LEARN 2 MOVE 0-2 years: effects of a new intervention program in infants at very high risk for cerebral palsy; a randomized controlled trial

Background

Bronchiolitis is the most common reason for admission of infants to hospital in developed countries. Fluid replacement therapy is required in about 30% of children admitted with bronchiolitis. There are currently two techniques of fluid replacement therapy that are used with the same frequency-intravenous (IV) or nasogastric (NG). The evidence to determine the optimum route of hydration therapy for infants with bronchiolitis is inadequate. This randomised trial will be the first to provide good quality evidence of whether nasogastric rehydration (NGR) offers benefits over intravenous rehydration (IVR) using the clinically relevant continuous outcome measure of duration of hospital admission.

Methods/Design

A prospective randomised multi-centre trial in Australia and New Zealand where children between 2 and 12 months of age with bronchiolitis, needing non oral fluid replacement, are randomised to receive either intravenous (IV) or nasogastric (NG) rehydration. 750 patients admitted to participating hospitals will be recruited, and will be followed daily during the admission and by telephone 1 week after discharge. Patients with chronic respiratory, cardiac, or neurological disease; choanal atresia; needing IV fluid resuscitation; needing an IV for other reasons, and those requiring CPAP or ventilation are excluded. The primary endpoint is duration of hospital admission. Secondary outcomes are complications, need for ICU admission, parental satisfaction, and an economic evaluation. Results will be analysed using t-test for continuous data, and chi squared for categorical data. Non parametric data will be log transformed.

Discussion

This trial will define the role of NGR and IVR in bronchiolitis

Trail registration

The trial is registered with the Australian and New Zealand Clinical Trials Registry - ACTRN12605000033640     

Dysmorphism in non-syndromic autism: <Emphasis Type="Italic">A cross-sectional study</Emphasis>

Objectives

To determine the effect of association of dysembryogenesis (manifested by presence of dysmorphic markers) on the developmental profile of autistic children.

Methods

26 autistic children were classified into complex autism (if they had specific dysmorphic markers) or essential autism (in the absence of dysmorphic markers) using the Miles Autism Dysmorphology Measure (ADM). The developmental abilities (Griffith’s Mental Development Scales) and the clinical severity (Childhood Autism Rating Scale) of both groups were compared. The prevalence of dysmorphic markers was also determined in 140 non-autistic controls.

Results

Children with complex autism had poorer development (General Quotient 29.4 vs 34.0, P=0.06) and earlier onset of autistic symptoms (18 vs 24 mo, P=0.05). Dysmorphic markers were significantly more in autistic children compared to normal children (27% vs 10%, P=0.002).

Conclusions

Dysembryogenesis may contribute to the clinical heterogeneity of autistic children.

     

Reaktivierung nach einer Herpes-simplex-Enzephalitis

Background

In case of relapse after Herpes simplex encephalitis (HSE) a clear distinction between recurrent virus infection and autoimmune disease is frequently not possible and both pathophysiological mechanisms can occur simultaneously.

Case

We report on a 4 year old boy who was admitted in stupor 10 days after HSE.

Treatment and follow-up

Treatment with aciclovir, immunoglobulins, phenobarbital und tiapridex had no effect. The child developed severe neurological deficits. After 6 months of inpatient rehabilitation his motor status returned to normal while substantial impairment of speech and attention remained.

Conclusions

Early relapse after HSE occurs within 2–4 weeks after the initial disease. Clinical presentation includes various neurological symptoms in combination with fever and impairment of consciousness. We recommend CSF testing and MRI after completion of the initial antiviral therapy.     

Hypertonic (3%) saline Vs 0.9% saline nebulization for acute viral bronchiolitis: A randomized controlled trial

Objective

To compare the length of hospital stay (primary) and improvement in clinical severity scores (secondary) among children with bronchiolitis nebulized with 3 % hypertonic saline or 0.9% saline.

Design

Randomized double blind controlled trial.

Setting

Tertiary care teaching hospital.

Patients

Hospitalized children (1–24 months) with acute bronchiolitis of moderate severity.

