What 2012 general paediatrics

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What 2012 general paediatrics

  1. 1. WHAT YOU SHOULD HAVE READ BUT….2012  General Paediatrics Bonomo Beatrice Caldonazzi Federico Cattazzo Elena Deganello Marco Gallo Giuseppe Mazzei FedericaAttilio Boner Melotti Giulia Paiola GiuliaUniversity of Olivieri FrancescaVerona, Italy Tenero Laura Tezza Giovanna Villotti Valentina
  2. 2. •antibiotici
  3. 3. 5 vs 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Molyneux, Lancet 2011;377:1837 % Outcomes 1004 children with 30 – purulent meningitis 25 – 26% 27% (S.pneumoniae, H.influ 20 – enzae B, N.meningitidis) 15 – aged 2 mo-12 yrs. 10 – 496 ceftriaxone 05 – 6% 0% 0% 0% 0% 4% 4% 4% for 5 days. 00 – 508 ceftriaxone for 10 days.
  4. 4. 5 vs 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Molyneux, Lancet 2011;377:1837 % Outcomes 1004 children with •Hearing loss 30 – purulent meningitis 25 – 26% 27% •Visual loss (S.pneumoniae, H.influ 20 – enzae •Cranial nerve palsy B, N.meningitidis) 15 – •Afebrile seizures aged 2 mo-12 yrs. 10 – •Hydrocephalus 496 ceftriaxone 05 – 6% 0% 0% 0% 0% 4% 4% 4% for 5 days. •Developmental 00 – 508 ceftriaxone delay for 10 days.
  5. 5. 5 vs 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Molyneux, Lancet 2011;377:1837 In children beyond % Outcomes the neonatal 1004 children with 30 – age-group with purulent meningitis 25 – 27% 26% purulent meningitis (S.pneumoniae, H.influ 20 – (S.pneumoniae, H.influ enzae enzae B B, N.meningitidis) 15 – or N.meningitidis) aged 2 mo.-12stable who are yrs. 10 – 496 ceftriaxoneof by day 5 05 – 6% for 5 days. treatment, ceftriaxone 0% 0% 0% 0% 4% 4% 4% 00 – the antibiotic can be 508 ceftriaxone safely discontinued. for 10 days.
  6. 6. •Avvelenamenti•Incidenti: domestici & fuori casa
  7. 7. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337 % children who had never received dog bite prevent education 100 – 90 – 80 – Cross-sectional study. 70 – 300 parent/guardian-child pairs presenting with 60 – 50 – 70% nonurgent complaints 40 – or dog bites. 30 – 20 – 10 – 0
  8. 8. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:3371) Children are highly vulnerable to dog bites and make up a large percentage of dog bite victims.2) Younger children, aged 5 to 9 yrs, are disproportionately at risk, with the highest incidence among all children and a large portion of their injuries occurring to the head, face, or neck.3) Consequences of dog bite injuries can be temporary or lasting and include pain, disfigurement, infection, time lost from school or employment, fear, and anxiety. Evidence of post-traumatic stress disorder 1 month after injury has been seen in over 50% of children who have been bitten by a dog.
  9. 9. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:3374) Dog ownership does not necessarily equate to knowledge of how to prevent dog bites, evidenced by the fact that the majority of dog bites to children are by familiar dog.5) Having an experience of a dog bite does not mean that the victim or his or her family member has subsequently learned how to prevent dog bites.6) Dog bite recommendations are typically stated in the negative tense (eg, ‗‗Do not pet a dog that is behind a fence‘‘ and ‗‗Do not pet a dog that is eating‘‘).
  10. 10. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  11. 11. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  12. 12. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  13. 13. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  14. 14. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  15. 15. Dog Bite Prevention: An Assessment of Child Knowledge. Dixon, J Pediatr 2012;160:337
  16. 16. Grandparents Driving Grandchildren: An Evaluation of Child Passenger Safety and Injuries Henretig, Pediatrics 2011;128:289 OR for injuries 1.0 – Motor vehicle crashes involving children aged ≤15 years. Grandparent-driven 0.5 – vs parent-driven 0.50 vehicles. 0.0 in grandparent-driven crashes
  17. 17. Grandparents Driving Grandchildren: An Evaluation of Child Passenger Safety and Injuries Henretig, Pediatrics 2011;128:289 OR for injuries Although nearly 1.0 – Motor vehicle crashes all children involving childrento have were reported aged ≤15 years. been restrained, childre Grandparent-driven n in crashes with 0.5 – vs parent-driven drivers grandparent 0.50 vehicles. used optimal restraint slightly less often. 0.0 in grandparent-driven crashes
  18. 18. Grandparents Driving Grandchildren: An Evaluation of Child Passenger Safety and Injuries Henretig, Pediatrics 2011;128:289 OR for injuries Grandchildren 1.0 – Motor vehiclebe safer seem to crashes involving children driven in crashes when aged by grandparents ≤15 years. than by their parents. Grandparent-driven 0.5 – However, safety could be vs parent-driven enhanced if grandparents 0.50 vehicles. followed current child-restraint guidelines. 0.0 in grandparent-driven crashes
  19. 19. Abuso nelBAMBINO
  20. 20. Abusive head trauma during a time of increased unemployment: a multicenter analysis Berger Pediatrics 2011;128:637 Overall rate of AHT in 100.000 15 – Abusive head trauma 14.7 10 – (AHT). on In 442 children younger than 5 yrs. 05 – 8.9 100.000 on 5 ½ yrs study period. 100.000 00 Before the During the recession recession
  21. 21. Abusive head trauma during a time of increased unemployment: a multicenter analysis Berger Pediatrics 2011;128:637 Overall rate of AHT in 100.000 15 – The rate of AHT Abusive head trauma increased 14.7 10 – (AHT). significantly on In 442 children months during the 19 youngeran economic of than 5 yrs. 05 – 8.9 100.000 on recession compared 5 ½ yrs study period. with the 47 months 100.000 00 before the recession. Before the During the recession recession
  22. 22. Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review Kemp Arch dis Child 2011;96:1103 OR for abusive head trauma Neuroradiological 9.0 – features that 8.0 – differentiate 7.0 – 8.2 abusive head 6.0 – trauma (AHT) 5.0 – from 4.0 – non-abusive 3.0 – head trauma (nAHT). 2.0 – 21 studies of children predominantly <3 yrs. 1.0 – 0 0 0.1 Subdural Extradural haemorrhages haemorrhages
  23. 23. Recidivism in the Child Protection System. Identifying Children at Greatest Risk of Reabuse Among Those Remaining in the Home. Dakil APAM 2011;165:1006 Incidence of Reabuse. A 5-year prospective 50 – cohort study. Children reported to the 40 – 45% child protection system 30 – for child abuse. 20 – A total of 2578 children remained in the home 10 – following an abuse report. 0
  24. 24. Recidivism in the Child Protection System. Identifying Children at Greatest Risk of Reabuse Among Those Remaining in the Home. Dakil APAM 2011;165:1006 Incidence of Reabuse. 1) children with A 5-year prospective 50 – behavior cohort study. problems, 2) Children reported toan caregivers with the 40 – 45% child protection system abuse history and 30 – for 3) families with an child abuse. 20 – A total of 2578lower than annual income children remained$20the home in 000 10 – were more likely following an abuse report. to be rereported. 0
  25. 25. FEVER andFEVER CONTROL
  26. 26. Paracetamol prescription by age or by weight? Lenney, Arch Dis Child 2012;97:277 New dosing tables
  27. 27. Paracetamol prescription by age or by weight? Lenney, Arch Dis Child 2012;97:277 New dosing tables In general, childrens dosages are based on a single dose of 10 (7.5-15) mg paracetamol per kilogram bodyweight, which can be repeated 4-6 hourly, not exceeding four doses per 24 hours. (TACHIPIRINA 120 mg/5 ml sciroppo TACHIPIRINA 100 mg/ml gocce orali, soluzione)
  28. 28. Prospective Longitudinal Study of Signs and Symptoms Associated With Primary Tooth Eruption Ramos-Jorge Pediatrics 2011;128:471 Tympanic and Axillary Temperature Determined on Noneruption Days, Day Before Eruption, Day of Eruption, and Day After Eruption An 8- month, longitudinal study. 47 infants receiving care at home between 5 and 15 months. Daily tympanic and axillary temperature reading.
