Omental infarction in an overweight child: conservative treatment is a safe approach.

A previously healthy but overweight (body mass index (BMI) of 24.4) adolescent boy presented with fever and significant right-sided abdominal pain. An abdominal ultrasound scan revealed an omental infarction (OI), which was treated conservatively. OI has been described in overweight teenage children with abdominal trauma but can be missed if not considered. A missed diagnosis could result in an unnecessary laparotomy or laparoscopic surgery. Although CT is the gold standard for diagnosis, ultrasonography is an effective approach to identifying OI in children. The benefits of early diagnosis of OI by abdominal ultrasound include a shorter hospital stay and a reduction in unnecessary investigations and surgery.

Post-COVID mRNA vaccine myocarditis in children: report of two cases.

The SARS-COV-2 pandemic led to the development of several vaccinations to contain the disease. The Pfizer-BioNTech COVID-19 (BNT162b2) vaccine was recommended on May 2021 for use in children above 12 years and older. The vaccine is safe, well tolerated and highly effective. Initial reports showed no serious adverse events; however, cases of myocarditis in young healthy male adolescents have been reported. We report two cases of myocarditis/perimyocarditis who presented with short history of chest pain following administration of the second dose of the MRN COVID-19 vaccine.

Diabetic ketoacidosis fluid management in children: systematic review and meta-analyses.

IMPORTANCE: Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, which may lead to significant morbidity and mortality. OBJECTIVES: To compare the safety and efficacy of liberalised versus conservative intravenous fluid regimens in the management of DKA in children. DATA SOURCE AND STUDY SELECTION: Databases from inception to January 2022: MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were included. Only randomised controlled trials (RCTs) that included children aged under 18 years were assessed. Two reviewers performed data assessment and extraction. DATA EXTRACTION AND SYNTHESIS: Three studies out of 1536 citations were included. MAIN OUTCOMES: The time to the recovery from the DKA; the frequency of paeditric intensive care unit (PICU) admissions; development of brain oedema; reduction in Glasgow Coma Scale (GCS); development of acute kidney injury and all-cause mortality. RESULTS: We included three RCTs (n=1457). No evidence of difference was noted in the GCS reduction (risk ratio (RR)=0.77, 95% CI 0.44 to 1.36) or development of brain oedema (RR=0.50, 95% CI 0.15 to 1.68). The time to recovery from DKA was longer in the conservative group (mean difference=1.42, 95% CI 0.28 to 2.56). Time to hospital discharge, adverse or serious adverse events were comparable in the two studied groups. CONCLUSION: There is no evidence from this meta-analysis that rate of fluid administration has any effect on adverse neurological and other outcomes or length of hospital stay.

Tipping the Balance: Vitamin D Inadequacy in Children Impacts the Major Gut Bacterial Phyla.

Vitamin D inadequacy appears to be on the rise globally, and it has been linked to an increased risk of osteoporosis, as well as metabolic, cardiovascular, and autoimmune diseases. Vitamin D concentrations are partially determined by genetic factors. Specific single nucleotide polymorphisms (SNPs) in genes involved in vitamin D transport, metabolism, or binding have been found to be associated with its serum concentration, and these SNPs differ among ethnicities. Vitamin D has also been suggested to be a regulator of the gut microbiota and vitamin D deficiency as the possible cause of gut microbial dysbiosis and inflammation. This pilot study aims to fill the gap in our understanding of the prevalence, cause, and implications of vitamin D inadequacy in a pediatric population residing in Qatar. Blood and fecal samples were collected from healthy subjects aged 4-14 years. Blood was used to measure serum metabolite of vitamin D, 25-hydroxycholecalciferol 25(OH)D. To evaluate the composition of the gut microbiota, fecal samples were subjected to 16S rRNA gene sequencing. High levels of vitamin D deficiency/insufficiency were observed in our cohort with 97% of the subjects falling into the inadequate category (with serum 25(OH)D < 75 nmol/L). The CT genotype in rs12512631, an SNP in the GC gene, was associated with low serum levels of vitamin D (ANOVA, p = 0.0356) and was abundant in deficient compared to non-deficient subjects. Overall gut microbial community structure was significantly different between the deficient (D) and non-deficient (ND) groups (Bray Curtis dissimilarity p = 0.049), with deficient subjects also displaying reduced gut microbial diversity. Significant differences were observed among the two major gut phyla, Firmicutes (F) and Bacteroidetes (B), where deficient subjects displayed a higher B/F ratio (p = 0.0097) compared to ND. Vitamin D deficient children also demonstrated gut enterotypes dominated by the genus Prevotella as opposed to Bacteroides. Our findings suggest that pediatric vitamin D inadequacy significantly impacts the gut microbiota. We also highlight the importance of considering host genetics and baseline gut microbiome composition in interpreting the clinical outcomes related to vitamin D deficiency as well as designing better personalized strategies for therapeutic interventions.