Intervention

Nebulization of 4 ml of 3% hypertonic saline or 4 mL of 0.9% saline, along with 2.5 mg salbutamol, at 4-hourly intervals till the patient was ready for discharge.

Results

Baseline characteristics were similar in two groups. Median clinical severity score at admission was 6 (IQR-1) in both the groups. Clinical severity scores monitored afterwards 12-hourly till discharge (132 h) did not show statistically significant differences in 3% and 0.9% saline groups. Mean length of hospital stay (time to reach predefined clinical severity score<3) was 63.93 ± 22.43 h in 3% saline group and 63.51 ± 21.27 h in 0.9% saline group (P=0.878). No adverse events were reported by the parents, caregivers or treating medical attendants in both groups.

Conclusion

Nebulized 3 % saline is not superior to 0.9% saline in infants with clinically diagnosed acute bronchiolitis.     

Oral zinc supplementation for reducing mortality in probable neonatal sepsis: A double blind randomized placebo controlled trial

Objective

To study the role of Zinc in the treatment of neonatal sepsis.

Design

Double blind, randomized, placebo controlled trial.

Setting

Tertiary Care Hospital.

Participants

614 neonates with probable neonatal sepsis.

Intervention

The drug group (n=307) received 1mg/kg/day of elemental zinc, and placebo group (n=307) received the placebo, in addition to antibiotic therapy and supportive care, till the final outcome (discharge/death).

Outcome Measures

Decrease in mortality rates (primary outcome), duration of hospital stay and need of higher lines of antibiotic therapy (secondary outcomes) were tested.

Results

Baseline characteristics of the two groups were similar. No statistically significant differences between drug and placebo group were found in mortality rate (9.77% vs 7.81 %; P=0.393), mean duration of hospital stay (142.85±69.41 hrs, vs. 147.99±73.13 hrs; P=0.841), and requirement of higher lines of antibiotic therapy (13.35% vs 12.05%, P=0.628) after supplementation.

Conclusions

This study does not report decrease in mortality rates, duration of hospital stay and requirement of higher lines of antibiotic therapy following zinc supplementation in neonatal sepsis.     

Effectiveness of anti scorpion venom for red scorpion envenomation

Objective

To study the efficacy of anti-scorpion venom plus prazocin.

Methods

Comparison of clinical features, outcome and duration of stay between children receiving anti-scorpion venom plus prazocin or prazocin alone for management of red scorpion envenomation.

Results

Requirement for dopamine and requirement and duration of dobutamine therapy were significantly less in patients received anti-venom plus prazocin than those had prazocin only. Faster recovery was seen in cases who received antiscorpion venom plus prazocin than prazocin only group.

Conclusion

Anti-scorpion venom plus prazosin was safe and more effective than prazocin alone for scorpion envenomation.     

Sonographie extrapulmonaler Befunde bei Kindern und Jugendlichen mit zystischer Fibrose

Background

Cystic fibrosis has the second highest incidence of an autosomal recessive hereditary disease in the Caucasian population. Pulmonary alteration in association with heart failure are limiting prognostic factors. Diagnose of the disease is mostly established in neonates due to intestinal symptoms. These symptoms, as well as pulmonary manifestations, exist with varying severity. The aim of this study is the presentation of intestinal findings during ultrasound of patients with cystic fibrosis.

Patients and Methods

Currently, the pediatricians and specialists in pediatric radiology in our clinic care for 72 patients with cystic fibrosis. The findings using ultrasound (Elegra, Siemens and Sonos 4500, Agilent Technologies) were regularly recorded during routine examinations.

Results

Cystic fibrosis causes alterations of varying severity and frequency, mainly affecting the pancreas, liver, bladder and intestinal tract.

Conclusion

Ultrasound is a suitable imaging method for diagnosis and the detection of complications due to intestinal alterations in patients with cystic fibrosis. It is also suitable for following the course of the disease.     

Methylphenidat mit modifizierter Freisetzung in der Routineversorgung

Background

This open label multi-centre non-interventional study examines the effectiveness and tolerability of a modified-release methylphenidate (MPH) preparation with a 50% immediate-release component (Medikinet? retard) in children and adolescents with attention deficit hyperactivity disorder (ADHD).

