World journal of clinical pediatrics最新文献

The diagnosis of gastroesophageal reflux (GERD) in children is a complex and challenging task that requires meticulous attention to detail and a deep understanding of pediatric physiology. It is absolutely crucial to distinguish between the benign chalasia of infancy and the more serious pathologic GERD. Recent advancements have shown that Combined Multichannel Intraluminal Impedance and pondus hydrogenii measurement offer superior diagnostic accuracy. The role of nuclear scans in diagnosing GERD remains an area of ongoing research. The management of GERD in children follows a stepwise approach, starting with medical therapy and progressing to surgical intervention if necessary.

Background: Hypertension (HTN) is a significant global health concern due to its rising prevalence and associated risks of cardiovascular disease, chronic kidney disease, and other comorbidities. The increasing rates of HTN among youth have been partly attributed to the global rise in childhood obesity, lipid abnormalities, and sedentary lifestyles.

Aim: To investigate the independent associations of aerobic fitness (AF), the triglyceride-to-high-density lipoprotein cholesterol (TG/HDL-C) ratio, visceral adiposity index (VAI), and resting blood pressure (BP) in Nigerian adolescents.

Methods: A multistage sampling technique was used to select 403 in-school adolescents aged 11-19 years in Kogi East, Nigeria. Participants were assessed for AF, TG/HDL-C ratio, VAI, systolic BP (SBP), and diastolic BP (DBP). The associations between the independent variables and the risk of systolic and diastolic HTN were examined using multivariate regression models, controlling for age and maturity status. Receiver operating characteristics curve (ROC) and area under the curve (AUC) were employed to determine the predictive capacities of the independent variables.

Results: The overall prevalence of systolic HTN was 5.5% (girls: 7%; boys: 4%) while diastolic HTN was 12.7% (girls: 16.9%; boys: 8.4%). Among girls, all independent variables showed significant associations with SBP, including fitness (P < 0.001), TG/HDL-C (P < 0.001), and VAI (P < 0.001), with VAI showing the strongest association. In boys, all independent variables except VAI (P = 0.063) were significantly associated with SBP, with fitness showing the stronger predictive power (Fitness, P < 0.001; TG/HDL-C, P = 0.029). For DBP, all independent variables, except fitness in girls (P = 0.099), were significantly associated (P < 0.001) in both sexes. Unfit boys were 1.1 times more likely to develop systolic HTN (95%CI: 1.01-1.15, P = 0.018) and had 1.1 times higher odds of developing diastolic HTN (95%CI: 1.03-1.13, P = 0.001). Only the ROC for DBP turned up significant (P < 0.001) AUCs for TG/HDL-C and VAI in girls only, with 0.6 and 1.0 thresholds respectively.

Conclusion: AF, dyslipidemia, and visceral adipose tissue dysfunction were independently associated with the risk of HTN in Nigerian adolescents. These findings highlight the importance of promoting a healthy diet and encouraging aerobic physical activity among adolescents to reduce the risk of HTN.

Background: Mucopolysaccharidosis type II (MPS II) is a chronic inherited disease with multiorgan involvement, a progressive course, and restricted life expectancy.

Aim: To evaluate the predictors of fatal outcomes in MPS II patients.

Methods: In the retrospective cohort study, the clinical, laboratory data and enzyme replacement therapy (ERT) (84.2%) of about 160 patients were extracted and analyzed from the Russian MPS II registry, with death as a primary outcome. We compared patients who died (n = 20; 12.5%) with severe form (n = 13; 68.4%) and attenuated form (n = 6, 31.6%) to 140 alive patients.

Results: Fatal outcomes occurred in 5%, 35%, 20%, and 40% of patients before 10, 10-14, 15-19, and ≥ 20 years. The most common causes of death were cardiovascular (29.4%), respiratory failure (17.6%), including pneumonia (17.6%), and their associations (17.6%) and MPS II progression (11.8%). Acute or chronic respiratory failure was in 53%. Died patients had higher birth weight, higher age of diagnosis, and start of ERT. Hydrocephalus, hydrocephalus bypass surgery, epilepsy, difficulty swallowing, and impaired movement after 12 years of age were significantly more common in the deceased patients. Cox regression analysis has revealed the following time-dependent covariates of the lethal outcome: 1^st-year psychomotor development delay, delayed mental and speech development, hydrocephalus, swallow disorders, impossible walking at age > 12 years, respiratory disorders, tracheostomy, neuronopathic form.

