Echocardiography in children with Down syndrome

Congenital heart disease is a common problem in children with Down syndrome (DS). Echocardiography plays an important role in the detection of both structural and functional abnormalities in this group of patients. Fetal echocardiography can help in the early recognition of DS by detecting soft markers of DS, but its main role is to define the exact nature of the suspected cardiac problem in the fetus. Postnatal echocardiography is mandatory in the first month of life for all neonates with DS. It is also indicated before any cardiac surgery and for serial follow-up after cardiac surgery. In this article, we discuss the types and mechanism of cardiac abnormalities in DS children and the role of both fetal and postnatal echocardiography in the detection of these abnormalities.

Imaging evaluation of hemoptysis in children

Hemoptysis is an uncommon but distressing symptom in children. It poses a diagnostic challenge as it is difficult to elicit a clear history and perform thorough physical examination in a child. The cause of hemoptysis in children can vary with the child's age. It can range from infection, milk protein allergy and congenital heart disease in early childhood, to vasculitis, bronchial tumor and bronchiectasis in older children. Acute lower respiratory tract infections are the most common cause of pediatric hemoptysis. The objective of imaging is to identify the source of bleeding, underlying primary cause, and serve as a roadmap for invasive procedures. Hemoptysis originates primarily from the bronchial arteries. The imaging modalities available for the diagnostic evaluation of hemoptysis include chest radiography, multi-detector computed tomography (MDCT), magnetic resonance imaging (MRI) and catheter angiography. Chest radiography is the initial screening tool. It can help in lateralizing the bleeding with high degree of accuracy and can detect several parenchymal and pleural abnormalities. However, it may be normal in up to 30% cases. MDCT is a rapid, non-invasive multiplanar imaging modality. It aids in evaluation of hemoptysis by depiction of underlying disease, assessment of consequences of hemorrhage and provides panoramic view of the thoracic vasculature. The various structures which need to be assessed carefully include the pulmonary parenchyma, tracheobronchial tree, pulmonary arteries, bronchial arteries and non-bronchial systemic arteries. Since the use of MDCT entails radiation exposure, optimal low dose protocols should be used so as to keep radiation dose as low as reasonably achievable. MRI and catheter angiography have limited application.

Indoor smoke and prenatal and childhood growth: The role of (gestational) age

Growth at birth and during infancy predicts several outcomes in the immediate future as well as in the long term. Weight and height are commonly used surrogates of growth, however, infants and young children are constantly growing unlike adults. Hence, weight and height alone are insufficient measures of growth if the time component is not associated with them. Recent studies have investigated the relationship between indoor air pollution and growth using height and weight. In this commentary, I have argued using a directed acyclic graph, that a causal association between indoor pollution exposure and growth at birth cannot be established unless birth weight is adjusted for gestational age. Furthermore, to make any causal inference between growth during the first few years of life and indoor exposure, in addition to age standardization, studies must also account for fetal growth to discount any continuation of prenatal effects, which may be in the causal pathway. A careful consideration is warranted from future studies investigating these relationships.

Tramadol use in pediatric sickle cell disease patients with vaso-occlusive crisis

AIM: To evaluate whether the addition of scheduled oral tramadol to intravenous morphine and intravenous ketorolac reduces morphine requirements.

METHODS: This single-centered, Institutional Review Board-approved, retrospective study at Moses Cone Memorial Hospital included pediatric patients who were ≥ 2 years old with vaso-occlusive crisis (VOC) caused by sickle cell disease (SCD), were on morphine patient-controlled analgesia (PCA), and had scheduled oral tramadol added to their standard pain regimen. The study population was admitted between March 2008 and March 2011. The data was collected from electronic records and included age, weight, morphine use, tramadol use, hemoglobin, pain scores, number of days on PCA, length of hospital stay, respiratory rate, and polyethylene glycol use. Thirty patients were analyzed as independent admissions and seven patients as paired admissions.

