Children, Volume 8, Issue 3 (March 2021) – 82 articles

This article presents a classification of lower limb musculoskeletal pathology (MSP) for ambulant children with cerebral palsy (CP) to identify key features from infancy to adulthood. The classification aims to improve communication, and to guide referral for interventions, which if timed appropriately, may optimise long-term musculoskeletal health and function. Consensus was achieved by discussion between staff in a Motion Analysis Laboratory (MAL). A four-stage classification system was developed: Stage 1: Hypertonia: Abnormal postures are dynamic. Stage 2: Contracture: Fixed shortening of one or more muscle-tendon units. Stage 3: Bone and joint deformity: Torsional deformities and/or joint instability (e.g., hip displacement or pes valgus), usually accompanied by contractures. Stage 4: Decompensation: Severe pathology where restoration of optimal joint and muscle-tendon function is not possible. Reliability of the classification was tested using the presentation of 16 clinical cases to a group of experienced observers, on two occasions, two weeks apart. Reliability was found to be very good to excellent, with mean Fleiss’ kappa ranging from 0.72 to 0.84. Four-stages are proposed to classify lower limb MSP in children with CP. The classification was reliable in a group of clinicians who work together. We emphasise the features of decompensated MSP in the lower limb, which may not always benefit from reconstructive surgery and which can be avoided by timely intervention. Full article

Background: ALG13-CDG belongs to the congenital disorders of glycosylation (CDG), which is an expanding group of multisystemic metabolic disorders caused by the N-linked, O-linked oligosaccharides, shared substrates, glycophosphatidylinositol (GPI) anchors, and dolichols pathways with high genetic heterogeneity. Thus, as far as clinical presentation, laboratory findings, and treatment are concerned, many questions are to be answered. Three individuals presented here may serve as a good example of clinical heterogeneity. This manuscript describes the first metabolomic analysis using NMR in three patients with epileptic encephalopathy due to the recurrent c.320A>G variant in ALG13, characterized to date only in about 60 individuals (mostly female). This is an important preliminary step in the understanding of the pathogenesis of the disease associated with this variant in the rare genetic condition. The disease is assumed to be a disorder of N-glycosylation given that this is the only known function of the ALG13 protein. Despite this, protein electrophoresis, which is abnormal in most conditions due to abnormalities in N-glycosylation, has been normal or only mildly abnormal in the ALG13 patients. Methods: Nuclear magnetic resonance (NMR) spectroscopy in conjunction with multivariate and univariate modelling were used to analyze the metabolic profile of the blood serum samples acquired from the studied patients. Results: Three metabolites were identified as potential biomarkers: betaine, N-acetyl-glycoprotein, and carnitine. Conclusions: Since presented data are the first to be collected so far, they need be verified in further studies. Our intention was to turn attention toward possible CDG-ALG13 laboratory markers that would have clinical significance. Full article

Pediatric palliative care is a growing field in which the currently available resources are still insufficient to meet the palliative care needs of children worldwide. Specifically, in Latin America, pediatric palliative care services have emerged unevenly and are still considered underdeveloped when compared to other regions of the world. A crucial step in developing pediatric palliative care (PPC) programs is delineating quality indicators; however, no consensus has been reached on the outcomes or how to measure the impact of PPC. Additionally, Latin America has unique sociocultural characteristics that impact the perception, acceptance, enrollment and implementation of palliative care services. To date, no defined set of quality indicators has been proposed for the region. This article explores the limitations of current available quality indicators and describes the Latin American context and how it affects PPC development. This information can help guide the creation of standards of care and quality indicators that meet local PPC needs while considering the sociocultural landscape of Latin America and its population. Full article