  29. 29. Prospective Longitudinal Study of Signs and Symptoms Associated With Primary Tooth Eruption Ramos-Jorge Pediatrics 2011;128:471 Tympanic and Axillary Temperature Determined on Noneruption Days, Day Before Eruption, The most frequent Day of Eruption, and Day After Eruption signs and symptoms An 8- associated with month, longitudinal teething were: irritability study.(47 infantsincreased p<0.001), receiving salivation (p<0.001), care at home between runny nose 5 and 15 months. (p<0.001), and loss of appetite (p<0.001). Daily tympanic and axillary temperature reading.
  30. 30. Prospective Longitudinal Study of Signs and Symptoms Associated With Primary Tooth Eruption Ramos-Jorge Pediatrics 2011;128:471 Tympanic and Axillary Temperature Determined on Noneruption Days, Day Before Eruption, Day of Eruption, and Day After Eruption Occurrence of An 8- severe signs month, longitudinal study. and symptoms, such 47 infants receiving care as home between at fever, could not be 5 and 15 months. attributed to Daily tympanic and teething. axillary temperature reading.
  31. 31. AlimentazioneLatte materno Formule
  32. 32. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355• The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-administered scale. Cox, Br J Psychiatry 1987;150:782 Benvenuti, J Affect Disord 1999;53:137• Maternal depression is suspected when a mother scores higher than a cut-off value (usually >9 or >12).• Recent data suggest that mothers with high EPDS scores (>12) tend to breast feed less in the first 2 months, but it is not known if mothers with mild depressive symptoms and with normal scores are at increased risk.
  33. 33. Edimburg Postnatal Depression Scale (EPDS) http://www.google.it/urlsa=t&rct=j&q=edinburgh+postnatal+depression+scale+italian o&source= www.envicon.it
  34. 34. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355 % mothers with EPDS>9 20 – Edinburgh Postnatal Depression Scale (EPDS). 15 – 15.7% Later breast feeding problems. 10 – 592 mothers of a healthy baby. 05 – Feeding method recorded at 12–14 wks. 00
  35. 35. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355 Distribution of EPDS scores and the odds of bottle feeding at each score. Edinburgh Postnatal Depression Scale 0 (EPDS). Later breast feeding problems. 592 mothers of a healthy baby. Feeding method recorded at 12–14 wks.
  36. 36. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355 Distribution of EPDS scores and the Mothers with odds of bottle feeding at each score. Edinburgh Postnatal higher EPDS Depression Scale 0 were more likely (EPDS). to bottle feed Later breast feeding at 3 months. problems. The odds of bottle 592 mothers feeding increased of a healthy baby. with EPDS Feeding method at result, even low scores. recorded at 12–14 wks.
  37. 37. Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding Gagliardi, Arch Dis Child 2012;97:355 Distribution of EPDS scores and the There odds of bottle feeding at each score. was no cut-off Edinburgh Postnatal Depression Scale risk under which no 0 increase was seen. (EPDS). Later breast feeding problems.of bottle the OR feeding associated 592 mothers with healthy baby.of of a an increase 1 point in the EPDS Feeding method score was 1.06 recorded at 12–14 wks. ( p=0.02),
  38. 38. Breastfeeding is associated with increased lung function at 18 years of age: a cohort Study Soto-Ramı´rez, Eur Respir J 2012;39:985 Effect of breastfeeding (FVC) (Litres) at 18 yrs of age by height A birth cohort. Breastfeeding duration. Spirometric tests at 10 and 18 yrs.
  39. 39. Association of Exclusive Breastfeeding Duration and Fibrinogen Levels in Childhood and Adolescence Labayen I, APAM 2012;166:56 Mean fasting serum fibrinogen levels according to duration of exclusive 704 children age breastfeeding duration in the whole sample(A) 9.5 yrs. 665 adolescents 15.5 yrs. Fasting fibrinogen level.
  40. 40. Erythrocyte zinc levels in children with bronchial asthma Yilmaz Pediatr Pulmonol 2011;46:1189 Mean concentrations of erythrocyte zinc (μg/dl) 1500 – Erythrocyte zinc levels. ns 1000 – 1215.8 1206 67 asthmatic and 45 healthy children. 0500 – 0000 Asthmatics Controls
  41. 41. Erythrocyte zinc levels in children with bronchial asthma Yilmaz Pediatr Pulmonol 2011;46:1189 Mean concentrations (μg/dl) of erythrocyte zinc in children hospitalized for an asthma attack in the previous 12 mo. 1500 – p<0.0001 Erythrocyte zinc levels. 1248 1000 – 1095 67 asthmatic and 45 healthy children. 0500 – 0000 NO YES
  42. 42. Erythrocyte zinc levels in children with bronchial asthma Yilmaz Pediatr Pulmonol 2011;46:1189 The decreased amount of antioxidants in the diet in recent years has been reported to contribute to the increased incidence of asthma. Romieu I Am J Respir Crit Care Med 2002; 166: 703-709 Glutathione peroxidase and superoxide dismutase, the important antioxidant enzymes of the body, contain zinc in their structure. Wright DT Environ Health Perspect 1994; 102: 85-90 Therefore, zinc is an important antioxidant element. It is found in the respiratory tract epithelium, plays a role in the regulation of the cellular and humoral immune response and possesses antiapoptotic and anti-inflammatory features indicating a possible role in asthma pathogenesis and treatment. Zalevski PD, Pharmacol Ther 2005; 105: 127 -149 Truong-Tran AQ, Am J Physiol Lung Cell Mol Physiol 2000; 279: 1172-1183
  43. 43. Erythrocyte zinc levels in children with bronchial asthma Yilmaz Pediatr Pulmonol 2011;46:1189 Allergen-sensitized mice where zinc-deficiency was created through diet showed 1.6 and 3.2 times the rate of the number of airway eosinophils and epithelial cell apoptosis, respectively, than those fed a diet containing normal amounts of zinc. Truong-Tran AQ, Am J Respir Cell Mol Biol 2002; 27: 286–296 Airway epithelial damage plays an important role in asthma pathogenesis Zalevski PD, Pharmacol Ther 2005; 105: 127-149 . The damage to this barrier function is directly related to caspase 3 activation and the proteolysis of proteins that No provide intercellular connection. Zinc protect airway epithelial integrity by both preventing caspase 3 activation and the lysis of proteins that provide intercellular connection.
  44. 44. A randomized controlled trial of zinc as adjuvant therapy for severe pneumonia in young children Basnet Pediatrics 2012;129:701 610 children aged 2 to 35 months. HR in zinc supplemented for Severe pneumonia defined by the World Health Organization as cough and/or breathing combined 1.0 – 1.10 with lower chest indrawing. All children 0.88 0.5 – antibiotic treatment. Zinc (10mg in 2- to 11- month-olds and 20mg in older children) or placebo 0 daily for up to 14 days. Faster Treatment recovery failure
  45. 45. A randomized controlled trial of zinc as adjuvant therapy for severe pneumonia in young children Basnet Pediatrics 2012;129:701 610 children aged 2 to 35 months. HR in zinc supplemented for Adjunct treatment Severe pneumonia defined with zinc by the World Health Organization as cough time reduced the to cessation and/or breathing combined 1.0 – 1.10 with lower chest indrawing. of severe pneumonia All children the risk 0.88 and antibiotic treatment. 0.5 – of treatment failure Zinc (10mg in 2- to 11- only marginally month-olds and 20mg in . older children) or placebo 0 daily for up to 14 days. Faster Treatment recovery failure
  46. 46. •Vitamina D•deficit
  47. 47. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485 Analyses revealed no Serum 25(OH)-vitamin D significant associations concentrations. between maternal 743 Caucasian women at 25(OH)-vitamin D 18 weeks pregnancy serum quartiles and (grouped into quartiles). offspring behavioral/ emotional problems Child Behavior Checklist at any age. at 2, 5, 8, 10, 14, and 17 years of age. But…….
  48. 48. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485 There were significant linear trends between quartiles of Serum 25(OH)-vitamin D maternal vitamin D levels and concentrations. language impairment at 5 and 10 years of age.The risk of 743 Caucasian women at women with vitamin D 18 weeks pregnancy insufficiency (≤46 nmol/L) (grouped into quartiles). during pregnancy having a child with clinically Child Behavior Checklist significant language at 2, 5, 8, 10, 14, and 17 difficulties was increased years of age. close to 2x compared with women with vitamin D levels ≥70 nmol/L.
  49. 49. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485 Proportion of offspring with mild or moderate-severe language impairmentat 5 (Y5)a and 10 years (Y10)b of age according to maternalserum 25(OH)-vitamin D levels at 18 weeks’ pregnancy.
