Effectiveness of Exercise on Sleep Quality in Attention Deficit Hyperactivity Disorder: A Systematic Review and Meta-Analysis

Objective: This study aimed to systematically review the available evidence on the effects of exercise training programs on sleep quality in attention deficit hyperactivity disorder. Methods: Studies were searched in five electronic databases until March 2024. The methodological quality of the included studies was assessed using the Physiotherapy Evidence Database and Methodological Index for Non-Randomized Studies scales. Results: A total of five randomized clinical trials, two non-randomized comparative studies, and one single-arm trial were included. Self-reported sleep quality (n = 7) and objective sleep status (n = 3) were the main outcomes analyzed. Generally, exercise induced positive effects on self-reported sleep outcomes. The performed meta-analysis with data from 131 participants indicated that exercise showed a non-significant trend towards increasing objective sleep duration (Hedges' g -2.67; 95% CI -11.33; 5.99, p = 0.185). While exercise appears safe for individuals with attention deficit hyperactivity disorder, its efficacy in managing sleep disturbances in this population remains uncertain. Conclusions: While there is evidence suggesting a positive impact of exercise on self-reported sleep quality, its efficacy for improving sleep duration could not be confirmed.

Unlocking autism's complexity: the Move Initiative's path to comprehensive motor function analysis

The long-standing practice of using manualized inventories and observational assessments to diagnose and track motor function in autism overlooks critical data invisible to the naked eye. This subjective approach can introduce biases and hinder the translation of research into clinical applications that rely on objective markers of brain-body connections. Meanwhile, we are experiencing a digital healthcare revolution, marked by innovations in the collection and analysis of electronic health records, personal genomes, and diverse physiological measurements. Advanced technologies, including current wearable devices, integrate both active and passive (sensor-based) data collection, providing a more comprehensive view of human health. Despite advances in sensors, wearables, algorithms, machine learning, and agentic AI, autism research remains siloed, with many tools inaccessible to affected families and care teams. There is a pressing need to merge these technological advances and expedite their translation into accessible, scalable tools and solutions to diversify scientific understanding. In response, this Perspective introduces the Move Initiative, a coalition spearheaded by the nonprofit 2 m Foundation, composed of self-advocates, families, clinicians, researchers, entrepreneurs, and investors who aim to advance and refine the measurement of movement in autism. Move will make motor screenings more dynamic and longitudinal while supporting continuous assessment of targeted interventions. By fostering cross-disciplinary collaboration, Move seeks to accelerate the integration of the expanding knowledge base into widespread practice. Deep, longitudinal, multi-modal profiling of individuals with Autism Spectrum Disorder offers an opportunity to address gaps in current data and methods, enabling new avenues of inquiry and a more comprehensive understanding of this complex, heterogeneous condition.

Prevalence of Hypovitaminosis D in Pregnancy and Potential Benefits of Oral Supplementation

OBJECTIVE

 This study aimed to evaluate prevalence of hypovitaminosis D in a cohort of Italian pregnant women, and to evaluate potential benefits of oral supplementation STUDY DESIGN:  Observational cohort of women with singleton gestations who were referred to our institution for first trimester prenatal visit. Screening for hypovitaminosis D was performed at the time of first trimester routine scan between 11 and 13 weeks of gestations. Women were offered measurement of serum 25-hydroxyvitamin D (25[OH]D). Levels of 25(OH)D are interpreted as follows: 12 to <20 ng/mL: Vitamin D insufficiency; < 12 ng/mL: Vitamin D deficiency. Women with Vitamin D insufficiency or deficiency were offered daily oral supplementation at the dose of 2.000 UI, along with folic acid. The primary outcome was the prevalence of hypovitaminosis D in our cohort.

RESULTS

 During the study period, between January 2023 and January 2024, 250 pregnant women were included in the study and screened for 25(OH)D. More than half of the screened women had 25(OH)D < 20 ng/mL, with a prevalence of <12 ng/mL of 14%. Out of the 140 (140/250 = 56%) women with 25(OH)D < 20 ng/mL, 127/140 (90%) accepted supplementation with Vitamin D, whereas 13 refused the therapy for fear of teratogenic effects of the fetus. The overall rate of preterm delivery before 37 weeks was 8.4%, whereas the incidence of preeclampsia was 2.8%. Rate of preterm delivery was higher in women who did not received supplementation (9.5 vs. 30.8%), but the study was not powered for such comparison.

CONCLUSION

 Hypovitaminosis D has high prevalence in pregnant women. Universal screening in the first trimester with measurement of serum 25-hydroxyvitamin D (25[OH]D) can identify women at risk that may benefit of oral supplementation.

KEY POINTS

· Hypovitaminosis D has high prevalence in pregnant women.. · Universal screening with measurement of serum 25(OH)D can identify women at risk.. · Oral supplementation can be recommended in women with vitamin D insufficiency..

Neighbourhood socioeconomic conditions and emergency admissions for ambulatory care sensitive conditions in children: a longitudinal ecological analysis in England, 2012-2017

BACKGROUND

Ambulatory care sensitive conditions (ACSCs) are those for which hospital admission could be prevented by interventions in primary care. Children living in socioeconomic disadvantage have higher rates of emergency admissions for ACSCs than their more affluent counterparts. Emergency admissions for ACSCs have been increasing, but few studies have assessed how changing socioeconomic conditions (SECs) have impacted this. This study investigates the association between local SECs and emergency ACS hospital admissions in children in England.

METHODS

We examined longitudinal trends in emergency admission rates for ACSCs and investigate the association between local SECs and these admissions in children over time in England, using time-varying neighbourhood unemployment as a proxy for SECs. Fixed-effect regression models assessed the relationship between changes in neighbourhood unemployment and admission rates, controlling for unmeasured time-invariant confounding of each neighbourhood. We also explore the extent to which this relationship differs by acute and chronic ACSCs and is explained by access to primary and secondary care.

RESULTS

Between 2012 and 2017, paediatric emergency admissions for acute ACSCs increased, while admissions for chronic ACSCs decreased. At the neighbourhood level, each 1% point increase in unemployment was associated with a 3.9% and 2.7% increase in the rate of emergency admissions for acute ACSCs, for children aged 0-9 years and 10-19 years, respectively. A 2.6% increase in admission rates for chronic ACSCs was observed, driven by an association in 0-9 years old. Adjustment for primary and secondary care access did not meaningfully attenuate the magnitude of this association.

CONCLUSIONS

Increasing trends in neighbourhood unemployment were associated with increases in paediatric emergency admission rates for ACSCs in England. This was not explained by available measures of differential access to care, suggesting policy interventions should address the causes of unemployment and poverty in addition to health system factors to reduce emergency admissions for ACSCs.

Inhalation of multiple pen caps causing bronchial foreign bodies: a rare case in an older child

BACKGROUND

Foreign body inhalation is rare in older children, often leading to underdiagnosis and delayed treatment. Most cases involve a single foreign body, but instances of multiple foreign bodies are exceedingly uncommon. This report presents a case of an elder child who inhaled two pen caps, emphasizing the need for clinical vigilance and thorough medical history collection.

CASE PRESENTATION

A twelve-year-old boy was admitted with a persistent cough lasting over two months, accompanied by sputum with a peculiar odor. Previous treatments with oral Cefdinir (0.1 g, three times daily) and inhaled Budesonide Suspension had not improved his condition. Physical examination revealed decreased breath sounds on the right side without signs of respiratory distress or wheezing. Imaging studies, including chest X-ray and CT scan, along with bronchoscopy, confirmed the presence of two foreign bodies in the right bronchus. The patient was started on anti-infective therapy to address any underlying infection before proceeding with removal. A combination of flexible bronchoscopy and rigid bronchoscopy, supplemented by a cryotherapy instrument, successfully extracted the pen caps. Post-procedure assessments indicated that the patient's body temperature returned to normal, cough symptoms resolved, and lung ventilation significantly improved.

CONCLUSION

This case highlights the critical need for clinicians to remain vigilant regarding bronchial foreign bodies in older children. The rare occurrence of multiple foreign bodies, particularly resulting from active inhalation, necessitates a comprehensive medical history during patient evaluation. Early recognition and intervention can lead to significant improvements in patient outcomes, underscoring the importance of thorough clinical assessment in similar cases.

Executive function is associated with behaviour problems in children and adolescents with cerebral palsy and intellectual disability

BACKGROUND

Children and adolescents with cerebral palsy (CP) commonly have behaviour problems. The present study aimed to determine which of the most common clinical features experienced by children and adolescents with CP and intellectual disability are associated with behaviour problems.

METHOD

We investigated 11 possible associated variables including epilepsy, visual and hearing impairments, motor difficulties, communication and speech difficulties, pain, sleep disturbance, executive function (EF) deficits, type of CP, and parent stress. Thirty-eight parents or guardians of children aged 6 to 17 years with CP and intellectual disability (parent informed) completed proxy and self-report standardised questionnaires.

