Community‐acquired pneumonia in children: what’s old? What’s new?

Community‐acquired pneumonia (CAP) still remains a significant cause for childhood morbidity worldwide. Streptococcus pneumoniae is the most important causative agent at all ages. Respiratory syncytial virus is common in young children, and Mycoplasma pneumoniae in schoolchildren. Paediatric CAP is universally treated with antibiotics; amoxicillin is the drug of choice for presumably pneumococcal and a macrolide for presumably atypical bacterial cases. Because of globally increased resistances, macrolides are not safety for pneumococcal CAP. At present, available prospective research data on the epidemiology of paediatric CAP in western countries are from 1970s to 1980s; correspondingly, data on bacterial aetiology are mainly from 1980s to 1990s. Current concepts on pneumococcal aetiology are mostly based on poorly validated antibody assays. Most data on clinical characteristics in children’s CAP, as well as on antibiotic treatment come from developing countries, thus not being directly applicable in western communities. Recent viral studies have revealed the role of rhinoviruses, metapneumovirus and bocavirus in the aetiology of paediatric CAP. This review critically summarizes the available data on epidemiology, aetiology, clinical presentation, treatment and outcome of CAP in children, with special focus on the newest microbial findings, the age and applicability of the data and the need of new studies.     

Using computerized games to teach face recognition skills to children with autism spectrum disorder: the Let’s Face It! program

Background: An emerging body of evidence indicates that relative to typically developing children, children with autism are selectively impaired in their ability to recognize facial identity. A critical question is whether face recognition skills can be enhanced through a direct training intervention. Methods: In a randomized clinical trial, children diagnosed with autism spectrum disorder were pre‐screened with a battery of subtests (the Let’s Face It! Skills battery) examining face and object processing abilities. Participants who were significantly impaired in their face processing abilities were assigned to either a treatment or a waitlist group. Children in the treatment group (N = 42) received 20 hours of face training with the Let’s Face It! (LFI!) computer‐based intervention. The LFI! program is comprised of seven interactive computer games that target the specific face impairments associated with autism, including the recognition of identity across image changes in expression, viewpoint and features, analytic and holistic face processing strategies and attention to information in the eye region. Time 1 and Time 2 performance for the treatment and waitlist groups was assessed with the Let’s Face It! Skills battery. Results: The main finding was that relative to the control group (N = 37), children in the face training group demonstrated reliable improvements in their analytic recognition of mouth features and holistic recognition of a face based on its eyes features. Conclusion: These results indicate that a relatively short‐term intervention program can produce measurable improvements in the face recognition skills of children with autism. As a treatment for face processing deficits, the Let’s Face It! program has advantages of being cost‐free, adaptable to the specific learning needs of the individual child and suitable for home and school applications.     

Can community health workers manage uncomplicated severe acute malnutrition? A review of operational experiences in delivering severe acute malnutrition treatment through community health platforms

Community health workers (CHWs) play an important role in the detection and referral of children with severe acute malnutrition (SAM) in many countries. However, distance to health facilities remains a significant obstacle for caregivers to attend treatment services, resulting in SAM treatment coverage rates below 40% in most areas of intervention. The inclusion of SAM treatment into the current curative tasks of CHWs has been proposed as an approach to increase coverage. A literature review of operational experiences was conducted to identify opportunities and challenges associated with this model. A total of 18 studies providing evidence on coverage, clinical outcomes, quality of care, and/or cost‐effectiveness were identified. The studies demonstrate that CHWs can identify and treat uncomplicated cases of SAM, achieving cure rates above the minimum standards and reducing default rates to less than 8%. Although the evidence is limited, these findings suggest that early detection and treatment in the community can increase coverage of SAM in a cost‐effective manner. Adequate training and close supervision were found to be essential to ensure high‐quality performance of CHWs. Motivation through financial compensation and other incentives, which improve their social recognition, was also found to be an important factor contributing to high‐quality performance. Another common challenge affecting performance is insufficient stock of key commodities (i.e., ready‐to‐use therapeutic food). The review of the evidence ultimately demonstrates that the successful delivery of SAM treatment via CHWs will require adaptations in nutrition and health policy and practice.     

