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Vol 13, No 1
Vol 13, No 1 January 2017 ISSN 1708-8569
 
Personal viewpoint
Review articles
Meta-analysis
Original articles
Clinical image
   
Personal viewpoint:
Clearing the air: discrepant policy and practice concerning neonatal cannabinoid exposure
  James Patrick Ronayne, Anthony Heard, James William Antoon
 
  [Abstract] [Full Text] [PDF]  
Review articles:
Sleep disordered breathing in children with achondroplasia
  Marco Zaffanello, Gaetano Cantalupo, Giorgio Piacentini, Emma Gasperi, Luana Nosetti,
 
Background:
Children with achondroplasia often have breathing problems, especially during sleep. The most important treatments are adenotonsillectomy (for treating upper obstruction) and/or neurosurgery (for resolving cervicomedullar junction stenosis).
Data sources:
We reviewed the scientific literature on polysomnographic investigations which assessed the severity of respiratory disorders during sleep.
Results:
Recent findings have highlighted the importance of clinical investigations in patients with achondroplasia, differentiating between those that look for neurological patterns and those that look for respiratory problems during sleep. In particular, magnetic resonance imaging (MRI) and somatosensory evoked potentials are the main tools to evaluate necessary neurosurgery and over myelopathy, respectively.
Conclusions:
The use of polysomnography enables clinicians to identify children with upper airway obstruction and to quantify disease severity; it is not suitable for MRI and/or neurosurgery considerations.
 
Key words: achondroplasia; children; polysomnography; sleep disordered breathing; upper respiratory tract obstruction
  [Abstract] [Full Text] [PDF]  
Vitamin K supplementation to prevent hemorrhagic morbidity and mortality of newborns in India and China
  Rajesh Kumar Rai, Jing Luo, Theodore Herzl Tulchinsky
 
Background:
Vitamin K deficiency bleeding (VKDB) can cause prolonged and bleeding (intracranial hemorrhage) among newborns, which can be life-threatening or lead to long-term morbidity. The aim of this review article is to reiterate empirical evidence to support the argument that vitamin K should be mandatory for newborns in India and China, as well as in other countries with a high burden of neonatal deaths.
Data sources:
Studies were integrated from the PubMed/MEDLINE database search, as well as related literature available elsewhere.
Results:
Both India and China have been slow in adopting an effective program for administering vitamin K injections to newborns to prevent VKDB-related morbidity and mortality. VKDB cases in China and India have shown inadequate attention to routine use of vitamin K by injection.
Conclusions:
While no reliable data are publicly available, the issue of VKDB is at last receiving some attention from the Chinese public health system as well as the Indian government. In both countries, routine vitamin K administration to newborns would prove to be a cost-effective intervention to reduce preventable neonatal morbidity and mortality. VKDB is a global neonatal care issue, including countries where parental resistance is preventing babies from defense against this life-threatening condition.
 
Key words: global health; hemorrhagic disease of the newborn; intracranial hemorrhage; neonatal mortality; vitamin K defi ciency bleeding disorder
  [Abstract] [Full Text] [PDF]  
Meta-analysis:
Adjuvant steroid treatment following Kasai portoenterostomy and clinical outcomes of biliary atresia patients: an updated meta-analysis
  Min-Zhong Zhang, Peng-Cheng Xun, Ka He, Wei Cai
 
