Toronto, Canada

Author Affiliations: Divisions of Pediatric Emergency Medicine (Glatstein M) and Clinical Pharmacology and Toxicology (Scolnik D), the Hospital for Sick Children, University of Toronto, Canada

Corresponding Author: Dennis Scolnik, MB ChB, Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and                      Toxicology, the Hospital for Sick Children, University of Toronto, Canada (Tel: 416 813 7500; Email: dennis.scolnik@sickkids.ca).

Philadelphia, USA

Author Affiliations: Department of Pediatrics, Division of Neonatology, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA (Schutzman DL, Porat R, Salvador A, Janeczko M)

Corresponding Author: David L Schutzman, 5501 Old York Road, Lifter Bldg., Suite 2601, Philadelphia, PA 19141, USA (Tel: 215-456-6698; Fax: 215-456-6769; Email: schutzmand@einstein.edu)

Background: With increasing survival of extremely premature infants, emphasis is now focused on the quality of these survivors' lives. Possibly the most important factor in the premature's ability to survive in the NICU and thrive is the ability to replicate in utero growth through enteral and parenteral nutrition.

Data Sources: Current literature and review articles were retrieved from PubMed and personal files of the authors.

Results: The use and complications of the various components of total parenteral nutrition (TPN) were reviewed. The composition of appropriate enteral feeds for the premature was reviewed as was the difficulties associated with the establishment of adequate enteral feeds in the premature infants.

Conclusions: Early initiation of amino acids in TPN and timely increases in the components of TPN can improve the caloric intake of prematures. Enteral feeds, particularly of breast milk, may be started within the first few days of life in all but hemodynamically unstable prematures. Newer lipid preparations show promise in reversing the hepatic damage of TPN associated cholestatic jaundice.

Key words: enteral nutrition; infant; parenteral nutrition; premature; newborn

World J Pediatr 2008;4(4):248-253

Edmonton, Alberta, Canada

Author Affiliations: Department of Pediatrics and Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada (Dansereau AM, Robinson JL)

Corresponding Author: Joan L. Robinson, Room 8213, Aberhart Centre One, 11402 University Avenue, Edmonton, AB, T6G 2J3, Canada (Tel: 780-407-1680; Fax: 780-407-7136; Email: jr3@ualberta.ca)

Background: This review was designed to summarize published data on the efficacy and safety of live viral vaccines for measles, mumps, rubella, or varicella in post-transplant patients currently on immunosuppression.

Data sources: Medline, EMBASE and Evidence Based Medicine Reviews were searched from 1966 to November 2007 for case reports or studies describing the efficacy and/or safety of live attenuated measles, mumps, rubella, or varicella vaccine in children on immunosuppression following solid organ, bone marrow or stem cell transplantation.

Results: The review identified 6 case series and 2 case reports describing 114 solid organ transplant recipients and one case series describing 27 bone marrow transplant recipients who had received a combined total of 206 doses of live varicella, measles, mumps, or rubella vaccine while on immunosuppression. Post-immunization titers were in the immune range in 109 of the 171 situations where they were measured following a single dose of vaccine (64%) and in 15 of 22 situations following 2 doses (68%). There were no major safety concerns in this small sample.

Conclusion: There are insufficient published data to derive evidence-based guidelines for use of live viral vaccines in transplant recipients on immunosuppression but preliminary data on efficacy and safety suggest that the use of these live viral vaccines in transplant recipients still on immunosuppression could be a reasonable strategy.

Key words: measles vaccine; transplantation; vaccination; varicella vaccine

                  World J Pediatr 2008;4(4):254-258

Munich, Germany

Author Affiliations: Arteriosklerose-Präventions-Institut Munich–Nuremberg, Germany (Schwandt P, Haas GM); Ludwig-Maximilians Universität Munich, Germany (Schwandt P); Isfahan Cardiovascular Research Center, Isfahan University of Medical Sciences, Iran (Kelishadi R)

Corresponding Author: Peter Schwandt, Arteriosklerose-Präventions-Institut München–Nürnberg, Wilbrechtstr. 95, D-81477 München, Germany (Tel: +49-89-7904191; Email: api.schwandt.haas@t-online.de)

Background: Waist circumference (WC) is a sensitive marker for abdominal obesity in the pediatric age group. However, WC is influenced by age, sex, ethnicity and body mass index (BMI), causing difficulties in the selection of the most appropriate cut-off value. Considering the lack of reference values in Germany, we developed age- and gender-specific WC smoothed reference curves in German children, and compared them with reference curves obtained from different countries.

Methods: A representative sample of 3531 German children (1788 boys, 1743 girls) aged 3-11 years participating in the Prevention Education Program (PEP) Family Heart Study was studied. WC was measured according to the recommendations of the World Health Organization, then age- and sex-specific WC reference curves were constructed and smoothed using the LMS method and SPSS 14.0 for statistical analysis.

