Appendicitis in children less than five years old:A challenge for the general practitioner

Acute appendicitis is one of the most common indications for abdominal surgery in pediatrics with peak incidence in the second decade of life. Acute appendicitis in the first years of life is an uncommon event. The clinical presentation is often varied and the diagnosis may be overshadowed by other medical conditions.Gastroenteritis is the most common misdiagnosis, with a history of diarrhea present in 33% to 41% of patients. Pain is the most common presenting symptom in children less than 5 years old, followed by vomiting, fever, anorexia and diarrhea. The most common physical sign is focal tenderness(61% of the patients) followed by guarding(55%), diffuse tenderness(39%), rebound(32%), and mass(6%). Neonatal appendicitis is a very rare disease with high mortality; presenting symptoms are nonspecific with abdominal distension representing the main clinical presentation. The younger the patient, the earlier perforation occurs: 70% of patients less than 3 years develop a perforation within 48 h of onset of symptoms. A timely diagnosis reduces the risk of complications. We highlight the epidemiology, pathophysiology, clinical signs and laboratory clues of appendicitis in young children and suggest an algorithm for early diagnosis.     

Langerhans cell histiocytosis in children less than 2 years of age

OBJECTIVE: To study the clinical profile and outcome of langerhans cell histiocytosis in children upto 2 years of life. DESIGN: Retrospective analysis. METHODS: Medical records of Children upto 2 years of age with a diagnosis of langerhans cell histiocytosis (LCH) were analyzed. Their clinical pattern, treatment modalities and outcome were studied. The patients Were categorized into 2 groups according to their clinical presentation: (i) Subject without organ dysfunction; and (ii) cases with organ dysfunction. Treatment considered of surgical intervention, radiotherapy, chemotherapy or combination of all these modalities depending upto the extent of disease. RESULTS:There were 20 children upto 2 years of age with histiocytosis during the 12 year period (January 1983 - December 1994). The median age at diagnosis was 18 months (range 52 days - 24 months). Of the twenty patients,13 patients didn't have organ dysfunction and 7 had organ dysfunction. Out of the 13 children without organ dysfunction eleven patients received treatment and all of them are alive free of disease with a median follow up of 62 months. But all children with organ dysfunction succumbed to disease within a few weeks. CONCLUSION: Children under 2 years of age with localised and or multifocal LCH without organ dysfunction have a good prognosis and they should not be exposed to aggressive form of treatment. All children with organ dysfunction require multi-agent chemotherapy.     

Renal transplantation in children less than 5 years of age.

19 young children (less than 5 years old) have received 31 renal transplants from 4 live relatives and 27 cadaver donors. The 2-year allograft survival rate for the patients receiving their 1st allograft from the 4 live donors was 75 +/- 22% while for the patients receiving their 1st allograft from 15 cadaver donors was 26 +/- 11%. 10 children are currently surviving with functioning allographs (7 cadavers and 3 live relatives); 4 have died and 5 are undergoing dialysis after the loss of at least one allograft. Despite the poor allograft survival rate the fact that 7 children are surviving with cadaver allografts indicates that the lack of a living related donor should not prevent transplants in young children.     

Rotavirus diarrhea among children less than 5 years of age in urban Ghana

We collected clinical and morphologic data from children with diarrhea attending 3 diverse hospitals/clinics in Accra. Stool samples were tested for rotavirus and Cryptosporidium spp. In all, 58% of the children with diarrhea had rotavirus infections, 25% of which were of the G3 sero/genotype. The most common strains were G3P [6] (18.8%) and G2P [6] (12.5%). Cryptosporidium spp. infections were uncommon (3/143, 2.0%).     

3岁以下肺炎住院患儿的病原学研究

目的：肺炎是小儿时期,尤其是3岁以下儿童的常见疾病,有较高的发病率和病死率。在发展中国家,病原菌以细菌感染相对多见,而病原菌的分布则随着年代不同而发生变化。该研究的目的是了解3岁以下肺炎住院患儿的深部痰液的病原学种类及分布,以期更好的指导临床用药。方法：对苏州儿童医院2006年3月至2007年1月 316 例肺炎患儿进行呼吸道深部吸痰,对其进行常见病原学检测,并分析比较。结果：316例患儿痰标本中,病原体检出率为60.8%,其中细菌检出率为51.3%,病毒总检出率为6.3%。细菌、病毒混合检出率为3.5%;细菌感染中以流感嗜血杆菌（14.6%）和肺炎链球菌（10.1%）为主;病毒感染则以呼吸道合胞病毒（4.0%）和腺病毒（3.6%）为主。结论：苏州地区3岁以下儿童的肺炎主要是由细菌感染引起的,以革兰阴性杆菌为主,流感杆菌是主要的致病菌,其次是肺炎链球菌。     

Bacterial etiology of acute myringitis in children less than two years of age.

