Play therapy in children with autism: Its role, implications, and limitations

Play is a pleasurable physical or mental activity that enhances the child’s skills involving negotiation abilities, problem-solving, manual dexterity, sharing, decision-making, and working in a group. Play affects all the brain's areas, structures, and functions. Children with autism have adaptive behavior, adaptive response, and social interaction limitations. This review explores the different applications of play therapy in helping children with autism disorder. Play is usually significantly impaired in children with autism. Play therapy is mainly intended to help children to honor their unique mental abilities and developmental levels. The main aim of play therapy is to prevent or solve psychosocial difficulties and achieve optimal child-healthy growth and development. Play therapy helps children with autism to engage in play activities of their interest and choice to express themselves in the most comfortable ways. It changes their way of self-expression from unwanted behaviors to more non-injurious expressive behavior using toys or activities of their choice as their words. Play therapy also helps those children to experience feeling out various interaction styles. Every child with autism is unique and responds differently. Therefore, different types of intervention, like play therapy, could fit the differences in children with autism. Proper evaluation of the child is mandatory to evaluate which type fits the child more than the others. This narrative review revised the different types of play therapy that could fit children with autism in an evidence-based way. Despite weak evidence, play therapy still has potential benefits for patients and their families.

Adipocytokine profile in children with Kawasaki disease

This letter to editor discusses on the publication on adipocytokine profile in children with Kawasaki disease. Concerns on confounding factors are raised and discussed.

Tangled relationship between insulin resistance and microalbuminuria in children with obesity

Childhood obesity represents a complex disease with a well-known cardiometabolic burden including fatty liver, type 2 diabetes, metabolic syndrome, and cardiovascular disease. From a pathogenic point of view, insulin resistance (IR) represents the key factor underlying the spectrum of these obesity consequences. As observed in adults, recent data supported the occurrence of microalbuminuria (MA) as marker of early kidney dysfunction and its potential link with cardiometabolic factors also in children with obesity. In fact, a well-documented pathophysiological hypothesis both in adults and children supported an intimate correlation with the major feature of obesity such as IR through the influence of insulin on renal hemodynamics. Based on the clinical and prognostic relevance of this relationship in daily practice (including an increased risk of chronic kidney disease development overtime), more scientific attention needs to be paid to the evaluation of early kidney damage in children with obesity. In this paper, we attempt to address three debated questions regarding the intriguing liaison between IR and MA in children with obesity: (1) What is the prevalence of pediatric MA? (2) What is the state of art of MA in children with obesity? and (3) Is there a link between IR and MA in children with obesity?

Insulin pumps in children - a systematic review

BACKGROUND

Insulin pump therapy is a real breakthrough in managing diabetes Mellitus, particularly in children. It can deliver a tiny amount of insulin and decreases the need for frequent needle injections. It also helps to maintain adequate and optimal glycemic control to reduce the risk of metabolic derangements in different tissues. Children are suitable candidates for pump therapy as they need a more freestyle and proper metabolic control to ensure adequate growth and development. Therefore, children and their caregivers should have proper education and training and understand the proper use of insulin pumps to achieve successful pump therapy. The pump therapy continuously improves to enhance its performance and increase its simulation of the human pancreas. Nonetheless, there is yet a long way to reach the desired goal.

AIM

To review discusses the history of pump development, its indications, types, proper use, special conditions that may enface the children and their families while using the pump, its general care, and its advantages and disadvantages.

METHODS

We conducted comprehensive literature searches of electronic databases until June 30, 2022, related to pump therapy in children and published in the English language.

RESULTS

We included 118 articles concerned with insulin pumps, 61 were reviews, systemic reviews, and meta-analyses, 47 were primary research studies with strong design, and ten were guidelines.

CONCLUSION

The insulin pump provides fewer needles and can provide very tiny insulin doses, a convenient and more flexible way to modify the needed insulin physiologically, like the human pancreas, and can offer adequate and optimal glycemic control to reduce the risk of metabolic derangements in different tissues.

Cow’s milk-induced gastrointestinal disorders: From infancy to adulthood

Milk is related to many gastrointestinal disorders from the cradle to the grave due to the many milk ingredients that can trigger gastrointestinal discomfort and disorders. Cow’s milk protein allergy (CMPA) is the most common food allergy, especially in infancy and childhood, which may persist into adulthood. There are three main types of CMPA; immunoglobulin E (IgE)-mediated CMPA, non-IgE-mediated CMPA, and mixed type. CMPA appears before the first birthday in almost all cases. Symptoms may start even during the neonatal period and can be severe enough to simulate neonatal sepsis. CMPA (often non-IgE mediated) can present with symptoms of gastroesophageal reflux, eosinophilic esophagitis, hemorrhagic gastritis, food protein-induced protein-losing enteropathy, and food protein-induced enterocolitis syndrome. Most CMPAs are benign and outgrown during childhood. CMPA is not as common in adults as in children, but when present, it is usually severe with a protracted course. Lactose intolerance is a prevalent condition characterized by the development of many symptoms related to the consumption of foods containing lactose. Lactose intolerance has four typical types: Developmental, congenital, primary, and secondary. Lactose intolerance and CMPA may be the underlying pathophysiologic mechanisms for many functional gastrointestinal disorders in children and adults. They are also common in inflammatory bowel diseases. Milk consumption may have preventive or promoter effects on cancer development. Milk may also become a source of microbial infection in humans, causing a wide array of diseases, and may help increase the prevalence of antimicrobial resistance. This editorial summarizes the common milk-related disorders and their symptoms from childhood to adulthood.

Childhood constipation: Current status, challenges, and future perspectives

Constipation in children is a major health issue around the world, with a global prevalence of 9.5%. They present to clinicians with a myriad of clinical signs. The Rome IV symptom-based criteria are used to diagnose functional constipation. Functional constipation is also a huge financial burden for healthcare system and has a detrimental impact on health-related quality of life of children. There are various risk factors identified globally, including centrally connected factors such as child abuse, emotional and behavioral issues, and psychological stress. Constipation is also precipitated by a low-fiber diet, physical inactivity, and an altered intestinal microbiome. The main pathophysiological mechanism is stool withholding, while altered rectal function, anal sphincter, pelvic floor, and colonic dysfunction also play important roles. Clinical evaluation is critical in making a diagnosis, and most investigations are only required in refractory patients. In the treatment of childhood constipation, both nonpharmacological (education and de-mystification, dietary changes, toilet training, behavioral interventions, biofeedback, and pelvic floor physiotherapy), and pharmacological (osmotic and stimulant laxatives and novel drugs like prucalopride and lubiprostone) interventions are used. For children with refractory constipation, transanal irrigation, botulinum toxin, neuromodulation, and surgical treatments are reserved. While frequent use of probiotics is still in the experimental stage, healthy dietary habits, living a healthy lifestyle and limiting exposure to stressful events, are all beneficial preventive measures.

Three novel homozygous ITGB2 mutations among two patients with leukocyte adhesion defect type-1: Two case reports

BACKGROUND

A leukocyte adhesion defect (LAD) is a rare primary immunodeficiency disorder. LAD type 1 (LAD-1) is the most common, which is caused by ITGB2 mutation resulting in dysfunction of β2 integrin, which impairs leukocyte adherence to the endothelium.

CASE SUMMARY

The first two cases of LAD-1 in Thailand presented with recurrent omphalitis, soft tissue infection, marked leukocytosis, and neutrophilia. One patient experienced delayed umbilical cord separation. Mutation analysis was performed by direct DNA sequencing of the ITGB2 gene. The results revealed two novel homozygous missense mutations, c.920C>T (p.Leu307Pro) in exon 8 and c.758G>A (p.Arg253His) in exon 7, and one novel homozygous nonsense mutation, c.262C>T (p.Gln88Ter) in exon 4, in the genomic DNA of the first and second patients, respectively. Heterozygous mutations were identified in the parents of both patients, suggesting a carrier status. The patients were administered intravenous antibiotics for infections with good clinical responses. Hematopoietic stem cell transplantation could not be performed due to the unavailability of matched donors. However, a significant decline in infections was observed after antibiotic prophylaxis. Several follow-up visits were conducted for both patients. They are currently 6 years old.

CONCLUSION

Molecular analysis is essential for definitive diagnosis, early treatment implementation, and prevention of LAD-1 in future pregnancy.

Rational use of antibiotics in children with diabetic ketoacidosis needs attention

Diabetic ketoacidosis (DKA) in children may lead to acute kidney injury (AKI). Among 45 children with DKA in our center, eight cases had AKI on admission, and in one child, his kidney function did not recover until 3 mo after discharge. This child was treated with antibiotics (cephalosporin), and we cannot rule out delayed AKI recovery due to the combined effects of the drug and the disease. Pediatricians should be concerned about the impact of nephrotoxic drug and disease interactions on children's kidney function, and need to follow up children with DKA and AKI to determine the development of AKI.

Utilization of chest tube as an esophagus stent in pediatric caustic injuries: A retrospective study

BACKGROUND

The management of caustic esophageal burns in the pediatric population has changed over the years, while the most optimal management with regards to effectiveness, availability, and cost-beneficent stays controvertible.

AIM

To describe how to utilize a chest tube for esophageal stenting in pediatrics.

