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Social determinants of health (SDoH) influence overall health, although little is known about the SDoH for pediatric patients requiring surgical services. This study aims to describe SDoH for pediatric surgical patients attending out-patient, community, and outreach clinics, as well as demonstrate the feasibility of identifying and addressing SDoH and Adverse Childhood Experiences (ACEs) when appropriate. A cross-sectional study using surveys evaluating SDoH that were distributed to families attending pediatric surgical clinics over a two-year period. The pilot survey used validated questions and was later refined to a shorter version with questions on: Barriers to care, Economic factors, Adversity, Resiliency and Social capital (BEARS). Data was analyzed with descriptive and inferential statistics. 851 families across 13 clinics participated. One third of families reported not having a primary health care provider or being unable to turn to them for additional support. One in four families were found to have a household income less than the Canadian after-tax low-income threshold (<$40,000 CAD). Two-thirds of families answered questions about ACEs, and those with more ACEs were more likely to report a low income. Forty percent of families rarely or only sometimes had adequate social support. This survey tool enabled discussions between families and care providers, which allowed clinicians to appropriately follow-up with families and refer them to social work for further support when indicated. Addressing concerns around SDoH within a busy surgical clinical is feasible and may positively affect long-term health outcomes and equitable resource allocation. IV. [Display omitted] • What is currently known about this topic? Healthcare providers recognize social determinants of health (SDoH) affect a child's overall health and access to healthcare. SDoH for pediatric surgical patients in a socialized healthcare system are not well known, and more understanding is needed on how surgical disciplines can discuss and support families with SDoH. • What new information is contained in this article? SDoH for 851 families attending pediatric surgical clinics are summarized. A survey using validated questions, and later refined to a shorter version is described (B arriers to care, E conomic factors, A dversity, R esiliency, S ocial capital). The questionnaire supported discussions with families and allowed for appropriate referrals to, and follow-up with social work. [ABSTRACT FROM AUTHOR]

Push-PEG (percutaneous endoscopic gastrostomy) with T-fastener fixation (PEG-T) allows one-step insertion of a balloon tube or button, and avoids contamination of the stoma by oral bacteria. However, PEG-T is a technically more demanding procedure with a significant learning curve. The aim of the present study was to compare outcomes after PEG-T and pull-PEG in a setting where both procedures were well established. The study is a prospective cohort study including all patients between 0 and 18 year undergoing PEG-T and pull-PEG between 2017 and 2020 at a combined local and tertiary referral center. Complications and parent reported outcomes were recorded during hospital stay, after 14 days and 3 months postoperatively. 82 (93%) of eligible PEG-T and 37 (86%) pull-PEG patients were included. The groups were not significantly different with regard to age or weight. Malignant disorders and heart conditions were more frequent in the pull-PEG group, whilst neurodevelopmental disorders were more frequent in the PEG-T group (p < 0.001). 54% in both groups had a complication within 2 weeks. Late complications (between 2 weeks and 3 months postoperatively) occurred in 63% PEG-T vs 62% pull-PEG patients (p = 0.896). More parents in the pull-PEG group (49%) reported that the gastrostomy tube restricted their child's activity, compared to PEG-T (24%) (p = 0.01). At 3 months follow-up, more pull-PEG patients (43%) reported discomfort from the gastrostomy compared to PEG-T (21%) (p = 0.03). Overall complication rates were approximately similar, but pull-PEG was associated with more discomfort and restriction of activity. Treatment study level II. • Few studies have compared outcomes after gastrostomy placement with pull-PEG or push-PEG technique, or asked parents/patients about their experiences. • Pull-PEG was associated with more discomfort and restriction of activity than push-PEG. The overall complication rates between pull-PEG and PEG-T were approximately similar. [ABSTRACT FROM AUTHOR]

Surgical intervention is advisable for both asymptomatic and symptomatic CCAM children. This study aims to compare and analyze the efficacy of thoracoscopic and Da Vinci robot-assisted procedures in the management of CCAM among pediatric patients. The clinical data of 188 pediatric patients diagnosed with CCAM and admitted to the Children's Hospital, Zhejiang University School of Medicine, from April 2019 to April 2023 were retrospectively analyzed. The Clavien-Dindo classification was employed for the systematic categorization of postoperative complications. The demographic and clinical characteristics of the patients were comparable between the two groups. Postoperative outcomes, such as the chest tube indwelling rate (92.6% vs 36.2%, p < 0.001∗), chest tube duration (2.0 (2.0–3.0) days vs 1.0 (1.0–2.0) days, p < 0.001∗), and length of postoperative hospital stay (6.0 (5.0–7.0) days vs 5.0 (5.0–6.0) days, p < 0.001∗), favored RATS over VATS. Additionally, there was no significant difference in complications between the two group, but the p-value is in a critical state. Ⅲa complications (mainly composed of postoperative thoracentesis procedures) manifesting as a higher rate in the RATS, nearly double that observed in the VATS. Robot-assisted thoracoscopic lung resection is demonstrated to be safe and feasible, with notable advantages in short-term postoperative clinical outcomes. Nevertheless, the practicality and long-term benefits of this technique necessitate further refinement and dedicated study. LEVEL III. [ABSTRACT FROM AUTHOR]

IntroductionData examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children.MethodsThis retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications.ResultsOf 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications.ConclusionsPostoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients.Level of evidenceIii, Respiratory complications.

Pediatric trauma is a significant cause of child mortality, and the absence of non-technical skills (NTS) among health providers is linked with errors in patients' care. In this study, we evaluate the effectiveness of a structured debriefing protocol in enhancing NTS during pediatric trauma simulation. A total of 45 medical students were successfully recruited from two medical schools, one in Brazil and one in Canada. Medical students were assigned to a control (N = 20) or intervention group (N = 25) in a randomized control trial. Following simulated scenarios, participants in the intervention group underwent NTS debriefing, while the control received standard debriefing based on the Advanced Trauma Life Support (ATLS) protocol. Students' confidence, NTS level, and performance were measured through self-assessment surveys, the Non-Technical Skills for Surgeons (NOTSS) score, and adherence to the trauma protocol, respectively. Baseline characteristics and outcomes were compared using t -tests, Mann–Whitney, Wilcoxon signed-rank Kruskal–Wallis, ANOVA, and a repeated-measures ANCOVA. A significance level was set at p < 0.05. The workshop increased students' confidence in leading trauma resuscitation regardless of their assignment to condition. While controlling for covariates, students in the intervention group significantly improved their overall NOTSS compared to those in the control and in all categories: situational awareness, decision-making, communication and teamwork, and leadership. The intervention teams also demonstrated a significant increase in completing trauma protocol steps. Implementing structured debriefing focusing on NTS enhanced these skills and improved adherence to protocol among medical students managing pediatric trauma-simulated scenarios. These findings support integrating NTS training in pediatric trauma education. I. • Errors in pediatric trauma care can be addressed by better non-technical skills among healthcare professionals. However, there is still a gap in how we should teach these skills. • A structured debriefing focused on non-technical skills significantly improved trainees' non-technical skills and improved adherence to the trauma protocol. • Findings of this trial support the integration of non-technical skills training in pediatric trauma education. [ABSTRACT FROM AUTHOR]

There is limited literature on how acute appendicitis, the most common acute children's surgical illness, affects the family. We conducted a prospective study to assess the impact of educational materials on parents' anxiety and productivity during the child's illness. A quasi-experimental clinical trial was conducted among parents of children undergoing laparoscopic appendectomy. In Phase I, parents received the standard explanations at diagnosis and throughout the postoperative period. In Phase II, parents also received a comprehensive educational brochure on pediatric appendicitis at diagnosis. The primary outcome, parental preoperative anxiety, was assessed using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The secondary outcome, parental productivity, was evaluated through a post-recovery online questionnaire based on the Productivity and Disease Questionnaire (PRODISQ). Baseline characteristics and outcomes were compared between the two cohorts using t -tests, Mann–Whitney, chi-square, or Fischer's exact test as appropriate. Phases I and II included 67 and 66 families, respectively. Patient demographics and disease severity were similar between both groups. Of the 53 parents (80.3%) in Phase II who answered the postoperative questionnaire, most recommended the booklet (96.2%), as it decreased their stress (78.0%) and enhanced their understanding of appendicitis (94.1%). However, the two groups showed similar preoperative anxiety levels and postoperative productivity loss. Educational materials increased satisfaction with surgical care but did not mitigate the high parental preoperative anxiety levels and postoperative productivity loss. Additional research is required to elucidate interventions that may improve these important patient and family-centered outcomes. Non-Randomized Clinical Trial. II. [ABSTRACT FROM AUTHOR]

