Current Pediatric Reviews - Volume 17, Issue 3, 2021

Background: In December 2019, a local outbreak of pneumonia was presented in Wuhan (China) and quickly identified to be caused by a novel coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The disease caused by SARS-CoV-2 was named COVID-19 and was soon declared a pandemic because of the millions of infections and thousands of deaths worldwide. Children infected with SARS-CoV-2 usually develop the asymptomatic or mild type of disease compared to adults. They are also more likely to have atypical and non-specific clinical manifestations than adults. Methods: A literature search was performed through PubMed and Scopus to summarize the extrapulmonary manifestations of SARS-CoV-2 infection in children since the beginning of the pandemic. Peer-reviewed papers in English were retrieved using the following keywords and combinations: ‘pediatric,’ ‘child,’ ‘infant,’ ‘neonate,’ ‘novel coronavirus,’ ‘SARS-CoV-2,’ ‘COVID 19’ and ‘gastrointestinal,’ ‘renal,’ ‘cardiac,’ ‘dermatologic’ or ‘ophthalmologic’. We included published case series and case reports providing clinical symptoms and signs in SARS-CoV2 pediatric patients. Results: Although fever and symptoms of upper respiratory infection are the most frequently presented, a variety of other atypical presentations has also been reported. The clinical spectrum includes dermatological, ophthalmological, neurological, cardiovascular, renal, reproductive, and gastrointestinal presentations. In addition, a rare multi-inflammatory syndrome associated with SARS-- CoV-2 infection has been reported in children, often leading to shock and requiring inotropic support and mechanical ventilation. Conclusion: Clinicians need to be aware of the wider range of extrapulmonary atypical manifestations of SARS-CoV-2 infection in children, so that appropriate testing, treatment, and public health measures can be implemented rapidly.

Epigenetic alterations in our genetic material can lead to heritable changes in the risk, clinical manifestations, course, and outcomes of many diseases. Understanding these epigenetic mechanisms can help in identifying potential therapeutic targets. This is especially important in necrotizing enterocolitis (NEC), where prenatal as well as postnatal factors impact susceptibility to this devastating condition, but our therapeutic options are limited. Developmental factors affecting intestinal structure and function, our immune system, gut microbiome, and postnatal enteral nutrition are all thought to play a prominent role in this disease. In this manuscript, we have reviewed the epigenetic mechanisms involved in NEC. These include key developmental changes in DNA methylation in the immature intestine, the role of long non-coding RNA (lncRNA) in maintaining intestinal barrier function, epigenetic influences of prenatal inflammation on immunological pathways in NEC pathogenesis such as Toll-Like Receptor 4 (TLR4) and epigenetic changes associated with enteral feeding causing upregulation of pro-inflammatory genes. We have assimilated research findings from our own laboratory with an extensive review of the literature utilizing key terms in multiple databases, including PubMed, EMBASE, and Science Direct.

The novel coronavirus disease COVID-19 has had a clear and direct impact on the physical health of human beings. However, the mental health toll associated with this global pandemic is only beginning to be understood. Although children and adolescents have been largely spared from the more severe symptoms associated with the disease, global health organizations such as the United Nations have suggested that COVID-19 may have the longest and most severe impact on children and adolescents due to the socioeconomic, physical, psychological impacts associated with the disease itself and the measures taken to stop transmission, such as physical distancing. This paper provides an overview of the evolutionary basis for community and the ways that social and physical distancing measures to contain COVID-19 threaten the important social learning and support that community provides. It then discusses how this pandemic is likely to impact the mental health of children and adolescents, based on research from prior pandemics, recommendations from global health authorities, and emerging data on the impacts of COVID-19. Finally, we offer evidence-based suggestions on how to mitigate the effects of physical and social distancing.

