood oxygen saturation were observed. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), urea nitrogen (BUN), and creatinine (Cr) levels were tested. General dose of ketamine, the time of onset and duration of anesthesia and postoperative recovery, anesthesia effect, and adverse reaction were subsequently compared. High‐performance liquid chromatography was employed to detect ketamine concentration at different time points after administration, and the postoperative cognition function was further evaluated.

Results

Intra‐ and post‐operation, the rising degree of ALT, AST, BUN, and Cr in patients treated with ketamine was higher than those in patients treated with the ketamine‐lidocaine complex. General dose of ketamine, the time of onset and duration of anesthesia, postoperative recovery time, and the incidence rate of adverse reaction in patients treated with ketamine‐lidocaine complex were lower, but the concentration of ketamine was higher compared to the patients treated with ketamine. In patients treated with the ketamine‐lidocaine complex, elimination half‐life of ketamine was prolonged, the area under curve was increased, and the plasma clearance rate was decreased relative to those with ketamine alone.

Conclusions

Ketamine combined with lidocaine may be beneficial in shortening the onset of anesthesia, promoting postoperative awake, prolonging elimination half‐life, increasing area under curve, and decreasing plasma clearance rate and incidence of adverse reactions.

Spinal anesthesia in children: most pediatric urologists are not on board

OBJECTIVE

In 2016, the Food and Drug Administration issued a warning on general anesthetic medications used for lengthy procedures (>3 h) in children younger than 3 years. Spinal anesthesia can be a safe alternative to general anesthesia for many pediatric urology procedures. It can shorten total operating room (OR) time, provide excellent pain control, and allow parents to reunite with their child immediately after surgery. However, use of spinal anesthesia can also directly affect the operating surgeon (awake patient, time constraints of spinal, and prolonged preoperative time). Members of the Societies for Pediatric Urology (SPU) and European Society of Pediatric Urology (ESPU) were surveyed to get their opinions on the use of spinal anesthesia for routine pediatric urology procedures. It was hypothesized that half of pediatric urologists would favor spinal anesthesia and that SPU members would be more likely to favor spinal anesthesia than their European colleagues.

MATERIALS AND METHODS

A short survey with five clinical scenarios was created. Scenarios assessed physicians' recommendations regarding timing and the type of anesthesia (general or spinal) for common pediatric urology procedures: undescended testicle, inguinal hernia, hypospadias, phimosis, and phimosis with penoscrotal webbing. Surveys were emailed to members of the SPU and ESPU. Responses and demographic information were collected and analyzed.

RESULTS

The survey was completed by 113 SPU members (46% response rate for members who opened the invitation) and 109 ESPU members. For all clinical scenarios, < 20% of pediatric urologists from the SPU and <25% from the ESPU favor doing any procedure with spinal anesthesia. The majority of respondents practice in children's hospitals with pediatric anesthesiologists, but roughly half of the responders (54% SPU and 43% ESPU) do not think their anesthesia colleagues would be comfortable performing spinal anesthesia. Furthermore, only 51% of SPU and 36% of ESPU members discuss the possible neurodevelopmental side-effects of anesthesia with parents; similarly, less than half of all respondents think their anesthesia colleagues address these potential side-effects when obtaining consent. The only significant difference between SPU and ESPU responses was that ESPU members tended to delay penile surgery more than SPU respondents.

CONCLUSION

Whether general anesthesia has any effect on the developing brain of children undergoing routine pediatric urology procedures is unclear. Yet, few pediatric urologists, independent of their region of practice, prefer spinal to general anesthesia. Collaboration in the OR is the key to success, and it is important that pediatric urologists and pediatric anesthesiologists work together to balance the benefits and risks of general and spinal anesthesia.

Conscious Sedation for Pediatric Peritonsillar Abscess: Comparison of Anesthetic Approaches

Objective

To compare the efficacy, safety, and cost of incision and drainage (I&D) for pediatric patients with peritonsillar abscesses (PTAs) under conscious sedation (CS) versus unsedated (awake) and general anesthesia (GA).

Study Design

Case series with chart review.

Setting

Tertiary pediatric hospital.

