WHAT YOU SHOULD HAVE READ BUT….2010 <ul><li>General Paediatrics </li></ul>University of Verona, Italy Attilio Boner
<ul><li>antibiotici </li></ul>
Prescribing competence of junior doctors:  does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>Prescribing for chil...
Prescribing competence of junior doctors:  does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>Junior doctors’ pres...
Prescribing competence of junior doctors:  does it add up? L Kidd, Arch Dis Child 2010;95:219 undergraduate training both ...
Prescribing competence of junior doctors:  does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>30 junior doctors we...
Prescribing competence of junior doctors:  does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>30 junior doctors we...
Prescribing competence of junior doctors:  does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>30 junior doctors we...
<ul><li>Sulfonamides  were associated with: </li></ul><ul><li>Case-control study  of  women  who had pregnancies affected ...
<ul><li>Case-control study  of  women  who had pregnancies affected by  major birth defects  (n=13155) and  control women ...
% children receiving  antibiotics 19.5% Intervention 40.8% Control Effect of using an interactive booklet about childhood ...
% of parents who said they would seek care in the future if their child developed a similar illness 55.3% Intervention 76....
<ul><li>Avvelenamenti </li></ul><ul><li>Incidenti domestici </li></ul>
<ul><li>Venous samples at age 30 months </li></ul><ul><li>Avon Longitudinal Study of Parents and Children (ALSPAC) (488 ca...
<ul><li>Venous samples at age 30 months </li></ul><ul><li>Avon Longitudinal Study of Parents and Children (ALSPAC) (488 ca...
<ul><li>Venous samples at age 30 months </li></ul><ul><li>Avon Longitudinal Study of Parents and Children (ALSPAC) (488 ca...
<ul><li>Venous samples at age 30 months </li></ul><ul><li>Avon Longitudinal Study of Parents and Children (ALSPAC) (488 ca...
<ul><li>72  motor vehicle passengers aged 0–16 years  ( 58  <12 years of age,  14  ≥ 12 years of age) </li></ul>SPINAL INJ...
<ul><li>72  motor vehicle passengers aged 0–16 years  ( 58  <12 years of age,  14  ≥ 12 years of age) </li></ul>SPINAL INJ...
Abuso IL BAMBINO BATTUTO
Nonaccidental Head Injury Is the Most Common Cause of Subdural Bleeding in Infants <1 Year of Age  Matschke  Pediatrics 20...
Nonaccidental Head Injury Is the Most Common Cause of Subdural Bleeding in Infants <1 Year of Age  Matschke  Pediatrics 20...
Screening for Occult Abdominal Trauma in Children With Suspected Physical Abuse  Lane  Pediatrics 2009;124:1595 % CHILDREN...
Screening for Occult Abdominal Trauma in Children With Suspected Physical Abuse  Lane  Pediatrics 2009;124:1595 % CHILDREN...
30 – 20 – 10 – 0 OR  FOR OCCULT ABDOMINAL TRAUMA SREENING 20.4 8.5 CONSULTATION WITH THE CHILD PROTECTION TEAM <ul><li>Our...
Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma Pierce  Pediatrics 2010;125:67 <ul><li...
Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma Pierce  Pediatrics 2010;125:67 Compari...
Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma Pierce  Pediatrics 2010;125:67 Bruise ...
WHICH CLINICAL FEATURES DISTINGUISH INFLICTED FROM NONINFLICTED BRAIN INJURY?  A SYSTEMATIC REVIEW  Maguire   Arch Dis Chi...
WHICH CLINICAL FEATURES DISTINGUISH INFLICTED FROM NONINFLICTED BRAIN INJURY?  A SYSTEMATIC REVIEW  Maguire   Arch Dis Chi...
<ul><li>1046  adolescents  aged 13 to 21 years </li></ul><ul><li>Self-report questionnaire </li></ul><ul><li>On average, a...
SCREENING FOR TRAUMATIC EXPOSURE AND POSTTRAUMATIC STRESS SYMPTOMS IN ADOLESCENTS  IN THE WAR AFFECTED EASTERN DEMOCRATIC ...
SCREENING FOR TRAUMATIC EXPOSURE AND POSTTRAUMATIC STRESS SYMPTOMS IN ADOLESCENTS  IN THE WAR AFFECTED EASTERN DEMOCRATIC ...
FEVER CONTROL
<ul><li>231  children   who experienced their first febrile seizure </li></ul><ul><li>2 years  follow-up </li></ul><ul><li...
ANTIPYRETIC AGENTS FOR PREVENTING RECURRENCES OF FEBRILE SEIZURES  Strengell  Arch Ped Adoles Med 2009;163:799 <ul><li>231...
PAIN CONTROL
<ul><li>261 children,  2-12 years, </li></ul><ul><li>tonsillectomy and adenoidectomy </li></ul>Pediatric Pain After Ambula...
Pediatric Pain After Ambulatory Surgery: Where's the Medication?   Fortier  Pediatrics 2009;124;e588   % CHILDREN 67% EXPE...
Pediatric Pain After Ambulatory Surgery: Where's the Medication?   Fortier  Pediatrics 2009;124;e588   % CHILDREN 67% EXPE...
<ul><li>Minerali </li></ul><ul><li>ferro </li></ul>
In Utero Iron Status and Auditory Neural Maturation in Premature Infants as Evaluated by Auditory Brainstem Response  Amin...
In Utero Iron Status and Auditory Neural Maturation in Premature Infants as Evaluated by Auditory Brainstem Response  Amin...
<ul><li>Minerali </li></ul><ul><li>zinco </li></ul>
<ul><li>Vitamine </li></ul>
<ul><li>Vitamina D </li></ul>
Vitamin D deficiency in young children with severe acute lower respiratory infection   McNally, Ped Pul 2009;44:981 <ul><l...
Vitamin D deficiency in young children with severe acute lower respiratory infection   McNally, Ped Pul 2009;44:981 <ul><l...
Vitamin D deficiency in young children with severe acute lower respiratory infection   McNally, Ped Pul 2009;44:981 <ul><l...
Vitamin D deficiency in young children with severe acute lower respiratory infection   McNally, Ped Pul 2009;44:981 <ul><l...
Vitamin D deficiency in young children with severe acute lower respiratory infection   McNally, Ped Pul 2009;44:981 <ul><l...
<ul><li>Vitamin D influences antimicrobial activity, inflammation, and coagulation partly by regulating calcium and phosph...
Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and...
Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and...
Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and...
Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospecti...
19.9 35.2 <ul><li>Prospective cohort study. </li></ul><ul><li>152 children aged  2-59 months with very severe pneumonia (V...
Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospecti...
19.9 35.2 <ul><li>Prospective cohort study. </li></ul><ul><li>152 children aged  2-59 months with very severe pneumonia (V...
Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population Reis  Pediatrics 2009; 124:e3...
Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population Reis  Pediatrics 2009; 124:e3...
In the Lowest Quartile (<15 ng/ml) vs the Highest Quartile (>26 ng/ml) OR for  2.36 LOW HIGH-DENSITY LIPOPROTEIN CHOLESTER...
<ul><li>Retrospective record review of pediatric outpatients  (age, 2-18 years)  </li></ul><ul><li>simultaneous measuremen...
Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients   Johnson  J...
Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients   Johnson  J...
Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients   Johnson  J...
<ul><li>Children aged 1 to 21 </li></ul><ul><li>years ( n =  6275) </li></ul><ul><li>Serum 25(OH)D  deficiency (<15 ng/mL)...
<ul><li>Children aged 1 to 21 </li></ul><ul><li>years ( n =  6275) </li></ul><ul><li>Serum 25(OH)D  deficiency (<15 ng/mL)...
OR   FOR VIT D DEFICIENCY (<15 ng/mL) 1.16 DRANK MILK LESS THAN ONCE A WEEK OLDER GIRLS 5 – 4 – 3 – 2   – 1 – 0 1.6 4.9 1....
<ul><li>25(OH)D deficiency (<15 ng/ml)  compared with those  </li></ul><ul><li>with 25(OH)D levels ≥30 ng/mL.was associate...
Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor  Pediatrics 2010;125:105 <ul><li>Networ...
Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor  Pediatrics 2010;125:105 <ul><li>Networ...
Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor  Pediatrics 2010;125:105 <ul><li>Networ...
Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor  Pediatrics 2010;125:105 <ul><li>Networ...
Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D?  Mansbach  Pediatr...
Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D?  Mansbach  Pediatr...
Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D?  Mansbach  Pediatr...
CARDIOLOGY
<ul><li>107 patients  (19 neonates and  88 children) with a diagnosis of  A rterial  I schemic  S troke ( AIS ) </li></ul>...
% OF INPATIENTS AT THE TIME OF STROKE 60 - 50 – 40 – 30 – 20 – 10 – 0 58% Delayed Recognition of Initial Stroke in Childre...
Delayed Recognition of Initial Stroke in Children: Need for Increased Awareness  Srinivasan Pediatrics 2009;124;e227
Kawasaki Disease at the Extremes of the Age Spectrum  Manlhiot  Pediatrics 2009; 124:e410 <ul><li>Retrospective review  </...
Kawasaki Disease at the Extremes of the Age Spectrum  Manlhiot  Pediatrics 2009; 124:e410 <ul><li>Retrospective review  </...
Kawasaki Disease at the Extremes of the Age Spectrum  Manlhiot  Pediatrics 2009; 124:e410 <ul><li>Retrospective review  </...
Kawasaki Disease at the Extremes of the Age Spectrum  Manlhiot  Pediatrics 2009; 124:e410 <ul><li>Retrospective review  </...
<ul><li>1-year prospective multicenter cohort study </li></ul><ul><li>Patients <18 years old admitted for prolonged but in...
<ul><li>1-year prospective multicenter cohort study </li></ul><ul><li>Patients <18 years old admitted for prolonged but in...
Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement of American Heart Association  Newburger P...
Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement of American Heart Association  Newburger P...
Laboratory findings in acute Kawasaki disease *  (Thrombocytopenia in sone infants) *
Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committe...
Refractory pneumonia and high fever Falcini,  Lancet 2010;373:1818 <ul><li>A previously healthy 30-month-old girl was seen...
Refractory pneumonia and high fever Falcini,  Lancet 2010;373:1818 <ul><li>A repeat full blood count showed: </li></ul><ul...
Refractory pneumonia and high fever Falcini,  Lancet 2010;373:1818 (A) Frontal view showing marked pleural effusion on the...
Refractory pneumonia and high fever Falcini,  Lancet 2010;373:1818 <ul><li>Kawasaki disease  is a multisystemic vasculitis...
Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease   Ugi  ERJ  2010;35:452  <ul><li...
Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease   Ugi  ERJ  2010;35:452  <ul><li...
Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease   Ugi  ERJ  2010;35:452  <ul><li...
Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease   Ugi  ERJ  2010;35:452  <ul><li...
Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease   Ugi  ERJ  2010;35:452  <ul><li...
Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease   Ugi  ERJ  2010;35:452  <ul><li...
Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease   Ugi  ERJ  2010;35:452  <ul><li...
200 – 150 – 100 – 50 – 0 <ul><li>28 patients with KD (7-20 years after acute illness)  </li></ul><ul><li>27 age-matched he...
100 – 75 – 50 – 25 – 0 <ul><li>28 patients with KD (7-20 years after acute illness)  </li></ul><ul><li>27 age-matched heal...
100 – 75 – 50 – 25 – 0 <ul><li>28 patients with KD (7-20 years after acute illness)  </li></ul><ul><li>27 age-matched heal...
<ul><li>28 patients with KD (7-20 years after acute illness)  </li></ul><ul><li>27 age-matched healthy control </li></ul><...
Early Life Origins of Low-Grade Inflammation and Atherosclerosis Risk in Children and Adolescents Idoia Labayen, J  Ped 20...
Early Life Origins of Low-Grade Inflammation and Atherosclerosis Risk in Children and Adolescents Idoia Labayen, J  Ped 20...
Simple Table to Identify Children and Adolescents Needing Further Evaluation of Blood Pressure  Kaelber  Pediatrics 2009;1...
Preventing Surgical-Site Infections in Nasal Carriers of  Staphylococcus aureus  Lonneke G.M. Bode. NEJM 2010 (362): 9-17 ...
<ul><li>Identification of  S. aureus   nasal carriers by real-time polymerase-chain-reaction   (PCR).  </li></ul><ul><li>T...
<ul><li>Identification of  S. aureus   nasal carriers by real-time polymerase-chain-reaction   (PCR).  </li></ul><ul><li>T...
<ul><li>Identification of  S. aureus   nasal carriers by real-time polymerase-chain-reaction   (PCR).  </li></ul><ul><li>T...
<ul><li>Nasal carriers   of  S. aureus  are also colonized at extranasal sites.  It is   unlikely that nasal application o...
Minimizing Surgical-Site Infections  RP Wenzel, NEJM 2010 (362): 75-77   <ul><li>Some experts estimate that the total numb...
Minimizing Surgical-Site Infections  RP Wenzel, NEJM 2010: 362: 75-77   <ul><li>Chlorhexidine–alcohol has been recommended...
Chronic fatigue syndrome
Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents Katz  Pediatrics 2009;124:189 <ul><li>301 adolescen...
Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents Katz  Pediatrics 2009;124:189 <ul><li>301 adolescen...
Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents Katz  Pediatrics 2009;124:189 <ul><li>301 adolescen...
The chronic fatigue syndrome: a comprehensive approach to its definition and study.  Fukuda K, Ann Intern Med. 1994;121:95...
Risk Factors for Persistent Fatigue With Significant School Absence in Children and Adolescent  Robert Pediatrics 2009;124...
2 – 1 – 0 1.4 2.1 2.0 1.8 1.7 1.8 1.9 SLEEP PROBLEMS BLURRED VISION PAIN IN ARMS OR LEGS BACK PAIN COSTIPATION MEMORY DEFI...
<ul><li>Chronic fatigue syndrome ( CFS ) or myalgic encephalopathy ( ME ) </li></ul><ul><li>20 children  with a diagnosis ...
<ul><li>Chronic fatigue syndrome (CFS)  or  myalgic encephalopathy (ME)  is the commonest cause of school absence in the U...
<ul><li>68% of children report that having CFS/ME prevented them attending school at some stage, with a mean  time out  of...
<ul><li>Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) </li></ul><ul><li>Spence Children’s Anxiety Scale (SCAS) ...
<ul><li>Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) </li></ul><ul><li>Spence Children’s Anxiety Scale (SCAS) ...
<ul><li>Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) </li></ul><ul><li>Spence Children’s Anxiety Scale (SCAS) ...
<ul><li>Prevalence of frequent absence (>20% of the school year) </li></ul><ul><li>secondary schools in Edinburgh </li></u...
FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY  Jones   Arch Dis Child 2009;94:763 ...
FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY  Jones   Arch Dis Child 2009;94:763 ...
FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY  Jones   Arch Dis Child 2009;94:763 ...
FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY  Jones   Arch Dis Child 2009;94:763 ...
FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY  Jones   Arch Dis Child 2009;94:763 ...
Dermatology
Propranolol for Severe Infantile Hemangiomas:  Follow-Up Report  Sans   Pediatrics 2009;124:e423   <ul><li>32 children (me...
Propranolol for Severe Infantile Hemangiomas:  Follow-Up Report  Sans   Pediatrics 2009;124:e423   1)  Infantile hemangiom...
Propranolol for Severe Infantile Hemangiomas:  Follow-Up Report  Sans   Pediatrics 2009;124:e423   A)  10% of IHs require ...
Propranolol for Severe Infantile Hemangiomas:  Follow-Up Report  Sans   Pediatrics 2009;124:e423   A)  10% of IHs require ...
Propranolol for Severe Infantile Hemangiomas:  Follow-Up Report  Sans   Pediatrics 2009;124:e423   Patient  with palpebral...
Propranolol for Severe Infantile Hemangiomas:  Follow-Up Report  Sans   Pediatrics 2009;124:e423   Patient with a painful ...
Propranolol for Severe Infantile Hemangiomas:  Follow-Up Report  Sans   Pediatrics 2009;124:e423   Patient at risk of cosm...
Propranolol for Severe Infantile Hemangiomas:  Follow-Up Report  Sans   Pediatrics 2009;124:e423   Patient with a life-thr...
Propranolol for Severe Infantile Hemangiomas:  Follow-Up Report  Sans   Pediatrics 2009;124:e423   α )  Propranolol is a n...
<ul><li>A 9-year-old boy presented to the emergency room with various macular erythematoses and ecchymotic lesions with ge...
<ul><li>His grandmother mentioned that she had noticed that her albuterol inhaler had run out before she had expected. </l...
An Unusual Dermatosis in a Child  García  J Pediatr 2010;156:505 <ul><li>Dermatitis artefacta  is a self-inflected dermato...
Emergency Department
MAKING CHOICES: WHY PARENTS PRESENT TO THE EMERGENCY DEPARTMENT FOR NON-URGENT CARE  Williams   Arch Dis Child 2009;94:817...
Emergency Department Reliance: A Discriminatory Measure of Frequent Emergency Department Users Kroner  Pediatrics 2010;125...
Emergency Department Reliance: A Discriminatory Measure of Frequent Emergency Department Users Kroner  Pediatrics 2010;125...
gastroenterology
% children with AGE treated according to guidelines 65.5% 80 – 60 – 40 – 20 – 0 The Applicability and Efficacy of Guidelin...
% children with AGE treated according to guidelines 65.5% 80 – 60 – 40 – 20 – 0 The Applicability and Efficacy of Guidelin...
DURATION OF DIARRHEA (hours) 83.3 90.9 Group A Group B 100 – 80 – 60 – 40 – 20 – 0 <ul><li>A 2-hour course based on the gu...
The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis (AGE) in Outpatient Children: A F...
Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Ty...
Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Ty...
<ul><li>124 children admitted for surgery. </li></ul><ul><li>0.9% saline solution (NS) or 0.45% saline solution (N/2) sali...
Questionnaire-Based Case Finding of Celiac Disease in a Population of 8- to 9-Year-Old Children   Toftedal  Pediatrics 201...
Questionnaire-Based Case Finding of Celiac Disease in a Population of 8- to 9-Year-Old Children   Toftedal  Pediatrics 201...
<ul><li>9880 children aged 8 to 9 years. </li></ul><ul><li>A questionnaire on the basis of 5 simple items suggestive of CD...
% children with  acute gastroenteritis at the time of gluten introduction 2.3% 1.8% CD subjects Controls ns Infectious Dis...
% children with  acute gastroenteritis at the time of gluten introduction 2.3% 1.8% CD subjects Controls Infectious Diseas...
The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing  McGowan  Pediatrics 2009;12...
The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing  McGowan  Pediatrics 2009;12...
The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing  McGowan  Pediatrics 2009;12...
The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing  McGowan  Pediatrics 2009;12...
Minutes crying  and fussing 500 – 400 – 300 – 200 – 100 – 0 YES 103 Altered Fecal Microflora and Increased Fecal Calprotec...
Fecal calprotectin  levels mcg/g  500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Cal...
Fecal calprotectin  levels mcg/g  500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Cal...
Fecal calprotectin  levels mcg/g  500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Cal...
Fecal calprotectin  levels mcg/g  500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Cal...
Fecal calprotectin  levels mcg/g  500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Cal...
<ul><li>children affected by IBS according to Rome II criteria (n = 43) </li></ul><ul><li>control population (n = 56) </li...
<ul><li>children affected by IBS according to Rome II criteria (n = 43) </li></ul><ul><li>control population (n = 56) </li...
Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Chil...
Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Chil...
Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Chil...
<ul><li>rectal sensory threshold for pain (RSTP) </li></ul><ul><li>51 patients with abdominal pain  >2 months </li></ul><u...
Increased Auditory Startle Reflex in Children with Functional Abdominal Pain  Bakker   J Pediatr   2010;156:285   <ul><li>...
The multiple muscle ASR (response probability, 0% to 100%), for the 8 repetitive stimuli,  is significantly enlarged in pa...
The multiple muscle ASR (response probability, 0% to 100%), for the 8 repetitive stimuli,  is significantly enlarged in pa...
Recurrent Abdominal Pain in Childhood Urolithiasis  Polito  Pediatrics 2009;124:e1088 <ul><li>1000 children with reccurent...
Recurrent Abdominal Pain in Childhood Urolithiasis  Polito  Pediatrics 2009;124:e1088 % children undergoing abdominal ultr...
Recurrent Abdominal Pain in Childhood Urolithiasis  Polito  Pediatrics 2009;124:e1088 % children undergoing abdominal ultr...
Recurrent Abdominal Pain in Childhood Urolithiasis  Polito  Pediatrics 2009;124:e1088 % children undergoing abdominal ultr...
Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG  Bekkali  Pediatrics 2009;12...
Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG  Bekkali  Pediatrics 2009;12...
Lactobacillus Reuteri In Infants With Functional Chronic Constipation: A Doubleblinded, Randomized, Placebo-controlled Stu...
Objectives:  To determine the benefits of  Lactobacillus rhamnosus  GG (LGG) in an extensively hydrolyzed casein formula (...
Fecal calprotectin µg/g stool 326 Hematochezia 38 Control <ul><li>30 infants with hematochezia. </li></ul><ul><li>32 contr...
Lactobacillus  GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Ext...
Decrease in fecal calprotectin µg/g stool in infants with hematochezia  after 4 week of -225  µg/g BREAST FEEDING without ...
Decrease in fecal calprotectin µg/g stool in infants with hematochezia  after 4 week of -225  µg/g BREAST FEEDING NUTRAMIG...
<ul><li>30 of 52 consecutive infants presenting with  frequent regurgitation  and reflux-associated symptoms  occurring ma...
A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SY...
A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SY...
A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SY...
 
<ul><li>Intensive care </li></ul>
<ul><li>77 intensive care units.  </li></ul><ul><li>2,796 patients.  </li></ul>% PATIENTS WHO DIED 41.6% 50 – 40 – 30 – 20...
Effectiveness of Treatments for Severe Sepsis:  A Prospective, Multicenter, Observational Study   Ferrer   AJRCCM   2009:1...
Association Between ICU Admission During Morning Rounds and Mortality  Afessa CHEST 2009; 136:1489 <ul><li>Retrospective s...
Association Between ICU Admission During Morning Rounds and Mortality  Afessa CHEST 2009; 136:1489 <ul><li>Retrospective s...
Association Between ICU Admission During Morning Rounds and Mortality  Afessa CHEST 2009; 136:1489 <ul><li>Retrospective s...
Initiation of Inappropriate Antimicrobial Therapy Results in a Fivefold Reduction of Survival in Human Septic Shock   Kuma...
52% % PATIENTS SURVIVING 60 – 50 – 40 – 30 – 20 – 10 - 0 10.3% APPROPRIATE INAPPROPRIATE INITIAL T
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  1. 1. WHAT YOU SHOULD HAVE READ BUT….2010 <ul><li>General Paediatrics </li></ul>University of Verona, Italy Attilio Boner
  2. 2. <ul><li>antibiotici </li></ul>
  3. 3. Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>Prescribing for children is more complicated than for adults, with doses calculated according to weight, surface area or postnatal age; </li></ul><ul><li>The General Medical Council emphasises the importance of being able “to work out drug dosages, and write safe prescriptions for different types of drugs,” and that graduates should “have the ability to calculate drug dosages”. </li></ul>
  4. 4. Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>Junior doctors’ prescribing competency should not be assumed; </li></ul><ul><li>Only three out of 319 centres in the UK declared that they routinely provide assessment of paediatric prescribing competency; </li></ul><ul><li>Only 31% of junior doctors answered correctly, in an assessment of paediatric prescribing competency. </li></ul>
  5. 5. Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219 undergraduate training both at a national level following GMC guidance General Medical Council. Tomorrow’s doctors. London: General Medical Council, 2003. http://www.gmc-uk.org/education/undergraduate/GMC_tomorrows_doctors.pdf
  6. 6. Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>30 junior doctors were assessed in 2007 </li></ul><ul><li>32 in 2001–2004 </li></ul>Example of four prescribing questions involving commonly used medicines
  7. 7. Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>30 junior doctors were assessed in 2007 </li></ul><ul><li>32 in 2001–2004 </li></ul>100 - 90 - 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % junior doctors answering correctly the 4 questions 2001-2004 2007 31% 73.3%
  8. 8. Prescribing competence of junior doctors: does it add up? L Kidd, Arch Dis Child 2010;95:219 <ul><li>30 junior doctors were assessed in 2007 </li></ul><ul><li>32 in 2001–2004 </li></ul>100 - 90 - 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % junior doctors answering correctly the 4 questions 2001-2004 2007 31% 73.3% Ongoing monitoring of junior doctors’ prescribing ability has demonstrated improvements which may be due to local and national training initiatives
  9. 9. <ul><li>Sulfonamides were associated with: </li></ul><ul><li>Case-control study of women who had pregnancies affected by major birth defects (n=13155) and control women randomly selected from the same geographical regions (n=4941) </li></ul><ul><li>Reported maternal use of antibacterials ( 1 month before pregnancy through the end of the first trimester ) </li></ul>ANTIBACTERIAL MEDICATION USE DURING PREGNANCY AND RISK OF BIRTH DEFECTS Crider Arch Ped Adoles Med 2009;163:978 <ul><li>Anencephaly (OR=3.4) </li></ul><ul><li>Coarctation of the aorta (OR=2.7) </li></ul><ul><li>Choanal atresia (OR=8.0) </li></ul><ul><li>Diaphragmatic hernia (OR=2.4) </li></ul><ul><li>Nitrofurantois were associated with: </li></ul><ul><li>Hypoplastic left heart syndrome (OR=4.2) </li></ul><ul><li>Cleft lip with cleft palate (OR=2.1) </li></ul>
  10. 10. <ul><li>Case-control study of women who had pregnancies affected by major birth defects (n=13155) and control women randomly selected from the same geographical regions (n=4941) </li></ul><ul><li>Reported maternal use of antibacterials ( 1 month before pregnancy through the end of the first trimester ) </li></ul><ul><li>Sulfonamides were associated with: </li></ul>ANTIBACTERIAL MEDICATION USE DURING PREGNANCY AND RISK OF BIRTH DEFECTS Crider Arch Ped Adoles Med 2009;163:978 <ul><li>Anencephaly (OR=3.4) </li></ul><ul><li>Coarctation of the aorta (OR=2.7) </li></ul><ul><li>Choanal atresia (OR=8.0) </li></ul><ul><li>Diaphragmatic hernia (OR=2.4) </li></ul><ul><li>Nitrofurantois were associated with: </li></ul><ul><li>Hypoplastic left heart syndrome (OR=4.2) </li></ul><ul><li>Cleft lip with cleft palate (OR=2.1) </li></ul>Reassuringly, penicillins, erythromycins , and cephalosporins , although used commonly by pregnant women, were not associated with many birth defects
  11. 11. % children receiving antibiotics 19.5% Intervention 40.8% Control Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial Francis BMJ 2009;339:b2885 <ul><li>61 general practices in Wales and England. </li></ul><ul><li>558 children, ages 6 months to 14 years, who presented to primary care with an acute respiratory tract infection with ≤7 days of symptoms. </li></ul><ul><li>Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections. ( www.equipstudy.com ) </li></ul>p<0.001 50 – 40 – 30 – 20 – 10 – 0
  12. 12. % of parents who said they would seek care in the future if their child developed a similar illness 55.3% Intervention 76.4% Control Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial Francis BMJ 2009;339:b2885 80 – 60 – 40 – 20 – 0 <ul><li>61 general practices in Wales and England. </li></ul><ul><li>558 children, ages 6 months to 14 years, who presented to primary care with an acute respiratory tract infection with ≤7 days of symptoms. </li></ul><ul><li>Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections. ( www.equipstudy.com ) </li></ul>OR =0.34
