What 2012 general paediatrics

WHAT YOU SHOULD HAVE READ BUT….2012

 General
Paediatrics
Bonomo Beatrice
Caldonazzi Federico
Cattazzo Elena
Deganello Marco
Gallo Giuseppe
Mazzei Federica
Attilio Boner Melotti Giulia
Paiola Giulia
University of
Olivieri Francesca
Verona, Italy
Tenero Laura
Tezza Giovanna
Villotti Valentina

5 vs 10 days of treatment with ceftriaxone for bacterial
meningitis in children: a double-blind randomised
equivalence study. Molyneux, Lancet 2011;377:1837

% Outcomes
 1004 children with 30 –

purulent meningitis 25 – 26%
27%
(S.pneumoniae, H.influ 20 –
enzae
B, N.meningitidis) 15 –

aged 2 mo-12 yrs. 10 –

 496 ceftriaxone 05 – 6%
0% 0% 0% 0% 4% 4% 4%
for 5 days. 00 –

 508 ceftriaxone
for 10 days.


% Outcomes
 1004 children with
•Hearing loss
30 –

27%
•Visual loss
enzae
•Cranial nerve palsy
•Afebrile seizures
aged 2 mo-12 yrs. 10 –

•Hydrocephalus
 496 ceftriaxone 05 – 6%
0% 0% 0% 0% 4% 4% 4%
for 5 days.
•Developmental 00 –

 508 ceftriaxone
delay
for 10 days.


In children beyond % Outcomes
the neonatal
 1004 children with 30 –

age-group with
26%
purulent meningitis
(S.pneumoniae, H.influ
enzae
enzae B
or N.meningitidis)
aged 2 mo.-12stable
who are
yrs. 10 –

 496 ceftriaxoneof
by day 5 05 – 6%
for 5 days. treatment,
ceftriaxone 0% 0% 0% 0% 4% 4% 4%
00 –
the antibiotic can be
 508 ceftriaxone
safely discontinued.
for 10 days.

•Avvelenamenti
•Incidenti:
domestici & fuori casa

Dog Bite Prevention: An Assessment of Child Knowledge.
Dixon, J Pediatr 2012;160:337

% children who had never received
dog bite prevent education
100 –
90 –
80 –
 Cross-sectional study. 70 –

 300 parent/guardian-child
pairs presenting with
60 –
50 –
70%
nonurgent complaints 40 –

or dog bites. 30 –
20 –
10 –
0


1) Children are highly vulnerable to dog bites and make up a large
percentage of dog bite victims.
2) Younger children, aged 5 to 9 yrs, are disproportionately at
risk, with the highest incidence among all children and a large
portion of their injuries occurring to the head, face, or neck.
3) Consequences of dog bite injuries can be temporary or lasting
and include pain, disfigurement, infection, time lost from school
or employment, fear, and anxiety. Evidence of post-traumatic
stress disorder 1 month after injury has been seen in over 50%
of children who have been bitten by a dog.


4) Dog ownership does not necessarily equate to knowledge of how
to prevent dog bites, evidenced by the fact that the majority of
dog bites to children are by familiar dog.
5) Having an experience of a dog bite does not mean that the
victim or his or her family member has subsequently learned how
to prevent dog bites.
6) Dog bite recommendations are typically stated in the negative
tense (eg, ‗‗Do not pet a dog that is behind a fence‘‘ and ‗‗Do not
pet a dog that is eating‘‘).

Grandparents Driving Grandchildren:
An Evaluation of Child Passenger Safety and Injuries
Henretig, Pediatrics 2011;128:289

OR for injuries
1.0 –
 Motor vehicle crashes
involving children
aged ≤15 years.

 Grandparent-driven 0.5 –
vs parent-driven 0.50
vehicles.

0.0
in grandparent-driven
crashes


OR for injuries
Although nearly 1.0 –
 Motor vehicle crashes
all children
involving childrento have
were reported
aged ≤15 years.
been
restrained, childre
 Grandparent-driven
n in crashes with 0.5 –
vs parent-driven drivers
grandparent 0.50
vehicles.
used optimal restraint
slightly less often.
0.0
crashes


OR for injuries
Grandchildren 1.0 –
 Motor vehiclebe safer
seem to crashes
involving children driven
in crashes when
aged by grandparents
≤15 years.
than by their parents.
 Grandparent-driven 0.5 –
However, safety could be
vs parent-driven
enhanced if grandparents 0.50
vehicles.
followed current
child-restraint
guidelines.
0.0
crashes

Abusive head trauma during a time of increased
unemployment: a multicenter analysis
Berger Pediatrics 2011;128:637

Overall rate of AHT in 100.000
15 –

 Abusive head trauma 14.7
10 –
(AHT).
on
 In 442 children
younger than 5 yrs. 05 – 8.9 100.000
on
 5 ½ yrs study period. 100.000
00
Before the During the
recession recession

Abusive head trauma during a time of increased
unemployment: a multicenter analysis
Berger Pediatrics 2011;128:637

Overall rate of AHT in 100.000
15 –
The rate of AHT
 Abusive head trauma
increased
14.7
10 –
(AHT).
significantly on
 In 442 children months
during the 19
youngeran economic
of than 5 yrs. 05 – 8.9 100.000
on
recession compared
 5 ½ yrs study period.
with the 47 months 100.000
00
before the recession. Before the During the
recession recession

Neuroimaging: what neuroradiological features
distinguish abusive from non-abusive head trauma?
A systematic review Kemp Arch dis Child 2011;96:1103

OR for abusive head trauma
 Neuroradiological 9.0 –
features that 8.0 –
differentiate 7.0 –
8.2
abusive head 6.0 –
trauma (AHT) 5.0 –
from
4.0 –
non-abusive
3.0 –
head trauma (nAHT).
2.0 –

 21 studies of children
predominantly <3 yrs.
1.0 –
0 0
0.1
Subdural Extradural
haemorrhages haemorrhages

Recidivism in the Child Protection System. Identifying
Children at Greatest Risk of Reabuse Among Those
Remaining in the Home. Dakil APAM 2011;165:1006

Incidence of Reabuse.

 A 5-year prospective 50 –
cohort study.
 Children reported to the
40 –
45%
child protection system 30 –
for child abuse.
20 –
 A total of 2578 children
remained in the home 10 –
following an abuse report.
0

Recidivism in the Child Protection System. Identifying
Children at Greatest Risk of Reabuse Among Those
Remaining in the Home. Dakil APAM 2011;165:1006

Incidence of Reabuse.

1) children with
 A 5-year prospective 50 –
behavior
cohort study.
problems, 2)
 Children reported toan
caregivers with the
40 –
45%
child protection system
abuse history and 30 –
for 3) families with an
child abuse.
20 –
 A total of 2578lower than
annual income children
remained$20the home
in 000 10 –
were more likely
following an abuse report.
to be rereported. 0

FEVER

and

FEVER CONTROL

Paracetamol prescription by age or by weight?
Lenney, Arch Dis Child 2012;97:277
New dosing tables

Paracetamol prescription by age or by weight?
Lenney, Arch Dis Child 2012;97:277
New dosing tables

In general, children's dosages are based on a
single dose of 10 (7.5-15) mg paracetamol per kilogram body
weight, which can be repeated 4-6 hourly, not exceeding four doses
per 24 hours. (TACHIPIRINA 120 mg/5 ml sciroppo TACHIPIRINA 100 mg/ml gocce orali, soluzione)

Prospective Longitudinal Study of Signs and
Symptoms Associated With Primary Tooth Eruption
Ramos-Jorge Pediatrics 2011;128:471

Tympanic and Axillary Temperature Determined on
Noneruption Days, Day Before Eruption,
Day of Eruption, and Day After Eruption

 An 8-
month, longitudinal
study.
 47 infants receiving
care at home between
5 and 15 months.
 Daily tympanic and
axillary temperature
reading.