METHODS

Data regarding the etiology, treatment, and complications of caustic injury in pediatrics over 10 years was collected retrospectively. Furthermore, data regarding the patient's follow-up who underwent esophageal chest tube (ECT) were collected. The ECT was prepared by carving a narrowed section in the chest tube while maintaining the radiopaque section. The ECT will then be positioned from the cricopharyngeal and exited through the nostril and fixed on the patient's cheek.

RESULTS

During the period of our study, data from 57 patients with an average age of 2.5 years (range 1-12; SD = 1.7) were obtained. The results showed that 89% of esophageal injury was due to alkaline and 9.4% were caused by acidic agents. The treatment methods showed that 29 patients (50.8%) recovered with dilatation alone. In 16 patients (28.06%), the esophageal repair was performed by using the colon, and in 5 patients (8.7%), other surgical methods were used and in 7 patients (12.2%), the ECT stents were used. ECT was inserted in 7 cases with a mean age of 2 (range: 1.5-3) years who were classified as grade IIB or III. Grading was performed by endoscopy assessment on the first day. Antibiotics and corticosteroids were administrated as initial medical management for all patients. ECT implantation was done during the first 8 d for 5 out of 7 cases (mean: 3.8 d). For the 2 patients, ECT was used after 27 (patient 6) d and 83 (patient 7) d. The reason for late stenting in these patients was a postponed referral to our center, in which patient 7 even received 4 dilation episodes before visiting our center. ECT was removed after an average of 44 d in the first 5 patients, while in the other 2 patients (6 and 7) was 2 and 1 wk, respectively. There was no complication related to, or failure of, stent placement. It is worth mentioning that none of the 7 ECT cases required gastrostomy or jejunostomy.

CONCLUSION

The ECT method introduced in our study can be used as a broadly available, economic, and easy-use facility for esophageal stenting, particularly in developing countries and emergency departments which have limited access to modern equipment. Further multicenter studies with higher volume patients are required for further deployment of this method.

Children with type 1 diabetes in COVID-19 pandemic: Difficulties and solutions

Children/adolescents with type 1 diabetes (T1D) require holistic approach and continuous care. However, the coronavirus disease 2019 (COVID-19) pandemic has made challenges for the T1D children and their caregivers, professionals, and the healthcare system. This minireview aims to consolidate and discuss the difficulties and solutions of children with type 1 diabetes in the COVID-19 pandemic. T1D has been the most common type of diabetes in children and adolescents and the last decades has seen a rapid increase in the prevalence of T1D in youths worldwide, which deserves a public concern particularly in the COVID-19 pandemic. As reported in previous studies, T1D is a risk factor related to severe cases, while the virus may induce new-onset diabetes and serious complications. Moreover, restriction strategies influence medical availability and lifestyle, impact glycemic control and compilation management, and thus pose stress on families and health providers of youths with T1D, especially on those with certain fragile conditions. Therefore, special treatment plans are required for children provided by caregivers and the local health system. Latest health tools such as improved medical devices and telemedicine service, as well as a combined support may benefit in this period. This minireview emphasises that continued medical access and support are required to prevent deteriorated condition of children and adolescents with diabetes throughout this pandemic. Therefore, strategies are supposed to be formulated to mitigate the difficulties and stress among this group, particularly in the most at-risk population. Proposed solutions in this minireview may help individuals and the health system to overcome these problems and help youths with T1D in better diabetes management during such emergency situations.

Effects of adherence to the Mediterranean diet in children and adolescents with irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a highly prevalent gastrointestinal disorder in children and adults, which increased over the past twenty years. The Mediterranean diet is a well-known diet full of antioxidants and anti-inflammatory ingredients.

AIM

To evaluate the safety, tolerability, and effects of adherence to the Mediterranean diet on disease patterns in children and adolescents with IBS.

METHODS

This prospective, cross-sectional case-controlled study included 100 consecutive IBS patients diagnosed according to Rome IV criteria, aged 12-18 years. Patients were subdivided into two groups (50 patients each); Group I received a Mediterranean diet, and Group II on their regular diet for six months. Besides IBS scores (IBS-SSS, IBS-QoL, and total score), different clinical and laboratory parameters were evaluated at the start and end of the study.

RESULTS

The Mediterranean diet was safe and well-tolerated in IBS patients. IBS children and adolescents with good adherence to the Mediterranean diet (KIDMED Score ≥ 8 points); group I showed significant improvement in IBS scores. IBS-SSS in the Mediterranean diet group was 237.2 ± 65 at the beginning of the study and decreased to 163.2 ± 33.8 at the end of the study (P < 0.001). It did not show a significant improvement in the group with a regular diet (248.3 ± 71.1 at the beginning of the study compared to 228.5 ± 54.3 at the study end with P < 0.05). The mean IBS-SSS in the Mediterranean diet group significantly improved compared with the group with a regular diet. Mean IBS-QoL in group I improved from 57.3 ± 12.9 at the start of the study to 72.4 ± 11.2 at the study end (P < 0.001) and significantly improved when compared to its level in group II at the study end (59.2 ± 12.7 with P < 0.001), while group II showed no significant improvement in IBS-QoL at the study end when compared to the beginning of the study (59.2 ± 11.7 with P >0.05). The mean total IBS score in group I became 28.8 ± 11.2 at the end of our study compared to 24.1 ± 10.4 at the start (P < 0.05) and significantly improved when compared to its level in group II at the end of the study (22.1 ± 12.5 with P < 0.05), while in group II, non-significant improvement in the total score at the end of our study compared to its mean level at the start of the study (22.8 ± 13.5 with P > 0.05).

CONCLUSION

The Mediterranean diet was safe and associated with significant improvement in IBS scores in children and adolescent patients with IBS.

Impact of sports participation on cardiovascular health markers of children and adolescents: Systematic review and meta-analysis

BACKGROUND

Cardiovascular diseases have a high prevalence in adults and their development begins in the first decades of life. On the other hand, sports participation in childhood and adolescence provides benefits which can delay the onset of these diseases.

AIM

To synthesize the available literature on the impact of sports participation on cardiovascular outcomes in children and adolescents.

METHODS

This systematic review was conducted on studies of children and adolescents (aged 8-18 years) who regularly practiced a sport and had reported cardiovascular outcomes (blood pressure and intima-media thickness) recorded. The Medline/PubMed, SciELO, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Bireme databases were searched.

RESULTS

In total, 3314 publications for blood pressure and 122 publications for intima-media thickness were identified in the databases. After exclusions (e.g., duplicate articles, animal studies and those that did not meet the inclusion criteria), four publications for blood pressure (449 adolescents) and two publications for intima-media thickness were included (402 adolescents). For blood pressure, all publications were longitudinal in design (follow-up ranging from 12 wk to 12 mo) and involved adolescents aged from 8 years to 18 years of age. For intima-media thickness, both publications were longitudinal in design and involved adolescents aged from 11 years to 18 years of age.

CONCLUSION

Sports participation seems to promote benefits to cardiovascular structure and function in adolescents. However, studies with adolescents are scarce and further research is needed to understand this phenomenon.

Children with lysinuric protein intolerance: Experience from a lower middle income country

BACKGROUND

Lysinuric protein intolerance (LPI) is an inborn error of metabolism consequential to recessive mutations in the SLC7A7 gene. The metabolic imbalance in absorption and excretion of dibasic amino acids is considered the basis of LPI. The disease results from protein intolerance with signs and symptoms oscillating from cerebral impairment, respiratory involvement, renal failure and autoimmune complications.

AIM

To determine biochemical and clinical presentation of cases with biochemical picture suggestive of LPI in Pakistani children.

METHODS

The study was conducted at the Biochemical Genetic Lab, Department of Pathology and Laboratory Medicine, AKU Plasma, and urine amino acid quantification data from January 2013 to October 2018 was included in this study. The amino acids were analyzed by high performance liquid chromatography. Prestructured requisition forms were used to obtain the clinicopathological data. Statistical analysis was done by Microsoft Excel 2017.

RESULTS

A total of 6 patients were recognized. All the patients were male (100%). The mean age was 24 mo ± 10 d. All the patients had low plasma concentration of lysine, ornithine and arginine, whereas increased levels of lysine, ornithine and arginine in urine were observed in 2 patients. History of consanguineous marriage was present in all patients (100%). The most observed clinical symptom was feeding difficulty followed by failure to thrive (83.3%) and developmental delay (66.6%). Hepatomegaly was present in all patients (100%). No mutation analysis was done.

CONCLUSION

This study portrays the biochemical and clinical spectrum of LPI in Pakistan. Although clinical manifestations appeared in the first 2 years of life, most of them suffered a delay in undergoing diagnostic workup.

Hereditary fructose intolerance: A comprehensive review

Hereditary fructose intolerance (HFI) is a rare autosomal recessive inherited disorder that occurs due to the mutation of enzyme aldolase B located on chromosome 9q22.3. A fructose load leads to the rapid accumulation of fructose 1-phosphate and manifests with its downstream effects. Most commonly children are affected with gastrointestinal symptoms, feeding issues, aversion to sweets and hypoglycemia. Liver manifestations include an asymptomatic increase of transaminases, steatohepatitis and rarely liver failure. Renal involvement usually occurs in the form of proximal renal tubular acidosis and may lead to chronic renal insufficiency. For confirmation, a genetic test is favored over the measurement of aldolase B activity in the liver biopsy specimen. The crux of HFI management lies in the absolute avoidance of foods containing fructose, sucrose, and sorbitol (FSS). There are many dilemmas regarding tolerance, dietary restriction and occurrence of steatohepatitis. Patients with HFI who adhere strictly to FSS free diet have an excellent prognosis with a normal lifespan. This review attempts to increase awareness and provide a comprehensive review of this rare but treatable disorder.

