Three-Year Surveillance of Intussusception in Children in Switzerland

Michael Buettcher, Gurli Baer, Jan Bonhoeffer, Urs B. Schaad and Ulrich Heininger
Pediatrics 2007;120;473-480
DOI: 10.1542/peds.2007-0035

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ARTICLE

Three-Year Surveillance of Intussusception in

Children in Switzerland
Michael Buettcher, MD, Gurli Baer, MD, Jan Bonhoeffer, MD, Urs B. Schaad, MD, Ulrich Heininger, MD

Division of Pediatric Infectious Diseases, University Children’s Hospital, Basel, Switzerland

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. We attempted to obtain baseline data on the incidence of intussusception
and its association with gastroenteritis in a cross-sectional observational study in
www.pediatrics.org/cgi/doi/10.1542/
children. peds.2007-0035
METHODS. Admissions to all 38 pediatric units in Switzerland because of intussus- doi:10.1542/peds.2007-0035
ception were reported to the Swiss Pediatric Surveillance Unit from April 2003 to Drs Buettcher and Baer contributed equally
to this study.
March 2006. Patient and disease characteristics were assessed prospectively with
Key Words
the use of a standardized questionnaire based on the case definition for intussus- intussusception, epidemiology,
ception developed by the Brighton Collaboration. Completeness of reporting was Switzerland, rotavirus vaccine
verified through capture-recapture analysis. Abbreviations
SPSU—Swiss Pediatric Surveillance Unit
RESULTS. There were 294 patients with reported intussusception; 35 cases were ICD-10 —International Classification of
Diseases, 10th Revision
excluded for various reasons, and 29 additional patients were identified through SQ—standardized questionnaire
International Classification of Diseases, 10th Revision, codes. After capture-recapture Accepted for publication Apr 3, 2007
analysis, we estimated underreporting to the Swiss Pediatric Surveillance Unit to Address correspondence to Ulrich Heininger,
be 32% and we calculated a true number of 381 intussusception episodes. The MD, Division of Pediatric Infectious Diseases,
University Children’s Hospital Basel, PO Box
highest level of diagnostic certainty was reached by 248 patients, and 20 fulfilled 4005, Basel, Switzerland. E-mail: ulrich.
level 2 criteria; for the remaining 20 patients, available information was insuffi- heininger@ukbb.ch
cient. The mean age of the patients was 2.7 years. The yearly mean incidence of PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2007 by the
intussusception was 38, 31, and 26 cases per 100 000 live births in the first, second, American Academy of Pediatrics
and third year of life, respectively, with no apparent seasonality. Seventy patients
had a history of coinciding gastroenteritis, and 5 of 61 tested positive for rotavirus.
Spontaneous devagination was observed for 38 patients; enemas reduced intus-
susception successfully in 183 cases, whereas surgical treatment was required in
67. All patients recovered without sequelae.
CONCLUSIONS. This is the first prospective nationwide surveillance of intussusception
in childhood using a standardized case definition. Most cases occurred beyond
infancy, and association with rotavirus gastroenteritis was rare.