The most frequent Day of Eruption, and Day After Eruption
signs and symptoms
 An 8-
associated with
month, longitudinal
teething were:
irritability
study.
(47 infantsincreased
p<0.001),
receiving
salivation (p<0.001),
care at home between
runny nose
5 and 15 months.
(p<0.001), and loss of
appetite (p<0.001).
reading.


Day of Eruption, and Day After Eruption

Occurrence of
 An 8-
severe signs
month, longitudinal
study. and
symptoms, such
 47 infants receiving
care as home between
at fever,
could not be
5 and 15 months.
attributed to
teething.
reading.

Alimentazione
Latte materno
Formule

Symptoms of maternal depression immediately after
delivery predict unsuccessful breast feeding
Gagliardi, Arch Dis Child 2012;97:355

• The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item
self-administered scale.
Cox, Br J Psychiatry 1987;150:782
Benvenuti, J Affect Disord 1999;53:137

• Maternal depression is suspected when a mother scores higher
than a cut-off value (usually >9 or >12).

• Recent data suggest that mothers with high EPDS scores (>12)
tend to breast feed less in the first 2 months, but it is not known
if mothers with mild depressive symptoms and with normal scores
are at increased risk.

Edimburg Postnatal
Depression Scale (EPDS)

http://www.google.it/url
sa=t&rct=j&q=edinburgh+postnatal+depression+scale+italian
o&source=

www.envicon.it

% mothers with EPDS>9
20 –
 Edinburgh Postnatal
Depression Scale
(EPDS). 15 – 15.7%
 Later breast feeding
problems. 10 –
 592 mothers
of a healthy baby. 05 –
 Feeding method
recorded at 12–14 wks. 00


Distribution of EPDS scores and the
odds of bottle feeding at each score.
Depression Scale

0
(EPDS).
problems.
 592 mothers
of a healthy baby.
 Feeding method
recorded at 12–14 wks.


Mothers with odds of bottle feeding at each score.
higher EPDS
Depression Scale

0
were more likely
(EPDS).
to bottle feed
at 3 months.
problems.
The odds of bottle
 592 mothers
feeding increased
of a healthy baby.
with EPDS
 Feeding method at
result, even
low scores.


There
odds of bottle feeding at each score.
was no cut-off
Depression Scale risk
under which no

0
increase was seen.
(EPDS).
problems.of bottle
the OR
feeding associated
 592 mothers
with healthy baby.of
of a an increase
1 point in the EPDS
 Feeding method
score was 1.06
( p=0.02),

Breastfeeding is associated with increased lung
function at 18 years of age: a cohort Study
Soto-Ramı´rez, Eur Respir J 2012;39:985

Effect of breastfeeding (FVC) (Litres)
at 18 yrs of age by height
 A birth cohort.
 Breastfeeding
duration.

 Spirometric tests
at 10 and 18 yrs.

Association of Exclusive Breastfeeding Duration and
Fibrinogen Levels in Childhood and Adolescence
Labayen I, APAM 2012;166:56
Mean fasting serum fibrinogen levels
according to duration of exclusive
 704 children age breastfeeding duration in the whole sample(A)
9.5 yrs.

 665 adolescents
15.5 yrs.

 Fasting fibrinogen
level.

Erythrocyte zinc levels in children with bronchial asthma
Yilmaz Pediatr Pulmonol 2011;46:1189

Mean concentrations of
erythrocyte zinc (μg/dl)
1500 –

 Erythrocyte zinc levels. ns
1000 – 1215.8 1206
 67 asthmatic and
45 healthy children. 0500 –

0000
Asthmatics Controls


Mean concentrations (μg/dl)
of erythrocyte zinc
in children hospitalized for an asthma
attack in the previous 12 mo.
1500 –
p<0.0001
 Erythrocyte zinc levels. 1248
1000 –
1095
 67 asthmatic and
45 healthy children. 0500 –

0000
NO YES


 The decreased amount of antioxidants in the diet in
recent years has been reported to contribute to the
increased incidence of asthma.
Romieu I Am J Respir Crit Care Med 2002; 166: 703-709
 Glutathione peroxidase and superoxide dismutase, the important
antioxidant enzymes of the body, contain zinc in their structure.
Wright DT Environ Health Perspect 1994; 102: 85-90
 Therefore, zinc is an important antioxidant element.
 It is found in the respiratory tract epithelium, plays a role
in the regulation of the cellular and humoral immune response
and possesses antiapoptotic and anti-inflammatory features
indicating a possible role in asthma pathogenesis and treatment.
Zalevski PD, Pharmacol Ther 2005; 105: 127 -149
Truong-Tran AQ, Am J Physiol Lung Cell Mol Physiol 2000; 279: 1172-1183


 Allergen-sensitized mice where zinc-deficiency was created
through diet showed 1.6 and 3.2 times the rate of the number
of airway eosinophils and epithelial cell
apoptosis, respectively, than those fed a diet containing normal
amounts of zinc. Truong-Tran AQ, Am J Respir Cell Mol Biol
2002; 27: 286–296
 Airway epithelial damage plays an important role in asthma
pathogenesis Zalevski PD, Pharmacol Ther 2005; 105: 127-149 .
The damage to this barrier function is directly related to
caspase 3 activation and the proteolysis of proteins that No
provide intercellular connection.
 Zinc protect airway epithelial integrity by both
preventing caspase 3 activation and the lysis of
proteins that provide intercellular connection.

A randomized controlled trial of zinc as adjuvant therapy
for severe pneumonia in young children
Basnet Pediatrics 2012;129:701

 610 children
aged 2 to 35 months. HR in zinc supplemented for
 Severe pneumonia defined
by the World Health
Organization as cough
and/or breathing combined
1.0 –
1.10
with lower chest indrawing.
 All children
0.88
0.5 –
antibiotic treatment.
 Zinc (10mg in 2- to 11-
month-olds and 20mg in
older children) or placebo 0
daily for up to 14 days.
Faster Treatment
recovery failure

A randomized controlled trial of zinc as adjuvant therapy
for severe pneumonia in young children
Basnet Pediatrics 2012;129:701

 610 children
aged 2 to 35 months. HR in zinc supplemented for
Adjunct treatment
 Severe pneumonia defined
with zinc
by the World Health
Organization as cough time
reduced the
to cessation
and/or breathing combined
1.0 –
1.10
with lower chest indrawing.
of severe pneumonia
 All children the risk
0.88
and
antibiotic treatment.
0.5 –

of treatment failure
 Zinc (10mg in 2- to 11-
only marginally
month-olds and 20mg in .
older children) or placebo 0
daily for up to 14 days.
Faster Treatment
recovery failure

Maternal Serum Vitamin D Levels During Pregnancy
and Offspring Neurocognitive Development
Whitehouse, Pediatrics 2012;129;485

Analyses revealed no
 Serum 25(OH)-vitamin D significant associations
concentrations.
between maternal
 743 Caucasian women at 25(OH)-vitamin D
18 weeks pregnancy serum quartiles and
(grouped into quartiles). offspring behavioral/
emotional problems
 Child Behavior Checklist at any age.
at 2, 5, 8, 10, 14, and 17
years of age.
But…….

There were significant linear
trends between quartiles of
 Serum 25(OH)-vitamin D maternal vitamin D levels and
concentrations. language impairment at 5 and
10 years of age.The risk of
 743 Caucasian women at women with vitamin D
18 weeks pregnancy insufficiency (≤46 nmol/L)
(grouped into quartiles). during pregnancy having a
child with clinically
 Child Behavior Checklist significant language
at 2, 5, 8, 10, 14, and 17 difficulties was increased
years of age. close to 2x compared with
women with vitamin D
levels ≥70 nmol/L.


Proportion of offspring
with mild or moderate-severe
language impairment
at 5 (Y5)a and 10 years (Y10)b
of age according to maternal
serum 25(OH)-vitamin D levels
at 18 weeks’ pregnancy.