We aimed to identify clinical characteristics, risk factors for diagnosis, and describe outcomes among children with AHT. We performed an observational cohort study in tertiary care hospitals from 14 countries across Asia and Ibero-America. We included patients <5 years old who were admitted to participating pediatric intensive care units (PICUs) with moderate to severe traumatic brain injury (TBI). We performed descriptive analysis and multivariable logistic regression for risk factors of AHT. 47 (12%) out of 392 patients were diagnosed with AHT. Compared to those with accidental injuries, children with AHT were more frequently < 2 years old (42, 89.4% vs 133, 38.6%, p < 0.001), more likely to arrive by private transportation (25, 53.2%, vs 88, 25.7%, p < 0.001), but less likely to have multiple injuries (14, 29.8% vs 158, 45.8%, p = 0.038). The AHT group was more likely to suffer subdural hemorrhage (SDH) (39, 83.0% vs 89, 25.8%, p < 0.001), require antiepileptic medications (41, 87.2% vs 209, 60.6%, p < 0.001), and neurosurgical interventions (27, 57.40% vs 143, 41.40%, p = 0.038). Mortality, PICU length of stay, and functional outcomes at 3 months were similar in both groups. In the multivariable logistic regression, age <2 years old (aOR 8.44, 95%CI 3.07-23.2), presence of seizures (aOR 3.43, 95%CI 1.60-7.36), and presence of SDH (aOR 9.58, 95%CI 4.10-22.39) were independently associated with AHT. AHT diagnosis represented 12% of our TBI cohort. Overall, children with AHT required more neurosurgical interventions and the use of anti-epileptic medications. Children younger than 2 years and with SDH were independently associated with a diagnosis of AHT. Observational cohort study. III. [ABSTRACT FROM AUTHOR]

BACKGROUND: Children with obesity frequently have functional impairment after critical illness. Although obesity increases morbidity risk after trauma, the association with functional outcomes in children is unknown. OBJECTIVE: To evaluate the association of weight with functional impairment at hospital discharge in children with serious injuries. METHODS: This secondary analysis of a multicenter prospective study included children

BACKGROUND: Hepatoblastoma (HB) requires surgical resection for cure, but only 20-30% of patients have resectable disease at diagnosis. Patients who undergo partial hepatectomy at diagnosis have historically received 4-6 cycles of adjuvant chemotherapy; however, those with 100% well-differentiated fetal histology (WDF) have been observed to have excellent outcomes when treated with surgery alone. PATIENTS AND METHODS: Patients on the Childrens Oncology Group non randomized, multicenter phase III study, AHEP0731, were stratified based on Evans stage, tumor histology, and serum alpha-fetoprotein level at diagnosis. Patients were eligible for the very low risk stratum of surgery and observation if they had a complete resection at diagnosis and rapid central histologic review demonstrated HB with 100% WDF histology. RESULTS: A total of 8 eligible patients were enrolled on study between September 14, 2009 and May 28, 2014. Outcome current to 06/30/2020 was used in this analysis. The median age at enrollment was 22.5 months (range: 8-84 months) and the median AFP at enrollment was 714 ng/ml (range: 18-77,747 ng/mL). With a median follow-up of 6.6 years (range: 3.6-9.8 years), the 5-year event-free (EFS) and overall survival (OS) were both 100%. CONCLUSION: This report supports that HB with 100% WDF histology completely resected at diagnosis is curable with surgery only. The development of evidence-based surgical guidelines utilizing criteria based on PRETEXT group, vascular involvement (annotation factors), tumor-specific histology and corresponding biology will be crucial for optimizing which patients are candidates for resection at diagnosis followed by observation. LEVEL OF EVIDENCE: Prognosis study, Level I evidence.

Healthcare-associated pressure injuries (HAPI) are known to be associated with medical devices and are preventable. Cervical spine immobilization is commonly utilized in injured children prior to clinical clearance or for treatment of an unstable cervical spinal injury. The frequency of HAPI has been quantified in adults with cervical spine immobilization but has not been well-described in children. The aim of this study was to describe characteristics of children who developed HAPI associated with cervical immobilization. We analyzed a retrospective cohort of children (0–18 years) who developed a stage two or greater cervical HAPI. This cohort was drawn from an overall sample of 49,218 registry patients treated over a five-year period (2017–2021) at ten pediatric trauma centers. Patient demographics, injury characteristics, and cervical immobilization were tabulated to describe the population. The cohort included 32 children with stage two or greater cervical HAPI. The median age was 5 years (IQR 2–13) and 78% (n = 25) were admitted to the intensive care unit. The median (IQR) time to diagnosis of HAPI was 11 (7–21) days post-injury. The majority of cervical HAPI (78%, 25/32) occurred in children requiring immobilization for cervical injuries, with only four children developing HAPI after wearing a prophylactic cervical collar in the absence of a cervical spine injury. Advanced-stage HAPI associated with cervical collar use in pediatric trauma patients is rare and usually occurs in patients with cervical spine injuries requiring immobilization for treatment. More expedient cervical spine clearance with MRI is unlikely to substantially reduce cervical HAPI in injured children. Level III (Epidemiologic and Prognostic). What is currently known about this topic? • Healthcare-associated pressure injury is known to occur in children with medical devices, but the true incidence associated with cervical collars in pediatric trauma patients is not known. What new information is contained in this article? • Advanced stage pressure injuries associated with cervical collars are rare, and most commonly occur in patients with injuries that require immobilization and not with short-term use of prophylactic cervical immobilization while injuries are defined. [ABSTRACT FROM AUTHOR]

In patients with anorectal malformation (ARM), a divided descending colostomy is associated with high complication rates, including wound infection, dehiscence, and prolapse, and it places a significant burden on caregivers. To decrease the chances of such complications, we modified our approach for colostomy fashioning by keeping an intact skin bridge between the colostomy and mucous fistula. The objective was to compare the rate of complications among patients diagnosed with ARM who underwent a modified divided descending colostomy and classical descending colostomy. We included all the patients diagnosed with ARM who underwent a divided colostomy with modified (group A) or classical technique (group B) in the last 5 years. The type of approach used to fashion the stoma was based on the surgeon's preference than on patients' selection criteria. All patients were followed and monitored for postoperative complications. SPSS version 26 was used to analyze the data. A total of 62 patients with ARM underwent the colostomy creation; 27 in group A and 35 in group B. Males were more in both groups and other demographic variables were comparable. The most common associated anomalies were cardiac (58%). The mean duration of surgery was 72.2 ± 18.26 min in group A while 91.25 ± 21.43 min in group B (P = 0.000). The mean hospital stay was 4.28 ± 3.63 days in group A while 7.97 ± 6.12 days in group B (P = 0.007). The overall complication rate was 14.8% in group A and 34.2% in group B (P = 0.082). The modified approach to fashioning a divided colostomy is easily reproducible and carries a low risk of postoperative complications. IV. [Display omitted] • What is currently known about this topic? Divided pelvic colostomy for high anorectal malformation has been a standard for years, but it is associated with high stoma-related complications. • What new information is contained in this article? With our modified technique of leaving an intact skin bridge between two stomas, we were able to achieve no wound infection and minimal other stoma complications. [ABSTRACT FROM AUTHOR]

