Pediatric Annals

Case Challenges 

A 6-week-old Boy with Apnea and Abdominal Distention

Lauri Blanch, MD; Kristi Williams, MD; Matthew Sigley, DO

Abstract

A 6-week-old boy in respiratory distress presented to the Emergency Department via ambulance. Earlier that day, he woke from his nap screaming and was inconsolable for several hours. Then he suddenly became apneic and cyanotic, and an ambulance was called. Emergency personnel engaged in resuscitative measures, including offering blow-by oxygen and establishing intravenous access en route to the nearest emergency room.

On arrival, the boy is ill appearing and drowsy. His respiratory rate is 50, and oxygen saturation is 70% on room air. His abdomen appears distended. An NG tube is placed and drains 150 cc of bilious liquid. A stool sample is positive for occult blood. CPAP was immediately initiated secondary to the boy’s respiratory status, but persistent hypoxemia and respiratory distress necessitate emergent intubation, mechanical ventilation, and transfer to the PICU.

The boy’s past medical history is significant for a 36-week gestation and a subsequent 1-week NICU stay for transient tachypnea of the newborn and hyperbilirubinemia. At home, he feeds and stools normally. He is taking Zantac for gastroesophageal reflux.

An initial chest radiograph shows left-sided airspace disease with pleural effusion. An upper GI study shows poor gastric emptying and cannot exclude malrotation. General Surgery is consulted, and the boy is taken to the OR for an exploratory laparoscopy. Intraoperatively the boy has normal anatomy, and no etiology is discovered for his abdominal distention. The infant successfully extubates, starts on regular feeds, and transfers to the general pediatrics inpatient floor.

The evening prior to discharge to home, he has another episode of irritability, respiratory distress, cyanosis, and bilious NG tube drainage. At this time a 3 x 4 cm mass is palpated in the left upper abdomen, so the team obtains emergent abdominal and pelvic computerized tomography (CT) scans and chest radiographs, in addition to initiating resuscitative measures.

Coronal contrast enhanced CT images show herniation of large and small bowel with mesentery into the left hemithorax. A structural defect in the left hemidiaphragm is seen (see Figure 1; small arrows). The mass in the left upper abdomen is the spleen next to a dilated stomach (see Figure 1; large arrow), which extends to the right abdomen.

Frontal chest radiograph reveals opacification of the left hemithorax, rightward mediastinal shift, and dilatation of the stomach and a loop of small bowel (see Figure 2).

Figure 1. Coronal contrast enhanced CT image
Figure 1. Coronal contrast enhanced CT image showing herniation of large and small bowel into the left hemithorax.
Figure 2. Front chest radiograph
Figure 2. Frontal chest radiograph showing opacification of the left hemithorax, rightward mediastinal shift, and dilation of the stomach and small bowel.

Diagnosis: Late-presenting Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) occurs when abdominal viscera migrate through a defect in the diaphragm into the thoracic cavity.

The CDH defect results from incomplete closure of the pleuroperitoneal folds during the embryologic formation of the diaphragm by the seventh week of gestation. Based on the location of the defect, different types of CDH result: Congenital left-sided Bochdalek hernias (through the foramen of Bochdalek) make up the majority of CDH. The incidence of CDH is 1 in 2,200 to 3,000 live births, with 5% to 25% of CDH presenting beyond the neonatal period.

Several differences exist in the clinical manifestations of neonatal CDH as compared with late-presenting CDH. Typically, neonates with CDH demonstrate severe respiratory distress within the first few hours or days of life. However, late-presenting CDH produce varied symptoms, including respiratory symptoms (cough, respiratory distress, recurrent pneumonias, cyanosis), gastrointestinal symptoms (vomiting, feeding difficulties, abdominal pain, failure to thrive), or no symptoms. Due to the variety of clinical symptoms, late-presenting CDH are often misdiagnosed initially, whereas the diagnosis of neonatal CDH is typically straightforward and may even be detectable on prenatal ultrasound.1 Despite the differences in presenting clinical symptoms and diagnosis, the 2:1 male:female ratio and the location of the CDH (left > right > bilateral) are similar in neonatal and late-presenting CDH. (See Table for comparison of neonatal and late-presenting CDH.)