Adipocytokine profile in children with Kawasaki disease at a mean follow-up period of 5.5 years: A study from North India

BACKGROUND

Kawasaki disease (KD) is an acute self-limited vasculitis with a predilection for coronary arteries. Children with KD may have altered lipid metabolism and abnormal lipid profiles that may last for prolonged periods. However, there is a paucity of literature on the role of adipocytokines in KD.

AIM

To estimate the levels of adipocytokines (adiponectin, leptin and resistin) during the convalescent phase of KD.

METHODS

Twenty children, who had KD at least three years earlier, were enrolled in this study. In addition, 20 healthy controls were also enrolled. Clinical and laboratory profiles of patients were obtained from hospital records. Serum adiponectin, leptin and resistin levels were estimated by enzyme-linked immunosorbent assay.

RESULTS

Mean age of the patients in the study group was 10.15 ± 3 years and the male: female ratio was 1.5:1. Median serum resistin levels in patients with KD (27.77 ng/mL; [IQR: 18.66, 48.90]) were decreased compared to controls (21.20 ng/mL; [IQR: 14.80, 27.00]) (P = 0.04). Median serum leptin levels in cases and controls were 1.83 ng/mL; (IQR: 1.13, 3.80), and 1.10 ng/mL; (IQR: 0.41, 2.88), respectively (P = 0.09). Median serum adiponectin levels were similar in both cases (12.20 µg/mL; [IQR: 9.76, 17.97]) and controls (13.95 µg/mL; [IQR: 11.17, 22.58]); (P = 0.18). There was no significant difference in all 3 adipocytokines between children with (4/20) and without coronary artery abnormalities (16/20).

CONCLUSION

Serum resistin levels were significantly elevated in patients with KD during the convalescent phase compared to controls. Serum leptin levels appeared to be higher in patients with KD, although the difference was not statistically significant. Adiponectin levels were similar in both cases and controls. Raised resistin and leptin levels may partially explain lipid perturbations observed during the convalescent phase of KD.

Prevalence, phenotype and medication for the pediatric inflammatory bowel disease population of a state in Southeastern Brazil

BACKGROUND

Inflammatory bowel disease (IBD) can lead to social and economic impacts worldwide. In Brazil, where its adult prevalence is increasing, the epidemiology of the pediatric population is not well known, although there is a documented increase in pediatric IBD incidence worldwide. Brazil has continental dimensions, and Espírito Santo is a state of southeastern Brazil, the region with the highest demographic densities and is the economically most important in the country.

AIM

To assess the prevalence, incidence, phenotype and medications in a Southeastern Brazilian pediatric population.

METHODS

Data were retrieved from the Public Medication-Dispensing System of the Department of Health in Espírito Santo state from documentation required to have access to highly expensive medication from August 1, 2012 to July 31, 2014. There were 1048 registered patients with IBD of all ages, and of these patients, the cases ≤ 17 years were selected. The data were obtained through the analysis of administrative requests for these medications and included medical reports, endoscopy exams, histopathology and imaging tests, which followed the Clinical Protocols and Therapeutic Guidelines of the Brazilian Government. Only confirmed cases of IBD were included in the study.

RESULTS

There were 55 pediatric patients/1048 registered patients (5.34%), with Crohn's disease (CD) representing 30/55 (55%), ulcerative colitis (UC) 24/55 (43.6%) and 1 unclassified IBD, a significant difference from adult patients (P = 0.004). The prevalence of IBD in pediatric patients was 5.02 cases/100.000 inhabitants; the incidence in 2014 was 1.36 cases/100.000 inhabitants. The mean age at diagnosis was 12.2 years (± 4.2). There were 7 children diagnosed up to 6 years old, 7 between 7 to 10 years old and 41 between 11 and ≤ 17 years old. There was no difference in the distribution of UC and CD between these age categories (P = 0.743). There was no difference in gender distribution in relation to adults. Children and adolescents with UC had a predominance of pancolitis, unlike adults (P = 0.001), and used aminosalicylates and immunomodulators for their treatment. Pediatric patients with CD did not present a difference in disease location but had a higher frequency of fistulizing behavior (P = 0.03) and perianal disease phenotype (P = 0.007) than adult patients. Patients with CD used more immunomodulators and biological therapy. Treatment with biological therapy was more frequently used in pediatric patients than in adults (P < 0.001).

CONCLUSION

Although the data from this study demonstrate that incidence and prevalence rates are low in southeastern Brazil, these data demonstrate the severity of IBD in pediatric patients, with the need for early diagnosis and therapy, avoiding serious damage.

Frequency of celiac disease and distribution of HLA-DQ2/DQ8 haplotypes among siblings of children with celiac disease

BACKGROUND

Celiac disease (CD) is a multifactorial disease, but genetic factors play a major role in its etiology. It has been known that human leucocyte antigen (HLA)-DQ2/DQ8 haplotypes are one of the most important predisposing genetic factors. The risk of developing CD in first-degree relatives and especially siblings of celiac patients is quite high because of having the same HLA haplotypes.

AIM

To evaluate the frequency of CD and the distribution of the HLA-DQ2/DQ8 haplotypes in siblings of celiac patients.

METHODS

Patients with biopsy-proven CD and their siblings were included in the study; those who did not have HLA genotyping were excluded from the study. All siblings were on a gluten-containing diet. The HLA genotyping, tissue transglutaminase antibody IgA antibody test, and total IgA test were performed in all participants.

RESULTS

A total of 57 celiac patients and their 112 siblings were included in the study. The mean age of celiac patients and siblings were 10.30 ± 3.87 years and 9.90 ± 6.11 years, respectively. HLA-DQ2/DQ8 alleles were detected in 98.2% of patients with CD and 90.2% of siblings of celiac patients. HLA-DQ genotypes were present in all siblings diagnosed with CD. Tissue transglutaminase antibody IgA test was found to be positive in 16 siblings. CD was diagnosed in 12 siblings (10.7%) by intestinal biopsy.

CONCLUSION

The prevalence of CD was found to be 10.7% in siblings of celiac patients in our study. One-third of the siblings diagnosed with CD were asymptomatic. We detected HLA-DQ alleles in 98.2% of celiac patients and 100% in siblings diagnosed with CD. In addition, 1 of the 2 siblings was diagnosed with CD 1 year later and the other 4 years later. Therefore, we suggest that siblings of celiac patients should be followed up with clinical findings as well as HLA analysis and serological examination. Since the risk of developing CD is much higher in asymptomatic siblings, we recommend that siblings should be screened for CD even if they are asymptomatic.

Bleeding per rectum in pediatric population: A pictorial review

Bleeding per rectum in children can be seen in congenital as well as acquired conditions that may require medical or surgical management. The present review article is aimed to discuss the imaging findings of some common and uncommon causes of bleeding per rectum in children.

Global research production in neonatal abstinence syndrome: A bibliometric analysis

BACKGROUND

Recently, neonatal abstinence syndrome (NAS) emerged as a significant global concern with a dramatic increase in healthcare expenditures. The incidence of the NAS has increased notably in the past decade and emergence as a global public health problem.

AIM

To evaluate the development and trend of global NAS research from 1958 to 2019 by bibliometric analysis.

METHODS

Analyzed aspects included publication output per year, language, document types, journals, countries/territories, h-index, authors, and top research priorities. The VOSviewer was used to determine the top research priorities, and trends, and to present bibliometric networks concerning various dimensions, such as co-authorship, authors, and countries.

RESULTS

A total of 1738 articles were retrieved in the Scopus database from 1958 to 2019. It was found that the great majority of the total NAS documents (n = 1295) were original articles followed by reviews (n = 268) and letters (n = 48). The most productive countries in the NAS field were the United States (n = 833), Canada (n = 112), the United Kingdom (n = 111), and Germany (n = 77). Treatment and hospital outcomes in NAS, evidence-based nurse-driven interventions for the care of newborns with NAS, and a systematic reviews and network meta-analysis for therapeutic approaches of NAS were found in recent years (after 2010), compared with terms such as pathophysiology, mechanisms of NAS, and signs and symptoms in the early years.

CONCLUSION

Treatment and pediatric outcomes and the effectiveness of pharmacological treatment may be frontiers in the NAS field, and continued efforts from researchers are needed in those topics.

Management of sleep disorders among children and adolescents with neurodevelopmental disorders: A practical guide for clinicians

There is a complex relationship between sleep disorders and childhood neurodevelopmental, emotional, behavioral and intellectual disorders (NDEBID). NDEBID include several conditions such as attention deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, epilepsy and learning (intellectual) disorders. Up to 75% of children and young people (CYP) with NDEBID are known to experience different types of insomnia, compared to 3% to 36% in normally developing population. Sleep disorders affect 15% to 19% of adolescents with no disability, in comparison with 26% to 36% among CYP with moderate learning disability (LD) and 44% among those with severe LD. Chronic sleep deprivation is associated with significant risks of behavioural problems, impaired cognitive development and learning abilities, poor memory, mood disorders and school problems. It also increases the risk of other health outcomes, such as obesity and metabolic consequences, significantly impacting on the wellbeing of other family members. This narrative review of the extant literature provides a brief overview of sleep physiology, aetiology, classification and prevalence of sleep disorders among CYP with NDEBIDs. It outlines various strategies for the management, including parenting training/psychoeducation, use of cognitive-behavioral strategies and pharmacotherapy. Practical management including assessment, investigations, care plan formulation and follow-up are outlined in a flow chart.

