Nephrotoxicity--what do we know and what don't we know?

Nephrotoxicity is the development of functional or structural kidney damage after exposure to one or more of a wide variety of drugs, other treatments or exogenous toxins, and may lead to a variety of functional consequences and structural lesions. Nephrotoxicity is important as it may occur in a substantial proportion of children treated with certain drugs and occasionally lead to severe renal impairment that may prevent the delivery of optimal anticancer treatment and/or reduce the quality of life of long-term survivors. This article describes what is currently known about nephrotoxicity occurring in children treated for malignancy by summarizing published information about the clinical characteristics and long-term outcome of, and the risk factors for the development of, ifosfamide and platinum-induced renal toxicity. Published guidelines for the evaluation and surveillance of nephrotoxicity, and the still incomplete understanding of its pathogenesis, are also outlined. Many gaps in our knowledge of nephrotoxicity are highlighted, including the lack of detailed knowledge about its overall incidence and very long-term impact, the nephrotoxic potential of new drugs, the efficacy of surveillance protocols, the relevance of proteinuria as a component of nephrotoxicity, and our current inability to reliably predict or prevent many episodes of nephrotoxicity.     

Vaccine refusal – what we need to know

Objective

Opposition to vaccines is not a new event, and appeared soon after the introduction of the smallpox vaccine in the late 18th century. The purpose of this review is to educate healthcare professionals about vaccine hesitancy and refusal, its causes and consequences, and make suggestions to address this challenge.

The effects of infant media usage: what do we know and what should we learn?

The rise of infant TV viewing began in the late 1990s and has become an increasingly common occurrence. Today, over 90% of children begin watching TV regularly before the age of 2 years in spite of recommendations to the contrary. This article reviews what is known about the effects of infant TV viewing on multiple domains of child development including language, cognition and attentional capacity as well as directions for future research.
Conclusion: No studies to date have demonstrated benefits associated with early infant TV viewing. The preponderance of existing evidence suggests the potential for harm. Parents should exercise due caution in exposing infants to excessive media.     

Meconium aspiration syndrome: do we know?

Meconium is a common finding in amniotic fluid and placental specimens, particularly in the term or post-term pregnancy. The most important consequence of meconium-stained amniotic fluid (MSAF) is meconium aspiration syndrome (MAS), and at least 5% of infants born through MSAF develop MAS. MAS continues to be a threat to many newborns throughout the world, with a case fatality rate of 5% (as much as 40%), in addition to short- and long-term pulmonary and neurodevelopmental sequelae. The exact pathophysiology of meconium passage into the amniotic fluid and consequences of meconium aspiration are unknown. There are three prevailing and possibly compatible theories for mechanisms of meconium release. Firstly, meconium passage is probably related with the maturation of the gastrointestinal tract, because meconium passage in the preterm third trimester fetus has been reported to be a rare event, as typically it occurs near or post-term. Secondly, an alternate hypothesis for in utero meconium passage is that pathologic processes, such as stress via hypoxia or infection, can trigger meconium passage. However, the predictive values of MSAF for fetal distress and acidosis at birth are poor and controversial. Thirdly, an alternative route for the presence of MSAF in the presence of fetal hypoxia is reduced clearance of defecated meconium due to impaired fetal swallowing or unidentified placental dysfunction in addition to or instead of an increase in its passage. The pathophysiology of MAS is multifactorial and extremely complex. Meconium causes mechanical obstruction and pulmonary air leak, induces surfactant inactivation, causes pulmonary inflammation, and induces apoptosis. Preventing prolonged pregnancy by labor induction might reduce the risk of MSAF. Labor induction with prostaglandins appears to be associated with the occurrence of MSAF. Amnioinfusion for suspected umbilical cord compression has no clear effect on the occurrence of MSAF. Intrapartum suctioning of the naso- and oropharynx before delivery of the shoulders as well as postnatal endotracheal suctioning of vigorous infants with MSAF are no longer recommended. Currently, endotracheal suction is recommended only in neonates born through MSAF who are not vigorous at birth. Indications for mechanical ventilation in infants with MAS are arbitrary. Surfactant administration may reduce the severity of MAS. Bronchoalveolar lavage with surfactant in infants with MAS is risky and it cannot be recommended for routine use. At present, there is insufficient evidence to propose routine steroid therapy in the management of MAS. Although prophylactic antibiotics in infants with MAS are not justified, most of these patients receive antibiotics during the first days of life, before the diagnosis of pneumonia can be completely ruled out. Children surviving severe MAS are in fact reported to have higher prevalence of asthmatic symptoms and bronchiolar hyperreactivity than children in the general population. It remains undetermined how often and at what intensity systemic inflammation occurs in association with MAS and what its significance is for the outcome of infants with severe MAS.     