Comparison of Neonatal and Late-presenting CDH

Neonatal CDH Late-presenting CDH
Age < 1 month > 1 month
Male:female ratio 2:1 2:1
Symptoms Respiratory distress/failure Respiratory, gastrointestinal, respiratory and gastrointestinal, or asymptomatic
Side of Defect Left or right Left or right
Morbidity/mortality Respiratory complications often due to lung hypoplasia Complications from interventions performed based on initial misdiagnosis; sepsis, respiratory insufficiency


Diagnosing CDH beyond the neonatal period poses a challenge due to the varied symptoms, both acute and chronic, which patients can have. The initial imaging study chosen often depends on the presenting symptoms of the patient. Chest radiographs and contrast studies of the gastrointestinal tract are the most frequently obtained imaging studies in patients ultimately diagnosed with late-presenting CDH.2 Approximately one-half of patients with late-presenting CDH are diagnosed by chest radiography alone. Other imaging modalities are often needed for diagnosis, because chest radiographs can be normal if abdominal viscera are not in the thoracic cavity at the time of the radiograph, as demonstrated in this case when positive pressure ventilation transiently reduced the hernia. Initial chest radiographs can also be misinterpreted as pneumonia, pneumothorax, or effusion. In these cases, misdiagnosis often leads to other comorbidities, such as chest tube placement with resultant bowel perforation.2,3

As in our patient, an initial surgical procedure does not always reveal the diaphragmatic defect. Several reports document patients undergoing surgical repair for other abnormalities (pyloromyotomy for pyloric stenosis, thoracotomy for empyema, laparatomy for ileus) who were later diagnosed with CDH and required further surgical intervention. All of these patients had no diaphragmatic pathology noted during the first surgical procedure.2

Once diagnosed, surgical intervention is necessary to correct the defect and prevent complications from occurring. Currently, surgeons use a laparoscopic approach to repair the diaphragmatic defect by repositioning the displaced viscera into their appropriate location and approximating the margins of the defect. The laparoscopic approach, as compared with the thoracoscopic approach used in the past, enables surgeons to concurrently assess abdominal viscera and repair complications (malrotation, necrotic bowel resulting from vascular compromise, and bowel perforation).1,4

Patients with late-presenting CDH have a more favorable prognosis than do patients who present in the neonatal period, which could be attributed to less severe or absent lung hypoplasia. However, pulmonary hypoplasia can also occur with late-presenting CDH. Other associated malformations include malrotation (most commonly), pulmonary sequestration, cardiac anomalies (atrial septal defect, and ventricular septal defect), umbilical hernia, and wandering spleen.5

SUMMARY

Late-presenting CDH can present with a variety of symptoms. Radiographic evaluation may initially be normal or interpreted. It is important for clinicians to consider late-presenting CDH in the differential diagnosis of patients with respiratory and gastrointestinal symptoms.

REFERENCES

  1. Elhalaby EA, Abo Sikeena MH. Delayed presentation of congenital diaphragmatic hernia. Pediatr Surg Int. 2002;18(5-6):480-485.
  2. Baglaj M, Dorobisz U. Late-presenting congenital diaphragmatic hernia in children: a literature review. Pediatr Radiol. 2005;35(5):478-488.
  3. Cigdem MK, Onen A, Otcu S, Okur H. Late presentation of Bochdalek-type congenital diaphragmatic hernia in children: a 23-year experience at a single center. Surg Today. 2007;37(8):642-645.
  4. Baglaj M. Late-presenting congenital diaphragmatic hernia in children: a clinical spectrum. Pediatr Surg Int. 2004;2(9):658-669.
  5. Hosgor M, Karaca I, Karkiner A, et al. Associated malformations in delayed presentation of congenital diaphragmatic hernia. J Pediatr Surg. 2004;39(7):1073-1076.

SUGGESTED READING

Congenital Diaphragmatic Hernia Study Group. Congenital diaphragmatic hernia study group. Late-presenting congenital diaphragmatic hernia. J Pediatr Surg. 2005;40(12):1839-1843.

ABOUT THE AUTHORS

Lauri Blanch, MD; and Kristi Williams, MD, are attending physicians at The Children’s Mercy Hospital in Kansas City, Missouri. Matthew Sigley, DO, is a radiology resident at the University of Missouri Kansas City.

Address correspondence to: Lauri Blanch, MD, The Children’s Mercy Hospital, 2401 Gillham Road, 5 West, Kansas City, MO 64109; or e-mail lblanch@gmail.com.