Background:
It is controversial whether adjuvant steroid treatment should be given to biliary atresia (BA) patients following a Kasai portoenterostomy (KPE). This study aimed to quantitatively and systematically evaluate the effect of adjuvant steroid therapy post-KPE in relation to major clinical outcomes of BA patients.
Methods:
We systematically reviewed the literature in PubMed, Embase, the Cochrane Library, China Knowledge Resource Integrated Database, Wanfang Database, Scholarly and Academic Information Navigator and manually searched for relevant papers published before August, 2015. We extracted data on the effects of steroid treatment following KPE on clinical outcome, including jaundice free rate and native liver survival rate at 6 months, 1 or 2 years after KPE. The weighted overall relative risk (RR) and 95% confidence intervals (CIs) were calculated by using a random-effects model.
Results:
Eight cohort studies and two randomized controlled trials (RCTs) were identified (n=998). Of them, 6 cohort studies and 2 trials investigated the effect of steroid treatment as compared to non-users or placebo (n=566), and 2 cohort studies compared the effects of high-dose to low-dose steroid treatment (n=432). Steroid usage increased the clearance rates of jaundice at 6 months (pooled RR: 1.32; 95% CI: 0.995-1.76; I2=72.6%) and 1 year (pooled RR: 1.35; 95% CI: 1.12-1.61; I2=0.0%), but not 2 years (pooled RR: 0.82; 95% CI: 0.55-1.22; I2=0.0%) after KPE. There was no solid evidence supporting that steroid treatment would improve native liver survival rate at 6 months (pooled RR: 1.02; 95% CI: 0.90-1.15; I2=0.0%), 1 year (pooled RR: 1.10; 95% CI: 0.91-1.34; I2=35.2%) or 2 years (pooled RR: 1.00; 95% CI: 0.73-1.35; I2=57.4%) after KPE.
Conclusions:
Adjuvant steroid treatment following KPE may improve short-term (¡Ü1 year) clearance rate of jaundice, but no significant effects on long-term (¡İ2 years) clearance rate of jaundice and native liver survival rate. Studies on doses and duration of steroids, and long-term follow-up studies are warranted.
 
Key words: biliary atresia; Kasai portoenterostomy; steroid treatment
  [Abstract] [Full Text] [PDF]  
Original articles:
Efficacy and tolerability of a polysaccharide-resin-honey based cough syrup as compared to carbocysteine syrup for children with colds: a randomized, single-blinded, multicenter study
  Herman Avner Cohen, Moshe Hoshen, Shmuel Gur, Arie Bahir, Yoseph Laks, Hannah Blau
 
Background:
Available pediatric treatments for acute cough are limited by lack of demonstrated efficacy. The objective of this trial is to compare the effects of a polysaccharide-resin-honey based cough syrup, and carbocysteine syrups on nocturnal and daytime cough associated with childhood upper respiratory tract infections (URIs).
Methods:
Using a single-blind randomization design, the study recruited children from 4 general pediatric community clinics. Participants included 150 children aged 2 to 5 years with an URI, nocturnal and daytime cough and illness duration of ¡Ü7 days. To be eligible, children had to be free of medication on the day before presentation. A survey was administered to parents on 4 consecutive days beginning from the day of presentation in clinic. Children received the study preparation on the first evening and then 3 times per day for 3 further days. Main outcome measures were cough frequency, cough severity, bothersome nature of cough, and quality of sleep for both child and parent.
Results:
Both preparations were well tolerated and cough improved over the study period. After one night and on all survey days, there was a significantly better result for polysaccharide-resin-honey (P<0.05) for all the main outcome measures. The trend of improvement over the 4 days was steeper for polysaccharide-resin-honey (P<0.05) with regards to all cough parameters.
Conclusions:
Both polysaccharide-resin-honey and carbocysteine cough syrups were well tolerated in children over 2 years of age. The polysaccharide-resin-honey syrup was associated with a more rapid and greater improvement in all clinical cough symptoms measured, beginning from the first night of therapy. Both nocturnal and daytime cough improved, as did sleep quality for both children and parents.
 
Key words: cough; children; upper respiratory tract infection
  [Abstract] [Full Text] [PDF]  
Endothelial nitric oxide synthase gene polymorphisms are associated with sensitization to seasonal aeroallergens in asthmatic children
  Maria Iordanidou, Emmanouil Paraskakis, Anna Tavridou, Athanasios Chatzimichael,
 
Background:
Childhood asthma phenotype is the consequence of interaction between environment and genetic factors. Nitric oxide (NO) formation is affected by polymorphisms in nitric oxide synthase (NOS) enzymes, which play a significant role as inflammatory factors in the airways. This study was undertaken to estimate the correlation of -786C>T and 894G>T polymorphisms of the eNOS gene with the sensitization of asthmatic children to common aeroallergens.
Methods:
A total of 193 asthmatic children and 96 healthy controls, who were of Mediterranean origin, living in the same geographical area, were enrolled in the study. 894G>T and -786T/C polymorphisms of the eNOS gene were analyzed using a PCR-RFLP method.
Results:
The 894GG genotype was more frequent (68.6%) in children with asthma sensitized to Oleaeuropaea than in those with asthma non-sensitized (43.0%) (P=0.004). Likewise, -786TT genotype frequency was higher in children with asthma sensitized to Oleaeuropaea (51.0%) than in those with asthma nonsensitized (31.7%) to this allergen (P=0.035). For the aeroallergens Parietariajudaica and mixed grass, the frequency of -786C allele carriage was associated with protection from sensitization to Parietariajudaica and mixed grass in asthmatic children (P=0.021 and P=0.017, respectively). In the healthy control group, the genotype frequencies for these polymorphisms were similar to genotype frequencies of children with asthma non-sensitized to these three specific aeroallergens.
Conclusion:
In children with asthma, 894G>T and -786T/C polymorphisms of the eNOS gene were correlated with sensitization to common seasonal aeroallergens.
 
