BMC Pediatrics

Published by Springer Nature
Online ISSN: 1471-2431
Learn more about this page
Recent publications
Comparison of chest computed tomography images during hospitalization. a 2020-11-12 Diffuse ground-glass opacities in both lungs. b 2020-11-16 No significant improvement was observed. c 2020-12-14 Significant improvement was observed
Background Hyper IgM syndromes (HIGMS) are a group of rare primary immunodeficiency disorders. There are limited reports about HIGMS combined with severe eosinophilia. Case presentation In this report, we described a 2-year-old boy with chronic cough and symptoms of hypoxia. Lung computed tomography (CT) scan showed that diffuse ground-glass changes and eosinophils in peripheral blood increased significantly. Subsequent tests revealed a notable decrease in serum IgG and IgA. The lymphocyte subgroup classification was basically normal. Pneumocystis jirovecii were detected from the bronchoalveolar lavage fluid (BALF) of the patient by metagenomic next-generation sequencing (mNGS). After treatments of caspofungin combined with sulfamethoxazole, intravenous immunoglobulin (IVIG) replacement and anti-inflammatory steroid, the clinical symptoms and pulmonary imaging noticeably improved. The absolute eosinophil count (AEC) also returned to normal range. X-linked hyper IgM syndrome was confirmed by gene test. Two months after the diagnosis, the patient underwent allogeneic stem cell transplantation (HSCT) and has recovered well. Conclusions Children with HIGMS are prone to opportunistic infections such as Pneumocystis jirovecii pneumonia (PJP). Diffuse interstitial lung disease and hypoglobulinemia in a young child predict the diagnosis of a primary immunodeficiency (PID). mNGS has obvious advantages for obtaining etiological diagnosis of children with PIDs. Severe eosinophilia is rarely reported in this kind of PIDs. Considering literature review and the corresponding reaction to steroid, we proposed that eosinophilia in HIGMS might be related to infections. Steroid therapy can quickly relieve eosinophilia but is easy to rebound if the reduction is too fast. Once the diagnosis of HIGMS is confirmed, the earlier the HSCT, the better the prognosis.
 
Selection of the final population from the complete sample of Medical Expenditure Panel Survey respondents. Legend: "Selection of the final population from the complete sample of Medical Expenditure Panel Survey respondents. "
Background The Supplemental Nutrition Assistance Program (SNAP) has well-established positive impacts on child health outcomes, including increased birth weight and decreased likelihood of underweight status. Studies in adult populations suggest that SNAP is associated with lower health care costs, although less is known in children. Methods Retrospective analysis of U.S. children (age <18 years) living in low-income households (< 200% of the federal poverty level) in the 2013-2017 Medical Expenditure Panel Survey. We used multivariable regression, adjusting for sociodemographic and clinical covariates, to model the effect of continuous SNAP enrollment on health expenditures as compared to non-enrollees at 12 and 24 months. Results The sample included 5,626 children, of whom 49.2% consistently received SNAP for the entire two-year survey period. Compared with SNAP non-recipients, SNAP-recipient households more often had incomes below 100% FPL (78.3% vs 37.9%), and children in SNAP-recipient households were more often publicly insured (94.9% vs 64.5%). Unadjusted expenditures were lower for children in SNAP-recipient households at 12 ($1222 vs $1603) and 24 months ($2447 vs $3009). However, when adjusting for sociodemographic and clinical differences, no statistically significant differences in health care expenditures, including emergency department, inpatient, outpatient, and prescription costs, were identified. Conclusion SNAP participant children experience heightened social hardships across multiple domains. There were no differences in short term health care costs based on SNAP enrollment when accounting for differences in sociodemographic and clinical factors. Despite demonstrated child health benefits, we found that sustained enrollment in SNAP over a two-year period did not generate significant short- term health care cost reductions. Our findings suggest that although SNAP is intended to act as a benefit towards the health and well-being of its recipients, unlike among adults, it may not reduce health care costs among children.
 
Background Recognizing the level of glycemic control of a client is an important measure/tool to prevent acquiring complications and risk of death from diabetes. However, the other most important variable, which is the time that the patient stayed in that poor glycemic level before reaching optimal glycemic control, has not been studied so far. Therefore, this study aim to estimate time to first optimal glycemic control and identify predictors among type 1 diabetic children in Bahir Dar city public referral hospitals, Northwest, Ethiopia, 2021. Methods A Retrospective cohort study was conducted at Bahir Dar city public referral hospitals among a randomly selected sample of 385 patients with type 1 diabetes who were on follow up from January 1, 2016 to February30, 2021.Data were collected by using a data abstraction tool and then entered into Epi-data version 4.6 and exported into STATA 14.0 statistical software. Descriptive statistics, Kaplan Meier plots and median survival times, Log-rank test and Cox-proportional hazard regression were used for reporting the findings of this study. After performing Cox-proportional hazard regression, model goodness-of-fit and assumptions were checked. Finally, the association between independent variables and time to first optimal glycemic control in months was assessed using the multivariable Cox Proportional Hazard model and variables with a p-value < 0.05 were considered as statistically significant. Results Median survival time to first optimal glycemic control among type 1 diabetic clients was 8 months (95%CI: 6.9–8.9). The first optimal glycemic achievement rate was 8.2 (95%CI: 7.2–9.2) per 100 person/month observation. Factors that affect time to first optimal glycemic control were age > 10–14 years (AHR = 0.32;95%CI = 0.19–0.55), increased weight (AHR = 0.96;95%CI = 0.94–0.99), having primary care giver (AHR = 2.09;95%CI = 1.39–3.13), insulin dose (AHR = 1.05;95%CI = 1.03–1.08), duration of diabetes ≥4 years (AHR = 0.64;95%CI = 0.44–0.94), adherence to diabetic care (AHR = 9.72;95%CI = 6.09–15.51), carbohydrate counting (AHR = 2.43;95%CI = 1.12–5.26), and comorbidity (AHR = 0.72;95%CI = 0.53–0.98). Conclusion The median survival time to first optimal glycemic control in this study was long. Age, weight, primary care giver, insulin dose, duration of diabetes, adherence, and carbohydrate counting, including history of comorbidity were determinant factors. Giving attention for overweight and comorbid illness prevention, increasing either the dose or frequency of insulin during initial treatment; counseling parent (for both the mother and father) about adherence to diabetic care focusing on insulin drugs and how to audit their children’s diet as prescription helps to reduce the length of glycemic control.
 
Background: The neurological examination of an unwell neonate can aid management, such as deciding if hypothermia treatment is warranted in hypoxic ischaemic encephalopathy or directing investigations in hypotonic neonates.Current standardised examinations are not designed for unwell or ventilated neonates, and it is unclear how confident paediatricians feel about the examination or what aspects they perform. Aim: This study aimed to review the confidence of UK paediatricians on the neurological examination in unwell neonates, describe their attitudes towards it, and determine what could improve practice. Methods: An explanatory sequential mixed methods approach (QUAN → QUAL) with equal weighting between stages. A survey on attitudes to the neonatal neurological examination was sent to all UK neonatal units and members of the British Paediatric Neurology Association. Volunteers were sought for semi-structured interviews. Thematic analysis was used to interpret qualitative data, which was triangulated with quantitative questionnaire data. Results: One hundred ninety-three surveys were returned, 31.0% from neonatologists, 9.3% paediatric neurologist. The median range for confidence was 4 (IQR3-5). Twenty-three interviews occurred. Thematic analysis revealed three themes: “Current culture on neonatal units”, “ Practicalities of the neurological examination in unwell neonates”, and “Changing the culture”. Most interviewees did not feel confident performing or interpreting the neurological examination in unwell neonates. Many units had a culture of seeing it as low priority, did not see its relevance in the acute management of unwell neonates. A few interviewees worked in units with a positive culture towards the neurological examination who used adapted standardised examinations and provided training. 72% of questionnaire responders wanted a new standardised neurological examination designed for the unwell neonate, which should be short, utilise pictures like the Hammersmith Neonatal Neurological Examination, contain an assessment of consciousness, be developmentally appropriate and achievable in unwell, ventilated neonates, be accompanied by a schematic to aid interpretation, and for greater training and assessments of competence. Conclusions: There are barriers preventing paediatricians being able to perform a neurological examination in unwell neonates, and a culture of neurophobia is common. A new standardised examination is needed, alongside aids to interpretation, training, and assessment.
 
Flowchart of the selection and distribution of individuals in the groups
Survival in newborns with low 5-minute Apgar score. Legend: Survival analysis of birth injury and type of delivery variable in newborns with low 5-minute APGAR score
Background The 5-minute APGAR score is clinically used as a screening tool to assess how the newborn has reacted to previous care, remaining relevant for predicting neonatal survival. This study aimed to analyze the determinants of the 5th minute APGAR score, and the factors associated with the death and survival of newborns with low APGAR scores hospitalized in the neonatal intensive care unit (NICU) at a referral public hospital in North Brazil. Methods This was a hospital-based retrospective case-control study with 277 medical records. Newborns who presented with a 1-minute APGAR score < 7 followed by a 5-minute APGAR score < 7 were considered cases, while a score ≥ 7 was categorized as controls. Univariate and multivariable logistic regression analyses were used to establish the determinant factors of the low APGAR score and death outcome in this group. Survival curves were obtained using the Kaplan-Meier estimator, and then univariate and multivariate Cox regression was performed. Results After adjusted analysis, the factor associated with low APGAR scores was vaginal delivery (OR = 3.25, 95%CI = 1.60–6.62, p = 0.001). Birth injury (OR = 0.39, 95%CI = 0.19–0.83, p = 0.014) was associated with upper APGAR scores. No significant independent associations were observed between the variables analyzed and death in the low APGAR score group. The Kaplan-Meier curve showed that individuals who presented Cesarean delivery had a shorter survival time in the ICU. Conclusion In this setting, a 5-minute Apgar score < 7 was associated with the occurrence of vaginal delivery and birth injury with a 5-minute Apgar score ≥ 7. Survival in ICU was lower in newborns that were delivered via cesarean section.
 
Background Neurally adjusted ventilatory assist is an emerging mode of respiratory support that uses the electrical activity of the diaphragm (Edi) to provide synchronised inspiratory pressure support, proportional to an infant’s changing inspiratory effort. Data on Edi reference values for neonates are limited. The objective of this study was to establish reference Edi values for preterm and term neonates who are not receiving respiratory support. Methods This was a prospective observational study of newborn infants breathing spontaneously in room air. The Edi waveform was monitored by a specialised naso/orogastric feeding tube with embedded electrodes positioned at the level of the diaphragm. Edi minimums and peaks were recorded continuously for 4 h without changes to routine clinical handling. Results Twenty-four newborn infants (16 preterm [< 37 weeks’ gestation]; 8 term) were studied. All infants were breathing comfortably in room air at the time of study. Edi data were successfully captured in all infants. The mean (±SD) Edi minimum was 3.02 (±0.94) μV and the mean Edi peak was 10.13 (±3.50) μV. In preterm infants the mean (±SD) Edi minimum was 3.05 (±0.91) μV and the mean Edi peak was 9.36 (±2.13) μV. In term infants the mean (±SD) Edi minimum was 2.97 (±1.05) μV and the mean Edi peak was 11.66 (±5.14) μV. Conclusion Reference Edi values were established for both preterm and term neonates. These values can be used as a guide when monitoring breathing support and when using diaphragm-triggered modes of respiratory support in newborn infants
 
of main themes and subthemes
Background The neurological examination of an unwell neonate can aid management, such as deciding if hypothermia treatment is warranted in hypoxic ischaemic encephalopathy or directing investigations in hypotonic neonates. Current standardised examinations are not designed for unwell or ventilated neonates, and it is unclear how confident paediatricians feel about the examination or what aspects they perform. Aim This study aimed to review the confidence of UK paediatricians on the neurological examination in unwell neonates, describe their attitudes towards it, and determine what could improve practice. Methods An explanatory sequential mixed methods approach (QUAN → QUAL) with equal weighting between stages. A survey on attitudes to the neonatal neurological examination was sent to all UK neonatal units and members of the British Paediatric Neurology Association. Volunteers were sought for semi-structured interviews. Thematic analysis was used to interpret qualitative data, which was triangulated with quantitative questionnaire data. Results One hundred ninety-three surveys were returned, 31.0% from neonatologists, 9.3% paediatric neurologist. The median range for confidence was 4 (IQR3-5). Twenty-three interviews occurred. Thematic analysis revealed three themes: “Current culture on neonatal units”, “ Practicalities of the neurological examination in unwell neonates”, and “Changing the culture”. Most interviewees did not feel confident performing or interpreting the neurological examination in unwell neonates. Many units had a culture of seeing it as low priority, did not see its relevance in the acute management of unwell neonates. A few interviewees worked in units with a positive culture towards the neurological examination who used adapted standardised examinations and provided training. 72% of questionnaire responders wanted a new standardised neurological examination designed for the unwell neonate, which should be short, utilise pictures like the Hammersmith Neonatal Neurological Examination, contain an assessment of consciousness, be developmentally appropriate and achievable in unwell, ventilated neonates, be accompanied by a schematic to aid interpretation, and for greater training and assessments of competence. Conclusions There are barriers preventing paediatricians being able to perform a neurological examination in unwell neonates, and a culture of neurophobia is common. A new standardised examination is needed, alongside aids to interpretation, training, and assessment.
 
