Children, Volume 7, Issue 12 (December 2020) – 62 articles

Pediatric Palliative Care (PPC) addresses children, adolescents, and young adults with a broad spectrum of underlying diseases. A substantial proportion of these patients have irreversible conditions accompanied by Severe Neurological Impairment (SNI). For the treatment of pain and dyspnea, strong opioids are widely used in PPC. Nonetheless, there is considerable uncertainty regarding the opioid-related side effects in pediatric patients with SNI, particularly concerning Opioid-Induced Respiratory Depression (OIRD). Research on pain and OIRD in pediatric patients with SNI is limited. Using scoping review methodology, we performed a systematic literature search for OIRD in pediatric patients with SNI. Out of n = 521 identified articles, n = 6 studies were included in the review. Most studies examined the effects of short-term intravenous opioid therapy. The incidence of OIRD varied between 0.13% and 4.6%; besides SNI, comorbidities, and polypharmacy were the most relevant risk factors. Additionally, three clinical cases of OIRD in PPC patients receiving oral or transdermal opioids are presented and discussed. The case reports indicate that the risk factors identified in the scoping review also apply to adolescents and young adults with SNI receiving low-dose oral or transdermal opioid therapy. However, the risk of OIRD should never be a barrier to adequate symptom relief. We recommend careful consideration and systematic observation of opioid therapy in this population of patients. Full article

To explore factors influencing adolescents and young adults’ (AYAs) risk perception of COVID-19 and adherence to public health measures, we conducted a cross-sectional online survey of AYAs (14–22 years old) from Quebec (Canada) recruited through school and community partners in April 2020 during the first wave of the COVID-19 pandemic. The study included 3037 participants (mean age = 17.7 years, 74.6% female). AYAs had higher mean (standard deviation (SD)) risk perception of COVID-19 for their relatives (8.2 (1.9)) than for themselves (5.6 (2.6)) (p < 0.001). Factors associated with higher risk perception included higher disease knowledge (adjusted odds ratio (aOR) 1.06, 95% CI 1.01–1.11), presence of chronic disease (aOR 2.31, 95%CI 1.82–2.93) and use of immunosuppressants (aOR 2.53, 95%CI 1.67–3.87). AYAs with a higher risk perception (aOR 1.06, 95%CI 1.02–1.10) those wishing to help flatten the disease curve (aOR 1.18, 95%CI 1.12–1.25) or to protect their family/friends (aOR 1.14, 95%CI 1.05–1.24) were more likely to engage in preventive behaviors. Self-perceived risk and desire to protect others were significantly associated with adherence to preventive measures among youth. These findings may help inform public health messaging to AYAs in the current and future pandemics. Full article

Emotional intelligence skills in students may be related with physical and mental health, within and outside the academic field. Strengthening these skills can lead to greater overall well-being, lower use of substances, and improved academic performance, as well as reduced aggressive behaviours. The objective of this study was to analyse the levels of emotional intelligence (differentiating between the dimensions: emotional Attention, Clarity, and Repair) among high school students and examine its relationship with academic performance and emotional well-being, considering if there are differences between boys and girls and between different grades. A cross-sectional descriptive study was developed on a sample of 333 High School students using the Trait Meta-Mood Scale (TMMS) and KIDSCREEN-10 Index tools. Differences in emotional intelligence were observed between boys and girls for the three dimensions, and a relationship between emotional intelligence and student well-being was appreciated. No relationships were found between emotional intelligence and academic performance, nor have any differences been observed between the different courses analysed. It cannot be concluded that academic performance is related to emotional intelligence, but a relationship between well-being and emotional intelligence is found. Full article

Neonatal early-onset sepsis (EOS) is defined as an invasive infection that occurs in the first 72 h of life. The incidence of EOS varies from 0.5–2% live births in developed countries, up to 9.8% live births in low resource settings, generating a high mortality rate, especially in extremely low birth weight neonates. Clinical signs are nonspecific, leading to a late diagnosis and high mortality. Currently, there are several markers used for sepsis evaluation, such as hematological indices, acute phase reactants, cytokines, which by themselves do not show acceptable sensitivity and specificity for the diagnosis of EOS in neonates. Newer and more selective markers have surfaced recently, such as presepsin and endocan, but they are currently only in the experimental research stages. This comprehensive review article is based on the role of biomarkers currently in use or in the research phase from a basic, translational, and clinical viewpoint that helps us to improve the quality of neonatal early-onset sepsis diagnosis and management. Full article

