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## Complete Summary

#### GUIDELINE TITLE

Evidence based clinical practice guideline hypertrophic pyloric
stenosis.

#### BIBLIOGRAPHIC SOURCE(S)

Cincinnati Children\'s Hospital Medical Center. Evidence based clinical
practice guideline for hypertrophic pyloric stenosis. Cincinnati (OH):
Cincinnati Children\'s Hospital Medical Center; 2007 Nov 14. 17 p. \[185
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children\'s
Hospital Medical Center. Evidence based clinical practice guideline for
hypertrophic pyloric stenosis. Cincinnati (OH): Cincinnati Children\'s
Hospital Medical Center; 2001 Aug 8. 16 p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hypertrophic pyloric stenosis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Gastroenterology\
Pediatrics\
Radiology\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Pharmacists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide evidence based clinical practice guidelines for the
management of children with hypertrophic pyloric stenosis

#### TARGET POPULATION

-   Children \<3 months of age with signs, symptoms, or exam findings
    suggesting a diagnosis of hypertrophic pyloric stenosis

These guidelines are not intended for use in patients with:

-   Suspected sepsis

-   Bilious vomiting suggesting intestinal obstruction

-   History or presence of significant comorbidities or chronic
    conditions which would alter approaches to care

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnostic Assessment**

1.  Assessment of signs and symptoms with physical examination,
    palpation of the hypertrophic pyloric muscle mass, and estimation of
    dehydration

2.  Laboratory assessment including electrolytes

3.  Ultrasound exam (US)

4.  Upper gastrointestinal series (UGI)

**Surgical Correction and Postoperative Management**

1.  Ramstedt pyloromyotomy

2.  Anesthetic management

3.  Pain assessment and management using the Neonatal Infant Pain Scale,
    wound infiltration with local anesthetic (e.g., bupivacaine), and
    administration of acetaminophen

4.  Infection prophylaxis with cefazolin or clindamycin

5.  Feeding advancement

6.  Parent education and counseling

#### MAJOR OUTCOMES CONSIDERED

-   Sensitivity, specificity, accuracy, and predictive value of
    diagnostic instruments

-   Rates of postoperative infection

-   Rates and severity of postoperative vomiting

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

To select evidence for critical appraisal by the group for the update of
this guideline, the Medline, EmBase, CINAHL, and the Cochrane databases
were searched. Evidence from 2000 and before was verified for inclusion
in the guidelines. Evidence from January 2001 to January 2007 was
reviewed to generate an unrefined, \"combined evidence\" database using
a search strategy focused on answering clinical questions relevant to
hypertrophic pyloric stenosis, employing a combination of Boolean
searching on human-indexed thesaurus terms (e.g., Medical Subject
Heading \[MeSH\] headings using an OVID MedLine interface) and \"natural
language\" searching on keywords in the title, abstract, and indexing
terms. The citations were reduced by eliminating duplicates, non-English
articles, and adult articles. The resulting titles, abstracts, and full
text articles were reviewed by a methodologist to eliminate low quality
and irrelevant citations. During the course of the guideline
development, additional clinical questions were generated and subjected
to the search process, and some relevant review articles were
identified. December, 2000 was the last date for which literature was
reviewed for the previous version of this guideline. The details of that
review strategy are not documented. However, all previous citations were
reviewed for appropriateness to this revision.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The recommendations contained in this guideline were formulated by an
interdisciplinary working group which performed systematic and critical
literature reviews, using a grading scale, and examined current local
clinical practices.

Recommendations have been formulated by a consensus process directed by
best evidence, patient and family preference and clinical expertise.
During formulation of these guidelines, the committee members have
remained cognizant of controversies and disagreements over the
management of these patients. They have tried to resolve controversial
issues by consensus where possible and, when not possible, to offer
optional approaches to care in the form of information that includes
best supporting evidence of efficacy for alternative choices.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines have been reviewed and approved by clinical experts not
involved in the development process, senior management, Risk Management
& Corporate Compliance, other appropriate hospital committees, and other
individuals as appropriate to their intended purposes.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Each recommendation is followed by an evidence classification
identifying the type of supporting evidence. Definitions for the types
of evidence are presented at the end of the \"Major Recommendations\"
field.