Metatarsus adductus: Development of a non‐surgical treatment pathway

Metatarsus adductus (MA) occurs in one to two cases per 1000 births and is the most common congenital foot deformity in newborns. The appearance is that of a curved or adducted forefoot with a normal hindfoot. A systematic literature review was conducted to answer the following question: For a child who presents with MA, what is the most evidence‐based conservative treatment option? Thirteen articles were reviewed using the National Health and Medical Research Council levels of evidence and guidelines for clinical practice. Conservative treatment options reported on included the following: no treatment, stretching, splinting, serial casting, sitting and sleeping positions and footwear/orthotics. There was strong evidence supporting no treatment in the case of flexible MA. Some limited evidence was found for the treatment of semi‐rigid MA. Clinicians should use these recommendations together with clinical experience when advising parents on treatment of MA.     

Multisystem inflammatory syndrome associated with COVID-19 from the pediatric emergency physician's point of view

ObjectiveMultisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) is a rare and challenging diagnosis requiring early treatment. The diagnostic criteria involve clinical, laboratory, and complementary tests. This review aims to draw pediatrician attention to this diagnosis, suggesting early treatment strategies, and proposing a pediatric emergency care flowchart.SourcesThe PubMed/MEDLINE/WHO COVID-19 databases were reviewed for original and review articles, systematic reviews, meta-analyses, case series, and recommendations from medical societies and health organizations published through July 3, 2020. The reference lists of the selected articles were manually searched to identify any additional articles.Summary of the findingsCOVID-19 infection is less severe in children than in adults, but can present as MIS-C, even in patients without comorbidities. There is evidence of an exacerbated inflammatory response with potential systemic injury, and it may present with aspects similar to those of Kawasaki disease, toxic shock syndrome, and macrophage activation syndrome. MIS-C can develop weeks after COVID-19 infection, suggesting an immunomediated cause. The most frequent clinical manifestations include fever, gastrointestinal symptoms, rash, mucous membrane changes, and cardiac dysfunction. Elevated inflammatory markers, lymphopenia, and coagulopathy are common laboratory findings. Supportive treatment and early immunomodulation can control the intense inflammatory response and reduce complications and mortality.ConclusionsMIS-C associated with COVID-19 is serious, rare, and potentially fatal. The emergency department pediatrician must recognize and treat it early using immunomodulatory strategies to reduce systemic injury. Further studies are needed to identify the disease pathogenesis and establish the most appropriate treatment.     

Predictive factors for the persistence of cow’s milk allergy

Santos A, Dias A, Pinheiro JA. Predictive factors for the persistence of cow’s milk allergy.
Pediatr Allergy Immunol 2010: 21: 1127–1134.
© 2010 John Wiley & Sons A/S Cow’s milk allergy (CMA) is usually transient, but recent studies have shown a later acquisition of tolerance to CM. Our aims were to characterize a population of Portuguese children with CMA and to identify predictive factors for the persistence of this food allergy. Children with CMA observed in our Paediatric Allergy Clinic between 1997 and 2006 were selected. Demographic and clinical data were collected from medical records. The group of children who tolerated CM before the age of 2 was compared with the group of children who tolerated CM beyond that age or persisted with CMA until the end of the study. Multivariate logistic regression analysis was used to investigate independent predictive factors for the persistence of CMA beyond the age of 2. In the subgroup of children with IgE‐mediated CMA, the acquisition of tolerance was analysed using Cox regression. In this population of 139 children, the majority presented more than one symptom (73%) affecting more than one organ (51%), with cutaneous (81%), gastrointestinal (55%), respiratory (16%) manifestations and/or anaphylaxis (3%). Thirty‐two per cent developed asthma, 20% atopic eczema, 20% rhinoconjunctivitis and 19% other food allergies over time. The acquisition of tolerance was different in the whole population versus the subgroup with IgE‐mediated CMA: 34%versus 0% at the age of 2, 55%versus 22% at the age of 5 and 68%versus 43% at the age of 10. Immediate allergic symptoms, asthma and other food allergies were independent factors for the persistence of CMA beyond the age of 2. Higher maximum weal diameter on skin prick test to CM and higher maximum level of specific IgE to CM were associated with reduced likelihood of acquiring tolerance in the subgroup of children with IgE‐mediated CMA. In conclusion, children with IgE‐mediated CMA acquire tolerance to CM at older age. Clinical parameters and allergy tests may be helpful in defining prognosis. CM‐allergic children tend to develop other atopic conditions and need specialized follow‐up in the long term.     

