Optimizing Oxygen Delivery by Low-Flow Nasal Cannula to Small Infants: A Bench Study.

BACKGROUND: In infants treated with a low-flow nasal cannula (LFNC), the oxygen concentration delivered to the lungs (i.e., the effective FiO2) is difficult to estimate. The existing mathematical formulas rely on important assumptions regarding the values of respiratory parameters and, thus, may be inaccurate. We aimed to assess oxygen delivery by LFNC to small infants using realistic simulations on a mechanical breathing model. METHODS: A mechanical breathing simulator (infant upper-airway replica, single-space breathing compartment, electric motor, microcontroller) was developed. Breathing simulations (n = 1200) were performed at various tidal volume (VT), inspiratory time (Ti), and respiratory rate (RR) combinations and different cannula flows. RESULTS: Minute ventilation (MV) was the most significant predictor of effective FiO2. FiO2 was higher at lower VT and higher Ti values. Benaron and Benitz's formula underestimated the effective FiO2 at lower MV values, while Finer's formula significantly overestimated it. A set of predictive FiO2 charts was developed based on cannula flow, infant body weight, and RR. CONCLUSIONS: The effective FiO2 delivered by LFNC to small infants critically depends on VT, Ti, and RR. However, since VT and Ti values are not available in clinical practice, the existing mathematical formulas may be inaccurate. Our novel predictive FiO2 charts could assist in optimizing oxygen delivery by LFNC using easy-to-obtain parameters, such as infant body weight and RR.

Primary Omental Torsion in Children in the Laparoscopy Era: What Have we Learned so far?

BACKGROUND/AIM: Primary omental torsion is uncommon, mimicking appendicitis and other acute abdominal pathologies. It often escapes diagnosis on imaging investigation or conventional open laparotomy. This study aimed to evaluate the effect of laparoscopy on the various parameters of this entity, including incidence, diagnosis, and treatment. MATERIALS AND METHODS: A systematic review was performed, including PubMed and Scopus databases, without a time limit, following the PRISMA principles. A total of 16 articles from January 2000 to December 2023, corresponding to 56 children with primary omental torsion, complied with the research criteria. RESULTS: Primary omental torsion was associated with obesity. Symptoms were right abdomen oriented, often compared to those of acute appendicitis. Preoperative ultrasound displayed low diagnostic accuracy, whereas computerized tomography diagnosed only two thirds of cases. In all patients, the vermiform appendix was normal. CONCLUSION: Laparoscopy affected both diagnosis and treatment of primary omental torsion in children. Easy peritoneal cavity access rendered possible the diagnosis of cases previously discharged as abdominal pain of unknown etiology. Combined with the increased pediatric obesity, it also affected primary omental torsion incidence. The recent pathogenetic theories may be better supported today, as laparoscopy provides a detailed view in situ, and facilitates harvesting of fat tissue from the omentum for molecular investigation. The diagnostic efficiency of laparoscopy is superior to ultrasonography and computerized tomography. Finally, the removal of the ischemic omentum is technically easier compared to the open laparotomy alternative with all the technical difficulties of traction of a vulnerable hemorrhagic tissue through a small incision.

Soluble urokinase plasminogen activator receptor (suPAR) in children with obesity or type 1 diabetes as a marker of endothelial dysfunction: a cross-sectional study.

