Gastric rupture associated with prolonged crying in a newborn undergoing circumcision

Etiology of neonatal gastric perforation: a review of 20 years' experience

PURPOSE

Gastric perforation (GP) of the newborn is a rare, serious, and life-threatening problem, and its etiology remains unclear. Although historically GP has often been described as "spontaneous'', some cases are non-spontaneous. The aim of the present study was to review cases of GP and to discuss its etiology in a single prefecture in Japan over a period of 20 years.

METHODS

Eleven cases with GP that underwent surgery in 4 institutions in the Chiba Prefecture from 1991 to 2010 were reviewed and divided into 2 groups: the early (1991-2000, n = 7) and late (2001-2010, n = 4) groups.

RESULTS

No factors were observed that could have caused GP other than malformations associated with distal obstruction (3 midgut volvulus, 1 jejunal stenosis, 1 diaphragm eventration). Distal obstruction was present in 1 case in the early group and all 4 cases in the late group (p = 0.015). While the incidence of GP did not change over the 20-year period reviewed, the incidence of GP without distal obstruction significantly decreased in the late group.

CONCLUSION

The proportion of patients with GP and distal obstruction increased and true "spontaneous" cases of GP decreased over time. The possible presence of distal obstruction should be evaluated during surgery for GP.

Gastric rupture with pneumoperitoneum after mouth-to-nose breathing in an infant

BACKGROUND

Gastric rupture with resulting tension pneumoperitoneum occurs rarely in infants. It may be associated with resuscitative efforts.

OBJECTIVES

This report presents a unique case of gastric rupture and illustrates the factors necessary for prompt recognition and treatment.

CASE REPORT

The patient was a 16-week-old infant with nasal congestion whose father had attempted to clear her nose by a mouth-to-mouth-and-nose maneuver. The alert and attentive patient presented to the Emergency Department in respiratory distress, with marked abdominal distention. She was diagnosed with a massive tension pneumoperitoneum, which was decompressed by needle aspiration. A laceration of the lesser curvature of the stomach was repaired at laparotomy; the patient recovered uneventfully.

CONCLUSION

Tension pneumoperitoneum is rarely seen but has key defining elements. A simple procedure is critical to relief of the condition.

Pain relief for neonatal circumcision

BACKGROUND

Circumcision is a painful procedure that many newborn males undergo in the first few days after birth. Interventions are available to reduce pain at circumcision; however, many newborns are circumcised without pain management.

OBJECTIVES

The objective of this review was to assess the effectiveness and safety of interventions for reducing pain at neonatal circumcision.

SEARCH STRATEGY

We searched Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004), MEDLINE (1966 - April 2004), EMBASE (1988 - 2004 week 19), CINAHL (1982 - May week 1 2004), Dissertation Abstracts (1986 - May 2004), Proceedings of the World Congress on Pain (1993 - 1999), and reference lists of articles. Language restrictions were not imposed.

SELECTION CRITERIA

Randomised controlled trials comparing pain interventions with placebo or no treatment or comparing two active pain interventions in male term or preterm infants undergoing circumcision.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed trial quality and extracted data. Ten authors were contacted for additional information. Adverse effects information was obtained from the trial reports. For meta-analysis, data on a continuous scale were reported as weighted mean difference (WMD) or, when the units were not compatible, as standardized mean difference.