Gastrointestinal manifestations of COVID-19 in children: a systematic review and meta-analysis.

OBJECTIVES: To summarise the published evidence on the gastrointestinal manifestations of COVID-19 in children and to determine the prevalence of gastrointestinal symptoms. METHODS: In this systematic review and meta-analysis, we searched PubMed, Embase, CINAHL and the WHO's database of publications on novel coronavirus. We included English language studies that had described original demographic and clinical characteristics of children diagnosed with COVID-19 and reported on the presence or absence of gastrointestinal symptoms. Meta-analysis was conducted using the random-effects model. The pooled prevalence of gastrointestinal symptoms was expressed as proportion and 95% CI. RESULTS: The search identified 269 citations. Thirteen studies (nine case series and four case reports) comprising data for 284 patients were included. Overall, we rated four studies as having a low risk of bias, eight studies as moderate and one study as high risk of bias. In a meta-analysis of nine studies, comprising 280 patients, the pooled prevalence of all gastrointestinal symptoms was 22.8% (95% CI 13.1% to 35.2%; I2=54%). Diarrhoea was the most commonly reported gastrointestinal symptom followed by vomiting and abdominal pain. CONCLUSIONS: Nearly a quarter of children with COVID-19 have gastrointestinal symptoms. It is important for clinicians to be aware of the gastrointestinal manifestation of COVID-19. PROSPERO REGISTRATION NUMBER: CRD42020177569.

Levetiracetam for convulsive status epilepticus in childhood: systematic review and meta-analysis.

IMPORTANCE: Prolonged seizures are life-threatening emergencies associated with significant morbidity. OBJECTIVE: To determine the efficacy and safety of levetiracetam in treating convulsive status epilepticus (CSE) in childhood. DATA SOURCES AND STUDY SELECTIONS: PubMed, Embase, the Cochrane Central Register of Controlled Trials and Cumulative Index to Nursing and Allied Health Literature were searched from inception up to April 2020. Only randomised controlled trials (RCTs) that included children aged 1 month-18 years were assessed. Two reviewers performed data assessment and extraction. DATA EXTRACTION AND SYNTHESIS: Ten studies out of the 20 637 citations identified were included. MAIN OUTCOMES: Cessation of seizure activities, time to cessation of seizure activities, need for rapid sequence intubation (RSI), intensive care unit (ICU) admission, recurrence of seizures at 24 hours, adverse events and all-cause mortality. RESULTS: We included 10 RCTs (n=1907). There was no significant difference in cessation of seizure activities when levetiracetam was compared with phenytoin (risk ratio (RR)=1.03, 95% CI 0.98 to 1.09), levetiracetam to fosphenytoin (RR=1.16, 95% CI 1.00 to 1.35) or levetiracetam to valproate (RR=1.10, 95% CI 0.94 to 1.27). No differences were found in relation to the timing of cessation of seizures for levetiracetam versus phenytoin (mean difference (MD)=-0.45, 95% CI -1.83 to 0.93), or levetiracetam versus fosphenytoin (MD=-0.70, 95% CI -4.26 to 2.86). There were no significant differences with regard to ICU admissions, adverse events, recurrence of seizure at 24 hours, RSI and all-cause mortality. CONCLUSION: Levetiracetam is comparable to phenytoin, fosphenytoin and valproate as a second line treatment of paediatric CSE.

Systematic review with meta-analysis: the efficacy of tranexamic acid in upper gastrointestinal bleeding.