Background: Currently, to the best of our knowledge, no findings exist concerning the needs of professionals in specialized pediatric palliative care (PPC) regarding electronic health records (EHRs). Several studies have highlighted benefits concerning the use of EHRs in pediatrics. However, usability is strongly affected by the degree of adaptivity to the context of application. The aim of this study is to examine the needs of professionals concerning an EHR in the specialized PPC inpatient and outpatient settings. Methods: A qualitative research design was chosen to address the complex aspects of user demands. Focus group interviews and semi-structured one-on-one interviews were conducted with PPC professionals. N = 23 participants from inpatient and N = 11 participants from outpatient settings of specialized PPC representing various professions took part in the study. Results: The findings could be grouped into four categories: (1) attitude towards the current methods of documentation, (2) attitude towards electronic documentation in general, (3) general requirements for an EHR, and (4) content requirements for an EHR. Conclusions: Professionals in specialized PPC expect and experience many benefits of using electronic documentation. Their requirements for an EHR for inpatient and outpatient settings of PPC are largely consistent with EHRs for pediatrics. However, individual specifications and adaptations are necessary for this particular setting. Full article

Physical education should focus not only on students’ motor and emotional development but also on their cognitive development. The purpose of the present study was to examine whether elementary students’ health-related knowledge and physical activity-related goal setting increased after they participated in a program. The program aimed at promoting after school physical activity among students. Participants were 244 fifth- and sixth-grade students (116 boys and 128 girls). Students’ knowledge was examined by means of a multiple-choice test, cognitive assignments and a retrospective pre–post questionnaire. The results from the three measures indicated that students enhanced their knowledge both regarding the health benefits of physical activity (PA) and effective goal setting. Hence, it can be argued that the program was effective in promoting students’ skills and knowledge related to PA. Full article

Background: Recently, the new definition of Metabolic (dysfunction) associated fatty liver disease (MAFLD) has gained remarkable scientific interest. We aimed to evaluate the effectiveness of MAFLD definition in selecting obese children at higher cardiovascular risk. Methods: A total of 954 obese children and adolescents was retrospectively enrolled. Clinical, biochemical, and metabolic evaluations were performed. Hepatic steatosis was assessed by liver ultrasound. According to the metabolic status, the population was divided in three groups. Group 1 included obese patients without both non-alcoholic fatty liver disease (NAFLD) and metabolic dysregulation; group 2 included patients with obesity and NAFLD (then encompassing one MAFLD criterion); group 3 included patients with obesity, NAFLD and evidence of metabolic dysregulation (then encompassing more than 1 MAFLD criteria). Results: Patients of Group 3 showed a worse cardiometabolic profile, as also proven by the higher percentage of prediabetes (defined as the presence of impaired fasting glucose or impaired glucose tolerance) compared to other groups (p = 0.001). Conclusions: MAFLD criteria in obese children seem to be less accurate in identifying patients having an intrinsic higher cardiometabolic risk. This suggests the need for a more accurate definition in the context of pediatric obesity. Full article

Infants born through meconium-stained amniotic fluid (MSAF) are 100 times more likely than infants born through clear amniotic fluid to develop respiratory distress in the neonatal period. Meconium aspiration syndrome (MAS) is a common cause of respiratory distress in term and post-mature neonates. MAS is defined as respiratory distress accompanied by a supplemental oxygen requirement in an infant born with MSAF, in the absence of any other identified etiology to explain the symptoms. Therapy for MAS is supportive, and should be tailored to each infant’s specific pathophysiology. In cases of MAS with severe persistent pulmonary hypertension of the newborn (PPHN), patients may remain hypoxic despite aggressive ventilation, and in these cases surfactant, inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO) can be life-saving. Long-term prognosis for MAS is more related to severity of initial hypoxemia and possible neurological insult than to the pulmonary pathology. Full article

(1) Background: The preoccupation with the increasing appearance of eating disorders (ED) in athletes continues to grow, especially in athletes who practice team sports. ED severely affects the eating habits of the athletes, who tend to use unhealthy approaches to control their body weight. The development of nutritional education and early interventions by training staff is essential, and these factors are widely perceived as beneficial in sports medicine. This study evaluates the frequency at which beach handball (BH) players develop ED, also comparing the differences by sex and age (junior: adolescents vs. senior: young adults). In addition, the relation between body composition variables and ED was studied. (2) Methods: A descriptive and cross-sectional study was carried out in 69 top elite handball players (36 males and 33 females) from the Spanish National BH Team; who were separated by age (junior: adolescents and senior: young adults). The athletes completed the Eating Attitudes Test in its 26 item version (EAT-26). (3) Results: The prevalence of ED indicated that 11% of females had a high possibility of developing an ED, and 3% of males. Regarding the EAT-26 total score and subscales, no significant differences were found between female and male participants, or between the junior and senior categories. The correlations showed an association between body composition, in terms of body mass index, and the EAT-26 total score in both males and females. In the case of males, the correlation was negative. (4) Conclusions: Although there are no significant differences between sex or categories, it has been found that elite athletes are a population that is at high risk of developing ED. Full article

