Journal of Pediatric Surgery Article Review: October 2021

Published: 2021-11-16

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Ellen Cisco — host
Rod Gerardo — host
Brittany Johnson — guest
Paul Tam — guest
Nigel Hall — guest
Richard Wood — guest

Chapters

0:05Child Physical Abuse Follow-up Care Study — Discussion of Texas Children's Hospital study examining longitudinal care needs in children treated for physical abuse, revealing surprisingly high follow-up rates (85%) but identifying opportunities for improvement through medical home models and coordinated multidisciplinary appointments.
4:39Necrotizing Enterocolitis Surgical Timing and Outcomes — Review of UK population-based study on surgical NEC showing that babies who fail medical management have longer time to surgery and worse outcomes compared to those operated for perforation or clinical deterioration, highlighting the need for better objective clinical markers and treatment algorithms.
9:59Bowel Management Program One-Year Outcomes — Analysis of Nationwide Children's Hospital bowel management program for anorectal malformations showing 70% success rate at one year with improved quality of life in continent patients, but identifying a concerning 30% who remain incontinent and require further research and intervention.
13:46Spine Anomalies and Spinal Cord Abnormalities in Anorectal Malformations — Discussion of Italian study demonstrating correlation between vertebral/sacral bone anomalies and spinal cord abnormalities in anorectal malformation patients, emphasizing the need for routine spinal imaging (MRI or ultrasound) and multidisciplinary team management.

Key claims

1:44The study used a trauma database to track non-accidental trauma patients and examined their hospital course, injuries, consults, discharge instructions, and actual follow-up visits over one year — Brittany Johnson
2:19Follow-up rates for child physical abuse victims were actually quite high, representing an opportunity since families are trying to make appointments — Brittany Johnson
3:18Pediatric surgery could adopt the model used for children with complex medical conditions where all appointments are scheduled on one day to decrease burden on families — Brittany Johnson
3:5885% follow-up rate was observed in the child physical abuse cohort — Paul Tam
5:15The UK NEC study was a whole population-based study including all 27 pediatric surgery centers in the UK over one year — Nigel Hall
5:47Primary outcomes measured were death or parental nutrition requirement at 28 days after surgery — Nigel Hall
6:57About 130 babies with NEC were included, with approximately half having bowel perforation — Nigel Hall
7:08Of babies without perforation, one-third were critically ill and proceeded quickly to surgery, while two-thirds eventually had surgery for failed medical treatment — Nigel Hall
7:30Babies in the failed medical treatment group had the longest time from presentation to operation and the worst outcomes — Nigel Hall
8:32There are currently no objective clinical markers or novel biomarkers to help make earlier surgical decisions in NEC — Rod Gerardo
10:37The bowel management program at Nationwide Children's started recording outcomes in a standardized way in 2015 using standardized definitions and patient-reported outcome measures — Richard Wood
11:32One-year measurement was chosen instead of one week because it demonstrates sustained changes within the patient's normal environment — Richard Wood
11:59Children who achieved continence had significantly improved quality of life, while those who remained incontinent showed no quality of life improvement — Richard Wood
12:1230% of patients in the bowel management program still struggled with fecal incontinence after one year — Ellen Cisco
12:5670% of children in bowel management programs do well, requiring focus on the remaining 30% who do not improve — Richard Wood
14:59The Italian anorectal malformation study analyzed 350 patients between 1999 and 2019, representing one of the largest series — Ellen Cisco
15:29The study demonstrated a close relation between spinal cord abnormalities and spinal bone anomalies in anorectal malformation patients — Ellen Cisco
15:44Patients without sacral or vertebral anomalies can still have spinal cord abnormalities, making MRI necessary for complete evaluation — Ellen Cisco
16:34Radiographs are not a good substitute for ultrasound or MRI in detecting spinal cord abnormalities — Paul Tam

