Watchful Waiting in Pediatric Acute Otitis Media: A Real Practice Approach or an Intangible Desideratum?

Acute otitis media (AOM) in children is one of the leading causes of health care visits and antibiotic prescriptions worldwide. The overall aim of the current study is twofold: 1. to analyze and discuss the antibiotic prescription patterns in AOM in children without complications or risk factors and 2. to assess to what extent the watchful-waiting approach is a real practice or a mere desideratum. We performed an electronic search in the PubMed and Embase databases from 2013 to 2023 to capture original research studies investigating antibiotic prescribing patterns for AOM in children. Among the 12 papers included in the analysis, the antibiotic prescription rate ranged from 44.8% to 98%. Our study reveals similarities regarding the use of amoxicillin as a first-line antibiotic in pediatric AOM, but also discrepancies in the watchful-waiting approach attitude and in the choice of second or third-line antimicrobial agents. The proportion of cases managed with the watchful-waiting approach ranged from 7.5% (Australia) to 55.2% (Finland). Denmark was the only country reporting penicillin V as a first-choice regimen for children with AOM, which fulfils the guidelines' recommendations. The most unsatisfying rate of amoxicillin use was recorded in Japan, contrary to the recommendations of local guidelines. The use of quinolones was reported in two out of twelve studies, with the highest proportion in Japan, where tosufloxacin was used in 21.4% of the total number of cases. The duration of the antibiotic regimens was analyzed in three out of twelve papers. Since global antibiotic overuse contributes to the emergence of antibiotic resistant bacteria, new strategies are needed to increase the rate of watchful waiting and to promote the judicious use of antibiotics.

Identifying Childhood Risk Factors for Hepatitis B with a Focus on Vertical Transmission.

BACKGROUND: Despite worldwide vaccination efforts, Hepatitis B virus (HBV) infection remains a significant global health burden, particularly in regions where vertical transmission is prevalent. Given Romania's history as an endemic area for hepatitis B from the 1990s until the early 2000s and the previously high infection rates among children, it is crucial to continually evaluate HBV infection in this population to monitor current trends, assess the long-term impact of vaccination programs, and address any remaining gaps in prevention and treatment efforts. This study aims to identify childhood risk factors associated with HBV acquisition, examining the role of maternal HBV status in child HBV infection, focusing on vertical transmission among a cohort of 654 children, with maternal infection as the independent variable and child infection as the dependent variable. METHODS: We assessed potential risk factors and vaccination coverage among these children. The cohort included 148 children who tested positive for chronic hepatitis B from those 654 tested for HBsAg. Anamnestic data and vaccination history were analyzed, with particular attention to birth type and surgical interventions. RESULTS: Of the 148 HBV-positive children, 80.4% were delivered naturally. Among these, 130 had received hepatitis B vaccination, and 5 were also given hepatitis B immunoglobulin at birth, 4 of whom were born via cesarean section. In the control group, comprising 418 vaccinated children, a lesser proportion were unvaccinated (2.2%). Documented surgical interventions included general and dental surgeries, as well as a single blood transfusion. CONCLUSIONS: The study emphasizes the need for comprehensive vaccination strategies and illuminates potential correlations between birth type and vaccination status with childhood HBV infection. Crucially, it highlights the necessity of diligent monitoring and treatment of pregnant women with HBV to prevent vertical transmission as effectively as possible.

Insights into the Natural and Treatment Courses of Hepatitis B in Children: A Retrospective Study.

Chronic Hepatitis B virus (HBV) infection in children remains a significant public health challenge. The natural history and treatment outcomes of HBV can vary widely, influencing management strategies. This retrospective study was conducted in Northeast Romania and involved a cohort of 148 pediatric patients diagnosed with chronic viral Hepatitis B. Of these, 59 children underwent antiviral treatment while 89 were not treated. One of the main objectives was the rate of HBeAg (Hepatitis B-e antigen) seroconversion, a marker of disease progression and response to therapy. Among the treated group, 26 children (44%) achieved HBeAg seroconversion following therapy. In contrast, 44 of the untreated children (49%) experienced spontaneous HBeAg seroconversion, indicating a substantial rate of natural resolution within this population subset. The findings highlight a significant proportion of spontaneous seroconversion in untreated pediatric patients, suggesting a potential re-evaluation of treatment criteria and timing for children with chronic HBV infection. The comparable rates of seroconversion between treated and untreated cohorts underscore the need for individualized treatment approaches based on a combination of virological, biochemical, and clinical parameters. Further studies are required to refine management strategies to optimize long-term outcomes in pediatric HBV infections.