This study aimed to investigate sex difference in the functional movement in the adolescent period. Seven hundred and thirty adolescents (365 boys) aged 16–17 years participated in the study. The participants performed standardized Functional Movement Screen™ (FMS^TM) protocol and a t-test was used to examine sex differences in the total functional movement screen score, while the chi-square test was used to determine sex differences in the proportion of dysfunctional movement and movement asymmetries within the individual FMS^TM tests. Girls demonstrated higher total FMS^TM score compared to boys (12.7 ± 2.3 and 12.2 ± 2.4, respectively; p = 0.0054). Sex differences were present in several individual functional movement patterns where boys demonstrated higher prevalence of dysfunctional movement compared to girls in patterns that challenge mobility and flexibility of the body (inline lunge: 32% vs. 22%, df = 1, p = 0.0009; shoulder mobility: 47% vs. 26%, df = 1, p < 0.0001; and active straight leg raise: 31% vs. 9%, df = 1, p < 0.0001), while girls underperformed in tests that have higher demands for upper-body strength and abdominal stabilization (trunk stability push-up: 81% vs. 44%, df = 1, p < 0.0001; and rotary stability: 54% vs. 44%, df = 1, p = 0.0075). Findings of this study suggest that sex dimorphisms exist in functional movement patterns in the period of mid-adolescence. The results of this research need to be considered while using FMS^TM as a screening tool, as well as the reference standard for exercise intervention among the secondary school-aged population. Full article

While each route of therapeutic drug delivery has its own advantages and limitations, oral delivery is often favored because it offers convenient painless administration, sustained delivery, prolonged shelf life, and often lower manufacturing cost. Its limitations include mucus and epithelial cell barriers in the gastrointestinal (GI) tract that can block access of larger molecules including Therapeutic protein or peptide-based drugs (TPPs), resulting in reduced bioavailability. This review describes these barriers and discusses different strategies used to modify TPPs to enhance their oral bioavailability and/or to increase their absorption. Some seek to stabilize the TTPs to prevent their degradation by proteolytic enzymes in the GI tract by administering them together with protease inhibitors, while others modify TPPs with mucoadhesive polymers like polyethylene glycol (PEG) to allow them to interact with the mucus layer, thereby delaying their clearance. The further barrier provided by the epithelial cell membrane can be overcome by the addition of a cell-penetrating peptide (CPP) and the use of a carrier molecule such as a liposome, microsphere, or nanosphere to transport the TPP-CPP chimera. Enteric coatings have also been used to help TPPs reach the small intestine. Key efficacious TPP formulations that have been approved for clinical use will be discussed. Full article

(1) Background: anthropometric measurements with calipers are used to objectify cranial asymmetry in positional plagiocephaly but there is controversy regarding the reliability of different methodologies. Purpose: to analyze the interrater and intrarater reliability of direct anthropometric measurements with caliper on defined craniofacial references in infants with positional plagiocephaly. (2) Methods: 62 subjects (<28 weeks), with a difference of at least 5 mm between cranial diagonal diameters. Maximal cranial circumference, length and width and diagonal cranial diameters were measured. Intrarater (2 measurements) and interrater (2 raters) reliability was analyzed. (3) Results: intra- and interrater reliability of the maximal cranial length and width and right cranial diagonal was excellent: intraclass correlation coefficient (ICC) > 0.9. Intrarater and interrater reliability for the left cranial diagonal was excellent: ICC > 0.9 and difference in agreement in the Bland-Altman plot 0.0 mm, respectively. Intrarater and interrater reliability for the maximal cranial circumference was good: differences in agreement in Bland-Altman plots: intra: −0.03 cm; inter: −0.12 cm. (4) Conclusions: anthropometric measurements in a sample of infants with moderate positional plagiocephaly have shown excellent intra- and interrater reliability for maximal cranial length, maximal cranial width, and right and left cranial diagonals, and good intra- and interrater reliability in maximal cranial circumference measurement. Full article

The prevalence of childhood obesity has increased over the years in the United States and contributed to a rise in metabolic syndrome and non-alcoholic fatty liver disease (NAFLD). Animal studies suggested the role of histamine blockade on mesenteric lymphatics tone, contributing to weight gain and hepatic steatosis. This study aimed to investigate an association between antihistamines (AH) use in children and obesity. A single-center retrospective cohort study on children with a diagnosis of NAFLD, followed in the gastroenterology clinic, was performed between January 2018 and April 2019. The demographics, medications, and body mass index (BMI) were assessed. Participants were divided into an AH group with documented use and comparison group, antihistamine naïve. Of the 32 participants in the study, 13 used AH, and 19 did not. Antihistamine users had a mean increase in BMI percentile per year of 1.17 compared to a decrease of 0.06 in comparison group (p = 0.0008). AH usage correlated with a mean increase in BMI z-score of 0.23 per year, as opposed to a decrease by 0.012 in comparison group (p = 0.0016). No difference was found in triglycerides (TG), glucose, and liver enzymes. AH use increases BMI percentiles and z-scores over time and is associated with obesity in children. Full article