Practitioner Review: The victims and juvenile perpetrators of child sexual abuse – assessment and intervention

Background: The assessment of victims of child sexual abuse (CSA) is now a recognized aspect of clinical work for both CAMH and adult services. As juvenile perpetrators of CSA are responsible for a significant minority of the sexual assaults on other children, CAMH services are increasingly approached to assess these oversexualized younger children or sexually abusive adolescents. A developmental approach to assessment and treatment intervention is essential in all these cases. Method: This review examines research on the characteristics of child victims and perpetrators of CSA. It describes evidence‐based approaches to assessment and treatment of both groups of children. A selective review of MEDLINE, Psycinfo, Cochrane Library, and other databases was undertaken. Recommendations are made for clinical practice and future research. Findings: The characteristics of CSA victims are well known and those of juvenile perpetrators of sexual abuse are becoming recognized. Assessment approaches for both groups of children should be delivered within a safeguarding context where risk to victims is minimized. Risk assessment instruments should be used only as adjuncts to a full clinical assessment. Given high levels of psychiatric comorbidity, assessment, treatment, and other interventions should be undertaken by mental health trained staff. Conclusions: Victims and perpetrators of CSA present challenges and opportunities for professional intervention. Their complex presentations mean that their needs should be met by highly trained staff. However, their youth and developmental immaturity also give an opportunity to nip problem symptoms and behaviors in the bud. The key is in the earliest possible intervention with both groups. Future research should focus on long‐term adult outcomes for both child victims and children who perpetrate CSA. Adult outcomes of treated children could identify problems and/or strengths in parenting the next generation and also the persistence and/or desistence of sexualized or abusive behavior.     

Management guidelines for mucopolysaccharidosis VI

Mucopolysaccharidosis VI (Maroteaux-Lamy syndrome) is a lysosomal storage disease that is characterized by systemic clinical manifestations and significant functional impairment. Diagnosis and management are often challenging because of the considerable variability in symptom presentation and rate of progression. The optimal standard of care should be based on evidence from randomized, controlled trials, meta-analyses, systematic reviews, and expert opinion. In support of this goal, comprehensive management guidelines have been drafted by an international group of experts in the management of patients with mucopolysaccharidosis VI. The guidelines provide a detailed outline of disease manifestations by body system, recommendations for regular assessments, and an overview of current treatment options.     

One Child's Food Fight: A Case Study of Oral Immunotherapy Treatment for Food Allergies

The prevalence of food allergy has risen dramatically in the last two decades. Primary care providers encounter food-allergic children on a daily basis. Although the standard of care has traditionally been strict avoidance of the allergen and advisement to carry an epinephrine autoinjector in case of an accidental exposure resulting in a severe reaction, food allergy research has progressed in the past decade concerning various immunotherapies that may provide an alternate treatment strategy. Oral immunotherapy (OIT), performed under the supervision of an allergist, is the most widely studied of these therapies. In the past, OIT has been available in the realm of clinical trials, but it is now being offered by a small but increasing number of allergists in private practice throughout the United States. Pediatric primary care clinicians should be aware of both the risks and possible benefits of this treatment, because they are likely to encounter patients who may inquire about OIT in their practices. In this case report, use of OIT will be reviewed in the treatment of a food-allergic child.     

Henoch-Schönlein purpura nephritis in children: risk factors, prevention and treatment

Aim:  To identify risk factors for a child with Henoch-Schönlein purpura (HSP) either to develop nephritis (HSPN) or to contract progressive course and to obtain the currently available evidence on the efficacy of treatment options in both preventing and treating the established renal disease.
Method:  Review of the literature published over the last two decades.
Results:  Persistent or recurrent purpura, severe abdominal symptoms and an older age proved as the most significant risk factors for later HSPN. The risks of long-term renal impairment are the highest in children having at presentation nephritic/nephrotic syndrome and/or more than 50% of glomeruli occupied by large crescents or sclerosing lesions. Randomized controlled trials (RCT) do not support short course prednisone at presentation of HSP in preventing persistent renal disease. Many uncontrolled studies using various treatment regimens have reported outcomes considered better than expected. However, the data from RCTs are sparse and no treatment options for the established renal disease can be currently recommended based on RCTs.
Conclusion:  Severity and/or duration of extrarenal HSP symptoms and an older age are the most significant risk factors for developing HSPN, whereas clinical and histological severity at HSPN onset are in general predictive of a long-term renal impairment. The existing evidence does not support of short course prednisone in preventing persistent renal disease. A well-designed RCTs are needed in children with moderately severe or rapidly progressive (crescentic) HSPN.     