RESULTS

EF deficits and parent stress were significantly associated with behavioural problems.

CONCLUSION

For children and adolescents with CP and intellectual disability, the present study suggests close attention should be placed on specific clinical features including EF deficits and parent stress when considering variables associated with behaviour problems.

Hospitalization Trends and Healthcare Resource Utilization for Fecal Impactions in Pediatric Patients with Functional Constipation

Objectives: To analyze the clinical characteristics, trends in hospitalization, and healthcare resource utilization of pediatric patients with fecal impaction. Methods: We utilized the Healthcare Cost and Utilization Project (HCUP) databases, including the National Inpatient Sample (NIS) and the Kids Inpatient Database (KID) datasets from 2011 to 2019, to include all hospitalizations of patients up to 18 years of age with a primary diagnosis of (1) fecal impaction or (2) a primary diagnosis of abdominal pain or constipation with a secondary diagnosis of fecal impaction. The study analyzed various comorbid factors and clinical characteristics of these patients. For healthcare resource utilization, we analyzed the length of hospital stays and total hospital charges, adjusted for inflation. Results: A total of 23,570 admissions due to fecal impactions in children between the years 2011 and 2019 were analyzed, contributing to 0.18% of the total pediatric admissions. Hospitalization rates nearly doubled from 2011 (0.15%) to 2019 (0.29%). The mean hospitalization charges also trended upwards from 15,234 USD in 2011 to 22,487 USD in 2019. The inflation-adjusted annual rate of increase in hospital charges during this period was 5.9% per year. Aggressive fecal disimpaction procedures (either manual or surgical) were performed in approximately 3% of these admissions. Multivariate regression showed that older children (13-18 years of age) were more likely to require aggressive disimpaction. Female children, those with Hispanic ethnicity, and those with obesity were less likely to be associated with the need for disimpaction. Conclusions: Hospitalizations for fecal impaction have increased significantly over the past decade, creating a substantial burden on healthcare resources. Our study highlights the importance of aggressive outpatient management strategies with close follow-up for fecal impactions, which will potentially minimize these hospitalizations.

Evaluation of the Frequency of HLA-DQ2/DQ8 Genes Among Patients with Celiac Disease and Those on a Gluten-Free Diet

BACKGROUND

Celiac disease (CD) is a chronic, permanent, gluten-dependent disease that manifests itself with inflammation of the small intestine and malabsorption in genetically predisposed individuals with HLA-DQ2 and -DQ8 (human leukocyte antigen) histocompatibility antigens.

OBJECTIVE

The diagnostic criteria for celiac disease have undergone numerous modifications over the years. The aim of the study is to evaluate the frequency of HLA-DQ2/DQ8 genes in a group of patients with celiac disease diagnosed in 1980-2010 in order to verify the primary diagnosis of CD.

METHODS

The study group included 50 patients, 13 men and 37 women, who had been diagnosed with celiac disease many years ago based on histopathological criteria and improvement of health condition after receiving a gluten-free diet. The control group consisted of 31 healthy volunteers, 18 women and 13 men. All subjects underwent a genetic analysis assessing the presence of histocompatibility antigens HLA-DQ2.2, -DQ2.5, and -DQ8, along with the assessment of alleles encoding the α and β subunits of the antigens, according to European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines from 2020, using the EUROarray technique at EUROIMMUNE®.

RESULTS

In the study group, 12 (24%) patients did not meet the genetic criteria. Among the remaining patients (Group 1) with celiac disease, the presence of HLA-DQ2.5 (50.0% vs. 9.68%; p < 0.01) and the co-occurrence of both alleles of HLA-DQ2 (31.6% vs. 6.45%; p < 0.05) were detected significantly more frequently than in the control group. Among patients with celiac disease, the prevalence of HLA-DQ8 was also slightly more frequent (13.2% vs. 3.23%; p > 0.05). Patients who did not meet the genetic criteria for celiac disease (Group 2) had a single string α-HLA-DQ2.5 significantly more often than control subjects (66.67% vs. 38.71%; p < 0.05).

CONCLUSIONS

Among patients with celiac disease diagnosed before 2010, based on the 2020 ESPGHAN criteria, it is advisable to verify the previous diagnosis, taking into account genetic criteria.

Socioeconomic disparities in mortality from indoor air pollution: A multi-country study

BACKGROUND

Indoor air pollution is a major public health concern, contributing to approximately 2.9 million deaths and 81.1 million disability-adjusted life years lost annually. This issue disproportionately affects underprivileged communities that depend on solid fuels for cooking. As a result, these communities suffer from heightened exposure to indoor air pollutants, which increases the risk of morbidity, mortality, and worsening health disparities.

OBJECTIVE

This study investigates the association between socioeconomic status and mortality related to indoor air pollution across multiple countries.

METHODS

Data from the 2019 Demographic and Health Survey, WHO, and World Bank were utilized to examine the impact of socioeconomic status on indoor air pollution-related mortality. The primary outcome was mortality associated with solid fuel use, with income quintiles as the independent variable. Linear and logistic regression analyses were applied to assess these relationships.

RESULTS

Logistic regression analysis revealed a strong negative association where household income increases and indoor air pollution-related mortality significantly decreases. Specifically, Households in the highest income quartile showed a 22% reduction progressively in the odds of mortality risk compared to the lowest income quintile. Additionally, access to clean fuel correlated with a 0.59 times lower odds of mortality, highlighting the clean energy sources' protecting effect.

CONCLUSION

The findings highlight the critical need to prioritize clean fuel access, particularly in low-income communities, to reduce indoor air pollution mortality. Policies should focus on increasing clean energy accessibility and supporting vulnerable populations through targeted subsidies and poverty alleviation programs to reduce indoor air pollution exposure disparities.

Clinical Features of Human Parvovirus B19-Associated Encephalitis Identified in the Dakar Region, Senegal, and Viral Genome Characterization

Neurological manifestations associated with human parvovirus B19 (B19V) infections are rare and varied. Acute encephalitis and encephalopathy are the most common, accounting for 38.8% of all neurological manifestations associated with human B19V. Herein, we report on the clinical features of 13 laboratory-confirmed human cases of B19V-associated encephalitis in Senegal in the framework of a hospital-based surveillance of acute viral encephalitis conducted from 2021 to 2023. Overall, B19V was detected from 13 cerebrospinal fluid samples using specific real time PCR. The mean age was 16.7 years among B19V-positive patients, with a higher prevalence in 0-5-year-old children and the sex ratio (male/female) was 2.25. The B19V-positive patients mainly exhibited hypoleukocytosis, normal glycorrhachia, and normal proteinorrachia in the cerebrospinal fluid. While the main neurological symptoms included meningeal and infectious syndromes. Furthermore, three complete B19V genome sequences were successfully characterized using next-generation sequencing. The newly characterized sequences belonged to the genotype 1a and represent, to date, the first complete B19V genome sequences from Senegal. These sequences could be useful not only in future phylodynamic studies of B19V but also in the development of prevention or treatment countermeasures. Our study is noteworthy for the identification of acute B19V-associated encephalitis in Senegal More investigations on the risk factors associated with B19V transmission in Africa are warranted.

Gender differences in behavioral and emotional problems among school children and adolescents in China: National survey findings from a comparative network perspective

BACKGROUND

Behavioral and emotional problems are common and often co-occur during childhood and adolescence. The aim of this study was to assess gender differences in the network structures of behavioral and emotional problems of children and adolescents in China based on a national survey.

METHODS

The Parent version of Achenbach' s Child Behavior Checklist (CBCL) was used to assess behavioral and emotional problems. To account for potential confounding factors in comparisons between boys and girls, propensity score matching was utilized. Network model differences were assessed using Network Comparison Test (NCT).

RESULTS

Data from 60,715 children and adolescents were included for analyses. Boys exhibited more severe total behavioral and emotional problems compared to girls. While several edges showed significant differences between boys and girls, the strongest association was consistently found between "Attention problems" (CBCL6) and "Aggressive behavior"(CBCL8) in both boys and girls, regardless of age. Network centrality was higher among adolescents compared to children. The most central problems commonly found across different genders and age groups were "Aggressive behavior" (CBCL8) (centrality values were 1.142 for boys aged 6-11 years, 1.051 for boys aged 12-16 years, 1.148 for girls aged 6-11 years, and 1.028 for girls aged 12-16 years), "Anxious/depressed" (CBCL1) (centrality values of 0.892 for boys aged between 6 and 11 years, 1.031 for boys aged 12-16 years, 0.951 for girls aged 6-11 years, and 1.099 for girls aged 12-16 years) and "Social problems" (CBCL4) (centrality values of 1.080 for boys aged 6-11 years, 0.978 for boys aged 12-16 years, 1.086 for girls aged between 6 and 11 years, and 0.929 for girls aged 12-16 years).