Turnaround times for molecular testing of pediatric viral cerebrospinal fluid samples in United Kingdom laboratories

BACKGROUND

Rapid molecular testing has revolutionized the management of suspected viral meningitis and encephalitis by providing an etiological diagnosis in < 90 min with potential to improve outcomes and shorten inpatient stays. However, use of molecular assays can vary widely.

AIM

To evaluate current practice for molecular testing of pediatric cerebrospinal fluid (CSF) samples across the United Kingdom using a structured questionnaire.

METHODS

A structured telephone questionnaire survey was conducted between July and August 2020. Data was collected on the availability of viral CSF nucleic acid amplification testing (NAAT), criteria used for testing and turnaround times including the impact of the coronavirus disease 2019 pandemic.

RESULTS

Of 196/212 (92%) microbiology laboratories responded; 63/196 (32%) were excluded from final analysis as they had no on-site microbiology laboratory and outsourced their samples. Of 133 Laboratories included in the study, 47/133 (35%) had onsite facilities for viral CSF NAAT. Hospitals currently undertaking onsite NAAT (n = 47) had much faster turnaround times with 39 centers (83%) providing results in ≤ 24 h as compared to those referring samples to neighboring laboratories (5/86; 6%).

CONCLUSION

Onsite/near-patient rapid NAAT (including polymerase chain reaction) is recommended wherever possible to optimize patient management in the acute setting.

Advances in pediatric non-alcoholic fatty liver disease: From genetics to lipidomics

As a result of the obesity epidemic, non-alcoholic fatty liver disease (NAFLD) represents a global medical concern in childhood with a closely related increased cardiometabolic risk. Knowledge on NAFLD pathophysiology has been largely expanded over the last decades. Besides the well-known key NAFLD genes (including the I148M variant of the PNPLA3 gene, the E167K allele of the TM6SF2, the GCKR gene, the MBOAT7-TMC4 rs641738 variant, and the rs72613567:TA variant in the HSD17B13 gene), an intriguing pathogenic role has also been demonstrated for the gut microbiota. More interestingly, evidence has added new factors involved in the “multiple hits” theory. In particular, omics determinants have been highlighted as potential innovative markers for NAFLD diagnosis and treatment. In fact, different branches of omics including metabolomics, lipidomics (in particular sphingolipids and ceramides), transcriptomics (including micro RNAs), epigenomics (such as DNA methylation), proteomics, and glycomics represent the most attractive pathogenic elements in NAFLD development, by providing insightful perspectives in this field. In this perspective, we aimed to provide a comprehensive overview of NAFLD pathophysiology in children, from the oldest pathogenic elements (including genetics) to the newest intriguing perspectives (such as omics branches).

Serologic, endoscopic and pathologic findings in pediatric celiac disease: A single center experience in a low/middle income country

BACKGROUND

Studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of celiac disease (CD).

AIM

To describe the serology, endoscopic and histological findings in typical and atypical presentations of pediatric CD at a tertiary referral hospital in an African low/middle income country (LMIC).

METHODS

This observational study was conducted on 199 patients with CD from 2010 to 2019. The patients were divided into typical and atypical groups according to the presenting symptoms including 120 and 79 patients respectively. Serology, upper gastrointestinal endoscopy with duodenal biopsy were performed for patients who had symptoms suggestive of CD. The severity of the intestinal damage was graded according to the histo-pathologic Marsh-Oberhuber classification.

RESULTS

Chronic diarrhea was the main intestinal presentation in the typical group. Anemia was the most common extraintestinal symptom in both the typical and atypical group. Marsh-Oberhuber type 3b and 3c was significantly higher in the seropositive patients with a P value of 0.007. A significant correlation was observed between the histological grade of the biopsied duodenal mucosa and the clinical presentation (P < 0.001). Age was significantly higher in the atypical group (P value < 0.001).

CONCLUSION

Although typical CD was observed in 120 patients in this study, the clinical variability of the condition was frequently observed. Age only was a significant predictor for the appearance of atypical CD. Therefore, CD presentations in LMIC are not different from industrialized countries.

Preferred practice guidelines for retinopathy of prematurity screening during the COVID-19 pandemic

Retinopathy of prematurity (ROP) is the leading cause of preventable infant blindness in the world and predominantly affects babies who are born low birth weight and premature. India has the largest number of surviving preterm births born annually. ROP blindness can be largely prevented if there is a robust screening program which detects treatment requiring disease in time. ROP treatment must be provided within 48 h of reaching this threshold of treatment making it a relative emergency. During the severe acute respiratory syndrome-coronavirus disease 2019 pandemic in 2020 ROP screening was disrupted throughout the world due to lockdowns and restriction of movement of these infants, their families, specialists and healthcare workers. The Indian ROP Society issued guidelines for ROP screening and treatment in March 2020, which was aimed at preserving the chain-of-care despite the potential limitations and hazards during the (ongoing) pandemic. This preferred practice guideline is summarized in this manuscript.

Food allergy in children—the current status and the way forward

Food allergy in children is a major health concern, and its prevalence is rising. It is often over-diagnosed by parents, resulting occasionally in unnecessary exclusion of some important food. It also causes stress, anxiety, and even depression in parents and affects the family’s quality of life. Current diagnostic tests are useful when interpreted in the context of the clinical history, although cross-sensitivity and inability to predict the severity of the allergic reactions remain major limitations. Although the oral food challenge is the current gold standard for making the diagnosis, it is only available to a small number of patients because of its requirement in time and medical personnel. New diagnostic methods have recently emerged, such as the Component Resolved Diagnostics and the Basophil Activation Test, but their use is still limited, and the latter lacks standardisation. Currently, there is no definite treatment available to induce life-long natural tolerance and cure for food allergy. Presently available treatments only aim to decrease the occurrence of anaphylaxis by enabling the child to tolerate small amounts of the offending food, usually taken by accident. New evidence supports the early introduction of the allergenic food to infants to decrease the incidence of food allergy. If standardised and widely implemented, this may result in decreasing the prevalence of food allergy.

Non-pharmacological management of pediatric functional abdominal pain disorders: Current evidence and future perspectives

Functional abdominal pain disorders (FAPDs) are an important and prevalent cause of functional gastrointestinal disorders among children, encompassing the diagnoses of functional dyspepsia, irritable bowel syndrome, abdominal migraine, and the one not previously present in Rome III, functional abdominal pain not otherwise specified. In the absence of sufficiently effective and safe pharmacological treatments for this public problem, non-pharmacological therapies emerge as a viable means of treating these patients, avoiding not only possible side effects, but also unnecessary prescription, since many of the pharmacological treatments prescribed do not have good efficacy when compared to placebo. Thus, the present study provides a review of current and relevant evidence on non-pharmacological management of FAPDs, covering the most commonly indicated treatments, from cognitive behavioral therapy to meditation, acupuncture, yoga, massage, spinal manipulation, moxibustion, and physical activities. In addition, this article also analyzes the quality of publications in the area, assessing whether it is possible to state if non-pharmacological therapies are viable, safe, and sufficiently well-based for an appropriate and effective prescription of these treatments. Finally, it is possible to observe an increase not only in the number of publications on the non-pharmacological treatments for FAPDs in recent years, but also an increase in the quality of these publications. Finally, the sample selection of satisfactory age groups in these studies enables the formulation of specific guidelines for this age group, thus avoiding the need for adaptation of prescriptions initially made for adults, but for children use.

Classification, prevalence and integrated care for neurodevelopmental and child mental health disorders: A brief overview for paediatricians

‘Neurodevelopmental disorders’ comprise a group of congenital or acquired long-term conditions that are attributed to disturbance of the brain and or neuromuscular system and create functional limitations, including autism spectrum disorder, attention deficit/ hyperactivity disorder, tic disorder/ Tourette’s syndrome, developmental language disorders and intellectual disability. Cerebral palsy and epilepsy are often associated with these conditions within the broader framework of paediatric neurodisability. Co-occurrence with each other and with other mental health disorders including anxiety and mood disorders and behavioural disturbance is often the norm. Together these are referred to as neurodevelopmental, emotional, behavioural, and intellectual disorders (NDEBIDs) in this paper. Varying prevalence rates for NDEBID have been reported in developed countries, up to 15%, based on varying methodologies and definitions. NDEBIDs are commonly managed by either child health paediatricians or child/ adolescent mental health (CAMH) professionals, working within multidisciplinary teams alongside social care, education, allied healthcare practitioners and voluntary sector. Fragmented services are common problems for children and young people with multi-morbidity, and often complicated by sub-threshold diagnoses. Despite repeated reviews, limited consensus among clinicians about classification of the various NDEBIDs may hamper service improvement based upon research. The recently developed “Mental, Behavioural and Neurodevelopmental disorder” chapter of the International Classification of Diseases-11 offers a way forward. In this narrative review we search the extant literature and discussed a brief overview of the aetiology and prevalence of NDEBID, enumerate common problems associated with current classification systems and provide recommendations for a more integrated approach to the nosology and clinical care of these related conditions.

Pediatric Anesthesia Emergence Delirium Scale: A diagnostic meta-analysis

BACKGROUND

Emergence delirium (EmD) is a troublesome motoric, emotional, and cognitive disturbance associated with morbidity. It is often misdiagnosed despite being present in a substantial proportion of children and adolescents during emergence from anesthesia.