The perception and identification of facial emotions in individuals with autism spectrum disorders using the Let’s Face It! Emotion Skills Battery

Background: Although impaired social–emotional ability is a hallmark of autism spectrum disorder (ASD), the perceptual skills and mediating strategies contributing to the social deficits of autism are not well understood. A perceptual skill that is fundamental to effective social communication is the ability to accurately perceive and interpret facial emotions. To evaluate the expression processing of participants with ASD, we designed the Let’s Face It! Emotion Skills Battery (LFI! Battery), a computer‐based assessment composed of three subscales measuring verbal and perceptual skills implicated in the recognition of facial emotions. Methods: We administered the LFI! Battery to groups of participants with ASD and typically developing control (TDC) participants that were matched for age and IQ. Results: On the Name Game labeling task, participants with ASD (N = 68) performed on par with TDC individuals (N = 66) in their ability to name the facial emotions of happy, sad, disgust and surprise and were only impaired in their ability to identify the angry expression. On the Matchmaker Expression task that measures the recognition of facial emotions across different facial identities, the ASD participants (N = 66) performed reliably worse than TDC participants (N = 67) on the emotions of happy, sad, disgust, frighten and angry. In the Parts–Wholes test of perceptual strategies of expression, the TDC participants (N = 67) displayed more holistic encoding for the eyes than the mouths in expressive faces whereas ASD participants (N = 66) exhibited the reverse pattern of holistic recognition for the mouth and analytic recognition of the eyes. Conclusion: In summary, findings from the LFI! Battery show that participants with ASD were able to label the basic facial emotions (with the exception of angry expression) on par with age‐ and IQ‐matched TDC participants. However, participants with ASD were impaired in their ability to generalize facial emotions across different identities and showed a tendency to recognize the mouth feature holistically and the eyes as isolated parts.     

Intrusive thoughts and young children’s knowledge about thinking following a natural disaster

Background: Hurricane Katrina devastated the Mississippi Gulf Coast in August 2005. Intrusive re‐experiencing is a common posttraumatic stress symptom. However, young children with limited introspection skills might have difficulties identifying their intrusive thoughts. Method: A sample of 165 5‐ to 9‐year‐old children were surveyed about their unwanted intrusive thoughts and their knowledge about thinking, 10 months following the hurricane. Results: Results replicate and extend the findings from a previous study ( Sprung, 2008 ). Although there was no difference in the overall occurrence of intrusive thoughts, there was a striking difference between hurricane‐exposed and control children in their contents. Children’s knowledge about thinking was linked to their ability to report on their negative intrusive thoughts, even taking language ability into account. Conclusion: There is a shift toward negative content following hurricane exposure compared with non‐hurricane‐exposed children and knowledge about thinking is linked to the reporting of such intrusive thoughts. Implications for current research on autobiographical memory and for interventions following potentially traumatic events are discussed.     

Curing dyslexia and attention‐deficit hyperactivity disorder by training motor co‐ordination: Miracle or myth?

Dore Achievement Centres are springing up world-wide with a mission to cure cerebellar developmental delay, thought to be the cause of dyslexia, attention-deficit hyperactivity disorder, dyspraxia and Asperger's syndrome. Remarkable success is claimed for an exercise-based treatment that is designed to accelerate cerebellar development. Unfortunately, the published studies are seriously flawed. On measures where control data are available, there is no credible evidence of significant gains in literacy associated with this intervention. There are no published studies on efficacy with the clinical groups for whom the programme is advocated. It is important that family practitioners and paediatricians are aware that the claims made for this expensive treatment are misleading.     

G × E interaction in the organization of attachment: mothers’ responsiveness as a moderator of children’s genotypes

Background: Scholars acknowledge that both biologically‐founded child temperament and environmental factors are influential in determining the quality of infant–mother attachment. We present evidence for gene by environment (G × E) interaction in the organization of attachment. Methods: Participants were 88 typically developing infants and their mothers. Molecular genetic measures of the infants focused on the polymorphism in the serotonin transporter gene (5‐HTTLPR, ss/sl vs. ll genotype). Mothers’ responsiveness to their infants at 7 months was observed in lengthy naturalistic interactions, and was conceptualized as the environmental influence. Results: For infants with a short allele (ss/sl ), variation in mothers’ responsiveness was significantly associated with attachment security, assessed at 15 months in the Strange Situation. For those infants, low responsiveness predicted particularly high risk for insecure attachment, and high responsiveness offset that risk. For infants homozygous for the long allele (ll ), there was no association between responsiveness and attachment organization. Conclusions: The findings show that the quality of early care serves to amplify or offset the risk conferred by genotype.     