**Clinical Assessment**

**History of Symptoms**

1.  It is recommended that practitioners consider the diagnosis of
    hypertrophic pyloric stenosis (HPS) in an otherwise healthy infant
    between the age of 2 and 12 weeks of life who presents with
    projectile and/or frequent episodes of non-bilious emesis with or
    without associated weight loss. Increasing frequency and volume of
    vomiting, despite trials of small frequent feedings of formula,
    breast milk, and Pedialyte, often are suggestive of HPS (Smith,
    Mihalov, & Shields, 1999 \[D\]; Breaux & Georgeson, 1986 \[D\]).

**Physical Exam**

1.  In an infant with the above history, palpation of the hypertrophic
    pyloric muscle mass (also called the *olive*) in the epigastrium or
    right upper quadrant (RUQ) by a skilled examiner is pathognomonic
    for the diagnosis of HPS. If the olive is palpated, no additional
    diagnostic testing may be necessary. Gastric distension or visible
    gastric peristalsis, seen as a wave of contraction from the left
    upper quadrant to the epigastrium, may be seen in some cases
    (Murtagh et al., 1992 \[S\]; Spicer, 1982 \[S\]). The inability of a
    clinician to palpate an olive does not rule out the diagnosis of HPS
    (Forman, Leonidas, & Kronfeld, 1990 \[C,D\]).

    -   **Note 1**: Several methods for olive palpation are recommended
        (Garcia & Randolph, 1990 \[S\], Spicer, 1982 \[S\]). One method
        is described below.

        -   Remove the child\'s clothing so as to expose the abdomen.
            Allow patient to relax by sucking on sugar water while lying
            supine in the parent\'s lap.

        -   Gently elevate the child\'s feet and flex the legs (this
            relaxes the abdominal wall).

        -   Place examining hand between the child\'s legs so that the
            fingers rest on the abdominal wall. Using fingertips,
            palpate the inferior margin of the liver edge

        -   Slide fingertips under the liver edge and superiorly under
            liver, then posteriorly to the back of the abdomen.

        -   With fingers flexed and palpating the posterior abdomen,
            draw fingers inferiorly along abdominal wall. The \"olive\"
            will pop under the fingers.

        -   The mobility of the pyloric olive in all 4 directions
            distinguishes hypertrophic pyloric stenosis from a
            retroperitoneal mass.

        -   When palpable, the olive will feel smooth and hard, oblong,
            and approximately 1.5 to 2.0 centimeters in size.

    -   **Note 2**: The ability to palpate the olive varies with the
        experience and persistence of the examiner and ranges from 40%
        to 100% (Murtagh et al., 1992 \[S\]).

**Estimating Dehydration in Hypertrophic Pyloric Stenosis**

1.  Dehydration may be encountered in patients with HPS. Estimating
    dehydration is an important first step in determining optimal
    approaches to diagnose HPS. Acute body weight changes provide the
    best measure of dehydration in a young child (Duggan et al., 1996
    \[C\]; Gorelick, Shaw, & Murphy, 1997\* \[C\]). Mucous membrane
    hydration, capillary refill time (Saavedra, Harris, & Finberg, 1991
    \[D\]), absence of tears, and alterations in mental status are the
    next best associated measures. The presence of any three or more of
    these latter four signs has a sensitivity of 87% and specificity of
    82% for detecting a deficit of 5% or more (Duggan et al., 1996
    \[C\]; Gorelick, Shaw, & Murphy, 1997\* \[C\]). (See Table 1 in the
    original guideline document for physical parameters associated with
    degree of dehydration.)

> \* Population studied was one month to 5 years of age. Other
> considerations may apply for children less than one month of age.

**Laboratory Assessment**

1.  The assessment of electrolyte status is not routinely indicated in
    the early diagnosis of HPS. Once a diagnosis is confirmed, it is
    recommended that the electrolyte status of the patient be checked
    pre-operatively and any significant abnormalities in electrolytes or
    hydration status be addressed prior to surgery. The Cincinnati
    Children\'s Hospital Medical Center Department of Anesthesiology
    (CHMCC) suggests a pre-operative bicarbonate level of
    [\<]{.underline}30 mEq/L, be achieved before surgical correction is
    performed (Local expert consensus \[E\]; Bissonnette & Sullivan,
    1991 \[S\]; Habre et al., 1999 \[D\]; Goh et al., 1990 \[C\]; Graham
    et al., 1993 \[D\]).