Pediatric obesity and type 1 diabetes mellitus (T1DM) represent two common chronic diseases associated with chronic inflammation, endothelial dysfunction and long-term complications. The aim of the present study was to assess the possible diagnostic and prognostic value of soluble urokinase plasminogen activator receptor (suPAR), a marker of inflammation and impaired endothelial function, in children with the diseases. In this cross-sectional study, children and adolescents with T1DM (N = 41) or obesity (N = 37), aged < 18 years old, and without proteinuria were included, together with children of similar age and without evident morbidity that served as controls (N = 42). Serum samples were obtained during standard outpatient follow up and the urokinase-type plasminogen activator receptor (suPAR) concentrations were measured using a commercially available sandwich ELISA kit (DUP00, R&D systems). Clinical and biochemical indices that were also assessed include body mass index (BMI) z-score, Tanner stages, glycosylated haemoglobin (HbA1c), fasting lipid profile and serum creatinine. Mean serum suPAR levels were significantly higher in patients with obesity compared to patients with T1DM and controls, while children with T1DM had similar suPAR levels to controls. Also, serum suPAR levels showed a negative correlation with age (Spearman rho -0.359, p < 0.001) and serum creatinine levels (Spearman rho -0.334, p = 0.005), and a positive correlation with BMI z-score (Spearman rho 0.354, p = 0.009) in the whole cohort.  Conclusion: Serum suPAR may be a useful predictive marker of inflammation or endothelial dysfunction for children with obesity and T1DM, as well as a promising therapeutic target. Further studies are needed in order to clarify whether the reported differences in suPAR levels could reflect a greater impairment of the inflammation status and endothelial function in children with obesity compared to children with T1DM. What is Known: • Paediatric obesity and type 1 diabetes are characterised by chronic inflammation and metabolic dysregulation. • Urokinase plasminogen activator receptor (uPAR) has been proposed as a useful biomarker for chronic inflammation and cardiovascular risk in adults. What is New: • Serum suPAR levels were increased in children and adolescents with obesity compared to those with T1DM and healthy controls; thus, obesity may affect the inflammatory status and endothelial function to a higher degree than T1DM during childhood. • Serum suPAR may serve as a diagnostic and predictive marker of inflammation and endothelial dysfunction for children and adolescents with obesity and T1DM.

Monocyte Chemoattractant Protein-1 (MCP-1), Activin-A and Clusterin in Children and Adolescents with Obesity or Type-1 Diabetes Mellitus.

Inflammation plays a crucial role in diabetes and obesity through macrophage activation. Macrophage chemoattractant protein-1 (MCP-1), activin-A, and clusterin are chemokines with known roles in diabetes and obesity. The aim of this study is to investigate their possible diagnostic and/or early prognostic values in children and adolescents with obesity and type-1 diabetes mellitus (T1DM). METHODS: We obtained serum samples from children and adolescents with a history of T1DM or obesity, in order to measure and compare MCP-1, activin-A, and clusterin concentrations. RESULTS: Forty-three subjects were included in each of the three groups (controls, T1DM, and obesity). MCP-1 values were positively correlated to BMI z-score. Activin-A was increased in children with obesity compared to the control group. A trend for higher values was detected in children with T1DM. MCP-1 and activin-A levels were positively correlated. Clusterin levels showed a trend towards lower values in children with T1DM or obesity compared to the control group and were negatively correlated to renal function. CONCLUSIONS: The inflammation markers MCP-1, activin-A, and clusterin are not altered in children with T1DM. Conversely, obesity in children is positively correlated to serum MCP-1 values and characterized by higher activin-A levels, which may reflect an already established systematic inflammation with obesity since childhood.

Knowledge and attitudes of medical students about clinical aspects of congenital cytomegalovirus infection in newborns: A nationwide cross-sectional study in Greece.

Introduction: Cytomegalovirus (CMV) is the most frequent cause of congenital infection worldwide causing severe morbidity in newborns, infants, and children. Despite the clinical importance of congenital CMV (cCMV) infection, studies conducted so far indicate that there is limited awareness in the medical community in the field. The aim of this study was to assess Greek medical students' knowledge on cCMV infection. Methods: We performed a questionnaire-based nationwide cross-sectional study. A convenience sample of medical students from seven medical schools was enrolled. Results: Of the 562 respondents, 54,8% considered themselves undereducated on cCMV infection. However, almost half of the participants could correctly recognize some basic principles of cCMV infection including ways of transmission, diagnosis and treatment, while there were aspects of cCMV infection with knowledge deficit. The year of study had a positive impact on the level of knowledge with students of higher years of study being of more sufficient education on the specific topic. Conclusion: Overall, our study indicates a discrepancy between self-reported awareness and the level of knowledge among medical students in Greece. Further educational opportunities about cCMV should be offered, particularly in areas of the curriculum involving the care of women and children. Establishing medical students' solid background on the disease burden and educating them about preventative strategies for at-risk populations, should be the main pillars of such efforts in order to promote confidence in managing these cases in their future professional careers.

Parental Home Safety Practices for Domestic Accident Prevention: How Prepared Were Parents for COVID-19 Confinement? A Cross-Sectional Study.