Dr. Blanch; Dr. Williams; and Dr. Sigley have disclosed no relevant financial relationships.

Abstract

A 6-week-old boy in respiratory distress presented to the Emergency Department via ambulance. Earlier that day, he woke from his nap screaming and was inconsolable for several hours. Then he suddenly became apneic and cyanotic, and an ambulance was called. Emergency personnel engaged in resuscitative measures, including offering blow-by oxygen and establishing intravenous access en route to the nearest emergency room.

On arrival, the boy is ill appearing and drowsy. His respiratory rate is 50, and oxygen saturation is 70% on room air. His abdomen appears distended. An NG tube is placed and drains 150 cc of bilious liquid. A stool sample is positive for occult blood. CPAP was immediately initiated secondary to the boy’s respiratory status, but persistent hypoxemia and respiratory distress necessitate emergent intubation, mechanical ventilation, and transfer to the PICU.

The boy’s past medical history is significant for a 36-week gestation and a subsequent 1-week NICU stay for transient tachypnea of the newborn and hyperbilirubinemia. At home, he feeds and stools normally. He is taking Zantac for gastroesophageal reflux.

An initial chest radiograph shows left-sided airspace disease with pleural effusion. An upper GI study shows poor gastric emptying and cannot exclude malrotation. General Surgery is consulted, and the boy is taken to the OR for an exploratory laparoscopy. Intraoperatively the boy has normal anatomy, and no etiology is discovered for his abdominal distention. The infant successfully extubates, starts on regular feeds, and transfers to the general pediatrics inpatient floor.

The evening prior to discharge to home, he has another episode of irritability, respiratory distress, cyanosis, and bilious NG tube drainage. At this time a 3 x 4 cm mass is palpated in the left upper abdomen, so the team obtains emergent abdominal and pelvic computerized tomography (CT) scans and chest radiographs, in addition to initiating resuscitative measures.

Coronal contrast enhanced CT images show herniation of large and small bowel with mesentery into the left hemithorax. A structural defect in the left hemidiaphragm is seen (see Figure 1; small arrows). The mass in the left upper abdomen is the spleen next to a dilated stomach (see Figure 1; large arrow), which extends to the right abdomen.

Frontal chest radiograph reveals opacification of the left hemithorax, rightward mediastinal shift, and dilatation of the stomach and a loop of small bowel (see Figure 2).

Figure 1. Coronal contrast enhanced CT image
Figure 1. Coronal contrast enhanced CT image showing herniation of large and small bowel into the left hemithorax.
Figure 2. Front chest radiograph
Figure 2. Frontal chest radiograph showing opacification of the left hemithorax, rightward mediastinal shift, and dilation of the stomach and small bowel.

Diagnosis: Late-presenting Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) occurs when abdominal viscera migrate through a defect in the diaphragm into the thoracic cavity.

The CDH defect results from incomplete closure of the pleuroperitoneal folds during the embryologic formation of the diaphragm by the seventh week of gestation. Based on the location of the defect, different types of CDH result: Congenital left-sided Bochdalek hernias (through the foramen of Bochdalek) make up the majority of CDH. The incidence of CDH is 1 in 2,200 to 3,000 live births, with 5% to 25% of CDH presenting beyond the neonatal period.

Several differences exist in the clinical manifestations of neonatal CDH as compared with late-presenting CDH. Typically, neonates with CDH demonstrate severe respiratory distress within the first few hours or days of life. However, late-presenting CDH produce varied symptoms, including respiratory symptoms (cough, respiratory distress, recurrent pneumonias, cyanosis), gastrointestinal symptoms (vomiting, feeding difficulties, abdominal pain, failure to thrive), or no symptoms. Due to the variety of clinical symptoms, late-presenting CDH are often misdiagnosed initially, whereas the diagnosis of neonatal CDH is typically straightforward and may even be detectable on prenatal ultrasound.1 Despite the differences in presenting clinical symptoms and diagnosis, the 2:1 male:female ratio and the location of the CDH (left > right > bilateral) are similar in neonatal and late-presenting CDH. (See Table for comparison of neonatal and late-presenting CDH.)

