Características epidemiológicas y microbiológicas de los episodios de Neutropenia Febril (NF) en niños con cáncer en el Hospital del Niño - Dr. José Renán Esquivel (HNJRE)

Introducción: La neutropenia febril (NF) constituye una complicación frecuente, considerada una urgencia infectológica en los pacientes con cáncer que reciben tratamiento mielosupresor. Metodología: Se realizó un estudio retrospectivo descriptivo a través de la revisión de los expedientes de todos los episodios de NF secundarios a quimioterapia ingresados en el Hospital del Niño - Dr. José Renán Esquivel durante el periodo de enero a diciembre de 2017. Resultados: El estudio consistió en la evaluación de características epidemiológicas e identificación de agentes infecciosos en 49 casos de NF, y 104 eventos febriles. Se observó que el 51% de los casos eran varones, con una edad promedio de 7 años, y recuperación de NF en los primeros 7 días del 68%. La mayoría de las hospitalizaciones (53,8%) duraron de 1 a 7 días, con una relación directa con los días de fiebre y la presencia de neutropenia. La letalidad registrada fue de 6.1%. Los agentes etiológicos más frecuentes fueron la Pseudomonas aeruginosa, los Estafilococos coagulasa negativos y Staphylococcus aureus meticilino sensible. Conclusión: Los hallazgos permiten conocer la epidemiología actual de los pacientes con NF que se admiten al hospital, con el fin de optimizar el tratamiento para reducir la tasa de letalidad. (provisto por Infomedic International)

Introduction: Febrile neutropenia (NF) constitutes a frequent complication, considered an infectious emergency in cancer patients receiving myelosuppressive treatment. Methodology: A descriptive retrospective study was conducted by reviewing the records of all episodes of NF secondary to chemotherapy admitted to the Hospital del Niño - Dr. José Renán Esquivel during the period from January to December 2017. Results: The study consisted of the evaluation of epidemiological characteristics and identification of infectious agents in 49 cases of NF, and 104 febrile events. It was observed that 51% of the cases were male, with a mean age of 7 years, and recovery from NF in the first 7 days of 68%. Most hospitalizations (53.8%) lasted from 1 to 7 days, with a direct relationship with the number of days of fever and the presence of neutropenia. The case fatality rate was 6.1%. The most frequent etiological agents were Pseudomonas aeruginosa, coagulase-negative Staphylococci and methicillin-sensitive Staphylococcus aureus. Conclusion: The findings provide insight into the current epidemiology of patients with NF admitted to the hospital, in order to optimize treatment to reduce the case-fatality rate. (provided by Infomedic International)

Editorial: Agresión sexual en menores de 18 años / Editorial: Sexual assault in children under 18 years of age

El Estado panameño ratificó en el año 1990 la Convención sobre los Derechos del Niño y con ello asumió el compromiso de crear mecanismos para la protección de la niñez y la adolescencia, pero las actuales estadísticas señalan que los derechos de protección del menor siguen siendo vulnerados y van en aumento especialmente en las regiones comarcales indígenas en el país. Como vemos en el informe anual del Ministerio Público de Panamá para el año 2021 se registraron un total de 2,257 casos de "acceso sexual con una persona mayor de catorce (14) años y menor de dieciocho (18)" (artículo 176 del código penal) que representó un aumento del 18 % comparado a los 1,913 casos en 2020.

The Panamanian State ratified the Convention on the Rights of the Child in 1990 and thereby assumed the commitment to create mechanisms for the protection of children and adolescents, but current statistics indicate that the protection rights of minors continue to be violated and they are on the increase, especially in the indigenous regional regions of the country. As we see in the annual report of the Public Ministry of Panama for the year 2021, a total of 2,257 cases of "sexual access with a person over fourteen (14) years of age and under eighteen (18)" were registered (article 176 of the penal code ) which represented an increase of 18% compared to the 1,913 cases in 2020.

Variantes del SARS-Cov-2 / Variants of SARS-Cov-2

Desde la aparición de los primeros casos o clusters de cuadros de neumonia de Covid 19 en Wuhan, en la provincia de Hubei en China a finales de noviembre-diciembre del 2019, el SARS-Cov-2 ha representado un reto para la comunidad científica, primero encontrar el agente etiológico y posterior la aparición de las nuevas variantes, denominación dada a la evolución del virus original o salvaje debido a cambios en el código genético (mutación genética) que ocurren durante la replicación del genoma en este caso del SARS-Cov-2. Estas nuevas mutaciones pueden variar del original en mayor velocidad de transmisión, mayor virulencia, que interfieran en la protección del individuo vacunado antes las nuevas variantes, inmunidad del individuo que ha padecido la infección, menor efectividad de los tratamientos, fallas en los métodos diagnósticos.