(1) Background: Children are susceptible to home injuries. How prepared parents were to protect their children from accidents before and during the COVID-19 quarantine is uncertain. (2) Methods: We conducted a community-based, cross-sectional study in Greece between November and December 2021. We asked parents to complete an anonymous questionnaire voluntarily. Questions focused on accident-preventive measures taken at home during the COVID-19 quarantine. (3) Results: A greater proportion of parents took protective measures for a safer home before the lockdown than during the quarantine, while an interesting percentage of parents never utilized preventive measures for their children. Slightly more than half (58.6%) of parents did not seem to worry about a possible increase in domestic accidents during the quarantine. It was observed that those who had one or two children took more protective measures than those with more than two children. Older parents seemed to explain to their children how to access emergency services more often. Mothers stayed at home with the children more often, and their education affected the presence of some of the assessed measures. In our logistic regression modeling, parental concern about accidents was more related to the incidence of an accident during the pandemic and attendance at seminars. (4) Conclusions: Although the COVID-19 lockdowns disorganized family life, parents were aware of the importance of their parenting role in creating a safe environment for children, but according to the study, there is room for improvement.

Ileocolic Intussusception in Infancy is not Always Idiopathic - Adenomyoma as the Leading Point.

BACKGROUND Intussusception is a frequent abdominal emergency in infancy, requiring immediate diagnosis and therapeutic intervention. In approximately 90% of cases, intussusception seems to be idiopathic. There has been a reported association of intussusception with lymphoid hyperplasia of Peyer patches in the terminal ileum, possibly acting as the triggering factor. Clinical presentation varies substantially, while the etiology seems idiopathic in most reported cases. CASE REPORT This case describes a previously healthy 2-month-old girl who presented with an episode of non-bilious vomiting and deterioration during the 12 hours preceding the visit. Abdominal ultrasonography revealed the typical target sign in the right iliac fossa, without visible peristalsis, confirming the diagnosis of intussusception. Failure of non-surgical reduction led to emergency laparotomy with the working diagnosis of intussusception due to Meckel's diverticulum. However, laparotomy instead revealed an adenomyoma of the small intestine, a rare benign tumor-like lesion, as the pathological lead point. CONCLUSIONS This case is interesting for 2 distinct reasons. Not only does it underline the need to maintain a high index of suspicion for triggering factors, even in patients within atypically affected age groups, but it also adds to the remarkably limited selection of reported adenomyomas of the small intestine acting as the pathological lead point for intussusception. In this case report, we aspire to emphasize that especially in patients outside the most affected age group, pediatric surgeons should remain aware of the possibility of adenomyoma as a pathological lead point.

Infantile hemangiomas screening modalities for primary care physicians.

Infantile hemangiomas are the most common benign vascular tumors in children. They present a characteristic natural history of spontaneous involution after a phase of initial proliferation. A small but significant minority demonstrates incomplete regression or complications and requires prompt intervention. Prediction of the evolution of infantile hemangiomas is challenging because of their morphological and behavioral heterogeneity. The decision between referral for treatment and observation is sometimes difficult, especially among non-expert physicians, with the risk of missing the period for optimizing outcomes in case of delayed intervention. The aim of this review is to update our knowledge, especially of the primary care providers, regarding the ongoing difficulties of the early clinical evaluation of infantile hemangiomas, and to outline the importance of current practical scoring tools for the identification of the lesions which require expert consultation and referral.

Diabetic Ketoacidosis in Children and Adolescents; Diagnostic and Therapeutic Pitfalls.

Diabetic ketoacidosis (DKA) represents an acute, severe complication of relative insulin deficiency and a common presentation of Type 1 Diabetes Mellitus (T1DM) primarily and, occasionally, Type 2 Diabetes Mellitus (T2DM) in children and adolescents. It is characterized by the biochemical triad of hyperglycaemia, ketonaemia and/or ketonuria, and acidaemia. Clinical symptoms include dehydration, tachypnoea, gastrointestinal symptoms, and reduced level of consciousness, precipitated by a variably long period of polyuria, polydipsia, and weight loss. The present review aims to summarize potential pitfalls in the diagnosis and management of DKA. A literature review was conducted using the Pubmed/Medline and Scopus databases including articles published from 2000 onwards. Diagnostic challenges include differentiating between T1DM and T2DM, between DKA and hyperosmolar hyperglycaemic state (HHS), and between DKA and alternative diagnoses presenting with overlapping symptoms, such as pneumonia, asthma exacerbation, urinary tract infection, gastroenteritis, acute abdomen, and central nervous system infection. The mainstays of DKA management include careful fluid resuscitation, timely intravenous insulin administration, restoration of shifting electrolyte disorders and addressing underlying precipitating factors. However, evidence suggests that optimal treatment remains a therapeutic challenge. Accurate and rapid diagnosis, prompt intervention, and meticulous monitoring are of major importance to break the vicious cycle of life-threatening events and prevent severe complications during this potentially fatal medical emergency.