Introduction: Ethiopia is a rapidly developing country in Eastern Africa. In total, 43.2% of the population are younger than 15. In contrast, until a few years ago, pediatric surgery was only available in Addis Ababa. Now, Ethiopia is making great efforts to improve the care of children who require surgery. JimmaChild was established to set up a pediatric surgery in Jimma. Material and methods: JimmaChild developed from a scientific collaboration between Jimma University (JU) and Ludwig-Maximilians-University. The project was developed and realized by Ethiopian and German colleagues. A curriculum was written for this purpose. The pediatric surgical training of the fellows was carried out on-site by German pediatric surgeons. Results: A new pediatric surgery was established at JU with its own operating room, ward, and staff. After two and a half years, two fellows completed their final examinations as pediatric surgeons. Among others, 850 elective surgeries were performed, 82% assisted by the German colleagues. The German colleagues rated the preparation for the trip, the on-site support, and the professional progress of the fellows mostly as good to very good. Reported problems in the program flow were also recognized and solved in part. Conclusions: The best possible integration of the project into existing structures was achieved by close cooperation of Ethiopian and German colleagues during the project development. Problems were identified and addressed early on by external monitoring. As the project responsibility was mainly with the Ethiopian colleagues, a department was created that now exists independently of external funding and trains its own fellows. Full article

The purpose of our study was to explore the association of acculturation and Latino parent behavioral and psychosocial characteristics. A cross-sectional survey was conducted with 197 parent-children triads. Participating parents completed survey questions encompassing oral health knowledge, behaviors and beliefs from a validated oral health instrument. The mean score for acculturation in this sample was 3.8, where acculturation was dichotomized to a categorical variable. The bivariate associations between the independent variables (caregiver psychosocial factors and socio-economic factors (SES) factors) and acculturation (more/less acculturated) were conducted using logistic regression analysis, and for the final model a multivariate logistic regression model was used. In the bivariate analyses, less acculturated parents reported lower oral health knowledge (p = 0.02), higher social support (p = 0.028) and chronic stress (p = 0.015) and lower perceived susceptibility to dental caries in their children (p = 0.039). The bivariate analysis demonstrated that less acculturated parents had less education and employment (p < 0.0001) than more acculturated parents. The multivariate logistic model demonstrated that social support (p = 0.028), chronic stress (p = 0.015) and health beliefs as barriers to access dental care (p = 0.039) were higher in less acculturated parents compared to more acculturated parents. Less acculturated parents demonstrated lower oral health knowledge, higher stress and more barriers to accessing oral health care for their children. Oral health interventions for Latino families should incorporate strategies that include consideration of parental oral health beliefs. Full article

IMPORTANCE: Postoperative bleeding is a common and potentially life-threatening complication. Precise identification of risk factors in addition to the basic ones, such as coagulation parameters, is certainly very desirable. OBJECTIVE: The aim of this study was to identify other possible risk factors for bleeding after adenoidectomy in children. DESIGN: This observational prospective study enrolled children undergoing adenoidectomy from October 2019 to February 2020, then evaluated the influence of possible risk factors for bleeding. SETTING: Tertiary pediatric otorhinolaryngology center. PARTICIPANTS: A total of 288 children aged 0–18 years undergoing adenoidectomy for recurrent upper respiratory tract infections, recurrent acute otitis media, secretory otitis media, and obstructive sleep apnea syndrome. MAIN OUTCOMES AND MEASURES: Increased blood pressure and time of surgery were identified as risk factors for bleeding after adenoidectomy. RESULTS: Elevated systolic (p = 0.046), diastolic (p = 0.012), and mean arterial blood pressure (p = 0.007) (Mann–Whitney U test) as adjusted for age-specific distributions and with corrections for height and weight, as well as time length of surgery (p < 0.001) (Fisher’s exact test) were revealed as statistically significant risk factors for postoperative bleeding. Atmospheric pressure, surgeon’s level of experiences, chronic inflammatory content in adenoid vegetation (AV), size of AV, recidivism of AV, recurrent infections of the upper respiratory tract, type of anesthesia, long-term using of drugs, and positive coagulation questionnaire or pathology in standard coagulation tests were not found to be risk factors for bleeding after adenoidectomy. CONCLUSIONS AND RELEVANCE: In this prospective study within a well-defined population of children, we evaluated increased blood pressure and time of surgery as risk factors for bleeding after adenoidectomy. These data bring new information that complements current knowledge in this field. Full article