BACKGROUND: Upper gastrointestinal bleeding is a common medical emergency associated with substantial mortality. Tranexamic acid may be effective for reducing mortality in upper gastrointestinal bleeding. AIM: To examine the effects of tranexamic acid in upper gastrointestinal bleeding by systematic review and meta-analysis. METHODS: We searched PubMed, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL) and other relevant websites for randomised controlled trials investigating the effect of tranexamic acid published from inception to December 10, 2019. The primary outcome of interest was mortality. Estimates of effect were pooled with a random effects model. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: The search identified 1572 citations. Eleven trials comprising 2076 patients were eligible for inclusion. Of these, 10 trials (2013 patients) compared tranexamic acid with placebo. Risk of death was significantly reduced in patients who received tranexamic acid compared with those who received placebo (RR 0.59, 95% CI 0.43-0.82, P = 0.001) with no significant heterogeneity noted among studies (I2  = 0%, P = 0.81). The GRADE assessment rated the quality of the evidence for mortality as moderate due to risk of bias. There were no statistically significant differences between tranexamic acid and placebo for the prevention of re-bleeding, need for surgical interventions, need for blood transfusions or frequency of thromboembolic events. CONCLUSIONS: Moderate-quality evidence shows that tranexamic acid is superior to placebo for the reduction in mortality in patients with upper gastrointestinal bleeding. While our findings lend further support to the use of tranexamic acid for treating patients with upper gastrointestinal bleeding, additional higher-quality trials are needed.

Melatonin for the management of sleep problems in children with neurodevelopmental disorders: a systematic review and meta-analysis.

IMPORTANCE: Children with neurodevelopmental disorders have a higher prevalence of sleep disturbances. Currently there is variation in the use of melatonin; hence, an up-to-date systematic review is indicated to summarise the current available evidence. OBJECTIVE: To determine the efficacy and safety of melatonin as therapy for sleep problems in children with neurodevelopmental disorders. DATA SOURCES AND STUDY SELECTIONS: PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials were searched from inception up to January 2018. Two reviewers performed data assessment and extraction. We assessed randomised controlled trials that compared melatonin with placebo or other intervention for the management of sleep disorders in children (<18 years) with neurodevelopmental disorders. DATA EXTRACTION AND SYNTHESIS: We identified 3262 citations and included 13 studies in this meta-analysis. MAIN OUTCOMES: Main outcomes included total sleep time, sleep onset latency, frequency of nocturnal awakenings and adverse events. RESULTS: Thirteen randomised controlled trials (n=682) met the inclusion criteria. A meta-analysis of nine studies (n=541) showed that melatonin significantly improved total sleep time compared with placebo (mean difference (MD)=48.26 min, 95% CI 36.78 to 59.73, I2=31%). In 11 studies (n=581), sleep onset latency improved significantly with melatonin use (MD=-28.97, 95% CI -39.78 to -18.17). No difference was noted in the frequency of nocturnal awakenings (MD=-0.49, 95% CI -1.71 to 0.73). No medication-related serious adverse event was reported. CONCLUSION: Melatonin appeared safe and effective in improving sleep in the studied children. The overall quality of the evidence is limited due to heterogeneity and inconsistency. Further research is needed.

Patent foramen ovale (PFO) closure versus medical therapy for prevention of recurrent stroke in patients with prior cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: We performed a systematic review and meta-analysis of randomized controlled trials to assess the effect of closure of a patent foramen ovale (PFO) compared with medical therapy for the prevention of stroke in patients with prior cryptogenic stroke. BACKGROUND: The role of PFO closure in reducing risk of stroke in patients with prior cryptogenic stroke has been controversial. METHODS: We searched PubMed, Embase, CINAHL, and CENTRAL for randomized trials investigating PFO closure versus medical therapy. We assessed trial bias and the quality of evidence for main outcomes was rated using GRADE. The primary outcome of interest was the occurrence of stroke. Estimates of effect were pooled with a random-effects model. This study is registered with PROSPERO (CRD42017081579). RESULTS: We included five trials, comprising data for 3,440 adults randomized to receive PFO closure (n = 1,829) or medical therapy (n = 1,611). Mean follow-up ranged from 2 years to 5.4 years across the trials. Patients treated with PFO closure had a lower risk of stroke (RR 0.39, 95% CI 0.18-0.88, I2 = 57%, P = 0.02) compared with those treated with medical therapy. Subgroup analyses showed that the beneficial effect of PFO closure on a composite outcome of cerebrovascular events is more pronounced in patients with a large PFO shunt (RR 0.25, 95% CI 0.12-0.54, I2 = 0%, P = 0.0004), male patients (RR 0.34, 95% CI 0.15-0.75, I2 = 36%, P = 0.07), and those aged ≤45 years (RR 0.35, 95% CI 0.15-0.79, I2 = 0%, P = 0.01). CONCLUSIONS: PFO closure reduced risk of stroke compared with medical therapy. PFO closure is a therapeutic option that should be offered to adults with cryptogenic stroke.

