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

Corresponding Author: Joan L Robinson, MD, FRCPC Room 8213, Aberhart Centre One, 11402 University Avenue, Edmonton, AB Canada T6G 2J3 (Tel: 780-407-3666; Fax: 780-407-7136;  Email: jr3@ualberta.ca)

doi:10.1007/s12519-011-0240-5

Background: There are no previous systematic reviews of published pediatric case series describing the etiology of fever of unknown origin (FUO). The purpose of collecting these data is to determine the etiologies for children with FUO in both developing and developed countries.

Methods: The database Ovid Medline R (1950 to August 2009 week 4) and Ovid Embase (1980 to 2010 week 2) were used to conduct the search. Studies in any language were included if they provided the diagnosis in a series of 10 or more children with FUO. The diagnosis of each child at the time of publication of the study was recorded.

Results: There were 18 studies that met the inclusion criteria, describing 1638 children. The diagnosis at the time of publication was malignancy for 93 children (6%), collagen vascular disease for 150 (9%), miscellaneous non-infectious conditions for 179 (11%), infection for 832 (51%), and no diagnosis for 384 (23%). There were 491 bacterial infections (59% of all infections) with common diagnoses being brucellosis, tuberculosis, and typhoid fever in developing countries, osteomyelitis, tuberculosis, and Bartonellosis in developed countries, and urinary tract infections in both. For children with no diagnosis after investigations, most had fever that ultimately resolved with no sequelae.

Conclusions: About half of FUOs in published case series are ultimately shown to be due to infections with collagen vascular disease and malignancy also being common diagnoses. However, there is such a wide variety of possibilities that investigations should primarily be driven by the clinical story.

Key words: collagen vascular disease; fever of unknown origin; infection; malignancy

                    World J Pediatr 2011;7(1):5-10

Author Affiliations: State University of New York at Stony Brook, Stony Brook, New York 11791, USA (Shah S)

Corresponding Author: Shetal Shah, MD, FAAP, Assistant Professor of Neonatal Medicine, State University of New York at Stony Brook, Department of Pediatrics, Division of Neonatology, Health Science Center tower 11th Floor 060, Stony Brook, New York 11791, USA (Tel: 631-444-7653; Email: shetal.shah@stonybrook.edu)

doi:10.1007/s12519-010-0201-4

Background: Exogenous surfactant is currently administered via intra-tracheal instillation, a method which can increase the possibility of clinical instability in the peri-surfactant administration period. Since its introduction, there has been an increase in understanding of the pathology of respiratory distress syndrome and surfactant biology. This includes development of a potential nebulized surfactant which has the potential to increase the number, safety and timely administration of the medication in preterm infants.

Data sources: Based on recent original publications in the field of surfactant biology, we reviewed our experience with surfactant administration and discussed the available evidence on nebulized surfactant and outlined potential barriers toward widespread introduction of this therapy.

Results: Surfactant has revolutionized modern neonatal management and nebulized surfactant is attractive and a vector for administration. However, issues regarding cost-effectiveness, development of nebulizer devices capable of administration, deposition of medication in the airway and dosing strategies remain unresolved.

Conclusions: Nebulized surfactant has the potential to be a therapeutic breakthrough by eliminating the potent volu-and-baro-traumatic effects of mechanical ventilation in the peri-surfactant period. Nebulization would likely lead to increased administration immediately after birth and more emphasis on non-invasive ventilator strategies. These features will aid clinical implementation of nebulized surfactant as a standard of treatment after introduction.

Key words: nebulization; neonatal respiratory disease; surfactant

                  World J Pediatr 2011;7(1):11-15

Gerda-Maria Haas, Evelyn Liepold, Peter Schwandt

Muenchen and Nuernberg, Germany

Author Affiliations: Arteriosklerose-Praeventions-Institut Muenchen and Nuernberg, Germany (Haas GM, Liepold E, Schwandt P)

Corresponding Author: Peter Schwandt, Arteriosklerose-Praeventions-Institut Muenchen and Nuernberg, Germany (Tel: +49 89 7904191; Fax: +49 89 74994941; Email: API.Schwandt.Haas@t-online.de)

doi:10.1007/s12519-011-0241-4

Background: Because the body composition of adolescents varies more than that of adults and anthropometric parameters are regularly used for pediatric body fat measurements, we developed age-, gender-, and ethnicity-specific reference values for waist circumference (WC), hip circumference (HC), waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), and skinfold thickness (SFT) in German adolescents.