Liver hydatid cyst affects approximately 95% of the world's echinococcosis cases. Despite advances in treatment, the recurrence rate remains high and is influenced by several factors that are yet to be determined. The objective of this study was to identify the predictive factors of liver hydatid cyst recurrence following surgery in children and to establish a treatment regimen aimed at preventing this postoperative morbidity. A bi-centric retrospective descriptive and analytic study was conducted involving 122 children who underwent surgery for liver hydatid cysts between January 1st, 2009, and December 31st, 2017. All factors that could potentially contribute to recurrence were thoroughly investigated. The data was processed using SPSS.v21, and a significant level of p-value 0.05 was applied. Out of the 122 children, 20 patients experienced cyst recurrence (16.39%). Among them, there were nine girls and eleven boys. The median time of recurrence was 16.5 months. Abdominal ultrasonography demonstrated efficacy in detecting recurrence. Several factors were identified as predictors of postoperative recurrence, including intimate contact of the hydatid cyst with the large vessels (p = 0.031), intraperitoneal effusion (p = 0.042), bile duct dilation (p = 0.032), and postoperative spontaneous discontinuation of medical treatment (p = 0.010). Among these factors, two independent risk factors for recurrence were identified: intimate contact of the hydatid cyst with the large vessels (p = 0.011) and the presence of an intraperitoneal effusion (p = 0.018). Our study has identified several predictors of postoperative recurrence, including two previously undocumented risk factors in the literature. Awareness of these risk factors can assist surgeons in implementing preventive measures to avoid the recurrence of hydatid cysts. Prognosis study Level II. [ABSTRACT FROM AUTHOR]

IntroductionFirearms and motor vehicle collisions (MVC) are leading causes of mortality in children. We hypothesized that firearm injuries would have a higher mortality than MVCs in children and a higher level of resource utilization METHODS: Trauma patients

PurposeFunctional outcomes have been proposed for assessing quality of pediatric trauma care. Outcomes assessments often rely on Abbreviated Injury Scale (AIS) severity scores to adjust for injury characteristics, but the relationship between AIS severity and functional impairment is unknown. This study's primary aim was to quantify functional impairment associated with increasing AIS severity scores within body regions. The secondary aim was to assess differences in impairment between body regions based on AIS severity.MethodsChildren with serious (AIS≥ 3) isolated body region injuries enrolled in a multicenter prospective study were analyzed. The primary outcome was functional status at discharge measured using the Functional Status Scale (FSS). Discharge FSS was compared (1) within each body region across increasing AIS severity scores, and (2) between body regions for injuries with matching AIS scores.ResultsThe study included 266 children, with 16% having abnormal FSS at discharge. Worse FSS was associated with increasing AIS severity only for spine injuries. Abnormal FSS was observed in a greater proportion of head injury patients with a severely impaired initial Glasgow Coma Scale (GCS) (GCS

BackgroundEconomic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period.MethodsWe conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data.ResultsThere were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality.ConclusionsApparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.

BackgroundAbusive head trauma (AHT) is a leading cause of morbidity and mortality among young children. We aimed to evaluate the long-term impact of AHT.MethodsUsing administrative claims from 2000-2018, children

BackgroundThere is little information on the effects of Pseudomonas infection on outcomes in perforated appendicitis. As Pseudomonas is not covered by many empiric appendicitis antibiotic regiments, we hypothesized that children with Pseudomonas would have worse outcomes.MethodsPatients

Esophago-vascular fistulae in children are almost uniformly fatal with death occurring by exsanguination. We present a single centre series of five surviving patients, a proposal for management and literature review. Patients were identified from surgical logbooks, surgeon recollection and discharge coding data. Demographics, symptoms, co-morbidities, radiology, management and follow up details were recorded. Five patients (1M, 4F) were identified. Four were aorto-esophageal and one caroto-esophageal. Median age at initial presentation was 44 (8–177) months. Four patients had cross sectional imaging prior to surgery. Median time from presentation to combined entero-vascular surgery was 15 (0–419) days. Four patients required repair on cardio-pulmonary bypass with four undergoing staged surgical procedures. All required combined esophageal and cardio-vascular surgery. Length of PICU stay following combined surgery was 4 (2–60) days and overall hospital stay was 53 (15–84) days. Median follow up was 51 (17–61) months. Two patients had esophageal atresia and trachea-esophageal fistula managed as neonates. Three had no co-morbidities. Four had esophageal foreign bodies:1 esophageal stent, 2 button batteries, 1 chicken bone. One patient had a complication following colonic interposition. Four patients required an esophagostomy at the time of definitive surgery. All patients were alive and well at last follow up with one having successful reconnection surgery. In this series, outcomes were favourable. Multidisciplinary discussion and surgery are mandatory. If hemorrhage is controlled at presentation, then survival to discharge is possible but the magnitude of surgical intervention is both significant and very high risk. Level 3. • What is currently known on this topic? EVF has a mortality rate of 82% and no iterative review of consecutive survivors exists. Management is individualised due to the rarity of cases. • What new information is contained in this article? Key initial intervention is stabilisation followed by immediate transfer to a unit with pediatric general surgery, cardiac surgery and interventional radiology. [ABSTRACT FROM AUTHOR]

Esophageal injury after caustic ingestion can vary in severity and may result in significant long-term morbidity due to stricture development. The optimal management remains unknown. We aim to determine the incidence of esophageal stricture due to caustic ingestion and quantify current procedural and operative management strategies. The Pediatric Health Information System (PHIS) was utilized to identify patients 0–18 years old who experienced caustic ingestion from January 2007–September 2015 and developed subsequent esophageal stricture until December 2021. Post-injury procedural and operative management was identified utilizing ICD-9/10 procedure codes for esophagogastroduodenoscopy (EGD), esophageal dilation, gastrostomy tube placement, fundoplication, tracheostomy, and major esophageal surgery. 1,588 patients from 40 hospitals experienced caustic ingestion of which 56.6% were male, 32.5% non-Hispanic White, and the median age at time of injury was 2.2 years (IQR: 1.4,4.8). Median length of initial admission was 1.0 day (IQR: 1.0, 3.0). 171/1,588 (10.8%) developed esophageal stricture. Among those who developed stricture, 144 (84.2%) underwent at least 1 additional EGD, 138 (80.7%) underwent dilation, 70 (40.9%) underwent gastrostomy tube, 6 (3.5%) underwent fundoplication, 10 (5.8%) underwent tracheostomy, and 40 (23.4%) underwent major esophageal surgery. Patients underwent a median of 9 dilations (IQR 3, 20). Major surgery was performed at a median of 208 (IQR: 74, 480) days after caustic ingestion. Many patients with esophageal stricture after caustic ingestion will require multiple procedural interventions and potentially major surgery. These patients may benefit from early multi-disciplinary care coordination and the development of a best-practice treatment algorithm. III. • Caustic ingestion in the pediatric population is highly morbid with a significant procedure burden. • 80% of patients required esophageal dilation with a median of 9 dilations performed. • Nearly 25% of patients require major esophageal surgery. [ABSTRACT FROM AUTHOR]

BackgroundTrauma is the leading cause of death in children. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control, but its potential benefit has not been assessed in children. We hypothesized that there are pediatric patients who may benefit from REBOA.MethodsTrauma patients

BackgroundTraumatic brain injury (TBI) is the leading cause of death and disability in young children; however, the impact of mechanism on outcomes has not been fully evaluated. We hypothesized that children with TBI due to abuse would have a higher mortality than children with accidental TBI due to motor vehicle collisions (MVC).MethodsWe performed a retrospective review of the National Kids' Inpatient (KID) hospitalizations database of children

Background/purposeCholedochal cysts are congenital dilations of the bile ducts, and are associated with an increased risk of malignant transformation. The purpose of this study is to report the outcomes of a large series of patients with choledochal cysts and to highlight our analysis of one patient who developed malignancy after cyst resection.MethodsWe conducted a retrospective review of patients

