Search

Aim: Injuries involving non-motorised wheeled recreational vehicles (NMWRV) and bicycles are a common cause for hospitalisation in children. Studies show that helmet use whilst bicycle riding can decrease mortality and morbidity due to head injury. However, there remains an important proportion of children who are non-helmet users (NHU). This study aims to investigate helmet use and attitudes and injury patterns in children presenting with trauma after riding bicycles and other NMWRVs., Methods: A prospective cohort study was undertaken over 8 months of children aged 0-16 years, who presented with injury secondary to bicycle or NMWRV to the emergency department of two tertiary paediatric centres. Demographics, incident, injury severity and attitudes towards helmet use were compared between helmet users and NHU., Results: A total of 342 children were included - 41% (n = 139) scooter riders, 39% (n = 133) bicyclists, 18% (n = 61) skateboarders and 2% (n = 9) in-line skaters. Of those interviewed (n = 161), 58% (n = 93) wore a helmet, with children riding bicycles significantly more likely to be helmeted than NMWRV (75 vs. 48%, P = 0.01). NHU were more likely to be admitted to hospital (P = 0.05) and to sustain a major head injury (P = 0.009). The main influence on helmet use was parental rules. The biggest factor influencing non-helmet use was perceived low levels of danger., Conclusions: Despite legislation mandating this, helmet use is not universal in cyclists, particularly younger riders. Even fewer NMWRV riders use them. To promote helmet use, a multifaceted approach aimed at altering community norms and individual behaviours and attitudes is required., (© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Paediatric trauma centres seek to optimise the care of injured children. Trends in state-wide paediatric care and outcomes have not been examined in detail in Australia. This study examines temporal trends in paediatric trauma outcomes and factors influencing survival and length of stay. A retrospective review was conducted using data from the NSW Trauma Registry during 2003-2008 for children aged 15 years and younger who were severely injured (injury severity score >15). To examine trauma outcomes descriptive statistics and multivariable logistic and linear regression were conducted. There were 1138 children severely injured. Two-thirds were male. Road trauma and falls were the most common injury mechanisms and over one-third of incidents occurred in the home. Forty-eight percent of violence-related injuries were experienced by infants aged less than 1 year. For the majority of children definitive care was provided at a paediatric trauma centre, but less than one-third of children were taken directly to a paediatric trauma centre post-injury. Children who received definitive treatment at a paediatric trauma centre had between 3 and 6 times higher odds of having a survival advantage than if treated at an adult trauma centre. The number of severe injury presentations to the 14 major trauma centres in NSW remains constant. It is possible that injury prevention measures are having a limited effect on severe injury in NSW. This research provides stimulus for change in the provision and co-ordination in the delivery of trauma care for injured children., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Purpose: Neonatal neuroblastoma (NNBL) is a rare tumour with few reported cases in the literature. The prognosis of NNBL is unclear with reported survival between 76 and 91%. The growing use of ante-natal ultrasound (USS) in recent years has resulted in an increasing incidence of NNBL. The purpose of this study is to review our experience with incidence, clinical features and outcome of NNBL in those children diagnosed ante-natally compared to those diagnosed post-natally., Methods: Twelve cases of NNBL were detected ante-natally or in the neonatal period (0-28 days) from a cohort of 120 children diagnosed with neuroblastoma (10%) over a 10-year period at the study institutions. Review of these 12 children forms the basis of this report., Results: Ante-natal diagnosis (ADNB) was made in six children (50%) and post-natal diagnosis (PDNB) in six (50%). Tumour site in both cohorts were predominantly adrenal and tumour staging was similar in both groups. There was no difference in outcome in ADNB compared to PDNB with overall 100% survival for the entire group., Conclusions: NNBL is a subset of neuroblastoma with apparent excellent outcome irrespective of the time of diagnosis. Clinical features and outcomes of ADNB are no different to PDNB.

