Iranian Journal of Pediatrics
Volume:33 Issue: 4, Aug 2023

Neuroimmunological diseases in children encompass a range of disorders that lead to neurological complications in patients due to immune responses and systemic circulating antibodies. Limited research has been conducted on therapeutic plasma exchange’s efficacy and potential side effects in children with neuroimmunological diseases.

This study aimed to investigate this procedure’s effectiveness and potential side effects in children afflicted by these diseases.

This cross-sectional study examined a cohort of 18 children with neuroimmunological diseases who were admitted to the neurology department of Mofid Hospital over one year from March 2021 and underwent therapeutic plasma exchange.

The study included 18 patients, with an equal distribution of 9 females and 9 males. A total of 121 procedures were performed across 6 different disease groups: Multiple Sclerosis (22%, n = 4), Autoimmune Encephalitis (22%, n = 4), Neuromyelitis Optica Spectrum Disorder (22%, n = 4), Guillain-Barré syndrome (22%, n = 4), Acute Disseminated Encephalomyelitis (6%, n = 1), and Optic Neuritis (6%, n = 1). Following the plasma exchange, 17 patients (95%) showed immediate clinical improvement, while one patient diagnosed with optic neuritis did not respond to the treatment. During the follow-up period, 14 patients (78%) demonstrated significant improvement, one patient (6%) showed moderate improvement, and two patients (11%) exhibited mild improvement compared to their pre-plasmapheresis condition. Laboratory examinations revealed that only one patient experienced thrombocytopenia, which resolved without requiring treatment. No complications were observed during the follow-up visits for any of the patients.

Plasma exchange is a safe procedure for children with neuroimmunological diseases and yields favorable clinical responses.

Functional constipation (FC) is a common major problem in children. This study compared Jujube paste and polyethylene glycol (PEG) as laxative drugs in children with FC. Ziziphus Jujuba Mill (Jujube) was selected according to traditional Iranian medicine because it is native to Iran and a large extent of Asia, is safe and easy to access, with acceptable taste to children.

This randomized controlled clinical trial was performed on 128 children aged 2 to 12 with FC according toRomeIV criteria. Patients were randomly divided into two groups of Jujube paste and PEG and underwent four weeks of treatment. The efficacy, safety, and tolerability of the Jujube oral product were compared with PEG.

Following four weeks of therapy, all clinical symptoms of constipation according to Rome IV criteria were improved significantly in both groups (P < 0.05). In all the seven criteria of Rome IV, Jujube paste was as effective as PEG and even stronger in reducing stool stiffness (P < 0.0001). Nohazardous side effect was reported in the two groups. Moreover, the medication acceptance rate was higher in the group receiving Jujube paste than in the group receiving PEG.

Jujube paste is as effective as PEG in pediatric FC. This product has high nutritional value and antioxidant properties, so it can be a safe substitute for PEG in pediatric FC.

Febrile seizures are defined as seizures associated with a febrile illness that developed without central nervous system infection or acute electrolyte imbalance, intoxication, trauma, and metabolic disorder in children aged 1 month to 5 years without previous afebrile seizures. Various studies show a relationship between zinc levels and febrile seizures.

The purpose of this study was to examine the relationship between serum zinc levels and febrile seizures.

This prospective, cross-sectional, and descriptive study was conducted from 04/10/2021 to 04/02/2022. A total of 85 children aged 6 months to 5 years admitted to the pediatric emergency service of the Republic of Turkey Ministry of Health Cemil Ta¸scıo˘glu City Hospital were included in the study. The patients who met the inclusion criteria and whose consent was obtained were included in the study. Complex and febrile status patients were not included in the study due to the small number of patients. The cases included in the study were divided into 2 groups of patients and healthy controls. The patients with fever were divided into 2 groups, including those with and without febrile seizures. The levels of zinc and complete blood count parameters were measured in the blood samples taken from all the patients. IBM SPSS 22 package software was used for the statistical examination of the data.