Retroperitoneal pyeloplasty (RP) for pediatric ureteropelvic junction obstruction (UPJO) performed using retroperitoneoscopy (retro-RP) or robotic assistance (robo-RP) were compared. All subjects were Japanese, matched for age, weight, and RP diameters. All RP were performed in the lateral decubitus position at a single institute by the same team using identical protocols. Five independent surgeons were asked to score intraoperative video recordings for perceived difficulty of suturing (DOS; 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; 1 = easy) and rank RP as +1 if robo-RP appeared to be superior, 0 if they appeared to be the same, and −1 if robo-RP appeared to be inferior. Robo-RP performed 2018-2022 (n = 22) were matched with retro-RP performed 2011-2019 (n = 34). Mean overall operative times were similar (robo-RP: 305.2 ± 57.8 min versus retro-RP: 340.0 ± 117.9 min; p = 0.19), but securing the larger retroperitoneal space required for robo-RP took significantly longer; 50.8 ± 13.9 min versus 24.3 ± 9.6 min; p < 0.0001. Total anastomotic time (TAT) and TAT per suture were both significantly shorter for robo-RP (p < 0.0001). The coefficient of variation for time taken to place one suture was smaller for robo-RP than for retro-RP. DOS was lower for robo-RP with less variance (p < 0.01). Robo-RP had shorter drainage tube insertion, ambulated quicker postoperatively, and shorter hospitalization. Retro-RP had anastomotic complications; leaks (n = 2) and strictures (n = 2, requiring conventional open re-pyeloplasty). Robo-RP had no anastomotic complications and was ranked +1 unanimously. The RP anastomosis was quicker with less complications and more precise with robotic assistance in matched patients under similar circumstances. Should RP be indicated, robo-RP is recommended. III. • Retroperitoneal pyeloplasty with and without robotic assistance were compared to establish superiority. • Pyeloplasty anastomosis with robotic assistance was significantly quicker with lower variation. • Retroperitoneoscopy were complicated by anastomotic leaks and strictures while robotic had no complications. [ABSTRACT FROM AUTHOR]

BackgroundBlunt pancreatic injury is frequently managed nonoperatively in children. Nutritional support practices - either enteral or parenteral - are heterogeneous and lack evidence-based guidelines. We hypothesized that use of parenteral nutrition (PN) in children with nonoperatively managed blunt pancreatic injury would 1) be associated with longer hospital stay and more frequent complications, and 2) differ in frequency by trauma center type.MethodsWe conducted a retrospective cohort study using the National Trauma Data Bank (2007-2016). Children (≤18 years) with blunt pancreatic injury were included. Patients were excluded for duodenal injury, mortality

BackgroundThe histopathological assessment of pediatric liver tumors at presentation is critical to establish a diagnosis, guide treatment, and collect appropriate research samples. The purpose of this study was to evaluate complications associated with different approaches to liver biopsy for newly diagnosed hepatoblastoma.MethodsChildren with hepatoblastoma were enrolled on Children's Oncology Group study AHEP0731 (September 2009-March 2012). This analysis evaluated the study cohort of initially unresectable patients who therefore underwent a biopsy procedure at diagnosis. The primary endpoint was clinically significant postbiopsy hemorrhage, defined as requiring red blood cell transfusion.ResultsWe identified 121 children who underwent open (n = 76, 63%), laparoscopic (n = 17, 14%), or percutaneous (n = 28, 23%) liver biopsies. All biopsy procedures yielded adequate tissue for diagnosis. Postbiopsy hemorrhage requiring transfusion occurred after 26% (n = 31) of biopsies. Need for blood product transfusion most frequently occurred following open (n = 27/76, 36%) and laparoscopic (n = 4/17, 24%) biopsies, compared with percutaneous (n = 0/28, 0%) biopsies (p

Trust is central to the therapeutic relationship between patients and their providers, yet little is known about how it is developed in the unique context of children facing surgical emergencies. We sought to identify factors fostering trust development, gaps, and areas for improvement. We searched eight databases from inception to June 2021 to identify studies focusing on trust in pediatric surgical and urgent care settings. PRISMA-ScR protocols were followed, and screening carried out by two independent reviewers. Data collection included study characteristics, outcomes, and results. Out of 5578 articles screened, 12 fulfilled the inclusion criteria. Four major trust constructs were identified: competence, communication, dependability, and caring. Despite various instruments used, all studies reported a high level of parental trust. Nearly all studies (11/12) noted trust depending on parents' sociodemographic background, with ethnicity (3/12) and level of education and language barriers (2/12) limiting parents' confidence in physicians. High trust levels significantly correlated with effective communication and perceived quality of care. Most effective interventions enhancing trust included communication and caring trust constructs (10/12) rather than competence and dependability (5/12). Parents' individual experiences, development of compassionate interactions, and practice of family-centered care appeared important in developing trust. Improving communication and providing compassionate care, as well as encouraging a patient-centered approach, appear to be most effective in promoting trust in pediatric surgical and urgent settings. Our findings can guide future educational interventions towards strengthening parental trust and promoting child- and family-centered care in pediatric surgical settings. 1. [ABSTRACT FROM AUTHOR]

Clinical prediction tools (CPTs) are decision-making instruments utilizing patient data to predict specific clinical outcomes, risk-stratify patients, or suggest personalized diagnostic or therapeutic options. Recent advancements in artificial intelligence have resulted in a proliferation of CPTs created using machine learning (ML)–yet the clinical applicability of ML-based CPTs and their validation in clinical settings remain unclear. This systematic review aims to compare the validity and clinical efficacy of ML-based to traditional CPTs in pediatric surgery. Nine databases were searched from 2000 until July 9, 2021 to retrieve articles reporting on CPTs and ML for pediatric surgical conditions. PRISMA standards were followed, and screening was performed by two independent reviewers in Rayyan, with a third reviewer resolving conflicts. Risk of bias was assessed using the PROBAST. Out of 8300 studies, 48 met the inclusion criteria. The most represented surgical specialties were pediatric general (14), neurosurgery (13) and cardiac surgery (12). Prognostic (26) CPTs were the most represented type of surgical pediatric CPTs followed by diagnostic (10), interventional (9), and risk stratifying (2). One study included a CPT for diagnostic, interventional and prognostic purposes. 81% of studies compared their CPT to ML-based CPTs, statistical CPTs, or the unaided clinician, but lacked external validation and/or evidence of clinical implementation. While most studies claim significant potential improvements by incorporating ML-based CPTs in pediatric surgical decision-making, both external validation and clinical application remains limited. Further studies must focus on validating existing instruments or developing validated tools, and incorporating them in the clinical workflow. Systematic Review Level III • Clinical prediction tools (CPTs) are decision-making instruments utilizing patient data to predict specific outcomes. • CPTs were first developed using statistical models and are now increasingly being supplemented by machine learning (ML). • This review investigated the clinical validity and applicability of ML-based versus statistical CPTs in pediatric surgery. [ABSTRACT FROM AUTHOR]

Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are increasingly recognized as important health care quality indicators. PREMs measure patients' perception of the care they have received, differing from satisfaction ratings, which measure their expectations. The use of PREMs in pediatric surgery is limited, prompting this systematic review to assess their characteristics and identify areas for improvement. A search was conducted in eight databases from inception until January 12, 2022, to identify PREMs used with pediatric surgical patients, with no language restrictions. We focused on studies of patient experience but also included studies that assessed satisfaction and sampled experience domains. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool. Following title and abstract screening of 2633 studies, 51 were included for full-text review, of which 22 were subsequently excluded because they measured only patient satisfaction rather than experience, and 14 were excluded for a range of other reasons. Out of the 15 included studies, questionnaires used in 12 studies were proxy-reported by parents and in 3 by both parents and children; none focused only on the child. Most instruments were developed in-house for each specific study, without patients' involvement in the process, and were not validated. Although PROMs are increasingly used in pediatric surgery, PREMs are not yet in use, being typically substituted by satisfaction surveys. Significant efforts are needed to develop and implement PREMs in pediatric surgical care, in order to effectively capture children's and families' voices. IV [ABSTRACT FROM AUTHOR]