Aim: To describe the management, morbidity and mortality of infants admitted to a tertiary paediatric hospital in New South Wales, Australia with a diagnosis of sacrococcygeal teratoma (SCT)., Methods: All neonates admitted to the neonatal intensive care unit with a SCT between January 1996 and December 2008 were included in this retrospective review. Data collected included maternal and neonatal demographics, time of diagnosis, tumour characteristics, surgical treatment, operative complications and outcomes., Results: Seventeen infants with a diagnosis of SCT were included in the study. Of these infants, the majority (70%) were born at term, and eight had a prenatal diagnosis made during the second trimester. Associated anomalies were detected in seven infants (41.8%), with renal anomalies being the most common. Tumour histology included mature (50%, n= 8), yolk sac tumour (18.75%, n= 3), immature (6.25%, n= 1) and mature with mixed elements (25%, n= 4). Recurrent disease occurred in two infants within 4-18 months of the primary resection, with one infant suffering a second recurrence. Only one child died prior to surgery, giving a survival rate of 94%, and mean age at follow-up was 32 months. Long-term sequelae found in four babies included revision of scar, vesicoureteric reflux, post-surgical neurogenic bladder and osteotomy for hip dysplasia., Conclusions: The overall survival of neonatal SCT is high. While this is a small series, our results are consistent with the literature. Important components of management include timely diagnosis, multidisciplinary planning, long-term follow-up and intervention for functional sequelae., (© 2011 The Authors. Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Aim: To determine the frequency and presenting features of infants with delayed diagnosis of anorectal malformations (ARM) referred to an Australian tertiary paediatric institution., Methods: Infants referred to our institution with a final diagnosis of ARM were retrospectively reviewed between 2001 and 2009. The first cohort consisted of patients that were referred between November 2001 and November 2006 with the diagnosis of an ARM that had been delayed for more than 48 h. The second cohort was those referred between December 2006 and May 2009 with whom the diagnosis of ARM had not been made within 24 h of birth., Results: Nineteen infants were referred with delayed diagnosis of an ARM over the 7.5 years of the study. Of 44 patients referred to our institution between December 2006 and May 2009, diagnosis of an ARM was delayed more than 24 h in 14 (32%). There was no difference in gender, birth weight, prematurity, type of malformation or presence of associated anomalies between those with timely and delayed diagnosis of their ARM. A significantly greater proportion of those with a delayed diagnosis presented with obstructive symptoms (86% vs. 27%, P < 0.001), including abdominal distension (57%) and delayed passage of meconium or stool (29%). Despite undergoing neonatal examination, the diagnosis of ARM was missed in 12 patients overall., Conclusion: Delayed diagnosis of an ARM appears to be common, occurring in approximately 32% of patients referred to our institution over the last 2.5 years. Current guidelines appear insufficient to ensure prompt diagnosis of ARM.

Objective: To increase the evidence base by characterizing various features of pediatric sports-related abdominal injuries., Design: A review of the trauma database at The Children's Hospital at Westmead was undertaken for all abdominal injuries presenting to the emergency department between 2001 and 2006., Setting: The Children's Hospital at Westmead is a tertiary-level pediatric trauma center servicing Sydney's west. It sees approximately 50,000 patients a year., Participants: Only those injuries occurring during an organized sport were included for analysis. Thirty-three of the original 513 patients were eligible for inclusion., Main Outcome Measures: The data collected included basic demographics, mechanism of injury, sport injury, time to presentation, length of stay, diagnoses, treatment, and complications. Injury severity scores were assigned retrospectively., Results: Males sustained more injuries than females. Collisions and falls were the most common modes of injury. Rugby was the most common sport for injury. Most patients presented within 12 hours, and most presented with musculoskeletal injuries. Injury severity was usually mild; treatment, conservative; length of stay, short; and complications, uncommon. When characteristics were compared by sex, males had mostly collision injuries in high-impact/contact sports, with females having more falls in other sports. When characteristics were compared by age, the only statistically significant difference was in the organ injured: older children had more single solid organ injuries, and younger children had more multiple and hollow viscus injuries., Conclusions: Sports-related abdominal injuries in children are mostly minor and not as common as other injury mechanisms. Despite this, they can be serious, with early diagnosis often delayed because of their subtle nature. Sports-related abdominal injuries in children require a high index of suspicion in the part of the clinician if they are to be recognized early and managed effectively.

A sinus tract presenting with an opening around the angle of mandible is suggestive of first cleft remnant. We present the case of a 4-year-old boy with a recurrent discharging sinus around the angle of the right mandible whose internal opening was near the tonsil on imaging. Complete excision was performed with facial nerve monitoring. We discuss technical aspects of the surgery and possible embryology.

Eight children suffered drowning or near-drowning in Sydney pools over an 11-day period in January 2007. Four received basic life support (BLS) within 5 minutes of immersion and survived with good functional neurological outcomes. The other four were not discovered for >or= 5 minutes and all died. This cluster serves as a reminder that timely effective bystander BLS is crucial to survival and good clinical outcomes in near-drowning episodes.