Flowchart of the systematic selection process
Gravel diagram of the K-means cluster analysis
Cluster characteristics based on the measurement of diet knowledge (cluster A, cluster B, cluster C). LOF, LOS, VOF, DHIF, LOSF, LOAP, AAM, MDP, BBP, PA, IPA, HB, ESF, RG, LA, VE, and EAM correspond to the code of Q1 to Q17 in Table 1, respectively
Background A lack of adequate dietary knowledge may result in poor health. The purpose of this study was to study the association between dietary knowledge and overweight/obesity in children and adolescents. Method Data from the China Health and Nutrition Survey (CHNS) 2004, 2006, 2009, 2011, and 2015 were used in this cross-sectional study. The dietary knowledge of children and adolescents was evaluated by the questionnaire in the database. The overweight and obesity status was evaluated by body mass index (BMI). Cluster analysis was performed to establish different groups based on dietary knowledge level. Logistic regression analysis and subgroup analysis were conducted. Results A total of 2,701 children and adolescents were finally selected. Cluster A (n = 837, 30.99%), Cluster B (n = 1,264, 46.80%) and Cluster C (n = 600, 22.21%) were high, medium and low dietary knowledge level, respectively. Participants with high dietary knowledge levels [OR = 0.56 (95%CI: 1.40–0.78)] may be negatively associated with overweight and obesity. Similar results were found among adolescents, males, females, people living in eastern and northeastern China, and rural areas, after adjusting for age, gender, geographic region, maternal education level, alcohol consumption, waist-to-hip ratio, systolic blood pressure and diastolic blood pressure. Conclusion Improving the dietary knowledge level of children and adolescents was associated with decreased risk of overweight and obesity. Our study provided a theoretical basis for the relationship between dietary knowledge and overweight/obesity in Chinese children and adolescents and suggested strengthening the publicity and popularization of dietary knowledge in schools and communities.
 
Child weight curve table
Background Maternal education is one of the main ways to improve children's nutritional behaviors and development. The purpose of this study is to investigate the effect of educational intervention based on Health Belief Model (HBM) on mothers monitoring growth of 6–12 months child with growth disorders in Ghirokarzin city, Fars Provonce, Iran. Methods This quasi-experimental study was conducted on mothers of 6–12 months children with growth disorders of Ghirokarzin city, Fars province, Iran in 2021–2022. One hundred twenty mothers of 6–12 months child with growth disorders in Ghirokarzin city were selected using random sampling method and were divided into two groups of intervention (60) and control (60). The experimental group received training on the HBM constructs. Both groups completed the questionnaire before and three months after.intervention. A questionnaire beased on Health Belief Model constructs were used to collect information. The data was analyzed with SPSS 22 software using paired t-tests, Chi-square tests, and independent t-tests, with a significance level of 0.05. Results Three months after the educational intervention, the experimental group showed a significant increase in terms of knowledge, HBM constructs, weight of the children and feeding behavior. Conclusion This study showed the educational intervention based on the HBM improved the knowledge and feeding behavior of mothers and improved Growth Disorders of child. Hence, this model can act as a framework for designing and implementing educational interventions for prevention of growth disorders in children.
 
Relative frequency comparison of antimicrobial resistance rates among (A) serogroups, and (B) serotypes of Salmonella isolates. TS = Trimethoprim\Sulfamethoxazole, AMP = Ampicillin, AZT = Azithromycin, CFT = Ceftriaxone, CIP = Ciprofloxacin. *N = Indicates the number of isolates
Comparison of biofilm production by Salmonella isolates according to (A) serogroups, and (B) serotypes; (C) Relative frequency of occurrence of virulence genes among various Salmonella serotypes. SE = Salmonella Enteritidis, ST = Salmonella Typhimurium, SI = Salmonella Infantis, SN = Salmonella Newport, NT = Not typed
Comprehensive comparison of characteristics of Salmonella isolates according to serogroup, serotype, and biotype, including antimicrobial susceptibility and biofilm production. SE = Salmonella Enteritidis, ST = Salmonella Typhimurium, SI = Salmonella Infantis, SN = Salmonella Newport, NT = Not typed. All NT biotypes were categorized by designated B, C, or D serogroups. (R) = Resistant, ( +) = Gene detected. TS = Trimethoprim\Sulfamethoxazole, AMP = Ampicillin, AZT = Azithromycin, CFT = Ceftriaxone, CIP = Ciprofloxacin. Shades of color represent strength of biofilm production. [ = Strong biofilm formation,  = Moderate,  = Weak,  = No biofilm]
Background/significance Salmonella gastroenteritis causes significant morbidity among pediatric patients, mainly in developing world, such as the Middle East and North Africa (MENA) region. Concurrently, data from MENA countries like Iran, regarding prevalence of Salmonella serotypes, antimicrobial susceptibility, and biofilm production is scarce. Material & methods Slide agglutination was used to determine the serogroup of 140 Salmonella isolates recovered from 4477 stool specimens collected from children with gastroenteritis, and isolates were serotyped by PCR assay. The antimicrobial susceptibility of isolates to five first line drugs was assessed by disk diffusion assay using CLSI guidelines. Semi-quantitative evaluation of biofilm production was done by microtiter plate assay followed by PCR detection of biofilm-associated virulence genes csgD, pefA, and bcsA for each isolate. Results Nearly 94% of Salmonella isolates were recovered from ≤ 5-year-old patients, and 99% of isolates were non-typhoidal. While we found extensive diversity among Salmonella isolates, serogroup D (46%) predominated, and Salmonella Enteritidis (41%) was the most common serotype that showed the highest antimicrobial susceptibility rate (> 96%). For the first time in Iran, S. Newport serotype from human specimens was isolated. Most isolates were sensitive to all test antimicrobials, but 35% of isolates were not-typed (NT) that showed the highest resistance with 48% being resistant to ≥ 1 test antimicrobial. Majority of isolates made weak (or no) biofilm, and we found a weak association between antimicrobial susceptibility, biofilm production, or virulence genes csgD, pefA, and bcsA. Conclusions The most effective measure that may control pediatric salmonellosis outbreaks is raising awareness of parents of preschoolers about food safety. Isolation of highly diverse Salmonella serotypes, including many commonly isolated from animals, indicates widespread contamination of the food chain. Majority of serotypes were sensitive to first-line antimicrobials, thus presently, pediatric Salmonella infections in this region may be controlled by conventional antimicrobials. However, despite the current trend, an imminent emergence of resistant Salmonella strains is foreseen, since various serotypes resistant to > 1 antimicrobial agent are typically associated with animals. Our results warrant further investigation that includes correlation analysis of clinical data regarding treatment outcomes, and serotype attributes like virulence genes.
 
Flowchart of the study’s recruitment process. FP: family physician
Proportion of all patients (%) treated with antibiotics for each type of infection
Antibiotic prescribing according to FP practice location in the two groups
Background Although self-limiting viral infections are predominant, children with acute infections are often prescribed antibiotics by family physicians. The aim of the study is to evaluate the impact of two interventions, namely C-reactive protein point-of-care testing and educational training, on antibiotic prescribing by family physicians. Methods This randomised controlled intervention study included acutely ill children consulted by 80 family physicians from urban and rural practices in Latvia. The family physicians were divided into two groups of 40. The family physicians in the intervention group received both interventions, i.e. C-reactive protein point-of-care testing and educational training, whereas the family physicians in the control group continued to dispense their standard care. The primary outcome measure was the antibiotic prescribing at the index consultation (delayed or immediate prescription) in both study groups. The secondary outcome was CRP testing per study group. Patient- and family physician- related predictors of antibiotic prescribing were analysed as associated independent variables. Practice location effect on the outcomes was specially addressed, similar to other scientific literature. Results In total, 2039 children with acute infections were enrolled in the study. The most common infections observed were upper and lower respiratory tract infections. Overall, 29.8% ( n = 607) of the study population received antibiotic prescription. Our binary logistic regression analysis did not find a statistically significant association between antibiotic prescriptions and the implemented interventions. In the control group of family physicians, a rural location was associated with more frequent antibiotic prescribing and minimal use of CRP testing of venous blood samples. However, in the intervention group of family physicians, a rural location was associated with a higher level of C-reactive protein point-of-care testing. Furthermore, in rural areas, a significant reduction in antibiotic prescribing was observed in the intervention group compared with the control group (29.0% ( n = 118) and 37.8% ( n = 128), respectively, p = 0.01). Conclusion Our results show that the availabilty of C-reactive protein point-of-care testing and educational training for family physicians did not reduce antibiotic prescribing. Nevertheless, our data indicate that regional variations in antibiotic-prescribing habits exist and the implemented interventions had an effect on family physicians practices in rural areas.
 
Background Autonomy is recognized as important for individual well-being and constitutes one dimension in the KIDSCREEN-instrument measuring health related quality of life (HRQoL) in children and adolescents. However, the autonomy questions in KIDSCREEN are restricted to opportunities to influence leisure time activities, which is a form of autonomy as volition. Yet, there are other aspects of autonomy that might be related to adolescent’s HRQoL. The aims of the present study were first to investigate the psychometric properties of a scale measuring autonomy in adolescence from a control perspective (AAC) including its relation to the autonomy dimension in KIDSCREEN, and second; to investigate AACs ability to predict each of the 10 dimensions constituting KIDSCREEN. Methods Students (n = 154) aged 15–16 years who were recruited from schools located in both low (two schools) and high (two schools) socioeconomic status (SES) areas in Sweden participated in a cross-sectional study. The adolescents answered a questionnaire including a new 6-item scale measuring perceived autonomy and HRQoL assessed by the KIDSCREEN-52 instrument. A factor analyses was computed to investigate the relation between the items in the AAC scale and the autonomy items in the KIDSCREEN instrument. Hierarchical regression analyses were computed to investigate if the AAC scale predicted HRQoL in any of the 10 dimensions in KIDSCREEN after controlling for gender, SES and the original autonomy scale included in KIDSCREEN. Results The factor analysis showed that all the items from the autonomy scale loaded in one factor and that all the items from the AAC scale loaded in another dimension. The hierarchical regression models showed that the AAC scale uniquely predicted HRQoL in all dimensions of the KIDSCREEN instrument after controlling for gender, SES and the original autonomy scale included in KIDSCREEN-52. A high level of perceived autonomy was associated with a high level of HRQoL for both scales. Conclusion A new scale for measuring autonomy from a control perspective has been presented and shown to differ from autonomy as volition. Both forms of autonomy are positively related to HRQoL in adolescence 15–16 years old.
 
