The social role of pediatrics in the past and present times.

Pediatrics and society are closely related. This link is as old as the history of Pediatrics, and dates to the second half of the eighteenth century. The vocation of the first European pediatric schools, indeed, was clinical and scientific, as well as social. The founding fathers of Pediatrics were scientists of great talent, and many of them benefactors and philanthropists. They spent their lives assisting the suffering childhood, and became promoters and organizers of social securities for the poorest and most vulnerable categories. The attention to the problems of abandonment was closely linked to study, prevention, and treatment of pathologies (especially infectious, deficiency and neurological ones). The profile and activity of pediatricians grew in the following decades after the birth of the first pediatric schools. The University institutions contributed to provide a further impulse to childcare as well as cultural authority, also thanks to the foundation of the first chairs and scientific journals of Pediatrics. The relevance and prestige of the studies performed rapidly spread throughout Europe, and also reached our country, contributing to a progressive and relevant improvement in the quality of children's care, and in the meantime to the decrease of neonatal and infant mortality rates.Today's pediatricians, as in the past, must spend his efforts to face the needs of children and their families, be their social receptor, interpreter if necessary, and credible and authoritative interlocutor beside institutions. The current coronavirus pandemic dramatically exposed social inequalities and inequities. In this new scenario, the pediatrician's role of defender of all children becomes even more necessary and indispensable. Here we trace the historical steps which led to the birth and development of pediatrics, as independent medical discipline with ethical and social vocation. Its rise within the University institutions is analyzed, as well as the contribution of the greatest European and Italian masters. Finally, the role of today's pediatrician is described, his responsibilities also in dealing with new health critical issues, related to the biological, cultural, and psychological changes of the patients of present days. He must have holistic competences, to effectively take care of all children. In addition, he must socially act to guarantee the best possible context for the well-being of the child.

[Zinc and its relation to insulin resistance in children]. / El zinc y su relación con la resistencia a la insulina en los niños.

INTRODUCTION: Zinc is an essential trace element involved in catalytic, structural, and regulatory functions, participating also in the metabolism of nutrients. Its role in insulin resistance appears to be of great importance, as it is involved in oxidative stress, the endocrine regulation of insulin, and the regulation of glucose uptake. For this reason, both intake and serum levels of zinc are inversely related to insulin resistance. Currently, zinc intake in children is low, and zinc deficiency exists in a significant proportion. Zinc can be found in meat, fish, eggs, and dairy products. Although it certainly is present in foods of plant origin, their high phytate contents generally reduce its bioavailability. For this reason, it is important to monitor intake throughout childhood, and to consider supplementation in children with insulin resistance or obesity.

INTRODUCCIÓN: El zinc es un oligoelemento esencial involucrado en funciones catalíticas, estructurales y de regulación, además de participar en el metabolismo de los nutrientes. Su función en la resistencia a la insulina parece tener gran importancia, ya que tiene relación con el estrés oxidativo, la regulación endocrina de la insulina y la regulación de la captación de glucosa. Por esta razón, tanto la ingesta como los niveles séricos de zinc se relacionan inversamente con la resistencia a la insulina. A día de hoy, la ingesta de zinc es insuficiente en muchos niños y existe deficiencia de este mineral en una importante proporción. El zinc lo podemos encontrar en carnes, pescados, huevos y lácteos. Aunque es cierto que también existe en los alimentos de origen vegetal, generalmente, su alto contenido en fitatos reduce la biodisponibilidad del zinc. Por esta razón es importante vigilar la ingesta a lo largo de toda la etapa infantil y considerar la suplementación en los niños con resistencia a la insulina u obesidad.

Use of Complementary and Alternative Medicine in Pediatric Respiratory Diseases.

In this study, our purpose was to determine prevalence of complementary and alternative medicine (CAM) in pediatric respiratory diseases and methods of CAM use accordingly. Each of the CAM treatment has a special risk/benefit combination and it is absolutely crucial for health care professionals to question those methods.