Methods: A representative sample of 1633 boys and 1391 girls aged 12–18 years participated in this cross-sectional study. Weight, height, body mass index (BMI), WC, HC, WHR, WHtR, and SFT were measured and smoothed; age-, gender-, and ethnicity-specific reference curves were developed using the LMS method.

Results: Females were significantly heavier than males at 12 years. Beyond age 14 males were significantly heavier and taller than females. The SFT sum increased continuously (+20%) in females and was significantly higher (7.4 mm) than in males. At the 90th percentile, SFT_triceps decreased (−12%) in males but increased (+11%) in females; SFT_subscapular increased in both genders. From 12 to 18 years, WHtR and WHR remained constant, whereas WC and HC increased in both genders. WHtR was the best predictor for abdominal obesity in males (area under the curve [AUC] 0.974 ± 0.004) and females (AUC 0.986 ± 0.003), followed by body fat percentage (AUC 0.937 ± 0.008) in males and WHR (AUC 0.935 ± 0.009) in females.

Conclusion: These age- and gender-specific percentile curves for SFT, WC, HC, WHR, and WHtR, derived from a large national sample of German adolescents, may be useful for developing international reference values for waist circumference and other predictors of adult obesity.

Key words:  German adolescents; skinfold thickness; waist circumference; waist-to-height ratio; waist-to-hip ratio

                     World J Pediatr 2011;7(1):16-23

Author Affiliations: Division of Pediatrics, Tor Vergata University, Rome, Italy (Angelini F, Corrente S, Silenzi R, Polito A, Di Cesare S, Yammine ML, Rossi P, Moschese V, Chini L); DPUO, Bambino Gesù Children's Hospital, Rome, Italy (Angelini F, Pacciani V, Rossi P); Division of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy (Alessandra Di Pede); Division of Pediatric Medicine, Bambino Gesù Children's Hospital, Rome, Italy (Riccardi C)

Corresponding Author: Federica Angelini, MD, PhD, University Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Piazza S.Onofrio 4, 00165 Roma, Italy (Tel: +39 (06) 72596823; Fax +39 (06) 72596822; Email: angelini@med.uniroma2.it)

Background: The importance of dendritic cells (DCs) in the initiation of the Th2-mediated inflammatory response to allergens is well known and more recently it has been proposed that DCs have a pivotal role in maintaining tolerance to allergens. The aim of this study was to investigate whether the success of sublingual immunotherapy (SLIT) in allergic asthma is mediated by the induction of changes of DCs functions.

Methods: Ten children with allergic asthma sensitive to house dust mite were studied before and after 12 months of SLIT. Immature DCs were derived from peripheral blood monocytes cultured for 6 days in presence of interleukin (IL)-4 and GM-CSF and stimulated with lipopolysaccharide for the last 24 hours to induce maturation.

Results: After 12 months of SLIT, mature DCs derived from SLIT-treated patients showed a statistically significant defect of CD86 up-regulation, an increase of IL-10, and a reduction of IL-12 production.

Conclusion: SLIT induces changes in DCs functions that might be responsible for an impairment of T cell activation or drive T cells towards a regulatory activity, thus restoring immune tolerance to allergens.

Key words: allergy; CD86; dendritic cells; IL-10; sublingual immunotherapy

                   World J Pediatr 2017;7(1):24-30

Corresponding Author: Samiran Bisai, Department of Anthropology, Vidyasagar University, Midnapore 721102, West Bengal, India (Email: sbisai@hotmail.com)

doi:10.1007/s12519-010-0239-3

Background: Nutritional status of tribal children in West Bengal has not been investigated adequately. The present study was undertaken to determine the prevalence of underweight, stunting and wasting in Kora-Mudi children of Paschim Medinipur, West Bengal, India.

Methods: A cross sectional study was undertaken in two villages of the Paschim Medinipur District. Of 119 children aged 2-13 years, 59 boys and 60 girls were studied. Height and weight measurements were made by standard techniques. Children were considered as underweight, stunting and wasting if their weight-for-age, height-for-age and weight-for-height Z-scores <-2.0 SD of the National Center for Health Statistics reference standards.