    -   **Note 1**: Earlier studies indicated that up to 10% of patients
        with HPS present with electrolyte abnormalities including
        hypokalemia and hypochloremic alkalosis (Chen et al., 1996
        \[D\]; Papadakis et al., 1999 \[D\]). More recent studies report
        fewer metabolic derangements (Poon et al., 1996 \[D\]).

**Referral for Further Evaluation of HPS**

1.  In children who present with HPS symptoms but are deemed to be well
    hydrated, factors influencing the next step include the time of day,
    severity of symptoms, and social situation. If the child is well
    hydrated and the social situation permits, the patient may be
    scheduled for an elective outpatient radiologic evaluation or direct
    referral to a pediatric surgeon within 24 hours of this visit. Under
    these circumstances, parents are instructed to call if signs and
    symptoms of dehydration develop (Abbas, Weiss, & Alvear, 1999
    \[D\]).

    -   **Note 1**: Palpation of an olive by an experienced examiner,
        such as a pediatric surgeon, may obviate need for a confirmatory
        imaging study. This is due to the high specificity of positive
        exam (Forman, Leonidas, & Kronfeld, 1990 \[C, D\]; Breaux &
        Georgeson, 1986 \[D\]; Macdessi & Oates, 1993 \[D\]; Godbole et
        al., 1996 \[C\]; White et al., 1998 \[Q\]).

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2.  It is recommended that the infant be referred to the Emergency
    Department for evaluation and treatment with intravenous fluids if
    dehydration is suspected clinically or the social situation warrants
    more immediate action (Local expert consensus \[E\]).

**Radiologic Assessment**

1.  The diagnosis of HPS can be made with imaging by an ultrasound exam
    (US) or fluoroscopic upper gastrointestinal series (UGI). These
    imaging tests have similar performance in terms of sensitivity and
    specificity for the diagnosis of HPS (see Table 2 in the original
    guideline document). In the absence of a large prospective
    comparison study with receiver operating characteristic (ROC)
    analysis or a meta-analysis of existing studies, neither test can be
    proved as clearly superior in the diagnosis of HPS. UGI is superior
    to US in diagnosing some other conditions associated with vomiting
    in infants, such as gastroesophageal reflux, malrotation, and
    gastric webs (Cohen et al., 2000 \[E\]). However, sonography has
    certain advantages over UGI, including the absence of ionizing
    radiation exposure and lack of oral contrast use which eliminates
    the risk of barium aspiration or intraperitoneal barium spillage
    during surgery. This has led to US becoming the standard or
    preferred initial imaging method when HPS is the most likely
    diagnosis (Blumhagen & Noble, 1983 \[C & D\]; Khamapirad & Athey,
    1983 \[D\]; Hayden et al., 1984 \[D\]; Stunden, LeQuesne, & Little,
    1986 \[C\]; Weiskittel, Leary, & Blane, 1989 \[O\]; Garcia &
    Randolph, 1990 \[S\]; Rollins et al., 1991 \[C\]; Hernanz-Schulman
    et al., 1994 \[D\]; Cohen et al., 2000 \[E\]).

2.  A persistent pyloric muscle thickness \>3-4 mm or pyloric length
    \>15-18 mm in the presence of functional gastric outlet obstruction
    is generally considered in the diagnostic range for HPS by US. There
    is not strong agreement in the literature regarding the optimal size
    threshold for diagnosis. Many studies show pyloric size overlap
    between HPS and non-HPS cases, and the diagnostic performance of
    specific size thresholds varies across studies (Haller & Cohen, 1986
    \[E\]; Stunden, LeQuesne, & Little, 1986 \[C\]; Mollitt et al., 1987
    \[D\]; Lund Kofoed et al., 1988 \[C\]; Blumhagen et al., 1988 \[C &
    D\]; Westra et al., 1989 \[C\]; Philippin & Zieger, 1989 \[D\];
    O\'Keefe et al., 1991 \[D\]; Lamki et al., 1993 \[C & D\];
    Hernanz-Schulman et al., 1994 \[D\]; Neilson & Hollman, 1994 \[D\];
    Godbole et al., 1996 \[C\]; Rohrschneider et al., 1998 \[C\]; Cohen
    et al., 1998 \[D\]). The use of smaller diagnostic size thresholds
    may be more applicable in younger or smaller neonates (Cohen et al.,
    2000 \[E\]). With any size cut-off there is a reciprocal
    relationship of sensitivity and specificity, where a larger size
    cut-off will increase specificity at the expense of sensitivity, and
    a smaller size cut-off will increase sensitivity at the expense of
    specificity. The dynamic evaluation of gastric emptying by real-time
    US is important, particularly in cases with borderline size
    measurements (Strauss et al., 1981 \[D\]; Ball, Atkinson, & Gay,
    1983 \[C\]; Stunden, LeQuesne, & Little, 1986 \[C\]; Mollitt et al.,
    1987 \[D\]; Hernanz-Schulman et al., 1994 \[D\]; Nielson & Hollman,
    1994 \[D\]; Godbole et al., 1996 \[C\]; Cohen et al., 1998 \[D\];
    Rohrschneider et al., 1998 \[D\]). Many experienced sonologists rely
    more on a subjective visual impression of the pyloric size and
    gastric emptying than on pyloric measurements (Hayden et al., 1984
    \[D\]; Blumhagen, 1986 \[E\]; Westra et al., 1989 \[C\]; Godbole et
    al., 1996 \[C\]).