Background: Metabolic Syndrome (MetS) has a high prevalence in children, and its presence increases in those with a high BMI. This fact confirms the need for early detection to avoid the development of other comorbidities. Non-invasive variables are presented as a cost-effective and easy to apply alternative in any clinical setting. Aim: To propose a non-invasive method for the early diagnosis of MetS in overweight and obese Chilean children. Methods: We conducted a cross-sectional study on 221 children aged 6 to 11 years. We carried out multivariate logistic regressions, receiver operating characteristic curves, and discriminant analysis to determine the predictive capacity of non-invasive variables. The proposed new method for early detection of MetS is based on clinical decision trees. Results: The prevalence of MetS was 26.7%. The area under the curve for the BMI and waist circumference was 0.827 and 0.808, respectively. Two decision trees were calculated: the first included blood pressure (≥104.5/69 mmHg), BMI (≥23.5 Kg/m²) and WHtR (≥0.55); the second used BMI (≥23.5 Kg/m²) and WHtR (≥0.55), with validity index of 74.7% and 80.5%, respectively. Conclusions: Early detection of MetS is possible through non-invasive methods in overweight and obese children. Two models (Clinical decision trees) based on anthropometric (non-invasive) variables with acceptable validity indexes have been presented. Clinical decision trees can be applied in different clinical and non-clinical settings, adapting to the tools available, being an economical and easy to measurement option. These methods reduce the use of blood tests to those patients who require confirmation. Full article

Patients with acute respiratory distress syndrome (ARDS) commonly have dependent atelectasis and heterogeneous lung disease. Due to the heterogenous lung volumes seen, the application of positive end expiratory pressure (PEEP) can have both beneficial and deleterious effects. Alternating supine and prone positioning may be beneficial in ARDS by providing more homogenous distribution of PEEP and decreasing intrapulmonary shunt. In pediatrics, the pediatric acute lung injury and consensus conference (PALICC) recommended to consider it in severe pediatric ARDS (PARDS). Manually prone positioning patients can be burdensome in larger patients. In adults, the use of rotational beds has eased care of these patients. There is little published data about rotational bed therapy in children. Therefore, we sought to describe the use of a rotational bed in children with PARDS. We performed a retrospective case series of children who utilized a rotational bed as an adjunctive therapy for their PARDS. Patient data were collected and analyzed. Descriptive statistical analyses were performed and reported. Oxygenation indices (OI) pre- and post-prone positioning were analyzed. Twelve patients with PARDS were treated with a rotational bed with minimal adverse events. There were no complications noted. Three patients had malfunctioning of their arterial line while on the rotational bed. Oxygenation indices improved over time in 11 of the 12 patients included in the study while on the rotational bed. Rotational beds can be safely utilized in pediatric patients. In larger children with PARDS, where it may be more difficult to perform a manual prone position, use of a rotational bed can be considered a safe alternative. Full article

Gastroschisis, the most common type of abdominal wall defect, has seen a steady increase in its prevalence over the past several decades. It is identified, both prenatally and postnatally, by the location of the defect, most often to the right of a normally-inserted umbilical cord. It disproportionately affects young mothers, and appears to be associated with environmental factors. However, the contribution of genetic factors to the overall risk remains unknown. While approximately 10% of infants with gastroschisis have intestinal atresia, extraintestinal anomalies are rare. Prenatal ultrasound scans are useful for early diagnosis and identification of features that predict a high likelihood of associated bowel atresia. The timing and mode of delivery for mothers with fetuses with gastroschisis have been somewhat controversial, but there is no convincing evidence to support routine preterm delivery or elective cesarean section in the absence of obstetric indications. Postnatal surgical management is dictated by the condition of the bowel and the abdominal domain. The surgical options include either primary reduction and closure or staged reduction with placement of a silo followed by delayed closure. The overall prognosis for infants with gastroschisis, in terms of both survival as well as long-term outcomes, is excellent. However, the management and outcomes of a subset of infants with complex gastroschisis, especially those who develop short bowel syndrome (SBS), remains challenging. Future research should be directed towards identification of epidemiological factors contributing to its rising incidence, improvement in the management of SBS, and obstetric/fetal interventions to minimize intestinal damage. Full article