Results: The overall prevalence of underweight, stunting and wasting was 52.9%, 49.6% and 22.7%, respectively. About 16.0%, 24.4% and 1.7% of children were found to be severely underweight, stunted and wasted. The prevalence of underweight, stunting and wasting was higher in preschool children than in school going children. The chance of underweight, stunting and wasting was 1.80, 1.10 and 1.58 times greater in preschool children than in school going children. Moreover, the prevalence of underweight, stunting and wasting was higher in boys than in girls. The boys had 1.45, 1.66 and 2.02 times greater risk to be underweight, stunted and wasted. According to the WHO classification of severity in malnutrition, the overall prevalence of underweight, stunting and wasting was as high as ≥30%, ≥40 and ≥15%.

Conclusions: The nutritional status of Kora-Mudi children in West Bengal is critical. Appropriate measures should be taken by the respective authorities to improve childhood health and nutritional status.

Key words: Kora-Mudi; stunting; undernutrition; underweight; wasting

                   World J Pediatr 2011;7(1);31-36

Author Affiliations: Department of Pediatrics, Social Pediatrics Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey (Özmert EN, Özdemir R, Pektaş A); Department of Pediatrics, Başkent University Faculty of Medicine Ankara, Turkey (Üçkardeş Y); Department of Social Pediatrics, Hacettepe University Institute of Child Health, Ankara, Turkey (Yurdakök K)

Corresponding Author: Elif N. Özmert, MD, PhD, Department of Pediatrics, Social Pediatrics Unit, Hacettepe University Faculty of Medicine, 06100, Sıhhıye, Ankara, Turkey (Email: nozmert@hacettepe.edu.tr)

doi:10.1007/s12519-011-0243-2

Background: Television, computer and other causes of increased inactivity are reported to be among the major causes of obesity. This cross-sectional study was aimed to evaluate the effect of television viewing and other daily activities on body mass index (BMI) z-score of early adolescents.

Methods: A total of 860 students and their parents (581) from different socioeconomic level schools were included. They were instructed to fill in a self-designed questionnaire. Weight and height were measured, and BMI z-scores were calculated.

Results: BMI z-score was higher in boys and in those attending high socioeconomic level schools. Children with a BMI z-score >2SD watched television (2.5±0.9 h/day) longer than those with <-2SD (1.6±0.8 h/day) (P=0.027). The three categories (<-2SD, -2SD–2SD, >2SD) differed significantly according to maternal (P<0.05) and paternal (P<0.005) BMI. Linear logistic regression analysis revealed that socioeconomic level, maternal BMI and paternal BMI are factors affecting BMI z-score significantly.

Conclusion: Genetic and/or family environment which may affect the nutrition and activity of adolescents seems to be the most important factor affecting their BMI z-score.

Key words: activity; body mass index;   television

                    World J Pediatr 2011;7(1):37-40

Author Affiliations: Department of Medical Statistics & Epidemiology, Hamad General Hospital & Hamad Medical Corporation, Doha, Qatar and Department of Evidence for Population Health Unit, School of Epidemiology and Health Sciences, The University of Manchester, Manchester, UK (Bener A); WHO, EMRO Regional Adviser, Healthy Lifestyle Promotion/Injury and Violence Prevention and Disability, Cairo, Egypt (Hussain SJ, Abou-Taleb H); Global Forum for Health Research, WHO, Geneva, Switzerland (Ghaffar A); WHO/EMRO Temporary Adviser, Head, Department of Pediatrics, Suez Canal University, Egypt (El-Sayed HF)

Corresponding Author: Abdulbari Bener, Advisor to WHO, Consultant and Head, Department of Medical Statistics, Hamad General Hospital, Hamad Medical Corporation, and Weill Cornell Medical College, PO Box 3050, Doha, State of Qatar (Tel: +974-439 3765/6;  Fax: +974-439 3769; Email: abener@hmc.org.qa; abb2007@qatar-med.cornell.edu)

Background: The aim of this study was to explore the trends in injury mortality in children aged 0-18 years in the State of Qatar. No such study has been conducted previously in Qatar.

Methods: Univariate statistical analysis was used in this retrospective descriptive study. A total of 2934 children aged 0-18 years who died due to injuries in the period of 1 January 1993 to 31 December 2007 were studied.