• Shared decision-making is critical to patient-centered care in pediatric surgery. • Shared decision-making can be performed effectively in a high acuity surgical setting in children. • Treatment choice requires timely, informed decisions that allow for incorporation of personal values, and preferences. • Nonoperative management of uncomplicated appendicitis is an effective treatment alternative that maybe preferred by families. Nonoperative management (NOM) of uncomplicated appendicitis is a safe and effective treatment alternative to surgery that may be preferred by some families. Surgery and NOM differ significantly in their associated risks and benefits. Choosing a treatment for acute appendicitis requires patients and their caregivers to make timely, informed decisions that allow for incorporation of personal perspectives, values, and preferences. This article will address the concept of shared decision-making and establish its role in patient-centered care. It will demonstrate the effectiveness of shared decision-making in a high acuity surgical setting for children and highlight how the choice for management of acute appendicitis may be impacted by patients' and families' individualized circumstances and values. [ABSTRACT FROM AUTHOR]

• Multiple modes of treatment to address symptomatic PU are described, however, management needs to be individualised based on clinical circumstances of each affected child. • Specific anatomical variations of insertion of vasa in the utricle need to be identified prior to intervention as these may influence the surgical approach. Prostatic utricle (PU) has been described in children with hypospadias, posterior urethral valves (PUV), variances of sex characteristics and normal external genitalia. Intervention may be required in symptomatic cases, but clinical characteristics vary, requiring individualisation of management. We describe our experience with this condition. Retrospective review of males noted to have PU on cystoscopy (2009–2020) at a single centre. Presentation, management and outcomes were recorded (Variances of sex characteristics excluded). Of 1060 male children who underwent cystoscopy for various reasons, PU was recorded in 36 (3.4%), indications for cystoscopy being hypospadias in 28, PUV in 3, urinary tract infections (UTI) in 3 and hydronephrosis in 2. Six (16.7%) developed epididymo-orchitis. All 6 had Ikoma Grade II PU. Case 1 (16 years,UTI) was managed with intravenous antibiotics. Case 2 (8 years,hypospadias) underwent laying open of urethral stricture. Case 3 (5 years,PUV) underwent laparoscopic PU excision. Cases 4 and 5 (3 and 6 years, hypospadias) underwent cystoscopic injection of bulking agent near the insertion of the vasa. Case 6 (3 years,hypospadias) underwent laparoscopic PU excision with vasal disconnection (vasal openings at dome of utricle rather than base) following failed endoscopic management. Median follow-up was 36 (0–206) months. All remained asymptomatic with normal testicular volumes for age at current follow-up. Multiple treatment options to address a symptomatic PU have been described and enable surgeons to individualise treatment based on clinical circumstances. It is important to identify variations in anatomy of vasal connection to PU to plan appropriate management. IV (Retrospective study) [ABSTRACT FROM AUTHOR]

• What is known about this topic? • Percutaneous endoscopic gastrostomy with push technique is more complex and has a higher number of early complicatons compared to pull technique. • What new information is contained in this article? • A detailed treatment protocol and limited number of physicians performing the procedure reduced the complication rate related to tube dislocations and migrated T-fasteners. Percutaneous endoscopic gastrostomy with push technique (PEG-T) is increasingly used in pediatric patients. In a retrospective study of PEG-T (cohort 1) we reported frequent complications related to T-fasteners and tube dislodgment. The aim of this study was to assess complications after implementation of a strict treatment protocol, and to compare these with the previous retrospective study. The study is a prospective study of PEG-T placement performed between 2017 and 2020 (cohort 2) in pediatric patients (0–18 years). Complications were recorded during hospital stay, fourteen days and three months postoperatively, graded according to the Clavien-Dindo classification and categorized as early (<30 days) or late (>30 days). In total 82 patients were included, of which 52 (60%) had neurologic impairments. Median age and weight were 2.0 years [6 months-18.1 years] and 13.4 kg [3.5–51.5 kg], respectively. There was a significant reduction in median operating time from 28 min [10–65 min] in cohort 1 to 15 min [6–35 min] in cohort 2 (p <0.001), number of patients with early tube dislodgement (cohort 1: 9 (10%) vs cohort 2: 1 (1%), p = 0.012), and number of patients with late migrated T-fasteners (cohort 1: 11 (13%) vs cohort 2: 1 (1%), p = 0.004). We experienced less migrated T-fasteners and tube dislodgment after implementation of strict treatment protocol. Treatment study level III. [ABSTRACT FROM AUTHOR]

Pathophysiology of appendicitis is associated with the underlying inflammatory processes. Ethyl pyruvate (EP) has potent antioxidant and anti inflammatory properties. In this study, we aimed to investigate the effects of EP on the treatment of appendicitis and to examine whether adding EP to the antibiotic treatment could increases the effectiveness of the treatment in a rat appendicitis model. Thirty two Wistar rats, which had previously created appendicitis, were randomly divided into 4 groups: Group 1 (0.1 ml saline solution), Group 2 (15 mg/kg ceftriaxone), Group 3 (50 mg/kg EP), Group 4 (EP 50 mg/kg + ceftriaxone 15 mg/kg). In all groups, saline solution, ceftriaxone and EP were administered intraperitoneally and the same procedure was repeated twice a day for the following five days. On day 6, the rats underwent relaparotomy and then intraabdominal findings were recorded. Histopathological examination and interleukin 6 (IL 6) level were performed on appendiceal specimens. Intra abdominal adhesion score was significantly lower in Group 4 than in Group 1. Total inflammation score was significantly lower in Group 2 than in Group 1 and was significantly lower in Group 4 than in Group 3 and 1. IL 6 level was significantly lower in Group 4 than in Group 3 and 1. We found that adding EP to the antibiotic therapy increased the efficacy of the treatment in the rat appendicitis model. Further studies are required to apply our findings to the clinical setting. [ABSTRACT FROM AUTHOR]

