Intussusception in neonates and young infants is rare, with limited data to guide management. This study aims to characterize the presentation, management, and outcomes of intussusception in infants ≤100 days of age. Radiology reports were searched for the keyword “intussusception” in infants ≤100 days over a 24-year period (January 1, 2000-July 31, 2024). Patient charts were reviewed, and cases with negative imaging studies were excluded. Data were analyzed for patient demographics, presenting symptoms, imaging, and management approach, including operative or non-operative interventions. Intussusceptions were classified as small bowel–small bowel (SB/SB), enteric tube–related SB/SB, or ileocolic. Of 301 charts reviewed, 124 neonates and young infants ≤100 days of age met inclusion criteria (median age, 55 days; range, 0–100 days). SB/SB intussusception accounted for 94/124 cases (76

There is a paucity of information in the literature regarding preoperative sonography recognition of a defect in the intestinal wall due to perforation in neonates, infants, and young children. To illustrate a group of neonates, infants, and young children, with a variety of causes of intestinal perforation, in whom the defect in the intestinal wall was correctly recognized preoperatively on sonography. Our aim is to increase the awareness of this imaging finding in this age group. Retrospective analysis of clinical, imaging, surgical, and histologic findings in seven young children with intestinal perforation in whom the defect in the intestinal wall was recognized preoperatively on sonography and confirmed at surgery and histology. The seven patients included five males and two females. Six were premature (22–28 weeks) and one was full term (38 weeks). All seven presented with clinical findings of an acute intestinal episode between 1 day and 15 months of age. Abdominal radiographs showed a distended abdomen with a relative paucity of bowel gas in four, and in the other three, there were multiple loops of dilated gas-filled intestine. Pneumoperitoneum was present in two. Sonography confirmed the presence of a large amount of echogenic ascites in all seven. The intestinal wall appeared variably thickened or thinned, with increased echogenicity in all. The defect of the intestinal wall, due to perforation, was located on sonography in all seven and showed communication between the intestinal intraluminal fluid content and the echogenic ascites in all seven. Tiny echogenic bubbles of gas were noted passing from the intraluminal space into the peritoneal cavity in two. Pneumoperitoneum was also noted on sonography in four. At surgery, the defect in the intestinal wall was located in the small intestine in four and in the large intestine in three. This study illustrates seven young children in whom an intestinal defect, due to perforation, was correctly recognized on sonography preoperatively. Sonography proved more useful than the abdominal radiographs in documenting the presence of perforation. Pediatric radiologists should make the effort to search throughout the entire abdomen and pelvis for the presence of an intestinal wall defect due to perforation on sonography in neonates, infants, and young children with an acute abdominal episode, especially in the absence of pneumoperitoneum on plain radiographs and sonography. Its recognition preoperatively will facilitate a rapid diagnosis and will direct appropriate management.

We present the case of a 9-year-old girl who developed striking bone changes following two years of denosumab therapy for giant cell lesions of the jaw.

Ultrasound is the modality of choice for the diagnosis of hypertrophic pyloric stenosis (HPS). The evolution of high-frequency transducers in ultrasound has led to inconsistent ways of measuring the pylorus. To standardize the measurements and evaluate the appearance of the normal and hypertrophied pylorus with high-frequency transducers. We retrospectively analyzed abdominal ultrasounds of infants with suspected HPS from January 2019-December 2020. We classified the layers of the pylorus while assessing the stratified appearance. Two pediatric radiologists measured the muscle thickness of the pylorus independently by two methods for interrater agreement. Measurement (a) includes the muscularis propria and muscularis mucosa. Measurement (b) includes only the muscularis propria. We also evaluated the echogenicity of the muscularis propria. The interrater agreement, mean, range of the muscle thickness, and the diagnostic accuracy of the two sets of measurements were calculated. We included 300 infants (114 F:186 M), 59 with HPS and 241 normal cases. There was a strong agreement between the readers assessed in the first 100 cases, and ICC was 0.99 (95