  50. 50. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485Association Between Maternal 25(OH)-Vitamin D Concentration at 18 Weeks’ Pregnancy and Offspring Language Impairment During Childhood
  51. 51. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485Association Between Maternal 25(OH)-Vitamin D Concentration Vitamin DWeeks’ Pregnancy and Offspring at 18 performs a number of biological Language Impairment fundamental to functions that are During Childhood neurodevelopment, including a signaling role in neuronal differentiation, a regulation role in the metabolism of neurotrophic factors and neurotoxins, and a protective role during brain inflammation.
  52. 52. Maternal Serum Vitamin D Levels During Pregnancy and Offspring Neurocognitive Development Whitehouse, Pediatrics 2012;129;485Association Between Maternal 25(OH)-Vitamin D Concentration Vitamin18 Weeks’ Pregnancy and Offspring in at D may also be indirectly involved Language Impairment During Childhood fetal brain growth through its role in a number of endocrine functions. Reduced levels of vitamin D may disrupt 1 or more of these functions during critical phases of neurodevelopment.
  53. 53. Cord Blood Vitamin D Deficiency Is Associated With Respiratory Syncytial Virus Bronchiolitis Belderbos Pediatrics 2011;127:e1513 156 healthy term Cord blood concentrations of 25-OHD in neonates. neonates who subsequently developed RSV LRTI (n=18) and those who did not (n=138) 25-hydroxyvitamin D (25-OHD) in cord blood plasma. Lower respiratory tract infection (LRTI) caused by Respiratory Syncytial Virus (RSV) in the first year of life, defined as LRTI symptoms and presence of RSV RNA in a nose-throat specimen.
  54. 54. Cord Blood Vitamin D Deficiency Is Associated With Respiratory Syncytial Virus Bronchiolitis Belderbos Pediatrics 2011;127:e1513 156 healthy term Relative Risk (RR) of RSV LRTI per quartile of 25-OHD levels. neonates. Because of the limited number of cases, the lower quartiles (25 nmol/L, n=7; and 25–49 nmol/L, n=29) were pooled 25-hydroxyvitamin D (25-OHD) in cord blood plasma. Lower respiratory tract infection (LRTI) caused by Respiratory Syncytial Virus (RSV) in the first year of life, defined as LRTI symptoms and presence of RSV RNA in a nose-throat specimen.
  55. 55. Cord Blood Vitamin D Deficiency Is Associated With Respiratory Syncytial Virus Bronchiolitis Belderbos Pediatrics 2011;127:e1513 156 healthy term Relative Risk (RR) of RSV LRTI per quartile of 25-OHD levels. neonates. Because of the limited number of cases, the lower quartiles Vitamin D (25 nmol/L, n=7; and 25–49 nmol/L, n=29) were pooled 25-hydroxyvitamin D deficiency in (25-OHD) in cord blood healthy neonates is plasma. associated with Lower respiratory tract increased risk of infection (LRTI) caused RSV LRTI in the by Respiratory Syncytial Virus (RSV) in year first the first of life. year of life, defined as LRTI symptoms and presence of RSV RNA in a nose-throat specimen.
  56. 56. Cord Blood Vitamin D Deficiency Is Associated With Respiratory Syncytial Virus Bronchiolitis Belderbos Pediatrics 2011;127:e1513 156 healthy term Relative Risk (RR) of RSV LRTI per quartile of 25-OHD levels. neonates. Because of the limited number of cases, the lower quartiles Intensified (25 nmol/L, n=7; and 25–49 nmol/L, n=29) were pooled 25-hydroxyvitamin D D routine vitamin (25-OHD) in cord blood supplementation plasma. during pregnancy may be a useful Lower respiratory tract infection (LRTI) caused strategy to prevent by Respiratory Syncytial RSV LRTI Virus (RSV) in the first year during defined as of life, infancy. LRTI symptoms and presence of RSV RNA in a nose-throat specimen.
  57. 57. A cross-sectional study of vitamin D and insulin resistance in children Kelly Arch Dis Child 2011;96:447 Cross-sectional study of 85 (4–18 yrs). % children with vitamin D 50 – Fasting blood glucose, insulin and 25- 40 – 47% OH-D were measured. 30 – Homeostasis model 20 – 26% 27% assessment (HOMA), a measure 10 – of insulin sensitivity, was 0 calculated as (fasting sufficient intermediate insufficient blood glucose (≥75 nmol/l) (50–75 nmol/l) (25–50 nmol/l) (mmol/l)×insulin (μU/ml))/22.5.
  58. 58. A cross-sectional study of vitamin D and insulin resistance in children Kelly Arch Dis Child 2011;96:447 Cross-sectional study of 85 (4–18 yrs). % children with vitamin D Lower 25-OH-D 50 –was associated with Fasting blood higher , fasting blood glucose insulin and 25- 40 – 47% OH-D were measured. glucose, 30 – insulin andmodel Homeostasis HOMA 20 – 26% 27% after assessment (HOMA), a measure adjustment for 10 – of insulin sensitivity, was puberty calculated as (fasting 0 sufficient intermediate insufficient and BMI-Z. blood glucose (≥75 nmol/l) (50–75 nmol/l) (25–50 nmol/l) (mmol/l)×insulin (μU/ml))/22.5.
  59. 59. Vitamin D Deficiency, Adiposity, and Cardiometabolic Risk in Urban Schoolchildren Sacheck, J Ped 2011;159:945 263 schoolchildren living in % children northeastern US. 80 – Serum 25-hydroxyvitamin D [25(OH)D]. 70 – 60 – 74.6% Body mass index (BMI) z-score (BMIz). 50 – 6 cardiometabolic risk factors: 40 – - total cholesterol; 30 – - HDL cholesterol; 20 – - LDL cholesterol; - triglycerides; 10 – - interleukin-6; 0 Vitamin D deficient - C-reactive protein [CRP]. [25(OH)D <50 nmol/L]
  60. 60. Vitamin D Deficiency, Adiposity, and Cardiometabolic Risk in Urban Schoolchildren Sacheck, J Ped 2011;159:945 263 schoolchildren living in % children northeastern US. 80 – Serum 25-hydroxyvitamin D The 25(OH)D level [25(OH)D]. 70 – 60 – 74.6% was not associated Body mass index (BMI) z-score (BMIz). with 50 – BMIz, but was 6 cardiometabolic risk factors: 40 – positively associated - total cholesterol; 30 – -with cholesterol; HDL the cardiometabolic 20 – risk factor - LDL cholesterol; - triglycerides; 10 – - interleukin-6; 0 Vitamin D deficient - C-reactive protein [CRP]. [25(OH)D <50 nmol/L]
  61. 61. Determinants of 25(OH)D Sufficiency in Obese Minority Children:Selecting Outcome Measures and Analytic Approaches Zhou, J Ped 2011;158:930 Smoothed relationships of Systolic Blood Pressure to Vitamin D levels Serum 25-(OH) vitamin D (ng/mL). (r=-0.261; P=0.038) 140 healthy obese children age 6 to 21 years.
  62. 62. Determinants of 25(OH)D Sufficiency in Obese Minority Children:Selecting Outcome Measures and Analytic Approaches Zhou, J Ped 2011;158:930 Smoothed relationships of Systolic Blood Pressure to Vitamin D levels Serum 25-(OH) Systolic blood vitamin D. (r=-0.261; P=0.038) pressure (SBP) was significantly 140 healthy obese children age 6 with correlated to 21 years. 25(OH)D.
  63. 63. Recent trends and clinical features of childhood vitamin D deficiency presenting to a children’s hospital in Glasgow Ahmed Arch Dis Child 2011;96:694 Number of cases presenting each year between 2002 and 2008 categorized Between 2002 and 2008. according to four broad ethnic backgrounds.Cases of symptomaticvitamin D deficiency.(bowed legs, fractures, limbpain, X-ray which highlightedrickets, swollen wrists, asymptomatichypocalcaemia, raised alkalinephosphatase (ALP)concentration, developmentaldelay, cardiac failure andhypocalcaemia and which resolvedfollowing treatment with calcium andvitamin D.)
