Akron Children Research Articles

The Hidden Value of Variation in Practice.

* Abbreviations: CF — : cystic fibrosis CFF — : Cystic Fibrosis Foundation Although new disease modifying therapies offer promise, current management of cystic fibrosis (CF) lung disease is largely based on 2 strategies: first, decreasing the day-to-day burden of inflammation and mucus in the airways and, second, managing pulmonary exacerbations: acute episodes of increased symptoms thought to reflect periods of inflammation associated with bacterial infection. A mainstay of treating CF exacerbations has been using ≥1 intravenous antibiotics in the hospital accompanied by supportive measures, including intensified airway clearance. Investigators using the Epidemiologic Study of Cystic Fibrosis1 and the Cystic Fibrosis Foundation (CFF) Patient Registry2 have previously pointed out variation in CF care practices, particularly in therapies used for outpatient care. In this issue of Pediatrics , Cogen et al3 (“Characterization of Inpatient Cystic Fibrosis Pulmonary Exacerbations Using the Pediatric Health Information System Database”) use a novel data source from children’s hospitals to document surprising variation in many aspects of the inpatient management of CF exacerbations among 38 children’s hospitals participating in the CFF Care Center Network. Why is … Address correspondence to John T. McBride, MD, Department of Pediatrics, Akron Children’s Hospital, 2 Perkins Sq, Akron, Ohio 44308. E-mail: jtmcbride{at}gmail.com

Hydroxyurea to Treat Pediatric Sickle Cell Disease in Haiti - a Preliminary Report

Introduction. Haiti is the poorest nation in the Western Hemisphere, and the prevalence of sickle cell disease (SCD) in thatnation is twice that among African-Americans in the United States. Patients with SCD in Haiti have limited access to preventative care and disease management measures due to scarce healthcare resources. Hydroxyurea (HU) is a compelling option for the amelioration of complications of SCD in Haiti due to its relatively low cost, proven safety, and well-documented efficacy. Hydroxyurea programs have been implemented in India and in several African settings, however little data existto demonstrate the acceptability or feasibility of such an effort in Haiti.Study Design/Objectives. This is an open label, single arm pilot study with the primary objective of examining the acceptability and feasibility of the use of HU to treat children with SCD in an existing pediatric SCD program in Port-au-Prince, Haiti. Acceptability was defined as enrollment of a minimum of two-thirds of patients who are offered participation in the study. Feasibility was defined as two thirds of the enrolled patients being compliant with a defined minimum number of mandated study visits, lab draws, and HU doses. Secondary objectives include documenting the effect of HU on renal, hepatic, and bone marrow function as well as describing the incidence of clinical events in Haitian sickle cell patients taking HU.Methods. Patients with HbSS disease, age 2-15 years, who met minimum hematologic, renal, and hepatic parameters, were eligible for the study. Patients were approached for inclusion into the study consecutively during three separate enrollment periods from November 2015 through June 2016. The starting dose of Hydroxyurea (capsule and suspension form were available) was 20mg/kg which was increased to a maximum dose of 25mg/kg. Study visits occurred every 4 to 8 weeks at which point laboratory and clinical efficacy parameters, as well as potential adverse effects history were collected and dose modifications occurred. The study period for each patient will last 1 year. Akron Children's Hospital (ACH) IRB and the Haitian National Ethics Board approved the study. Funding for this project is provided through grants from the American Academy of Pediatrics and the ACH Foundation.Results. The study is ongoing with the enrollment period being closed as of June 2016. Forty-three patients have been enrolled, with a mean length of participation of 17.6 weeks (range 0-32 weeks).Forty-seven patients were offered participation in the study and 45 signed consent and underwent the screening process, generating an acceptability measure of 95.7%. Two out of the 45 screened patients were excluded based on results from screening labs (1 non-HbSS on confirmatory electrophoresis, 1 severe anemia) resulting in the final enrollment of 43 patients (23M:20F, mean age 9 years). Feasibility is being actively assessed.There have been no serious adverse events and no deaths. Three out of 43 enrolled patients were lost to follow-up and removed from the study due to missing 3 consecutive study visits (see figure 1). Compliance with mandated study visits was high among the enrolled patients with an attendance of 92.9% of the visits. Percent attainment of mandated laboratory tests is shown in table 1. No patients have had HU dose interruptions based on abnormal lab tests. Sixteen study patients have 6 month hematologic laboratory data available at this time: mean Hemoglobin and MCV have increased from 7.1 to 7.9g/dL and 90.6 to 107.1fL, respectively, and mean WBC and platelet count have decreased from 18.0 to 12.4(10^9/mL) and 557 to 413(10^9/mL), respectively.Conclusion. Results suggest that HU isan acceptable option for treating children with sickle cell disease in Haiti. Our preliminary data show that HU is feasible, safe, and effective in this setting. Challenges exist in ensuring reliable laboratory follow-up and will likely have to be addressed on an individual clinic and laboratory basis. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