We have recently noted some sonographic features in necrotizing enterocolitis that have received little or no attention in the current literature. These include thickening of the mesentery, hyperechogenicity of intraluminal intestinal contents, abnormalities of the abdominal wall, and poor definition of the intestinal wall. It has been our impression that the above four sonographic findings are generally seen in neonates with more severe necrotizing enterocolitis and may be useful in predicting outcome. The aim of this study is, firstly, to review a large series of neonates, known to have clinical NEC, to document how frequently the above four sonographic features occur in neonates with necrotizing enterocolitis and, secondly, to determine whether they are predictive of outcome. We retrospectively analyzed the clinical, radiographic, sonographic, and surgical findings in neonates with necrotizing enterocolitis between 2018 and 2021. The neonates were categorized into two groups based on outcome. Group A included neonates with a favorable outcome defined as successful medical treatment with no surgical intervention. Group B included neonates with an unfavorable outcome defined as failed medical treatment requiring surgery (for acute complications or late strictures) or death because of necrotizing enterocolitis. The sonographic examinations were reviewed with attention to the features of mesenteric thickening, hyperechogenicity of intraluminal intestinal contents, abnormalities of the abdominal wall, and poor definition of the intestinal wall. We then determined the association of these four findings with the two groups. We included 102 neonates with clinical necrotizing enterocolitis: 45 in group A and 57 in group B. Neonates in group B were born at a significantly earlier gestational age (median 25 weeks, range 22–38 weeks) and had a significantly lower birth weight (median 715.5 g, range 404–3120 g) than those in group A (median age 32 weeks, range 22–39 weeks, p = 0.003; median weight 1190 g, range 480–4500 g, p = 0.002). The four sonographic features were present in both study groups but with different frequency. More importantly, all four were statistically significantly more frequently present in neonates in group B compared to group A: (i) mesenteric thickening, A = 31 (69

ThyroidVol. 33, No. 5 Research LettersDoes Ultrasound Really Contribute to Detection of Residual/Recurrent Disease After Pediatric Thyroidectomy? Preliminary Data Supporting a “Thyroglobulin-First” ApproachChantal Anne Lebbink, Hanneke Margo van Santen, Alan Daneman, and Jonathan Daniel WassermanChantal Anne Lebbinkhttps://orcid.org/0000-0002-9897-334XDepartment of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, The Netherlands.Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.Search for more papers by this author, Hanneke Margo van Santenhttps://orcid.org/0000-0002-6773-6931Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, The Netherlands.Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.Search for more papers by this author, Alan DanemanDepartment of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.Search for more papers by this author, and Jonathan Daniel WassermanAddress correspondence to: Jonathan D. Wasserman, MD, PhD, Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, M5G 1X8 Toronto, Canada E-mail Address: [email protected]https://orcid.org/0000-0001-7088-8146Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.Search for more papers by this authorPublished Online:4 May 2023https://doi.org/10.1089/thy.2022.0576AboutSectionsView articleView Full TextSupplemental MaterialPDF/EPUBView Supplemental Data Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 33Issue 5May 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Chantal Anne Lebbink, Hanneke Margo van Santen, Alan Daneman, and Jonathan Daniel Wasserman.Does Ultrasound Really Contribute to Detection of Residual/Recurrent Disease After Pediatric Thyroidectomy? Preliminary Data Supporting a “Thyroglobulin-First” Approach.Thyroid®.May 2023.645-649.http://doi.org/10.1089/thy.2022.0576Published in Volume: 33 Issue 5: May 4, 2023Online Ahead of Editing: April 4, 2023PDF download

Necrotizing enterocolitis (NEC) is a common condition in the neonatal intensive care unit that continues to present challenges in terms of diagnosis and management. Traditionally NEC has been diagnosed and managed by clinical and radiographic findings, but US has shown promise in characterizing and prognosticating NEC. In this manuscript we review the abdominal US technique for NEC, the clinical significance of individual sonographic findings of NEC, and how US can be integrated in the clinical decision process for diagnosing and managing NEC. We also discuss the potential value-added role of a limited abdominal US protocol that focuses on the sonographic findings most indicative of a poor prognosis to include pneumoperitoneum, complex free fluid and focal fluid collections.