Association Between Maternal 25(OH)-Vitamin D Concentration
at 18 Weeks’ Pregnancy and Offspring
Language Impairment During Childhood


Vitamin DWeeks’ Pregnancy and Offspring
at 18 performs a number of biological
Language Impairment fundamental to
functions that are During Childhood
neurodevelopment, including a signaling role in
neuronal differentiation, a regulation role in the
metabolism of neurotrophic factors and
neurotoxins, and a protective role during brain
inflammation.


Vitamin18 Weeks’ Pregnancy and Offspring in
at D may also be indirectly involved
Language Impairment During Childhood
fetal brain growth through its role in a number
of endocrine functions.

Reduced levels of vitamin D
may disrupt 1 or more of these functions
during critical phases of
neurodevelopment.

Cord Blood Vitamin D Deficiency Is Associated With
Respiratory Syncytial Virus Bronchiolitis
Belderbos Pediatrics 2011;127:e1513
 156 healthy term Cord blood concentrations of 25-OHD in
neonates. neonates who subsequently developed RSV
LRTI (n=18) and those who did not (n=138)
 25-hydroxyvitamin D
(25-OHD) in cord blood
plasma.

 Lower respiratory tract
infection (LRTI) caused
by Respiratory Syncytial
Virus (RSV) in the first
year of life, defined as
LRTI symptoms and
presence of RSV RNA in
a nose-throat specimen.

 156 healthy term Relative Risk (RR) of RSV LRTI per
quartile of 25-OHD levels.
neonates. Because of the limited number of cases, the lower quartiles
(25 nmol/L, n=7; and 25–49 nmol/L, n=29) were pooled

plasma.

LRTI symptoms and


Vitamin D (25 nmol/L, n=7; and 25–49 nmol/L, n=29) were pooled

deficiency in
healthy neonates is
plasma.
associated with
increased risk of
RSV LRTI in the
Virus (RSV) in year
first the first
of life.
LRTI symptoms and

Intensified (25 nmol/L, n=7; and 25–49 nmol/L, n=29) were pooled

 25-hydroxyvitamin D D
routine vitamin
supplementation
plasma.
during pregnancy
may be a useful
strategy to prevent
RSV LRTI
year during defined as
of life, infancy.
LRTI symptoms and

A cross-sectional study of vitamin D and insulin
resistance in children Kelly Arch Dis Child 2011;96:447

 Cross-sectional study of
85 (4–18 yrs). % children with vitamin D
50 –
 Fasting blood
glucose, insulin and 25- 40 – 47%
OH-D were measured.
30 –

 Homeostasis model 20 – 26% 27%
assessment
(HOMA), a measure 10 –
of insulin sensitivity, was
0
calculated as (fasting sufficient intermediate insufficient
blood glucose (≥75 nmol/l) (50–75 nmol/l) (25–50 nmol/l)
(mmol/l)×insulin
(μU/ml))/22.5.

A cross-sectional study of vitamin D and insulin
resistance in children Kelly Arch Dis Child 2011;96:447

 Cross-sectional study of
85 (4–18 yrs). % children with vitamin D
Lower 25-OH-D
50 –
was associated with
Fasting blood
higher , fasting blood
glucose insulin and 25- 40 – 47%
OH-D were measured.
glucose, 30 –

 insulin andmodel
Homeostasis HOMA 20 – 26% 27%
after
assessment
(HOMA), a measure
adjustment for 10 –
of insulin sensitivity, was
puberty
calculated as (fasting
0
sufficient intermediate insufficient
and BMI-Z.
blood glucose (≥75 nmol/l) (50–75 nmol/l) (25–50 nmol/l)
(mmol/l)×insulin
(μU/ml))/22.5.

Vitamin D Deficiency, Adiposity, and
Cardiometabolic Risk in Urban Schoolchildren
Sacheck, J Ped 2011;159:945

 263 schoolchildren living in % children
northeastern US. 80 –

 Serum 25-hydroxyvitamin D
[25(OH)D].
70 –

60 –
74.6%
 Body mass index (BMI) z-score
(BMIz). 50 –

 6 cardiometabolic risk factors: 40 –
- total cholesterol; 30 –
- HDL cholesterol;
20 –
- LDL cholesterol;
- triglycerides; 10 –

- interleukin-6; 0
Vitamin D deficient
- C-reactive protein [CRP]. [25(OH)D <50 nmol/L]

Vitamin D Deficiency, Adiposity, and
Cardiometabolic Risk in Urban Schoolchildren
Sacheck, J Ped 2011;159:945

 263 schoolchildren living in % children
northeastern US. 80 –

 Serum 25-hydroxyvitamin D
The 25(OH)D level
[25(OH)D].
70 –

60 –
74.6%
was not associated
 Body mass index (BMI) z-score
(BMIz). with 50 –

BMIz, but was
 6 cardiometabolic risk factors: 40 –
positively associated
- total cholesterol; 30 –
-with cholesterol;
HDL the cardiometabolic
20 –
risk factor
- LDL cholesterol;
- triglycerides; 10 –

- interleukin-6; 0
Vitamin D deficient
- C-reactive protein [CRP]. [25(OH)D <50 nmol/L]

Determinants of 25(OH)D Sufficiency
in Obese Minority Children:
Selecting Outcome Measures and Analytic Approaches
Zhou, J Ped 2011;158:930
Smoothed relationships of Systolic Blood
Pressure to Vitamin D levels

 Serum 25-(OH)
vitamin D (ng/mL). (r=-0.261; P=0.038)

 140 healthy obese
children age 6 to
21 years.

Determinants of 25(OH)D Sufficiency
in Obese Minority Children:
Selecting Outcome Measures and Analytic Approaches
Zhou, J Ped 2011;158:930
Smoothed relationships of Systolic Blood
Pressure to Vitamin D levels

 Serum 25-(OH)
Systolic blood
vitamin D. (r=-0.261; P=0.038)
pressure (SBP)
was significantly
 140 healthy obese
children age 6 with
correlated to
21 years.
25(OH)D.

Recent trends and clinical features of childhood
vitamin D deficiency presenting to a children’s
hospital in Glasgow
Ahmed Arch Dis Child 2011;96:694
Number of cases presenting each year
between 2002 and 2008 categorized
 Between 2002 and 2008. according to four broad ethnic backgrounds.

Cases of symptomatic
vitamin D deficiency.
(bowed legs, fractures, limb
pain, X-ray which highlighted
rickets, swollen wrists, asymptomatic
hypocalcaemia, raised alkaline
phosphatase (ALP)
concentration, developmental
delay, cardiac failure and
hypocalcaemia and which resolved
following treatment with calcium and
vitamin D.)

hospital in Glasgow
Reason for referral for investigation and
management of 160 children with suspected
 Between 2002 and 2008. of cases D deficiency according to age
The number vitamin of vitamin D
deficiency is currently increasing.
categories at presentation.
The change in the relative proportion of
(bowed legs, fractures, limbfrom different ethnic origins
cases
pain, X-ray which highlighted reflects the
changing patterns of immigration
phosphatase (ALP) and birth patterns
delay, cardiac failure and in the West of Scotland.
vitamin D.)

hospital in Glasgow
Reason for referral for investigation and
management of 160 children with suspected
 Between 2002 and 2008. vitamin D deficiency according to age

It is imperative that the categories at presentation.

vitamin D deficiency. priority remains the
first
(bowed legs, fractures, limb
pain, eradication of
X-ray which highlighted

profound, symptomatic
phosphatase (ALP)
delay, cardiac failure and
vitamin D.)

•Vitamina D
•raccomandazioni

The 2011 report on dietary reference intakes for
calcium and vitamin D from the Institute of Medicine:
what clinicians need to know.
Ross AC, J Clin Endocrinol Metab. 2011;96:53-8.

RDA = Recommended Dietary Allowance; UL= tolerable upper intake level; c= not well defined


Dietary Reference
Intake
shown in Table 1
are based on dietary
requirements
using bone health as
an indicator.

