Pediatricians lack knowledge for the diagnosis and management of functional constipation in children over 6 mo of age

AIM

To assess the knowledge of general pediatricians througout Indonesia about the diagnosis and treatment of childhood constipation.

METHODS

A comprehensive questionnaire was distributed to general pediatricians from several teaching hospitals and government hospitals all over Indonesia.

RESULTS

Data were obtained from 100 pediatricians, with a mean of 78.34 ± 18.00 mo clinical practice, from 20 cities throughout Indonesia. Suspicion of constipation in a child over 6 mo of age arises when the child presents with a decreased frequency of bowel movements (according to 87% of participants) with a mean of one bowel movement per 3.59 ± 1.0 d, hard stools (83%), blood in the stools (36%), fecal incontinence (33%), and/or difficulty in defecating (47%). Only 26 pediatricians prescribe pharmacologic treatment as first therapeutic approach, while the vast majority prefers nonpharmacologic treatment, mostly (according to 68%) The preferred nonpharmacologic treatment are high-fiber diet (96%), increased fluid intake (90%), toilet training (74%), and abdominal massage (49%). Duration of non-pharmacological treatment was limited to 1 to 2 wk. Seventy percent of the pediatricians recommending toilet training could only mention some elements of the technique, and only 15% was able to explain it fully and correctly. Lactulose is the most frequent pharmacologic intervention used (87% of the participants), and rectal treatment with sodium citrate, sodium lauryl sulfo acetate, and sorbitol is the most frequent rectal treatment (85%). Only 51% will prescribe rectal treatment for fecal impaction. The majority of the pediatricians (69%) expect a positive response during the first week with a mean (± SD) of 4.1 (± 2.56) d. Most participants (86%) treat during one month or even less. And the majority (67%) stops treatment when the frequency and/or consistency of the stools have become normal, or if the patient had no longer complaints.

CONCLUSION

These data provide an insight on the diagnosis and management of constipation in childhood in Indonesia. Although general pediatricians are aware of some important aspects of the diagnosis and mangement of constipation, overall knowledge is limited. Efforts should be made to improve the distribution of existing guidelines. These findings highlight and confirm the difficulties in spreading existing information from guidelines to general pediatricians.

Clinical profile and outcomes of pediatric endogenous endophthalmitis: A report of 11 cases from South India

AIM

To study the clinical profile and outcomes of pediatric endogenous endophthalmitis from a tertiary eye hospital in South India.

METHODS

A total of 13 eyes of 11 children presented to us with varied symptoms and presentations of endogenous endophthalmitis, over a five-year period from January 2010 to December 2015 were studied. Except for two eyes of a patient, vitreous aspirates were cultured from all 11 eyes to isolate the causative organism. These eleven eyes also received intravitreal injections. All patients were treated with systemic antibiotics.

RESULTS

Two cases had bilateral endophthalmitis. Ages ranged from 4 d to 11 years. Five cases were undiagnosed and treated, before being referred to our center. Ten of the 13 eyes underwent a core vitrectomy. The vitrectomy was done at an average on the second day after presenting (range 0-20 d). Five of the 11 vitreous aspirates showed isolates. The incriminating organisms were bacteria in three and fungus in two. An underlying predisposing factor was found in seven patients. At a mean follow-up 21.5 mo, outcome was good in 7 eyes of 6 cases (54%), five eyes of four cases (38%) ended up with phthisis bulbi while one child died of systemic complications.

CONCLUSION

Endogenous endophthalmitis is a challenge for ophthalmologists. Early diagnosis and intervention is the key for a better outcome.

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.

Sublingual immunotherapy for pediatric allergic rhinitis: The clinical evidence

Allergic rhinitis is estimated to affect 10%-20% of pediatric population and it is caused by the IgE-sensitization to environmental allergens, most importantly grass pollens and house dust mites. Allergic rhinitis can influence patient’s daily activity severely and may precede the development of asthma, especially if it is not diagnosed and treated correctly. In addition to subcutaneous immunotherapy, sublingual immunotherapy (SLIT) represents the only treatment being potentially able to cure allergic respiratory diseases, by modulating the immune system activity. This review clearly summarizes and analyzes the available randomized, double-blinded, placebo-controlled trials, which aimed at evaluating the effectiveness and the safety of grass pollen and house dust mite SLIT for the specific treatment of pediatric allergic rhinitis. Our analysis demonstrates the good evidence supporting the efficacy of SLIT for allergic rhinitis to grass pollens in children, whereas trials regarding pediatric allergic rhinitis to house dust mites present lower quality, although several studies supported its usefulness.