AIM

To evaluate the summary diagnostic accuracy of Pediatric Anesthesia Emergence Delirium Scale (PAEDS) for EmD among children and adolescents.

METHODS

Two researchers electronically and hand searched the published literature from May 2004 to February 2021 that evaluated the diagnostic accuracy of PAEDS for EmD among children and adolescents, using appropriate terms. Two independent researchers extracted the diagnostic parameters and appraised the study quality with QUADAS-2. Overall, the diagnostic accuracy of the measures was calculated with the summary receiver operating characteristic curve (SROC), the summary sensitivity and specificity, and diagnostic odds ratio (DOR) for EmD. Various diagnostic cut-off points were evaluated for their diagnostic accuracy. Heterogeneity was analyzed by meta-regression.

RESULTS

Nine diagnostic accuracy studies of EmD that conformed to our selection criteria and PRISMA guidelines were included in the final analysis. There was no publication bias. The area under the SROC was 0.97 (95% confidence interval [CI]: 95%-98%). Summary sensitivity and specificity were 0.91 (95%CI: 0.81-0.96; I² = 92.93%) and 0.94 (95%CI: 0.89-0.97; I² = 87.44%), respectively. The summary DOR was 148.33 (95%CI: 48.32-455.32). The effect size for the subgroup analysis of PAEDS cut-off scores of < 10, ≥ 10, and ≥ 12 was 3.73, 2.19, and 2.93, respectively; they were not statistically significantly different. The setting of the study and reference standard were statistically significantly related to the sensitivity of PAEDS but not specificity.

CONCLUSION

The PAEDS is an accurate diagnostic measure for the diagnosis of EmD among children and adolescents. Further studies should document its clinical utility.

Barriers and challenges affecting parents’ use of adrenaline auto-injector in children with anaphylaxis

BACKGROUND

Anaphylaxis is a life-threatening condition that develops as a reaction to exposure to an allergen which can be found in common foods such as cow's milk, egg, fish, and nuts in children. The use of an intramuscular adrenaline auto-injector (AAI) is considered the most essential treatment in these situations and parents and caregivers are always encouraged to carry this device for use in an emergency which commonly takes place in public places such as restaurants, schools, and parks, where medical staff are not guaranteed to be available. However, previous studies, in different settings, have reported underuse of the AAI by parents.

AIM

To explore the reasons for underutilisation of the AAI in our community.

METHODS

A cohort of parents attending the paediatric allergy clinic at Al Ain Hospital in the United Arab Emirates completed a questionnaire survey aimed at assessing their understanding and knowledge of their child's allergy management, including their aptitude with the use of the AAI, as well as their competence and comfort in providing this treatment in an emergency.

RESULTS

Of 47 parents participating in the study, 39 were Emirati parents (83% and most parents who completed the survey were mothers (66%). As expected, food was the main cause of allergic reactions requiring prescription of the auto-injector device. Tree nuts and peanuts were noted to be the most common offending food in these children (62% and 38%, respectively). A doctor provided demonstrations and training on using the auto-injector device to 94% of the parents. More than two-thirds of the parents and caregivers (79%) were deemed knowledgeable on the indication for use of the device. Reluctance to administer the device was expressed by many of the parents, despite their satisfaction with the coaching they received on using the device in the study.

CONCLUSION

Ongoing coaching and teaching of parents on use of the AAI is paramount. However, this should be carried out together with psychological support to aid the parents to eliminate their hesitancy and acquire sufficient confidence in using the device when needed. Group teaching and sharing experiences is an excellent educational technique in a non-formal setting. Paediatric clinic play therapists can also have a role in needle phobia desensitisation for parents and children. More research is needed to explore the lack of empowerment and other reasons behind their fear and anxiety in using the device to plan effective interventions.

Epidemiology and phenotypes of diabetes in children and adolescents in non-European-origin populations in or from Western Pacific region

BACKGROUND

Type 1 diabetes (T1D) incidence varies substantially between countries/ territories, with most studies indicating increasing incidence. In Western Pacific region (WPR), reported rates are much lower than European-origin populations. In contrast, there are reports of substantial numbers of young people with type 2 diabetes (T2D). A deeper understanding of T1D and T2D in the WPR may illuminate factors important in pathogenesis of these conditions. Furthermore, with varying resources and funding for diabetes treatment in this region, there is a need to more clearly determine the current burden of disease and also any gaps in knowledge.

AIM

To compile and summarise published epidemiologic and phenotypic data on childhood diabetes in non-European populations in and from WPR.

METHODS

Research articles were systematically searched from PubMed (MEDLINE), Embase, Cochrane library, and gray literature. Primary outcome measures were incidence and prevalence, with secondary measures including phenotypic descriptions of diabetes, including diabetes type categorization, presence of diabetic ketoacidosis (DKA) at onset, autoantibody positivity, C-peptide levels, and human leucocyte antigen phenotype. Extracted data were collected using a customized template. Three hundred and thirty relevant records were identified from 16 countries/territories, with analysis conducted on 265 (80.3%) records published from the year 2000.

RESULTS

T1D incidence ranged from < 1-7.3/100000 individuals/year, rates were highest in emigrant/ mixed populations and lowest in South-East Asia, with most countries/territories (71.4%) having no data since 1999. Incidence was increasing in all six countries/territories with data (annual increases 0.5%-14.2%, highest in China). Peak age-of-onset was 10-14 years, with a female case excess. Rate of DKA at onset varied from 19.3%-70%. Pancreatic autoantibodies at diagnosis were similar to European-origin populations, with glutamic acid decarboxylase-65 autoantibody frequency of 44.1%-64.5%, insulinoma-associated 2 autoantibody 43.5%-70.7%, and zinc transporter-8 autoantibody frequency 54.3% (one study). Fulminant T1D also occurs. T2D was not uncommon, with incidence in Japan and one Chinese study exceeding T1D rates. Monogenic forms also occurred in a number of countries.

CONCLUSION

T1D is less common, but generally has a classic phenotype. Some countries/ territories have rapidly increasing incidence. T2D is relatively common. Registries and studies are needed to fill many information gaps.

Functional constipation in Bangladeshi school aged children: A hidden misty at community

BACKGROUND

Constipation is a common problem in children and a frequent cause of hospital visit in both primary & specialized care, which needs proper evaluation & management. Presentation of constipation is variable among children. In Bangladesh there has been no published data regarding constipation in community among school aged children.

AIM

To determine the magnitude of functional constipation and its risk factors in community among Bangladeshi school children.

METHODS

This descriptive cross sectional study was conducted in different schools of Dhaka division, Bangladesh. All school aged children between 5-16 years of age who attended school were included in this study. Samples were collected randomly. Proper clinical history & physical examinations (without digital rectal examination) & available investigations (if done previously) were recorded. Diagnosis of functional constipation was done by Rome IV criteria and was compared with children without constipation. Children with any red flag sign, known chronic disease or any findings suggestive of organic disease and on treatment of constipation were excluded. Statistical analysis of the results was done by using Windows based software device with Statistical Packages for Social Science 20. For all statistical tests, P value of less than 0.05 was considered as statistically significant.

RESULTS

Total study populations were 707 and male was 443 and female 264. Among them, 134 (19%) children had constipation. In constipated children, 78 children fulfilled the Rome IV criteria for functional constipation and it was 11% of total population. Mean age of children having functional constipation was 11.24 ± 3.54 years and Male female ratio was 1:1.78. Anorexia, nausea, abdominal pain, hard stool, blood with hard stool, alternate hard and loose stool and fecal mass in left iliac fossa were analyzed between two group and all were significantly higher in children with functional constipation group. Children of school, where toilet numbers were inadequate had 2.5 times more constipation risk in comparison to children of school with adequate toilet number (OR = 2.493, 95%CI: 1.214-5.120). Children who feel embarrassed to use toilet at school, had 3.6 times higher risk of constipation (OR = 3.552, 95%CI: 1.435-8.794). Here children with H/O affected sibs and parents/grandparents had 4 and 2.6 times more chance of constipation respectively in comparison to children without H/O affected sibs (OR = 3.977, 95%CI: 1.884–8.397) and parents/grandparents (OR = 2.569, 95%CI: 1.172-5.629). Children with inadequate fluid intake had 2 times more risk of constipation in comparison to children with adequate fluid intake (OR = 1.972, 95%CI: 1.135-3.426). Children who passed electronic screen time of > 2 h/d had 2 times more chance of constipation in comparison to children who passed electronic screen time < 2 h (OR = 2.138, 95%CI: 1.063-4.301).

CONCLUSION

Constipation is not uncommon in Bangladeshi school aged children. Inadequate toilet number, family history of constipation, inadequate fluid intake, feeling embarrassed to use toilet at school, and electronic screen time for > 2 h/d were found as risk factors in the present study for functional constipation.

Druggable monogenic immune defects hidden in diverse medical specialties: Focus on overlap syndromes

In the last two decades two new paradigms changed our way of perceiving primary immunodeficiencies: An increasing number of immune defects are more associated with inflammatory or autoimmune features rather than with infections. Some primary immune defects are due to hyperactive pathways that can be targeted by specific inhibitors, providing innovative precision treatments that can change the natural history of diseases. In this article we review some of these “druggable” inborn errors of immunity and describe how they can be suspected and diagnosed in diverse pediatric and adult medicine specialties. Since the availability of precision treatments can dramatically impact the course of these diseases, preventing the development of organ damage, it is crucial to widen the awareness of these conditions and to provide practical hints for a prompt detection and cure.