RESULTS: Eighteen pediatric SCD patients with VOC received morphine PCA and intravenous ketorolac and twelve patients received morphine PCA and intravenous ketorolac and scheduled oral tramadol. Baseline characteristics were similar between both groups with the exception of the average weight, which was greater in the tramadol group than in the morphine group. The average morphine requirements in patients with and without the use of tramadol were similar, both for the independent admissions [0.58 mg/kg per day vs 0.65 mg/kg per day (P = 0.31)] and the paired admissions [0.71 mg/kg per day vs 0.77 mg/kg per day (P = 0.5)]. The daily polyethylene glycol requirement was less in the tramadol group for both the independent [0.5 g/kg per day vs 0.6 g/kg per day (P = 0.64)] and paired admissions analyses [and 0.41 g/kg per day vs 0.55 g/kg per day (P = 0.67)].

CONCLUSION: The addition of scheduled tramadol in patients receiving concomitant morphine and ketorolac demonstrates a trend toward decreased morphine and polyethylene glycol use.

Pediatric vs adult pulmonary tuberculosis: A retrospective computed tomography study

AIM: To compare the manifestations of chest tuberculosis (TB) in pediatric and adult patients based on contrast enhanced computed tomography of chest.

METHODS: This was a retrospective study consisting of 152 patients of chest TB including 48 children and 104 adults who had undergone contrast enhanced computed tomography of chest prior to treatment. The patterns and severity of parenchymal, mediastinal and pleural manifestations were analyzed and compared among different age groups.

RESULTS: Parenchymal changes observed include consolidation, air space nodules, miliary TB, cavitation, bronchiectasis and fibrosis and these were noted in 60% of children, 71% of adolescents and 76.9% of adults. These changes were more common in right upper lobe in all age groups. There was no significant difference in the frequency of these changes (except nodules) in different age groups. Centrilobular nodules were seen less commonly in children less than 10 years (P = 0.028). Pleural effusion was noted in 28 (18.42%) patients and pericardial effusion in 8 (5.3%) patients. No significant difference in the serosal involvement is seen among children and adults. Mediastinal adenopathy was seen 70% of children, 76.3% adolescents and 76.9% of adults and paratracheal nodes were seen most frequently. Nodes had similar features (except matting) among all age groups. Matting of nodes was seen more commonly in children (P = 0.014).

CONCLUSION: Pediatric chest tuberculosis can have severe parenchymal lesions and nodal involvement similar to adults. The destructive lung changes observed in children needs immediate attention in view of the longer life span they have and hence in formulating optimal treatment strategies.

Bacterial colonization and intestinal mucosal barrier development

The intestinal tract is colonized soon after birth with a variety of ingested environmental and maternal microflora. This process is influenced by many factors including mode of delivery, diet, environment, and the use of antibiotics. Normal intestinal microflora provides protection against infection, ensures tolerance to foods, and contributes to nutrient digestion and energy harvest. In addition, enteral feeding and colonization with the normal commensal flora are necessary for the maintenance of intestinal barrier function and play a vital role in the regulation of intestinal barrier function. Intestinal commensal microorganisms also provide signals that foster normal immune system development and influence the ensuing immune responses. There is increasingly recognition that alterations of the microbial gut flora and associated changes in intestinal barrier function may be related to certain diseases of the gastrointestinal tract. This review summarizes recent advances in understanding the complex ecosystem of intestinal microbiota and its role in regulating intestinal barrier function and a few common pediatric diseases. Disruption in the establishment of a stable normal gut microflora may contribute to the pathogenesis of diseases including inflammatory bowel disease, nosocomial infection, and neonatal necrotizing enterocolitis.

Potential for treatment of severe autism in tuberous sclerosis complex

The Food and Drug Administration (FDA) has approved two mechanism-based treatments for tuberous sclerosis complex (TSC)-everolimus and vigabatrin. However, these treatments have not been systematically studied in individuals with TSC and severe autism. The aim of this review is to identify the clinical features of severe autism in TSC, applicable preclinical models, and potential barriers that may warrant strategic planning in the design phase of clinical trial development. A comprehensive search strategy was formed and searched across PubMed, Embase and SCOPUS from their inception to 2/21/12, 3/16/12, and 3/12/12 respectively. After the final search date, relevant, updated articles were selected from PubMed abstracts generated electronically and emailed daily from PubMed. The references of selected articles were searched, and relevant articles were selected. A search of clinicaltrials.gov was completed using the search term “TSC” and “tuberous sclerosis complex”. Autism has been reported in as many as 60% of individuals with TSC; however, review of the literature revealed few data to support clear classification of the severity of autism in TSC. Variability was identified in the diagnostic approach, assessment of cognition, and functional outcome among the reviewed studies and case reports. Objective outcome measures were not used in many early studies; however, diffusion tensor imaging of white matter, neurophysiologic variability in infantile spasms, and cortical tuber subcategories were examined in recent studies and may be useful for objective classification of TSC in future studies. Mechanism-based treatments for TSC are currently available. However, this literature review revealed two potential barriers to successful design and implementation of clinical trials in individuals with severe autism-an unclear definition of the population and lack of validated outcome measures. Recent studies of objective outcome measures in TSC and further study of applicable preclinical models present an opportunity to overcome these barriers.