Subjects and Methods

Records for all pediatric patients (<18 years) treated for PTAs in the emergency department from 2005 to 2015 were reviewed and stratified into awake, CS, and GA groups for comparison. The primary outcome measure was procedure tolerance, with secondary measures including return to the emergency department within 15 days, complications, and facility costs associated with treatment.

Results

A total of 188 patients were identified. The median age was 14 years (interquartile range, 9-16). Awake drainage with injected local anesthetic was used in 115 children; 62 underwent CS; and 11 underwent GA. Over 92% of the children tolerated I&D regardless of anesthesia, with no difference among groups ( P = .60). None of those who underwent I&D via CS returned to the emergency department within 15 days of the procedure, as compared with 5.2% for the awake group and 9.1% for the GA group ( P = .06). None in the GA or awake group had a complication associated with the procedure, as opposed to 9.6% in the CS group ( P = .02). Complications included apnea and dental trauma (2 children each) and transient hypotension and desaturation (1 each). Cost was highest in the GA group and lowest for the awake group ( P < .0001).

Conclusion

CS for PTA I&D is a viable treatment option with tolerance and success similar to that of the awake and GA groups. Complications were observed for those who underwent CS, but they were manageable.

Is contralateral inguinal exploration necessary in preterm girls undergoing inguinal hernia repair during the first months of life?

BACKGROUND

To assess the need for contralateral surgical exploration in preterm girls with symptomatic unilateral inguinal hernia.

METHODS

The medical data of girls operated for inguinal hernia between 2004 and 2016 in a single pediatric surgery center were retrospectively collected. Preterm girls operated for unilateral hernia before 6 months of life were selected (55/517 cases) to assess the incidence and risk factors for contralateral metachronous inguinal hernia (CMIH).

RESULTS

CMIH was observed in 7% of cases (4 girls with a right inguinal hernia in 3 cases) at a mean age of 4.2 years. Only one case occurred early (3 months). Birth weight and term were comparable (1674 ± 620 g and 32 ± 5 WA without CMIH vs. 1694 ± 582 g and 33 ± 3 WA with CMIH).

CONCLUSION

Contralateral inguinal hernia is very rare and generally occurs several years after inguinal repair surgery in preterm girls, which should encourage practitioners to follow these children throughout childhood for the subsequent development of inguinal hernia. This study did not find any arguments in favor of systematic contralateral exploration in preterm girls.

Risk of ADHD After Multiple Exposures to General Anesthesia: A Nationwide Retrospective Cohort Study

OBJECTIVE

To study the association between general anesthesia exposure before age 3 years and having a later ADHD diagnosis.

METHOD

In a birth cohort, data were collected from a nationwide population database for children born between 1997 and 1999 who were exposed to general anesthesia before their third birthday. Age- and gender-matched enrollees without general anesthesia exposure were taken as the comparison. Groups were compared to identify the incidence of ADHD after age 4 and anesthesia-related predictive factors.

RESULTS

Among the 1,146 exposed children, 74 ADHD cases were identified, and 158 ADHD cases were identified in 3,438 matched controls. After adjusting for comorbid conditions and possible confounding factors, if exposure on more than one occasion or ≥3 hr, an increased likelihood of having a later ADHD diagnosis was found (HR, 1.71 and 2.43, respectively).

CONCLUSION

Children with multiple or ≥3 hr general anesthesia exposures before age 3 years have an increased likelihood of a later ADHD diagnosis.

Pediatric anesthesia and neurotoxicity: what the radiologist needs to know

The use of cross-sectional imaging in the pediatric population continues to rise, particularly the use of MRI. Limiting motion artifact requires cooperative subjects who do not move during imaging, so there has been an increase in the need for pediatric sedation or anesthesia. Over the last decade, concern has increased that exposure to anesthesia might be associated with long-term cognitive deficits. In this review we report current understanding of the effects of anesthesia on the pediatric population, with special focus on long-term developmental and cognitive outcomes, and suggest how radiologists can use new technologies or imaging strategies to mitigate or minimize these potential risks.