Conclusion: Increased birth weight, delayed diagnosis and the start of ERT, and development of neuronopathic form with impossible walking after 12 years were the main predictors of the fatal outcome.

Background: Point-of-care ultrasound (POCUS) is the use of portable ultrasound devices by trained healthcare professionals to diagnose and monitor medical conditions directly at the patient's bedside, such as in emergency settings. We described a case where POCUS use, in Pediatric Emergency Department, allowed an early diagnosis and timely management in the surgical department, with a favorable outcome for child. Therefore we write this case because it is desirable to popularize ultrasound as the fifth pillar of clinical examination especially in Emergency Department.

Case summary: A 13-year-old girl with acute gastrointestinal symptoms, such as vomit and abdominal and lumbar pains. Upon physical examination, the patient had localized abdominal pain in the left lower quadrant. Ultrasonography performed at the bedside revealed an enlarged left ovary with an irregular structure containing a 3 cm cyst. These findings raised suspicion of ovarian torsion. The child transferred to Gynecology Surgery Unit, where she was taken emergently to the operating room.

Conclusion: It is desirable to spread POCUS in emergency settings where it allows a significant saving of time in patient management.

Background: Measles is a highly contagious disease that caused by a measles virus. While measles vaccination is highly effective in preventing the disease, those who are unvaccinated or have not completed the vaccine series are at significant risk.

Aim: To assess the clinical characteristics and outcomes of measles in vaccinated vs unvaccinated children in Ramadi city.

Methods: Clinically confirmed cases of measles at Al-Ramadi Teaching Hospital for Maternity and Children, identified between June and December 2023, were enrolled in this prospective cohort study. The cases were divided into two groups (vaccinated and unvaccinated). The clinical characteristics and outcomes were compared between unvaccinated and vaccinated children.

Results: Of 289 kids, there were 222 (76.8%) children under 5 years old, and 161 (55.7%) boys. Around 2/3^rd children were unvaccinated. Besides, only 5 (4.9%) kids from the vaccinated group received three doses. Fever, maculopapular rashes, and cough were the most common manifestations. Unvaccinated children had higher rate of developing complications (pneumonia and diarrhea with P values 0.001 and 0.01 respectively), longer hospital admission period (P value = 0.008), and the need for respiratory care unit (RCU) admission comparing with the vaccinated children (4 cases for unvaccinated group vs 1 case for vaccinated group).

Conclusion: Unvaccinated kids were associated with more complications, longer admission hospital stays, and RCU admission. We recommend that public health directors utilize artificial intelligence tools to help control future measles epidemics.

Background: Gastrointestinal diseases in young children are often anatomic or inflammatory in nature and can present with symptoms similar to those of Cow's milk protein allergy (CMPA), complicating diagnosis. This case series highlights 3 pediatric patients initially misdiagnosed with CMPA, emphasizing the need for a thorough evaluation.

Case summary: Case 1: A 3-year-old child with chronic abdominal distension and constipation was initially treated for CMPA and was later diagnosed with Hirschsprung disease through rectal biopsy. Surgical intervention involved a laparoscopic colostomy followed by a pull-through procedure, leading to a successful recovery. Case 2: A 2-month-old infant presented with greenish-yellow vomiting and abdominal distension. Initially misdiagnosed with CMPA, further investigation using barium studies revealed partial intestinal malrotation. The patient underwent a laparoscopic Ladd's procedure and recovered well. Case 3: A 6-month-old infant with persistent vomiting and failure to thrive had been treated for CMPA. Detailed imaging studies indicated achalasia. The child underwent a Heller myotomy, which resulted in significant symptom improvement and weight gain.

Conclusion: Thorough evaluation of gastrointestinal symptoms is necessary in children. A high suspicion for alternative diagnoses will prevent delays in accurate diagnosis and proper treatment, leading to improved outcomes.