Pediatric Perspectives on Liver Cirrhosis: Unravelling Clinical Patterns and Therapeutic Challenges.

Background: Liver cirrhosis presents significant challenges in the pediatric population due to a complex interplay of etiological factors, clinical manifestations, and limited therapeutic options. The leading contributors to cirrhosis among pediatric patients are chronic cholestasis, metabolic disorders present from birth, and long-term hepatitis. Materials and method: Our narrative review aimed to synthesize literature data on the etiology, clinical picture, diagnostic techniques, optimal management of complications, and timely transplantation. Results: The epidemiology of liver cirrhosis in pediatric patients is evolving. The introduction of a universal vaccination and effective long-term viral suppression in viral hepatitis have significantly decreased complications rates. Liver transplantation programs worldwide have also improved the management of cirrhosis complications. Conclusions: Early diagnosis, comprehensive management strategies, and advancements in treatment modalities are critical for improving outcomes. Understanding these differences is crucial in providing age-appropriate care and support for those affected by cirrhosis.

Diagnosis and Management of Gastrointestinal Manifestations in Children with Cystic Fibrosis.

Cystic fibrosis (CF) is primarily known for its pulmonary consequences, which are extensively explored in the existing literature. However, it is noteworthy that individuals with CF commonly display gastrointestinal (G-I) manifestations due to the substantial presence of the cystic fibrosis transmembrane conductance regulator (CFTR) protein in the intestinal tract. Recognized as pivotal nonpulmonary aspects of CF, G-I manifestations exhibit a diverse spectrum. Identifying and effectively managing these manifestations are crucial for sustaining health and influencing the overall quality of life for CF patients. This review aims to synthesize existing knowledge, providing a comprehensive overview of the G-I manifestations associated with CF. Each specific G-I manifestation, along with the diagnostic methodologies and therapeutic approaches, is delineated, encompassing the impact of innovative treatments targeting the fundamental effects of CF on the G-I tract. The findings underscore the imperative for prompt diagnosis and meticulous management of G-I manifestations, necessitating a multidisciplinary team approach for optimal care and enhancement of the quality of life for affected individuals. In conclusion, the authors emphasize the urgency for further clinical studies to establish a more robust evidence base for managing G-I symptoms within the context of this chronic disease. Such endeavors are deemed essential for advancing understanding and refining the clinical care of CF patients with G-I manifestations.

Exploring the Microbial Landscape: Gut Dysbiosis and Therapeutic Strategies in Pancreatitis-A Narrative Review.

The gut microbiota is emerging as an important contributor to the homeostasis of the human body through its involvement in nutrition and metabolism, protection against pathogens, and the development and modulation of the immune system. It has therefore become an important research topic in recent decades. Although the association between intestinal dysbiosis and numerous digestive pathologies has been thoroughly researched, its involvement in pancreatic diseases constitutes a novelty in the specialized literature. In recent years, growing evidence has pointed to the critical involvement of the pancreas in regulating the intestinal microbiota, as well as the impact of the intestinal microbiota on pancreatic physiology, which implies the existence of a bidirectional connection known as the "gut-pancreas axis". It is theorized that any change at either of these levels triggers a response in the other component, hence leading to the evolution of pancreatitis. However, there are not enough data to determine whether gut dysbiosis is an underlying cause or a result of pancreatitis; therefore, more research is needed in this area. The purpose of this narrative review is to highlight the role of gut dysbiosis in the pathogenesis of acute and chronic pancreatitis, its evolution, and the prospect of employing the microbiota as a therapeutic intervention for pancreatitis.

Emerging role of the gut microbiome in post-infectious irritable bowel syndrome: A literature review.

