The relationship of vitamin D deficiency and childhood diarrhea: a systematic review and meta-analysis.

INTRODUCTION: Vitamin D deficiency may increase the risk of childhood diarrhea. We aim to carry out a review and meta-analysis of the evidence relating vitamin D insufficiency to childhood diarrhea. METHODS: We searched PubMed, Ovid, Scopus, and Cochrane Library (from inception to August 2022), then independently reviewed the eligibility, and read full-text reviews for selected articles. Keywords used were 'vitamin D', '25-hydroxyvitamin D', 'vitamin D deficiency', 'diarrhea', 'gastroenteritis', 'children', and 'pediatric'. The search was limited to studies only in English and with available full-text. Year limitation was not applied in our search. Unpublished trials, dissertations, preliminary reports, conference abstracts, and repositories were excluded from the study. Newcastle-Ottawa Scale was used as the risk of bias assessment tool. Meta-analysis using the random-effects model was done. RESULTS: Out of 5,565 articles, 12 articles were included in our systematic review, however only 7 articles were eligible for meta-analysis. Meta-analysis showed a statistically significant association between vitamin D deficiency and diarrhea in children in developing countries (OR = 1.79; 95% CI = 1.15 to 2.80; p = 0.01). On the secondary outcome, the association of vitamin D deficiency and duration or recurrences of diarrhea are conflicting. CONCLUSIONS: There is an association between vitamin D deficiency and the prevalence of diarrhea. Future studies should evaluate the causal association, the impact of vitamin D deficiency on the severity of diarrhea, and whether vitamin D deficiency treatments affects the prevalence of diarrhea.

Prophylactic Antibiotics to Prevent Cholangitis in Children with Biliary Atresia After Kasai Portoenterostomy: A Meta-Analysis.

OBJECTIVES: A connection between the bowel and bile ducts after the Kasai hepatoportoenterostomy (HPE) procedure poses a risk of ascending cholangitis. There were only a few evidence-based consensuses on the benefits of prophylactic antibiotics. This study aims to assess the value of prophylactic antibiotics in reducing the risk of cholangitis following the Kasai HPE procedure. METHODS: Meta-analysis is performed using random-effects model from the search result of 5 online databases (PubMed, Google Scholar, EBSCO MEDLINE, ClinicalTrials.gov , and EuropePMC) from inception to October 27, 2021. The keywords used were "antibiotic," "antimicrobial," "Kasai," "portoenterostomy," "biliary atresia," and "bile duct atresia." Cochrane Risk of Bias tool and Newcastle-Ottawa Scale is used to assess the risk of bias. The outcomes are incidence of cholangitis and native liver survival. RESULTS: Six studies consisting of 4 cohorts and 2 cross-sectional studies were extracted. A total of 714 patients reported different cholangitis incidence after prophylactic antibiotics administration post-Kasai HPE. The incidence of cholangitis following Kasai HPE was not statistically significant among participants. There is conflicting evidence on the efficacy of antibiotics in prolonging native liver survival. CONCLUSIONS: The existing evidence does not support the administration of prophylactic antibiotics in preventing cholangitis after Kasai HPE among biliary atresia patients. Additionally, their roles in native liver survival are still inconclusive. The fact that there were heterogeneous method and antibiotic usage between existing studies must also be highlighted for better design in future studies.

Relationship of Functional Constipation and Growth Status: A Systematic Review and Meta-Analysis.

OBJECTIVES: Functional constipation (FC) and malnutrition are 2 of the most common diseases affecting children worldwide with long-term consequences. We hereby performed a systematic review and meta-analysis to analyze the relationship between these 2 entities. METHODS: We searched PubMed, American Academics of Pediatrics (AAP), Cochrane, ClinicalTrials.gov (from inception to December 11, 2021) using "constipation," "growth," and "children" as the keywords. Newcastle-Ottawa Scale was used as the risk of bias assessment tool. Meta-analysis using the random-effects model was done. RESULTS: Eighteen studies involving 33,410 children were chosen in this study. Meta-analysis of all the studies showed statistically significant relationship between FC with both overweight/obesity [odds ratio (OR) = 1.75; 95% confidence interval (CI) = 1.11-2.76; P = 0.02], in Asian countries subgroup, and undernutrition (OR = 2.38; 95% CI = 1.43-3.97; P < 0.001) in Asian countries using ROME criteria's subgroup. Normal weight patients were also more prevalent in non-FC patients in Asia (OR = 0.54; 95% CI = 0.38-0.76; P < 0.001). The relationship between FC and short stature is still inconclusive. CONCLUSIONS: FC is correlated with the prevalence of both overweight/obesity and undernutrition. Future studies should evaluate the causal relationship and whether FC treatment could help.