Pediatric Osteopathic Manipulative Medicine: A Scoping Review.

CONTEXT: A common reproach precluding the use of osteopathic manipulative medicine (OMM) in pediatrics is a lack of evidence regarding its safety, feasibility, and effectiveness. OBJECTIVE: We conducted a systematic, scoping review of pediatric osteopathic medicine to identify gaps in the literature and make recommendations for future research. DATA SOURCES: We searched 10 databases using 6 key words and medical subject heading terms for any primary articles reporting OMM use in children published from database inception until initiation of the study. STUDY SELECTION: Articles were selected if they reported primary data on OMM conducted in the United States on patient(s) 0 to 18 years old. DATA EXTRACTION: Baseline study characteristics were collected from each article and the Grading of Recommendations, Assessment, Development, and Evaluations system was used to critically appraise each study. RESULTS: Database search yielded 315 unique articles with 30 studies fulfilling inclusion and exclusion criteria. Of these, 13 reported the data required to demonstrate statistically significant results, and no significant adverse events were reported. The majority of studies were graded as providing weak clinical evidence because of significant methodologic flaws and biases. LIMITATIONS: The review was limited to US-based studies and reports. Minimal discrepancies between reviewers were resolved via an objective third reviewer. CONCLUSIONS: There is little strong, scientific, evidence-based literature demonstrating the therapeutic benefit of OMM for pediatric care. No strong clinical recommendations can be made, but it can be medically tolerated given its low risk profile. High-quality, scientifically rigorous OMM research is required to evaluate safety, feasibility, and efficacy in pediatrics.

Four innovations: A robust integrated behavioral health program in pediatric primary care.

The increase in behavioral health problems presenting in pediatric primary care (PPC) has led to a greater focus on the prevention and treatment of mental health concerns. As a result, care has shifted from colocation to integrated PPC models. However, the literature provides limited guidance on the development and implementation of integrated PPC models that aim to transform both PPC and the larger health care system. We developed an integrated behavioral health (IBH) approach modeled with fidelity to the Integrated Practice Assessment Tool to fully integrate behavioral health into PPC. Over the 4 years since the application of our model, we have been successful in the development of an integration process and model for practice transformation of an urban PPC center and the spread and scale of IBH services to 2 additional clinics. Four elements combine to make our integrated behavioral health program novel: (a) clear mission and vision, (b) provision of universal prevention services, (c) continuous quality improvement, and (d) emphasis on practice and systems transformation. Trends in practice and scholarly inquiry indicate the need for robust pediatric IBH models, with a clear mission and vision; articulation of how research informs the development and implementation of the model; and infrastructure to meaningfully examine the model's impact. Cognizant of these needs, Cincinnati Children's Hospital Medical Center developed an IBH program. We provide key learnings for IBH program development, PPC transformation, and innovative systems redesign. We describe these elements and make recommendations for future research and practice. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Current and emerging biologics for the treatment of pediatric atopic dermatitis.

INTRODUCTION: Atopic dermatitis (AD) is a chronic inflammatory skin condition characterized by erythematous lesions, pruritus, and a skin barrier defect. Long-term treatment in children is challenging, as there is only one Food and Drug Administration-approved systemic medication. Current treatments may have limited efficacy or serious side effects in children. With a deeper understanding of AD pathogenesis and the advent of target-specific medications, several biologics are undergoing clinical trials for future use in pediatric AD. AREAS COVERED: This article reviews the current and emerging biologic therapies for treatment of pediatric AD. It allows for comprehensive comparison of medications and their clinical trials to help providers optimize patient treatment plans while providing expert insight into upcoming advancements in the treatment of pediatric AD. EXPERT OPINION: Treating pediatric AD is complicated given the variety of disease severity, psychosocial impact, and relative lack of approved medications for severe disease. Given the safety data on dupilumab, newer biologics will likely be second-line. We do not yet understand the long-term impact of newer biologics on an immature immune system, nor do we fully understand their risks and toxicities. We should proceed optimistically, yet cautiously, with the study of biologics in children.