Post-infectious irritable bowel syndrome (PI-IBS) is a particular type of IBS, with symptom onset after an acute episode of infectious gastroenteritis. Despite infectious disease resolution and clearance of the inciting pathogen agent, 10% of patients will develop PI-IBS. In susceptible individuals, the exposure to pathogenic organisms leads to a marked shift in the gut microbiota with prolonged changes in host-microbiota interactions. These changes can affect the gut-brain axis and the visceral sensitivity, disrupting the intestinal barrier, altering neuromuscular function, triggering persistent low inflammation, and sustaining the onset of IBS symptoms. There is no specific treatment strategy for PI-IBS. Different drug classes can be used to treat PI-IBS similar to patients with IBS in general, guided by their clinical symptoms. This review summarizes the current evidence for microbial dysbiosis in PI-IBS and analyzes the available data regarding the role of the microbiome in mediating the central and peripheral dysfunctions that lead to IBS symptoms. It also discusses the current state of evidence on therapies targeting the microbiome in the management of PI-IBS. The results of microbial modulation strategies used in relieving IBS symptomatology are encouraging. Several studies on PI-IBS animal models reported promising results. However, published data that describe the efficacy and safety of microbial targeted therapy in PI-IBS patients are scarce. Future research is required.

The Gut Microbiome and Its Implication in the Mucosal Digestive Disorders.

The gastrointestinal (GI) tract is one of the most studied compartments of the human body as it hosts the largest microbial community including trillions of germs. The relationship between the human and its associated flora is complex, as the microbiome plays an important role in nutrition, metabolism and immune function. With a dynamic composition, influenced by many intrinsic and extrinsic factors, there is an equilibrium maintained in the composition of GI microbiota, translated as "eubiosis". Any disruption of the microbiota leads to the development of different local and systemic diseases. This article reviews the human GI microbiome's composition and function in healthy individuals as well as its involvement in the pathogenesis of different digestive disorders. It also highlights the possibility to consider flora manipulation a therapeutic option when treating GI diseases.

ATOPIC DERMATITIS--CLINICAL EPIDEMIOLOGY AND IMMUNOLOGICAL CORRELATIONS.

AIM: Medical records from 2010-2014 were retrospectively reviewed and analyzed in view of determining the correlations between the clinical severity of atopic dermatitis (AD) and total IgE level, eosinophilia, place of residence, family history of atopy, type of birth, and natural or artificial feeding. MATERIAL AND METHODS: Following medical record review, 296 cases diagnosed with AD were included in the study. Statistical analysis was performed using SPSS v20 for determining the frequency and testing the hypotheses, for p < 0.05, by t tests and One-Way ANOVA. RESULTS: Of the 296 cases, 53% were male children and 47% female children aged 1 month to 16 years. According to total serum IgE level, 49.3% of patients had elevated IgE levels, 20.6% normal levels and in 30.03% of cases it was not determined. According to the SCORAD, children had mild AD in 20% of cases, moderate in 70%, and severe in 10%. The independent samples t tests showed a statistically significant difference between the means demonstrating correlations between IgE level and place of residence (p < 0.01), family history of atopy (p < 0.01), baby feeding (p < 0.01), and by one-way ANOVA for SCORAD (p < 0.05). CONCLUSIONS: Atopy in AD can be influenced by complex factors, both internal and environmental, but this remains a controversial topic. External factors acting on a background genetically predisposed to atopy trigger the manifestation of AD.

[Liver involvement in celiac disease in children]. / Afectarea hepatica în boala celiaca la copil.

