小儿腰椎间盘突出症

对小儿椎间盘突出症的病因,症状与体征进行总结,以提高其诊断治疗。方法对１９９０－１９９７年收治的１４例小儿腰椎间盘突出症资料进行总结,男９例,女５例,年龄６－１４岁,１０岁以上１３例。该病以外伤或重复性创伤为其原因。     

Presentation and progression of a disc cyst in a pediatric patient

Disc cysts are rare intraspinal extradural lesions that communicate with the intervertebral disc and can mimic the symptoms of acute lumbar disc herniation. Initially reported in the Japanese-language literature as a new entity (discal cyst), there are few documented cases in North America, and only 1 prior case in the pediatric population. The authors present the case of a 16-year-old girl with an intervertebral disc cyst causing lumbar radiculopathy that progressed despite conservative treatment. All medical records, imaging studies, intraoperative findings, and pertinent literature were reviewed. Serial preoperative MR imaging revealed enlargement of the intraspinal cyst at the L4-5 level, resulting in compression of the right L-5 nerve root. Enlargement of the cyst occurred over a 4-month period despite conservative treatment with physical therapy and corticosteroid injections. Microsurgical discectomy and excision of the cyst resulted in complete resolution of the preoperative radiculopathy. An intervertebral disc cyst is a rare entity in the adult population and exceedingly rare in the pediatric population but should remain in the differential diagnosis of any intraspinal extradural mass. The authors hypothesize that there exists a spectrum of this entity that may not be responsive to conservative therapy. Cyst excision alone or in conjunction with microsurgical discectomy is safe and effective in treating radiculopathy caused by disc cysts.     

Unilateral partial hemilaminectomy for disc removal in a 1-year-old child

Intravertebral disc herniation is common in adults, often due to degenerative processes. The occurrence of disc herniation is rare in children and is usually related to traumatic injury. The authors present an unusual case of a 13-month-old boy with L5-S1 lumbar disc herniation. The disc was removed via a unilateral partial hemilaminectomy approach, sparing the spinal midline structural elements. Although rare, lumbar disc herniation should be in the differential diagnosis for children presenting with low-back pain and/or neurological deficit of the lower limbs.     

An experimental test of parenting practices as a mediator of early childhood physical aggression

Background:  Parenting practices predict early childhood physical aggression. Preventive interventions that alter parenting practices and aggression during early childhood provide the opportunity to test causal models of early childhood psychopathology. Although there have been several informative preventive intervention studies that test mediation models in older children, no such studies have been conducted with younger children at high risk for psychopathology.
Method:  Within the context of a randomized controlled trial, we examined whether changes in parenting practices mediate the effects of a family intervention on observed physical aggression among African American and Latino younger siblings of adjudicated youths.
Results:  Improved parenting practices partially mediated the intervention effect on physical aggression. Improvements in harsh parenting, responsive parenting, and stimulating parenting explained a significant amount of the intervention effect on child physical aggression observed in the context of parent–child interactions. Parenting practices accounted for 38% of the intervention effect on physical aggression.
Conclusions:  There was support for the hypothesized model of the prevention of physical aggression during early childhood. Intervention benefits on parenting practices partially accounted for intervention effects on physical aggression in young high-risk children.     

Utility of MR imaging in pediatric spinal cord injury

We evaluated the utility of MR imaging in pediatric patients with acute and subacute spinal cord injuries. MR imaging of 22 pediatric patients with suspected traumatic spinal cord injuries was reviewed. MR findings were correlated with physical examination and compared to available radiographs and CT examinations performed at time of presentation. Twelve patients had abnormalities on MR imaging. Seven had spinal cord contusions; five contusions were hemorrhagic. Five of seven patients with cord contusion had normal radiographs and CT exams. Six patients with normal radiographs and CT examinations had abnormal MR studies revealing cord contusion, ligamentous injury, disc herniation, and epidural hematoma. MR is useful in initial evaluation of pediatric patients with spinal cord injuries and in prognosis of future neurologic function. In the setting of spinal cord symptomatology and negative radiographic studies, MR imaging should be performed. Surgically correctable causes of cord compression demonstrated by MR imaging include disc herniation, epidural hematoma, and retropulsed fracture fragments. The entity of spinal cord injury without radiographic abnormality is a diagnosis of exclusion which should only be made after radiologic investigation with radiographs, high-resolution thin-section CT, and MR imaging.     