RDA = Recommended Dietary Allowance; UL= tolerable upper intake level; c= not well defined

For vitamin D, the 2011 Dietary Reference Intake (DRIs) are
based primarily on the integration of bone health outcomes with
evidence concerning 25OHD levels, which suggest that levels of
16 ng/ml (40 nmol/liter) meet the needs of approximately half the
population (median population requirement), and levels of at least
20 ng/ml (50 nmol/liter) meet the needs of at least 97.5% of the
population.

These levels will be useful to clinicians as they consider
management of patients under their care.

Thus, serum 25OHD levels above 50 ng/ml (125 nmol/liter) should
raise concerns among clinicians about potential adverse effects.

The IOM D-lemma.
Holick MF. Public Health Nutr. 2011;14:939-41

Pregnant and lactating women
need more than 15µg (600 IU)
vitamin D/d.

However in forty mother–infant pairs where
70% of the women were taking on average
15µg vitamin D/d, it was reported that 76% of the mothers and
81% of the newborns at the time of birth had 25-hydroxyvitamin
D level <20 ng/ml
Lee JM, Smith JR, Philipp BL et al. Vitamin D deficiency in a healthy group of
mothers and newborn infants. Clin Pediatr 2007;46:42–44.

The IOM D-lemma.
Holick MF. Public Health Nutr. 2011;14:939-41

Furthermore it was reported that
Pre-eclampsia
Bodnar LM, J Clin Endocrinol
Metab, 2007; 92: 3517–3522.

and

the need for a primary
Caesarean section
Merewood A, J Clin Endocrinol Metab. 2009;
94: 940–945.

were associated with
Vitamin D deficiency (<20 ng/mL).

Inappropriate and inconsistent modalities of treatment of
vitamin D deficiency in children
Gupta Arch Did Child 2011;96:787

• Pearce and Cheetham (BMJ 2010;340:b5664) in their article on
―Diagnosis and management of vitamin D deficiency‖, quite
clearly recommend the use of calciferol (3000-6000 IU/day)
in the treatment of vitamin D deficiency in children.

• Expert opinion from the British Society for Paediatric
Endocrinology and Diabetes also confirm this reccomendation.

Micronutrienti:
Acido folico
Fatty Acids
DHA EPA

High Folate Intake Is Related to Better Academic
Achievement in Swedish Adolescents
Nilsson, Pediatrics 2011;128:e358

An increased plasma total homocysteine (tHcy)
serves as a marker for functional deficiency of certain B
vitamins, such as B12, B6, riboflavin, and, in particular, folate.
The genetic model disease homocystinuria is characterized by
high plasma tHcy levels, mental retardation, and a range of
psychiatric symptoms, in addition to premature atherosclerosis.
In more recent studies, links have been found between
impaired homocysteine metabolism and a wide range of
neuropsychiatric conditions such as
depression, cognitive impairment, and dementia
in adult populations and in the elderly.

 386 Swedish adolescents
aged 15 yrs.
 The sum of school grades in
10 core subjects obtained Academic achievement
in the final semester of was
compulsory 9 years of strongly correlated to
schooling used as outcome tertiles of tHcy
measure of academic (negatively; P=0.023)
achievement. and to
Adolescents are vulnerable tertiles of folate intake
to increased plasma total (positively; P<0.001).
homocysteine (tHcy) and to
insufficient folate status.

Folic Acid Use in Pregnancy and the Development of
Atopy, Asthma, and Lung Function in Childhood
Magdelijns Pediatrics 2011;128:e144

 KOALA Birth Cohort •Maternal folic acid supplement
Study (n=2834). use during pregnancy was not
 Data on eczema associated with increased risk
and wheeze at of wheeze, lung
3, 7, 12, and 24 function, asthma, or related
months, 4 atopic outcomes in the
to 5 years, and offspring.
6 to 7 years.

 Intracellular folic acid
•Maternal ICF level in late
pregnancy was inversely
(ICF) determined in
blood samples taken at associated with asthma risk at
~35 weeks of pregnancy age 6 to 7 years in a
(n=837). dose-dependent manner

Folic Acid Use in Pregnancy and the Development of
Atopy, Asthma, and Lung Function in Childhood
Magdelijns Pediatrics 2011;128:e144

OR for asthma at 6-7 yrs
1.0 –
1.0
p<0.05 for trend
0.73
0.5 –
0.46 0.41
0.31
0.0
1st Quintile 2nd Quintile 3rd Quintile 4th Quintile 5th Quintile
(≤ 480 nmol/L) (481–643 (644–862 (863–1139 (≥ 1140 nmol/L)
nmol/L) nmol/L) nmol/L)
Intracellular folic acid Levels (Divided Into Quintiles)

Decreased Postnatal Docosahexaenoic and Arachidonic
Acid Blood Levels in Premature Infants are Associated
with Neonatal Morbidities Martin, J Ped 2011;159:743

88 infants born at <30 Docosahexaenoic acid
weeks‘ gestation. (DHA) and
arachidonic acid
Fatty acid profiles levels declined
during the first rapidly in the first
postnatal month. postnatal week, with
a concomitant
Infant increase in linoleic
outcomes, including
acid levels.
chronic lung disease
(CLD).


88 infants born at <30
weeks‘ gestation.

Fatty acid profiles
during the first
postnatal month.

Infant
outcomes, including
(CLD).


OR for chronic lung disease
88 infants born at <30 3 –
weeks‘ gestation.

Fatty acid profiles 2 –
2.5
during the first
postnatal month.
1 –
Infant
outcomes, including
0
(CLD).
Decreased DHA level


HR for late onset sepsis
88 infants born at <30 3 –
weeks‘ gestation.

Fatty acid profiles 2 –
during the first
postnatal month.
1 –
1.4
Infant
outcomes, including
0
(CLD).
Decreased arachidonic acid level

High-Dose Docosahexaenoic Acid Supplementation of
Preterm Infants: Respiratory and Allergy Outcomes
Manley Pediatrics 2011;128:e71

 657 preterm infants 33 weeks‘ RR of BDP in all infants with
gestation who consumed a birth weight of 1250 g
expressed breast milk from 1.0 –
mothers taking either 0.9 –
tuna oil (high-DHA diet) or 0.8 –

0.75
0.7 –
soy oil (standard-DHA)
0.6 –
capsules. 0.5 –
0.4 – p=0.04
 Incidence of bronchopulmonary 0.3 –
dysplasia (BPD) and parental 0.2 –
0.1 –
reporting of atopic conditions
0
over the first 18 months of DHA diet
life.

High-Dose Docosahexaenoic Acid Supplementation of
Preterm Infants: Respiratory and Allergy Outcomes
Manley Pediatrics 2011;128:e71

 657 preterm infants 33 weeks‘ RR of reported hay fever
gestation who consumed in all infants at either
expressed breast milk from 12 or 18 months
1.0 –
mothers taking either
0.9 –
tuna oil (high-DHA diet) or 0.8 –
soy oil (standard-DHA) 0.7 –
capsules. 0.6 –
0.5 –
0.4 –
 Incidence of bronchopulmonary
dysplasia (BPD) and parental
0.3 –
0.2 –
0.41
reporting of atopic conditions 0.1 –
p=0.03
over the first 18 months of 0
life. DHA diet

Impaired Fetal Growth and Arterial Wall Thickening:
A Randomized Trial of Omega-3 Supplementation
Skilton, Pediatrics 2012;129;e698

WHAT’S KNOWN ON THIS SUBJECT:
Impaired fetal growth is an independent risk factor for
cardiovascular diseases in adulthood and is associated with
arterial wall thickening, a noninvasive measure of subclinical
atherosclerosis, in early childhood. No preventive strategy has
been identified.

WHAT THIS STUDY ADDS: Dietary omega-3 fatty acid
supplementation in early childhood prevented the association of
impaired fetal growth with arterial wall thickening, suggesting
that this early-life intervention may mitigate the risk of
cardiovascular disease in those with impaired fetal growth.