Comparison of Neonatal and Late-presenting CDH

Neonatal CDH Late-presenting CDH
Age < 1 month > 1 month
Male:female ratio 2:1 2:1
Symptoms Respiratory distress/failure Respiratory, gastrointestinal, respiratory and gastrointestinal, or asymptomatic
Side of Defect Left or right Left or right
Morbidity/mortality Respiratory complications often due to lung hypoplasia Complications from interventions performed based on initial misdiagnosis; sepsis, respiratory insufficiency


Diagnosing CDH beyond the neonatal period poses a challenge due to the varied symptoms, both acute and chronic, which patients can have. The initial imaging study chosen often depends on the presenting symptoms of the patient. Chest radiographs and contrast studies of the gastrointestinal tract are the most frequently obtained imaging studies in patients ultimately diagnosed with late-presenting CDH.2 Approximately one-half of patients with late-presenting CDH are diagnosed by chest radiography alone. Other imaging modalities are often needed for diagnosis, because chest radiographs can be normal if abdominal viscera are not in the thoracic cavity at the time of the radiograph, as demonstrated in this case when positive pressure ventilation transiently reduced the hernia. Initial chest radiographs can also be misinterpreted as pneumonia, pneumothorax, or effusion. In these cases, misdiagnosis often leads to other comorbidities, such as chest tube placement with resultant bowel perforation.2,3

As in our patient, an initial surgical procedure does not always reveal the diaphragmatic defect. Several reports document patients undergoing surgical repair for other abnormalities (pyloromyotomy for pyloric stenosis, thoracotomy for empyema, laparatomy for ileus) who were later diagnosed with CDH and required further surgical intervention. All of these patients had no diaphragmatic pathology noted during the first surgical procedure.2

Once diagnosed, surgical intervention is necessary to correct the defect and prevent complications from occurring. Currently, surgeons use a laparoscopic approach to repair the diaphragmatic defect by repositioning the displaced viscera into their appropriate location and approximating the margins of the defect. The laparoscopic approach, as compared with the thoracoscopic approach used in the past, enables surgeons to concurrently assess abdominal viscera and repair complications (malrotation, necrotic bowel resulting from vascular compromise, and bowel perforation).1,4

Patients with late-presenting CDH have a more favorable prognosis than do patients who present in the neonatal period, which could be attributed to less severe or absent lung hypoplasia. However, pulmonary hypoplasia can also occur with late-presenting CDH. Other associated malformations include malrotation (most commonly), pulmonary sequestration, cardiac anomalies (atrial septal defect, and ventricular septal defect), umbilical hernia, and wandering spleen.5

SUMMARY

Late-presenting CDH can present with a variety of symptoms. Radiographic evaluation may initially be normal or interpreted. It is important for clinicians to consider late-presenting CDH in the differential diagnosis of patients with respiratory and gastrointestinal symptoms.

REFERENCES

  1. Elhalaby EA, Abo Sikeena MH. Delayed presentation of congenital diaphragmatic hernia. Pediatr Surg Int. 2002;18(5-6):480-485.
  2. Baglaj M, Dorobisz U. Late-presenting congenital diaphragmatic hernia in children: a literature review. Pediatr Radiol. 2005;35(5):478-488.
  3. Cigdem MK, Onen A, Otcu S, Okur H. Late presentation of Bochdalek-type congenital diaphragmatic hernia in children: a 23-year experience at a single center. Surg Today. 2007;37(8):642-645.
  4. Baglaj M. Late-presenting congenital diaphragmatic hernia in children: a clinical spectrum. Pediatr Surg Int. 2004;2(9):658-669.
  5. Hosgor M, Karaca I, Karkiner A, et al. Associated malformations in delayed presentation of congenital diaphragmatic hernia. J Pediatr Surg. 2004;39(7):1073-1076.

SUGGESTED READING

Congenital Diaphragmatic Hernia Study Group. Congenital diaphragmatic hernia study group. Late-presenting congenital diaphragmatic hernia. J Pediatr Surg. 2005;40(12):1839-1843.

ABOUT THE AUTHORS

Lauri Blanch, MD; and Kristi Williams, MD, are attending physicians at The Children’s Mercy Hospital in Kansas City, Missouri. Matthew Sigley, DO, is a radiology resident at the University of Missouri Kansas City.

Address correspondence to: Lauri Blanch, MD, The Children’s Mercy Hospital, 2401 Gillham Road, 5 West, Kansas City, MO 64109; or e-mail lblanch@gmail.com.

Dr. Blanch; Dr. Williams; and Dr. Sigley have disclosed no relevant financial relationships.