Current status of nitrous oxide use in pediatric patients

Nitrous oxide is one of the most commonly used inhalational anesthetic agents used in practice. It is a cost-effective, pleasant, safe, and versatile anesthetic agent with many desirable properties like good quality analgesia, decreased awareness, accelerated induction and recovery from anesthesia, and reduced utilization of other expensive inhalational agents with potential cost savings. The use of nitrous oxide has been questioned by a lot of studies and case reports perceiving its adverse systemic, hematological, immune, and neurologic adverse effects. However, the literature in the recent past has tried to resolve the controversies related to its use. The concerns over an increase in cardiovascular complications and mortality following nitrous oxide use have been negated by recent data. However, its use in certain vulnerable populations like children with cobalamin and folate deficiency or defects in their metabolic pathways remains a cause of concern for its toxic effects. In this narrative review, we aim to discuss the pharmacological properties of nitrous oxide, the potential advantages and drawbacks of the use of nitrous oxide in children, address the neurodevelopmental and other systemic effects, and throw light on the evidence regarding the safety of nitrous oxide use and its current role in pediatric procedural sedation and anesthesia practice. The literature related to its use in the pediatric population for painful procedures and surgeries has been summarized.

Prevalence of intellectual disability in India: A meta-analysis

BACKGROUND

Burden due to intellectual disability (ID) is only third to the depressive disorders and anxiety disorders in India. This national burden significantly contributes to the global burden of ID and hence one has to think globally and act locally to reduce this burden. At its best the collective prevalence of ID is in the form of narrative reviews. There is an urgent need to document the summary prevalence of ID to enhance further policymaking, national programs and resource allocation.

AIM

To establish the summary prevalence of ID during the past 60 years in India.

METHODS

Two researchers independently and electronically searched PubMed, Scopus, and the Cochrane library from January 1961 to December 2020 using appropriate search terms. Two other investigators extracted the study design, setting, participant characteristics, and measures used to identify ID. Two other researchers appraised the quality of the studies using the Joanna Briggs Institute critical appraisal format for Prevalence Studies. Funnel plot and Egger’s regression test were used to ascertain the publication and small study effect on the prevalence. To evaluate the summary prevalence of ID, we used the random effects model with arcsine square-root transformation. Heterogeneity of I² ≥ 50% was considered substantial and we determined the heterogeneity with meta-regression. The analyses were performed using STATA (version 16).

RESULTS

Nineteen studies were included in the meta-analysis. There was publication bias; the trim-and-fill method was used to further ascertain bias. Concerns with control of confounders and the reliable measure of outcome were noted in the critical appraisal. The summary prevalence of ID was 2% [(95%CI: 2%, 3%); I² = 98%] and the adjusted summary prevalence was 1.4%. Meta-regression demonstrated that age of the participants was statistically significantly related to the prevalence; other factors did not influence the prevalence or heterogeneity.

CONCLUSION

The summary prevalence of ID in India was established to be 2% taking into consideration the individual prevalence studies over the last six decades. This knowledge should improve the existing disability and mental health policies, national programs and service delivery to reduce the national and global burden associated with ID.

Psychotropic drug abuse in pregnancy and its impact on child neurodevelopment: A review

Substance abuse by women of child-bearing age and fetal in utero drug exposure has increased in the number of infants born with health issues. Prenatal exposure to psychoactive substances can lead to neurological and neurodevelopmental deficits later in life. Useful data concerning the effects of psychoactive drugs on fetal neurodevelopmental status are sparse. Understanding the neurodevelopmental consequences of prenatally drug-exposed children has become a pressing global concern. The aim of this review is to gather current evidence and information on neurodevelopmental outcomes of in utero drug exposure. A literature search was performed on the PubMed, Scopus, and Google Scholar databases using the terms “psychotropic drugs”, “neurodevelopmental consequences”, “prenatal drug exposure”, and “pregnancy”. Available studies on in utero drug exposure were reviewed and found to support the idea that some degree of health issues are present in fetuses and children. Different psychoactive substances have profound neurodevelopmental consequences, such as structural brain changes, poor attention span, Down syndrome, attention deficit hyperactivity disorder, autism spectrum disorder, imbalances in neurotransmitter levels, and many structural deficits. The pervasive use of psychoactive drugs in women of child-bearing age is an important health concern. Further scientific efforts are needed to investigate the effect of prenatal exposure to psychoactive drugs on children.

Hereditary pancreatitis: An updated review in pediatrics

Hereditary Pancreatitis (HP) has emerged as a significant cause of acute, acute recurrent and chronic pancreatitis in the pediatric population. Given that it presents similarly to other causes of pancreatitis, a positive family history and/or isolation of a gene mutation are vital in its designation. Inheritance patterns remain complex, but mutations involving the PRSS1, SPINK1, CFTR and CTRC genes are commonly implicated. Since being first described in 1952, dozens of genetic alterations that modify the action of pancreatic enzymes have been identified. Among children, these variants have been isolated in more than 50% of patients with chronic pancreatitis. Recent research has noted that such mutations in PRSS1, SPINK1 and CFTR genes are also associated with a faster progression from acute pancreatitis to chronic pancreatitis. Patients with HP are at increased risk of developing diabetes mellitus, exocrine pancreatic insufficiency, and pancreatic adenocarcinoma. Management follows a multi-disciplinary approach with avoidance of triggers, surveillance of associated conditions, treatment of pancreatic insufficiency and use of endoscopic and surgical interventions for complications. With significant sequela, morbidity and a progressive nature, a thorough understanding of the etiology, pathophysiologic mechanisms, diagnostic evaluation, current management strategies and future research considerations for this evolving disease entity in pediatrics is warranted.

Tissue Doppler, speckling tracking and four-dimensional echocardiographic assessment of right ventricular function in children with dilated cardiomyopathy

BACKGROUND

Right ventricular (RV) function is frequently overlooked during dilated cardiomyopathy (DCM) evaluation.

AIM

To evaluate RV function in children with idiopathic DCM using relatively recent echocardiographic modalities.

METHODS

We prospectively studied the cardiac function in 50 children with idiopathic DCM and 50 healthy children as a control group, using four-dimensional echocardiography (4-DE), Tissue Doppler Imaging (TDI), and two-dimensional-speckles tracking echocardiography (2-D-STE). RV EF was measured by 4-DE.

RESULTS

The auto left (LV) ejection fractions (EF) measured by 2-D-STE were significantly lower in the patients' group than in the control. The sphericity index was also significantly lower in children with DCM than in the control. RV EF measured by 4-DE was significantly lower in the patient's group than the control. RV S wave, e´/a' ratio, myocardial performance index (MPI), and tricuspid annular plane systolic excursion (TAPSE) were significantly impaired in children with DCM than in control. Both LV and RV global longitudinal strains (GLS) were significantly reduced in children with DCM than in control. RVGLS was significantly associated with the duration since diagnosis, tricuspid annulus S wave, RV MPI, and TAPSE, but not with the age of the patients, RV EF, or e´/a' ratio.

CONCLUSION

There was impairment of the RV LGS and other systolic and diastolic parameters in children with DCM. STE and TDI can help to detect the early decline of RV function.

Sickle cell nephropathy: A review of novel biomarkers and their potential roles in early detection of renal involvement

Whether the underlying mutations are homozygous, heterozygous, or co-inherited with other hemoglobinopathies, sickle cell disease is known to afflict the kidneys, leading to the clinical entity known as sickle cell nephropathy (SCN). Although common, SCN remains diagnostically elusive. Conventional studies performed in the context of renal disorders often fail to detect early stage SCN. This makes the quest for early diagnosis and treatment more challenging, and it increases the burden of chronic kidney disease-related morbidity among patients. Novel diagnostic tools have been employed to overcome this limitation. In this study, we discuss various biomarkers of SCN, including those employed in clinical practice and others recently identified in experimental settings, such as markers of vascular injury, endothelial dysfunction, tubulo-glomerular damage, and oxidative stress. These include kidney injury molecule-1, monocyte chemoattractant protein-1, N-acetyl-B-D-glucosaminidase, ceruloplasmin, orosomucoid, nephrin, and cation channels, among others. Furthermore, we explore the potential of novel biomarkers for refining diagnostic and therapeutic approaches and describe some obstacles that still need to be overcome. We highlight the importance of a collaborative approach to standardize the use of promising new biomarkers. Finally, we outline the limitations of conventional markers of renal damage as extensions of the pathogenic process occurring at the level of the organ and its functional subunits, with a discussion of the expected pattern of clinical and biochemical progression among patients with SCN.

Vestibular function for children with insulin dependent diabetes using cervical vestibular evoked myogenic potentials testing

BACKGROUND

Healthy vestibular system adjusts balance during static and dynamic conditions. This is important for normal development (standing up and walking). Vestipulopathies (central and peripheral) are common complications of diabetes in adult population. Related studies are scare in children with type 1 diabetes (T1D).

AIM

To assess saccular function of otolith organ in children with T1D and predictors for its dysfunction.

METHODS

Cervical vestibular evoked myogenic potential (cVEMP) was used for objective evaluation.