Necrotizing enterocolitis is one of the most frequent and severe gastrointestinal diseases that affect preterm newborns in Neonatal Intensive Care Units. It was firstly described in 1960s, but this clinical entity was not widely recognized until the advent of modern neonatal intensive care. The disease is characterized by submucosal edema, infiltration of intestinal wall by immune cells, specifically neutrophils and, in severe forms, wall necrosis that leads to intestinal perforation. Its incidence is inversely associated to birth weight and gestational age. Necrotizing enterocolitis has been responsible for high rates of morbidity and mortality (15-30%), despite improvements made in neonatal care in the last decades. The challenge is to optimize strategies for early diagnosis, define the best medical and surgical treatments and standardize preventive measures. Several biomarkers have been proposed for the early prediction of necrotizing enterocolitis onset in preterm newborns and can be useful not only for diagnostic purposes but also for prediction of disease progression and severity. The purpose of this paper is to illustrate the most recent evidence regarding the diagnosis and prevention of necrotizing enterocolitis. This manuscript contributes to clinical decision-making in preterm neonates at high risk of developing necrotizing enterocolitis.

Background: Pityriasis rosea is a common acute, self-limited papulosquamous dermatosis that primarily affects children and young adults. The condition and its clinical variants may pose a diagnostic challenge, especially in the absence of the herald patch. Objective: This article aimed to familiarize pediatricians with clinical manifestations, evaluation, diagnosis, and management of pityriasis rosea. Methods: A search was conducted in March 2020 in Pubmed Clinical Queries using the key term ” pityriasis rosea”. The search strategy included all clinical trials (including open trials, non-randomized controlled trials, and randomized controlled trials), observational studies, and reviews (including narrative reviews and meta-analyses) published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article. Results: Pityriasis rosea occurs mainly in individuals between 10 and 35 years of age with a peak during adolescence. Human herpesvirus (HHV)-7 and HHV-6 have been implicated as the causative agents in some patients with pityriasis rosea. A mild prodrome consisting of headaches, fever, malaise, fatigue, anorexia, sore throat, enlarged lymph nodes and arthralgia is present in about 5% of patients. The most common presenting sign, found in approximately 80% of patients, is a “herald” or “mother” patch which is larger and more noticeable than the lesions of the later eruption. A generalized, bilateral, symmetrical eruption develops in approximately 4 to 14 days and continues to erupt in crops over the next 12 to 21 days. Typical lesions are 0.5 to 1 cm, oval or elliptical, dull pink or salmon-colored macules with a delicate collarette of scales at the periphery. The long axes tend to be oriented along the skin lines of cleavage (Langer lines). Lesions on the back may have a characteristic “Christmas tree”, whereas lesions on the upper chest may have a V-shaped pattern. There are many conditions that may mimic pityriasis rosea. Pityriasis rosea in the absence of the herald patch and its variants may pose a diagnostic challenge. The typical course is 6 to 8 weeks. In the vast majority of cases, reassurance and symptomatic treatment should suffice. Active intervention may be considered for individuals with severe or recurrent pityriasis rosea and pregnant women with the disease. Treatment options include acyclovir, macrolides (in particular, erythromycin), and ultraviolet phototherapy. If active intervention is needed, there is evidence supporting the use of oral acyclovir to shorten the duration of illness. Conclusion: Pityriasis rosea is a common, acute, self-limiting exanthematous skin disease that primarily affects children and young adults. The condition is characterized by a “herald patch” after which oval erythematous squamous lesions appear along Langer's lines of cleavage on the trunk and proximal extremities, giving it a “Christmas tree” appearance. The disease presenting in its classical form can easily be diagnosed. Clinical variants of the disease may pose a diagnostic challenge for the general pediatrician. Knowledge of the disease is essential to allow prompt diagnosis and to avoid unnecessary investigations.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic is caused by the third known zoonotic coronavirus. It is a disease that does not spare any age group. The scientific community has been inundated with information since January. This review aims to summarise pertinent information related to COVID-19 in children. Methods: A literature search was conducted in 2020 on the PubMed, MEDLINE, and Embase databases, with the keyword “COVID 19” and “children”. A bibliographic search of articles included was also undertaken. The abstracts were scanned to assess their appropriateness to be included in this narrative review. This was updated on the 11th April, 2020. Results: The aetiology, transmission, incubation, pathophysiology, clinical features and complications, and management are discussed. Conclusion: Our understanding of COVID-19 is evolving as more reports are published. The growth of SARS-CoV2 is limited in children and they are often asymptomatic. The disease course is also milder. Continued research to understand its effect on children is important to help us manage the disease in these vulnerable populations in a timely fashion.

