Outcome of duct‐to‐duct vs. Roux‐en‐Y hepaticojejunostomy biliary anastomoses in below 15‐kg pediatric liver transplant recipients

The best type of biliary anastomosis to use in lower weight pediatric liver transplant recipients is debatable. In this study, we share a single center's experience comparing the rate of anastomotic biliary complications based on the type of biliary anastomosis performed in this population of patients. A retrospective review of pediatric liver transplants for recipients weighing <15 kg from 11/2003 till 12/2011 was performed. Patients were grouped based on the type of biliary anastomosis into two groups: duct‐to‐duct (d‐d) and Roux‐en‐Y hepaticojejunostomy (h‐j) anastomoses. A total of 24 patients (12 males, 12 females) with a mean age of 26 ± 20 months and a mean weight of 9.27 ± 2.63 kg (range = 5.3–13.9 kg) were studied. All anastomotic complications occurred in patients who received left lateral segments. No statistical differences were found in the post‐operative biliary (p = 0.86) or vascular (p = 0.99) complications between the two groups. Acknowledging the limited sample size, our data suggest that duct‐to‐duct anastomosis can be performed safely in pediatric liver transplantation recipients weighing below 15 kg.     

Beyond gastrointestinal graft‐versus‐host disease. A lesson to learn

Gassas A, Zaidman I, Schechter T, Doyle J. Beyond gastrointestinal graft‐versus‐host disease. A lesson to learn.
Pediatr Transplantation 2011: 15: E139–E141.
© 2010 John Wiley & Sons A/S. Abstract: The authors present a child with severe GvHD of GI tract with typical presentation of ileus and abdominal pain. However, the severe GvHD has led to multiple intermittent intussusceptions with resultant ischemic segments of the small bowel leading to sub‐acute mechanical intestinal obstruction. The clinical presentation of the mechanical intestinal obstruction was identical to the preceding ileus GvHD presentation. This has led to continuation of the conservative management with immunosuppressant therapy and delaying further investigation and surgical intervention. Once a barium study demonstrated the severe bowel constriction, laparoscopic surgical resection was necessary with excellent results. The resected small bowel showed multiple segments of ischemic ileitis leading to ulceration and severe stricture. The resection margins showed regenerating mucosa with no ulceration, but with focal evidence of mild GvHD.     

Early wheezing phenotypes and cognitive development of 3‐yr‐olds. Community‐recruited birth cohort study

Jedrychowski W, Perera FP, Jankowski J, Maugeri U, Mrozek‐Budzyn D, Mroz E, Flak E, Skarupa A, Edwards S, Lisowska‐Miszczyk I. Early wheezing phenotypes and cognitive development of 3‐yr‐olds. Community‐recruited birth cohort study.
Pediatr Allergy Immunol 2010: 21: 550–556.
© 2009 John Wiley & Sons A/S The main purpose of the study was to answer the question whether young children without clinical diagnosis of asthma but experiencing early wheezing disorders and therefore being at high risk of developing asthma may have cognitive deficits. In the ongoing birth cohort study wheezing symptoms were recorded postpartum over two first years of age and subsequently cognitive status of children at the age of 3 yr was assessed with the Bayley Mental Development Index (MDI). In the statistical analysis a wide range of modifying and confounding factors (maternal education, gender of children, prenatal exposure to lead and environmental tobacco smoke (ETS) were considered to assess the independent effect of early wheezing phenotypes on cognitive development of children. The MDI score correlated inversely with the number of wheezing days recorded over 24 months (r = ?0.13, p = 0.007), lead cord blood concentration (r = ?0.12, p = ?0.02), number of siblings (r = ?0.17, p = 0.0006) and the number of cigarettes smoked daily by other household members at home over the pregnancy period (r = ?0.18, p = 0.0002). While the children who experienced wheezing over the first year of age showed deficit of 2 MDI scores (beta coeff. = ?2.31, 95%CI: ?4.63 to 0.02), those with persistent wheezing had the score deficit of 4 points (beta coeff. = ?4.41, 95%CI: ?8.27 to ?0.55). To our knowledge, it is the first report in the iterature showing that early wheezing is associated the cognitive deficit in a community‐recruited very young children. Observed cognitive deficit in early wheezers may be caused by RSV infections or can be related to lower lung function attributed to persistent wheezing, which reducing oxygen supply would affect rapidly developing brain.     