Post-Traumatic Stress as a Psychological Effect of Mild Head Injuries in Children.

BACKGROUND: Head trauma is one of the most common pediatric emergencies. While the psychological effects of severe head injuries are well studied, the psychological consequences of mild head injuries often go overlooked. Head injuries with a Glasgow Coma Scale score of 13-15, with symptoms such as headache, vomiting, brief loss of consciousness, transient amnesia, and absence of focal neurological signs, are defined as mild. The aim of this study is to evaluate the stress of children with mild head injuries and their parents' relevant perception during the early post-traumatic period. METHODS: This is a prospective cross-sectional study on a cohort of children with mild head injuries and their parents. Two questionnaires were implemented, the Child Trauma Screening Questionnaire (CTSQ) which was compiled by the children, and the Children's Revised Impact of Event Scale (CRIES-13), compiled by their parents. Both questionnaires are widely used and reliable. The first presents an excellent predictive ability in children with a risk of post-traumatic stress disorder, while the second is a weighted self-completed detecting instrument for the measurement of post-traumatic stress in children and adolescents, with a detailed evaluation of their reactions to the traumatic incident. The participants responded one week and one month after the traumatic event. RESULTS: A total of 175 children aged 6-14 years and 174 parents participated in the study. Stress was diagnosed in 33.7% of children after one week, and in 9.9% after one month. Parental responses suggesting stress presence in their children were 19.0% and 3.9%, respectively. These outcomes showed that mild head injuries are not so innocent. They are often underestimated by their parents and may generate a psychological burden to the children during the early post-traumatic period. CONCLUSIONS: Mild head injuries may affect the emotional welfare of children. Healthcare providers should understand the importance of the psychological effect of this overlooked type of injury. They should be trained in the psychological effect of trauma and be aware of this probability, promptly notify the parents accordingly, and provide psychological assistance beyond medical treatment. Follow-up and support are needed to avoid the possibility of future post-traumatic stress disorder. More extensive research is needed as the outcomes of this study regarded a limited population in numbers, age, and survey period. Furthermore, many children with mild head injuries do not ever visit the emergency department and stay at home unrecorded. Community-based research on the topic should therefore be considered.

Association of the Bacteria of the Vermiform Appendix and the Peritoneal Cavity with Complicated Acute Appendicitis in Children.

BACKGROUND: Primary infection has been questioned as the pathogenetic cause of acute appendicitis. We attempted to identify the bacteria involved and to investigate if their species, types, or combinations affected the severity of acute appendicitis in children. METHODS: Samples from both the appendiceal lumen and the peritoneal cavity of 72 children who underwent appendectomy were collected to perform bacterial culture analysis. The outcomes were studied to identify if and how they were associated with the severity of the disease. Regression analysis was performed to identify any risk factors associated with complicated appendicitis. RESULTS: Escherichia coli, Pseudomonas aeruginosa, and Streptococcus species were the most common pathogens found in the study population. The same microorganisms, either combined or separate, were the most common in the appendiceal lumen and the peritoneal cavity of patients with complicated appendicitis. Gram-negative bacteria and polymicrobial cultures in the peritoneal fluid and in the appendiceal lumen were associated with complicated appendicitis. Polymicrobial cultures in the peritoneal cavity presented a four times higher risk of complicated appendicitis. CONCLUSIONS: Polymicrobial presentation and Gram-negative bacteria are associated with complicated appendicitis. Antibiotic regimens should target the combinations of the most frequently identified pathogens, speculating the value of early antipseudomonal intervention.

Ceftriaxone Administration Associated with Lithiasis in Children: Guilty or Not? A Systematic Review.