  64. 64. Recent trends and clinical features of childhood vitamin D deficiency presenting to a children’s hospital in Glasgow Ahmed Arch Dis Child 2011;96:694 Reason for referral for investigation and management of 160 children with suspected Between 2002 and 2008. of cases D deficiency according to age The number vitamin of vitamin D deficiency is currently increasing. categories at presentation.Cases of symptomatic The change in the relative proportion ofvitamin D deficiency.(bowed legs, fractures, limbfrom different ethnic origins casespain, X-ray which highlighted reflects therickets, swollen wrists, asymptomatic changing patterns of immigrationhypocalcaemia, raised alkalinephosphatase (ALP) and birth patternsconcentration, developmentaldelay, cardiac failure and in the West of Scotland.hypocalcaemia and which resolvedfollowing treatment with calcium andvitamin D.)
  65. 65. Recent trends and clinical features of childhood vitamin D deficiency presenting to a children’s hospital in Glasgow Ahmed Arch Dis Child 2011;96:694 Reason for referral for investigation and management of 160 children with suspected Between 2002 and 2008. vitamin D deficiency according to ageCases of symptomatic It is imperative that the categories at presentation.vitamin D deficiency. priority remains the first(bowed legs, fractures, limbpain, eradication of X-ray which highlighted profound, symptomaticrickets, swollen wrists, asymptomatichypocalcaemia, raised alkalinephosphatase (ALP) vitamin D deficiency.concentration, developmentaldelay, cardiac failure andhypocalcaemia and which resolvedfollowing treatment with calcium andvitamin D.)
  66. 66. •Vitamina D•raccomandazioni
  67. 67. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. Ross AC, J Clin Endocrinol Metab. 2011;96:53-8.RDA = Recommended Dietary Allowance; UL= tolerable upper intake level; c= not well defined
  68. 68. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. Ross AC, J Clin Endocrinol Metab. 2011;96:53-8. Dietary Reference Intake shown in Table 1 are based on dietary requirements using bone health as an indicator.RDA = Recommended Dietary Allowance; UL= tolerable upper intake level; c= not well defined
  69. 69. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. Ross AC, J Clin Endocrinol Metab. 2011;96:53-8.For vitamin D, the 2011 Dietary Reference Intake (DRIs) arebased primarily on the integration of bone health outcomes withevidence concerning 25OHD levels, which suggest that levels of16 ng/ml (40 nmol/liter) meet the needs of approximately half thepopulation (median population requirement), and levels of at least20 ng/ml (50 nmol/liter) meet the needs of at least 97.5% of thepopulation.These levels will be useful to clinicians as they considermanagement of patients under their care.Thus, serum 25OHD levels above 50 ng/ml (125 nmol/liter) shouldraise concerns among clinicians about potential adverse effects.
  70. 70. The IOM D-lemma. Holick MF. Public Health Nutr. 2011;14:939-41Pregnant and lactating womenneed more than 15µg (600 IU)vitamin D/d.However in forty mother–infant pairs where70% of the women were taking on average15µg vitamin D/d, it was reported that 76% of the mothers and81% of the newborns at the time of birth had 25-hydroxyvitaminD level <20 ng/mlLee JM, Smith JR, Philipp BL et al. Vitamin D deficiency in a healthy group ofmothers and newborn infants. Clin Pediatr 2007;46:42–44.
  71. 71. The IOM D-lemma. Holick MF. Public Health Nutr. 2011;14:939-41Furthermore it was reported thatPre-eclampsiaBodnar LM, J Clin EndocrinolMetab, 2007; 92: 3517–3522.andthe need for a primaryCaesarean sectionMerewood A, J Clin Endocrinol Metab. 2009;94: 940–945.were associated withVitamin D deficiency (<20 ng/mL).
  72. 72. Inappropriate and inconsistent modalities of treatment of vitamin D deficiency in children Gupta Arch Did Child 2011;96:787 • Pearce and Cheetham (BMJ 2010;340:b5664) in their article on ―Diagnosis and management of vitamin D deficiency‖, quite clearly recommend the use of calciferol (3000-6000 IU/day) in the treatment of vitamin D deficiency in children. • Expert opinion from the British Society for Paediatric Endocrinology and Diabetes also confirm this reccomendation.
  73. 73. Micronutrienti:Acido folicoFatty AcidsDHA EPA
  74. 74. High Folate Intake Is Related to Better Academic Achievement in Swedish Adolescents Nilsson, Pediatrics 2011;128:e358An increased plasma total homocysteine (tHcy)serves as a marker for functional deficiency of certain Bvitamins, such as B12, B6, riboflavin, and, in particular, folate.The genetic model disease homocystinuria is characterized byhigh plasma tHcy levels, mental retardation, and a range ofpsychiatric symptoms, in addition to premature atherosclerosis.In more recent studies, links have been found betweenimpaired homocysteine metabolism and a wide range ofneuropsychiatric conditions such asdepression, cognitive impairment, and dementiain adult populations and in the elderly.
  75. 75. High Folate Intake Is Related to Better Academic Achievement in Swedish Adolescents Nilsson, Pediatrics 2011;128:e358 386 Swedish adolescents aged 15 yrs. The sum of school grades in 10 core subjects obtained Academic achievement in the final semester of was compulsory 9 years of strongly correlated to schooling used as outcome tertiles of tHcy measure of academic (negatively; P=0.023) achievement. and toAdolescents are vulnerable tertiles of folate intake to increased plasma total (positively; P<0.001). homocysteine (tHcy) and to insufficient folate status.
  76. 76. High Folate Intake Is Related to Better Academic Achievement in Swedish Adolescents Nilsson, Pediatrics 2011;128:e358
  77. 77. Folic Acid Use in Pregnancy and the Development of Atopy, Asthma, and Lung Function in Childhood Magdelijns Pediatrics 2011;128:e144 KOALA Birth Cohort •Maternal folic acid supplement Study (n=2834). use during pregnancy was not Data on eczema associated with increased risk and wheeze at of wheeze, lung 3, 7, 12, and 24 function, asthma, or related months, 4 atopic outcomes in the to 5 years, and offspring. 6 to 7 years. Intracellular folic acid •Maternal ICF level in late pregnancy was inversely (ICF) determined in blood samples taken at associated with asthma risk at ~35 weeks of pregnancy age 6 to 7 years in a (n=837). dose-dependent manner
  78. 78. Folic Acid Use in Pregnancy and the Development of Atopy, Asthma, and Lung Function in Childhood Magdelijns Pediatrics 2011;128:e144 OR for asthma at 6-7 yrs1.0 – 1.0 p<0.05 for trend 0.730.5 – 0.46 0.41 0.310.0 1st Quintile 2nd Quintile 3rd Quintile 4th Quintile 5th Quintile (≤ 480 nmol/L) (481–643 (644–862 (863–1139 (≥ 1140 nmol/L) nmol/L) nmol/L) nmol/L) Intracellular folic acid Levels (Divided Into Quintiles)
  79. 79. Decreased Postnatal Docosahexaenoic and ArachidonicAcid Blood Levels in Premature Infants are Associatedwith Neonatal Morbidities Martin, J Ped 2011;159:74388 infants born at <30 Docosahexaenoic acid weeks‘ gestation. (DHA) and arachidonic acidFatty acid profiles levels declined during the first rapidly in the first postnatal month. postnatal week, with a concomitantInfant increase in linoleic outcomes, including acid levels. chronic lung disease (CLD).
  80. 80. Decreased Postnatal Docosahexaenoic and ArachidonicAcid Blood Levels in Premature Infants are Associatedwith Neonatal Morbidities Martin, J Ped 2011;159:74388 infants born at <30 weeks‘ gestation.Fatty acid profiles during the first postnatal month.Infant outcomes, including chronic lung disease (CLD).
  81. 81. Decreased Postnatal Docosahexaenoic and ArachidonicAcid Blood Levels in Premature Infants are Associatedwith Neonatal Morbidities Martin, J Ped 2011;159:743 OR for chronic lung disease88 infants born at <30 3 – weeks‘ gestation.Fatty acid profiles 2 – 2.5 during the first postnatal month. 1 –Infant outcomes, including chronic lung disease 0 (CLD). Decreased DHA level
  82. 82. Decreased Postnatal Docosahexaenoic and ArachidonicAcid Blood Levels in Premature Infants are Associatedwith Neonatal Morbidities Martin, J Ped 2011;159:743 HR for late onset sepsis88 infants born at <30 3 – weeks‘ gestation.Fatty acid profiles 2 – during the first postnatal month. 1 – 1.4Infant outcomes, including chronic lung disease 0 (CLD). Decreased arachidonic acid level
  83. 83. High-Dose Docosahexaenoic Acid Supplementation of Preterm Infants: Respiratory and Allergy Outcomes Manley Pediatrics 2011;128:e71 657 preterm infants 33 weeks‘ RR of BDP in all infants with gestation who consumed a birth weight of 1250 g expressed breast milk from 1.0 – mothers taking either 0.9 – tuna oil (high-DHA diet) or 0.8 – 0.75 0.7 – soy oil (standard-DHA) 0.6 – capsules. 0.5 – 0.4 – p=0.04 Incidence of bronchopulmonary 0.3 – dysplasia (BPD) and parental 0.2 – 0.1 – reporting of atopic conditions 0 over the first 18 months of DHA diet life.