MAIN RESULTS

Thirty-five trials involving 1,984 newborns were included. Thirty-three trials enrolled healthy, full term neonates, and two enrolled infants born preterm. Fourteen trials involving 592 newborns compared dorsal penile nerve block (DPNB) with placebo or no treatment. Compared to placebo/no treatment, DPNB demonstrated significantly lower heart rate [WMD -35 bpm, 95% CI -41 to -30], decreased time crying [WMD -54 %, 95% CI -64 to -44], and increased oxygen saturation [WMD 3.2 %, 95% CI 2.7 to 3.7]. Six trials involving 190 newborns compared eutectic mixture of analgesics (EMLA) with placebo. EMLA demonstrated significantly lower facial action scores [WMD -46.5, 95% CI -80.4 to -12.6], decreased time crying [WMD - 15.8 %, 95% CI -20.8 to -6.8] and lower heart rate [WMD -15 bpm, 95% CI -19 to -10]. DPNB, compared with EMLA in four trials involving 164 newborns, demonstrated significantly lower heart rate [WMD -17 bpm, 95% CI -23 to -11] and pain scores. When compared with sucrose in two trials involving 126 newborns, DPNB demonstrated less time crying [MD -166 s, 95% CI -211 to -121], and lower heart rate [WMD -27 bpm, 95% CI -33 to -20]. Results obtained for trials comparing oral sucrose and oral analgesics to placebo, and trials of environmental modification were either inconsistent or were not significantly different. Adverse effects included gagging, choking, and emesis in placebo/untreated groups. Minor bleeding, swelling and hematoma were reported with DPNB. Erythema and mild skin pallor were observed with the use of EMLA. Methaemoglobin levels were evaluated in two trials of EMLA, and results were within normal limits.

REVIEWERS' CONCLUSIONS

DPNB was the most frequently studied intervention and was the most effective for circumcision pain. Compared to placebo, EMLA was also effective, but was not as effective as DPNB. Both interventions appear to be safe for use in newborns. None of the studied interventions completely eliminated the pain response to circumcision.

Infant crying: nature, physiologic consequences, and select interventions

This article describes the nature of infant crying, the physiologic events and changes associated with it, and appropriate nursing interventions for infant crying. A cry is a series of four movements that basically resembles a Valsalva maneuver. Documented immediate and long-term sequelae of crying include increased heart rate and blood pressure, reduced oxygen level, elevated cerebral blood pressure, initiation of the stress response, depleted energy reserves and oxygen, interrupted mother-infant interaction, brain injury, and cardiac dysfunction. Caregivers are encouraged to answer infant cries swiftly, consistently, and comprehensively. Kangaroo care is an efficient method for preventing, minimizing, and halting crying. Other interventions for crying include swaddled holding, a pacifier, sugar water, a sweet-tasting nonsucrose solution, heartbeat sounds, distraction by lullabies or mother's voice, rhythmic movement, and reduction of external stimuli.

Gastric distension, cerebral palsy and unexpected death

Two cases of unexpected death from massive gastric dilatation in individuals with severe spastic quadraparesis aged 14 and 20 years, respectively, are reported. Spontaneous rupture of the stomach occurred in one case. Predisposing factors to gastric dilatation associated with cerebral palsy include autonomic neuropathy, neuromuscular incoordination, air swallowing and malposition of the stomach. Death may be due to compromise of respiratory function caused by lung compression by the dilated stomach, or to peritonitis with sepsis. Acute gastric dilatation, with or without rupture, should be considered a potential cause of unexpected death in individuals with severe mental and physical disabilities.

Stomach rupture associated with physical struggle in a child

A 5-year-old girl with spontaneous rupture of the stomach was treated successfully with excision of the ischemic edges of the perforation with primary repair. In this case, vigorous resistance against medical measurement resulted in rupture of the stomach, which was already distended with a large amount of fluid and air. The child survived following immediate surgical intervention and intensive postoperative care.

Acute obstructive uropathy--a rare complication of circumcision

We report a rare complication of ritual circumcision in an 8-week-old boy. He presented 1 week after the procedure with reduced urine output, a grossly distended bladder and marked bilateral hydroureteronephrosis on ultrasonography. The acute partial urinary obstruction was due to the dressing which was applied after surgical removal of the foreskin and to oedema of the glans. He had abnormal renal function (creatinine 85 mumol/l, urea 8.5 mmol/l) and a hyperkalaemic metabolic acidosis with hyponatraemia (Na 127 mmol/l, K 6.9 mmol/l, HCO3 16 mmol/l), which were attributed to obstructive uropathy. Because of prolonged secondary bladder dysfunction he required urinary catheterisation for 1 week. There was significant post obstructive diuresis and parenteral fluid therapy was given for 7 days. Whilst urinary retention is a well recognized complication of circumcision, this is the first report of significant obstructive uropathy and renal impairment due to surgical excision of the foreskin.