Italian Journal of Pediatrics - Latest Articles

Epidemiology and associations with climatic conditions of Mycoplasma pneumoniae and Chlamydophila pneumoniae infections among Chinese children hospitalized with acute respiratory infections

Zhengrong Chen — 2013-05-25T00:00:00Z

Background: The incidence of severe acute respiratory tract infections in children caused by Mycoplasma pneumoniae (syn. Schizoplasma pneumoniae) and Chlamydophila pneumoniae (formerly Chlamydia pneumoniae) varies greatly from year to year and place to place around the world. This study investigated the epidemiology of M. pneumoniae and C. pneumoniae infections among children hospitalized with acute respiratory infections in Suzhou, China in the year 2006, and associations between incidence rates and climatic conditions. Methods: Nasopharyngeal aspirates obtained from 1598 patients (aged 26.4 +/- 28.3 months; range, 1 month to 13 years) were analyzed with real-time PCR and ELISA. Meteorological data were obtained from the weather bureau. Results: About 18.5% of patients were infected with M. pneumoniae and, C. pneumoniae, or both. Isolated M. pneumoniae infection was positively correlated with increasing age (chi2 = 34.76, P < 0.0001). Incidence of M. pneumoniae infection was seasonal with a peak in summer (P < 0.0001) and minimum in winter (P = 0.0001), whereas C. pneumoniae infection was low only in autumn (P = 0.02). Monthly mean temperature was strongly correlated with the incidence of M. pneumoniae infection (r = 0.825, P = 0.001). Conclusions: M. pneumoniae and C. pneumoniae are important infectious agents in hospitalized children with acute respiratory tract infections. M. pneumoniae infection showed a strong direct correlation with environmental temperature.

A neonatal case of 3-hydroxy-3-methylglutaric-coenzyme A lyase deficiency

Francesca Santarelli — 2013-05-24T00:00:00Z

3-hydroxy-3-methylglutaric aciduria (OMIM 246450) is a rare autosomal recessive inborn of metabolism due to the deficiency of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) lyase, an enzyme involved both in the ketogenic pathway and leucine catabolism. Acute decompensations present with lethargy, cianosis, hypotonia, vomiting and metabolic acidosis with hypoketotic hypoglycemia. We report the case of a 3 days male with sudden hypoglycemic crisis initially misdiagnosed as a sepsis. HMG-CoA lyase deficiency was achieved through acyl-carnitines profile (showing a typical increasing of 3-hydroxy-isovaleryl and 3-hethylglutaryl carnitines) and urinary organic acids analysis (disclosing elevation of 3-hydroxy-3-methylglutaric, 3-methyl-glutaconic, 3-methylglutaric and 3-hydroxyisovaleric acids). This case underlines the need of suspecting such inborn metabolic disorder in cases with hypoglycemia and metabolic acidosis. Acyl-carnitine and urinary organic acids profiles are essential to achieve a prompt diagnosis of treatable metabolic disorders in order to prevent their acute crisis with serious or even fatal consequences

Dyke-Davidoff-Masson syndrome: case report of fetal unilateral ventriculomegaly and hypoplastic left middle cerebral artery

Ettore Piro — 2013-05-14T00:00:00Z

Prenatal ultrasonographic detection of unilateral cerebral ventriculomegaly arises suspicionof pathological condition related to cerebrospinal fluid flow obstruction or cerebralparenchimal pathology. Dyke-Davidoff-Masson syndrome is a rare condition characterizedby cerebral hemiatrophy, calvarial thickening, skull and facial asymmetry, contralateralhemiparesis, cognitive impairment and seizures. Congenital and acquired types arerecognized and have been described, mainly in late childhood, adolescence and adult ages.We describe a female infant with prenatal diagnosis of unilateral left ventriculomegaly inwhich early brain MRI and contrast enhanced-MRI angiography, showed cerebral lefthemiatrophy associated with reduced caliber of the left middle cerebral artery revealing thecharacteristic findings of the Dyke-Davidoff-Masson syndrome. Prenatal imaging, cerebralvascular anomaly responsible for the cerebral hemiatrophy and the early clinical evolutionhave never been described before in such a young child and complete theacquired clinicaldescriptions in older children. Differential diagnosis, genetic investigations, neurophysiologicassessments, short term clinical and developmental follow up are described. Dyke-DavidoffMasson syndrome must be ruled out in differential diagnosis of fetal unilateralventriculomegaly. Early clinical assessment, differential diagnosis and cerebral imagingincluding cerebral MRI angiography allow the clinicians to diagnose also in early infancy thisrare condition.