Background: Drowning remains the third leading cause of unintentional injury death for adolescents in the United States. Aims: This study described adolescent swimming lessons, behaviors (life jacket wear while boating) and comfort (swimming in deep water) and their association with protective and risk factors and risk-taking behaviors reported by Washington State students in Grades 8, 10, 12, primarily comprised of youth ages 13 to 18 years. Methods: This study used the 2014 Washington State Healthy Youth Survey (HYS), a publicly available dataset. Results: Most students reported having had swimming lessons, using life jackets, and comfort in deep water. Differences reflected racial, ethnic and socioeconomic disparities: being White or Caucasian, speaking English at home and higher maternal education. Lowest rates of comfort in deep water were among Hispanics or Latino/Latinas followed by Blacks or African Americans. Greater life jacket wear while boating was reported by females, those in lower grades and negatively associated with alcohol consumption, sexual activity and texting while driving. Having had swimming lessons was associated with fewer risk-taking behaviors. Conclusions: The HYS was useful to benchmark and identify factors associated with drowning risk among adolescents. It suggests a need to reframe approaches to promote water safety to adolescents and their families. Multivariate analysis of this data could identify the key determinants amongst the racial, ethnic, and socioeconomic disparities noted and provide stronger estimation of risk-taking and protective behaviors. Full article

Whole-school physical activity (PA) promotion programmes are recommended to increase youth PA. Evaluation of programmes is essential to ensure practice is guided by evidence. This paper evaluates the Active School Flag (ASF), a whole-school PA promotion programme in Ireland, using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. ASF was evaluated across three levels—(1) administration, (2) application, (3) outcomes—using a mixed-methods case study design. Existing data sources were reviewed, the programme coordinator was interviewed, and a pilot study was conducted to investigate impact on 3rd and 5th class students (3 schools, n = 126 students, age range 8–12 years). In-school Moderate to Vigorous Physical Activity (MVPA; by accelerometery), motivation for PA (BREQ), PA self-efficacy (PASES), school affect and peer social support (Kidscreen27) were measured pre-programme (0 months), post-programme (8 months), and at retention (12 months). Teacher perceptions of classroom behaviour (CBAST) were also measured pre- and post-programme. ASF has been successful in engaging 46% of primary schools nationally. Students’ in-school moderate–vigorous PA increased in all pilot-study schools from pre-programme to retention (η² = 0.68–0.84). ASF programme design facilitates implementation fidelity, adoption and maintenance through buy in from schools and government stakeholders. ASF presents as an effective PA promotion programme in the short-to-medium term for primary schools. This RE-AIM evaluation provides evidence of ASF effectiveness, alongside valuable findings that could support programme improvement, and inform future similar programmes. Full article

Process evaluations can help to optimise the implementation of school-based physical activity interventions. The purpose of this paper is to describe the process evaluation of a school-based high-intensity interval training (HIIT) program for older adolescent students, known as Burn 2 Learn (B2L). B2L was evaluated via a cluster randomised controlled trial in 20 secondary schools (10 intervention, 10 control) in New South Wales, Australia. Teachers (n = 22 (55% female)) from the 10 intervention schools, delivered the program over three phases (Phases 1 and 2, 6 months; Phase 3, 6 months) to older adolescent students (n = 337 (50% female); mean ± standard deviation (SD) age = 16.0 ± 0.4 years). Process evaluation data were collected across the 12-month study period. Teachers delivered 2.0 ± 0.8 and 1.7 ± 0.6 sessions/week in Phases 1 and 2 respectively (mean total 25.9 ± 5.2), but only 0.6 ± 0.7 sessions/week in Phase 3. Observational data showed that session quality was high, however heart rate (HR) data indicated that only half of the students reached the prescribed threshold of ≥85% predicted HR_max during sessions. Over 80% of teachers reported they intended to deliver the B2L program to future student cohorts. Almost 70% of students indicated they intended to participate in HIIT in the future. Teachers considered the program to be adaptable, and both students and teachers were satisfied with the intervention. B2L was implemented with moderate-to-high fidelity in Phases 1 and 2, but low in Phase 3. Our findings add to the relatively scant process evaluation literature focused on the delivery of school-based physical activity programs. Full article