Remote ischemic conditioning (RIC) is a maneuver involving brief cycles of ischemia reperfusion in an individual’s limb. In the early stage of experimental NEC, RIC decreased intestinal injury and prolonged survival by counteracting the derangements in intestinal microcirculation. A single-center phase I study demonstrated that the performance of RIC was safe in neonates with NEC. The aim of this phase II RCT was to evaluate the safety and feasibility of RIC, to identify challenges in recruitment, retainment, and to inform a phase III RCT to evaluate efficacy. RIC will be performed by trained research personnel and will consist of four cycles of limb ischemia (4-min via cuff inflation) followed by reperfusion (4-min via cuff deflation), repeated on two consecutive days post randomization. The primary endpoint of this RCT is feasibility and acceptability of recruiting and randomizing neonates within 24 h from NEC diagnosis as well as masking and completing the RIC intervention. We created a novel international consortium for this trial and created a consensus on the diagnostic criteria for NEC and protocol for the trial. The phase II multicenter-masked feasibility RCT will be conducted at 12 centers in Canada, USA, Sweden, The Netherlands, UK, and Spain. The inclusion criteria are: gestational age < 33 weeks, weight ≥ 750 g, NEC receiving medical treatment, and diagnosis established within previous 24 h. Neonates will be randomized to RIC (intervention) or no-RIC (control) and will continue to receive standard management of NEC. We expect to recruit and randomize 40% of eligible patients in the collaborating centers (78 patients; 39/arm) in 30 months. Bayesian methods will be used to combine uninformative prior distributions with the corresponding observed proportions from this trial to determine posterior distributions for parameters of feasibility. The newly established NEC consortium has generated novel data on NEC diagnosis and defined the feasibility parameters for the introduction of a novel treatment in NEC. This phase II RCT will inform a future phase III RCT to evaluate the efficacy and safety of RIC in early-stage NEC.

CONTEXT:Idiopathic infantile hypercalcemia (IIH), an uncommon disorder characterized by elevated serum concentrations of 1,25 dihydroxyvitamin D (1,25(OH)2D) and low parathyroid hormone (PTH) levels, may present with mild to severe hypercalcemia during the first months of life. Biallelic variants in the CYP24A1 or SLC34A1 genes are associated with severe IIH. Little is known about milder forms.OBJECTIVE:This work aims to characterize the genetic associations and biochemical profile of mild IIH.METHODS:This is a cross-sectional study including children between age 6 months and 17 years with IIH who were followed in the Calcium Clinic at the Hospital for Sick Children (SickKids), Toronto, Canada. Twenty children with mild IIH on calcium-restricted diets were evaluated. We performed a dietary assessment and analyzed biochemical measures including vitamin D metabolites and performed a stepwise molecular genetic analysis. Complementary biochemical assessments and renal ultrasounds were offered to first-degree family members of positive probands.RESULTS:The median age was 16 months. Median serum levels of calcium (2.69 mmol/L), urinary calcium:creatinine ratio (0.72 mmol/mmol), and 1,25(OH)2D (209 pmol/L) were elevated, whereas intact PTH was low normal (22.5 ng/L). Mean 1,25(OH)2D/PTH and 1,25(OH)2D/25(OH)D ratios were increased by comparison to healthy controls. Eleven individuals (55%) had renal calcification. Genetic variants were common (65%), with the majority being heterozygous variants in SLC34A1 and SLC34A3, while a minority showed variants of CYP24A1 and other genes related to hypercalciuria.CONCLUSION:The milder form of IIH has a distinctive vitamin D metabolite profile and is primarily associated with heterozygous SLC34A1 and SLC34A3 variants.

The clinical and plain radiographic differentiation of congenital intrinsic duodenal anomalies (atresia, web, stenosis) from intestinal malrotation is not always clear. Although sonography has been documented as an important diagnostic tool in the differentiation of these two entities, its role is still not widely appreciated and it is still not universally utilized in this clinical setting. To assess the usefulness of sonographic features of the duodenal and gastric wall in the differentiation of congenital intrinsic duodenal anomalies from midgut malrotation in a large series of neonates and to compare them with other features on abdominal radiographs, ultrasound and upper gastrointestinal series. Using the surgical database at our tertiary pediatric hospital, we identified neonates who had surgically proven congenital intrinsic duodenal anomalies or malrotation over a period of 15 years (2000–2015). We reviewed imaging findings in both groups of neonates (blinded to the final diagnosis) with attention to the echogenicity and thickness of the wall of the duodenum and stomach, the relationship between the superior mesenteric artery and vein, the position of the third portion of the duodenum and the presence of the whirlpool sign. Findings were compared between the groups using the unpaired t-test and Fisher exact test. We included 107 neonates in the study, 40 with a congenital intrinsic duodenal anomaly, 49 with malrotation (36 with volvulus) and 18 with a combination of both. Duodenal and gastric wall thickening and hyperechogenicity were significantly more common in the group with a congenital intrinsic duodenal anomaly compared to those with malrotation (P<0.0001). Conversely, an abnormal relationship between the superior mesenteric artery and vein, abnormal position of the third part of the duodenum, and the whirlpool sign were significantly more common in neonates with malrotation than in those with congenital intrinsic duodenal anomalies (P<0.0001). Duodenal or gastric wall thickening, and increased wall echogenicity are helpful sonographic features in the differentiation of congenital intrinsic duodenal anomalies from malrotation. Evaluation of the duodenal and gastric wall should thus be added to the features routinely assessed on ultrasound examinations in the clinical setting of suspected duodenal obstruction in the neonate.