CONCLUSION

Testing effective interventions that address aggressive behavior, anxiety/depression, and social problems may be beneficial for reducing risk of psychopathology among children and adolescents.

Impact of calcineurin inhibitors on gut microbiota: Focus on tacrolimus with evidence from in vivo and clinical studies

Calcineurin Inhibitors (CNIs), including tacrolimus and cyclosporine A, are the most widely used immunosuppressive drugs in solid organ transplantation. Those drugs play a pivotal role in preventing graft rejection and reducing autoimmunity. However, recent studies indicate that CNIs can disrupt the composition of gut microbiota or result in "gut dysbiosis". This dysbiosis has been shown to be a significant factor in reducing host immunity by decreasing innate immune cells and impairing metabolic regulation, leading to lipid and glucose accumulation. Several in vivo and clinical studies have demonstrated a mechanistic link between gut dysbiosis and the side effects of CNI. Those studies have unveiled that gut dysbiosis induced by CNIs contributes to adverse effects such as hyperglycemia, nephrotoxicity, and diarrhea. These adverse effects of the induced gut dysbiosis require interventions to restore microbial balance. Probiotics and dietary supplements have emerged as potential interventions to mitigate the side effects of gut dysbiosis caused by CNIs. In this complex relationship between CNI treatment, gut dysbiosis, and interventions, several types of gut microbiota and host immunity are involved. However, the mechanisms underlying these relationships remain elusive. Therefore, the aim of this review is to comprehensively summarize and discuss the major findings from in vivo and clinical data regarding the impact of treatment with CNIs on gut microbiota. This review also explores interventions to mitigate dysbiosis for therapeutic approaches of the side effects of CNIs. The possible underlying mechanisms of CNIs-induced gut dysbiosis with or without interventions are also presented and discussed.

The Impact of a Music- and Movement-Based Intervention on Motor Competence, Social Engagement, and Behavior in Children with Autism Spectrum Disorder

BACKGROUND/OBJECTIVES

The main objective of this manuscript is to evaluate the effects of training, music, and movement intervention on motor functions, social engagement, and behaviors in autistic children.

METHODS

Twenty-one children with a diagnosis of mild autism spectrum disorder (ASD), with an age range of 5-to-13 years, were divided into two groups: the experimental group (n = 10) and the control group (n = 11). All participants were examined before (T0) and after the intervention (T1) to evaluate their motor functions (Bruininks-Oseretsky Motor Performance Test (BOT-2)), maladaptive behavior (RCS (Response to Challenge Scale)), and enjoyment and engagement (PACES (Physical Activity Enjoyment Scale)).

RESULTS

Statistical analysis showed that music and movement intervention significantly improved motor functions such as balance and bilateral coordination (p < 0.0001), social engagement (p = 0.002), and adaptive behaviors (p = 0.005) in children with ASD. Our research supports the feasibility of music and movement intervention and documents the interest in participating in children with ASD.

CONCLUSIONS

This study demonstrates the benefits of movement and music interventions and can be considered a useful way to manage autism spectrum disorders in the future.

Convergence of autism proteins at the cilium

Hundreds of high-confidence autism genes have been identified, yet the relevant etiological mechanisms remain unclear. Gene ontology analyses have repeatedly identified enrichment of proteins with annotated functions in gene expression regulation and neuronal communication. However, proteins are often pleiotropic and these annotations are inherently incomplete. Our recent autism functional genetics work has suggested that these genes may share a common mechanism at the cilium, a membrane-bound organelle critical for neurogenesis, brain patterning, and neuronal activity-all processes strongly implicated in autism. Moreover, autism commonly co-occurs with conditions that are known to involve ciliary-related pathologies, including congenital heart disease, hydrocephalus, and blindness. However, the role of autism genes at the cilium has not been systematically investigated. Here we demonstrate that autism proteins spanning disparate functional annotations converge in expression, localization, and function at cilia, and that patients with pathogenic variants in these genes have cilia-related co-occurring conditions and biomarkers of disrupted ciliary function. This degree of convergence among genes spanning diverse functional annotations strongly suggests that cilia are relevant to autism, as well as to commonly co-occurring conditions, and that this organelle should be explored further for therapeutic potential.

Microalgae-based bacteria for oral treatment of ASD through enhanced intestinal colonization and homeostasis

Rationale: Exogenous supplementation of beneficial intestinal bacteria can alleviate the behavioural symptoms of psychiatric disorders, such as autism spectrum disorder (ASD), through gut-brain interactions. However, the application of beneficial bacteria, such as Lactobacillus reuteri (L. reuteri), for treating ASD is hindered by limited gut colonization. Methods: Utilizing Spirulina platensis (SP) as a natural microcarrier for intestinal bacteria, a safer and more natural binding approach was employed to bind intestinal bacteria to the surface of SP to produce SP-intestinal bacteria. Due to the high adhesion efficiency and long residence time of SP in the intestines, SP-intestinal bacteria exhibit stronger intestinal colonization ability and better therapeutic effects on ASD. Results: SP is an effective carrier that can bind and deliver bacteria of different shapes and with different gram-staining properties. SP-intestinal bacteria exhibited enhanced colonization capabilities both ex vivo and in vivo. Further research showed that SP-L. reuteri had greater intestinal colonization efficiency than L. reuteri. SP-L. reuteri showed a stronger therapeutic effect on alleviating social deficits in an ASD mouse model by modulating the gut microbiota, enhancing intestinal barrier integrity, reducing lipopolysaccharide entry into the blood and mediating the neuroinflammatory response in the paraventricular thalamic nucleus. Conclusions: This study reports a microalgae-assisted intestinal bacterial delivery system for enhancing intestinal bacterial transplantation for gut-brain axis- or other intestinal-related diseases.

The effectiveness of play therapy on depression and anxiety in hospitalized children with cancer: a systematic review

BACKGROUND

The presence of cancer and its treatment will induce anxiety and various effects, not only on a physical level but also on a psychological level. Play therapy can be used by children to articulate their emotions and foster proficient communication with healthcare professionals and caregivers. Play therapy emerges as a highly effective method for the management of illness in children diagnosed with cancer.

MATERIAL AND METHODS

A thorough search was conducted across multiple databases including PubMed, Web of Science, Scopus, Google Scholar, and Cochrane Library. Our review included only interventional studies published from inception to 1 March 2024 that investigated the impact of play therapy on depression and anxiety in hospitalized children with cancer. For each study, information was gathered regarding the study's objective, participant characteristics, conditions, intervention details, comparisons made, study duration, and outcome measures.

RESULTS

Following the retrieval of 2158 records, 12 studies were found to meet the eligibility criteria and were thus selected to include in the synthesis. Play therapy has been explored in several studies using interventions like cognitive-behavioral-based play therapy, family-based play therapy, group-based play therapy, virtual reality-based play therapy, and play therapy combined with other therapeutic approaches. Specifically, six studies investigated the effects of play therapy on anxiety, two studies on depression, and four studies on anxiety and depression.

CONCLUSION

Play therapy is highly recommended due to its simplicity, minimal requirement of tools and materials, ease of implementation, affordability, and suitability for hospitalized preschool and school-age children with cancer.

Bronchiolitis Severity Affects Blood Count and Inflammatory Marker Levels: A Real-Life Experience

BACKGROUND

Bronchiolitis is the most common cause of lower respiratory tract infection (LRTI) in the first year of life. We analyzed the association between complete blood count (CBC), c-reactive protein (CRP), and novel inflammatory indexes (NLR, PLR, MLR, ELR, LMR, NPR, LPR, LNR, PNR, SII, SIRI) in predicting bronchiolitis severity at hospital admission.

METHODS

We retrospectively collected data from 95 infants hospitalized for bronchiolitis in a third-level hospital during three epidemic seasons. Five outcomes of severity were analyzed: BRAS; pediatric intensive care unit (PICU) admission; ventilatory support; intravenous (IV) rehydration; and length of stay (LOS).

RESULTS

Lower age and weight at admission were statistically associated with four of the five severity outcomes. Prolonged LOS (≥6 days) was associated with high values of total white blood cells, lymphocytes, and eosinophils. Only three inflammatory indexes (PLR, MLR, and PNR) showed a significant association with one outcome (prolonged LOS). A new index (RBC/AiW/1000) was statistically associated with each severity outcome for a value > 350.

CONCLUSIONS

We proposed a comprehensive analysis of the association between CBC, CRP, and novel inflammatory indexes and bronchiolitis severity. RBC/AiW/1000 could represent a future predictive marker of disease severity at hospital admission in infants with bronchiolitis.