25th Anniversary State-of-the-Art Expert Discussion With Todd A. Ponsky, MD, FACS, on the Advances of Surgical Practice in Pediatric Hernia Repair.

Dr. Todd A. Ponsky is currently Associate Professor of Surgery and Pediatrics at Northeast Ohio Medical University and a Pediatric Surgeon at Akron Children's Hospital. He attended medical school at Case Western Reserve University in Cleveland, OH, from 1995 to 1999, Residency in General Surgery at The George Washington University in Washington, DC, from 1999 to 2005, Pediatric Surgery Fellowship at Children's National Medical Center in Washington, DC, from 2005 to 2007, and an Advanced Minimally Invasive Pediatric Surgery Fellowship at The Rocky Mountain Hospital for Children in Denver, CO, from 2007 to 2008. Dr. Ponsky has a particular interest in minimally invasive pediatric surgery. He has trained over 200 surgeons in single-port and needlescopic surgery. He has written over 60 manuscripts and almost 20 book chapters. He has a strong focus on surgical education and virtual education and has directed over 20 national/international courses. He has won numerous teaching awards, including “The Faculty Teaching Award” at Case Western Reserve University's Department of Surgery in his first year as a faculty member. He is a reviewer for over 15 medical journals and is on four editorial boards. He is on the leadership of four national societies and has been Program Chair and is currently serving as Secretary on the Executive Committee of The International Pediatric Endosurgery Group (IPEG). He is involved in both outcomes and animal research with a focus on inguinal hernia physiology, foregut motility, and gastric stimulation, as well as endoscopic repair techniques for pure esophageal atresia. He has a wife, Diana, and three daughters, Sasha, Josie, and Ella.

Discordant circulating fetal DNA and subsequent cytogenetics reveal false negative, placental mosaic, and fetal mosaic cfDNA genotypes.

BackgroundThe American College of Obstetrics and Gynecology (ACOG) and Maternal Fetal Medicine (MFM) Societies recommended that abnormal cfDNA fetal results should be confirmed by amniocentesis and karyotyping. Our results demonstrate that normal cfDNA results inconsistent with high-resolution abnormal ultrasounds should be confirmed by karyotyping following a substantial frequency of incorrect cfDNA results.MethodsHistorical review of our ~4,000 signed prenatal karyotypes found ~24% of reported abnormalities would not have been detected by cfDNA. Akron Children’s Hospital Cytogenetics Laboratory has completed 28 abnormal cfDNA cases among the 112 amniocenteses karyotyped.ResultsFollowing abnormal cfDNA results our karyotypes confirmed only 60% of the cfDNA results were consistent. Our cases found a normal cfDNA test result followed by a 20 weeks anatomical ultrasound detected a false negative trisomy 18 cfDNA result. One cfDNA result that reported trisomy 21 in the fetus was confirmed by karyotyping which also added an originally undetected balanced reciprocal translocation. Another reported karyotyped case followed by a repeated microarray of pure fetal DNA, together revealed one phenotypically normal newborn with a complex mosaic karyotype substantially decreasing the newborn’s eventual reproductive fitness. This second case establishes the importance of karyotyping the placenta and cord or peripheral blood when inconsistent or mosaic results are identified following an abnormal cfDNA result with a normal newborn phenotype without a prenatal karyotype.ConclusionsThese Maternal Fetal Medicine referrals demonstrate that positive NIPT results identify an increased abnormal karyotypic frequency as well as a substantial proportion of discordant fetal results. Our results found: (1) a normal NIPT test result followed by a 20 week anatomical ultrasound detected a false negative trisomy 18 NIPT result, (2) a substantial proportion of abnormal NIPT tests identify chromosomal mosaicism that may or may not be confined to the placenta, (3) follow up karyotyping should be completed on the newborn placenta and peripheral blood when the amniocyte karyotype does not confirm the NIPT reported abnormality in order to identify ongoing risk of developing mosaic symptoms, and (4) karyotyping all high risk fetuses tested by amniocentesis defines the 24% of chromosome abnormalities not currently screened by NIPT.Electronic supplementary materialThe online version of this article (doi:10.1186/s12967-015-0569-y) contains supplementary material, which is available to authorized users.

