A Comparative Study of Febrile Seizures and Febrile Convulsions Associated With Mild Gastroenteritis.

BACKGROUND: Children presenting with complex febrile seizures (FS) have an increased risk of developing epilepsy. This study aimed to investigate the occurrence of complex seizures in children presenting with FS and those with both convulsions associated with mild gastroenteritis (CwG) and fever. METHODS: Children admitted to our Pediatric Emergency Department between January 2017 and April 2019 with seizures were enrolled in this cross-sectional study. Patients were grouped according to the etiology as FS and febrile CwG. FS classification criteria of simple FS and complex FS was applied to both groups to allow a comparison between them. Prevalence ratios (PRs) of complex seizures, estimated through a log binomial model, were used to compare the occurrence of complex seizures between the two groups, using the FS group as reference category. RESULTS: A total of 294 patients were enrolled: 231 with FS and 63 with febrile CwG. Complex seizures occurred in 31 patients with FS (13.4%) and 21 patients (33.3%) with febrile CwG. The PR of complex seizures was 2.48 (95% confidence interval, 1.54 to 4.01). CONCLUSIONS: Children with febrile CwG showed a higher rate of complex seizures when compared with those with FS.

Extrarenal Immune-Mediated Disorders Linked with Acute Poststreptococcal Glomerulonephritis: a Systematic Review.

Streptococcus A infections have been associated with immune-mediated sequelae including acute glomerulonephritis, acute rheumatic fever, thrombocytopenia, hemolytic anemia, Henoch-Schönlein purpura, arthritis, uveitis, guttate psoriasis, and erythema nodosum. Available reviews do not report the occurrence of acute poststreptococcal glomerulonephritis in association with one of the mentioned conditions. We performed a systematic review of the literature on extrarenal immune-mediated disorders associated with acute poststreptococcal glomerulonephritis. The principles recommended by the Economic and Social Research Council guidance on the conduct of narrative synthesis and on the Preferred Reporting Items for Meta-Analyses and Systematic Reviews were used. We identified 41 original articles, published after 1965, which reported on 52 patients (34 males and 18 females aged from 1.7 to 57 years, median 9) affected by acute poststreptococcal glomerulonephritis associated with a further poststreptococcal disease: 29 cases with rheumatic fever (17 males and 12 females aged 3.0 to 57, median 17 years), 16 with hematologic diseases such as thrombocytopenia or hemolytic anemia (13 males and 3 females aged 1.8 to 13, median 6.0 years) and seven with Henoch-Schönlein syndrome, reactive arthritis or uveitis (4 males and 3 females aged 1.7 to 14, median 7.0 years). Patients affected by acute poststreptococcal glomerulonephritis associated with acute rheumatic fever were on the average older (P < 0.05) than patients with acute poststreptococcal glomerulonephritis associated with thrombocytopenia, hemolytic anemia, Henoch-Schönlein syndrome, reactive arthritis or uveitis. Five large case series describing 2058 patients affected by acute poststreptococcal glomerulonephritis did not mention its occurrence in association with further immune-mediated disorders. This systematic review points out that acute poststreptococcal glomerulonephritis can be associated, albeit rarely, with rheumatic fever, thrombocytopenia, hemolytic anemia, Henoch-Schönlein syndrome, reactive arthritis, or uveitis.

Hyponatremia in infants with community-acquired infections on hospital admission.