UNLABELLED: Celiac disease (CD) is an autoimmune systemic enteropathy triggered by gluten intake in patients with genetic susceptibility, characterized by clinic polymorphism: classic forms, mainly with digestive features, and atypical forms, liver involvement being a part of them. In present, any unknown cytolysis requires screening serologic determinations for CD. AIMS: to assess the presence of liver manifestations in children diagnosed with CD, the outcome of liver function with gluten-free diet (GFD) and also to emphasize the importance of the immunological screening for CD in patients with unknown etiology liver dysfunctions. MATERIAL AND METHODS: The trial was formed by 120 patients diagnosed with CD between January 2007 - December 2010 in 2nd and 3rd Pediatric Clinics of "Sf. Maria" Hospital Iasi; liver function was assessed; viral hepatitis and autoimmune hepatitis markers were determined; all patients were given GFD, hepatoprotective agents and antivirals specific to each form of hepatitis; the transaminases level variation was followed in time. RESULTS: 12 of the CD diagnosed patients (10, 14%) had altered liver function at the onset of disease; the only abnormality was the increased transaminases level in 57, 14% of cases; HBsAg was found positive in 33, 33% (4 cases); liver biopsy in one patient evidenced steatosis. The study has shown that 4% of the patients with cryptogenetic hepatitis have a silent form of CD, the serologic screening for AGA, AEA, ATGA being essential for diagnosis. CONCLUSIONS: we have to rule out CD in patients with liver disease of unknown etiology, before we consider it as "cryptogenetic"; occurrence of cytolysis in the absence of positive viral markers requires the assessment of screening tests for CD.

[Hepato-pulmonary syndrome]. / Sindromul hepato-pulmonar (shp).

The hepato-pulmonary syndrome (HPS) is a rare complication of liver cirrhosis, with poor outcome; the term includes liver disease, increased alveolo-arterial gradient and intrapulmonary vascular dilations, described by Fluckiger, Kennedy and Knudson. HPS impairs survival in cirrhotic patients and the posttransplant outcome is altered in correlation with severity of HPS. Combined determination of SaO2 in clino- and orthostatic position by a pulsoximeter is a simple test for HPS identification in patients with chronic liver disease or non-cirrhotic portal hypertension.

[Evidence of intraepithelial lymphocytes through immunocytochemistry stains in children with celiac disease]. / Evidentierea limfocitelor intraepiteliale prin coloratii imunohistochimice la copiii cu boala celiaca.

UNLABELLED: The purpose of of this study is to identify IELs through immunocytochemistry stains for counting infiltration duodenal mucosa with T lymphocytes in children with celiac disease. MATERIAL AND METHOD: It was selected up simptomatology (abdominal pain, anorexia, failure thrive, chronic diarheea), features immunology(positifs tissue transglutaminase antibodies) and considering the histopathologic results (IELs > 30/100 enterocytes, crypt hyperplasia and villous atrophy) we made two groups: first group (13 children with celiac disease of 53 children with celiac disease) and second group (13 children with chronic duodenitis nonspecific). For evidence of intraepithelial lymphocytes T using immunocytochemistry tehnicque (immunohistochemical staining) Envision with antibody anti CD 3 from Dako firme. Corresponding Marsh clasification considering patological IELs > 30/100 enterocytes. Statitics method was used The Student' t test. RESULTS: Analyse IELs in two groups our show difference statistics to demonstrate with the Student' t test (t = -12.237; p = 0.003). CONCLUSION: An increase IELs is helpful in recognising early and bordeline, but the finding is not specific. The histopathologic exam remains the gold standard for celiac disease.

[Helicobacter pylori infection in children with celiac disease]. / Infectia cu Helicobacter pylori la copiii cu boala celiaca.

UNLABELLED: The purpose of this study is to evaluate symptomatology, endoscopic and histopathologic changes of Helicobacter pylori infection and gastritis lesions without Helicobacter pylori infection on children diagnosed with celiac disease. MATERIAL AND METHOD: 15 children under gluten-free diet were selected and, because of the recurrence of the dyspeptic syndrome, an upper digestive endoscopy associated with histopathologic exam was performed. Considering the histopathologic result we made two groups: first group (8 children with celiac disease and Helicobacter pylori infection) and second group (7 children with celiac disease without Helicobacter pylori infection, but associated with gastritis lesions). RESULTS: The main symptom was diffuse abdominal pain in both groups. The endoscopic antrum aspects were congestive with striped aspect (first group--12.5%, second group--42.9%) and congestive with nodulation (first group--25%, second group--14.3%). The histopathologic diagnosis were: moderate active chronic pangastritis (first group--25%, second group--14.3%) moderate active chronic gastritis (first group--25%,second group--14.3%), lymphocytic gastritis (first group--12.5%, second group--14.3%). CONCLUSION: The histopathologic exam remains the gold standard for celiac disease, gastritis lesions and Helicobacter pylori infection.

Glycogen storage disease type I--between chronic ambulatory follow-up and pediatric emergency.