Considerations for general anaesthesia in Parkinson's disease

Parkinson's disease is a common neurodegenerative disorder in the elderly which when present has a significant influence on surgical management. These patients necessitate additional perioperative and anaesthetic considerations across disease specific domains as well as in relation to the respiratory and cardiovascular systems. This brief review focuses on the factors which contribute to perioperative morbidity, including the use of medications that may exacerbate symptoms or adversely interact with treatments for Parkinson's disease. Recommended dosing practices to reduce complications during hospitalisation are covered. In addition, recent concerns regarding anaesthetic exposure in early childhood as a risk factor for the development of Parkinson's disease are discussed in light of data from animal models of anaesthetic neurotoxicity and epidemiological studies.

Early postnatal exposure to isoflurane causes cognitive deficits and disrupts development of newborn hippocampal neurons via activation of the mTOR pathway

Clinical and preclinical studies indicate that early postnatal exposure to anesthetics can lead to lasting deficits in learning and other cognitive processes. The mechanism underlying this phenomenon has not been clarified and there is no treatment currently available. Recent evidence suggests that anesthetics might cause persistent deficits in cognitive function by disrupting key events in brain development. The hippocampus, a brain region that is critical for learning and memory, contains a large number of neurons that develop in the early postnatal period, which are thus vulnerable to perturbation by anesthetic exposure. Using an in vivo mouse model we demonstrate abnormal development of dendrite arbors and dendritic spines in newly generated dentate gyrus granule cell neurons of the hippocampus after a clinically relevant isoflurane anesthesia exposure conducted at an early postnatal age. Furthermore, we find that isoflurane causes a sustained increase in activity in the mechanistic target of rapamycin pathway, and that inhibition of this pathway with rapamycin not only reverses the observed changes in neuronal development, but also substantially improves performance on behavioral tasks of spatial learning and memory that are impaired by isoflurane exposure. We conclude that isoflurane disrupts the development of hippocampal neurons generated in the early postnatal period by activating a well-defined neurodevelopmental disease pathway and that this phenotype can be reversed by pharmacologic inhibition.

The United States Food and Drug Administration has recently warned that exposure to anesthetic and sedative drugs during the third trimester of prenatal development and during the first 3 years of life may cause lasting impairments in cognitive function. The mechanisms by which this undesirable side effect occurs are unknown. In this manuscript, we present evidence in mice that early developmental exposure to isoflurane, a canonical general anesthetic, disrupts the appropriate development of neurons in the hippocampus, a brain region associated with learning and memory. Isoflurane also causes up-regulation of the mechanistic target of rapamycin (mTOR) pathway, a signaling system that has been associated with other neurodevelopmental cognitive disorders. Treatment with an inhibitor of the mTOR pathway after isoflurane exposure normalizes neuronal development and also ameliorates the impairments in learning induced by isoflurane. We conclude that early exposure to isoflurane can cause learning deficits via actions on the mTOR pathway, and that this mechanism represents a potentially druggable target to minimize the side effects of anesthetics on the developing brain.

A "Wear and Tear" Hypothesis to Explain Sudden Infant Death Syndrome

Sudden infant death syndrome (SIDS) is the leading cause of death among USA infants under 1 year of age accounting for ~2,700 deaths per year. Although formally SIDS dates back at least 2,000 years and was even mentioned in the Hebrew Bible (Kings 3:19), its etiology remains unexplained prompting the CDC to initiate a sudden unexpected infant death case registry in 2010. Due to their total dependence, the ability of the infant to allostatically regulate stressors and stress responses shaped by genetic and environmental factors is severely constrained. We propose that SIDS is the result of cumulative painful, stressful, or traumatic exposures that begin in utero and tax neonatal regulatory systems incompatible with allostasis. We also identify several putative biochemical mechanisms involved in SIDS. We argue that the important characteristics of SIDS, namely male predominance (60:40), the significantly different SIDS rate among USA Hispanics (80% lower) compared to whites, 50% of cases occurring between 7.6 and 17.6 weeks after birth with only 10% after 24.7 weeks, and seasonal variation with most cases occurring during winter, are all associated with common environmental stressors, such as neonatal circumcision and seasonal illnesses. We predict that neonatal circumcision is associated with hypersensitivity to pain and decreased heart rate variability, which increase the risk for SIDS. We also predict that neonatal male circumcision will account for the SIDS gender bias and that groups that practice high male circumcision rates, such as USA whites, will have higher SIDS rates compared to groups with lower circumcision rates. SIDS rates will also be higher in USA states where Medicaid covers circumcision and lower among people that do not practice neonatal circumcision and/or cannot afford to pay for circumcision. We last predict that winter-born premature infants who are circumcised will be at higher risk of SIDS compared to infants who experienced fewer nociceptive exposures. All these predictions are testable experimentally using animal models or cohort studies in humans. Our hypothesis provides new insights into novel risk factors for SIDS that can reduce its risk by modifying current infant care practices to reduce nociceptive exposures.