Endobronchial tumor in children: Unusual finding in recurrent pneumonia, report of three cases

We are reporting 3 cases of pediatric endobronchial tumors presented with recurrent pneumonia. The median age of patients, at time of presentation, was 10.6 years. All patients presented with recurrent pneumonia with a mean time to occurrence, after onset of symptoms, of 14 mo. Bronchoscopy was early performed as part of diagnostic work-up and it revealed an endobronchial mass in every case. Complete surgical resection was performed in all cases, with lung preservation in two of them. Neither post-operative chemotherapy nor radiotherapy was required. The mean duration of follow-up was 7 years and all patients are still alive and disease-free. Recurrent pneumonia, in pediatrics, should raise the suspicion of an obstructing lesion, congenital malformation or systemic disease. A systematic approach is useful for organize the clinicians initial workup. Prompt diagnosis allows parenchymal-sparing surgery, which offers the best chance of cure and reduces clinical and functional complications in these patients.

Reducing childhood obesity through coordinated care: Development of a park prescription program

Major hindrances to controlling the current childhood obesity epidemic include access to prevention and/or treatment programs that are affordable, provide minimal barriers for participation, and are available to the general public. Moreover, successful childhood obesity prevention efforts will require coordinated partnerships in multiple sectors such as government, health care, school/afterschool, and the community but very few documented sustainable programs currently exist. Effective, community-based health and wellness programs with a focus on maintaining healthy weight via physical activity and healthy eating have the potential to be a powerful referral resource for pediatricians and other healthcare professionals who have young patients who are overweight/obese. The Miami Dade County Department of Parks, Recreation and Open Spaces in partnership with the University of Miami UHealth Systems have created a "Park Prescription Program (Parks Rx 4Health(TM))" that formally coordinates pediatricians, families, parents, caregivers, and child/adolescents to provide daily obesity-prevention activities. This Parks Rx 4Health(TM) program that we describe here allows UHealth pediatricians to seamlessly refer their overweight and obese patients to Fit2Play(TM), an evidence-based, park-based afterschool health and wellness program. Measurable outcomes that include body mass index, blood pressure, fitness, and nutrition knowledge are being collected at baseline and at 3-and 6-mo after referral to document patient progress. Results are then shared with the referring physician so they can follow up with the patient if necessary. Identifying successful models that integrate primary care, public health, and community-based efforts is important to accelerating progress in preventing childhood obesity. Effective, community-based health and wellness programs with a focus on physical activity and nutrition education could be a powerful referral resource for pediatricians who have obese patients.

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.

Use of corticosteroids during acute phase of Kawasaki disease

In spite of initial intravenous immunoglobulin (IVIG) treatment, a significant number of patients are unresponsive to it and are at a higher risk for coronary artery lesions. Corticosteroids have been used as a secondary drug or used in combination with IVIG. Three options of using corticosteroids for the treatment of patients during the acute phase of Kawasaki disease, have been considered. The first is their use exclusively for patients unresponsive to IVIG treatment. The second is their use in combination with IVIG as the routine first line therapy for all patients. The last is the use in the combination as the first line therapy for selected patients at a high risk being unresponsive to initial IVIG. However, it is uncertain that the corticosteroids as the second line treatment are better than the additional IVIG in patients unresponsive to initial IVIG. The combination of corticosteroids and IVIG as the routine first line therapy also have not enough evidences. The last option of using corticosteroids - the combination of corticosteroids and IVIG in patients at high risk of unresponsiveness, is a properly reasonable treatment strategy. However, there have been no globally standardized predictive models for the unresponsiveness to initial IVIG treatment. Therefore, future investigations to determine the best predictive model are necessary.