Using non-pharmacological interventions to manage medical procedure-induced anxiety in children: a framework to guide best practice

Medical procedure-induced anxiety in children can have short- and long-term negative effects. Research shows that children's anxiety can be affected by non-pharmacological interventions and adults' behaviours in a complex manner. This article presents a scoping review of the literature on non-pharmacological interventions to manage medical procedure-induced anxiety in children. Based on this review, the authors propose a framework comprising six strategies for effective non-pharmacological management of medical procedure-induced anxiety in children. A real-life, and anonymised, example is used to illustrate this framework in practice.

Long COVID in Children and Adolescents: Mechanisms, Symptoms, and Long-Term Impact on Health-A Comprehensive Review

Long COVID, also known as post-acute sequelae of SARS-CoV-2 infection (PASC), is increasingly recognized as a condition affecting not only adults but also children and adolescents. While children often experience milder acute COVID-19 symptoms compared to adults, some develop persistent physical, psychological, and neurological symptoms lasting for weeks or months after initial infection. The most commonly reported symptoms include debilitating fatigue, respiratory issues, headaches, muscle pain, gastrointestinal disturbances, and cognitive difficulties, which significantly impact daily activities, schooling, and social interactions. Additionally, many children with long COVID experience psychological symptoms, such as anxiety, depression, mood swings, and irritability, likely exacerbated by prolonged illness and lifestyle disruptions. Risk factors for long COVID in children include pre-existing health conditions such as asthma, obesity, and neurological disorders, with adolescents and females seemingly more affected. Hypothesized mechanisms underlying long COVID include chronic immune dysregulation, persistent viral particles stimulating inflammation, autonomic nervous system dysfunction, and mitochondrial impairment, which may collectively contribute to the variety of observed symptoms. Long-term outcomes remain uncertain; however, long COVID can lead to school absenteeism, social withdrawal, and psychological distress, potentially affecting cognitive development. Severe cases may develop chronic conditions such as postural orthostatic tachycardia syndrome (POTS) and reduced exercise tolerance. This review synthesizes the existing literature on long COVID in children, examining its prevalence, symptomatology, risk factors, and potential mechanisms, with an emphasis on the need for further clinical studies. While existing research largely relies on surveys and self-reported data, clinical assessments are essential to accurately characterize long COVID in pediatric populations and to guide effective management strategies.

Protective or limited? Maternal antibodies and RSV-associated lower respiratory tract infection in hospitalized infants aged 28-90 days

Background

Respiratory syncytial virus (RSV) is a major cause of severe health problems in newborns and young children. The protective role and limitations of serum maternal RSV antibodies in infants under 3 months remain controversial.

Methods

A two-center prospective study from 2020 to 2023 recruited infants (n=286) admitted to the respiratory departments of two children's hospitals in southwestern and southeastern China during RSV epidemic. These infants were hospitalized with lower respiratory tract infections (LRTI). We evaluated the relationship between serum RSV Prefusion (Pre-F), postfusion (Post-F) IgG levels, subtype neutralizing antibodies, and the incidence of RSV infection, as well as the relationship between these maternal antibodies and severity of disease. Since this prospective study only included data from RSV epidemic, we retrospectively reviewed medical records from the Children's Hospital of Chongqing Medical University for the years 2019 to 2023 (n=3467) to analyze population characteristics during both RSV epidemic and non-epidemic periods, using the same inclusion and exclusion criteria.

Result

There were no significant differences in RSV Pre-F IgG, Post-F IgG, or RSV A or B neutralizing antibody levels between the RSV infected and non-infected groups during the epidemic. While RSV Pre-F IgG antibody was inversely correlated with disease severity, RSV Post-F IgG, and RSV A and B neutralizing antibodies did not show a similar correlation across the three illness severity categories. Additionally, there were no differences in age, gender, or illness severity distribution among hospitalized patients during epidemic and non-epidemic periods.

Conclusion

Serum maternal antibody levels offer insufficient protection against RSV-associated LRTI in hospitalized infants aged 28 to 90 days.

Construction of a nomogram model to predict the risk of retinopathy of prematurity reactivate after intravitreal anti-vascular endothelial growth factor therapy: a retrospective study

Objective

To explore the risk factors for the reactivate of retinopathy of prematurity (ROP) after intravitreal injection of anti-vascular endothelial growth factor (VEGF) and to construct a nomogram model to predict the risk of ROP reactivate.

Methods

A retrospective analysis was conducted on 185 ROP children who underwent anti-VEGF treatment at the First Affiliated Hospital of Zhengzhou University from January 2017 to October 2023. They were randomly divided into a training set (129 cases) and a validation set (56 cases) at a ratio of 7:3. The training set was further divided into a reactivate group (n = 18) and a non-reactivate group (n = 111) based on whether ROP recurred after treatment. Multivariable logistic regression analysis was used to screen for risk factors for ROP reactivate. A nomogram model was constructed using R software and validated using the validation set. The discrimination, calibration, and clinical net benefit of the model were evaluated using the receiver operating characteristic curve (ROC curve), calibration curve, and decision curve analysis, respectively.

Results

Multivariable logistic regression analysis showed that the number of red blood cell transfusions, use of pulmonary surfactant (PS) 2 times or more, and preoperative fundus hemorrhage were independent risk factors for ROP reactivate (P < 0.05). The area under the ROC curve (AUC) of the training set was 0.810 (95% CI: 0.706-0.914), and that of the validation set was 0.756 (95% CI: 0.639-0.873). The Hosmer-Leme show goodness-of-fit test indicated a good fit of the model (P = 0.31). Calibration curve analysis and decision curve analysis suggested high predictive efficacy and clinical application value of the model.

Conclusions

The number of red blood cell transfusions, use of PS 2 times or more, and preoperative fundus hemorrhage are independent risk factors for ROP reactivate. The nomogram model constructed based on these factors has high predictive efficacy and clinical application value.

Impact of proxymetacaine on the dynamics of cyclopentolate in White 6- to 7-year-olds

PURPOSE

This study compared the efficacy of cyclopentolate hydrochloride at 10-, 20- and 30-min post-instillation in White 6- to 7-year-olds, with and without prior instillation of proxymetacaine hydrochloride. The primary aim was to determine if accurate autorefraction values can be obtained sooner than the current standard of 30-min post-cycloplegia. The secondary aim was to investigate whether proxymetacaine hydrochloride enhances the efficiency of cyclopentolate.

METHODS

Participants were 112 White 6- to 7-year-olds from the Child Eye Health Study. The right eye received 0.5% proxymetacaine hydrochloride and 1.0% cyclopentolate hydrochloride, and the left eye received only 1.0% cyclopentolate hydrochloride. Non-cycloplegic and cycloplegic refractive error (at 0, 10, 20 and 30 min) was measured using a binocular, open-field autorefractometer. Data were analysed through paired t-tests, concordance analysis, linear regression, equivalence testing and Bland-Altman analysis, using the 95% limits of agreement.

RESULTS

Mean spherical equivalent refraction (SER) (SD) in the right eye at 0-, 10-, 20- and 30-min post-instillation was 0.62 (1.45) D, 1.52 (1.80) D, 1.64 (1.81) D and 1.72 (1.80) D, respectively. Mean left eye SER (SD) were 0.68 (1.24) D, 1.42 (1.66) D, 1.56 (1.66) D and 1.68 (1.72) D, respectively. Bland-Altman analysis showed a high level of agreement, and equivalence testing confirmed that there was no clinically significant difference in SER at 20 and 30 min in both eyes (within ±0.50 D), with mean differences of 0.08 (0.23) D in the right eye and 0.13 (0.30) D in the left eye (p = 0.21). However, SER at 10 and 30 min were equivalent in the right eye only.

CONCLUSIONS

Accurate autorefraction values can be obtained 20-min post-instillation of 1.0% cyclopentolate in white children aged 6-7 years, potentially reducing clinical testing times. Proxymetacaine pre-instillation allows for reliable measurements as early as 10-min post-instillation of cyclopentolate. Further research is needed to validate these findings in non-White populations and to determine the safe discharge time post-proxymetacaine instillation.

[Insomnia in children]

Healthy sleep is essential for a child's full growth and development. To assess the quality of sleep, it is necessary to be clearly guided by the dynamics of its standards depending on age. Insomnia in children has a number of features compared to adults. Clinical variants of acute and chronic insomnia are associated with stress, childhood somatic pathology, and hyperactivation of the central nervous system. Children with concomitant neuropsychiatric pathology are prone to severe insomnia. The presence of negative associations of falling asleep in the first year of life contributes to the formation of insomnia in young children. In adolescents, insomnia is associated with sleep hygiene disorders and has a psychophysiological character. Treatment of insomnia in children includes normalization of sleep hygiene, the use of behavioral therapy methods, and prescribing pharmaceutical drugs with age restrictions. The safety profile plays a fundamental role in the drug therapy of childhood insomnia.