Methods

A total of 447 patients aged 6?C17?years with ADHD and an indication for treatment with this preparation were included. Primary outcome measures were ADHD severity and side effects evaluated by the physicians and the parents at the start of the medication changeover and 4?C6?weeks later.

Results

ADHD symptom severity declined significantly. Oppositional behavior and side effects as evaluated by the parents were also reduced.

Conclusions

This MPH preparation causes a further reduction of ADHD symptoms in hitherto sub-optimally treated patients. It is well tolerated and has been proven to be effective in clinical routine care.     

Schnarchen bei Kindern

Background

Snoring in children is a prevalent symptom and may be an indicator of obstructive sleep apnoea. Despite its importance, there is no national guideline on its appropriate management.

Objective

To provide recommendations for the management of snoring in children and adolescents treated in a primary care setting.

Methods

A total of 16 national paediatric sleep experts were included in a Delphi process and formulated recommendations in the form of a step-wise work-up procedure.

Results

The following 8 steps were developed: (1) Identification of true cases of habitual snoring. (2) Identification of high-risk patients who should undergo polysomnography in a sleep laboratory. (3) Identification of mild cases that may be treated with anti-inflammatory medication. (4) Identification of cases that should be referred to an otorhinolaryngologist for potential surgery. (5) Performance of polysomnography in cases that remain unclear despite steps 3 and 4 to rule out obstructive sleep apnoea. (6) Reconsideration of surgery in cases with moderate to severe obstructive sleep apnoea. (7) Identification of severe sleep apnoea cases requiring continuous positive airway pressure therapy. (8) Identification of cases suitable for orthodontic treatment, craniofacial surgery or speech therapy.

Conclusion

This guideline should help to improve the management of snoring children and adolescents in Germany.     

Invasive Infektion durch Streptococcus pneumoniae Serotyp 8 im Säuglingsalter

Background

Despite the (now) extended spectrum of pneumococcal vaccination by PCV13 (PCV: pneumococcal conjugate vaccine), invasive pneumococcal disease continues to occur.

Case

We report on a 4-month-old female infant who was admitted to the pediatric hospital because of high fever and decreased oral intake of 2 day’s duration prior to admission.

Diagnosis

After extensive diagnostics (blood work, catheter urinalysis, cerebrospinal fluid analysis and culture, blood culture, catheter urine culture, throat swab, stool test, sonography of the brain), a diagnosis of invasive infection by Streptococcus pneumoniae serotype 8 (meningitis, sepsis) was made. The hospital course was complicated by cerebral empyema.

Conclusion

Consideration should be given to adding more serotypes to the conjugate vaccine, especially those which are known for invasive infections, as in our case, serotype 8.     

Effect of probiotics on allergic rhinitis in Df, Dp or dust-sensitive children: A randomized double blind controlled trial

Objective

To study, we examined the effect of Lactobacillus salivarius on the clinical symptoms and medication use among children with established allergic rhinitis (AR).

Design

Double blind, randomized, controlled trial.

Setting

Hualien Tzu-Chi General Hospital.

Methods

Atopic children with current allergic rhinitis received 4 × 10⁹ colony forming units/g of Lactobacillus salivarius (n=99) or placebo (n=100) daily as a powder mixed with food or water for 12 weeks. The SCORing Allergic rhinitis index (specific symptoms scores [SSS] and symptom medication scores [SMS]), which measures the extent and severity of AR, was assessed in each subject at each of the visits — 2 weeks prior to treatment initiation (visit 0), at the beginning of the treatment (visit 1), then at 4 (visit 2), 8 (visit 3) and 12 weeks (visit 4) after starting treatment. The WBC, RBC, platelet and, eosinophil counts as well as the IgE antibody levels of the individuals were evaluated before and after 3 months of treatment.

Results

The major outcome, indicating the efficacy of Lactobacillus salivarius treatment, was the reduction in rhinitis symptoms and drug scores. No significant statistical differences were found between baseline or 12 weeks in the probiotic and placebo groups for any immunological or blood cell variables.

Conclusions

Our study demonstrates that Lactobacillus salivarius treatment reduces rhinitis symptoms and drug usage in children with allergic rhinitis.     