The commencement and maintenance of exclusive breastfeeding (EB) are dependent on several mother–infant factors. To analyse the prevalence of EB during four different periods and to analyse the factors that can affect its maintenance, we performed a prospective, observational, longitudinal study of 236 mothers and their child between 37 and 42 weeks of gestation and weighing more than 2.5 kg. Four interviews were conducted (T1: on discharge, T2: at 15 days, T3: at one month, T4: at three months). The results showed that EB decreased considerably at three months (69.5% vs. 47.46%). The factors that reduced the risk of abandonment were as following: having decided before giving birth that one wants to offer breastfeeding (T2: odds ratio (OR): 0.02, p = 0.001), T3 (OR: 0.04, p = 0.001) and T4 (OR: 0.07, p = 0.01)) and having previous experience with EB (T2 (OR: 0.36, p = 0.01), T3 (OR: 0.42 p = 0.02) and T4 (OR: 0.51, p = 0.03)). The factors that increased the risk of EB abandonment were offering feeding bottles in the hospital (T2 (OR: 11. 06, p = 0.001); T3 (OR: 5.51, p = 0.001) and T4 (OR: 4.43, p = 0.001)) and thinking that the infant is not satisfied (T2 (OR: 2.39, p = 0.01) and T3 (OR: 2.34, p = 0.01)). In conclusion, the abandonment of EB in the first three months is associated with sociodemographic and clinical variables and psychological factors such as insecurity and doubts of the mother during the process and the absence of a favourable close environment. Full article

The positive effects of dance on health indices in youth are widely recognized, but participation in dance is accompanied with a certain risk of injury. This prospective study aimed to investigate injury occurrence and to evaluate the possible influences of specific predictors on the occurrence of musculoskeletal problems and injuries in adolescent dancers. Participants were 126 dancers (21 males; 11–18 years), who were competitors in the urban dance, rock and roll, and standard/Latin dance genres. Predictors included sociodemographic factors, anthropometric/body build indices, sport (dance) factors, and dynamic balance. The outcome variable was injury status, and this was evaluated by the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC). Predictors were evaluated at baseline, and outcomes were continuously monitored during the study period of 3 months. During the study course, 53% of dancers reported the occurrence of a musculoskeletal problem/injury, and dancers suffered from an average of 0.72 injuries over the study period (95% CI: 0.28–1.41), giving a yearly injury rate of 280%. Gender and dance styles were not significantly related to the occurrence of injury. Higher risk for injury was evidenced in older and more experienced dancers. Dynamic balance, as measured by the Star Excursion Balance Test (SEBT), was a significant protective factor of injury occurrence, irrespective of age/experience in dance. Knowing the simplicity and applicability of the SEBT, continuous monitoring of dynamic balance in adolescent dancers is encouraged. In order to prevent the occurrence of musculoskeletal problems/injuries in youth dancers, we suggest the incorporation of specific interventions aimed at improving dynamic balance. Full article

Sequence variants in genes involved in the immune system have previously been linked to neutropenia as well as infections in cancer patients. Sequence variants in genes coding for TLR4, MBL, and IL-1Ra were investigated in relation to clinical utility of identifying severe episodes of febrile neutropenia (FN) in a cohort of children undergoing treatment for acute lymphoblastic leukemia. The study included 122 children, where data on FN and microbiological findings were retrospectively collected from medical records. Sequence variants in genes coding for MBL, TLR4, and IL-1Ra were identified by pyrosequencing, TaqMan SNP genotyping assay, and gel electrophoresis. A total of 380 episodes of FN were identified and in 139 episodes, there was a microbiological defined infection. Age and treatment intensity were all associated with the risk of developing FN. No sequence variant was associated to increased numbers of FN episodes. Two sequence variants in the TLR4 gene increased the risk of viral infection, whilst sequence variants in the IL-1Ra gene were associated to a decreased risk of bacterial blood-stream infection (BSI). The investigated sequence variants did not associate with increased risk for FN or to severe infections, as to why the clinical utility as a risk-stratification tool is low. Most episodes of FN were classified as fever with unknown origin, emphasizing the need for improved microbial detection methods. Full article

