Actions to Avoid in Pain Management and Sedoanalgesia Procedures in Pediatric Emergencies.

OBJECTIVES: The aim of this study was to show the process of elaboration and the results obtained of the list of "do not do" recommendations for pain management and sedoanalgesia procedures in pediatric patients within the Working Group on Analgesia and Sedation of the Spanish Society of Pediatric Emergencies (Grupo de Trabajo de Analgesia y Sedación de la Sociedad Española de Urgencias de Pediatría [GTAS-SEUP]). METHODS: The process of drawing up the list was carried out in 3 phases: (1) "brainstorming," open to all members of the GTAS-SEUP; (2) selection of recommendations, after a modified Delphi methodology; and (3) drafting and consensus of the final document. RESULTS: Initially, 57 proposed recommendations were obtained, which were reduced to 39 by unifying those that were similar. Of the 14 "do not do" in pain management, 6 were accepted: 3 in the first round and 3 in the second round. Of the 25 "do not do" recommendations for sedoanalgesia procedures, 6 were accepted: 4 in the first round and 2 in the second round. The final text consisted of 12 actions to avoid, 6 referring to pain management and 6 to sedoanalgesia procedures. CONCLUSIONS: The list of "do not do" recommendations for pain management and sedoanalgesia procedures in the pediatric patient is a consensual tool, within the GTAS-SEUP. These recommendations promote an improvement in the quality of care offered to these patients, based on avoiding unnecessary measures, which can sometimes be harmful.

Update of the consensus document on the aetiology, diagnosis and treatment of acute otitis media and sinusitis.

Update of the consensus on acute otitis media (AOM) (2012) and sinusitis (2013) following the introduction of pneumococcal vaccines in the immunization schedule, and related changes, such as epidemiological variation, colonization by of nonvaccine serotypes and emerging antimicrobial resistances. A majority of studies show that the introduction of the pneumococcal 13-valent conjugate vaccine has been followed by a reduction in the nasopharyngeal carriage of pneumococcus, with an increase in the proportion of drug-resistant nonvaccine serotypes. The diagnosis of AOM is still clinical, although more stringent criteria are proposed, which are based on the visualization of abnormalities in the tympanic membrane and the findings of pneumatic otoscopy performed by trained clinicians. The routine diagnosis of sinusitis is also clinical, and the use of imaging is restricted to the assessment of complications. Analgesia with acetaminophen or ibuprofen is the cornerstone of AOM management; watchful waiting or delayed antibiotic prescription may be suitable strategies in select patients. The first-line antibiotic drug in children with AOM and sinusitis and moderate to severe disease is still high-dose amoxicillin, or amoxicillin-clavulanic acid in select cases. Short-course regimens lasting 5-7 days are recommended for patients with uncomplicated disease, no risk factors and a mild presentation. In allergic patients, the selection of the antibiotic agent must be individualized based on severity and whether or not the allergy is IgE-mediated. In recurrent AOM, the choice between watchful waiting, antibiotic prophylaxis or surgery must be individualized based on the clinical characteristics of the patient.

Actualización del documento de consenso sobre etiología, diagnóstico y tratamiento de la otitis media aguda y sinusitis / Update of the consensus document on the aetiology, diagnosis and treatment of acute otitis media and sinusitis

Actualización de los documentos de consenso de OMA (2012) y sinusitis (2013) tras la introducción de las vacunas antineumocócicas en el calendario vacunal, tras los cambios derivados de las variaciones epidemiológicas, colonización por serotipos no vacunales y la aparición de resistencias. Según la mayoría de los estudios, la introducción de la vacuna antineumocócica conjugada tridecavalente (VNC-13) se ha traducido en un descenso de la colonización nasofaríngea por neumococo, con un aumento porcentual de serotipos resistentes no cubiertos. El diagnóstico de la OMA continúa siendo clínico, aunque se proponen criterios más rigurosos, apoyados en la visualización de alteraciones en la membrana timpánica y la otoscopia neumática realizada por personal entrenado. El diagnóstico rutinario de la sinusitis es clínico y la realización de pruebas de imagen está limitada al diagnóstico de complicaciones asociadas. La analgesia con paracetamol o ibuprofeno es la base del tratamiento en la OMA; la conducta expectante o la prescripción antibiótica diferida podrían ser estrategias adecuadas en pacientes seleccionados. El tratamiento antibiótico de elección en niños con OMA y sinusitis aguda con síntomas moderados-graves continúa siendo la amoxicilina a dosis altas o la amoxicilina-clavulánico en casos seleccionados. En cuadros no complicados, sin factores de riesgo y con buena evolución se proponen pautas cortas de 5-7 días. En pacientes alérgicos se debe individualizar especialmente la indicación de tratamiento antibiótico, que dependerá del estado clínico y si existe o no alergia IgE-mediada. En la OMA recurrente, la elección entre un manejo expectante, profilaxis antibiótica o cirugía se debe individualizar según las características del paciente. (AU)