Acute flaccid paralysis in a patient with sacral dimple

Sacral dimples are the most common cutaneous anomaly detected during neonatal spinal examination. Congenital dermal sinus tract, a rare type of spinal dysraphism, occurs along the midline neuraxis from occiput down to the sacral region. It is often diagnosed in the presence of a sacral dimple together with skin signs, local infection, meningitis, abscess, or abnormal neurological examination. We report a case of acute flaccid paralysis with sensory level in a 4 mo old female infant with sacral dimple, diagnosed by magnetic resonance imaging to be a paraspinal subdural abscess. Surgical exploration revealed a congenital dermal sinus tract extending from the subdural abscess down to the sacral dimple and open to the exterior with a minute opening.

Indoor air pollution and respiratory health of children in the developing world

Indoor air pollution (IAP) is a key contributor to the global burden of disease mainly in developing countries. The use of solid fuel for cooking and heating is the main source of IAP in developing countries, accounting for an estimated 3.5 million deaths and 4.5% of Disability-Adjusted Life Years in 2010. Other sources of IAP include indoor smoking, infiltration of pollutants from outdoor sources and substances emitted from an array of human utilities and biological materials. Children are among the most vulnerable groups for adverse effects of IAP. The respiratory system is a primary target of air pollutants resulting in a wide range of acute and chronic effects. The spectrum of respiratory adverse effects ranges from mild subclinical changes and mild symptoms to life threatening conditions and even death. However, IAP is a modifiable risk factor having potential mitigating interventions. Possible interventions range from simple behavior change to structural changes and from shifting of unclean cooking fuel to clean cooking fuel. Shifting from use of solid fuel to clean fuel invariably reduces household air pollution in developing countries, but such a change is challenging. This review aims to summarize the available information on IAP exposure during childhood and its effects on respiratory health in developing countries. It specifically discusses the common sources of IAP, susceptibility of children to air pollution, mechanisms of action, common respiratory conditions, preventive and mitigating strategies.

Neonates need tailored drug formulations

Drugs are very strong tools used to improve outcome in neonates. Despite this fact and in contrast to tailored perfusion equipment, incubators or ventilators for neonates, we still commonly use drug formulations initially developed for adults. We would like to make the point that drug formulations given to neonates need to be tailored for this age group. Besides the obvious need to search for active compounds that take the pathophysiology of the newborn into account, this includes the dosage and formulation. The dosage or concentration should facilitate the administration of low amounts and be flexible since clearance is lower in neonates with additional extensive between-individual variability. Formulations need to be tailored for dosage variability in the low ranges and also to the clinical characteristics of neonates. A specific focus of interest during neonatal drug development therefore is a need to quantify and limit excipient exposure based on the available knowledge of their safety or toxicity. Until such tailored vials and formulations become available, compounding practices for drug formulations in neonates should be evaluated to guarantee the correct dosing, product stability and safety.

Fever management: Evidence vs current practice

Fever is a very common complaint in children and is the single most common non-trauma-related reason for a visit to the emergency department. Parents are concerned about fever and it’s potential complications. The biological value of fever (i.e., whether it is beneficial or harmful) is disputed and it is being vigorously treated with the belief of preventing complications such as brain injury and febrile seizures. The practice of alternating antipyretics has become widespread at home and on paediatric wards without supporting scientific evidence. There is still a significant contrast between the current concept and practice, and the scientific evidence. Why is that the case in such a common complaint like fever The article will discuss the significant contrast between the current concepts and practice of fever management on one hand, and the scientific evidence against such concepts and practice.