  84. 84. High-Dose Docosahexaenoic Acid Supplementation of Preterm Infants: Respiratory and Allergy Outcomes Manley Pediatrics 2011;128:e71 657 preterm infants 33 weeks‘ RR of reported hay fever gestation who consumed in all infants at either expressed breast milk from 12 or 18 months 1.0 – mothers taking either 0.9 – tuna oil (high-DHA diet) or 0.8 – soy oil (standard-DHA) 0.7 – capsules. 0.6 – 0.5 – 0.4 – Incidence of bronchopulmonary dysplasia (BPD) and parental 0.3 – 0.2 – 0.41 reporting of atopic conditions 0.1 – p=0.03 over the first 18 months of 0 life. DHA diet
  85. 85. Impaired Fetal Growth and Arterial Wall Thickening:A Randomized Trial of Omega-3 Supplementation Skilton, Pediatrics 2012;129;e698 WHAT’S KNOWN ON THIS SUBJECT: Impaired fetal growth is an independent risk factor for cardiovascular diseases in adulthood and is associated with arterial wall thickening, a noninvasive measure of subclinicalatherosclerosis, in early childhood. No preventive strategy has been identified. WHAT THIS STUDY ADDS: Dietary omega-3 fatty acidsupplementation in early childhood prevented the association of impaired fetal growth with arterial wall thickening, suggesting that this early-life intervention may mitigate the risk of cardiovascular disease in those with impaired fetal growth.
  86. 86. Impaired Fetal Growth and Arterial Wall Thickening: A Randomized Trial of Omega-3 Supplementation Skilton, Pediatrics 2012;129;e698 616 children born at term. Fetal growth was inversely associated with carotid Either a 500-mg-daily fish oil intima-media supplement and canola based margarines and cooking oil thickness (IMT), (omega-3 group). but this was prevented in the omega-3 group. 500-mg-daily sunflower oil supplement and omega-6 fatty Pheterogeneity = 0.02 acid–rich margarines and cooking oil (control group). From the start of bottle-feeding or 6 months of age until 5 years of age.
  87. 87. Impaired Fetal Growth and Arterial Wall Thickening: A Randomized Trial of Omega-3 Supplementation Skilton, Pediatrics 2012;129;e698 616 children born at term. Fetal growth was inversely The inverse association associated with carotid Either a 500-mg-daily fish oil intima-media of fetal growth with supplement and canola based margarines wallcooking oil arterial and thickness thickness (IMT), (omega-3 group). can be at age 8 yrs but this was prevented prevented by dietary in the omega-3 group. 500-mg-daily sunflower oil omega-3 fatty acid supplement and omega-6 fatty Pheterogeneity = 0.02 supplementation acid–rich margarines and cooking over the first oil (control group). 5 years of life. From the start of bottle-feeding or 6 months of age until 5 years of age.
  88. 88. CARDIOLOGYmalformations
  89. 89. Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study. Ewer, Lancet 2011;378:785 Number of babies with major congenital heart disease 6 maternity units in the UK. 60 – 20055 asymptomatic 53 50 – newborn babies. 40 – Pulse oximetry before discharge. (0.26%) 30 – Infants who did not achieve (24 critical) oxygen saturation thresholds 20 – underwent echocardiography. 10 – 0
  90. 90. Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease SECTION ON CARDIOLOGYAND CARDIAC SURGERY EXECUTIVE COMMITTEE Pediatrics 2012;129;190 The screening is targeted toward healthy newborn infants in the newborn nursery. Screening should be performed with motion-tolerant pulse oximeters. Screening should not be undertaken until 24 hours of life or as late as possible if early discharge is planned to reduce the number of false positive results.
  91. 91. Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease SECTION ON CARDIOLOGYAND CARDIAC SURGERY EXECUTIVE COMMITTEE Pediatrics 2012;129;190 •O2 saturations should be obtained in the right hand and one foot. •Screening that has a pulse oximetry reading of ≥95% in either extremity with a ≤3% absolute difference between the upper and lower extremity would be considered a pass, and the screening would end. It is recommended that repeated measurements be performed in those cases in which the initial screening result was positive, again in an effort to reduce false-positive results. •Infants with saturations <90% should receive immediate evaluation.
  92. 92. Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease SECTION ON CARDIOLOGYAND CARDIAC SURGERY EXECUTIVE COMMITTEE Pediatrics 2012;129;190 •O2 saturations should be obtained in the right hand and one foot. •Screening that has a pulse oximetry reading of ≥95% in either In the event of a positive screening extremity with a ≤3% absolute differenceexcluded result, CCHD needs to be between the upper and lower extremity would be considered a pass, and the screening with a diagnostic echocardiogram. would end. It is recommended that repeated measurements be performed Infectious andwhich the initial screening result in those cases in pulmonary causes was positive, again in an effort to reduce excluded. of hypoxemia should also be false-positive results. •Infants with saturations <90% should receive immediate evaluation.
  93. 93. CARDIOLOGY-dolore toracico-tachicardia-sincope collasso
  94. 94. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:2221) The diagnosis of orthostatic intolerance (OI) and postural orthostatic tachycardia syndrome (POTS) is based on a symptomatic, excessive orthostatic rise in heart rate (HR).2) Common symptoms of OI and POTS include lightheadedness, palpitations, pre-syncopal feelings, tremulousness, and leg weakness when assuming the upright position.3) These symptoms are considered related to a combination of reduced cerebral perfusion and increased sympathetic activation.4) OI and POTS occur predominately in females, with female:male of approximately 5:1.
  95. 95. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 Orthostatic HR increment 654 pediatric patients during head-up tilt in normal controls referred with symptoms and patients with symptoms of OI of orthostatic intolerance OI. 106 normal controls aged 8-19 yrs. Standardized autonomic testing, including 5 min of 70° head-up tilt after supine resting for at least 30 min.
  96. 96. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 Orthostatic HR increment 654 pediatric patients during head-up tilt in normal controls referred with symptoms and patients with symptoms of OI of orthostatic intolerance The HR increment OI. was mildly higher in patients referred 106 normalOI/POTS, for controls aged 8-19 yrs. but there was considerable overlap Standardizedthe patient between autonomic testing, includinggroups. and control 5 min of 70° head-up tilt after supine resting for at least 30 min.
  97. 97. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 Our study demonstrates that: an orthostatic HR increment of 30 bpm (the main diagnostic criterion for OI in adults) is still well within the normal range for children and adolescents. x
  98. 98. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 We suggest the following diagnostic criteria for Pediatric Orthostatic Intolerance:1) Symptoms of OI, such as lightheadedness and palpitations, occurring frequently (>50% of the time) when assuming the upright position &2) orthostatic HR increment ≥40 bpm within 5 minutes of head-up tilt. OI=orthostatic intolerance POTS= postural tachycardia syndrome
  99. 99. Postural Tachycardia in Children and Adolescents: What is Abnormal? Singer, J Pediatr 2012;160:222 We suggest the following diagnostic criteria for pediatric postural orthostatic tachycardia syndrome:1) Symptoms and HR increment fulfilling criteria for pediatric OI &2) absolute orthostatic HR ≥130 bpm (for age ≤13 years), or ≥120 bpm (for age ≥14 years) within 5 minutes of head-up tilt. OI=orthostatic intolerance POTS= postural tachycardia syndrome
  100. 100. Plasma Hydrogen Sulfide (H2S) in Differential Diagnosis between Vasovagal Syncope and Postural Orthostatic Tachycardia Syndrome in Children, Zhang, J Pediatr 2012;160:2271) Orthostatic intolerance (OI) is a constellation of signs and symptoms that are elicited by standing upright and relieved by recumbency. Symptoms include headache, nausea, abdominal pain, lightheadedness, diminished concentration, tremulousness, syncope, near syncope, and hyperpnea.2) Postural orthostatic tachycardia syndrome (POTS) and vasovagal syncope (VVS) are common causes of OI in children.3) POTS is defined operationally by symptoms of OI in association with excessive tachycardia.4) Vaso Vagal Syndrome is defined by a sudden transient loss of consciousness and postural tone caused by blood pressure drops and bradicardia with consequent cerebral hypoperfusion.