Results: WC increased with age in both boys and girls. Boys had higher values of WC than girls at every age and percentile level. 4.1% of the boys and 2.8% of the girls had WC values >97th percentile as compared to 6.3% of the boys and 4.9% of the girls with >97th percentile of BMI (severe obesity). 3.1% of the boys and 2% of the girls had both risk factors. Because 85.3% of the boys and 87.3% of the girls with WC<90th percentile had normal weight, this cut-off point might be appropriate for defining high WC.

Conclusions: These first WC reference curves of German children can be added to the existing international curves for children; comparison of different populations demonstrated that the German values are in the middle range of the curves obtained in different countries. Our findings about significant differences between the reference curves obtained in various regions emphasize the necessity of developing population-specific percentiles, and to use them in clinical and epidemiological studies among children.

Key words: children; Germany; international comparison; waist circumference

                 World J Pediatr 2008;4(4):259-266

Belgrade, Serbia

Author Affiliations: Children's Hospital for Lung Diseases and Tuberculosis, Medical Center "Dr Dragiša Mišović", Belgrade 11000, Serbia (Živković Z, Radić S, Cerović S); Medical Faculty, University of Belgrade, Belgrade 11000, Serbia (Vukašinović Z)

Corresponding Author: Zorica Živkovic, MD, PhD, Children's Hospital for Lung Diseases and Tuberculosis, Medical Center "Dr Dragiša Mišović", Jovana Marinovića 4, Belgrade 11000, Serbia (Tel: +381 11 2661887; Fax: +381 11 3066970; Email: zoricazivkovic@yahoo.com)

Background: This study was undertaken to analyze the clinical efficiency of Asthma Education Intervention (AEI, Asthma School) in children and their parents, a program was designed to produce acceptable asthma knowledge and to improve the treatment.

Methods: This study assessed the effectiveness of an educational intervention within 12 months after attending Asthma School. The study was designed as a population based cohort study. The project endorsed by the European Respiratory Society (ERS) Educational Grant was launched in 2004 and finished in 2006, but the Asthma School continued working. Three hundred and two asthmatics recruited during hospital treatment  of acute asthma exacerbation completed the study together with their parents. The intervention group of 231 asthmatics received full Asthma School program. The non-intervention group enrolled 71 asthmatics receiving usual instructions for asthma management. Clinical and educational outcomes were investigated immediately after completion of the program and 12 months later.

Results: Significant achievements were found in the intervention group in asthma knowledge (baseline score 63%, 82% after 12 months, P<0.05), compliance (70% before, 90% after), and inhalation technique (20% before, 70% after). No change was found in the attitude and behavior regarding asthma prognosis in adolescent patients and parents.

Conclusion: This study together with others clearly confirm the effectiveness of educational intervention for childhood asthma.

Key words: asthma; education; follow-up; intervention; self-management

                                                                                                             World J Pediatr 2008;4(4):267-273

Lublin, Poland

Author Affiliations: Department of Pediatric Endocrinology and Neurology, Medical University of Lublin, 20-093 Lublin, ul. Chodzki 2, Poland (Ben-Skowronek I, Szewczyk L); Department of Pathomorphology, Medical University in Lublin, 20-093 Lublin ul, Jaczewskiego 8, Poland (Sierocinska-Sawa J, Korobowicz E)

Corresponding Author: Ben-Skowronek Iwona, Department of Pediatric Endocrinology and Neurology, Medical University of Lublin, 20-093 Lublin, ul. Chodzki 2, Poland (Tel: +86-48817185440; Email: skowroneki@interia.pl; iwona-ben-skowronek@wp.pl)

Background: This study was undertaken to analyze subsets of lymphocytes in peripheral blood in the early phase and in the thyroid tissue in the late phase of Graves' disease (GD) in children.

Methods: The study included 30 children with GD and 30 healthy children. Monoclonal antibodies were used to define peripheral blood lymphocyte subsets and they were analyzed using the flow cytometer Ortho Diagnostic System. After thyroidectomy, T cells were detected by CD3, CD4, CD8 antibodies, B cells by CD79α antibodies, and the antigen presenting dendritic cells (APCs) by CD1α antibodies (DakoCytomation) in the thyroid tissue.

Results: Before the treatment, an increased percentage of CD4+ T helper cells and B cells and decreased CD8+ T suppressor/cytotoxic cells were observed in peripheral blood in all the GD children. The number of lymphocytes and dendritic cells in the thyroid tissue increased in the children with GD in comparison to the control group, especially T cells subsets CD4+ and CD8+ and CD79α+ B cells. The percentage of T cells in the thyroid tissue was lower and that of B cells was higher than in peripheral blood. In their structure, thyrocytes can have components similar to α-chains connected with β-microglobulins, which were characteristic for APCs.