Participants' characteristics
The categories, subcategories, and examples of the codes of the study
Background Chronic pain (CP) among adolescents has received less attention than adultsandthere is limited qualitative studies about it in Iran. This study explored the experience of CP among adolescents. Methods This exploratory qualitative study was conducted in April–October 2019. Participants were 14 adolescent students purposively recruited from schools in Shiraz, Iran. Semi-structured interviews were conducted for data collection and data analysis was done through conventional content analysis. Findings Adolescents’ experiences of CP came into nine subcategories and three main categories, namely perceived suffering, attempt to overcome pain, and attempt to find sources of support. Conclusion Adolescents with CP experience physical and mental suffering and attempt to manage their pain and its associated suffering through different physical and psychological strategies and using different sources of support such as family, peers, healthcare providers, and school staff.
 
Background Bacterial infection of adenoid is currently considered to be an important cause of adenoid hypertrophy (AH) in children. Although several bacteriology studies on adenoid diseases have been reported, the aerobic bacterial study regarding risk factors and antibiotic sensitivity of AH in Chinese children is lacking. This study aims to investigate the risk factors for aerobic bacterial colonization of AH in Chinese children and to elucidate aerobic bacterial profiles and antibiotic sensitivity. Methods Samples were collected from the adenoid core and surface tissue of 466 children undergoing adenoidectomy. Aerobic cultures and antibiotic sensitivity were observed. The risk factors for bacterial colonization of adenoid were analyzed statistically. Results A total of 143 children could be detected opportunistic pathogens in adenoid surface and/or core tissue, with a carriage rate of 30.7%. The presence of chronic rhinosinusitis, tonsillar hypertrophy and adenoidal size were the risk factors for aerobic bacterial colonization of adenoid in univariate analysis. Multivariate analysis showed that chronic rhinosinusitis and tonsil hypertrophy were significant variables associated with the aerobic bacterial colonization. The most frequently isolated aerobic bacteria were Haemophilus influenzae, followed by Staphylococcus aureus and Streptococcus pneumoniae. There was no statistically significant difference in bacterial species between the adenoid surface and core. The above common bacteria were more sensitive to cephalosporins and quinolones antibiotics, and significantly resistant to penicillin antibiotics and non-β-lactamase inhibitors. Conclusion Our results provide recent aerobic bacterial profiles for AH among Chinese children and confirm the risk factors and antibiotic sensitivity. This study contributes to understanding the role of different risk factors in the development of AH and will be helpful to the treatment of AH among Chinese children.
 
(continued)
(continued)
Comparison of prevalence, clinical management and outcome of NRF of current study with previous surveys
Background: To explore the prevalence, outcome and perinatal risks of neonatal hypoxemic respiratory failure (NRF) in a survey of all livebirths from a regional network of perinatal-neonatal care during the transition period after 5-year universal health insurance implemented in China. Methods: Clinical data of all neonatal respiratory morbidities in Huai'an were retrospectively collected in the regional perinatal network database of all livebirths as vital statistics in 2015. NRF was defined as hypoxemia requiring continuous positive airway pressure (CPAP) and/or mechanical ventilation (MV) for at least 24 h. Mortality risks of antenatal and perinatal morbidities, major respiratory therapies and complications were analyzed by multivariable logistic regression model. Results: There were 788 NRF cases identified in 9.9% (7960) hospitalized, or 13.3‰ (59056) livebirths, in which 6.7% received intensive care and 93.0% critical care. The major underlying morbidities were respiratory distress syndrome (RDS, 36.4%) and pneumonia/sepsis (35.3%), treated mainly by CPAP, MV and surfactant. Significantly improved outcomes by surfactant in RDS were in patients with birthweight (BW) < 1500 g or gestational age (GA) < 32 weeks. The overall mortality rate in NRF was 18.4% whereas for those of BW < 1000 g and GA < 28 weeks, 70% and 54%, respectively. The multivariable regression analysis showed the highest odds for NRF death among meconium aspiration syndrome, congenital anomalies, BW < 1500 g and necrotizing enterocolitis, whereas born in level III hospitals, cesarean delivery, CPAP and MV were associated with markedly reduced death odds. Conclusions: The salient findings with associated risk estimates reflected efficiency of respiratory support as critical care in a prefectural regional network infrastructure for annual livebirths in 5.6 million inhabitants. It implicated the representativeness of contemporaneous perinatal-neonatal care standard at medium to medium-high level, in one/fourth of the population of China, aiming at saving more life of very critical and preterm infants for better survival.
 
Type I. Expansive and osteolytic bone destruction of the right temporal with iso-density soft tissue mass was shown, and the lesion penetrated through the cranial plate involving the dura (a, arrow). Residual bone fragments in the lesion were observed (b, arrow). Craniectomy and cranioplasty were performed (c, arrow). Histopathologic examination (H&E stain, × 100) of the specimen showed proliferation of spindled fibroblasts/myofibroblasts are arranged in bundles, and the myxoid stroma was loose and edema (d). Immunohistochemistry displays positive SMA staining (e, smooth muscle actin, × 200)
TypeII. A scalp mass was observed in the right frontotemporal region (a, arrow), with mild erosion of the outer skull plate (b, arrow). Histopathologic examination (H&E stain, × 100) of the specimen showed proliferation of spindled fibroblasts/myofibroblasts are arranged in bundles (c)
Type III. A scalp mass was observed in the occipital region (a, arrow), with normal skull (b, arrow). Enhanced CT showed mild enhancement of the scalp mass (c, arrow). Histopathologic examination (H&E stain, × 100) showed proliferation of spindled fibroblasts/myofibroblasts (d)
Background Cranial fasciitis (CF) is a rare benign fibroproliferative lesion of the skull. To date, the summarized radiologic characteristics and the subtype of the disease have not been reported. our purpose was to summarize the characteristic clinicoradiology features and management of CF and to improve the knowledge of radiologists and clinicians. Methods We searched our institution’s database and retrieved the clinical and radiologic data of CF patients confirmed by histopathological examination. The clinicoradiology features and management of CF were analysed retrospectively. Results A total of 14 CF patients were included. A total of 85.7% of the patients presented with a painless, firm, nonmobile and single mass. Tenderness and multiple masses were found in 14.3% of the patients. The mass was clearly increased in 2 patients and gradually increased in 5 patients in the short term. We divided these patients into three types based on the CT characteristics. The characteristic features of type I (9 patients) presented as an expansive and osteolytic bone destruction with a soft tissue mass. Type II (2 patients) presented as a scalp mass with mild erosion of the outer skull plate. Type III (3 patients) presented as a scalp mass without skull destruction. All patients underwent surgical resection. For type I patients, craniectomy and cranioplasty were performed. For type II patients, complete excision of the scalp mass with local skull curettage was performed. For type III patients, complete excision of the scalp mass was performed. There were no cases of recurrence after follow-up. Conclusions CF usually presents as a painless, firm, nonmobile and single mass with a clear boundary. There are generally three types of MSCT findings: bone destruction with a soft tissue mass, a scalp mass with erosion of the skull and a scalp mass. Different management strategies should be utilized for the various types of CF.
 
Number of publications (y-axis) by starting year of cohort (x-axis) (size reflects population size, color reflects country of cohort)
Network analysis of the 13 predominant key areas of the 45 birth cohorts (number of cohorts addressing that area)
Background Knowing the research issues addressed by other cohorts when setting up new cohorts allows researchers to avoid unnecessary duplication of efforts, while permitting collaborations, including data merging data, to better tackle knowledge gaps. This study describes the topics addressed by European birth cohorts, the interaction between these cohort interests and aims, and describes the scientific publications deriving from the cohorts. Methods A previous study found 66 pregnancy and 45 birth cohorts in Europe. In this study, between August and October 2020, the predominant key areas addressed by the 45 birth cohorts identified in the previous study were evaluated, as were the publications found in PubMed that were associated with the 45 cohorts. A network analysis was performed to show the connections between the 13 key areas identified. A focus on a topic in common between two areas was provided, describing the related publications. Results A total of 1512 references were found in PubMed (148 publications per cohort). Thirteen predominant key areas were identified, the most common of which was “Environmental” (addressed by 20 cohorts). The Environmental, Genes, and Lifestyle exposure areas were the prevalent topics characterizing the network figure. The Environmental area had the largest number of interactions with the other areas, while the Prematurity area (4 cohorts) the least. The focus provided on smoking led to the comparison of 35 publications from the Environmental group of cohorts and 22 from the Prematurity group, but their objectives did not overlap. Conclusions The results of this descriptive study show that the environment is a priority research area for cohorts in Europe and that cohorts with different research areas may have study issues in common, but may approach them from different viewpoints. Birth cohorts have wide-ranging aims and it would be almost impossible, and undesirable, to have perfectly overlapping and comparable objectives, but joining efforts would permit maximum use of available resources.
 
Distribution of per cent variation between period 2 and 1 in the absolute number of ED visits (a), the absolute number of UTI diagnoses (b), and UTI diagnosis rate (c) between the centres participating in the study. A paired analysis was performed to detect the general trend prevailing in centres
Histogram of age distribution of patients with diagnosis of febrile UTI. The distribution is absolutely not normal, as shown also by a Shapiro Wilk test (p value < 0.001)
Background The first Covid-19 pandemic affected the epidemiology of several diseases. A general reduction in the emergency department (ED) accesses was observed during this period, both in adult and pediatric contexts. Methods This retrospective study was conducted on the behalf of the Italian Society of Pediatric Nephrology (SINePe) in 17 Italian pediatric EDs in March and April 2020, comparing them with data from the same periods in 2018 and 2019. The total number of pediatric (age 0–18 years) ED visits, the number of febrile urinary tract infection (UTI) diagnoses, and clinical and laboratory parameters were retrospectively collected. Results The total number of febrile UTI diagnoses was 339 (73 in 2020, 140 in 2019, and 126 in 2018). During the first Covid-19 pandemic, the total number of ED visits decreased by 75.1%, the total number of febrile UTI diagnoses by 45.1%, with an increase in the UTI diagnosis rate (+ 121.7%). The data collected revealed an increased rate of patients with two or more days of fever before admission (p = 0.02), a significant increase in hospitalization rate (+ 17.5%, p = 0.008) and also in values of C reactive protein (CRP) (p = 0.006). In 2020, intravenous antibiotics use was significantly higher than in 2018 and 2019 (+ 15%, p = 0.025). Urine cultures showed higher Pseudomonas aeruginosa and Enterococcus faecalis percentages and lower rates of Escherichia coli (p = 0.02). Conclusions The first wave of the Covid-19 pandemic had an essential impact on managing febrile UTIs in the ED, causing an absolute reduction of cases referring to the ED but with higher clinical severity. Children with febrile UTI were more severely ill than the previous two years, probably due to delayed access caused by the fear of potential hospital-acquired Sars-Cov-2 infection. The possible increase in consequent kidney scarring in this population should be considered.
 
Comparison of blood pressure of children with and without sickle cell disease (SCD) by sex and height percentile. Significance codes: *** = p< 0.001, ** = p< 0.01, * = p<0.05, NS = not significant (p>0.05) Red = SCD, green = non-SCD 2004, blue = non-SCD 2017
Background Sickle cell disease (SCD) is associated with an increased risk of cardiovascular disease that may be due to a variety of possible risk factors, including abnormal blood pressure. Blood pressure (BP) of children and adolescents with SCD has been reported to be lower compared to the BP of the general pediatric population. Methods To confirm this prior observation, we compared reference BP values for children with SCD with reference BP values of the general pediatric population. We hypothesized that children with SCD do not have lower BPs than children without SCD. Results Systolic BP differed for both males and females, over the different age groups between pediatric subjects with and without SCD. Systolic BP was higher in children with SCD, in both obese and non-obese populations. Diastolic BP did not differ between the groups. Conclusions Our analysis demonstrated that systolic BP values are indeed higher in children with SCD than in the general pediatric population. This finding is consistent with the most recent literature showing abnormal BP patterns in the SCD pediatric population utilizing 24-hour BP monitoring devices. This is an important step for recognizing abnormal BP as a risk factor for cardio- and neurovascular events in SCD.
 