Corticosteroids for Preventing Caustic Esophageal Strictures: Systematic Review and Meta-analysis.

OBJECTIVES: Caustic ingestion can have a complicated clinical course. Corticosteroids are widely used but there is uncertainty about its role in preventing esophageal stricture formation following caustic ingestion. This systematic review and meta-analysis assessed the available clinical evidence regarding the efficacy and safety of corticosteroids for preventing esophageal strictures following caustic injury. METHODS: We assessed randomized controlled trials (RCTs) that compared corticosteroids versus no corticosteroids in the prevention of esophageal stricture formation following caustic ingestion. We searched the following databases from inception to March 2017: PubMed, Embase, and the Cochrane Central Register of Controlled Trials. Two reviewers retrieved eligible articles, assessed risk of bias, and performed data extraction. The main outcome measure was the prevention of esophageal stricture formation. RESULTS: The search identified 763 citations. Three RCTs involving 244 participants met the inclusion criteria. There was no benefit of corticosteroids in the prevention of esophageal strictures following the ingestion of caustic materials (risk ratio [RR] = 0.63, 95% CI = 0.29-1.37). CONCLUSIONS: The available evidence does not support the use of corticosteroids for the prevention of esophageal strictures following caustic ingestion. The overall quality of the evidence is limited because of methodological weaknesses and small sample sizes in the primary studies.

Antenatal Bartter syndrome presenting with vomiting and constipation mimicking subacute intestinal obstruction in a 20-day-old neonate.

Antenatal Bartter syndrome is a rare condition that can present with different clinical features. These features include early onset maternal polyhydramnios, failure to thrive, prematurity and nephrocalcinosis.We are presenting this 20-day-old girl who had an antenatal history of polyhydramnios. She developed persistent non-bilious vomiting that was associated with constipation soon after birth. She presented with failure to thrive and features suggestive of intestinal obstruction. On the initial evaluation, she was noted to have hypokalaemic, hyponatraemic metabolic alkalosis. The initial work-up was done to exclude surgical and renal causes of her presentation, and the diagnosis was confirmed by gene analysis to be type III-classic Bartter syndrome. She was closely monitored for her growth and development with the appropriate salt replacement therapy.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates).