Aerophagia Study in Indonesia: Prevalence and Association With Family-related Stress.

BACKGROUND: Aerophagia is a functional gastrointestinal disorder characterized by repeated air swallowing leading to chronic abdominal distension. Symptoms can be long lasting, lead to frustration, and distress. This study describes prevalence, related factors, and symptomatology of aerophagia, together with its relationship with emotional stress. MATERIALS AND METHODS: Cross-sectional study. Adolescents aged 10 to 17 years from selected state schools by convenient sampling from Jakarta, Indonesia, were recruited. Rome III self-administered questionnaire was used to compile data on gastrointestinal symptoms. Data on sociodemographic characteristics, intestinal and extraintestinal symptoms, and stressful life events were collected using a separate questionnaire. RESULTS: A total of 1796 questionnaires were included in the analysis [males 732 (40.8%), mean age 13.58 (SD 0.992) years]. There were 81 (4.5%) subjects diagnosed with aerophagia. When the criterion of belching was removed from the diagnosis of aerophagia, the prevalence drops to only 2 (0.1%). subjects. Bivariate analysis showed that sociodemographic factors have no correlation with aerophagia. In subjects with aerophagia, among the intestinal-related and extraintestinal symptoms, only loss of appetite was significantly more common in the aerophagia population (33.3%) when compared with controls (22.8%). Death of a close family member [adjusted odds ratio (OR), 2.78; 95% confidence interval (CI), 1.46-5.31; P=0.002], divorce or separation of parents (adjusted OR, 2.54; 95% CI, 1.38-4.66; P=0.003), and divorce followed by separate individual remarriage of parents (adjusted OR, 2.01; 95% CI, 1.01-3.98; P=0.046) were found to be significantly associated with aerophagia by multivariate analysis. CONCLUSIONS: The prevalence of aerophagia was found in 4.5% of Indonesian school-aged children according to Rome III criteria, but the prevalence was found only 0.1% if the belching is removed from the criteria. Besides the main symptoms, only loss of appetite was significantly more common in aerophagia among intestinal-related and extraintestinal symptoms. Family-related stress showed a significant correlation with aerophagia.

Functional abdominal pain disorders in adolescents in Indonesia and their association with family related stress.

BACKGROUND: Functional abdominal pain disorders (FAPD) have been widely reported as a major group of gastrointestinal disorders across the world. This study describes the prevalence, related factors, symptomatology and its relationship to emotional stress in Indonesian adolescents. METHODS: This is a cross-sectional study. Adolescents aged 10 to 17 years from nine randomly selected state schools from five districts of Jakarta, Indonesia, were invited to participate. A translated and validated Rome-III self-administered-questionnaire was used to collect data on gastrointestinal symptoms. Data on sociodemographic characteristics, intestinal as well as extra-intestinal symptoms, and exposure to stressful life events were also collected using a separate validated questionnaire. RESULTS: A total of 1813 questionnaires were included in the analysis [males 739 (40.8%) mean age of 13.54 years + 0.89]. Of them, 209 children (11.5%) fulfilled Rome III criteria of FAPD. Functional abdominal pain (FAP) was reported as the most prevalent subtype (5.8%), followed by functional dyspepsia (3.3%), irritable bowel syndrome (2%) and abdominal migraine (0.4%). The prevalence was higher in girls (p < 0.05) and those exposed to family-related stressful life events (p < 0.05). They include divorce or separation of parents (adjusted OR 2.55, 95% CI 1.75-3.7, p = < 0.001), death of a close family member (adjusted OR 2.24, 95% CI 1.39-3.59, P = 0.001), and father's alcoholism (adjusted OR 1.94, 95% CI 1.22-3.1, P = 0.005). CONCLUSIONS: FAPD are common paediatric entities among Indonesian adolescents with a prevalence of 11.5%. FAPD were noted to be higher in girls and adolescents exposed to family-related stressful life events.