  13. 13. <ul><li>Avvelenamenti </li></ul><ul><li>Incidenti domestici </li></ul>
  14. 14. <ul><li>Venous samples at age 30 months </li></ul><ul><li>Avon Longitudinal Study of Parents and Children (ALSPAC) (488 cases) </li></ul><ul><li>Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) at age 7–8 years </li></ul>EFFECTS OF EARLY CHILDHOOD LEAD EXPOSURE ON ACADEMIC PERFORMANCE AND BEHAVIOUR OF SCHOOL AGE CHILDREN Chandramouli Arch Dis Child 2009;94:844
  15. 15. <ul><li>Venous samples at age 30 months </li></ul><ul><li>Avon Longitudinal Study of Parents and Children (ALSPAC) (488 cases) </li></ul><ul><li>Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) at age 7–8 years </li></ul>EFFECTS OF EARLY CHILDHOOD LEAD EXPOSURE ON ACADEMIC PERFORMANCE AND BEHAVIOUR OF SCHOOL AGE CHILDREN Chandramouli Arch Dis Child 2009;94:844 <ul><li>Lead-based paint </li></ul><ul><li>Household dust </li></ul><ul><li>Lead water pipes </li></ul><ul><li>Soil around the home </li></ul><ul><li>Herbal and traditional remedies </li></ul><ul><li>Old-fashioned/ethnic make-up </li></ul><ul><li>Lead glazed pottery/crystal </li></ul><ul><li>Paint on children’s toys </li></ul><ul><li>Children’s bead necklaces </li></ul><ul><li>Christmas lights </li></ul><ul><li>Lead smelters/industries </li></ul>Sources of lead
  16. 16. <ul><li>Venous samples at age 30 months </li></ul><ul><li>Avon Longitudinal Study of Parents and Children (ALSPAC) (488 cases) </li></ul><ul><li>Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) at age 7–8 years </li></ul>EFFECTS OF EARLY CHILDHOOD LEAD EXPOSURE ON ACADEMIC PERFORMANCE AND BEHAVIOUR OF SCHOOL AGE CHILDREN Chandramouli Arch Dis Child 2009;94:844 Effect of blood lead concentration on writing. KS1, Key Stage 1
  17. 17. <ul><li>Venous samples at age 30 months </li></ul><ul><li>Avon Longitudinal Study of Parents and Children (ALSPAC) (488 cases) </li></ul><ul><li>Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) at age 7–8 years </li></ul>EFFECTS OF EARLY CHILDHOOD LEAD EXPOSURE ON ACADEMIC PERFORMANCE AND BEHAVIOUR OF SCHOOL AGE CHILDREN Chandramouli Arch Dis Child 2009;94:844 Effect of blood lead concentration on writing. KS1, Key Stage 1 Exposure to lead early in childhood has effects on subsequent educational attainment, even at blood levels below 10 µg/dl. These data suggest that the threshold for clinical concern should be reduced to 5 µg/dl
  18. 18. <ul><li>72 motor vehicle passengers aged 0–16 years ( 58 <12 years of age, 14 ≥ 12 years of age) </li></ul>SPINAL INJURY IN MOTOR VEHICLE CRASHES: ELEVATED RISK PERSISTS UP TO 12 YEARS OF AGE Brown Arch Dis Child 2009;94:546 OR for serious spinal injury 7.1 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 IN CHILDREN AGED <12 YEARS
  19. 19. <ul><li>72 motor vehicle passengers aged 0–16 years ( 58 <12 years of age, 14 ≥ 12 years of age) </li></ul>SPINAL INJURY IN MOTOR VEHICLE CRASHES: ELEVATED RISK PERSISTS UP TO 12 YEARS OF AGE Brown Arch Dis Child 2009;94:546 OR for serious spinal injury 7.1 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 <ul><li>Children up to age 12 have an elevated risk of serious spinal injury in car crashes. </li></ul><ul><li>Use of adult seatbelts alone before age 12 may increase a child’s risk of serious spinal injury </li></ul>IN CHILDREN AGED <12 YEARS
  20. 20. Abuso IL BAMBINO BATTUTO
  21. 21. Nonaccidental Head Injury Is the Most Common Cause of Subdural Bleeding in Infants <1 Year of Age Matschke Pediatrics 2009;124:1587 <ul><li>715 autopsies of infants <1 year of age. </li></ul>% OF CASES WITH SUBDURAL BLEEDING 7% 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0
  22. 22. Nonaccidental Head Injury Is the Most Common Cause of Subdural Bleeding in Infants <1 Year of Age Matschke Pediatrics 2009;124:1587 % OF CASES WITH SUBDURAL BLEEDING 82.4% 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 5.2% 8.0% NON-ACCIDENTAL HEAD INJURY OTHER CAUSES OF DEATH UNEXPLAINED CT scan
  23. 23. Screening for Occult Abdominal Trauma in Children With Suspected Physical Abuse Lane Pediatrics 2009;124:1595 % CHILDREN WHO WERE SCREENED FOR OCCULT ABDOMINAL TRAUMA 20% 30 – 20 – 10 – 0 <ul><li>Occult abdominal trauma (OAT) </li></ul><ul><li>Liver and pancreatic enzyme measurements </li></ul><ul><li>244 children evaluated for abusive injury </li></ul>
  24. 24. Screening for Occult Abdominal Trauma in Children With Suspected Physical Abuse Lane Pediatrics 2009;124:1595 % CHILDREN WHO WERE SCREENED FOR OCCULT ABDOMINAL TRAUMA 30 – 20 – 10 – 0 20% Positive results were identified for 41% of those screened <ul><li>Occult abdominal trauma (OAT) </li></ul><ul><li>Liver and pancreatic enzyme measurements </li></ul><ul><li>244 children evaluated for abusive injury </li></ul>
  25. 25. 30 – 20 – 10 – 0 OR FOR OCCULT ABDOMINAL TRAUMA SREENING 20.4 8.5 CONSULTATION WITH THE CHILD PROTECTION TEAM <ul><li>Our findings support OAT screening with liver and pancreatic enzyme measurements for physically abused children. </li></ul><ul><li>This study also supports the importance of subspecialty input, especially that of a child protection team. </li></ul>CHILDREN PRESENTING WITH PROBABLE ABUSIVE HEAD TRAUMA Screening for Occult Abdominal Trauma in Children With Suspected Physical Abuse Lane Pediatrics 2009;124:1595
  26. 26. Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma Pierce Pediatrics 2010;125:67 <ul><li>Children 0 to 48 months of age because of trauma </li></ul><ul><li>Victims of physical abuse (N =42) </li></ul><ul><li>Control subjects (N=53) accidental trauma </li></ul>Characteristics predictive of abuse were bruising on the torso , ear , or neck for a child ≤4 years of age and bruising in any region for an infant <4 months of age.
  27. 27. Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma Pierce Pediatrics 2010;125:67 Comparison of cumulative numbers of bruises for patients with abusive versus accidental trauma. Several bruises are present in case of abuse
  28. 28. Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma Pierce Pediatrics 2010;125:67 Bruise distribution for patients with abusive and accidental trauma. * Indicates regions significantly predictive of abusive trauma * * * * * *
  29. 29. WHICH CLINICAL FEATURES DISTINGUISH INFLICTED FROM NONINFLICTED BRAIN INJURY? A SYSTEMATIC REVIEW Maguire Arch Dis Child 2009;94:860 <ul><li>14 studies representing 1655 children </li></ul>APNOEA 17.0 p<0.001 RETINAL HEAMORRHAGE RIB FRACTURES 20 – 15 – 10 – 5 – 0 In a child with intracranial injury OR for inflicted brain injury 3.5 p=0.03 3.03
  30. 30. WHICH CLINICAL FEATURES DISTINGUISH INFLICTED FROM NONINFLICTED BRAIN INJURY? A SYSTEMATIC REVIEW Maguire Arch Dis Child 2009;94:860 <ul><li>14 studies representing 1655 children </li></ul>APNOEA 17.0 p<0.001 RETINAL HEAMORRHAGE RIB FRACTURES 20 – 15 – 10 – 5 – 0 In a child with intracranial injury OR for inflicted brain injury 3.5 p=0.03 3.03 Seizures and long bone fractures were not discriminatory, and skull fracture and head/neck bruising were more associated with niBI
  31. 31. <ul><li>1046 adolescents aged 13 to 21 years </li></ul><ul><li>Self-report questionnaire </li></ul><ul><li>On average, adolescents were exposed to 4.71 traumatic events </li></ul>% subjects with symptom criteria for post traumatic stress disorder 60 – 50 – 40 – 30 – 20 – 10 – 0 52.2% SCREENING FOR TRAUMATIC EXPOSURE AND POSTTRAUMATIC STRESS SYMPTOMS IN ADOLESCENTS IN THE WAR AFFECTED EASTERN DEMOCRATIC REPUBLIC OF CONGO Mels Arch Ped Adoles Med 2009;163:525
  32. 32. SCREENING FOR TRAUMATIC EXPOSURE AND POSTTRAUMATIC STRESS SYMPTOMS IN ADOLESCENTS IN THE WAR AFFECTED EASTERN DEMOCRATIC REPUBLIC OF CONGO Mels Arch Ped Adoles Med 2009;163:525 <ul><li>During the conflict, civilians were targeted for massacre , mutilation , rape , cannibalism , torture , house-to-house raids , or the looting and burning of their houses and sometimes entire villages </li></ul><ul><li>Moreover, all associated armed groups recruited children for military service , amounting to an estimated 30000 child soldiers participating in conflicts </li></ul>
  33. 33. SCREENING FOR TRAUMATIC EXPOSURE AND POSTTRAUMATIC STRESS SYMPTOMS IN ADOLESCENTS IN THE WAR AFFECTED EASTERN DEMOCRATIC REPUBLIC OF CONGO Mels Arch Ped Adoles Med 2009;163:525 <ul><li>During the conflict, civilians were targeted for massacre, mutilation, rape, cannibalism, torture, house-to-house raids, or the looting and burning of their houses and sometimes entire villages </li></ul><ul><li>Moreover, all associated armed groups recruited children for military service , amounting to an estimated 30 000 child soldiers participating in conflicts </li></ul>stupro saccheggio
  34. 34. FEVER CONTROL
  35. 35. <ul><li>231 children who experienced their first febrile seizure </li></ul><ul><li>2 years follow-up </li></ul><ul><li>All febrile episodes during follow-up were treated first with either rectal diclofenac or placebo . After 8 hours, treatment was continued with oral ibuprofen, acetaminophen, or placebo </li></ul>% children experiencing recurrent febrile seizure 30 – 25 – 20 – 15 – 10 – 5 – 0 23.4% ANTIPYRETIC AGENTS FOR PREVENTING RECURRENCES OF FEBRILE SEIZURES Strengell Arch Ped Adoles Med 2009;163:799 23.5% ANTIPIRETICS PLACEBO
  36. 36. ANTIPYRETIC AGENTS FOR PREVENTING RECURRENCES OF FEBRILE SEIZURES Strengell Arch Ped Adoles Med 2009;163:799 <ul><li>231 children who experienced their first febrile seizure </li></ul><ul><li>2 years follow-up </li></ul><ul><li>All febrile episodes during follow-up were treated first with either rectal diclofenac or placebo . After 8 hours, treatment was continued with oral ibuprofen, acetaminophen, or placebo </li></ul>% children experiencing recurrent febrile seizure 30 – 25 – 20 – 15 – 10 – 5 – 0 23.4% 23.5% ANTIPIRETICS PLACEBO Fever was significantly higher during the episodes with seizure than in those without seizure (39.7°C vs 38.9°C; difference, p<0.001 ) and this phenomenon was independent of the medication given
  37. 37. PAIN CONTROL
  38. 38. <ul><li>261 children, 2-12 years, </li></ul><ul><li>tonsillectomy and adenoidectomy </li></ul>Pediatric Pain After Ambulatory Surgery: Where's the Medication? Fortier Pediatrics 2009;124;e588 % CHILDREN 86% EXPERIENCING SIGNIFICANT PAIN 24% RECEIVED 0 OR JUST 1 MEDICATION DOSE ON THE 1 st DAY AT HOME 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0
  39. 39. Pediatric Pain After Ambulatory Surgery: Where's the Medication? Fortier Pediatrics 2009;124;e588 % CHILDREN 67% EXPERIENCING SIGNIFICANT PAIN 41% RECEIVED 0 OR JUST 1 MEDICATION DOSE ON THE 3 rd DAY AT HOME 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 <ul><li>261 children, 2-12 years, </li></ul><ul><li>tonsillectomy and adenoidectomy </li></ul>
  40. 40. Pediatric Pain After Ambulatory Surgery: Where's the Medication? Fortier Pediatrics 2009;124;e588 % CHILDREN 67% EXPERIENCING SIGNIFICANT PAIN 41% RECEIVED 0 OR JUST 1 MEDICATION DOSE 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 <ul><li>261 children, 2-12 years, </li></ul><ul><li>tonsillectomy and adenoidectomy </li></ul>A large proportion of children receive little analgesic medication after surgery ON THE 3 rd DAY AT HOME
  41. 41. <ul><li>Minerali </li></ul><ul><li>ferro </li></ul>
  42. 42. In Utero Iron Status and Auditory Neural Maturation in Premature Infants as Evaluated by Auditory Brainstem Response Amin J Pediatr 2010;156:377 Bilateral monaural a uditory b rainstem evoked r esponse ( ABR ) was assessed using 80-dB nHL click stimuli at a repetition rate of 29.9/seconds within 48 hours after birth. <ul><li>Cord ferritin (CF). </li></ul><ul><li>Auditory neural maturation. </li></ul><ul><li>Infants with latent iron deficiency (CF 11-75 ng/mL) and infants with normal iron status (CF > 75 ng/mL). </li></ul><ul><li>27-33 weeks gestational age. </li></ul>
  43. 43. In Utero Iron Status and Auditory Neural Maturation in Premature Infants as Evaluated by Auditory Brainstem Response Amin J Pediatr 2010;156:377 <ul><li>Cord ferritin (CF). </li></ul><ul><li>Auditory neural maturation. </li></ul><ul><li>Infants with latent iron deficiency (CF 11-75 ng/mL) and infants with normal iron status (CF > 75 ng/mL). </li></ul><ul><li>27-33 weeks gestational age. </li></ul>infants with latent iron deficiency had significantly prolonged absolute wave latencies and decreased frequency of mature ABR waveforms compared with the infants with normal iron status.
  44. 44. <ul><li>Minerali </li></ul><ul><li>zinco </li></ul>
  45. 45. <ul><li>Vitamine </li></ul>
  46. 46. <ul><li>Vitamina D </li></ul>
  47. 47. Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981 <ul><li>Serum 25 hydroxyvitamin D [25(OH)D] levels. </li></ul><ul><li>Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI) </li></ul><ul><li>Subjects without respiratory symptoms (n = 92). </li></ul>
  48. 48. Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981 <ul><li>Serum 25 hydroxyvitamin D [25(OH)D] levels. </li></ul><ul><li>Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI) </li></ul><ul><li>Subjects without respiratory symptoms (n = 92). </li></ul>The mean vitamin D level for the entire ALRI group was not significantly different from the control group (81 ± 40 vs. 83 ± 30 nmol/L, respectively).
