First emerging evidence of the relationship between Onuf's nucleus degeneration and reduced sperm number following spinal subarachnoid haemorrhage: Experimental study.

Lumbosacral pathologies can lead to infertility. Onuf's nucleus changes in these pathologies may have a role in low sperm number. This study aims to investigate the relationship between Onuf's nucleus degeneration and sperm number following spinal subarachnoid haemorrhage. 22 rabbits were used. They were divided into three groups; five of them were used as the control (GI), five as the SHAM (GII) and twelve as the study groups (GIII). The study group received 0.7 ccs autologous blood into the spinal subarachnoid space at the T12-L1 level. After two weeks, all animals were decapitated, and S1-S3 laminectomy was done. Neurodegenerative changes of Onuf's nucleus, pudendal ganglia (S3) following two weeks after spinal SAH, were examined; sperm numbers were calculated. Degenerated neuron density of the Onuf's nucleus (n/mm3 ), the pudendal ganglia (S3) (n/mm3 ) and mean sperm numbers were calculated as 5 ± 2, 8 ± 3/mm3 and 98.345 ± 12.776/mm3 in the control (GI), 20 ± 5/mm3 , 243 ± 66/mm3 and 91.841 ± 9.654/mm3 in the SHAM (GII), 143 ± 39/mm3 , 2,350 ± 320/mm3 and 68.549 ± 5.540/mm3 in the study group (GIII). In conclusion, there were statistically significant differences between groups. Onuf's nucleus may be responsible for decreased sperm number following spinal SAH.

Dual energy CT in necrotizing enterocolitis; a novel diagnostic approach.

BACKGROUND: Necrotizing enterocolitis (NEC) is one of the most important causes of morbidity and mortality in premature infants. Although there are no specific diagnostic tools, the main factors affecting prognosis are clinical and laboratory findings, and early diagnosis and treatment. In this study, we demonstrate the importance of dual-energy computed tomography (DECT) in confirming intestinal ischemia in neonates with NEC. METHODS: Patients diagnosed with NEC in a neonatal intensive care unit were staged according to modified Bell's classification, and DECT was performed on patients with NEC stages 2-A, 2-B and 3-A. According to their DECT reports, these patients were then separated into two groups: those with intestinal ischemia and those without intestinal ischemia. The patients with intestinal ischemia were evaluated using surgical reports, and the other patients were evaluated using clinical findings. RESULTS: DECT was performed in 21 patients with NEC stages 2-A, 2-B and 3-A. Twelve patients (57.1%) without ischemia were followed up without surgery. Nine patients (42.9%) with ischemia on DECT were operated on, and resection and anastomosis or ileostomy and colostomy were performed. DISCUSSION: In patients with NEC, DECT significantly increases overall diagnostic confidence in assessing intestinal necrosis when compared with traditional diagnostic methods.

Disruption of the network between Onuf's nucleus and myenteric ganglia, and developing Hirschsprung-like disease following spinal subarachnoid haemorrhage: an experimental study.

Purpose/Aim of the study: Auerbach/Meissner network of lower abdominopelvic organs managed by parasympathetic nerve fibres of lumbosacral roots arising from Onuf's nucleus located in conus medullaris. Aim of this study is to evaluate if there is any relationship between Onuf's nucleus ischemia and Auerbach/Meissner network degeneration following spinal subarachnoid haemorrhage (SAH). Materials and Methods: Study was conducted on 24 male rabbits included control (Group I, n = 5), serum saline-SHAM (Group II, n = 5), and spinal SAH (Group III, n = 14) groups. Spinal SAH performed by injecting homologous blood into subarachnoid space at Th12-L4 level and followed three weeks. Live and degenerated neuron densities of Onuf's nucleus, Auerbach and Meissner ganglia (n/mm3) were determined by Stereological methods. Results: The mean degenerated neuron density of Onuf's nucleus was significantly higher in Group III than in Groups I-II (152 ± 26, 2 ± 1 and 5 ± 2/mm3 respectively, p < 0.005). The degenerated neuron density of Auerbach's ganglia was significantly higher in Group III than in Groups I-II (365 ± 112, 3 ± 1 and 9 ± 3/mm3 respectively, p < 0.005). The degenerated neuron density of Meissner's ganglia was significantly higher in Group III than in Groups I-II (413 ± 132, 2 ± 1 and 11 ± 4/mm3 respectively, p < 0.005). Conclusions: Onuf's nucleus pathologies should be considered as Auerbach/Meissner ganglia degeneration and also related Hirschsprung-like diseases in the future.