Epidemiology of Paediatric constipation in Indonesia and its association with exposure to stressful life events.

BACKGROUND: We aimed to study the epidemiology and risk factors, including exposure to emotional stress, for constipation in Indonesian children and adolescents of 10-17 year age group. METHODS: A cross-sectional survey using a validated, self-administered questionnaire was conducted in randomly selected children and adolescents in nine state junior high schools from five districts of Jakarta. All of them were from urban areas. Constipation was defined as a diagnosis by using the Rome III criteria. RESULTS: Of 1796 children included in the analysis, 328 (18.3%; 95% CI 016-0.2) had constipation. Females and those residing in North Jakarta showed risks associated with constipation in school-age children and adolescents. Symptoms independently associated with constipation were abdominal pain (64% vs 43.3% of control) and straining (22.9% vs 6.3%). The prevalence of constipation was significantly higher in those with stressful life events such as father's alcoholism (adjusted OR 1.91, 95% CI 1.27-2.89, P = 0.002), severe illness of a close family member (adjusted OR 1.77, 95% CI 1.12-2.80, P = 0.014), hospitalization of the child for another illness (adjusted OR 1.68, 95% CI 1.22-2.31, P < 0.001), being bullied at school (adjusted OR 1.67, 95% CI 1.01-2.76, P = 0.047) and loss of a parent's job (adjusted OR 1.39, 95% CI 1.03-1.88, P = 0.034). CONCLUSIONS: Constipation in children and adolescent is a significant health problem, affecting almost 20% of Indonesian school-age children and adolescents. Common school and home related stressful life events appear to have predisposed these children to develop constipation.

Agreement test of transcutaneous bilirubin and bilistick with serum bilirubin in preterm infants receiving phototherapy.

BACKGROUND: This study compares the minimally invasive Bilistick and a noninvasive method with standard Total Serum Bilirubin (TSB) measurement in preterm newborns receiving phototherapy. We assess the agreement of Transcutaneous Bilirubinometer (TcB) and Bilistick bilirubin measurements with standard TSB measurement in preterm infants receiving phototherapy. METHODS: Bilirubin was measured by using TcB and Bilistick in 94 preterm infants in RSCM Jakarta Neonatal Ward from October 2016 to March 2017, with gestational ages of < 35 weeks, before phototherapy and after 24 and 48 h of phototherapy. RESULTS: There was significant correlation before, at 24 and 48 h of phototherapy between TSB and either TcB (r = 0.874; r = 0.889; r = 0.878 respectively; p < 0.0001), or Bilistick (r = 0.868; r = 0.877; r = 0.918 respectively; p < 0.0001). The mean difference and limits of agreement before, at 24 and 48 h of phototherapy between TcB and TSB were 0.81 ± 1.51 mg/dL (- 2.14 to 3.77 mg/dL); 0.43 ± 1.57 mg/dL (- 2.66 to 3.51 mg/dL); 0.41 ± 1.58 mg/dL (- 2.69 to 3.50 mg/dL), respectively. For Bilistick they were - 1.50 ± 1.47 mg/dL (- 4.38 to 1.38 mg/dL); - 1.43 ± 1.47 mg/dL (- 4.32 to 1.46 mg/dL); - 1,15 ± 1.31 mg/dL (- 3,72 to 1,42 mg/dL), respectively. CONCLUSIONS: Both methods are reliable for measuring TSB before, during, and after phototherapy in preterm infants. TcB tends to overestimate while Bilistick underestimates TSB.

Growth of Indonesian Infants Compared With World Health Organization Growth Standards.

