Growth potential of U-clip interrupted versus polypropylene running suture anastomosis in congenital cardiac surgery: intermediate term results

Although U-clip anastomoses were studied for hemodynamics and patency, their potential for unimpeded growth after congenital cardiovascular surgery has not been investigated yet. In 53 children aged 2.1+/-3.3 years operated on between March 1998 and August 2005 growth of U-clip (U) vs. polypropylene running sutured (P) anastomoses in coarctation repair (Coarc; n=26), bi-directional Glenn (BDG; n=13) and arterial switch operation (ASO; n=14) was retrospectively analysed. Coarc showed 2.39+/-4.33 vs. 3.09+/-2.24 mm of growth during the observation period (21+/-16 vs. 30+/-27 months); no growth (0 vs.16%), restenosis (14 vs. 37%) and reinterventions (14 vs. 11%) were similar (all in U vs. P, P=ns). BDG showed 3.68+/-3.43 vs. 2.50+/-2.55 mm (P=ns) of growth during 15+/-5 vs. 29+/-18 months (P=0.046); no growth (17 vs. 0%), stenosis (0 vs. 14%) and reinterventions (0%) were similar in U vs. P, respectively (P=ns). Main pulmonary artery (MPA) anastomosis in ASO showed 0.28+/-1.73 vs. 1.30+/-3.16 mm of growth during 8+/-14 vs. 28+/-28 months; no growth (60 vs. 14%), stenosis (50 vs. 63%) and reinterventions (0%) were similar (all in U vs. P, P=ns). Anastomotic growth, stenosis and reintervention rates show no difference between interrupted U-clip and polypropylene running sutured technique in Coarc repair, BDG and MPA anastomosis in ASO.

[Growth: what is normal?]

Growth is an inherent property of life, which has to be checked and controlled by any general physician following children. Therefore, the common knowledge about the normal pattern/course of growth is essential in order to act proactively whenever the child's growth does not progress adequately.

The importance of growth hormone in the regulation of erythropoiesis, red cell mass, and plasma volume in adults with growth hormone deficiency

Total body water (TBW) is reduced in adult GH deficiency (GHD) largely due to a reduction of extracellular water. It is unknown whether total blood volume (TBV) contributes to the reduced extracellular water in GHD. GH and insulin-like growth factor I (IGF-I) have been demonstrated to stimulate erythropoiesis in vitro, in animal models, and in growing children. Whether GH has a regulatory effect on red cell mass (RCM) in adults is not known. We analyzed body composition by bioelectrical impedance and used standard radionuclide dilution methods to measure RCM and plasma volume (PV) along with measuring full blood count, ferritin, vitamin B12, red cell folate, IGF-I, IGF-binding protein-3, and erythropoietin in 13 adult patients with GHD as part of a 3-month, double blind, placebo-controlled trial of GH (0.036 U/kg.day). TBW and lean body mass significantly increased by 2.5 +/- 0.53 kg (mean +/- SEM; P < 0.004) and 3.4 +/- 0.73 kg (P < 0.004), respectively, and fat mass significantly decreased by 2.4 +/- 0.32 kg (P < 0.001) in the GH-treated group. The baseline RCM of all patients with GHD was lower than the predicted normal values (1635 +/- 108 vs. 1850 +/- 104 mL; P < 0.002). GH significantly increased RCM, PV, and TBV by 183 +/- 43 (P < 0.006), 350 +/- 117 (P < 0.03), and 515 +/- 109 (P < 0.004) mL, respectively. The red cell count increased by 0.36 +/- 0.116 x 10(12)/L (P < 0.03) with a decrease in ferritin levels by 39.1 +/- 4.84 micrograms/L (P < 0.001) after GH treatment. Serum IGF-I and IGF-binding protein-3 concentrations increased by 3.0 +/- 0.43 (P < 0.001) and 1.3 +/- 0.15 (P < 0.001) SD, respectively, but the erythropoietin concentration was unchanged after GH treatment. No significant changes in body composition or blood volume were recorded in the placebo group. Significant positive correlations could be established between changes in TBW and TBV, lean body mass and TBV (r = 0.78; P < 0.04 and r = 0.77; P < 0.04, respectively), and a significant negative correlation existed between changes in fat mass and changes in TBV in the GH-treated group (r = -0.95; P < 0.02). We conclude that 1) erythropoiesis is impaired in GHD; 2) GH stimulates erythropoiesis in adult GHD; and 3) GH increases PV and TBV, which may contribute to the increased exercise performance seen in these patients.