PEDIATRICS Volume 120, Number 3, September 2007 473

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I NTUSSUSCEPTION IS DEFINED as the invagination of a
proximal segment of intestine into a distal segment of
intestine, usually ileocolic.1 This results in obstruction of
bowel passage, constriction of the mesentery, and ob-
struction of the venous blood flow, which is character-
ized by sudden onset of colicky abdominal pain. The
mean age at diagnosis ranges from 7 to 14 months in
studies including different age groups.2–4 Estimates for
yearly incidence range from 0.5 to 2.24 cases per 1000
infants or young children.3–9 Intussusception peaks have
been observed to coincide with seasonal viral gastroen-
teritis. One study in France noted a significant peak of
intussusception cases in spring,6 and a retrospective hos-
pital chart study in Tanzania found that most of the cases
presented from January to March and from July to Sep-
tember.10 However, the great majority of studies did not
find any seasonality in the occurrence of intussuscep-
tion.11–21 Diagnosis is made through ultrasonography
and/or radiographically guided enema; the latter is also
the treatment of choice unless symptoms have been
present for a long time and the child’s condition is crit-
ical. In that case, and if repositioning via enema fails,
surgery is necessary. The cause of intussusception is
unknown in most cases.22
In 1999, an orally administered, live attenuated rota-
virus vaccine was licensed in the United States and else-
where (RotaShield; Wyeth-Ayerst, Marietta, PA).
Shortly after implementation of mass immunization in
the United States, concerns regarding an association of
rotavirus vaccine with intussusception were raised (in
October 1999); after additional investigation, the vaccine
was withdrawn from the market.23 New orally adminis-
tered, live attenuated rotavirus vaccines have been li-
censed recently in the United States, Europe, and else-
where. During prelicensure studies, no evidence for an
increased risk for intussusception was found for these
new vaccines.16,24 However, local epidemiologic baseline
data on intussusception are important for safety moni-
toring after widespread use of these vaccines.
With this background, the primary goal of our study
was to determine the incidence and clinical and epide-
miologic characteristics of intussusception in children in
Switzerland. A secondary goal was to assess a possible
association between rotavirus gastroenteritis and intus-
susception.
METHODS
Case Definition
Cases with a discharge diagnosis of intussusception were
categorized by the central study investigators (Drs
Buettcher and Baer) in levels of diagnostic certainty,
according to the case definition developed by the Brigh-
ton Collaboration Working Group for Intussusception.25
Briefly, level 1 requires the demonstration of invagina-
tion of the intestine at surgery and/or through either air-
474 BUETTCHER et al
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or liquid-contrast enema, the demonstration of an intra-
abdominal mass on abdominal ultrasound scans, with
specific characteristic features and proven to be reduced
by hydrostatic enema on postreduction ultrasound
scans, and/or the demonstration of invagination of the
intestine at autopsy. If level 1 criteria are not fulfilled,
then various combinations of major and minor clinical
criteria may define cases at levels 2 and 3 (see ref 25 for
details).
Concurrent gastroenteritis and concurrent upper re-
spiratory tract infection were defined as the presence of
vomiting and ⱖ1 loose bowel movement and rhinitis,
conjunctivitis, pharyngitis, and/or acute otitis media, re-
spectively, at the time of intussusception. In accordance
with the Brighton Collaboration case definition,25 typical
findings on abdominal radiographs were defined as fluid
levels and dilated bowel loops. Intermittent intussuscep-
tion was defined as intussusception that was present at
level 1, 2, or 3 of diagnostic certainty at admission and
resolved spontaneously during the hospital stay without
any intervention (such as hydrostatic enema) or was no
longer present during surgery.
Swiss Pediatric Surveillance Unit
The Swiss Pediatric Surveillance Unit (SPSU) was estab-
lished in 1995 to assess the epidemiologic features of
selected childhood diseases leading to hospitalization. It
is operated under the auspices of the Swiss Pediatric
Society and the Swiss Federal Office of Public Health.
The study period for intussusception surveillance was
from April 1, 2003, to March 31, 2006.
This was a cross-sectional observational study. Before
the start of the surveillance, all 38 pediatric and associ-
ated pediatric surgery units in Switzerland received in-
formation on the project, including the study protocol
and a sample of the standardized questionnaire (SQ)
(available from the authors on request), which included
questions on demographic characteristics, clinical signs
and symptoms, results of ultrasonography, radiology,
and/or surgery, and final outcome, including complica-
tions.
At the end of each month, reporting forms were
mailed to all units. For each reported case of intussus-
ception, the respective attending pediatrician or surgeon
had to complete the SQ and send it to our central study
office. On receipt, the SQs were reviewed for complete-
ness by the central study investigators (Drs Buettcher
and Baer). In cases with missing or inconclusive data,
the respective attending pediatrician or surgeon was
contacted immediately via telephone or fax machine, to
clarify the issue. After clarification, data were entered
into the database.
In Switzerland, children with suspected intussuscep-
tion are admitted to the hospital, where appropriate
management (including radiographic diagnosis and all
treatment modalities) can be provided as necessary. The
likelihood that cases were managed on an outpatient
basis is very low.