Open questions

What specific barriers prevent the 30% of bowel management patients from achieving continence, and what targeted interventions could address them?
Can machine learning algorithms or novel biomarkers identify which NEC patients need early surgery before clinical deterioration?
Is follow-up compliance different between non-accidental trauma patients and accidental trauma patients?
What is the optimal imaging modality (ultrasound vs MRI) for detecting spinal cord abnormalities in anorectal malformation patients across different practice settings?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Longitudinal Care After Child Physical Abuse: What Happens When They Go Home

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Matters

Pediatric surgeons routinely identify and treat injuries from child physical abuse — rib fractures, solid organ injuries, intracranial hemorrhage 1:44. The acute management is protocol-driven and well-documented. What happens after discharge is far less structured 1:44. These children face ongoing medical needs, developmental surveillance, mental health follow-up, and coordination with child protective services, yet no standardized system ensures they receive it 1:44. The question is not whether follow-up is recommended — it always is — but whether it actually occurs, and whether surgical teams bear responsibility for making it happen 1:44.

The Core Problem

A child admitted for non-accidental trauma typically leaves the hospital with a discharge plan listing multiple follow-up appointments: surgery, neurosurgery, ophthalmology, developmental pediatrics, social work, perhaps others 1:44. Each service schedules independently. The family — often in crisis, sometimes under investigation, frequently lacking reliable transportation — must navigate this fragmented system while managing the child's recovery 2:19. The assumption has been that compliance is poor and that these families simply do not follow through 2:19.

A study from Texas Children's Hospital challenged that assumption 1:44. Researchers tracked non-accidental trauma patients for one year, comparing recommended follow-up visits against actual attendance 1:44. The finding was unexpected: 85% follow-up rates 3:58. One of the discussants noted that the rates themselves were actually quite high 2:19, and that families are making efforts to attend these appointments despite the barriers 2:19. The problem is not parental disengagement. The problem is that the system makes follow-up unnecessarily difficult 2:19.

The Medical Home Model

Pediatric subspecialties managing complex chronic conditions — cystic fibrosis, sickle cell disease, spina bifida — have long used coordinated care models in which all appointments occur on a single day 3:18. One clinic visit addresses multiple needs: the pulmonologist, the nutritionist, the social worker, the physical therapist. The family makes one trip. The team communicates in real time.

This model could be adapted for children recovering from physical abuse 3:18. One of the discussants asked, "Why can't we do that in pediatric surgery for these patients? If they need to see multiple services, we can decrease the burden on the families and make sure that all of us are available on one day" [q4]. The infrastructure exists in most pediatric hospitals 3:18. What is missing is the recognition that surgical teams have ongoing responsibility for these children's health and must serve as advocates beyond the acute injury 3:18.

What Follow-Up Should Include

The study documented which services were recommended but did not prescribe a standard panel 1:44. In practice, follow-up needs vary by injury pattern 1:44. A child with healing rib fractures may need only surgical reassessment. A child with traumatic brain injury requires neurosurgery, ophthalmology, and developmental monitoring 1:44. Nearly all benefit from ongoing social work involvement and coordination with child protective services 1:44.

The next research step, the authors suggested, is to examine those who did not follow up and identify specific barriers — transportation, language, mistrust of the medical system, competing demands from other agencies 2:19. Accidental trauma patients could serve as a comparison group to determine whether the barriers are unique to abuse cases or generalizable to all injured children 2:19.

Where Practice Varies

No consensus exists on who owns this coordination 3:18. Some institutions assign a case manager. Others rely on the primary care physician, though many of these children lack an established medical home. Some surgical teams schedule the first follow-up visit before discharge and leave subsequent coordination to the family. The Texas Children's study did not compare models, only outcomes under the existing fragmented approach 1:44.

The medical home concept also raises practical questions 3:18. Should the surgical team convene the multidisciplinary clinic, or should another service — developmental pediatrics, child advocacy — take the lead? Should this be a standing clinic or assembled ad hoc for each case? These are operational details, but they determine whether the model is scalable.

