Children, Volume 6, Issue 5 (May 2019) – 10 articles

Pediatric transverse myelitis (TM) is an acquired, immune-mediated disorder that leads to injury of the spinal cord and often manifests as weakness, numbness, bowel dysfunction, and/or bladder dysfunction. Multiple etiologies for myelitis can result in a similar clinical presentation, including idiopathic transverse myelitis (TM), multiple sclerosis (MS), neuromyeltis optica spectrum disorder (NMOSD) associated with anti-aquaporin 4 antibodies, MOG antibody-associated disease, and acute flaccid myelitis (AFM). Diagnosis relies on clinical recognition of the syndrome and confirming inflammation through imaging and/or laboratory studies. Acute treatment is targeted at decreasing immune-mediated injury, and chronic preventative therapy may be indicated if TM is determined to be a manifestation of a relapsing disorder (i.e., NMOSD). Timely recognition and treatment of acute transverse myelitis is essential, as it can be associated with significant morbidity and long-term disability. Full article

Aortic valve stenosis in children is a congenital heart defect that causes fixed form of hemodynamically significant left ventricular outflow tract obstruction with progressive course. Neonates and young infants who have aortic valve stenosis, usually develop congestive heart failure. Children and adolescents who have aortic valve stenosis, are mostly asymptomatic, although they may carry a small but significant risk of sudden death. Transcatheter or surgical intervention is indicated for symptomatic patients or those with moderate to severe left ventricular outflow tract obstruction. Many may need reintervention. Full article

The Textbook of Neonatal Resuscitation, seventh edition, does not suggest routine endotracheal suctioning for non-vigorous infants born through meconium-stained amniotic fluid. We compared 301,150 infants at ≥35 weeks’ gestational age inborn at 311 Vermont Oxford Network member centers in the United States (U.S.) and admitted to neonatal intensive care units (NICU) who were born before (2013 to 2015) and after (2017) the guideline change. Logistic regression models adjusting for clustering of infants within centers were used to calculate risk ratios. NICU admissions for infants with a diagnosis of meconium aspiration syndrome (MAS) decreased from 1.8% to 1.5% (risk ratio: 0.82; 95% confidence interval: 0.68, 0.97) and delivery room endotracheal suctioning in this group decreased from 57.0% to 28.9% (0.51; 0.41, 0.62). Treatment with conventional or high frequency ventilation, inhaled nitric oxide, or extracorporeal membrane oxygenation remained unchanged 42.3% vs. 40.3% (0.95; 0.80, 1.13) among infants with MAS and 9.1% vs. 8.2% (0.91; 0.87, 0.95) among infants without MAS. The use of surfactant among infants with MAS increased from 24.6% to 30% (1.22; 1.02, 1.48). Mortality (2.6 to 2.9%, 1.12; 0.74, 1.69) and moderate/severe hypoxic-ischemic encephalopathy (5.4 to 6.8%, 1.24; 0.91, 1.69) increased slightly in 2017. Subgroup analyses of infants with 1 min Apgar scores of ≤3 found similar results. While NICU admissions for MAS and tracheal suctioning decreased after the introduction of the new guideline with no subsequent increase in severe respiratory distress among infants with and without a MAS diagnosis, limitations in our study preclude inferring that the new guideline is safe or effective. Full article

There is a lack of consensus regarding the preoperative pulmonary valve (PV) Z-score “cut-off” in tetralogy of Fallot (ToF) patients to attempt a successful valve sparing surgery (VSS). Therefore, the aim of this study was to review the available evidence regarding the association between preoperative PV Z-score and rate of re-intervention for residual right ventricular outflow tract (RVOT) obstruction, i.e. successful valve sparing surgery. A systematic search of studies reporting outcomes of VSS for ToF was performed utilizing PubMed, EMBASE, and Scopus databases. Patients with ToF variants such as pulmonary atresia, major aortopulmonary collaterals, absent pulmonary valve, associated atrioventricular septal defect, and discontinuous pulmonary arteries were excluded. Out of 712 screened publications, 15 studies met inclusion criteria. A total of 1091 patients had surgery at a median age and weight of 6.9 months and 7.2 kg, respectively. VSS was performed on the basis of intraoperative PV assessment in 14 out of 15 studies. The median preoperative PV Z-score was −1.7 (0 to −4.9) with a median re-intervention rate of 4.7% (0–36.8%) during a median follow-up of 2.83 years (1.4–15.8 years). Quantitatively, there was no correlation between decreasing preoperative PV Z-scores and increasing RVOT re-intervention rates with a correlation coefficient of −0.03 and an associated p-value of 0.91. In observational studies, VSS for ToF repair was based on intraoperative evaluation and sizing of the PV following complete relief of all levels of obstruction of the RVOT, rather than pre-operative echocardiography derived PV Z-scores. Full article

Compounding pharmacy has an important role to play in the field of pediatric medicine. These specialized pharmacies can offer solutions to the unique patient needs that arise in the pediatric population. Medication can be tailored to the child to allow better compliance in cases when the commercial product is unable to meet the needs of the patient. For example, a suspension, suppository, or lozenge formulation is sometimes needed when the manufactured products are only offered as solid oral dosage forms. Sensory processing disorder (SPD), patients with food allergies, and specific dietary needs can also be a big challenge for caregivers and practitioners who need alternatives to the commercially available forms. Three example cases are presented to help describe the process of collaboration between the pharmacist, patient, and doctor to solve the patient’s needs. Full article