Acute moderate to severe gastroenteritis is traditionally associated with hypernatremia but recent observations suggest that hypernatremia is currently less common than hyponatremia. The latter has sometimes been documented also in children with acute community-acquired diseases, such as bronchiolitis and pyelonephritis. We investigated the prevalence of dysnatremia in children with acute moderate severe gastroenteritis, bronchiolitis and pyelonephritis. This prospective observational study included 400 consecutive previously healthy infants ≥4 weeks to ≤24 months of age (232 males and 168 females): 160 with gastroenteritis and relevant dehydration, 160 with moderate-severe bronchiolitis and 80 with pyelonephritis admitted to our emergency department between 2009 and 2017. Circulating sodium was determined by means of direct potentiometry. For analysis, the Kruskal-Wallis test and the Fisher's exact test were used. Hyponatremia was found in 214 of the 400 patients. It was common in gastroenteritis (43%) and significantly more frequent in bronchiolitis (57%) and pyelonephritis (68%). Patients with hyponatremia were significantly younger than those without hyponatremia (3.9 [1.6-13] versus 7.5 [3.4-14] months). The gender ratio was similar in children with and without hyponatremia. Hyponatremia was associated with further metabolic abnormalities (hypokalemia, hyperkalemia, metabolic acidosis or metabolic alkalosis) in gastroenteritis (71%) and pyelonephritis (54%), and always isolated in bronchiolitis. In conclusion, hyponatremia is common at presentation among previously healthy infants with gastroenteritis, bronchiolitis or pyelonephritis. These data have relevant consequences for the nutrition and rehydration management in these conditions.

Systematic review finds that fever phobia is a worldwide issue among caregivers and healthcare providers.

AIM: Fever phobia describes exaggerated concerns about the consequences of childhood fever and broader awareness is needed in everyday clinical practice. We investigated the factors associated with fever phobia in caregivers and healthcare providers and the geographical distribution of the issue. METHODS: The National Library of Medicine, Excerpta Medica and Google Scholar databases were searched. RESULTS: We retrieved 76 papers, published in English from 1985 to 2018, which covered wide areas of Asia, Europe, America, Africa and Australia. The occurrence of fever phobia was confirmed in 65 papers covering 26 521 caregivers. A number of factors were significantly associated with fever phobia, including low educational or socioeconomic levels, a history of febrile seizures in the child and young maternal age. Fever phobia was also more common in Bedouins and in people from Latin America, Southern Italy and Turkey. There were also 15 papers that addressed fever phobia among 4566 healthcare providers. All the reports suggested that a fear of fever and a tendency to over treat was common among physicians and nurses. CONCLUSION: Fever phobia was a common world phenomena that affected caregivers and healthcare providers.

Idiopathic systemic capillary leak syndrome (Clarkson syndrome) in childhood: systematic literature review.

Approximately 500 cases of idiopathic systemic capillary leak syndrome (Clarkson syndrome) have been reported worldwide. This life-threatening condition is characterized by episodes of increase in vascular permeability with loss of fluid into the interstitium and presents with acute onset of edema, signs of tissue hypoperfusion, hemoconcentration, and low blood protein level. It has been diagnosed mainly in middle-aged adults with a monoclonal gammopathy. We performed a systematic review of the literature on Clarkson syndrome in subjects ≤ 18 years of age. We identified 24 reports, published since 1989, providing data on 32 otherwise healthy subjects, who experienced 67 well-documented episodes of Clarkson syndrome. The condition affected more frequently girls (21, 66%) than boys, presented throughout childhood, and was preceded by a mostly viral illness in 75% of cases. A monoclonal gammopathy was never reported. Uncompensated circulatory shock, muscle compartment syndrome, acute kidney injury, pulmonary edema, and either pleural or pericardial effusion were, in decreasing order of frequency, the most common complications. Four patients died.Conclusion: Clarkson syndrome develops not only in adulthood but also in childhood. In this age group, this condition is not linked to a monoclonal gammopathy. What is Known: • Clarkson syndrome is a rare condition that has been diagnosed mainly in middle-aged adults and is mostly linked to a monoclonal gammopathy. What is New: • In subjects ≤ 18 years of age, Clarkson syndrome is not linked to a monoclonal gammopathy.

Bioimpedance Spectroscopy Imprecisely Assesses Lean Body Mass in Pediatric Dialysis Patients.