Forensic medical evaluation of children who present with suspected sexual abuse: How do we know what we know?

The past 40 years have seen significant changes in the way children's genital findings are interpreted in the context of suspected sexual abuse. Many findings previously thought to be diagnostic of sexual abuse are now recognised to be normal variants, caused by other medical conditions or have insufficient specificity to make a definite diagnosis of abuse. Use of the Adams classification in recent years has provided a common language and practical framework for describing and categorising genital findings in children. This review article addresses our current understanding of how to interpret genital findings in children, the evidence on which this interpretation is based, gaps that remain in our knowledge and suggestions for future research.     

Growth disturbances of the distal tibia after physeal separation--what do we know, what do we believe we know? A review of current literature

PURPOSE: Although they are the most frequent physeal separations of the lower limb, epiphyseal separations (Salter I and II) of the distal tibia are rare injuries, peaking in adolescence. Generally they are considered lobe benign fractures with a low rate of complications. However, in the literature, concrete statements on the incidence of fracture-associated growth disturbances are infrequent and inconsistent, even contradictory. MATERIALS AND METHODS: A review of textbooks, classical references and recent literature was performed to identify the available evidence on distal tibia physeal separations. RESULTS: A review of the literature showed that most authors agree that conservative, nonoperative treatment is the preferred treatment. But opinions differ on almost all essential fundamentals of treatment. Neither the potential for growth-associated spontaneous correction of posttraumatic axis deviations nor the tolerable degree of axial deviations are evaluated homogenously. Opinions also vary greatly concerning the frequency of posttraumatic growth disturbances, the influence of the mechanism of injury and the amount of primary axial deviation. The most consistent statement in the literature is that poor results of both closed and open reduction lead to an increasing number of growth disturbances, which may include the assumption that not only trauma but operative procedures, too, can be the reason for restrictive physeal plate disturbances. CONCLUSIONS: There are two major deficiencies in most of the reviewed literature. The first is that the numbers of cases reported in each article are low due to the rarity of the injury. The second deficiency is that many studies report "physeal injuries" but do not clearly distinguish physeal separations (Salter I and II) from epiphyseal fractures (Salter III and IV) and transitional fractures, all involving the physeal plate, but in completely different ways with completely different prognoses. A prospective multicenter study is taking place.     

Minimizing radiation injury and neoplastic effects during pediatric fluoroscopy: what should we know?

Radiation-induced injuries from fluoroscopic procedures in pediatric patients have occurred, and young patients are at greatest risk of many radiation-induced neoplasms. Some fluoroscopists have been injured from their use of fluoroscopy, and they are known to be at risk of radiation-induced neoplasm when radiation is not well-controlled. This article reviews the circumstances that lead to radiation injury and delineates some procedural methods to avoid injury and limit radiation exposure to both the patient and the fluoroscopist.     

Nutritional status of affluent Indian school children: what and how much do we know?