Development and tracking of central patterns of subcutaneous fat of rural South African youth: Ellisras longitudinal study

Background

Children with Fetal Alcohol Spectrum Disorders (FASD) may have significant neurobehavioural problems persisting into adulthood. Early diagnosis may decrease the risk of adverse life outcomes. However, little is known about effective interventions for children with FASD. Our aim is to conduct a systematic review of the literature to identify and evaluate the evidence for pharmacological and non-pharmacological interventions for children with FASD.

Methods

We did an electronic search of the Cochrane Library, MEDLINE, EMBASE, PsychINFO, CINAHL and ERIC for clinical studies (Randomized controlled trials (RCT), quasi RCT, controlled trials and pre- and post-intervention studies) which evaluated pharmacological, behavioural, speech therapy, occupational therapy, physiotherapy, psychosocial and educational interventions and early intervention programs. Participants were aged under 18 years with a diagnosis of a FASD. Selection of studies for inclusion and assessment of study quality was undertaken independently by two reviewers. Meta-analysis was not possible due to diversity in the interventions and outcome measures.

Results

Twelve studies met the inclusion criteria. Methodological weaknesses were common, including small sample sizes; inadequate study design and short term follow up. Pharmacological interventions, evaluated in two studies (both RCT) showed some benefit from stimulant medications. Educational and learning strategies (three RCT) were evaluated in seven studies. There was some evidence to suggest that virtual reality training, cognitive control therapy, language and literacy therapy, mathematics intervention and rehearsal training for memory may be beneficial strategies. Three studies evaluating social communication and behavioural strategies (two RCT) suggested that social skills training may improve social skills and behaviour at home and Attention Process Training may improve attention.

Conclusion

There is limited good quality evidence for specific interventions for managing FASD, however seven randomized controlled trials that address specific functional deficits of children with FASD are underway or recently completed.     

Effect of proton pump inhibition on acid, weakly acid and weakly alkaline gastro-esophageal reflux in children

Background

The effect of proton pump inhibitors on the characteristics of gastroesophageal reflux (GER) in children and adolescents was evaluated.

Methods

Twenty-one children and adolescents with symptoms suggesting GER disease (GERD) underwent upper endoscopy and a 24-hour multichannel intraluminal impedance/pH (MII-pH) monitoring before and at the end of 2 months of therapy with proton pump inhibitors (PPIs).

Results

Fourteen (67%) patients reported clinically relevant symptom improvement after 2 months of PPIs intake. At the first endoscopy, 8 (38%) patients had macroscopic signs of reflux esophagitis; after two months of therapy, 6/8 (75%) patients had a complete mucosal recovery. There was a significant reduction in the total percentage of mean acid reflux time (from 13.1% to 3.8%), and the De Meester score dropped to normal (from 46.4 to 13.1). The mean number of acid refluxes decreased significantly from 48 to 15 per 24 hours, while inversely, the mean number of weakly acid refluxes increased significantly from 26 to 64 per 24 hours. PPI therapy did not affect the total number of reflux episodes, the number of liquid and mixed refluxes, the duration of esophageal bolus exposure and proximal extent of the reflux.

Conclusions

In children and adolescents with GERD, PPIs do not affect the total number of reflux episodes. PPIs only decrease the acidity of refluxate. Nevertheless, the majority of patients with typical reflux symptoms may report symptom improvement. Esophagitis can be healed after PPI treatment. The treatment of weakly acid and weakly alkaline reflux remains a challenge for physicians in the future.     

Propranolol Treatment of Complicated Hemangiomas

Objectives

To evaluate laboratory and radiological features of hemangiomas in childhood in addition to efficacy and safety of propranolol as a first-line treatment of complicated hemangiomas retrospectively.

Methods

The files of 60 patients who were diagnosed as capillary hemangioma were evaluated retrospectively. Fourteen children with complicated hemangiomas treated with propranolol were analysed, in terms of side effects, efficacy and duration of treatment.

Results

These fourteen patients (23 %) were treated with propranolol because of ulcerated, infected and/or deep seated localisations. The duration of treatment with propranolol were between 3 and 12 mo (median: 6 mo). Bronchospasm was observed in one patient during treatment. Except for two patients, all of them responded to propranolol treatment with limited side effects.