  49. 49. Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981 <ul><li>Serum 25 hydroxyvitamin D [25(OH)D] levels. </li></ul><ul><li>Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI) </li></ul><ul><li>Subjects without respiratory symptoms (n = 92). </li></ul>87 49 P=0.001
  50. 50. Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981 <ul><li>Serum 25 hydroxyvitamin D [25(OH)D] levels. </li></ul><ul><li>Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI) </li></ul><ul><li>Subjects without respiratory symptoms (n = 92). </li></ul>The mean vitamin D level for the ALRI subjects admitted to the pediatric intensive care unit (49 ± 24 nmol/L) was significantly lower (p=0.001) than that observed for both control (83 ± 30 nmol/L) and ALRI subjects admitted to the general pediatrics ward (87 ± 39 nmol/L). P=0.001 87 49
  51. 51. Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981 <ul><li>Serum 25 hydroxyvitamin D [25(OH)D] levels. </li></ul><ul><li>Young children with bronchiolitis (n = 55) or pneumonia (n = 50). (ALRI) </li></ul><ul><li>Subjects without respiratory symptoms (n = 92). </li></ul>P=0.001 Vitamin D deficiency (<50 nmol/L) remained associated with ALRI requiring admission to pediatric intensive care unit after the inclusion of prematurity into a multivariate logistic regression model. 87 49
  52. 52. <ul><li>Vitamin D influences antimicrobial activity, inflammation, and coagulation partly by regulating calcium and phosphorous homeostasis and by acting on lymphocytes , neutrophils , macrophages , and respiratory epithelial cells through vitamin D receptors . </li></ul><ul><li>In addition, the activity of Toll-like receptor (TLR)-4 , responsible for initiating the immune response through pathogen associated </li></ul><ul><li>molecular patterns, are modulated by vitamin D. </li></ul><ul><li>Vitamin D also stimulates the innate immune system through vitamin D receptor-dependent expression of antimicrobial peptides ( cathelicidin and defensins ) and regulation of TLR signaling. Human antimicrobial peptides synthesized and expressed by macrophages, </li></ul><ul><li>neutrophils, and respiratory epithelium have activity against bacteria and some respiratory viruses, including influenza and respiratory syncytial virus </li></ul>Vitamin D deficiency in young children with severe acute lower respiratory infection McNally, Ped Pul 2009;44:981
  53. 53. Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey. Ginde AA Arch Intern Med. 2009;169:384-90. 30 – 20 – 10 – 0 24% % patients with recent URTI 25(OH)D level ng/mL < 10 10-<30 20% ≥ 30 17% P<0.001 for trend OR=1.36 OR=1.24 OR=1.0 <ul><li>Vitamin D levels in 18883 participants ≥12 years in the Third National Health and Nutrition Examination Survey in the USA; </li></ul><ul><li>Symptoms suggestive of an URTI in the preceding few days . </li></ul>
  54. 54. Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey. Ginde AA Arch Intern Med. 2009;169:384-90. 30 – 20 – 10 – 0 24% % patients with recent URTI 25(OH)D level ng/mL < 10 10-<30 20% ≥ 30 17% P<0.001 for trend OR=1.36 OR=1.24 OR=1.0 <ul><li>Vitamin D levels in 18883 participants ≥12 years in the Third National Health and Nutrition Examination Survey in the USA; </li></ul><ul><li>Symptoms suggestive of an URTI in the preceding few days. </li></ul>The association between 25(OH)D level and URTI seemed to be stronger in individuals with asthma (OR, 5.67) and chronic obstructive pulmonary disease (OR, 2.26).
  55. 55. Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey. Ginde AA Arch Intern Med. 2009;169:384-90. 30 – 20 – 10 – 0 24% % patients with recent URTI 25(OH)D level ng/mL < 10 10-<30 20% ≥ 30 17% P<0.001 for trend OR=1.36 OR=1.24 OR=1.0 <ul><li>Vitamin D levels in 18883 participants ≥12 years in the Third National Health and Nutrition Examination Survey in the USA; </li></ul><ul><li>Symptoms suggestive of an URTI in the preceding few days. </li></ul>patients with asthma had an odds ratio of 5.67 of recent URTI with vitamin D levels ,<10 ng/ml compared with those with vitamin D levels >30 ng/ml, and for COPD the odds ratio was 2.26.
  56. 56. Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospective cohort study Banajeh, Ped Pul 2009;44:1207 19.9 35.2 <ul><li>Prospective cohort study. </li></ul><ul><li>152 children aged 2-59 months with very severe pneumonia (VSP). </li></ul>50 – 40 – 30 – 20 – 10 – 0 37.2% 47.3% p=0.019 % circulating neutrophils ≤ 30nmol/L >30nmol/L Vitamin D levels
  57. 57. 19.9 35.2 <ul><li>Prospective cohort study. </li></ul><ul><li>152 children aged 2-59 months with very severe pneumonia (VSP). </li></ul>85.9% 89.8% Day–5 Oxigen saturation ≤ 30nmol/L >30nmol/L 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 p=0.03 Vitamin D levels Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospective cohort study Banajeh, Ped Pul 2009;44:1207
  58. 58. Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospective cohort study Banajeh, Ped Pul 2009;44:1207 19.9 35.2 <ul><li>Prospective cohort study. </li></ul><ul><li>152 children aged 2-59 months with very severe pneumonia (VSP). </li></ul>25 – 20 – 15 – 10 – 5 – 0 20.6% 6% p=0.031 % treatment failure Vitamin D levels ≤30nmol/L rachitic non-rachitic
  59. 59. 19.9 35.2 <ul><li>Prospective cohort study. </li></ul><ul><li>152 children aged 2-59 months with very severe pneumonia (VSP). </li></ul>85.9% 89.8% ≤ 30nmol/L >30nmol/L 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 p=0.03 Vitamin D levels Nutritional rickets and vitamin D deficiency Association with the outcomes of childhood very severe pneumonia: A prospective cohort study Banajeh, Ped Pul 2009;44:1207 Vitamin D deficiency is significantly associated with treatment outcome and significantly predicts both reduced circulating PMNs, and Day-5 hypoxemia (SpO 2 % <88%). Day–5 Oxigen saturation
  60. 60. Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population Reis Pediatrics 2009; 124:e371 <ul><li>3577 adolescents. </li></ul>MEAN 25(OH) Vitamin D ng/ml BLACK MEXICAN AMERICAN WHITE 30 – 20 – 10 – 0 15.5 21.5 28 p<0.001 p<0.001
  61. 61. Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population Reis Pediatrics 2009; 124:e371 <ul><li>3577 adolescents. </li></ul>BLACK MEXICAN AMERICAN WHITE 30 – 20 – 10 – 0 15.5 21.5 28 p<0.001 p<0.001 Low 25(OH)D levels were strongly associated with overweight status and abdominal obesity ( P for trend.<001) with high systolic blood pressure ( P =.02) and plasma glucose concentrations ( P =.01). MEAN 25(OH) Vitamin D ng/ml
  62. 62. In the Lowest Quartile (<15 ng/ml) vs the Highest Quartile (>26 ng/ml) OR for 2.36 LOW HIGH-DENSITY LIPOPROTEIN CHOLESTEROL HYPERTENSION HYPERGLICEMIA 4 – 3 – 2 – 1 – 0 1.54 3.88 2.54 METABOLIC SY Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population Reis Pediatrics 2009; 124:e371
  63. 63. <ul><li>Retrospective record review of pediatric outpatients (age, 2-18 years) </li></ul><ul><li>simultaneous measurement of 25-hydroxyvitamin D and fasting plasma glucose (n = 302) or a lipid panel (n = 177). </li></ul>Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients Johnson J Pediatr 2010;156:444 Correlation between 25(OH) D level and fasting plasma glucose
  64. 64. Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients Johnson J Pediatr 2010;156:444 Correlation between 25(OH) D level and HDL level <ul><li>Retrospective record review of pediatric outpatients (age, 2-18 years) </li></ul><ul><li>simultaneous measurement of 25-hydroxyvitamin D and fasting plasma glucose (n = 302) or a lipid panel (n = 177). </li></ul>
  65. 65. Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients Johnson J Pediatr 2010;156:444 Comparison of fasting glucose, total cholesterol, HDL, triglyceride, and non-HDL levels in subjects with 25(OH)D levels greater or less than 30 ng/mL (*p=0.002; **p<0.001) <ul><li>Retrospective record review of pediatric outpatients (age, 2-18 years) </li></ul><ul><li>simultaneous measurement of 25-hydroxyvitamin D and fasting plasma glucose (n = 302) or a lipid panel (n = 177). </li></ul>
  66. 66. Relationships between 25-Hydroxyvitamin D Levels and Plasma Glucose and Lipid Levels in Pediatric Outpatients Johnson J Pediatr 2010;156:444 Comparison of fasting glucose, total cholesterol, HDL, triglyceride, and non-HDL levels in subjects with 25(OH)D levels greater or less than 30 ng/mL (*p=0.002; **p<0.001) <ul><li>Retrospective record review of pediatric outpatients (age, 2-18 years) </li></ul><ul><li>simultaneous measurement of 25-hydroxyvitamin D and fasting plasma glucose (n = 302) or a lipid panel (n = 177). </li></ul>Low 25(OH) D levels in children and adolescents are associated with higher plasma glucose and lower HDL concentrations.
  67. 67. <ul><li>Children aged 1 to 21 </li></ul><ul><li>years ( n = 6275) </li></ul><ul><li>Serum 25(OH)D deficiency (<15 ng/mL) and insufficiency (15–29 ng/mL), </li></ul>Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004 Kumar Pediatrics 2009;124;e362 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % CHILDREN 9% Deficent (<15 mg/ml) 61% Insufficient (15-29 mg/ml) VITAMIN D
  68. 68. <ul><li>Children aged 1 to 21 </li></ul><ul><li>years ( n = 6275) </li></ul><ul><li>Serum 25(OH)D deficiency (<15 ng/mL) and insufficiency (15–29 ng/mL), </li></ul>Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004 Kumar Pediatrics 2009;124;e362 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 % CHILDREN 9% Deficent (<15 mg/ml) 61% Insufficient (15-29 mg/ml) VITAMIN D Only 4% had taken 400 IU of vitamin D per day for the past 30 days.
  69. 69. OR FOR VIT D DEFICIENCY (<15 ng/mL) 1.16 DRANK MILK LESS THAN ONCE A WEEK OLDER GIRLS 5 – 4 – 3 – 2 – 1 – 0 1.6 4.9 1.9 OBESE 21.9 1.9 BLACK >4 HOURS OF TELEVISION VIDEO OR COMPUTER/DAY 0.4 VITAMIN D SUPPLEMEN-TATION Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004 Kumar Pediatrics 2009;124;e362
  70. 70. <ul><li>25(OH)D deficiency (<15 ng/ml) compared with those </li></ul><ul><li>with 25(OH)D levels ≥30 ng/mL.was associated with: </li></ul><ul><li>elevated parathyroid hormone levels (OR: 3.6), </li></ul><ul><li>higher systolic blood pressure (OR:2.24) </li></ul><ul><li>lower serum level of high-density lipoprotein cholesterol (OR: 3.03) </li></ul>Prevalence and Associations of 25-Hydroxyvitamin D Deficiency in US Children: NHANES 2001-2004 Kumar Pediatrics 2009;124;e362
  71. 71. Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor Pediatrics 2010;125:105 <ul><li>Network pediatricians completed a survey </li></ul><ul><li>Parents of children 6 to 24 months old </li></ul>% pediatricians recommending vitamin D supplementation for all breastfed infants 36.4% 40 – 30 – 20 – 10 – 0
  72. 72. Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor Pediatrics 2010;125:105 <ul><li>Network pediatricians completed a survey </li></ul><ul><li>Parents of children 6 to 24 months old </li></ul>% breast fed infants for ≥6 mo supplemented with vit D 15.9% 20 – 15 - 10 – 5 - 0
  73. 73. Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor Pediatrics 2010;125:105 <ul><li>Network pediatricians completed a survey </li></ul><ul><li>Parents of children 6 to 24 months old </li></ul>% breast fed infants for ≥6 mo supplemented with vit D 15.9% 20 – 15 - 10 – 5 - 0 OD for supplementation=7.8 if pediatricians gave advice
  74. 74. Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods Taylor Pediatrics 2010;125:105 <ul><li>Network pediatricians completed a survey </li></ul><ul><li>Parents of children 6 to 24 months old </li></ul>% advised parents who gave the supplementation to their child 44.6% 50 - 40 – 30 – 20 – 10 – 0
  75. 75. Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D? Mansbach Pediatrics 2009;124:1404 <ul><li>4558 US children aged 1 to 11 years. </li></ul><ul><li>Serum 25(OH)D levels by radioimmunoassay. </li></ul><ul><li>categorized as <25, <50, and <75 nmol/L. (≈ 10, 20, 30 ng/mL) </li></ul>1% 18% 69% % CHILDREN WITH <25 <50 <75 Vitamin D serum levels nmol/L 70 – 60 - 50 - 40 - 30 – 20 – 10 – 0
  76. 76. Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D? Mansbach Pediatrics 2009;124:1404 <ul><li>4558 US children aged 1 to 11 years. </li></ul><ul><li>Serum 25(OH)D levels by radioimmunoassay. </li></ul><ul><li>categorized as <25, <50, and <75 nmol/L. </li></ul>1% 18% 69% % CHILDREN WITH <25 <50 <75 Vitamin D serum levels nmol/L 70 – 60 - 50 - 40 - 30 – 20 – 10 – 0 The prevalence of serum 25(OH)D levels of <75 nmol/L was higher among children aged 6 to 11 years (73%) compared with children aged 1 to 5 years (63%); girls (71%) compared with boys (67%); and black (92%) children.
  77. 77. Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D? Mansbach Pediatrics 2009;124:1404 <ul><li>4558 US children aged 1 to 11 years. </li></ul><ul><li>Serum 25(OH)D levels by radioimmunoassay. </li></ul><ul><li>categorized as <25, <50, and <75 nmol/L. </li></ul>1% 18% 69% % CHILDREN WITH <25 <50 <75 Vitamin D serum levels nmol/L 70 – 60 - 50 - 40 - 30 – 20 – 10 – 0 The American Academy of Pediatrics recommendations for vitamin D intakes of 400 IU with a 25(OH)D threshold for vitamin D sufficiency of 50 nmol/L are largely based on studies in non-Hispanic white infants.