Diagnostic performance of diffusion-weighted MR imaging in detecting acute appendicitis in children: comparison with conventional MRI and surgical findings.

PURPOSE: To determine the value of diffusion-weighted MRI for the diagnosis of acute appendicitis in children. MATERIALS AND METHODS: Forty-five consecutive patients with a clinical diagnosis of acute appendicitis underwent abdominal MRI; 39 were operated on for acute appendicitis. First, the diffusion-weighted imaging (DWI) alone was reviewed, followed by conventional MRI alone, and then conventional MRI and DWI were reviewed by two observers within a consensus. The surgical findings were compared with the MRI. Sensitivity, specificity, and accuracy were calculated for DWI, conventional MRI, and combined DWI and conventional MRI for the depiction of acute appendicitis. RESULTS: A combination of DWI and conventional MRI was the most sensitive and the most accurate, with corresponding sensitivity and accuracy of 0.92 and 0.92, respectively. Using DWI alone the sensitivity and accuracy was found to be 0.78 and 0.77, respectively. Using conventional MRI alone, sensitivity of 0.81 and accuracy of 0.82 was found for the consensus of the two observers. CONCLUSION: The use of combination of DWI and conventional MRI is a valuable technique in the diagnosis of acute appendicitis in children.

Transverse testicular ectopia.

Described herein are six cases of transverse testicular ectopia. All patients who underwent orchidopexy at the one pediatric surgical unit between October 2001 and January 2008 were evaluated. The medical records of all patients diagnosed with transverse testicular ectopia were evaluated retrospectively. Five patients (84%) were admitted with a symptomatic right inguinal hernia and empty scrotum on the left side. Only one child (16%) had left-sided hernia and right non-palpable testis (age ranged from 1 month to 3 years). Four patients (66%) were diagnosed in the operating theatre and the last two (33%) on inguinal ultrasound preoperatively. Magnetic resonance imaging was also performed in the last patient. Herniorrhaphy with fixation of the ectopic gonad to the opposite hemiscrotum through a transseptal incision was performed in all patients. Postoperative complications were not observed.

Management of pancreatic and duodenal trauma in childhood: a university hospital experience over a 10-year period.

PURPOSE: Duodenal/pancreatic injuries occur in less than 10% of intra-abdominal injuries in pediatric blunt trauma. Isolated duodenal/pancreatic injuries occur in two-thirds of cases, while combined injuries occur in the remaining. This study aimed to investigate pediatric patients with pancreatic and duodenal trauma. METHODS: Data from 31 patients admitted to Atatürk University, Medical Faculty, Department of Pediatric Surgery for pancreatic/duodenal trauma between 2010 and 2019 were retrospectively analyzed. Age/gender, province of origin, duration before hospital admission, trauma type, injured organs, injury severity, diagnostic and therapeutic modalities, complications, hospitalization duration, blood transfusion requirement, and mortality rate were recorded. RESULTS: Twenty-four patients were male, and 7 were female. The mean age was 9 years. The leading cause was bicycle accidents, with 12 cases, followed by traffic accidents/bumps, with 7 cases each. Comorbid organ injuries accompanied 18 cases. Duodenal trauma was most commonly accompanied by liver injuries (4/8), whereas pancreatic injury by pulmonary injuries (7/23). Serum amylase at initial hospital presentation was elevated in 83.9% of the patients. Thirty patients underwent abdominal CT, and FAST was performed in 20. While 54.8% of the patients were conservatively managed, 45.2% underwent surgery. CONCLUSION: Because of the anatomical proximity of the pancreas and the duodenum, both organs should be considered being co-affected by a localized trauma. Radiologic confirmation of perforation in duodenal trauma and an intra-abdominal pancreatic pseudocyst in pancreatic trauma are the most critical surgical indications of pancreaticoduodenal trauma. Conservative management's success is increased in the absence of duodenal perforation and cases of non-symptomatic pancreatic pseudocyst.

Clinical characteristics of neonates with VACTERL association.