Food protein induced enterocolitis syndrome caused by rice beverage

Lucia Caminiti — 2013-05-14T00:00:00Z

Food protein-induced enterocolitis syndrome (FPIES) is an uncommon and potentially severe non IgE-mediated gastrointestinal food allergy. It is usually caused by cow's milk or soy proteins, but may also be triggered by ingestion of solid foods. The diagnosis is made on the basis of clinical history and symptoms. Management of acute phase requires fluid resuscitation and intravenous steroids administration, but avoidance of offending foods is the only effective therapeutic option.Infant with FPIES presented to our emergency department with vomiting, watery stools, hypothension and metabolic acidosis after ingestion of rice beverage. Intravenous fluids and steroids were administered with good clinical response. Subsequently, a double blind placebo control food challenge (DBPCFC) was performed using rice beverage and hydrolyzed formula (eHF) as placebo. The "rice based formula" induced emesis, diarrhoea and lethargy. Laboratory investigations reveal an increase of absolute count of neutrophils and the presence of faecal eosinophils. The patient was treated with both intravenous hydration and steroids. According to Powell criteria, oral food challenge was considered positive and diagnosis of FPIES induced by rice beverage was made. Patient was discharged at home with the indication to avoid rice and any rice beverage as well as to reintroduce hydrolyzed formula. A case of FPIES induced by rice beverage has never been reported. The present case clearly shows that also beverage containing rice proteins can be responsible of FPIES. For this reason, the use of rice beverage as cow's milk substitute for the treatment of non IgE-mediated food allergy should be avoided.

Improvement of dysphagia in a child affected by Pompe disease treated with enzyme replacement therapy

Simona Fecarotta — 2013-05-13T00:00:00Z

Aim: Dysphagia is a known complication in Pompe Disease (PD), a severe metabolic myopathy due to alpha-glucosidase deficiency. Enzyme replacement therapy (ERT) with alglucosidase alfa is the only approved therapy for PD. Presently no data are available on the effects of ERT on dysphagia in PD patients. The aim of this work is to evaluate the course of this complication in a 6 years old boy affected by PD after treatment with ERT. Methods: Dysphagia was assessed by Videofluoroscopic Swallowing Study (VFSS) at baseline, before the start of ERT and after 36 months of therapy. We used the Dysphagia Severity Rating Scale (DSS) to define the severity grade of dysphagia. Results: VFSS performed at baseline revealed complete incoordination of oral stage swallowing which was classified as a grade 1 dysphagia according to DSS. After 36 months of treatment VFSS revealed normal swallowing, classified as grade 0 by DSS. Conclusion: Our results suggest that ERT is effective in improving dysphagia. VFSS may be a useful tool to investigate and monitor swallowing disorders in patients affected by PD.

Modulation of airway epithelial cell functions by Pidotimod: NF-kB cytoplasmatic expression and its nuclear translocation are associated with an increased TLR-2 expression

