Iranian Journal of Pediatrics
Volume:31 Issue: 1, Feb 2021

Neonates are vulnerable to COVID-19 infection. Its estimated rate in this age group is unknown. There is a robust transmission of COVID-19 from human-to-human. The result of all COVID-19 PCR tests on the amniotic fluid, placenta, cord, and breast milk was negative. The nasopharyngeal swab test of COVID-19 PCR in 56% of neonates was positive. 46.6% of neonates were asymptomatic, and in the others, the most common symptoms were: shortness of breath, tachypnea, cough, apnea, temperature instability, tachycardia. The possibility of vertical transmission (maternal-fetal) of COVID-19 is unknown. Because the most infected neonates with COVID-19 are asymptomatic, the transmission of the disease to other family members is very likely.

Context:

 Novel coronavirus (COVID-19) has become a new public health crisis, posing a great threat to the people all around the world. We aimed to review the articles on COVID-19 in pediatric population to help physicians and other healthcare workers understand the importance of detecting silent disease carriers in this age group and stop further transmission to other healthy individuals and manage symptomatic patients based on the latest recommendations.

 We searched databases including PubMed, Scopus, Google Scholar, and Medline and reviewed 70 articles from December 2019 to mid-July 2020. Relevant articles about COVID-19 in children were included.

 According to the latest reports, 1% - 5% of infected patients were under 19 years old. Death in this age group was rare but it can occur in children with severe disease. The overall course of disease -mainly pulmonary involvement- of the infected children tend to be milder than adults. This may be related to both host factors and exposure. The lab tests and computed tomography (CT) scan findings are nonspecific and milder compared to those in older ages. The cornerstone of COVID-19 management in pediatric group is supportive care. Of note, there is not any approved specific drug for treatment of children affected by COVID-19.

 COVID-19 disease characteristics in children are not yet fully established, which poses a significant problem for pediatric medical specialists. It should be considered that most children are asymptomatic or have mild symptoms. Critical cases, although uncommon, can occur especially in children with underlying diseases.

 To investigate the expression of CD64 and CD11b neutrophils in neonates with necrotizing enterocolitis (NEC) and to evaluate the diagnostic value of CD64 and CD11b in identifying NEC in neonates.

 A total of 138 newborns, admitted to our neonatal intensive care unit from October 2018 to March 2020, were recruited in this study. The subjects were divided into the NEC and control groups, according to the method of case-control. The expression of CD64, CD11b, and C-reactive protein (CRP) was measured in the peripheral blood, the sensitivity and specificity of each index in diagnosing NEC were compared, and their diagnostic value was examined.

 The corrected gestational age of the NEC and control groups was 32.29 ± 1.85 and 33.24 ± 1.98 weeks, respectively. The mean birth weight of the two groups was 1654 ± 373 and 1746 ± 400 g, respectively. Also, the mean age at sampling was 11.6 ± 3.11 and 11.7 ± 3.14 days in the NEC and control groups, respectively. Gender, corrected gestational age, mean birth weight, and sampling age were not significantly different between the groups (P > 0.05). The CD64 and CD11b expression levels were higher in the NEC group, compared to the control group (P < 0.01). Comparison of the NEC group by stage showed that the CD64 and CD11b indices were the highest in stage III, followed by stage II and stage I (P = 0.01). However, both indices showed a downward trend during the recovery period (P < 0.01). A CD64 level ≥ 0.71, a CD11b level of 1.94, and a CRP level ≥ 7.38 were considered as the best diagnostic criteria. The highest exponential sensitivity (82.7%) was attributed to the CD64 index, followed by CD11b (50.8%) and CRP (39.1%). The highest sensitivity (89%) was obtained by a combination of two indices (one positive index); also, when both indices were positive, the highest specificity (87%) was reported. The sensitivity of combined indices for NEC diagnosis in stage I, II and III were 84.4%, 95.7%, and 92.9%, respectively.

 The expression levels of CD64 and CD11b neutrophils in neonatal NEC increased and was associated with the severity of NEC. Monitoring of changes in the two indices had a clinical value in the diagnosis of NEC. In conclusion, the combined use of these two indices can be more valuable in the diagnosis of neonatal NEC.