Background The survival of HIV-infected infants depends on early identification and initiation on effective treatment. HIV-exposed infants are tested at 6 weeks of age; however, testing for HIV sooner (e.g., shortly after birth) can identify in utero infection, which is associated with rapid progression. Infant early diagnostic virologic tests often have long turnaround times, reducing the utility of early testing. Point-of-care (POC) testing allows neonates born in health facilities to get results prior to discharge. This study aimed to understand the views of mothers and health workers regarding the use and acceptability of POC birth testing. Methods Beginning in 2018, Zimbabwe offered standard HIV testing at birth to high-risk HIV-exposed infants; as part of a pilot program, at 10 selected hospitals, POC birth testing (BT) was offered to every HIV-exposed infant. In order to understand experiences at the selected sites, 48 interviews were held: 23 with mothers and 25 with health workers, including 6 nurses-in-charge. Participants were purposively sampled across the participating sites. Interviews were held in English, Shona, or Ndebele, and transcribed in English. Line-by-line coding was carried out, and the constant comparison method of analysis was used to identify key themes for each respondent type. Results Findings were organized under four themes: challenges with BT, acceptability of BT, benefits of BT, and recommendations for BT programs. Overall, BT was well accepted by mothers and health workers because it encouraged mothers to better care for their uninfected newborns or initiate treatment more rapidly for infected infants. While the benefits were well understood, mothers felt there were some challenges, namely that they should be informed in advance about testing procedures and tested in a more private setting. Mothers and HCWs also recommended improving awareness of BT, both among health care workers and in the community in general, as well as ensuring that facilities are well-stocked with supplies and can deliver results in a timely way before scaling up programs. Conclusions Mothers and health workers strongly support implementation and expansion of birth testing programs due to the benefits for newborns. The challenges noted should be taken as planning guidance, rather than reasons to delay or discontinue birth testing programs.
 
MRI results. A Volumetric T1 brain MRI axial and B Sagittal planes show a diffuse lissencephaly-pachygyria spectrum predominantly in the posterior areas methylation study for Angelman syndrome was normal and the sequencing of ARX and MECP2 showed no pathogenic mutations
Variant impact at genome and protein level. A IGV view of the reads mapping onto the gene PAFAH1B1. The gene’s structure is shown on top and the exon, where the mutation is located is marked with an asterisk. The reads are shown in gray and the Insertion is marked in violet. The inserted G is shown on top of the reference genome. The originated premature stop codon is also marked. B Sanger sequencing of the variant in mother (top) and patient (bottom). Mother presents no variant, while patient variant was confirmed. C Top view of the truncated LIS1 beta propeller in orange. The C-terminal region of 27 residues introduced between the frameshift and the stop codon is painted in red. For reference, the wild-type crystal structure of LIS1 (PDB access code 1VYH) is shown superimposed as a transparent grey cartoon. Also, eight crucial interacting residues are indicated in atom sticks, completely absent from the hypothetical truncated LIS1
Background Lissencephaly (LIS) is a cortical malformation, characterized by smooth or nearly smooth cerebral surface and a shortage of gyral and sulcal development, which is caused by deficient neuronal migration during embryogenesis. Neuronal migration involves many gene products, among which is the product of the PAFAH1B1 gene, associated with this disease. LIS is a rare disease, characterized by low population frequency, and with non-specific clinical symptoms such as early epilepsy, developmental delay or cerebral palsy-like motor problems. Given that high-throughput sequencing techniques have been improving diagnosis, we have chosen this technique for addressing this patient. Case presentation We present the case of a seven years old male patient with an undiagnosed rare disease, with non-specific clinical symptoms possibly compatible with lissencephaly. The patient was enrolled in a study that included the sequencing of his whole genome. Sequence data was analyzed following a bioinformatic pipeline. The variants obtained were annotated and then subjected to different filters for prioritization. Also mitochondrial genome was analyzed. A novel candidate frameshift insertion in known PAFAH1B1 gene was found, explaining the index case phenotype. The assessment through in silico tools reported that it causes nonsense mediated mechanisms and that it is damaging with high confidence scores. The insertion causes a change in the reading frame, and produces a premature stop codon, severely affecting the protein function and probably the silencing of one allele. The healthy mother did not carry the mutation, and the unaffected father was not available for analysis. Conclusions Through this work we found a novel de novo mutation in LIS1/PAFAH1B1 gene, as a likely cause of a rare disease in a young boy with non-specific clinical symptoms. The mutation found correlates with the phenotype studied since the loss of function in the gene product has already been described in this condition. Since there are no other variants in the PAFAH1B1 gene with low population frequency and due to family history, a de novo disease mechanism is proposed.
 
Flowchart for patient inclusion
Nomogram for predicting the occurrence of preterm birth in pregnant women
Background Preterm birth is serious public health worldwide, and early prediction of preterm birth in pregnant women may provide assistance for timely intervention and reduction of preterm birth. This study aimed to develop a preterm birth prediction model that is readily available and convenient for clinical application. Methods Data used in this case-control study were extracted from the National Vital Statistics System (NVSS) database between 2018 and 2019. Univariate and multivariate logistic regression analyses were utilized to find factors associated with preterm birth. Odds ratio (OR) and 95% confidence interval (CI) were used as effect measures. The area under the curve (AUC), accuracy, sensitivity, and specificity were utilized as model performance evaluation metrics. Results Data from 3,006,989 pregnant women in 2019 and 3,039,922 pregnant women in 2018 were used for the model establishment and external validation, respectively. Of these 3,006,989 pregnant women, 324,700 (10.8%) had a preterm birth. Higher education level of pregnant women [bachelor (OR = 0.82; 95%CI, 0.81–0.84); master or above (OR = 0.82; 95%CI, 0.81–0.83)], pre-pregnancy overweight (OR = 0.96; 95%CI, 0.95–0.98) and obesity (OR = 0.94; 95%CI, 0.93–0.96), and prenatal care (OR = 0.48; 95%CI, 0.47–0.50) were associated with a reduced risk of preterm birth, while age ≥ 35 years (OR = 1.27; 95%CI, 1.26–1.29), black race (OR = 1.26; 95%CI, 1.23–1.29), pre-pregnancy underweight (OR = 1.26; 95%CI, 1.22–1.30), pregnancy smoking (OR = 1.27; 95%CI, 1.24–1.30), pre-pregnancy diabetes (OR = 2.08; 95%CI, 1.99–2.16), pre-pregnancy hypertension (OR = 2.22; 95%CI, 2.16–2.29), previous preterm birth (OR = 2.95; 95%CI, 2.88–3.01), and plurality (OR = 12.99; 95%CI, 12.73–13.24) were related to an increased risk of preterm birth. The AUC and accuracy of the prediction model in the testing set were 0.688 (95%CI, 0.686–0.689) and 0.762 (95%CI, 0.762–0.763), respectively. In addition, a nomogram based on information on pregnant women and their spouses was established to predict the risk of preterm birth in pregnant women. Conclusions The nomogram for predicting the risk of preterm birth in pregnant women had a good performance and the relevant predictors are readily available clinically, which may provide a simple tool for the prediction of preterm birth.
 
Shows Vt in ml/kg of each infant. Reference lines indicate a target range of 4 – 8 ml/kg. The two patients in dark grey (17 and 18) were the two infants who were intubated
Shows flow and pressure wave forms as an example for inadequate ventilation (A), appropriate ventilation (B) and excessive ventilation (C). A1 shows inadequate ventilation due to obstruction: although pressure is applied, there is almost no airflow. A2 shows inadequate ventilation due to mask leak: there is very little airflow coming back during expiration. B is an example of appropriate ventilation: there is no leak and VTe is in the target range. C shows excessive ventilation
Shows development of Vt over time. Quartile 1 summarizes the first 25% of time of PPV, quartile 2 25–50% of time, quartile 3 50–75% of time and quartile 4 75–100% of time, respectively
Background We sought to assess tidal volumes in (near) term infants during delivery room stabilization. Methods Secondary analysis of a prospective study comparing two facemasks used for positive pressure ventilation (PPV) in newborn infants ≥ 34 weeks gestation. PPV was provided with a T-piece device with a PIP of 30 cmH2O and positive end-expiratory airway pressure of 5 cmH2O. Expired tidal volumes (Vt) were measured with a respiratory function monitor. Target range for Vt was defined to be 4 – 8 ml/kg. Results Twenty-three infants with a median (IQR) gestational age of 38.1 (36.4 – 39.0) weeks received 1828 inflations with a median Vt of 4.6 (3.3 – 6.2) ml/kg. Median Vt was in the target range in 12 infants (52%), lower in 9 (39%) and higher in 2 (9%). Thirty-six (25—27) % of the inflations were in the target rage over the duration of PPV while 42 (25 – 65) % and 10 (3 – 33) % were above and below target range. Conclusions Variability of expiratory tidal volume delivered to term and late preterm infants was wide. Reliance on standard pressures and clinical signs may be insufficient to provide safe and effective ventilation in the delivery room. Trial registration This is a secondary analysis of a prospectively registered randomized controlled trial (ACTRN12616000768493).
 
Objectives To determine if children with idiopathic toe walking (ITW) reach Australian 24-hour movement guidelines. Additional objectives were to identify any factors associated with moderate to vigorous physical activity time of children with ITW. Design Cross sectional. Setting Private practice, public health outpatient, community clinics. Participants Children between 4 and 14 years, who toe walked and had no medical conditions known to cause ITW. Outcome measures Physical activity intensity, sedentary behaviour and sleep data were collected via an ActiGraph. Physical activity level intensity data were triangulated with the Child Leisure Activities Study Survey (CLASS) to highlight the subjective nature of parent-reported measures. Health related quality of life information was collected using the Parent-Proxy and Child-Self Report Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scale. Regression analyses were used to explore individual factors associated with moderate to vigorous physical activity. Results Twenty-seven participants, 17(63%) male, age mean = 6.62 (SD = 2.29) years, provided information on physical activity (CLASS n = 18, ActiGraph n = 22), physical functioning and psychosocial functioning domains on the PedsQL (Parent-Proxy n = 25, Child n = 22). All participants exceeded Australian recommendations for physical activity, 44% (8/18) met recommended screen time amounts, and two (9%) met recommended sleep times. The Child-Self Report PedsQL scale score of social functioning was the only factor associated with an increase in physical activity (Coef = 0.48, 95%CI = 0.09 to 0.87, p = 0.019). Conclusion Participants achieved high levels of daily moderate to vigorous physical activity, and this was associated with social functioning. Given current uncertainty regarding benefits and effectiveness of treatment choices for children who have ITW, these findings should encourage clinicians to consider how their treatment recommendations interact with the PA level and sleep of children with ITW. Any treatment choice should also be implemented with consideration of how it may impact social functioning. This study had a small sample size therefore results should be cautiously interpreted and not generalised to all children with ITW.
 