Celiac Disease as a Cause of Malabsorption: A Clinic-Pathological Series of Five Cases

Introduction

Celiac disease (CD) also called gluten-sensitive enteropathy is a noninfectious and an autoimmune cause of malabsorption. It can be difficult to diagnose because of wide range of gastrointestinal and extraintestinal symptoms.

Case Presentation

Here, we present 5 cases of CD out of total 160 patients assessed for malabsorption at a tertiary care facility in western Maharashtra between 2022 and 2023. The male-to-female ratio was 1.5:1, and the age of patients ranged from 2 to 60. Chronic diarrhea was the most prevalent symptom, followed by weight loss and stomach pain. In each case, laboratory results showed elevated tissue transglutaminase IgA (tTG-IgA), along with varied levels of calcium and vitamin D deficiency. Two cases had normal endoscopic findings, one had whitish granular mucosa, while 2 cases had duodenal fold scalloping. Histopathological analysis verified the diagnosis, classifying the cases as Marsh types 3a, 3b, and 3c. There was no relationship between the severity of the histopathology and tTG-IgA levels.

Conclusion

This case series of 5 cases takes into account the prevalence of CD as a cause of malabsorption in western India. It also emphasizes the significance of taking CD into account in patients with malabsorption and the necessity of following a multidisciplinary approach encompassing nutritional assessment, clinical evaluation, histopathology, and serology for an accurate diagnosis and course of treatment.

A Randomized Controlled Trial of the Effects of Organizational Skills Training on Children With Attention Deficit Hyperactivity Disorder in China

BACKGROUND

In addition to attention and hyperactivity problems, children with attention deficit hyperactivity disorder (ADHD) have poorer organizational skills needed to manage time and materials. This study examines the improvement of organizational skills in children with ADHD by studying organizational skills training (OST).

METHODS

This was a prospective, randomized controlled trial. Between September 2023 and January 2024, 70 children with a diagnosis of ADHD and at least one domain of executive dysfunction (EF) were divided into two groups. The conventional group was treated with medication, biofeedback, and behavioral interventions based on the children's actual condition. The OST group received OST in addition to the conventional group.

RESULTS

The mean age of the children was 8.33 ± 1.62 years. A total of 66 children completed the intervention and follow-up, 32 in the conventional group and 34 in the OST group. There were no differences between the two groups of children in terms of their preintervention scores on the BRIEF, SNAP-IV, or IVA-CPT. Postintervention scores on the behavioral scales decreased (p < .05), and IVA-CPT scores increased (p < .05) in both groups compared with those in the preintervention period. The OST group had a lower BRIEF (p = .019) and SNAP-IV Attention deficit subscale (p = .046) and a higher IVA-CPT Attention deficit Index (p = .032) than the conventional group after the intervention. The percentage of children with a normal BRIEF total score in the OST group was 79.41% (27/34) after the intervention, which was greater than the 37.50% (12/32) in the conventional group (p = .001). Compared with the OST group, children in the conventional group were at greater risk of having BRIEF scores that remained abnormal after the intervention. Analysis of covariance revealed a statistically significant effect of group (p = .008), preintervention BRIEF (p < .001), and participation score (p = .036) on postintervention BRIEF.

CONCLUSION

OST can further improve organizational skills in daily life in children with ADHD while improving core symptoms of attention deficit in addition to conventional treatment. The effect of OST on BRIEF is also influenced by the child's BRIEF status at the baseline level and the level of cooperation during the intervention.

TRIAL REGISTRATION

The randomized controlled trial registration number was ChiCTR2300075744.

Short-term outcomes of oropharyngeal administration of colostrum in preterm neonates: a double-blind placebocontrolled randomized trial

BACKGROUND

The oropharyngeal administration of colostrum (OAC) in neonates has several benefits.

PURPOSE

To investigate the short-term outcomes of OAC in preterm neonates.

METHODS

We performed this 2-arm, double-blind, placebo-controlled randomized trial at a tertiary neonatal center in Iran in 2021-2023. The intervention and control arms received 0.2 mL of their mother's colostrum or distilled water via oropharyngeal administration every 6 hours for 3 days starting from birth until 72 hours of age. The main study outcomes were neonatal death, the incidence of necrotizing enterocolitis, sepsis, retinopathy of prematurity (ROP), length of hospital stay, and period to full enteral feeding. A regression analysis was used to adjust for possible confounders.

RESULTS

A total of 126 neonates (mean gestational age, 30.05 weeks) were randomized to the intervention and placebo groups (n=63 each) and had a mean±standard deviation weight of 1,247±193 g versus 1,156±215 g (P=0.013) and 1- and 5-min Apgar scores of 6.35 versus 5.38 (P=0.003) and 7.84 versus 7.13 (P=0.001), respectively. The mortality rate was 12.7% in the intervention group versus 14.3% in the placebo group (P=0.794). The necrotizing enterocolitis rate was significantly lower in the intervention versus placebo arm (11.1% vs. 28.6%, respectively, P=0.010), as was the clinically suspected sepsis rate (15.9% vs. 39.7%, respectively, P=0.004). The ROP and bronchopulmonary dysplasia rates did not differ significantly between groups after the adjustment for confounders. The mean length of hospital stay was shorter in the intervention group (26.1 days vs. 37.32 days, P=0.023). Moreover, the mean duration of antibiotic therapy and period to full feeding were significantly shorter in the intervention group.

CONCLUSION

OAC could effectively decrease the incidence of complications in preterm infants and facilitate earlier patient discharge.

Cohort multiple randomized controlled trial in pediatric asthma to assess the long- and short-term effects of eHealth interventions: protocol of the CIRCUS study

BACKGROUND

Asthma is one of childhood's most prevalent chronic conditions significantly impacting the quality of life. Current asthma management lacks real-time, objective, and longitudinal monitoring reflected by a high prevalence of uncontrolled asthma. Long-term home monitoring promises to establish new clinical endpoints for timely anticipation. In addition, integrating eHealth interventions holds promise for timely and appropriate medical anticipation for controlling symptoms and preventing asthma exacerbations.

OBJECTIVES

This study aims to provide a pragmatic study design for gaining insight into longitudinal monitoring, assessing, and comparing eHealth interventions' short- and long-term effects on improving pediatric asthma care.

DESIGN

The CIRCUS study design is a cohort multiple randomized controlled trial (cmRCT) with a dynamic cohort of 300 pediatric asthma patients.

METHODS

The study gathers observational and patient-reported measurements at set moments including patient characteristics, healthcare utilization, and asthma, clinical, and environmental outcomes. Participants are randomly appointed to the intervention or control group. The effects of the eHealth interventions are assessed and compared to the control group, deploying the CIRCUS outcomes. The participants continue in the CIRCUS cohort after completing the intervention and its follow-up.

RESULTS

This study was ethically approved by the Medical Research Ethics Committee (NL85668.100.23) on February 15th, 2024.

DISCUSSION

The CIRCUS study can provide a rich and unique dataset that can improve insight into risk factors of asthma exacerbations and yield new clinical endpoints. Furthermore, the effects of eHealth interventions can be assessed and compared with each other both short- and long-term. In addition, patient groups within the patient population can be discerned to tailor eHealth interventions to personalized needs on improving asthma management.

CONCLUSION

In conclusion, CIRCUS can provide valuable clinical data to discern risk factors for asthma exacerbations, identify and compare effective scalable eHealth solutions, and improve pediatric asthma care.Trial registration: The protocol is registered at ClinicalTrials.gov (NCT06278662).

Clinical Care Trajectory Assessment of Children With Congenital Diaphragmatic Hernia and Neurodevelopmental Impairment

BACKGROUND

Interdisciplinary long-term health surveillance identifies opportunities to mitigate CDH-related multisystem morbidity, particularly in patients with neurodevelopmental impairment (NDI). However, no studies to date have assessed the impact of these morbidities on the patient/family. Our aim was to describe the clinical trajectory of patients with CDH and NDI (CDH-NDI), and to explore the lived experience and satisfaction of families with existing support resources.

METHODS

A multi-phase explanatory study (REB 2023-8964) was conducted. Phase 1: Review of clinical data for CDH-NDI patients attending a longitudinal follow-up clinic; Phase 2: Satisfaction assessment of CDH-NDI families with existing hospital resources. Standard statistical analyses were performed for Phases 1 and 2, respectively.

RESULTS

Of 91 patients included, 27 had NDI, stratified into mild (n = 2), moderate (n = 7), and severe (n = 18) cohorts. Ventilation (16 vs. 8; p < 0.001), ICU (34 vs. 18; p < 0.001) and hospital (41 vs. 22; p < 0.001) days were significantly longer in the severe cohort. The severe cohort required significantly more unscheduled visits, particularly in the first four years of life (p < 0.05). Despite high family satisfaction with existing resources, team communication during ICU-ward transfers could be improved. Parents also desired to share experiences with other CDH families.