Conclusions

The present results support that propranolol is safe and effective treatment choice for complicated infantile hemangiomas, because of minimal side effects and encouraging response rates (80 %). In addition, the authors suggest that routine cranial radiological imagings might not be necessary for hemangiomas without any neurological symptoms.     

YKL-40 levels are associated with disease severity and prognosis of viral pneumonia,but not available in bacterial pneumonia in children

Background

Viral pneumonia is the main type of community-acquired pneumonia (CAP) in children. YKL-40, a chitinase-like protein, is regarded as a biomarker of the degree of inflammation.

Methods

Children who were diagnosed with CAP, including viral pneumonia, bacterial pneumonia, and dual infection, were included in the cohort study. The pathogenic diagnosis depended on PCR and immunoassay test. YKL-40 levels were examined twice by enzyme-linked immunoassay (ELISA).

Results

Serum YKL-40 levels were higher in patients with pneumonia than in healthy controls. The admission levels of YKL-40 in serum and Bronchoalveolar lavage (BALFs) indicated a positive correlation with the serum levels of C-reactive protein and other inflammatory cytokines (IL-6 and TNF-α). The disease severity have no correlation with the admission serum levels of YKL-40. Meanwhile, reductions in YKL-40 levels from initial admission levels to day 5 post-admission were correlated with disease severity. The multiple logistic analysis indicated the decreased extent of serum YKL-40 level as an independent prognostic predictor of severe cases in patients with viral pneumonia.

Conclusions

Reductions in serum YKL-40 levels on day 5 after receiving therapy is a possible prognostic biomarker for children with viral pneumonia.

     

Deferoxamine-induced dysplasia-like skeletal abnormalities at radiography and MRI

Background

Current thalassemia major treatment includes blood transfusion and iron chelation, which is associated with growth disturbances and radiographic changes in the long bone metaphyses.

Objective

To explore and discuss the spectrum of deferoxamine-induced bone-dysplasia-like changes in children with thalassemia major in Egypt.

Materials and methods

We studied 59 Egyptian children with thalassemia major and generalized arthralgia. All started deferoxamine treatment at 3 years of age. We conducted skeletal survey and MRI of both knees in radiographically positive children. Each child’s age, serum ferritin, age of onset and duration of therapy were compared with the radiologic findings.

Results

Twenty-two (37.3%) children had variable degrees of skeletal dysplasia-like changes similar to those described with deferoxamine intake, mostly around the knees. Mild dysplasia-like changes were seen in 4 (18%) children; moderate changes were seen in 11 (50%) children and severe changes were seen in 7 (31.8%) children. No statistically significant relationships were detected between bone changes and the children’s age, age of starting deferoxamine, duration of therapy, or serum ferritin level.

Conclusion

A wider spectrum of deferoxamine-induced bone-dysplasia-like changes was recognized despite delayed onset and small doses of therapy. These changes should be considered as a possible cause of arthropathy in children with thalassemia major, especially symptomatic children.     

Efficacy of levamisole in children with frequently relapsing and steroid-dependent nephrotic syndrome

Objectives

To assess the efficacy of levamisole in frequently relapsing nephrotic syndrome and steroid-dependent nephrotic syndrome.

Study Design

Retrospective analysis of hospital case records.

Setting

Pediatric nephrology department of a tertiary referral pediatric hospital.

Participants

62 children with frequently relapsing nephrotic syndrome and 35 children with steroid-dependent nephrotic syndrome.

Methods

Case records of children who were diagnosed as steroid-dependant or frequently-relapsing nephrotic syndrome from June 2004 to June 2011, were reviewed. Levamisole was given daily (2 mg/kg/d) along with tapering doses of alternate day steroids after remission on daily steroids.

Results

Levamisole was effective in 77.3% children with a better (80.6%) efficacy in frequently relapsing nephrotic syndrome. A total of 34 children completed 1 year follow-up post levamisole therapy. The cumulative mean (SD) steroid dose 1-year before therapy was 4109(1154) mg/m² and 1-year post therapy was 661 (11) mg/m² (P<0.001). The relapses were also less during the period of post-levamisole therapy.