Regreso a clases / Back to school

La posición de la Sociedad Panameña de Pediatría del regreso a las clases se expresa en su comunicado del 24 de agosto del 2021 a la comunidad "la SPP reitera que el regreso presencial a las escuelas es impostergable, pero bajo estrictas medidas de bioseguridad como higiene frecuente de manos con agua y jabón o desinfectantes que contengan al menos alcohol al 70%, uso de mascarillas cubriendo boca y nariz, mantener buena ventilación y distanciamiento físico mínimo de 1 metro. Que se deberá tomar en cuenta el comportamiento epidemiológico de la enfermedad en las diferentes comunidades." Esta posición se refuerza con las estadísticas, el 90% de los docentes y administrativos escolares están vacunados, desde inicio de agosto 2021 se comenzó la vacunación en barrido de mayores de 12 años, el 60% de la población ha recibido al menos 1 dosis de la vacuna y un 36% las dos dosis, a pesar de la tercera ola los casos se han mantenido en descenso con la vacunación. Según la Unicef en su informe, cerca del 60% de los menores en edad escolar de la región en Latinoamérica perdieron el año lectivo. Y dos tercios de los países donde la mayoría de los colegios están cerrados de manera permanente se encuentran en nuestra región. Unicef refiere que, en promedio, las escuelas en América Latina y el Caribe permanecieron cerradas durante 158 días, lo que supera ampliamente la media global de 95 días de cierre, mientras que Panamá es el país con mayor número de días sin educación presencial o semipresencial, 16 meses (480 días). Las escuelas, añade el estudio, solo estuvieron abiertas durante seis días en promedio entre marzo de 2020 y febrero de 2021 a nivel latinoamericano y a nivel mundial esa cifra es de 37 días. El Ministerio de Educación de Panamá (Meduca) prevé para el año 2022 el regreso a clases presenciales, una vez se alcancen las coberturas del 80% a finales del 2021 y seguirán las indicaciones del Ministerio de Salud. Pero debemos recordar que las escuelas brindan más que solo el aprendizaje académico a los niños y adolescentes no solo es leer, escribir y aprender materias como matemáticas, ciencias, español; los estudiantes además aprenden habilidades sociales y emocionales, hacen ejercicio, tienen acceso a internet, el uso del comedor escolar (que para muchos en Latinoamérica en las áreas de pobreza extrema representa su única comida diaria). La Academia Americana de Pediatría (APP)2 señala que las investigaciones han demostrado que la apertura de escuelas generalmente no aumenta significativamente la transmisión comunitaria si es implementado con el requerimiento de mascarillas y otras medidas de seguridad. Que la preocupación por el surgimiento de variantes de COVID-19 (como la delta) pueden aumentar el riesgo de transmisión y provocar un empeoramiento de la enfermedad, se ha visto que dada la efectividad de las precauciones de seguridad cuando se usan las mascarillas de manera constante, los niños corren un mayor riesgo de sufrir problemas de salud mental y retrasos en el desarrollo si se pierden el aprendizaje en la escuela.