Patients Identified According to International Classification of

Diseases, 10th Revision (ICD-10) Codes
To evaluate completeness of SPSU reporting and to re-
fine incidence estimates, we performed a capture-recap-
ture analysis after completion of the study. The second
independent data source was medical charts of children
admitted to 8 of the 38 units during the study period.
The 8 units were selected according to their numbers of
reported cases, that is, 2 with the highest numbers of
reported cases, 2 with median numbers of reports, 2
with the lowest numbers of reports (but ⬎0), and 2 that
reported no cases. Cases were identified from the hospi-
tals’ databases with ICD-10 codes K56.1 (acute intussus-
ception of the intestine) and K38.8 (acute intussuscep-
tion of the appendix). All pertinent records of previously
unreported cases of intussusception were reviewed by
staff members of the respective hospitals and were en-
tered into the SQ by the staff members or by the central
investigators (Drs Buettcher and Baer).
Statistical Analyses
Statistical analyses were performed with SPSS 13.0.0
(SPSS Inc, Chicago, IL). Data on the general population
during the study period were obtained from the Swiss
Federal Office of Statistics.26 Independent proportions
were compared by using the Pearson ␹2 test. P values of
⬍.05 were considered significant.
Reported cases were categorized into levels of diag-
nostic certainty, with the Brighton Collaboration case
definition for acute intussusception, independently by 2
of us (Drs Buettcher and Baer), followed by calculation
of interobserver agreement (␬ value) as described previ-
ously.27 The capture-recapture analysis was performed
according to the Chapman-Wittes adjustment of the Lin-
coln-Petersen maximal likelihood estimate.28
RESULTS
Surveillance and Capture-Recapture Analysis
A total of 294 cases were reported via SPSU during the
3-year study period. Thirty-five reports needed to be
excluded (mainly because of duplicate reporting of pa-
tients who were transferred from a local pediatric unit to
a nearby larger unit for additional treatment; in those
instances, the reports from the unit where the patient
was finally treated were used for analysis). With the
remaining 259 cases and an additional 29 cases identi-
fied through ICD-10 codes in the capture-recapture
analysis, a total of 288 cases were available for final
analyses (Fig 1). Twenty-seven (9%) of 288 question-
naires were incomplete and needed to be clarified
through contact with the responsible physician or sur-
geon.
FIGURE 1
Profile of study population. IS indicates intussusception. a Category as defined by the
Brighton Collaboration.25
The results of the capture-recapture analysis are pre-
sented in Table 1. The completeness of SPSU reporting
and ICD-10 code identification was 0.68 and 0.76, re-
spectively (P ⫽ .978). Therefore, a 32% rate of under-
reporting to the SPSU can be assumed, and the estimated
true number of cases of intussusception leading to hos-
pitalization during the 3-year study period is 381 rather
than 259.
Epidemiologic and Clinical Characteristics
Of the 288 patients, 194 (67%) were male; 8 (3%) were
former preterm infants; 39 (13%) had comorbidities,
with cystic fibrosis (n ⫽ 6) and constipation (n ⫽ 5)
being most frequent; and 18 (6%) had a history of
previous intussusception (13 with 1 previous episode
and 5 with ⬎1 previous episode). The mean age of the
patients was 2.7 years (median: 1.9 years; interquartile
range: 0.9 –3.4 years). Infants (ie, ⬍12 months of age)
represented the largest single age group, and more cases
occurred in the second half, compared with the first half,
of the first year of life (Fig 2).
The mean duration of hospitalization was 4.3 days
(median: 2.5 days; interquartile range: 1–5 days). At
admission, 70 cases (24%) presented with concurrent
gastroenteritis; in 5 (8%) of 61 cases in which specific
TABLE 1 Capture-Recapture Analysis Using SPSU Reporting and
ICD-10 Codes as Independent Data Sources
Identified With n
ICD-10 Codes
Reported by Not Reported Total
SPSU by SPSU
Yes 62 29 91
No 19 9a 28
Total 81 38 119
Results are based on 110 cases from 8 selected pediatric units.
a Undiscovered cases calculated in capture-recapture analysis.