When to Involve Coordinated Care

Any child admitted for suspected or confirmed non-accidental trauma should trigger a discharge planning process that includes follow-up coordination 1:44. The threshold is the injury itself, not its severity 1:44. Even children with isolated fractures benefit from developmental surveillance and social work follow-up, because the risk factors that led to the injury — parental stress, substance use, mental illness, poverty — do not resolve when the fracture heals 1:44.

The 85% follow-up rate suggests that families will engage if the system makes it feasible 3:58. The opportunity is not to improve compliance — compliance is already high — but to reduce the burden of achieving it 2:19. Coordinated multidisciplinary appointments are the mechanism 3:18. The surgical team's role is to ensure they happen 3:18.

Takeaways from this story

85% of child abuse victims attend recommended follow-up, suggesting the barrier is system fragmentation, not family disengagement.
Coordinating all post-discharge appointments on a single day reduces burden and mirrors successful models in other pediatric conditions.
Surgical teams have ongoing responsibility for these children's health beyond treating the acute injury.

Topic overview

Two research residents from Cincinnati Children's Hospital review four articles from the October 2021 Journal of Pediatric Surgery, selected by Dr. Paul Tam. The discussion covers longitudinal care needs in child physical abuse victims, surgical timing and outcomes in necrotizing enterocolitis, one-year outcomes of bowel management programs for anorectal malformations, and the predictive value of spine bone anomalies for spinal cord abnormalities in anorectal malformation patients. A recurring theme across all articles is the critical importance of multidisciplinary care for complex pediatric surgical patients.

Key takeaways

85% follow-up compliance in child abuse victims suggests opportunity for medical home models consolidating appointments on single days (2:19)
NEC patients with failed medical treatment had longest time to surgery and worst outcomes; no objective markers exist for earlier decisions (7:08)
One-year bowel management outcomes show 70% continence success with significant QOL gains; 30% remain incontinent without improvement (11:59)
Anorectal malformation patients without sacral anomalies can still have spinal cord abnormalities; MRI necessary, radiographs inadequate (15:44)

Keywords

child physical abuse non-accidental trauma necrotizing enterocolitis NEC fecal incontinence anorectal malformations tethered cord spinal cord abnormalities bowel perforation bowel management program laparoscopy endoscopy Cincinnati Children's Hospital University of Hong Kong Texas Children's Hospital

Hashtags

#PediatricSurgery #ChildAbuse #NEC #TraumaCare

Transcript

Click "Show Transcript" to view the full text (17744 characters)