From Drug-Induced Developmental Neuroapoptosis to Pediatric Anesthetic Neurotoxicity-Where Are We Now?

The fetal and neonatal periods are critical and sensitive periods for neurodevelopment, and involve rapid brain growth in addition to natural programmed cell death (i.e., apoptosis) and synaptic pruning. Apoptosis is an important process for neurodevelopment, preventing redundant, faulty, or unused neurons from cluttering the developing brain. However, animal studies have shown massive neuronal cell death by apoptosis can also be caused by exposure to several classes of drugs, namely gamma-aminobutyric acid (GABA) agonists and N-methyl-d-aspartate (NMDA) antagonists that are commonly used in pediatric anesthesia. This form of neurotoxic insult could cause a major disruption in brain development with the potential to permanently shape behavior and cognitive ability. Evidence does suggest that psychoactive drugs alter neurodevelopment and synaptic plasticity in the animal brain, which, in the human brain, may translate to permanent neurodevelopmental changes associated with long-term intellectual disability. This paper reviews the seminal animal research on drug-induced developmental apoptosis and the subsequent clinical studies that have been conducted thus far. In humans, there is growing evidence that suggests anesthetics have the potential to harm the developing brain, but the long-term outcome is not definitive and causality has not been determined. The consensus is that there is more work to be done using both animal models and human clinical studies.

Tympanostomy tube placement in awake, unrestrained pediatric patients: A prospective, multicenter study

OBJECTIVES

Tympanostomy tube (tube) placement is the most common pediatric otolaryngologic surgery in the United States. Most surgeries are performed in an operating-room setting under general anesthesia due to the lack of tolerable and reliable local anesthesia methods suitable for pediatric patients, and concerns regarding myringotomy procedures in a mobile child. This study evaluated the safety and efficacy of an iontophoresis system (IPS) to achieve local anesthesia in combination with a tube delivery system (TDS) for tube placement in pediatric patients in an office setting.

METHODS

A prospective, single-arm study was conducted at 9 otolaryngology sites in the United States. Participants included pediatric patients aged 6 months to less than 22 years requiring tube placement. Patients were prepared for the procedure using behavioral support techniques and tube placement was attempted under local anesthesia using the IPS in conjunction with the TDS. No physical restraints were allowed and no anxiolytics, analgesics, or sedatives were permitted. Safety was assessed through the occurrence of adverse events and success rates for tube placement under local anesthesia were determined. Tolerability of the procedure was evaluated using the 5-point Wong-Baker FACES Pain Rating Scale and parental satisfaction was assessed using a postoperative survey.

RESULTS

Seventy patients (127 ears) were enrolled in the study [mean (SD) age=7.0 (3.9) years]. No serious adverse events occurred in the 70 enrolled patients. Tube placement using the TDS was successful in 96.6% (114/118) of attempted ears. A single TDS was required in 105 ears, while more than 1 device was required in 9 ears. Of the 70 patients enrolled in study, 63 (90.0%) successfully received tubes in all indicated ears during their in-office visit. The mean (SD) change in pain score from pre-anesthesia to post-surgery was +0.9 (1.8). Favorable ratings for overall satisfaction with the in-office procedure were obtained from 96.9% (63/65) of respondents. Tube retention at 2 weeks was 99.1%. As only 15 patients were enrolled who were 3 years old or younger, the ability to generalize these results to younger patients is limited.