The position of the Panamanian Society of Pediatrics on the return to school is expressed in its communiqué of August 24, 2021 to the community "the SPP reiterates that the return to school is urgent, but under strict biosecurity measures such as frequent hand hygiene with soap and water or disinfectants containing at least 70% alcohol, use of masks covering the mouth and nose, maintaining good ventilation and a minimum physical distance of 1 meter. That the epidemiological behavior of the disease in the different communities should be taken into account". This position is reinforced by statistics, 90% of teachers and school administrators are vaccinated, since the beginning of August 2021 vaccination began in sweep of over 12 years, 60% of the population has received at least 1 dose of the vaccine and 36% two doses, despite the third wave cases have continued to decline with vaccination. According to Unicef in its report1 , nearly 60% of school-age children in the Latin American region missed the school year. And two thirds of the countries where most schools are permanently closed are in our region. Unicef reports that, on average, schools in Latin America and the Caribbean remained closed for 158 days, far exceeding the global average of 95 days of closure, while Panama is the country with the highest number of days without face-to-face or semi-presential education, 16 months (480 days). Schools, the study adds, were only open for six days on average between March 2020 and February 2021 at the Latin American level and globally that figure is 37 days. The Panamanian Ministry of Education (Meduca) foresees a return to on-site classes by 2022, once 80% coverage is reached by the end of 2021 and will follow the indications of the Ministry of Health. But we must remember that schools provide more than just academic learning to children and adolescents is not only reading, writing and learning subjects such as math, science, Spanish; students also learn social and emotional skills, exercise, have access to internet, the use of the school canteen (which for many in Latin America in areas of extreme poverty represents their only daily meal). The American Academy of Pediatrics (APP)2 notes that research has shown that the opening of schools generally does not significantly increase community transmission if implemented with the requirement for facemasks and other safety measures. That concerns about the emergence of COVID-19 variants (such as delta) may increase the risk of transmission and lead to worsening disease, it has been shown that given the effectiveness of safety precautions when masks are worn consistently, children are at increased risk for mental health problems and developmental delays if they miss out on learning in school.

La actividad física y su importancia en los niños / Physical activity and its importance in children

A nivel mundial, la obesidad casi se ha duplicado desde 1980. En 2014, el 10 % de los hombres y el 14 % de las mujeres de 18 años o más eran obesos. En el 2019 el número de niños menores de 5 años con sobrepeso fue de 39 millones, cerca de 340 millones de niños y adolescentes estaban en sobrepeso o tenían obesidad. Es por esto qué debemos como pediatras estimular la actividad física en nuestros pacientes, iniciando desde lactantes.

Globally, obesity has nearly doubled since 1980. In 2014, 10% of men and 14% of women aged 18 and over were obese. In 2019 the number of children under 5 years of age who were overweight was 39 million, about 340 million children and adolescents were overweight or obese.1 That is why we as pediatricians must stimulate physical activity in our patients, starting from infants.

La Salud Integral del niño y adolescente en tiempos de Pandemia / Comprehensive child and adolescent health in times of Pandemic

Las respuestas de los niños y adolescentes a los eventos estresantes (pandemias, desastres naturales, etc) son únicas y variadas. Algunos niños pueden estar irritables, otros presentan comportamientos de regresión, trastornos en el sueño, en sus hábitos de comer o comportamiento en su entorno habitual, que necesitan de atención adicional.

The responses of children and adolescents to stressful events (pandemics, natural disasters, etc.) are unique and varied. Some children may be irritable, others show regression behaviors, sleep disturbances, eating habits, or behavior in their usual environment, which need additional attention.

Las mascotas y el desarrollo emocional o salud de los niños y adolescentes

Los animales de compañía (incluidos caballos, perros, gatos, conejos y otros roedores) tienen el potencial de promover el desarrollo emocional saludable de los jóvenes de muchas maneras, como lo demuestra la investigación en Interacciones entre humanos y animales.

Desafío diagnóstico

Presentación de caso clínico para su diagnóstico, recién nacido masculino de 12 días de vida, historia de 4 días con lesiones ampollares, generalizadas, fiebre, mal estado general, áreas de celulitis en tórax , choque tóxico.

Editorial: El pediatra y la publicación científica / Editorial: El pediatra y la publicación científica

El Pediatra y la publicación científica, dirigido a tomar conciencia que en su día a día, se encuentran casos clínicos que merecen publicarse, que se puede realizar una investigación sencilla con toda la información que pasa por sus manos, si seguimos una metodología.

A randomized, open-label study of the safety and efficacy of switching stavudine or zidovudine to tenofovir disoproxil fumarate in HIV-1-infected children with virologic suppression.