The expansion in medical student numbers has been associated with a move to increase the amount of time students spend in rural and remote locations. Providing an equivalent educational experience for students in surgical subspecialties in this setting is a logistical challenge. We sought to address this issue by providing synchronous tutorials in paediatric surgery using videoconferencing (VC) at two rural sites with the tutor located at a metropolitan paediatric clinical school. Between March 2005 and July 2006, 43 graduate students in the University of Sydney Medical Program were assigned to receive the paediatric component of the course at one of two sites within the School of Rural Health. During this 9-week rotation, students were involved in two or three surgical tutorials by videoconference. Students were then invited to complete a confidential, anonymous 20-point structured evaluation using a Likert scale. Valid responses were received from 40 students, a response rate of 93%. There were 21 females (52%), with 21 students based in Dubbo and 19 in Orange. Students agreed or strongly agreed that VC surgical tutorials were useful, the content well covered and student involvement encouraged (mean scores 4.7, 4.5 and 4.5; standard deviation 0.56, 0.72 and 0.72, respectively). Overall, the majority of students strongly agreed that participation in VC of surgical tutorials was valuable (mean 4.68, standard deviation 0.57). VC surgical tutorials were highly valued by graduate medical students as an educational method. Our data suggest that tutorials can be successfully provided at remote sites using VC.

Background: The diagnosis of intestinal injuries in children after blunt abdominal trauma can be difficult and delayed. Most children who suffer blunt abdominal trauma are managed nonoperatively, making the diagnosis of intestinal injuries more difficult. We sought to gain information about children who develop intestinal obstruction after blunt abdominal trauma by reviewing our experience., Methods: Review of records from a pediatric tertiary care center over an 11.5-year period revealed 5 patients who developed small bowel obstruction after blunt trauma to the abdomen. The details of these patients were studied., Results: All patients were previously managed nonoperatively for blunt abdominal trauma. Intestinal obstruction developed 2 weeks to 1 year (median, 21 days) after the trauma. Abdominal x-ray, computerized tomography scan, or barium meal studies were used to establish the diagnosis. The pathology was either a stricture, an old perforation, or adhesions causing the intestinal obstruction. Laparotomy with resection and anastomosis was curative., Conclusions: Posttraumatic small bowel obstruction is a clinical entity that needs to be watched for in all patients managed nonoperatively for blunt abdominal trauma.

Objective: To study the appropriateness of, and time taken, to transfer pediatric trauma patients in New South Wales to The Children's Hospital at Westmead (CHW), a pediatric trauma center., Methods: All trauma patients transferred to CHW from June 2003 to July 2004 were included in the study. Indications and time periods relevant to the transfer of the patient from the referring institute were retrieved and analyzed. Pediatric and adult retrieval services were compared., Results: Three hundred ninety-eight patients were transferred to CHW, of whom 332 were from the metropolitan region. Falls and burns were the commonest mechanism of injury. Burn was the commonest indication for transfer (107 of 398). Mean Injury Severity Score was eight. Nearly half the patients had minor injuries (Injury Severity Score<9). Patients spent an average of 5 hours at the referring hospital. Pediatric retrieval ambulances had significantly longer mean transfer times than did nonpediatric ambulance services with a total time spent of about 2.64 hours versus 1.30 hours, respectively. For aeromedical transfers, on the other hand, the difference between pediatric retrieval services and nonpediatric air ambulances was not significant., Conclusions: The majority of the patients transferred had minor injuries. Pediatric trauma patients spend considerable time in their referring hospitals. Pediatric retrieval services appear to take significantly longer to transfer patients than nonpediatric ambulance transfers even after allowing for patient age and injury severity. Although this did not result in mortality or morbidity, there appears to be considerable scope for a reduction in transfer times through better coordination of these services.

Background: Adrenal injuries following blunt abdominal trauma is uncommon. Recent increased detection of traumatic adrenal haemorrhage (TAH) prompted this study., Methods: Cases were identified from retrospective search of the trauma and medical imaging database for the period 1998-2004. Medical records were reviewed and data analysed to identify mechanism of injury, imaging findings, associated injuries, presence of hypotension, length of stay and follow up., Results: Eleven children were identified with TAH. Right adrenal was commonly injured. Motor vehicle injury was the commonest mechanism. All injuries were identified on initial computed tomography, and all but one had associated abdominal injuries. There were no deaths. Ultrasound showed resolution within 3 months in six patients., Conclusion: TAH is an uncommon injury that is rarely isolated. Although initial diagnosis is made on computed tomography, ultrasound appears adequate for follow up. TAH appears to be an incidental finding that resolves on follow-up imaging.

The diagnosis and management of a 14-year-old girl with isolated traumatic transection of the prepylorus after a motor vehicle accident are presented. Abdominal computed tomography was useful in the diagnosis of pneumoperitoneum associated with hollow viscous injury. Rapid diagnosis and surgical repair of this unusual injury resulted in an uncomplicated recovery.

Traumatic spinal epidural hematoma is rare in children. The presentation could be nonspecific, leading to a delay in diagnosis. We present an infant who sustained an epidural hematoma after a "trivial" injury. The delay in diagnosis led to minor neurological deficit at 6-week follow-up. Irritability and torticollis after a neck trauma in an afebrile child should alert to the possibility of spinal cord compression. Early imaging and early decompression will minimize morbidity.