Lithiasis is a known side effect of ceftriaxone administration in children. Sex, age, weight, dosage, and duration of intake have been reported as risk factors for the formation of calcification or stones in the bile and urine excretory systems of children who received ceftriaxone. The purpose of this systematic review is to investigate the reported effects of ceftriaxone administration in pediatric patients who were admitted to a hospital due to infection, the likelihood of gallstones, nephroliths, or precipitations in both the biliary and urinary systems, as well as investigate the relationship with their mother's history during pregnancy. Original studies and literature reviews from the PubMed database were included in the study. No time limit related to research or publication was set for the articles. The results were evaluated, aiming to understand the outcomes and identify any predisposing factors relevant to this side effect. Of the 181 found articles, 33 were appropriate for inclusion in the systematic review. The administered dose of ceftriaxone presented variability. Symptoms, such as abdominal pain and vomiting, were associated with ceftriaxone-related lithiasis in many cases. It was noted that most of the results were the outcomes of retrospective observation and not of prospective randomized research. Definitively, more randomized control studies with long-term outcomes are needed to identify the exact association between ceftriaxone and lithiasis in children.

An approximation method for the prevention of knot formation during catheterization in children.

INTRODUCTION: Knotting during urethral catheterization in children is an unpleasant situation. We aimed to minimize this risk. METHOD: To prevent knot formation, we must understand its nature. We focused on the simplest, and most fundamental, known as overhand knot. RESULTS: Calculating the maximum length of catheter inserted in the bladder without risk of knotting, we estimated the minimum length of catheter needed for an overhand knot. DISCUSSION: This theoretical approach provides a rough estimation which may contribute to secure catheterization. CONCLUSION: Adding the calculated length to the appropriate for gender and age urethral length, may reduce knotting risk.

The Psychological Impact of COVID-19 Admission on Families: Results from a Nationwide Sample in Greece.

The aim of the present study was to assess the psychological impact of hospitalization during the COVID-19 pandemic on parents and their offspring. We performed a nationwide cross-sectional study in Greece based on an Internet questionnaire survey. A convenience sample of parents whose offspring had been hospitalized due to COVID-19 (including multisystem inflammatory syndrome in children, MIS-C), diagnosed with COVID-19 but not hospitalized, and hospitalized for another reason during the pandemic were enrolled. Parental stress was assessed using the Perceived Stress Scale (PSS) and the Revised Impact of Event Scale (IES-R) tools, and childhood mental wellbeing with the Children's Revised Impact of Event 13 (CRIES-13) scale. Out of 214 received responses, stress levels were significantly higher in parents whose children had been admitted for COVID-19 or MIS-C versus those not admitted or admitted for other reasons (p < 0.001, for PSS/IES-R). Parental and childhood stress levels were correlated. In the multivariable linear regression analysis, children's hospitalization because of COVID-19 or MIS-C, younger parental age, the existence of comorbidities, and another family member's hospitalization because of COVID-19 were independent factors for higher stress. In light of the above, stricter hospital admission criteria for COVID-19 could be implemented, and psychological support for eventually admitted families may be beneficial.

Knowledge and Attitudes of Medical and Nursing Students in Greece Regarding Child Abuse and Neglect.

Data on the knowledge and attitudes of healthcare practitioners in training regarding child abuse and neglect (CAN) are scarce. The aim of this study was to investigate the knowledge and attitudes regarding CAN of medical and nursing students in Greek universities. We performed a questionnaire-based e-survey on a convenience sample of students and recruited 609 students (366 medical and 243 nursing). An unsatisfactory level of knowledge in the field was reported overall. Most of the students (92.2%) were aware of their future responsibility to protect vulnerable children and report suspected cases of CAN; at the same time, they were willing to obtain further education. Based on the above, appropriate training in the undergraduate curriculum should be developed in order to strengthen future healthcare practitioners and boost their confidence in dealing with suspected cases of CAN and protect children's welfare.

Is It Safe to Stay at Home? Parents' Perceptions of Child Home Injuries during the COVID-19 Lockdown.