Neonatal risks from in vitro fertilization and delayed motherhood

Delayed childbearing (DC) is common in most Western countries. The average age of first-time mothers increased in United States from 21.4 years in 1970 to 25.0 years in 2006 and from 25.4 to 30.8 years in Australia in the same period. It is commonly believed that this has no ominous consequences. But several negative consequences of this behavior are described: stillbirth, prematurity, twins, birth anomalies. Age also decreases women’s fertility, thus many couples undergo in vitro fertilization. And we highlight a paradox: medical reproduction techniques decreases their effectiveness with maternal age, but their availability can be an incentive to postpone parenthood. Of course the risks of delayed parenthood involve a minority of cases, but are parents entitled to accept any risk on the behalf of their baby A complete information would make people cautious before deciding to postpone childbearing, though this is often an obliged rather that a free choice: the consumerist society pressure and the difficulty to find an employment have their heavy weight in this choice. But if this choice is not really free, people’s interest is to overcome these pressures and to claim for a real broad choice on when becoming parent, despite the pressures made by their cultural environment to postpone parenthood. Moreover, even reproductive techniques have some risks. Unfortunately, mass media often praise and endorse DC, disregarding the increase of premature babies born because of DC, a real alarm for public health. Pediatricians should discourage the culture that makes DC a normal event.

Maternal mental disorders in pregnancy and the puerperium and risks to infant health

Prenatal and postnatal period presents the highest prevalence of mental disorders in women’s lives and depression is the most frequent one, affecting approximately one in every five mothers. The aggravating factor here is that during this period psychiatric symptoms affect not only women’s health and well-being but may also interfere in the infant’s intra and extra-uterine development. Although the causes of the relationship between maternal mental disorders and possible risks to a child’s health and development remain unknown, it is suspected that these risks may be related to the use of psychotropic drugs during pregnancy, to substance abuse and the mother’s lifestyle. Moreover, after delivery, maternal mental disorders may also impair the ties of affection (bonding) with the newborn and the maternal capacity of caring in the post-partum period thus increasing the risk for infant infection and malnutrition, impaired child growth that is expressed in low weight and height for age, and even behavioral problems and vulnerability to presenting mental disorders in adulthood. Generally speaking, research on this theme can be divided into the type of mental disorder analyzed: studies that research minor mental disorders during pregnancy such as depression and anxiety find an association between these maternal disorders and obstetric complications such as prematurity and low birth weight, whereas studies that evaluate severe maternal mental disorders such as schizophrenia and bipolar disorder have found not only an association with general obstetric complications as well as with congenital malformations and perinatal mortality. Therefore, the success of infant growth care programs also depends on the mother’s mental well being. Such findings have led to the need for new public policies in the field of maternal-infant care geared toward the population of mothers. However, more research is necessary so as to confirm the association between all factors with greater scientific rigor.

Metabolically obese normal-weight children

Non-obese children with elevated serum insulin levels and metabolic disorders such as, hyperglycemia, hypertension, and/or hypertriglyceridemia are a subset of children in high risk of developing cardiovascular disease later in life. Since usually the health policies for the prevention of the obesity associated disorders in children are based on the screening focused on the obese, frequently the metabolically obese normal-weight (MONW) children are not identified in primary care setting. Given that characterization of the MONW children is an important public health issue, and that a large amount of resources might be unnecessarily used in the screening of metabolic risk of nonobese children; we review data regarding criteria for the early recognition of this subset of children in high risk of developing cardiovascular disease. Results of our review suggests that the presence of family history of type 2 diabetes and/or hypertension, the elevated percentage of body fat, and the high birth-weight should be taken into account as criteria of high cardiovascular risk, irrespective of obesity.

Profound deafness and the acquisition of spoken language in children

Profound congenital sensorineural hearing loss (SNHL) is not so infrequent, affecting 1 to 2 of every 1000 newborns in western countries. Nevertheless, universal hearing screening programs have not been widely applied, although such programs are already established for metabolic diseases. The acquisition of spoken language is a time-dependent process, and some form linguistic input should be present before the first 6 mo of life for a child to become linguistically competent. Therefore, profoundly deaf children should be detected early, and referred timely for the process of auditory rehabilitation to be initiated. Hearing assessment methods should reflect the behavioural audiogram in an accurate manner. Additional disabilities also need to be taken into account. Profound congenital SNHL is managed by a multidisciplinary team. Affected infants should be bilaterally fitted with hearing aids, no later than 3 mo after birth. They should be monitored until the first year of age. If they are not progressing linguistically, cochlear implantation can be considered after thorough preoperative assessment. Prelingually deaf children develop significant speech perception and production abilities, and speech intelligibility over time, following cochlear implantation. Age at intervention and oral communication, are the most important determinants of outcomes. Realistic parental expectations are also essential. Cochlear implant programs deserve the strong support of community members, professional bodies, and political authorities in order to be successful, and maximize the future earnings of pediatric cochlear implantation for human societies.