RESULTS

The study included 40 patients (boys = 15; girls = 25). Patients had mean age of 13.63 ± 1.50 years, duration of diabetes of 5.62 ± 2.80 years, frequent attacks of diabetic ketoacidosis (55%) and hypoglycemia (30%), hyperlipidemia (20%), hypertension (12.5%) and peripheral neuropathy (40%). Dizziness was found in 10%. Compared to healthy children (n = 25), patients had prolonged cVEMP P1 and N1 latencies and reduced P1-N1 amplitude. Bilateral cVEMP abnormalities were found in 60% (vs 25% for unilateral abnormalities). Higher frequencies and severe vestibulopathies were found with chronic diabetes of > 5 years, hemoglobin A1c values > 7%, frequent diabetic ketoacidosis and hypoglycemic attacks and presence of dizziness. Regression analyses showed that predictors for prolonged P1 latencies and reduced P1-N1 amplitudes were only chronic diabetes (> 5 years) {odds ratio (OR) = 2.80 [95% confidence interval (CI): 1.80–5.33], P = 0.01; OR = 3.42 (95%CI: 2.82–6.81)} and its severity (hemoglobin A1c > 7%) [OR = 3.05 (95%CI: 2.55–6.82), P = 0.01; OR = 4.20 (95%CI: 3.55–8.50), P = 0.001].

CONCLUSION

Dysfunction or injury of the saccular macula and its pathways is prevalent in children with T1D. Optimum glycemic control is important to prevent diabetes related vestipulopathies.

Correlation of cardiac troponin T levels with inotrope requirement, hypoxic-ischemic encephalopathy, and survival in asphyxiated neonates

BACKGROUND

Cardiac involvement in neonates with perinatal asphyxia not only complicates perinatal management but also contributes to increased mortality.

AIM

To assess cardiac troponin T (cTnT) levels in asphyxiated neonates and their correlation with echocardiography findings, inotrope requirement, hypoxic-ischemic encephalopathy (HIE) stages, and mortality.

METHODS

cTnT levels, echocardiographic findings, the requirement of inotropes, HIE stages, and outcome were studied in neonates of gestational age ≥ 34 wk with perinatal asphyxia.

RESULTS

Among 57 neonates with perinatal asphyxia, male gender, cesarean section, forceps/vacuum-assisted vaginal delivery and late preterm included 33 (57.9%), 23 (40.4%), 3 (5.3%), and 12 (21.1%) respectively. The mean gestational age was 38.4 wk (1.6 wk). HIE stages I, II, and III were observed in 7 (12.3%), 37 (64.9%), and 9 (15.8%) neonates respectively. 26 (45.6%) neonates had echocardiographic changes and 19 (33.3%) required inotropes. cTnT levels were elevated in 41 (71.9%) neonates [median (IQR); 0.285 (0.211-0.422) ng/mL]. The Median cTnT level showed an increasing trend with increasing changes in echocardiography (P = 0.002). Two neonates with mitral regurgitation and global hypokinesia had the highest cTnT levels (1.99 and 0.651 ng/mL). Of 31 neonates with normal echocardiography, 18 (58.06%) showed elevated cTnT. cTnT levels were significantly higher in those who required inotropic support than those who did not (P = 0.007). Neonates with HIE stage III had significantly higher cTnT levels compared to those with HIE stage I/II (P = 0.013). Survivors had lower median cTnT levels [0.210 (0.122-0.316) ng/mL] than who succumbed [0.597 (0.356-1.146) ng/mL].

CONCLUSION

cTnT levels suggestive of cardiac involvement were observed in 71.9% of asphyxiated neonates. cTnT levels correlated with echocardiography findings, inotrope requirement, HIE stages, and mortality.

Levels of vocational satisfaction, burnout and compassion fatigue of health professionals working in pediatric clinics

BACKGROUND

Burnout and compassion fatigue are affecting the quality of professional life.

AIM

To investigate the levels of vocational satisfaction, burnout, and compassion fatigue and factors that may be related to health professionals working in children’s clinics.

METHODS

The study sample was in the west of Turkey. Data were collected using the questionnaire form and the quality of life scale for employees.

RESULTS

The findings obtained in this study showed that the level of vocational satisfaction of female health professionals and the burnout level of male health professionals were higher. The professional satisfaction of the doctors was lower than that of the nurses and midwives, and the mean score of burnout and fatigue was high.

CONCLUSION

Further studies are needed on this topic to help improve the factors that may affect the professional quality of life of health professionals.

Impact of stimulant medication on behaviour and executive functions in children with attention-deficit/hyperactivity disorder

BACKGROUND

Children with attention-deficit/hyperactivity disorder (ADHD) often exhibit behaviour challenges and deficits in executive functions (EF). Psychostimulant medications [e.g., methylphenidate (MPH)] are commonly prescribed for children with ADHD and are considered effective in 70% of the cases. Furthermore, only a handful of studies have investigated the long-term impact of MPH medication on EF and behaviour.

AIM

To evaluate behaviour and EF challenges in children with ADHD who were involved in an MPH treatment trial across three-time points.

METHODS

Thirty-seven children with ADHD completed a stimulant medication trial to study the short- and long-term impact of medication. Children with ADHD completed three neuropsychological assessments [Continuous Performance Test (CPT)-II, Digit Span Backwards and Spatial Span Backwards]. Parents of children with ADHD completed behaviour rating scales [Behaviour Rating Inventory of Executive Functioning (BRIEF) and Behaviour Assessment System for Children-Second Edition (BASC-2)]. Participants were evaluated at: (1) Baseline (no medication); and (2) Best-dose (BD; following four-week MPH treatment). Additionally, 18 participants returned for a long-term naturalistic follow up (FU; up to two years following BD).

RESULTS

Repeated measure analyses of variance found significant effects of time on two subscales of BRIEF and four subscales of BASC-2. Neuropsychological assessments showed some improvement, but not on all tasks following the medication trial. These improvements did not sustain at FU, with increases in EF and behaviour challenges, and a decline in performance on the CPT-II task being observed.

CONCLUSION

Parents of children with ADHD reported improvements in EF and behaviours during the MPH trial but were not sustained at FU. Combining screening tools and neuropsychological assessments may be useful for monitoring medication responses.

Pediatric firearm-associated fractures: Analysis of management and outcomes

BACKGROUND

Firearm-associated injuries (FAIs) are among the leading causes of morbidity and mortality in children living in the United States. Most victims of such injuries survive, but may experience compromised function related to musculoskeletal injuries. Although complex firearm-associated fractures (FAFs) often require specialized orthopaedic, vascular, and plastic surgical intervention, there is minimal research describing their management and outcomes. The purpose of this study is to describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries.

AIM

To describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries.

METHODS

A retrospective chart review was performed at a major, pediatric level 1 trauma center. The study included patients aged 18 or younger who presented with FAIs between 2008-2018. Additional data was collected on patients with FAFs including demographic and clinical data such as age, sex, race, payor type, fracture location, injury severity score (ISS), and radiographic and clinical outcomes. The management of FAFs was analyzed as well as need for readmission and reoperation. Descriptive statistics were used to summarize the results and univariate analyses were performed to assess differences between groups.

RESULTS

Between 2008 and 2018, there were a total of 61 patients who presented with FAIs. In this cohort, 21 patients (34%) sustained FAFs (25 fractures) with a mean age of 11 (Range: 10 mo to 18 years old) at the time of presentation. Approximately 52% (n = 11) of patients with FAFs were male, 76% (n = 8 and n = 8, respectively) identified as black or other, and 71% (n = 15) had government insurance. FAFs were most commonly noted in the upper extremity (n = 7) and lower extremity (n = 6). In patients with FAFs, the mean ISS at presentation was 11.38 (Range: 2-38), and 24% of patients (n = 5) were classified as having a major trauma. There were no significant differences in age, sex, race, and payor type in FAF patients that presented with and without major trauma (P > 0.05). When comparing FAF and non-FAF patients, there was a statistically significant difference in ISS (11.38 vs 14.45, P = 0.02). In total, 33% (n = 7) of patients with FAFs required orthopaedic surgical management, which was most commonly comprised of debridement (n = 6/7, 86%), and 14% (n = 1/7) of these patients required coordinated care with plastic and/or vascular surgery. There were no significant differences in age and payor type in patients with FAFs treated with and without orthopaedic surgery. Of the patients with FAFs, 52% (n = 11) had a minimum 90-d follow-up, and 48% (n = 10) had a minimum 2-year follow-up. Two patients were readmitted within 90-d, while one patient required a reoperation within 2-years.

CONCLUSION

Over 25% of FAIs in pediatric patients result in FAFs. FAFs often present to pediatric trauma centers and the majority of these injuries occur in non-Caucasian males with government insurance. Most FAFs do not need orthopaedic surgical management; 14% of these injuries require subspecialty care by orthopaedic surgery, vascular surgery, or plastic surgery. Patients with FAFs also have lower ISS compared to patients who sustained FAIs without fracture. Thus, these patients should be treated at pediatric trauma centers with specialty care and additional research is needed to focus prevention efforts, understand reasons for poor follow-up, and evaluate outcomes after injury.