Anterior Cruciate Ligament Injuries in Children and Adolescents: A Review of the Recent Literature

In contrast to the treatment of avulsion lesions of the anterior cruciate ligament (ACL) the management of intrasubstance ACL tears in the skeletally immature patient remains controversial. Prospective studies could show that conservative treatment results in severe instability with concomitant intraarticular damage and poor function of the knee. Reconstruction of a torn ACL always carries the risk of damaging the open growth plates; with consecutively affecting the longitudinal or axial growth of the lower extremity either on the femoral or the tibial side. Thus, several surgical procedures are available to prevent adverse events mentioned above. The purpose of this study is to review the recent literature regarding the treatment algorithm for ACL injuries in skeletally immature patients. This review will (1) investigate the indications for ACL surgery in children; (2) determine if a surgical procedure is clinically superior in skeletally immature patients; and (3) correlate the adverse events with the surgical technique.

Mid-term results of transphyseal anterior cruciate ligament reconstruction in children and adolescents

BACKGROUND Optimal therapy for anterior cruciate ligament (ACL) rupture in the paediatric population still provokes controversy. Although conservative and operative treatments are both applied, operative therapy is slightly favored. Among available surgical techniques are physeal-sparing reconstruction and transphyseal graft fixation. The aim of this study was to present our mid-term results after transphyseal ACL reconstruction. METHODS Fifteen young patients (mean age=12.8±2.6, range=6.2-15.8years, Tanner stage=2-4) with open physis and traumatic anterior cruciate rupture who had undergone transphyseal ACL reconstruction with unilateral quadriceps tendon graft were prospectively analyzed. All children were submitted to radiological evaluation to determine the presence of clearly open growth plates in both the distal femur and proximal tibia. Postoperatively, all patients were treated according to a standardized rehabilitation protocol and evaluated by radiographic analysis and the Lysholm-Gillquist and IKDC 2000 scores. Their health-related quality of life was measured using the SF-12 PCS (physical component summary) and MCS (mental component summary) questionnaires. RESULTS Mean postoperative follow-up was 4.1years. Mean Lysholm-Gillquist score was 94.0. Thirteen of the 15 knees were considered nearly normal on the IKDC 2000 score. The mean SF-12 questionnaire score was 54.0±4.8 for SF-12 PCS and 59.1±3.7 for SF-12 MCS. No reruptures were observed. Radiological analysis detected one knee with valgus deformity. All patients had a normal gait pattern without restrictions. CONCLUSION Transphyseal reconstruction of the anterior cruciate ligament shows satisfactory mid-term results in the immature patient.

Preterm birth, infant weight gain, and childhood asthma risk: A meta-analysis of 147,000 European children