BACKGROUND: The VACTERL association (VA) is the non-random co-occurrence of vertebral anomalies, anal atresia, cardiovascular malformations, tracheoesophageal fistula and/or esophageal atresia, renal anomalies, and/or limb anomalies, and is referred to by the first letters of its components. Studies investigating the clinical characteristics of VA patients and probing of the observed current six component types are limited, and none of them is focused on neonates. We investigated the clinical characteristics of our patients diagnosed as having VA in the newborn period. METHODS: We retrospectively reviewed the neonates whose final diagnosis was VACTERL association. Presence of at least three components of previously reported six anomalies was accepted as VACTERL association. Sex, birthweight, gestational age, postnatal age, anomalies of the systems that are included in VA, and the other features were recorded. RESULTS: There was a male predominance (14/11) of 28 patients; and there were three patients with ambiguous genitalia. The most common observed VACTERL component was vertebral anomalies (n= 26), followed by anal atresia (n= 19), tracheoesophageal fistula/esophageal atresia (n= 17), renal anomalies (n= 15), limb anomalies (n= 15) and cardiac anomalies (n= 14). The most frequent combination was VCTL (n= 4). Fifteen (57%) patients had non-VACTERL anomalies and the most frequent of these was ambiguous genitalia (n= 3). CONCLUSION: VA patients may have different clinical characteristics in different populations, and clinicians may miss some component features if the patients are evaluated after the neonatal period.

The protective effects of metyrosine, lacidipine, clonidine, and moxonidine on kidney damage induced by unilateral ureteral obstruction in rats.

PURPOSE: To investigate the effects of metyrosine, lacidipine, clonidine, and moxonidine on the renal damage in rats with unilateral ureteral ligation by examining the histological evidence of parenchymal damage and tubular dilatation, as well as biochemical changes indicating cell membrane damage and DNA oxidation. METHODS: Thirty-six albino Wistar rats were randomly divided into six equal groups: a healthy (intact) group, a unilateral ureteral ligation (control) group, and four drug treatment groups given metyrosine (50 mg/kg), lacidipine (2 mg/kg), clonidine (0.075 mg/kg), or moxonidine (0.2 mg/kg), respectively, for 10 days. The latter five groups underwent ligation of the left ureter. Ten days after the operation, we removed both kidneys from each rat in the control and drug treatment groups for renal pathological and biochemical [malondialdehyde (MDA), total glutathione, 8-hydroxy-2-deoxyguanine (8-OH-Gua)] examinations. Spectrophotometric assays were used to detect the malondialdehyde and total glutathione levels of the renal tissue. High-performance liquid chromatography was used to measure the 8-hydroxy-2-deoxyguanine levels. RESULTS: When the drug treatment groups were compared with the control group, the drug treatment groups' total glutathione level was higher and their malondialdehyde level was lower than that of the control group (P < 0.05), especially in the clonidine group (P < 0.0001). The 8-hydroxy-2-deoxyguanine levels of the drug treatment groups, except the lacidipine group, were significantly lower than that of the control group (P < 0.0001). There was no significant difference between the contralateral kidneys of the treatment groups and control group, according to the biochemical results. As revealed via light microscopy, clonidine and moxonidine treatment significantly reduced the tubular and glomerular damage, as well as the tubular dilation. The interstitial inflammation of the kidneys in the lacidipine group was higher than that of the other treatment groups. However, the apoptotic cell count was at a high level in both the lacidipine and metyrosine groups. The increase in the collagen content was most pronounced in the lacidipine and metyrosine groups. An examination of the contralateral kidneys showed no marked pathological findings. CONCLUSIONS: The use of a direct or indirect α2-adrenergic receptor agonist for the temporary treatment of unilateral ureteral obstruction-induced renal damage may be important for preventing renal structural injury. A more advanced study is necessary to determine the mechanisms underlying the protective effects of these drugs with regard to renal damage in ureteral obstruction.

The effects of montelukast on antioxidant enzymes and proinflammatory cytokines on the heart, liver, lungs, and kidneys in a rat model of cecal ligation and puncture-induced sepsis.