Update of the consensus on acute otitis media (AOM) (2012) and sinusitis (2013) following the introduction of pneumococcal vaccines in the immunization schedule, and related changes, such as epidemiological variation, colonization by of nonvaccine serotypes and emerging antimicrobial resistances. A majority of studies show that the introduction of the pneumococcal 13-valent conjugate vaccine has been followed by a reduction in the nasopharyngeal carriage of pneumococcus, with an increase in the proportion of drug-resistant nonvaccine serotypes. The diagnosis of AOM is still clinical, although more stringent criteria are proposed, which are based on the visualization of abnormalities in the tympanic membrane and the findings of pneumatic otoscopy performed by trained clinicians. The routine diagnosis of sinusitis is also clinical, and the use of imaging is restricted to the assessment of complications. Analgesia with acetaminophen or ibuprofen is the cornerstone of AOM management; watchful waiting or delayed antibiotic prescription may be suitable strategies in select patients. The first-line antibiotic drug in children with AOM and sinusitis and moderate to severe disease is still high-dose amoxicillin, or amoxicillin-clavulanic acid in select cases. Short-course regimens lasting 5–7 days are recommended for patients with uncomplicated disease, no risk factors and a mild presentation. In allergic patients, the selection of the antibiotic agent must be individualized based on severity and whether or not the allergy is IgE-mediated. In recurrent AOM, the choice between watchful waiting, antibiotic prophylaxis or surgery must be individualized based on the clinical characteristics of the patient. (AU)

Very Early Presentation of Extrahepatic Portal Vein Obstruction Causing Portal Hypertension in an Infant: Uncertainties in the Management and Therapeutic Limitations.

Extrahepatic portal vein obstruction, although rare in children, is a significant cause of portal hypertension (PHT) leading to life-threatening gastrointestinal bleeding in the pediatric age group. PHT may also lead to other complications such as hyperesplenism, cholangyopathy, ascites, and even hepatopulmonary syndrome and portopulmonary hypertension that may require organ transplantation. Herein we report the case of an asymptomatic 11-month-old infant wherein a hepatomegaly and cavernous transformation of the portal vein was detected by liver ultrasound. Neither signs of thrombosis in arteriovenous system, nor affectation of biliary tract were identified in the magnetic resonance imaging study. A significant enlargement of the caudate lobe of the liver was reported. No risk factors were detected. The differential diagnosis performed was extensive. Inherited thrombophilia and storage disorders were especially considered. Liver biopsy was normal. Upper gastrointestinal esophagogastroduodenoscopy detected two small varicose cords on the distal third of the esophagus. Finding a cavernous transformation of the portal vein with evidence of collateral circulation in such an early age is a challenging condition for professionals, since PHT may lead to severe complications during childhood and can compromise growth and development. Evidence-based guidelines for the management of PHT in adults have been published. However, follow-up and treatment of pediatric patients have not yet been standardized. Moreover, management of PHT in infants faces particular difficulties such as technical restrictions that could hinder their treatment.

Longitudinal Study of Cytokine Expression, Lipid Profile and Neuronal Growth Factors in Human Breast Milk from Term and Preterm Deliveries.