CONCLUSIONS

In this study, use of the IPS and TDS technologies enabled safe, reliable, and tolerable placement of tubes in awake, unrestrained pediatric patients.

Neonatal anesthesia: how we manage our most vulnerable patients

Neonates undergoing surgery are at higher risk than older children for anesthesia-related adverse events. During the perioperative period, the maintenance of optimal hemodynamics in these patients is challenging and requires a thorough understanding of neonatal physiology and pharmacology. Data from animals and human cohort studies have shown relation of the currently used anesthetics may associate with neurotoxic brain injury that lead to later neurodevelopmental impairment in the developing brain. In this review, the unique neonatal physiologic and pharmacologic features and anesthesia-related neurotoxicity will be discussed.

Impact of drainage technique on pediatric pyeloplasty: Comparative analysis of externalized uretero-pyelostomy versus double-J internal stents

INTRODUCTION

Pediatric pyeloplasty with double J (DJ) stent drainage requires manipulation of the uretero-vesical junction (UVJ) and a second anesthetic for removal. Externalized uretero-pyelostomy (EUP) stents avoid these issues. We report outcomes of laparoscopic and open pyeloplasty with EUP compared to DJ stents in children.

METHODS

We retrospectively reviewed 76 consecutive children who underwent pyeloplasty for ureteropelvic junction (UPJ) obstruction over a 1-year period by 5 pediatric urologists at a single institution. The exclusion criteria included patients with concomitant urological procedures, other urinary drainage strategies, "stentless" pyeloplasty or patients without follow-up data. Based on surgeon preference, 24 patients had a EUP stent and 38 had a DJ stent placed.

RESULTS

The mean follow-up was 23.8 ± 10.9 months and 21.1 ± 11.1 months for the EUP and DJ stent groups, respectively (p = 0.32). The mean age was 40 ± 54 months and 80 ± 78 months for the EUP and DJ groups, respectively (p = 0.04). The EUP group had a greater proportion of open pyeloplasties (n = 17, 71%) versus the DJ group (n = 16, 42%; p = 0.04). There were no statistically significant differences in operative time, length of stay, and overall complication rate between groups. Complications were divided by timing of complication (intraoperative, before and after 3 months) and according to the Clavien Classification system. There were no statistically significant differences between these subgroups. The limitations of this study include small sample size, potential selection bias, and heterogeneity between both study groups.

CONCLUSIONS

Pyeloplasty using EUP stents does not incur prolonged operative time, longer length of stay or higher complication rate when compared to DJ stents. Within the limitations of this study, EUP stents may be a safe alternative to DJ stents.

Gastroscopy in pediatric surgery: indications, complications, outcomes, and ethical aspects

Background. The aim of this study was to map gastroscopies performed at a single tertiary pediatric surgery centre to investigate indications, complications, outcomes, and ethical aspects. Material and Methods. A retrospective study of gastroscopies performed during two time periods (2001-2004 and 2011-2014) was conducted. Data regarding indications, outcomes, and complications of pediatric gastroscopies were analysed from a prospectively collected database. Results. The indications for gastroscopies changed over time. Therefore, 376 gastroscopies performed from 2011 through 2014 were studied separately. The median patient was four years old. The predominant indications were laparoscopic gastrostomy (40%), investigation of gastroenterological conditions (22%), obstruction in the upper gastrointestinal tract (20%), gastroesophageal reflux disease (GERD) (15%), and other indications (3%). Percentages of gastroscopies with no positive findings for each condition were laparoscopic gastrostomy, 100%; gastroenterological conditions, 46%; obstruction in the upper gastrointestinal tract, 36%; GERD, 51%. Furthermore, gastroscopies did not lead to any further action or change in treatment in 45% of gastroenterological conditions and 72% of GERD cases. The overall complication rate was 1%. Conclusion. The results are valuable to educate pediatric surgeons and to inform health care planning when including gastroscopy within clinical practice.