Assessment of adherence to guidelines for using progesterone to prevent recurrent preterm birth

Objective: To assess if women with recurrent preterm birth had been offered, received, and adhered to progesterone supplementation guidelines and to ascertain reasons for failure to follow guidelines.Methods: Charts of infants who were products of recurrent spontaneous preterm birth were reviewed at four neonatal intensive care units of Akron Children’s Hospital. Mothers of identified infants were interviewed and charts abstracted to determine: if progesterone was offered; acceptance of progesterone; compliance with progesterone; and reasons why progesterone was declined.Results: One hundred twenty-eight mothers with a recurrent spontaneous preterm birth were identified and 98 consented to participate. 62.2% (61/98) of the interviewed mothers reported that they were offered progesterone. Of the women offered progesterone, 82% (50/61) accepted treatment and 18.0% (11/61) declined. One woman who accepted progesterone did not receive it. Of the women who received progesterone, 18.4% (9/49) reported compliance failure. Of the women who did not receive progesterone, 75.5% (37/49) reported that they were not offered progesterone and 89.2% (33/37) of the women not offered progesterone reported that their care providers were aware of their prior preterm delivery.Conclusions: Only 50% (49/98) of women who were candidates for progesterone received treatment. The main reason for women not receiving treatment was not being offered progesterone by their caregiver.

An Initial, Prospective Exploration of Specific Stressors for Parents of Children Admitted to an Inpatient Psychiatric Unit

Increased parental stress has a negative effect on a child’s symptoms, which worsens pathology. No studies have been conducted looking at parental stress for children admitted to an inpatient psychiatric unit, and an examination of these stressors may lead to interventions which could benefit the recovery of children with mental illness. Methods: 66 caregivers of children admitted to the psychiatric unit at Akron Children’s Hospital took a 10-question survey designed by investigators. Demographic information and chart review was conducted, and an additional standardized instrument evaluating parental stress was given to parents with children under age 12. Results: The average T-score on the Parental Stress Index Short Form for these parents is 59.5, which is in the 80th percentile for parent-child dysfunctional relationship, which indicates high stress. Parents are stressed most about the child’s future, safety of the child and family, balancing the needs of other family members in addition to the child’s need for treatment, confusion about the diagnosis, financial aspects, personal emotional health, and stigma. Conclusions: This pilot study has a sample size of 66 parents and caregivers, which exceeds previous studies. Our results parallel findings of other studies looking at stress in parents of children admitted to medical units as well as children in outpatient mental health treatment. Parents felt significant distress and lack of confidence, and parental education level did not affect concern about stigma or confusion related to their child’s diagnosis. These results support an intervention for greater parent psycho-education and peer support prior to their child’s discharge.

Primary pediatric palliative care: psychological and social support for children and families.

1. Cassandra D. Hirsh, DO* 2. Sarah Friebert, MD* 1. *Haslinger Family Pediatric Palliative Care Center, Akron Children’s Hospital, Akron, OH Families of children with complex, chronic, and/or life-limiting conditions experience unmet psychological, emotional, practical, and spiritual needs. Primary care pediatricians may lack sufficient knowledge, training, and/or resources to address these needs; pediatric palliative care teams can offer additional support services to families. After completing this article, readers should be able to: 1. Recognize when a pediatric palliative care consultation would be appropriate to help the patient and family deal with psychosocial stressors related to diagnosis or illness. 2. Describe the roles of the various members of the palliative care interdisciplinary team in providing psychosocial and social support to a patient or family with a child who has a complex, chronic, or potentially life-limiting condition. 3. Understand the role overlap among various clinicians on a palliative care interdisciplinary team. Imagine 2 parents, Amy and Todd, sitting in a room in the pediatric intensive care unit. Their formerly healthy 2-month-old son, Jack, was recently diagnosed as having spinal muscular atrophy (SMA) type 1 during an admission for respiratory failure secondary to respiratory syncytial virus. He is now extubated and pain free, and his parents have met with the intensivist, neurologist, and pulmonologist regarding what SMA is and how Jack’s life will be affected. For the parents, many questions remain: How will we cope with the changes that are happening in our life? How will we afford the specialized care Jack will require? How will we be able to juggle work and other responsibilities to go to multiple medical appointments? Will this affect our marriage? Will this exacerbate our own medical conditions? How will we obtain the supplies we need to care for all of Jack’s …