    -   **Note 1**: An US exam is technically nondiagnostic when the
        pyloric region is inadequately visualized. This may occur from
        excessive patient motion or from obscuration or displacement out
        of the field of view by excessive gastric contents. At the
        discretion of the sonologist, a nasogastric tube may be placed
        to empty the stomach and facilitate pyloric visualization. If
        the US exam remains nondiagnostic due to technical factors, an
        UGI is suggested.

    -   **Note 2**: Cases with borderline pyloric size measurements by
        ultrasound may represent pylorospasm or HPS in evolution.
        Persistent pyloric muscular thickening and functional gastric
        outlet obstruction suggests HPS. If pyloric muscular thickening
        and gastric outlet obstruction are transient, pylorospasm is
        implied (Cohen et al., 1998 \[D\]).

    -   **Note 3**: Despite careful attention to pyloric size
        measurements and pyloric function by real-time US observation,
        some US exams may be inconclusive, particularly those with
        borderline size measurements. Patients with an inconclusive US
        exam may undergo an UGI or may be followed closely clinically
        with repeated physical exams and/or additional imaging studies
        as indicated. Follow-up is highly recommended as some of these
        cases may progress to frank HPS, with reported time periods
        ranging from a few days to greater than one month (Tunell &
        Wilson, 1984 \[C\]; Blumhagen et al., 1988 \[D\]; O\'Keefe et
        al., 1991 \[D\]; Lamki et al., 1993 \[C & D\]; Hallam et al.,
        1995 \[D\]; Godbole et al., 1996 \[C\]; Bergami et al., 1996
        \[C\]).

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3.  An UGI is favored over US as the most cost-effective initial imaging
    study when:

    a.  The clinical presentation of the vomiting infant is atypical for
        HPS (e.g., bilious emesis, emesis present since birth, patient
        age extreme) and favors other conditions more amenable to
        diagnosis by UGI such as gastroesophageal reflux (GER) or
        malrotation (Olson, Hernandez, & Hirschl, 1998 \[Q\]; Foley et
        al., 1989 \[C\]; Forman, Leonidas, & Kronfeld, 1990 \[C & D\]).

    b.  An UGI planned if the US is negative (a negative US leading to
        an UGI does not save the patient radiation exposure and
        increases the overall cost of imaging (Cohen et al., 2000
        \[E\]).

        -   **Note 1**: The primary criterion for the diagnosis of HPS
            by UGI is a narrowed, elongated pyloric channel with pyloric
            mass effect on the stomach and duodenum. This may produce a
            string sign, double tract sign, beak sign, or pyloric teat
            sign. Ancillary findings of HPS on UGI are gastric
            hyperperistalsis, large volume gastric residue, and delayed
            gastric emptying (Shopfner, Kalmon, & Coin, 1964 \[D\];
            Shuman, Darling, & Fisher, 1967 \[D\]; Cremin & Klein, 1968
            \[D\]).

        -   **Note 2**: As with US, some UGI studies may be
            inconclusive. These cases may undergo an US or be followed
            closely clinically with repeated physical exams and/or
            additional imaging studies as indicated.

