Current Pediatric Reviews (v.6, #3)

Intranasal diamorphine is a rapid, effective, analgesia, with few side effects, giving it multiple advantages over other forms of analgesia. It is also importantly a needle free alternative, acceptable to children, parents and medical staff. Due to these advantages, it is thought to be increasingly used in Paediatric A, and possibly the most popular analgesia for severe acute pain, despite being unlicensed. However, there is little quantified data on the extent of its usage. In order to clarify this, we surveyed all 214 NHS A departments in England in Wales with the scenario of an uncomplicated long bone fracture. There were 116 responses (75and#x25; return rate), showing that 60and#x25; of departments were using intranasal opioid (90and#x25; diamorphine) as 1st line and 70and#x25; as 1st or 2nd line analgesia for long bone fracture. When compared to any other drugs used, intranasal diamorphine was nearly four times more likely to be used as the 1st line analgesia. Despite being unlicensed, intranasal diamorphine is widely accepted and the most commonly used analgesia in Paediatric A for acute pain in long bone fracture. This article also reviews the literature on intranasal diamorphine with an emphasis on Paediatric usage.

Laparoscopic Reconstructive Surgery in Pediatric Urology: An Overview of Current Options by Yoshiyuki Kojima, Keiichi Tozawa, Kenjiro Kohri, Yutaro Hayashi (156-165).
Open surgery remains the standard surgical repair for urological anomalies in the pediatric population; however, with the development of instruments and the innovation of pediatric urologists, laparoscopic reconstructive surgery has gained acceptance as a feasible and reliable treatment associated with minimal morbidity, because it has several advantages over standard open reconstructive surgery. The main advantages of laparoscopic reconstructive surgery include improved cosmetic outcome, more rapid recovery, less postoperative pain, and consequently, lower analgesic requirements and shorter hospital stays. In addition, these surgeries enable increased magnification and improve visualization. On the other hand, the limitations and difficulty of laparoscopic suturing may be one of the major disadvantages to the widespread application of laparoscopic reconstructive surgery, because laparoscopic suturing in children is challenging and time-consuming and requires a learning curve. Robotic-assisted laparoscopic surgery has several advantages over conventional laparoscopic surgery, with the main advantage being the simplification and precision of exposure and suturing because of an increased degree of freedom and a magnified 3-dimensional view. These features make robotic-assisted laparoscopic surgery ideal for complex reconstructive surgery, and the number of robotic systems has increased in recent years. In this review, we discuss the recent advances in laparoscopic reconstructive surgery for urological anomalies in the pediatric population, and provide a critical summary of current knowledge on its indications, procedures and outcome. In conclusion, almost all operations that are classically performed as open reconstructive surgery for children with urological anomalies could be replaced with laparoscopic surgery and established as minimally invasive surgery in the future.

Dorsal Stream Dysfunction in Children. A Review and an Approach to Diagnosis and Management by Catriona Macintyre-Beon, Hussein Ibrahim, Isobel Hay, Debbie Cockburn, Julie Calvert, Gordon N. Dutton, Richard Bowman (166-182).
The classical model of how the human visual system works is that image data are transferred from the eyes to the occipital cortex where the picture is and#x201C;seenand#x201D;. Damage to the parts of the brain serving vision causes visual field impairment and reduced visual acuities. However, additional impairment of higher visual processing is common and may go unrecognised. Two higher visual pathways have recently been described, the dorsal and ventral streams. The dorsal stream connects the occipital lobes and posterior parietal lobes. It serves to appraise the whole scene, and perceive elements within the scene. It facilitates visual guidance of movement, by interacting with area V5 of the middle temporal lobes, or motion perception centre. It is automatic, immediate and unconscious. It is and#x2018;on lineand#x2019; and is not memory based. Damage impairs visual guidance of movement (optic ataxia) and visual search. The ventral stream links the occipital and temporal lobes, which contain the and#x201C;image librariesand#x201D;. Recognition of faces, shapes, objects and routes, is attained by matching incoming data with and#x201C;library dataand#x201D;. Dorsal stream dysfunction results from posterior parietal damage and is associated with cerebral palsy, periventricular white matter injury, premature birth, hydrocephalus and Williams' syndrome, and similar visual difficulties are becoming apparent in children with autistic spectrum disorder. Ventral stream dysfunction is less frequent and usually accompanies dorsal stream dysfunction. It is not uncommon in children with hydrocephalus. A specific disorder of dorsal stream dysfunction is emerging, comprising difficulty handling the complexity of a visual scene (of varying degree) with impaired visual guidance of the limb movement (optic ataxia). Commonly, but not always this is associated with reduced visual acuities and visual field impairment, and occasionally with impaired recognition of people (which could be called and#x201C;dorsal stream dysfunction plusand#x201D;).

