Current Pediatric Reviews - Volume 13, Issue 2, 2017

Background: Minor head trauma is one of the leading causes of accessing pediatric emergency departments; however, only a limited number of patients develops clinically relevant brain injuries. Objectives: The aim of this review is to provide physicians a clinical pathway for managing pediatric minor head trauma. Methods: A Pubmed/Medline search was conducted through the following entries: “minor head trauma”, “mild head trauma”, “minor head injury”, “mild head injury” or “acute head trauma”. All the studies including pediatric samples between 2000 and 2015 were considered for a critical review. A few articles written before 2000 were analyzed for their relevance. Results: The Pediatric Emergency Care Applied Research Network (PECARN) algorithm identified children with a very low risk for clinically relevant brain injuries (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, no severe headache, no evident clinical worsening over time and no multiple symptoms) and offered the only validated clinical prediction rule to select candidates for CT scans. Other proposed clinical prediction rules (including NEXUS II, CHALICE and CATCH), that were not validated, have a lower sensitivity than PECARN algorithm. Skull X-ray, cerebral magnetic resonance and cranial ultrasonography could provide useful information in selected cases. Conclusions: The critical use of PECARN rule represents the best validated clinical tool for the early identification of children with a clinically relevant brain injury. Its application should be integrated with physician experience and judgement, parental compliance and clinical observation.

Background: Graft versus host disease (GVHD) is a significant complication following hematopoietic stem cell transplantation in the pediatric population. The most common clinical manifestation of GVHD is in the skin. This article will present a review of key concepts related to pediatric cutaneous GVHD, including pathophysiology, clinical epidemiology, diagnosis, and treatment options. Objective: GVHD is an immune-mediated process characterized by an inflammatory immune response in acute GVHD and mixed inflammatory and fibrotic states in chronic GVHD. The clinical presentations of cutaneous GVHD are heterogeneous. Method: Acute cutaneous GVHD classically presents as an erythematous morbilliform eruption appearing within a few weeks after transplantation. Chronic cutaneous GVHD may manifest as poikiloderma, lichenoid lesions, or sclerodermatous changes. The sclerodermatous form of cutaneous GVHD is associated with substantial long-term morbidity, including joint contractures, myalgias, and mobility restriction. Results: First-line pharmacologic treatment options typically include corticosteroids and in some cases, calcineurin inhibitors. Biologics and immunotherapies are an active area of investigation for GVHD that is refractory to corticosteroid treatment. Non-pharmacologic treatment options that have shown benefit for cutaneous GVHD include extracorporeal photopheresis and phototherapy. Conclusion: Accurate diagnosis and treatment of cutaneous GVHD is essential to preventing and alleviating the long-term sequelae and morbidity associated with this condition.

Background: Developmental Coordination Disorder (DCD) is a neurological impairment occurring in nearly 6% of general population, and sometimes mimics other developmental disorders like Attention Deficit Hyperactivity Disorder (ADHD) or, in the most severe cases, intellectual deficiency. Objectives: To review the general portrait of DCD, the physiology, the clinical assessments, and to provide an overview of functional studies on the subject. We finally report some proposed DCD managements which vary depending on the manifestation of the disorder and on the goals of the therapy. Results: DCD can be stated as a sum of fine motor, perceptual visual and executive difficulties, emerging during childhood brain development and lasting throughout adulthood. Even if DCD can be isolated from other co-morbidities in certain individuals, it is still difficult to categorize it in delimited subclasses of characteristics, e.g. problems of vision or language. The findings in functional imaging also diverge in locating the cerebral deficit for a given motor task. Conclusion: Finding a single explanation seems difficult as many cerebral regions are associated with DCD and many clinical aspects are involved, but, further studies could explore genetic (or epigenetic) explanation for the prevalence of DCD in population.

