Texture analysis of periventricular echogenicity on neonatal cranial ultrasound predicts periventricular leukomalacia.

BACKGROUND: White matter periventricular echogenicity detected in neonatal cranial ultrasound (US) scans may be followed by cystic periventricular leukomalacia (PVL) or might resolve. Serial US are therefore needed to clarify the outcome. Texture analysis is a computerized method to analyze images and distinguish findings that are undetectable by the human eye. OBJECTIVE: To test whether texture analysis can differentiate echogenicities that resolve from those that develop cystic PVL. MATERIAL AND METHODS: Neonates with echogenicities on their initial US scan were studied; texture analysis was performed on the coronal and sagittal sections. Texture parameters were entered into a linear discriminant analysis (LDA) to classify the scans along two axes called most discriminant features (MDF) 1 and 2. RESULTS: We studied twenty infants with periventricular echogenicities on initial scans; ten of them later resolved (group A), while the other ten infants developed cystic PVL (group B). The classification accuracy was 66% and 82% for group A and B on sagittal sections, and 75%, and 80% on coronal. In the coronal and sagittal plane respectively, a MDF1 value of 0.98 and 0.24 and an MDF2 value of 0.86 and 0.001 provided the best sensitivity, specificity, positive and negative likelihood ratio. CONCLUSION: Texture analysis is a promising objective tool to early identify which cranial echogenicity that will develop into cystic PVL.

PFAPA with facial swelling- a new association?

PFAPA (periodic fever, apthous stomatitis, pharyngitis, cervical adenitis) is a rare condition of unknown cause affecting children. Although the exact etiology is unknown, inflammatory, immunological or genetic causes have been suggested. The diagnosis is made by exclusion of other causes of periodic fever. Although management is essentially symptomatic, single corticosteroid dose, tonsillectomy and Cimetidine has been shown to be associated with resolution of symptoms. Although abdominal pain and genital ulcers have been reported in association with PFAPA, unilateral transient facial swelling has not been previously reported. The authors present a hitherto unreported association of PFAPA with recurrent episodes of unilateral facial swelling.

Longitudinal study of vitamin D status in the 1st 6 months of life.

UNLABELLED: Although hypovitaminosis D has been reported in the neonatal period and infancy, there is currently little information on the longitudinal changes in vitamin D status throughout early infancy. AIM: To estimate, in Al Ain, UAE, the prevalence of vitamin D deficiency and longitudinal changes and risk factors in infants between birth and 6 months of age. METHODS: Serum 25-OH-vitamin-D levels were measured after birth and 6 months later in 27 infants of mothers of Middle Eastern or Asian origin who were pregnant between the months of September and November 2007. RESULTS: At delivery, mean (SD) maternal serum 25-OH-vitamin-D level was 35.5 nmol/L (24.7); five mothers (22%, 95% CI 0.7-43) had adequate serum levels (>50 mmol/L), 11 (48%, 95% CI 27-70) insufficient levels (25-50 nmol/L) and seven (30%, 95% CI 13-53) deficient (<25 nmol/L) levels. Serum 25-OH-vitamin-D levels were adequate in eight infants (30%, CI 14-50%), insufficient in 13 (48%, CI 28-60%) and deficient in six (22%, CI 8.5-42%). Despite recommendations, none had received any vitamin D supplementation since birth. Despite the high prevalence of hypovitaminosis D at birth and the lack of pharmacological supplementation, the number of infants with adequate levels at 6 months of age rose to 20 (87%, CI 66-97%). No infant had deficiency (CI 0-21%) and three (13%, CI 27-33%) had insufficiency. Adequate levels were detected in four infants who were partially breastfed [mean (SD) 108.5 (20.7) nmol/L] and in only 84% of the 19 exclusively breastfed infants [mean (SD) 96.2 (44.5) nmol/L] but the difference was not statistically significant. Although serum levels improved at 6 months, it occurred more slowly in exclusively breastfed infants. CONCLUSION: In the absence of vitamin D supplementation, guidelines for vitamin D supplementation in infancy still need to be followed because the mechanisms for normalisation are not clearly understood.

Churg-strauss syndrome without respiratory symptoms in a child.