Introduction: The diagnosis and management of biliary dyskinesia in children and adolescents remains variable and controversial. The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP) performed a systematic review of the literature to develop evidence-based recommendations., Methods: Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on diagnostic criteria, indications for cholecystectomy, short and long-term outcomes, predictors of success/benefit, and outcomes of medical management. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Risk of bias was assessed using Methodologic Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized., Results: The diagnostic criteria for biliary dyskinesia in children and adolescents are not clearly defined. Cholecystectomy may provide long-term partial or complete relief in some patients; however, there are no reliable predictors of symptom relief. Some patients may experience resolution of symptoms with non-operative management., Conclusions: Pediatric biliary dyskinesia remains an ill-defined clinical entity. Pediatric-specific guidelines are necessary to better characterize the condition, guide work-up, and provide management recommendations. Prospective studies are necessary to more reliably identify patients who may benefit from cholecystectomy., Level of Evidence: Level 3-4., Type of Study: Systematic Review of Level 3-4 Studies., Competing Interests: Conflict of interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Children with total colonic Hirschsprung disease (TCHD) are a unique group of patients with pre- and postoperative management challenges. This review provides a rational, expert-based approach to diagnosing and managing TCHD., Methods: The guidelines were developed by the Hirschsprung Disease Interest Group members established by the American Pediatric Surgical Association (APSA) Board of Governors. Group discussions, literature review, and expert consensus were used to summarize the current knowledge regarding diagnosis, staged approach, the timing of pull-through, and pre-and postoperative management in children with TCHD., Results: This paper presents recommendations for managing TCHD before and after reconstruction, including diagnostic criteria, surgical approaches, bowel management, diet, antibiotic prophylaxis, colonic irrigations, and post-surgical considerations., Conclusions: A clear understanding of the unique challenges posed by TCHD and consensus on its treatment are lacking in the literature. This review standardizes this patient group's pre- and postoperative management., Level of Evidence: V., Competing Interests: Conflict of interest The authors report no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Postoperative maintenance fluids are traditionally provided via hypotonic dextrose containing fluids administered intravenously by continuous infusion. We hypothesized that scheduled weight-based boluses of balanced salt solution would be more physiologic, reduce fluid volumes, and improve patient comfort., Methods: As part of an IRB-approved randomized controlled trial (Boluses of Ringer's in Surgical Kids, BRiSK), we randomized patients aged 1-21 years undergoing elective abdominal or thoracic surgery to post-operatively receive weight-based D 5 0.45NS+20mEq/L KCl at a continuous rate or intermittent boluses of Lactated Ringer's solution until oral liquid toleration. Patients with nephropathy, diabetes, or receiving parenteral nutrition were excluded. We analyzed electrolytes, urine output, fluid volume, and adverse events., Results: We enrolled and randomized 60 patients: 29 to continuous fluids and 31 to bolus fluids. One patient from the bolus group dropped out. No patients crossed over due to difficulties with application of the bolus protocol. There were no baseline differences between groups with a mean age of 12.6 ± 1.4yr and weight of 50.9 ± 7.2 kg. There were no serious adverse events or electrolyte disturbances in either group. Patients in the bolus group received significantly less total fluid than those in the continuous group (0.43 mL/kg/h vs 1.1 mL/kg/h, p < 0.001) with no difference in urine output [1.4 ± 0.2 mL/kg/h vs 1.6 ± 0.3 mL/kg/h, p = 0.211]. There were two episodes of mild hypoglycemia in the bolus group compared to seven episodes of mild hyperglycemia in the continuous group., Conclusions: Administration of post-operative intravenous fluids as boluses of balanced salt solution is feasible, safe, and results in significantly less fluid administered compared to a traditional continuous protocol., Level of Evidence: II., Competing Interests: Conflict of interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Aims: Indocyanine Green Fluorescence (ICG-F)- guided surgery is becoming an increasingly helpful tool in pediatric surgical care. This consensus statement investigates the utility of ICG-F in various pediatric surgical applications, primarily focusing on its evidence base, safety, indications, use across different surgical specialties and dosing strategies. The aim is to establish an international consensus for ICG-F use in pediatric surgery., Methods: An international panel of 15 pediatric surgeons from 9 countries was assembled. The structured process consisted of a rapid scoping review, iterative discussion sessions, mixed-methods studies with key stakeholders, and voting rounds on individual statements to create draft consensus statements., Results: 100 articles were identified during the review and summarized by application. Based on this condensed evidence, consensus statements were generated after 3 iterative rounds of anonymous voting. Key areas of agreement were quality of evidence, the safety of ICG, pediatric surgical indications, utilization per surgical specialty, and dosing of ICG., Conclusion: This consensus statement aims to guide healthcare professionals in managing ICG-F use in pediatric surgical cases based on the best available evidence, key stakeholder consultation, and expert opinions. Despite ICG-F's promising potential, the need for higher-quality evidence, prospective trials, and safety studies is underscored. The consensus also provides a framework for pediatric surgeons to utilize ICG-F effectively., Level of Evidence: III., Competing Interests: Conflict of interest All authors have no disclosures or conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Pediatric trauma centers have had challenges meeting the American College of Surgeons criteria for screening and intervening for alcohol with adolescent trauma patients. The study objective was to conduct an implementation trial to evaluate the effectiveness of the Science to Service Laboratory (SSL) implementation strategy in improving alcohol and other drugs (AOD) screening, brief intervention, and referral to treatment (SBIRT) delivery at pediatric trauma centers., Methods: Using a stepped wedge cross-over cluster randomized design, 10 US pediatric trauma centers received the SSL implementation strategy to deliver SBIRT with admitted adolescent (12-17 years old) trauma patients. The strategy adapted three core SSL elements: didactic training, performance feedback, and facilitation. The main outcome measured was SBIRT reach. Data were collected from each center's electronic health record (EHR) during pre- and post-implementation wedges (2018-2022)., Results: EHR data from 8461 adolescent patients were extracted. Aggregated across all sites, the reach of screening with a validated AOD screening tool increased significantly from 25.2% (95% CI: 23.9, 26.5%) of adolescents during pre-implementation to 47.7% (95% CI: 46.3%, 49.2%) post-implementation. There was variability of change across centers. Brief interventions continued to be delivered at high levels to identified adolescents. Referral to primary care providers for further AOD discussion or referral to specialty service for adolescents with high risk use did not improve post-implementation and remained low., Conclusions: The SSL implementation strategy can be successfully utilized by pediatric trauma centers to improve AOD screening, but challenges exist in connecting adolescents for continuation of AOD discussions after discharge., Level of Evidence: Level II, Therapeutic., Competing Interests: Conflicts of interest None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: For all fertility preservation (FP) cases at our institution, a biopsy is performed for routine pathology from all gonadal tissue removed. This is not standard at all centers. We reviewed our experience with biopsy for pathological evaluation of ovarian and testicular specimens in FP cases to determine clinical utility., Methods: The medical records of individuals who underwent ovarian tissue cryopreservation (OTC) or testicular tissue cryopreservation (TTC) between 2011 and 2023 were retrospectively reviewed under an IRB-approved study at a free-standing tertiary care children's hospital. Patient demographics, diagnosis, operative characteristics, and pathology results were collected., Results: One-hundred and eighty-three patients underwent OTC, and 134 patients underwent TTC. All patients had their gonadal tissue biopsied for routine pathology. Malignancy was identified in the biopsies of 4 OTC patients (2.2%) and 2 TTC patients (1.5%). Two OTC patients (1.1%) and 2 TTC patients (1.5%) did not have germ cells identified in their biopsy. All OTC and TTC patients and families elected to continue storing tissue for FP after discussion of pathology findings., Conclusions: Pathology results provide another data point to help inform patients and their families when making decisions on ovarian or testicular tissue storage and on how tissue may be utilized in the future to restore fertility and/or hormones. There is a low rate of identifying malignancy in gonadal tissue biopsies taken from FP specimens even in patients with known malignancy. However, when malignancy was identified, it could be unexpected and alter the diagnosis and treatment plan significantly for patients., Level of Evidence: IV., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: We implemented a pediatric Brain Injury Guideline (pBIG) to stratify traumatic brain injuries (TBI) and allow management of less severe cases without repeat CT imaging or neurosurgical consultation. Injuries were classified as mild (pBIG1), moderate (pBIG2), severe (pBIG3) or isolated skull fracture (ISF) based on neurologic status, size and number of bleeds. We hypothesize that pediatric TBIs can be safely managed with this guideline., Methods: Isolated TBIs (<18 years) were queried from the Pediatric Trauma Registry after pBIG implementation from July 2021-March 2023. Datasets included age, injury specifics, repeat head CTs, neurosurgical consultations and interventions. Analysis was performed with Stata, with significance set at p < 0.05., Results: A total of 139 children with a median age of 2.8 years were included. Skull fractures (113, 81%) and subdural hematomas (54, 39%) were the most common injuries. Repeat head CTs were obtained in 44 (32%) and neurosurgical consultation in 89 (64%). Overall guideline compliance was 83.5%, with best performance in the pBIG3 category (96%). One pBIG1 patient had increasing symptoms requiring upgrade, neurosurgical consultation and repeat head CT, but no intervention. Five children (3.6%; 4 isolated skull fracture, 1 pBIG3) had post-discharge ED visits and 1 (0.7%, ISF) had a post-discharge CT. Three (2.2%) children, all in the pBIG3 group, died from their TBIs., Conclusions: Adherence to the algorithm was 83.5%, with the lowest compliance in the moderate TBI (pBIG2) category. This group had a high rate of neurosurgical consultation suggesting uneasiness with independent management of moderate injuries when compared to minor TBIs or isolated skull fracture. Outcomes with the use of the pBIG algorithm were otherwise acceptable., Level of Evidence: Level IV, Therapeutic/Care Management., Competing Interests: Conflict of interest There are no conflicts of interest with this work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