BACKGROUND: Acute myringitis is an inflammation of the tympanic membrane that occurs alone or in association with external otitis or otitis media. The two clinical entities, based on physical examination, are bullous myringitis and hemorrhagic myringitis. OBJECTIVES: To investigate the association of concomitant middle ear disease with acute myringitis and to analyze the bacteriologic findings of the middle ear fluid in children with acute myringitis. METHODS: A prospective longitudinal cohort study of 2028 children age 7 to 24 months at primary care level in the Finnish Otitis Media Vaccine Trial. Matched case-control design for analysis of bacterial pathogen distribution. RESULTS: There were 82 children in whom 92 ears were diagnosed with acute bullous myringitis and 37 children in whom 40 ears were diagnosed with hemorrhagic myringitis during the follow-up. Middle ear disease was associated with bullous myringitis in 97% of ears and with hemorrhagic myringitis in 82% of ears. Bacterial pathogen distribution was similar to that of acute otitis media, although a higher proportion of Streptococcus pneumoniae was detected in both bullous and hemorrhagic acute myringitis. CONCLUSIONS: Middle ear fluid was present in vast majority of ears with acute myringitis in young children. The same etiologic bacteria were found in acute myringitis as in acute otitis media, but S. pneumoniae was the major pathogen. Acute bullous myringitis should be treated as acute otitis media in children <2 years of age.     

Acute diarrhea in children less than 3 years of age: Enteropathogens isolated in patient's stools, compared with a control group

OBJECTIVES: To observe the occurrence of different etiological agents of acute diarrhea (AD) in stool specimens of patients and children in a control group. MATERIAL AND METHODS: 100 children less than three years of age with AD were studied as well as 100 controls, between November 1993 and May 1994. Stool specimens were collected in both groups and the following enteropathogens were searched for: Rotavirus, Escherichia coli (EPEC, ETEC, EIEC, EHEC), Salmonella sp, Shigella sp, Campylobacter jejuni, Campylobacter coli, Yersinia enterocolitica, Cryptosporidium sp, Giardia lamblia, Entamoeba histolytica. Statistical analysis using the exact Fisher test (at significance level p<0,05) was done. The mean age was 12,5 months, with more cases in patients less than 6 months (35%). Children were seen at the emergency section on an average fifth day after the start of the diarrhea. Most came from homes with basical sanitary conditions. Watery diarrhea was more frequent than bloody diarrhea with mucus, at a proportion of 4:1. RESULTS: Rotavirus was the most frequent agent: 21% in the AD group and 3% in the control group (p= 0,0001). Shigella sp was isolated in 7% of the AD group and none of the control group (p= 0,0140). EPEC was detected in 13% of AD cases and 7% in the control group (p= 0,2381) but the classical subgroups O55, O111, O119 were only isolated from the patients with AD. The other enteropathogens were infrequently detected or in equal proportion in both groups. Rotavirus and EPEC were the more frequently isolated agents in watery diarrhea, while Shigella sp was the predominant agent found in bloody stools with mucus. CONCLUSIONS: Rotavirus was the most common causative agent in AD. The detection of Rotavirus and Shigella sp nearly exclusively in patients with AD confirms the high patogenicity of these etiological agents when compared to the others. Escherichia coli (EPEC) diagnosed by polyvalent sera does not confirm its respective diarrheogenic property due to isolation in the same proportion among patients with AD and controls. Monovalent antisera made possible the detection of classical subgroups of EPEC O111, O119, O55 isolated only from AD patients, confirming the already known high patogenicity of these strains.     

Deaths among children less than two years of age receiving palivizumab: an analysis of comorbidities

BACKGROUND: Palivizumab (Synagis) is used for prophylaxis against respiratory syncytial virus infection among children at high risk for respiratory syncytial virus disease. A number of deaths after palivizumab use among children <2 years have been reported to the Food and Drug Administration. We assessed available information, including the extent to which preexisting medical conditions may have put these children at higher than normal risk of death. METHODS: We reviewed reports of deaths to the Food and Drug Administration (June 1998 to December 2001) among children <2 years of age who received palivizumab. RESULTS: There were 133 deaths reported after palivizumab use. Median age at death was 5 months, and 54% of the children were male. At least one congenital anomaly was reported in 85 cases (64%), and 44% of cases had multiple anomalies. Of the 100 cases with reported gestational age at birth, 36% were severely premature (<28 weeks), 48% were moderately premature (28 to 36 weeks) and 16% had normal gestational age. Only 2% of all cases were full term and were born without congenital anomalies; 50% had both conditions, 34% had prematurity alone and 14% had congenital anomalies alone. A cause of death was reported for 88 (66%) cases; most (38%) died from their congenital anomalies or from respiratory infections (23%). CONCLUSIONS: Most children dying after palivizumab treatment were at increased risk of death; many had multiple congenital anomalies and/or premature birth. Patterns of outcomes and the reported medical course did not suggest that palivizumab further elevated the risk of death. Current data do not alter the safety and efficacy assessment that led to the licensure of palivizumab.     