OBJECTIVES: Alterations in body compositions are strongly associated with poor outcomes in end-stage renal disease patients. Hence, assessment of lean body mass is crucial for clinically monitoring these patients. The use of multifrequency bioimpedance spectroscopy measurements has also been advocated, but their usefulness in children is questioned. We investigated whether their application is appropriate for lean body mass measurement in pediatric patients receiving chronic dialysis. METHODS: Lean body mass estimates as assessed by multifrequency bioimpedance spectroscopy and by deuterium dilution were obtained for 15 patients (mean age 10.9 ±â€Š3.6 years). RESULTS: Lean body mass (mean ±â€Šstandard deviation) determined by bioimpedance was 24.2 ±â€Š10.7 and 24.4 ±â€Š10.3 kg by deuterium technique. Bland-Altman analysis showed a mean (±standard deviation) difference between the 2 methods of -0.25 ±â€Š2.30 kg with 95% limits of agreement of -4.80 to 4.25 kg. In a multiple linear regression model, the hydration status was associated with measurement bias after adjusting for age, sex, weight, and body surface area. CONCLUSIONS: Our results show a high level of agreement between measurements by bioimpedance and deuterium technique, but the limits of agreement were wide. These findings do not support the use of bioimpedance to individually assess lean body mass in pediatric dialysis patients with and without overhydration.

Clinical Practice: Nausea and vomiting in acute gastroenteritis: physiopathology and management.

Currently recommended management of acute gastroenteritis is supportive. Although the affected children habitually have vomiting, recommendations do not focus on the correction of this symptom. In this condition, elevated ketone bodies and stimuli initiated by gut mucosa damage produced by the enteral pathogen likely underlay nausea and vomiting. As compared to 0.9% saline, intravenous administration of a dextrose-containing bolus of 0.9% saline is associated with a greater reduction of circulating ketones and a shorter duration of nausea and vomiting. Nonetheless, this treatment strategy is not followed by a lower rate of hospitalization. CONCLUSION: Well-designed investigations suggest that antagonists of the type 3 serotonin receptor, most frequently oral ondansetron, reduce the rate of vomiting, improve the tolerance of oral rehydration, and reduce the need for intravenous rehydration. What is Known: • Although children with gastroenteritis habitually have vomiting, current recommendations do not focus on the correction of this symptom. What is New: • Recently acquired evidence supports the prescription of ondansetron, an antagonist of the type 3 serotonin receptor, to increase the success rate of oral rehydration therapy.

D-lactic acidosis in humans: systematic literature review.

BACKGROUND: D-lactic acidosis is an uncommon and challenging form of metabolic acidosis that may develop in short bowel syndrome. It has been documented exclusively in case reports and small case series. METHODS: We performed a review of the literature in the National Library of Medicine and Excerpta Medica databases. RESULTS: We identified 84 original reports published between 1977 and 2017. D-lactic acidosis was observed in 98 individuals ranging in age from 7 months to 86 years with short bowel syndrome. The clinical presentation included Kussmaul breathing, confusion, slurred speech, and gait disturbances. Furthermore, among 99 consecutive patients with short bowel syndrome, 21 reported having episodes with symptoms consistent with D-lactic acidosis. In addition, D-lactic acid might also contribute to acidosis in diabetes mellitus. Finally, abnormally high D-lactic acid was documented after administration or ingestion of large amounts of propylene glycol, as paraneoplastic phenomenon and perhaps also in a so far poorly characterized inherited inborn error of metabolism. CONCLUSIONS: In humans with short bowel syndrome (or carbohydrate malabsorption), D-lactic acidosis is likely rather common and under-recognized. This condition should be included in the differential diagnosis of unexplained high-gap metabolic acidosis where the anion causing the acidosis is not known. Furthermore, diabetic acidosis might be caused by accumulation of both ketone bodies and D-lactic acid. Finally, there are endogenous sources of D-lactic acid in subjects with propylene glycol intoxication.

Predictive value of EEG for febrile seizure recurrence.