BACKGROUND: Direct laryngoscopy is the method currently used for tracheal intubation in children. It occasionally offers unexpectedly poor laryngeal views. Indirect laryngoscopy involves visualizing the vocal cords by means other than obtaining a direct sight, with the potential to improve outcomes. We reviewed the current available literature and performed a meta-analysis to compare direct versus indirect laryngoscopy, or videolaryngoscopy, with regards to efficacy and adverse effects. OBJECTIVES: To assess the efficacy of indirect laryngoscopy, or videolaryngoscopy, versus direct laryngoscopy for intubation of children with regards to intubation time, number of attempts at intubation, and adverse haemodynamic responses to endotracheal intubation. We also assessed other adverse responses to intubation, such as trauma to oral, pharyngeal, and laryngeal structures, and we assessed vocal cord view scores. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and trial registers (www.clinicaltrials.gov and www.controlledtrials) in November 2015. We reran the search in January 2017. We added new studies of potential interest to a list of 'Studies awaiting classification' and will incorporate them into formal review findings during the review update. We performed reference checking and citation searching and contacted the authors of unpublished data to ask for more information. We applied no language restrictions. SELECTION CRITERIA: We included only randomized controlled trials. Participants were children aged 28 days to 18 years. Investigators performed intubations using any type of indirect laryngoscopes, or videolaryngoscopes, versus direct laryngoscopes. DATA COLLECTION AND ANALYSIS: We used Cochrane standard methodological procedures. Two review authors independently reviewed titles, extracted data, and assessed risk of bias. MAIN RESULTS: We included 12 studies (803 children) in this review and meta-analysis. We identified three studies that are awaiting classification and two ongoing studies.Trial results show that a longer intubation time was required when indirect laryngoscopy, or videolaryngoscopy, was used instead of direct laryngoscopy (12 trials; n = 798; mean difference (MD) 5.49 seconds, 95% confidence interval (CI) 1.37 to 9.60; I2 = 90%; very low-quality evidence). Researchers found no significant differences between direct and indirect laryngoscopy on assessment of success of the first attempt at intubation (11 trials; n = 749; risk ratio (RR) 0.96, 95% CI 0.91 to 1.02; I2 = 67%; low-quality evidence) and observed that unsuccessful intubation (five trials; n = 263) was significantly increased in the indirect laryngoscopy, or videolaryngoscopy, group (RR 4.93, 95% CI 1.33 to 18.31; I2 = 0%; low-quality evidence). Five studies reported the effect of intubation on oxygen saturation (n = 272; very low-quality evidence). Five children had desaturation during intubation: one from the direct laryngoscopy group and four from the indirect laryngoscopy, or videolaryngoscopy, group.Two studies (n = 100) reported other haemodynamic responses to intubation (very low-quality evidence). One study reported a significant increase in heart rate five minutes after intubation in the indirect laryngoscopy group (P = 0.007); the other study found that the heart rate change in the direct laryngoscopy group was significantly less than the heart rate change in the indirect laryngoscopy, or videolaryngoscopy, group (P < 0.001). A total of five studies (n = 244; very low-quality evidence) looked at evidence of trauma resulting from intubation. Investigators reported that only two children from the direct laryngoscopy group had trauma compared with no children in the indirect laryngoscopy, or videolaryngoscopy, group.Use of indirect laryngoscopy, or videolaryngoscopy, improved the percentage of glottic opening (five trials; n = 256). Studies noted no significant difference in Cormack and Lehane score (C&L) grade 1 (three trials; n = 190; RR 1.06, 95% CI 0.93 to 1.21; I2 = 59%). AUTHORS' CONCLUSIONS: Evidence suggests that indirect laryngoscopy, or videolaryngoscopy, leads to prolonged intubation time with an increased rate of intubation failure when compared with direct laryngoscopy (very low-quality evidence due to imprecision, inconsistency, and study limitations). Review authors had difficulty reaching conclusions on adverse haemodynamic responses and other adverse effects of intubation, as only a few children were reported to have these outcomes. Use of indirect laryngoscopy, or videolaryngoscopy, might lead to improved vocal cord view, but marked heterogeneity between studies made it difficult for review authors to reach conclusions on this outcome.

Pediatric case of acute right-sided abdominal pain: diagnosis is not always appendicitis.

Omental infarction (OI) is a rare cause of acute abdominal pain occurring in 0.1% of children, which is typically diagnosed during surgery for suspected appendicitis. We present the case of a 7-year-old Pakistani girl. She presented with acute, severe, progressive, right-sided abdominal pain, which was present for 12 hours before presentation. No constitutional symptoms such as fever, anorexia, nausea or vomiting were present. Clinical examination revealed an adequately growing child following the 50th centile. She had severe generalized abdominal tenderness with rebound tenderness and guarding, mainly on the right lower abdominal quadrant, with all other system examinations normal. She had mildly increased inflammatory markers, and her initial abdominal ultrasound scan result was within normal limits. She had laparoscopic surgery following a diagnosis of suspected acute appendicitis; however, an intraoperative diagnosis of OI was made. This was later confirmed by histopathology. This case report highlights the importance of including OI in the differential diagnosis list of acute abdominal pain in children, in addition to the importance of computed tomography (CT) as the gold standard tool to aid diagnosis. In the presence of typical symptoms and signs of OI, a CT scan can assist and guide the management of similar cases. This course of action is suggested for the reason that OI typically runs a self-limited course and conservative care may be the most appropriate recommended course of action. Consequently, unnecessary operations could be avoided due to the diagnosis confirmation of studying images.