Churg-Strauss Syndrome (CSS) is rare in children. It consists of a small- and medium-sized vessel vasculitis, with skin and peripheral nerve involvement. It is characterized by eosinophilia, extravascular necrotizing granuloma, and eosinophilic infiltration of multiple organs particularly the lungs, but may also involve the gastrointestinal tract, the heart, and the kidneys. The condition is usually associated with a preceding history of asthma or allergic sinusitis. It has rarely been reported in children, where most of the cases had pre-existing asthma, allergic rhinitis, or atopic disease. We report a 10-year-old Arab girl proven to have CSS, with no history of asthma or allergic rhinitis, who presented with tender cutaneous nodules of lower extremities, foot drop, and peripheral eosinophilia, without any clinical respiratory symptoms or signs.

Overweight and obesity in pregnancy do not adversely affect neonatal outcomes: new evidence.

We studied neonatal outcomes of infants of obese mothers in a cohort of 6,125 deliveries, using logistic multivariate analysis to remove the role of potential confounding variables. Although, as in previous reports, the crude unadjusted prevalence of several adverse neonatal outcomes was higher in these infants, the multivariable analysis revealed that only two outcomes remained significantly associated with maternal overweight and obesity: neonatal macrosomia (adjusted odds ratios aOR 1.4, p < 0.001) and meconium aspiration syndrome (aOR 1.6, p = 0.05), indicating that the unadjusted association with the other outcomes was caused by confounding factors. Nonetheless, as macrosomia is associated with increased health risks both to the mothers and their infants, and maternal obesity with considerable maternal morbidity during pregnancy, these results should not lead to complacency, but instead encourage better prevention of obesity in general and during pregnancy in particular.

Antibiotic resistance trends in paediatric community-acquired first urinary tract infections in the United Arab Emirates.

We analysed the trend of antibiotic resistance of community-acquired uropathogens over a 4-year period in a cohort of children with a first episode of culture-proven urinary tract infection presenting to the department of paediatrics at a large general secondary care hospital in the United Arab Emirates. Comparisons were made between 2 time periods: 2003-04 versus 2005-06 for 145 children aged 2 months to 12 years of age. Although some changes in resistance were observed for some antibiotics between the 2 time periods, the differences were not significant, nor were the trends, except for a significant increase in resistance to nitrofurantoin (from 5.4% to 35.6%), with a significant increasing trend over the 4 years.

Maternal vitamin D status throughout and after pregnancy.

Prospective longitudinal study of vitamin D status and its risk factors in 75 pregnant women from early pregnancy until 6 months postpartum, by serial measurement of serum 25 (OH) vitamin D levels. The serum levels at booking were not significantly different between nationalities (p = 0.06), parity (p = 0.2), education levels (p = 0.4), dress code (p > 0.5), consumption of vitamin D fortified milk (p = 0.2) or, fatty fish (p = 0.5), sun-exposed body surface area (p = 0.3), weekly time exposed to the sun (p = 0.08) or the sun exposure index (p = 0.2). Vitamin D status progressively worsened as the proportion with adequate serum levels fell from 31% at the antenatal visit, to 23% after birth and 17%, 6 months later (p = 0.02). While 80% of mothers who were exclusively breast-feeding had low vitamin D levels 6 months after delivery, this occurred in only 67% of those partially breast-feeding (p = 0.6).

Comparison of erythrocyte indices to differentiate between iron deficiency and alpha-thalassaemias in children with microcytosis and/or hypochromia.

Erythrocyte indices used to differentiate between iron deficiency anaemia (IDA) and thalassaemias have been studied mainly in countries with a high prevalence of IDA or beta-thalassaemias. This study was carried out in the United Arab Emirates where alpha-thalassaemias are prevalent. We studied the predictive value and Youden index of several indices in 85 children aged 6 months to 12 years with microcytosis and/or hypochromia, with or without anaemia (determined by serum measurement of iron or therapeutic iron trial). The best discriminatory indices for detecting IDA versus alpha-thalassaemias were a Green-King index > 65 (correctly identified 75.3% of children, Youden index 44.3) and red cell distribution width >14% (correctly identified 57.8%, Youden index 38.1).