CONCLUSION

CDH children with NDI require increased support, particularly in the first four years of life. While clinic satisfaction is high, improvement of team communication and access to support resources remain high priorities for parents.

LEVEL OF EVIDENCE

Level II (prospectively collected data, retrospective analysis).

The Gut Microbiome and Its Multifaceted Role in Cancer Metabolism, Initiation, and Progression: Insights and Therapeutic Implications

This review summarizes the intricate relationship between the microbiome and cancer initiation and development. Microbiome alterations impact metabolic pathways, immune responses, and gene expression, which can accelerate or mitigate cancer progression. We examine how dysbiosis affects tumor growth, metastasis, and treatment resistance. Additionally, we discuss the potential of microbiome-targeted therapies, such as probiotics and fecal microbiota transplants, to modulate cancer metabolism. These interventions offer the possibility of reversing or controlling cancer progression, enhancing the efficacy of traditional treatments like chemotherapy and immunotherapy. Despite promising developments, challenges remain in identifying key microbial species and pathways and validating microbiome-targeted therapies through large-scale clinical trials. Nonetheless, the intersection of microbiome research and cancer initiation and development presents an exciting frontier for innovative therapies. This review offers a fresh perspective on cancer initiation and development by integrating microbiome insights, highlighting the potential for interdisciplinary research to enhance our understanding of cancer progression and treatment strategies.

Cellular mechanisms of acute rhabdomyolysis in inherited metabolic diseases

Acute rhabdomyolysis (RM) constitutes a life-threatening emergency resulting from the (acute) breakdown of skeletal myofibers, characterized by a plasma creatine kinase (CK) level exceeding 1000 IU/L in response to a precipitating factor. Genetic predisposition, particularly inherited metabolic diseases, often underlie RM, contributing to recurrent episodes. Both sporadic and congenital forms of RM share common triggers. Considering the skeletal muscle's urgent need to rapidly adjust to environmental cues, sustaining sufficient energy levels and functional autophagy and mitophagy processes are vital for its preservation and response to stressors. Crucially, the composition of membrane lipids, along with lipid and calcium transport, and the availability of adenosine triphosphate (ATP), influence membrane biophysical properties, membrane curvature in skeletal muscle, calcium channel signaling regulation, and determine the characteristics of autophagic organelles. Consequently, a genetic defect involving ATP depletion, aberrant calcium release, abnormal lipid metabolism and/or lipid or calcium transport, and/or impaired anterograde trafficking may disrupt autophagy resulting in RM. The complex composition of lipid membranes also alters Toll-like receptor signaling and viral replication. In response, infections, recognized triggers of RM, stimulate increased levels of inflammatory cytokines, affecting skeletal muscle integrity, energy metabolism, and cellular trafficking, while elevated temperatures can reduce the activity of thermolabile enzymes. Overall, several mechanisms can account for RMs and may be associated in the same disease-causing RM.

Photoacoustic imaging for non-invasive assessment of biomarkers of intestinal injury in experimental necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is an often-lethal disease of the premature infant intestinal tract, exacerbated by significant diagnostic difficulties. In NEC, the intestine exhibits hypoperfusion and dysmotility, contributing to disease pathogenesis. However, these features cannot be accurately and quantitively assessed with current imaging modalities. We have previously demonstrated the ability of photoacoustic imaging (PAI) to non-invasively assess intestinal tissue oxygenation and motility in a healthy neonatal rat model.

METHODS

In this first-in-disease application, we evaluated NEC using PAI to assess intestinal health biomarkers in an experimental model of NEC. NEC was induced in neonatal rats from birth to 4-days. Healthy breastfed (BF) and NEC rat pups were imaged at 2- and 4-days.

RESULTS

Intestinal tissue oxygen saturation was measured with PAI, and NEC pups showed significant decreases at 2- and 4-days. Ultrasound and PAI cine recordings were used to capture intestinal peristalsis and contrast agent transit within the intestine. Intestinal motility, assessed using computational intestinal deformation analysis, demonstrated significant reductions in both early and established NEC. NEC damage was confirmed with histology and dysmotility was confirmed by small intestinal transit assay.

CONCLUSION

This preclinical study presents PAI as an emerging diagnostic imaging modality for intestinal disease assessment in premature infants.

IMPACT

Necrotizing enterocolitis (NEC) is a devastating intestinal disease affecting premature infants with significant mortality. NEC presents significant clinical diagnostic difficulties, with limited diagnostic confidence complicating timely and effective interventional efforts. This study is an important foundational first-in-disease preclinical study that establishes the utility for PAI to detect changes in intestinal tissue oxygenation and intestinal motility with NEC disease induction and progression. This study demonstrates the feasibility and exceptional promise for the use of PAI to non-invasively assess oxygenation and motility in the healthy and diseased infant intestine.

Utility of fecal calprotectin in the diagnosis of inflammatory bowel diseases

Introduction: Inflammatory bowel disease involves two main disorders: Crohn's disease and ulcerative colitis. Colonoscopy with biopsy is considered the gold standard for the diagnosis of IBD, although these are invasive and costly techniques. In recent years, fecal calprotectin has gained relevance as a non-invasive biomarker with significant clinical utility. The effectiveness of fecal calprotectin has been demonstrated in distinguishing between IBD and irritable bowel syndrome, predicting endoscopic and histological activity, as well as disease recurrence.Objective: Review the current literature on the clinical utility of fecal calprotectin in the diagnosis and management of inflammatory bowel diseases.Methods: Systematic review based on the PRISMA method, of studies obtained through searches in Scopus, PubMed, Virtual Health Library, Web of Science, Latindex, and Google Scholar. Primary and secondary studies published in the last five years in English and Spanish were included.Results: Nineteen studies were analyzed, describing high sensitivity and specificity in distinguishing IBD from IBS, helping to reduce the rate of unnecessary colonoscopies in patients with non-specific gastrointestinal symptoms. Additionally, fecal calprotectin was found to significantly correlate with endoscopic and histological activity.Conclusions: Fecal calprotectin is a reliable biomarker of mucosal inflammation, capable of identifying patients with a higher likelihood of having IBD, allowing for better management of colonoscopy resources and reducing associated costs.

Exploring the oral health status of children living with hypoxic ischemic encephalopathy (HIE): A caregiver described self-report

INTRODUCTION

Hypoxic Ischemic Encephalopathy (HIE) is a birth complication due to loss of oxygen flow, resulting in a wide range of physical and cognitive differences often requiring support from multidisciplinary healthcare teams. Despite this population's increased need, little is known about their oral health status and the role of the dentist as a member of the care team.

METHODS

A 32-item oral health questionnaire was shared to 8700 members within the patient advocacy non-profit, Hope for HIE's, Facebook group. The survey assessed caregiver-reported oral health status and facilitators and barriers to receiving dental care.

RESULTS

Two hundred sixty-two individuals responded to the survey. The majority were white (90%, 177/196) parents of children with HIE (99%, 259/262) that lived in the U.S. (76%, 148/195) and cared for children under 3 (42%, 106/251). 36% (85/236) reported cavity experience, 81% (180/223) reported visiting the dentist for a dental check-up, however, 58% (147/255) considered the dentist to be a member of their child's care team.

CONCLUSION

Children diagnosed with HIE likely experience similar oral health status as their peers, however, qualitative developmental work is necessary to assess facilitators and barriers to receiving dental care, and how to integrate the dentist into the care team.

A comprehensive review on arsenic exposure and risk assessment in infants and young children diets: Health implications and mitigation interventions in a global perspective

The early stages of human development are critical for growth, and exposure to arsenic, particularly through the placenta and dietary sources, poses significant health risks. Despite extensive research, significant gaps remain in our comprehension of regional disparities in arsenic exposure and its cumulative impacts during these developmental stages. We hypothesize that infants in certain regions are at greater risk of arsenic exposure and its associated health complications. This review aims to fill these gaps by providing a comprehensive synthesis of epidemiological evidence related to arsenic exposure during early life, with an emphasis on the underlying mechanisms of arsenic toxicity that contribute to adverse health outcomes, including neurodevelopmental impairments, immune dysfunction, cardiovascular diseases, and cancer. Further, by systematically comparing dietary arsenic exposure in infants across Asia, the Americas, and Europe, our findings reveal that infants in Bangladesh, Pakistan, and India, exposed to levels significantly exceeding the health reference value range of 0.3-8 µg/kg/day, are particularly vulnerable to dietary inorganic arsenic. This comparative analysis not only highlights geographic disparities in exposure but also underscores the variability in regulatory frameworks. Finally, the review identifies early life as a critical window for dietary arsenic exposure and offers evidence-based recommendations for mitigating arsenic contamination in infant foods. These strategies include improved agricultural practices, dietary modifications, stricter regulatory limits on arsenic in infant products, and encouragement of low-arsenic dietary alternatives. Our work establishes the framework for future research and policy development aimed at reducing the burden of arsenic exposure from source to table and effectively addressing this significant public health challenge.

