Pediatrics in Clinics: highlights

EDITORIAL

Pediatrics in Clinics: highlights

Mauricio Rocha e Silva

Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo/SP, Brazil

As a multidisciplinary medical journal CLINICS has covered virtually every medical area. We here highlight one of our strongest fields, Pediatrics, responsible for slightly over 10% of all our original research papers over 2010-11.

CARDIOVASCULAR

Sellami et al. (1) examined the effect of the histocompatibility antigen HA-1 disparity on the incidence of both acute and chronic graft-versus-host disease in Tunisian recipients of hematopoietic stem cells in 60 patients and their 60 respective sibling hematopoietic stem cell donors. Their findings support previously reported data suggesting a significant association between HA-1 disparity and the risk of acute graft-versus-host disease following hematopoietic stem cell transplantation. Tedde et al. (2) compared bar displacement and complication rates in three retrospective series of mostly pediatric patients operated on by the same surgical team for pectus excavatus: (i) original, unmodified Nuss technique; (ii): "third point fixation" technique; and (iii) correction performed with modifications to the stabilizer and stabilizer position. With bar displacement and instability no longer significant postoperative risks, the Nuss technique should be considered among the available options for the surgical correction of pectus excavatum in pediatric patients. Dutra et al. (3) aimed to test five microsatellite markers (D7S1870, D7S489, D7S613, D7S2476, and D7S489) for the diagnosis of Williams-Beuren syndrome, to determine the size and parental origin of microdeletion, compare the clinical characteristics in 97 patients with different sizes of the deletion and parental origin. Microdeletions were present in 84 (86.6%) patients. Maternal deletions were found in 52.4%, paternal deletions in 47.6% of patients. Supraventricular aortic stenosis, ocular and urinary abnormalities were more frequent in the patients with a deletion. They conclude that the use of the five microsatellite markers was informative in all patients, and may thus be considered as an alternative method for molecular diagnosis in Williams-Beuren syndrome. Kayiran et al. (4) described the demographic, clinical, and laboratory features of 30 children, aged <5 years, with Kawasaki disease managed at the American Hospital, Istanbul, Turkey. Coronary artery abnormalities were detected in nine patients. They claim that this study is the most comprehensive series of children from Turkey with KD included in Medline. Orlando et al. (5) analyzed the results of treating 39 deep venous malformations patients with low doses of ethanol. Patients were followed up prospectively over a median period of 18 months. All of the lesions affected limbs, and the main symptom reported was pain (97.4%). Each patient underwent fortnightly alcohol application sessions under local anesthesia on an outpatient basis. Symptoms completely disappeared in 14 patients (35.9%) and improved in 24 (61.5%). They conclude that deep venous malformation patients using ethanol at low doses was effective, with a low complication rate.

INFECTIOUS DISEASES

Contri et al. (6) described nutritional status, body composition and lipid profile in children and adolescents receiving protease inhibitors and conclude that the use of protease inhibitors, per se, does not seem to significantly interfere with anthropometric measures, body composition and food intake of HIV-infected children and adolescents. However, this antiretroviral therapy was associated with a significant increase in triglyceride and LDL-cholesterol in our subjects. Nakano et al. (7) examined the antimicrobial resistance profile and the prevalence of resistance genes in Bacteroides spp. and Parabacteroides distasonis strains isolated from children's intestinal microbiota. Their results indicate an increase in the resistance to several antibiotics in intestinal Bacteroides spp. and Parabacteroides distasonis and demonstrate that these microorganisms harbor antimicrobial resistance genes that may be transferred to other susceptible intestinal strains. Hepatitis was the object of four studies. Carrilho et al. (8) performed a national survey to update hepatocellular carcinoma epidemiology in Brazil and determined the clinical and epidemiological profiles of patients in different Brazilian regions. They conclude that the epidemiology, classification, and therapy selection for hepatocellular carcinoma varied among Brazilian regions. Hepatitis C infection was the most common etiology of liver cirrhosis; chemoembolization was the most common therapy employed. Liver cirrhosis was the main risk factor for its development in Brazil. Because of its intimate relationship with the gastrointestinal tract four papers on Toxocara are included here. Simbalista et al. (9) described the evolution and outcome of children hospitalized with community-acquired pneumonia receiving penicillin (inclusion criteria: age >2 months; IV penicillin G: 200,000 IU/kg/day for >48 h; chest x-ray results). Of 154 studied cases, 123 (80%) and 40 (26%) had pulmonary infiltrate or pleural effusion, respectively. Penicillin G successfully treated 82% (126/154) of the study group and improvement was marked on the first day of treatment. Adenovirus studies are described in two articles. Nishiwaki-Dantas et al. (10) who sought to identify Chlamydia trachomatis via polymerase chain reaction vs. direct fluorescent antibody assay in patients with vernal keratoconjunctivitis. The direct fluorescent antibody assay detected Chlamydia trachomatis in a 49.4% of vernal keratoconjunctivitis patients, while the polymerase chain reaction only succeeded in 20% of cases. Although the diagnosis of trachoma is essentially clinical, the disease may not be detected in vernal keratoconjunctivitis patients. Due to the high frequency of chlamydial infection detected in patients with vernal keratoconjunctivitis, we suggest considering routine laboratory tests to detect Chlamydia trachomatis in patients with severe and refractory allergic disease.