Comparison of erythrocyte indices to differentiate between iron deficiency and alpha-thalassaemias in children with microcytosis and/or hypochromia

Erythrocyte indices used to differentiate between iron deficiency anaemia [IDA] and thalassaemias have been studied mainly in countries with a high prevalence of IDA or beta-thalassaemias. This study was carried out in the United Arab Emirates where alpha-thalassaemias are prevalent. We studied the predictive value and Youden index of several indices in 85 children aged 6 months to 12 years with microcytosis and/or hypochromia, with or without anaemia [determined by serum measurement of iron or therapeutic iron trial]. The best discriminatory indices for detecting IDA versus alpha-thalassaemias were a Green -King index > 65 [correctly identified 75.3% of children, Youden index 44.3] and red cell distribution width > 14% [correctly identified 57.8%, Youden index 38.1]

Antibiotic resistance trends in paediatric community-acquired first urinary tract infections in the United Arab Emirates

We analysed the trend of antibiotic resistance of community-acquired uropathogens over a 4-year period in a cohort of children with a first episode of culture-proven urinary tract infection presenting to the department of paediatrics at a large general secondary care hospital in the United Arab Emirates. Comparisons were made between 2 time periods: 2003-04 versus 2005-06 for 145 children aged 2 months to 12 years of age. Although some changes in resistance were observed for some antibiotics between the 2 time periods, the differences were not significant, nor were the trends, except for a significant increase in resistance to nitrofurantoin [from 5.4% to 35.6%], with a significant increasing trend over the 4 years

Infants of diabetic mothers with abnormal fetal growth missed by standard growth charts.

Diabetic pregnancies may result in fetal macrosomia when glycaemia is poorly controlled, and when associated with diabetic vasculopathy, with small for gestational age (SGA) neonates. Both groups of infants have high neonatal morbidity. As fetal growth depends on maternal genetic influences, ethnic group or parity, relying exclusively on population-based growth charts may wrongly categorise the growth pattern of these infants. We compared neonatal morbidity and mortality of a cohort of 214 infants of diabetic mothers (IDM), identified either by population standards or by customised birth weight percentiles (adjusted for maternal height, booking weight, parity, ethnic origin, gestational age at delivery and sex). A total of 68 (31.8%) were diagnosed with macrosomia, 11 (16%) of whom were identified by the customised growth method alone, and 16 were diagnosed as SGA (7.5%), of whom the majority (13 or 81.2%) were identified by the customised growth method alone. None had increased mortality and morbidity.

Renal power Doppler ultrasound does not predict renal scarring after urinary tract infection.

OBJECTIVE: Young children may develop renal scarring following a urinary tract infection (UTI) especially after pyelonephritis which is difficult to diagnose. Permanent renal scars are diagnosed by dimercapto-succinic acid (DMSA) scan several months later. To decrease unnecessary exposure to radiation, we investigate the role of renal power Doppler (RPD) in predicting those who may not require a late DMSA scan. METHODS: Children under four years of age with a first UTI underwent an RPD study soon after diagnosis, and a DMSA scintigraphy six months later. The predictive values of the early RPD to detect DMSA renal scarring were calculated. RESULTS: Twenty three children (median age 30 months) were enrolled: 13 had a febrile presentation, two with bacteraemia. Permanent scarring occurred in three children (13%). In the 46 kidney units studied, initial RPD was abnormal in two and late DMSA abnormal in three units. Overall concordance between RPD and DMSA was 93.5%. The sensitivity of RPD for renal scar as per DMSA was 33.3%, specificity 97.7%; positive predictive value 50% and a negative predictive value of 95.4%. CONCLUSIONS: RPD offered no advantage over ultrasound to predict renal scarring and cannot be recommended to predict renal scarring following UTI.

Dilated cardiomyopathy secondary to nutritional rickets.

Two 9-month-old breastfed infants presented with congestive heart failure secondary to dilated cardiomyopathy. No underlying aetiology was found, except for the presence of advanced rickets. Following treatment with vitamin D and calcium supplements, both infants quickly recovered normal myocardial function.

First and recurrent pediatric urinary tract infections: do they have different antibiotic susceptibilities?