OBJECTIVES: The ability of the World Health Organization (WHO) growth standards to represent the growth of South East Asian infants has been questioned. The aim of this study was to provide contemporary data on the growth of Indonesian breast-fed and formula-fed infants, compared with the WHO growth standards. METHODS: A prospective cohort study of 160 normal healthy infants was undertaken in a suburban area of South Jakarta, Indonesia. Infants from 2 to 6 weeks of age were recruited, and they consumed exclusively either breast milk or infant formula for at least 6 months, with follow-up until 12 months of age. RESULTS: Overall, the infants in the present study were lighter (weight-for-age), were shorter (length-for-age), and had smaller head circumferences (head circumference-for-age) than the average WHO Growth Reference Study population but were of similar proportion (weight-for-length). Compared with the WHO Growth Reference Study, the z scores for weight-for-age, length-for-age, and head circumference-for-age in the Indonesian children fell from birth to 6 weeks of age and then increased until 3 months of age in both the breast-fed and the formula-fed infants. At 6 weeks of age, the weight-for-age z scores fell below -2 standard deviations for 16 (20.5%) breast-fed and 40 (51.3%) formula-fed infants, and the length-for-age z scores fell below -2 standard deviations for 31 (39.7%) breast-fed and 41 (52.6%) formula-fed infants. CONCLUSION: The WHO growth standards do not reflect the growth of the present cohort of Indonesian infants and may overestimate the levels of underweight and stunted children.

Seroconversion among children with HBsAg-positive mothers in Indonesia and factors affecting the anti-HBs titers.

Background and aim: Around 2% of newborns are at risk of hepatitis B virus (HBV) infection from their mothers. To prevent this, infants born to HBsAg-positive mothers are given hepatitis B immune globulin (HBIG) and hepatitis B (HB) vaccine as immunoprophylaxis. This study aims to investigate the efficacy of immunoprophylaxis in infants born to HBsAg-positive mothers and the contributing factors. Methods: The study was conducted on a group of 87 children, ranging from nine months to under 36 months, born to HBsAg-positive mothers and received immunoprophylaxis within 24 h after birth followed by a national immunization schedule at the Community Health Center (CHC) in three administrative cities of DKI Jakarta. We measured the levels of HBsAg and anti-HBs, and utilized ordinal logistic regression models to identify factors that influence the anti-HBs titers after vaccination. Results: Out of 87 children, only one child had positive HBsAg results. The data showed that 88.5% of the children had seroprotection with anti-HBs levels ≥10 mIU/mL. Additionally, 48.3% of the children had a high protective response with anti-HBs levels ≥100 mIU/mL, while 11.5% had a non-protective response. Children under one year of age, with a family history of HBV carriers, and who received five doses of the HB vaccine exhibited higher levels of anti-HBs titer category with adjusted OR 3.9 (95%CI: 1.3-11.6), 5.3 (95%CI: 1.1-27.4), and 8.3 (95%CI: 2-34.8), respectively. Conclusion: The administration of HBIG and HB vaccine successfully prevented vertical transmission, resulting in a high seroprotection rate.

Occult Amebiasis among Pediatric with Enterocolitis in National Referral Hospital in Indonesia.