Musculoskeletal pain is common in the general pediatric population and is a challenge to youth, their parents, and society. The majority of children experiencing musculoskeletal pain will recover; however, a small subgroup of youth develops chronic pain. There is limited understanding of the factors that affect the transition from acute to chronic pain in youth. This review introduces sleep deficiency in the acute to chronic pain transition, exploring the potential mediational or mechanistic role and pathways of sleep in this process, including the interaction with sensory, psychological, and social components of pain and highlighting new avenues for treatment. Biological mechanisms include the increased production of inflammatory mediators and the effect on the hypothalamus-pituitary-adrenal (HPA) axis and on the dopaminergic signaling. Psychological and social components include the effect of sleep on the emotional-affective and behavioral components of pain, the negative impact on daily and social activities and coping strategies and on the reward system, increased pain catastrophizing, fear of pain, pain-related anxiety, hypervigilance, and social isolation. Future longitudinal studies are needed to elucidate these mechanistic pathways of the effect of sleep on the transition from acute to chronic pain, which may lead to the development of new treatment targets to prevent this transition. Full article

Historically, mountainous areas of Morocco have been affected by endemic goiter and severe iodine deficiency. In 1995, Morocco legislated salt iodization to reduce iodine deficiency. There has been no national survey of iodine nutrition in school-age children for nearly 3 decades. Our aim was to assess iodine nutrition in a national sample of 6–12-year-old children in Morocco to inform the national salt iodization strategy. In this cross-sectional household-based survey, we randomly recruited healthy 6–12-year-old children from 180 clusters in four geographic zones (north and east, central, north and south) covering the 12 regions of Morocco. A questionnaire was completed, including socio-economic status and parental level of education. In addition, anthropometric measurements were taken to assess nutrition status, and a spot urine sample was collected to measure urinary iodine concentration (UIC). A total of 3118 households were surveyed, and 1043 eligible children were recruited, 56% from urban areas and 44% from rural areas. At the national level, the percentage of surveyed samples with UIC < 50 μg/L was 21.6% (19.2%; 24.2%), which exceeds the WHO suggestion of no more than 20% of samples below 50 μg/L, despite an adequate level of median urinary iodine concentration (mUIC) at 117.4 µg/L (110.2; 123.3). There were no statistically significant differences in mUIC comparing urban vs. rural areas and socio-economic status. However, the mUIC was significantly lower in the central (high-altitude non-coastal) zone (p < 0.004), where the mUIC (95% CI) was deficient at 89.2 µg/L (80.8; 102.9). There was also a significant difference in the mUIC by head of household education level (p = 0.008). The mUIC in Moroccan children >100 µg/L indicates iodine sufficiency at the national level. However, the percentage of surveyed samples with UIC < 50 μg/L above suggests that a significant proportion of children remain at risk for iodine deficiency, and it appears those at greatest risk are residing in the central (high altitude non-coastal) zone. A national level mUIC value may conceal discrepancies in iodine intake among different sub-groups, including those defined by geographic region. Full article

Terminal cancer pain remains one of the most distressing aspects of pediatric oncology practice. Opioids are the cornerstone of cancer pain management at end-of-life and fortunately, most pain at end-of-life can be managed successfully. This article presents a practical step-by-step approach to alleviating pediatric terminal cancer pain, which can be delivered across settings. Full article