Background: Intra-arterial chemotherapy (IAC) has become a first-line standard treatment for retinoblastoma (RB). However, studies describing its adverse events are sparse, especially from the developing world. Our study described the outcomes and adverse events from a single center in South India.

Aim: To describe the challenges, treatment outcomes, and complications of selective IAC for RB in Indian eyes.

Methods: This study was a single center, retrospective study that included 17 patients with RB who underwent IAC using melphalan (5/7.5 mg) and topotecan (1/2 mg) (n = 12) or melphalan (5 mg) alone (n = 3) or triple therapy that included carboplatin (30 mg) along with these drugs (n = 2) between January 2018 and December 2023. In all, 17 IAC procedures were performed using selective ophthalmic artery cannulation. Treatment outcomes were evaluated in terms of tumor control, vitreous and subretinal seed control, complications, and globe salvage rates.

Results: Out of the 17 patients, 11 were diagnosed with unilateral RB and 6 were diagnosed with bilateral RB. The mean age at the time of diagnosis was 19.8 months. The mean interval between the first symptom and presentation was 6.5 months. IAC was employed as the primary (n = 9) or secondary (n = 8) modality of treatment. Each eye received a mean of 1.5 IAC sessions (median: 1 session; range: 1-3 sessions). Eyes were classified according to the international classification of RB as group B (n = 5), group C (n = 1), group D (n = 4), and group E (n = 7). Following IAC, complete regression of the main tumor was seen in 15 eyes (88%) and partial regression in 2 eyes (12%). Globe salvage was achieved in 15 eyes (88%). Adverse effects included vitreous hemorrhage (n = 3), rhegmatogenous retinal detachment (n = 2), choroidal ischemia (n = 1), isolated subretinal hemorrhage (n = 2), retinal pigment epithelium degeneration (n = 2), forehead pigmentation (n = 1), third nerve palsy with complete ptosis (n = 1), and 30-degree exotropia (n = 1). The mean follow-up period was 28.6 months (median: 24 months, range: 1-72 months).

Conclusion: IAC is an effective way to control RB and globe preservation. In the Indian context we encountered many challenges highlighting the importance of case selection. Further studies in India are required to thoroughly understand IAC as a treatment for RB.

Background: Small intestinal bacterial overgrowth (SIBO) is suspected and excluded frequently in functional gastrointestinal (GI) disorders. Children presenting with various esophago-gastro-duodenal (upper GI) symptoms are rarely subjected to investigations for SIBO.

Aim: To estimate the frequency of SIBO in children having functional upper GI symptoms (as cases) and to compare the result of the SIBO status to that of the controls.

Methods: Children aged 6 to 18 who presented with upper GI symptoms were selected for the study. All children were subjected to upper GI endoscopy before being advised of any proton pump inhibitors (PPIs). Children with normal endoscopy were assigned as cases, and children having any endoscopic lesion were designated as controls. Both groups were subjected to a glucose-hydrogen breath test by Bedfont Gastrolyser.

Results: A total of 129 consecutive children who were naive to PPIs and had normal baseline investigations were included in the study. Among them, 67 patients had endoscopic lesions and served as the control group, with six cases being excluded due to the presence of Helicobacter pylori in gastric biopsies. Sixty-two children with normal endoscopy results formed the case group. In the case group, 35 children (59%) tested positive for hydrogen breath tests, compared to 13 children (21%) in the control group. The calculated odds ratio was 5.38 (95% confidence interval: 2.41-12.0), which was statistically significant. Further analysis of symptoms revealed that nausea, halitosis, foul-smelling eructation, and epigastric fullness were positive predictors of SIBO.

Conclusion: It is worthwhile to investigate and treat SIBO in all children presenting with upper GI symptoms that are not explained by endoscopy findings.

Background: Necrotizing enterocolitis (NEC) remains a prominent gastrointestinal emergency among infants, particularly term infants with congenital heart defects (CHD) being at high risk. The molecular processes that contribute to NEC have yet to be completely understood. The high mortality rates necessitate an active search for noninvasive biomarkers that can aid in the preclinical diagnosis and prognosis of NEC. MicroRNAs (miRs), which are involved in many biological processes in both health and disease, have been discovered to play an important role in regulating inflammation and immune responses via various signaling pathways.