Results: The leading causes of death were road traffic injuries (RTIs) (71.3%), drowning (9.3%) and accidental falls (6.0%). Injury death rates were higher in citizens (57.7%) than in non-citizens (42.3%). The children of 15-18 years old had the highest frequency of injury deaths (34.4%), followed by children of 10-14 years old (21.3%). The mortality rate of RTI per 100 000 population increased remarkably in the year 2005 compared to previous years.

Conclusions: The present study suggests that RTI is a major cause of childhood death. Injury mortality is higher in boys than in girls. During the period of 1993-2007, there was a dramatic increase in childhood mortality caused by RTI. This study highlights the burden of RTI caused mortalities in children, which requires immediate action.

Key words:  childhood injury; epidemiology; intentional injury; mortality; prevention; unintentional injury

World J Pediatr 2011;7(1):41-44

Author Affiliations: Department of Pulmonary and Infectious Diseases, Beijing Children's Hospital affiliated to Capital Medical University, Beijing, China (Gao LW, Shen KL); Department of Virology Laboratory, Beijing Children's Hospital affiliated to Capital Medical University, Beijing, China (Xie ZD, Liu YY, Wang Y)

Corresponding Author: Prof. Kun-Ling Shen, Department of Pulmonary and Infectious Diseases, Beijing Children's Hospital affiliated to Capital Medical University, Beijing 100045, China (Email: kunlingshen@hotmail.com)

Background: Infectious mononucleosis (IM) is a self-limited disease, but a few cases may have severe complications. This retrospective study was to explore the epidemiologic and clinical characteristics of IM associated with Epstein-Barr virus infection (EBV-IM) in children.

Methods: Hospitalized patients with EBV-IM were enrolled during January 2005 to October 2008 in Beijing Children's Hospital Affiliated to Capital Medical University. All patients were divided into four groups: <1 year (group I), 1 to 3 years (group II), 3 to 6 years (group III), and ≥6 years (group IV). The epidemiology and clinical characteristics were compared among the four groups.

Results: Totally 418 patients were enrolled, with 245 boys and 173 girls. Fever, lymphadenopathy and pharyngitis were three main manifestations of the patients. The incidences of hepatomegaly, splenomegaly and rash were higher in the patients aged below 6 years, and with age increment the incidences lowered. In contrast, the patients aged <1 year had the lowest incidence of tonsillopharyngitis. The total white blood cell count was higher in the infantile group than in the other groups (P=0.038). The infantile group had significantly lower levels of serum alanine aminotransferase and aspartate aminotransferase than the older groups (P=0.007 and P=0.012 respectively). The percentage of CD4⁺ T cell subset decreased and the percentage of CD8⁺ T cell subset increased with age increment.

Conclusions: The incidence of EBV-IM peaked in children at age of 4 to 6 years in Northern China. Most of the patients had the classic triad of fever, lymphadenopathy and pharyngitis. Clinical symptoms, signs, laboratory findings and complications of patients varied with ages.

Key words: children; Epstein-Barr virus; infectious mononucleosis

World J Pediatr 2011;7(1):45-49

Author Affiliations: Ege University, Faculty of Medicine, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Bornova, Izmir, Turkey (Cakir M, Ozgenc F, Yusekaya HA, Ecevit CO, Yagci RV)

Corresponding Author: Murat Cakir, Ege University, Faculty of Medicine, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Bornova, Izmir, Turkey (Tel: 0 532 681 0318; Email: muratcak@hotmail.com)

Background: We aimed to analyze clinical and inflammatory markers of steroid non-response in patients with moderate/severe ulcerative colitis (UC) at the time of diagnosis.

Methods: This study included patients who were graded as having moderate/severe UC and received corticosteroids as first-line therapy. Demographic, clinical and laboratory findings and pediatric ulcerative colitis activity scores (PUCAS) were recorded. Response to corticosteroids was assessed 30 days after the induction and long-term therapy.