NEUROLOGY

Samelli et al. (11) developed and analyzed the efficacy of a low-cost screening tool to identify and classify hearing loss in children. A total of 214 (2- 10 years) children participated in this study. A conductive hearing loss was found in 39% of children, sensorineural hearing loss in 7.4%, and normal hearing in 53.3%. The results suggest that the questionnaire could be used as a screening tool to classify children with normal hearing or hearing loss and according to the type of hearing loss based on the total questionnaire score. Gonçalves et al. (12) evaluated neurophysiological auditory brainstem responses to clicks and repeated speech stimuli to determine if they differ between typically developing children and children with phonological disorders. They conclude that the early stages of the auditory pathway processing of an acoustic stimulus are not similar in typically developing children and those with phonological disorders. These findings suggest that there are brainstem auditory pathway abnormalities in children with phonological disorders. Unlu et al. (13) described through a retrospective study the effect of multilevel botulin toxin-A injections in the lower extremities, focusing mainly on gross motor function and functional status in 72 cerebral palsy patients (mean age 6.7 years). They claim that a single multilevel BTX-A injection reduces spasticity and improves motor function in children with cerebral palsy. Bern et al. (14) evaluated a retrospective cohort of Wilson's disease patients from southern Brazil during a 40-year follow-up period in what is claimed to be the first retrospective description of a population of Wilson's disease patients of mainly European continental origin who live in southern Brazil. They find that Wilson's disease is treatable if correctly diagnosed, and an adequate quality of life can be achieved, resulting in a long overall survival. Olandoski et al. (15) analyzed the evolution of renal function in patients with congenital neurogenic bladder by reviewing the records of 58 pediatric patients with respect to the following attributes: gender, age, etiology of neurogenic bladder, reason for referral, medical/surgical management, episodes of treated urinary tract infections, urodynamics, DMSA scintigraphy, weight, height, blood pressure, glomerular filtration rate, microalbuminuria and metabolic acidosis. The mean age at presentation was 4.2 +/- 3.5 years. They conclude that patient referral to a pediatric nephrologist was late. A reduction in the number of urinary tract infections was observed with adequate treatment, but microalbuminuria and metabolic acidosis occurred frequently despite adequate management.

NUTRITION

Aprile et al. (16) described the growth and clinical evolution of 30 very low birth weight infants fed during hospital stay with milk from a human milk bank according to the caloric-protein value vs. 10 fed milk from their own mothers and conclude that milk from the human bank allowed a satisfactory growth and good clinical evolution for these infants. Balaban et al. (17) investigated whether early weaning constitutes a risk factor for overweight at preschool age and identified other factors that affect this association through a case-control study of 366 children aged 2 to 6 years (176 boys and 190 girls) from three Brazilian cities. They conclude that the potential protective effect of breastfeeding against overweight among preschool children is weaker than genetic and other environmental factors. Nascimento et al. (18) analyzed in 409 preschool children (3.2 + 0.3 years) the usefulness of the weight gain/ height gain ratio from birth to two and three years of age as a predictive risk indicator of excess weight at preschool age. Prevalence of excess weight was 28.8%, of overweight and obesity, 8.8%. The correlation coefficients between the body mass index z-scores of the preschool children and the birth weights or body mass indices at birth were low (0.09 and 0.10, respectively). They found that, regardless of weight/ height at birth, the mean ratio between the weight gain per g/cm of height growth from birth correlated strongly with body mass index of preschool children. This ratio may be a good indicator of the risk of excess weight and obesity in preschool-aged children. Vanderlei et al. (19) compared the autonomic function of 121 obese and eutrophic children (8-12 years) by analyzing heart rate variability. The obese children exhibited modifications in heart rate variability, characterized by a reduction in both sympathetic and parasympathetic activity. These findings stress the need for the early holistic care of obese children to avoid future complications.