We investigated the potential protective effects of montelukast (MLK) on cecal ligation and puncture (CLP)-induced tissue injury in vital organs - liver, heart, kidneys, and especially lungs - through inhibition of the proinflammatory cytokine response and the generation of reactive oxygen species (ROS) in rats. The rat groups were (1) a 10-mg/kg MLK-treated CLP group; (2) a 20-mg/kg MLK-treated CLP group; (3) a 20-mg/kg MLK-treated, sham-operated group; (4) a CLP control group; and (5) a sham-operated control group. MLK treatment significantly decreased proinflammatory (tumor necrosis factor-alpha, interleukin-6) cytokine levels following CLP. The lipid peroxide level increased in the lung, heart, liver, and kidney tissues after CLP-induced sepsis, and myeloperoxidase activity increased in the lung, heart, and liver tissues. MLK attenuated this elevation in all tissues except the kidney, dose dependently. The glutathione levels and superoxide dismutase activity were significantly increased in the lung, liver, and kidney tissues after MLK treatment. MLK treatment after CLP also potentially reduced mortality. The lung and kidney tissues were the most protected by MLK under sepsis conditions. We can suggest that MLK reverses the systemic inflammatory reaction to polymicrobial sepsis and thereby reduces multiple organ failure.

Does obesity limit the sonographic diagnosis of appendicitis in children?

PURPOSE: The purpose of this study is to evaluate whether obesity has a negative impact on the ultrasound (US) visualization of the appendix in children clinically diagnosed with appendicitis. METHODS: The medical records and US examinations of 122 children who underwent surgery due to acute or perforated appendicitis between February 2007 and January 2010 were reviewed. The body mass index (BMI) of each child was calculated and children were placed in one of three categories: group 1, underweight (BMI <10th percentile); group 2, normal weight (BMI between 10th and 85th percentiles); and group 3, overweight (BMI >85th percentile). US findings were classified as nonvisualized, normal, or inflamed appendix. The visualization rates of the appendix were compared between the three groups and the diagnostic accuracy of the US examination was calculated based on the histopathological results for each group. RESULTS: There was no statistical difference between the three groups with regard to the visualization of the appendix by US. Diagnostic accuracy of US was 90.4%, 80.5%, and 80% in group 1, group 2, and group 3, respectively. CONCLUSION: The findings of our study, in contrast to the findings of other reported studies, demonstrate that obesity does not affect the success rate of US in the visualization of the inflamed appendix in children.

An unusual cause of acute abdominal pain in a child: an inverted Meckel diverticulum: report of a case.

Inverted Meckel diverticulum has been reported as a lead point for intussusception in children. However all cases of isolated inversion of a Meckel diverticulum have involved adults in whom the diagnosis was clinically unexpected. We describe the sonographic appearance of isolated inversion of Meckel diverticulum in a 3-year-old boy with acute abdominal symptoms.

Chest wall lipoblastomatosis in a 2-year-old girl: a case report and literature review.

Lipoblastoma is an uncommon tumor of adipose tissue that usually occurs in infancy and early childhood. They predominantly locate in the extremities, but are less frequently found in the head and neck region, trunk and various other locations. The most common sign is a rapidly growing mass. In spite of their potential for local invasion and rapid growth, they are benign tumors and have no distant metastasis. Although more than 180 cases of lipoblastoma distributed over various parts of the body have been reported, only nine cases were located in the thoracic wall. We present the case of a two-year-old girl with lipoblastomatosis of the chest wall that was identified by histologic examination. In this article, the English literature on this disorder is briefly reviewed.

Effects of Laparoscopic Hernia Repair by PIRS (Percutan Internal Ring Suturing) Technique on Testicular Artery Blood Supply.

Purpose: Percutaneous internal ring suturing technique (PIRS) is a minimally invasive technique in pediatric inguinal hernia repair. In the present study, a negative effect on testicular blood flow using PIRS technique has been investigated. Methods: Forty male patients were included in the study prospectively. Two groups were formed as conventional open surgery (Group I) and PIRS technique (Group II). The resistive index (RI) value of the testicular artery was measured prospectively by using SMI (superb micro-vascular imaging) software with the color doppler ultrasound technique preoperatively and postoperatively at the first month. Results: Inguinal hernia was present on the left in 35% (n = 14) of the patients and on the right in 65% (n = 26) of the patients. There was no statistically significant difference (p = 0.727) between Group I and II with regard to preoperative RI value (0.66 ± 0.07 vs. 0.66 ± 0.45, respectively). Similarly, there was no statistically significant difference (p = 0.220) between Group I and II with regard to the RI values measured at the postoperative first month (0.58 ± 0.04 vs. 0.60 ± 0.04, respectively). Although the postoperative RI values decreased compared to the preoperative values in both groups, this difference was not statistically significant. (p = 0.447 in Group I, and p = 0.175 in Group II for intragroup comparison). Conclusions: Besides PIRS technique has the advantages provided by all other laparoscopic techniques defined for inguinal hernia repair, there is no significant difference between this technique and conventional open surgery with regard to testicular blood flow. It is an innovative candidate technique instead of the open surgery method besides its additional advantages.