**Surgical Correction**

HPS is corrected surgically by Ramstedt pyloromyotomy. The pylorus may
be accessed by various incision techniques including transverse right
upper quadrant, circumumbilical, and laparoscopic. All methods are
considered acceptable practice with minimal differences in outcomes
noted (Hingston, 1996 \[D\]; Tan & Bianchi, 1986 \[C\]; Poli-Merol et
al., 1996 \[C\]; Leinwand, Shaul, & Anderson, 1999 \[D\]; Fujimoto et
al., 1999 \[C\]; Fitzgerald et al., 1990 \[D\]).

**Anesthetic Management**

1.  Infants with HPS have a functional gastric outlet obstruction that
    may place them at a greater risk for aspiration of gastric contents
    during induction of anesthesia (Cook-Sather et al., 1998 \[E\]).
    Regardless of whether the stomach contents were aspirated prior to
    the infant\'s arrival in the operating theater, it is recommended
    that precautions be taken to prevent pulmonary aspiration. These
    maneuvers include oral/nasogastric suction prior to induction of
    anesthesia and maintaining cricoid pressure (Sellick\'s maneuver)
    during induction of anesthesia (Bissonnette & Sullivan, 1991\[S\]).

**Pain Management**

1.  Pain management is important for optimal patient outcomes. It is
    recommended that pain be routinely assessed using standard age
    appropriate scales (Salantera et al., 1999 \[C\]).

2.  It is recommended that the \"Neonatal Infant Pain Scale\" be
    utilized for pain assessment.

    -   **Note 1**: Valuable information regarding pain management may
        also be obtained through the measurement of physiologic changes,
        behavioral observation, and caregiver/parental input (Finley &
        McGrath, 1998 \[S\]).

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3.  It is recommended that the wound be infiltrated with a local
    anesthetic (i.e., bupivacaine 0.125% up to 1mL/kg) at the conclusion
    of the surgical procedure. Wound infiltration with local anesthetic
    has been shown to decrease postoperative analgesic requirements
    (Habre et al., 1999 \[D\]).

4.  Further analgesia, if necessary, may be accomplished via the
    administration of acetaminophen (15 mg/kg/dose every 4 to 6 hours.
    Not to exceed 5 doses in 24 hours.) (Bissonnette & Sullivan, 1991
    \[S\]; Habre et al., 1999 \[D\]). Use of opioids may potentiate the
    risk of respiratory depression in infants undergoing pyloromyotomy
    (Habre et al., 1999 \[D\]). Therefore, it is recommended that
    narcotics not be administered in the routine post-operative pain
    management of these infants.

**Surgical Site Infection Prophylaxis**

1.  It is recommended that one dose of cefazolin, 25 mg/kg of body
    weight, be used to decrease the risk of surgical site infection in
    all patients. In the event of penicillin allergy, it is recommended
    that clindamycin, 10 mg/kg of body weight, be the alternative
    antibiotic of choice.

    -   **Note 1**: *Staphylococcus aureus* is the most common organism
        associated with wound infections in patients who have undergone
        pyloromyotomy (Rao & Youngson, 1989 \[D\]; Mangram et al., 1999
        \[E\])

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2.  To assure adequate blood level at the time of incision, it is
    recommended that antibiotics be given approximately 30 minutes prior
    to surgery (Mangram et al., 1999 \[E\]). Therefore, it is
    recommended that prophylactic antibiotics be given in the
    perioperative care before induction and the practice of giving
    antibiotics \"on call to the operating room\" be discouraged as
    delays in patient transport or schedule changes may result in
    suboptimal blood and tissue levels (Page et al., 1993 \[S\]; Silver
    et al., 1996 \[D\]).

    -   **Note 1**: For cephalosporins, adequate blood levels are
        achieved and sustained for 3 to 4 hours. If the interval between
        antibiotic administration and closure of the surgical incision
        is greater than 4 hours, the administration of an additional
        dose may be considered (Mangram et al., 1999 \[E\]).

    -   **Note 2**: Although rates of infection appear to be higher in
        the umbilical route, the administration of antibiotics reduced
        the risk of infection in both groups (Leinwand, Shaul, &
        Anderson, 2000 \[D\]).

**Feeding Advancement**

1.  Vomiting following pyloromyotomy is usually self limiting. Although
    frequency of vomiting is related to type of feeding regimen,
    duration is independent of the timetable or composition of
    post-operative dietary regimen (Carpenter et al., 1999 \[D\];
    Georgeson et al., 1993 \[D\]; Gollin et al., 2000 \[D\]; Wheeler et
    al., 1990 \[C\]). It is recommended that following pyloromyotomy,
    infants be fed early and with regular formula or breast milk.