Results: Twenty-eight children were diagnosed as having moderate/severe UC. Their mean age ± SD was 12.2 ± 4 years, and 17% were under 5 years of age. PUCAS at their initial admission was 56.9 ± 11.8. UC was observed at the left colon in 9 patients (32.1%), and pancolitis in 19 (67.9%). At the end of the 30th day, UC was completely remitted in 15 patients (53.5%), partially remitted in 2 (7.1%), and no response in 11 (39.2%). Short-term follow-up showed partial remission in 2 patients, and overall remission with steroid in 17 (60.7%). Non-responders were given second-line treatment; steroid dependency was documented in 2 patients (7.1%) and another 2 (7.1%) patients underwent colectomy. Predictors for steroid non-response were analyzed and only PUCAS at the initial admission was found to be associated with non-response to steroids (51.4 ± 11.4 vs. 65.4 ± 6.8, P<0.05).

Conclusions: Approximately half of the pediatric patients had complete response to steroid therapy in a long period. PUCAS could be used as a potential marker of "failed response" to steroid, but should be supported with a number of prospective randomized controlled studies.

Key words:  children; corticosteroid; ulcerative colitis

World J Pediatr 2011;7(1):50-53

Author Affiliations: Department of Pediatrics, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, 56000 Kuala Lumpur, Malaysia (Ong LC, Chandran V); Department of Pediatrics, Institute of Pediatrics, Jalan Raja Muda, 50300 Kuala Lumpur, Malaysia (Norshireen NAR)

Corresponding Author: Ong Lai Choo, MRCP, Department of Pediatrics, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia (Tel: 603 91455383; Fax: 603 91456637; Email: onglc@ppukm.ukm.my)

Background: This study aimed to compare mental health of mothers of children with spina bifida with mothers of able-bodied controls.

Methods: Eighty-one mothers of children with spina bifida aged 1-18 years completed the General Health Questionnaire-12 (GHQ-12) and Parenting Stress Index Short Form (PSI/SF). The controls were 69 mothers of children with acute, non-disabling illnesses. Each child's adaptive skills were assessed using the Vineland Adaptive Behaviour Scales (VABS). Logistic regression analysis was used to determine factors related to a high GHQ score (≥3) in all patients.

Results: Compared to the controls, mothers of children with spina bifida had lower educational levels and were more likely to be the main caregivers and not working. Nineteen (23.5%) of them had a high GHQ score compared to 5 (7.2%) of the controls. They also had significantly higher scores for total PSI/SF and the parent domain, difficult child (DC) and parent-child dysfunctional interaction subscales. Children with spina bifida had lower scores for the composite VABS and communication, socialization, daily living skills and motor sub-domain than the controls. Spina bifida (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.30-14.23), higher DC scores (OR 1.1, 95% CI 1.00-1.16), and higher life stress scores (OR 1.1, 95% CI 1.01-1.71) were associated with a high GHQ score.

Conclusion: Spina bifida, recent stressful life change events and maternal perception of a child as 'difficult' are associated with poor maternal psychological health.

Key words: life change events; mental health; parent-child relations; spina bifida

World J Pediatr 2011;7(1):54-59

Author Affiliations: Mansoura University Children's Hospital, Hematology and Oncology Unit (Al-Tonbary YA, Sarhan MM, El-Ashry RA, El-Sharkawy AA), Unit of Infectious Diseases (Soliman OE, Hegazi MA), Clinical Pathology Department (Salama OS, Yahya R), Mansoura University, Egypt

Corresponding Author: Prof. Youssef Al-Tonbary, Mansoura University Children's Hospital, Mansoura, Egypt (Tel: +20123165302; Fax: +20502262307; Email: ytonbary@gmail.com)

Background: Pediatric hematology/oncology patients are faced with an increased risk of nosocomial infections (NIs) that vary in different populations and different institutions with considerable morbidity and mortality. This study was undertaken to assess the frequency and patterns of NIs in 1564 pediatric patients and to determine the prevalence of causative organisms and their antimicrobial sensitivity.

Methods: A retrospective analysis was made in the patients admitted between January 2007 and January 2008 to the pediatric hematoloy/oncology unit of Mansoura University, Egypt. The 1564 patients showed 2084 admissions and 27 092 inpatient days. The Centers for Disease Control and Prevention criteria were used as a standard definition for NI.