The COVID-19 pandemic and stay-at-home regulations have increased child home injuries. This study illustrates the type and frequency of child home injuries in Greece during the COVID-19 lockdown. Moreover, the survey reports the results on parents' proposals regarding child injuries at home during the COVID-19 quarantine. A community-based, cross-sectional, descriptive study was conducted from November to December 2021 in Greece. Parents were asked to voluntarily complete an anonymous questionnaire, designed for the needs of the research. A statistical analysis of the data was performed using the Kolmogorov-Smirnov and Shapiro-Wilk tests for a normal distribution, a chi-squared (χ2) test to compare percentages among different groups and a non-parametric Mann-Whitney U test to determine the differences in Likert scale variables between two groups. A total of 130 parents with at least one child were questioned through an online questionnaire survey. Of the parents, 39.3%, stated that the number of accidents in their home increased. The most frequent accidents were injuries (49.3%). Most of the accidents occurred inside the house (75.8%) and were observed among children aged 0-4 years. A high percentage of children's accidents was observed in rural/island areas or in the suburbs. Children who were with either their father or mother had one accident, and a higher number of accidents occurred when the children were with their grandparents, with the nanny or alone. For those parents who had difficulty supervising their child, child accidents increased compared to parents who had the ability to supervise. It was noticed that parents who knew how to provide a safe home stated that the number of accidents remained the same. Parents must organize a safer home. Authorities should educate parents on child injury prevention and provide them with financial facilities to provide a safer house.

Parental and Pediatricians' Attitudes towards COVID-19 Vaccination for Children: Results from Nationwide Samples in Greece.

Although many studies have examined factors associated with COVID-19 vaccination and healthcare professionals' attitudes towards vaccines, less is known about parents' and pediatricians' attitudes towards COVID-19 vaccination for children. Using two cross-sectional surveys from November to December 2021 in Greece, we aimed to assess parental intention to vaccinate their 5 to 17 years old children against COVID-19 and to evaluate pediatricians' attitudes towards children's vaccination against COVID-19. Overall, 439 parents and 135 pediatricians participated. Of them, 240 (54.7%) intended to vaccinate their children against COVID-19. The most commonly reported reasons for non-intention were the short length of clinical trials and the fear of side effects. Only 16.6% of non-intenders would vaccinate their children if the pediatrician recommended it. The factors associated with higher intention to get vaccinated were a parent's own vaccination against COVID-19, trust in official healthcare guidelines, increased trust in the state and the healthcare system during the pandemic, and older age. Of the pediatricians, 92.6% recommended children's vaccination, and 75.6% agreed with mandating the vaccine. These findings suggest the need to tailor easy-to-understand messages by well-informed pediatricians to address safety concerns, educate, and clarify misconceptions through targeted interventions among those who currently do not wish to vaccinate their children.

Exercise Limitation in Children and Adolescents with Mild-to-Moderate Asthma.

BACKGROUND: Children with uncontrolled asthma are less tolerant to exercise due to ventilatory limitation, exercise-induced bronchoconstriction (EIB), or physical deconditioning. The contribution of these factors in children with controlled mild-to-moderate asthma is unknown. OBJECTIVE: To explore the underlying mechanisms of reduced exercise capacity in children with controlled mild-to-moderate asthma. METHODS: This was a cross-sectional study of 45 children and adolescents (age 8-18 years) with controlled mild-to-moderate asthma (asthma control test score 21-25) and 61 age-matched healthy controls. All participants completed a physical activity questionnaire and performed spirometry and cardiopulmonary exercise testing (CPET; maximal incremental protocol). Spirometric indices and CPET parameters were compared between the two groups. The effect of EIB (FEV1 decrease >10% post CPET), ventilatory limitation and physical deconditioning on maximum oxygen uptake (O2peak), was assessed by multivariable linear regression. RESULTS: 62.2% of children with asthma and 29.5% of controls (P = 0.002) were categorized as inactive. Reduced exercise capacity (O2peak <80%) was noted in 53.3% of asthmatics and 16.4% of controls (P < 0.001). EIB was documented in 11.1% of participants with asthma. Physical deconditioning was noted in 37.8% of children with asthma and in 14.8% of controls (P = 0.013). Physical deconditioning emerged as the only significant determinant of O2peak, irrespective of asthma diagnosis, body mass index, ventilatory limitation and EIB. CONCLUSION: Children with controlled mild-to-moderate asthma are less tolerant to strenuous exercise than their healthy peers. The decreased exercise capacity in this population should mainly be attributed to physical deconditioning, while the contribution of ventilatory limitation and EIB is rather small.