A flow chart depicting the selection of study participants
Feature importance scores for A Model 1 – five perinatal features, B Model 2—respiratory model data for day of life 1, C Model 3 – respiratory model data for day of life 1–7, and D Model 4 – respiratory model data for day of life 1–14. Feature importance scores were calculated based on permuting the values of the indicated feature followed by re-building the model and calculating the decrease in prediction accuracy. The scores were normalized between 0 and 100, with 0 being least important, and 100 being most important. The scores were obtained by running the varImp() function from the caret package
BPD-free survival probabilities of female, appropriate for gestational age, white, antenatally non-smoking exposed infants born at 23, 26, and 29 weeks of gestation intubated at birth for indicated periods. The error bars indicate standard errors of the probabilities. This plot depicts the simulated results from Scenario 1 (see text)
BPD-free survival probabilities of female, appropriate for gestational age, white, antenatally non-smoking exposed infants born at 26 weeks of gestation intubated at birth for the indicated periods followed by extubating to either continuous positive airway pressure (CPAP)/high-flow nasal cannula (HFNC) or to non-invasive positive pressure ventilation (NIPPV)/non-invasive neurally adjusted ventilatory assist (nNAVA). The error bars indicate standard errors of the probabilities. This plot depicts the simulated results from Scenario 2 (see text)
BPD-free survival probabilities of female, appropriate for gestational age, white, antenatally non-smoking exposed infants born at 26 weeks of gestation intubated at birth for one full day, followed by extubation between day of life 1 and 2, and reintubation following the indicated periods of time. In the control infant, there was no reintubation. Statistical comparison of the probability of BPD-free survival was made between the control infant and each of the infants who were reintubated individually using Student’s t-test. The asterisk sign (*) indicates p-value < 0.05. The error bars indicate standard errors of the probabilities. This plot depicts the simulated results from Scenario 3 (see text)
Background Bronchopulmonary dysplasia (BPD) is one of the most common and serious sequelae of prematurity. Prompt diagnosis using prediction tools is crucial for early intervention and prevention of further adverse effects. This study aims to develop a BPD-free survival prediction tool based on the concept of the developmental origin of BPD with machine learning. Methods Datasets comprising perinatal factors and early postnatal respiratory support were used for initial model development, followed by combining the two models into a final ensemble model using logistic regression. Simulation of clinical scenarios was performed. Results Data from 689 infants were included in the study. We randomly selected data from 80% of infants for model development and used the remaining 20% for validation. The performance of the final model was assessed by receiver operating characteristics which showed 0.921 (95% CI: 0.899–0.943) and 0.899 (95% CI: 0.848–0.949) for the training and the validation datasets, respectively. Simulation data suggests that extubating to CPAP is superior to NIPPV in BPD-free survival. Additionally, successful extubation may be defined as no reintubation for 9 days following initial extubation. Conclusions Machine learning-based BPD prediction based on perinatal features and respiratory data may have clinical applicability to promote early targeted intervention in high-risk infants.
 
HPV PROTECT intervention
Hybrid type 1 effectiveness-implementation trial design
Stepped-wedge cluster-randomized trial design
Study schema
Background Childhood cancer survivors are at high risk for developing new cancers (such as cervical and anal cancer) caused by persistent infection with the human papillomavirus (HPV). HPV vaccination is effective in preventing the infections that lead to these cancers, but HPV vaccine uptake is low among young cancer survivors. Lack of a healthcare provider recommendation is the most common reason that cancer survivors fail to initiate the HPV vaccine. Strategies that are most successful in increasing HPV vaccine uptake in the general population focus on enhancing healthcare provider skills to effectively recommend the vaccine, and reducing barriers faced by the young people and their parents in receiving the vaccine. This study will evaluate the effectiveness and implementation of an evidence-based healthcare provider-focused intervention (HPV PROTECT) adapted for use in pediatric oncology clinics, to increase HPV vaccine uptake among cancer survivors 9 to 17 years of age. Methods This study uses a hybrid type 1 effectiveness-implementation approach. We will test the effectiveness of the HPV PROTECT intervention using a stepped-wedge cluster-randomized trial across a multi-state sample of pediatric oncology clinics. We will evaluate implementation (provider perspectives regarding intervention feasibility, acceptability and appropriateness in the pediatric oncology setting, provider fidelity to intervention components and change in provider HPV vaccine-related knowledge and practices [e.g., providing vaccine recommendations, identifying and reducing barriers to vaccination]) using a mixed methods approach. Discussion This multisite trial will address important gaps in knowledge relevant to the prevention of HPV-related malignancies in young cancer survivors by testing the effectiveness of an evidence-based provider-directed intervention, adapted for the pediatric oncology setting, to increase HPV vaccine initiation in young cancer survivors receiving care in pediatric oncology clinics, and by procuring information regarding intervention delivery to inform future implementation efforts. If proven effective, HPV PROTECT will be readily disseminable for testing in the larger pediatric oncology community to increase HPV vaccine uptake in cancer survivors, facilitating protection against HPV-related morbidities for this vulnerable population. Trial registration ClinicalTrials.gov Identifier: NCT04469569, prospectively registered on July 14, 2020.
 
Prevalence of anemia among children aged 0–59 months and the chronology of various efforts to improve their nutritional status, India: 1950–2016
Prevalence of anemia among children aged 0–59 months and the chronology of various efforts to improve their nutritional status, Bangladesh: 1971–2016
Prevalence of anemia among children aged 0–59 months and the chronology of various efforts to improve their nutritional status Nepal: 1978–2016
Prevalence of anemia among children aged 0–59 months and the chronology of various efforts to improve their nutritional status, Pakistan: 1950–2016
Background Despite policies and social development, childhood malnutrition remains a significant public health and social challenge in many south Asian countries. Also, there is a lack of study for a comparative understanding between the nutrition policies and nutritional status of under-5 children in south Asian countries. In this context, the present study aims to understand the comparative evolution of nutritional policies and programs in south Asian countries between 1950 to 2016 and assess current nutritional status of children under the age of 5 in Bangladesh, India, Nepal, and Pakistan. Methods This study obtained yearly anaemia data from the Global Health Observatory Data Repository (World Health Statistics) from 1990 to 2016 for comparative analysis. The most recent Demographic Health Survey (DHS) rounds have been taken for four south Asian nations. Bivariate analysis and classical figures have been utilised to demonstrate the findings. Results In Bangladesh, Nepal, India, and Pakistan, the prevalence of anaemia decreased by 33%, 31%, 20%, and 12% from 1990 to 2016, respectively. While analysis of the policy and programs, the problem of under-nutrition in all selected countries stems from the lack of serious implementation of National Nutrition Policies. Conclusion This study suggests that the national nutrition programs require inter-sectoral coordination between central ministries within countries to reduce the anaemia level. In light of Sustainable Development Goals (SDG), a multi-faceted policy should be implemented to prevent and control malnutrition problems in these countries.
 
Abdominal ultrasound showed a huge mass in the right adrenal gland
Abdominal MRI showed the adrenal hemorrhage(3.1*3.6 cm)
Background ABO blood group incompatibility, neonatal sepsis, G-6-PD deficiency, thyroid dysfunction, and hereditary spherocytosis are all probable causes of neonatal hyperbilirubinemia. However, the etiology of some hyperbilirubinemia is extremely complicated, which may be caused by multiple factors, resulting in severe jaundice. We report a case of severe jaundice due to three causes, showing the significance for the investigation of the etiology of neonatal hyperbilirubinemia. Case presentation At 96 h of life, a full-term and vaginal delivery male infant with yellowish discoloration of body was transferred to our hospital. When he entered neonatal intensive care unit on the fourth day after birth, he developed jaundice and the transcutaneous bilirubin was 28 mg/dl. Total bilirubin was 540.2 μmol/L, while the indirect bilirubin was 516.7 μmol/L. Both parents and the baby’s blood types were O Rh(D +), and direct coomb’s test was negative. But mother’s indirect coomb’s test was positive. Investigating for minor blood group revealed that the father’s blood type of Rh was CCDee, the mather’s was ccDEE, and CcDEe for the baby. After intensive phototherapy and double volume exchange transfusion, the total bilirubin remained at 303 μmol/L. At day 10, the bilirubin level was 303.5 μmol/L, intensive phototherapy was continued, and intravenous immunoglobulin was used again. The test for thyroid hormones at day 10, the TSH was 13.334mIU/L. And the screening for congenital hypothyroidism showed the TSH was 33mIU/L. Because of the palpable abdominal mass, ultrasound and MRI was done, showed a huge mass in the right adrenal gland. Brainstem auditory evoked potential was performed at day 7, which indicated hearing impairment (65db for left ear and 70db for the right). Euthyrox and intermittent phototherapy were given as following treatment. The jaundice did not subside until the 12th day. Conclusion Even if their parents' ABO blood group and Rh (d) are consistent, a Coomb test is required for newborns with hyperbilirubinemia since they may have minor blood group incompatibilities. When bilirubin rises rapidly or the clinical treatment effect is inadequate, additional causes should be aggressively screened. Adrenal ultrasound should be performed on newborns with palpable abdominal mass, anemia and jaundice to determine whether there is adrenal hemorrhage.
 
Background Birth asphyxia leads to profound systemic and neurological sequela to decrease blood flow or oxygen to the fetus followed by lethal progressive or irreversible life-long pathologies. In low resource setting countries, birth asphyxia remains a critical condition. This study aimed to develop and validate prognostic risk scores to forecast birth asphyxia using maternal and neonatal characteristics in south Gondar zone hospitals. Methods Prospective cohorts of 404 pregnant women were included in the model in south Gondar Zone Hospitals, Northwest Ethiopia. To recognize potential prognostic determinants for birth asphyxia, multivariable logistic regression was applied. The model discrimination probability was checked using the receiver operating characteristic curve (AUROC) and the model calibration plot was assessed using the ‘givitiR’ R-package. To check the clinical importance of the model, a cost-benefit analysis was done through a decision curve and the model was internally validated using bootstrapping. Lastly, a risk score prediction measurement was established for simple application. Results Of 404, 108 (26.73%) (95% CI: 22.6–31.3) newborns were exposed to birth asphyxia during the follow-up time. Premature rupture of membrane, meconium aspiration syndrome, malpresentation, prolonged labor, Preterm, and tight nuchal was the significant prognostic predictors of birth asphyxia. The AUROC curve for birth asphyxia was 88.6% (95% CI: 84.6-92.2%), which indicated that the tool identified the newborns at risk for birth asphyxia very well. The AUROC of the simplified risk score algorithm, was 87.9 (95% CI, 84.0– 91.7%) and the risk score value of 2 was selected as the optimal cut-off value, with a sensitivity of 78.87%, a specificity of 83.26%, a positive predictive value of 63.23%, and a negative predictive value of 91.52%. Conclusions We established birth asphyxia prediction tools by applying non-sophisticated maternal and neonatal characteristics for resource scares countries. The driven score has very good discriminative ability and prediction performance. This risk score tool would allow reducing neonatal morbidity and mortality related to birth asphyxia. Consequently, it will improve the overall neonatal health / under-five child health in low-income countries.
 
Comparison of the AL in only children vs. multiples by sex and grade. Comparison of the rates of AL > 24 mm in only children and multiples overall and by sex (A). Comparison of the rate of AL > 24 mm by grade in only children and multiples (B). *, P < 0.05; **, P < 0.01; ***P < 0.001
Descriptive characteristics of the study population
Background This study aimed to investigate the differences in optical axial length and close-work activities between only children and children with siblings in Wenzhou. Methods This was a cross-sectional population-based study. In total, 2913 school-aged children and their parents in Wenzhou were included as study subjects from April to May 2021. Data regarding the optical axial length, spherical equivalent refraction, number of children in a family, parental myopia, and close-work activities were collected through eye examinations and questionnaires. A multivariable logistic regression was used to analyze the association between the number of children in a family and optical axial length. Results The children were aged 9.80 ± 3.41 years. The overall percentage of children with an axial length > 24 mm was 38.9%, 44.5% in only children and 35.6% in multiples. The multivariable logistic regression analysis showed that the odds of having an AL > 24 mm were 1.24 times higher in only children than in multiples (OR: 1.24, 95% CI: 1.025–1.480, P = 0.028). Only children were 1.331 times more likely to perform homework > 1 h on weekends than multiples (OR: 1.331, 95% CI: 1.049–1.688, P = 0.019). Only children in upper grades were 1.543 times more likely to perform homework > 1 h on weekends than multiples (OR: 1.543, 95% CI: 1.065–2.235, P = 0.025). Boys who were only children were more likely to attend three or more extracurricular classes for academic subjects than multiples (OR: 1.224, 95% CI: 1.011–1.562, P = 0.004). Conclusions Being an only child may be associated with a higher risk of myopia and higher odds of close-work behaviors. Only children, especially those in upper grades, are more likely to spend more time on homework than their peers who are multiples. Only children, especially boys, are more likely to attend extracurricular classes in academic subjects. Trial registration This trial is registered as ChiCTR1900020584 at www.Chictr.org.cn .
 