BACKGROUND: Enterocolitis and gastroenteritis remain major health problems, particularly in children living in developing countries. Intestinal protozoa, such as Entamoeba histolytica, Blastocystis, and Cyclospora, are frequently associated with these conditions. Amebic colitis can cause serious complications, including fulminant necrotizing colitis, toxic megacolon, extraintestinal amebiasis, and stunting in children. The diagnosis of amoebiasis is challenging, relying on microscopic examination, which cannot distinguish E. histolytica from the nonpathogenic E. dispar and E. moshkovskii. Therefore, this study aimed to identify intestinal parasites, particularly Entamoeba, their prevalence, and the clinical characteristics of patients admitted for enterocolitis and gastroenteritis at a tertiary-referral hospital. MATERIAL AND METHODS: A cross-sectional, retrospective study was conducted at a national, tertiary-referral government hospital, in Jakarta. Of the 111 retrieved medical records from hospitalized patients with enterocolitis and gastroenteritis, for which parasitology feces were examined, 54 fecal samples (48.6%) were still available in the parasitology laboratory storage. All fecal samples underwent the following tests: 1) direct stool examination, after staining with 1% Lugol's solution, and using the water-ether concentration method; 2) modified acid-fast staining for coccidian parasites; 3) Jones' culture medium to detect Blastocystis; 4) copro-antigen assay to detect Cryptosporidium and Giardia; and 5) a polymerase chain reaction (PCR) assay to identify Entamoeba. Clinical and demographic data were obtained from the medical records. RESULTS: Largely, patients (44.1%) were from the cohort of young children ≤5 years old, followed by adults aged 19-60 years old (24.3%). Both cohorts exhibited polyparasitism. Intestinal parasites were detected in 17 out of the 54 samples (31.4%). These included 6 (11.1%), 2 (3.7%),5 (9.2%), 3 (5.5%), 2 (3.7%), and 1 (1.8%) samples that were positive for Blastocystis, E dispar, E. histolytica, E. moshkovskii, Cryptosporidium, and Dientamoeba fragilis, respectively. PCR analysis revealed that 10 samples were positive for Entamoeba infection, eight of which originated from pediatric patients. CONCLUSION: At a national tertiary-referral hospital in Indonesia, Entamoeba infection was the most prevalent parasite among pediatric patients with enterocolitis. E. histolytica and E. moshkovskii were the two main species identified by PCR. Therefore, PCR assays and fecal occult-blood tests are recommended in cases of enterocolitis and gastroenteritis.

Granulocyte Colony-stimulating Factor Improves Innate Immunity in Pediatric Pretransplant Patients.

Background: Children with decompensated cirrhosis (DC) awaiting LT suffer from infection linked to high pediatric end-stage liver disease (PELD) scores and mortality. Granulocyte colony-stimulating factor (G-CSF) therapy has shown promising results in adult DC. Our study investigated G-CSF as an optimizing treatment for pre-transplant DC, exploring its effect on cytokine activity. Methods: An open-label, randomized controlled trial included DC patients aged 3 months-12 years. The intervention group (n=26) received 12 G-CSF courses injected subcutaneously (5 µg/kg/day) plus DC standard medical treatment (SMT). The control group (n = 24) received SMT. We obtained PELD scores, tumor necrosis factor (TNF)-α, interleukin (IL)-10, hepatocyte growth factor (HGF), CD34+ mobilization, liver function, leukocyte and neutrophil counts. Infection and side effects were documented. Results: There was no significant difference in PELD scores between the groups after 3 months G-CSF treatment. Decreased TNF-α (p < 0.001) and increased IL-10 and HGF (p = 0.003 for both markers) were shown 1 month following G-CSF treatment. Alanine aminotransferase (ALT) levels improved significantly (p = 0.038). Significant increase in leucocyte and neutrophil counts (p < 0.001) and a lower incidence of sepsis (p = 0.04) were shown after intervention. There was no significant difference in survival (p = 0.372). Conclusion: Following 3 months of G-CSF treatment, PELD scores did not show significant improvement. G-CSF reversed the cytokine profiles in DC, resulting in reduced TNF-α and increased IL-10. HGF significantly improved, indicating hepatic regeneration. Significantly decreased occurrence of sepsis following G-CSF treatment indicated improved clinical outcome.

The significance of Meckel's scan in pediatric gastrointestinal bleeding cases: A case report.