Breast milk (BM) is considered as a reference for infant nutrition. The role of bioactive components, such as cytokines, hormones, growth factors (GFs) and fatty acids (FAs) is poorly known, but they might be implicated in immune response development. The aim of this study was to identify the lipid profile and the spectrum of cytokines and neuronal GF in BM samples and analyse the influence of gestational age and lactation time on these components. This study used a longitudinal prospective method for the characterization of cytokines, FAs and GFs global profiles in 120 BM samples from 40 healthy mothers (20 preterm and 20 term) collected as colostrum, transitional and mature milk. The cytokines were analysed by protein array (Ray Bio® Human Cytokine Array G6. Ray Biotech, Inc. Norcross, GA, USA) and the FAs were analysed by gas chromatography. The FA profile was similar between the term and the preterm BM samples. Omega-3-α-linoleic and docosahexaenoic acid (DHA) and omega-6-linoleic acid were the most abundant in the term and preterm samples during lactation. Omega-3 ETA and omega-3 EPA we observed exclusively in the preterm samples. The cytokine profile showed a different trend based on gestational age. A significantly higher expression of neurotrophic factors was found in the mature preterm milk samples as compared to the mature term samples. Our study is the first to identify the influence and interactions of perinatal factors on cytokine, GFs and FAs in human milk.

Norovirus infections and seroprevalence of genotype GII.4-specific antibodies in a Spanish population.

Genotype II.4 noroviruses (NoVs) are a leading cause of epidemic acute gastroenteritis in children and adults worldwide. The prevalence of different NoV genotypes causing outbreaks and sporadic cases of acute gastroenteritis in the region of Valencia, Spain, during a 4-year period (2008-11) was investigated. NoVs were detected in 42 out of 55 (76.3%) outbreaks and in 26 out of 332 (7.8%) sporadic cases of acute gastroenteritis. Genogroup GII strains were predominant in outbreaks and sporadic cases. Different genotype GII.4 variants were found (Yerseke_2006a, Den Haag_2006b, Apeldoorn_2007, and New Orleans_2009), with the latter variant detected most frequently (35.3%). A recombinant P domain of the NoV GII.4 Apeldoorn_2007 variant was produced in Escherichia coli and used as the coating antigen in an enzyme immunoassay to survey the IgG antibody seroprevalence against NoV GII.4 in a Spanish population. Baculovirus-expressed virus-like particles (VLPs) of NoV GII.4 Den Haag_2006b variant were also produced and used as antigen to compare seroreactivity. Of the 434 serum specimens analyzed, 429 (98.6%) had antibodies against the P domain. The comparison of reactivities of 30 serum samples to the NoV GII.4 P polypeptide and VLP showed reproducible results with a correlation coefficient of r = 0.794. Titers of antibodies to the P domain increased gradually and significantly with age, reaching the highest levels at the age group of 41-50 years. These results confirm the high prevalence of NoV GII.4 infections in Valencia from early childhood.

Norovirus GII.4 antibodies in breast milk and serum samples: their role preventing virus-like particles binding to their receptors.

BACKGROUND: Norovirus GII.4 genotype is a leading cause of nonbacterial gastroenteritis in infants. Effective vaccines against noroviruses are not yet available, enhancing the interest of the protection mechanisms elicited by breast milk that may contain norovirus-specific antibodies and histo-blood group antigens. The aims of our study were to analyze norovirus GII.4-specific antibodies in breast milk and serum and to assess their blocking activity on recombinant norovirus virus-like particles (VLPs) binding to saliva. METHODS: Mature milk and serum from 108 mothers were analyzed for specific IgA to norovirus GII.4-2006b and for their blocking activity on the binding of norovirus GII.4-2006b VLPs to fucosyltransferase FUT2-positive and negative saliva. Norovirus GII.4-2006b-specific IgG antibodies were also analyzed in serum samples. RESULTS: Higher specific IgA titers were detected in mature milk (75%) than in serum samples (62%), showing a correlation between both results (ρ = 0.427, P = 0.000). However, only 56.3% of the serum samples contained norovirus-specific IgG. Almost all mature milk samples (99.1%) inhibited the binding of norovirus VLPs to FUT2-negative saliva; however, only 25% did so to FUT2-positive saliva (P = 0.000). Ninety percent of serum samples inhibited the binding of norovirus VLPs to FUT2-negative saliva. CONCLUSIONS: Breast milk inhibits norovirus GII.4-2006b VLPs binding to receptors in saliva, and anti-norovirus IgA antibodies are only partly responsible for this activity. The FUT2 status of the receptor seems to be a strong predictor of this effect, but more studies to ascertain the participation of histo-blood group antigens in the protection against norovirus infections elicited by breast milk are required.