  101. 101. Plasma Hydrogen Sulfide (H2S) in Differential Diagnosis between Vasovagal Syncope and Postural OrthostaticTachycardia Syndrome in Children, Zhang, J Pediatr 2012;160:227 Plasma concentrations of H2S in the Vasovagal syncope control, POTS and VVS groups. (VVS) (n=17). Postural Orthostatic Tachycardia Syndrome (POTS) in children (n=60). Healthy children (control group) (n=28). Plasma concentrations of hydrogen sulfide H2S.(acido solfidrico)
  102. 102. Plasma Hydrogen Sulfide (H2S) in Differential Diagnosis between Vasovagal Syncope and Postural OrthostaticTachycardia Syndrome in Children, Zhang, J Pediatr 2012;160:2271) Hydrogen sulfide (H2S) had long been known as a toxic gas, but only recently has it been regarded as a novel endogenous gasotransmitter.2) It is produced endogenously in mammalian tissues from L-cysteine by mainly 3 enzymes: cystathionine b-synthetase, cystathionine γ- lyase, and 3-mercaptosulfurtransferase.3) H2S could be produced by vascular smooth muscle cells and endothelial cells. It contributes to endothelium-dependent vasorelaxation and exerts regulatory effects on the pathogenesis of various diseases, such as hypertension, pulmonary hypertension and shock.4) For POTS, the abnormal vascular relaxation and cardiothoracic hypovolemia are thought to be the mechanisms.
  103. 103. Dermatology
  104. 104. Association of microbial IgE sensitizations with asthma in young children with atopic dermatitis Ong, Ann Allergy Asthma Immunol 2012;108:206 OR for persistent asthma 53 children (1-6 yrs) 5 – with mild to moderate AD. Total serum IgE and 4 – 4.3 4.2 specific IgE for: - inhalant allergens 3 – 3.5 - common food 2- - microbial allergens (Staphylococcal 1 – enterotoxins, Aspergillus fumigatus, Cladosporium Nature Genetics, 00 2006:38:399 herbarum, Malassezia C albicans C herbarum Malassezia species, and Candida albicans). SENSITIZATION to
  105. 105. Association of microbial IgE sensitizations with asthma in young children with atopic dermatitis Ong, Ann Allergy Asthma Immunol 2012;108:206 OR for persistent asthma 53 children (1-6 yrs) 5 – with mild to moderate AD. Total serum IgE and Persistent asthma 4 – 4.3 4.2 specific IgE for: was associated with - inhalant allergens 3 – 3.5 - common food IgE fungal 2- sensitizations. - microbial allergens (Staphylococcal 1 – enterotoxins, Aspergillus fumigatus, Cladosporium Nature Genetics, 00 2006:38:399 herbarum, Malassezia C albicans C herbarum Malassezia species, and Candida albicans). SENSITIZATION to
  106. 106. Depression, anxiety and dermatologic quality of life in adolescents with atopic dermatitis Slattery JACI 2011;128:668 % children with anxiety 30 – disorders 36 adolescents, mean age 20 – 26% 14.7 yrs with AD. Social SCORAD index. anxiety 10 – Children‘s Depression disordes was 6% most common Inventory and the 3% (14%) Multidimensional Anxiety 0 Scale for Children. AD Community estimates
  107. 107. Depression, anxiety and dermatologic quality of life in adolescents with atopic dermatitis Slattery JACI 2011;128:668 % children with current depressive disorders 10 – 36 adolescents, mean age 14.7 yrs with AD. 9% 6% 05 – SCORAD index. Children‘s Depression Inventory and the Multidimensional Anxiety 0 Scale for Children. AD Community estimates
  108. 108. Depression, anxiety and dermatologic quality of life in adolescents with atopic dermatitis Slattery JACI 2011;128:668 % children with current depressive disorders Subjective report 10 – of sleep loss was the 36 adolescents,severity only AD mean age 14.7 yrs with AD. 9% measure found 05 6% – SCORAD index. to be associated with symptoms Children‘s Depression Inventorydepression. of and the Multidimensional Anxiety 0 Scale for Children. AD Community estimates
  109. 109. Emollients, education and quality of life: the RCPCH care pathway for children with eczema Cox Arch dis Child 2011;96:i19The Royal College of Paediatrics andChild Health (RCPCH)• Effective eczema management is holistic and encompasses: - assessment of severity and impact on quality of life, - treatment of the inflamed epidermal skin barrier, - recognition and treatment of infection, - assessment and management of environmental and allergy trigger.• Patient and family education which seeks to maximise understanding and concordance with treatment is also important in all children with eczema.
  110. 110. Emollients, education and quality of life: the RCPCH care pathway for children with eczema Cox Arch dis Child 2011;96:i19Stepped approach to treatment
  111. 111. Effect of moisturizers on epidermal barrier function. Lodén M. Clin Dermatol. 2012;30:286-96. Time to outbreak of eczema in patients with controlledA daily moisturizing atopic eczema being treated with a barrier-improvingroutine is a vital part moisturizer, being untreated or a being treated with aof the management of potentially barrier deteriorating moisturizerpatients with atopic (vaseline suggested to promote relapse of eczema).dermatitis and otherdry skin conditions.The composition ofthe moisturizerdetermines whetherthe treatmentstrengthens ordeteriorates the skinbarrierfunction, which mayhave consequences forthe outcome of thedermatitis.
  112. 112. A pilot study of silver-loaded cellulose fabric with incorporated seaweed for the treatment of atopicdermatitis.Park KY, Clin Exp Dermatol. 2012 [Epub ahead of print]newly developed silver-loadedcellulose fabric with incorporatedseaweed,12 subjects with mild tomoderate atopic dermatitis into a Silverclinical control study. loadedThe subjects wore a two-piecegarment (top and leggings), each Cottonpiece of which was divided into 100%two parts: one side was made ofSkinDoctor(®) fabric, and theother of 100% cotton
  113. 113. A pilot study of silver-loaded cellulose fabric with incorporated seaweed for the treatment of atopicdermatitis.Park KY, Clin Exp Dermatol. 2012 [Epub ahead of print] Mean SCORAD index of areas covered with SkinDoctor compared with thosenewly developed silver-loaded covered with cottoncellulose fabric with incorporatedseaweed,12 subjects with mild tomoderate atopic dermatitis into aclinical control study.The subjects wore a two-piecegarment (top and leggings), eachpiece of which was divided intotwo parts: one side was made ofSkinDoctor(®) fabric, and theother of 100% cotton
  114. 114. New Insights About Infant and Toddler Skin:Implications for Sun Protection Paller Pediatrics 2011;128:92 Infant epidermal structure 1) The outermost layer of (SC) epidermis, the SC, protects skin from adverse environmental conditions, including ultraviolet radiation (UVR) penetration and systemic absorption of topically applied materials such as sunscreens. 2) Although the SC is present at birth, it gains thickness, hydration capacity, and acidification throughout infancy as it increases its capacity to adapt
  115. 115. New Insights About Infant and Toddler Skin:Implications for Sun Protection Paller Pediatrics 2011;128:92 1) Accumulating evidence suggests not only that the skin‘s barrier protection remains immature throughout at least the first 2 years of life but also that accumulation of UVR-induced changes in the skin may begin as early as the first summer of life. 2) Such evidence affirms the importance of sun protection during the infant and toddler years.
  116. 116. Prospective Study of Sunburn and Sun BehaviorPatterns During Adolescence Dusza, Pediatrics 2012;129;309 1) Melanoma is a significant and growing public health concern. 2) UV light radiation (UVR) exposure is the most important modifiable melanoma risk factor. 3) Studies have shown that intense, intermittent exposures to UVR, as measured by sunburn frequency, have a higher melanoma-attributable risk than chronic UVR exposure. 4) UVR exposures at an early age are particularly important for the development of cutaneous melanoma in adulthood. 5) A recent meta-analysis of 51 studies found that ever reporting a sunburn during childhood almost 2X the risk for the development of cutaneous melanoma in adulthood.