Parental acceptability of the watchful waiting approach in pediatric acute otitis media

AIM: To determine parental knowledge about acute otitis media (AOM) and its antibiotic therapy, antibiotic resistance and the willingness to comply with the watchful waiting (WW) approach in primary care settings in southern Israel.

METHODS: The study was conducted in 3 primary care clinics and the pediatric emergency room of Soroka University Medical Center. Questionnaires (20 questions on education background, previous AOM experience, knowledge on antimicrobial resistance and attitude vs the WW approach) were filled by 600 parents (150 at each centers) of children < 6 years of age.

RESULTS: Mothers represented 69% of parents; 2% had an education of < 10 school years, 46% had high-school education and 17% had an academic degree. 69% parents reported previous experience with AOM and 56% thought that antibiotics represent the only treatment for AOM. Knowledge on bacterial resistance to antibiotics was reported by 57% of the parents; 86% parents were willing to accept/probably accept the WW approach for their children. Logistic regression analysis revealed a significant association between parental education and knowledge about bacterial resistance to antibiotics and that previous experience with AOM was significantly associated with reluctance to accept the WW approach. More parents with knowledge on bacterial resistance were willing to accept the WW approach compared with parents without such knowledge. No correlation was found between the education level and willingness to accept the WW approach.

CONCLUSION: A significant correlation was found between previous parental education and experience with AOM and the knowledge about antibiotic use, bacterial resistance and acceptance of the WW approach.

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.

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.

Should dopamine be the first line inotrope in the treatment of neonatal hypotension? Review of the evidence

AIM: To determine if dopamine is effective in treating neonatal hypotension and safe to use comparing to other inotropes.

METHODS: This is a review of evidence on inotropic treatment of neonatal hypotension. Databases searched were MEDLINE and the Cochrane Library, a total of 134 studies were identified. Only studies with high quality evidence (level 1a and b and 2a) were included. After review, only eight studies were included in the final analysis. Pooled risk ratios derived for each outcome [Mantel-Haenzel (M-H) fixed effect] with CI, as reported in the Cochrane reviews were plotted in forest plot form.

RESULTS: Eight articles met inclusion criteria, which all included treatment in preterm infants. Dopamine increased mean arterial blood pressure (BP) (n = 163; r = 0.88, 95%CI: 0.76 to 0.94) and systolic BP (n = 142; r = 0.81, 95%CI: 0.42 to 0.94) comparing to placebo. Dopamine has been shown overall to be statistically more effective in increasing BP than dobutamine (n = 251, r = 0.26, 95%CI: 0.20-0.32). However there were no differences in short term outcomes (periventricular leucomalacia, periventricular haemorrhage) and mortality between both drugs. There is no statistical evidence of dopamine being more effective than adrenaline or corticosteroids. There was no difference in morbidity and mortality outcomes when dopamine was compared to hydrocortisone (RR 1.81, 95%CI: 0.18 to 18.39) or adrenaline.

CONCLUSION: In preterms, dopamine is the most studied drug, and we suggest it could be used as first line treatment in hypotension.

Gastrointestinal and nutritional care in pediatric neuromuscular disorders

Neuromuscular diseases (NMDs) affect the development and growth of the neuromuscular system in children. The pathology can occur anywhere along the neuromuscular pathway, from the brain to the nerves to the muscle fibers. These diseases have a profound impact on the quality of life not only of children but also of their families. The predominant manifestation in NMDs is hypotonia, which leads to muscle weakness and fatigue, reduced mobility, and decreased physical performance. However, multiple organ systems can be affected, with resulting orthopedic, cardiac, infectious, respiratory, and nutritional problems. Children with NMD present an increased risk for several dietary and feeding difficulties because of their neuromuscular diagnosis, presentation, and severity. These problems include chronic gastrointestinal issues (constipation, dysphagia, gastroesophageal reflux, and diarrhea), dysphagia, malnutrition, and body composition alterations. As a result, compared to the overall pediatric population, infants and children with NMD are more likely to be malnourished, ranging from failure to thrive to overweight or obesity. Disease-specific guidelines vary in level of detail and recommendations for dietary management. Overall, nutritional data available are sparse, with the exception of Duchenne muscular dystrophy, spinal muscular atrophy, and congenital muscular dystrophy. The purpose of this review is to describe the spectrum of nutritional challenges in children with NMD and to summarize the main dietary and gastrointestinal recommendations for each neuromuscular disorder to provide guidance for daily clinical practice.