Young children (<5 yr) and adolescents (>12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor

Objective:  To determine whether there are different rates of partial remission in preschool, school-age children, and adolescents with type 1 diabetes mellitus (T1DM) and to identify clinical characteristics that are associated with increased rate of partial remission.
Design/methods:  A total of 152 consecutive patients with newly diagnosed T1DM in 2004 were studied. Clinical characteristics at diagnosis, hemoglobin A1C (HbA1C), and total daily insulin dose (TDD) at 3-month interval follow-up for 1 yr were analyzed in each age-group (group 1, aged <5 yr; group 2, aged 5–12 yr; and group 3, aged >12 yr). Partial remission was defined as TDD <0.5 units/kg/d with HbA1C <8% assessed at 6 months after diagnosis.
Results:  Young children (group 1, 26.8%) and adolescents (group 3, 29%) had low rates of partial remission compared with school-age children (group 2, 56%, p = 0.002). There were no differences in the rates of diabetic ketoacidosis (DKA), autoantibody frequency, and HbA1C at diagnosis between age-groups. DKA at diagnosis was associated with less likelihood of having partial remission (p < 0.001). There were no associations between gender, autoantibodies, and HbA1C at diagnosis and the rate of partial remission.
Conclusions:  Young children and adolescent children with T1DM had a low rate of partial remission. Metabolic control was poorest in young children, whereas higher dose insulin in adolescents because of insulin resistance contributes to less likelihood of having partial remission. DKA at diagnosis was associated with low rate of partial remission. It is possible that the low frequency of honeymoon phase in young children reflects more aggressive beta-cell destruction in young children.     

Neurological presentations of conversion disorders in a group of Singapore children

Background: Neurological presentations of conversion disorders in children are not uncommon. Conversion disorders mimicking neurological conditions constitute a group of underdiagnosed conditions.
Methods: This was a retrospective study of 13 children with neurological presentations of conversion disorders who were admitted to hospital. Patients were followed for 1–4 years.
Results: Paralysis was the most common neurological symptom, patients presented with multiple, complex conversion symptoms and other neurological symptoms such as seizures and headache. The affected children underwent complete physical, neurological examination and psychological evaluation. Investigations included blood tests, cranial imaging and electroencephalography. Most common external environmental factors detected were school stress and change in family situation. Five of 13 patients had family members who were reported to have medical conditions with presentations similar to patients' neurological and psychological problem. All the patients were admitted, five patients required multiple admissions. Ten patients eventually had good outcome in terms of academic grades and social functioning.
Conclusion: Diagnosis of conversion disorders mimicking neurological conditions can be challenging. There is a need to heighten awareness of this entity for early recognition and diagnosis. Awareness of this entity coupled with a high index of suspicion can facilitate accurate and earlier diagnosis.     

Different neurocognitive functions regulating physical aggression and hyperactivity in early childhood

Background:  There are strong parallels between early childhood and adolescent behavior problems. However, we do not know if behavioral symptoms associate with neurocognitive processes in very young children as they do in older children.
Methods:  We studied a population-based birth cohort of children ( N  =   1,950) whose developmental trajectories of physical aggression and hyperactivity were assessed between the ages of 17 and 41 months. We measured the following neurocognitive abilities at 41 months of age: Receptive vocabulary, visuospatial organization, and short-term memory.
Results:  After controlling for other neurocognitive abilities, frequent physical aggression was related specifically to receptive vocabulary deficits ( p  < .0001) while frequent hyperactivity was related specifically to deficits of visuospatial organization ( p  < .0001). The pattern of associations was robust despite controls for socioeconomic and perinatal status.
Conclusions:  The different neurocognitive correlates of physical aggression and hyperactivity problems observed during adolescence are apparent in early childhood. Whereas physical aggression problems are associated with language deficits, hyperactivity problems are related to non-verbal deficits.     

Autoimmune characteristics in Japanese children diagnosed with type 1 diabetes before 5 years of age