Hey, this is Ellen at Cisco, research resident at Cincinnati Children's Hospital. And Rod Gerardo, the other research resident at Cincinnati Children's Hospital. Ellen, what are we doing? We're going back to another installment of our article reviews from the Journal of Pediatric Surgery. So this is the October edition. We talked to a few authors again, and this time, Doctor Paul Tam chose these articles for us to review. I'm Paul Cham, um, chair professor of pediatric Surgery at the University of Hong Kong, also the regional, uh, editor for Journal of Pediatric Surgery. All of the articles that we talk about, we're going to give you a link below. So you can scroll down under the media player, click on the link, you can open up any of these, read along with us while you're listening, whether it's in the Stare pediatric surgery app or Apple Podcasts, Spotify, SoundCloud, Stitcher. OK, so first, we have an article. Out of Texas Children's Hospital. It's called What Happens after the Hospital, an Analysis of Longitudinal care needs in Children treated for Child Physical abuse. So we were lucky enough to sit down with the author. She is a general surgery resident. My name is um Brittany Johnson, and I'm a 4th-year categorical general surgery resident at the University of Mississippi Medical Center. And I did 2 years of dedicated clinical research um at Texas Children's Hospital. And she summarized this very eloquently. There are a lot of studies that talk about, you know, identifying patients in the ER, kind of documenting the injury pattern, but we were really wondering, especially with the children that have more serious injuries, what happens to them when they go home. We have a database within our hospital that tracks all of our trauma patients, so that's what we used and went through and pulled out the non-accidental traumas. Then we kinda looked at each patient, looked at their hospital course, what were their injuries, you know, what consults did they have, and then we looked at their discharge instructions, like what follow-up was recommended. And then came back and followed them for a year to see how many of those visits that were recommended they actually made. There was a pretty surprising finding in the results here. It surprised us and even surprised Brittany when she talked about it. I do think the rates themselves were actually quite high to where the patients aren't following up as recommended, but the rates are not low. Um, so I think my interpretation of it is that that's actually an opportunity that these families are trying to make these appointments. This article, you know, the results really highlighted the need for multidisciplinary care in trauma patients in general and patients coming in with, um, after physical abuse. And the potential need for a medical home, as Brittany pointed out. We might congratulate ourselves for having done a good job in perhaps saving the kid and identifying the problem, but perhaps not aware that we have a responsibility uh for the long-term health and uh we have to be advocates for the children. Something that we can help them with, you know, if there's Developing a medical home. We talked about that in the paper to have all of the visits done at one time. You, you can see a lot of the other systems in pediatrics, they do that. When you think of the, the kids that have complex medical um conditions, they will make all of those appointments on one day. You know, why can't we do that in pediatric surgery for these patients? If they need to see multiple services, we can decrease the burden on the families and make sure that all of us are available on one day. Yeah, I, I, I think that that is it could be with a follow-up article, could be a very, it's a unique idea. I think it could be very helpful. Um, it's hard at a given hospital to, to change the whole infrastructure for that, but I think that we're moving to multidisciplinary care and this is one example of that. And the fact that, you know, we're seeing 85% follow-up is surprising to me and, and Encouraging. So I think the next step would be looking specifically at the patients that did have lower follow-up and talking to those families. Then we can figure out and better understand what their reasons were so that we can attack them. I think the other thing is looking at, um, we mentioned briefly looking at accidental trauma as a comparison to this study so that we can say is the follow-up really any different, you know. Do the non-accidental traumas have a lower rate of follow-up compared to the accidental trauma? You know, is this something that is common to all of our patients, you know, so I think those would be the two next steps. The next one is called Surgical necrotizing enterocolitis Association Between Surgical Indication, Timing, and Outcomes, and this article is out of the UK. Yeah, Southampton. We got to talk to the senior author, Doctor Nigel Hall. Thanks for inviting me to this podcast. Um, my name is Nigel Hall. I'm a pediatric surgeon at Southampton Children's Hospital, which is on the south coast of the United Kingdom. Uh, and I'm associate professor here at the University of Southampton. So he described the general premise of this article. So this was, um, a secondary analysis of a prospectively collected observational study that took place um in all 27 pediatric surgery centers in the UK. So, it's a whole population-based study, which I think is one of its strengths. Um, and it was, uh, through this, uh, organization called BBSC that was led by a collaborator, Professor Marion Knight, who really is the brains behind this organization. And the data set comprised data from a year's worth of babies who had surgery for NEC in the UK. What we wanted to look at as the primary outcomes were death or parental nutrition requirement at 28 days after surgery. What we looked at was the reason why. My surgeon said