  78. 78. CARDIOLOGY
  79. 79. <ul><li>107 patients (19 neonates and 88 children) with a diagnosis of A rterial I schemic S troke ( AIS ) </li></ul>Delayed Recognition of Initial Stroke in Children: Need for Increased Awareness Srinivasan Pediatrics 2009;124;e227 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 MEDIAN TIME TO AIS DIAGNOSIS (HOURS) 87.9 NEONATES p=0.002 24.8 CHILDREN
  80. 80. % OF INPATIENTS AT THE TIME OF STROKE 60 - 50 – 40 – 30 – 20 – 10 – 0 58% Delayed Recognition of Initial Stroke in Children: Need for Increased Awareness Srinivasan Pediatrics 2009;124;e227 <ul><li>107 patients (19 neonates and 88 children) with a diagnosis of A rterial I schemic S troke ( AIS ) </li></ul>
  81. 81. Delayed Recognition of Initial Stroke in Children: Need for Increased Awareness Srinivasan Pediatrics 2009;124;e227
  82. 82. Kawasaki Disease at the Extremes of the Age Spectrum Manlhiot Pediatrics 2009; 124:e410 <ul><li>Retrospective review </li></ul><ul><li>1374 Patients were stratified into 5 groups on the basis of age at diagnosis. </li></ul>% children <0.5 4% 8% 19% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% 6% 0.5-1 1-4 5-9 >9 Years at Diagnosis
  83. 83. Kawasaki Disease at the Extremes of the Age Spectrum Manlhiot Pediatrics 2009; 124:e410 <ul><li>Retrospective review </li></ul><ul><li>1374 Patients were stratified into 5 groups on the basis of age at diagnosis. </li></ul>% children <0.5 4% 8% 19% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% 6% 0.5-1 1-4 5-9 >9 Years at Diagnosis Patients <1 year of age and those >9 years of age were more likely to have coronary artery abnormalities
  84. 84. Kawasaki Disease at the Extremes of the Age Spectrum Manlhiot Pediatrics 2009; 124:e410 <ul><li>Retrospective review </li></ul><ul><li>1374 Patients were stratified into 5 groups on the basis of age at diagnosis. </li></ul>% children <0.5 4% 8% 19% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% 6% 0.5-1 1-4 5-9 >9 Years at Diagnosis Patients at both extremes of the age spectrum were more likely to present with <4 of the classic KD features
  85. 85. Kawasaki Disease at the Extremes of the Age Spectrum Manlhiot Pediatrics 2009; 124:e410 <ul><li>Retrospective review </li></ul><ul><li>1374 Patients were stratified into 5 groups on the basis of age at diagnosis. </li></ul>% children <0.5 4% 8% 19% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% 6% 0.5-1 1-4 5-9 >9 Years at Diagnosis Patients >9 years of age were less likely to receive intravenous immunoglobulin treatment
  86. 86. <ul><li>1-year prospective multicenter cohort study </li></ul><ul><li>Patients <18 years old admitted for prolonged but initially unexplained fever or suspected KD </li></ul><ul><li>Diagnosis of KD in 39 children </li></ul>Increased Detection Rate of Kawasaki Disease Using New Diagnostic Algorithm, Including Early Use of Echocardiography T Heuclin, J Ped 2009;155;695 had incomplete KD met the classic case definition KD uncertain, but successfully treated for it n° children 30 – 20 – 10 – 0 26 7 6
  87. 87. <ul><li>1-year prospective multicenter cohort study </li></ul><ul><li>Patients <18 years old admitted for prolonged but initially unexplained fever or suspected KD </li></ul><ul><li>Diagnosis of KD in 39 children </li></ul>Increased Detection Rate of Kawasaki Disease Using New Diagnostic Algorithm, Including Early Use of Echocardiography T Heuclin, J Ped 2009;155;695 had incomplete KD met the classic case definition KD uncertain, but successfully treated for it n° children 30 – 20 – 10 – 0 26 7 6 Cardiac ultrasound scanning was helpful in the diagnosis of 6 of 7 patients with incomplete KD
  88. 88. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement of American Heart Association Newburger Pediatrics 2004;114:1708 Classic clinical criteria of Kawasaki Disease Fever persisting at least 5 days Presence of at least 4 principal features: 1) Changes in extremities Acute: Erythema of palms, soles; edema of hands, feet Subacute: Periungual peeling of fingers, toes in weeks 2 and 3 2) Polymorphous exanthem 3) Bilateral bulbar conjunctival injection without exudate 4) Changes in lips and oral cavity: Erythema, lips cracking, strawberry tongue, diffuse injection of oral and pharyngeal mucosae 5) Cervical lymphadenopathy (1.5-cm diameter), usually unilateral
  89. 89. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement of American Heart Association Newburger Pediatrics 2004;114:1708 Classic clinical criteria of Kawasaki Disease Fever persisting at least 5 days Presence of at least 4 principal features: 1) Changes in extremities Acute: Erythema of palms, soles; edema of hands, feet Subacute: Periungual peeling of fingers, toes in weeks 2 and 3 2) Polymorphous exanthem 3) Bilateral bulbar conjunctival injection without exudate 4) Changes in lips and oral cavity: Erythema, lips cracking, strawberry tongue, diffuse injection of oral and pharyngeal mucosae 5) Cervical lymphadenopathy (1.5-cm diameter), usually unilateral Patients with fever of at least 5 days and < 4 principal criteria can be diagnosed with Kawasaki disease when coronary artery abnormalities are detected by 2-dimensional echocardiography or angiography.
  90. 90. Laboratory findings in acute Kawasaki disease * (Thrombocytopenia in sone infants) *
  91. 91. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Newburger JW, Pediatrics. 2004 Dec;114:1708-33.
  92. 92. Refractory pneumonia and high fever Falcini, Lancet 2010;373:1818 <ul><li>A previously healthy 30-month-old girl was seen with a 7-day history of fever up to 40°C; </li></ul><ul><li>Tests for common viral and bacterial infections were negative; </li></ul><ul><li>Intravenous ceftriaxone and oral clarithromycin yelded no effect; </li></ul><ul><li>Chest radiography showed a massive right-sided pleural effusion; </li></ul><ul><li>meropenem and fluconazole were initiated </li></ul>
  93. 93. Refractory pneumonia and high fever Falcini, Lancet 2010;373:1818 <ul><li>A repeat full blood count showed: </li></ul><ul><li>leucocytosis (21·8×109/L), </li></ul><ul><li>anaemia (haemoglobin 95 g/L), </li></ul><ul><li>thrombocytosis (platelets 71·0×109/L), </li></ul><ul><li>raised aspartate and alanine amino-transferases, </li></ul><ul><li>VES and PCR very high; </li></ul><ul><li>Bilateral conjunctival redness appeared on day 10; </li></ul><ul><li>Echocardiogram showed a pericardial effusion, and dilatation of the right coronary artery (Z score=3·23) </li></ul>
  94. 94. Refractory pneumonia and high fever Falcini, Lancet 2010;373:1818 (A) Frontal view showing marked pleural effusion on the right. (B) After therapy with IVIg and methylprednisolone
  95. 95. Refractory pneumonia and high fever Falcini, Lancet 2010;373:1818 <ul><li>Kawasaki disease is a multisystemic vasculitis complicated </li></ul><ul><li>by coronary damage in around 25–35% of untreated patients; </li></ul><ul><li>Delayed diagnosis and treatment are risks for long-term heart damage; </li></ul><ul><li>Diagnosis is challenging and often delayed when patients do not completely meet the criteria for Kawasaki disease; </li></ul><ul><li>Some of these cases are diagnosed as incomplete or atypical Kawasaki disease according to specific criteria; </li></ul><ul><li>In contrast to other vasculitides, lung involvement is seldom reported in Kawasaki disease; </li></ul><ul><li>In our patient, the appearance of conjunctival redness was crucial in making the correct diagnosis . </li></ul>
  96. 96. Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452 <ul><li>Slowly resolving or nonresolving pneumonia is a challenge for physicians. </li></ul><ul><li>The most common clinical error when approaching these patients is to subsequently treat the patient with different antibiotics over an extended period of time, without questioning the cause of treatment failure. </li></ul><ul><li>Mostly, slowly resolving pneumonias are due to host defence or infectious causes . </li></ul><ul><li>Nonresolving pneumonias are usually of noninfectious origin and, in the majority of cases, require invasive diagnostic techniques to be confirmed. </li></ul>
  97. 97. Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452 <ul><li>A 19-yr-old male developed dyspnoea, dry cough and bilateral reticulo-nodular infiltrates on chest radiograph. </li></ul><ul><li>On admission he was still febrile (38.5°C), had generalised oedema and required 6 L·min –1 oxygen to achieve a saturation of 96%. </li></ul><ul><li>On physical examination crackles were noted on lung auscultation, along with bi-basal dullness to percussion of the thorax. </li></ul>
  98. 98. Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452 <ul><li>Additionally, bilateral conjunctival injections, cervical and axillary lymphadenopathy and markedly reddened pharynx were observed. </li></ul><ul><li>Computed tomography scan revealed massive bilateral pleural effusions with bilaterally disseminated patchy infiltrates and ground-glass alterations , modest pericardial effusion and enlarged axillary and mediastinal lymph-nodes. </li></ul>
  99. 99. Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452 <ul><li>Additionally, bilateral conjunctival injections, cervical and axillary lymphadenopathy and markedly reddened pharynx were observed. </li></ul><ul><li>Computed tomography scan revealed massive bilateral pleural effusions with bilaterally disseminated patchy infiltrates and ground-glass alterations , modest pericardial effusion and enlarged axillary and mediastinal lymph-nodes. </li></ul>Based on the assumption of progressive, therapy was piperacillin/tazobactam and clarithromycin.
  100. 100. Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452 <ul><li>Maculo-squamous exanthema was progressive and he developed palmo-plantar desquamations . </li></ul><ul><li>He remained febrile and serological markers of infections continued to be elevated. </li></ul><ul><li>All serological and rheumatological analyses, as well as microbiology and virology were negative. </li></ul>
  101. 101. Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452 <ul><li>Maculo-squamous exanthema was progressive and he developed palmo-plantar desquamations. </li></ul><ul><li>He remained febrile and serological markers of infections continued to be elevated. </li></ul><ul><li>All serological and rheumatological analyses, as well as microbiology and virology were negative. </li></ul>The next diagnostic step would have been bronchoscopy including bronchoalveolar lavage.
  102. 102. Nonresolving pneumonia and rash in an adult: pulmonary involvements in Kawasaki's disease Ugi ERJ 2010;35:452 <ul><li>As no infectious aetiology could be established and the patient fulfilled the major criteria for the diagnosis of Kawasaki's disease , antibiotic treatment was withdrawn and high-dose intravenous immunoglobulins at a dose of 2.0 g per kg bodyweight and acetylsalicylic acid were administered. </li></ul><ul><li>The patient remained febrile for >30 h after administration of the first dose of i.v. immunoglobulins; thus, a second dose was given , according to the American Heart Association's statement on the management of Kawasaki's disease. </li></ul><ul><li>Thereafter, the patient was finally afebrile. </li></ul>
  103. 103. 200 – 150 – 100 – 50 – 0 <ul><li>28 patients with KD (7-20 years after acute illness) </li></ul><ul><li>27 age-matched healthy control </li></ul><ul><li>carotid intimal-medial thickness (CIMT) </li></ul><ul><li>with vascular ultrasound scanning and arterial stiffness with applanation tonometry </li></ul>Colesterol (mg/dL) Kawasaki Atherosclerosis in Survivors of Kawasaki Disease M Gupta-Malhotra, J Ped 2009;155;572 control 175 mg 157 mg P=0.034
  104. 104. 100 – 75 – 50 – 25 – 0 <ul><li>28 patients with KD (7-20 years after acute illness) </li></ul><ul><li>27 age-matched healthy control </li></ul><ul><li>carotid intimal-medial thickness (CIMT) </li></ul><ul><li>with vascular ultrasound scanning and arterial stiffness with applanation tonometry </li></ul>Apolipoprotein B (mg/mL) Kawasaki Atherosclerosis in Survivors of Kawasaki Disease M Gupta-Malhotra, J Ped 2009;155;572 control 78 mg 65 mg P=0.004
  105. 105. 100 – 75 – 50 – 25 – 0 <ul><li>28 patients with KD (7-20 years after acute illness) </li></ul><ul><li>27 age-matched healthy control </li></ul><ul><li>carotid intimal-medial thickness (CIMT) </li></ul><ul><li>with vascular ultrasound scanning and arterial stiffness with applanation tonometry </li></ul>Apolipoprotein B (mg/mL) Kawasaki Atherosclerosis in Survivors of Kawasaki Disease M Gupta-Malhotra, J Ped 2009;155;572 control 78 mg 65 mg P=0.004 Small but significant differences in cholesterol and apolipoprotein B levels could suggest increased future risk for atherosclerosis
  106. 106. <ul><li>28 patients with KD (7-20 years after acute illness) </li></ul><ul><li>27 age-matched healthy control </li></ul><ul><li>carotid intimal-medial thickness (CIMT) </li></ul><ul><li>with vascular ultrasound scanning and arterial stiffness with applanation tonometry </li></ul>Atherosclerosis in Survivors of Kawasaki Disease M Gupta-Malhotra, J Ped 2009;155;572
  107. 107. Early Life Origins of Low-Grade Inflammation and Atherosclerosis Risk in Children and Adolescents Idoia Labayen, J Ped 2009;155:673 <ul><li>166 children and 126 adolescents from the Swedish part of the European Youth Heart Study </li></ul><ul><li>Low-grade inflammatory markers include C-reactive protein, fibrinogen, and complement factors </li></ul><ul><li>C3 and C4 </li></ul><ul><li>Birth weight was negatively associated with: </li></ul><ul><li>fibrinogen (P = 0.036); </li></ul><ul><li>C3 (P = 0.010); </li></ul><ul><li>C4 (P = 0.031). </li></ul>
  108. 108. Early Life Origins of Low-Grade Inflammation and Atherosclerosis Risk in Children and Adolescents Idoia Labayen, J Ped 2009;155:673 <ul><li>Our results showed that smaller birth weight is associated with chronic low-grade inflammation in children and adolescents. </li></ul><ul><li>Because of the implication of complement factors on atherosclerosis process, these results contribute to explain the increased cardiovascular risk associated with low birth weight. </li></ul>
  109. 109. Simple Table to Identify Children and Adolescents Needing Further Evaluation of Blood Pressure Kaelber Pediatrics 2009;123:e972 <ul><li>Threshold value of abnormal systolic and diastolic blood pressure, by gender, for each year of life (ages 3 to >18) </li></ul><ul><li>Any blood pressure readings ≥ than these values represent blood pressures in the prehypertensive, stage 1 hypertensive, or stage 2 hypertensive range and should be further evaluated by a physician. </li></ul>
  110. 110. Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010 (362): 9-17 Background Nasal carriers of Staphylococcus aureus are at increased risk for health care–associated infections with this organism. Decolonization of nasal and extranasal sites on hospital admission may reduce this risk.