The Hawley retainer (HR) and the vacuum-formed retainer (VFR) are the most common removable retainers in orthodontic treatments. The aim of this retrospective study was to comparatively analyze the behavior of two types of removable retainers—HRs and VFRs—in terms of retainer damage, loss, and the rate of installation of mild or severe relapse that required recourse to certain therapeutic interventions. The study was performed on 618 orthodontic patients aged 11–17 years, average age 13.98 ± 1.51, out of which 57% were patients having VFRs and the remaining 43% having HRs in the upper arch. We performed an analysis of the two groups of patients—HRs group and VFRs group—at 6 months (T1) and at 12 months (T2) after the application of the retainer. The results showed that 6% of all the retainers were damaged, mostly at T2 (54.1%). Seven percent of all the retainers were lost, mostly at T1 (58.1%). Of all the patients, 9.1% presented mild relapse, mostly at T1 (58.9%), while 2.6% presented severe relapse. The VFRs were significantly more frequently associated with the occurrence of damage than the HRs (p < 0.001). Severe relapse was more frequently associated with the HRs rather than with VFRs (p < 0.05). Full article

The aim of this article was to analyze the evidence regarding the effectiveness of intervention programs for children with autism based on the participation of their parents. To obtain the data, a systematic search was carried out in four databases (PsycARTICLES (ProQuest), ERIC (ProQuest), PubMed (ProQuest), and Scopus). The retrieved documents were refined under the inclusion/exclusion criteria, and a total of 51 empirical studies were selected. These studies were first classified according to the function of the intervention objective and, later, by the methodology applied (19 studies were based on comprehensive interventions, 11 focused on the nuclear symptoms of autism spectrum disorder (ASD), 12 focused on the promotion of positive parenting, and nine interactions focused on child play). Once all of the documents had been analyzed, the evidence indicated scientific efficacy in most studies, mainly in those based on child development and the application of behavioral analysis principles. Moreover, the positive influence of parent participation in such programs was demonstrated. Full article

Policy has been developed to promote the conduct of high-quality pediatric randomized controlled trials (RCTs). Whether these strategies have influenced publication trends in high-impact journals is unknown. We aim to evaluate characteristics, citation patterns, and publication trends of pediatric RCTs published in general medical journals (GMJs) compared with adult RCTs over a 13-year period. Studies were identified using Medline, and impact metrics were collected from Web of Science and Scopus. All RCTs published from 2005–2018 in 7 GMJs with the highest impact factors were identified for analysis. A random sample of matched pediatric and adult RCTs were assessed for publication characteristics, academic and non-academic citation. Citations were counted from publication until June 2019. Among 4146 RCTs, 2794 (67.3%) enrolled adults, 591 (14.2%) enrolled children, and 761 RCTs (18.3%) enrolled adult and pediatric patients. Adult RCTs published in GMJs grew by 5.1 publications per year (95% CI: 3.3–6.9), while the number of pediatric RCTs did not show significant change (−0.4 RCTs/year, 95% CI: −1.4–0.6). Adult RCTs were cited more than pediatric RCTs (median(IQR): 29.9 (68.5–462.8) citations/year vs. 13.2 (6.8–24.9) citations/year; p < 0.001); however, social media attention was similar (median(IQR) Altmetric Attention Score: 37 (13.75–133.8) vs. 26 (6.2–107.5); p = 0.25). Despite policies which may facilitate conduct of pediatric RCTs, the publishing gap in high-impact GMJs is widening. Full article

Background: Due to the frequency and severity of cold symptoms in children, and the risk of associated complications, effective treatments are urgently needed. Here we evaluated the safety profile and treatment benefits of Echinacea in children with acute cold and flu symptoms. Methods: A total of 79 children (4–12 years) were randomized to a treatment regimen of three or five times daily Echinaforce Junior tablets (total of 1200 or 2000 mg Echinacea extract, EFJ) for the prospective treatment of upcoming cold and flu episodes at first signs. Parents recorded respiratory symptoms daily during episodes in their child and physicians and parents subjectively rated tolerability. Results: EFJ was used to treat 130 cold episodes in 68 children and was very well tolerated by more than 96% positive physician’s ratings. EFJ-treated cold episodes lasted 7.5 days on average, with nine out of 10 episodes being fully resolved after 10 days. Five EFJ tablets daily reduced the average episode duration by up to 1.7 days (p < 0.02) in comparison to three EFJ tablets daily regimen. Effective symptom resolution finally contributed to a low antibiotic prescription rate in this study of 4.6%. Conclusions: EFJ tablets present a valuable option for the treatment of acute cold episodes in children showing a wide safety margin and increased therapeutic benefits at five tablets daily. Full article