Impact of a New Preoperative Immune-Nutrition Protocol Using Zinc on Hospital Outcomes of Children with Hirschsprung's Disease: A Novel Randomized Controlled Trial

Purpose

Research proved the beneficial effect of Zinc on human health and Gastrointestinal tract inflammatory diseases. We propose that zinc would be of value in children with Hirschsprung's disease (HD) undergoing elective pull-through surgery. This study was carried out to determine the influence of preoperative zinc intake on postoperative outcomes, especially the hospital length of stay in patients diagnosed with HD as a primary outcome. Other outcomes include identification of the nutritional and inflammatory status including the nutritional and inflammatory markers in children with HD with possible impacts on hospital outcomes.

Methods

This is a randomized interventional control study that was applied to 50 children diagnosed with HD who underwent elective pull-through surgery. We randomly allocated 25 diagnosed with HD who underwent elective pull-through surgery. We randomly allocated 25 patients to zinc treatment.

Results

The results demonstrated that the interventional group had a lower incidence of complications (20%) when compared to the control group (64%), with a significant p-value of 0.002. In addition, less incidence of Hirschsprung's associated enterocolitis (HAEC) (12% vs. 40%) and skin excoriation (8% vs. 32%) were documented in the interventional group compared to the controls respectively.

Conclusion

Pre-operative zinc supplementation may have a beneficial impact on HD children undergoing elective pull-through surgery as regards outcomes such as HAEC and skin excoriation.

Headache outpatient clinic in a pediatric tertiary care facility

BACKGROUND

Pediatric headaches are considered an underdiagnosed condition, and yet can have a significant impact on a child's daily life. We recently opened a pediatric headache outpatient clinic at a tertiary care pediatric facility to better assist patients with unmanaged headaches.

METHODS

We retrospectively analyzed the medical records of pediatric headache patients who first visited our headache outpatient clinic from its opening in May 2022-October 2023. Clinical findings were compared with data from pediatric headache patients seen in our department during the 11 years before the headache outpatient clinic was established.

RESULTS

Sixty-eight patients (39 boys and 29 girls) made their first visit to our headache outpatient clinic. The monthly frequency of patient visits was significantly higher than that before clinic establishment. Headaches were described as frequent and affected daily life. More than half of patients had migraines, with primary headaches accounting for approximately 60% of cases. Secondary headaches included adjustment disorder and orthostatic dysregulation. All patients were instructed on nonpharmacological lifestyle guidance. In roughly half of patients, nonpharmacological therapy plus acute abortive therapy were sufficient to improve headaches. Ultimately, over 80% of patients experienced some headache relief.

CONCLUSION

Pediatric patients seeking a headache cure may be more common than previously thought. To point the way for those patients, additional pediatric headache specialists and headache outpatient clinics should be considered.

A Review of Pediatric Appendicitis Imaging Trends from 2006-2020 Using the Nationwide Emergency Department Sample

BACKGROUND

Appendicitis is a common surgical emergency in the pediatric population, affecting over 70,000 children per year in the United States alone. While historically practitioners predominately used computed tomography (CT) as the main diagnostic imaging modality, multiple professional societies have released guidelines recommending an ultrasound (US) first strategy when using imaging to confirm suspected appendicitis in pediatric populations. To date, no studies have quantified the change in imaging trends for pediatric appendicitis across the spectrum of healthcare facilities in the United States utilizing the Nationwide Emergency Department Sample (NEDS).

OBJECTIVES

We aimed to evaluate the imaging trends for pediatric appendicitis across the nation, stratified by age and gender. Specifically, we wanted to delineate the use of CT alone versus US alone or US first imaging strategies.

METHODS

This retrospective cross-sectional study utilized data from the NEDS spanning from 2006 through 2020. We examined and analyzed the total number of patients, the number of patients with available imaging data, sex, age, and included imaging modalities utilizing descriptive statistics and regression analyses. Similarly, regression analysis was employed to discern differences in imaging rates in time intervals following societal imaging recommendations.

RESULTS

From 2006 to 2020 the database recorded 160,828 encounters for pediatric appendicitis. Imaging data was available for 101,248 encounters, accounting for 63% of the total sample. Over the study period, both rates of "US only" and "US first" imaging modalities increased (from 5.5% to 38.9% and 8.9% to 55.6%, respectively), while rates of CT utilization in isolation declined (from 91.1% to 44%).

CONCLUSION

While there is an increasing trend towards US being used as the first imaging modality to diagnose pediatric appendicitis across the spectrum of facilities included in the NEDS, continued utilization of CT to diagnose appendicitis remains unacceptably high in the pediatric population within the limits of this retrospective study.

Selective Mutism in the Context of Autism and Bilingualism

CASE

Juan is a 5-year-old boy who has been followed by a developmental-behavioral pediatrician and pediatric neuropsychologist since being diagnosed with language delay and autism spectrum disorder at age 2 years. He is otherwise healthy and was born at term after a healthy pregnancy. His primary language is Spanish, and he has minimal interactions in English. His first words were at 20 months; they were not functional but rather words related to his interests such as "train." He began using 2 to 3-word phrases shortly after but only to request needs. He began speaking in complete sentences at age 4 years.A neuropsychological evaluation was conducted at age 2 years during which Juan demonstrated repetitive behaviors such as hand-flapping, toe-walking, body rocking, and head banging. He displayed sensory seeking behaviors such as rubbing items on his face and close visual inspection. He did not respond to his name and his use of eye contact was inconsistent. He demonstrated rigidity and difficulty transitioning between activities. He did not engage in social reciprocity, and his facial expressions were limited. Minimal spontaneous language was observed, and expressive language largely consisted of echolalia in both languages. Juan was diagnosed with autism spectrum disorder and applied behavior analysis, speech and language therapy, and occupational therapy were recommended.Developmental-behavioral follow-up over the next 2 years noted improvements in behavior, transitions, and social interactions. He participated in early childhood intervention and early childhood special education with significant advances for speech and language in English and Spanish, demonstrating a large vocabulary. At 4 years, parents noted Juan to have reluctance to speak in English. He stopped speaking in English entirely for 3 weeks, though he continued to speak in Spanish. When he resumed speaking in English, it was only with people he knew well (e.g., parents, teachers, babysitter). In clinic, he did not speak to the English-speaking developmental-behavioral pediatrician but spoke in short sentences to the Spanish-speaking neuropsychologist.A repeat neuropsychological evaluation completed at age 5 years revealed that Juan had stopped speaking in English completely, even among those previously deemed "safe." Results were consistent with average cognitive abilities with a strength in verbal skills. Juan's single-word vocabulary in Spanish was exceptionally high. He did not provide expressive responses in English, but his receptive English vocabulary was high average. He responded to English language with nonverbal gestures or spoken language in Spanish. Parents reported Juan to display increased anxiety accompanied by extreme school refusal, behavioral difficulties, and reluctance to leave the home.Given this information, what are your diagnostic considerations and treatment recommendations?

Serological testing for celiac disease in children

INTRODUCTION

Celiac disease is one of the most common chronic immune-mediated gastrointestinal conditions, characterized by the presence of disease-specific serum antibodies against self-antigen transglutaminase 2. Even though modern serological assays can identify most untreated celiac disease patients and are also increasingly being used to establish a diagnosis, several challenges are associated with the tests, including a lack of standardization, the variable sensitivity and specificity of commercial assays, and inadequate sensitivity for monitoring adherence to a gluten-free diet.

AREAS COVERED

This narrative review outlines the current use of serological tests in case-finding and screening, as well as in the follow-up of dietary treatment. Additionally, the possible challenges and pitfalls of serological tests, along with future directions, are addressed.

EXPERT OPINION

The excellent accuracy of modern autoantibody tests, especially for greatly elevated levels of transglutaminase 2 antibodies and positive endomysial antibodies, enables using serological testing in establishing a diagnosis. However, better international standardization of the assays is required, the necessity of endomysial antibody testing needs to be further scrutinized, and additional research is needed to improve noninvasive tools for follow-up and to further expand the no-biopsy criteria for celiac disease.

Safety and efficacy of early augmentation with Transcranial Direct Current Stimulation (tDCS) in adolescents with Major Depressive Disorder: A randomized controlled trial

BACKGROUND

Transcranial Direct Current Stimulation (tDCS) is an emerging modality with demonstrated efficacy in Major Depressive Disorder (MDD), however, there is paucity of research in adolescent depression. This study attempts to evaluate the safety and efficacy of tDCS in adolescents with MDD as an early augmentation to drug therapy.