 616 children born at term. Fetal growth was inversely
associated with carotid
 Either a 500-mg-daily fish oil intima-media
supplement and canola based
margarines and cooking oil
thickness (IMT),
(omega-3 group). but this was prevented
in the omega-3 group.
 500-mg-daily sunflower oil
supplement and omega-6 fatty Pheterogeneity = 0.02
acid–rich margarines and cooking
oil (control group).

 From the start of bottle-feeding
or 6 months of age until 5 years
of age.


 616 children born at term. Fetal growth was inversely
The inverse association associated with carotid
 Either a 500-mg-daily fish oil intima-media
of fetal growth with
supplement and canola based
margarines wallcooking oil
arterial and thickness thickness (IMT),
(omega-3 group). can be
at age 8 yrs but this was prevented
prevented by dietary in the omega-3 group.
 500-mg-daily sunflower oil
omega-3 fatty acid
supplement and omega-6 fatty Pheterogeneity = 0.02
supplementation
acid–rich margarines and cooking
over the first
oil (control group).
5 years of life.
 From the start of bottle-feeding
or 6 months of age until 5 years
of age.

Pulse oximetry screening for congenital heart defects in
newborn infants (PulseOx): a test accuracy study.
Ewer, Lancet 2011;378:785

Number of babies with
major congenital heart disease

 6 maternity units in the UK. 60 –

 20055 asymptomatic
53
50 –
newborn babies.
40 –
 Pulse oximetry before discharge. (0.26%)
30 –
 Infants who did not achieve (24 critical)
oxygen saturation thresholds 20 –
underwent echocardiography.
10 –

0

Endorsement of Health and Human Services
Recommendation for Pulse Oximetry Screening for
Critical Congenital Heart Disease SECTION ON CARDIOLOGY
AND CARDIAC SURGERY EXECUTIVE COMMITTEE Pediatrics 2012;129;190

The screening is targeted toward healthy
newborn infants in the newborn nursery.

Screening should be performed with motion-tolerant
pulse oximeters.

Screening should not be undertaken until 24 hours
of life or as late as possible if early discharge
is planned to reduce the number of false positive
results.


•O2 saturations should be obtained in the right hand and one foot.
•Screening that has a pulse oximetry reading of ≥95% in either
extremity with a ≤3% absolute difference between the upper and
lower extremity would be considered a pass, and the screening
would end. It is recommended that repeated measurements be
performed in those cases in which the initial screening result
was positive, again in an effort to reduce
false-positive results.

•Infants with saturations <90% should receive
immediate evaluation.


•O2 saturations should be obtained in the right hand and one foot.
•Screening that has a pulse oximetry reading of ≥95% in either
In the event of a positive screening
extremity with a ≤3% absolute differenceexcluded
result, CCHD needs to be between the upper and
lower extremity would be considered a pass, and the screening
with a diagnostic echocardiogram.
would end. It is recommended that repeated measurements be
performed Infectious andwhich the initial screening result
in those cases in pulmonary causes
was positive, again in an effort to reduce excluded.
of hypoxemia should also be
false-positive results.

•Infants with saturations <90% should receive
immediate evaluation.

CARDIOLOGY
-dolore toracico
-tachicardia
-sincope collasso

Postural Tachycardia in Children and Adolescents:
What is Abnormal? Singer, J Pediatr 2012;160:222

1) The diagnosis of orthostatic intolerance (OI) and
postural orthostatic tachycardia syndrome (POTS) is based on a
symptomatic, excessive orthostatic rise in heart rate (HR).
2) Common symptoms of OI and POTS include
lightheadedness, palpitations, pre-syncopal
feelings, tremulousness, and leg weakness when assuming the
upright position.
3) These symptoms are considered related to a combination of
reduced cerebral perfusion and increased sympathetic
activation.
4) OI and POTS occur predominately in females, with
female:male of approximately 5:1.


Orthostatic HR increment
 654 pediatric patients during head-up tilt in normal controls
referred with symptoms and patients with symptoms of OI
of orthostatic intolerance
OI.

 106 normal controls
aged 8-19 yrs.

 Standardized autonomic
testing, including
5 min of 70° head-up tilt
after supine resting
for at least 30 min.


Orthostatic HR increment
 654 pediatric patients during head-up tilt in normal controls
referred with symptoms and patients with symptoms of OI
of orthostatic intolerance
The HR increment
OI. was mildly higher
in patients referred
 106 normalOI/POTS,
for controls
aged 8-19 yrs.
but there was
considerable overlap
 Standardizedthe patient
between autonomic
testing, includinggroups.
and control
5 min of 70° head-up tilt
after supine resting
for at least 30 min.


Our study demonstrates that:

an orthostatic HR increment of 30 bpm
(the main diagnostic criterion for OI in adults)
is still well within the normal range for children
and adolescents.
x


We suggest the following diagnostic criteria for
Pediatric Orthostatic Intolerance:

1) Symptoms of OI, such as lightheadedness and
palpitations, occurring frequently (>50% of the time)
when assuming the upright position
&
2) orthostatic HR increment ≥40 bpm within 5 minutes
of head-up tilt.
OI=orthostatic intolerance
POTS= postural tachycardia syndrome


We suggest the following diagnostic criteria for
pediatric postural orthostatic tachycardia syndrome:

1) Symptoms and HR increment fulfilling criteria for
pediatric OI
&
2) absolute orthostatic HR ≥130 bpm (for age ≤13
years), or ≥120 bpm (for age ≥14 years) within 5
minutes of head-up tilt.
OI=orthostatic intolerance
POTS= postural tachycardia syndrome

Plasma Hydrogen Sulfide (H2S) in Differential Diagnosis
between Vasovagal Syncope and Postural Orthostatic
Tachycardia Syndrome in Children, Zhang, J Pediatr 2012;160:227

1) Orthostatic intolerance (OI) is a constellation of signs and
symptoms that are elicited by standing upright and relieved by
recumbency. Symptoms include headache, nausea, abdominal
pain, lightheadedness, diminished
concentration, tremulousness, syncope, near syncope, and
hyperpnea.
2) Postural orthostatic tachycardia syndrome (POTS) and vasovagal
syncope (VVS) are common causes of OI in children.
3) POTS is defined operationally by symptoms of OI in association
with excessive tachycardia.
4) Vaso Vagal Syndrome is defined by a sudden transient loss of
consciousness and postural tone caused by blood pressure drops
and bradicardia with consequent cerebral hypoperfusion.


Plasma concentrations of H2S in the
 Vasovagal syncope control, POTS and VVS groups.
(VVS) (n=17).
 Postural Orthostatic
Tachycardia Syndrome
(POTS) in children
(n=60).
 Healthy children
(control group) (n=28).
 Plasma concentrations
of hydrogen sulfide
H2S.(acido solfidrico)


1) Hydrogen sulfide (H2S) had long been known as a toxic gas, but only
recently has it been regarded as a novel endogenous gasotransmitter.
2) It is produced endogenously in mammalian tissues from L-cysteine
by mainly 3 enzymes: cystathionine b-synthetase, cystathionine γ-
lyase, and 3-mercaptosulfurtransferase.
3) H2S could be produced by vascular smooth muscle cells and
endothelial cells. It contributes to endothelium-dependent
vasorelaxation and exerts regulatory effects on the pathogenesis
of various diseases, such as hypertension, pulmonary hypertension
and shock.
4) For POTS, the abnormal vascular relaxation and cardiothoracic
hypovolemia are thought to be the mechanisms.