Aim: To study the diagnostic accuracy and clinical efficacy of surgeon-performed focused abdominal sonography (FAST) in paediatric blunt abdominal trauma (BAT)., Materials and Method: This was a prospective, single blinded study conducted at The Children's Hospital at Westmead Sydney (CHW). All patients with BAT that justified a trauma call activated on presentation to the Emergency Department (ED) had a FAST performed by the Trauma Fellow. The attending surgical team was blinded to the result of the FAST. An independent radiologist reviewed the FAST pictures, and the findings were compared with computerised tomography (CT), ultrasound (US), laparotomy and the clinical outcome of the patient. Sensitivity, specificity and predictive values were calculated., Results: A total of 85 patients (39 M; 26 F) were enrolled in the study between February 2002 and January 2003. The age ranged between 4 months and 16 years. The mean Injury Severity Score (ISS) was 6 (range 1-38). FAST was performed in a mean time of 3 min. Inter-rater agreement was 96%. FAST was positive in nine as confirmed by a CT scan of the abdomen. Three patients underwent laparotomy, two for bowel injuries and one for a Grade III liver laceration. Of the remaining 76, 19 had a CT, which showed evidence of intra-abdominal injury in seven patients. There were two false negative studies resulting in a sensitivity of 81%, specificity of 100%, negative predictive value of 97%, positive predictive value of 100% and an accuracy of 97%., Conclusions: Surgeon-performed FAST for BAT was safe and accurate with a high specificity. It would seem a potentially valuable tool in the evaluation of paediatric blunt trauma victims for free fluid within the peritoneal cavity.

Pneumothorax after blunt chest trauma in the absence of rib fractures is uncommon and has only rarely been reported as a result of sporting activity. Presentation may vary from an apparently normal physical examination in the presence of a small pneumothorax to hemodynamic compromise in the presence of a tension pneumothorax. High fitness levels in athletes may result in failure to recognize symptoms and delay diagnosis, potentially increasing morbidity. It is imperative for the emergency physician to exclude pneumothorax in children who present with chest pain after blunt chest trauma from sports injury. We report our experience with and the management of 3 patients with pneumothoraces.

Diaphragmatic injuries following blunt trauma are rare. From January 1988 to February 2002 eight children were treated at the Children's Hospital at Westmead for diaphragmatic injury. Male to female ration was 5:3. Motor vehicle crashes were the most common cause. The injury was left-sided in four, right sided in three and central in one. Initial plain radiograph and computerised tomography detected the injury in 50% of cases. Laparotomy, contrast study and autopsy identified the rupture in one each. Associated injuries were present in all cases. Seven children had laparotomy and repair of the diaphragmatic rupture. The commonest site of rupture was posterolateral (37.5%). Diagnosis was delayed in two cases. There were two deaths (25% mortality) in the series, both due to associated injuries. Although rare, diaphragmatic rupture must be considered in any child with thoracoabdominal injury. Diagnosis may be difficult and require extensive investigation. Mortality usually results from associated injuries.

Background: There are limited data on the incidence of delayed diagnosis of injuries in children. We sought to investigate the role of an extended tertiary survey in pediatric trauma patients., Methods: All children that were admitted to The Children's Hospital at Westmead with an Injury Severity Score (ISS) >/= 9 were included in the study. The trauma fellow performed the tertiary survey the day after admission. This was repeated after extubation in ventilated patients and in head injury patients when they were more mobile and cooperative., Results: Seventy-six patients satisfied the criteria for the study (50 boys and 26 girls). Age ranged from 1 month to 15 years. The median ISS was 14. Sixteen (16%) of the patients had missed injuries, of which skeletal injuries were the most common (10 of 12). Delayed diagnosis of injury occurred most frequently in children involved in motor vehicle injuries. Sixty-six (66%) of the injuries were detected within the first 24 hours. Inadequate assessment and head injury were the most common contributing factors., Conclusion: The incidence of missed injury (16%) in our study was comparable to reported figures in the adult literature. There was no correlation between missed injuries and intensive care unit stay or ISS. Head injury often delayed diagnosis and thus ongoing evaluation in this group is recommended. Missed injuries did not result in mortality, but there was significant associated morbidity. A tertiary survey should be part of the evaluation of the pediatric trauma patient.

Retrocaval ureter is a relatively rare anomaly that usually manifests in the third or fourth decades. Symptoms are due to ureteric obstruction, either extrinsic by the abnormal inferior vena cava (IVC), or intrinsic ureteric hypoplasia. Surgery is needed for symptomatic cases and involves transection and relocation of the ureter anterior to the IVC. We report our experience with two such children who needed surgery because of increasing hydronephrosis and who have done well since.