PNEUMOLOGY

Guimaraes et al. (20) assessed pulmonary function and the prevalence of atopy in 85 school-age children who were very low birth weight as infants and compared those who had bronchopulmonary dysplasia to those who did not. Their data showed no significant differences in lung function between bronchopulmonary dysplasia and no bronchopulmonary dysplasia patients at school age and no evidence of an association between atopy and bronchopulmonary dysplasia. Soeiro Ade et al. (21) described the demographic data, etiology, and pulmonary histopathological findings of different diseases in the autopsies of 4,710 patients (age range: 1-99 years) with acute respiratory failure. Bronchopneumonia was the most common diagnosis in these cases. The most prevalent pulmonary histopathological pattern was diffuse alveolar damage, which was associated with different inflammatory conditions. Further studies are necessary to elucidate the complete pathophysiological mechanisms involved with each disease and the development of acute respiratory failure. Stollar et al. (22) studied correlations between forced expiratory volume in one second (FEV1), chest radiography, chest computed tomography, 6-minute walk test, and Shwachman-Kulczycki score in 43 pediatric patients with cystic fibrosis and tested whether the Shwachman-Kulczycki score is still useful in monitoring the severity of the disease. They conclude that this score remains an useful tool for monitoring the severity of cystic fibrosis, adequately reflecting the functional impairment and chest radiography and tomography changes, especially in patients with greater impairment of lung function. Caution should be exercised when assessing patients with mild lung disease, because its limitations therein should be considered.

ONCOLOGY

Estrozi and Bacchi (23) described some clinical pathological characteristics of neuroendocrine tumors of the gastroenteropancreatic tract in Brazilian patients. The study investigated clinical pathological features of 773 Brazilian gastroenteropancreatic neuroendocrine tumor cases from all the geographic regions of Brazil. They conclude that in this series, the proportion of NET cases in the total number of surgical pathology cases at their institution over the past 12 years is increasing. Guaico et al. (24) provide clinical pathological characteristics of 1,301 cases of pediatric/ adolescent lymphomas in patients from different geographic regions of Brazil and conclude that some of the results found in this study may reflect the heterogeneous socioeconomical status and environmental factors of the Brazilian population in different regions. Tamashiro et al. (25) assessed clinical and laboratory features that differentiate acute lymphoblastic leukemia from systemic juvenile idiopathic arthritis at disease onset in 102 systemic juvenile idiopathic arthritis patients retrospectively evaluated. Their study emphasizes the importance of investigating leukemia in patients presenting with musculoskeletal manifestations and, in particular, limb pain associated with thrombocytopenia. Vaisman et al. (26) designed a study to evaluate 65 patients (4-20 years of age) with differentiated thyroid carcinoma diagnosed before 20 years of age and to determine the factors associated with the response to the initial therapy. They conclude that metastases, both lymph nodal and distant, are important predictors of the persistence of disease after initial therapy in children and adolescents with differentiated thyroid cancer.

GASTROENTEROLOGY

Castro-Antunes et al. (27) evaluated the frequencies of the HLA genotypes DQ2 and DQ8 and the alleles Al*05, Al*0201, Bl*0201 and Bl*0302 in individuals with celiac disease in Recife, northeastern Brazil. They conclude that celiac disease was associated with the genotypes DQ2 and DQ8. DQ2 predominated, but the frequency distribution was different from what has been found in European populations and was closer to what has been found in the Americas. The high frequencies of the HLA genotypes DQ2 and DQ8 that were found in first-degree relatives would make it difficult to use these HLA genotypes for routine diagnosis of celiac disease in this group. Hong et al. (28) aimed to develop a decision model based on classification and regression tree analysis for the prediction of large esophageal varices in cirrhotic patients. They conclude that a decision tree model that consists of spleen width, portal vein diameter and prothrombin time may be useful for prediction of large esophageal varices in cirrhotic patients.