Background:  Several studies have shown that the autoimmune features in young children with type 1 diabetes differ from those in older pediatric patients as well as adults. The purpose of the present study was to examine the prevalence of β-cell autoantibodies, glutamic acid decarboxylase antibodies (GADA), and antibodies to the protein tyrosine phosphatase-related molecule IA-2 (IA-2A), at the time of diagnosis in Japanese children with type 1 diabetes who were younger than 5 years at diagnosis.
Methods:  Subjects consisted of 23 Japanese children (nine boys, 14 girls), 3.1 ± 1.3 years of age at diagnosis (range, 1.1–4.8 years). The majority had severe metabolic decompensation accompanied by complete absence of β-cell function at diagnosis. We found 41.7% to have suffered viral infections before disease onset.
Results:  The prevalence of antibodies to GAD and IA-2 at diagnosis in these subjects was significantly lower than those in older patients diagnosed after 5 years of age (31.6 % vs 86.3% and 47.1% vs 82.5%, P  < 0.0001 and P  = 0.0064, respectively). Among 17 patients in whom both antibodies were measured, only two (11.8%) had both GADA and IA-2A, three (17.6%) had GADA alone, six (35.3%) had IA-2A alone, and six (35.3%) had neither GADA nor IA2-A.
Conclusions:  Non-autoimmune mechanisms or age-related differences in autoimmunity could be involved in the pathogenesis of diabetes in young patients.     

Bochdalek diaphragmatic hernia: not only a neonatal disease

Aims: To characterise the clinical manifestations of late presenting Bochdalek diaphragmatic hernia (DH), the incidence of misdiagnosis, and prognosis; and to explore the sequence of events that leads to this clinical picture. Methods: Retrospective chart review. All children with Bochdalek DH were identified. Children 1 month of age and older at the time of diagnosis were included. Results: Twenty two children with Bochdalek DH met the inclusion criteria. Three clinical presentations could be defined. Fourteen children presented with acute onset of symptoms, predominantly vomiting and respiratory distress. Four had chronic non-specific gastrointestinal or respiratory symptoms, and in four the DH was found incidentally. Although five children were initially misdiagnosed, in 20 children (91%) the correct diagnosis was made on x ray examination. One child experienced a complicated course when the x ray picture was misinterpreted as pneumothorax. All children had favourable outcome. Two children had previously normal chest imaging, suggesting acquired herniation. A large pleural effusion without DH in a 9.5 year old girl with an abdominal infection prior to presenting with herniation suggests a pre-existing defect in the diaphragm. Conclusions: Late presenting Bochdalek DH can present with acute or chronic gastrointestinal, or less frequently, respiratory symptoms. It can also be found incidentally. Misdiagnosis can result in significant morbidity. Favourable outcome is expected when the correct diagnosis is made. The sequence of events is probably herniation of abdominal viscera through a pre-existing diaphragmatic defect. Although rare, DH should be considered in any child presenting with respiratory distress or with symptoms suggestive of gastrointestinal obstruction.     

Bochdalek diaphragmatic hernia: not only a neonatal disease.

AIMS: To characterise the clinical manifestations of late presenting Bochdalek diaphragmatic hernia (DH), the incidence of misdiagnosis, and prognosis; and to explore the sequence of events that leads to this clinical picture. METHODS: Retrospective chart review. All children with Bochdalek DH were identified. Children 1 month of age and older at the time of diagnosis were included. RESULTS: Twenty two children with Bochdalek DH met the inclusion criteria. Three clinical presentations could be defined. Fourteen children presented with acute onset of symptoms, predominantly vomiting and respiratory distress. Four had chronic non-specific gastrointestinal or respiratory symptoms, and in four the DH was found incidentally. Although five children were initially misdiagnosed, in 20 children (91%) the correct diagnosis was made on x ray examination. One child experienced a complicated course when the x ray picture was misinterpreted as pneumothorax. All children had favourable outcome. Two children had previously normal chest imaging, suggesting acquired herniation. A large pleural effusion without DH in a 9.5 year old girl with an abdominal infection prior to presenting with herniation suggests a pre-existing defect in the diaphragm. CONCLUSIONS: Late presenting Bochdalek DH can present with acute or chronic gastrointestinal, or less frequently, respiratory symptoms. It can also be found incidentally. Misdiagnosis can result in significant morbidity. Favourable outcome is expected when the correct diagnosis is made. The sequence of events is probably herniation of abdominal viscera through a pre-existing diaphragmatic defect. Although rare, DH should be considered in any child presenting with respiratory distress or with symptoms suggestive of gastrointestinal obstruction.     