  117. 117. Prospective Study of Sunburn and Sun Behavior Patterns During Adolescence Dusza, Pediatrics 2012;129;309 % students reported having at least 1 sunburn during the previous summer 60 - A prospective, population- 50 – 53% 55% based study in 360 40 – fifthgrade children (∼10 years of age). 30 – At baseline 20 – (September–October 2004) and 10 – again 3 years later (September–October 2007). 000 2004 2007
  118. 118. Prospective Study of Sunburn and Sun Behavior Patterns During Adolescence Dusza, Pediatrics 2012;129;309 % children reporting “often or always” use of sunscreen when outside for at least 6 hours in the summer 60 - A prospective, population- 50 – based study in 360 40 – 50% fifthgrade children p<0.001 (∼10 years of age). 30 – At baseline (September– October 2004) and 20 – 25% again 3 years later 10 – (September–October 2007). 000 2004 2007
  119. 119. Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections Williams Pediatrics 2011;128:e479 OR for treatment failures Retrospective cohort of 2.5 – 6407children 0 to 17 yrs. Treatment of pediatric 2.0 – 2.23 skin and soft-tissue 1.5 – 1.92 infections (SSTIs). 1.0 – Treatment failure 0.5 – (SSTI ≤14 days after the treatment of incident 0 0 SSTI) and recurrence Trimethoprim β-lactams -sulfamethoxazole (SSTI >15 and ≤365 days). Compared with clindamycin
  120. 120. Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections Williams Pediatrics 2011;128:e479 Retrospective cohort of OR for recurrences 6407children 0 to 17 yrs. Treatment of pediatric 1.5 – 1.26 skin and soft-tissue 1.49 infections (SSTIs). 1.0 – Treatment failure 0.5 – (SSTI ≤14 days after the treatment of incident 0 0 Trimethoprim β-lactams SSTI) and recurrence -sulfamethoxazole (SSTI >15 and ≤365 days). Compared with clindamycin
  121. 121. Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections Williams Pediatrics 2011;128:e479• The growing burden of community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA), which is estimated to account for70% of staphylococcal infections in some regions of the United States, is a major problem in childhood.• A frequent cause of skin and soft-tissue infections (SSTIs), CA-MRSA infections often are more severe and lead to poor clinical outcomes.• CA-MRSA isolates are uniformly resistant to β-lactam antibiotics, previously the most commonly used agents for SSTIs, which makes prompt recognition and initiation of effective empiric therapy for CA-MRSA extremely important.
  122. 122. Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections Williams Pediatrics 2011;128:e479• The growing burden of community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA), which is estimated to account for70% of staphylococcal infections in some regions of the United States, is a major problem in childhood. Currently,• A frequent cause most commonly recommended, the of skin and soft-tissue infections (SSTIs), orally administered antibiotics CA-MRSA infections often are more severe and lead to poor clinical outcomes. SSTIs include clindamycin for pediatric• CA-MRSA (10-25 mg/kg/day in 3-4 divided doses) isolates are uniformly resistant to β-lactam antibiotics, and trimethoprim-sulfamethoxazole. previously the most commonly used agents for SSTIs, which makes prompt di TM/Kg/die) (6 mg recognition and initiation of effective empiric therapy for CA-MRSA extremely important.
  123. 123. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:631) Growth hormone (GH) therapy has now been available for over 5 decades, with all GH now biosynthetically produced, and administered by daily injection2) Paediatric GH is currently licensed in 6 different conditions: growth hormone deficiency (GHD), Turner syndrome (TS), small for gestational age (SGA), Prader-Willi syndrome (PWS), chronic renal insufficiency (CRI) and short stature due to SHOX deficiency (short stature homeobox- containing gene); all of these have been ratified by the most recent (2010) NICE review3) Whilst the primary purpose of paediatric GH therapy in most indications is to improve short and long-term growth, in others (eg. PWS) it has a role in improvement of body composition
  124. 124. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63 Doses of growth hormone (GH) for paediatric GH licenses
  125. 125. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63 Growth hormone deficiency (GHD)This is the commonest endocrine disorder presenting with shortstature. Most (~70%) of patients with GHD have an isolateddeficiency of GH.The commonest causes of GHD are as follows:- Congenital (midline embryonic anomalies and transcription factor defects)- Acquired (tumour, trauma, irradiation, infiltration, infection)- IdiopathicThe classical clinical phenotype includes:- short stature (both in relation to peers and also parents)- poor growth (Height Velocity <25th centile for at least 1 year)- delayed bone age (with associated delayed dentition and puberty)GHD is confirmed by a peak plasma GH level <6.7 μg/L to twoprovocative tests
  126. 126. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63Turner syndrome (TS)This is the commonest gonadal dysgenesis infemales (1 in 2000), and is due to abnormalitieswithin the X-chromosome (45 XO).The short stature in TS is multifactorial, due toa combination of: intrauterine growthretardation, poor growth in childhood, anabsent pubertal growth spurt and amild skeletal dysplasia, for example, shortneck, wide carrying angle, hand and nail abnormalities.As a result final height is reduced by 21 cm from mid-parentalheight.Different studies indicate that the earlier GH is started thebetter the height outcome; in addition to GH therapy sex hormones
  127. 127. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63Prader-Willi syndrome (PWS)PWS is a dysmorphic syndrome withclinical features including shortstature, hypogonadism, obesity, abnormal bodycomposition, hypotonia, hyperphagia andlearning and behavioural problems.It is due to loss of paternally derivedgenes on 15q.In PWS the aim of therapy is bothto improve body composition as well as promoting growth, and GHresults in improvements in both height, body composition and musclestrength/tone. There have, however, been several reports of suddendeath in PWS patients treated with GH, especially if patients areseverely obese, and in these patients sleep studies should be
  128. 128. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63 Small for gestational age (SGA)SGA is usually defined as a birth weight and/or length more than−2.5 SDS below the mean.These patients are a heterogeneous group, including normalchildren, and those growth retarded by maternal, placental and fetalfactors. Approximately 80% of children born SGA show catch-upgrowth in the 6 months of life.Overall, approximately 10% of patients born SGA remain short(height <−2 SDS).GH is licensed for children born SGA who fail to show catch-upgrowth (HV SDS <0 during the last year) by 4 years of age orlater, and who are short both compared to their peers(height <−2.5 SD) and parents (parental adjusted height <−1 SD).
  129. 129. Indications for growth hormone therapy in children Kirk, Arch Dis Child 2012;97:63 Small for gestational age (SGA)SGA is usually defined as a birth weight and/or length more than−2.5 SDS below the mean.These patients are a heterogeneous group, including normalchildren, and those growthHeight + by maternal,Height + and fetal BOYS: Cm: (Fathers retarded Mothers placental 13) / 2factors. Approximately 80% of children born SGA show catch-upgrowth in the 6 months of life.Overall, approximately 10% of patients + Mothers Height) / 2 GIRLS: Cm: (Fathers Height - 13 born SGA remain short(height <−2 SDS).GH is licensed for children born SGA who fail to show catch-upgrowth (HV SDS <0 during the last year) by 4 years of age orlater, and who are short both compared to their peers(height <−2.5 SD) and parents (parental adjusted height <−1 SD).
  130. 130. A multi-center controlled trial of growth hormone treatment in children with cystic fibrosis Stalvey Pediatr Pulmonol 2012;47:252 Height standard deviation score (SDS) by visit (as randomized subjects) 68 prepubertal children <14 years with CF. Daily rhGH (Nutropin AQ) or no treatment (control) for 12 months, followed by a 6-month observation (month 18).
  131. 131. A multi-center controlled trial of growth hormone treatment in children with cystic fibrosis Stalvey Pediatr Pulmonol 2012;47:252 Weight and lean body mass (LBM) change from baseline to Month 12 (as randomized subjects) 68 prepubertal children <14 years with CF. Daily rhGH (Nutropin AQ) or no treatment (control) for 12 months, followed by a 6-month observation (month 18).
