Does Gluten-Free Diet Protect Children with Celiac Disease from Low Bone Density?

Objective: We aimed to assess the effect and duration of gluten-free diet on bone health in children with celiac disease in our study. Methods: Sixty three patients with celiac disease (CD) formed the study group. They were divided into two subgroups according to their dietary compliance. Bone mineral density (BMD) values of the patients at two and five years of gluten-free diet (GFD) were determined. Findings : The relationship between BMD and compliance to GFD was found to be statistically significant (P<0.01). BMD z-scores were increased (0.12±0.15 and 0.10±0.14 units respectively) (P<0.01). The patients in group 1 and 2 had mean -1.18±0.83 and -2.06±0.73 z-scores in the first DXA. In the second DXA, these values were -1.10±0.73 and-1.94±0.93 respectively. Conclusion: Dietary compliance is important for bone health, and the time needed to normalize the BMD is not known. Patients with positive anti-endomysium antibody (EMA), poor dietary history and history of bone pain should be evaluated with DXA during follow-up.Key Words: Celiac, Gluten Free Diet, Low Bone Density, Bone Mineral Density     

What is New in the Management of Childhood Asthma?

Asthma still causes considerable morbidity and mortality globally and minimal improvement has been seen in key outcomes over the last decade despite increasing treatment costs. This review summarizes recent advances in the management of asthma in children and adolescents. It focuses on the need for personalized treatment plans based on heterogenous asthma pathophysiology, the use of the terminology ‘asthma attack’ over exacerbation to instill widespread understanding of severity, and the need for every attack to trigger a structured review and focused strategy. The authors discuss difficulties in diagnosing asthma, accuracy and use of Fractional exhaled nitric oxide both as second line test and as a method to monitor treatment adherence or guide the choice of pharmacotherapy. The authors discuss acute and long-term management of asthma. Asthma treatment goals are to minimize symptom burden, prevent attacks and (where possible) reduce risk and impact of progressive pathophysiology and adverse outcomes. The authors discuss pharmacological management; optimal use of short acting β₂ agonists, long acting muscarinic antagonist (tiotropium), use of which is relatively new in pediatrics, allergen specific immunotherapy, biological monoclonal antibody treatment, azalide antibiotic azithromycin, and the use of vitamin D. They also discuss electronic monitoring and adherence devices, direct observation of therapy via mobile device, temperature controlled laminar airflow device, and the importance of considering when symptoms may actually result from dysfunctional breathing rather than asthma.     

Could Lower Bone Turnover be a Cause of Chest Pain During Childhood?

Chest pain, a frequent complaint during childhood, rarely originates from a cardiac pathology. Although it usually is idiopathic, it also could be associated with psychogenic, musculoskeletal, respiratory, and digestive disorders. This study aimed to investigate a possible relation between bone mineral density and chest pain in children. Bone mineral density and bone metabolism parameters were measured for 50 children with chest pain, and the findings were compared with those for 40 age- and sex-matched healthy children. Most of the cases (64%) were in the idiopathic group, and musculoskeletal chest pain was the second most frequent complaint (12%). Although bone mineral densities and osteocalcin levels did not differ significantly between the whole chest pain group and the control group, both were found to be lower in the musculoskeletal chest pain group than in other groups and the control group (p < 0.05). Musculoskeletal chest pain may be related to reduced bone mineral metabolism, and monitoring of risk factors is of particular importance.     

Breastfeeding and Childhood Cancer: Is Breastfeeding Preventative to Childhood Cancer?

Breastfeeding is well-known to have a protective effect against infection in infants. It has been suggested that breast milk may play a role in the prevention of certain childhood cancer. We investigated this issue in a case-control study comprising 300 patients with childhood cancer. There was 73 patients (24.3%) with leukemia, 82 patients (27.3%) with lymphoma, and 146 patients (48.4%) with solid tumors (brain tumors, neuroblastoma, soft tissue sarcomas, germ cell tumors, renal tumor, bone tumor, retinoblastoma, hepatoblastoma, and others) and 316 controls matched for age and sex. Breastfeeding duration of the control group was found to be significantly longer than the patient group (X² = 57.774; P < .001). In conclusion, breastfeeding was found to be inversely associated with pediatric cancer in our study.     

Childhood head injuries: accidental or inflicted?