Meckel's diverticulum is the most prevalent congenital anomaly of the gastrointestinal tract, identified in 2% of the population according to autopsy studies. Most patients remain asymptomatic throughout their lives and are typically diagnosed when complications arise. The diagnosis can be challenging, but imaging is crucial for promptly identifying and distinguishing it from other conditions that have similar clinical manifestations. A 13-year-old male was admitted with a 5-day history of rectal bleeding. The patient continued to experience painless gastrointestinal bleeding, indicating the performance of a Tc-99m pertechnetate scintigraphy or Meckel's scan. Planar images revealed focal uptake within the right hemiabdomen, suggestive of the presence of a Meckel's diverticulum. Subsequent laparotomy surgery confirmed the presence of a Meckel's diverticulum located 50 cm from the ileocecal valve. Histopathological examination of the resected specimen confirmed Meckel's diverticulum with ectopic gastric mucosa. This patient with Meckel's diverticulum exhibited minimal abdominal symptoms, and there were no other complications such as intussusception, which could lead to bowel obstruction. Technetium-99m pertechnetate scintigraphy is a common method for evaluating children with unexplained gastrointestinal tract bleeding. SPECT/CT fusion imaging enables the simultaneous fusion of functional and anatomical information, preventing false-negative scintigraphy examinations. Its capability to precisely localize activity in abnormal structures contributes to accurate scan interpretation. Complications of Meckel's diverticulum are uncommon and pose a diagnostic challenge. Through comprehensive history-taking, physical examination, and nuclear imaging, the diagnosis can be identified, and surgical intervention can be performed to achieve the best possible outcome for the patient.

Prognostic value of biochemical liver parameters in neonatal sepsis-associated cholestasis.

AIMS: The aim of the study was to evaluate the significance of total bilirubin, aspartate transaminase (AST), alanine transaminase and gamma-glutamyltransferase (GGT) for predicting outcome in sepsis-associated cholestasis. METHODS: A retrospective cohort review of the hospital records was performed in 181 neonates admitted to the Neonatal Care Unit. A comparison was performed between subjects with low and high liver values based on cut-off values from ROC analysis. We defined poor prognosis to be when a subject had prolonged cholestasis of more than 3.5 months, developed severe sepsis, septic shock or had a fatal outcome. RESULTS: The majority of the subjects were male (56%), preterm (56%) and had early onset sepsis (73%). The poor prognosis group had lower initial values of GGT compared with the good prognosis group (P = 0.003). Serum GGT (cut-off value of 85.5 U/L) and AST (cut-off value of 51 U/L) showed significant correlation with the outcome following multivariate analysis. The odds ratio (OR) of low GGT and high AST were OR 4.3 (95% CI:1.6 to 11.8) and OR 2.9 (95% CI:1.1 to 8), respectively, for poor prognosis. In subjects with normal AST values, those with low GGT value had relative risk of 2.52 (95% CI:1.4 to 3.5) for poorer prognosis compared with those with normal or high GGT. CONCLUSION: Serum GGT and AST values can be used to predict the prognosis of patients with sepsis-associated cholestasis.

Comparison of stool microbiota compositions, stool alpha1-antitrypsin and calprotectin concentrations, and diarrhoeal morbidity of Indonesian infants fed breast milk or probiotic/prebiotic-supplemented formula.

AIM: The composition of faecal microbiota of babies is known to be influenced by diet. Faecal calprotectin and α1-antitrypsin concentrations may be associated with mucosal permeability and inflammation. We aimed to assess whether there was any difference after consumption of a probiotic/prebiotic formula on faecal microbiota composition, calprotectin and α1-antitrypsin levels, and diarrhoea in comparison with breast milk-fed Indonesian infants. METHODS: One hundred sixty infants, 2 to 6 weeks old, were recruited to the study. They were either breastfed or formula fed (80 per group). Faecal samples were collected at recruitment and 3 months later. Bacterial groups characteristic of the human faecal microbiota were quantified in faeces by quantitative polymerase chain reaction. Calprotectin and α1-antitrypsin concentrations were measured using commercial kits. Details of diarrhoeal morbidity were documented and rated for severity. RESULTS: The compositions of the faecal microbiota of formula-fed compared with breast milk-fed children were similar except that the probiotic strain Bifidobacterium animalis subsp. lactis DR10 was more abundant after 3 months consumption of the formula. Alpha1-antitrypsin levels were higher in breastfed compared with formula-fed infants. The occurrence of diarrhoea did not differ between the groups of babies. CONCLUSION: Feeding Indonesian babies with a probiotic/prebiotic formula did not produce marked differences in the composition of the faecal microbiota in comparison with breast milk. Detrimental effects of formula feeding on biomarkers of mucosal health were not observed.