Sucrose and warmth for analgesia in healthy newborns: an RCT

BACKGROUND AND OBJECTIVE

Increasing data suggest that neonatal pain has long-term consequences. Nonpharmacologic techniques (sucrose taste, pacifier suckling, breastfeeding) are effective and now widely used to combat minor neonatal pain. This study examined the analgesic effect of sucrose combined with radiant warmth compared with the taste of sucrose alone during a painful procedure in healthy full-term newborns.

METHODS

A randomized, controlled trial included 29 healthy, full-term newborns born at the University of Chicago Hospital. Both groups of infants were given 1.0 mL of 25% sucrose solution 2 minutes before the vaccination, and 1 group additionally was given radiant warmth from an infant warmer before the vaccination. We assessed pain by comparing differences in cry, grimace, heart rate variability (ie, respiratory sinus arrhythmia), and heart rate between the groups.

RESULTS

The sucrose plus warmer group cried and grimaced for 50% less time after the vaccination than the sucrose alone group (P < .05, respectively). The sucrose plus warmer group had lower heart rate and heart rate variability (ie, respiratory sinus arrhythmia) responses compared with the sucrose alone group (P < .01), reflecting a greater ability to physiologically regulate in response to the painful vaccination.

CONCLUSIONS

The combination of sucrose and radiant warmth is an effective analgesic in newborns and reduces pain better than sucrose alone. The ready availability of this practical nonpharmacologic technique has the potential to reduce the burden of newborn pain.

Ilfeld abduction orthosis is an effective second-line treatment after failure of Pavlik harness for infants with developmental dysplasia of the hip

BACKGROUND

Closed reduction and spica casting is the most commonly recommended choice for infants with developmental dysplasia of the hip (DDH) for whom Pavlik harness treatment has failed, but it requires general anesthesia in addition to the challenges of spica cast care. The purposes of this study were to evaluate the effectiveness of Ilfeld bracing for infants for whom Pavlik harness treatment is unsuccessful and to compare these results with those for a similar cohort of patients directly undergoing closed reduction and spica casting.

METHODS

We reviewed the cases of a consecutive series of children with DDH who had failure of Pavlik harness treatment and were subsequently managed with Ilfeld bracing (the BR cohort) and compared this cohort with a similar historical group of infants who had failure of Pavlik harness treatment but had standard closed reduction and spica casting (the CR cohort). The cohorts were compared with respect to clinical and ultrasonographic data at the time of Pavlik discontinuation. At one year, the hip stability and acetabular index were assessed; the presence of osteonecrosis was graded according to the criteria described by Salter et al.

RESULTS

Twenty-eight hips (nineteen infants) made up the BR cohort and twenty-two hips (sixteen infants) made up the CR cohort. Ultrasonographic indices (including the alpha angle and the percentage of femoral head coverage) were comparable between the two cohorts (p=0.66 and 0.19, respectively). Following treatment, a stable reduction was achieved in twenty-three (82%) of twenty-eight hips in the BR cohort compared with twenty (91%) of twenty-two hips in the CR cohort. At one year, acetabular indices were similar between both cohorts (mean and standard deviation, 27°±6° for the BR cohort versus 27°±5° for the CR cohort; p=0.62); however, osteonecrosis developed in three hips in the CR cohort compared with none in the BR cohort.

CONCLUSIONS

In our series of infants with DDH for whom Pavlik harness treatment had failed, Ilfeld bracing had success rates comparable with those for closed reduction and spica cast treatment. With the added advantages of avoiding general anesthesia and spica casting as well as a potentially lower rate of osteonecrosis, rigid abduction bracing should be considered as the next step for infants who have had failed Pavlik harness treatment prior to proceeding with closed reduction and spica casting.