The male sex has been suggested to predominate in paediatric patients with arterial ischemic stroke (AIS), especially in newborns. The explanation for this phenomenon remains unsatisfactory since it focuses on the analysis of the potential relationship with trauma and arterial dissection. In turn, in some populations of young adults, men suffer from AIS more frequently than women, which may be related to the protective role of oestrogen. On the other hand, certain data indicate that women dominate over men. Some of the disparities in the frequencies of particular symptoms of AIS and poststroke consequences in both children and young adults have been suggested; however, data are scarce. Unfortunately, the low number of studies on the subject does not allow certain conclusions to be drawn. For adults, more data are available for patients aged over 60 years, the results of which are more obvious. The present literature review aimed to discuss available data on the prevalence of AIS, its clinical presentations, and poststroke consequences in regard to the sex of young patients. We considered young patients to be children from birth up to the age of 19 years of life and young adults to be individuals up to the age of 55 years. The role of sex hormones in AIS and possible gender differences in genetic risk factors for AIS were also discussed briefly. Full article

Preterm infants with respiratory distress may require mechanical ventilation which is associated with increased pulmonary morbidities. Prompt and successful extubation to noninvasive support is a pressing goal. In this communication, we show original data that increased recurring intermittent hypoxemia (IH, oxygen saturation <80%) may be associated with extubation failure at 72 h in a cohort of neonates <30 weeks gestational age. Current-generation bedside high-resolution pulse oximeters provide saturation profiles that may be of use in identifying extubation readiness and failure. A larger prospective study that utilizes intermittent hypoxemia as an adjunct predictor for extubation readiness is warranted. Full article

Families living in under-resourced communities are at risk of obesity and obesity-related chronic diseases. To develop effective interventions, it is important to identify parent and child perspectives of factors that influence food-related choices and decisions. This paper reports qualitative findings from a larger mixed method study investigating this topic. Hybrid thematic analysis was used to code and analyze the interviews. Family-generated photographs of factors influencing food choices were discussed during the interviews. Qualitative findings were organized by the socio-ecological model. Verbatim quotes and photographs were used to support themes. Thirty-six interviews were conducted (18 parents, 18 children). Findings from parents revealed personal (e.g., culture, beliefs, time), family (e.g., mother, child, father, health, finances, cohesiveness), environmental (e.g., availability, convenience, cost), and other (e.g., school food) factors influenced food choices. Similarly, child-reported influences were personal (e.g., preferences, beliefs, taste), family (e.g., mother, family encouragement, father, family time), social (e.g., school, friends), environmental (e.g., availability), and other (e.g., media, sports). The socio-ecological model provided a useful framework for identifying factors that influence food choices and decisions of families living in under-resourced communities. A deeper understanding of these factors could enhance both responsiveness and effectiveness of interventions to enhance diet and reduce obesity risk in families living in under-resourced communities. Full article

Background: overweight and obese individuals may often face aggressive messages or comments on the internet. This study attempts to evaluate the association between cyberbullying victimization and overweight/obesity in adolescents participating in the European Network for Addictive Behavior (EU NET ADB) survey. Methods: a school-based cross-sectional study of adolescents aged 14–17.9 years was conducted (n = 8785) within the EU NET ADB survey, including data from seven European countries (Germany, Greece, Iceland, the Netherlands, Romania, Poland, Spain). Complex samples and univariate and multivariate logistic regression analyses were performed. Results: overall, overweight adolescents were more likely to have been cyberbullied compared to their normal weight peers (adjusted OR (Odds ratio) = 1.20, CI (confidence intervals): 1.01–1.42); this association was pronounced in Germany (adjusted OR = 1.58, CI: 1.11–2.25). In Iceland, obese adolescents reported cyberbullying victimization more frequently compared to their normal weight peers (adjusted OR = 2.87, 95% CI: 1.00–8.19). No significant associations with cyberbullying victimization were identified either for obese or overweight adolescents in Greece, Spain, Romania, Poland, and the Netherlands. Conclusions: this study reveals an overall association between cyberbullying victimization and overweight on the basis of a sizable, representative sample of adolescent population from seven European countries. Country-specific differences might reflect differential behavioral perceptions, but also normalization aspects. Full article