  111. 111. <ul><li>Identification of S. aureus nasal carriers by real-time polymerase-chain-reaction (PCR). </li></ul><ul><li>Treatment with mupirocin nasal ointment and chlorhexidine soap or placebo for five days. </li></ul><ul><li>1251 patients positive for S. aureus. </li></ul>10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 3.4% 7.7% Rate of S. aureus infection mupirocin–chlorhexidine group placebo group RR=0.42 p=0,008 Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010;362:9-17
  112. 112. <ul><li>Identification of S. aureus nasal carriers by real-time polymerase-chain-reaction (PCR). </li></ul><ul><li>Treatment with mupirocin nasal ointment and chlorhexidine soap or placebo for five days. </li></ul><ul><li>1251 patients positive for S. aureus. </li></ul>10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 3.4% 7.7% Rate of S. aureus infection mupirocin–chlorhexidine group placebo group RR=0.42 p=0,008 Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010;362:9-17 The effect of mupirocin–chlorhexidine treatment was most pronounced for deep surgical-site infections (relative risk = 0.21)
  113. 113. <ul><li>Identification of S. aureus nasal carriers by real-time polymerase-chain-reaction (PCR). </li></ul><ul><li>Treatment with mupirocin nasal ointment and chlorhexidine soap or placebo for five days. </li></ul><ul><li>1251 patients positive for S. aureus. </li></ul>10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 3.4% 7.7% Rate of S. aureus infection mupirocin–chlorhexidine group placebo group RR=0.42 p=0,008 Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010;362:9-17 The usual therapeutic regimen for mupirocin is 3 times daily application for 1 week
  114. 114. <ul><li>Nasal carriers of S. aureus are also colonized at extranasal sites. It is unlikely that nasal application of mupirocin will directly affect these sites. However, decolonization of the skin can be achieved by washing with disinfecting soap, such as chlorhexidine gluconate products. </li></ul><ul><li>Mupirocin and chlorhexidine are considered to be relatively safe. However, since S. aureus strains can become resistant to mupirocin, we recommend restricting the use of this agent to known carriers who are at risk for infection. </li></ul><ul><li>The prevalence of methicillin-resistant S. aureus carriage in the Netherlands is only 0.03%. </li></ul><ul><li>It is plausible that this strategy would also be effective in carriers of methicillin-resistant strains of S. aureus that are susceptible to mupirocin. </li></ul>Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus Lonneke G.M. Bode. NEJM 2010;362:9-17
  115. 115. Minimizing Surgical-Site Infections RP Wenzel, NEJM 2010 (362): 75-77 <ul><li>Some experts estimate that the total number of human cells is 10 13 and the total number of colonizing microbes is 10 14 . </li></ul><ul><li>Results of a recent metaanalysis suggested that topical mupirocin applied intranasally would reduce the rate of surgical-site infections due to S. aureus by 45% in the subgroup of patients who are carriers. </li></ul><ul><li>The skin is an important extranasal reservoir not only for S. aureus but also for other organisms implicated in postoperative infections. </li></ul>
  116. 116. Minimizing Surgical-Site Infections RP Wenzel, NEJM 2010: 362: 75-77 <ul><li>Chlorhexidine–alcohol has been recommended by the Centers for Disease Control and Prevention as the antiseptic of choice to reduce vascular catheter–associated bloodstream infections. </li></ul><ul><li>Compared with povidone–iodine, the chlorhexidine– alcohol solution has been found to reduce catheter-associated infections by approximately 50%. </li></ul>
  117. 117. Chronic fatigue syndrome
  118. 118. Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents Katz Pediatrics 2009;124:189 <ul><li>301 adolescents with infectious mononucleosis </li></ul><ul><li>a telephone interview </li></ul>13% 15 – 10 – 5 – 0 7% 4% % ADOLESCENTS WHO MET THE CRITERIA FOR CHRONIC FATIGUE SYNDROME 6 12 24 MONTH POST MONONUCLEOSIS
  119. 119. Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents Katz Pediatrics 2009;124:189 <ul><li>301 adolescents with infectious mononucleosis </li></ul><ul><li>a telephone interview </li></ul>13% 15 – 10 – 5 – 0 7% 4% % ADOLESCENTS WHO MET THE CRITERIA FOR CHRONIC FATIGUE SYNDROME 6 12 24 MONTH POST MONONUCLEOSIS All 13 adolescents with chronic fatigue syndrome 24 months after infectious mononucleosis were female
  120. 120. Chronic Fatigue Syndrome After Infectious Mononucleosis in Adolescents Katz Pediatrics 2009;124:189 <ul><li>301 adolescents with infectious mononucleosis </li></ul><ul><li>a telephone interview </li></ul>13% 15 – 10 – 5 – 0 7% 4% % ADOLESCENTS WHO MET THE CRITERIA FOR CHRONIC FATIGUE SYNDROME 6 12 24 MONTH POST MONONUCLEOSIS Infectious mononucleosis may be a risk factor for chronic fatigue syndrome in adolescents
  121. 121. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Fukuda K, Ann Intern Med. 1994;121:953–959 <ul><li>Major Classification Criteria: </li></ul><ul><li>Persistent or relapsing chronic fatigue that is of new or definite onset (has not been lifelong); and results in substantial reduction in previous levels of occupational, educational, social, or personal activities ; </li></ul><ul><li>The concurrent occurrence of four or more of the following symptoms, persisted or recurred during 6 or more consecutive months: </li></ul><ul><li>1. self-reported impairment in short-term memory or concentration </li></ul><ul><li>2. tender cervical or axillary lymph nodes </li></ul><ul><li>3. muscle pain, multijoint pain without joint swelling or redness; </li></ul><ul><li>4. headaches of a new type, pattern, or severity; </li></ul><ul><li>5. unrefreshing sleep; </li></ul><ul><li>6. postexertional malaise lasting more than 24 hours. </li></ul>
  122. 122. Risk Factors for Persistent Fatigue With Significant School Absence in Children and Adolescent Robert Pediatrics 2009;124;e89 <ul><li>91 patients, aged 8 to 18 years </li></ul><ul><li>Questionnaires about sleep, somatic symptoms, physical activity, and fatigue </li></ul><ul><li>Follow-up: 12 mounths </li></ul>50.6% % CHILDREN AT FOLLOW-UP 60 – 50 – 40 – 30 – 20 – 10 – 0 29.1% 20.3% PERSISTENT FATIGUE IMPROVEMENT PERSISTENT FATIGUE WITH SIGNIFICANT SCHOOL ABSENCE
  123. 123. 2 – 1 – 0 1.4 2.1 2.0 1.8 1.7 1.8 1.9 SLEEP PROBLEMS BLURRED VISION PAIN IN ARMS OR LEGS BACK PAIN COSTIPATION MEMORY DEFICITS HOT AND COLD SPELLS OR FOR PERSISTENCE Risk Factors for Persistent Fatigue With Significant School Absence in Children and Adolescent Robert Pediatrics 2009;124;e89
  124. 124. <ul><li>Chronic fatigue syndrome ( CFS ) or myalgic encephalopathy ( ME ) </li></ul><ul><li>20 children with a diagnosis of CFS/ME </li></ul><ul><li>10 tests to measure: processing speed; attention; immediate and delayed memory; working memory; executive function </li></ul><ul><li>Children with CFS/ME, their parents and teachers described problems with focussed attention , sustained attention , recall and stress </li></ul><ul><li>These cognitive problems may explain some of the educational difficulties associated with CFS </li></ul>MEMORY AND ATTENTION PROBLEMS IN CHILDREN WITH CHRONIC FATIGUE SYNDROME OR MYALGIC ENCEPHALOPATHY Haig-ferguson Arch Dis Child 2009;94:757
  125. 125. <ul><li>Chronic fatigue syndrome (CFS) or myalgic encephalopathy (ME) is the commonest cause of school absence in the UK. It is a relatively common condition, affecting between 0.1% and 2% of children aged under 18 years. </li></ul><ul><li>CFS/ME is defined as “generalised fatigue persisting after routine tests and investigations have failed to identify an obvious underlying cause” </li></ul><ul><li>A minimum of 3 months of fatigue is required before a diagnosis of CFS/ME is made in children. </li></ul>ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752
  126. 126. <ul><li>68% of children report that having CFS/ME prevented them attending school at some stage, with a mean time out of school estimated at more than one academic year . </li></ul><ul><li>Children with CFS/ME can also have poor physical function, with over 57% of children being bed-bound at some stage. </li></ul>ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752
  127. 127. <ul><li>Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) </li></ul><ul><li>Spence Children’s Anxiety Scale (SCAS) and Hospital Anxiety and Depression Scale (HADS) </li></ul><ul><li>211 children with CFS/ME </li></ul>% children attending ≤40% of school days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752
  128. 128. <ul><li>Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) </li></ul><ul><li>Spence Children’s Anxiety Scale (SCAS) and Hospital Anxiety and Depression Scale (HADS) </li></ul><ul><li>211 children with CFS/ME </li></ul>% children attending ≤40% of school days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752 The factor most strongly associated with reduced school attendance was poor physical function . Worse physical function was associated with higher levels of fatigue, pain and low mood
  129. 129. <ul><li>Chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) </li></ul><ul><li>Spence Children’s Anxiety Scale (SCAS) and Hospital Anxiety and Depression Scale (HADS) </li></ul><ul><li>211 children with CFS/ME </li></ul>% children attending ≤40% of school days 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 62% ASSOCIATION BETWEEN SCHOOL ABSENCE AND PHYSICAL FUNCTION IN PAEDIATRIC CHRONIC FATIGUE SYNDROME/ MYALGIC ENCEPHALOPATHY Crawley Arch Dis Child 2009;94:752 We found no evidence that school attendance was associated with anxiety measured either by the SCAS or the HADS
  130. 130. <ul><li>Prevalence of frequent absence (>20% of the school year) </li></ul><ul><li>secondary schools in Edinburgh </li></ul><ul><li>cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group) </li></ul>2.5 – 2.0 – 1.5 – 1.0 – 0.5 – 0 2.2% FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with frequent medical absences
  131. 131. FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with frequent medical absences 11 – 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 8% 11% SERIOUS ORGANIC DISEASE SYMPTOM-DEFINED SYNDROMES <ul><li>Prevalence of frequent absence (>20% of the school year) </li></ul><ul><li>secondary schools in Edinburgh </li></ul><ul><li>cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group) </li></ul>
  132. 132. FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with frequent medical absences 11 – 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 8% 11% SERIOUS ORGANIC DISEASE SYMPTOM-DEFINED SYNDROMES <ul><li>Prevalence of frequent absence (>20% of the school year) </li></ul><ul><li>secondary schools in Edinburgh </li></ul><ul><li>cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group) </li></ul>The remainder had physical symptoms and minor medical illness
  133. 133. FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with psychiatric disorders CONTROLS 50 – 40 – 30 – 20 – 10 – 0 CASES p<0.001 17% 45% <ul><li>Prevalence of frequent absence (>20% of the school year) </li></ul><ul><li>secondary schools in Edinburgh </li></ul><ul><li>cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group) </li></ul>
  134. 134. FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 % children with psychiatric disorders CONTROLS 50 – 40 – 30 – 20 – 10 – 0 CASES p<0.001 17% 45% <ul><li>Prevalence of frequent absence (>20% of the school year) </li></ul><ul><li>secondary schools in Edinburgh </li></ul><ul><li>cases were those with frequent medical absence and controls those with a good attendance record (best 10% of year group) </li></ul>Only 34% with a psychiatric diagnosis had attended NHS psychiatric services
  135. 135. FREQUENT MEDICAL ABSENCES IN SECONDARY SCHOOL STUDENTS: SURVEY AND CASE–CONTROL STUDY Jones Arch Dis Child 2009;94:763 ADHD , attention deficit hyperactivity disorder; DISC , Diagnostic Interview Schedule for Children; OCD , obsessive compulsive disorder; OR , odds ratio; PTSD , post-traumatic stress disorder; SDQ , Strengths and Difficulties Questionnaire for SDQ
  136. 136. Dermatology
  137. 137. Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 <ul><li>32 children (mean age: 4.2 mo) with infantile hemangiomas. </li></ul><ul><li>Clinical and ultrasound evaluations. </li></ul><ul><li>Propranolol 2 to 3 mg/kg per day, in 2 or 3 divided doses . </li></ul><ul><li>Blood pressure and heart rate were monitored during the first 6 hours of treatment. In the absence of side effects, treatment was continued at home. </li></ul><ul><li>Ultrasound after 60 days of treatment. </li></ul>1) Immediate effects on color and growth were noted in all cases. 2) In ulcerated IHs, complete healing occurred in2 months. 3) Objective clinical and ultrasound evidence of longer-term regression was seen in 2 months.
  138. 138. Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 1) Infantile hemangiomas (IHs) are the most-common soft-tissue tumors of infancy, occurring in 4% to 10% of children 1 year of age , with a clear female predominance. 2) At birth , IHs may not be apparent or may appear as flat circumscribed lesions with telangiectatic vessels on the surface. Within the first weeks of life, IHs enter a phase of rapid growth with superficial and/or deep components, which lasts usually 3 to 6 months and sometimes up to 24 months . 3) A period of stabilization for a few months follows, and spontaneous involution usually occurs in several years. 4) Regression is complete for 60% of 4-year-old patients and 76% of 7-year-old patients .
  139. 139. Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 A) 10% of IHs require treatment during the proliferative phase, because of life-threatening locations , local complications , or cosmetic/functional risks . B) IHs can be life-threatening when present in upper airways and liver, inducing acute respiratory failure and congestive heart failure, respectively. C) Local complications such as hemorrhage, ulceration, and necrosis can be very painful and may lead to scars that are difficult to repair. D) IHs in some locations can impair sensory functions; for example, IHs of the upper eyelid can induce anisometropia, astigmatism, and amblyopia. IHs in other locations, such as the lip, nasal tip, or ear, may lead to permanent deformities.
  140. 140. Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 A) 10% of IHs require treatment during the proliferative phase, because of life-threatening locations , local complications , or cosmetic/functional risks . B) IHs can be life-threatening when present in upper airways and liver, inducing acute respiratory failure and congestive heart failure, respectively. C) Local complications such as hemorrhage, ulceration, and necrosis can be very painful and may lead to scars that are difficult to repair. D) IHs in some locations can impair sensory functions; for example, IHs of the upper eyelid can induce anisometropia, astigmatism, and amblyopia. IHs in other locations, such as the lip, nasal tip, or ear, may lead to permanent deformities. We observed serendipitously that propranolol , a well-tolerated, nonselective, β -adrenergic receptor blocker commonly used for cardiologic indications in young children, can control the growth of IHs efficiently.
  141. 141. Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 Patient with palpebral occlusion. A, Palpebral occlusion at 2 months of age, after 1 week of systemic steroid treatment (2 mg/kg per day) and 1 day before treatment with propranolol. B, Spontaneous eye reopening after 7 days of propranolol treatment at 2 mg/kg per day. C, Further improvement after 2 months of propranolol treatment while prednisone treatment was tapered progressively. D, Residual telangiectases at 12 months of age, after cessation of propranolol treatment. Time 0 7 days after 2 months 12 months
  142. 142. Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 Patient with a painful ulcerated IH. Standard treatment with wound care dressings and analgesics was also used. A, At 5 months of age, 1 day before treatment with propranolol. B, Beginning of healing after 2 weeks of propranolol treatment at 2 mg/kg per day. C, Limited ulceration relapse at 8 months of age, after 3 months of propranolol treatment. Complete healing was achieved after the propranolol dosage was increased to 3 mg/kg per day. After 2 weeks
  143. 143. Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 Patient at risk of cosmetic disfigurement and ulceration because of a large IH of the inferior lip. A, At 4 months of age, 1 day before treatment with propranolol. B, After 2 months of propranolol treatment at 2 mg/kg per day. C, After 3 months of propranolol treatment at 2 mg/kg per day. D, After 5 months of propranolol treatment at 2 mg/kg per day.
  144. 144. Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 Patient with a life-threatening laryngeal IH. The improvement of the cutaneous component should be noted. A, At 2 months of age, 1 day before treatment with propranolol. B, Seven days after initiation of propranolol treatment at 2 mg/kg per day, with a change in color from intense red to purple and palpable softening. C, Further improvement after 2 months of propranolol treatment at 2 mg/kg per day. D, Residual telangiectases at 11 months of age, 1 month after cessation of propranolol treatment.