Optimal birth weight percentile cut‐offs in defining small‐ or large‐for‐gestational‐age

Aims: It remains questionable what birth weight for gestational age percentile cut‐offs should be used in defining clinically important poor or excessive foetal growth. We aimed to evaluate the optimal birth weight percentile cut‐offs for defining small‐ or large‐for‐gestational‐age (SGA or LGA). Methods: In a birth cohort‐based analysis of 17 979 120 non‐malformation singleton live births, U.S. 1995–2001, we assessed the optimal birth weight percentile cut‐offs for defining SGA and LGA. The 25th–75th percentile group served as the reference. Primary outcomes are the risk ratios (RR) of neonatal death and low 5‐min Apgar score (<4) comparing SGA or LGA versus the reference group. More than 2‐fold risk elevations were considered clinically significant. Results: The 15th birth weight cut‐off already identified SGA infants at more than 2‐fold risk of neonatal death at pre‐term, term or post‐term, except for extremely pre‐term births <28 weeks (continuous risk reductions over increasing birth weight percentiles). LGA was associated with a reduced risk of low 5‐min Apgar score at pre‐term, but an elevated risk at term and post‐term. The 97th cut‐off identified LGA infants at 2‐fold risk of low 5‐min Apgar at term. Conclusion: The commonly used 10th and 90th birth weight percentile cut‐offs for defining SGA and LGA respectively seem largely arbitrary. The 15th and 97th percentiles may be the optimal cut‐offs to define SGA and LGA respectively.     

Acute graft‐versus‐host disease in pediatric allogeneic hematopoietic stem cell transplantation. Single‐center experience during 10 yr

a‐GvHD may complicate allogeneic HSCT. In this retrospective single‐center study, we evaluated incidence and risk factors of a‐GvHD in 197 consecutive allogeneic pediatric HSCTs applying Glucksberg and NIH a‐GvHD classifications. Among 179 eligible transplants, the cumulative incidence of grade 0–I a‐GvHD was 48% and grade II–IV was 52%. None of the considered variables significantly influenced the incidence of grade II–IV a‐GvHD. Malignancy and myeloablation were associated with an increased risk of classic a‐GvHD (p < 0.01). Seventy‐two percentage of children are alive, with a significant difference in OS and TRM between grade 0 and I vs. grade II and IV a‐GvHD; this observation was reproduced in the non‐malignant setting, while only a disparity in TRM was evidenced in children with malignancy. In our experience, the incidence of a‐GvHD was similar, regardless of donor type. Myeloablation and malignant disease represented the only risk factors for classic a‐GvHD. Our results highlight the need for a better prevention of this complication in the non‐malignant setting.     

Effect of PMX‐DHP for sepsis due to ESBL‐producing E. coli in an extremely low‐birthweight infant

We report a case of early onset sepsis caused by (CTX for cefotaximase and M for Munich)‐type extended‐spectrum β ‐lactamase‐producing Escherichia coli (ESBL E. coli) in a preterm infant weighing 601 g. He was given meropenem and treated for endotoxin absorption with polymyxin B‐immobilized fibers with only 8 mL of priming volume. The patient survived without any short‐term neurological or respiratory sequelae. The choice of antibiotics is particularly important in seriously ill neonates with sepsis due to ESBL‐producing organisms. Polymyxin B hemoperfusion might be an innovative therapy for severe neonatal sepsis and could improve outcome even in an extremely low‐birthweight infant.