Aspiration in infants and children

Aspiration of an exfoliated primary molar in a child with cerebral palsy: A case report

Foreign body aspiration is a concern in children which may occur with anything introduced to the oral cavity and can result in significant morbidity and mortality. Food and foreign objects are the most commonly aspirated objects in young children. Aspiration of a normally exfoliated primary tooth is thought to be extremely rare, if not unheard-of. The purpose of this case report is to describe the events occurring to a 10-year-old child with a cerebral palsy presenting with signs and symptoms of respiratory distress due to aspiration of a naturally exfoliated primary molar. Recommendations are provided for delivery of appropriate anticipatory guidance, management of exfoliating primary teeth, and safe clinical practice.

Mimics of child abuse: Can choking explain abusive head trauma?

Choking is one of the alternative explanations of abusive head trauma in children that have been offered in courtroom testimony and in the media. Most of these explanations - including choking - are not scientifically supported. This article highlights four points. (1) The origins of choking as an explanation for intracranial and retinal hemorrhages are speculative. (2) Choking has been used in high profile court testimony as an explanation for the death of a child thought to have been abused. (3) A case report that proposes choking as an alternative explanation for the death of a child diagnosed with abusive head trauma includes omissions and misrepresentations of facts. (4) There was a decision by the editor of the journal that published the case report that it was not necessary to include all the facts of the case; moreover, the editor indicated that facts are not required when presenting an alternative explanation. The use of scientifically unsupported alternative explanations for abusive head trauma based on inaccurate and biased information constitutes further victimization of the abused child and represents a travesty of justice.

Imaging of nonaccidental injury and the mimics: issues and controversies in the era of evidence-based medicine

Because of the controversy involving the determination of child abuse, or nonaccidental injury (NAI), radiologists must be familiar with the issues, literature, and principles of evidence-based medicine to understand the role of imaging. Children with suspected NAI must receive protective evaluation along with a timely and complete clinical and imaging work-up. Imaging findings cannot stand alone and must be correlated with clinical findings, laboratory testing, and pathologic and forensic examinations. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive clinical, imaging, biomechanical, or pathology findings.

Shaken baby syndrome: does it exist?

The original (1993) definition of Shaken Baby Syndrome (SBS) specifies a group of infants with a history of dysphagia, presenting in a comatose state with respiratory difficulty progressing to apnoea or bradycardia requiring cardiopulmonary resuscitation. It is stated that retinal and vitreous haemorrhages are characteristic of SBS, and that subdural haemorrhage caused by shearing forces disrupting small bridging veins is a common result of shaking, but visible cerebral contusions are unusual.

COMMENT

Experimental studies of whiplash injuries in primates in the 1960s showed that when coma was induced cerebral contusions were usually visible, but where the impulse was insufficient to induce coma no damage of any sort was found. Two modes of injury were established, having different impulse thresholds. At the lower threshold it was possible to study injury to axons, e.g. compare the effect of varying the plane of rotation, without inducing subdural bleeding. Contusions were usually observed in this mode, which was considered to be due to separation of the pia mater from the cortex due to trabecular tension. Subdural bleeding could be added by raising the impulse above the second threshold. Thus contusions can occur without subdural bleeding but not vice versa in whiplash injury.

HYPOTHESIS

The SBS definition is internally inconsistent. By specifying that contusions are rarely seen it seems to rule out whiplash on which the concept of Shaken Baby Syndrome is based. The definition is consistent with dysphagic accidents leading to aspiration, a Dysphagic Infant Death Syndrome in which the carer plays no part.

Foreign body removal by flexible fiberoptic bronchoscopy in infants and children

Rigid bronchoscopy is the preferred method for removal of foreign bodies lodged in the airways, but some studies found that flexible bronchoscopy can also achieve a high success rate. The aim of the present work was to report our experience in using flexible bronchoscopy for foreign body retrieval in infants and children. Reports of all bronchoscopies performed from 1994-2003 at a tertiary-level pediatric hospital in Mexico City were reviewed. Those with a final diagnosis of foreign body aspiration were analyzed. Of 2,376 bronchoscopies performed during the study period, 59 (2.5%) yielded a final diagnosis of foreign body aspiration: 28 lodged in the right bronchi, 15 in the left bronchi, and those remaining, in the larynx or trachea. Foreign bodies were organic in nature in 38 (64.4%), mainly peanuts, pumpkin seeds, and beans, while 21 (35.6%) were inorganic, mainly pen caps and pins. In 23 cases, flexible bronchoscopy was attempted as the initial therapeutic procedure. Among these latter patients, the procedure was successful in 21 (91.3%). Ages of these 21 patients ranged from 9 months to 16 years (median, 5 years). The only two patients in whom foreign bodies could not be removed through flexible bronchoscopy were males, 2 years of age, both with a peanut lodged in right main bronchus. In conclusion, flexible bronchoscopy must be taken into account as initial therapeutic method for foreign body removal in infants and children.