Treatment Options for Cyclic Vomiting Syndrome: A Real-World, Single-Center Experience with Systematic Literature Review and Meta-Analysis.

The optimal therapeutic management of cyclic vomiting syndrome (CVS) remains elusive. The objective of this study was to document our clinical experience in the Pediatric Department of San Marco Hospital and to survey the literature on pediatric CVS treatment, aiming to update the guidance on the most effective treatment strategies for this not-so-uncommon condition. Data from 70 patients with CVS, admitted to our Pediatric Department between September 2011 and December 2021, were aggregated and included in the study. A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool and the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2) method. Treatment responses, as observed both in the literature and in our own experience, are variable. In our cohort, topiramate demonstrated superiority over other pharmacological treatments, exhibiting an efficacy of 85% in the patients treated. A universally accepted treatment protocol for pediatric CVS has yet to be established. The efficacy of first-line treatments is generally suboptimal, suggesting that topiramate might serve as a safe and effective primary therapeutic option for pediatric CVS.

Respiratory Changes in Ventilated and Not-Ventilated Neonates During and After Whole-Body Hypothermia: A Multicenter Retrospective Study.

The aim of this study was to describe whether whole-body hypothermia induced different respiratory changes in both invasively and noninvasively ventilated newborns and spontaneously breathing asphyxiated newborns during the course and after therapeutic hypothermia (TH). Data of 44 asphyxiated newborns undergoing TH at five different neonatal intensive care units in southern Italy were collected retrospectively between January 2018 and January 2021. For each type of ventilation, patient data on pH, partial pressure of Carbon Dioxide (pCO2), base excess, lactate, and heart rate were recorded before cooling was started and at 24, 48, 72, and 96 hours from its initiation. Patients were later subgrouped into spontaneously breathing, noninvasively ventilated, and mechanically ventilated groups. The average trend of each parameter was reported, and a nonparametric statistical analysis of differences among groups before initiation and at 96 hours was performed using the Kruskal-Wallis test. Our results confirmed previous findings (supported by a small amount of literature) that no increase in requests for respiratory support is recorded in asphyxiated newborns undergoing TH during and after the rewarming phase. Furthermore, no statistically significant differences in the analyzed parameters were found among spontaneously breathing, noninvasively ventilated, and mechanically ventilated newborns, suggesting that changes in parameters might be attributable to TH itself rather than to an improvement in the respiratory condition over time; otherwise, a difference between spontaneously breathing patients, by definition "stable" from a respiratory point of view, and those requiring any type of respiratory support would have been expected.

Impressive efficacy of the ketogenic diet in a KCNQ2 encephalopathy infant: a case report and exhaustive literature review.

Background: KCNQ2 encephalopathy is characterized by neonatal-onset epilepsy and developmental impairment, due to "de novo" KCNQ2 pathogenic variants. According to literature data, sodium channel blocking agents appear to be the best treatment options for the disease. Reports describing the use of ketogenic diet (KD) in the KCNQ2 pediatric population are limited. The non-conservative amino acid substitution p.Ser122Leu in KCNQ2 is associated with a broad spectrum of inheritance modalities, clinical phenotypes and outcomes; no previous reports of the same variant treated with KD are available in literature. Case Description: We described a 22-month-old female with seizure onset on day 2 of life. At three months of age, she presented refractory status epilepticus (SE) that did not respond to midazolam and carbamazepine, which was added once a "de novo" p.Ser122Leu KCNQ2 variant was demonstrated. KD was the only treatment that led to cessation of seizures. The baby maintained seizures remission and achieved neurodevelopmental milestones. Conclusions: To define an overt genotype-phenotype correlation for KCNQ2 pathogenic variants is a challenge; we propose the KD as a valuable treatment for refractory seizures and impaired neurodevelopment in infants harboring "de novo" mutations in the KCNQ2 gene.

Prolonged Background Suppression Induced by Anticonvulsants Misleading Amplitude-Integrated Electroencephalography's Interpretation: A Single Case Report.

Prognostic role of the amplitude-integrated electroencephalography (aEEG) is undeniable, but few works focused on the contribution of medications in misleading its interpretation. We report the case of an asphyxiated newborn enrolled for therapeutic hypothermia (TH) that required the simultaneous use of three anticonvulsants, whose administration resulted in a comatose state and in a switch to a flat trace on the aEEG. The prolonged flat trace on the aEEG, pointing toward a state of irreversible brain damage, led to early stop of TH to prevent therapeutic obstinacy; unexpectedly, once Midazolam was weaned off, the aEEG recovered to a discontinuous pattern. The case emphasizes the aEEG's noninfallibility and advises clinicians to consider the potential misleading effects of depressant medications on its interpretation in asphyxiated newborns undergoing TH.

aEEG vs cEEG's sensivity for seizure detection in the setting of neonatal intensive care units: A systematic review and meta-analysis.