Conclusion

Levamisole is an effective alternative therapy in frequently relapsing and steroid-dependent nephrotic syndrome.     

Quality of Life in Children with Asthma in Rio de Janeiro, Brazil

Objectives

To evaluate the impact of asthma on activity limitation, symptoms and emotional function in the health-related quality of life (HRQL) of asthmatic children.

Methods

A cross-sectional study involving 59 children of 7 to 12 y of age. A standardized version of the Pediatric Asthma Quality of Life Questionnaire was used to evaluate HRQL and the current criteria for socioeconomic stratification in Brazil were used to assess socioeconomic status. Independent variables evaluated included clinical and sociodemographic characteristics. The association between mean HRQL scores and the independent variables was evaluated using the Mann-Whitney, Kruskal-Wallis and Dunn tests. Statistical significance was defined as a p-value?<?0.05.

Results

Thirty-two families (56.1 %) had a total household income of more than two minimum wages, while 37 families (62.7 %) were considered lower middle class. Mean overall HRQL score was 4.8?±?1.3 (out of a maximum score of 7), suggesting reasonable HRQL. There was a weak association between independent variables and mean overall HRQL scores and the mean scores in the emotional function domain. Higher socioeconomic status was related to higher scores for the symptoms domain (p?=?0.041). Furthermore, children exposed to indoor mould reported greater impairment in the symptoms domain(p?=?0.022). The severity of asthma was associated with the activity limitation domain (p?=?0.025).

Conclusions

These results showed a reasonable mean HRQL score and an association between the severity of asthma and the activity limitation domain.     

Diagnosis, misdiagnosis, and associated diseases of achalasia in children and adolescents: a twelve-year single center experience

Purpose

Although achalasia is a rare disorder in children, its symptom may mimic common childhood diseases. This study aimed to assess the diagnosis and management of achalasia in children and adolescents in a Brazilian single center during a 12-year period.

Methods

Patients with achalasia were identified from a database built during the period of January 2000?CJanuary 2012 from a Pediatric Gastroenterology reference center. Information regarding demographic data, clinical symptoms, diagnosis, treatment, and long-term follow-up were described.

Results

Thirteen patients were studied; median age was 7 (1?C14)?years. Most frequent symptoms were vomiting (84.6?%) and dysphagia (69.2?%). Weight loss occurred in 46.0?% of patients and chronic cough in 46.1?%. Associated disorders were Down??s syndrome, Allgrove syndrome, and congenital central hypoventilation syndrome. Achalasia was misdiagnosed with anorexia nervosa. Six patients were previously treated as having gastroesophageal reflux disease and asthma. Five patients had pneumatic balloon dilation as initial therapy whereas five had esophageal myotomy. Finally, 11 patients had surgical therapy with a favorable follow-up.

Conclusion

Achalasia symptoms may mimic common diseases in children, and therefore, may delay the diagnosis. This study emphasizes the importance of the clinical symptoms for the diagnosis of achalasia, mainly in those cases with associated disorders.     

Idiopathic Hypereosinophilic Syndrome in Children: 3 Cases with Review of Literature

Objectives

To highlight the varied clinical manifestations and management of idiopathic hypereosinophilic syndrome, a rare disorder in children.

Methods

Retrospective review of case records of 3 patients who were diagnosed to have idiopathic hypereosinophilic syndrome (IHES) in a tertiary referral centre between 1997 and 2010 was performed. These 3 children presented with different symptoms and the first case had cardiac involvement. All had very high absolute eosinophil count (cells/mm³) 43,206, 9,082, 2,925, respectively. Diagnosis was confirmed by bone marrow biopsy in all three cases and supported by liver biopsy in the first two cases and inguinal lymphnode biopsy in the last case. All 3 children responded to treatment with steroids, with only second patient requiring hydroxyurea to control disease.

Results

Case 1 and 2 are on follow up for 13 y and 10 y respectively and both are asymptomatic. Case 3 expired due to sepsis 1 mo after diagnosis.

Conclusions

Treatment with steroids with or without hydroxyurea gave good response in all 3 cases. Hence, they still remain the gold standard for the treatment of IHES in children.