BACKGROUND: The safety and efficacy of tenofovir disoproxil fumarate (TDF) in HIV-1-infected children have not been evaluated in a randomized controlled trial. METHODS: Subjects (2 to <16 years) on a stavudine (d4T) or zidovudine (ZDV) containing regimen with HIV-1 RNA <400 copies/mL were randomized to either switch d4T or ZDV to TDF or continue d4T or ZDV. The primary endpoint was the proportion of subjects with HIV-1 RNA < 400 copies/mL at Week 48 with a prespecified noninferiority margin of 15%. After the 48-week randomized phase, eligible subjects were rolled over to an extension phase. RESULTS: Ninety-seven children (48 TDF vs. 49 d4T or ZDV) were randomized and treated. The percent of subjects who maintained virologic suppression in the TDF versus d4T or ZDV group at Week 24 were 93.8% versus 89.8% (difference 4.0%; 95% confidence interval:: -6.9% to 14.9%) and at Week 48 were 83.3% versus 91.8% (difference: -8.5%; 95% confidence interval: -21.5% to 4.5%; missing = failure, intent-to-treat analysis). No subjects discontinued study drug because of an adverse event in the 48 weeks of randomized phase. Four subjects discontinued TDF because of proximal renal tubulopathy in the extension phase. CONCLUSIONS: Our study did not demonstrate noninferiority of TDF versus d4T or ZDV at Week 48. Overall safety and tolerability of TDF in children were consistent with adults. TDF may be considered as an alternative to d4T or ZDV in HIV-infected children.

Eastern equine encephalitis in Latin America.

BACKGROUND: The eastern equine encephalitis (EEE) and Venezuelan equine encephalitis (VEE) viruses are pathogens that infect humans and horses in the Americas. Outbreaks of neurologic disease in humans and horses were reported in Panama from May through early August 2010. METHODS: We performed antibody assays and tests to detect viral RNA and isolate the viruses in serum samples from hospitalized patients. Additional cases were identified with enhanced surveillance. RESULTS: A total of 19 patients were hospitalized for encephalitis. Among them, 7 had confirmed EEE, 3 had VEE, and 1 was infected with both viruses; 3 patients died, 1 of whom had confirmed VEE. The clinical findings for patients with EEE included brain lesions, seizures that evolved to status epilepticus, and neurologic sequelae. An additional 99 suspected or probable cases of alphavirus infection were detected during active surveillance. In total, 13 cases were confirmed as EEE, along with 11 cases of VEE and 1 case of dual infection. A total of 50 cases in horses were confirmed as EEE and 8 as VEE; mixed etiologic factors were associated with 11 cases in horses. Phylogenetic analyses of isolates from 2 cases of equine infection with the EEE virus and 1 case of human infection with the VEE virus indicated that the viruses were of enzootic lineages previously identified in Panama rather than new introductions. CONCLUSIONS: Cases of EEE in humans in Latin America may be the result of ecologic changes that increased human contact with enzootic transmission cycles, genetic changes in EEE viral strains that resulted in increased human virulence, or an altered host range. (Funded by the National Institutes of Health and the Secretaría Nacional de Ciencia, Tecnología e Innovación, Panama.).

Mortality and long-term virologic outcomes in children and infants treated with lopinavir/ritonavir.

BACKGROUND: There is scant data on young children receiving protease inhibitor-based therapy in real-life resource-limited settings and on the optimal timing of therapy among children who survive infancy. Our aim was to evaluate outcomes at the Hospital del Niño, Panama, where children have been routinely treated with lopinavir/ritonavir (LPV/r)-based therapy since 2002. METHODS: Retrospective cohort analysis of all HIV-infected children enrolled in care between January 1, 1991, and June 1, 2011. Kaplan-Meier method and Cox proportional hazards regression were used to evaluate death, virologic suppression and virologic rebound. RESULTS: Of 399 children contributing 1944 person-years of follow-up, 254 (63.7%) were treated with LPV/r and 94 (23.6%) were never treated with antiretrovirals (ARVs). Among infants, improved survival was associated with male gender (hazard rate of death[HRdeath] 0.54, 95% confidence interval [CI]: 0.32-0.92) and treatment with highly active antiretroviral therapy (HRdeath 0.32, 95% CI: 0.12-0.83), whereas residence outside of Panama City was associated with poorer survival (HRdeath 1.72, 95% CI: 1.01-2.94). Among children who survived to 1 year of age without exposure to ARVs, LPV/r-based therapy improved survival (HRdeath 0.07, 95% CI: 0.01-0.33). Virologic suppression was achieved in 42.1%, 70.5% and 85.1% by 12, 24 and 60 months of follow-up among children treated with LPV/r. Virologic suppression was not associated with prior ARV exposure or age at initiation of therapy but was associated with residence outside of Panama City (HR suppression 1.93, 95% CI: 1.19-3.14). Patients with a baseline viral load >100,000 copies/mL were less likely to achieve suppression (HR suppression 0.37, 95% CI: 0.21-0.66). No children who achieved virologic suppression after initiating LPV/r died. CONCLUSIONS: LPV/r-based therapy improved survival not only in infants but also in children over 1 year of age. Age at initiation of LPV/r-based therapy or prior ARVs did not impact virologic outcomes.