    -   **Note 1**: The composition of feeding, and the rate of
        advancement (Georgeson et al., 1993 \[D\]; Leinwand, Shaul, &
        Anderson, 2000 \[D\]; Gollin et al., 2000 \[D\]) may affect the
        incidence or severity of vomiting post-regimen, but ultimately
        does not affect time to full feedings, discharge, or post
        operative weight gain (Foster & Lewis, 1989 \[D\]). (See Table 3
        in the original guideline document.)

    -   **Note 2**: Duration of post-procedure vomiting is variable,
        with reports of 3.5% to 24% of infants with continued emesis
        more than 48 hours after surgery (Carpenter et al., 1999 \[D\];
        Scharli & Leditschke, 1968 \[C\]; Wheeler et al., 1990 \[C\]).

    -   **Note 3**: The most significant predictor of post-operative
        emesis is the duration and severity of pre-operative vomiting
        and is frequently manifested by electrolyte abnormalities
        (Gollin et al., 2000 \[D\]).

    -   **Note 4**: Postoperatively, infants may be fed volumes based on
        feedings taken pre-operatively (Local expert consensus, \[E\]).

**Discharge Criteria**

1.  Otherwise healthy infants may be discharged once they have tolerated
    two to three full feedings and/or at the discretion of the Health
    Care Provider (Carpenter et al., 1999 \[D\]). Infants with
    significant pre-operative vomiting, severe electrolyte imbalance, or
    malnutrition may need a longer period of recovery.

2.  Counseling of parents regarding post-operative emesis, assessment of
    hydration status, and signs and symptoms of infection are essential
    components of patient/family education (Local expert consensus,
    \[E\]).

**Definitions**:

**Cincinnati Children\'s Hospital Medical Center Evidence Grading
Scale**

M: Meta-analysis or Systematic Review\
A: Randomized controlled trial: large sample\
B: Randomized controlled trial: small sample\
C: Prospective trial or large case series\
D: Retrospective analysis\
O: Other evidence\
S: Review Article\
E: Expert opinion or consensus\
F: Basic Laboratory Research\
L: Legal requirement\
Q: Decision analysis\
X: No evidence

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for the
diagnosis of hypertrophic pyloric stenosis.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=12095)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is classified for each recommendation (see \"Major
Recommendations\").

**Evidence Grading Scale**

M: Meta-analysis or Systematic Review\
A: Randomized controlled trial: large sample\
B: Randomized controlled trial: small sample\
C: Prospective trial or large case series\
D: Retrospective analysis\
O: Other evidence\
S: Review Article\
E: Expert opinion or consensus\
F: Basic Laboratory Research\
L: Legal requirement\
Q: Decision analysis\
X: No evidence

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Successful treatment of hypertrophic pyloric stenosis

#### POTENTIAL HARMS

-   Upper gastrointestinal series caries the risk of ionizing radiation
    exposure, barium aspiration, and intraperitoneal barium spillage
    during surgery.

-   Infants with hypertrophic pyloric stenosis have a functional gastric
    outlet obstruction that may place them at a greater risk for
    aspiration of gastric contents during induction of anesthesia.

-   Surgical procedures carry a risk of infection.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These recommendations result from review of literature and practices
current at the time of their formulations. This guideline does not
preclude using care modalities proven efficacious in studies published
subsequent to the current revision of this document. The guideline
document is not intended to impose standards of care preventing
selective variances from the guidelines to meet the specific and unique
requirements of individual patients. Adherence to this pathway is
voluntary. The physician in light of the individual circumstances
presented by the patient must make the ultimate judgment regarding the
priority of any specific procedure.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Appropriate companion documents have been developed to assist in the
effective dissemination and implementation of the guideline.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Cincinnati Children\'s Hospital Medical Center. Evidence based clinical
practice guideline for hypertrophic pyloric stenosis. Cincinnati (OH):
Cincinnati Children\'s Hospital Medical Center; 2007 Nov 14. 17 p. \[185
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2001 Aug 8 (revised 2007 Nov 4)

#### GUIDELINE DEVELOPER(S)

Cincinnati Children\'s Hospital Medical Center - Hospital/Medical Center

#### SOURCE(S) OF FUNDING

Cincinnati Children\'s Hospital Medical Center

#### GUIDELINE COMMITTEE

Hypertrophic Pyloric Stenosis Guideline Team

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Community Physician*: Lynn Croteau, MD, Pediatrics