Association of microbial IgE sensitizations with asthma
in young children with atopic dermatitis
Ong, Ann Allergy Asthma Immunol 2012;108:206
OR for persistent asthma
 53 children (1-6 yrs) 5 –
with mild to moderate AD.
 Total serum IgE and 4 – 4.3 4.2
specific IgE for:
- inhalant allergens 3 – 3.5
- common food
2-
- microbial allergens
(Staphylococcal
1 –
enterotoxins, Aspergillus
fumigatus, Cladosporium Nature Genetics,
00 2006:38:399
herbarum, Malassezia C albicans C herbarum Malassezia
species, and Candida albicans).
SENSITIZATION to

Association of microbial IgE sensitizations with asthma
in young children with atopic dermatitis
Ong, Ann Allergy Asthma Immunol 2012;108:206
OR for persistent asthma
 53 children (1-6 yrs) 5 –
with mild to moderate AD.
 Total serum IgE and
Persistent asthma
4 – 4.3 4.2
specific IgE for:
was associated with
- inhalant allergens 3 – 3.5
- common food IgE
fungal
2-
sensitizations.
- microbial allergens
(Staphylococcal
1 –
enterotoxins, Aspergillus
fumigatus, Cladosporium Nature Genetics,
00 2006:38:399
herbarum, Malassezia C albicans C herbarum Malassezia
species, and Candida albicans).
SENSITIZATION to

Depression, anxiety and dermatologic quality of life
in adolescents with atopic dermatitis
Slattery JACI 2011;128:668
% children with anxiety
30 – disorders

 36 adolescents, mean age 20 – 26%
14.7 yrs with AD.
Social
 SCORAD index. anxiety
10 –
 Children‘s Depression disordes was 6%
most common
Inventory and the 3%
(14%)
Multidimensional Anxiety 0
Scale for Children. AD Community
estimates

% children with current
depressive disorders
10 –

 36 adolescents, mean age
14.7 yrs with AD.
9%
6%
05 –
 SCORAD index.
 Children‘s Depression
Inventory and the
estimates

% children with current
depressive disorders
Subjective report 10 –

of sleep loss was the
 36 adolescents,severity
only AD mean age
14.7 yrs with AD.
9%
measure found 05
6%
–
 SCORAD index.
to be associated
with symptoms
 Children‘s Depression
Inventorydepression.
of and the
estimates

Emollients, education and quality of life: the RCPCH
care pathway for children with eczema
Cox Arch dis Child 2011;96:i19

The Royal College of Paediatrics and
Child Health (RCPCH)
• Effective eczema management is holistic and encompasses:
- assessment of severity and impact on quality of
life, - treatment of the inflamed epidermal skin
barrier, - recognition and treatment of
infection, - assessment and
management of environmental and allergy trigger.

• Patient and family education which seeks to maximise
understanding and concordance with treatment is also important
in all children with eczema.

Emollients, education and quality of life: the RCPCH
care pathway for children with eczema
Cox Arch dis Child 2011;96:i19

Stepped approach to treatment

Effect of moisturizers on epidermal barrier function.
Lodén M. Clin Dermatol. 2012;30:286-96.
Time to outbreak of eczema in patients with controlled
A daily moisturizing atopic eczema being treated with a barrier-improving
routine is a vital part moisturizer, being untreated or a being treated with a
of the management of potentially barrier deteriorating moisturizer
patients with atopic (vaseline suggested to promote relapse of eczema).
dermatitis and other
dry skin conditions.
The composition of
the moisturizer
determines whether
the treatment
strengthens or
deteriorates the skin
barrier
function, which may
have consequences for
the outcome of the
dermatitis.

A pilot study of silver-loaded cellulose fabric with
incorporated seaweed for the treatment of atopic
dermatitis.Park KY, Clin Exp Dermatol. 2012 [Epub ahead of print]

newly developed silver-loaded
cellulose fabric with incorporated
seaweed,
12 subjects with mild to
moderate atopic dermatitis into a Silver
clinical control study. loaded
The subjects wore a two-piece
garment (top and leggings), each Cotton
piece of which was divided into 100%
two parts: one side was made of
SkinDoctor(®) fabric, and the
other of 100% cotton

A pilot study of silver-loaded cellulose fabric with
incorporated seaweed for the treatment of atopic
dermatitis.Park KY, Clin Exp Dermatol. 2012 [Epub ahead of print]
Mean SCORAD index of areas covered
with SkinDoctor compared with those
newly developed silver-loaded covered with cotton
cellulose fabric with incorporated
seaweed,
12 subjects with mild to
moderate atopic dermatitis into a
clinical control study.
The subjects wore a two-piece
garment (top and leggings), each
piece of which was divided into
two parts: one side was made of
SkinDoctor(®) fabric, and the
other of 100% cotton

New Insights About Infant and Toddler Skin:
Implications for Sun Protection Paller Pediatrics 2011;128:92
Infant epidermal structure
1) The outermost layer of
(SC) epidermis, the SC, protects
skin from adverse
environmental
conditions, including ultraviolet
radiation (UVR) penetration and
systemic absorption of topically
applied materials such as
sunscreens.

2) Although the SC is present at
birth, it gains
thickness, hydration
capacity, and acidification
throughout infancy as it
increases its capacity to adapt

New Insights About Infant and Toddler Skin:
Implications for Sun Protection Paller Pediatrics 2011;128:92

1) Accumulating evidence suggests not only that the
skin‘s barrier protection remains immature
throughout at least the first 2 years of life but also
that accumulation of UVR-induced changes in the
skin may begin as early as the first summer of life.

2) Such evidence affirms the importance of sun
protection during the infant and toddler years.

Prospective Study of Sunburn and Sun Behavior
Patterns During Adolescence Dusza, Pediatrics 2012;129;309

1) Melanoma is a significant and growing public health concern.

2) UV light radiation (UVR) exposure is the most important modifiable
melanoma risk factor.

3) Studies have shown that intense, intermittent exposures to UVR, as
measured by sunburn frequency, have a higher melanoma-attributable
risk than chronic UVR exposure.

4) UVR exposures at an early age are particularly important for the
development of cutaneous melanoma in adulthood.

5) A recent meta-analysis of 51 studies found that ever reporting a
sunburn during childhood almost 2X the risk for the development of
cutaneous melanoma in adulthood.

% students reported having at least
1 sunburn during the previous summer
60 -

 A prospective, population- 50 –
53% 55%
based study in 360
40 –
fifthgrade children
(∼10 years of age). 30 –

 At baseline 20 –
(September–October 2004)
and 10 –
again 3 years later
(September–October 2007). 000
2004 2007

% children reporting “often or always”
use of sunscreen when outside for at
least 6 hours in the summer
60 -

 A prospective, population- 50 –
based study in 360
40 –
50%
fifthgrade children p<0.001
(∼10 years of age). 30 –

 At baseline (September–
October 2004) and
20 – 25%
again 3 years later 10 –
(September–October 2007).
000
2004 2007

Comparative Effectiveness of Antibiotic Treatment
Strategies for Pediatric Skin and Soft-Tissue
Infections Williams Pediatrics 2011;128:e479

OR for treatment failures
 Retrospective cohort of 2.5 –
6407children 0 to 17 yrs.
 Treatment of pediatric
2.0 –
2.23
skin and soft-tissue 1.5 – 1.92
infections (SSTIs). 1.0 –
 Treatment failure
0.5 –
(SSTI ≤14 days after
the treatment of incident 0 0
SSTI) and recurrence Trimethoprim β-lactams
-sulfamethoxazole
(SSTI >15 and ≤365 days).
Compared with
clindamycin


 Retrospective cohort of OR for recurrences
6407children 0 to 17 yrs.
 Treatment of pediatric 1.5 – 1.26
skin and soft-tissue 1.49
infections (SSTIs). 1.0 –

 Treatment failure 0.5 –
(SSTI ≤14 days after
the treatment of incident 0 0
Trimethoprim β-lactams
SSTI) and recurrence -sulfamethoxazole
(SSTI >15 and ≤365 days). Compared with
clindamycin


• The growing burden of community-associated (CA)
methicillin-resistant Staphylococcus aureus (MRSA), which is
estimated to account for70% of staphylococcal infections in some
regions of the United States, is a major problem in childhood.
• A frequent cause of skin and soft-tissue infections
(SSTIs), CA-MRSA infections often are more severe and lead
to poor clinical outcomes.
• CA-MRSA isolates are uniformly resistant to β-lactam
antibiotics, previously the most commonly used agents for
SSTIs, which makes prompt recognition and initiation of effective
empiric therapy for CA-MRSA extremely important.