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.

Using quality improvement methods to increase use of pain prevention strategies for childhood vaccination

AIM

To increase evidence-based pain prevention strategy use during routine vaccinations in a pediatric primary care clinic using quality improvement methodology.

METHODS

Specific intervention strategies (i.e., comfort positioning, nonnutritive sucking and sucrose analgesia, distraction) were identified, selected and introduced in three waves, using a Plan-Do-Study-Act framework. System-wide change was measured from baseline to post-intervention by: (1) percent of vaccination visits during which an evidence-based pain prevention strategy was reported as being used; and (2) caregiver satisfaction ratings following the visit. Additionally, self-reported staff and caregiver attitudes and beliefs about pain prevention were measured at baseline and 1-year post-intervention to assess for possible long-term cultural shifts.

RESULTS

Significant improvements were noted post-intervention. Use of at least one pain prevention strategy was documented at 99% of patient visits and 94% of caregivers were satisfied or very satisfied with the pain prevention care received. Parents/caregivers reported greater satisfaction with the specific pain prevention strategy used [t(143) = 2.50, P≤ 0.05], as well as greater agreement that the pain prevention strategies used helped their children’s pain [t(180) = 2.17, P≤ 0.05] and that they would be willing to use the same strategy again in the future [t(179) = 3.26, P≤ 0.001] as compared to baseline. Staff and caregivers also demonstrated a shift in attitudes from baseline to 1-year post-intervention. Specifically, staff reported greater agreement that the pain felt from vaccinations can result in harmful effects [2.47 vs 3.10; t(70) = -2.11, P≤ 0.05], less agreement that pain from vaccinations is “just part of the process” [3.94 vs 3.23; t(70) = 2.61, P≤ 0.05], and less agreement that parents expect their children to experience pain during vaccinations [4.81 vs 4.38; t(69) = 2.24, P≤ 0.05]. Parents/caregivers reported more favorable attitudes about pain prevention strategies for vaccinations across a variety of areas, including safety, cost, time, and effectiveness, as well as less concern about the pain their children experience with vaccination [4.08 vs 3.26; t(557) = 6.38, P≤ 0.001], less need for additional pain prevention strategies [3.33 vs 2.81; t(476) = 4.51, P≤ 0.001], and greater agreement that their doctors’ office currently offers pain prevention for vaccinations [3.40 vs 3.75; t(433) = -2.39, P≤ 0.05].

CONCLUSION

Quality improvement methodology can be used to help close the gap in implementing pain prevention strategies during routine vaccination procedures for children.

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.

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.

Use of laparoscopy as the initial surgical approach of impalpable testes: 10-year experience

AIM: To review the experience in the management of impalpable testes using laparoscopy as the initial approach and the need for inguinal exploration.

METHODS: From January 2004 to June 2014, 339 patients with undescended testes underwent operation in our institute. Fifty patients (15%) had impalpable testes. All children with impalpable testes underwent initial laparoscopy. A retrospective review was conducted on this group of patients and the outcome was analyzed.

RESULTS: Forty children had unilateral impalpable testis. Ten children had bilateral impalpable testes. Thirty-one children (78%) in the unilateral group underwent subsequent inguinal exploration while 4 children (40%) in the bilateral group underwent inguinal exploration (P < 0.05). Orchidopexy was performed in 16 children (40%) in the unilateral group and 9 children (90%) in the bilateral group (P < 0.05). Regarding the 24 children with unilateral impalpable testis and underwent orchidectomy for testicular nubbin (n = 19) or atrophic testes (n = 2) or has vanishing testes (n = 3); contralateral testicular hypertrophy was noticed in 10 (41%). No intra-operative complication was encountered. Two children after staged Fowler-Stephens procedure and 1 child after inguinal orchidopexy had atrophic testes.

