Iranian Journal of Pediatrics
Volume:29 Issue: 5, Oct 2019

To compare various treatment methods of postpneumonic empyema (PPE) in children.

Six hundred eighty one (302 females and 379 males) pediatric PPE patients were studied at two different centers between 2000 and 2016. The average age was 4.8 years that ranged from 30 days to 15 years. The patients were considered in six groups. The initial treatments, thoracentesis (group A), chest tube drainage (group B), fibrinolytic therapy (group C), decortication following chest tube drainage (group D), video-assisted thoracoscopic surgery (VATS) (group E) and primary operation without chest tube drainage (group F), were applied to the patients.

Success rates were 100%, 47.3%, 82.7%, 100%, 100%, and 100% for thoracentesis, chest tube drainage, fibrinolytic treatment, chest tube drainage, decortication following chest tube drainage, VATS and primer operation, respectively. The overall response rate of fibrinolytic therapy was 82.7% (n = 67). Fourteen of 81 (17.2%) patients who went through fibrinolytic instillation did not respond to treatment; these recovered after the application of thoracotomy and VATS. In addition to decortication pulmonary resections were performed in 15 patients. Overall mortality rate was 1.32%. There was no operative mortality. Postoperative morbidity included wound infection in 22, delayed expansion in 17, and atelectasis in 40 patients.

Chest tube drainage can be said to be an efficient and safe primary treatment for PPE in children. In cases when chest tube drainage fails to satisfy, decortication with thoracotomy can be applied well with low mortality and morbidity rates.

Vitamin B12 has an important role in neuronal development of children. Autonomic nervous dysfunction which can be hidden by compensating mechanisms also accompanies vitamin B12 deficiency. However, in children, there is still limited data about this effect of vitamin B12 deficiency. The aim of this study was to evaluate the autonomic activity in vitamin B12 deficient children by analyzing the heart rate variability (HRV) with Holter monitoring. HRV parameters of 37 children who were diagnosed with vitamin B12 deficiency were compared those of 25 age and sex matched healthy controls. All of the heart rate variability parameters (time-domain and frequency-domain) were reduced in the vitamin B12 deficient group compared with controls. The search for factors modifying heart rate variability yielded that serum vitamin B12 level was significantly effective on both time-domain and frequency-domain HRV parameters. A positive correlation was also found between vitamin B12 levels and the mean of the 5 minute RR interval standard deviations (SDNNi), the square root of the mean of the squared differences of two consecutive RR intervals (RMSSD), low-frequency power (LF) parameters (P < 0.05, r: 0.285, 0.262, 0.246, respectively). In conclusion, vitamin B12 deficiency can cause autonomic dysfunction in children.
 

 Hypothalamic-pituitary-adrenal (HPA) axis suppression is the most important systemic side effect associated with inhaled corticosteroids (ICS) therapy.

 To evaluate the prevalence and determinants of hypothalamic-pituitary-adrenal (HPA) axis suppression in asthmatic children on ICSs.

 A total of 92 children aged 6 to 18 years, diagnosed with persistent asthma, and receiving regular ICS therapy for a minimum of 3 months, without any systemic steroid therapy within the last 3 months, were enrolled in the study. Clinical and demographic variables were recorded. HPA axis suppression was measured by morning cortisol levels and confirmed by low-dose adrenocorticotropic hormone stimulation test.

 Of 92 enrolled patients, 51 (55.4%) were male. The mean age was 10.1 ± 2.6 years. HPA axis suppression was observed in two (2.1%) patients. The body mass index (BMI) values were significantly lower in the HPA axis suppression group compared to the other enrollees. No relationship was observed between the HPA axis suppression and the ICS dose, duration of therapy or co-administration of long-acting beta-agonists or nasal steroids.

 In our study, the prevalence of HPA axis suppression was 2.1%. Children with persistent asthma who has been treated with regular ICS should be screened for HPA axis suppression.

 Acute lymphoblastic leukemia (ALL) is the most common malignancy in children. Epigenetic factors especially DNA methylation of promoter associated cytosine connected to guanine by phosphodiester bond (CpG islands) are considered as one of the most effective mechanisms in pathogenesis of ALL and have been demonstrated as a biomarker for lineage and subtype classification, prognostication, and disease progression.

 In the present study, we examined the relationship between the promoter hypermethylation of the mir-200b and mir-34a regulator genes on the Notch signaling pathway in patients with ALL and controls in order to investigate association between promoter hypermethylation and development, progression and clinical factors.