Influenza-related hospitalisations in children

Aim:   To describe the disease burden, clinical pattern and outcome of influenza-related hospitalisations in children.
Methods:   This is a retrospective study carried out in a regional hospital in Hong Kong. Children hospitalised with established diagnosis of influenza infection from January to June of 2005 were studied. Length of hospitalisation, demographic characteristics, symptoms, clinical diagnosis and complications of influenza infection were analysed.
Results:   Influenza A infection accounted for 93.5% of these hospitalisations. Children less than 5 years of age comprised 70% of admission. Highest rate of admission occurred in May and April. One fourth of emergency admission during the study period and over 70% in the peak season was a result of influenza-related illness. Underlying medical disease was observed in 14.6% of children. Mean duration of hospitalisation was 3.0 days. Fever was the commonest presenting symptoms. Fever lasting for 7 days or more was observed in one-fifth of patients. Respiratory tract diseases (upper and lower) were the most frequent non-neurological diagnosis. Febrile convulsion was the complication observed in 27.6% of admission. One patient died as a result of acute necrotising encephalopathy.
Conclusion:   Influenza contributed to heavy health-care burden. Mortality was rare but did occur. Hospitalisations occurred in both healthy children and those with underlying chronic illness. Young children played an important role in such hospitalisations. Means to prevent influenza-associated morbidity and mortality especially among young children are needed.     

Head circumference and development in young children after renal transplantation

Background:  Growth impairment, microcephaly and developmental delay in young children with chronic renal failure improve after successful renal transplantation. There have been few reports on head circumference (HC) and development after transplantation.
Method:  Standard deviation scores (SDS) of height and HC and developmental quotient (DQ) after successful renal transplantation were evaluated in 12 recipients under 5 years of age. At the time of transplantation their mean age was 2.5 years and mean bodyweight was 9.0 kg.
Results:  Mean height SDS was −3.0 at transplantation and increased to −2.3 at 1 year after transplant (P = 0.002). Mean HC-SDS increased from −1.4 to −0.9 at 1 year after transplant (P = 0.02). As for each category of DQ examined 1 year after transplant, mean scores of gross motor function, basic practice, personal relations, speech and recognition increased from 69 to 90 (P = 0.007), from 77 to 102 (P = 0.02), from 87 to 103 (P = 0.04), from 71 to 90 (P = 0.0006), and from 88 to 101 (P = 0.03), respectively.
Conclusion:  In young children, physical growth, HC growth and DQ scores increased 1 year after transplantation. Dialysis and transplantation program should be planned in young children with end-stage renal failure in anticipation of growth and development of each patient.     

Lower limb and back pain in Guillain-Barré syndrome and associated contrast enhancement in MRI of the cauda equina

This study assesses the frequency of lower limb and back pain in children with Guillain-Barré syndrome and reviews the magnetic resonance imaging results of those undergoing spinal imaging. Over an 8-y period, nine children presented with various combinations of severe back pain, leg pains, impairment of gait and bladder dysfunction. Guillain-Barré syndrome was confirmed on clinical examination and peripheral electrophysiology ( n = 8). Magnetic resonance imaging in four patients, following contrast injection, showed enhancement of the cauda equine and, additionally, of the cervical nerve roots in one of the patients. A further patient, who was not scanned with contrast, had abnormal thickening of the lumbar roots. Carbamazepine and steroids were effectively used for analgesia in three cases. All the patients recovered.
Conclusion: Guillain-Barré syndrome should be considered in the differential diagnosis of children presenting with back and/or leg pain. Early diagnosis ensures prompt monitoring for autonomic dysfunction and respiratory compromise.     

Adrenal cortical tumours: 25 years' experience at the Royal Children's Hospital, Melbourne

Aims:    Adrenal cortical tumours remain a rare entity with inconsistent consensus about treatment and follow up. This article reviews 25 years of experience in the Royal Children's Hospital, Melbourne, Australia.
Methods:    All records with the diagnosis of adrenal adenoma or carcinoma between 1976 and 2001 were reviewed, excluding tumours of the adrenal medulla. Details were recorded for age, gender, family history, presentation, biochemistry, imaging, histology, diagnosis, treatment and outcome.
Results:    Twelve children (six boys, six girls) were diagnosed with adrenal cortical tumours in this period. Median age at diagnosis was 2.5 years (range 0.5−15.6 years). Six of the 12 children presented with virilization. The remaining six identified by ultrasound performed for hemi-hypertrophy (2), hypertension (2), and fever with abdominal pain (2). Five children had a family history of tumour and two of these five had a p53 mutation demonstrated on molecular genetic analysis. Tumours in five of the 12 children were defined as malignant on histology. Surgery was deemed curative in nine cases. Only one case required further surgery and two required chemotherapy. Time since diagnosis ranged from 1 to 25.8 years. Two children died from complications of the tumour. One other child died following development of a second tumour.
Conclusion:    Adrenal cortical tumours should always be considered in the differential for adrenal hormone excess. New information provided by mutational analysis may predict ongoing risks. Lifelong regular follow up is required.     