Unspecific congenital toxoplasmosis in a two-month-old baby.

A two-month-old baby boy diagnosed with unspecific congenital toxoplasmosis was referred by a pediatrician to the Clinical Parasitology referral center at the Faculty of Medicine, Universitas Indonesia. Baby was post-hospitalized in the NICU and required ventilation support for one month. Furthermore, there was history of from various medical conditions, such as intracranial bleeding, convulsion, hypertrophic cardiomyopathy, retinopathy, and renal failure. After two month, there was no significant weight gain, anti-Toxoplasma IgM showed positive results, and anti-Toxoplasma IgM and IgG of the mother were also positive. Baby and mother were successfully treated with pyrimethamine, cotrimoxazole, and folinic acid for one month. At 2 years, there signs of normal motoric, eye, and hearing development with underdeveloped kidneys. Therefore, pre-pregnancy counseling and education aimed at preventing toxoplasmosis during pregnancy should be increased and conducted routinely by health workers or trained cadres to reduce the risk of fetal defects.

The Comparison of Cerebral Oxygenation among Mechanically Ventilated Children Receiving Protocolized Sedation and Analgesia versus Clinician's Decision in Pediatric Intensive Care Unit.

Introduction: Adequate sedation and analgesia are two crucial factors affecting recovery of intensive care patients. Improper use of sedation and analgesia in intensive care patients may adversely lead to brain oxygen desaturation. This study aims to determine cerebral oxygenation as measured by near-infrared spectroscopy (NIRS) and inotropic interventions received among mechanically ventilated children in the pediatric intensive care unit (PICU). Methods: This study is a nested case - control study in the PICU of Indonesian tertiary hospital. Children aged 1 month to 17 years on mechanical ventilation and were given sedation and analgesia were included in the study. Subjects were divided into two groups according to the protocol of the main study (Clinical Trial ID NCT04788589). Cerebral oxygenation was measured by NIRS at five time points (before sedation, 5-min, 1, 6, and 12 h after sedation). Results: Thirty-nine of the 69 subjects were categorized into the protocol group and the rest were in the control group. A decrease of >20% NIRS values was found among subjects in the protocol group at 5-min (6.7%), 1-h (11.1%), 6-h (26.3%), and 12-h (23.8%) time-point. The mean NIRS value was lower and the inotropic intervention was more common in the control group (without protocol), although not statistically significant. Conclusion: This study found that mechanically ventilated children who received sedation and analgesia based on the protocol had a greater decrease of >20% NIRS values compared to the other group. The use of sedation and analgesia protocols must be applied in selected patients after careful consideration.

The efficacy and safety of first-line anti-seizure medications as substitution therapy for children with drug-resistant epilepsy: a randomized controlled trial protocol.

Although many anti-seizure medications (ASMs) are available, treatment failure, known as drug-resistant epilepsy (DRE), still occurs in around 30% of children with epilepsy. Second-line ASMs are usually used as substitution therapy in DRE to control seizures, although international consensus is not available yet. Previous studies focus on comparing the ASMs, whether as add-on or substitution therapy, mainly conducted in newly diagnosed epilepsy. However, the study that investigated first-line ASMs as substitution therapy compared to second-line ones, particularly among DRE children, is still lacking. A randomized controlled trial (RCT) enrolling 102 participants, aged 1-18, at three referral hospitals in Indonesia will be conducted, dividing them into intervention and control groups. The intervention group will be treated with first-line ASMs as the substitution therapy, while the other in the control group will get second-line ASMs. The primary outcome measure is the proportion difference of responders between groups who get first-line and second-line ASMs in 14 weeks of intervention. Clinical trial registration: ClinicalTrials.gov, identifier NCT05697614.

Association Between Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire Score, Endoscopy and Biopsy in Children with Clinical Gastroesophageal Reflux Disease: A Prospective Study.