While the earliest published health disparity research in the United States dates to 1899, the field was not formally established until the late 20th century. Initially focused on race and ethnicity, the field has broadened to include socioeconomic status. Several measures have been developed to quantify socioeconomic disadvantage, including the Social Vulnerability Index, Area Deprivation Index, and Child Opportunity Index. These indices have been validated and demonstrate correlation with health outcomes. However, socioeconomic status cannot fully explain health inequities experienced by people of minoritized racial and ethnic identities. Three generations of health disparities research have been described-identification of disparities, root analysis, and development of interventions to mitigate health inequities. While there has been an increase in publication of health disparity research, there is little third generation work. It is imperative that health disparities research move beyond defining the problem and toward interventions that will reduce health inequities. LEVELS OF EVIDENCE: Level IV., Competing Interests: Conflicts of interest We have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Paediatric healthcare for children with HIV involves managing complex challenges, including severe perineal issues that significantly affect their quality of life. We introduce the term "perineal disintegration syndrome" (PDS) to describe conditions characterised by abscesses and various fistulae involving the anus, rectum, urethra, or reproductive tracts. The literature on PDS is limited and lacks a standardised treatment approach and universally accepted terminology. Our proposal for a new term aims to standardise nomenclature and stimulate targeted research to improve management and outcomes for this vulnerable group., Objectives: The aim of the study was to conduct a comprehensive analysis of the existing literature on PDS in paediatric HIV patients to uncover key findings, identify knowledge gaps, and outline practical implications and recommendations for clinical care and future research., Methods: A systematic search across databases with comprehensive keywords identified relevant articles on PDS in paediatric HIV patients was conducted., Results: The review emphasises the focus of PDS literature in African nations, highlighting the urgent need for research and clinical attention in HIV/AIDS-burdened regions. Challenges in diagnosing and managing PDS, uncertainties in its causes, and the lack of standardised management approaches in resource-constrained settings were revealed., Conclusion: This review emphasises the importance of prospective research, standardised protocols and patient-centred multidisciplinary care in managing PDS in paediatric HIV patients to improve care and outcomes of this population., Level of Evidence: I., Competing Interests: Conflicts of interest The authors have no conflict of interest to declare., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The long-term effects of childhood surgery scars on health status, quality of life (QoL), self-esteem, and body image remain uncertain. This study explores these effects in school-aged children., Methods: We conducted a retrospective cohort study involving 454 children (58% boys; 8-17 years) who had undergone surgical correction of anatomical anomalies or neonatal ECMO. Data included patient-reported scar perception and scar-related embarrassment, along with psychological assessment via questionnaires., Results: About 34% of children rated their scars as 'nice-looking', 49% as 'indifferent', and 12% as 'rather ugly'. Most children (91%) never experienced scar-related embarrassment, while frequent embarrassment was reported by 3%. Surgical scar correction was desired by 6% of the 8-year-olds and 19% of the 17-year-olds. Scar perception did not significantly affect health status or QoL. However, negative scar perception was associated with lower self-esteem in girls and a more negative body image in boys. Girls were more likely to report negative scar perception (OR: 1.54, 95%-CI: 1.06-2.24) and scar-related embarrassment (OR: 4.29, 95%-CI: 1.77-10.44)., Conclusion: Children who underwent surgery in the neonatal period and subsequently grew up with scars resulting thereof, mostly perceive them either indifferently or positively, with minimal effect on health status and QoL. Nonetheless, some children, particularly girls, experienced negative perceptions of their scars, although scar-related embarrassment was rare. We recommend integrating scar assessment into routine follow-up at ages 12 and 17, and offering appropriate and timely guidance and support to children at risk for negative effects of scars., Level of Evidence: III., Competing Interests: Conflicts of interest The authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: This study aims to assess the long-term outcomes of a modified pneumatic reduction protocol for intussusception at the Vietnam National Hospital of Pediatrics, an institution with a significant patient load in a lower-middle-income country., Patients and Methods: A single center, retrospective cohort observational study was conducted to examine patients who underwent modified fluoroscopic-guided air-enema reduction (FGAR) for intussusception from January 2016 to December 2017. Data on patient demographics, complication rates, and the incidence of long-term recurrence was collected., Results: Between January 2016 and December 2017, a total of 3562 patients underwent modified FGAR at our institution, including 2313 males (64.9%) and 1249 females (35.1%). The median age was 19 months (range: 1-170), and the median FGAR procedure duration was 4 min (range: 2-24). The median hospital stay was 1 day (range: 1-31). Successful reduction was achieved in 98.7% of cases, with 43 unsuccessful cases and 4 cases of perforated bowel requiring surgery. Twenty patients, presenting with severe symptoms due to delayed treatment seeking, were admitted to the pediatric intensive care unit (ICU) post-FGAR. No mortality or severe morbidity was reported. Over a median 6-year follow-up, intussusception recurred in 198 patients, accounting for 5.6% of the cohort, with 97% of recurrences occurring within the first year post-reduction. Infants and children under 12 months of age had the highest complication rates, including failed FGAR, complicated intussusception, ICU admission, or recurrence, compared to other age groups, and this difference was statistically significant (p < 0.05)., Conclusion: The modified FGAR protocol has been demonstrated to be safe and feasible, with a very high success rate, low complication rate, and low recurrence rate. Although further comparative studies are needed to confirm its reproducibility, it should be considered a promising approach for children in low-to middle-income countries., Level of Evidence: Level III., Competing Interests: Conflict of interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: To compare penile problems in circumcised relative to uncircumcised boys, and to determine which providers performing the circumcision have fewer post-circumcision problems., Methods: CPT codes in the 2011-2020 MarketScan database were used to identify boys who had a circumcision. Uncircumcised control subjects of the same age, state of residence, and insurance type were selected. The primary outcome was a penile problem, defined as penis-specific infection, inflammation, and urethral stricture/stenosis, among others. The secondary outcomes were procedure-related complications limited to 28 days after circumcision, and whether post-circumcision problems varied by the clinician performing the procedure. ICD-9/10 diagnostic codes were used to identify these problems., Results: We identified ∼850,000 cases and ∼850,000 matched controls. Overall, the rate of penile problems within the first five years of life was 1.7% in circumcised boys versus 0.5% in uncircumcised boys (p < 0.05). Multivariable regression models showed that the risk of penile problems was 2.9-fold higher among circumcised compared to uncircumcised males (95%CI [2.8-3], p < 0.001). Compared to males circumcised by pediatricians, those circumcised by surgeons had 2.1-fold higher penile problems in the year after circumcision (95% CI [2-2.3], p < 0.001). Procedure-related complications within 28 days of circumcision were infrequent (0.5%), with the most common being penile edema (0.2%)., Conclusions: Penile problems are very infrequent in boys in the first five years of life. However, when they occur, they are 3x more likely to occur in circumcised boys relative to uncircumcised boys. Penile problems are more likely to occur in boys circumcised by surgeons., Levels of Evidence: Level II., Type of Study: Prognosis study., Competing Interests: Conflict of interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In this study, two fibrin sealant products, Fibrin Sealant Grifols (FS Grifols 80 mg/mL fibrinogen; 500 IU/mL thrombin) and Evicel (fibrinogen 55-85 mg/mL; thrombin 800-1200 IU/mL) were studied for efficacy in achieving hemostasis at a targeted bleeding site (TBS) on parenchymous or soft tissue in pediatric surgeries., Methods: This phase 3, single-blind, active comparator, non-inferiority trial compared the number of patients achieving hemostasis at a TBS at four (T 4 - primary endpoint), seven (T 7 ) and 10 (T 10 ) minutes after application, Safety and tolerability were assessed by recording adverse events during and after procedures. Eligible patients were <18 years old undergoing elective, open, non-cardiac thoracic, abdominal or pelvic surgeries. Preterm (<37 weeks gestation) and newborn (0-27 days) infants were eligible., Results: At T 4 , 98.7% of FS Grifols group (n = 91) and 95.4% of the Evicel group (n = 87) achieved hemostasis. All patients with residual bleeding at T 4 were undergoing soft tissue surgery. All patients