INTENSIVE CARE AND ANESTHESIA

Costa et al. (29) endeavored to use the pediatric risk of mortality tool to determine mortality risk factors in a tertiary pediatric intensive care units: 359 patients were included; the variables that were found to be risk factors for death were multiple organ dysfunction syndrome, mechanical ventilation, use of vasoactive drugs, hospital-acquired infection, parenteral nutrition and duration of hospitalization. Fifty-four patients died; pediatric risk of mortality score was significantly lower in survivors. They conclude that the pediatric risk of mortality score showed adequate discriminatory capacity and thus constitutes a useful tool for the assessment of prognosis for pediatric patients admitted to a tertiary pediatric intensive care units. Shoroghi et al. (30) investigated and compared the efficacy of oral midazolam with two different dosages in orange juice on perioperative hemodynamics and behavioral changes in 90 children who underwent skin laser treatment in an academic educational Hospital. They were randomly assigned to 1 of 3 groups of 30 each: the placebo group received 0.1 ml/kg orange flavored juice, group 2 and 3 receiving 0.5 and 1 mg/kg of midazolam mixed in an equal volume of orange juice, respectively. The main outcome measures included the mask acceptance, patients' behavioral scales and postoperative events. They conclude that the 1 mg.kg(-l) midazolam optimized the children's behavior during skin laser treatment with no serious adverse effects, enhancing their parents' satisfactions about the sedative protocol.

ORTHOPEDICS

Chen et al. (31) determine the features of earthquake-related pelvic crush fractures versus non-earthquake fractures with digital radiography and multidetector row computed tomography and conclude that earthquake-related pelvic crush fractures can be characterized by a high incidence of pelvic fractures occurring in the pubis, comminuted fractures, and Type C fractures predominantly composed by subtype C3, despite a low incidence of multiple fractures. Frequency of occurrence in children was reported. Chu et al. (32) compared the features of head traumas caused by the Sichuan earthquake with those of other common head traumas using multidetector computed tomography. They focused the differences between fractures and intracranial injuries and the relationships between extracranial and intracranial injuries. As depicted with computed tomography, the severity of earthquake-related head traumas in survivors was milder, and isolated extracranial injuries were more common in earthquake-related head traumas than in non-earthquake-related injuries, which may have been the result of different injury causes, mechanisms and settings. Occurrence of lesions in children is described.

PSYCHIATRY

Zappitelli et al. (33) endeavored to identify psychiatric diagnoses in a sample of 35 children (6-17 years) who had at least one parent with bipolar disorder type I. Their results support previous findings of an increased risk for developing psychopathology, predominantly mood and disruptive disorders, in the offspring of bipolar individuals. Prospective studies with larger samples are needed to confirm and expand these results. Lin et al. (34) evaluated the risks and rates of readmission and their predictors at 14 days, one year, and five years after discharge for the psychiatric population in Taiwan through a prospective study based on claims from 44,237 first-time hospitalized psychiatric patients discharged in 2000, who were followed for up to five years after discharge. The study found that the significant predictors for psychiatric readmission 14 days to five years after discharge were essentially the same except for patient's age and hospital accreditation level. This study also highlighted the importance of socioeconomic factors in the prediction of readmission.

