Journal: Clinical pediatrics
Celiac disease is a gluten enteropathy that is treated with dietary elimination of gluten. Exposure to nondietary sources of gluten, which are used in the manufacture of products such as plastics, dental equipment, and cosmetics, can also trigger or exacerbate disease. We report the case of a 9-year-old child who presented with nonspecific abdominal discomfort with abnormal serology for celiac disease. She underwent duodenal biopsies that revealed Marsh 3B histopathology. Despite strict dietary elimination of gluten, she continued to be symptomatic and demonstrate positive serum markers for active disease. It was then discovered that the child was exposed to gluten from her orthodontic retainer that contained a plasticized methacrylate polymer. Gluten is a common additive in plastics. She discontinued its use and demonstrated symptom resolution and complete normalization of serology. All possible sources of gluten, including nondietary, must be considered when managing a child with celiac disease.
Inhaled corticosteroids (ICS) are drugs of choice for persistent asthma. Less than 500 µg/d of fluticasone are believed to be safe. We found 92 cases of adrenal suppression in PubMed; among these cases there were 13 children who took 500 µg/d or less of fluticasone. Adrenal insufficiency was diagnosed in a 7-year-old boy on 460 µg ICS for 16 months, with a diagnosis of chronic persistent asthma. A random cortisol was nondetectable as was an early morning cortisol. ICS have greatly improved the day-to-day lives of children with chronic persistent asthma. Parents of children younger than 12 years, who use at least 400 µg of inhaled fluticasone (or bioequivalent), must be given oral and written instructions about warning symptoms of hypocortisolism. Major stress such as surgery, gastrointestinal, bronchopulmonary, or other systemic infections, and heat stress may mandate a written plan of action for use by hospital physicians.
Hemophagocytic lymphohistiocytosis (HLH) is a severe inflammatory disorder characterized by activation and proliferation of lymphocytes and histiocytes with cytokine release and uncontrolled hemophagocytosis, especially late in the course of the disease. Clinical features include relapsing fevers, hepatosplenomegaly, cytopenias, lymphadenopathy, and coagulopathy. The diagnosis can be challenging, as the early signs and symptoms are nonspecific and no specific laboratory tests exist. This syndrome is frequently not recognized and has a significant mortality rate. Typical scenarios in which HLH should be considered include mononucleosis (fever, hepatosplenomegaly, and lymphadenopathy) in an infant or young child, aseptic meningitis associated with cytopenias, or a viral syndrome-like illness with cytopenias and lymphadenopathy or splenomegaly, for example. Our approach includes measuring a ferritin level as a screening tool early in the course of such an illness. Two cases of HLH are reviewed, illustrating the frequent complexity of these cases and potential pitfalls to making a prompt diagnosis.
Background. Eye movements are necessary for the physical act of reading and have been shown to relate to underlying cognitive and visuoattentional processes during reading. The purpose of this study was to determine the effect of saccadic training using the King-Devick remediation software on reading fluency. Methods. In this prospective, single-blinded, randomized, crossover trial, a cohort of elementary students received standardized reading fluency testing pre- and posttreatment. Treatment consisted of in-school training 20 minutes per day, 3 days per week for 6 weeks. Results. The treatment group had significantly higher reading fluency scores after treatment (P < .001), and posttreatment scores were significantly higher than the control group (P < .005). Conclusion. Saccadic training can significantly improve reading fluency. We hypothesize that this improvement in reading fluency is a result of rigorous practice of eye movements and shifting visuospatial attention, which are vital to the act of reading.
Objective: Current guidelines for Kawasaki disease (KD) recommend intravenous immunoglobulin infusion and echocardiography. However, no previous studies have evaluated the relationship between the treating hospital’s concordance with guidelines and the prevention of coronary artery aneurysm in patients with KD. Study Design: KD patients between 2010 and 2013 were identified in a Japanese national inpatient database. Guideline concordance was defined as the proportions of patients who received echocardiography as well as treatment with both immunoglobulin and aspirin, which were divided into quartiles. Multivariable logistic regression analysis was conducted to examine the association between the guideline concordance and the occurrence of coronary artery aneurysm with adjustment for patient backgrounds. Results: In sum, 20 156 patients with KD were identified. The very high (>83.3%) concordance group had a lower rate of coronary artery aneurysm than the very low (<59.0%) concordance group (4.9% vs 9.9%; odds ratio, 0.45; 95% CI, 0.27 to 0.74; P = .002). Conclusion: All patients with KD should be treated according to the guidelines.