OBJECTIVE: To define the role of the EEG in predicting recurrence of febrile seizures (FS) in children after a first FS. METHODS: Children with a first simple or complex FS who underwent EEG at our hospital were retrospectively enrolled. EEG recordings were classified in three groups: normal, abnormal (slow activity or epileptiform discharges), and pseudo-petit mal discharge (PPMD) pattern. Children were followed-up for at least three years. RESULTS: A total of 126 patients met the entry criteria, and 113 of them completed the follow-up. Risk of FS recurrence decreased linearly with increasing age (-2% per month). The risk was higher among patients with PPMD pattern (absolute risk 86%, adjusted relative risk 2.00) and abnormal EEG (epileptiform discharges: absolute risk 71%, adjusted relative risk 2.00; slow activity: absolute risk 56%, adjusted relative risk 1.44), compared with those with normal EEG (absolute risk 41%). CONCLUSIONS: PPMD and abnormal EEG should be considered as an independent risk factor for FS recurrence.

Electrical impedance tomography in children with community acquired pneumonia: preliminary data.

BACKGROUND: Electrical impedance tomography (EIT) is a noninvasive pulmonary function test that provides spatial and temporal information of changes in regional lung ventilation. We aimed to assess the feasibility of EIT as a supplementary tool in the evaluation of community acquired pneumonia in children. Furthermore, we performed a prospective evaluation of regional lung ventilation changes during a six-month follow-up period. METHODS: We enrolled otherwise healthy children aged 2-15 years with radiological diagnosis of community acquired pneumonia on admission at pediatric emergency department. Chest EIT was performed at enrollment, at three and six-months from baseline. RESULTS: Nineteen children were enrolled. A significant agreement between EIT and chest radiography in identifying the affected lung (left or right) was observed (Cohen K statistic = 0.73, 95% CI 0.5-0.98). Ventilation improvement was documented at three-month follow-up, but a full recovery only at six months. CONCLUSION: EIT reliably provides additional information on lung ventilation disorders due to CAP in children. It further allows bedside, real time and radiation free monitoring of lung functional recovery. Future studies are needed to expand the generalizability of this method and evaluate effectiveness on clinical practice.

Hyponatremia in infants with new onset moderate-severe bronchiolitis: A cross-sectional study.

BACKGROUND: The reported cumulative prevalence of hyponatremia (sodium <135 mmol/L) in bronchiolitis is 28%. However, sodium level was never measured by direct potentiometry, the method recommended by the International Federation of Clinical Chemistry and Laboratory Medicine. Aim of this study was to assess the prevalence of hyponatremia, measured by direct potentiometry, in infants with moderate-severe bronchiolitis. METHODS: A prospective cross-sectional study was conducted in infants ≥1month and ≤24months of age with bronchiolitis. RESULTS: 160 consecutive infants were enrolled. Hyponatremia was observed in 91 (57%) patients and occurred more commonly in infants ≤6 months than in older infant (P < 0.005). CONCLUSION: The first study on sodium level measured by the direct potentiometry in infants with bronchiolitis points out that the prevalence of hyponatremia is two-fold higher than so far reported.

Neonatal Systemic Lupus Erythematosus Syndrome: a Comprehensive Review.

Neonatal lupus erythematosus is an uncommon syndrome, which is caused by transplacental passage of maternal autoantibodies to Sjögren's syndrome A or B autoantigens. The clinical presentation includes distinctive cutaneous lesions resembling those seen in systemic lupus erythematosus, hepatobiliary disease, and cytopenias, which disappear with the clearance of maternal autoantibodies. The most severe presentation is a total atrioventricular heart block, which begins during the second trimester of gestation and is irreversible. The risk of having a child with neonatal lupus erythematosus in mothers who test positive for autoantibodies to Sjögren's syndrome autoantigens is approximately 2% for first pregnancies or if previous babies were healthy. The risk increases by approximately tenfold if a previous child had neonatal lupus erythematosus syndrome. The diagnosis of neonatal lupus erythematosus is made when the mother has autoantibodies to Sjögren's syndrome autoantigens, and the fetus or newborn develops atrioventricular heart block, or the newborn develops the typical rash or hepatic or hematologic manifestations in the absence of other explanation. Fetal echocardiography from the 16th to the 26th week of gestation is advised in mothers with autoantibodies to Sjögren autoantigens. The detection of a slow fetal heart rate or the postnatal diagnosis of atrioventricular heart block warrants immediate maternal testing for these autoantibodies if not previously tested.