PEDIATRICS Volume 120, Number 3, September 2007 475

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FIGURE 2
Age distribution of all intussusception cases (n ⫽ 288). Inset, Age distribution of intussusception cases in infants (0 –12 months; n ⫽ 83).
tests were performed, rotavirus was detected in stool
samples. The distributions of all cases and cases of intus-
susception associated with gastroenteritis were similar
across seasons (Fig 3), with no apparent peak between
December and April, when most cases of rotavirus gas-
troenteritis occur in Switzerland.29 An additional 45 chil-
dren (16%) had coinciding illnesses other than gastro-
enteritis, with upper respiratory tract infections (n ⫽ 19)
being most frequent.
During the study period, there were an average of
72 550 live births per year in Switzerland.26 The mean
yearly incidence rates of intussusception in the first,
second, and third year of life were 38, 31, and 26 cases
per 100 000, respectively, with some variation from year
to year (Fig 4). With the capture-recapture analysis
taken into account, however, the true incidence rates
can be estimated to be 56, 46, and 38 cases per 100 000,
respectively.
The most frequently observed symptoms of patients
were abdominal pain (92%), vomiting (53%), and pallor
476 BUETTCHER et al
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(45%) (Table 2). “Red currant jelly” stools were seen in
36 cases (13%). Infants (n ⫽ 83), being the largest age
group, presented mainly with abdominal pain (n ⫽ 67;
81%), vomiting (n ⫽ 56; 66%), and bloody stools (n ⫽
47; 57%).
Of the cases (n ⫽ 281) for which the onset of symp-
toms before admission to the hospital was known (in
hours), 146 (52%) had symptoms for ⬍24 hours, 54
(19%) for ⬎24 hours but ⬍48 hours, and 81 (29%) for
⬎48 hours. When we compared patients hospitalized
within 24 hours after the onset of illness with those with
illness for ⬎24 hours before admission, red currant jelly
stools were present in similar proportions (27 of 146
patients, 18%, versus 20 of 135 patients, 15%; P ⫽ .41),
whereas a palpable abdominal mass was observed more
frequently for patients with early presentation (77 of 146
patients, 53%, versus 49 of 135 patients, 36%; P ⫽ .006).
Ultrasonography was the most frequently used
method for diagnosis, and it confirmed intussusception
for 236 (85%) of 278 patients. Intermittent intussuscep-
 35

30

25

20
FIGURE 3
Seasonal distribution of all intussusception cases (black 15
bars; n ⫽ 288) and cases associated with gastroenteritis
(gray bars; n ⫽ 70), according to month of occurrence
10
(cumulative for 3 study years).

Au gu st
Ap ri l

Ju ly
Marc h

Oct obe r
May

Ju ne

No ve mb er
Jan ua ry

Fe brua ry

Se ptem ber

Decem ber
FIGURE 4
Incidence (cases per 100 000 live births per
year) of intussusception according to study
year and age group in children up to 3 years
of age.

tion was found for 31 patients (11%), ultrasound ruled
out intussusception for 2 patients (1%), and findings
were inconclusive for 9 patients (3%). Abdominal radio-
graphs were performed for 90 patients; 67 (74%) re-
vealed typical findings of intussusception and another 19
(21%) were consistent with intussusception, as were 3
of 4 abdominal computed tomograms. Of the 188 cases
with specific information available, 156 (83%) were il-
eocolic, 31 (16%) were ileoileal, and 1 (0.5%) was colo-
colic.
Outcomes
Of the 288 patients, 183 (63%) were treated successfully
through hydrostatic reduction of intussusception,
whereas 67 (23%) required surgical treatment (after
unsuccessful conservative treatment for 36 patients, af-
ter relapse for 14, and as the primary intervention for
17). Meckel diverticulum (n ⫽ 6) and intestinal lym-
phoma (n ⫽ 3) were discovered as obvious causes of
intussusception during surgery. Intussusception oc-
curred as a complication of gastrointestinal vasculitis
with Henoch-Schönlein purpura in 7 patients; in the
great majority of the remaining cases (272 of 288 cases,
94%), the underlying cause of intussusception remained
unknown. Thirty-eight patients (13%) recovered with
spontaneous devagination early during their hospital
stays.
The categorization of intussusception cases according
to the level of diagnostic certainty (Brighton Collabora-
tion case definition) is presented in Table 3. The great
majority of cases fulfilled the criteria for the highest level
of diagnostic certainty, and agreement between the 2
independent observers (Drs Buettcher and Baer) who
reviewed and classified the reported cases was 0.96 (␬