A 6-week-old boy in respiratory distress presented to the Emergency Department via ambulance. Earlier that day, he woke from his nap screaming and was inconsolable for several hours. Then he suddenly became apneic and cyanotic, and an ambulance was called. Emergency personnel engaged in resuscitative measures, including offering blow-by oxygen and establishing intravenous access en route to the nearest emergency room.

On arrival, the boy is ill appearing and drowsy. His respiratory rate is 50, and oxygen saturation is 70% on room air. His abdomen appears distended. An NG tube is placed and drains 150 cc of bilious liquid. A stool sample is positive for occult blood. CPAP was immediately initiated secondary to the boy’s respiratory status, but persistent hypoxemia and respiratory distress necessitate emergent intubation, mechanical ventilation, and transfer to the PICU.

The boy’s past medical history is significant for a 36-week gestation and a subsequent 1-week NICU stay for transient tachypnea of the newborn and hyperbilirubinemia. At home, he feeds and stools normally. He is taking Zantac for gastroesophageal reflux.

An initial chest radiograph shows left-sided airspace disease with pleural effusion. An upper GI study shows poor gastric emptying and cannot exclude malrotation. General Surgery is consulted, and the boy is taken to the OR for an exploratory laparoscopy. Intraoperatively the boy has normal anatomy, and no etiology is discovered for his abdominal distention. The infant successfully extubates, starts on regular feeds, and transfers to the general pediatrics inpatient floor.

The evening prior to discharge to home, he has another episode of irritability, respiratory distress, cyanosis, and bilious NG tube drainage. At this time a 3 x 4 cm mass is palpated in the left upper abdomen, so the team obtains emergent abdominal and pelvic computerized tomography (CT) scans and chest radiographs, in addition to initiating resuscitative measures.

Coronal contrast enhanced CT images show herniation of large and small bowel with mesentery into the left hemithorax. A structural defect in the left hemidiaphragm is seen (see Figure 1; small arrows). The mass in the left upper abdomen is the spleen next to a dilated stomach (see Figure 1; large arrow), which extends to the right abdomen.

Frontal chest radiograph reveals opacification of the left hemithorax, rightward mediastinal shift, and dilatation of the stomach and a loop of small bowel (see Figure 2).

Figure 1. Coronal contrast enhanced CT image
Figure 1. Coronal contrast enhanced CT image showing herniation of large and small bowel into the left hemithorax.
Figure 2. Front chest radiograph
Figure 2. Frontal chest radiograph showing opacification of the left hemithorax, rightward mediastinal shift, and dilation of the stomach and small bowel.

Diagnosis: Late-presenting Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) occurs when abdominal viscera migrate through a defect in the diaphragm into the thoracic cavity.

The CDH defect results from incomplete closure of the pleuroperitoneal folds during the embryologic formation of the diaphragm by the seventh week of gestation. Based on the location of the defect, different types of CDH result: Congenital left-sided Bochdalek hernias (through the foramen of Bochdalek) make up the majority of CDH. The incidence of CDH is 1 in 2,200 to 3,000 live births, with 5% to 25% of CDH presenting beyond the neonatal period.

Several differences exist in the clinical manifestations of neonatal CDH as compared with late-presenting CDH. Typically, neonates with CDH demonstrate severe respiratory distress within the first few hours or days of life. However, late-presenting CDH produce varied symptoms, including respiratory symptoms (cough, respiratory distress, recurrent pneumonias, cyanosis), gastrointestinal symptoms (vomiting, feeding difficulties, abdominal pain, failure to thrive), or no symptoms. Due to the variety of clinical symptoms, late-presenting CDH are often misdiagnosed initially, whereas the diagnosis of neonatal CDH is typically straightforward and may even be detectable on prenatal ultrasound.1 Despite the differences in presenting clinical symptoms and diagnosis, the 2:1 male:female ratio and the location of the CDH (left > right > bilateral) are similar in neonatal and late-presenting CDH. (See Table for comparison of neonatal and late-presenting CDH.)