Liver chemistry in new-onset Henoch-Schönlein syndrome.

BACKGROUND: Henoch-Schönlein syndrome is a systemic small-vessel leukocytoclastic vasculitis that usually present with cutaneous, gastrointestinal, articular and renal manifestations. Little is known on liver involvement in this syndrome. This study investigated liver chemistry and creatine kinase in Henoch-Schönlein children. CASE PRESENTATION: Alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase, lactate dehydrogenase, total bilirubin, prothrombin time and creatine kinase were assessed in 75 consecutive pediatric patients (41 boys and 34 girls aged from 2.9 to 17 years) with new-onset Henoch-Schönlein syndrome. Mildly altered values were found in 7 (9%) patients (5 boys and 2 girls aged from 3.3 to 17 years). In the mentioned cases, all tests returned to normal at a 2-4-week follow-up. CONCLUSIONS: This preliminary study points out that altered and self-remitting liver parameters occur in approximately 10% of children with Henoch-Schönlein syndrome.

Cutaneous Manifestations of Small-Vessel Leukocytoclastic Vasculitides in Childhood.

In childhood, cutaneous small-vessel vasculitides include Henoch-Schönlein syndrome, a systemic vasculitis, and Finkelstein-Seidlmayer syndrome, a skin-limited vasculitis. Both Henoch-Schönlein and Finkelstein-Seidlmayer syndromes are seen more frequently in white or Asian compared with black children and occur especially in winter and spring with a male-to-female ratio of approximately 2:1. In everyday clinical practice, both conditions are diagnosed on clinical grounds without histological confirmation. The characteristic cutaneous hallmarks of Henoch-Schönlein syndrome include a purpuric rash in all and a subcutaneous edema in approximately every second case, which are often preceded by non-specific red or pink macular elements that mimic a non-itching urticarial rash. Recent data point out that Henoch-Schönlein children often present further cutaneous findings such as Köbnerization, Rumpel-Leede capillary fragility phenomenon, and blistering eruptions. Children with Finkelstein-Seidlmayer syndrome are usually ≤24 months of age and not ill-appearing. They present with (a) large, round, red to purpuric plaques (often with a targetoid appearance) predominantly over the cheeks, ears, and extremities and (b) often tender non-pitting edema of the distal extremities, ears, and face (without pruritus). Both in Henoch-Schönlein syndrome and Finkelstein-Seidlmayer syndrome, there is often scrotal involvement. The cutaneous findings remit without sequelae within 2 months in Henoch-Schönlein and 3 weeks in Finkelstein-Seidlmayer syndrome.

Electrolyte and Acid-Base Abnormalities in Infants with Community-Acquired Acute Pyelonephritis: Prospective Cross-Sectional Study.

BACKGROUND: Retrospective case series suggest that abnormalities in fluid, electrolyte, and acid-base homeostasis may occur among infants with a febrile urinary tract infection. Potentially inaccurate laboratory methods of sodium testing have often been used. METHODS: Between January 2009 and June 2016, we managed 80 previously healthy infants (52 males and 28 females) ≥4 weeks to ≤24 months of age with their first episode of acute pyelonephritis. Ionized sodium, ionized potassium and ionized chloride were determined by direct potentiometry, as recommended by the International Federation of Clinical Chemistry. Bicarbonate was calculated from pH and carbon dioxide pressure. RESULTS: Electrolyte or acid-base abnormalities were disclosed in 59 (74%) of the 80 infants: hyponatremia (n = 54), hypobicarbonatemia (n = 18), hyperkalemia (n = 14), hyperbicarbonatemia (n = 6), hypochloremia (n = 3), hypokalemia (n = 3), and hyperchloremia (n = 1). None of the patients was found to be hypernatremic. Patients with and without electrolyte or acid-base abnormalities did not differ with respect to age, sex distribution, and whole blood glucose. Blood tonicity was lower and poor fluid intake, frequent regurgitations or loose stools more common among infants with electrolyte or acid-base abnormalities. CONCLUSIONS: This prospective cross-sectional study shows that electrolyte or acid-base abnormalities, most frequently hyponatremia, occur in approximately 3 quarters of infants with acute pyelonephritis.