More than one-third of adolescents experience recurrent headaches. Usually, these headaches are of primary origin and modulated by different biological and psychosocial factors. While parents are often consulted in scientific research and medical care about the nature of their child’s headache, it is unclear to what extent parents and their children agree upon the factors that cause them. Adolescents’ own attributions of headaches have rarely been investigated, and it is unclear how those attributions affect behavioral and emotional outcomes. In the present study, adolescents with chronic headaches (N = 248) and their parents (N = 120) rated the influence of various biological and psychosocial factors on the adolescents’ headaches. Associations between these factors and several behavioral and emotional outcomes were examined. The most frequently reported factor by both samples was stress; however, concordance between parents and adolescents was generally low. The factor “other disease” was significantly associated with medication consumption and school absence. This study is one of the first to provide insights into adolescents’ own attributions of headaches. Furthermore, the significant associations of the factor with behavioral outcomes reveal the importance of understanding personal explanatory models of headache. Future studies should examine associations between subjective headache causes and the individual’s experience of the disorder to improve headache interventions. Full article

Children of mothers with depressive symptoms are at a higher risk for psychosocial, behavioral, and developmental problems. However, the effects of maternal depression on children’s physical growth are not well understood. To address the gaps in the literature, this study examined the association between maternal depressive symptoms, breastfeeding behaviors, and child weight outcomes. Data from 204 mother–child dyads who participated in the STRONG Kids 1 Study were used. Mothers and children were assessed twice when the children were 3 and 4 years old. Height and weight measurements of children and mothers were collected by trained researchers during both assessments. Multiple linear regression and analysis of covariance tests were used to examine the associations between maternal depressive symptoms, breastfeeding, and age and sex-adjusted child body mass index percentile. Recurrent maternal depressive symptoms when the child was 3 and 4 years old were not associated with child body mass index percentiles (BMI-P) at age 4. Mothers who breastfed for at least 6 months had significantly lower depressive symptoms when their children were 3 years of age, but the differences did not persist at age 4. In this community sample, maternal depressive symptoms were not associated with child BMI-P, regardless of breastfeeding duration. Full article

This study systematically reviewed the literature on perceived school safety. We investigated the prevalence, factors and associated mental health difficulties, as well as cross-cultural findings. Five databases were searched up to 9 February 2021 for peer-reviewed papers published in English. We included quantitative studies that explored the perception of school safety among children and adolescents. The reference lists of the selected papers were also searched. We conducted a narrative synthesis of the included studies. The review included 43 papers. The mean prevalence of the students who felt unsafe at school was 19.4% and ranged from 6.1% to 69.1%. Their perceived safety was associated with a wide range of personal, school, and social factors. Not feeling safe at school was related to being victimized and mental health difficulties, including depressive symptoms and suicidal behavior. Higher perceived school safety was associated with measures such as the presence of a security officer and fair school rule enforcement. The results showed the lack of cross-cultural studies on perceived school safety. Empirical studies are needed that examine the mechanisms of school safety, using valid measures. A clear definition of school safety should be considered a key aspect of future studies. Full article

Adolescent lesbian, gay, and bisexual (LGB) romantic partners face the challenge of developing satisfactory relationships while managing stressors associated with being members of a stigmatized minority group due to their sexual minority status. The aims of this study were to explore and describe relationship dynamics among LGB adolescents that are in committed same-sex relationships in Portugal, to assess levels of satisfaction with their relationships, and to assess whether LGB oppression was associated with the likelihood of anticipating and experiencing problems within the relationship. A sample of 182 self-identified LGB adolescents (mean age = 17.89 years; SD = 1.99), completed an online survey consisting of various sociodemographic measures, a relationship dynamics questionnaire, a self-assessment of relationship satisfaction, and an adapted version of the Gay and Lesbian Oppressive Situations Inventory. Results show that participants were highly satisfied with their relationships, except those who were non-monogamous and less committed to their relationships. Participants showed moderate levels of LGB oppression situations, and, as demonstrated by the hierarchical multiple regression analysis, age (being older), having lower levels of commitment, and being exposed to higher levels of exclusion, rejection, and separation were strong predictors of lower levels of relationship satisfaction. Full article