BACKGROUND AND AIMS: To describe the characteristics of patients with type I glycogenosis, the presentation types, the main clinical signs, the diagnostic criteria and also the disease outcomes on long term follow-up. METHODS: The study group consisted of 6 patients (medium age 3 years 6 months) admitted in hospital between 2001 and 2005 and followed-up for 1 to 5 years. The sex ratio was 1:1. RESULTS: The referral reasons varied from hepatomegaly incidentally discovered (3 of 6 patients) to abdominal pain (4 of 6 patients), growth failure (3 of 6 patients), symptoms of hypoglycemia (3 of 6 patients), recurrent epistaxis (1 patient). Hepatomegaly was present in all cases. Biological profile: hypoglycemia, increased transaminase values, hypertriglyceridemia, lactic acidosis, normal uric acid levels. Two patients had neutropenia and other two had increased glomerular filtration rate. Liver biopsy showed glycogen-laden hepatocytes and markedly increased fat. Four patients had type Ia and 2 patients type Ib glycogenosis. The therapy consisted of: diet, ursodeoxycholic acid, granulocyte colony-stimulating factor, broad spectrum antibiotics for those with type Ib glycogenosis. The follow-up parameters were clinical, biological, imaging. Metabolic interventions and antiinfectious therapy were necessary. All patients are alive, two of them on the waiting list for liver transplantation. CONCLUSIONS: Glycogen storage disease type I is a rare condition, but with possible life-threatening consequences. It has to be kept in mind whenever important hepatomegaly and/or hypoglycemia are present.

[Malnutrition and complex nutritional therapy in cystic fibrosis]. / Malnutritia si terapia complexa nutritionala în fibroza chistica de pancreas.

Good nutrition is essential for normal growth and development. Cystic fibrosis (CF) is commonly associated with energy deficiency in children. Malnutrition is a very frequent complication and contributes significantly toward morbidity in CF. Although malnutrition due to pancreatic enzyme insufficiency is correctable, the majority of CF patients are underweight and have short stature. During the last few decades, improved treatment measures and nutritional support in CF have increased survival and quality of life in these patients. Patients with CF must receive a hypercaloric and hyper-proteic diet, with a high fat content, a normal quantity of carbohydrates and with pancreatic and liposoluble vitamin supplements in case of pancreatic insufficiency.

[Obesity in children: new controversies and present prevention measures]. / Obezitatea copilului--noi paradigme si masuri preventive actuale.

The authors realise a synthesis on classical data and recent pathogenic explanations in childhood obesity. The obesity is a nutritional disorder of great interest nowadays and surpasses the incidence of the major problem of pediatrics until now--the malnutrition. There is documented data concerning the global incidence of obesity which is continuously growing when it comes to children. That is why the prophylaxis must become a priority by using measures in the first period of life (natural feeding, the need of late diversification, the avoidance of hyperproteic diets). The recent pathogenic data and the long term populational studies change the old conceptions regarding the risk of some categories of children. Thus mother's malnutrition, the low birth weight, children that followed hyperproteic diets paradoxically represent categories of risk for obesity. A recent recorded phenomenon, which amplifies the risk for obesity is the early adiposity rebound which is recorded nowadays even for ages lower than five years. There are described the hormonal mechanisms involved in appetite and satiety up to the receptor level: leptin, ghrelin, adiponectin, endocannabinoid receptors. There are pointed out all the long term risk elements (high birth weight, low birth weight, the pregnant woman's nutrition) and the modern medical treatments for obesity.

[Celiac disease associated with Helicobacter pylori infection]. / Boala celiaca asociata cu infectia cu Helicobacter pylori.

Celiac disease, also known as gluten-sensitive enteropathy, is an autoimmune enteropathy caused by the ingestion of gluten-containing grains in susceptible subjects. The authors present a 3 years and 5 months old girl diagnosed with celiac disease at 1 year and 5 months old. Initially, the evolution after gluten-free diet was favorable. After 2 years the child presented abdominal pain and anorexia. The IgA antigliadin antibodies had normal values. The gastric biopsy found Helicobacter pylori gastritis. After treatment for Helicobacter pylori eradication the symptoms disappeared.