When the cases included in this study were divided according to gender, 33 (38.8%) and 52 (61.2%) patients were female and male, respectively. The mean age of the cases was 29.2 ± 15.9 months (range: 6 - 60). Of the 85 participating cases, 30 patients had febrile seizures, 30 were only febrile patients, and 25 were healthy controls. When zinc levels were compared between the groups, the plasma zinc levels of the febrile seizures and febrile groups were observed to be lower than the healthy control group (P < 0.05).

In this study, the group consisting of patients with febrile seizures and the groups of patients who had a fever but did not have febrile seizures during the study had reduced serum zinc levels than the control group consisting of healthy patients without fever.

Intrapleural instillation of fibrinolytic agents is novel in treating empyema. Although the efficacy of this method for treating empyema remains a topic of debate among experts, several studies have shown that the results of this technique are almost equivalent to surgical operations in the lower stages of the disease. However, in more advanced stages of empyema, surgery may be required. Despite the worldwide use of fibrinolytic agents instead of surgical procedures, the benefits of using these agents postoperatively still need to be defined.

In this prospective study, we aimed to compare the effects of streptokinase and alteplase in managing empyema in patients who underwent any surgical operations.

We prospectively compared the outcomes of using alteplase and streptokinase in children who underwent surgical operations for empyema between 2015 and 2022. Following the surgery, fibrinolytic agents were instilled through thoracostomy tubes according to a specific protocol. The length of stay, frequency of complications, need for another surgery, and mortality were measured in each group.

Among 53 patients who met the inclusion criteria, 31 (58.5%) patients received streptokinase postoperatively, while the others were treated using alteplase. The length of stay after the surgery, wound infection, and mortality rate did not differ significantly between the groups (P-value = 0.394, 0.080, 0.767, respectively). However, the need for another surgery due to unexpanded lungs was significantly lower in the alteplase group (0% vs. 19.4%, P = 0.028).

Alteplase as an intrapleural fibrinolytic is more effective than streptokinase in patients who underwent surgical operations due to empyema. The need for another surgery following the instillation of alteplase through chest tubes postoperatively may be decreased.

Dysphagia is a frequent complication defined as difficulty in any stage of swallowing. Infants with a history of mechanical ventilation might show difficulty in coordinating pharyngeal muscles resulting in dysphagia.

The present study aimed to show the prevalence of swallowing disorders and associated symptoms among high-risk infants with a history of prolonged mechanical ventilation.

A quasi-experimental study was conducted at the Breastfeeding Research Center, Tehran, Iran. All the neonates with a history of prolonged mechanical ventilation entered the study. Parents were asked to respond to a provided questionnaire regarding their infants’ swallowing disorders. Accordingly, the infants with any symptoms were considered candidates for intervention. The parents also received simple training to perform oral sensorimotor stimulation protocol for their children. Through a follow-up visit, the questionnaire was filled up for every infant. Finally, all the data related to the responses before and after interventions were compared to show the possible effects of the interventions.

A total of 25 infants entered the study. The mean mechanical ventilation period was 15.95 ± 6.644 days. Concerning the frequency of swallowing complications, 24 infants (96%) had different degrees of dysphagia. After 3 - 6 months of interventions, the number of cases with symptoms of coughing (P = 0.016), spitting food out by mouth (P = 0.0001), choking (P = 0.016), humid breath (P = 0.031), poor weight gain (P = 0.002), and the need to cut food into small pieces (P = 0.004) was significantly lower than the number of cases suffering from such complications before the intervention. The results also showed that after 3 - 6 months of interventions, dysphagia symptoms in 10 out of 24 infants (41.66%) entirely and in others (38.44%) partially improved.

The results of the present study delineated that infants with a history of prolonged mechanical ventilation were at greater risk of swallowing complications. The early diagnosis and implementation of oral sensorimotor interventions could improve different symptoms of dysphagia.

Children with congenital heart diseases (CHDs) often require cardiac surgery, whose outcome depends on many preoperative, intraoperative, and postoperative factors.