Conclusions: The primary defect of immunoregulation in children with GD is probably dependent on a large number and the activity of T helper cells and on a small number and hypofunction of T suppressor cells. The amount of lymphocytes decreased proportionally to the duration of methimazole treatment. The thyrocytes probably can present antigens.

Key words: Graves' disease; lymphocyte subsets; thyroid

                  World J Pediatr 2008;4(4):274-282

Shanghai, China

Author Affiliations: The Center for Pediatric Liver diseases, Children's Hospital of Fudan University; The Department of Pediatrics, Shanghai Medical College of Fudan University (Wang JS, Wang XH, Zhu QR, Wang ZL, Zheng S); The Department of Pathology (Hu XQ), Shanghai Medical College of Fudan University, Shanghai 200032, China

Corresponding Author: Jian-She Wang, PhD, MD, Children's Hospital of Fudan University, 183 Fenglin Road, Shanghai 200032, China (Tel: +86-21-64160705; Fax: +86-21-64931901; Email: jshwang@shmu.edu.cn)

Background: Alagille syndrome (AS) is regarded as the most common cause of chronic cholestasis in childhood associated with specific phenotypic features in western countries. This study was undertaken to investigate the significance of AS in Chinese children with chronic cholestasis and to describe its clinical and histological features.

Methods: From October 2004 to January 2007, 157 children who presented with conjugated jaundice from less than 3 months of age were admitted to a tertiary hospital in Shanghai. Investigations of the heart, spine, eyes and kidneys were conducted in 13 children who experienced prolonged cholestasis beyond 1 year of age after exclusion of biliary atresia and familial progressive intrahepatic cholestasis type 1 or 2. In patients with interlobular bile duct paucity, AS was diagnosed if 3 or more of the following 5 major features were present: cardiac murmur, posterior embryotoxon, butterfly-like vertebrae, renal abnormalities and characteristic faces. In patients without interlobular bile duct paucity or who did not receive liver biopsy, 4 or more features were required for the diagnosis.

Results: Of the 13 children, 6 were diagnosed with AS at ages ranging from 1 year and 7 months to 3 years and 11 months. Jaundice was noticed in early infancy and then pruritus developed in all the 6 patients, of whom 5 presented with acholic stool and 4 had been misdiagnosed as having presumed biliary atresia by hepatobiliary scintigraphy or laparoscopic cholangiography. Biochemical examinations demonstrated increased concentration of total bile acid and hyperlipidemia. Interlobular bile duct paucity was demonstrated histologically in 5 patients who received liver biopsy. Vertebral abnormalities, heart murmur, characteristic faces and failure to thrive were found in all the 6 patients. Two patients had evidence of renal involvement. Micropenis, empty scrotum, and gall stone were seen in 1 patient.

Conclusion: AS is also an important cause of prolonged cholestasis in Chinese children. It is difficult to differentiate AS from biliary atresia. Liver biopsy and spine X-ray may be helpful in the early detection of AS.

Key words: Alagille syndrome; biliary atresia; cholestasis

                                    World J Pediatr 2008;4(4):283-288

Binzhou, China

Author Affiliations: Diagnostics Teaching and Research Office, Clinical Institute, Binzhou Medical University, Binzhou 256603, China (Sun YP, Zhang B); Health Statistics Teaching and Research Office, Binzhou Medical College, Binzhou 256603, China (Dong ZJ); Department of Child Health Care, The Affiliated Hospital of Qingdao University, School of Medicine, Qingdao 266003, China (Yi MJ); Department of Pediatrics, Binzhou Vocational College, Binzhou 256600, China (Sun DF); Mental Health Teaching and Research Office, Binzhou Medical University, Binzhou 256603, China (Shi SS)

Corresponding Author: Yan-Ping Sun, Department of Diagnostics, Clinical Institute, Binzhou Medical University, No. 522 3rd Huanghe Road, Binzhou 256603, China (Tel: +86-13854309245; Fax: +86-543-3162505; Email: bzsyp@163.com)

Background： Childhood sexual abuse (CSA) seriously enfluences children's psychological status. This study aimed to investigate the relationship between CSA and the psychiatric disorders.

Methods: An anonymous and retrospective questionnaire survey was carried out in 1307 college students (aged 18-25 years; 701 females, 606 males) to investigate the participants' CSA experience by means of a complete random sampling method. The Symptom Check-List-90 (SCL-90) test was used to study the victims' psychiatric aspects.