 Genomic DNA was extracted from 60 samples (30 blood samples from leukemia patients and 30 normal samples) and modified by sodium bisulfite. Methylation-specific PCR was used to analyze the promoter methylation status of mir-34a and mir200b genes in the studied population. The results were analyzed with SPSS software version 20.

 Our results showed significant association of mir-200b (P < 0.0001) and mir-34a (P < 0.004) genes hypermethylation with ALL. Also there was significant relationship between hypermethylation of mir-200b gene with family history (P = 0.003) and platelets (P = 0.01), and methylation of mir-34a gene with cancer state (P = 0.003) and Hb (P = 0.001) in ALL.

 In this study, we emphasized the important role of epigenetics on acute lymphoblastic leukemia development and progression. Our results showed that analysis of the methylation status of mir200b and mir-34a genes can provide novel prognostic markers for ALL.
 

 The mental health of multicultural adolescents is an important social issue. We explored the differences in adolescents’ mental health, including suicide modalities, between adolescents in multicultural and those in monocultural families.

 The results of 13th Korean Youth Risk Behavior Web-Based Survey (KYRBS) in 2017 were used. KYRBS is a cross-sectional survey, and the participants were drawn as stratified multistage clustered samples from 400 middle and 400 high schools in Korea. Student participation was voluntary and anonymous in this self-report, web-based survey.

 Of the targeted 64991 adolescents, 62276 (response rate 95.8%) participated, and 58052 were finally included in this survey. The multicultural adolescents made up 1.56% of the participants, with female predominance and, compared with the monocultural adolescents, they were younger, shorter, and slenderer, and had lower parent educational status, lower self-recognized academic performance, lower economic status, and used smartphone longer time. Depressive mood was not statistically significantly higher, but suicidal ideation, plans, and attempts were higher in the multicultural adolescents. Daily smoking and drinking status, lower economic status, poorer self-recognized academic performance, and multicultural background itself, were positively related to suicidal attempts, and of these factors, the odds ratio was highest for a multicultural background, at 9.50.

 Multicultural adolescents tend to have much higher risk of suicidality problems. Therefore, more intensive education and practical prevention strategies are needed to reduce the suicidal behaviors of multicultural adolescents.
 

 The increasing trend of both obesity and postural disorders in pediatric population.

 We aimed to determine the prevalence of lower extremities' postural disorders among school children in Qom province, Iran.

 In this cross-sectional study, a representative sample of schoolchildren aged 6 - 7 years was selected by multi-stage clustering method from all urban and rural regions of Qom province. Presence of postural deformities of lower limbs, including genu valgum, genu varum and flat foot were evaluated and recorded. Prevalences of deformities in different categories of weight status (underweight, normal and overweight) were compared.

 Out of 20000 school children 1450 students were randomly selected. Genu valgum, genu varum and flat foot was present in 256 (17.7%), 351 (24.2%) and 194 (13.38%) of studied population. 1021 (70.41%), 161 (11.1%) and 268 (18.48%) students were normal weight, underweight and overweight/obese, respectively. Prevalence of flat foot and genu valgum was significantly higher in obese/overweight students (P < 0.01). Mean of skin fold thickness was significantly higher in students with genu valgum (P < 0.001). A significant relation existed only between occurrence of lower limb postural deformities and body mass index [OR = 1.89, CI (95%) = 1.18 - 3.03].

 The findings of this study indicate that prevalence of genu valgum and flat foot are higher in overweight/obese children. In addition to early diagnosis and timely treatment of the deformities, developing and validation of a multidisciplinary care for obese and overweight children to reduce the occurrence of obesity related musculoskeletal complications is of importance.
 

 The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) was based on the sequential organ failure assessment (SOFA) score. Matics and Sanchez-Pinto contrived a SOFA score designed specifically for pediatric patients (pSOFA) to evaluate the prognosis of children with sepsis according to the degree of organ dysfunction.

 The aim of our study was to evaluate the predictive validity of the pSOFA for in-hospital mortality in children with sepsis in a pediatric intensive care unit (PICU) of a developing country.

 This was a single-center retrospective observational study. The data of 516 children diagnosed with sepsis according to the 2005 International Pediatric Sepsis Consensus Conference was retrospectively analyzed. The patients were divided into survivor group and non-survivor group according to the clinical outcome of 28 days after admission. The variables of pSOFA score, PELOD-2 score and P-MODS were collected and scored. Receiver operating characteristic (ROC) curve was plotted; the efficiency of the pSOFA score for predicting death was evaluated by the area under ROC curve (AUC).