METHODS

Adolescents with MDD aged 10-18 years were enrolled in the study and allocated to active or sham groups as per randomization. Sertraline was given in the range of 25-50 mg to each participant. After baseline assessments, 10 sessions of tDCS were given with 2 mA current for 20 minutes, keeping anode at left DLPFC and cathode at right DLPFC. Side effects were assessed and rating scales were reapplied at 2 weeks and then 6 weeks. Results were analyzed.

RESULTS

A total of 32 patients were analysed (15-active, 17-sham). At 2 weeks, the BDI and BAI scores of the true group were significantly lower than the sham group, and the reduction in the scores of the former was statistically greater. This significance did not persist at 6 weeks, and the reduction in the scores of the two groups was significantly different from baseline to 2-weeks and 6-weeks. Response and remission rates were higher in the active group at 6 weeks. Adverse effects were comparable.

CONCLUSION

tDCS is safe and effective for early augmentation of drugs in adolescents with MDD. However, effects do not last long after termination of sessions. Further studies are needed with a larger sample size and longer follow-ups.

IUPHAR review: Targeted therapies of signaling pathways based on the gut microbiome in autism spectrum disorders: Mechanistic and therapeutic applications

Autism spectrum disorders (ASD) are complex neurodevelopmental disorders characterized by impairments in social interaction, communication and repetitive activities. Gut microbiota significantly influences behavior and neurodevelopment by regulating the gut-brain axis. This review explores gut microbiota-influenced treatments for ASD, focusing on their therapeutic applications and mechanistic insights. In addition, this review discusses the interactions between gut microbiota and the immune, metabolic and neuroendocrine systems, focusing on crucial microbial metabolites including short-chain fatty acids (SCFAs) and several neurotransmitters. Furthermore, the review explores various therapy methods including fecal microbiota transplantation, dietary modifications, probiotics and prebiotics and evaluates their safety and efficacy in reducing ASD symptoms. The discussion shows the potential of customized microbiome-based therapeutics and the integration of multi-omics methods to understand the underlying mechanisms. Moreover, the review explores the intricate relationship between gut microbiota and ASD, aiming to develop innovative therapies that utilize the gut microbiome to improve the clinical outcomes of ASD patients. Microbial metabolites such as neurotransmitter precursors, tryptophan metabolites and SCFAs affect brain development and behavior. Symptoms of ASD are linked to changes in these metabolites. Dysbiosis in the gut microbiome may impact neuroinflammatory processes linked to autism, negatively affecting immune signaling pathways. Research indicates that probiotics and prebiotics can improve gut microbiota and alleviate symptoms in ASD patients. Fecal microbiota transplantation may also improve behavioral symptoms and restore gut microbiota balance. The review emphasizes the need for further research on gut microbiota modification as a potential therapeutic approach for ASD, highlighting its potential in clinical settings.

Distinct Clinical Presentations of Vein of Galen Aneurysmal Malformation: A Case Series

We present two cases of vein of Galen aneurysmal malformation, detected in early life, with differing outcomes. This suggests that early detection of this malformation in fetuses or neonates does not necessarily indicate a poor prognosis, highlighting the need for vigilant monitoring and timely intervention to optimize outcomes.

Assessing the Use and Acceptability of Virtual Reality to Assist Coping in Children Undergoing Clinical Procedures

PURPOSE

Virtual reality is used as a distraction tool during medical procedures that can cause anxiety and pain. We assessed the usefulness, engagement, value and feasibility of virtual reality to help children cope with routine clinical procedures.

DESIGN AND METHODS

Quality improvement study. Children, 4-16 years old, were given the option to use virtual reality during their procedure in oncology, immunology or diabetes clinics, or during an induction of general anesthesia. The emotional state of the child was documented using the children's emotional manifestation scale. We assessed feedback from patients, parents, and clinicians.

RESULTS

Across all clinics, children responded positively to the virtual reality and 80% would choose to use virtual reality again for health-related procedures. Parents and clinicians, respectively, reported that virtual reality helped children tolerate the procedure (82% and 87%), engaged children well (82% and 89%) and was a valuable tool (85% and 98%). Clinicians (90%) endorsed the feasibility of using virtual reality during procedures.

PRACTICE IMPLICATIONS

This project demonstrated that virtual reality can be implemented as a useful, engaging and feasible tool to help children tolerate a variety of routine medical procedures. However, ensuring comfortable fit of virtual reality devices and diversifying the visual content is necessary.

EAACI guidelines on the management of IgE-mediated food allergy

This European Academy of Allergy and Clinical Immunology (EAACI) guideline provides recommendations for the management of IgE-mediated food allergy and was developed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Following the confirmation of IgE-mediated food allergy diagnosis, allergen avoidance and dietary advice (with support of a specialised dietitian, if possible) together with the provision of a written treatment plan, education on the recognition of allergic symptoms and prescription of medication including adrenaline using an auto-injector are essential. Patients with significant anxiety and requirement for coping strategies may benefit from support from a clinical psychologist. As immunomodulatory interventions, omalizumab is suggested for treatment of IgE-mediated food allergy in children from the age of 1 and adults; and oral allergen-specific immunotherapy is recommended for children and adolescents with peanut allergy and suggested for milk and egg allergies (generally after 4 years of age for milk and egg). Sublingual and epicutaneous immunotherapy are suggested for peanut allergy but are not yet available at the point of care. Future research into disease modifying treatments for IgE-mediated food allergy are highly needed, with standardised and patient-focused protocols and outcomes.

The parent-doctor-child triangle: a structural equation modeling-based study in pediatric outpatient clinics in Indonesia

PURPOSE

Parental satisfaction is essential for evaluating pediatric care quality and influences healthcare practices and performance. Pediatric patients frequently experience anxiety, affecting their and their parents' satisfaction. Nurses play a key role in reducing anxiety and improving care interactions. Meeting parents' expectations shapes long-term outcomes and impacts the hospital's reputation. While instruments such as the Child ZAP (Zufriedenheit in der Arztpraxis) provide comprehensive measures of satisfaction, their use in Indonesia has not been explored. This study aimed to validate the Child ZAP and offer insights to improve pediatric care quality in Indonesia.

METHODS

A cross-sectional study was conducted with 139 mothers whose children were older than 5 years and received treatment at private hospitals. Structured questionnaires were analyzed using partial least squared-structural equation modeling in SmartPLS 4, and a disjoint two-stage method was used to test dimensionality.

RESULTS

All hypotheses were significant (p<.05), demonstrating strong support. All Child ZAP dimensions, treated as lower-order constructs, effectively measured parents' satisfaction as a higher-order construct. Overall parental satisfaction significantly influenced behavioral intention and mediated its relationship with Child ZAP. The mother's and the child's age served as moderating factors. The research model exhibited strong predictive power, underscoring pediatric nurses' pivotal role in improving communication among parents, physicians, and children to ensure quality care.

CONCLUSION

The Child ZAP instrument effectively evaluates parental satisfaction by examining how children interact and communicate with medical staff. It assesses doctors' engagement with children and their communication skills, highlighting nurses' essential role in providing family-centered pediatric care.

Quantitative EEG features during the first day correlate to clinical outcome in perinatal asphyxia

OBJECTIVE

To assess whether computational electroencephalogram (EEG) measures during the first day of life correlate to clinical outcomes in infants with perinatal asphyxia with or without hypoxic-ischemic encephalopathy (HIE).

METHODS

We analyzed four-channel EEG monitoring data from 91 newborn infants after perinatal asphyxia. Altogether 42 automatically computed amplitude- and synchrony-related EEG features were extracted as 2-hourly average at very early (6 h) and early (24 h) postnatal age; they were correlated to the severity of HIE in all infants, and to four clinical outcomes available in a subcohort of 40 newborns: time to full oral feeding (nasogastric tube NGT), neonatal brain MRI, Hammersmith Infant Neurological Examination (HINE) at three months, and Griffiths Scales at two years.

RESULTS

At 6 h, altogether 14 (33%) EEG features correlated significantly to the HIE grade ([r]= 0.39-0.61, p < 0.05), and one feature correlated to NGT ([r]= 0.50). At 24 h, altogether 13 (31%) EEG features correlated significantly to the HIE grade ([r]= 0.39-0.56), six features correlated to NGT ([r]= 0.36-0.49) and HINE ([r]= 0.39-0.61), while no features correlated to MRI or Griffiths Scales.

CONCLUSIONS

Our results show that the automatically computed measures of early cortical activity may provide outcome biomarkers for clinical and research purposes.

IMPACT

The early EEG background and its recovery after perinatal asphyxia reflect initial severity of encephalopathy and its clinical recovery, respectively. Computational EEG features from the early hours of life show robust correlations to HIE grades and to early clinical outcomes. Computational EEG features may have potential to be used as cortical activity biomarkers in early hours after perinatal asphyxia.