Managing Paediatric Growth Disorders: Integrating Technology Into a Personalised Approach

Long-term growth management can be challenging for patients, families and healthcare professionals (HCP). Personalised optimal responses to growth hormone (GH) therapy depend on the creation of a good working relationship between the patient and family and the HCPs responsible for care. Current unmet needs in growth management will be discussed, focusing on the likelihood of a poor growth response and its identification and management with emphasis on the importance of good adherence to GH therapy. Digital tools are now available to record injections and communicate accurate adherence data to the HCP and patient. Psychological barriers to good adherence will be covered, with techniques identified to change behaviour and improve outcome. Motivational interviewing is a valuable skill in this respect and should be taught to both medical and nursing HCPs to enhance the quality of the relationship with the patient and family. Key messages are, firstly, the importance of personalised care with the HCP using acquired psychological skills to prevent and manage poor adherence. Secondly, a human-eHealth partnership is necessary to maximise the benefit of new digital tools to aid in successful growth management.

The Role of Integrated Care in a Medical Home for Patients With a Fetal Alcohol Spectrum Disorder.

Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe preventable birth defects and intellectual and/or developmental disabilities resulting from prenatal alcohol exposure. The American Academy of Pediatrics has a previous clinical report in which diagnostic criteria for a child with an FASD are discussed and tools to assist pediatricians with its management can be found. This clinical report is intended to foster pediatrician awareness of approaches for screening for prenatal alcohol exposure in clinical practice, to guide management of a child with an FASD after the diagnosis is made, and to summarize available resources for FASD management.

Pediatric palliative oncology: the state of the science and art of caring for children with cancer.

PURPOSE OF REVIEW: Pediatric palliative oncology (PPO) is an emerging field that integrates the principles of palliative care early into the illness trajectory of children with cancer. PPO providers work with interdisciplinary clinicians to provide optimal medical and psychosocial care to children with cancer and their families. Ongoing advances in the field of pediatric oncology, including new treatment options for progressive cancers, necessitate the early integration of palliative care tenets including holistic care, high-quality communication, and assessment and management of refractory symptoms. RECENT FINDINGS: Research in this emerging field has expanded dramatically over the past several years. This review will focus on advancements within several key areas of the field, specifically regarding investigation of the communication needs and preferences of patients and families, exploration of educational initiatives and interventions to teach PPO principles to clinicians, study of patient-reported and parent-reported tools to better assess and manage refractory symptoms, and development of novel models to integrate palliative care within pediatric oncology. SUMMARY: Research findings in the field of PPO, concurrent with advances in the treatment of pediatric cancer, may help improve survival and quality of life for children with cancer.

Biologic therapies for refractory juvenile dermatomyositis: five years of experience of the Childhood Arthritis and Rheumatology Research Alliance in North America.

BACKGROUND: The prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960's with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011-2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA). METHODS: The JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011-2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013-2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting. RESULTS: One hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups. CONCLUSIONS: Our CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future. Significance and Innovations This is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years. This experience with biologic therapies for refractory JDM may aid pediatric rheumatologists in the current treatment of these children and form a basis for further clinical research into the comparative effectiveness and safety of biologics for refractory JDM.

Clinicoepidemiological profiles, clinical practices, and the impact of holistic care interventions on outcomes of pediatric hematolymphoid malignancies - A 7-year audit of the pediatric hematolymphoid disease management group at Tata Memorial Hospital.