 The epidemiology of Kawasaki disease (KD) suggests that an infectious agent may be a potential disease trigger in susceptible children. Several studies have shown that the cause of KD may be associated with Mycoplasma pneumoniae (M. pneumoniae) infection.

 We aimed to investigate the relationship between M. pneumoniae infection and coronary artery aneurysm (CAA) in children with KD in China.

 From January 2015 to December 2018, a total of 330 children with KD met the inclusion criteria. Relevant data were extracted and analysed.

 The children were stratified into two groups according to M. pneumoniae infection status. Significant differences were identified in the proportion of patients with fever > 10 days, the occurrence of small CAA, and the average serum sodium, pre-albumin (PA), and albumin levels but not in the occurrence of medium and giant CAA between the two groups. According to binary logistic regression, M. pneumoniae infection (OR: 0.515; 95% CI: 0.309 - 0.860; P = 0.011), serum sodium levels (OR: 0.910; 95% CI: 0.851 - 0.972; P =0.005), and PA (OR: 0.900; 95% CI: 0.854 - 0.949; P ≤ 0.001) levels were independently associated with occurrence of small CAA.

 We demonstrated that M. pneumoniae infection, serum sodium and PA levels are inversely related to the occurrence of small CAA. These results suggest that M. pneumoniae infection may be associated with a decreased incidence of small CAA. Further large-sample studies are needed.

 According to the instructions of Iranian traditional medicine (ITM), modification of breast milk through nursing mothers, is the first step in the treatment of infant disorders. In fact, maternal lifestyle, especially diet and eating habits, can change the quality and quantity of breast milk. The modern medical literature emphasizes that exclusive breastfeeding is the optimal nutrition for infants with gastroesophageal reflux disease (GERD).

 The present study was conducted to evaluate the effect of maternal eating principles and diet based on ITM on infantile GERD symptoms.

 Exclusive-breastfeeding, under 5 - month infants with clinical diagnosis of GERD and their nursing mothers, were selected for this 6-weeks parallel randomized, controlled trial. All participants were randomly assigned to the intervention and the control group. The mothers of infants in the intervention group received ITM-based dietary principles, and feeding-positioning modifications were trained to the mothers of all infants of both groups, because of observation of ethical issues (not deprived of standard treatment). Age-Specific Questionnaire for Infants (GSQ-I) was used to assess the frequency and intensity of the GERD symptoms. Measuring the difference between the mean Composite Symptom Score (CSS) in week 0, 4, and 6, between the intervention group and the control group, was the main outcome of this study.

 Both the intervention and control groups had statistically significant differences in the mean CSS of week 4 and 6 compared with baseline (P < 0.05). Also, there was a significant reduction of the mean CSS values in the intervention group compared to the control group (P < 0.05).

 Maternal eating principles and diet based on Iranian Traditional Medicine appears to affect the reduction of infantile GERD signs and symptoms.

Acute gastroenteritis is one of the most common diseases in children with a high rate of nausea and vomiting. Drugs such as ondansetron are used to treat vomiting.

The aim of the study was to compare the success rate of oral vs intramuscular ondansetron to reduce vomiting in children with acute gastroenteritis.

A single-blind randomized clinical trial study was conducted on 100 children with acute gastroenteritis. Two groups of patients were created; one group received an intramuscular injection of ondansetron and the other received oral ondansetron. The vomiting rate, hospitalization, and side effects were evaluated 30 minutes, 4, and 48 hours after drug administration.

Fifty-nine (59%) participants were boys. The mean age of the patients was 3.07 ± 2.20 years. There were no significant differences between the groups in terms of age, weight, and rate of vomiting before the treatment was launched. No significant difference between the drug administration route and the outcome of vomiting during the first half, 4, and 48 hours after receiving the drug was found either.

The study showed that the success rate of oral ondansetron did not vary significantly compared to intramuscular injection in terms of reducing the vomiting rate in children with acute gastroenteritis.

 This study aimed to investigate the spectrum of bacterial pathogens and their antimicrobial sensitivity in pediatric patients admitted with febrile neutropenia (FN) and hematologic malignancies.