Intravitreal bevacizumab for retinopathy of prematurity (ROP): the Akron Children's Hospital (ACH) experience

Intravitreal bevacizumab for retinopathy of prematurity (ROP): the Akron Children's Hospital (ACH) experience

Emergency mitigation and preparedness in healthcare facilities

The city of Akron, Ohio, has four major healthcare facilities: Akron General Medical Center, Summa Akron City Hospital, Summa St. Thomas, and Akron Children's Hospital. These institutions have implemented the preparedness and mitigative strategies to prepare for hazards affecting the community. Because of the wide population these facilities serve, it is crucial that an effective emergency management (EM) system be in place at each hospital. Archival research and interviews with the emergency managers of each hospital examine the preparedness of these establishments for disasters. Strengths and weaknesses of the EM systems are also discussed and include recommendations on ways to improve shortcomings. This research demonstrates how EM is evolving and improving in one of the most important critical infrastructure of a community.

Dedicated Pediatric Behavioral Health Unit

Pediatric mental health emergencies are an increasing part of emergency medical practice because emergency departments have become the safety net for a fragmented mental health infrastructure that is experiencing critical shortages in services in all sectors. The emergency services for behavioral health unit at Akron Children's Hospital is an innovative model for delivering care to pediatric patients with mental health emergencies. A multidisciplinary team using the expertise of emergency services, psychiatry, social work, parent advisory counsel, security services, and engineering/architecture developed the emergency services for behavioral health unit blueprint, process, and staffing model.

Pediatric Palliative Care Curriculum: Impact of "Pain Cards" on Pediatric Resident Education

sustain long-lasting hospice and palliative care programs. 2. Describe effective strategies to cultivate, engage, and sustain relationships with philanthropic individuals and organizations. 3. Outline a successful approach to enact immediately upon return from the conference to engage local funders, foundation, or development partners. Palliative care and hospice programs face increasingly stiff competition in the fundraising landscape, together with an ever-increasing dependence on outside funding to sustain growth of special programs such as pediatric services and fellowship training. Most hospice and palliative care professionals lack specific training in fundraising or philanthropic cultivation; in fact, we are usually trained that this is not our job or, more often, that we are crossing ethical boundaries if we are involved in fundraising. Yet our patients and families want to give to the people who have cared for them, and our programs will continue to depend on sources other than clinical revenue. This interactive session will explore myths and realities about funding through the lens of two programs that have successfully garnered large amounts of philanthropic support: San Diego Hospice, which receives $7.5 million annually in philanthropic support, including a $1.5 million endowment to support a fellow; and Akron Children’s Hospital, which has secured two endowments, one for the program and one to support the field’s first endowed chair in pediatric palliative care. Attendees will be exposed to role-plays demonstrating specific skills in solicitation of funds as well as specific ideas to raise money for program operations and for fellowship positions. Participants will also leave the session with a concrete plan to pursue and secure funding upon their return from the conference.

A Whirlwind Tour for Pediatric Programs Seeking the Joint Commission's Advanced Certification in Palliative Care (SA514)

A Whirlwind Tour for Pediatric Programs Seeking the Joint Commission’s Advanced Certification in Palliative Care (SA514) Tammy Kang, MD, The Children’s Hospital of Philadelphia, Philadelphia, PA. Sarah Friebert, MD, Akron Children’s Hospital, Akron, OH. Kathie Kobler, MS APN PCNS-BC, Advocate Lutheran General Hospital, Park Ridge, IL. (All authors listed above had no relevant financial relationships to disclose with the following exception: Kang is on the advisory board and received an honorarium from AstraZeneca Pharmaceuticals.)