Acute pain management: acetaminophen and ibuprofen are often under-dosed.

Most children with pain are managed by either acetaminophen or ibuprofen. However, no study has so far investigated if children are prescribed adequate doses of acetaminophen or ibuprofen in emergency department. Aim of this retrospective study was to investigate the prevalence of under-dosage of these drugs in children presenting with pain in emergency department. Children initially prescribed with acetaminophen or ibuprofen for pain management were included. The χ 2 automatic interaction detection method was used considering the percentage variation from the minimum of the appropriate dose as dependent variable while prescribed drug, age, gender, body weight, type of hospital (pediatric or general), and availability of internal guidelines on pediatric pain management in the emergency department as independent variables. Data on 1471 children managed for pain were available. Under-dosage was prescribed in 893 subjects (61%), of whom 577 were prescribed acetaminophen and 316 ibuprofen. The use of acetaminophen suppositories, body weight <12 kg or >40 kg, and the use of oral ibuprofen identified clusters of children associated with under-dosage prescription. CONCLUSION: Prescription of acetaminophen and ibuprofen was frequently under-dosed. The use of suppositories, lower and higher body weight, and the use of ibuprofen were associated with under-dosage. Under-dosing may reflect prescription of anti-pyretic doses. CLINICAL TRIAL REGISTRATION: Agenzia Italiana del Farmaco-Observational Study Register (RSO). Registration code: PIERRE/1 What is Known: • Pain is frequent in children presented to emergency department. • International recommendations on pain management are often not implemented. What is New: • Acetaminophen and ibuprofen were frequently underdosed in children prescribed for pain in the Italian emergency departments. • Under-dosage may be related to the habit of using acetaminophen and ibuprofen in the recommended range for fever treatment.

Recurrent Focal Myositis in Childhood: A Case Report and Systematic Review of the Literature.

BACKGROUND: Recurrent focal myositis in adulthood has been documented in case reports and case series. Existing textbooks and reviews do not mention or mention only in passing this entity in childhood. We present a patient with recurrent focal myositis and summarize available clinical, laboratory, management, and outcome data on this entity in the pediatric ages. METHOD: We describe a nine-year-old patient with recurrent myositis of the left biceps. The terms "myositis" and "relapsing" or "recurrent" or "recurrence" were searched using the United States National Library of Medicine and the Excerpta Medica Database. Pertinent secondary references were also screened. RESULTS: Another seven pediatric patients (five males and two females, median age ten years, interquartile range 7-14 years) with recurrent focal myositis were identified. In children, the calf was the most frequently involved muscle. Unlike adults, the myositis in children was usually painful. Episodes could be associated with normal or elevated erythrocyte sedimentation rate and blood levels of C-reactive protein, creatine kinase, and aspartate aminotransferase. Abnormalities of the creatine kinase value did not seem to be associated with a higher risk of recurrences. CONCLUSIONS: Focal myositis has a favorable outcome in children. Recurrent focal myositis is rare and usually benign in childhood. More data are needed to improve the understanding of this condition.

Acute Nonspecific Mesenteric Lymphadenitis: More Than "No Need for Surgery".

Acute nonspecific, or primary, mesenteric lymphadenitis is a self-limiting inflammatory condition affecting the mesenteric lymph nodes, whose presentation mimics appendicitis or intussusception. It typically occurs in children, adolescents, and young adults. White blood count and C-reactive protein are of limited usefulness in distinguishing between patients with and without mesenteric lymphadenitis. Ultrasonography, the mainstay of diagnosis, discloses 3 or more mesenteric lymph nodes with a short-axis diameter of 8 mm or more without any identifiable underlying inflammatory process. Once the diagnosis is established, supportive care including hydration and pain medication is advised. Furthermore, it is crucial to reassure patients and families by explaining the condition and stating that affected patients recover completely without residuals within 2-4 weeks.