We aimed to investigate the factors associated with in-hospital mortality among patients undergoing pediatric heart surgery for CHDs.

This retrospective cross-sectional study included patients younger than 18 years who underwent cardiac surgery due to CHDs at the Children’s Medical Center of Tehran University of Medical Sciences and were admitted to the open-heart surgery intensive care unit (OH-ICU) between March 2018 and March 2019. Patients with incomplete records were excluded. The collected data included age (months), weight (kg), type of congenital defect, duration of intensive care unit (ICU) stay, cardiopulmonary bypass (CPB) time, aortic cross-clamping (XCT) time, postoperative (day 1) platelet count and neutrophil-to-lymphocyte ratio (NLR), and mortality.

This study included 275 CHD patients who underwent cardiac surgery. The mean age and weight were 32.54 ± 37.4 months and 11.01 ± 8.43 kg, respectively. Those who died were younger (P = 0.05) and had lower weights (P = 0.001). An inverse relationship existed between thrombocytopeniaandmortality. TheNLRwashigher in thosewhosurvived(mean4.08 vs. 2.87), while the deceased patients had an extended duration of hospitalization, longer CPB time, and longer XCT time.

Younger age, lower body weight, lower NLR ratio, lower platelet count, longer intraoperative CPB time, and XCT time were not associated with increased in-hospital mortality following cardiac surgery for CHDs. The Risk Adjustment for Congenital Heart Surgery (RACHS-1) score was not significantly related to mortality. Also, CPB and XCT times were significantly longer in cyanotic than in non-cyanotic patients. Cyanotic patients also had significantly lower platelets than non-cyanotic patients after the operation. Large, multicenter studies are needed to further investigate the predictors of mortality following surgery for CHDs.

Bruxism is a parafunctional oral activity defined as excessive teeth grinding or jaw clenching. This disorder causes damage to the teeth and deforms them.

This is the first phase of the sleep bruxism and respiratory disorders assessment study in Kerman, Iran, which evaluated respiratory disorders and sleep bruxism in schoolchildren aged 8 - 11 years between 2018 - 2019.

A total of 573 primary school students aged 8 - 11 years were recruited for this cross-sectional study in Kerman between 2018 - 2019. The subjects were chosen randomly from 20 schools located throughout the city. Following permission from officials, 30 students from each school were admitted to the study randomly. The parents were invited to fill out a checklist that included a history of respiratory and sleep problems and signs of bruxism or abnormal jaw movements. Additionally, an examination was performed, and the symptoms of bruxism, such as tooth wear and restoration fractures, were documented.

The parents of 573 children were recruited to the study. The prevalence of bruxism and respiratory diseases was observed to be 20.6% (n = 118) and 26.5% (n = 152), respectively. The children with sound production had 2.3 times higher odds of bruxism prevalence than those without sound production (P = 0.004). However, children with temporomandibular joint and paranasal sinus sensitivity had 4.5 (P = 0.001) and 3.8 (P = 0.001) times higher odds, respectively. Additionally, the odds of bruxism prevalence were 1.4 times higher in children with respiratory disorders than those without (P = 0.001).

Bruxismwascommonin childrenwhohada respiratory disorder. Given the potential impact of bruxismonchildren’s dental health, it is important to pay special attention to the health status of children with respiratory disorders.

Urinary tract infections (UTIs) are among the most common bacterial infections in children. Urinalysis (UA) is a beneficial test for the preliminary diagnosis of UTIs. The presence of bacteriuria in UA can be determined by either an enhanced (using uncentrifuged Gram-stained specimens) or manual (using centrifuged specimens) technique. However, the diagnostic performance of enhanced UA is not well-established in childhood UTIs.

To assess the ability of enhanced and automated urinalysis to detect UTIs in children.