Beyond kidney stones: Why pediatricians should worry about hypercalciuria

The incidence of urolithiasis (UL) is increasing, and it has become more common in children and adolescents over the past few decades. Hypercalciuria is the leading metabolic risk factor of pediatric UL, and it has high morbidity, with or without lithiasis as hematuria and impairment of bone mass. The reduction in bone mineral density has already been described in pediatric idiopathic hypercalciuria (IH), and the precise mechanisms of bone loss or failure to achieve adequate bone mass gain remain unknown. A current understanding is that hypercalciuria throughout life can be considered a risk of change in bone structure and low bone mass throughout life. However, it is still not entirely known whether hypercalciuria throughout life can compromise the quality of the mass. The peak bone mass is achieved by late adolescence, peaking at the end of the second decade of life. This accumulation should occur without interference in order to achieve the peak of optimal bone mass. The bone mass acquired during childhood and adolescence is a major determinant of adult bone health, and its accumulation should occur without interference. This raises the critical question of whether adult osteoporosis and the risk of fractures are initiated during childhood. Pediatricians should be aware of this pediatric problem and investigate their patients. They should have the knowledge and ability to diagnose and initially manage patients with IH, with or without UL.

Healthcare staff as promoters of parental presence at anesthetic induction: Net Promoter Score survey

BACKGROUND

Surgical intervention is usually a traumatic event that causes stress and anxiety in the pediatric patient and the family environment. To reduce the harmful effects of presurgical anxiety, parental presence during induction of anesthesia (PPIA) is one of the more notable interventions used in medical centers. However, data on this measure are difficult to evaluate and often face resistance from healthcare staff.

AIM

To analyze the perception of the healthcare workers after the implementation of a PPIA program.

METHODS

A survey was developed and sent by email to all the healthcare staff working in the children’s area of a tertiary hospital. It consisted of 14 items divided into positive aspects of PPIA and negative aspects of PPIA evaluated with the use of a Likert scale (1 to 5). The demographics of the respondents were included in the data collected. The answers to the questions were interpreted through the Net Promoter Score (NPS). The statistical analysis compared the differences in the responses to each question of the survey made by the different groups of health personnel included.

RESULTS

A total of 141 surveys were sent out, with a response rate of 69%. Of the total number of responses, 68% were from women and 32% from men. The average age of the participants was 42.3 ± 10.6 years. As for the positive questions about the PPIA, 83% had an NPS > 50, and only one had a score between 0 and 50, which means that the quality of the service was rated as excellent or good by 100% of the respondents. On the other hand, 100% of the negative questions about the PPIA had a negative NPS. Responses to the question “PPIA increases patient safety” were significantly different (P = 0.037), with a lower percentage of pediatric surgeons (70%) thinking that PPIA increased patient safety, compared with anesthesiologists (90%), nursing (92%), and other medical personnel (96%).

CONCLUSION

The personnel who participated in the PPIA program at our center were in favor of implementation. There were no validated arguments to support worker resistance to the development of the PPIA.

Association of breastfeeding with tidal breathing analysis in infants with bronchiolitis

BACKGROUND

Tidal breathing flow-volume (TBFV) analysis provides important information about lung mechanics in infants.

AIM

To assess the effects of breastfeeding on the TBFV measurements of infants who recover from acute bronchiolitis.

METHODS

In this cross-sectional study, TBFV analysis was performed in infants with bronchiolitis prior to hospital discharge. The ratio of time to peak expiratory flow to total expiratory time (tPEF/tE) at baseline and after the administration of 400 mcg salbutamol was evaluated.

RESULTS

A total of 56 infants (35 boys), aged 7.4 ± 2.8 mo, were included. Of them, 12.5% were exposed to tobacco smoke and 41.1% were breastfed less than 2 mo. There were no differences in baseline TBFV measurements between the breastfeeding groups; however, those who breastfed longer than 2 mo had a greater change in tPEF/tE after bronchodilation (12% ± 10.4% vs 0.9% ± 7.1%; P < 0.001). Moreover, there was a clear dose-response relationship between tPEF/tE reversibility and duration of breastfeeding (P < 0.001). In multivariate regression analysis, infants who breastfed less (regression coefficient -0.335, P = 0.010) or were exposed to cigarette smoke (regression coefficient 0.353, P = 0.007) showed a greater change in tPEF/tE after bronchodilation, independent of sex, prematurity, and family history of asthma or atopy.

CONCLUSION

Infants who recover from bronchiolitis and have a shorter duration of breastfeeding or are exposed to cigarette smoke, have TBFV measurements indicative of obstructive lung disease.

Pediatrician-friendly perspectives on cognitive behavioral therapy for anxious youth: Current status and clinical implications for the next normal

Pediatric anxiety disorders are common and often debilitating conditions. Cognitive is a psychosocial intervention that represents a potentially powerful antidote to these disorders. This article reviews data from treatment outcome studies, meta-analyses, and systematic reviews as well as from moderation/mediational investigations. The literature supports the efficacy, effectiveness, and durability of positive treatment outcomes for pediatric anxiety disorders. Recommendations for clinical applications are suggested.

Prevalence of pulmonary hypertension among children with Down syndrome: A systematic review and meta-analysis

BACKGROUND

Pulmonary hypertension (PH) has serious short- and long-term consequences. PH is gaining increasing importance in high risk groups such as Down syndrome (DS) as it influences their overall survival and prognosis. Hence, there is a dire need to collate the prevalence rates of PH in order to undertake definitive measures for early diagnosis and management.

AIM

To determine the prevalence of PH in children with DS.

METHODS

The authors individually conducted a search of electronic databases manually (Cochrane library, PubMed, EMBASE, Scopus, Web of Science). Data extraction and quality control were independently performed by two reviewers and a third reviewer resolved any conflicts of opinion. The words used in the literature search were “pulmonary hypertension” and “pulmonary arterial hypertension”; “Down syndrome” and “trisomy 21” and “prevalence”. The data were analyzed by Comprehensive Meta-Analysis Software Version 2. Risk of bias assessment and STROBE checklist were used for quality assessment.

RESULTS

Of 1578 articles identified, 17 were selected for final analysis. The pooled prevalence of PH in these studies was 25.5%. Subgroup analysis was carried out for age, gender, region, year of publication, risk of bias and etiology of PH.

CONCLUSION

This review highlights the increasing prevalence of PH in children with DS. It is crucial for pediatricians to be aware of this morbid disease and channel their efforts towards earlier diagnosis and successful management. Community-based studies with a larger sample size of children with DS should be carried out to better characterize the epidemiology and underlying etiology of PH in DS.

Corrosive upper gastrointestinal strictures in children: Difficulties and dilemmas

Children constitute 80% of all corrosive ingestion cases. The majority of this burden is contributed by developing countries. Accidental ingestion is common in younger children (< 5 years) while suicidal ingestion is more common in adolescents. The severity of injury depends on nature of corrosive (alkali or acid), pH, amount of ingestion and site of exposure. There are multiple doubts and dilemmas which exist in management of both acute ingestion and chronic complications. Acute ingestion leads to skin, respiratory tract or upper gastrointestinal damage which may range from trivial to life threatening complications. Esophagogastroduodenoscopy is an important early investigation to decide for further course of management. The use of steroids for prevention of stricture is a debatable issue. Upper gastrointestinal stricture is a common long-term sequelae of severe corrosive injury which usually develops after three weeks of ingestion. The cornerstone of management of esophageal strictures is endoscopic bougie or balloon dilatations. In case of resistant strictures, newer adjunctive therapies like intralesional steroids, mitomycin and stents can be utilized along with endoscopic dilatation. Surgery is the final resort for strictures resistant to endoscopic dilatations and adjunctive therapies. There is no consensus on best esophageal replacement conduit. Pyloric strictures require balloon dilatation , failure of which requires surgery. Patients with post-corrosive strictures should be kept in long term follow-up due to significantly increased risk of carcinoma. Despite all the endoscopic and surgical options available, management of corrosive stricture in children is a daunting task due to high chances of recurrence, perforation and complications related to poor nutrition and surgery.

Treatment of alopecia totalis/universalis/focalis with vitamin D and analogs: Three case reports and a literature review

BACKGROUND

Alopecia areata (AA) is an inflammatory disease with autoimmune, environmental, and inherited components directed at the hair follicle, either limited to patchy hair loss over the scalp (Focalis, AF), total loss of scalp hair (Totalis, AT), or total loss of both scalp and body hair (Universalis, AU). Despite multiple treatment modalities, no therapy exists. Vitamin D deficiency in patients with AA/AT/AF influences disease severity and duration, inversely correlating with inflammation histologically.

CASE SUMMARY

Three girls presented with AT (P1), AU (P2), and AF (P3) at the ages of 1, 5, and 5 years, respectively. For P1-P2, all available treatments implemented for 2 years had failed. We started an initial 6-mo repletion with oral cholecalciferol 2000/4000 IU/d, with no apparent effect. Then we attempted immunomodulation using oral calcitriol and its analog paricalcitol. On calcitriol, 0.5 mcg/d P1 regrew hair within 6 mo. After 4 years, a relapse with loss of eyebrow hair was resolved after doubling the calcitriol dose to 0.5 mcg × 2/d; the results have been maintained for 6 years to date. On calcitriol, 0.25 mcg × 3/d P2 led to the development of asymptomatic hypercalcemia-hypercalciuria, which was immediately resolved by switching to paricalcitol 2 mcg × 3/d; mild tolerable hypercalciuria was maintained. Hair regrowth was observed at 6 mo, stabilizing only as fur at 12 mo. AF in P3 was resolved completely within 3 mo on a daily high dose (8000 IU) of cholecalciferol.

CONCLUSION

Vitamin D may have immunomodulating therapeutic impact on AT/AU/AF, which needs to be explored with further pilot clinical trials.