 This prospective, cross-sectional study was carried out on 65 children (60% boys, mean age 7.3 5.3 years) with hematologic malignancies and FN hospitalized at the Amir Hematology and Oncology Hospital, Shiraz, Iran, between December 2018 and May 2019. Samples were taken from blood, nose, axilla, and inguinal area (NAI). NAI cultures were repeated after 72 hours of admission, and blood culture was repeated if needed. A demographic questionnaire on age, sex, and admission time was filled out for each patient.

 The most common grown bacteria in the NAI samples were coagulase-negative staphylococci (CoNS). Second cultures from these sites revealed nosocomial contamination. Eighteen patients (27.7%) had positive blood cultures, with 61.1 % of the isolated pathogens being Gram-negative (mostly Escherichia coli and Pseudomonas aeroginosa) and 38.9% Gram-positive. The blood cultures results did not match those of the NAI cultures in 61.1% of the patients. About one-fourth of the Gram-negative pathogens isolated from blood were resistant to cefepime, the main empirical antibiotic for FN management at our center.

 Gram-negative bacteria are predominant organisms in pediatric FN patients at our center, most resistant to cefepime. If a similar antimicrobial sensitivity pattern is observed in future studies, a change in local guidelines might be considered for FN management.
 

 Inhalant anesthesia is one of the mainstays of pediatric anesthesia, and it is considered by the majority of pediatric anesthetists worldwide as the gold standard. On the other hand, total intravenous anesthesia (TIVA) is a very popular choice for routine pediatric anesthesia practice. Therefore, utilization of TIVA compared to the volatile anesthesia is still a topic of debate in successful anesthesia management.

 To compare TIVA vs sevoflurane-based anesthesia on the quality of recovery in children aged 2 to 10 years who had outpatient surgery.

 Eighty children, aged 2 to 10 years old undergoing outpatient surgery, were randomly divided into two groups (40 patients each). The TIVA group with propofol (T) received general anesthesia induced with midazolam 0.03 - 0.05 mg/kg, fentanyl 1 mcg/kg, propofol 3 - 5 mg/kg, 0.1 mg/kg lidocaine and maintenance with propofol 100 to 250 μg/kg.min and remifantanil 0.1 mcg/kg. The sevoflurane (S) group received general anesthesia induced with midazolam 0.03 - 0.05 mg/kg, fentanyl 1 mcg/kg, O2/sevoflurane 8 vol%, maintenance with 2 - 3 vol%. Demographic characteristics, awakening quality in recovery, hemodynamic status, and other complications such as patient agitation, pain, nausea, and vomiting were evaluated in both groups.

 Patients did not differ significantly in terms of demographic characteristics. The incidence of postoperative agitation was 62% higher in the sevoflurane group than the TIVA group (5%, P < 0.001). The highest percentage of pain was obtained as 52.5% in the sevoflurane group. Postoperative nausea and vomiting did not differ significantly among groups, and there was a significant decrease in the heart rate of the subjects in the T group as one of the hemodynamic variables (P = 0.01).

 Inhalation anesthesia with sevoflurane led to more rapid recovery from anesthesia, and TIVA with propofol injection reduced post-operative pain and agitation compared to patients receiving sevoflurane. Therefore, TIVA with propofol infusion is probably an effective technique to maintain general anesthesia in pediatric outpatient surgery and to increase parental satisfaction, and to reduce the workload of recovery room staff.

Neonatal chylothorax is a rare and potentially life-threatening condition with a reported incidence of 1 in 5,800 - 24,000 and a high mortality rate of up to 64%. Octreotide is one of the treatment options available to reduce both the splanchnic blood flow and the intestinal secretion of electrolytes and water. However, there is no uniform guideline for the optimal dosage of octreotide in the treatment of congenital chylothorax.

We present the case of a neonate diagnosed with congenital chylothorax. At birth, the neonate manifested severe respiratory distress warranting cardiopulmonary resuscitation for 25 min. During admission, intravenous octreotide treatment was initiated and feeding was changed from breast milk to a medium-chain triglyceride-enriched formula. Bilateral hilar enlargement and diffusely increased opacities waxed and waned, and we gradually increased the octreotide dosage daily by 1 ~ 2 mcg/kg/h. After 3 days of octreotide administration at the rate of 20 mcg/kg/h, chest x-ray showed regression of pleural effusion. The patient was discharged with full bottle feeding achieved.