Key words: asthma; atopy; genetics; nitric oxide
  [Abstract] [Full Text] [PDF]  
Bronchiolitis in young infants: is it a risk factor for recurrent wheezing in childhood?
  Firas Rinawi, Imad Kassis, Rina Tamir, Amir Kugelman, Isaac Srugo, Dan Miron
 
Background:
Acute bronchiolitis in infancy is considered a risk factor for recurrent wheezing episodes in childhood. The present study assessed prevalence, clinical manifestations and risk factors for recurrent wheezing events during the first 3 years of life and persistent wheezing events beyond this age in children hospitalized as young infants with acute bronchiolitis.
Methods:
Two groups of children aged 6 years were included. The study group comprised 150 children with a history of hospitalization for bronchiolitis, with the first event at <6 months of age. The control group comprised 66 age- and sex-matched children with no history of bronchiolitis before 6 months of age. Children in both groups had been followed until 6 years of age by their pediatricians; data were obtained retrospectively by reviewing ambulatory records during children¡¯s visits in pediatricians¡¯ clinics. The data included epidemiological parameters, prevalence, age at onset, number of and treatments given for episodes of wheezing events prior to 6 years of age, pathogens detected, and severity of acute bronchiolitis in the study group.
Results:
Overall, 58% and 27% of children in the study and control groups, respectively (P=0.001) had recurrent wheezing episodes prior to the age of 3 years. Children in the study group had earlier onset of recurrent wheezing, had more episodes of wheezing, and required more bronchodilator and systemic steroids treatments compared to the control group.
Conclusion:
Hospitalization within the first six months of life for acute bronchiolitis is an independent risk factor for recurrent wheezing episodes during the first 3 years of life.
 
Key words: acute bronchiolitis; recurrent wheezing; young infants
  [Abstract] [Full Text] [PDF]  
Analysis of the characteristics and management of critical values in a newborn tertiary center in China
  Zheng-Li Wang, Li-Zhong Du, Yi-Yu Chen, Lu-Quan Li, Qi Lu, Ying Liu, Lu-Ying Cao,
 
Background:
Critical value reporting has been widely adopted by hospitals throughout the world, but there were few reports about neonatal critical values. This study aimed to analyze characteristics of the neonatal critical values considered at our center and to provide information on improving neonatal intensive care.
Methods:
A retrospective study of critical values at a newborn tertiary center in China was conducted to assess neonatal critical values according to test, distribution, reporting time, patient outcome and the impact to the therapy.
Results:
In total, 926 critical values were recorded. Overall, 66.52% (616/926) of the items were reported within 24 hours of admission, 50.28% (465/926) during duty times and 54.75% (507/926) in the neonatal intensive care unit (NICU). The routine coagulation test was the most frequent source of critical values. Electrocardiography, blood gas analysis and therapeutic drug monitoring of drug levels were associated with the highest rates of treatment intervention (100%); routine coagulation tests were the lowest (23.14%). Sample quality was the main cause of false-positive critical values.
Conclusions:
The incidence of neonatal critical values peaked during the first 24 hours post-admission and during duty periods. Each newborn center needs to enact rapid treatment guidelines to address common critical values in order to facilitate clinical interventions. Periodically reviewing critical values could help to optimize clinical practices.
 