Results: The overall rate of NIs in all patients and neutropenic patients was 8.6 and 25.3 per 1000 patient-days respectively. The frequent sites of NIs were blood stream (42.7%), the respiratory system (25.3%), the urinary system (22.2%) and the central nervous system (9.8%), whereas nosocomial fever of unknown origin constituted 52.9% of cases. The incidence of NIs was significantly higher during neutropenic days (P<0.001). Gram-positive organisms represented 64.5% of pathogens (Staphylococci 71.5%, Streptococci 16%, and pneumococci 7%), and Gram-negative organisms represented 30% (E. coli 48.6%, Klebsiella 15.7%, Pseudomonas 35.7%, and C. albicans 5.5%). Positive cultures were more frequent in summer (July to September). Susceptibility of isolated organisms was relatively low (cefoperazone/sulbactam 49.9%, amikacin 35.9%, imipenem/cilastin 34.4%, cefoperazone 33.6%, and vancomycin 36.5%). Methicillin-resistant S. aureus, extended spectrum beta lactamase and vancomycin resistant enterococci represented 30%, 45% and 75% of isolated S. aureus, Gram-negative organisms and Enterococci, respectively.

Conclusions: Blood stream infection and fever of unknown origin are the most common nosocomial infections in pediatric hematology/oncology patients with a higher risk during neutropenic days. Isolated organisms are multi-drug resistant, predominantly Gram-positive pathogens with a high incidence of methicillin-resistant S. aureus, extended spectrum beta lactamase and vancomycin resistant enterococci organisms.

Key words: fever of unknown origin; hematology/oncology; nosocomial infections;  pediatric

Author Affiliations: Department of Pediatric Surgery, First Hospital  Affiliated to Zhengzhou University, Zhengzhou 450052, China (Dahal GR, Wang JX,  Guo LH )

Corresponding Author: Jia-Xiang Wang, PhD, Department of Pediatric Surgery, First Hospital Affiliated to Zhengzhou University, Zhengzhou 450052, China (Tel: 86-371-66913510; Fax: 86-371-66913510; Email: wjiaxiang@zzu.edu.cn)

Background: Single-stage transanal endorectal pull-through (TEPT) is a new technique for surgery of Hirschsprung's disease (HD). TEPT can be assisted by laparoscopy (laparoscopic assisted transanal pull-through, LATP) or with non-additional procedure (total transanal endorectal pull-through, TTEP). This study was undertaken to evaluate the long-term outcome of these approaches in children with HD.

Methods: We retrospectively studied 131 patients (112 males and 19 females) aged 7 days to 14 years who underwent single-stage TEPT from October 2003 to July 2008. The medical records were reviewed for pre-, intra- and immediate post-operative complications. The data on stool pattern and complications were collected during the follow-up. Outcome was measured by continence evaluation score.

Results: No patients had intraoperative complications, but 5 had minor immediate postoperative complications. Late postoperative complications in 12 patients included enterocolitis (4 patients, one with severe enterocolitis died 7 months after operation), soiling (6) and constipation (2). There was a significantly higher frequency of stool in patients aged more than 36 months and those with a resected colon more than 30 cm (P<0.05). LATP showed significantly higher frequency of stool and soiling (P<0.05). Of the 54 patients who were older than 3 years at the time of follow-up, continence score was normal in 10, good in 39, fair in 3, and poor in 2. Seventy-seven patients achieved good bowel control in 12.8±8.1 months after operation, 93.5% of whom within 24 months. Stool function was not improved in patients more than 30 months old after operation.

Conclusions: The long-term outcome of single stage TEPT was excellent. There were few postoperative complications, and stool pattern improved gradually to an excellent level within 24 months. Internal plication can be a good option for reducing the dilated proximal colon.

Key words: Hirschsprung's disease; internal plication; laparoscopic assisted transanal pull-through; postoperative outcome; total transanal endorectal pull through;   transanal endorectal pull-through

                                                                                                             World J Pediatr 2011;7(1):65-69

Author Affiliations: Department of General Surgery, Division of Pediatric Surgery, Kaiser Permanente, Los Angeles Medical Center 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA 90027, USA (Shekherdimian S, Lee SL); Department of Surgery, Division of Pediatric Surgery, UCLA Medical Center, Los Angeles, CA 90095, USA (Shekherdimian S, Lee SL)

Corresponding Author: Steven L. Lee, MD, Department of Surgery, Division of Pediatric Surgery, UCLA Medical Center, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095-7098, USA (Tel: 310-206-2429; Fax: 310-206-1120; Email: slleemd@yahoo.com)

Background: Age related differences in the management and outcomes of children with ileocolic intussusception have not been previously published. The purpose of this study is to compare the differences in diagnosis and treatment of pediatric ileocolic intussusception based upon age in general hospitals.