Results: 22.11% (155/701) of the female students and 14.69% (89/606) of the male students experienced physical and/or non-physical contact CSA before age 18, with a significant difference between female and male (P<0.05). And 11.43% (80/701) of the female students and 7.26% (44/606) of the male students experienced physical contact CSA (P<0.05). Most abusers were male and young people, and only a few of them used violence. 78.7% of the females experienced non-physical contact CSA from strangers, while 71.3% experienced physical contact CSA from acquaintances. 89.9% of the male victims knew the abusers before. Females were more likely than males to experience physical contact CSA from members of the family circles. The CSA incidence increased with age in females, while 54.7% of the male victims experienced CSA from 12 to 16 years. The students who experienced CSA had higher SCL-90 scores than those who did not in somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The more serious the CSA experience was, the higher SCL-90 scores of the psychiatric disorders would be.

Conclusions: CSA is not uncommon in adolescents. Girls are more likely to experience CSA than boys. About half of the abusers are the victims' close relatives, neighbors and teachers; most abusers were male. Personal experience of CSA may seriously affect the victims' psychological health.

Key words: childhood; psychiatric state; sexual abuse

World J Pediatr 2008;4(4):289-294

Author Affiliations: Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China (Zhang HY, Feng JX, Huang L, Wang G, Wei MF, Weng YZ)

Corresponding Author: Jie-Xiong Feng, MD, PhD, Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China (Tel: 86-27-83663808; Email: fengjiexiong@126.com)

Background: Some patients suspected with Hirschsprung's disease (HD), however, were diagnosed as having isolated hypoganglionosis according to the updated pathohistologic methods. This study was undertaken to investigate the diagnostic methods and the therapeutic results of isolated hypoganglionosis in children.

Methods: A retrospective analysis was made on 17 patients with isolated hypoganglionosis (hypoganglionosis group) identified pathologically after operation. The data included clinical presentations, barium enema, anorectal manometry, histochemical staining for acetylcholinesterase (AChE) before operation, histological results after operation and follow-up outcomes. The data of hypoganglionosis with HD (HD group) were compared retrospectively.

Results: Common complaint of the patients with hypoganglionosis and HD was intractable constipation. Barium enema showed typical narrowing and distended segment of the colon in 9 patients in the hypoganglionosis group (9/16) and in 15 patients in the HD group (15/18).  In the hypoganglionosis group, in 15 patients who underwent anorectal manometry only 5 showed absent rectal anal inhibitory reflex, significantly lower than the rate in the HD group (17/18) (P<0.05). From 16 patients in hypoganglionosis group, positive staining for AChE was noted in 3 patients (3/16, 18.8%), significantly lower than that in the HD group (16/18, 88.9%) (P<0.05). Thirteen patients in the hypoganglionosis group received subtotal colectomy, while only 5 patients needed subtotal colectomy in the HD group. In the hypoganglionosis group, except 2 patients who suffered from mild enterocolitis after operation and recovered after conservative therapy, all patients recovered uneventfully without wound dehiscence, intestinal fistula, fecal incontinence or constipation recurrence. In the HD group, one patient suffered from anastomotic leak and got secondary operation, one patient had anastomotic stricture at 1 year after operation and recovered by dilatation, and other three patients suffered from mild enterocolitis after operation and recovered after conservative therapy.

Conclusions: Hypoganglionosis is a common disease, and could be finally confirmed by full-thickness biopsies in different bowel segments. The resection range can be estimated according to barium enema and 24-hour delayed X-ray findings, by which the satisfactory result in short-term follow-up can be obtained.

Key words: constipation; Hirschsprung's disease; hypoganglionosis; surgery

                 World J Pediatr 2008;4(4):295-300

 Bern, Switzerland

Varanasi, India

Author Affiliations: Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, U.P. India (Pandey A, Gangopadhyay AN, Upadhyaya VD)

Corresponding Author: AN Gangopadhyay, Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, U.P. India (Tel: +91 542 2309527; Email: gangulybhu@rediffmail.com)

Background: Typhoid fever is a severe infective disease endemic in the areas where sanitation is poor. Its serious complication is bowel perforation with terminal ileum as the commonest perforation site. We report a case of an extremely unusual site of perforation in sigmoid colon due to typhoid fever.

Methods: An 18-month-old boy presented with no passage of flatus and feces along with guarding and rigidity. Exploratory laparotomy revealed sigmoid colon perforation and Widal test was strongly positive for typhoid fever. Sigmoid loop colostomy was performed on the patient.

Results: Postoperative period was uneventful. Colostomy started functioning on the 4th post-operative day. There was superficial wound dehiscence. The patient was given oral food intake on the 7th post-operative day. He was discharged from the hospital in satisfactory conditions on the 10th day after operation.

Conclusions: While tackling a case of enteric perforation suspected with typhoid fever, one should keep in mind the extremely rare site of sigmoid colon perforation.

Key words: intestinal perforation; sigmoid colon; typhoid fever

                 World J Pediatr 2008;4(4):305-307