OBJECTIVE: This paper reviews available literature on nutritional status of Indian school children 6-18 years from middle and high socio economic status (MHSES). METHODS: Literature search was conducted using Medline literature database search, followed by review of full length journal papers and unpublished materials such as research reports. RESULTS: Studies showed that anemia prevalence (hemoglobin concentration <120 g/L) ranged from 19 to 88% across five different cities in India. Other micronutrient deficiencies including, folate, riboflavin, niacin, vitamin C, vitamin A, and vitamin B12 were also present based on biochemical parameters in one study and clinical signs of deficiency in three other studies. Overweight and obesity were prevalent among 8.5-29.0% and 1.5-7.4% respectively among school children, as indicated by 11 studies. Predominant components in children's diet were cereals and pulses, followed by milk and milk products; the fruits and vegetables component was comparatively lower. CONCLUSION: Nutritional status of MHSES children in India needs attention especially with respect to the high prevalence of anemia, overweight and obesity. There are indications that micronutrient deficiencies exist, but sufficient data are lacking, in particular biochemical data. A current estimate, using well designed methodologies, of prevalence of micronutrient deficiencies and information on the etiology of anemia among children of MHSES groups would be valuable to help understand the nutritional status and extent of micronutrient malnutrition.     

Domestic humidifiers. What do we know about them?

Popular opinion assumes that environmental humidity relieves the clinical symptoms of respiratory tract diseases. Various types of home humidifiers are available on the market. Parents buy them in the belief that they will improve their children's well-being but are usually unaware of whether these devices provide a real benefit. Pediatricians should bear the main responsibility in the task of informing and guiding families in the use of home humidifiers but general lack of knowledge on the subject and the scarcity of published data make this task difficult. The aim of this review is to increase general knowledge of home humidifiers. We describe what they are, their main types, their basic functioning, advantages and disadvantages and the importance of suitable maintenance. We define what environmental humidity means, how it can change according to temperature and how it can influence human health. Finally, we suggest that optimal relative humidity is approximately 40-60 % and that it should be measured before using a home humidifier.     

Nutritional policies for late preterm and early term infants – can we do better?

Late preterm (LP) and early term (ET) infants can be considered the “great dissemblers”: they resemble healthy full-term infants in appearance, but their immaturity places them at increased risk of poor short- and long-term outcomes. Nutritional requirements are greater than for full-term babies, but there are few good data on the nutritional requirements for LP and ET babies, leading to substantial variation in practice. Recent data indicate that rapid growth may be beneficial for neurocognitive function but not for body composition and later metabolic health. Breastfeeding the LP or ET infant can be challenging, and mothers of these infants may need additional support to breastfeed successfully. Future research should investigate nutritional requirements of LP and ET infants for optimal growth, addressing both short- and long-term outcomes and the potential trade-off between neurocognitive and metabolic benefits.     

Optimal oxygen saturation for preterm babies. Do we really know?

Oxygen is the most commonly used 'drug' in neonatal units as an integral part of respiratory support. It has also been known for half of the century that it is easy to damage the eyes of preterm infants by giving too much oxygen especially in the first few weeks of life. Despite this knowledge there is still a wide variation in approaches to oxygen monitoring within neonatal units. A randomized controlled trial conducted more than 50 years ago first made clinicians aware of 'oxygen toxicity' in preterm infants, but no other controlled trial has ever been conducted since to clarify how much oxygen infants really need, or what oxygen saturation level is optimal in caring these preterm babies. Perhaps time has come for clinicians to resolve this 'uncertainty' by well-designed randomized trials.     

Nasal CPAP for neonates: what do we know in 2003?

Despite the acknowledged clinical usefulness of nasal CPAP, uncertainties regarding aspects of its application remain. Clinical indications for the application of nasal CPAP vary greatly between institutions. Furthermore, defining the optimal nasal CPAP system is complicated by the multiplicity of nasal CPAP devices and techniques available to the clinician. This review aims to identify what we know about nasal CPAP and what important questions remain.