BACKGROUND Preterm birth, low birth weight, and infant catch-up growth seem associated with an increased risk of respiratory diseases in later life, but individual studies showed conflicting results. OBJECTIVES We performed an individual participant data meta-analysis for 147,252 children of 31 birth cohort studies to determine the associations of birth and infant growth characteristics with the risks of preschool wheezing (1-4 years) and school-age asthma (5-10 years). METHODS First, we performed an adjusted 1-stage random-effect meta-analysis to assess the combined associations of gestational age, birth weight, and infant weight gain with childhood asthma. Second, we performed an adjusted 2-stage random-effect meta-analysis to assess the associations of preterm birth (gestational age <37 weeks) and low birth weight (<2500 g) with childhood asthma outcomes. RESULTS Younger gestational age at birth and higher infant weight gain were independently associated with higher risks of preschool wheezing and school-age asthma (P < .05). The inverse associations of birth weight with childhood asthma were explained by gestational age at birth. Compared with term-born children with normal infant weight gain, we observed the highest risks of school-age asthma in children born preterm with high infant weight gain (odds ratio [OR], 4.47; 95% CI, 2.58-7.76). Preterm birth was positively associated with an increased risk of preschool wheezing (pooled odds ratio [pOR], 1.34; 95% CI, 1.25-1.43) and school-age asthma (pOR, 1.40; 95% CI, 1.18-1.67) independent of birth weight. Weaker effect estimates were observed for the associations of low birth weight adjusted for gestational age at birth with preschool wheezing (pOR, 1.10; 95% CI, 1.00-1.21) and school-age asthma (pOR, 1.13; 95% CI, 1.01-1.27). CONCLUSION Younger gestational age at birth and higher infant weight gain were associated with childhood asthma outcomes. The associations of lower birth weight with childhood asthma were largely explained by gestational age at birth.

Household Hardships, Public Programs, and Their Associations with the Health and Development of Very Young Children: Insights from Children’s HealthWatch

America’s low-income families struggle to protect their children from multiple threats to their health and growth. Many research and advocacy groups explore the health and educational effects of food insecurity, but less is known about these effects on very young children. Children’s HealthWatch, a group of pediatric clinicians and public health researchers, has continuously collected data on the effects of food insecurity alone and in conjunction with other household hardships since 1998. The group’s peer reviewed research has shown that a number of economic risks at the household level, including food, housing and energy insecurity, tend to be correlated. These insecurities alone or in conjunction increase the risk that a young child will suffer various negative health consequences, including increases in lifetime hospitalizations, parental report of fair or poor health,1 or risk for developmental delays.2 Child food insecurity is an incremental risk indicator above and beyond the risk imposed by household-level food insecurity. The Children’sHealthwatch research also suggests public benefits programs modify some of these effects for families experiencing hardships. This empirical evidence is presented in a variety of public venues outside the usual scientific settings, such as congressional hearings, to support the needs of America’s most vulnerable population through policy change. Children’s HealthWatch research supports legislative solutions to food insecurity, including sustained funding for public programs and re-evaluation of the use of the Thrifty Food Plan as the basis of SNAP benefits calculations. Children’s HealthWatch is one of many models to support the American Academy of Pediatrics’ call to “stand up, speak up, and step up for children.”3 No isolated group or single intervention will solve child poverty or multiple hardships. However, working collaboratively each group has a role to play in supporting the health and well-being of young children and their families. 1. Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 2004;134:1432-1438. 2. Rose-Jacobs R, Black MM, Casey PH, et al. Household food insecurity: associations with at-risk infant and toddler development. Pediatrics. 2008;121:65-72. 3. AAP leader says to stand up, speak up, and step up for child health [news release]. Boston, MA: American Academy of Pediatrics; October 11, 2008. http://www2.aap.org/pressroom/nce/nce08childhealth.htm. Accessed January 1, 2012.

Left ventricular growth from age 8 to 18 and its anthropometric determinants: Longitudinal results from Project Heartbeat!