CONCLUSION: The use of laparoscopy in children with impalpable testes is a safe procedure and can guide the need for subsequent inguinal exploration. Children with unilateral impalpable testis were associated with an increased need for inguinal exploration after laparoscopy. Orchidopexies could be performed successfully in 90% of children with bilateral impalpable testes.

Skin disease and thyroid autoimmunity in atopic South Italian children

AIM

To verify the prevalence of thyroid autoimmunity (TA) and the possible association between atopy and TA in children affected by skin disease.

METHODS

Three hundred and twenty-four children consecutively referred due to skin disease symptoms to our Pediatric Department were enrolled. One hundred and eighty-seven were diagnosed with atopic dermatitis (AD), 95 with acute urticaria, 40 with chronic urticaria (CU), and 2 with alopecia areata (AA). According to the work-up for atopy, the children were divided into two groups: Atopics and non-atopics. TA was diagnosed by serum thyroid peroxidase autoantibodies and/or thyroglobulin autoantibodies levels more than twice normal values over a period of two months by immunoassay.

RESULTS

In all children with skin disease, a significant prevalence of TA in atopics compared with non-atopics (13.67% vs 2.67%, P = 0.0016) and a significant association between TA and atopy (OR = 5.76, 95%CI: 1.71-19.35) were observed. These findings were confirmed as significant in children with AD: TA in atopics was 11.5%, while TA in non-atopics was 2.7% (P = 0.03, OR = 4.68, 95%CI: 1.02-21.38). In addition, atopics with CU showed a significantly higher prevalence of TA (26.9%), but none of the non-atopics showed CU (P = 0.0326). On the other hand, atopics with AA showed a 100% (2 out of 2) prevalence of TA, compared with none of the non-atopics.

CONCLUSION

In children with skin disease, atopy seems to be associated with an increased risk of TA.

Critical evaluation of unscientific arguments disparaging affirmative infant male circumcision policy

We evaluate recent claims opposing infant male circumcision, a procedure now supported by the evidence-based policy of the American Academy of Pediatrics. We find those criticisms depend on speculative claims about the foreskin and obfuscation of the strong scientific evidence supporting pediatric policy development. An argument that circumcision should be delayed to allow a boy to make up his own mind as an adult fails to appreciate the psychological, scheduling and financial burdens later circumcision entails, so reducing the likelihood that it will occur. In contrast, early infant circumcision is convenient, safer, quicker, lower risk, healing is faster, cosmetic outcome is routinely good and the lifetime benefits accrue immediately. Benefits include reduction in urinary tract infections, inflammatory skin conditions, foreskin problems, and, when older, substantial protection against sexually transmitted infections and genital cancers in the male and his female sexual partners. Some authorities regard the failure to offer parents early infant circumcision as unethical, just as it would be unethical to fail to encourage the vaccination of children. In conclusion, the criticisms of evidence-based infant male circumcision policy are seriously flawed and should be dismissed as unhelpful to evidence-based development and implementation of pediatric policy intended to improve public health and individual wellbeing.

Outcomes of transconjuctival sutureless 27-gauge vitrectomy for stage 4 retinopathy of prematurity

AIM

To report our initial experience with lens-sparing vitrectomy for stage 4 retinopathy of prematurity using the 27-gauge (G) system.

METHODS

This retrospective case series involved nine eyes of five babies with active stage 4 ROP, who underwent 27-G lens-sparing vitrectomy. Surgery was done using 27-G valved cannulas and sclerotomies were made 1.5 mm from the limbus. Bilateral sequential vitrectomy was done in eight eyes.

RESULTS

At one-year follow-up, anatomical outcome was favourable in all nine (100%) eyes. High-speed cutting and smaller sclerotomies were helpful in reducing the intra and post-operative complications.

CONCLUSION

27-G vitrectomy is well suited for stage 4 ROP surgeries.

Screening for asymptomatic chlamydia and gonorrhea in adolescent males in an urban pediatric emergency department

AIM

To determine the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) in young men seeking care in the emergency department (ED) for non-sexually transmitted infection (STI) related symptoms.

METHODS

This was a prospective, cross-sectional study in an urban ED. The main outcome was the rate of positive CT and GC on urine nucleic acid amplification testing in males aged 16-21 presenting with non-STI related complaints.