 ROC curve analysis showed that the AUCs of the pSOFA score, PELOD-2 score and P-MODS predicting the prognosis of children with sepsis in a PICU of a developing country were 0.937, 0.916, and 0.761, respectively (all P < 0.05).

 The pSOFA score is effective and has the ability to assess the prognosis of children with sepsis in a PICU of a developing country.
 

 This prospective study was designed with the aim to evaluate the prevalence and risk factors of arterial and venous complications among children and adolescents during cardiac catheterization.

 All patients younger than 18 years who underwent cardiac catheterization from April 2016 to April 2017 were consecutively enrolled in this study.

 A total of 179 vascular accesses were performed, and most (70%) cases were interventional procedures. Totally 17 (14%) arterial and 16 (13%) venous events occurred, while 4% and 5% of them, respectively, were more serious. Half of the patients who underwent axillary artery access developed major or minor trauma, and these subtracted from total events of artery accesses, only 9% of femoral arteries developed minor or major complications. The more serious arterial complications were dissection, pseudo-aneurysm and fistula whereas in venous access they were pseudo-aneurysm and thrombosis. Serious and non-serious complications considered together, the mean age of those without complication was 1.9 ± 3.6 years and in complicated group it was 1.7 ± 2.6 years (P = 0.33), and the mean weight of non-complicated cases was 9.27 ± 7.9 kg and 8.51 ± 8.12 kg in the complicated group with no significant difference (P = 0.41), whereas the incidence of more serious vascular complications was highest among patients younger than 1 year of age, and less than 9 kilograms. 23% of the cases who underwent more than 3 tries for arterial and 100% for venous access showed the complications. Also few arterial tries resulted in unintentional venous complications and vice versa. None of the cases needed surgical or interventional therapy.

 Our study showed that venous complications are as high as arterial complications, although most of them are self-limited.

 The survival rate of neonatal giant omphaloceles has improved over the past 10 years, but the mortality rate remains at approximately 50% with traditional treatment. Delivery room surgery refers to a surgical procedure that is performed in the operating room to correct the structural defects of a newborn immediately after birth.

 This study aimed to investigate the application of delivery room surgery for giant omphaloceles in East China.

 Neonates meeting the inclusion criteria of having omphalocele defects larger than 5 cm or of having most of the liver protruding into the sac were enrolled in this retrospective study. Data were evaluated specifically to determine the role of delivery room surgery in reducing the mortality of newborns with giant omphaloceles (GOs) and to identify factors that could optimize the conditions for traditional operations. A total of 52 newborns with GOs from two tertiary centres of paediatric surgery were identified. The patients were divided into two groups, the delivery room surgery group (group D) and the traditional operation group (group T), based on the perinatal management and time of surgery.

 There was a significantly higher survival rate in the group D (77.8%) than in the group T (50%). The duration of ventilator use was 8.87 ± 10.12 days in the group D and 9.31 ± 7.75 days in the group T. The time of starting enteral nutrition was 12.88 ± 4.19 days in the group D and 16.75 ± 8.59 days in the group T. Newborns in the group T took more time to reach full enteral feeding. However, we did not find a significant difference in a comparison of the hospitalization time between the two groups (25.1 ± 18.1 days in the group D and 22.4 ± 11.1 days in the group T).

 The strategy of delivery room surgery appears to improve the survival of newborns with GOs and reduce family burden. A further reduction in mortality rates will depend on promoting the application of the delivery room surgical procedure.
 

 Comparison of midazolam and propofol has been done hoping to reduce the incidence rates of emergence agitation (EA) after anesthesia. Both drugs however, are still under inspection as for their effect on EA after using Isoflurane for maintenance of anesthesia.

 This study was designed for measuring the effect of either propofol or midazolam near the end of tonsillectomy operation on incidence of EA during the recovery phase.

 In this randomized, double-blind study, 90 children, aged 5 to 15, undergoing anesthesia with Isoflurane were randomly assigned to three groups receiving either propofol (group P), midazolam (group M) or saline (group S) near the end of anesthesia. Severity and incidence of EA were then calculated using the pediatric anesthesia emergence delirium (PAED) scale.

 The mean PAED score in group P was (2.87 ± 2.69) and (1.90 ± 2.55) in group M. Both were significantly lower than group S (7.60 ± 3.78) (P < 0.05). However, there was no statistical difference in the duration of post-anesthesia care unit (PACU) stay between groups P (42.50 ± 12.58) and M (48.33 ± 24.26), groups P and S (52.00 ± 10.64) and between groups M and S (P > 0.05). No significant difference was found between all groups for apnea and laryngospasm (P > 0.05).