This cross-sectional study was conducted on 191 children with the symptoms of UTI referred to Dr. Sheikh Hospital, Mashhad, Iran, from 2018 to 2019. Standard urinalysis, enhanced urinalysis, and quantitative urine culture were performed on specimens. A positive enhanced UA test was defined as  10 white blood cells per mL of urine and the presence of any bacteria per 10 high-power microscopic fields of a Gram-stained smear. A positive manual UA test was defined as  5 white blood cells per high-power field. The results of standard and enhanced UA were compared with urine culture findings to determine the accuracy of these two methods in detecting UTIs. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined for each test.

The results showed that the prevalence of UTI was 23%. Enhanced UA retrieved a sensitivity of 97.7%, specificity of 93.1%, PPV of 81.1%, and NPV of 99.3% for detecting UTIs. In standard UA, sensitivity, specificity, PPV, and NPV were 90.9%, 80.7%, 57.1%, and 96.6% for pyuria, 56.8%, 98.6%, 92.5%, and 88.4% for the nitrite test, 72.7%, 94.5%, 80%, and 92% for the leukocyte esterase test, respectively.

Enhanced UA had higher sensitivity, specificity, PPV, and NPV than standard UA.

Context: 

The present systematic review aimed to investigate whether the lung ultrasound score (LUS) can accurately predict surfactant administration in premature neonates with respiratory distress syndrome (RDS).

 The systematic review was conducted according to the Cochrane collaboration or the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. English language databases included PubMed, Ovid, Cochrane Library, Embase, Web of Science, and Scopus. The coverage date of this review was from the inception of each database to the end of May 2022. Data were extracted independently by two authors, assessed for quality using the quality assessment of diagnostic accuracy studies-2 (QUADAS-2) tool, and analyzed for heterogeneity using MetaDisc1.4 software.

 Seven eligible articles and 653 neonates were finally selected from 176 studies for meta-analysis. Considering the LUS to predict the surfactant need in premature neonates, we extracted the variable from the studies. Also, we plotted the summary receiver operating characteristic curve with an area under the curve (AUC) of 0.94 (95% confidence interval (CI): 0.92 - 0.95). Forest plots of the LUS showed a pooled sensitivity of 0.86 (95% CI: 0.82 - 0.90) and a pooled specificity of 0.79 (95% CI: 0.75 - 0.82). The Cochrane-Q test, chi-square test, and inconsistency index confirmed the heterogeneity of the non-threshold effect (I2 > 50% or P < 0.05). The meta-regression analysis showed that the relative diagnostic odds ratio for the number of recruited cases (> 100 vs. < 100) was 0.65 (95% CI: 0.33 - 0.98, P-value < 0.05). The comparison of the cut-offs of the 4 - 6 score vs. the 8 - 12 score yielded a Z of 21.44 (P < 0.001).

 The LUS accurately predicts the onset of RDS in premature neonates and can guide surfactant administration but is subject to the cut-off effect. Variation in cut-offs is related to gestational age and disease severity.

 During the COVID-19 pandemic, educational programs have increasingly relied on virtual methods.

 In this study, we compared the effects of in-person and virtual electroencephalography (EEG) training on the knowledge of pediatric and adult neurology residents.

 The study participants consisted of 30 pediatric and adult neurology residents who were recruited nationwide via a virtual network. They were randomly divided into two groups for in-person and virtual education, respectively. Prior to the first workshop session, participants completed a pre-test comprising 19 knowledge-related questions. Two interactive training sessions focusing on benign variants in EEG were conducted, including two in-person workshops for eight residents and two online workshops for 22 residents. Each session lasted one hour, with one held every two weeks. After the second session, participants were asked to complete a post-test consisting of 24 questions (identical to the pre-test) and five workshop satisfaction-related questions.

 Overall, the mean exam score after both the in-person and virtual workshops was significantly higher than the pretest score across all educational levels. The mean score differences in knowledge between the in-person and virtual groups after the workshop were similar, with no statistically significant difference. Approximately 90% of the participants believed that the workshop would be beneficial for their daily practice.

 Given the absence of a significant difference between in-person and virtual training methods in improving participants' knowledge and satisfaction with both approaches, we recommend integrating virtual EEG training into the educational protocol for pediatric and adult neurology residents. Nonetheless, larger sample size studies are required to further validate these findings.