  145. 145. Propranolol for Severe Infantile Hemangiomas: Follow-Up Report Sans Pediatrics 2009;124:e423 α ) Propranolol is a nonselective β -adrenergic receptor blocker. β ) Capillary endothelial cells express β 2 -adrenergic receptors , which modulate the release of nitric oxide, causing endothelium-dependent vasodilatation. γ ) β -Adrenergic receptor stimulation can induce modifications of signal transduction pathways of angiogenic factors such as VEGF or bFGF.
  146. 146. <ul><li>A 9-year-old boy presented to the emergency room with various macular erythematoses and ecchymotic lesions with geometric shapes and well-defined edges on his left hand and forearm. </li></ul><ul><li>The child denied that the lesions were self-inflicted. </li></ul>An Unusual Dermatosis in a Child García J Pediatr 2010;156:505
  147. 147. <ul><li>His grandmother mentioned that she had noticed that her albuterol inhaler had run out before she had expected. </li></ul><ul><li>We confirmed that the shape of the distal part of the inhaler corresponded exactly with the borders of the child’s skin lesions. </li></ul><ul><li>Finally, the child confessed that he had created the lesions by heating the inhaler on a vitroceramic hotplate and then applying it to his skin. </li></ul>An Unusual Dermatosis in a Child García J Pediatr 2010;156:505
  148. 148. An Unusual Dermatosis in a Child García J Pediatr 2010;156:505 <ul><li>Dermatitis artefacta is a self-inflected dermatologic injury. </li></ul><ul><li>It is rare in children, with the peak frequency occurring in adolescence. </li></ul><ul><li>The morphology of the skin lesions is variable and is typically dependent on the mechanism of injury. </li></ul><ul><li>Features may include sharp margins adjacent to normal skin, geometric shapes, and linear tracks. </li></ul><ul><li>The lesions are usually seen at sites accessible to the patient and do not conform to any known dermatologic condition. </li></ul>
  149. 149. Emergency Department
  150. 150. MAKING CHOICES: WHY PARENTS PRESENT TO THE EMERGENCY DEPARTMENT FOR NON-URGENT CARE Williams Arch Dis Child 2009;94:817 <ul><li>355 parents were surveyed </li></ul>RATED THEIR CHILD’S CONDITION AS MODERATE TO VERY SERIOUS SOUGHT ADVICE PRIOR TO ATTENDING THE EMERGENCY DEPARTMENT PRESENTED WITHIN 2-7 DAYS OF THE ONSET OF THE ILLNESS % parents 68% 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 54% 41%
  151. 151. Emergency Department Reliance: A Discriminatory Measure of Frequent Emergency Department Users Kroner Pediatrics 2010;125:133 <ul><li>Frequent ED users were defined as having 2 ≥ED visits/year </li></ul><ul><li>A total of 8823 children </li></ul>OR for frequent use of ED 0.55 1 – 0.5 - 0 0.72 Young children Children with special health care need
  152. 152. Emergency Department Reliance: A Discriminatory Measure of Frequent Emergency Department Users Kroner Pediatrics 2010;125:133 <ul><li>Frequent ED users were defined as having 2 ≥ED visits </li></ul><ul><li>A total of 8823 children </li></ul>OR for frequent use of ED 0.55 1 – 0.5 - 0 0.72 Young children Children with special health care need Whereas those with lower education and low income were more likely to have high EDR.
  153. 153. gastroenterology
  154. 154. % children with AGE treated according to guidelines 65.5% 80 – 60 – 40 – 20 – 0 The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis (AGE) in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians Albano J Pediatr 2010;156:226 <ul><li>A 2-hour course based on the guidelines for management of AGE. </li></ul><ul><li>75 primary care pediatricians underwent training in AGE management (group A) , and 75 pediatricians served as controls (group B) . </li></ul><ul><li>Each pediatrician enrolled 10 children age 1-36 months with acute-onset diarrhea. </li></ul><ul><li>Children in groups A (n = 617) and B (n = 692). </li></ul>3% Group A Group B
  155. 155. % children with AGE treated according to guidelines 65.5% 80 – 60 – 40 – 20 – 0 The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis (AGE) in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians Albano J Pediatr 2010;156:226 <ul><li>A 2-hour course based on the guidelines for management of AGE. </li></ul><ul><li>75 primary care pediatricians underwent training in AGE management (group A) , and 75 pediatricians served as controls (group B) . </li></ul><ul><li>Each pediatrician enrolled 10 children age 1-36 months with acute-onset diarrhea. </li></ul><ul><li>Children in groups A (n = 617) and B (n = 692). </li></ul>3% Group A Group B Most violations involved administration of unnecessary drugs or diets.
  156. 156. DURATION OF DIARRHEA (hours) 83.3 90.9 Group A Group B 100 – 80 – 60 – 40 – 20 – 0 <ul><li>A 2-hour course based on the guidelines for management of AGE. </li></ul><ul><li>75 primary care pediatricians underwent training in AGE management (group A) , and 75 pediatricians served as controls (group B) . </li></ul><ul><li>Each pediatrician enrolled 10 children age 1-36 months with acute-onset diarrhea. </li></ul><ul><li>Children in groups A (n = 617) and B (n = 692). </li></ul>The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis (AGE) in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians Albano J Pediatr 2010;156:226 P<0.001
  157. 157. The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis (AGE) in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians Albano J Pediatr 2010;156:226 The pediatricians in group A were instructed to adhere to 4 major recommendations in the guidelines: 1) rapid oral rehydration for 3-4 hours with hypoosmolar solution (Na 60 mmol/L); 2) rapid refeeding after 4 hours of rehydration with the child’s normal diet, including solids, full-strength milk, or formula, with no restriction of lactose intake; 3) avoidance of unnecessary medications; 4) avoidance of microbiological investigations.
  158. 158. Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate Neville J Pediatr 2010;156:313 Plasma sodium concentrations fell in both N/2 groups at T 8 (P < 0.01) <ul><li>124 children admitted for surgery. </li></ul><ul><li>0.9% saline solution (NS) or 0.45% saline solution (N/2) saline solution at 100% or 50% maintenance rates. </li></ul><ul><li>Plasma electrolytes, osmolality, and Antidiuretic hormone values 8 hours (T8), and 24 hours (T24; n = 67) after surgery. </li></ul>
  159. 159. Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate Neville J Pediatr 2010;156:313 <ul><li>124 children admitted for surgery. </li></ul><ul><li>0.9% saline solution (NS) or 0.45% saline solution (N/2) saline solution at 100% or 50% maintenance rates. </li></ul><ul><li>Plasma electrolytes, osmolality, and Antidiuretic hormone values 8 hours (T8), and 24 hours (T24; n = 67) after surgery. </li></ul>% children with hyponatriemia at T 8 10% 40 – 30 – 20 – 10 – 0 30% NS N/2 P=0.02
  160. 160. <ul><li>124 children admitted for surgery. </li></ul><ul><li>0.9% saline solution (NS) or 0.45% saline solution (N/2) saline solution at 100% or 50% maintenance rates. </li></ul><ul><li>Plasma electrolytes, osmolality, and Antidiuretic hormone values 8 hours (T8), and 24 hours (T24; n = 67) after surgery. </li></ul>Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A Prospective Randomized Study of Fluid Type versus Fluid Rate Neville J Pediatr 2010;156:313 % children with hyponatriemia at T 8 10% 40 – 30 – 20 – 10 – 0 30% NS N/2 P=0.02 On multiple linear regression analysis, fluid type, not rate determined risk of hyponatremia (P < 0.04).
  161. 161. Questionnaire-Based Case Finding of Celiac Disease in a Population of 8- to 9-Year-Old Children Toftedal Pediatrics 2010;125:e518 <ul><li>9880 children aged 8 to 9 years. </li></ul><ul><li>A questionnaire on the basis of 5 simple items suggestive of CD. </li></ul><ul><li>2835 children had 1 or more symptoms. These children were invited for IgA anti–tissue transglutaminase antibody. </li></ul>
  162. 162. Questionnaire-Based Case Finding of Celiac Disease in a Population of 8- to 9-Year-Old Children Toftedal Pediatrics 2010;125:e518 <ul><li>9880 children aged 8 to 9 years. </li></ul><ul><li>A questionnaire on the basis of 5 simple items suggestive of CD. </li></ul><ul><li>2835 children had 1 or more symptoms. These children were invited for IgA anti–tissue transglutaminase antibody. </li></ul>The proportion of patients with newly diagnosed CD was 1.22% (21 of 1720).
  163. 163. <ul><li>9880 children aged 8 to 9 years. </li></ul><ul><li>A questionnaire on the basis of 5 simple items suggestive of CD. </li></ul><ul><li>2835 children had 1 or more symptoms. These children were invited for IgA anti–tissue transglutaminase antibody. </li></ul>Questionnaire-Based Case Finding of Celiac Disease in a Population of 8- to 9-Year-Old Children Toftedal Pediatrics 2010;125:e518 A number of preclinical and low-grade symptomatic patients with CD may be identified by their responses to a mailed questionnaire.
  164. 164. % children with acute gastroenteritis at the time of gluten introduction 2.3% 1.8% CD subjects Controls ns Infectious Disease and Risk of Later Celiac Disease in Childhood Welander Pediatrics 2010;125:e530 <ul><li>To examine whether parent-reported infection at the time of gluten introduction increases the risk of future celiac disease (CD). </li></ul><ul><li>9408 children. </li></ul><ul><li>44 children with biopsy-verified CD diagnosed after 1 year of age </li></ul>3 – 2 – 1 – 0
  165. 165. % children with acute gastroenteritis at the time of gluten introduction 2.3% 1.8% CD subjects Controls Infectious Disease and Risk of Later Celiac Disease in Childhood Welander Pediatrics 2010;125:e530 <ul><li>To examine whether parent-reported infection at the time of gluten introduction increases the risk of future celiac disease (CD). </li></ul><ul><li>9408 children. </li></ul><ul><li>44 children with biopsy-verified CD diagnosed after 1 year of age </li></ul>3 – 2 – 1 – 0 Parent-reported infection at the time of gluten introduction is not a major risk factor for CD. ns
  166. 166. The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing McGowan Pediatrics 2009;124:1572 <ul><li>Impact of IgA endomysial antibody testing the incidence and clinical presentation of childhood celiac disease. </li></ul><ul><li>In 1990 –1996 (pretesting group) vs 2000 –2006 (testing group) </li></ul>MEDIAN AGE AT DIAGNOSIS (YEARS) 2.0 9.0 PRE-TESTING TESTING 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 P<0.001
  167. 167. The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing McGowan Pediatrics 2009;124:1572 Incidence of celiac disease (cases per 100.000 children) 2.0 7.3 PRE-TESTING TESTING 10 – 9 – 8 – 7 – 6 – 5 – 4 – 3 – 2 – 1 – 0 P=0.03 <ul><li>Impact of IgA endomysial antibody testing the incidence and clinical presentation of childhood celiac disease. </li></ul><ul><li>In 1990 –1996 (pretesting group) vs 2000 –2006 (testing group) </li></ul>
  168. 168. The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing McGowan Pediatrics 2009;124:1572 FREQUENCY OF CLASSIC CELIAC DISEASE PRESENTATION 67% 19% PRE-TESTING TESTING P=0.03 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 <ul><li>Impact of IgA endomysial antibody testing the incidence and clinical presentation of childhood celiac disease. </li></ul><ul><li>In 1990 –1996 (pretesting group) vs 2000 –2006 (testing group) </li></ul>
  169. 169. The Changing Face of Childhood Celiac Disease in North America: Impact of Serological Testing McGowan Pediatrics 2009;124:1572 In the testing group, 13 previously unrecognized clinical presentations were observed in 98 children, including <ul><li>35 with family history </li></ul><ul><li>18 with abdominal pain </li></ul><ul><li>14 with type1 diabetes mellitus. </li></ul>
  170. 170. Minutes crying and fussing 500 – 400 – 300 – 200 – 100 – 0 YES 103 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 314 colic <ul><li>36 term infants from 14 to 81 days </li></ul><ul><li>fecal calprotectin (a marker of neutrophil infiltration) </li></ul><ul><li>stool microorganisms </li></ul>
  171. 171. Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042 <ul><li>36 term infants from 14 to 81 days </li></ul><ul><li>fecal calprotectin (a marker of neutrophil infiltration) </li></ul><ul><li>stool microorganisms </li></ul>
  172. 172. Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042 Klebsiella species were detected in more colic patients than in control patients (8 vs 1, P = 0.02) <ul><li>36 term infants from 14 to 81 days </li></ul><ul><li>fecal calprotectin (a marker of neutrophil infiltration) </li></ul><ul><li>stool microorganisms </li></ul>
  173. 173. Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042 These differences could not be attributed to differences in formula versus breast milk feeding, consumption of elemental formula, or exposure to antibiotics <ul><li>36 term infants from 14 to 81 days </li></ul><ul><li>fecal calprotectin (a marker of neutrophil infiltration) </li></ul><ul><li>stool microorganisms </li></ul>
  174. 174. Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042 Infants with colic, a condition previously believed to be nonorganic in nature, have evidence of intestinal neutrophilic infiltration and a less diverse fecal microflora <ul><li>36 term infants from 14 to 81 days </li></ul><ul><li>fecal calprotectin (a marker of neutrophil infiltration) </li></ul><ul><li>stool microorganisms </li></ul>
  175. 175. Fecal calprotectin levels mcg/g 500 – 400 – 300 – 200 – 100 – 0 YES 197 Altered Fecal Microflora and Increased Fecal Calprotectin in Infants with Colic J. Rhoads, J Ped 2009;155;823 NO 413 colic P=0.042 We plan to prospectively study the effect of treatment of children with colic with a probiotic, Lactobacillus reuteri, in a placebo-controlled, masked investigation to confirm previous observations Savino, Pediatrics 2007;119:124 <ul><li>36 term infants from 14 to 81 days </li></ul><ul><li>fecal calprotectin (a marker of neutrophil infiltration) </li></ul><ul><li>stool microorganisms </li></ul>
  176. 176. <ul><li>children affected by IBS according to Rome II criteria (n = 43) </li></ul><ul><li>control population (n = 56) </li></ul><ul><li>lactulose/methane </li></ul><ul><li>breath test (LBT) to assess small intestinal bacterial overgrowth (SIBO) </li></ul>Prevalence of Small Intestinal Bacterial Overgrowth in Children with Irritable Bowel Syndrome: A Case-Control Study E Scarpellini, J Ped 2009;155:416 Prevalence of abnormal LBT ( bacterial overgrowth ) P<0.05
  177. 177. <ul><li>children affected by IBS according to Rome II criteria (n = 43) </li></ul><ul><li>control population (n = 56) </li></ul><ul><li>lactulose/methane </li></ul><ul><li>breath test (LBT) to assess small intestinal bacterial overgrowth (SIBO) </li></ul>Prevalence of Small Intestinal Bacterial Overgrowth in Children with Irritable Bowel Syndrome: A Case-Control Study E Scarpellini, J Ped 2009;155:416 P<0.05 Placebo-controlled interventional studies with antibiotics used to treat bacterial overgrowth are warranted to clarify the real impact of the disease on IBS symptoms Prevalence of abnormal LBT ( bacterial overgrowth )
  178. 178. Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Children U Halac, J Ped 2010;156:60 <ul><li>rectal sensory threshold for pain (RSTP) </li></ul><ul><li>51 patients with abdominal pain >2 months </li></ul><ul><li>a series of rectal distensions with an electronic barostat </li></ul><ul><li>35 patients had a functional gastrointestinal disorder (irritable bowel syndrome or functional </li></ul><ul><li>abdominal pain) </li></ul><ul><li>16 had an organic disease </li></ul>
  179. 179. Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Children U Halac, J Ped 2010;156:60
  180. 180. Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Children U Halac, J Ped 2010;156:60 P<0.001 <ul><li>rectal sensory threshold for pain (RSTP) </li></ul><ul><li>51 patients with abdominal pain >2 months </li></ul><ul><li>a series of rectal distensions with an electronic barostat </li></ul>FGID = functional gastrointestinal disease
  181. 181. <ul><li>rectal sensory threshold for pain (RSTP) </li></ul><ul><li>51 patients with abdominal pain >2 months </li></ul><ul><li>a series of rectal distensions with an electronic barostat </li></ul>Rectal Sensory Threshold for Pain is a Diagnostic Marker of Irritable Bowel Syndrome and Functional Abdominal Pain in Children U Halac, J Ped 2010;156:60 In children RSTP is a diagnostic marker of irritable bowel syndrome and functional abdominal pain P<0.001 FGID = functional gastrointestinal disease
  182. 182. Increased Auditory Startle Reflex in Children with Functional Abdominal Pain Bakker J Pediatr 2010;156:285 <ul><li>The activity of 6 left-sided muscles and the sympathetic skin response were obtained </li></ul><ul><li>by an electromyogram. </li></ul><ul><li>We presented sudden loud noises to the subjects through headphones. </li></ul><ul><li>Auditory startle reflexes. </li></ul><ul><li>20 children with irritable bowel syndrome (n=13), functional abdominal pain syndrome (n=7). </li></ul><ul><li>23 control subjects. </li></ul>
  183. 183. The multiple muscle ASR (response probability, 0% to 100%), for the 8 repetitive stimuli, is significantly enlarged in patients with abdominal pain (n = 20) compared with control subjects (n = 23) but not compared with patients with anxiety disorder (n = 25). Increased Auditory Startle Reflex in Children with Functional Abdominal Pain Bakker J Pediatr 2010;156:285 The multiple muscle ASR (EMG magnitude), for the 8 repetitive stimuli, is significantly enlarged in patients with abdominal pain (n = 20) compared with control subjects (n = 23) but not compared with patients with anxiety (n = 25).