  132. 132. A multi-center controlled trial of growth hormone treatment in children with cystic fibrosis Stalvey Pediatr Pulmonol 2012;47:252 350 – Increase in FVC (ml) 68 prepubertal children 300 – 325 p=0.032 <14 years with CF. ml 250 – Daily rhGH 200 – (Nutropin AQ) or no treatment (control) for 150 – 178 12 months, followed by 100 – ml a 6-month observation 150 – (month 18). 150 Rh GH Controls
  133. 133. A multi-center controlled trial of growth hormone treatment in children with cystic fibrosis Stalvey Pediatr Pulmonol 2012;47:252 Mean increase in FEV1 (ml) 300 – 68 prepubertal children 250 – <14 years with CF. p=0.004 Daily rhGH (Nutropin 200 – 224 AQ) or no treatment 150 – ml (control) for 12 100 – months, followed by a 108 6-month observation 150 – (month 18). ml 150 Rh GH Controls
  134. 134. 1) Quale di queste risposte è esatta:a) Se guidano i nonni ,è più facile che il bambino subisca un trauma in un eventuale incidente stradale.b) Se guidano i nonni, è meno probabile che il bambino subisca un trauma nell‘eventualità d‘incidente stradale, anche se è meno probabile che sia adeguatamente allacciato con le cinture di sicurezzac) Durante i periodi di recessione economica gli abusi sui minori si riduconod) Raramente l‘abuso su un minore è un fenomeno ricorrente
  135. 135. 1) Quale di queste risposte è esatta:a) Se guidano i nonni ,è più facile che il bambino subisca un trauma in un eventuale incidente stradale.b) Se guidano i nonni, è meno probabile che il bambino subisca un trauma nell’eventualità d’incidente stradale, anche se è meno probabile che sia adeguatamente allacciato con le cinture di sicurezzac) Durante i periodi di recessione economica gli abusi sui minori si riduconod) Raramente l‘abuso su un minore è un fenomeno ricorrente
  136. 136. 2) Quale di queste risposta è falsa:a) L‘eruzione dentaria si associa a comparsa di rialzo febbrile quasi sempreb) Le mamme con depressione post partum allattano al seno meno frequentemente delle mamme non depressec) L‘allattamento al seno aumenta lo sviluppo polmonared) L‘allattamento al seno riduce i livelli di fibrinogeno nel bambino
  137. 137. 2) Quale di queste risposta è falsa:a) L’eruzione dentaria si associa a comparsa di rialzo febbrile quasi sempreb) Le mamme con depressione post partum allattano al seno meno frequentemente delle mamme non depressec) L‘allattamento al seno aumenta lo sviluppo polmonared) L‘allattamento al seno riduce i livelli di fibrinogeno nel bambino
  138. 138. 3) Quale di queste risposta è esatta:a) Il difetto di zinco può favorire la presenza di asma più grave che richiede l‘ospedalizzazione e protegge marginalmente dalla comparsa di polmonite di lunga duratab) Il difetto di vitamina D in gravidanza non ha ripercussioni sul bambinoc) Il difetto di vitamina D non ha alcun effetto sul rischio di infezione da RSV e bronchiolited) Il difetto di vitamina D nel bambino non riduce la resistenza all‘insulina, non aumenta il rischio di glicemia più alta e non aumenta il rischio di pressione sistolica più alta nel bambino obeso
  139. 139. 3) Quale di queste risposta è esatta:a) Il difetto di zinco può favorire la presenza di asma più grave che richiede l’ospedalizzazione e protegge marginalmente dalla comparsa di polmonite di lunga duratab) Il difetto di vitamina D in gravidanza non ha ripercussioni sul bambinoc) Il difetto di vitamina D non ha alcun effetto sul rischio di infezione da RSV e bronchiolited) Il difetto di vitamina D nel bambino non riduce la resistenza all‘insulina, non aumenta il rischio di glicemia più alta e non aumenta il rischio di pressione sistolica più alta nel bambino obeso
  140. 140. 4) Livelli adeguati di acido folico:a) Si associano ad alti livelli di omocisteinab) Si associano ad un aumentato rischio di allergia in età prescolarec) Si associano a risultati scolastici migliorid) Nessuna delle risposte è corretta
  141. 141. 4) Livelli adeguati di acido folico:a) Si associano a alti livelli di omocisteinab) Si associano ad un aumentato rischio di allergia in età prescolarec) Si associano a risultati scolastici migliorid) Nessuna delle risposte è corretta
  142. 142. 5) La supplementazione con DHA durante la gravidanza e/o nei primi mesi di vita:a) Riduce il rischio di comparsa di displasia broncopolmonareb) Riduce il rischio di sepsi nei primi mesi di vitac) Riduce il rischio di aterosclerosid) Tutte le risposte sono corrette
  143. 143. 5) La supplementazione con DHA durante la gravidanza e/o nei primi mesi di vita:a) Riduce il rischio di comparsa di displasia broncopolmonareb) Riduce il rischio di sepsi nei primi mesi di vitac) Riduce il rischio di aterosclerosid) Tutte le risposte sono corrette
  144. 144. 6) La terapia con ormone della crescita:a) E‘ utilizzata nei bambini con difetto di GHb) Può essere utilizzata nella sindrome di Turner e nella sindrome di Prader Willic) Può essere utilizzata nell‘insufficienza renale e nella fibrosi cisticad) Tutte le risposte sono corrette
  145. 145. 6) La terapia con ormone della crescita:a) E‘ utilizzata nei bambini con difetto di GHb) Può essere utilizzata nella sindrome di Turner e nella sindrome di Prader Willic) Può essere utilizzata nell‘insufficienza renale e nella fibrosi cisticad) Tutte le risposte sono corrette
  146. 146. gastroenterology
  147. 147. Toddler diarrhoea: is it a useful diagnostic label? Powell, Arch Dis Child 2012;97:84Definition1) A variety of different terms, including irritable colon of childhood, irritable bowel syndrome (IBS) variant, fast transit diarrhoea, chronic nonspecific diarrhoea (CNSD) and non-specific diarrhoea in children, have been used to describe the typical presentation of toddler diarrhoea.2) CNSD typically presents between the age of 1 and 5 years and is self-limiting in 90% of cases.3) Toddler diarrhoea is a term coined many years ago to describe a young child who passes several loose stools a day but who is otherwise healthy with excellent growth and normal examination.
  148. 148. Toddler diarrhoea: is it a useful diagnostic label? Powell, Arch Dis Child 2012;97:84Suggested initial investigation Full blood count C reactive protein Erythrocyte sedimentation rate Coeliac disease screen—anti-tissue transglutaminase antibody and total serum IgA Stool culture (including Clostridium difficile and giardia)
  149. 149. Toddler diarrhoea: is it a useful diagnostic label? Powell, Arch Dis Child 2012;97:84Differential diagnoses1) A postenteritis syndrome/cow’s milk protein intolerance2) Excessive juice intake/fructose intolerance3) Chronic infection: - Giardia lamblia (giardiasis) - Cryptosporidium parvum (cryptosporidiosis)4) Coeliac disease5) Constipation with overflow diarrhoea6) Factitious diarrhoea and laxative use7) Inflammatory bowel disease8) IBS variant in childhood
  150. 150. Toddler diarrhoea: is it a useful diagnostic label? Powell, Arch Dis Child 2012;97:84Management strategies A 6-week trial of a cows milk- and egg-free diet with dietetic help Reduce fructose/juice intake Trial of metronidazole Loperamide for symptomatic relief once other diagnoses are excluded Reassurance Follow-up
  151. 151. Early Life Events: Infants with Pyloric Stenosis Have a Higher Risk of Developing Chronic Abdominal Pain in Childhood Saps, J Ped 2011;159:551 OR for chronic abdominal pain 100 children diagnosed with pyloric stenosis during infancy 5 - (cases). 4.3 4 – 91 siblings aged 4-20 yrs without a history of pyloric 3 – stenosis selected as controls. 2 – p=0.0045 Mean time to follow-up was 1 – 7.2 ± 1.6 yrs. 0 cases vs controls
  152. 152. Early Life Events: Infants with Pyloric Stenosis Have a Higher Risk of Developing Chronic Abdominal Pain in Childhood Saps, J Ped 2011;159:551 OR for pain-associated functional gastrointestinal 100 children diagnosed with disorder (irritable bowel pyloric stenosis during infancy syndrome, functional (cases). dyspepsia, functional abdominal 7 - pain) 91 siblings aged 4-20 yrs without a history of pyloric 6 - 5 - 6.8 stenosis selected as controls. 4 – 3 – Mean time to follow-up was 2 – p=0.043 7.2 ± 1.6 yrs. 1 – 0 cases vs controls
  153. 153. Randomized clinical trial of rapid versus 24-hour rehydration for children with acute gastroenteritis Powell Pediatrics 2011;128:e771 Standard Nasogastric Rehydration involved admission 254 children 6 to 72 to the hospital ward, where the months of age with estimated fluid deficit acute viral (5%–7% of body weight) gastroenteritis and was replaced with moderate dehydration. Oral Rehydration Solution Randomly to receive over 6 hours, at a constant rate, either standard through a nasogastric tube. nasogastric rehydration Patients were reassessed for signs (SNR) over 24 hours of dehydration after 6 hours. in the hospital ward or rapid nasogastric The 24-hour maintenance fluid rehydration (RNR) requirement then was administered over 4 hours in the ED. over the subsequent 18 hours.

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