 Administration of either midazolam or propofol near the end of operation may result in reduction of EA in children undergoing tonsillectomy after Isoflurane anesthesia.

 Lead poisoning is a preventable environmental disease, able to produce many problems, including gastrointestinal disorders.

 The aim of this study was to evaluate blood lead levels (BLLs) in children with chronic non-organic abdominal pain, constipation and growth retardation and whether there is a connection between BLLs and these functional disorders.

 In this cross-sectional study, fifty-five children aged 2 - 14 years with non-organic chronic abdominal pain, constipation and growth retardation were selected as a case group. Fifty-five healthy children of the same age acted as a control group. The blood lead level in all children was measured. Lead poisoning was considered when the level was higher than 5μg/dL.

 The mean lead level in the case group (4.34 μg/dL) was higher than in the control group (1.19 μg/dL). There is a significant relationship between BLL and gastrointestinal symptoms. (P=0.0001). Constipation was the most common (38.2%) gastrointestinal disorder. Anemia and living in old housing were most commonly found in the case group (73.9% vs. 12.5%), (43.5% vs. 16.1%), which was statistically significant as well.

 In the study, BLL in children with these disorders was significantly higher than healthy children. In this study, 23 patients had BLLs above 5 μg/dL, all of whom were in the case group. None of the children in the control group had BLL higher than 5 μg/dL. There were significant differences between the groups with anemia and living in old housing. Our patients presented symptoms at lower lead levels (less than 5 μg/dL) than estimated as toxic.
 

 Increasing the range of motion in joints is considered to be one of the most long term concerns in the treatment of cerebral palsy (CP).

 The purpose of this study was to investigate the effect of using whole body vibration (WBV) as a new therapeutic approach, with stretching exercises on the range of motion in lower extremities in children with CP.

 In this single-blind clinical trial, 20 children aged 4 to 12 years were enrolled. Participants were randomly divided into experimental and control groups. Control group received only passive static stretching exercise and experimental group received passive static stretching with WBV. Exercises were performed 3 times a week for 6 weeks. To collect data, Goniometry, modified Ashworth scale and 6 Minute Walk Test were used.

 The results of this study indicated that, stretching with WBV, increases active range of motion in hip flexion, abduction and ankle dorsal flexion and also can improve speed of walking in children with CP.

 According to the findings, the use of WBV can be considered as an effective treatment in increasing the range of motion and walking speed in CP children.

Respiratory syncytial virus (RVS) is the main cause of morbidity and mortality in the pediatric population.

The objective of the study was to compare the diagnostic accuracies of the colloidal-gold-Genesis and newly developed real-time RT-PCR-IngeniGen with an admitted real-time RT-PCR-HuaRuiAn as the gold standard for respiratory syncytial virus detection.

These three assays were performed on collected specimens.

Altogether 258 specimens were studied. Among them, real-time RT-PCR-HuaRuiAn detected the respiratory syncytial virus in 166 samples, while colloidal-gold-Genesis detected 171 samples and real-time RT-PCR-IngeniGen detected 168 samples as positive. The overall sensitivity for the detection of the respiratory syncytial virus in comparison to real-time RT-PCR-HuaRuiAn was 95.2% for colloidal-gold-Genesis and 100% for real-time RT-PCR-IngeniGen. The specificity was 85.9% for colloidal-gold-Genesis and 97.8% for real-time RT-PCR-IngeniGen. The positive likelihood ratio was 6.75 for colloidal-gold-Genesis and 45.45 for real-time RT-PCR-IngeniGen. The negative likelihood ratio was 0.06 for colloidal-gold-Genesis and 0.00 for real-time RT-PCR-IngeniGen. The cycle threshold value of real-time RT-PCR-IngeniGen was higher than that of real-time RT-PCR-HuaRuiAn.

Colloidal-gold-Genesis is a good alternative for fast screening of respiratory syncytial virus detection.

 Lobar atelectasis is one of the common problems in patients with cystic fibrosis and can be a cause of respiratory symptoms in these patients even in the absence of bacterial infection.

 Here we introduce a 9-year-old boy with cystic fibrosis who had many admissions because of respiratory distress due to lung collapse mainly caused by plastic bronchitis.

 In a number of patients with cystic fibrosis, lobar atelectasis is seen which is resistant to medical treatments. Early fiberoptic bronchoscopy as a measure for mechanical removal of the blocking agent and sometimes direct injection of drugs like dornase alfa into the bronchus is a successful modality in the treatment of lobar collapses in chronic pulmonary diseases.