The Use of Postoperative Restraints in Children after Cleft Lip or Cleft Palate Repair: A Preliminary Report

Purpose. This study examines whether the use of elbow restraints after cleft lip/palate repair has a relationship to postoperative complications. Methods. A comparative descriptive design was used to study a convenience sample of children undergoing repair of cleft lip/palate at Akron Children’s Hospital with Institutional Review Board approval. The children were randomized into intervention or control groups with use of elbow restraints considered the intervention. The study consists of two arms; one examined children after cleft lip repair, the second examined children after cleft palate repair. Repairs were performed by a single surgeon. Data collected included age, comorbidities, patient discomfort measured by pain score, frequency and duration of pain medications, use of pacifier or finger/thumb sucking, and postoperative complications including disruption of the suture line. Results. With 47 post palate repair patients and 47 post cleft repair patients, there is no significant difference () in the occurrence of postoperative complications. Conclusions. Study results provide prospective evidence to support postoperative observation of children by surgery staff and family following cleft lip or cleft palate repair without the use of elbow restraints. Clinicians should reevaluate the use of elbow restraints after cleft lip/palate repair based on the belief restraints prevent postoperative complications.

Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies.

Hypertension (HTN) in the pediatric population is estimated to have a world-wide prevalence of 2%–5%. As with adults, pediatric patients with HTN can present with hypertensive crises include hypertensive urgency and hypertensive emergencies. However, pediatric blood pressure problems have a greater chance of being from secondary causes of HTN, as opposed to primary HTN, than in adults. Thorough evaluation of a child with a hypertensive emergency includes accurate blood pressure readings, complete and focused symptom history, and appropriate past medical, surgical, and family history. Physical exam should include height, weight, four-limb blood pressures, a general overall examination and especially detailed cardiovascular and neurological examinations, including fundoscopic examination. Initial work-up should typically include electrocardiography, chest X-ray, serum chemistries, complete blood count, and urinalysis. Initial management of hypertensive emergencies generally includes the use of intravenous or oral antihypertensive medications, as well as appropriate, typically outpatient, follow-up. Emergency department goals for hypertensive crises are to (1) safely lower blood pressure, and (2) treat/minimize acute end organ damage, while (3) identifying underlying etiology. Intravenous antihypertensive medications are the treatment modality of choice for hypertensive emergencies with the goal of reducing systolic blood pressure by 25% of the original value over an 8-hour period.

Eradication of factor viii inhibitors in patients with mild and moderate hemophilia A

In hemophilia A, up to 25% of new antifactor VIII (FVIII) inhibitory antibodies (inhibitors) occur in patients with mild or moderate disease. Once the inhibitor develops, options for management include observation, immune modulation, and immune tolerance induction (ITI). Currently, there is little data to guide a clinician's management decisions. In a case series, eight of the 26 subjects with mild or moderate hemophilia complicated by an inhibitor underwent ITI; two were successful, two were unsuccessful, and four were partially successful. In a systematic review of the literature, 12 of the 16 patients with mild or moderate hemophilia responded to rituximab for treatment to eradicate the inhibitor. To increase our understanding of treatment options for inhibitor eradication in patients with mild or moderate hemophilia A complicated by an inhibitor, a secondary analysis of clinical and treatment characteristics in a cohort of 36 patients with mild or moderate hemophilia A and inhibitor was undertaken. In multivariate analyses, rituximab alone (n = 6) and other immune-modulating treatments alone (n = 2) were significantly associated with an increased likelihood of inhibitor clearance [hazard ratio (HR) = 4.4 (95% CI = 1.06–20.03) and 10.21 (95% CI = 1.17–78.28), respectively], whereas ITI alone (n = 9) was not [HR = 1.35 (95% CI = 0.44–4.07)].

ORAL PRESENTATION

ORAL PRESENTATION

Improving Care at Cystic Fibrosis Centers through Quality Improvement

Quality improvement (QI) using a clinical microsystems approach provides cystic fibrosis (CF) centers the opportunity to make a significant positive impact on the health of their patients. The availability of center-specific outcomes data and the support of the Cystic Fibrosis Foundation are important advantages for these quality improvement efforts. This article illustrates how the clinical microsystems methodology can improve care delivery and outcomes by describing the gradual application of quality improvement principles over the past 5 years by the CF team at the Lewis Walker Cystic Fibrosis Center at Akron Children's Hospital in Akron, Ohio. Using the example of a project to improve the pulmonary function of the pediatric patients at our center as a framework, we describe the QI process from the initial team-building phase, through the assessment of care processes, standardization of care, and developing a culture of continuous improvement. We outline how enthusiastic commitment from physician leadership, clinical managers and central administration, the availability of coaches, and an appreciation of the importance of measurement, patient involvement, communication, and standardization are critical components for successful process improvement.