Drowning is a leading cause of child death in the coastal Sundarbans region of India due to the presence of open water, lack of supervision and poor infrastructure, but no prevention programs are currently implemented. The World Health Organization has identified interventions that may prevent child drowning in rural low-and middle-income country contexts, including the provision of home-based barriers, supervised childcare, swim and rescue training and first responder training. Child health programs should consider the local context and identify barriers for implementation. To ensure the sustainability of any drowning prevention programs implemented, we conducted a qualitative study to identify the considerations for the implementation of these interventions, and to understand how existing government programs could be leveraged. We also identified key stakeholders for involvement. We found that contextual factors such as geography, cultural beliefs around drowning, as well as skillsets of local people, would influence program delivery. Government programs such as accredited social health activists (ASHAs) and self-help groups could be leveraged for program implementation, while Anganwadi centres would require additional support due to poor resourcing. Gaining government permissions to change Anganwadi processes to provide childcare services may be challenging. The results showed that adapting drowning programs to the Sundarbans context presents unique challenges and program customisation. Full article

(1) Background: We report the case of a patient with a unique clinical presentation of inability to cross crosswalks due to paroxysmal kinesigenic dyskinesia (PKD). (2) Case presentation: A 14-year-old boy presented with the inability to move his right leg at gait initiation from the standing position. This episode lasted for approximately 20–30 s and manifested 1–3 times a day. The difficulty in gait initiation usually occurred when the patient tried to cross crosswalks when the traffic light turned from red to blue. His right arm stiffened occasionally while trying to write with a pencil and eat food with a spoon or chopsticks. Other neurological manifestations and pain were absent during these episodes. No neurological symptoms were observed between the attacks. Brain magnetic resonance imaging did not reveal any abnormalities. A next-generation sequencing study revealed a pathological variant in the proline-rich transmembrane protein 2 (PRRT2) gene. The patient was diagnosed with PKD. His symptoms disappeared completely after treatment with carbamazepine (100 mg/day). (3) Conclusions: The symptoms of PKD can be successfully controlled using antiepileptic medications. Therefore, clinicians should be aware of the clinical manifestations of PKD to provide appropriate treatment. Full article

Although the benefits of disclosure are considerable, informing children with perinatal HIV of their own HIV status is often delayed to late adolescence. This study examined the social and contextual challenges that influence delaying disclosure to children and assessed the outcomes of delayed disclosure on the psychosocial health of children as perceived by the healthcare workers (HCWs) providing care to these children. Data were collected from HCWs via focus group discussions. Nurses, lay counsellors, social workers, and dieticians were selected from facilities in a rural South African health district. Thematic analysis was performed. The caregivers’ social context was the main barrier against informing children timely about their HIV diagnosis. The extent of the internalised HIV stigma influenced the delay in disclosing to the children. Delaying disclosure contributes to children’s refusing to take their medication, leads to the accidental disclosure of HIV, give rise to anger and resentment towards the caregiver, increase the risk of secondary transmitting of HIV, and poor health outcomes. It is essential to train HCWs to support caregivers and children through the disclosure process to ensure that caregivers realise the benefits of disclosure. Strategies to encourage caregivers to disclose early should be sensitive to their concerns about the negative impacts of disclosure. Full article

(1) Background: Chronic musculoskeletal pain (CMP) in adolescents can negatively affect physical, psychological, and social functioning, resulting in functional disability. This randomized controlled trial (RCT) aimed to evaluate the effectiveness of an outpatient rehabilitation program based on graded exposure in vivo (EP) compared with care as usual (CAU: interdisciplinary outpatient rehabilitation care). Both EP and CAU aim to improve functional ability in adolescents with CMP. (2) Methods: Pragmatic multicenter RCT with 12-month follow-up. Adolescents (12–21 years) with CMP were invited to participate. Primary outcome: functional disability; secondary outcomes: perceived harmfulness; pain catastrophizing; pain intensity. Data analysis: intention-to-treat linear mixed model. (3) Results: Sixty adolescents (mean 16 years) were randomized; data for 53 were analyzed. Adolescents in EP showed relevant and significant decreases in functional disability (estimated mean difference at least −8.81, p ≤ 0.01) compared with CAU at all times. Significant differences in favor of EP were found for perceived harmfulness at all times (p ≤ 0.002), for pain catastrophizing at 2 months (p = 0.039) and for pain intensity at 4 and 10 months (p ≤ 0.028). (4) Conclusion: EP leads to a significant and clinically relevant decrease in functional disability compared with usual care. Full article

Pediatric spontaneous pneumomediastinum is an uncommon condition associated with infection, trauma, or coexisting structural lung pathology. Exercise-related spontaneous subcutaneous emphysema and pneumomediastinum are rarely reported. However, severe pneumomediastinum may coexist with pneumothorax, pneumorrhachis, and subcutaneous emphysema, which can potentially lead to serious complications, including airway obstruction and pneumorrhachis. Therefore, early diagnosis and timely management are important for physicians to determine the etiology and prevent further damage. Here, we present a case of exercise-related spontaneous subcutaneous emphysema and pneumomediastinum to highlight the pathogenesis and suggest therapeutic strategies. Full article