Purpose: Gastro esophageal reflux disease (GERD) is a burdensome disease affecting many children. A clinical examination is reported to be unreliable to diagnose GERD in children. This study aimed to investigate the relationship between the Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire (PGSQ) and endoscopic and histopathological findings in children with symptoms suggesting GERD. Changes in the PGSQ score in children with esophagitis as response to one month therapy were recorded as secondary outcome. Methods: This is a prospective cohort study in the pediatric outpatient clinic in an Indonesian tertiary hospital. Children aged 2-17 years old with clinical symptoms suspected of GERD are included in the study. Blinded endoscopic and histopathological examination was performed in all patients before one month proton pump inhibitors (PPI) therapy. The PGSQ information was collected at inclusion and after one month PPI treatment. Results: Fifty-eight subjects were included. Esophagitis was found in 60.9% of subjects according to endoscopy and 58.6% according to histology. There was no significant relationship between the PGSQ score and endoscopic (p=0.781) nor biopsy (p=0.740) examinations. The PGSQ showed a low diagnostic value compared to endoscopy and biopsy (area under the curve [AUC] 0.477, p=0.477, 95% confidence interval [CI] 0.326-0.629 and AUC 0.474, p=0.740 (95% CI 0.321-0.627 respectively). The PGSQ improved significantly post one month of PPI treatment. Conclusion: The PGSQ cannot be used to diagnose esophagitis in children with clinical symptoms suggesting GERD. However, the PGSQ can be used to monitor the treatment response in children with esophagitis.

Clinical, laboratory, and radiologic characteristics of confirmed avian influenza (H5N1).

This was a cross sectional study to determine the clinical, laboratory and radiologic characteristics of confirmed avian influenza (AI) (H5N1) infection among children and adults. This study was conducted at Sulianti Saroso Infectious Diseases Hospital (SS-IDH), Jakarta among subjects confirmed to have AI infection hospitalized during September 2005 to August 2010. The proportion of confirmed AI patients was 33 out of 321 suspected and probable cases (10.2%). Of 26 subjects analyzed (7 subjects was excluded due to loss of or incomplete medical records), the median ages were 7 years and 25 years in children and adults, respectively (range 1 - 39 years). Prominent clinical features were respiratory symptoms [productive cough (13/13 children; 12/13 adults), dyspnea (12/13 children; 13/13 adults)], and fever (12/13 children; 12/13 adults). Leukopenia was found in 9 subjects in each group. Four children and 7 adults had lymphopenia, while thrombocytopenia was found in 7 children and 10 adults. Two children had an increased ALT, while most adults had an increased AST (10/13) and/or ALT (8/13). Bilateral infiltrates found in most subjects on chest x-ray who had clinical deterioration. Of the 3 children who survived out of 13 children with AI, they all had less severe clinical features and no central nervous system involvement, lymphopenia, thrombocytopenia, or increased creatinine level. None of the adults survived.

Role of ursodeoxycholic acid in neonatal indirect hyperbilirubinemia: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Neonatal jaundice is a transitional phenomenon affecting three out of five full-term newborns globally. Ursodeoxycholic acid could be beneficial in neonatal jaundice needing phototherapy.  METHODS: We searched PubMed, EBSCO, ProQuest, and Cochrane Library up to August 21st, 2021, for articles to be reviewed. Meta-analysis using random-effects model was performed. RESULTS: Eight studies involving 1116 neonates were chosen in this review; however, only five studies were included for meta-analysis. Phototherapy duration was significantly lower in the interventional group with high heterogeneities. Subgroup analysis of the phototherapy duration based on the risk of bias resulted in a shorter duration (mean difference (MD) = -17.82; 95% CI = -20.17 to -15.47; p = < 0.001) with low heterogeneity in the treatment group. Secondary outcome focusing on mean total serum bilirubin showed a lower mean total serum bilirubin in 48 h post-treatment (MD = -0.43; 95% CI = -0.64 to -0.22; p = < 0.0001) with low heterogeneities in Asian countries." CONCLUSIONS: Ursodeoxycholic acid might be considered as a novel adjuvant therapy in neonatal indirect hyperbilirubinemia to shorten the phototherapy duration and lower the mean total serum bilirubin.