achieved hemostasis by T 7 . At T 10 , all patients achieved hemostasis except one (FS Grifols (no observation recorded)). There were no incidents of persistent bleeding. For FS Grifols, 26.5% of patients had treatment-emergent adverse events (TEAEs) and 18.4% for Evicel. One TEAE (moderate procedural pain - FS Grifols group) was considered possibly related to study treatment. Three patients died for reasons unrelated to the study medications., Conclusions: FS Grifols was safe and effective at achieving hemostasis in pediatric patients having parenchymous or soft tissue surgeries. The efficacy of FS Grifols was non-inferior to Evicel., Level of Evidence: I., Competing Interests: Conflicts of interest LB, DG, AS, KK, and PV report no competing interests. EM, KH, MQ, and SC are employees of Grifols., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: This commentary discusses the social impact of bowel management programs (BMPs) on children with colorectal diseases, including anorectal malformations (ARM), Hirschsprung disease (HD), functional constipation (FC), and spina bifida. Previous studies focused on functional outcomes, but this study bridges the gap to daily life experiences., Methods: The study examined children's experiences in BMPs, focusing on school participation, vacation ability, and overall patient experience. Cleanliness, defined as fewer than one stool soiling episode per week, was achieved by 70% of participants., Results: Positive patient experiences were linked to achieving stool cleanliness, regardless of the management method. Invasive methods like enemas did not negatively affect experiences if cleanliness was maintained. Validated patient-reported experience measures (PREMs) and patient-reported outcomes measures (PROMs) were used, though the median age of 8.9 years posed limitations., Conclusion: The commentary highlights the significance of stool cleanliness in improving patient experiences and supports the effectiveness of various BMP methods. Future research should include longitudinal follow-ups to assess BMP durability and gather data from older children., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Congenital portosystemic shunts (CPSS) are rare congenital abnormalities causing abnormal blood flow between the portal vein and systemic circulation. This study reports on the peri-operative anticoagulation management of CPSS patients post closure, focusing on the incidence of thrombotic and bleeding complications., Methods: This is a single-center retrospective analysis of CPSS patients who underwent surgery or endovascular intervention between 2005 and 2021. The protocol included unfractionated heparin (UFH) during and immediately after surgery, followed by either warfarin or low molecular weight heparin (LMWH) postoperatively. Outcomes assessed included postoperative thrombotic and bleeding complications., Results: A total of 44 patients were included. Postoperatively, 89% received treatment-dose UFH, transitioning to warfarin or LMWH at discharge. Thrombotic complications occurred in 16% of patients, predominantly in the superior mesenteric vein. Surgical interventions and continuous infusion of tissue plasminogen activator (tPA) were used for clot resolution. Bleeding complications were observed in 64% of patients, primarily managed with transfusions and temporary UFH interruption. No deaths related to thrombotic, or bleeding events were reported., Conclusions: Our findings underscore the delicate balance required in anticoagulation management for CPSS patients, revealing an occurrence of both thrombotic and bleeding complications postoperatively., Levels of Evidence: Level II, retrospective study., Competing Interests: Conflicts of interest None of the authors have financial disclosures related to the submitted work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Our study examines if the disease severity profile of our Congenital Diaphragmatic Hernia (CDH) patient cohort adherent to long-term follow-up differs from patients lost to follow-up after discharge and examines factors associated with health care utilization., Methods: Retrospective review identified CDH survivors born 2005-2019 with index repair at our institution. Primary outcome was long-term follow-up status: "active" or "inactive" according to clinic guidelines. Markers of CDH disease severity including CDH defect classification, oxygen use, tube feeds at discharge, and sociodemographic factors were examined as exposures., Results: Of the 222 included patients, median age [IQR] was 10.2 years [6.7-14.3], 61% male, and 57 (26%) were insured by Medicaid. Sixty-three percent (139/222) of patients were adherent to follow-up. Seventy-six percent of patients discharged on tube feeds had active follow-up compared to 55% of patients who were not, with similar findings for oxygen at discharge (76% vs. 55%). Kaplan-Meier analysis showed patients with smaller defect size had earlier attrition compared to patients with larger defect size. Other race (Hispanic, Asian, Middle Eastern) patients had 2.87 higher odds of attrition compared to white patients (95% CI 1.18-7.0). Medicaid patients had 2.64 higher odds of attrition compared to private insurance (95% CI 1.23-5.66)., Conclusion: Loss to follow-up was associated with race and insurance type. Disease severity was similar between the active and inactive clinic cohorts. Long-term CDH clinic publications should examine attrition to ensure reported outcomes reflect the discharged population. This study identified important factors to inform targeted interventions for follow-up adherence., Level of Evidence: Level III., Competing Interests: Conflicts of interest Dr. Mary Mullen, discloses being on the Scientific Advisory Board of Altavant Sciences in November 2021. She completed this work in November 2021 and it was outside the scope of this manuscript., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Fecal incontinence is a common problem for children with repaired anorectal malformations (ARM) and has significant implications for initiating school. While sex, anatomy, and medical comorbidities are known to influence continence outcomes, the impact of socioeconomic factors and neighborhood-level disadvantage are less well understood., Methods: We performed a single-center retrospective review of all school-aged (5-18 years) children with ARM at a longitudinal pediatric surgery clinic. Demographic, clinical, and socioeconomic variables were abstracted via chart review and geocoding was performed to obtain Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) scores. Statistical analyses assessed for associations between the primary outcome of social continence (defined as no diaper usage and infrequent fecal accidents at age 5) and these variables., Results: 72 patients were included; of these, 45.8% were socially continent. On bivariate analysis, social continence was significantly associated with state ADI score as well as the SVI Housing characteristics score. These associations remained significant when adjusting for sex and medical comorbidities in separate multiple logistic regression models., Conclusion: The relative disadvantage of the neighborhood in which a child with ARM lives may play a role in their ability to achieve continence by school age. Efforts are warranted to identify and develop targeted interventions to for this pediatric population., Level of Evidence: IV., Competing Interests: Conflicts of interest The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee conducted a systematic review to describe the epidemiology of venous thromboembolism (VTE) in pediatric surgical and trauma patients and develop recommendations for screening and prophylaxis., Methods: The Medline (Ovid), Embase, Cochrane, and Web of Science databases were queried from January 2000 through December 2021. Search terms addressed the following topics: incidence, ultrasound screening, and mechanical and pharmacologic prophylaxis. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available literature., Results: One hundred twenty-four studies were included. The incidence of VTE in pediatric surgical populations is 0.29% (Range = 0.1%-0.48%) and directly correlates with surgery type, transfusion, prolonged anesthesia, malignancy, congenital heart disease, inflammatory bowel disease, infection, and female sex. The incidence of VTE in pediatric trauma populations is 0.25% (Range = 0.1%-0.8%) and directly correlates with injury severity, major surgery, central line placement, body mass index, spinal cord injury, and length-of-stay. Routine ultrasound screening for VTE is not recommended. Consider sequential compression devices in at-risk nonmobile, pediatric surgical patients when an appropriate sized device is available. Consider mechanical prophylaxis alone or with pharmacologic prophylaxis in adolescents >15 y and post-pubertal children <15 y with injury severity scores >25. When utilizing pharmacologic prophylaxis, low molecular weight heparin is superior to unfractionated heparin., Conclusions: While VTE remains an infrequent complication in children, consideration of mechanical and pharmacologic prophylaxis is appropriate in certain populations., Type of Study: Systematic Review of level 2-4 studies., Level of Evidence: Level 3-4., Competing Interests: Conflicts of interest The authors have no potential competing interests to disclose. The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government (CDR Donald Lucas, MC, USN). One author is a military Service member or employee of the U.S. Government. This work was prepared as part of his official duties. Title 17, U.S.C., §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C., §101 defines a U.S. Government work as a work prepared by a military Service member or employee of the U.S. Government as part of that person's official duties (CDR Donald Lucas, MC, USN)., (Copyright © 2024. Published by Elsevier Inc.)