Aim: To determine the plasma levels of miR-155, miR-221, miR-223, miR-320a, miR-451a as potential NEC biomarkers in term newborns with CHD.

Methods: This prospective cohort study included twenty-tree term newborns with CHD who underwent cardiac surgery on the median day of life (DOL) = 7. Nine of them developed NEC (Bell's stage IIA and IIIA) within 1 week of cardiac surgery (NEC newborns). Blood samples were collected before (median DOL = 5) and following (median DOL = 13) cardiac surgery. Levels of plasma miR-155-5p, miR-221-3p, miR-223-3p, miR-320a-3p, and miR-451a were determined using real-time polymerase chain reaction. The functional analysis was executed using the DIANA-miRPath v4.0.

Results: Preoperatively, NEC newborns had significantly lower plasma levels of miR-155 (2.70-fold, P = 0.020), miR-223 (2.42-fold, P = 0.030), and miR-320a (3.62-fold, P = 0.006) than newborns without NEC. Postoperatively, miR-451a levels differed significantly between the newborn groups, showing a 4.70-fold decrease (P = 0.014) in expression when clinical NEC symptoms appeared. According to receiver operating characteristic analysis, miR-320a was found to be the most effective predictive biomarker for NEC [area under the curve (AUC) = 0.835, 63% sensitivity, 100% specificity], while miR-451a was identified as a NEC biomarker (AUC = 0.835, 85.7% sensitivity, 76.9% specificity). Preoperatively, miR-155-5p, miR-223-3p, and miR-320a-3p were differentially expressed and targeted the forkhead box O and Hippo pathways (P < 0.01).

Conclusion: Our study demonstrates, for the first time, that plasma miR-320a-3p levels can be used as a preclinical biomarker for NEC in term newborns with CHD.

Background: Fibroadenomas (FA) and phyllodes tumors (PT) are fibroepithelial neoplasms and are difficult to differentiate radiographically and histologically. We present a partially infarcted borderline PT in an adolescent with rapid tumor enlargement within 24 hours. Tumor infarction made the diagnostic work-up difficult. Complete surgical excision is the standard of care for PTs. There is controversy regarding margin re-excision for borderline PTs. In this report, we discuss the diagnostic challenges of PT and the evolving concept of margin status on PT recurrence rate.

Case summary: A 14-year-old healthy female with no medical history presented with a painful right breast mass with no nipple discharge, trauma, or skin findings. The mass showed rapid enlargement over 24 hours, prompting a workup with ultrasound and core needle biopsy. The initial biopsy was limited due to large areas of infarction. Based on the scant viable tissue and considering the patient's age, the mass was favored to be a juvenile FA. The patient underwent excision of the mass. Final pathology confirmed a borderline PT with positive surgical margins. The patient underwent margin re-excision, which did not show any residual tumor. At the 6-month post-op visit, there was a mass-forming lesion on the breast ultrasound. Subsequent core needle biopsy showed benign breast parenchyma with scar formation. The primary goal of evaluation in pediatric breast masses is to do no harm. However, rapidly growing and symptomatic masses require a more extensive work-up including biopsy and surgical excision. We present a rapidly growing breast mass in a 14-year-old female which was diagnosed as a borderline PT on her excision specimen. The mass rapidly enlarged over 24 hours. The initial biopsy pathology was limited due to a large area of infarction. The patient underwent excision of the mass. Final pathology confirmed a borderline PT that extended into the surgical margin, resulting in an additional re-excision procedure. Accurate diagnosis prior to surgical intervention is crucial to avoid additional procedures. Although histological morphology remains the gold standard for diagnosis, immunohistochemistry and molecular studies have recently shown to improve the accuracy of diagnosis of PTs. Long-term clinical and pathologic follow-up of PTs in adolescent patients should be collectively studied to examine whether our current diagnostic criteria for PT can reliably predict tumor behavior in this age group.

Conclusion: Accurate diagnosis of PTs requires surgical excision. Tumor infarction may lead to rapid tumor enlargement, hindering the correct diagnosis. More research is needed on margin status and recurrence rate, especially in adolescent patients, to help establish the best possible care for this age group.