Factors influencing breastfeeding in children less than 2 years of age in Lao PDR

Aim: This study aimed to investigate the prevalence of, and factors influencing, exclusive breastfeeding (EBF) at 6 months and continued breastfeeding (CBF) at 2 years. Methods: Between January and February 2007, a cross‐sectional study was conducted using a semi‐structured questionnaire in 40 villages in the Vientiane capital and the Vientiane province of Lao PDR. A total of 400 mothers with children less than 2 years old were recruited by multistage random sampling. Based on the 1991 World Health Organization Breastfeeding Indicators, children were classified into three groups, 6–23‐month‐old children for assessing EBF at 6 months, 12–15‐month‐old children for CBF at 1 year and 20–23‐month‐old children for CBF at 2 years. Results: The prevalence of EBF at 6 months and CBF at 2 years were 19.4% (n= 283) and 18.6% (n= 43), respectively. Some of the factors influencing EBF at 6 months in a univariate logistic regression model included: location of residence, (OR: 19.19, 95% CI 6.96–57.01), ethnicity (OR: 3.15, 95% CI 1.63–6.08), encouragement of the child's father (OR: 9.03, 95%CI 1.21–67.57) and inter‐spousal communication (OR: 5.20, 95% CI 2.34–11.56). A majority of the mothers (75.0%) had watched television advertisements for infant formula from Thailand, and 48.4% reported that they wanted to buy formula milk after having watched them. Conclusion: This study showed a low prevalence of EBF at 6 months in the studied area in Lao PDR. Some of the factors that had a strong impact on EBF at 6 months included: location of residence, ethnicity, father's involvement, early breastfeeding plan, Mother's Card in antenatal care and television advertisement. There may be opportunities for government to review a range of policies relating to paternal involvement, antenatal care and formula advertising that could help to improve EBF rate.     

Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States

BACKGROUND: Human parainfluenza viruses 1 through 3 (HPIV-1-3) are important causes of respiratory tract infections in young children. This study sought to provide current estimates of HPIV-1-3-associated hospitalizations among US children. METHODS: Hospitalizations for bronchiolitis, bronchitis, croup and pneumonia among children age <5 years were determined for the years 1979 through 1997 using the National Hospital Discharge Survey. Average annual hospitalizations during the last 4 years of the study for each of these four diseases were multiplied by the proportions of each disease associated with HPIV-1-3 infection (as previously reported in hospital-based studies) to estimate hospitalizations potentially associated with HPIV-1-3 infections. Seasonal trends in HPIV-1-3-associated hospitalizations were compared with HPIV detections in the National Respiratory and Enteric Virus Surveillance System, which prospectively monitors respiratory viral detections throughout the United States. RESULTS: The proportions of hospitalizations associated with HPIV infection for each disease varied widely in the 6 hospital-based studies we selected. Consequently our annual estimated rates of hospitalization were broad: HPIV-1, 0.32 to 1.59 per 1,000 children; HPIV-2, 0.10 to 0.86 per 1,000 children; and HPIV-3, 0.48 to 2.6 per 1,000 children. Based on these data HPIV-1 may account for 5,800 to 28,900 annual hospitalizations; HPIV-2 for 1,800 to 15,600 hospitalizations; and HPIV-3 for 8,700 to 52,000 hospitalizations. CONCLUSIONS: We provide broad, serotype-specific estimates of US childhood hospitalizations associated with HPIV infections. More precise estimates of HPIV-associated hospitalizations would require large prospective studies of HPIV-associated diseases by more sensitive viral testing methods, such as polymerase chain reaction techniques.     

Motor vehicle accident trauma and restraint usage patterns in children less than 4 years of age

In a sample of children less than 4 years of age, treated in an emergency room after a motor vehicle accident, 22% were restrained in a child safety seat (improper and proper), 12% were restrained by a vehicle seat belt, and 70% were unrestrained. Trauma and injury patterns related to the various restraint use patterns are described. Most children in safety seats and seat-belted children, if injured, sustained minor contusions, abrasions, or lacerations. Injury among properly restrained children in safety seats was primarily the result of unavoidable mechanisms (eg, flying glass, intrusion). Improper use contributed to injury among safety-seat-restrained children, primarily by allowing the child to hit against the vehicle interior. Seat-belted children also were injured, primarily by hitting against the vehicle interior. Although some of the restrained children were seriously injured, in general, restrained children tended to sustain less serious and fewer injuries than the unrestrained children.     

Epidemiology and clinical presentation of shigellosis in children less than five years of age in rural Mozambique

Rectal swabs were collected from 1354 children <5 years of age with diarrhea attending Manhi?a District Hospital and from 227 healthy community controls. Shigellosis incidence was high among children aged 12-47 months (488.4/10(5) child-years at risk). Fever and dysentery were prominent clinical findings. Shigella was more frequently isolated from cases than controls (6.7% versus 0.4%, P = 0.004), and from dysentery than nondysenteric diarrhea (24.1% versus 3.5%, P < 0.001). Shigella flexneri 2a, S. sonnei, and S. flexneri 6, were the most prevalent serotypes.