RESULTS

Two hundred and eighty-four patients were enrolled, 271 were included in the final data analysis [age range 16-21, median: 18 (quartiles 16-18, 19-21)]. Overall, 17 (6.3%, 95%CI: 4%-10%) tested positive for CT and 0% (95%CI: 0%-2%) were found to have GC. The proportion of sexually active subjects was 71% (95%CI: 65%-76%) and 2% (95%CI: 0.6%-4%) reported sex with men. Previous STI testing was reported in 46% (95%CI: 43%-54%) and 13% (95%CI: 8%-20%) of those patients previously tested had a history of STI. Of the patients who tested positive for CT in the ED, 88% (95%CI: 64%-98%) were successfully followed up.

CONCLUSION

The prevalence of CT infection found by screening was 6.3%. Screening and follow-up from the ED was successful. The findings justify routine STI screening in male adolescents presenting to the ED with non-STI related complaints.

Cyclical vomiting syndrome: Recognition, assessment and management

Cyclical vomiting syndrome (CVS) is a functional, debilitating disorder of childhood frequently leading to hospitalization. Affected children usually experience a stereotypical pattern of vomiting though it may vary between different individuals. The vomiting is intense often bilious, and accompanied by disabling nausea. Identifiable precipitating factors for CVS include psychosocial stressors, infections, lack of sleep and occasionally even food triggers. Often, it may be difficult to distinguish episodes of CVS from other causes of acute abdomen and altered consciousness. Thus, the diagnosis of CVS remains largely one of exclusion. Investigations routinely done during the work-up of a child with suspected CVS include both blood and imaging modalities. Plasma lactate, ammonia, amino acid and acylcarnitine profiles as well as urine organic acid profile are indicated to exclude inborn errors of metabolism. The treatment remains challenging and targeted at prevention or shortening of the attacks and can be considered as abortive, supportive and prophylactic. Use of non-pharmacological therapy is also part of the management of CVS. The prognosis of CVS is variable. More insight into the pathogenesis of this disorder as well as role of non-pharmacological therapy is needed.

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.

Validation of a pediatric bedside tool to predict time to death after withdrawal of life support

AIM: To evaluate the accuracy of a tool developed to predict timing of death following withdrawal of life support in children.

METHODS: Pertinent variables for all pediatric deaths (age ≤ 21 years) from 1/2009 to 6/2014 in our pediatric intensive care unit (PICU) were extracted through a detailed review of the medical records. As originally described, a recently developed tool that predicts timing of death in children following withdrawal of life support (dallas predictor tool [DPT]) was used to calculate individual scores for each patient. Individual scores were calculated for prediction of death within 30 min (DPT30) and within 60 min (DPT60). For various resulting DPT30 and DPT60 scores, sensitivity, specificity and area under the receiver operating characteristic curve were calculated.

RESULTS: There were 8829 PICU admissions resulting in 132 (1.5%) deaths. Death followed withdrawal of life support in 70 patients (53%). After excluding subjects with insufficient data to calculate DPT scores, 62 subjects were analyzed. Average age of patients was 5.3 years (SD: 6.9), median time to death after withdrawal of life support was 25 min (range; 7 min to 16 h 54 min). Respiratory failure, shock and sepsis were the most common diagnoses. Thirty-seven patients (59.6%) died within 30 min of withdrawal of life support and 52 (83.8%) died within 60 min. DPT30 scores ranged from -17 to 16. A DPT30 score ≥ -3 was most predictive of death within that time period, with sensitivity = 0.76, specificity = 0.52, AUC = 0.69 and an overall classification accuracy = 66.1%. DPT60 scores ranged from -21 to 28. A DPT60 score ≥ -9 was most predictive of death within that time period, with sensitivity = 0.75, specificity = 0.80, AUC = 0.85 and an overall classification accuracy = 75.8%.

CONCLUSION: In this external cohort, the DPT is clinically relevant in predicting time from withdrawal of life support to death. In our patients, the DPT is more useful in predicting death within 60 min of withdrawal of life support than within 30 min. Furthermore, our analysis suggests optimal cut-off scores. Additional calibration and modifications of this important tool could help guide the intensive care team and families considering DCD.