Left ventricular mass (LVM) is a strong predictor of cardiovascular disease (CVD) in adults. However, normal growth of LVM in healthy children is not well understood, and previous results on independent effects of body size and body fatness on LVM have been inconsistent. The purpose of this study was (1) to establish the normal growth curve of LVM from age 8 to age 18, and evaluate the determinants of change in LVM with age, and (2) to assess the independent effects of body size and body fatness on LVM.^ In Project HeartBeat!, 678 healthy children aged 8, 11 and 14 years at baseline were enrolled and examined at 4-monthly intervals for up to 4 years. A synthetic cohort with continuous observations from age 8 to 18 years was constructed. A total of 4608 LVM measurements was made from M-mode echocardiography. The multilevel linear model was used for analysis.^ Sex-specific trajectories of normal growth of LVM from age 8 to 18 was displayed. On average, LVM was 15 g higher in males than females. Average LVM increased linearly in males from 78 g at age 8 to 145 g at age 18. For females, the trajectory was curvilinear, nearly constant after age 14. No significant racial differences were found. After adjustment for the effects of body size and body fatness, average LVM decreased slightly from age 8 to 18, and sex differences in changes of LVM remained constant.^ The impact of body size on LVM was examined by adding to a basic LVM-sex-age model one of 9 body size indicators. The impact of body fatness was tested by further introducing into each of the 9 LVM models (with one or another of the body size indicators) one of 4 body fatness indicators, yielding 36 models with different body size and body fatness combinations. The results indicated that effects of body size on LVM can be distinguished between fat-free body mass and fat body mass, both being independent, positive predictors. The former is the stronger determinant. When a non-fat-free body size indicator is used as predictor, the estimated residual effect of body fatness on LVM becomes negative. ^

Caries-preventive effectiveness of fluoride varnish as adjunct to oral health promotion and supervised tooth brushing in preschool children: a double-blind randomized controlled trial.

OBJECTIVES To evaluate the effect of biannual fluoride varnish applications in preschool children as an adjunct to school-based oral health promotion and supervised tooth brushing with 1000ppm fluoride toothpaste. METHODS 424 preschool children, 2-5 year of age, from 10 different pre schools in Athens were invited to this double-blind randomized controlled trial and 328 children completed the 2-year programme. All children received oral health education with hygiene instructions twice yearly and attended supervised tooth brushing once daily. The test group was treated with fluoride varnish (0.9% diflurosilane) biannually while the control group had placebo applications. The primary endpoints were caries prevalence and increment; secondary outcomes were gingival health, mutans streptococci growth and salivary buffer capacity. RESULTS The groups were balanced at baseline and no significant differences in caries prevalence or increment were displayed between the groups after 1 and 2 years, respectively. There was a reduced number of new pre-cavitated enamel lesions during the second year of the study (p=0.05) but the decrease was not statistically significant. The secondary endpoints were unaffected by the varnish treatments. CONCLUSIONS Under the present conditions, biannual fluoride varnish applications in preschool children did not show significant caries-preventive benefits when provided as an adjunct to school-based supervised tooth brushing with 1000ppm fluoride toothpaste. CLINICAL SIGNIFICANCE In community based, caries prevention programmes, for high caries risk preschool children, a fluoride varnish may add little to caries prevention, when 1000ppm fluoride toothpaste is used daily.

Fractures in Children and Adolescents

Fractures of the growing bone require fixation techniques, which preclude any injury to the growth plate regions. This requirement is met by Elastic Stable Intramedullary Nails (ESIN) which are positioned between both metaphyseal regions. Pronounced malposition and/or shortening, open fractures and fractures with impending skin perforation are indications for clavicle nailing in adolescents. Retrograde nailing with two elastic nails, inserted from lateral, is the method of choice for stabilization of humerus fractures. In radial neck fractures with severe tilting of the radial head, a retrograde nail may reduce and fix the head. In Monteggia lesions, the ulna fracture is reduced and fixed with an antegrade nail. Forearm fractures with unacceptable axial deviation are reduced and fixed with one antegrade nail in the ulna and a retrograde nail in the radius. Ascending elastic nailing is done for femur shaft and proximal femur fractures. The medial and lateral entry sites are located above the distal physis. End caps are used to prevent shortening in spiral and multiple segment fractures. Fractures of the distal third of the femur are nailed in a descending technique. The entry sites of two nails are located on the lateral cortex below the greater trochanter. Combined tibia and fibula fractures, open fractures and unstable fracture types such as spiral and multifragmental tibia fractures are good indications for ESIN. Descending nailing is the method of choice. The nail entry points are medially and laterally distal to the apophysis of the proximal tibia. Thorough knowledge of each fracture type, fracture location and age specific healing pattern is necessary for safe and effective treatment of pediatric fractures

Salt intake in children and its consequences on blood pressure.