*Cincinnati Children\'s Hospital Medical Center Physicians*: Mark
Arkovitz, MD, Fellow \-- Ped. Surgery; Paul Guillerman, MD, Radiology;
Richard Berlin, MD, Anesthesiology; Michael Josephs, MD, Fellow \-- Ped.
Surgery; Uma Kotagal, MBBS, MSc. Director HPCE; Scott Reeves, MD,
Emergency Medicine; Fred Ryckman, MD\*, Pediatric Surgery; Brad Warner,
MD, Pediatric Surgery

*Patient Services*: Kathleen Blair, RN, MS, Ed. Coordinator \-- OR; Dawn
Butler, PharmD, Pharmacy; Toral Freson, RN, MSN, CNP -- Ped Surgery;
Tammy Lingsch, RN, C5 Charge Nurse; Amy Sapsford, RD, Nutrition
Services; Marilyn Stoops, RN, MS, CPNP \-- Ped. Surgery; Laurie
Ravagnani, RN, MS, Emergency Department; Susan Ralston, PharmD, Pharmacy

*Clinical Effectiveness*: Mary Pat Alfaro, RD, MS, Research Coordinator;
Charlotte L. Anderson, RN, MS, Pathway/Guideline Admin; Betsy Bushman,
BA, Guideline Coordinator; Edward Donovan, MD\*, Medical Director;
Danette Stanko-Lopp, MA, MPH\*, Epidemiologist; Carol Tierney, RN,
MSN\*, Education Specialist; Kate Turck, BS, Decision Support Analyst

*Ad Hoc Advisors*: Richard Azizkhan, MD, Chair \-- Ped. Surgery; Melissa
Berner, ESQ, Legal Services; Thomas DeWitt, MD, General/Community Peds;
Michael Farrell, MD, Chief of Staff; Ken Goldschneider, MD, Pain
Management; Dorine Seaquist, RN, MS, VP Patient Services

\*Involved with the 2007 revision

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The guideline was developed without external funding. All Team Members
and Clinical Effectiveness support staff listed have declared whether
they have any conflict of interest and none were identified.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children\'s
Hospital Medical Center. Evidence based clinical practice guideline for
hypertrophic pyloric stenosis. Cincinnati (OH): Cincinnati Children\'s
Hospital Medical Center; 2001 Aug 8. 16 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Cincinnati Children\'s Hospital
Medical
Center](http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/default.htm).

Print copies: For information regarding the full-text guideline, print
copies, or evidence-based practice support services contact the
Children\'s Hospital Medical Center Health Policy and Clinical
Effectiveness Department at <HPCEInfo@chmcc.org>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Post operative orders for hypertrophic pyloric stenosis. Cincinnati
    (OH): Children\'s Hospital Medical Center; 2007 Nov. 1 p.

-   Hypertrophic pyloric stenosis discharge instructions. Cincinnati
    (OH): Children\'s Hospital Medical Center; 2007 Nov. 1 p.

Electronic copies: Available from the [Cincinnati Children\'s Hospital
Medical
Center](http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/hypertrophic.htm).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 28, 2002. The information
was verified by the guideline developer on June 21, 2002. This NGC
summary was updated by ECRI Institute on February 26, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original full-text guideline, which is
subject to the following copyright restrictions:

Copies of [Cincinnati Children´s Hospital Medical Center
(CCHMC)](http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/default.htm)
Evidence-Based Clinical Practice Guidelines (EBCG) are available online
and may be distributed by any organization for the global purpose of
improving child health outcomes. Examples of approved uses of CCHMC\'s
EBCG include the following:

-   Copies may be provided to anyone involved in the organization\'s
    process for developing and implementing evidence-based care
    guidelines.

-   Hyperlinks to the CCHMC website may be placed on the organization\'s
    website.

-   The EBCG may be adopted or adapted for use within the organization,
    provided that CCHMC receives appropriate attribution on all written
    or electronic documents.

-   Copies may be provided to patients and the clinicians who manage
    their care.

Notification of CCHMC at <HPCEInfo@cchmc.org> for any EBCG adopted,
adapted, implemented or hyperlinked to by a given organization and/or
user is appreciated.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008