Methods: A review was made of pediatric patients treated for intussusception at 11 hospitals between 1996 and 2007. The patients were divided into 3 groups based on age: group A: <6 months (n=37), group B: 6 months to 4 years (n=126), group C: >4 years (n=25). Diagnostic modality, operative reports, and hospital records were reviewed.

Results: Altogether 188 patients were treated for ileocolic intussusception. Contrast enema was performed in 80.3% of the patients. Initial treatment for the patients included contrast enema in 80.3%, immediate operation in 3.2%, and others in 16.5%. Older patients were less likely to undergo a contrast enema (P<0.05) but more likely to be successfully reduced. Patients in group A had the lowest rate of successful reduction (P<0.05). Overall, 3.2% of the patients were taken to the operating room without any diagnostic evaluations, but 65% of the patients ultimately required operative intervention. Patients in groups A and C were more likely to undergo an operation (P<0.05). Rates of bowel resection and length of hospital stay were similar among the three groups.

Conclusions: Enema reduction for ileocolic intussusception is moderately successful in general hospitals and lower than that reported in children's hospitals. The lowest reduction rate occurs in patients of less than 6 months old and the diagnosis of intussusception in older children is rarely made by contrast enema. There is a higher operative rate in children of less than 6 months or older than 4 years and the rate of intestinal resection is higher than that in children's hospitals.

Key words: contrast enema; Ileocolic intussusception; surgery

World J Pediatr 2011;7(1):70-73

Background: Craniopharyngioma is a frequent tumor in children with challenging surgical, endocrine, and visual consequences. We evaluated our experience in treating craniopharyngioma and its incidence in Macedonia.

Methods: Thirteen children (9 male and 4 female) with craniopharyngioma (age 9.55±3.74 years; range 2.90-15.11) who had been treated between 1989 and 2008 in Macedonia were reviewed.

Results: Initial signs were vision disturbances (10 children), seizures (1), growth retardation (13), and diabetes insipidus (DI) (2). All children were subjected to subtotal surgical removal. Cranial irradiation was performed in 12 of the 13 children, and intracystic bleomycin was given to one child. The patients were followed up for 6-229 months (mean ± SD: 107.00±74.04 months). All children had multiple pituitary deficiencies after surgical removal of the tumor. Body mass index increased from 16.93±6.34 standard deviation scores (SDS) at diagnosis to 26.33±5.91 SDS (P>0.005) at the last follow-up. DI was permanent in 9 of the 13 children, and multiple pituitary deficiencies were seen in all children. Treatment with growth hormone resulted in normalization of adult height from -1.27±1.52 SDS at the start of the treatment to -0.13±1.39 SDS at the last follow-up. The final height was not significantly lower than the genetic target height (P>0.005). The permanent deficit was visual impairment: blindness in one or both eyes in 4 children, bitemporal hemianopsia in 4, and other defects in 2. Recurrence of the disease was ruled out in one child after 31 months. No mortality was observed in the observation period of 104.92±76.11 months.

Conclusions: The overall incidence of craniopharyngioma in the period of 1989-2008 in Macedonia was 1.43 per 1 000 000 person-years. Subtotal resection and systematic irradiation showed good life quality of survivors.

Key words: craniopharyngioma; growth; incidence; outcome; partial resection

                   World J Pediatr 2011;7(1):74-78

Background: This study aimed to compare mental health of mothers of children with spina bifida with mothers of able-bodied controls.

Methods: Eighty-one mothers of children with spina bifida aged 1-18 years completed the General Health Questionnaire-12 (GHQ-12) and Parenting Stress Index Short Form (PSI/SF). The controls were 69 mothers of children with acute, non-disabling illnesses. Each child's adaptive skills were assessed using the Vineland Adaptive Behaviour Scales (VABS). Logistic regression analysis was used to determine factors related to a high GHQ score (≥3) in all patients.