Participación infantil y del adolescente en la educación para el desarrollo

La educación para el desarrollo tiene como fin , promover la ciudadanía global y que nuestra infancia se forme con una mentalidad abierta a los cambios sociales, políticos, ambientales y económicos que llevan a relevantes modificaciones a nivel local, regional o mundial en un futuro.

Cerebrospinal fluid and plasma concentrations of proinflammatory mediators in human immunodeficiency virus-infected children.

BACKGROUND: The pathogenesis of HIV encephalopathy is poorly understood especially in children. Studies suggest that HIV replication and the release of proinflammatory mediators in the central nervous system contribute to the pathogenesis of HIV dementia in adults. METHODS: Cerebrospinal fluid (CSF) and plasma samples from 23 HIV-infected children were longitudinally analyzed at Weeks 0, 8, 16 and 48 for HIV RNA and concentrations of the following proinflammatory mediators: monocyte chemotactic protein-1 (MCP-1), tumor necrosis factor-alpha, regulated upon activation, normal T cell expressed and secreted (RANTES), macrophage-inflammatory protein (MIP)-1-alpha, MIP-1-beta and matrix metalloproteinase-9 (MMP-9). RESULTS: All 23 children had detectable concentrations of MCP-1 in the CSF at all time points evaluated. However, of the remaining of proinflammatory mediators measured in CSF at baseline, only a few children had detectable concentrations: tumor necrosis factor-alpha, n = 1; RANTES, n = 5; MMP-9, n = 9; MIP-1-alpha and MIP-1-beta, n = 0. A reduction from baseline to Week 48 was observed in CSF concentrations of MCP-1 and, among children with detectable values, MMP-9, which paralleled declines in CSF HIV RNA. CONCLUSION: These results suggest that MCP-1 and MMP-9 may be involved in the pathogenesis of central nervous system disease in HIV-infected children.

Effect of combination antiretroviral therapy on cerebrospinal fluid HIV RNA, HIV resistance, and clinical manifestations of encephalopathy.

OBJECTIVES: This study evaluated the effect of treatment with abacavir/lamivudine/zidovudine versus lamivudine/zidovudine on cerebrospinal fluid (CSF) human immunodeficiency virus (HIV) RNA and clinical manifestations of HIV encephalopathy in children. STUDY DESIGN: HIV-infected children 7 months to 10 years of age (n = 23) were studied. CSF and plasma were obtained at baseline and weeks 8, 16, and 48. Genotype analysis of HIV was attempted at baseline and week 48. Neurologic evaluations were performed at baseline and weeks 16, 32, and 48. RESULTS: At baseline, 83% of children had >2.00 log(10) copies/mL HIV RNA in CSF, but only 10% had HIV RNA measurable at week 48. Among children in whom paired genotyping of HIV was possible, 8 of 11 had identical patterns in both CSF and plasma at baseline, whereas at week 48, only 1 of 9 children had similar patterns. Neurologic abnormalities were observed in 83% of children at baseline but only 35% of children at week 48 (P =.004), suggesting a benefit of treatment. CONCLUSIONS: Antiretroviral therapy was associated with a decline in CSF HIV RNA and an improvement in neurologic status. The development of genotypic mutations was different in CSF and plasma, suggesting discordant viral evolution. These results suggest that antiretroviral treatment in children should include agents with activity in the CNS.

El hijo de la adolescente / The child of the adolescent

Se realiza la revisión de los nacimientos en la Maternidad María Cantera de Remón del Hospital Santo Tomás durante el primer semestre de 1989. Se analizan las características de los recién nacidos de madres menores de 19 años. Se concluye que el 16.6 (por ciento) de los partos suceden en este grupo, que los recién nacidos no muestran diferencias estadísticamente significativas con respecto a los hijos de madres mayores de 19 años. Al analizar los recién nacidos hospitalizados en la Sala de Neonatología N§ 2 del Hospital del Niño se concluye que la prematuridad y bajo peso en el hijo de la adolescente, como causas de hospitalización, son significativamente mayores que para la población mayor de 19 años