Background: Household animal dander has been implicated as aeroallergen in childhood atopic diseases. Many parents seek healthcare advice if household pet keeping may be detrimental in atopic eczema (AE), allergic rhinitis and asthma. Aim: We investigated if skin sensitization by cat/dog dander was associated with disease severity and quality of life in children with AE. Methods: Demographics, skin prick test (SPT) results, disease severity (Nottingham eczema severity score NESS), Children Dermatology Life Quality Index (CDLQI), blood IgE and eosinophil counts of a cohort of AE patients were reviewed. Results: 325 AE patients followed at a pediatric dermatology clinic were evaluated. Personal history of asthma was lowest (20%) in the dog-dander-positive-group but highest (61%) in bothcat- and-dog-dander-positive group (p=0.007). Binomial logistic regression ascertained that catdander sensitization was associated with increasing age (adjusted odds ratio [aOR], 1.056; 95% Confidence Interval [CI], 1.006 to 1.109; p=0.029), dust-mite sensitization (aOR, 4.625; 95% CI, 1.444 to 14.815; p=0.010), food-allergen sensitization (aOR, 2.330; 95% CI, 1.259 to 4.310; p=0.007) and keeping-cat-ever (aOR, 7.325; 95% CI, 1.193 to 44.971; p=0.032); whereas dogdander sensitization was associated with dust-mite sensitization (aOR, 9.091; 95% CI, 1.148 to 71.980; p=0.037), food-allergen sensitization (aOR, 3.568; 95% CI, 1.341 to 9.492; p=0.011) and keeping-dog-ever (aOR, 6.809; 95% CI, 2.179 to 21.281; p=0.001). However, neither cat nor dog sensitization were associated with asthma, allergic rhinitis, parental or sibling atopic status, disease severity or quality of life. Conclusion: Physicians should advise parents that there is no direct correlation between AE severity, quality of life, asthma or allergic rhinitis with cutaneous sensitization to cats or dogs. Sensitized patients especially those with concomitant asthma and severe symptoms may consider non-furry alternatives if they plan to have a pet. Highly sensitized individuals, especially those with asthma co-morbidity, may have to remove their pet for a trial period to determine if symptoms improve.

Background: To identify the anthropometric variables in equations/reference values of impulse oscillometry system (IOS) parameters in preschoolers, children and adolescents. Method: Systematic search on the databases MEDLINE/Ovid, SCOPUS and SciELO using the key words “preschool, child and adolescent”, “impulse oscillometry”, “reference values” and its variations. Results: This review considered a total of 13 articles. The studies presented height, weight, sex and age as the variables correlated to oscillometric parameters. Most studies do not present the correlation values of analyzed variables, and only a few presented the results considering gender differences. The coefficients of determination of the equations were low, specially for the samples including preschoolers. Height was identified as the most influent predictive variable to IOS parameters in the studied age group. Conclusion: Anthropometric variables, especially height, plays an important role determining reference values/equations for oscillometric parameters, however, the data acquisition method should be standardized.

Background: Variation in neonatal skin changes and clinical presentation is a frequent occurrence. We studied the pattern of cutaneous manifestations in new-borns <72 hours of birth. Method: We included all live babies delivered in our hospital; Babies were categorised according to age, birth weight and gestational age. Neonates were examined within 24 hours of birth and daily for skin lesions for 72 hours. Skin lesions were categorised into physiological, transient eruptions, due to infections, congenital anomalies and miscellaneous. Results: Of 200 new-borns, 108 (54%) were females; 180 (90%) full term babies (37-41 weeks). Non-consanguinity was noted in parents of 175 (87.5%) babies. One hundred and thirty one (65%) babies were delivered normally by vaginal route, and 69 (34.5%) by Caesarean section. 176 (88.0%) were average birth weight babies. Mean±SD lesion burden/neonate was 3.925±1.2 (n=785 lesions, 1-8 lesions/neonate). Transient skin lesions were frequent (n=451 in 198 patients, Mean±SD 2.30±0.76) followed by physiological conditions (n=284, Mean±SD 1.44±0.82). Infectious, developmental, iatrogenic and miscellaneous lesions were less frequent (mean±SD lesions 0.015±0.12, 0.0115±0.32, 0.015±0.12, and 0.035±0.18, respectively). Statistically significant (p<0.001) relationship was noted between gestational age and number of lesions; more number of full term babies had lesions, while number of lesions (>6) were more in preterm babies. All lesions occurred within 24 hours of birth except erythema toxicum neonatorum (n=124) wherein 80 were seen on day 1, and 43 on day 2. Conclusion: We confirm the variation in cutaneous lesions and their time of onset in neonates. Transient and physiological changes are more frequent and disappeared spontaneously. Number of lesions/neonate was more in premature babies.