Acute septic arthritis in children

Background:  Acute septic arthritis is a health-care problem in growing children. The aim of the present study was to determine the demographic features, clinical presentation, diagnostic evaluation, treatment and outcome of children suffering from acute septic arthritis.
Methods:  Retrospective review of consecutive admissions of children ≤14 years of age with a bacteriologically and/or radiologically confirmed diagnosis of septic arthritis during the 10 year period, January 1997–December 2006 at King Fahad Hospital, King Abdulaziz Medical City was undertaken.
Results:  Sixty-five patients (male : female, 2.4:1), 10 days–14 years of age (mean ± SD: 3.3 ± 3.2 years), met the inclusion criteria. More than half of the patients were under 2 years. The most frequent clinical features were pain (92%), fever (77%), limitation of joint movement (77%) and joint swelling (72%). Joint involvement was monoarticular in 97% of knees, and hips were affected in 75% of patients. Bacteria were isolated from joint aspirate or blood in 28 patients (43%), and Staphylococcus aureus was the most common organism, comprising 39% of the total bacterial isolates. Radiological diagnostic findings were observed in 19 (32%) of 60 patients with plain radiographs, nine (69%) of 16 patients with sonograms of the hip, 36 (80%) of 45 patients with Tc-labeled bone scan and nine (100%) of nine patients with magnetic resonance imaging. The joint infection resolved with no sequelae in 46 patients who were followed up for 6–36 months, but two had bone deformity and 17 were lost to follow up.
Conclusion:  According to the present series, septic arthritis is most common in young infants, mainly monoarticular, and is frequently localized in the knee and hip joints. Early diagnosis and appropriate treatment are associated with excellent outcome.     

Children adopted from China: a prospective study of their growth and development

Background:  China has become a lead country for international adoption because of the relatively young age of the children and reported positive conditions of the orphanages. This study examined the process and outcome of growth and development of children adopted from China over their first two years with their adoptive families.
Method:  Seventy infant girls adopted from China at 8 to 21 months of age (Mean age = 13 months) were examined on arrival in Canada and 6, 12, and 24 months later. Comparisons were made with non-adopted Canadian girls of similar age and from a similar family background as adoptive parents on indices of growth and standardized measures of mental, psychomotor, and language development.
Results:  At arrival, children adopted from China were smaller physically and exhibited developmental delays compared to current peers. Children adopted from China were functioning in the average range on physical and developmental measures within the first 6 months following adoption. However, they were not performing as well as current peers until the end of their second year after adoption. Even then, there was developmental variation in relation to comparison children and continuation of relatively smaller size with respect to height, weight, and head circumference. Physical measurement was related to outcomes at various points on all developmental measures.
Conclusions:  Deprivation in experience in the first year of life has more long-lasting effects on physical growth than on mental development. The variable most consistently related to development was height-to-age ratio. As a measure of nutritional status, the findings reinforce the critical importance of early nutrition.     

Relating intimate partner violence to heath-care utilisation and injuries among Pacific children in Auckland: The Pacific Islands Families Study

Aim:   Despite well-known emotional and behavioural sequela, few studies investigate health-care utilisation and injury impacts of children exposed to intimate partner violence (IPV). This study examines the association between mothers' IPV experience and general practitioner (GP) and hospital presentations by their children within the first 6 years of life.
Methods:   In 2000, a cohort of Pacific infants born in Auckland was established. At 6 weeks, 2 years and 6 years post-partum, maternal home interviews were conducted and IPV experience elicited using the Conflict Tactic Scale, together with reports of children's GP and hospital visitations.
Results:   At 6 weeks, 2 years and 6 years, 1098, 921 and 799 participating mothers were in intimate relationships. Severe physical IPV was reported by 22.1, 23.0 and 7.1% of mothers, respectively, and minor IPV was reported by another 18.7, 16.9 and 6.1%, respectively. Compared with children without maternal physical IPV exposure, children of mothers disclosing severe physical IPV were 1.19 (95% confidence interval (CI): 1.08–1.31) times as likely to visit GPs, and children of mothers disclosing minor physical IPV were 1.13 (95% CI: 1.02–1.25) times as likely to visit GPs, after adjusting for socio-demographic, maternal mental health and other confounding factors. No significant association was found between maternal IPV and children's hospital visits, or GP or hospital visits for injury.
Conclusions:   IPV is common for many mothers of Pacific children, and is associated with significantly more GP visits for exposed children. Identification of maternal IPV during mothers' and children's GP and hospital visits may help guide services to prevent future presentations to children.