Bivalirudin during thrombolysis with catheter‐directed tPA in a heparin‐refractory patient: A case report

Venous thromboembolism has increasing significance in hospitalized pediatric patients. Patients who have life‐threatening or limb‐threatening thrombotic events require thrombolysis in addition to anticoagulation. In patients who show signs of heparin resistance or heparin‐induced thrombocytopenia, it is imperative to identify alternative therapeutic options. We present a child in whom bivalirudin was used for systemic anticoagulation during catheter‐directed thrombolysis along with tissue plasminogen activator (Alteplase^®) for the treatment of a near‐occlusive organ‐threatening thrombus. We also review the currently available literature on the use of combination therapy of an intravenous direct thrombin inhibitor with alteplase.     

Neurocritical care monitoring of encephalopathic children with acute liver failure: A systematic review

Research on non‐invasive neuromonitoring specific to PALF is limited. This systematic review identifies and synthesis the existing literature on non‐invasive approaches to monitoring for neurological sequelae in patients with PALF. A series of literature searches were performed to identify all publications pertaining to five different non‐invasive neuromonitoring modalities, in line with PRISMA guidelines. Each modality was selected on the basis of its potential for direct or indirect measurement of cerebral perfusion; studies on electroencephalographic monitoring were therefore not sought. Data were recorded on study design, patient population, comparator groups, and outcomes. A preponderance of observational studies was observed, most with a small sample size. Few incorporated direct comparisons of different modalities; in particular, comparison to invasive intracranial pressure monitoring was largely lacking. The integration of current evidence is considered in the context of the clinically significant distinctions between pediatric and adult ALF, as well as the implications for planning of future investigations to best support the evidence‐based clinical care of these patients.     

Understanding and managing pain in children with cerebral palsy

Pain in children with cerebral palsy is a common presentation. It is a complex topic with multiple causes, presentations, and effects. This makes assessment and management a huge challenge that requires multidisciplinary input. It can be further complicated by difficulties in communication and thus, expression of pain. Early recognition is vital as pain can impact a child's quality of life and participation in therapy and social activities. This review aims to explore what causes pain in children with cerebral palsy and how it is evaluated. Non-medical, medical, and surgical options for pain are also outlined with reference to side effects and evidence behind their efficacy. This review emphasises the need for further research to create thorough, reliable assessment tools and improve management techniques.     

Response to sirolimus in capillary lymphatic venous malformations and associated syndromes: Impact on symptomatology,quality of life,and radiographic response

Background

Capillary lymphatic venous malformations (CLVM) and associated syndromes, including Klippel–Trenaunay syndrome (KTS) and congenital lipomatous overgrowth, vascular malformation, epidermal nevi, skeletal, and spinal syndrome (CLOVES), are underrecognized disorders associated with high morbidity from chronic pain, recurrent infections, bleeding, and clotting complications. The rarity of these disorders and heterogeneity of clinical presentations make large-scale randomized clinical drug trials challenging. Identification of PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha [gene]) mutations in CLVM has made targeted medications, such as sirolimus, attractive treatment options. The aim of this study was to investigate the safety and efficacy of sirolimus therapy in CLVM.

Procedure

A combined prospective and retrospective cohort of pediatric and young adult patients with CLVM treated with sirolimus was evaluated for disease response, including symptom improvement, quality of life (QOL), and radiologic response. Sirolimus dosing regimens and toxicities were also assessed.

Results

Twenty-nine patients with CLVM, including KTS and CLOVES, were included. Ninety-three percent of patients reported improved QOL, and 86% had improvement in at least one symptom. Most significantly, improvement was noted in 100% of patients with bleeding and 89% with thrombotic complications with corresponding decreases in mean D-dimer (p = .008) and increases in mean fibrinogen (p = .016). No patients had progressive disease on sirolimus. Most common side effects included neutropenia, lymphopenia, infection, and aphthous ulcers/stomatitis. No toxicities were life-threatening, and none required long-term discontinuation of sirolimus.

Conclusion

Sirolimus appears to be effective at reducing complications and improving QOL in patients with CLVM and associated syndromes. In this patient cohort, sirolimus was well tolerated and resulted in few treatment-related toxicities.