Necrotizing enterocolitis (NEC) is a devastating disease of premature infants with high mortality rate, indicating the need for precision treatment. NEC is characterized by intestinal inflammation and ischemia, as well derangements in intestinal microcirculation. Remote ischemic conditioning (RIC) has emerged as a promising tool in protecting distant organs against ischemia-induced damage. However, the effectiveness of RIC against NEC is unknown. To address this gap, we aimed to determine the efficacy and mechanism of action of RIC in experimental NEC. NEC was induced in mouse pups between postnatal day (P) 5 and 9. RIC was applied through intermittent occlusion of hind limb blood flow. RIC, when administered in the early stages of disease progression, decreases intestinal injury and prolongs survival. The mechanism of action of RIC involves increasing intestinal perfusion through vasodilation mediated by nitric oxide and hydrogen sulfide. RIC is a viable and non-invasive treatment strategy for NEC.

Purpose To describe the postnatal outcome of fetal meconium peritonitis and identify prenatal predictors of neonatal surgery. Methods We retrospectively reviewed all fetuses with ultrasound findings suspicious for meconium peritonitis at a single center over a 10-year period. A systematic review and meta-analysis were then performed pooling our results with previous studies assessing prenatally diagnosed meconium peritonitis and postnatal outcome. Prenatal sonographic findings were analyzed to identify predictors for postnatal surgery. Results 34 cases suggestive of meconium peritonitis were diagnosed at our center. These were pooled with cases from 14 other studies yielding a total of 244 cases. Postnatal abdominal surgery was required in two thirds of case (66.5 %). The strongest predictor of neonatal surgery was meconium pseudocyst (OR [95 % CI] 6.75 [2.53-18.01]), followed by bowel dilation (OR [95 % CI] 4.17 [1.93-9.05]) and ascites (OR [95 % CI] 2.57 [1.07-5.24]). The most common cause of intestinal perforation and meconium peritonitis, found in 52.2 % of the cases, was small bowel atresia. Cystic fibrosis was diagnosed in 9.8 % of cases. Short-term neonatal outcomes were favorable, with a post-operative mortality rate of 8.1 % and a survival rate of 100 % in neonates not requiring surgery. Conclusion Meconium pseudocysts, bowel dilation, and ascites are prenatal predictors of neonatal surgery in cases of meconium peritonitis. Fetuses with these findings should be delivered in centers with pediatric surgery services. Though the prognosis is favorable, cystic fibrosis complicates postnatal outcomes.

Meconium peritonitis (MP) can be suspected prenatally, warranting investigation of cystic fibrosis (CF) and anticipating a possible need for neonatal surgery. The aims of this study were to describe the prenatal sonographic findings associated with a need for surgery and quantify the incidence of CF in neonates with a prenatal diagnosis of MP. A retrospective study of all fetuses with suspected MP, diagnosed at a single tertiary center between between 1/1/2009 and 1/7/2019. For neonates requiring surgery, surgical reports were obtained and reviewed. A comprehensive meta-analysis was performed by searching Medline, EMBASE, Cochrane, PubMed, Web of Science and CINAHL from 1995 to July 2019, with no language or regional restrictions, for studies assessing the incidence of CF and/or neonatal outcomes of prenatally suspected MP. The results of our cohort were pooled together with previous literature to identify the incidence of CF as well as prenatal sonographic findings associated with a need for neonatal surgery. During the 10-year study period 34 cases of suspected MP were followed in our center. CF was diagnosed in six (17.6%) cases. Eleven (32.3%) neonates required surgery, six of whom were diagnosed with small bowel atresia. Of the 665 citations identified in the literature, 18 studies were eligible for analysis (for a total of 264 fetuses, including our cohort). The pooled incidence of CF among fetuses with MP was 9.4% (12 cases of 128 tested). One hundred and sixty-five neonates (63%) required surgery. The prenatal sonographic finding most predictive of neonatal surgery was meconium pseudocyst (pooled OR=5.9, 95% CI 2.1-16.5), followed by bowel dilatation (pooled OR=4.0, 95% CI 1.6-9.8) and ascites (pooled OR=2.4, 95% CI 1.0-5.6). The majority of neonates with prenatally suspected MP will undergo neonatal surgery, particularly when they present with MPC, dilated bowel and ascites. Testing for CF is recommended in all such cases, as the diagnostic yield is high.