Sodium is the most abundant extracellular cation and therefore pivotal in determining fluid balance. At the beginning of life, a positive sodium balance is needed to grow. Newborns and preterm infants tend to lose sodium via their kidneys and therefore need adequate sodium intake. Among older children and adults, however, excessive salt intake leads to volume expansion and arterial hypertension. Children who are overweight, born preterm, or small for gestational age and African American children are at increased risk of developing high blood pressure due to a high salt intake because they are more likely to be salt sensitive. In the developed world, salt intake is generally above the recommended intake also among children. Although a positive sodium balance is needed for growth during the first year of life, in older children, a sodium-poor diet seems to have the same cardiovascular protective effects as among adults. This is relevant, since: (1) a blood pressure tracking phenomenon was recognized; (2) the development of taste preferences is important during childhood; and (3) salt intake is often associated with the consumption of sugar-sweetened beverages (predisposing children to weight gain).

Metamorphosis of human lumbar vertebrae induced by VEPTR growth modulation and stress shielding

INTRODUCTION Distraction-based spinal growth modulation by growing rods or vertical expandable prosthetic titanium ribs (VEPTRs) is the mainstay of instrumented operative strategies to correct early onset spinal deformities. In order to objectify the benefits, it has become common sense to measure the gain in spine height by assessing T1-S1 distance on anteroposterior (AP) radiographs. However, by ignoring growth changes on vertebral levels and by limiting measurement to one plane, valuable data is missed regarding the three-dimensional (3D) effects of growth modulation. This information might be interesting when it comes to final fusion or, even more so, when the protective growing implants are removed and the spine re-exposed to physiologic forces at the end of growth. METHODS The goal of this retrospective radiographic study was to assess the growth modulating impact of year-long, distraction-based VEPTR treatment on the morphology of single vertebral bodies. We digitally measured lumbar vertebral body height (VBH) and upper endplate depth (VBD) at the time of the index procedure and at follow-up in nine patients with rib-to-ileum constructs (G1) spanning an anatomically normal lumbar spine. Nine patients with congenital thoracic scoliosis and VEPTR rib-to-rib constructs, but uninstrumented lumbar spines, served as controls (G2). All had undergone more than eight half-yearly VEPTR expansions. A Wilcoxon signed-rank test was used for statistical comparison of initial and follow-up VBH, VBD and height/depth (H/D) ratio (significance level 0.05). RESULTS The average age was 7.1 years (G1) and 5.2 year (G2, p > 0.05) at initial surgery; the average overall follow-up time was 5.5 years (p = 1). In both groups, VBH increased significantly without a significant intergroup difference. Group 1 did not show significant growth in depth, whereas VBD increased significantly in the control group. As a consequence, the H/D ratio increased significantly in group 1 whereas it remained unchanged in group 2. The growth rate for height in mm/year was 1.4 (group 1) and 1.1 (group 2, p = 0.45), and for depth, it was -0.3 and 1.1 (p < 0.05), respectively. CONCLUSIONS VEPTR growth modulating treatment alters the geometry of vertebral bodies by increasing the H/D ratio. We hypothesize that the implant-related deprivation from axial loads (stress-shielding) impairs anteroposterior growth. The biomechanical consequence of such slender vertebrae when exposed to unprotected loads in case of definitive VEPTR removal at the end of growth is uncertain.

Challenges in Collating Spirometry Reference Data for South-Asian Children: An Observational Study.