they had decided to do the operation on these babies, and we also looked at the time period that elapsed between the baby presenting with a diagnosis of NEC and actually having their surgery. And he told us, you know, that he really wasn't surprised by these results and that, you know, finding. That babies with necrotizing enterocolitis who fail medical management and end up going to the operating room, end up doing worse than the patients who went to the operating room sooner because of perforation or suspicion for necrotic bowel. I think what this was, that one of the first opportunities we'd had was to really document what we thought, um, if you like, was our underlying hypothesis, was that there did seem to be, um, a relationship between the indication for surgery, so the reason why babies had surgery, um, and the time it took to get them to have surgery, and also the, um, outcome at the end of the day. So, so overall, there were about 130 babies with NEC in this population. Um, and about half of those, um, had a bowel perforation. And then of the other half of babies, what we found was about 1/3 of them were really, really poorly, and the surgeon decided at the time that they were just really sick, and they proceeded fairly quickly to have an operation as well. Then there was the, the 2/3 of the babies, if you like, who didn't have a perforation. And, and they eventually got an operation. So their indication for surgery was what we called failed medical treatment. And there were two things about that baby, that, that group of babies. One is that they had the longest time from presentation to actually getting their operation. And also, uh, in that group of babies, the outcomes were worst. Now, the next step of these results, I kind of thought, and Todd kind of thought. Could this maybe lead us to some sort of treatment algorithm, some sort of protocol. It's, it's about being able to identify the babies who need surgery early enough, and then also understand how surgeons make decisions about surgery. This article points out the problem of Gestalt and necrotizing enterocolitis. You know, it's really easy when they have free air. When they don't, we're all different and we don't have a defined protocol that's been built yet. And that's kind of what this article is sort of showing is that When you don't have A definitive protocol. Then you're gonna be hedging and hemming and hawing every day about do I go to the operating room. It is obvious that we currently do not have the objective clinical markers, whether they are the uh clinical features or uh novel biomarkers to help us make an earlier decision. To, uh, operate. Hopefully, this, um, has raised this part of the way we treat babies with NEC in, in people's minds as something that we could consider doing something about, but it's certainly going to be, I think, quite a lot of hard work to, to really change practice, but, but something that I really think is, is worth pursuing. I think this is a study to keep poking us in the side to say, let's figure out how to use either a machine learning algorithm or some more. Machine-directed way of analyzing the data where we can see what constellation of data points tells you when the best chance of there being a surgical problem is. And who knows, um, with AI Social media and all this digital knowledge, um, um, I can't help but feel that some of these. Should be introduced into our algorithm in managing patients rather than just the surgeon's um clinical decision. So then, the next one is out of Nationwide Children's Hospital, and it's called One Year Impact of a Bowel Management Program in Treating fecal incontinence in patients with anorectal malformations. And for this one, we talked to the first author, Doctor Wood. Hi, my name is Richard Wood. I'm the chief of Colorectal and pelvic reconstructive Surgery at Nationwide Children's in Columbus. And um it's great to be here. And he shared with us the, the outpatient bowel management program at Nationwide. Yeah, so we started working here in Columbus in 2014 and established a bowel management program. But um, It was really in 2015 that we started recording the outcomes in a standardized way because up until now, there really hasn't been The use of uh standardized definitions and patient reported outcomes and experience measures within this field. And so, we really wanted to do that in order to try and get a better understanding of the patient's experience of bowel management because after all, it's a quality of life, uh, tool. And so, we set up this cohort with um You know, all these standardized things in order to try and get an objective study of this patient population. It was an important paper because prior studies have looked more at short-term outcomes after bowel management programs and they decided to Look at the long-term outcomes and see if the good results are sustainable. We didn't want to measure it at one week because bowel management outcomes at one week really don't mean all that much in that, you know, it's an artificial environment. You've removed people out of the environment. And so we chose to do our measure at one year because we wanted to be able to show that this, the changes. that we had made were sustained and were sustained within their normal environment. But what we were able to show in the study was that if you look at the kids who were clean, their quality of life significantly improved. And if you look at the kids that are not clean, their quality of life did not improve at all. Even after a year, you know, there's still 30% of patients that they, that went through this program that were still struggling with fecal incontinence. And so then, you know, this paper also points to more research as far as addressing that group of patients. It's very sobering to realize that although you throw all these resources at these patients, you have a cohort