Background Hematopoietic stem cell transplantation (HSCT) is a treatment option with curative intent for patients with transfusion dependent thalassemia (TDT) but its application is limited by the lack of suitable donors and acceptability due to the related morbidity/mortality. Transplantation of autologous genetically modified hematopoietic cells, gene therapy (GT) is emerging as a promising treatment option for TDT as it eliminates graft versus host disease (GVHD) and need for immunosuppression. Early results of GT suggest that many, but not all patients achieve transfusion independence after the procedure. There is little information about the acceptability of GT in patients with TDT . We sought to examine patient/family knowledge about GT in TDT and to examine factors that influence decision-making about this therapy. Methods Parents of children with TDT and adults with TDT were who provided informed consent underwent semi-structured interviews to understand patient/family knowledge and decision-making regarding GT in TDT. Transcribed interviews were coded and the data was examined for emerging themes using a combination of thematic and content analysis. Results Twenty-five study participants with mean age of 38Y (17—52Y) including eight adults living with TDT, and 17 parents of children with TDT underwent semi-structured qualitative interviews. Participant responses coalesced around broad themes related to knowledge of GT, motivating/deterring factors and outcomes. Study participants expressed a desire for ‘cure’ from thalassemia including transfusion independence, chelation reduction and improved quality of life as motivators for considering GT. Insufficient knowledge about the process, long-term outcomes, safety, and side effects as well as the potential for death/failure of the procedure were deterrents for the consideration GT. Reduction in frequency of transfusions, even without elimination of transfusions was an acceptable outcome of GT for most participants. Participant choice for preferred treatment modality was split between indefinitely continuing transfusions which was familiar to them versus GT which was unfamiliar, and with an uncertain outcome. None of the participants had a matched sibling donor; alternate donor HSCT was the least preferred option in this group. Conclusion There is tempered excitement about GT in patients/families with TDT with a general willingness to accept transfusions reduction as the outcome.
 
(continued)
Nutrient intakes of study participants according to quartiles of dietary TAC
The association between dietary TAC and depression score
Background Oxidative stress is considered to be a contributory factor for depression, and is affected by the dietary intake of pro-and anti-oxidants. Dietary total antioxidant capacity (DTAC) is an index which is applied to estimate the cumulative power of antioxidants in the whole diet. The aim of this study was to determine the relationship between DTAC and prevalence of depression in adolescent girls. Methods A total of 741 Iranian adolescent girls aged 12–18 years were recruited into this cross-sectional study. Dietary intake and depression severity score were assessed using a food frequency questionnaire and Beck's depression inventory, respectively. To estimate the DTAC, the oxygen radical absorbance capacity method was used for selected foods. To explore the associations between DTAC and depression, logistic regression was applied using crude and adjusted models. Results Individuals in the greatest adherence to high DTAC had more intakes of whole grains, legumes, fruits, dried fruits, low fat dairy products, cruciferous vegetables, fiber, magnesium, vitamin C, folate, potassium, zinc, β-carotene, lutein, thiamin, riboflavin, niacin and vitamin B-6 and lower consumption of refined grains. Subjects in the highest quartile of DTAC had a 39% lower odds of depression compared to those in the first quartile (OR = 0.61; 95% CI: 0.38–0.97, P for trend = 0.012); these associations remained significant after adjustments in first, second and third (OR = 0.5; 95% CI: 0.28–0.92, P for trend < 0.001) adjusted models. Conclusions An inverse association was observed between the DTAC and the prevalence of depression in our population sample of adolescent girls. Further research needs to be conducted in different areas, including longitudinal studies with larger sample sizes.
 
Background: In community-acquired pneumonia (CAP), pulmonary vascular endothelial dysfunction, inflammation, and oxidative stress (OS) are prominent and interesting as the unfavorable clinical outcomes of it. Asthma as a common chronic respiratory disease may affect the clinical outcomes of pneumonia, but the exact mechanism of this effect remains unclear. The present study aimed to assess the effects of asthma on the OS, inflammation, and endothelial dysfunction biomarkers in the children pneumonia. Methods: A cross-sectional study designed with a total of 75 children including both severe CAP and asthma (as group I), severe CAP alone (as group II), and healthy children (as group III) was conducted. Fasting blood samples were taken to the assay of serum malondialdehyde (MDA), total antioxidant capacity (TAC), tumor necrosis factor-alpha (TNF-α), soluble vascular cell adhesion molecule-1 (sVCAM-1), and plasminogen activator inhibitor-1 (PAI-1). The mean of anthropometric and biochemical parameters was compared by ANOVA and Tukey post-hoc test between groups. Results: We observed TAC levels in groups I and II (0.997 ± 0.22 and 1.23 ± 0.21 mmol/l, respectively) were significantly lower compared with group III (1.46 ± 0.19 mmol/l, P value < 0.001). It was significantly higher in group II than in group I (P value < 0.001). Also, we observed MDA and TNF-α levels in groups I (6.94 ± 1.61 μmol/l, 7.34 ± 2.23 pg/ml, respectively) and II (2.57 ± 0.40 μmol/l, 5.54 ± 1.84 pg/ml, respectively) were significantly higher compared with group III (1.89 ± 0.27 μmol/l, 3.42 ± 1.32 pg/ml, P value < 0.001, P value < 0.001, respectively). VCAM-1 and PAI-1 levels as the endothelial dysfunction biomarkers were significantly higher in group I (1.5 ± 0.62 mmol/l, 10.52 ± 3.2 AU/ml, respectively) compared with groups II (1.06 ± 0.53 mmol/l and 8.23 ± 3.4 AU/ml; P value < 0.001, P value < 0.001, respectively) and III (0.6 ± 0.35 mmol/l and 2.39 ± 0.83 AU/ml; P value < 0.001, P value < 0.001, respectively). Also, VCAM-1 and PAI-1 levels were significantly higher in group II compared with groups III (P value < 0.001, P value < 0.001). Conclusions: Asthma can exacerbate the vascular dysfunction of pneumonia in children by increasing oxidative stress, inflammation, and endothelial dysfunction.
 
a Motivators to COVID-19 testing for Caregivers of Children with Medical Complexity. b Demotivators to COVID-19 testing for Caregivers of Children with Medical Complexity
(continued)
Background In-home direct antigen rapid testing (DART) plays a major role in COVID-19 mitigation and policy. However, perceptions of DART within high-risk, intellectually impaired child populations are unknown. This lack of research could negatively influence DART uptake and utility among those who stand to benefit most from DART. The purpose of this study was to describe caregivers’ perceptions of an in-home COVID-19 DART regimen in children with medical complexity, including the benefits and limitations of DART use. Methods This qualitative study was a subproject of the NIH Rapid Acceleration of Diagnostics Underserved Populations research program at the University of Wisconsin. We combined survey data and the thematic analysis of semi-structured interview data to understand caregivers’ perceptions of in-home COVID-19 testing and motivators to perform testing. Caregivers of children with medical complexity were recruited from the Pediatric Complex Care Program at the University of Wisconsin (PCCP). Data were collected between May and August 2021. Results Among n = 20 caregivers, 16/20 (80%) of their children had neurologic conditions and 12/20 (60%) used home oxygen. Survey data revealed that the largest caregiver motivators to test their child were to get early treatment if positive (18/20 [90%] of respondents agreed) and to let the child’s school know if the child was safe to attend (17/20 [85%] agreed). Demotivators to testing included that the child could still get COVID-19 later (7/20 [35%] agreed), and the need for officials to reach out to close contacts (6/20 [30%] agreed). From interview data, four overarching themes described perceptions of in-home COVID-19 testing: Caregivers perceived DART on a spectrum of 1) benign to traumatic and 2) simple to complex. Caregivers varied in the 3) extent to which DART contributed to their peace of mind and 4) implications of test results for their child. Conclusions Although participants often described DART as easy to administer and contributing to peace of mind, they also faced critical challenges and limitations using DART. Future research should investigate how to minimize the complexity of DART within high-risk populations, while leveraging DART to facilitate safe school attendance for children with medical complexity and reduce caregiver burden.
 
Background Defaulting is the most frequent cause of Community Management of Acute Malnutrition (CMAM) program failure. Lack of community sensitization, financial/opportunity costs and low quality of care have been recognized as the main driving factors for default in malnutrition programs. The present study aimed to evaluate if a logistic reorganization (generic outpatient department, OPD vs dedicated clinic, NRU) and a change in management (dedicated vs non dedicated staff) of the follow-up of children between 6 and 24 months of age with acute malnutrition, can reduce the default, relapse and readmission rate and increase the recovery rate. Methods Retrospective observational study on the impact of quality improvement interventions on rehabilitation outcomes of children (6–24 months) with acute malnutrition, admitted at the Catholic Mission Hospital of Chiulo (Angola) from January 2018 to February 2020. Main outcome measures were recovery rate, the default rate, the relapse rate, and the readmission rate. Results The intervention was associated with a decrease in the default rate from 89 to 76% ( p = 0.02). Recovery rate was 69% in OPD and 88% in NRU ( p = 0.25). Relapse rate was nil. Conclusions The present study supports the hypothesis that an improvement in quality of care can positively influence the rehabilitation outcomes of malnourished children. Further studies are needed to identify children at risk of low adherence to follow-up visits to increase the effectiveness of rehabilitation programs.
 
The Bedside Pediatric Early Warning System clinical indicators and subscores. *vital sign ranges are subdivided according to five age groups (0–3 months, 3–12 months, 1–4 years, 4–12 years, > 12 years). Note: adapted from Parshuram C. S. et al., 2011
Escalation index for patients with BedsidePEWS score ≥ 7: score items and points
Progression of the escalation of care and the BedsidePEWS of high-risk patients (BedsidePEWS ≥7). aData are from a total of 228 patients. The graph represents the trend of the median value of the Escalation Index and the highest BedsidePEWS during the 24 h observation period in the 99 patients urgently admitted to PICU and the 129 patients who stayed on a hospital ward. Legend: PICU = Pediatric Intensive Care Unit
Background: Escalation and de-escalation are a routine part of high-quality care that should be matched with clinical needs. The aim of this study was to describe escalation of care in relation to the occurrence and timing of Pediatric Intensive Care Unit (PICU) admission in a cohort of pediatric inpatients with acute worsening of their clinical condition. Methods: A monocentric, observational cohort study was performed from January to December 2018. Eligible patients were children: 1) admitted to one of the inpatient wards other than ICU; 2) under the age of 18 years at the time of admission; 3) with two or more Bedside-Paediatric-Early-Warning-System (BedsidePEWS) scores ≥ 7 recorded at a distance of at least one hour and for a period of 4 h during admission. The main outcome -the 24-h disposition - was defined as admission to PICU within 24-h of enrolment or staying in the inpatient ward. Escalation of care was measured using an eight-point scale-the Escalation Index (EI), developed by the authors. The EI was calculated every 6 h, starting from the moment the patient was considered eligible. Analyses used multivariate quantile and logistic regression models. Results: The 228 episodes included 574 EI calculated scores. The 24-h disposition was the ward in 129 (57%) and the PICU in 99 (43%) episodes. Patients who were admitted to PICU within 24-h had higher top EI scores [median (IQR) 6 (5-7) vs 4 (3-5), p < 0.001]; higher initial BedsidePEWS scores [median (IQR) 10(8-13) vs. 9 (8-11), p = 0.02], were less likely to have a chronic disease [n = 62 (63%) vs. n = 127 (98%), p < 0.0001], and were rated by physicians as being at a higher risk of having a cardiac arrest (p = 0.01) than patients remaining on the ward. The EI increased over 24 h before urgent admission to PICU or cardiac arrest by 0.53 every 6-h interval (CI 0.37-0.70, p < 0.001), while it decreased by 0.25 every 6-h interval (CI -0.36-0.15, p < 0.001) in patients who stayed on the wards. Conclusion: Escalation of care was related to temporal changes in severity of illness, patient background and environmental factors. The EI index can improve responses to evolving critical illness.
 