 Osteoporosis is a known entity in individuals with celiac disease (CD).

 The aim of this study was to evaluate bone mineral density (BMD) measurements in children with CD.

 This was a retrospective design study in a tertiary hospital in Turkey.

 Totally 106 patients were included, and the mean age was 10.2 ± 3.9 years. The mean L1-L4 Z score was 0.730 ± 0.197 (based on sex and height in Turkish children). About 20.7% (n = 22) had a history of at least one fracture and/or bone pain. Bone mineral density values obtained from lumbar (L1-L4) vertebrae were significantly lower in patients with a prior fracture and/or bone pain compared to the patient group without a fracture (0.822 ± 0.242 g/cm2 vs 0.706 ± 0.178 g/cm2, respectively; P = 0.047). L1-L4 Z score (based on sex and height in Turkish children) was lower in patients with a body mass index (BMI) SDS value below -2 (moderately or severely malnourished) than those with a BMI SDS above -2 (0.02 ± 1.19 vs 1.4 ± 1.82, respectively; P = 0.014). A moderate positive correlation (r = 0.547; P < 0.01) was found between somatomedin-C (IGF-1) level and L1-L4 BMD (g/cm2) measurement. It was remarkable that low BMD was not identified in any patients using L1-L4 Z-score by height and L1-L4 Z-score by age of Turkish children. Nine (8.5%) patients were found to have low BMD using the United States (US) age- and sex-specific L1-L4 Z-score from the GE Healthcare Lunar iDXA system.

 Bone mineral density should be screened considering risk factors for suboptimal bone health in children with celiac disease. False "normal" BMD interpretations can be avoided by taking into account the model of the BMD measuring device and by using the device's normal ranges in case of inconsistency with the Turkish reference values.

 Most cases of newborn hyperbilirubinemia are physiologic; however, excessive unconjugated bilirubin is a potential neurotoxin. Phototherapy treats moderate to severe hyperbilirubinemia. If phototherapy increases immunoglobulin G (IgG) clearance, there is a chance of humoral immune disorders.

 The purpose of the study was to investigate the effect of phototherapy on the level of IgG in neonates.

 This study investigated 40 full-term newborns with hyperbilirubinemia. Blood samples were taken before and 72 hours after phototherapy. The IgG level was measured by calorimetry tests.

 Phototherapy resulted in a decrease in IgG levels. The IgG level significantly decreased from 833.135 to 720.185 mg/dL. Before phototherapy, 12.5% of the population had low IgG levels; however, 32.5% had low IgG levels after the treatment.

 According to the results of the study, intensive phototherapy caused a reduction in IgG levels. Since there was no significant decrease in IgG levels in neonates who received conventional phototherapy, it can be concluded that this treatment is safe in terms of IgG levels.

 While severe hypoxia is known to contribute to neurotoxicity and lead to abnormal behavior, mild hypoxia may have beneficial effects mediated through endogenous adaptive responses.

 The present study aimed to investigate the effects of mild hypoxia postconditioning and long-term neurobehavioral ability rehabilitation after hypoxic-ischemic brain damage (HIBD).

 Seven-day-old rats underwent left carotid ligation followed by 2 hours of hypoxia stress. Rats received different protocols of mild hypoxia postconditioning for 5 days and underwent neurobehavioral testing during the last week of the study. Hypoxia-inducible factor 1 alpha (HIF-1a) expression was assessed, and neurobehavioral ability assays were performed.

 Compared with the HIBD group, rats postconditioning with mild hypoxia showed increased HIF-1a expression, and their brain functions were better in neurobehavioral analyses. The rehabilitation of brain functions may be associated with high HIF-1a expression and better behavioral performance.

 Our findings indicate that mild hypoxia postconditioning improves neurobehavioral ability, and HIF-1a may be a potential mediator of the observed effects. Our findings suggest that there may be clinical implications for treating infants with HIBD.