• The growing burden of community-associated (CA)
methicillin-resistant Staphylococcus aureus (MRSA), which is
estimated to account for70% of staphylococcal infections in some
regions of the United States, is a major problem in childhood.
Currently,
• A frequent cause most commonly recommended,
the of skin and soft-tissue infections
(SSTIs), orally administered antibiotics
CA-MRSA infections often are more severe and lead
to poor clinical outcomes. SSTIs include clindamycin
for pediatric
• CA-MRSA (10-25 mg/kg/day in 3-4 divided doses)
isolates are uniformly resistant to β-lactam
antibiotics, and trimethoprim-sulfamethoxazole.
previously the most commonly used agents for
SSTIs, which makes prompt di TM/Kg/die)
(6 mg recognition and initiation of effective
empiric therapy for CA-MRSA extremely important.

Indications for growth hormone therapy in children
Kirk, Arch Dis Child 2012;97:63

1) Growth hormone (GH) therapy has now been available
for over 5 decades, with all GH now biosynthetically
produced, and administered by daily injection
2) Paediatric GH is currently licensed in 6 different conditions:
growth hormone deficiency (GHD), Turner syndrome
(TS), small for gestational age (SGA), Prader-Willi
syndrome (PWS), chronic renal insufficiency (CRI) and short
stature due to SHOX deficiency (short stature homeobox-
containing gene); all of these have been ratified by the most
recent (2010) NICE review
3) Whilst the primary purpose of paediatric GH therapy in most
indications is to improve short and long-term growth, in others
(eg. PWS) it has a role in improvement of body composition


Doses of growth hormone (GH) for paediatric GH licenses


Growth hormone deficiency (GHD)
This is the commonest endocrine disorder presenting with short
stature. Most (~70%) of patients with GHD have an isolated
deficiency of GH.
The commonest causes of GHD are as follows:
- Congenital (midline embryonic anomalies and transcription factor defects)
- Acquired (tumour, trauma, irradiation, infiltration, infection)
- Idiopathic
The classical clinical phenotype includes:
- short stature (both in relation to peers and also parents)
- poor growth (Height Velocity <25th centile for at least 1 year)
- delayed bone age (with associated delayed dentition and puberty)
GHD is confirmed by a peak plasma GH level <6.7 μg/L to two
provocative tests


Turner syndrome (TS)
This is the commonest gonadal dysgenesis in
females (1 in 2000), and is due to abnormalities
within the X-chromosome (45 XO).
The short stature in TS is multifactorial, due to
a combination of: intrauterine growth
retardation, poor growth in childhood, an
absent pubertal growth spurt and a
mild skeletal dysplasia, for example, short
neck, wide carrying angle, hand and nail abnormalities.
As a result final height is reduced by 21 cm from mid-parental
height.
Different studies indicate that the earlier GH is started the
better the height outcome; in addition to GH therapy sex hormones

Prader-Willi syndrome (PWS)
PWS is a dysmorphic syndrome with
clinical features including short
stature, hypogonadism, obesity, abnor
mal body
composition, hypotonia, hyperphagia and
learning and behavioural problems.
It is due to loss of paternally derived
genes on 15q.
In PWS the aim of therapy is both
to improve body composition as well as promoting growth, and GH
results in improvements in both height, body composition and muscle
strength/tone. There have, however, been several reports of sudden
death in PWS patients treated with GH, especially if patients are
severely obese, and in these patients sleep studies should be


Small for gestational age (SGA)
SGA is usually defined as a birth weight and/or length more than
−2.5 SDS below the mean.
These patients are a heterogeneous group, including normal
children, and those growth retarded by maternal, placental and fetal
factors. Approximately 80% of children born SGA show catch-up
growth in the 6 months of life.
Overall, approximately 10% of patients born SGA remain short
(height <−2 SDS).
GH is licensed for children born SGA who fail to show catch-up
growth (HV SDS <0 during the last year) by 4 years of age or
later, and who are short both compared to their peers
(height <−2.5 SD) and parents (parental adjusted height <−1 SD).


Small for gestational age (SGA)
SGA is usually defined as a birth weight and/or length more than
−2.5 SDS below the mean.
These patients are a heterogeneous group, including normal
children, and those growthHeight + by maternal,Height + and fetal
BOYS: Cm: (Father's retarded Mother's placental 13) / 2
factors. Approximately 80% of children born SGA show catch-up
growth in the 6 months of life.
Overall, approximately 10% of patients + Mother's Height) / 2
GIRLS: Cm: (Father's Height - 13 born SGA remain short
(height <−2 SDS).
GH is licensed for children born SGA who fail to show catch-up
growth (HV SDS <0 during the last year) by 4 years of age or
later, and who are short both compared to their peers
(height <−2.5 SD) and parents (parental adjusted height <−1 SD).

A multi-center controlled trial of growth hormone
treatment in children with cystic fibrosis
Stalvey Pediatr Pulmonol 2012;47:252

Height standard deviation score (SDS)
by visit (as randomized subjects)

 68 prepubertal children
<14 years with CF.

 Daily rhGH
(Nutropin AQ) or no
treatment (control) for
12 months, followed by
a 6-month observation
(month 18).


Weight and lean body mass (LBM) change from
baseline to Month 12 (as randomized subjects)

 68 prepubertal children
<14 years with CF.

 Daily rhGH
(Nutropin AQ) or no
12 months, followed by
a 6-month observation
(month 18).


350 –
Increase in FVC (ml)

 68 prepubertal children 300 –
325 p=0.032
<14 years with CF.
ml
250 –

 Daily rhGH 200 –

(Nutropin AQ) or no
150 –
178
12 months, followed by 100 –
ml
a 6-month observation 150 –
(month 18).
150
Rh GH Controls


Mean increase in FEV1 (ml)
300 –

 68 prepubertal children 250 –
<14 years with CF. p=0.004

 Daily rhGH (Nutropin
200 –
224
AQ) or no treatment 150 –
ml
(control) for 12 100 –
months, followed by a 108
6-month observation 150 –
(month 18). ml
150
Rh GH Controls

1) Quale di queste risposte è esatta:

a) Se guidano i nonni ,è più facile che il bambino subisca
un trauma in un eventuale incidente stradale.
b) Se guidano i nonni, è meno probabile che il bambino
subisca un trauma nell‘eventualità d‘incidente
stradale, anche se è meno probabile che sia
adeguatamente allacciato con le cinture di sicurezza
c) Durante i periodi di recessione economica gli abusi
sui minori si riducono
d) Raramente l‘abuso su un minore è un fenomeno
ricorrente

1) Quale di queste risposte è esatta:

a) Se guidano i nonni ,è più facile che il bambino subisca
un trauma in un eventuale incidente stradale.
b) Se guidano i nonni, è meno probabile che il
bambino subisca un trauma nell’eventualità
d’incidente stradale, anche se è meno probabile
che sia adeguatamente allacciato con le cinture
di sicurezza
c) Durante i periodi di recessione economica gli abusi
sui minori si riducono
d) Raramente l‘abuso su un minore è un fenomeno
ricorrente

2) Quale di queste risposta è falsa:

a) L‘eruzione dentaria si associa a comparsa di rialzo
febbrile quasi sempre
b) Le mamme con depressione post partum allattano al
seno meno frequentemente delle mamme non
depresse
c) L‘allattamento al seno aumenta lo sviluppo polmonare
d) L‘allattamento al seno riduce i livelli di fibrinogeno
nel bambino