INTRODUCTION: The Pediatric Hematolymphoid Disease Management Group (PHL-DMG) at a tertiary cancer care hospital developed extensive patient support programs to improve retention and outcomes while focusing on protocols adapted to meet patient needs. An audit of measures and outcomes was done for a 7-year period from January 2010 to December 2016. MATERIALS AND METHODS: DMG protocols and patient support activities over the study period were documented and audited. Data was retrieved from internal databases and records. Measures taken and their impact were assessed by descriptive analytical tools. Survival outcomes were calculated using Kaplan-Meier method on SPSS v. 24™ software. RESULTS: Holistic patient support measures were undertaken through a charitable foundation entirely under pediatric oncology. Activities included infrastructure growth, socioeconomic support, provision of accommodation, nutrition, education, and multiple blood component donation drives. Patient registrations increased from 502 in 2009 to 874 in 2016, with the steepest rise in acute lymphoblastic leukemia (ALL) - 330 (2009) to 547 (2016). Treatment refusal and abandonment rates decreased from 32% to 3.4% over the same period, and male to female ratio decreased from 2.56 to 2.28:1. Early mortality in acute myeloid leukemia (AML) fell within 2 years from 26.7% in 2009 to 7%. Five-year overall survival (OS) was 69.5% for all patients registered in 2010, whereas disease-specific 5-year OS was ALL 67.1%, AML 49.3%, chronic myeloid leukemia 100%, Hodgkin lymphoma 90.4%, and non-Hodgkin lymphoma 74.2%. CONCLUSIONS: Holistic patient support-specific activities and adapted protocols made a measurable impact on patient outcomes. High survival outcomes of patients have been achieved despite relatively few receiving salvage therapies or stem cell transplant.

Progress in pediatrics in 2015: choices in allergy, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, nephrology, neurology, nutrition, oncology and pulmonology.

This review focuses key advances in different pediatric fields that were published in Italian Journal of Pediatrics and in international journals in 2015. Weaning studies continue to show promise for preventing food allergy. New diagnostic tools are available for identifying the allergic origin of allergic-like symptoms. Advances have been reported in obesity, short stature and autoimmune endocrine disorders. New molecules are offered to reduce weight gain and insulin-resistance in obese children. Regional investigations may provide suggestions for preventing short stature. Epidemiological studies have evidenced the high incidence of Graves' disease and Hashimoto's thyroiditis in patients with Down syndrome. Documentation of novel risk factors for celiac disease are of use to develop strategies for prevention in the population at-risk. Diagnostic criteria for non-celiac gluten sensitivity have been reported. Negative effect on nervous system development of the supernumerary X chromosome in Klinefelter syndrome has emerged. Improvements have been made in understanding rare diseases such as Rubinstein-Taybi syndrome. Eltrombopag is an effective therapy for immune trombocytopenia. Children with sickle-cell anemia are at risk for nocturnal enuresis. Invasive diseases caused by Streptococcus pyogenes are still common despite of vaccination. No difference in frequency of antibiotic prescriptions for acute otitis media between before the publication of the national guideline and after has been found. The importance of timing of iron administration in low birth weight infants, the effect of probiotics for preventing necrotising enterocolitis and perspectives for managing jaundice and cholestasis in neonates have been highlighted. New strategies have been developed to reduce the risk for relapse in nephrotic syndrome including prednisolone during upper respiratory infection. Insights into the pathophysiology of cerebral palsy, arterial ischemic stroke and acute encephalitis may drive advances in treatment. Recommendations on breastfeeding and complementary feeding have been updated. Novel treatments for rhabdomyosarcoma should be considered for paediatric patients. Control of risk factors for bronchiolitis and administration of pavilizumab for preventing respiratory syncytial virus infection may reduce hospitalization. Identification of risk factors for hospitalization in children with wheezing can improve the management of this disease. Deletions or mutations in genes encoding proteins for surfactant function may cause diffuse lung disease.

Proteomics applied to pediatric medicine: opportunities and challenges.