Arterial Duct Stenting in Congenital Heart Disease with Duct-Dependent Pulmonary Circulation by Giuseppe Santoro, Biagio Castaldi, Gianpiero Gaio, Maria Teresa Palladino, Carola Iacono, Raffaella Esposito, Giovanbattista Capozzi, Maria Giovanna Russo, Raffaele Calabro (183-191).
Background: Despite current trends toward early primary repair, surgical systemic-to-pulmonary artery shunt is still an invaluable palliative option in some high-risk patients with congenital heart disease and duct-dependent pulmonary blood flow. However, maintaining arterial duct patency by stent implantation has been proposed as an effective alternative to surgical palliation in neonates who are unsuitable for primary repair or in whom there is anticipated spontaneous improvement of oxygen saturation as the pulmonary vascular resistance decreases. Recent advances in technology has made arterial duct stenting a safe and feasible tool for short-term palliation of newborns and young infants with this pathophysiologic arrangement. This option might be even more advisable in low-weight newborns, who are at higher risk for surgical palliation or repair and in whom repeat stent dilatations could be effective in tailoring the pulmonary flow to the patient's growth. This paper highlights history, methodology and results of this innovative and minimally-invasive palliative option. Methods and Results: Following duct morphology evaluation, the stent is chosen to completely cover the entire ductal length and is dilated to about 75and#x25; of the proposed surgical shunt. The procedure can be performed from arterial or venous approach and is successfully completed in the vast majority of cases. Procedural failure mainly depends on ductal tortuosity, typically found in complex conotruncal anomalies such as tetralogy of Fallot or pulmonary atresia with ventricular septal defect. The morbidity rate ranges from 8 to 11and#x25; and mainly consists in stent embolization or thrombosis as well as vascular access injury. The mid-term fate of the stented duct is spontaneous, slow and progressive closure within a few months. However, the stented arterial duct promotes similar and more balanced pulmonary artery growth than surgical shunt over a mid-term follow-up. Conclusions: Arterial duct stenting is a technically feasible, safe and effective palliation in congenital heart disease with duct-dependent pulmonary circulation. The stented arterial duct is less durable than conventional surgical shunt but is highly effective in promoting global and balanced pulmonary artery growth.

Bronchiolitis Obliterans Following Lung Transplantation and Stem Cell Transplantation in Pediatric Patients by Heather D. Strawbridge, Jonathan E. Spahr, Csaba Galambos, Geoffrey Kurland (192-203).
Bronchiolitis obliterans (BO) is a relatively common chronic complication following pediatric lung or hematopoietic stem cell transplantation (HSCT) characterized clinically and physiologically by obstructive lung disease with air trapping and pathologically by obstruction and/or obliteration of smaller airways. It likely represents a and#x201C;final common pathwayand#x201D; of response to airway epithelial injury from a variety of agents or mechanisms. Bronchiolitis obliterans can have an insidious onset and is difficult to diagnose. Clinical suspicion and recognition of risk factors is important to identify BO since clinical symptoms are often not present at the onset of disease. Currently, there are no specific, effective, and safe treatment options for BO following lung transplantation or HSCT. Therefore, preventing BO is preferable to attempting to treat it. This review will describe the typical features of BO including: diagnostic criteria, epidemiology, radiology, physiology, pathology, prognosis, treatment, and directions for future research.

Antifungal Prophylaxis in the Preterm Infant by Aoife McMorrow, David G. Sweet (204-209).
Survival of extremely preterm infants is increasing and invasive fungal infection is an emerging problem in this vulnerable population. Fungal sepsis is associated with higher mortality and worse neurodevelopmental outcome than bacterial sepsis alone. The reported incidence varies widely amongst units, but can be as high as 20and#x25; of babies less than 1000g birth weight. Prophylactic antifungal drugs reduce fungal colonisation and infection rates in very low birth weight babies. However to date there is insufficient data to determine the impact on long term outcomes, and there are concerns about widespread use of antifungals because of the potential for toxic side effects and drug resistance. Nystatin, miconazole, fluconazole, and amphotericin B with flucytosine have all been used for antifungal prophylaxis. Of these, only nystatin and fluconazole have been shown to reduce invasive fungal infection in newborns. Recent surveys have shown that clinicians remain in equipoise regarding antifungal prophylaxis. Some centres have attempted to limit exposure to prophylactic fluconazole by selecting babies with additional risk factors for fungal sepsis and they report similar reductions in fungal infection rates. In this review we discuss the potential benefits and risks of fungal prophylaxis in very low birth weight babies.