OBJECTIVES: To determine the relative incidence of accidental and abusive causes of head injuries in children younger than 6.5 years, to identify the types of craniocerebral damage resulting from reported mechanisms of injury, and to assess the likelihood of injuries being accidental or inflicted. METHODS: Retrospective review of medical records of 287 children with head injuries aged 1 week to 6.5 years admitted to a metropolitan children's hospital from January 1986 through December 1991. Those patients with diagnoses of skull fracture; concussion; subarachnoid hemorrhage (SAH); subgaleal, epidural, or subdural hematoma (SDH); parenchymal contusion or laceration; and closed head injury were included. Criteria were used for inclusion in categories of definite abuse or accident. RESULTS: Accidents accounted for 81% of cases and definite abuse for 19%. The mean age of the accident group was 2.5 years and for the definite abuse group, 0.7 years. Major differences were seen in the incidence of the following: SDH, 10% in the the accident group and 46% in the the definite abuse group; SAH, 8% in accident group and 31% in the definite abuse abuse; and retinal hemorrhages, 2% in the accident group and 33% in the definite abuse group. Associated cutaneous injuries consistent with inflicted injury were seen in 16% of the accident group and 50% of the definite abuse group. Twenty-three percent of those in the accident group were injured in motor vehicle crashes (MVCs), 58% by falls, 2% in play activities, and the rest had insufficient medical record information. In 56% of those in the definite abuse group, there was no history to account for the injuries and no history of MVC. In 17%, a fall was said to have been the mechanism of injury. In 24%, inflicted injury was admitted. Mortality rates were 13% in the definite abuse group and 2% in the accident group. Median hospital stay was 9.5 days for the definite abuse group and 3 days for the accident group. In falls less than 4 feet in the accident group, 8% had SDH, 2% had SAH, and none had retinal hemorrhages; among those in the definite abuse group reportedly falling less than 4 feet, 38% had SDH, 38% had SAH, and 25% had retinal hemorrhages. CONCLUSIONS: A substantial percentage of head injuries requiring hospitalization in children younger than 6.5 years are attributable to inflicted injury. Subdural hematoma, subarachnoid hemorrhage, retinal hemorrhages, and associated cutaneous, skeletal, and visceral injuries are significantly more common in inflicted head injury than in accidental injury.     

Hodgkin-like Post-transplant Lymphoproliferative Disorder in Children: Does It Differ from Post-transplant Hodgkin Lymphoma?

Epstein-Barr virus (EBV)-mediated lymphoid proliferations occur in patients who are immunocompromised and are reported following bone marrow or solid organ transplantation. Most post-transplant lymphoproliferative disorders (PTLD) are polymorphic in appearance; some are monomorphic and can resemble conventional malignant lymphomas. PTLD that resembles Hodgkin lymphoma has been reported infrequently. We herein report seven cases of PTLD that have large numbers of Reed-Sternberg-like (RS-like) cells and highlight differences in the phenotype of these cases that may distinguish Hodgkin-like PTLD (HL-PTLD) from true Hodgkin lymphoma/disease (HD). All patients were in the second decade of life and were 8 months to 13 years following transplant. HL-PTLD involves lymph nodes that contain a mixed population of small to intermediate-sized lymphocytes with large mononuclear and occasionally binucleate RS-like cells. The large cells of HL-PTLD are pleomorphic B cells that react strongly for CD20 and/or CD79a, express CD30, but are usually negative for CD15 and have few mitoses. They are positive for EBV early RNA (EBER) using an EBER-1 probe, as are some of the background small lymphocytes. A single case of true Hodgkin lymphoma has highly atypical RS-like cells that contain numerous mitoses, does not have CD20 or CD79a reactivity, has CD15 and CD30 staining, and the EBER-1 probe is confined to the large cells only. All patients were managed by withdrawal of immunosuppression and variably treated with either antiviral or anti-CD20 monoclonal antibody, or with chemotherapy. A unique instance of evolution from a HL-PTLD to true HD is also illustrated. In conclusion, HL-PTLD and HD appear to be two related but immunophenotypically and biologically distinct forms of lymphoproliferation in post-transplant patients and may require different protocols for their management. This study was presented in part at the Society for Pediatric Pathology Interim Meeting, Cincinnati, Ohio, USA, October 2003.     

Does the Persistence of Development Delay Predict Receipt of Early Intervention Services?

ObjectiveTo examine how the persistence of infants' and toddlers' developmental delays affects their access to early intervention services (EI).MethodsUsing the Early Childhood Longitudinal Study, Birth cohort (ECLS-B), we examined receipt of EI at 24 months for each category of developmental change. Development delay was measured at 9 and 24 months and categorized as none (ie, within 1 SD below the mean), mild (ie, between 1 and 1.5 SD below the mean), and moderate/severe (more than 1.5 SD below the mean). Changes in the subjects' developmental skills between 9 and 24 months were calculated. For children with a delay at either time point, adjusted logistic regression models estimated the likelihood of receiving EI at 24 months.ResultsUse of EI varied across severity, type, and timing of developmental delay. Among the children with a cognitive delay, those with delays at 9 and 24 months were significantly more likely to receive EI at 24 months than peers whose delays improved, emerged, or worsened. Among the children with a motor delay, those with regression from normal to moderate/severe were significantly more likely to receive services than children with persistent delays (adjusted odds ratio 2.7, 95% confidence interval 1.1–6.6).ConclusionsExcept for children whose motor skills regress substantially, children with dynamic developmental delays are less likely than their peers with persistent delays to receive EI. This finding suggests the need for improved understanding of developmental surveillance, referral, and use of EI services.