of 30% that you have not improved their quality of life and that they're still having accidents. And we all know that kids are mean, so kids having accidents at school is a real problem. I think what I wanted to do with the study was lay down a baseline for Where do we go and which of the patients that we now need to drill into further. So now, I kind of know 70% of the kids are gonna do great. And what I really need to do is focus the attention on the other 30%. You know, another thing to point out is that, you know, not everybody that listens to this podcast is gonna have access to A bowel management program, um, and this is kind of what Todd thought about that. Honestly, a lot of people see the value of this, don't have the volume or the resources to build a formal program, and it's very reasonable to send these kids to a new Nearby bowel management program. I think this, this is uh something that is very uh practical and can be used by all surgeons, uh, this sort of message. Good article. A lot of really important people put this together, so it's worth your time to read. Yes, and the last one is also about patients with anorectal malformations. So this one is out of Italy, Rome, Italy. It's called Predictive Value of Spine Bone Anomalies for spinal cord abnormalities in patients with anorectal malformations. And we had the opportunity to talk to one of the neurosurgeons. Uh, hi, I am Giacomo Esposito. I am a neurosurgeon and, uh, um, I work in Bambino Jesus Intern Hospital in Rome. And we also want to very much thank, uh, Bambino Jesu Children's Hospital in Rome, Italy for working with us to coordinate, um, the chance to talk to Doctor Esposito. So, in this study, it was a retrospective review of patients with anor rectal malformations, and they were looking at the patients who, you know, did or did not have spinal cord abnormalities, and they were trying to see how they correlated with imaging findings of sacral or vertebral anomalies. Uh, the, um, the idea of, of, uh, this, uh, this article was born from, um, clinical, uh, practical, uh, um. Observation of this patient. Our, uh, our studies are retrospective study and we analyzed the uh 350 patients in a period between 1999 and 2019. Uh, I think that is, um, is one of the largest uh series. Um, and, you know, they wanted to see how How much they correlated, which they found that they did correlate quite well that patients with a sacral or vertebral anomaly were likely to have a spinal cord abnormality. I think that the, the, the main results of our, uh, uh, our article is uh, uh, to have demonstrate the, uh, the, the close relation between uh uh spinal cord and the spinal bonna. But they found that even though they correlated, there were still plenty of patients who did not have sacral vertebrallos, still had spinal cord abnormalities, and so they feel that MRI is still necessary to search for that spinal cord abnormality. After we, we actually spoke to a couple of pediatric colorectal surgeons that we know and Typically in the practice here or around us is to get an ultrasound um shortly after birth and that typically is sufficient to look for a spinal cord abnormality. And it sounds like in where Doctor Esposito is coming from, they have found MRI to be necessary to really look for those abnormalities. There's variability in the use of ultrasound for figuring out if a patient has a tethered cord. It looks like radiographs are not a good substitute. And so we're still back to ultrasound versus MRI and that still is not the same everywhere. Yeah, yeah, I don't know where in the world you are listening to our podcast, but go ahead and leave a comment below, whether you're in the stay current pediatric surgery app, or Spotify or Apple Podcasts, leave a comment. And let us know what is your practice to find spinal cord abnormalities in these children with interectal malformations. This Centresk review provides us with sufficient um knowledge that to convince anyone who is not doing regular uh or routine assessment of um the spinal cord and, and the spine. Um, and sacrum itself that they should be more serious with imaging. Doctor Esposito also pointed out in his, in our discussion and in the article the need for multidisciplinary care in these patients. Our study is interesting because, uh, um, uh, there, behind there is uh a multidisciplinary team. I Work together, uh, uh, general, uh, uh, surgeon, neonatal surgeon, and the urologist, and uh we create, uh, um, multidisciplinary team, a multidisciplinary workflow to the management of patients with anorectal malformation. And I think that's a theme from all of these articles is how many different Physicians and healthcare providers are involved in the care of these complex patients. Whether it is the pediatric trauma patient who necessitates follow-up or the bowel management patient who needs to see the surgeon, the nurse practitioner, maybe he sees GI, maybe he sees. Someone else, or it's, you know, in the NICU and you have a patient with necrotizing enterocolitis, it really, uh, it takes a village for a lot of these, and it probably should because, you know, I think it, I think it only benefits the patient to bring in other, other minds. So I think that's a good summary. Or summary statement about the multidisciplinary care and all these articles. We, we keep doing more of these, these podcasts. We'll have one coming out from the November issue. Yeah, keep your eyes peeled, ears peeled, or if there's an article that we didn't highlight that you really want us to talk about. Then find us on social media. Uh, subscribe to our YouTube channel. Download the state current pediatric surgery app. It's in the Apple App Store. It's in the Google Play Store. But until then, I'm Rod Gerardo. I'm Ellen and Cisco, and remember, remember, knowledge should be free. There we go.

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