Pediatric Urolithiasis: Clinical Predictors in the Emergency Department

The objective of this study was to identify factors that predict the presence of urolithiasis detected with unenhanced computed tomography (UCT) in children. A retrospective study of all subjects <21 years of age who presented to the emergency department at Akron Children's Hospital and underwent UCT of the abdomen between January 2002 and December 2005 was performed. Demographic, clinical, diagnostic, treatment, and disposition data were abstracted by using a standardized form. Univariate and logistic regression analyses of factors associated with urolithiasis were performed. A total of 339 eligible patients were identified, with 110 cases of urolithiasis detected with UCT for 95 individual patients. The mean age of the study patients was 14.4 years; 72 patients (66%) were female. In 17 cases (15%) of urolithiasis, initial urinalysis results were negative for blood. Fifty-seven stones (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children who did not have a stone identified through UCT, 23 cases (10%) of potentially significant, alternative diagnoses were identified. A history of urolithiasis, a history of nausea and vomiting, the presence of flank pain on examination, and >2 red blood cells per high-power field in urine microscopy were positively associated with urolithiasis. A history of fever or dysuria and costovertebral angle tenderness on physical examination were inversely associated with urolithiasis on UCT scans. UCT plays an important role in the diagnostic evaluation of children with flank pain. Approximately 15% of children with urolithiasis do not have hematuria.

Management of High-Order Multiple Births: Application of Lessons Learned Because of Participation in Vermont Oxford Network Collaboratives

The delivery and care of sextuplets is complex. Potentially better practices that were developed as part of the Vermont Oxford Network improvement collaboratives were used to prepare for a sextuplet delivery at Akron Children's Hospital. The team used potentially better practices that were learned from the Neonatal Intensive Care Quality Improvement Collaborative 2002 using multidisciplinary teams. There was extensive media coverage of the delivery. The goal was to use nearly all potentially better practices that focused on the goals of reducing nosocomial infection, reducing chronic lung disease, reducing radiograph use, reducing length of stay, reducing blood gas use, promoting nutrition, reducing intraventricular hemorrhage, and enriching family-centered care. The center aimed to use these 97 potentially better practices. Of the 97 possible potential better practices as set by the Neonatal Intensive Care Quality Improvement Collaborative 2002, 96 (99%) were used. This is a blueprint that any center that is faced with high-order multiple births could use as a reference point to begin planning. The team created a benchmark to achieve in every birth of very low birth weight infants and not just a special situation of high-order multiple births.

Gastroschisis: An 18-Year Review

From 1972 to 1990, 69 cases of gastroschisis were treated at Akron Children's Hospital Medical Center. Eighty-one percent of these patients underwent primary closure of their abdominal wall defect. Thirteen of 69 patients (19%) required Silastic silos with final closure in an average of 7.8 days. There was no sex predilection, the average birth weight was 2,473 g, and the mean gestational age was 36.3 weeks. Twenty-six percent had associated anomalies, the majority were intestinal atresia, volvulus, and/or undescended testicles. Seventy-seven percent of the infants were delivered vaginally. Fourteen children were delivered via cesarean section. Seven cesarean sections were done solely for prenatal ultrasonic identification of an abdominal wall defect. There was no improvement in hospital stay, complications, days until enteral feeds were tolerated, days intubated, or number of surgical procedures in this group. In 14 patients, mesh sheeting (Marlex, Silastic) was used in the final closure. Sixty-four percent of these incurred wound breakdown necessitating removal of the mesh. This compares with a 3.2% wound breakdown in the nonmesh group. The average hospital stay was 43.9 days and the average time to enteral feeds 20.2 days. Sixty-four percent of the patients required postoperative intubation for an average of 5.5 days. The overall mortality rate was 4.3%. The present data do not support gastroschisis alone as an indication for cesarean section. The data indicate that mesh be avoided in the final closure if possible and support a favorable prognosis for most babies.