Positron Emission Tomography with [(18)F]FLT Revealed Sevoflurane-Induced Inhibition of Neural Progenitor Cell Expansion in vivo

Neural progenitor cell expansion is critical for normal brain development and an appropriate response to injury. During the brain growth spurt, exposures to general anesthetics, which either block the N-methyl-d-aspartate receptor or enhance the γ-aminobutyric acid receptor type A can disturb neuronal transduction. This effect can be detrimental to brain development. Until now, the effects of anesthetic exposure on neural progenitor cell expansion in vivo had seldom been reported. Here, minimally invasive micro positron emission tomography (microPET) coupled with 3'-deoxy-3' [(18)F] fluoro-l-thymidine ([(18)F]FLT) was utilized to assess the effects of sevoflurane exposure on neural progenitor cell proliferation. FLT, a thymidine analog, is taken up by proliferating cells and phosphorylated in the cytoplasm, leading to its intracellular trapping. Intracellular retention of [(18)F]FLT, thus, represents an observable in vivo marker of cell proliferation. Here, postnatal day 7 rats (n = 11/group) were exposed to 2.5% sevoflurane or room air for 9 h. For up to 2 weeks following the exposure, standard uptake values (SUVs) for [(18)F]-FLT in the hippocampal formation were significantly attenuated in the sevoflurane-exposed rats (p < 0.0001), suggesting decreased uptake and retention of [(18)F]FLT (decreased proliferation) in these regions. Four weeks following exposure, SUVs for [(18)F]FLT were comparable in the sevoflurane-exposed rats and in controls. Co-administration of 7-nitroindazole (30 mg/kg, n = 5), a selective inhibitor of neuronal nitric oxide synthase, significantly attenuated the SUVs for [(18)F]FLT in both the air-exposed (p = 0.00006) and sevoflurane-exposed rats (p = 0.0427) in the first week following the exposure. These findings suggested that microPET in couple with [(18)F]FLT as cell proliferation marker could be used as a non-invasive modality to monitor the sevoflurane-induced inhibition of neural progenitor cell proliferation in vivo.

Pediatric chronic orchialgia: patient population and patterns of care

OBJECTIVE

A major hurdle in management of any chronic pain syndrome is understanding the population in which it occurs. We describe our pediatric population of patients with peripubertal and postpubertal chronic orchialgia.

PATIENTS AND METHODS

Pediatric patients ≥ 10 years of age seen between 2002 and 2012 were identified by ICD code 608.9, Male Genital Disorder NOS. Patients were included if they had orchialgia without identifiable cause lasting >3 months. Patient history, diagnostic evaluations, treatments, and outcomes were assessed.

RESULTS

Seventy-nine pediatric patients were identified. The mean age was 13.3 years (range 10-18); mean duration of orchialgia was 16.3 months (range 3-85). Thirty-three of 79 (42%) had concomitant medical conditions and/or psychiatric-behavioral issues. The mean follow-up was 7.1 months (range 0-70.4) with 41/79 (52%) having more than one office visit follow-up. Eleven patients were referred to a pediatric pain clinic; 10 out of 11 (91%) were evaluated there. Overall, 16 out of 41 (39%) had resolution of pain: nine out of 41 (22%) responding to conservative management vs seven of 10 (70%) responding to pain clinic management (3 to anti-neuropathic medications, 4 to nerve block).

CONCLUSION

Many pediatric patients with chronic orchialgia have co-morbidities amenable to multidisciplinary collaborative coordination of care. Referral to pediatric pain clinic can be of significant benefit.

Update on pediatric dermatologic surgery from tots to teens

PURPOSE OF REVIEW

Children and their parents typically present to pediatricians to discuss treatment options for melanocytic nevi, nevus sebaceus, port-wine stains, and hemangiomas. Each of these conditions may be medically managed, but in some situations surgical intervention may be preferable.

RECENT FINDINGS

Although recent studies have improved our understanding of melanoma risk among patients with congenital nevi, prospective trials are needed to more accurately assess whether surgical excision mitigates this risk. The risk of basal cell carcinoma within nevus sebaceus appears to be low, but more conclusive data requires further studies with modern immunohistochemical analysis. Pulsed dye laser is effective for treating port-wine stains, although the optimal timing is controversial. While oral and topical beta blockers have revolutionized the treatment of proliferating infantile hemangiomas, laser and/or surgical excision are useful in selected situations.

SUMMARY

Excisional and/or laser surgery are indicated for certain common dermatologic conditions in children, although the optimal timing of these interventions is often subjective. Pediatricians should be familiar with why and when to refer patients for surgery of these common dermatological conditions.