Background: Play-based activities can be a positive intervention to increase participation of overweight children. Metabolomics can reveal elemental shifts in the metabolome, lending to potential mechanistic explanations behind improvements in physiological systems. Objective: To elucidate dose-response urinary metabolomic signature shifts in overweight preadolescents following four or eight weeks of supervised play-based activity versus a typical summer break control group. We hypothesized that eight weeks of activity would cause the greatest shift in the metabolites. Study Design: Twenty-two recreationally active preadolescents (12 males, 10 females) were randomly assigned to a four-week (4w) or eight-week (8w) activity group or to a control group (C). Participants reported to the laboratory on two separate occasions during which descriptive characteristics were recorded and urine samples were obtained. Children in the 4w and 8w cohort were tested at the beginning and end of the four and eight weeks of a supervised play-based physical activity program where they were active for 6 hours a day, 5 days a week. Children in the C group were tested before and after eight weeks of an unsupervised summer break. Results: A valid supervised partial least squares discriminant analysis model was obtained between post-exercise subjects in 8w and C (3 components, R2X = 0.332, R2Y = 0.976, Q2 = 0.091). The eight week intervention yielded significant metabolomic changes in several identified compounds. Conclusion: When compared to a typical unsupervised summer break, a supervised play-based intervention provides enough of a stimulus for a shift in the metabolome.

Background: Pyelonephritis is the most common and important infection among Iranian pediatric population. Differentiation between upper and lower Urinary Tract Infection (UTI) is often difficult based on clinical data. Therefore, definite diagnosis is helpful for choosing appropriate antibiotic and decision for hospital admission. The main purpose of this study was todetermine the diagnostic value of serum STREM-1 level in children suspicious to UTI and differentiation of upper UTI and lower UTI. Material & Methods: This prospective cross sectional study (2010-2011) was performed to evaluate and compare the serum level of STREM- 1 (pg. /ml) in 36 diagnosed UTI patients (24 upper and 12 lower UTI) with 25 normal children (without UTI) in Rasoul Akram hospital, Tehran, Iran. The mean age of studied children was 3.64 years; 24 male and 37 female. Urinary analysis and urine culture were performed for all UTI cases and only the positive cultured cases with the same microorganism were enrolled in the study. Distinguishing the upper from lower UTI was done on the basis of clinical manifestation and laboratory tests and confirmed by Imaging studies (ultra sonography /or DMSA scan). Blood sampling was taken from all children and centrifuged .The level of STREM-1 (pg /ml) in all sera was determined by Enzyme immunoassay technique (Human TREM-1 immunoassay Sandwich test, Quantikine, R systems, Minneapolis; USA). Cut-off levels for STREM-1 were illustrated by ROC curve. The p<0.05 was considered as significant for differences between groups. Findings: The mean of STREM -1level had significant difference between overall cases of UTI (427.72pg/ml) and controls (124.24 pg. /ml; P =0.000) ; with cutoff point 111.5 pg./ml ; it had 83.3% sensitivity; and 60 % specificity to distinguish UTI from control. Serum STREM -1 level had no significantly difference between the upper and lower UTI (500pg/ml vs. 283 pg. /ml, P value=0.1) with cutoff point 132 pg./ml it had 83.3% sensitivity ; and 60 % specificity to distinguish upper UTI from lower UTI. Conclusion: Our study demonstrates that even low amount of serum STREM-1 (111.5 pg./ml) has 83.3% sensitivity ; and 60 % specificity to distinguish the UTI from normal cases (P value =0.000) but higher level (132 pg./ml) was needed for definite diagnosis (83.3% sensitivity; 60 % specificity) of upper and lower UTI. It is concluded that serum STREM-1 level test is a valuable tool for early diagnosis of the normal cases with false positive urine culture, or in highly suspicious upper UTI cases with false negative urine culture. Indeed higher titer of this biomarker could be helpful for discriminating the upper from lower UTI. Therefore adding this new biologic marker (STREM-1) to previous ones (CRP, PCT) is suggested to prevent the unnecessary hospital admission and empiric antibiotic therapy.