OTHER

Sole et al. (35), on behalf of the Online Latin American Survey of Anaphylaxis (OLASA) endeavored to identify the main clinical manifestations, triggers, and treatments of severe allergic reactions in patients who were seen by allergists from July 2008 to June 2010 in 15 Latin American countries and Portugal (n = 634): 31.5% 18 years old or less, 41.6% were male. Etiologic agents were identified in 87.4% of cases: drugs (31.2%), foods (23.3%), and insect stings (14.9%), but foods predominated in children. The main clinical manifestations were cutaneous. Treatment for acute anaphylactic reactions was not appropriate. They conclude that it is necessary to improve educational programs in order to enhance the knowledge on this potentially fatal emergency. Hua-Li et al. (36) explored the characteristics of seasonal distribution and the influences of meteorological factors including temperature and humidity on active systemic lupus erythematosus trough a retrospective analysis of 640 patients living in the city of Zhanjiang, China. In winter, when there are weaker ultraviolet (UV) rays, the ratio of patients with active SLE to total inpatients was 3.89%, which is significantly higher than in other seasons with stronger UV rays, including 2.17% in spring, 1.87% in summer and 2.12% in autumn. The number of patients with active SLE had significant negative correlation with mean temperature and was not significantly related to mean humidity. Active SLE has the characteristics of seasonal distribution and is associated with temperature. The mechanism remains to be further studied. Eren et al. (37) present special clinical and laboratory features of 294 cases of mushroom poisoning in a Turkish University Hospital (Cumhuriyet): of these 294 patients (age of 3-072, 173 were female, with 90 were under the age of 16 years). Mushrooms were consumed in the early summer by 173 patients. The onset of symptoms was within two hours for 101 patients and the most common first-noticed symptoms were gastrointestinal. Patients were discharged within one to ten days. Three patients suffering from poisoning caused by wild mushrooms died from fulminant hepatic failure. They conclude that education of the public about the consumption of mushrooms and education of health personnel working in health centers regarding early treatment and transfer to hospitals with appropriate facilities are important for decreasing the mortality. Ferrer et al. (38) described the causes of admission to the public health system for children from zero to nine years of age in the city of São Paulo during the years 2002 to 2006 and compare these results to those from the national data. Their findings show a paradoxical increase in the number of hospitalizations during an expansion of primary attention, indicating that the rise was not associated with a significant improvement in the quality of service. Fomin et al. (39) described clinical and laboratorial data and phenotypic characteristics of patients with DiGeorge Syndrome and point out the need of suspecting the presence of the syndrome in all patient presenting with heart defects, facial abnormalities (associated or not with hypocalcemia), and immunological disorders because although frequency of DGS is high, few patients with a confirmed diagnosis are followed up. Noma et al. (40) endeavored to identify barriers to attendance for eye examination of schoolchildren. Facilities offered in this project were: examination arranged during weekends, free transportation, spectacle donation and two different opportunities for exam. A questionnaire was applied, by interview, to a sample consisting of parents seen in a community project. Those who missed the first call and attended the recall were screened to identify the reasons for non-attendance. The main causes of absenteeism were lack of awareness and work commitment. Absenteeism could be overcome via improved structuring of the first call. The recall increases attendance coverage of target population by only 15.2%. Wang et al. (41) reported the incidence and recurrence of acute otitis media in Taiwan's pediatric population and that the annual incidence rate of was estimated to be 64.5 cases per 1,000 children. The overall one-year cumulative incidence rate of recurrence was 33.1%, and the incidence density rate was 33.5 cases per 100 person-years, with the highest figure (41.2 cases per 100 person-years) noted for children aged 0-2 years. They conclude that acute otitis media remains a major threat to children's health in Taiwan. Male children and very young children require more aggressive preventive strategies to reduce the risk of recurrence.

DENTISTRY

Areias et al. (42) characterized the environmental and host factors associated with dental caries in Portuguese children with and without Down syndrome through a sibling-matched, population-based, cross-sectional survey. They conclude that Portuguese children with Down syndrome have lower caries rates than children without Down syndrome. This claim that this reduced prevalence may be associated with the parents' greater concern about oral health care in Down syndrome children, resulting in their taking them sooner to visit a dentist, as well as to a higher bruxism prevalence and delayed tooth eruption. Carrillo et al. (43) characterized the population seen at the dentistry unit of the hematology-oncology service of a tertiary medical center in São Paulo and conclude that the characteristics of the studied population were similar to those of the general Brazilian and global populations, especially regarding gender and diagnosis distributions. The aim of implementation of the dentistry unit was to maintain good oral health and patients' quality of life, which is critical to provide oral care and prevent future oral problems. Motta et al. (44) endeavored to determine whether there is a correlation between halitosis and mouth breathing in 55 children between 3 and 14 years of age divided into two groups (nasal and mouth breathing) for the assessment of halitosis. There were a significantly greater number of boys with the mouth-breathing pattern than girls. A total of 23.6% of the participants had no mouth odor, 12.7% had mild odor, 12.7% had moderate odor and 50.9% had strong odor. There was a statistically significant association between halitosis and mouth breathing. They conclude that the occurrence of halitosis was high among the children evaluated, and there was a statistically significant association between halitosis and mouth breathing. Perinetti et al. (45) investigated whether malocclusal traits correlate with body posture alterations in 122 young subjects to determine

possible clinical applications. Their current findings, particularly with regard to the use of posturography as a diagnostic aid for subjects affected by dental malocclusion, do not support existence of clinically relevant correlations between malocclusal traits and body posture. Souza et al. (46) verified dental abnormalities and the oral health condition in pediatric patients suffering from hypophosphatemic rickets through a prospective study of oral conditions. This report employed a simple method to be easily reproducible: oral clinical exam and radiographic evaluation. They conclude that these patients frequently present dental alterations not completely recoverable with treatment (dental abscesses excepted) and need periodical oral examinations.

No potential conflict of interest was reported.

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• 6. Contri PV, Berchielli EM, Tremeschin MH, Negrini BV, Salomao RG, Monteiro JP. Nutritional status and lipid profile of HIV-positive children and adolescents using antiretroviral therapy. Clinics. 2011;66(6):997-1002, http://dx.doi.org/10.1590/S1807-59322011000400004
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Publication Dates

• Publication in this collection
  30 Aug 2012
• Date of issue
  Aug 2012