Antibiotic susceptibility studies in children rarely differentiate between first and recurrent urinary tract infections (UTI), although the latter, frequently associated with underlying urinary tract anomalies and antibiotic prophylaxis, are more likely to be associated with higher antibiotic resistance of uropathogens as a result. We investigated whether antibiotic resistance was different between first and recurrent UTIs in 250 episodes (145 first and 105 recurrent) in 154 children (2 months to 12 years of age) with culture proven UTI. According to univariate analysis, resistance to cefuroxime and gentamicin was significantly lower in recurrences. This association remained statistically significant in the multivariable analysis, with adjusted odds ratio OR of 0.8 for cefuroxime (p=0.04) and for gentamicin (p=0.003) after adjusting for the role of confounding factors. The risk of resistance to other antibiotics was otherwise similar for first and recurrent UTIs.

Risk of hypertension with multicystic kidney disease: a systematic review.

BACKGROUND: Children with multicystic kidney disease (MCKD) are increasingly managed conservatively, and are followed up throughout childhood because of the risk of hypertension highlighted in some reports. With this risk still poorly defined, the strategy and the duration of follow up do not seem to be based on evidence. METHODS: Systematic review of the literature for all published cohort studies (prospective and retrospective) of children diagnosed to have unilateral MCKD and managed conservatively. Exclusion criteria were bilateral MCKD, and nephrectomy (not for hypertension) during the follow up period. For children with MCKD, the probability of developing hypertension during the follow up period was estimated. RESULTS: From 29 reviewed studies, six cases of hypertension developed in 1115 eligible children. The mean probability of a child with unilateral MCKD developing hypertension was therefore 5.4 per 1000 (95% CI estimated at 1.9 to 11.7 per 1000). CONCLUSION: Although the risk of hypertension in MCKD is low, the results of this study do not allow firm recommendations on the frequency and duration of blood pressure measurement follow up for these children. Large prospective cohort studies with a very long duration of follow up are needed.

Risk of long term renal impairment and duration of follow up recommended for Henoch-Schonlein purpura with normal or minimal urinary findings: a systematic review.

BACKGROUND: The duration of follow up to assess the risk of long term renal impairment in Henoch-Schönlein purpura (HSP) without nephritic or nephrotic syndrome or renal failure on diagnosis remains undetermined. AIMS: To undertake a systematic review of the literature to assess whether the risk of long term renal impairment without renal involvement on diagnosis could be estimated and to determine the time period when renal involvement is very unlikely after the diagnosis of HSP. METHODS: Search of studies of unselected children with HSP, and available information on urinary findings, renal involvement, and long term renal function follow up. Studies of selected children with HSP nephropathy at diagnosis were excluded. RESULTS: Twelve studies of 1133 children were reviewed. The follow up period ranged from 6 weeks to 36 years. Proteinuria and/or haematuria, which occurred in 34.2%, of which only one fifth were in association with nephritic or nephrotic syndrome, developed in 85% of cases within 4 weeks of the diagnosis of HSP, in 91% within 6 weeks, and in 97% within 6 months. Permanent renal impairment never developed after normal urinalysis; it occurred in 1.6% of those with isolated urinary abnormalities, and in 19.5% of those who developed nephritic or nephrotic syndrome. CONCLUSION: No long term renal impairment occurred after normal urinalysis. Even if urinalysis is normal at presentation, the testing should be continued for six months. There is no need to follow up after the first six months those whose urinalysis remains normal.

Risk of Wilms' tumour with multicystic kidney disease: a systematic review.

BACKGROUND: Children with multicystic kidney disease (MCKD) are increasingly managed conservatively and are followed up throughout childhood because they are perceived to be at increased risk of developing Wilms' tumour. With this risk still poorly defined and somewhat controversial, the strategy and the duration of follow up do not seem to be based on evidence. METHODS: Systematic review of the literature for all published cohort studies (prospective and retrospective) of children diagnosed to have unilateral MCKD and managed conservatively. EXCLUSION CRITERIA: bilateral MCKD, nephrectomy (not for malignancy) during the follow up period. We estimated for children with MCKD the probability of developing Wilms' tumour during the follow up period, with 95% CI using the Poisson distribution. RESULTS: From 26 reviewed studies, no cases of Wilms' tumour developed in 1041 eligible children. The mean probability of a child with unilateral MCKD to develop Wilms' was therefore nil, with a 97.5% upper CI estimated at 0.0035 (or 3.5 per 1000 children). CONCLUSION: The development of a national or a European registry for children with MCKD would increase the precision of their risk estimate to develop Wilms' tumour. In the meantime, there is no evidence to support any of the different modalities for following up these children by ultrasound, if indeed such a strategy is necessary.