Comparison of Neonatal and Late-presenting CDH

Neonatal CDH Late-presenting CDH
Age < 1 month > 1 month
Male:female ratio 2:1 2:1
Symptoms Respiratory distress/failure Respiratory, gastrointestinal, respiratory and gastrointestinal, or asymptomatic
Side of Defect Left or right Left or right
Morbidity/mortality Respiratory complications often due to lung hypoplasia Complications from interventions performed based on initial misdiagnosis; sepsis, respiratory insufficiency


Diagnosing CDH beyond the neonatal period poses a challenge due to the varied symptoms, both acute and chronic, which patients can have. The initial imaging study chosen often depends on the presenting symptoms of the patient. Chest radiographs and contrast studies of the gastrointestinal tract are the most frequently obtained imaging studies in patients ultimately diagnosed with late-presenting CDH.2 Approximately one-half of patients with late-presenting CDH are diagnosed by chest radiography alone. Other imaging modalities are often needed for diagnosis, because chest radiographs can be normal if abdominal viscera are not in the thoracic cavity at the time of the radiograph, as demonstrated in this case when positive pressure ventilation transiently reduced the hernia. Initial chest radiographs can also be misinterpreted as pneumonia, pneumothorax, or effusion. In these cases, misdiagnosis often leads to other comorbidities, such as chest tube placement with resultant bowel perforation.2,3

As in our patient, an initial surgical procedure does not always reveal the diaphragmatic defect. Several reports document patients undergoing surgical repair for other abnormalities (pyloromyotomy for pyloric stenosis, thoracotomy for empyema, laparatomy for ileus) who were later diagnosed with CDH and required further surgical intervention. All of these patients had no diaphragmatic pathology noted during the first surgical procedure.2

Once diagnosed, surgical intervention is necessary to correct the defect and prevent complications from occurring. Currently, surgeons use a laparoscopic approach to repair the diaphragmatic defect by repositioning the displaced viscera into their appropriate location and approximating the margins of the defect. The laparoscopic approach, as compared with the thoracoscopic approach used in the past, enables surgeons to concurrently assess abdominal viscera and repair complications (malrotation, necrotic bowel resulting from vascular compromise, and bowel perforation).1,4

Patients with late-presenting CDH have a more favorable prognosis than do patients who present in the neonatal period, which could be attributed to less severe or absent lung hypoplasia. However, pulmonary hypoplasia can also occur with late-presenting CDH. Other associated malformations include malrotation (most commonly), pulmonary sequestration, cardiac anomalies (atrial septal defect, and ventricular septal defect), umbilical hernia, and wandering spleen.5

SUMMARY

Late-presenting CDH can present with a variety of symptoms. Radiographic evaluation may initially be normal or interpreted. It is important for clinicians to consider late-presenting CDH in the differential diagnosis of patients with respiratory and gastrointestinal symptoms.

REFERENCES

  1. Elhalaby EA, Abo Sikeena MH. Delayed presentation of congenital diaphragmatic hernia. Pediatr Surg Int. 2002;18(5-6):480-485.
  2. Baglaj M, Dorobisz U. Late-presenting congenital diaphragmatic hernia in children: a literature review. Pediatr Radiol. 2005;35(5):478-488.
  3. Cigdem MK, Onen A, Otcu S, Okur H. Late presentation of Bochdalek-type congenital diaphragmatic hernia in children: a 23-year experience at a single center. Surg Today. 2007;37(8):642-645.
  4. Baglaj M. Late-presenting congenital diaphragmatic hernia in children: a clinical spectrum. Pediatr Surg Int. 2004;2(9):658-669.
  5. Hosgor M, Karaca I, Karkiner A, et al. Associated malformations in delayed presentation of congenital diaphragmatic hernia. J Pediatr Surg. 2004;39(7):1073-1076.

SUGGESTED READING

Congenital Diaphragmatic Hernia Study Group. Congenital diaphragmatic hernia study group. Late-presenting congenital diaphragmatic hernia. J Pediatr Surg. 2005;40(12):1839-1843.

ABOUT THE AUTHORS

Lauri Blanch, MD; and Kristi Williams, MD, are attending physicians at The Children’s Mercy Hospital in Kansas City, Missouri. Matthew Sigley, DO, is a radiology resident at the University of Missouri Kansas City.

Address correspondence to: Lauri Blanch, MD, The Children’s Mercy Hospital, 2401 Gillham Road, 5 West, Kansas City, MO 64109; or e-mail lblanch@gmail.com.

Dr. Blanch; Dr. Williams; and Dr. Sigley have disclosed no relevant financial relationships.

10.3928/00904481-20090501-04

Sign up to receive

Journal E-contents