2) Quale di queste risposta è falsa:

a) L’eruzione dentaria si associa a comparsa di rialzo
febbrile quasi sempre
b) Le mamme con depressione post partum allattano al
seno meno frequentemente delle mamme non
depresse
c) L‘allattamento al seno aumenta lo sviluppo polmonare
d) L‘allattamento al seno riduce i livelli di fibrinogeno
nel bambino

3) Quale di queste risposta è esatta:

a) Il difetto di zinco può favorire la presenza di asma
più grave che richiede l‘ospedalizzazione e protegge
marginalmente dalla comparsa di polmonite di lunga
durata
b) Il difetto di vitamina D in gravidanza non ha
ripercussioni sul bambino
c) Il difetto di vitamina D non ha alcun effetto sul
rischio di infezione da RSV e bronchiolite
d) Il difetto di vitamina D nel bambino non riduce la
resistenza all‘insulina, non aumenta il rischio di
glicemia più alta e non aumenta il rischio di pressione
sistolica più alta nel bambino obeso

3) Quale di queste risposta è esatta:

a) Il difetto di zinco può favorire la presenza di
asma più grave che richiede l’ospedalizzazione
e protegge marginalmente dalla comparsa di
polmonite di lunga durata
b) Il difetto di vitamina D in gravidanza non ha
ripercussioni sul bambino
c) Il difetto di vitamina D non ha alcun effetto sul
rischio di infezione da RSV e bronchiolite
d) Il difetto di vitamina D nel bambino non riduce la
resistenza all‘insulina, non aumenta il rischio di
glicemia più alta e non aumenta il rischio di pressione
sistolica più alta nel bambino obeso

4) Livelli adeguati di acido folico:

a) Si associano ad alti livelli di omocisteina
b) Si associano ad un aumentato rischio di allergia
in età prescolare
c) Si associano a risultati scolastici migliori
d) Nessuna delle risposte è corretta

4) Livelli adeguati di acido folico:

a) Si associano a alti livelli di omocisteina
b) Si associano ad un aumentato rischio di allergia
in età prescolare
c) Si associano a risultati scolastici migliori
d) Nessuna delle risposte è corretta

5) La supplementazione con DHA durante la
gravidanza e/o nei primi mesi di vita:

a) Riduce il rischio di comparsa di displasia
broncopolmonare
b) Riduce il rischio di sepsi nei primi mesi di vita
c) Riduce il rischio di aterosclerosi
d) Tutte le risposte sono corrette

6) La terapia con ormone della crescita:

a) E‘ utilizzata nei bambini con difetto di GH
b) Può essere utilizzata nella sindrome di Turner
e nella sindrome di Prader Willi
c) Può essere utilizzata nell‘insufficienza renale
e nella fibrosi cistica
d) Tutte le risposte sono corrette

Toddler diarrhoea: is it a useful diagnostic label?
Powell, Arch Dis Child 2012;97:84

Definition
1) A variety of different terms, including irritable colon of
childhood, irritable bowel syndrome (IBS) variant, fast transit
diarrhoea, chronic nonspecific diarrhoea (CNSD) and non-specific
diarrhoea in children, have been used to describe the typical
presentation of toddler diarrhoea.
2) CNSD typically presents between the age of 1 and 5 years and is
self-limiting in 90% of cases.
3) Toddler diarrhoea is a term coined many years ago to describe a
young child who passes several loose stools a day but who is
otherwise healthy with excellent growth and normal examination.


Suggested initial investigation
 Full blood count
 C reactive protein
 Erythrocyte sedimentation rate
 Coeliac disease screen—anti-tissue transglutaminase antibody and
total serum IgA
 Stool culture (including Clostridium difficile and giardia)


Differential diagnoses
1) A postenteritis syndrome/cow’s milk protein intolerance
2) Excessive juice intake/fructose intolerance
3) Chronic infection: - Giardia lamblia (giardiasis)
- Cryptosporidium parvum (cryptosporidiosis)
4) Coeliac disease
5) Constipation with overflow diarrhoea
6) Factitious diarrhoea and laxative use
7) Inflammatory bowel disease
8) IBS variant in childhood


Management strategies
 A 6-week trial of a cow's milk- and egg-free diet with dietetic
help
 Reduce fructose/juice intake
 Trial of metronidazole
 Loperamide for symptomatic relief once other diagnoses are
excluded
 Reassurance
 Follow-up

Early Life Events: Infants with Pyloric Stenosis Have a
Higher Risk of Developing Chronic Abdominal Pain in
Childhood Saps, J Ped 2011;159:551

OR for chronic abdominal pain
 100 children diagnosed with
pyloric stenosis during infancy 5 -
(cases).

4.3
4 –
 91 siblings aged 4-20 yrs
without a history of pyloric 3 –

stenosis selected as controls. 2 –
p=0.0045
 Mean time to follow-up was 1 –
7.2 ± 1.6 yrs.
0
cases vs controls

Early Life Events: Infants with Pyloric Stenosis Have a
Higher Risk of Developing Chronic Abdominal Pain in
Childhood Saps, J Ped 2011;159:551

OR for pain-associated
functional gastrointestinal
 100 children diagnosed with disorder (irritable bowel
pyloric stenosis during infancy syndrome, functional
(cases). dyspepsia, functional abdominal
7 - pain)
 91 siblings aged 4-20 yrs
without a history of pyloric
6 -
5 - 6.8
stenosis selected as controls. 4 –
3 –
 Mean time to follow-up was 2 – p=0.043
7.2 ± 1.6 yrs. 1 –
0
cases vs controls

Randomized clinical trial of rapid versus 24-hour
rehydration for children with acute gastroenteritis
Powell Pediatrics 2011;128:e771
Standard Nasogastric
Rehydration involved admission
 254 children 6 to 72 to the hospital ward, where the
months of age with estimated fluid deficit
acute viral (5%–7% of body weight)
gastroenteritis and was replaced with
moderate dehydration. Oral Rehydration Solution
 Randomly to receive over 6 hours, at a constant rate,
either standard through a nasogastric tube.
nasogastric rehydration Patients were reassessed for signs
(SNR) over 24 hours of dehydration after 6 hours.
in the hospital ward
or rapid nasogastric The 24-hour maintenance fluid
rehydration (RNR) requirement then was administered
over 4 hours in the ED. over the subsequent 18 hours.


Rapid Nasogastric Rehydration
 254 children 6 to 72 consisted of 100 mL/kg Oral
months of age with Rehydration Solution, which was
acute viral administered over 4 hours
gastroenteritis and (25 mL/kg per hour)
moderate dehydration.
in the Emergency Department.
 Randomly to receive The patient then was discharged
either standard
nasogastric rehydration from the hospital and was
(SNR) over 24 hours reassessed by a nurse on the
in the hospital ward following day,
or rapid nasogastric either in a home visit or with a
rehydration (RNR)
over 4 hours in the ED. telephone call after 24 hours.


The primary failure rates were similar
for Rapid Nasogastric Rehydration
 254 childrentreatment
Primary 6 to 72 (RNR)
months of age with (11.8% [95% CI: 6.0%–17.6%])
acute viralwas defined
failure
and Standard Nasogastric Rehydration
as an additional loss
gastroenteritis and (SNR) (9.2% [95% CI: 3.7%–14.7%];
moderate at any time
of 2% dehydration. p=0.52).
during the rehydration
 Randomly to receive
either standard Secondary treatment failure was
process, compared
nasogastric rehydration more common in the SNR group
with the admission
(SNR) over 24 hours (44% [95% CI: 34.6%–53.4%])
in the hospital ward than in the RNR group
weight. (30.3% [95% CI: 22.5%–38.8%];
or rapid nasogastric
rehydration (RNR) over p= 0.03).
4 hours in the ED.

What 2012 general paediatrics

Recommended

Recommended

More Related Content

Similar to What 2012 general paediatrics

Similar to What 2012 general paediatrics (20)

More from Envicon Medical Srl

More from Envicon Medical Srl (20)

Recently uploaded

Recently uploaded (20)

What 2012 general paediatrics