The sonographic whirlpool sign of volvulus due to midgut malrotation is well recognized. However, variations of the whirlpool sign may be seen in other conditions, but this observation has received little attention in the literature. This study presents a series of neonates with a variety of causes of congenital intestinal obstruction, all associated with a whirlpool sign (unrelated to midgut volvulus), which was correctly recognized preoperatively on sonography. We also emphasize the pivotal role of sonography in managing congenital obstruction of the intestinal tract in neonates. This is a retrospective analysis of clinical, imaging and surgical findings in 11 neonates with congenital intestinal obstruction associated with a whirlpool sign (unrelated to midgut volvulus) that was recognized preoperatively on sonography and in whom the cause for the whirlpool was documented at surgery. Eleven neonates (eight male, three female) had clinical and radiographic evidence of intestinal obstruction in whom sonography depicted a whirlpool sign, which was recognized on the initial sonogram in nine and on a repeat sonogram in two. The whirlpool was located in the upper abdomen in only two, mid-abdomen in five and right lower quadrant in four. The whirlpool was only 1–2 cm in diameter. An upper gastrointestinal series in three neonates failed to depict the cause of obstruction. Contrast enema in three cases had findings suggesting the site of obstruction was in the ileum but none depicted the exact cause of the obstruction. At surgery, the whirlpool sign correlated with a segmental volvulus of the small intestine in eight neonates and with the coiled distal small intestine associated with apple-peel atresia in the other three. This study illustrates neonates in whom a whirlpool sign (unrelated to midgut volvulus) was correctly recognized on sonography before surgery. Sonography proved more useful than an upper gastrointestinal series or contrast enema in depicting the exact cause of the obstruction. Pediatric radiologists must make the effort to search throughout the entire abdomen and pelvis for a small whirlpool sign on sonography, even in the absence of midgut malrotation, in neonates with congenital intestinal obstruction. Its recognition preoperatively will facilitate a rapid diagnosis and will obviate the necessity for contrast examinations of the gastrointestinal tract, which require ionizing radiation.

Background:Human milk-based fortifiers (HMBFs) are being adopted in neonatal care to enrich the nutrients in human milk for very low birth weight (VLBW) infants despite being costly and there being limited efficacy data. No randomized clinical trial has evaluated the use of HMBF compared with bovine milk-based fortifiers (BMBFs) in the absence of formula feeding. Objective:To determine if HMBF compared with BMBF for routine nutrient enrichment of human milk improves feeding tolerance, reduces morbidity, reduces fecal calprotectin (a measure of gut inflammation), and supports the growth of infants <1250 g. Design:In this blinded randomized clinical trial, infants born weighing <1250 g were recruited from neonatal units in Ontario, Canada between August 2014 and November 2015. The infants were fed mother's milk and donor milk as required. Fortification commenced at 100 mL/kg per day of HMBF (0.81 kcal/mL) or BMBF (0.72 kcal/mL) and advanced at 140 mL/kg per day to 0.88 and 0.78 kcal/mL, respectively. The primary outcome was percentage of infants with a feeding interruption for ≥12 h or a >50% reduction in feeding volume. Secondary outcomes included a dichotomous mortality and morbidity index (i.e., affirmative for any one of death, late-onset sepsis, necrotizing enterocolitis, chronic lung disease, or severe retinopathy of prematurity), fecal calprotectin, and growth. Results:Of 232 eligible infants, 127 (54.7%) were randomized (n = 64 HMBF, n = 63 BMBF). Mean ± SD birth weight and gestational age of infants were 888 ± 201 g and 27.7 ± 2.5 wk, respectively. No statistically significant differences were identified in feeding interruptions [17/64 HMBF, 20/61 BMBF; unadjusted risk difference: -6.2% (95% CI: -22.2%, 9.8%)]. There was no statistically significant difference in the mortality and morbidity index (48.4% HMBF, 49.2% BMBF, adjusted P = 0.76), changes in fecal calprotectin, or growth z scores. Conclusions:Among infants born weighing <1250 g and exclusively fed human milk, the use of HMBF did not improve feeding tolerance or reduce mortality and morbidity compared with BMBF. This trial was registered at clinicaltrials.gov as NCT02137473.