Palliative Care (PC) is defined by the World Health Organization (WHO) as a support provided by multiple disciplines in order to improve the quality of life of both patients and their caregivers, throughout the disease course, from diagnosis to end-of-life. PC aims to prevent and treat symptoms and side effects of the disease and its treatment. PC is well developed in most high- -income countries; however in most low-income settings, where approximately 80% of patients with cancer requiring PC care for advanced disease live, PC services are still uncommon. Health indicators monitoring global PC development are policy, education, use of medicines, service provision and professional activity. Globally, PC development may be categorized as Group 1 (no known hospice-PC activity), Group 2 (capacity-building activity), Groups 3a Isolated PC provided, 3b Generalized PC provided, 4a hospice-PC services at a stage of integration into regular service provision, and 4b hospice-PC services at a stage of advanced integration into regular service provision. Spirituality is an essential element of patient-centered PC. The use of Complementary and Traditional Medicine (CTM) in Middle Eastern countries is widespread. There are wide discrepancies in cancer care and PC in many regions of the world. The Individualized Care Planning and Coordination (ICPC) Model is designed to facilitate the advance care planning with continuity of all the measures like symptom control or emotional, social and spiritual care of both the patient and the family during the disease steps like relapse or end of life.

Most pediatric patients with COVID-19 described in the literature have unusual or mild respiratory symptoms. Fever is usually a prominent feature. Cough is described frequently. Less common are sore throat, headache, productive cough, nausea, and diarrhea. Some studies estimate that children made up about 2% of the affected population. Nearly 1.2% of infected children need hospital treatment and some children require mechanical ventilation. The immune system in children is in its development stage, therefore the immune response to pathogens is different from adults.

In this clinical guidelines article, we first include a brief review of the epidemiology, pathogenesis, clinical diagnoses, and scoring-scales for pediatric atopic dermatitis (AD). We then offer a set of pharmacologic treatment guidelines for infants and toddlers (<2 years), children (2-12 years), and adolescents (>12 years). We recommend irritant avoidance and liberal emollient usage as the cornerstone of treatment in all age-groups. In infants <2 years, we recommend topical corticosteroids as first-line medication-based therapy. In infants as young as 3 months, pimecrolimus, a topical calcineurin inhibitor, may also be used. As a last resort in patients <2 years, non-traditional therapies, such as the Aron regime, may be a safer option for refractory or resistant AD before off- label medications are considered. In children and adolescents >2 years, topical corticosteroids are still considered first-line therapies, but there is sufficient safety data to utilize topical calcineurin inhibitors and topical PDE4 inhibitors as well. In children ages 2-12 years whose atopic dermatitis fails to respond to prior treatments, oral systemic immunosuppressants can be used. For adolescents >12, the biologic, dupilumab, is an additional therapeutic option. A trial of phototherapy may also be utilized in children, particularly in adolescents >12 years, if they have access to treatment. Although not currently approved for the treatment of AD, Janus-kinase (JAK) inhibitors represent a promising new class of biologics with recently completed phase III clinical trials (JADE-- MONO1/2).

Background: It was hypothesized that the oxytocin used during labor could increase the risk of neurodevelopmental disorders, such as ASD. Objective: This meta-analysis pooled all observational studies to obtain the association between labor induction and the risk of ASD among children. We identified all published studies up to August 2020 by search in PubMed, Scopus, Web of Science and gray literature. The pooled odds ratios (OR), relative ratio (RR) and 95% confidence intervals (CI (were calculated as random effect estimates of association among studies. Results: The pooled estimates of OR and RR reported a significant association between labor induction and ASD among children, respectively (OR = 1.09, 95% CI = 1.04 to 1.15) and (RR = 1.06, 95% CI = 1.02 to 1.09). The subgroup analyses were performed based on the adjusted form and design of studies. OR in crude and adjusted studies were reported to be 1.25(1.01, 1.49) and 1.08(1.02, 1.14), respectively. A significant association was found in adjusted and crude studies. There is no significant association between labor induction and ASD in case-control studies (OR=1.08, 95% CI = 0.99, 1.17). Conclusion: The findings showed that labor induction is associated with an increased risk of ASD among children. Therefore, the findings support that clinical use of oxytocin during labor has a significant negative impact on the long-term mental health of children.