METHODS Spirometry datasets from South-Asian children were collated from four centres in India and five within the UK. Records with transcription errors, missing values for height or spirometry, and implausible values were excluded(n = 110). RESULTS Following exclusions, cross-sectional data were available from 8,124 children (56.3% male; 5-17 years). When compared with GLI-predicted values from White Europeans, forced expired volume in 1s (FEV1) and forced vital capacity (FVC) in South-Asian children were on average 15% lower, ranging from 4-19% between centres. By contrast, proportional reductions in FEV1 and FVC within all but two datasets meant that the FEV1/FVC ratio remained independent of ethnicity. The 'GLI-Other' equation fitted data from North India reasonably well while 'GLI-Black' equations provided a better approximation for South-Asian data than the 'GLI-White' equation. However, marked discrepancies in the mean lung function z-scores between centres especially when examined according to socio-economic conditions precluded derivation of a single South-Asian GLI-adjustment. CONCLUSION Until improved and more robust prediction equations can be derived, we recommend the use of 'GLI-Black' equations for interpreting most South-Asian data, although 'GLI-Other' may be more appropriate for North Indian data. Prospective data collection using standardised protocols to explore potential sources of variation due to socio-economic circumstances, secular changes in growth/predictors of lung function and ethnicities within the South-Asian classification are urgently required.

Body fat distribution and serum lipids in children and adolescents

Previous studies of normal children have linked body fat but not body fat distribution (BFD), to higher blood pressures, lipids, and insulin resistance (Berenson et al., 1988) BFD is a well-established risk factor for cardiovascular disease in adults (Björntorp, 1988). This study investigates the relation of BFD and serum lipids at baseline in children from Project HeartBeat!, a study of the growth and development of cardiovascular risk factors in 678 children in three cohorts measured initially at ages 8, 11, and 14 years. Initially, two of four indices of BFD were significantly related to the lipids: ratio of upper to lower body skinfolds (ln US:LS) and conicity (C Index). A factor analysis reduced the information in the serum lipids to two vectors: (1) total cholesterol + LDL-cholesterol and (2) HDL-cholesterol − triglycerides, which together accounted for 85% of the lipid variation. Using each serum lipid and vector as separate dependent variables, linear and quadratic regression models were constructed to examine the predictive ability of the two BFD variables, controlling for total body fat, gender, ethnicity (Black, non-Black) and maturation. Linear models provided an acceptable fit. Percent body fat (%BF) was a significant predictor in each and every lipid model, independent of age, maturation, or ethnicity (p ≤ 0.05). No BFD variable entered the equation for total or LDL-cholesterol, although there was a significant maturity by BFD interaction for LDL (ln US:LS was a significant predictor in more mature individuals). Both %BF and BFD (by way of Conicity) were significant predictors of HDL-cholesterol and triglycerides (p ≤ 0.01). All models were statistically significant at a high level (p ≤ 0.01), but adjusted R 2's for all models were low (0.05–0.15). Body fat distribution is a significant predictor of lipids in normal children, but secondarily to %BF, and for LDL-cholesterol in particular, the relation is dependent on maturity status. ^

An investigation of the association between obesity, acanthosis nigricans, and fasting serum insulin level in 6--9 year old children living on the El Paso-Juarez U.S.-Mexico border

The objectives of this study were to investigate the relationship between fasting serum insulin levels and Acanthosis Nigricans (AN) (a dermatological condition characterized by hyperpigmentation and thickening of the skin in specific body areas such as the neck and knuckles) and obesity among 6 to 9 year old children. Children were selected at random from a pediatric clinic located on the U.S.-Mexico border. Because none of the children participants had a weight for height at or above the 97th percentile of the CDC growth charts, obesity was defined as weight for height at or above the 95th percentile and at risk of overweight between the 85 th and 95th percentiles of the CDC growth charts. Anthropometrics, blood samples for fasting serum insulin and blood glucose, and a picture of the neck were obtained at baseline (n = 85) and 6 months later (n = 49). None of the children partipating had high fasting serum insulin levels and only 2 children had AN degree 2 (moderately severe). At baseline children with a weight for height at or above the 95th, percentile had 15 units less of insulin than children who weighed less. However, 6 months later this was not confirmed, thus the baseline result is considered to be an anomaly. Eventhough statistical significance was not reached, results showed that children without AN had 5 percentiles lower weight for height than children with AN. The most important recommendation from this study is the need to monitor longitudinal growth in children to characterize the individual child's growth pattern. AN seems to be related to longitudinal growth changes. ^