Results: Compared to the controls, mothers of children with spina bifida had lower educational levels and were more likely to be the main caregivers and not working. Nineteen (23.5%) of them had a high GHQ score compared to 5 (7.2%) of the controls. They also had significantly higher scores for total PSI/SF and the parent domain, difficult child (DC) and parent-child dysfunctional interaction subscales. Children with spina bifida had lower scores for the composite VABS and communication, socialization, daily living skills and motor sub-domain than the controls. Spina bifida (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.30-14.23), higher DC scores (OR 1.1, 95% CI 1.00-1.16), and higher life stress scores (OR 1.1, 95% CI 1.01-1.71) were associated with a high GHQ score.

Conclusion: Spina bifida, recent stressful life change events and maternal perception of a child as 'difficult' are associated with poor maternal psychological health.

Key words: life change events; mental health; parent-child relations; spina bifida

World J Pediatr 2011;7(1):54-59

Background: Rectal suction biopsy is a safe and painless procedure commonly performed in pediatric surgical practice for the diagnosis of intestinal dysganglionosis.

Methods: We report a 3.5-year-old boy who experienced massive delayed bleeding after a rectal suction biopsy. Detailed information regarding clinical features, onset, management, and outcome are provided.

Results: Acute onset of massive bleeding occurred 4 days after a rectal suction biopsy was performed to rule out possible intestinal dysganglionosis. The complication was managed conservatively, but blood transfusion and hospitalization were required. No predisposing abnormalities were detected.

Conclusions: Massive bleeding after rectal suction biopsy is a well-known life-threatening complication. Nonetheless, such a delayed bleeding (up to 4 days after a rectal suction biopsy) has never been reported before. Parents should be made aware of this possibility and surgeons should be aware of this complication which can be scarcely predicted based on patient's and familial history.

Key words: complications; diagnosis; Hirschsprung; intestinal dysganglionosis; rectal suction biopsy

                  World J Pediatr 2011;7(1):83-85

Background: Antenatal variant of Bartter syndrome is characterized by a history of polyhydramnios, premature birth, metabolic alkalosis, hypokalemia, polyuria and renal salt wasting. In this report we present a premature female baby with antenatal Barter syndrome who had three episodes of urinary tract infection (UTI), without evidence for congenital anomaly of the kidneys or urinary tract.

Methods: Antenatal Bartter syndrome was diagnosed according to the standard criteria. Ultrasound scan and voiding cystourethrography were performed to exclude congenital anomaly of the kidneys and urinary tract.

Results: The baby presented with early hyperkalemia and acidosis. The typical biochemical features of the Bartter syndrome were observed in the second month. Despite appropriate treatment she had persistent hypercalciuria. The clinical course was complicated with recurrent episodes of febrile UTIs. Urinary tract system imaging did not demonstrate congenital anomalies. She finally died of severe dehydration, acidosis and renal failure.

Conclusion: Since no congenital anomaly of the kidneys or urinary tract was demonstrated in our patient, we believe that severe, persistent hypercalciuria is the most important risk factor for development of recurrent UTIs.

Key words: acidosis; antenatal Bartter syndrome; hypercalciuria; hyperkalemia; urinary tract infection

                   World J Pediatr 2011;7(1):86-88

Methods: We report a premature neonate with double outlet right ventricle and congestive heart failure who developed acute renal failure after administration of captopril at a low dose of 0.1 mg/kg per 8 hours.

Results: On the third day after captopril therapy, the levels of serum creatinine and blood urea nitrogen increased to 2.6 mg/dl and 73 mg/dl respectively, and hyperkalemia appeared. Captopril was discontinued immediately. On the fourth day, the infant developed oliguria which persisted for 24 hours and resolved on the fifth day when the serum potassium normalized to 4.5 mmol/L. The level of serum creatinine peaked at 3.9 mg/dL on the sixth day and gradually decreased to normal on the ninth day after administration of captopril. The captopril-induced acute renal failure resolved completely after cessation of the drug.

Conclusions: Attention should be given to captopril therapy in premature neonates with congestive heart failure secondary to congenital heart disease with large left-to-right shunts. Routine hemodynamic examination and biochemical monitoring are suggested before and during captopril therapy.

Key words: acute renal failure; captopril; congestive heart failure; neonate                 

World J Pediatr 2011;7(1):89-91