Key words: critical care; critical value; management strategies; newborn
  [Abstract] [Full Text] [PDF]  
Trajectory of cause of death among brought dead neonates in tertiary care public facilities of Pakistan: A multicenter study
  Muhammad Ayaz Mustufa, Munir Ahmed Sheikh, Ijaz-ul-Haque Taseer, Syed Jamal
 
Background:
Considering the fact that Pakistan is amongst the countries with very high neonatal mortality rates, we conducted a research study to determine the possible causes and characteristics of neonates presenting dead to the emergency department of tertiary public health care facilities of Pakistan using verbal autopsies.
Methods:
A descriptive case series study was conducted in emergency department/pediatrics ward/neonatal ward/nursery unit of ten tertiary care public health facilities, situated in seven major cities of Pakistan from November, 2011 to June, 2013. Precoded verbal autopsy proforma was used to collect information regarding cause of death, family narratives and other associated risks accountable for pathway to mortality.
Results:
We identified 431 neonates presenting dead to the emergency department (238 males and 193 females). Sepsis (26.7%), birth asphyxia (18.8%) and persistent pulmonary arrest (17.2%) were main primary causes of brought death. Around 72% brought dead neonates were referred from doctors/health care facilities and more than 28% caregivers mentioned that they were not informed about the diagnosis/ailment of their deceased newborn.
Conclusions:
Findings of our study suggest that infectious disease remains the main primary cause of neonatal mortality. Underweight in newborns (64%) was estimated as a leading associated risk. Delays in referrals to respective health care facility enlightened the concern of sub-standard prerequisites of neonatal care that could be one of the major contributing risk factor of high mortality rates.
 
Key words: autopsy; child health services; early childhood; emergency department use; neonatal mortality
  [Abstract] [Full Text] [PDF]  
A population-based study of prevalence of Down syndrome in Southern Thailand
  Somchit Jaruratanasirikul, Ounjai Kor-anantakul, Montira Chowvichian, Wannee
 
Background:
Down syndrome (DS) is the most common chromosomal disorder that causes mental retardation. In 2009, a population-based birth defects study was implemented in three provinces in southern Thailand. This study aimed to determine the prevalence of DS in the studied regions, and the proportion of DS fetuses detected by prenatal screening.
Methods:
Data were obtained from a population-based surveillance study undertaken during 2009-2013. Entries in the birth defects registry included live births, stillbirths after 24 weeks gestational age, and terminations of pregnancy following prenatal diagnosis. Infants with clinical characteristics of DS had a chromosomal study to make a definite diagnosis.
Results:
Of the total 186 393 births recorded during the study period, 226 DS cases were listed, giving a prevalence of 1.21 per 1000 births [95% confidence interval (CI) 1.05-1.37]. The median maternal age was 36.5 years with a percentage of maternal age ¡İ35 years of 60.6%. Seventy-seven cases (34.1% of all cases) were diagnosed prenatally and these pregnancies were terminated. The prevalence of DS per 1000 births was significantly higher in older women, from 0.47 (95% CI 0.28-0.67) in mothers aged <30 years to 0.88 (95% CI 0.59-1.17) in mothers 30-<35 years (P<0.01), and to 4.74 (95% CI 3.95-5.53) in mothers ¡İ35 years (P<0.001).
Conclusions:
The prevalence of DS significantly increased with maternal age. About 35% of DS cases were detected prenatally and later terminated. Hence, examining only registry live births will result in an inaccurate prevalence rate of DS.
 
Key words: birth defect registry; Down syndrome; prenatal screening; termination of pregnancy; trisomy 21
  [Abstract] [Full Text] [PDF]  
A pilot study using lactulose in management of minimal hepatic encephalopathy in children with extrahepatic portal vein obstruction
  Hanaa Mostafa El-Karaksy, Omneya Afi fi , Azza Bakry, Ann Abdel Kader, Noha Saber
 
Background:
Minimal hepatic encephalopathy (MHE) is not associated with overt neuropsychiatric symptoms but rather with subtle changes in psychometric and/or neurophysiologic tests. We aimed to diagnose MHE in children with extrahepatic portal vein obstruction (EHPVO) and to evaluate the effect of lactulose on MHE.
Methods:
A prospective study was carried out on 30 patients with EHPVO (21 males; mean age 10¡À2.5 years). The study was carried out in the Pediatric Hepatology Unit, Cairo University Pediatric Hospital, Cairo, Egypt, between 2011 and 2013. All patients were subjected to clinical and laboratory assessment, neuropsychmetric testing using the arabic version of Wechsler intelligence tests, neurophysiological testing by visual electroencephalogram and P300 event related potentials (ERP).
Results:
The prevalence of MHE among children with EHPVO was 20% (6/30). After randomization to treatment and no-treatment groups using lactulose, all tests were repeated after three months. Among four patients with MHE who received lactulose, three (75%) improved. On the other hand, one of the patients in the no-treatment group developed MHE. Only one patient in the treatment arm had to discontinue lactulose because of severe diarrhea.
Conclusions:
This pilot study revealed that the prevalence of MHE was 20%. Improvement on psychometic tests was seen in 75% of our patients (3/4) after treatment with lactulose. Lactulose treatment was well tolerated.
 