Asthma is the most frequent chronic inflammatory disease of the lower airways affecting children, and it can still be considered a challenge for pediatricians. Although most asthmatic patients are symptom-free with standard treatments, a small percentage of them suffer from uncontrolled persistent asthma. In these children, a multidisciplinary systematic assessment, including comorbidities, treatment-related issues, environmental exposures, and psychosocial factors is needed. The identification of modifiable factors is important to differentiate children with difficult asthma from those with true severe therapy-resistant asthma. Early intervention on modifiable factors for children with difficult asthma allows for better control of asthma without the need for invasive investigation and further escalation of treatment. Otherwise, addressing a correct diagnosis of true severe therapy-resistant asthma avoids diagnostic and therapeutic delays, allowing patients to benefit from using new and advanced biological therapies. Full article

Early childhood is important for future cognitive and educational outcomes. Programs overcoming barriers to engagement in early education for Indigenous children must address family cultural needs and target developmental delays. This systematic review identifies culturally adapted programs to improve developmental delays among young children, in response to an identified priority of a remote Indigenous community. Five databases (the Cochrane Library, Embase, Medline, Scopus and CINAHL) were searched for English language papers in January 2018. Study quality was assessed, and findings were analysed thematically. Findings were presented to the community at an event with key stakeholders, to determine their inclusion and face validity. Seven relevant studies, published between 1997 and 2013, were identified by the researchers and each study was supported by the community for inclusion. Three studies included on Native American children and four studies included children from non-Indigenous disadvantaged backgrounds. Findings were reported narratively across four themes: storytelling to improve educational outcomes; family involvement improved development; culturally adapted cognitive behavioural therapy to reduce trauma; rewards-based teaching to improve child attention. Limited published research on culturally adapted and safe interventions for children with developmental delays exists but these four themes from seven studies identify useful components to guide the community and early childhood program development. Full article

Creating social and physical environments that promote good health is a key component of a social determinants approach. For the parents of young children, a smartphone offers opportunities for social networking, photography and multi-tasking. Understanding the relationship between supervision, mobile phone use and injury in the playground setting is essential. This research explored parent mobile device use (MDU), parent–child interaction in the playground, parent attitudes and perceptions towards MDU and strategies used to limit MDU in the playground. A mixed-methods approach collected naturalistic observations of parents of children aged 0–5 (n = 85) and intercept interviews (n = 20) at four metropolitan playgrounds in Perth, Western Australia. Most frequently observed MDU was scrolling (75.5%) and telephone calls (13.9%). Increased duration of MDU resulted in a reduction in supervision, parent–child play and increased child injury potential. The camera function offered the most benefits. Strategies to prevent MDU included turning to silent mode, wearing a watch and environmental cues. MDU was found to contribute to reduced supervision of children, which is a risk factor for injury. This is an emerging area of injury prevention indicating a need for broader strategies addressing the complex interplay between the social determinants and the developmental younger years. Full article

Premature birth has been shown to be associated with adverse respiratory health in children and adults; children diagnosed with bronchopulmonary dysplasia (BPD) in infancy are at particularly high risk. Since its first description by Northway et al. about half a century ago, the definition of BPD has gone through several iterations reflecting the changes in the patient population, advancements in knowledge of lung development and injury, and improvements in perinatal care practices. One of the key benchmarks for optimally defining BPD has been the ability to predict long-term respiratory and health outcomes. This definition is needed by multiple stakeholders for hosts of reasons including: providing parents with some expectations for the future, to guide clinicians for developing longer term follow-up practices, to assist policy makers to allocate resources, and to support researchers involved in developing preventive or therapeutic strategies and designing studies with meaningful outcome measures. Long-term respiratory outcomes in preterm infants with BPD have shown variable results reflecting not only limitations of the current definition of BPD, but also potentially the impact of other prenatal, postnatal and childhood factors on the respiratory health. In this manuscript, we present an overview of the long-term respiratory outcomes in infants with BPD and discuss the role of other modifiable or non-modifiable factors affecting respiratory health in preterm infants. We will also discuss the limitations of using BPD as a predictor of respiratory morbidities and some of the recent advances in delineating the causes and severity of respiratory insufficiency in infants diagnosed with BPD. Full article