High-dose octreotide therapy (with doses up to 20 mcg/kg/h) may be recommended for patients with idiopathic congenital chylothorax. However, patients should be carefully monitored for side-effects such as hyperglycemia, necrotizing enterocolitis, transient hypothyroidism, and ileus.

 Most issues of micropenis boys include poor body image and quality of life.

 The purpose of this assay was to survey the relationship of anthropometric measures, testosterone, estradiol, gonadotropins and prolactin with stretched penile length (SPL) and flaccid glans-pubis length (GPL) in pre-pubertal boys with true small penis.

 This was prospective a cross-sectional observational study that was conducted in Imam Reza Hospital, Tehran, Iran from February 2015 to May 2020. The pre-pubertal children 7 - 14 years who referred with small penis size were evaluated by a pediatrician and urologist and, if they had true micropenis, they were enrolled in the study (n = 236). The anthropometric and hormonal measurements, SPL, GPL, and relationship of these variables were evaluated.

 Mean ages of children were 11.65 ± 1.59 years. Mean SPL and GPL were 2.95 ± 1.23 and 2.29 ± 1.06 cm, respectively. There was a significant relationship between SPL and GPL (r = 0.976, P = 0.000). SPL and GPL were not correlated with BMI (r = -0.182, P = 0.054; r = -0.161, P = 0.089, respectively). A significant correlation was found between SPL and GPL with height, FSH, LH, Testosterone and T/E ratio (P < 0.01) but no correlation with weight, estradiol and prolactin (> 0.05).

 According to the finding of present study, the flaccid measurement can be as helpful as stretched measurement if it is done from pubic bone to tip of glans. Retraining of primary health workers about age-related penile length may be reducing the misdiagnosis of micropenis and concerns of parents, especially in obese boys. The penile length in prepubertal children was not related to BMI and weight but was significantly related to height. Furthermore, Estradiol level is not related to penile length in children with micropenis.
 

 Due to the increasing prevalence of covid-19, the World Health Organization declared on 30 January 2020, the spread of the new coronavirus as a 6th public health emergency of international concern.

 To assess the extent of the disease in the pediatric population in our region, we conducted a clinical pediatric screening for Covid-19 and evaluated factors that affected its manifestation in children.

 In this study, 474761 children under 19 years of age were screened in two phases. In the first phase, 680 cases were considered as suspect and referred to the health centers, where the second phase of screening took place. Finally, 230 probable cases were referred to specialized centers for further investigation.

 Almost all of the cases had pneumonia and symptoms of shortness of breath, cough, and fever over 38°C (56.7%). Other clinical symptoms included hypotension (17.4%), Hemoptysis (16.1), sore throat (11.6%) and difficult breathing (6.7%). 26% of patients had a history of chronic disease (mainly pulmonary and cardiac). There was a statistically significant relationship between the probable causes and the symptoms of the disease (P < 0.05), between age and probable cases (P < 0.05), and between death and underlying disease (P < 0.05). However, of all the cases, only 15 (6.5%) had a positive PCR test, 39 patients were hospitalized (17%), 173 cases (75%) received outpatient treatment and 18 cases (7.8%) died.

 Children with shortness of breath, cough, pneumonia, fever over 38 and underlying disease are suspicious for Covid-19 and should be hospitalized to be evaluated with laboratory tests.

 To analyze the antibiotic resistance in children with acute appendicitis caused by Pseudomonas aeruginosa(P. aeruginosa), and to explore the predictors of infection and antibiotic resistance in children with acute appendicitis through blood biochemical indicators

 50 control children (with no bacteria detected in the culture) and 103 children with P. aeruginosa infection who were admitted to the general surgery department of Jiangxi children’s hospital and treated surgically from January 2015 to June 2019 were analyzed.