Burden of respiratory syncytial virus infection in young children

Respiratory syncytial virus (RSV) is the most frequent and important cause of lower respiratory tract infection in infants and children. It is a seasonal virus, with peak rates of infection occurring annually in the cold season in temperate climates, and in the rainy season, as temperatures fall, in tropical climates. High risk groups for severe RSV disease include infants below six mo of age, premature infants with or without chronic lung disease, infants with hemodynamically significant congenital heart disease, infants with immunodeficiency or cystic fibrosis, and infants with neuromuscular diseases. Mortality rates associated with RSV infection are generally low in previous healthy infants (below 1%), but increase significantly in children with underlying chronic conditions and comorbidities. Following early RSV lower respiratory tract infection, some patients experience recurrent episodes of wheezing mimicking early childhood asthma with persistence of lung function abnormalities until adolescence. There is currently no RSV vaccine available, but promising candidate vaccines are in development. Palivizumab, a monoclonal RSV antibody that is the only tool for immunoprophylaxis in high-risk infants, lowers the burden of RSV infection in certain carefully selected patient groups.

Pediatric palliative care - The role of the patient’s family

Whenever a child suffers, what does she or he cry Mother! What does that mean Palliative care is not a type of medicine based on objective evidence or statistics. The only relevant standard is the very individual quality of life. Nobody knows better what this actually means but the patient himself. Thus, if the mother’s presence has the biggest impact on a child’s wellbeing or comfort, she herself is the most valuable treatment modality. In nearly every publication dealing with pediatric palliative care, it is stated that palliative care does not only imply care for the sick child but also for the parents and the whole family. Usually, it is pointed out that they are suffering a lot as well. But helping them does also mean: helping the child! Of course, it means higher efforts, obligations and costs for the healthcare system. Thus the justification of this effort may be put in question; in particular, it may be argued that disorders of family members should, if necessary, be treated as such. But this is only one side of the coin! In the following, we will, based on published literature, look at the role of mothers, fathers, and siblings for the wellbeing of an ill or even dying child. As a conclusion, we will learn that if it is our task to give a dying child the best available care, helping mothers, fathers and sibling is an inevitable part of it.

Clinical pharmacological studies in children: From exploratory towards confirmation driven methodology

Just like children are not small adults, pediatric studies are not just subgroup-adult studies. Clinical pharmacology aims to predict these effects based on drug, population and/or patient-specific pharmacokinetics (concentration-time profiles) and -dynamics (concentration-effect profile). The most essential characteristics of childhood are growth and maturation. Both phenomena are most prominent during infancy making the claim that “an infant is not just a small child” as relevant compared to the paradigm that “a child is not just a small adult”. From a clinical pharmacology perspective, the consequence of such a dynamic setting is extensive variability throughout childhood in both the pharmacokinetics and pharmacodynamics. Trial design probably has impact on recruitment to an even greater extent compared to adult studies. In general, if a study is designed well, with a clear clinical question with which parents and children can identify, they are likely to consider participation. Open communication with all stakeholders involved will most likely result in ethically correct, practically feasible, scientifically sound, and economical reasonable studies to provide children with the appropriate treatment. From an academic perspective, feasibility, relevance, applicability and costs of clinical pharmacological studies in children can be significantly improved by new sampling concepts (e.g., saliva, urine, dried spot blood) and the systematic introduction of already known information into the trial design through model based pediatric drug development, that mainly affect feasibility of pharmacokinetic studies. In contrast, for the pharmacodynamic part of pediatric studies, development and validation of population specific biomarkers or robust outcome variables is urgently needed.

What is the purpose of launching the World Journal of Clinical Pediatrics?

The first issue of the World Journal of Clinical Pediatrics (WJCP), whose preparatory work was initiated on January 10, 2011, will be published on June 8, 2012. The WJCP editorial board has now been established and consists of 100 distinguished experts from 31 countries. Our purpose of launching the WJCP is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.