  184. 184. The multiple muscle ASR (response probability, 0% to 100%), for the 8 repetitive stimuli, is significantly enlarged in patients with abdominal pain (n = 20) compared with control subjects (n = 23) but not compared with patients with anxiety disorder (n = 25). Increased Auditory Startle Reflex in Children with Functional Abdominal Pain Bakker J Pediatr 2010;156:285 The multiple muscle ASR (EMG magnitude), for the 8 repetitive stimuli, is significantly enlarged in patients with abdominal pain (n = 20) compared with control subjects (n = 23) but not compared with patients with anxiety (n = 25). Children with abdominal pain–related functional gastrointestinal disorders may have a generalized hypersensitivity of the central nervous system.
  185. 185. Recurrent Abdominal Pain in Childhood Urolithiasis Polito Pediatrics 2009;124:e1088 <ul><li>1000 children with reccurent abdominal pain and diagnosed as having urolithiasis </li></ul>% CHILDREN WITH 53% NO HISTORY OF DYSURIA OR GROSS HEMATURIA PREVIOUSLY HOSPITALIZED FOR ABDOMINAL SYMPTOMS 60 – 50 – 40 – 30 – 20 – 10 – 0 29% 16% PREVIOUS APPENDECTOMY
  186. 186. Recurrent Abdominal Pain in Childhood Urolithiasis Polito Pediatrics 2009;124:e1088 % children undergoing abdominal ultrasonography not showing urinary stones 2-28 mounths before the diagnosis was made 40 – 30 – 20 – 10 – 0 37% <ul><li>1000 children with reccurent abdominal pain and diagnosed as having urolithiasis </li></ul>
  187. 187. Recurrent Abdominal Pain in Childhood Urolithiasis Polito Pediatrics 2009;124:e1088 % children undergoing abdominal ultrasonography not showing urinary stones 2-28 mounths before the diagnosis was made 40 – 30 – 20 – 10 – 0 37% <ul><li>1000 children with reccurent abdominal pain and diagnosed as having urolithiasis </li></ul>69% of subjects younger than 8 years of age had central/diffuse abdominal pain. The mean frequency of pain attacks was 4 to 9 times lower than in patients with functional or organic gastrointestinal RAP.
  188. 188. Recurrent Abdominal Pain in Childhood Urolithiasis Polito Pediatrics 2009;124:e1088 % children undergoing abdominal ultrasonography not showing urinary stones 2-28 mounths before the diagnosis was made 40 – 30 – 20 – 10 – 0 37% <ul><li>1000 children with reccurent abdominal pain and diagnosed as having urolithiasis </li></ul>The possibility of urolithiasis should be considered in children with RAP who have a family history of urolithiasis and/or infrequent pain attacks , even when dysuria and hematuria are lacking
  189. 189. Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG Bekkali Pediatrics 2009;124:e1108 <ul><li>Children (4 –16 years) with functional constipation . </li></ul><ul><li>Patients assigned to receive enemas once daily or polyethylene glycol ( PEG ) (1.5 g/kg per day) for 6 consecutive days. </li></ul>% SUCCESSFUL DISIMPACTION 80% 68% ENEMAS PEG 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 ns
  190. 190. Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG Bekkali Pediatrics 2009;124:e1108 <ul><li>Children (4 –16 years) with functional constipation . </li></ul><ul><li>Patients assigned to receive enemas once daily or polyethylene glycol ( PEG ) (1.5 g/kg per day) for 6 consecutive days. </li></ul>% SUCCESSFUL DISIMPACTION 80% 68% ENEMAS PEG 100 – 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 ns Enemas and PEG were equally effective
  191. 191. Lactobacillus Reuteri In Infants With Functional Chronic Constipation: A Doubleblinded, Randomized, Placebo-controlled Study. M. Martinelli J Pediatr 2010 in press <ul><li>44 infants with functional chronic constipation. (mean age 8.2 mo) </li></ul><ul><li>group A (n=22) L. Reuteri (5 drops) and </li></ul><ul><li>group B (n=22) placebo </li></ul><ul><li>once daily for 8 weeks. </li></ul><ul><li>Infants who received L. Reuteri had a significantly higher frequency of bowel movements than placebo </li></ul><ul><li>at week 2 of treatment (p=0.042), </li></ul><ul><li>at week 4 (p=0.008) and </li></ul><ul><li>at week 8 (p=0.027). </li></ul>
  192. 192. Objectives: To determine the benefits of Lactobacillus rhamnosus GG (LGG) in an extensively hydrolyzed casein formula (EHCF) in improving hematochezia and fecal calprotectin over EHCF alone. Study design: Fecal calprotectin was compared in 30 infants with hematochezia and 4 weeks after milk elimination with that of a healthy group. We also compared fecal calprotectin and hematochezia on 26 formula-fed infants randomly assigned to EHCF with LGG (Nutramigen LGG) (EHCF + LGG) or without (Nutramigen) (EHCF - LGG) and on 4 breastfed infants whose mothers eliminated dairy. Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397
  193. 193. Fecal calprotectin µg/g stool 326 Hematochezia 38 Control <ul><li>30 infants with hematochezia. </li></ul><ul><li>32 control infant. </li></ul>p<0.0001 Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397 350 – 300 – 250 – 200 – 150 – 100 – 50 – 0
  194. 194. Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397
  195. 195. Decrease in fecal calprotectin µg/g stool in infants with hematochezia after 4 week of -225 µg/g BREAST FEEDING without dairy NUTRAMIGEN <ul><li>30 infants with hematochezia. </li></ul><ul><li>32 control infant. </li></ul>Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397 0 – -50 – -100 – -200 – -250 – -112 µg/g -214 µg/g NUTRAMIGEN + Lactobacillus GG p<0.0001
  196. 196. Decrease in fecal calprotectin µg/g stool in infants with hematochezia after 4 week of -225 µg/g BREAST FEEDING NUTRAMIGEN <ul><li>30 infants with hematochezia. </li></ul><ul><li>32 control infant. </li></ul>Lactobacillus GG Improves Recovery in Infants with Blood in the Stools and Presumptive Allergic Colitis Compared with Extensively Hydrolyzed Formula Alone Baldassarre J Pediatr 2010;156:397 0 – -50 – -100 – -200 – -250 – -112 µg/g -214 µg/g NUTRAMIGEN + Lactobacillus GG p<0.0001 EHCF + LGG resulted in significant improvement of hematochezia and fecal calprotectin compared with the EHCF alone.
  197. 197. <ul><li>30 of 52 consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding </li></ul><ul><li>Multicare AR-Bed (Peos, Ninove, Belgium) </li></ul><ul><li>oesophageal pH monitoring at inclusion and after 1 week </li></ul>A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SYMPTOMS AND ACID REFLUX Vandenplas Arch Dis Child 2010;95:26 The Multicare AR-Bed
  198. 198. A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SYMPTOMS AND ACID REFLUX Vandenplas Arch Dis Child 2010;95:26 % children who did not tolerate the 40°positioning 30 – 20 – 10 – 0 27% <ul><li>30 of 52 consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding </li></ul><ul><li>Multicare AR-Bed (Peos, Ninove, Belgium) </li></ul><ul><li>oesophageal pH monitoring at inclusion and after 1 week </li></ul>
  199. 199. A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SYMPTOMS AND ACID REFLUX Vandenplas Arch Dis Child 2010;95:26 % children with improved ph monitoring 73% 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 <ul><li>30 of 52 consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding </li></ul><ul><li>Multicare AR-Bed (Peos, Ninove, Belgium) </li></ul><ul><li>oesophageal pH monitoring at inclusion and after 1 week </li></ul>
  200. 200. A PRELIMINARY REPORT ON THE EFFICACY OF THE MULTICARE AR-BED IN 3-WEEK–3-MONTH-OLD INFANTS ON REGURGITATION, ASSOCIATED SYMPTOMS AND ACID REFLUX Vandenplas Arch Dis Child 2010;95:26 % children with improved ph monitoring 73% 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 <ul><li>30 of 52 consecutive infants presenting with frequent regurgitation and reflux-associated symptoms occurring mainly during feeding </li></ul><ul><li>Multicare AR-Bed (Peos, Ninove, Belgium) </li></ul><ul><li>oesophageal pH monitoring at inclusion and after 1 week </li></ul>The mean duration of use of the Multicare AR-Bed was 3.2 months
  201. 202. <ul><li>Intensive care </li></ul>
  202. 203. <ul><li>77 intensive care units. </li></ul><ul><li>2,796 patients. </li></ul>% PATIENTS WHO DIED 41.6% 50 – 40 – 30 – 20 – 10 – 0 Effectiveness of Treatments for Severe Sepsis: A Prospective, Multicenter, Observational Study Ferrer AJRCCM 2009:180:861
  203. 204. Effectiveness of Treatments for Severe Sepsis: A Prospective, Multicenter, Observational Study Ferrer AJRCCM 2009:180:861 <ul><li>77 intensive care units. </li></ul><ul><li>2,796 patients. </li></ul>OR FOR DEATH 0.67 P=0.008 In subjects treated early with broad-spectrum antibiotic (treatment within 1 hour vs. no treatment within first 6 hours of diagnosis. 1.0 – 0.5 – 0
  204. 205. Association Between ICU Admission During Morning Rounds and Mortality Afessa CHEST 2009; 136:1489 <ul><li>Retrospective study (49844 patients). </li></ul><ul><li>Patients, 3,580 were admitted to the ICU during round time </li></ul><ul><li>(8:00 AM to 10:59 AM) </li></ul><ul><li>and 46,264 were admitted during non round time </li></ul><ul><li>(1:00 PM to 6:00 AM). </li></ul>% HOSPITAL MORTALITY RATE 20 – 15 – 10 – 5 – 0 16.2 % 8.8 % P<0.001 YES NO ROUND TIME OR=1.3
  205. 206. Association Between ICU Admission During Morning Rounds and Mortality Afessa CHEST 2009; 136:1489 <ul><li>Retrospective study (49844 patients). </li></ul><ul><li>Patients, 3,580 were admitted to the ICU during round time </li></ul><ul><li>(8:00 AM to 10:59 AM) </li></ul><ul><li>and 46,264 were admitted during non round time </li></ul><ul><li>(1:00 PM to 6:00 AM). </li></ul>% HOSPITAL MORTALITY RATE 20 – 15 – 10 – 5 – 0 16.2 % 8.8 % P<0.001 YES NO ROUND TIME OR=1.3 Most of the round-time ICU admissions and deaths occurred in the medical ICU
  206. 207. Association Between ICU Admission During Morning Rounds and Mortality Afessa CHEST 2009; 136:1489 <ul><li>Retrospective study (49844 patients). </li></ul><ul><li>Patients, 3,580 were admitted to the ICU during round time </li></ul><ul><li>(8:00 AM to 10:59 AM) </li></ul><ul><li>and 46,264 were admitted during non round time </li></ul><ul><li>(1:00 PM to 6:00 AM). </li></ul>% HOSPITAL MORTALITY RATE 20 – 15 – 10 – 5 – 0 16.2 % 8.8 % P<0.001 YES NO ROUND TIME OR=1.3 Rounds may include going from one patient bed to the next, not from the sickest patient to the least sick. This approach may result in delayed resuscitation of critically ill patients admitted to the ICU during rounds, providing a potential explanation for the increased mortality we observed in this study.
  207. 208. Initiation of Inappropriate Antimicrobial Therapy Results in a Fivefold Reduction of Survival in Human Septic Shock Kumar CHEST 2009; 136:1237 <ul><li>Appropriateness of initial antimicrobial therapy, retrospectively determined for 5,715 patients with septic shock </li></ul>80.1% % patients with appropriate antimicrobial agents 100 – 80 – 60 – 40 – 20 - 0
  208. 209. 52% % PATIENTS SURVIVING 60 – 50 – 40 – 30 – 20 – 10 - 0 10.3% APPROPRIATE INAPPROPRIATE INITIAL T

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