 Cefotaxime, cotrimoxazole and tetracycline had the highest drug resistance rates in children with appendicitis caused by P. aeruginosa, with (93.20%, 96/103), (93.20%, 96/103) and (93.20%, 96/103), respectively. There were significant pattern differences between the P. aeruginosa infected group and penicillin antibiotics resistant group. The combination of glutamyltranspeptidase (GGT), phosphorus (P), free fatty acid (FFA) and fibrinogen (CFbg) could effectively identify whether children with acute appendicitis were infected by P. aeruginosa and whether they were resistant to penicillin antibiotics. For the control group and P. aeruginosa infected group, area under the receiver operating characteristic (AUROC) value of the four indicators was 0.9034 (95% CI, 0.8514 - 0.9555), with a sensitivity and specificity of 84.76% and 87.93%, respectively. For the group with or without penicillin antibiotics resistance, the AUROC value was 0.9341 (95% CI, 0.8681 - 1.0000), with a sensitivity and specificity of 89.04% and 96.88%, respectively.

 Clinical blood biochemical indicators can reflect bacterial infection and antibiotic resistance in children with acute appendicitis to a certain extent, and the combination of GGT, P, FFA, and CFbg can predict P. aeruginosa infection and penicillin antibiotics resistance in children with acute appendicitis.

 There are limited data about the proper transcutaneous bilirubin measuring time to detect levels that are close to serum bilirubin levels after ending the phototherapy treatment.

 To compare the transcutaneous bilirubin and total serum bilirubin levels, and to evaluate the reliability of transcutaneous bilirubin measurements after phototherapy treatment of newborns because of hyperbilirubinemia.

 The study included 105 late preterm and term newborns consisting of 56 females (53.3%) and 49 males (46.6%), with gestational age 350/7 - 416/7 weeks who were treated with phototherapy. A Bilicheck (M&B-MBJ20) device was used for transcutaneous bilirubin measurements. The average of three measurements on the skin in the mid-sternal area were obtained. Correlations between transcutaneous bilirubin and venous bilirubin levels were evaluated 6 and 12 hours after phototherapy. Transcutaneous bilirubin measurements were performed simultaneously with blood collection or within a maximum ± 15 minutes time difference for total serum bilirubin.

 The average phototherapy time was 10 ± 2 (range, 8 - 12) hours. The average difference between transcutaneous bilirubin and venous bilirubin levels post phototherapy was 2.61 mg/dL after 6 hours and 0.8 mg/dL after 12 hours. The hematocrit levels of the patients ranged between 40 - 66% with an average of 53% ± 4.8, the median level was 51%. Correlation coefficients according to hours after treatment were high for the 6th hour (r = 0.76) and very high for the 12th hour.

 Jaundice scanning with transcutaneous bilirubin measurements 6 - 12 hours after the end of phototherapy is reliable and may be helpful in preventing additional blood collection from the heel.
 

 Rotavirus-induced diarrhea (RD) could cause disorders in food protein and fat metabolism of infants the changes of which have not been clearly revealed; however, relevant studies are limited.

 The aim was to investigate the changes of proteins, amino acids and fatty acids profiles in fecal samples of the infants caused by RD.

 A total of 30 fecal samples were collected from 15 RD infants and 15 healthy infants. The compositions of fecal proteins, amino acids and fatty acids profiles in all fecal samples were analyzed using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE), automatic amino acid analyzer and gas chromatography (GC), respectively.

 Compared to H infants, the feces in RD infants had lower contents of proteins with 50 - 55, 79 - 80, and 84 - 85 KDa, meanwhile higher contents of proteins with 67 - 69 KDa. The levels of aspartic acid, threonine, serine, glutamic acid, glycinc, alanine, valine, methionine, isoleucine, leucine, lysine, phenylalanine, histidine, arginine, and proline in the feces from RD infants were significantly lower than that of H infants (P < 0.05). The relative proportions of butyric acid, elaidic acid, linoleic acid, cis-11, 14-icotenic acid, cis-11, 14, 17- epoxyeicosatrienoic acids, cis-13, 16-docosanoic acid, and cis-7, 10, 13, 16,19 docosapentaenoic acid in feces from RD infants decreased significantly compared to those of H infants (P < 0.05). On the contrary, significant increases in the relative proportions of caprylic acid, decanoic acid, undecanoic acid, lauric acid, tridecanoic acid, myristic acid, myristoleic acid, palmitic acid, cis-10-heptadecaenoic acid, oleic acid, and γ-linoleic acid were found in the; feces of RD infants (P < .05).

 RD changed the proteins, amino acids, and fatty acids profiles in infants feces, which improved the understanding of relationship between RD and fecal metabolites profile.