Flow chart of patients enrolled in the SPECS trial.
ND Neurodevelopmental, SPECS Safe pediatric euglycemia after cardiac surgery, STD Standard care, TGC Tight glycemic control. 872 patients were eligible for 3-year-old follow-up, 269 had any follow-up between 30–42.5 months of age, and 214 had in-person testing. a 221 patients (97 TGC, 124 STD) without genetic anomaly. b 169 patients (72 TGC, 97 STD) without genetic anomaly
Background: Studies examining the impact of randomization As per standard instruction, city is required for affiliations; however, this information is missing in affiliation 6. Please check if the provided city is correct and amend if necessary. to tight glycemic control (TGC) and resultant hypoglycemia on later neurodevelopmental outcomes have produced mixed results. Our study examined this association in children undergoing cardiac surgery. Methods: Participants who were enrolled in the Safe Pediatric Euglycemia after Cardiac Surgery (SPECS) trial returned for neurodevelopmental (ND) follow-up between 30 to 42.5 months of age. ND outcomes were assessed using the Bayley Scales of Infant and Toddler Development, Third Edition. ND scores were compared between the TGC and standard care treatment groups and between patients with moderate to severe and no to mild hypoglycemia. As a secondary analysis, to increase sample size and power, we combined the three-year-old assessments with previously collected assessments done at < 30 months of age to further examine differences between groups longitudinally. Results: Among the 269 participants who completed neurodevelopmental evaluation (in-person testing or questionnaires) at three years of age (follow-up rate, 31%), there were no statistically significant differences in ND outcomes according to treatment group or hypoglycemia status. In the combined analysis of all evaluations (from 9 to 42.5 months of age), we found no treatment group differences. However, in these longitudinal analyses, children who experienced moderate to severe hypoglycemia had lower scores on the Bayley-III cognitive and motor domains compared to children with no to mild hypoglycemia. Conclusions: For infants undergoing cardiac surgery, there was no impact of tight glycemic control on neurodevelopmental outcomes. Moderate to severe hypoglycemia was associated with worse ND outcomes in longitudinal analyses. Trial registration: ClinicalTrials.gov NCT00443599. Registered: November 2016.
 
Structural equation model with autoregressive and lagged paths. Standardized coefficients are shown on each arrow; solid lines indicate statistically significant paths. Panel A presents the full model. Panel B presents the model for female children and Panel C for male children. Note: *** = p < .001, ** = p < .01, * = p < .05, + = p < .10; BMI = body mass index
Demographic and descriptive statistics M (SD) or Percentage (%)
Background Although associations between cumulative risk, sleep, and overweight/obesity have been demonstrated, few studies have examined relationships between these constructs longitudinally across childhood. This study investigated how cumulative risk and sleep duration are related to current and later child overweight/obesity in families across the United States sampled for high sociodemographic risk. Methods We conducted secondary analyses on 3690 families with recorded child height and weight within the Fragile Families and Child Well-Being Study. A cumulative risk composite (using nine variables indicating household/environmental, family, and sociodemographic risk) was calculated for each participant from ages 3-9 years. Path analyses were used to investigate associations between cumulative risk, parent-reported child sleep duration, and z-scored child body mass index (BMI) percentile at ages 3 through 9. Results Higher cumulative risk experienced at age 5 was associated with shorter sleep duration at year 9, b = − 0.35, p = .01, 95% CI [− 0.57, − 0.11]. At 5 years, longer sleep duration was associated with lower BMI, b = − 0.03, p = .03, 95% CI [− 0.06, − 0.01]. Higher cumulative risk at 9 years, b = − 0.34, p = .02, 95% CI [− 0.57, − 0.10], was concurrently associated with shorter sleep duration. Findings additionally differed by child sex, such that only male children showed an association between sleep duration and BMI. Conclusions Results partially supported hypothesized associations between child sleep duration, cumulative risk, and BMI emerging across childhood within a large, primarily low socioeconomic status sample. Findings suggest that reducing cumulative risk for families experiencing low income may support longer child sleep duration. Additionally, child sleep duration and BMI are concurrently related in early childhood for male children.
 
Pedigree of the family with BDB1. Black shading on the left half represents brachydactyly, and grey shading on the right half represents syndactyly. The proband is marked by an arrow
Phenotype of the proband and her mother. a A photograph of the proband's right hand before surgery. b An X-ray of the proband’s right hand before surgery. c A picture of the proband’s hands after the operation. d A photograph of the proband's feet. e A photograph of the mother’s hands after the operation. f A photograph of the mother’s feet
Gene variant analysis of a family with BDB1. a The novel heterozygous variant c.1320dupG, p.(Arg441Alafs*18) in ROR2 was verified by Sanger sequencing. The variant is marked by a red arrow. CS: Clone sequencing. b A schematic diagram showing the encoded domain structure of the ROR2 gene. A recurrent variant is marked in black, and the novel variant identified in this study is highlighted in red. This ROR2 variant results in the loss of the whole intracellular region
Three-dimensional structures of the wild-type and variant ROR2 proteins. Molecular modelling by Robetta showing that p.(Arg441Alafs*18) remarkably altered the tertiary structures of the remaining peptide chain of the ROR2 protein. a Wild-type; b Mutant type
Background Brachydactyly type B is an autosomal dominant disorder that is characterized by hypoplasia of the distal phalanges and nails and can be divided into brachydactyly type B1 (BDB1) and brachydactyly type B2 (BDB2). BDB1 is the most severe form of brachydactyly and is caused by truncating variants in the receptor tyrosine kinase–like orphan receptor 2 (ROR2) gene. Case presentation Here, we report a five-generation Chinese family with brachydactyly with or without syndactyly. The proband and her mother underwent digital separation in syndactyly, and the genetic analyses of the proband and her parents were provided. The novel heterozygous frameshift variant c.1320dupG, p.(Arg441Alafs*18) in the ROR2 gene was identified in the affected individuals by whole-exome sequencing and Sanger sequencing. The c.1320dupG variant in ROR2 is predicted to produce a truncated protein that lacks tyrosine kinase and serine/threonine- and proline-rich structures and remarkably alters the tertiary structures of the mutant ROR2 protein. Conclusion The c.1320dupG, p.(Arg441Alafs*18) variant in the ROR2 gene has not been reported in any databases thus far and therefore is novel. Our study extends the gene variant spectrum of brachydactyly and may provide information for the genetic counselling of family members.
 
Consort flow diagram for the trial
Background Chitosan is one of dietary fiber that has received great attention in improving obesity-related markers, but little is known on its effects on adolescents. Objectives To analyze the effects of chitosan supplementation on obesity-related cardiometabolic markers and appetite-related hormones in adolescents with overweight or obesity. Methods and analysis A randomized clinical trial was performed on 64 adolescents with overweight and obesity, who were randomly allocated to receive chitosan supplementation ( n = 32) or placebo as control (n = 32) for 12 weeks. Anthropometric measures, lipid and glycemic profiles, and appetite-related hormones were examined. Results Sixty-one participants completed study (chitosa n = 31, placebo = 30). Chitosan supplementation significantly improved anthropometric indicators of obesity (body weight: − 3.58 ± 2.17 kg, waist circumference: − 5.00 ± 3.11 cm, and body mass index: − 1.61 ± 0.99 kg/m ² and − 0.28 ± 0.19 Z-score), lipid (triglycerides: − 5.67 ± 9.24, total cholesterol: − 14.12 ± 13.34, LDL-C: − 7.18 ± 10.16, and HDL-C: 1.83 ± 4.64 mg/dL) and glycemic markers (insulin: − 5.51 ± 7.52 μIU/mL, fasting blood glucose: − 5.77 ± 6.93 mg/dL, and homeostasis model assessment of insulin resistance: − 0.24 ± 0.44), and appetite-related hormones (adiponectin: 1.69 ± 2.13 ng/dL, leptin − 19.40 ± 16.89, and neuropeptide Y: − 41.96 ± 79.34 ng/dL). When compared with the placebo group, chitosan supplementation had greater improvement in body weight, body mass index (kg/m ² and Z-score), waist circumference, as well as insulin, adiponectin, and leptin levels. Differences were significant according to P -value < 0.05. Conclusion Chitosan supplementation can improve cardiometabolic parameters (anthropometric indicators of obesity and lipid and glycemic markers) and appetite-related hormones (adiponectin, leptin, and NPY) in adolescents with overweight or obesity.
 
A Transhepatic percutaneous cholangiogram obtained at the time of liver biopsy. Arrowhead indicates cystic duct dilation. Arrow indicates CBD dilation. Asterisk marks location of filling defect near the ampulla. B Magnetic resonance cholangiopancreatography. Arrow indicates extrahepatic bile duct dilation. Asterisks marks location of theoretical stone
Percutaneous liver biopsy features: A Portal regions with mild increase in chronic inflammatory cells with occasional eosinophils and increased number of bile ducts (arrows; scale bar = 100 micrometers; H&E stain, original magnification 400x); B Prominent canalicular cholestasis with bile accumulation (arrows; space bar = 40 micrometers; H&E stain, original magnification 1,000x); C Bile duct proliferation associated with portal regions highlighted on CK7 immunohistochemical staining (space bar = 100 micrometers; original magnification 400x); D Canalicular bile with typical ultrastructural morphology and no features of Byler’s bile (arrows, space bar = 2 micrometer; transmission electron microscopy, original magnification 15,000x)
Laboratory values during evaluation of neonatal cholestasis
Background Jaundice within the first 1–2 weeks of a neonate’s life will generally self-resolve; however, if it lasts longer than this time frame it warrants further work up. Direct or conjugated hyperbilirubinemia can suggest neonatal cholestasis, which in turn reflects marked reduction in bile secretion and flow. The differential diagnosis for neonatal cholestasis is broad. Neonatal choledocholithiasis is a rare cause of neonatal cholestasis, but should be considered on the differential diagnosis for patients presenting with elevated conjugated bilirubin. Case presentation We describe an infant who presented with neonatal cholestasis. He subsequently underwent work up for biliary atresia, as this is one of the more time-sensitive diagnoses that must be made in neonates with conjugated hyperbilirubinemia. He was ultimately found to have choledocholithiasis on magnetic resonance cholangiopancreatography. He was managed conservatively with optimizing nutrition and ursodeoxycholic acid therapy. Conclusions We found that conservative management, specifically optimizing nutrition and treating with ursodeoxycholic acid, can be a sufficient approach to facilitating resolution of the choledocholithiasis and conjugated hyperbilirubinemia.
 