PEDIATRICS Volume 120, Number 3, September 2007 477

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 TABLE 2 Symptoms of Intussusception in Different Age Groups
Clinical Symptoms n (%) P (Infants vs
Children of ⱖ1 y)
All Infants Children of ⱖ1 y
(N ⫽ 288) (N⫽ 83) (N⫽ 205)
Abdominal pain 265 (92) 67 (81) 198 (97) ⬍.01
Vomiting 152 (53) 56 (66) 96 (47) .01
Pallor 130 (45) 39 (47) 91(44)
Abdominal mass 110 (38) 30 (36) 80 (39)
Lethargy 99 (34) 38 (46) 61 (30) .03
Bloody stools 72 (25) 47 (57) 25 (12) ⬍.01
Abdominal distention 59 (21) 21 (25) 38 (19)
Bile-stained vomiting 38 (13) 12 (15) 26 (13)
“Red currant jelly” stools 36 (13) 25 (30) 11 (5) ⬍.01
Blood in rectal examination 16 (6) 13 (16) 3 (2) ⬍.01
Hypovolemic shock 7 (2) 3 (4) 4 (2)
Rectal mass 1 (0.3) 1 (1) 0 (0) .03
P values of ⬍.05 are shown.

TABLE 3 Categorization of Intussusception Cases According to
Brighton Collaboration Case Definition
n (%)
Total
Level 1 diagnostic certainty 248 (86.1)
Level 2 diagnostic certainty 20 (6.9)
Level 3 diagnostic certainty 0 (0)
Insufficient information to meet case definition 20 (6.9)
Total 288 (100)
value). All patients recovered and were discharged with-
out apparent sequelae.
DISCUSSION
We surveyed prospectively the spectrum of clinical char-
acteristics, management, and outcomes of intussuscep-
tion in children and adolescents in Switzerland over a
3-year period, with the use of standardized criteria de-
fined by the Brighton Collaboration.25 Epidemiologic
and clinical characteristics of intussusception were stud-
ied previously,2–4,6,30 but none of those studies was per-
formed prospectively and standardized criteria were not
used to define cases.
In contrast, our study involved prospective nation-
wide surveillance of intussusception in children, and we
used standardized criteria for data collection. Two re-
cently published studies used a similar approach.11,19
However, those studies included only children ⬍2 years
of age, whereas our surveillance included children of
any age. An additional unique strength of our study was
the attempt to ascertain the completeness of reporting
through capture-recapture analysis using 2 data sources.
Surprisingly, the ICD-10 code search captured only 76%
of cases reported to the SPSU, which is remarkably sim-
ilar to previous SPSU surveillance of varicella hospital-
izations, for which the corresponding figure was 78%.31
In our experience, this is most likely explained by coding
mistakes in the hospital databases.
Underreporting is an inherent limitation of any sur-
veillance study. Capture-recapture methods allow esti-
Age of
⬍1 y mation of the degree of underreporting (ie, the number
73 (88.0) of unknown cases) and thus estimation of the true num-
6 (7.3) ber of cases. Our estimate is likely to be valid, because
0 (0) the probability of cases being recorded in one sample
4 (4.8) was independent of the probability of cases being re-
83 (100)
corded in the other, and cases were equally likely to be
captured in either sample.
As members of our group (with the use of data from
the first year of this study) and others showed previ-
ously, the case definition for intussusception developed
recently by the Brighton Collaboration is useful and
reliable,27 and 86% of reported cases reached the highest
level of diagnostic certainty. The triad of abdominal pain,
palpable abdominal mass, and red currant jelly stools has
been described as the typical presentation of intussus-
ception.5 In our study, abdominal pain, vomiting, and
pallor were the most prominent symptoms at presenta-
tion, whereas a palpable abdominal mass (38%) and red
currant jelly stools (13%) were less common. It could be
argued that the latter would be signs of progressed in-
tussusception. However, the presence of red currant jelly
stools was not dependent on the duration of illness, and
an abdominal mass was more often palpable in patients
with early (rather than late) presentation to the hospital.
Spontaneous devagination of intussusception has
been reported to occur in 4% to 10% of cases.32,33 We
observed this phenomenon in 13% of our cases. Possi-
bly, comparatively early presentation of children with
abdominal pain to hospitals and rapid availability of
imaging techniques allowed sensitive detection of cases.
Early relapse of intussusception after conservative inter-
vention occurred for 13% of patients, and 23% required
surgery during the course of their illness, which is in the
range of previous observations.3,6,32,34