Predeterminative role of Onuf's nucleus ischemia on mesenteric artery vasospasm in spinal subarachnoid hemorrhage: A preliminary experimental study.

BACKGROUND: Although posttraumatic mesenteric artery ischemia is attributed to various etiologies, sacral parasympathetic network/mesenteric artery relations have not been studied so far. The primary objective of this study is to elucidate whether there is a relationship between Onuf's nucleus ischemia and mesenteric artery vasospasm following subarachnoid hemorrhage (SAH). METHODS: This study was conducted on 22 rabbits. The animals were grouped as follows: 5 of animals control, 5 SHAM which saline was given, and 12 animals study group that was homologous blood injected into the spinal subarachnoid space at the Li level. Neurodegeneration in Onuf's nucleus, axonal degeneration of S2 roots, and mesenteric arteries vasospasm indexes (VSI; Wall surface/Lumen surface), brachias of mesentery arteries in various tissues and ischemic mucosal changes of intestines of all animals were determined histopathologically. Important degenerative changes were detected in axons in S2 roots and Onuf's nucleus in severe mesenteric artery vasospasm observed. RESULTS: The mean degenerated neuron density of Onuf's nucleus (n/mm3), degenerated axon density in S2 roots (n/mm2), and VSI values of mesenteric arteries of control, SHAM, and study groups were estimated as 5.00 ± 1.58, 4.00 ± 1.58, 1.76 ± 0.13; 18.29 ± 4.31, 11.00 ± 2.24, 2.23 ± 0.20; and 135.21 ± 30.75, 117.33 ± 22.11, 2.81 ± 0.44, respectively. Statistical analyses between the VSI values, mucosal ischemic changes degenerated neurons in Onuf's nucleus, and axons in S2 levels were meaningful (p < 0.005). CONCLUSION: We interestingly noticed that Onuf's nucleus-S2 roots complex degeneration plays an important role in mesenteric artery vasospasm and the development of intestinal ischemic mucosal changes following SAH which has not been extensively mentioned in the literature.

Genotoxic effect of albendazole in pediatric patients with hepatic hydatid disease.

OBJECTIVE: Hydatid disease occurs throughout the world and is treated with both surgery and medical administration of albendazole. Some adverse effects of albendazole are known. However, its genotoxic effect on humans has not been reported yet. In this study, we aimed to investigate the genotoxic effect of albendazole on human lymphocytes in vivo. METHODS: The study involved 14 children (eight males and six females) who had undergone operations for hepatic hydatid disease. The ages of the patients ranged from 6 to 13 years. Genotoxicity of albendazole was evaluated as the frequency of sister chromatid exchange (SCE) and micronucleated cells in the patient's lymphocytes. Prior to and after albendazole treatment, blood samples were obtained from these patients for SCE and micronucleus (MN) studies. SCE and MN frequencies of the patients were measured separately before and after albendazole treatment. RESULTS: All patient SCE values increased significantly after albendazole administration (p<0.001). Similarly, MN frequencies in all the patients increased significantly following albendazole treatment (p<0.001). CONCLUSION: This study revealed that both SCE and MN frequencies are higher after albendazole treatment. The results suggest that albendazole may be genotoxic to human lymphocytes in vivo.

Is Neuromuscular Blocker Necessary in Pediatric Patients Undergoing Laparoscopic Inguinal Hernia Repair with Percutaneous Internal Ring Suturing?