Meconium aspiration syndrome is a clinical condition characterized by respiratory failure occurring in neonates born through meconium-stained amniotic fluid. Worldwide, the incidence has declined in developed countries thanks to improved obstetric practices and perinatal care while challenges persist in developing countries. Despite the improved survival rate over the last decades, long-term morbidity among survivors remains a major concern. Since the 1960s, relevant changes have occurred in the perinatal and postnatal management of such patients but the most appropriate approach is still a matter of debate. This review offers an updated overview of the epidemiology, etiopathogenesis, diagnosis, management and prognosis of infants with meconium aspiration syndrome. Full article

Cervicothoracic neuroblastomas (NBs) pose unique surgical challenges due to the complexity of the neurovascular structures located in the thoracic inlet. To date, two main techniques have been reported to completely remove these tumours in children: the trans-manubrial and the trap-door approaches. Herein, the authors propose a third new surgical approach that allows a complete exposure of the posterior costovertebral space starting from the retro-clavicular space: Cervico-Parasternal Thoracotomy (CPT). The incision is made along the anterior margin of the sternocleidomastoid muscle until its sternal insertion, and then the incision proceeds vertically following the ipsilateral parasternal line. The major pectoralis muscle is detached, and the clavicle and the ribs are disarticulated from their sternal insertions. Following an accurate isolation of the major subclavian blood vessels and the brachial plexus roots, the tumour is then completely exposed and resected by switching from a frontal to a lateral view of the costo-vertebral space. By adopting this technique, five cervicothoracic NBs were completely resected in a median operative time of 370 min (range: 230–480 min). By proceeding in safety with the heart apart, neither vascular injuries nor nerve damages occurred, and all patients were safely discharged in a median postoperative time of 11 days (range: 7–14 days). At the last follow-up visit (median: 16 months, range: 13–21 months), all patients were alive and disease-free. Full article

Migraine headache is a common cause of pain and disability in children and adolescents and is a major contributor to frequently missed school days and limitations in activities. Of children and adolescents with migraine headache, approximately one-third have migraine with aura (MA). MA is often considered to be similar to migraine without aura (MO), and thus, many studies do not stratify patients based on the presence of aura. Because of this, treatment recommendations are often analogous between MA and MO, with a few notable exceptions. The purpose of this review is to highlight the current evidence demonstrating the unique pathophysiology, clinical characteristics, differential diagnosis, co-morbidities, and treatment recommendations and responses for pediatric MA. Full article

Advances in neuroimaging of the preterm infant have enhanced the ability to detect brain injury. This added information has been a blessing and a curse. Neuroimaging, particularly with magnetic resonance imaging, has provided greater insight into the patterns of injury and specific vulnerabilities. It has also provided a better understanding of the microscopic and functional impacts of subtle and significant injuries. While the ability to detect injury is important and irresistible, the evidence for how these injuries link to specific long-term outcomes is less clear. In addition, the impact on parents can be profound. This narrative summary will review the history and current state of brain imaging, focusing on magnetic resonance imaging in the preterm population and the current state of the evidence for how these patterns relate to long-term outcomes. Full article

Pulmonary ossification (PO) is a rare finding, characterized by mature bone formation in the lung parenchyma. We report a 20-year-old female patient diagnosed with fibrolamellar hepatocellular carcinoma (FL-HCC) and bilateral diffuse nodular PO. The patient presented with a unifocal left liver mass and multiple bilateral pulmonary lesions, which were treated as metastatic disease. The patient received neoadjuvant chemotherapy, followed by left hepatectomy, and bilateral staged thoracotomies for clearance of the pulmonary disease. The histology of the pulmonary nodules demonstrated nodular type PO. We present the history, the course of treatment, imaging, and histologic findings of this rare disease process that could mimic metastatic pulmonary disease. Full article