Sonia Carta — 2013-05-10T00:00:00Z

Background: Recurrent respiratory infections are one of the most important causes of morbidity in childhood. When immune functions are still largely immature, the airway epithelium plays a primary defensive role since, besides providing a physical barrier, it is also involved in the innate and the adaptive immune responses. A study was therefore designed to evaluate in vitro whether pidotimod, a synthetic dipeptide able to stimulate the inflammatory and immune effector cells, could activate bronchial epithelial cell functions involved in response to infections. Methods: BEAS-2B cell line (human bronchial epithelial cells infected with a replication-defective Adenovirus 12-SV40 virus hybrid) were cultured in the presence of pidotimod, with or without tumor necrosis factor (TNF)-alpha or zymosan to assess: a) intercellular adhesion molecule (ICAM)-1 expression, by flow cytometry; b) toll-like receptor (TLR)-2 expression and production, by immunofluorescence flow cytometry and western blotting; d) interleukin (IL)-8 release, by enzyme-linked immunosorbent assay (ELISA); e) activated extracellular-signal-regulated kinase (ERK1/2) phosphorylation and nuclear factor-kappa B (NF-kB) activation, by western blotting. Results: The constitutive expression of ICAM-1 and IL-8 release were significant up-regulated by TNF-alpha (ICAM-1) and by TNF-alpha and zymosan (IL-8), but not by pidotimod. In contrast, an increased TLR-2 expression was found after exposure to pidotimod 10 and 100 mug/ml (p < 0.05) and to the association pidotimod 100 mug/ml + TNF-alpha (p < 0.05). Western blot analysis substantiated that the constitutive TLR-2 expression was significantly increased after exposure to all the stimuli. Finally, while a remarkable inhibition of TNF-alpha -induced ERK1/2 phosphorylation was observed in the presence of pidotimod, both TNF-alpha and pidotimod were effective in inducing NF-kB protein expression in the cytoplasm and its nuclear translocation. Conclusion: Through different effects on ERK1/2 and NF-kB, pidotimod was able to increase the expression of TLR-2 proteins, surface molecules involved in the initiation of the innate response to infectious stimuli. The lack of effect on ICAM-1 expression, the receptor for rhinovirus, and on IL-8 release, the potent chemotactic factor for neutrophils (that are already present in sites of infection), may represent protective functions. If confirmed in vivo, these activities may, at least in part, clarify the mechanism of action of this molecule at airway level.

How to feed small for gestational age newborns

Giovanni Barone — 2013-05-10T00:00:00Z

Feeding small for gestational age (SGA) newborns is extremely challenging and the neonatologist should be brave and cautious at the same time. Although these babies have a high risk of milk intolerance and necrotising enterocolitis, enteral feeding guidelines are not well established and practice varies widely among different neonatal units. Currently available studies on this topic include extremely and very low birth weight neonates, but are not focused specifically on small for gestational age infants. This review analyzes papers focused on feeding interventions in order to provide the best available evidences about the optimum timing for introduction of enteral feeding, how fast feed volume can be advanced, which milk and which feeding method is more appropriate in SGA infants.

Bacteremia and resistant gram-negative pathogens among under-fives in Tanzania

Alexandra Christopher — 2013-05-08T00:00:00Z

Background: Antibiotic resistance is one of the most serious public health concerns worldwide and is increasing at an alarming rate, making daily treatment decisions more challenging. This study is aimed at identifying local bacterial isolates and their antimicrobial susceptibility patterns to avoid irrational antibiotic use, especially in settings where unguided management occurs and febrile illnesses are predominant.Material and methodsA hospital-based prospective cross-sectional study was conducted from September 2011 to February 2012. Febrile children were serially recruited and demographic and clinical data were collected using a standardized data collection tool. A blood culture was performed and identification of the isolates was undertaken using in-house biochemical tests. Susceptibility to common antibiotics was investigated using the disc diffusion methods. Results: Of the 1081 children admitted during the study period, 317 (29.3%) met the inclusion criteria and were recruited, of whom 195 (61.5%) and 122 (38.5%) were male and female respectively. The median age was 18 months with an interquartile range of 9 to 36 months. Of the 317 children, 251 (79.2%) were below or equal to 36 months of age. The prevalence of bacteremia was 6.6%. A higher prevalence of bacteraemia was observed in children below 36 months than in those >= 36 months (7.5% vs. 3.0%, p = 0.001). Predictors of bacteraemia were an axillary temperature of >38.5 [degree sign]C (OR =7, 95% CI = 2.2 - 14.8, p-value = 0.0001), a positive malaria slide (OR =5, 95% CI = 3.0 - 21.2, p-value = 0.0001) and a high neutrophils' count (OR =21 95% CI = 5.6 - 84, p-value = 0.0001). Escherichia coli and Klebsiella pneumoniae accounted for 7 (33.3%) and 6 (28.6%) of all the isolates respectively. Others gram-negatives bacteria were Citrobacter spp 2 (9.5%), Enterobacter spp 1 (4.25%), Pseudomonas spp 2 (9.5%), Proteus spp 1 (4.25%) and Salmonella spp 1 (4.25%). These isolates were highly resistant to ampicillin (95%), co-trimoxazole (90%), tetracycline (90%), gentamicin (80%), augmentin (80%), chloramphenicol (65%), ceftriaxone (35%), cefotaxime (35%) ciprofloxacin (30%), amikacin (30%), ceftazidime (25%) and norfloxacine (10%). Conclusion: Multi-resistant gram-negative bacteria are the commonest cause of bacteremia in under-fives attending the Bugando Medical Centre, Mwanza, Tanzania. A high body temperature, a positive malaria slide and a high absolute neutrophils' count were all independent risk factors found to predict bacteremia. A higher mortality rate was observed in children with bacteraemia. Continuous epidemiological surveillance should be conducted so that a proper and effective antibiotics management can be instituted, especially in children with a high grade fever, a positive malaria slide and a high neutrophils' count.