We enrolled 64 patients age 12 to 22 years with a diagnosis of poorly controlled persistent asthma in a 6-month longitudinal crossover study. During the 3 intervention months, participants created personalized text messages to be sent to their phones. Adherence was objectively monitored in 22 of the participants. The adolescent participants gave high ratings on the acceptability of the text messaging system. Asthma control improved from baseline to month 1 regardless of whether teens were in the texting or control group. While participants were in the texting group, their quality of life improved and worry about their asthma decreased. Receiving the text intervention resulted in an increase in adherence of 2.75% each month relative to no intervention, but the improvements were not sustained. There was modest improvement in asthma control and quality of life outcomes, as well as improved adherence during the texting intervention.
Objective. The objective of this study is to examine the associations between fast food consumption and the academic growth of 8544 fifth-grade children in reading, math, and science. Method. This study uses direct assessments of academic achievement and child-reported fast food consumption from a nationally representative sample of kindergartners followed through eighth grade. Results. More than two thirds of the sample reported some fast food consumption; 20% reported consuming at least 4 fast food meals in the prior week. Fast food consumption during fifth grade predicted lower levels of academic achievement in all 3 subjects in eighth grade, even when fifth grade academic scores and numerous potential confounding variables, including socioeconomic indicators, physical activity, and TV watching, were controlled for in the models. Conclusion. These results provide initial evidence that high levels of fast food consumption are predictive of slower growth in academic skills in a nationally representative sample of children.
Primary care providers are increasingly providing youth concussion care but report insufficient time and training, limiting adoption of best practices. We implemented a primary care-based intervention including an electronic health record-based clinical decision support tool (“SmartSet”) and in-person training. We evaluated consequent improvement in 2 key concussion management practices: (1) performance of a vestibular oculomotor examination and (2) discussion of return-to-learn/return-to-play (RTL/RTP) guidelines. Data were included from 7284 primary care patients aged 0 to 17 years with initial concussion visits between July 2010 and June 2014. We compared proportions of visits pre- and post-intervention in which the examination was performed or RTL/RTP guidelines provided. Examinations and RTL/RTP were documented for 1.8% and 19.0% of visits pre-intervention, respectively, compared with 71.1% and 72.9% post-intervention. A total of 95% of post-intervention examinations were documented within the SmartSet. An electronic clinical decision support tool, plus in-person training, may be key to changing primary care provider behavior around concussion care.
This study investigates the epidemiology of injuries associated with toys among US children by analyzing data from the National Electronic Injury Surveillance System. During 1990-2011, an estimated 3 278 073 (95% confidence interval = 2 762 281-3 793 865) children <18 years old were treated in US emergency departments for toy-related injuries, averaging 149 003 cases annually. The annual injury rate per 10 000 children increased significantly by 39.9% from 18.88 in 1990 to 26.42 in 2011. The number and rate of injuries peaked at age 2 years; 63.4% of patients were male; and 80.3% of injuries occurred at home. Ride-on toys accounted for 34.9% of injuries and 42.5% of hospital admissions. This study is the first to comprehensively investigate toy-related injuries among children using a nationally representative data set. The increasing number and rate of toy-related injuries to children, especially those associated with ride-on toys, underscore the need for increased efforts to prevent these injuries.
This study investigates pediatric injuries involving amusement rides treated in US emergency departments by retrospectively analyzing data from the National Electronic Injury Surveillance System. From 1990 to 2010, an estimated 92 885 children ≤17 years sought treatment in US hospital emergency departments for injuries involving amusement rides, yielding an annual average of 4423 injuries. The average annual injury rate was 6.24 injuries per 100 000 US children, and the mean patient age was 8.73 years. The head and neck was the most commonly injured body region (28.0%), and the most common type of injury was a soft tissue injury (29.4%). Falling in, on, off, or against the ride was the most frequent mechanism of injury (31.7%). Only 1.5% of injuries resulted in hospitalization. An improved national system for monitoring injuries involving amusement rides is needed. There are opportunities to improve the safety of amusement rides for children, especially to prevent injuries from falls.