Purpose The aim of this study is to evaluate operating conditions during general anesthesia with or without neuromuscular blocker (NMB) in patients undergoing percutaneous internal ring suturing (PIRS). Materials and Methods In this study, 40 patients, with American Society of Anesthesiologists I and II between the ages of 1 and 12 years, were randomly assigned to two groups to receive muscle relaxant with endotracheal tube (ETT) (ETT group) or without muscle relaxant with supreme laryngeal mask airway (sLMA) (LMA group). Anesthesia was maintained with sevoflurane in oxygen (Fio 2 0.3-0.5), thiopental sodium, fentanyl, and rocuronium in ETT group. In LMA group, same protocol was used without rocuronium. Heart rate, blood pressure, peak airway pressure, end-tidal carbon dioxide (EtCO2), and Spo 2 were recorded before and during pneumoperitoneum maintained at a pressure of 8 to 10 mm Hg. Duration of surgery, recovery time, anesthetic time, and grade of quality view were also recorded. Airway problems (cough, hoarseness, laryngospasm, and aspiration) were recorded. Results In LMA group, there was a statistically significant reduction in recovery time versus ETT group (11.6 ± 4.08 vs. 17.15 ± 5.32 minutes; p = 0,001). There were no statistically significant differences grade of quality view between the two groups (p = 0.548). There were no statistically significant differences in oxygen saturation (Spo 2), peak airway pressure, and EtCO2 between the two groups before or during insufflation (p > 0.05). Postoperative airway complications were significantly more prevalent in the ETT group. There was no case of inadequate ventilation, regurgitation, or aspiration recorded. Conclusion sLMA is safe and suitable alternative to ETT and NMB is not necessary in general anesthesia with sLMA, pediatric patients undergoing laparoscopic hernia repair with PIRS.

Intravesical catheter knotting: an unusual complication of suprapubic catheterization.

Suprapubic catheterization is commonly used to drain urine temporarily from the bladder. Although it is a commonly performed procedure, it is not without complications. Many of these complications related to surgical technique. However, some unpredictable complications are related to the catheter itself. Intravesical catheter knotting is a very rare event and usually has been reported in feeding catheters used as an urethral catheter. We report a case of a suprapubic Cystofix catheter knot, removed by sustained traction. This complication was probably due to an excessive length of catheter having been inserted into the bladder, thus forming redundant loops that increased the risk of bending onto itself.

Diagnosis and management of hydatid liver disease in children: a report of 156 patients with hydatid disease.

BACKGROUND/PURPOSE: There are many published reviews on adult hydatid disease and a guideline published by World Health Organization Informal Working Group (WHO-IWGE) in 2010. However, there are very few reports on hydatid liver disease in children with limited numbers of patients, and no comments were offered on childhood hydatid liver disease in the WHO-IWGE 2010 guideline. The aim of this study is to present our 17-year experience with 156 pediatric patients with hydatid liver disease and provide a treatment algorithm for children. METHODS: The clinical records of 156 children with hydatid liver disease treated from January 1994 to January 2011 were retrospectively reviewed. Patient sex, age at diagnosis, symptoms, disease location, cyst numbers and sizes, treatment choices, medical treatment duration, surgical methods, and complications were recorded. Treatment of liver hydatidosis included 3 different schedules: (1) small (<5 cm) liver cysts treated with albendazole (ABZ) only, (2) cysts (>5 cm) located at the liver surface treated with surgery combined with ABZ, and (3) all (>5 cm) liver cysts embedded deep in the liver parenchyme treated with percutaneous drainage and ABZ. Albendazole was given (10 mg/kg twice a day) and continued for 6 months after initial therapy. RESULTS: There were 92 boys and 64 girls with an average age of 9.2 years (range, 1.1-15 years). A total of 376 cysts were detected in 156 patients. The follow-up period ranged from 1 to 10 years (median, 6.5 years). Complications were classified according to the Dindo classification. After the first 6 months of therapy, grade I complications occurred in 12.1% of patients, grade II complications in 7.4%, and grade IIIb complications in 7.3%. There were no grade IIIa, IVa, or IVb complications. At 1 year, grade II complications were recorded in 9.6% of 15 patients, and grade IIIb complications, in 1.2% of patients. During the 17 years reviewed, there were no mortalities (0% grade V complications). CONCLUSIONS: Based on this experience, we believe that suitable treatment should be chosen based on factors such as cyst number, cyst location (on the surface or deep in the organ), proximity to vascular structures, whether the cyst is complicated, and additional organ involvement or not. In addition, although the results of our study mostly agree with the results in the WHO-IWGE 2010 report, there are some noticeable differences between these 2 studies. Hence, we believe that the WHO-IWGE 2010 recommendations should be updated by incorporating the childhood observations.