Progress in Pediatrics in 2012: choices in allergy, endocrinology, gastroenterology, hematology, infectious diseases, neurology, nutrition and respiratory tract illnesses

Carlo Caffarelli — 2013-05-08T00:00:00Z

In this review, we summarize the progresses in allergy, endocrinology, gastroenterology, hematology, infectious diseases, neurology, nutrition and respiratory tract illnesses that have been published in The Italian Journal of Pediatrics in 2012. The induction of Treg activity by probiotics might be effective for promoting tolerance towards food allergens. Nasal cytology is useful in patients with rhinitis for diagnosing chronic non-allergic non-infectious diseases. Atopic eczema is associated both with an aberrant skin matrix and impaired systemic immune response. Therefore, isolated topical treatment may have suboptimal effect. Diagnostic work-up of exercise-induced anaphylaxis, including exercise challenge test, is necessary to reach a diagnosis. Studies may support a role for nutrition on prevention of asthma and cardiovascular diseases. Clinicians need to early identify adolescent menstrual abnormalities to minimize sequelae, and to promote health information. In Multiple Endocrine Neoplasia type 2B investigations include acetylcholinesterase study of rectal mucosa followed by the molecular analysis of RET mutation. Low adherence to gluten-free diet and osteopenia are common problems in children with diabetes mellitus type 1 and celiac disease. In infantile colic, laboratory tests are usually unnecessary and the treatment is based on reassurance. Prevalence of obesity and stunting is elucidated by several studies. Evidences are growing that dietetic measures are needed to prevent obesity in children with acute leukemia. Treatment studies for infectious diseases show promise for probiotics along with standard triple therapy in children with Helicobacter pilori infection, while zinc has no effect on pneumonia. Educational programs about the proper management of the febrile child are warranted. A new hour-specific total serum bilirubin nomogram has been shown to be able to predict newborns without hyperbilirubinemia after 48 to 72 hours of life. Newborns with hypoxic-ischemic encephalopathy present ECG and cardiac enzymes alterations leading to reduced neonatal survival. Rehabilitation programs including sensory integration therapy and motor performance, may improve activities of daily life in children with developmental coordination disorder. Aerobic exercise training in addition to chest physiotherapy might be useful in children with cystic fibrosis. Studies on effectiveness of leukotriene receptor antagonists, alone or with other drugs in preschool wheezing are needed.

Serum hepcidin: indication of its role as an ¿acute phase¿ marker in febrile children

Lydia Kossiva — 2013-04-25T00:00:00Z

Background: Hepcidin is classified as a type II acute phase protein; its production is a component of the innate immune response to infections.ObjectiveTo evaluate the alterations of serum hepcidin in children during and following an acute febrile infection.Materials and methods22 children with fever of acute onset (< 6 hours) admitted to the 2nd Department of Pediatrics-University of Athens. Based on clinical and laboratory findings our sample formed two groups: the viral infection group (13 children) and the bacterial infection group (9 children). Hepcidin, ferritin and serum iron measurements were performed in all subjects. Results: Serum hepcidin values did not differ notably between children with viral and bacterial infection, but a significant reduction of hepcidin was noted in both groups post-infection. Conclusion: Our study provides clinical pediatric data on the role of hepcidin in the face of an acute infection. In our sample of children, hepcidin was found to rise during the acute infection and fall post-infection.