INTRODUCTION: Care in pediatrics often refers to treatments directed to adults. However, childhood is a specific life period, with molecular pathways connected to development and thereby it requires distinctive considerations and special treatments under disease. Proteomics can help to elucidate the molecular mechanisms underlying the human development and disease onset in pediatric age and this review is devoted to underline the results recently obtained in the field. AREAS COVERED: The contribution of proteomics to the characterization of physiological modifications occurring during human development is presented. The proteomic studies carried out to elucidate the molecular mechanisms underlying different pediatric pathologies and to discover new markers for early diagnosis and prognosis of disease, comprising genetic and systemic pathologies, sepsis and pediatric oncology are thereafter reported. The investigations concerning milk composition in human and farm mammals are also presented. Finally, the chances offered by the integration of different -omic platforms are discussed. Expert commentary: The growing utilization of holistic technologies such as proteomics, metabolomics and microbiomics will allow, in the near future, to define at the molecular level the complexity of human development and related diseases, with great benefit for future generations.

Pediatrics in 21st Century and Beyond.

Pediatrics is a dynamic discipline and there is awareness and hope for actualizing outstanding achievements in the field of child health in 21st century and beyond. Improved lifestyle and quality of children's health is likely to reduce the burden of adult diseases and enhance longevity because seeds of most adult diseases are sown in childhood. Identification and decoding of human genome is expected to revolutionize the practice of pediatrics. The day is not far off when a patient will walk into doctor's chamber with an electronic or digital health history on a CD or palmtop and a decoded genomic constitution. There will be reduced burden of genetic diseases because of selective abortions of "defective" fetuses and replacement of "bad" genes with "good" ones by genetic engineering. Availability of totipotent stem cells and developments in transplant technology are likely to revolutionize the management of a variety of hematologic cancers and life-threatening genetic disorders. The possibility of producing flawless designer babies by advances in assisted reproductive technologies (ARTs) is likely to be mired by several ethical and legal issues.The availability of newer vaccines by recombinant technology for emerging infective and for non-infective lifestyle diseases is likely to improve survival and quality of life. There is going to be a greater focus on the "patient" having the disease rather than "disease" per se by practicing holistic pediatrics by effective utilization of alternative or complementary strategies for health care. Due to advances in technology, pediatrics may get further dehumanized. A true healer cannot simply rely on technology; there must be a spiritual bond between the patient and the physician by exploiting the concept of psycho-neuro-immunology and body-mind interactions. In the years to come, physicians are likely to play "god" but medicine can't achieve immortality because anything born must die in accordance with nature's recycling blueprint. The medical science is likely to improve longevity but our goal should be to improve the quality of life.

Pediatric Chiropractic Care: The Subluxation Question And Referral Risk.

Chiropractors commonly treat children for a variety of ailments by manipulating the spine to correct a 'vertebral subluxation' or a 'vertebral subluxation complex' alleged to be a cause of disease. Such treatment might begin soon after a child is born. Both major American chiropractic associations - the International Chiropractic Association and the American Chiropractic Association - support chiropractic care for children, which includes subluxation correction as a treatment or preventive measure. I do not know of any credible evidence to support chiropractic subluxation theory. Any attempt to manipulate the immature, cartilaginous spine of a neonate or a small child to correct a putative chiropractic subluxation should be regarded as dangerous and unnecessary. Referral of a child to a chiropractor for such treatment should not be considered lest a bad outcome harms the child or leads to a charge of negligence or malpractice.

Nutritional assessment and intervention in a pediatric oncology unit.

Nutritional status in children with cancer is an important prognostic factor. Assessment consisting of anthropometry, biochemistry, clinical, and diet that needs to be done on diagnosis and regularly to ensure that patient's nutritional status does not deteriorate. In developing countries, assessment will depend on the availability of all resources, but monitoring is essential. The development of malnutrition during treatment is possible and the reasons are multifactorial. Nutrition plays a deciding role and a key factor in children with cancer and can influence their outcome.

[What's new in paediatric dermatology?]. / Quoi de neuf en dermatologie pédiatrique?

Regular analysis of the major journals in dermatology and paediatrics has been used to select forty articles which are representative of the past year in paediatric dermatology. This selection is not exhaustive but rather reflects the interests of the author and also the dominant topics in paediatric dermatology in 2013-2014.