Key words: children; extrahepatic portal vein obstruction; lactulose; minimal hepatic encephalopathy; neuropsychometric tests; P300 event-related potential
  [Abstract] [Full Text] [PDF]  
Hepatotoxicity induced by acute and chronic paracetamol overdose in children: Where do we stand?
  Hoi Yan Tong, Nicol¨¢s Medrano, Alberto Manuel Borobia, Jos¨¦ Antonio Ruiz, Ana Mar¨ªa
 
Background:
There are few data on hepatotoxicity induced by acute or chronic paracetamol poisoning in the pediatric population. Paracetamol poisoning data can reveal the weaknesses of paracetamol poisoning management guidelines.
Methods:
We retrospectively studied the patients of less than 18 years old with measurable paracetamol levels, who were brought to the emergency department (ED) of La Paz University Hospital, Madrid, Spain, for suspected paracetamol overdoses between 2005 and 2010.
Results:
Ninety-two patients with suspected paracetamol poisoning were identified. In 2007, the incidence of paracetamol poisoning in the pediatric population was 0.8 [Poisson-95% confidence interval (CI): 0.03-3.69] per 10 000 inhabitants aged less than 18 years. The incidence in the same year was 1.53 (Poisson-95% CI: 0.24-5.57) per 10 000 patients in the pediatric ED. The most common cause of poisoning was attempted suicide (47.8%) in teenagers with a median age of 15 years, followed by accidental poisoning (42.2%) in babies with a median age of 2.65 years. Difference was seen in the frequency of hepatotoxicity between acute and chronic poisoning cases. Only 1 of 49 patients with acute poisoning showed hepatotoxicity [acute liver failure (ALF)], whereas 7 of 8 patients with chronic poisoning showed hepatotoxicity (3 cases of ALF). The average time to medical care was 6.83 hours for acute poisoning and 52.3 hours for chronic poisoning (P<0.001).
Conclusions:
Chronic paracetamol poisoning is a potential risk factor for hepatotoxicity and acute liver failure. Delays in seeking medical help might be a contributing factor. Clinicians should have a higher index of clinical suspicion for this entity.
 
Key words: acute liver failure; hepatotoxicity; paracetamol; poisoning
  [Abstract] [Full Text] [PDF]  
Parental attitudes towards influenza vaccination for children in South India
  Chethan Ramprasad, Rajeev Zachariah, Mark Steinhoff, Anna Simon
 
Background:
The rate of influenza vaccination is low for children in India. The purpose of this study is to assess parental attitudes towards influenza vaccination in South India.
Methods:
Participants were parents who brought their children to the Well Baby Clinic of Christian Medical College Hospital, Vellore, India for routine immunization. Participants answered questions by written survey while waiting for their children¡¯s vaccination.
Results:
A total of 456 surveys were completed (403 parents did not opt for trivalent influenza vaccination and 53 opted for influenza vaccination). The majority (53.60%) of those parents who did not accept influenza vaccination identified the lack of a doctor¡¯s recommendation as the main reason. When asked separately, many non-acceptors (44.91%) indicated that they did not believe or were not sure that the influenza vaccine was effective. Nearly all non-acceptors (92.56%) stated that they would opt for influenza vaccination if a doctor recommended it.
Conclusions:
The most common reason that parents not opting for influenza vaccination for their children was the lack of recommendation by a doctor. The results of this study suggest that recommendation by a doctor is a more important factor than belief in efficacy, cost, or convenience in parental decision-making regarding childhood influenza vaccination in India, unlike the United States where parents are less likely to follow recommendations.
 
Key words: doctor recommendation; influenza; immunization parental attitudes; vaccination
  [Abstract] [Full Text] [PDF]  
Clinical image:
Trichobezoar and Rapunzel syndrome
  Zhi-Nan Sun, Dong-Lai Hu, Zhong-Mei Chen
 
  [Abstract] [Full Text] [PDF]  
   
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