Sunwa Kim, R Peverini, M Goldstein, Joanne Baerg , D Deming,  AO Hopper

 J. Chiaka Ejike, MD, FAAP1   Jennifer Newcombe, NP2    Joanne Baerg, MD3    Khaled Bahjri, MD, MPH4    Mudit Mathur, MD, FAAP1Background: ACS is well described in the adult, trauma and surgical patient population. Very little literature exists with regards to the pediatric population. The sparse reporting of it in the pediatric literature may be a reflection of a decreased awareness among pediatric health care providers.   Aim: To assess current knowledge and ability to identify ACS among pediatric heath care providers.  Design: A brief written survey administered as a questionnaire.    Subjects: Pediatric health care providers   Method: A questionnaire was distributed to nurses attending a national nursing critical care meeting and at an international pediatric critical care conference.  Results: Forty-six percent of 1107 questionnaires were completed and returned. The majority of participants included general Pediatricians, Pediatric Intensivists, Pediatric Nurses and others. Eighty-eight percent worked in an intensive care setting and 80% worked in a tertiary hospital setting. Seventy-seven percent of participants had heard of ACS. Participants working in an ICU or tertiary care setting were more likely to be aware of ACS. The IAP thresholds for defining ACS were variable among participants. About one-quarter of participants never measured IAP but when it was measured the method used was the intra-vesicle method. Two thirds of those who were aware had actual experience in managing a child with ACS.    Conclusion: Awareness and recognition of ACS needs to be further promoted among pediatric health care professionals and there needs to be more clarity in the definition ofACS in children. Patients at risk for developing IAH and ACS need to be monitored using more objective techniques more routinely according to the consensus recommendations by the WSACS.  

 co investigators- V. Kanthimathinathan*, D. Moores  * denotes resident

Purpose:              We sought to identify significant associations between gastroesophageal reflux disease (GERD) and weight loss in neonatal intensive care unit (NICU) infants. Methods:              After Institutional Review Board approval, infants born between January 2004 and December 2006, investigated by 24-hour pH-probe before age six months, were reviewed retrospectively. GERD was present if the pH < 4 for over 5% of 24 hours.  We examined growth curves at the initial pH-probe, 6 months later, and December 2009.  At the six-month evaluation, we compared infants who lost to infants who gained.  Logistic regression identified subgroups associated with weight loss independent of GERD.  Results:             Follow-up was complete for 191, 48(25.1%) lost and 143(74.9%) gained.  GERD was present in 87/191(45.5%), 31(35.6%) underwent fundoplication, 56(64.4%) received anti-reflux medications. Weight loss occurred in 21/87(24.1%) and was not from GERD in 20/21(95.2%). Between 6-30 months (median:  10 months) after their initial probe, 5/31(16.1%) fundoplication patients were vomiting, but gaining weight.  A pH-probe confirmed GERD.             GERD was absent in 104/191(54.5%). Weight loss occurred in 27/104(26.0%) and was not from GERD in 20/27(74.1%). Between 6-31 months (median: 11 months) after a negative probe, 7/27(26.0%) were vomiting and losing weight.  A pH-probe confirmed GERD.             Infants unable to feed orally (OR:2.68(95%CI:  1.24-5.85)), or with a genetic syndrome (OR:13.56(95%CI:  4.56-40.29)), lost independent of GERD. Conclusions:   If treated, GERD is not associated with weight loss in NICU infants.  Despite a negative pH-probe, pediatricians should inquire about GERD symptoms, and restudy infants before weight loss occurs.  Infants with inability to feed orally or genetic syndromes lose weight, independent of GERD.   

 

 ABSTRACT:   INTRODUCTION:   We present a case of endoscopy-guided placement of a pleuro-peritoneal shunt in a patient with primary lymphedema, multiple abdominal lymphoceles, an episode of spontaneous bacterial peritonitis and  recurring symptomatic  pleural effusions. CASE:  A fifteen year-old boy with primary lymphedema, had undergone multiple thoracenteses and chest tubes for a left pleural effusion.  An incision was made in the posterior axillary line at the sixth intercostal space.  The pleural portion of the shunt was placed in good position guided by the five millimeter, thirty-degree camera.    The shunt and pump chamber were tunneled under the skin.  A 5mm incision was made in the left upper quadrant, a purse string suture was placed in the posterior rectus sheath and the 5mm port was inserted into the abdomen under direct vision.   Pneumoperitoneum was obtained to a pressure of 13 mm Hg and the camera was inserted.  Multiple lymphoceles and   adhesions were identified. With laparoscopic guidance, an area was dissected in which to place the shunt.  Immediate good shunt function was observed. DISCUSSION:  This previously unreported use of endoscopy to successfully place a pleuro-peritoneal shunt, allowed a patient to be discharged from hospital free of oxygen and external tubes.    Information was obtained about the patient’s abdomen  which will guide future therapy.  

 

 

 Presented at the American Academy of Pediatrics, October 2003.

 

 Also presented as Poster at International Pediatric Endosurgery Group, Los Angeles CA 2003

 

 Presented as oral presentation at Canadian Association of Pediatric Surgeons, September 2002.

 

 Presented at Canadian Association of Pediatric Surgeons, Sept. 2000.

 Adam Woelk- Medical Student- supervision of Research Month

 

 

Introduction: NICU infants who require a gastrostomy, are frequently evaluated for GERD by 24-hour pH probe, despite the absence of symptoms. Objectives: 1) To identify the incidence of GERD in NICU infants requiring gastrostomy. 2) To identify factors associated with GERD. 3) To evaluate growth curves and identify development of GERD during follow-up. Methods: An IRB approved retrospective review was carried out between January 2004 and December 2006. 100 NICU infants under age 6 months, underwent a 24-hour pH probe prior to gastrostomy placement. Growth curves were reviewed at time of probe, 6 months later and at study completion (2-5 years follow-up). Data were analyzed by Chi-square and logistic regression. P values </= 0.05 were considered significant.  Results: Thirty-four infants (34%) had GERD. Factors associated with GERD on univariate analysis were: neurologic impairment (p=0.001), prematurity (p=0.001), aspiration symptoms (p=0.002), intraventricular hemorrhage (p=0.002), seizures (p=0.005), and vomiting (p=0.005). Independent predictors were: neurologic impairment, OR 7.1 (95%CI 1.9-26), prematurity, OR 4.6 (95%CI 1.7-12.8), aspiration, OR 3.6 (95%CI 1.1-12.0), and   vomiting, OR 3.4 (95%CI 1.4-8.0). Ninety-two infants(92%) had complete follow-up. Thirty (33%) had GERD and 62 (77%) did not. Despite initiation of therapy for GERD, 3/30 had recurrent symptoms of GERD but were growing well. All 62 who were GERD negative underwent only gastrostomy. Fifty-two of 62 continued to be symptom free and maintained their growth curves.    Ten of 62 began vomiting 3-24 months after the initial probe (median: 7 months) and were restudied. All had GERD and 8 were losing weight.  Conclusion: The incidence of GERD in NICU infants undergoing gastrostomy was 34%. Evaluation in this group should be directed to infants with neurologic impairment, prematurity, aspiration or vomiting. Infants without these factors may be over studied. Those without GERD at the time of initial gastrostomy, who subsequently develop GERD symptoms, should be re-evaluated promptly before they show evidence of failure to thrive.