AIM: Amplitude-integrated electroencephalography (aEEG)'s accuracy compared to conventional electroencephalography (cEEG) has not been fully established. The aim of our study was to conduct a systematic review on the sensitivity of the aEEG for neonatal seizure detection. METHODS: Studies from PubMed and Google Scholar databases comparing recordings of cEEG and aEEG in newborns were included according to the PRISMA method. A quality assessment using the QUADAS-2 tool was provided. A random-effect model was used to account for different sources of variations among studies. Publication biases were represented by a funnel plot, and funnel plot symmetry was assessed. RESULTS: Fourteen studies were reported; sensitivity of each diagnostic tool used (single-channel aEEG, two-channel aEEG, two-channel aEEG plus raw trace EEG) was compared to that of the gold-standard cEEG and to those of the other methods used. Overall sensitivity of the aEEG ranged from 31.25% to 90%. CONCLUSION: Our study provides evidence that sensitivity of aEEG varies significantly and that seizure detection rate is lower than that of cEEG. The two-channel aEEG with raw trace EEG shows a high sensitivity and might represent a valid alternative to the cEEG in the setting of neonatal intensive care units (NICUs).

Observational study on the efficiency of Neonatal Emergency Transport in reducing mortality and morbidity indexes in Sicily.

In these last 25 years, the Neonatal Emergency Transport (NET) service has been widely improved in Italy. To date, all National areas are covered by a NET service; 53 NET centers have been activated in all the Italian territory. Herein, the authors present an observational study to evaluate the rate of infantile mortality after introduction of NET in Sicily, and to study the efficiency of this service in reducing these rates of mortality in vulnerable neonates, transported from primary care birth centers to tertiary facilities to undergo to specialized NICU assistance. All neonates who required an emergency transport by NETS were included. No exclusions criteria were applied. Demographic and regional infantile mortality data, expressed as infant mortality rate, were selected by the official government database (ISTAT- National Statistic Institute- http://www.istat.it ). All data were respectively divided into three groups: data concerning transport, clinical condition, and mortality of the transported patients. We transported by NET 325 neonates. The analysis of the infant mortality rate (per 1.000 live births) in Catania from 2016 to 2018 was reduced compared to the same rate calculated before NETS activation (4.41 index before 2016 vs 4.17 index after 2016). These data showed an increase in other provinces (Enna, Caltanissetta, and Agrigento). 61% of neonates showed a respiratory disease. During the study period the proportion of neonates with a Mortality Index for Neonatal Transportation-MINT < 6 has been reduced, while there was an increase of neonates with higher Transport Risk Index of Physiologic Stability-TRIPS score results. The slight decrease of infantile mortality in Catania during the first three years after introduction of NET follows the same trend of all Italian territories, showing the importance of this service in reducing infantile mortality.

Treating the symptom or treating the disease in neonatal seizures: a systematic review of the literature.

AIM: The existing treatment options for neonatal seizures have expanded over the last few decades, but no consensus has been reached regarding the optimal therapeutic protocols. We systematically reviewed the available literature examining neonatal seizure treatments to clarify which drugs are the most effective for the treatment of specific neurologic disorders in newborns. METHOD: We reviewed all available, published, literature, identified using PubMed (published between August 1949 and November 2020), that focused on the pharmacological treatment of electroencephalogram (EEG)-confirmed neonatal seizures. RESULTS: Our search identified 427 articles, of which 67 were included in this review. Current knowledge allowed us to highlight the good clinical and electrographic responses of genetic early-onset epilepsies to sodium channel blockers and the overall good response to levetiracetam, whose administration has also been demonstrated to be safe in both full-term and preterm newborns. INTERPRETATION: Our work contributes by confirming the limited availability of evidence that can be used to guide the use of anticonvulsants to treat newborns in clinical practice and examining the efficacy and potentially harmful side effects of currently available drugs when used to treat the developing newborn brain; therefore, our work might also serve as a clinical reference for future studies.

Previously Unreported COL7A1 Mutation in a Somali Patient with Dystrophic Epidermolysis Bullosa.

Epidermolysis bullosa (EB) encompasses a group of inheritable skin disorders characterized by various degrees of epithelial fragility that lead to cutaneous and mucosal blistering following negligible mechanical traumas. These disorders are clinically and genetically heterogeneous, ranging from mild skin involvement to severe disabling conditions with associated manifestations affecting the gastrointestinal and vesico-urinary tracts. EB may be classified into 4 main categories: simplex, junctional, dystrophic, and Kindler syndrome. Clinically, EB may present as syndromic or nonsyndromic forms. EB subtypes have mainly reported a number of mutations in the candidate COL7A1 gene encoding type VII collagen, a major stabilizing molecule of the dermoepidermal junction. Herein, we report a Somali girl with dystrophic EB who showed a previously unreported missense variant c.6797G>T in exon 86 in COL7A1.