Background: The prevalence and severity of pain, nausea/vomiting, and anxiety (PNVA) among hospitalized children is not well established. We describe the prevalence and severity of PNVA among hospitalized patients from oncology, general pediatrics, and cardiology services in a tertiary care center. Methods: Patients were recruited on admission and enrolled if their caregiver consented, spoke English, and were anticipated to stay 2–30 days. Symptoms were measured weekdays using age-validated tools. PNVA symptoms were described and compared. Results: We enrolled 496 (49.4%) patients of 1005 admitted. Patients were predominantly Caucasian (57.9%) on their first admission (53.6%). The average (SD) age was 8.6 years (5.9) in oncology, 4.2 (5.3) in general pediatrics and 2.6 (4.0) in cardiology. 325 (65.6%) patients reported anxiety, 275 (55.4%) reported nausea and 256 (52.0%) reported pain. Mean (SD) severity out of 10 was 3.7 (2.5) for anxiety, 3.2 (2.1) for nausea and 3.0 (1.5) for pain. Prevalence of PNVA was no different between clinical programs, but pain (p = 0.008) and nausea (p = 0.006) severity were. PNVA symptom co-occurrence was positively correlated (p < 0.001). Conclusions: Anxiety was the most common and severe symptom for hospitalized children. Patients in oncology demonstrated the least severe pain and nausea with no difference in anxiety between services. Full article

Preschool is one of the most important periods in a child’s life, and it can influence their social development. A lack of attention to this important life period can increase the risk of serious injuries to a child’s growth and development. The aim of this study was to examine the level of social skills in preschool children from teachers’ perspectives and investigate the relationship between social skills and the child’s environmental and cultural background. A cross-sectional study was conducted on 546 children studying in the preschool centers of Rasht city, Iran. They were selected using a multistage cluster sampling method. Data was gathered using the children’s and teachers’ demographic questionnaire and the Social Skills Rating System-Teachers (SSRS-T). Descriptive and inferential statistics were used for data analysis via SPSS software. It was found that the majority of children had moderate skills in terms of cooperation, assertion, self-control, and total social skills. Also, a statistically significant association was reported between total social skill scores and the mother’s age, mother’s education level, mother’s job, family’s income, teacher teaching experiences, and number of children in each classroom. The Iranian children were at a relatively low risk of problems with social skills. To improve children’s social skills, more attention should be paid to factors related to familial and socioeconomic status such as income, parents’ education level, maternal age, teacher’s selection for this age group, and number of children in each classroom. Full article

The prevalence of obesity continues to rise in adult and pediatric populations throughout the world. Obesity has a direct impact on all organ systems, including the reproductive system. This review summarizes current knowledge about the effects of obesity on the male reproductive system across age, highlighting the need for more data in children and adolescents. Male hypogonadism is commonly seen in patients with obesity and affects the onset, duration, and progression of puberty. Different pathophysiologic mechanisms include increased peripheral conversion of testosterone to estrone and increased inflammation due to increased fat, both of which lead to suppression of the hypothalamic-pituitary-gonadotropin (HPG) axis and delayed development of secondary sexual characteristics in adolescent males. Evaluation of the HPG axis in obesity includes a thorough history to exclude other causes of hypogonadism and syndromic associations. Evaluation should also include investigating the complications of low testosterone, including increased visceral fat, decreased bone density, cardiovascular disease risk, and impaired mood and cognition, among others. The mainstay of treatment is weight reduction, but medications such as testosterone and clomiphene citrate used in adults, remain scarcely used in adolescents. Male hypogonadism associated with obesity is common and providers who care for adolescents and young adults with obesity should be aware of its impact and management. Full article

Background: Recently, the number of refugees in Germany has skyrocketed, leading to a marked increase in refugee children admitted to hospitals. This study describes the special characteristics encountered in pediatric surgical inpatient refugees compared to locally residing patients. Methods: Hospital records of minor refugees admitted to our department from 2005 up to and including 2015 were retrospectively reviewed. Demographic data, diagnoses, comorbidities, body mass indexes, hemoglobin values, and lengths of stay were extracted and statistically compared to local patients. Results: A total of 63 refugee children were analyzed and compared to 24,983 locally residing children. There was no difference in median body mass index (16.2 vs. 16.3, respectively, p = 0.26). However, refugee children had significantly lower hemoglobin values (11.95 vs. 12.79 g/dL, p < 0.0001) and were more likely to be colonized with methicillin-resistant Staphylococcus. aureus (8% vs. 0.04%, p < 0.01). Refugees were much more likely to present with burn injuries (16% versus 3% of admissions, p < 0.001), esophageal foreign bodies (4% vs. 0.5%, p < 0.001), as well as trauma, except for closed head injury. Conclusion: The cohort of refugee children in this study was found to be at a particular risk for suffering from burn injuries, trauma, foreign body aspirations, and anemia. Appropriate preventive measures and screening programs should be implemented accordingly. Full article