478 BUETTCHER et al
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 Only a minority of cases (24%) in this prospective
study had associated gastroenteritis and, despite the high
rate of rotavirus testing (61 of 70 cases), only 5 cases of
rotavirus infection were identified. Rotavirus infection
has a distinct seasonal pattern in Switzerland, with
yearly peaks between December and April,29 but no such
seasonality for intussusception was observed during the
3-year study period. In accordance with previous re-
ports, this indicates a lack of apparent association be-
tween these 2 entities.11,16,24,35–37
We found the highest incidence of intussusception in
infants (ie, 56 cases per 100 000). This is in accordance
with previous studies,3,4,8,19,30 but the rate is in the lower
part of the range from earlier reports that reported spe-
cifically the incidence in infants, from Venezuela (inci-
dence: 24 cases per 100 000),5 Chile (incidence: 33 cases
per 100 000),38 Vietnam (incidence: 302 cases per
100 000),11 Australia (incidence: 71–131 cases per
100 000),11,18 United Kingdom (incidence: 66 –100 cases
per 100 000),4,9 Israel (incidence: 224 cases per
100 000),3 and Singapore (incidence: 60 cases per
100 000).19 It is also low in the range (incidence: 50 –230
cases per 100 000) from studies that reported overall
incidence but not rates for specific age groups.5–8 Al-
though most previous studies found the majority of all
cases in infants,3–5,8,19,30 only 29% of our cases belonged
to that age group, and incidences in the second and third
years of life were similar to those in infants. The fact that
we did not restrict our surveillance to young children
probably explains this difference. Consequently, the
mean age (2.7 years) and median age (1.9 years) of our
patients were considerably higher than those in other
reports (mean age: 7–14 months).2–4 Interestingly, a
gradual and unexplained increase in the mean age of
patients with intussusception has been observed in Sin-
gapore,19 Taiwan,5 Denmark8 and the United States13 in
the recent past; this epidemiologic change might have
had occurred in Switzerland earlier, but there are no
data available for comparison.
CONCLUSIONS
This study provides the first estimate of the incidence of
intussusception in children in Switzerland obtained by
using a standardized case definition and data generated
through prospective surveillance. The data were ob-
tained throughout the nation and should be useful for
postmarketing safety surveillance if orally administered
rotavirus vaccines are used widely in the near future.
Given the comparatively low rate of intussuscep-
tion associated with RotaShield in the past (15 cases of
intussusception after administration of ⬃1.5 million
doses, of which 13 cases occurred after the first dose39)
and the small number of live births in Switzerland per
year (⬃72 000), the likelihood of determining an as-
sociation of intussusception with any new rotavirus
vaccine will be limited. However, standardized assess-
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ment of intussusception episodes is feasible, and in-
ternationally standardized postlicensure studies would
allow data comparability beyond any single country’s
pertinent population.
ACKNOWLEDGMENTS
An unrestricted research grant was provided by Glaxo
SmithKline.
We thank Dr Terhi Tapiainen for assisting in project
coordination during the first study year; Daniela Beeli,
SPSU secretary, for coordinating the report forms; Esther
Schilling, study secretary at the University Children’s
Hospital Basel, for keeping track of the reports; the SPSU
representatives of the respective pediatric and pediatric
surgical units in Switzerland (C. Aebi, E. Antonelli, W.
Baer, B. Berclaz, M. Bianchetti, M. Bittel, A. Blumberg,
H.-U. Bucher, L. Buetti, E. Bussmann, O. Carrel, P. O.
Cattin, A. Corboz, G. Délèze, P. Diebold, P. Dolivo, F.
Farron, M. Gehri, T. Gehrke, C.A. Haenggeli, P. S. Hüppi,
P. Imahorn, C. Kind, W. Kistler, B. Knöpfli, O. Lapaire,
B. Laubscher, U. Lips, N. Lutz, A. Malzacher, J. McDou-
gall, J.-L. Micheli, J. Mayr, M. Mönkhoff, V. Pezzoli,
B. M. Regazzoni, L. Reinhard, F. Renevey, P. Ri-
mensberger, H. Roten, C. Rudin, J. W. Salomon, V.
Schlumbom, M. Schwöbel, G. Staubli, C. Stüssi, R.
Tabin, B. Wildhaber, J. Wisser, M. Wopman, Z. Za-
chariou, U. G. Zeilinger, A. Zemmouri, and U. Zimmer-
mann) for providing reports; and all of the dedicated
physicians for taking care of the patients and helping to
complete the questionnaires.
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 Three-Year Surveillance of Intussusception in Children in Switzerland
Michael Buettcher, Gurli Baer, Jan Bonhoeffer, Urs B. Schaad and Ulrich Heininger
Pediatrics 2007;120;473-480
DOI: 10.1542/peds.2007-0035
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