While children’s independent mobility (CIM) is associated with various benefits, there is evidence of a generational decline in CIM in westernized countries; therefore, it is helpful to understand how CIM is currently negotiated between children and their parents. The purpose of this study was to examine children’s and parents’ perspectives and negotiations of CIM within the family unit. Face-to-face interviews and walk-along interviews were conducted with parents (n = 44) and children (n = 22), respectively. Interviews were audio-recorded and transcribed verbatim, and a thematic analysis was conducted. Four key preconditions were identified that facilitated negotiation of CIM within family units, including (1) the influence of parents’ childhood experiences regarding their view of CIM (e.g., positive interpretations of childhood on parenting practices), (2) the role of children’s individual characteristics on their independent mobility (e.g., child’s confidence in their abilities), (3) family communication as a key coping strategy (parent–parent and parent–child communication), and (4) the influence of positive perceptions of the social environment on CIM. The findings suggest that CIM thrives when these conditions are present; as a result, it may be particularly helpful to develop policies and programs that support children’s skill training, explore strategies to support communication between parents and children, and build neighbourhood connections. Full article

Mercaptopurine (MP) is a commonly used maintenance regimen for childhood acute lymphoblastic leukemia (ALL). However, 6-MP has a narrow therapeutic index, which causes dose-limiting toxicities in hematopoietic tissues. Recent studies reported several candidate pharmacogenetic markers such as TPMT, NUDT15, ITPA, and APEX1, which predict the possibility of 6-MP related toxicities. The aim of this study is to evaluate the effect of major variants of these genes on 6-MP intolerances and toxicities in pediatric acute lymphoblastic leukemia (ALL) patients. A total of 83 pediatric ALL patients were included (56 males and 27 females). The NUDT15 c.415C>T (rs116855232), NUDT15 c.55_56insGAGTCG (rs746071566), ITPA c.94C>A (rs1127354), ITPA c.IVS2+21A>C (rs7270101), APEX c.190A>G (rs2307486), and TPMT variants were analyzed by sanger sequencing. Correlations between indexes of 6-MP-related toxicities or 6-MP intolerance (absolute neutrophil count [ANC] at several time point, days of ANC < 1 × 10³/mm³, days of ANC < 0.5 × 10³/mm³, frequency of febrile neutropenia, maximum AST and ALT, 6-MP dose and 6-MP dose intensity during maintenance therapy) and genetic variations were analyzed. The NUDT15 c.415C>T allele carrier showed significantly low 6-MP doses at the final maintenance therapy period than the wild type carrier (p = 0.007). The 6-MP dose intensities at the sixth and final maintenance period were also significantly low in NUDT15 c.415C>T carriers (p = 0.003 and 0.008, respectively). However, indexes for neutropenia, days of febrile neutropenia, maximum AST, and ALT levels were not associated with the presence of c.415C>T as well as other analyzed variants. When analyzing the effect of the coexistence of NUDT15 c.415C>T and ITPA c.94C>A, no significant differences were found between the NUDT15 c.415C>T carrier and carrier with both variations. The NUDT15 c.415C>T was the most useful marker to predict 6-MP intolerance among analyzed variants in our study population. Although we could not find association of those variants with 6-MP induced toxicities and the synergistic effects of those variants, a well-planed larger scale study would be helpful in clarifying new candidates and their clinical effects. Full article

Aim: This study aimed to investigate an association between dental caries status and anthropometric measures in primary school children. Methods and Materials: An analytical cross-sectional study (n = 376) was conducted among primary school children (age range = 6–9 years) registered in private schools. Non-clinical data was gathered from parents of participating children through a self-administered structured questionnaire as well as from the children through an interviewer-administered questionnaire. Clinical data included the examination of dental caries using dmft/DMFT index and anthropometric measures including calculated z-scores of height-for-age (HAZ), weight-for-age (WAZ), BMI-for-age (BAZ), and physical examination. Inferential statistics included Kruskal Wallis and linear regression for univariate and multivariate analysis respectively. Results: The proportion of dental caries in primary and secondary dentition was 67.6% and 8.2% respectively. A significant association was observed between dental caries status and HAZ, WAZ, and BAZ (p < 0.001). An inverse relation was found between low, medium, and high dental caries categories and anthropometric measures. Conclusions: In the primary dentition, dental caries were significantly and inversely related to weight-for-age, height-for-age, and BMI-for-age. Hence, it can be concluded that among the low-income population dental caries is associated with lower anthropometric outcomes in children and therefore caries management should be considered an approach impacting overall health and quality of life. Full article