Food intake by the lactating women (n = 1238)
Introduction Food adequacy and dietary quality in the lactation period are fundamental for maternal and child health. Lactating mothers are vulnerable to malnutrition because of increased physiological demand, monotonous diet, lactogenesis process, and increased nutrient requirements. The micronutrient adequacy especially among women is not ensured in Indian diet. The dual course of gender bias and poverty, along with lack of knowledge about diet quality are significant impediments in maintaining minimum dietary diversity among Indian women. The study aimed to assess the prevalence of minimum dietary diversity and associated factors among lactating women. Methodology A community-based cross-sectional study was conducted among 1236 lactating women through a multistage sampling procedure in Haryana state, India. Data were collected in Computer-assisted personal interviewing (CAPI) using a pretested structured interview schedule. Minimum Dietary Diversity for Women by Food and Agriculture Organization (FAO) was used to calculate the minimum dietary diversity. Results The mean dietary diversity score among lactating women from the ten food groups was 6.35 ± 2.57 and the prevalence of minimum dietary diversity was 77.1%. The complete model revealed that both individual and household factors can explain the variation in dietary diversity intake. Furthermore, the result of model 2 explained that women aged 31 to 35 years (AOR 5.92,95% (1.87–18.77), graduation and above qualified women (AOR 1.98, 95% (0.96–4.09) and lactating women with high knowledge on nutrition (AOR 2.00, 95% (1.34–4.57) were the significant factors promoting minimum dietary diversity. Conclusion Three-fourths of the lactating women reached adequate minimum dietary diversity. Younger age, low educational level, and poor nutritional knowledge were significant constraints to achieving minimum dietary diversity. Further improvement in the minimum dietary diversity among lactating women is very much required. It is also advised that exiting platforms dispersing awareness on nutrition should be supported and strengthened.
 
The flowchart of recruitment and research
Top: Structures of the chosen RGBNs for boys over 14 years (left) and boys under 14 (right). Bottom: Structures of the chosen RGBNs for girls over 13 years (left) and girls under 13 years (right). W: weight, H: height, WC: waist circumference, HC: hip circumference, TF: trunk fat mass, TL: trunk lean mass, TB: trunk BMC, LF: leg fat mass, LL: leg lean mass, LB: leg BMC, AF: arm fat mass, AL: arm lean mass, AB: arm BMC
Scatter plots of RGBN prediction model for nine segmental compartments in relation to their DXA observation counterparts
Quality of fit between fat-free mass and fat mass as derived by DXA with their counterparts predicted by the RGBN
Quality of fit between fat free mass and fat mass as derived by DXA with their counterparts predicted by the RGBN
Background Adolescents' body composition is considered an important measure to evaluate health status. An examination of any of the segmental compartments by anthropometric indices is a more usable method than direct methods. Objectives To propose a method based on the network approach for predicting segmental body composition components in adolescent boys and girls using anthropometric measurements. Methods A dual-energy X-ray absorptiometry (DXA) dataset in the south of Iran, including 476 adolescents (235 girls and 241 boys) with a range of 9–18 years, was obtained. Several anthropometric prediction models based on the network approach were fitted to the training dataset (TRD 80%) using bnlearn, an R add-in package. The best fitted models were applied to the validation dataset (VAD 20%) to assess the prediction accuracy. Results Present equations consisting of age, weight, height, body mass index (BMI), and hip circumference accounted for 0.85 ( P < 0.001) of the variability of DXA values in the corresponding age groups of boys. Similarly, reasonable estimates of DXA values could be obtained from age, weight, height, and BMI in girls over 13 years, and from age, weight, height, BMI, and waist circumference in girls under 13 years, respectively, of 0.77 and 0.83 ( P < 0.001). Correlations between robust Gaussian Bayesian network (RGBN) predictions and DXA measurements were highly significant, averaging 0.87 for boys and 0.82 for girls ( P < 0.001). Conclusions The results revealed that, based on the present study’s predictive models, adolescents' body composition might be estimated by input anthropometric information. Given the flexibility and modeling of the present method to test different motivated hypotheses, its application to body compositional data is highly appealing.
 
a The photographs of a novel functional brace. b Mechanisms and effects of the functional brace for early correction of cubitus varus in young children
The clinical and radiographic results were assessed according to the Bellemore criteria. a Changes in the HEW angles after FBPT compared with the unaffected arm and the normal side. b The range of movement of the elbow joint is almost the same as for the normal arm in extension. c Compared with the normal side, statistically significant difference was found for the range of movement of the elbow joint in pre-treatment flexion. * P < 0.05, *** P < 0.001
Case 1: a Pre-operative clinical appearance of bilateral upper limb (left side cubitus varus deformity). b Pre-treatment imaging. c Patients with cubitus varus wearing the functional brace. d Clinical appearances of bilateral upper limb. e Post-treatment radiographs of bilateral upper limb at last follow up
Case 2: a Pre-treatment clinical appearance of left cubitus varus deformity. b,c X-ray and clinical appearance after wearing the functional brace, respectively. d Post-treatment radiograph of bilateral upper limb at 1 year. e,f Clinical photographs of bilateral upper limb at 1 year and last follow up, respectively
Background This study aimed to assess the clinical and radiologic outcomes of a functional brace in combination with physical therapy (FBPT) for early correction of cubitus varus in young children. Methods Eighteen consecutive patients with cubitus varus secondary to supracondylar fractures were enrolled between July 2017 and March 2019. We used the FBPT technique to correct varus and sagittal plane deformity for early cubitus varus in young children. The clinical evaluation included measurement of varus angulation, sagittal plane, and range of motion at three, six, and twelve months post-intervention. The clinical and radiographic results were assessed according to the Bellemore criteria. Results Pre-treatment humerus-elbow-wrist (HEW) angle measured on the affected side (varus deformity) ranged between -38° and -12° (average, -23.2°) while the post-treatment HEW angle ranged between -10° and + 15° (average, 8.8°). Compared with the unaffected side, no statistically significant difference was found in the affected side post-intervention ( P > 0.05). According to the Bellemore criteria, we got excellent results in fourteen patients (77.8%), good results in three patients (16.7%), and poor result in one patient (5.5%). All patients and their parents (except one patient with residual varus deformities) were satisfied with the functional and cosmetic outcomes. Conclusions The FBPT is effective for the treatment of cubitus varus in children, especially for young children within 6 months of the injury.
 
Baseline patient characteristics
Patient characteristics according to endoscopic and histologic findings
Univariate and multivariate regression analyses of histologic findings
Endoscopic findings in different groups of patients with abdominal pain
Background Large-scale data on esophagogastroduodenoscopy (EGD) in China are scarce. This study aimed to assess the indications and diagnostic yield of EGD in children and the relationship between factors (such as age, sex, and indications) and diagnostic yield. Methods We performed a prospective cross-sectional observational study involving patients aged < 18 years who underwent diagnostic EGD. The study was conducted in five children’s hospitals, each in a different city. Demographic features, indications for endoscopy, and endoscopic and histopathological findings were collected. Univariable and multivariable ordinal logistic regression analyses of the relationship between the factors and diagnostic yield were performed. Results The study included 2268 patients (male/female ratio, 1.3:1) with a median age of 8.68 years. Among the 2268 children, the most frequent indications were abdominal pain in 1954 (86.2%), recurrent vomiting in 706 (31.1%), weight loss in 343 (15.1%), and others. The endoscopic yield was 62.5% and was the highest in patients with dysphagia (90.9%). The histologic yield was 30.4% and was the highest in patients with unexplained anemia (45.5%). On multivariable regression analysis, the endoscopic yield was associated with dysphagia, gastrointestinal (GI) bleeding, and recurrent vomiting, and the histologic yield was associated with age. Different groups of patients with abdominal pain had variable probabilities of abnormal endoscopic findings. Conclusions The most frequent indication of pediatric EGD is abdominal pain, with variable probabilities of abnormal endoscopic findings in different groups. Endoscopic yield and histologic yield are associated with certain alarming features. Trial registration The trial registration number (ClinicalTrials. gov): NCT03603093 (The study was registered on 27/07/2018).
 
Measured lactate levels in the infant from 1st to 98th day of life. Visible peaks at different time points indicate lactate acidosis and suggesting episodes with ethanol intoxications. Notably, no further lactate acidosis occurred after finding out the cause of the condition after the 78th day of life
Decrease of serum ethanol concentrations measured in the infant during two episodes of lactic acidosis and clinical deprivation at initial symptomatic begin and after three and six hours. Notable are elevated initial serum levels and a rapid decrease after three hours to a non-detectable level after six hours under symptomatic treatment with intravenous fluids. DOL: day of life
After noting a particular smell of the mother’s provided milk, centrifugation of three milk aliquots was performed. Obvious is the two-phase composition of donor human (A) milk in cream and whey, whereas both cow’s milk (C) and the infant’s mother’s milk (B) show no separation
Mass spectral analysis of samples provided by the mother (samples A&B). Also demonstrated are typical spectra of cow‘s milk and human donor milk. As alpha-casein-S1 is a specific ingredient of cow’s milk and is not detectable in human milk (4th column), we proved the cocktail of cow‘s and human milk in our case
Background Ethanol intoxications in newborns are generally due to false preparation of formula with alcoholics or alcohol consumption by the breastfeeding mothers. Rarely, intoxications occur in hospitalized newborns, e.g., from excessive use of alcoholic hand sanitizers. We herein report a strange case of acute ethanol intoxications in our NICU. Case presentation An extremely premature infant (23 0/7 weeks gestational age, birthweight 580 g) suffered from repeated life-threatening events with hemodynamic compromise, apnea, and lactic acidosis while being treated in our neonatal intensive care unit (NICU). Symptomatic treatment with intravenous fluids and, if necessary, intubation and catecholamine therapy led to recovery after several hours each time. The episodes eventually turned out to be severe ethanol intoxications brought about by breast milk contaminated with ethanol. The breast milk was supplied by the infant’s mother, who consumed non-trivial amounts of alcohol to build up her strength and make herself produce more milk, which was recommended to her by a family member. Additionally, she supplemented her own mother’s milk with cow’s milk because she was worried her baby was underserved with her milk. The mother admitted to this in intensive conversations with our team and a professional translator. Conclusions This unique case underlines how different cultural dynamics can attribute to life-threatening events in the care of premature infants. It is important for us to emphasize that intensive communication and building a confident relationship with the parents of patients is essential to the work on NICUs. Child safeguarding issues and possibilities of intoxications have to stay in mind even in a supposedly safe space like the NICU.
 
Age distribution of study population by sex and nationality. Underneath histogram, in the Tufte plot, diamonds represents median value, gaps represent interquartile range, and lines represent whiskers
Average marginal effects model on covariate effect on probability of any surgical problem. Null value of effect on probability is 0. If confidence interval crosses this null value, the result was not significant
Importance Surgery is a foundational aspect to high functioning health care systems. In the wake of the Lancet Commission on Global Surgery, previous research has focused on defining the burden of surgical conditions among a pediatric population, however these studies often fail to include forced migrant or refugees. The goal of this study was to estimate the prevalence of pediatric surgical conditions among refugees in east Africa. Methods We used the previously validated Surgeons OverSeas Assessment of Surgical Need (SOSAS) that utilizes cross-sectional design with random cluster sampling to assess prevalence of surgical disease among participants aged 0 to 18 years in Nyarugusu refugee camp, Tanzania. We used descriptive and multivariable analyses including an average marginal effects model. Results A total of 1,658 participants were included in the study. The mean age of our sample was 8.3 ± 5.8 years. A total of 841 participants (50.7%) were male and 817 participants (49.3%) were female. A total of 513 (n = 30.9%) reported a history or presence of a problem that may be surgical in nature, and 280 (54.6%) of them reported the problem was ongoing or untreated. Overall, 16.9% had an ongoing problem that may be amenable to surgery. We found that increasing age and recent illness were associated with having a surgical problem on both our multivariable analyses. Conclusion To our knowledge, this is the first and largest study of prevalence of surgical conditions among refugee children in sub-Saharan Africa. We found that over 16% (one-in-six) of refugee children have a problem that may be amenable to surgery. Our results provide a benchmark upon which other studies in conflict or post-conflict zones with refugee or forced migrant populations may be compared.
 
a and b show the appearance of this boy when admitting to our hospital. His skin was hyperpigmented and hypotonic without subcutaneous fat. c reveals the boy gained weight and his skin color was relatively normal after treatment at 5 months of age and his mother held him on her leg (the photo was cropped)
Results of gene screening via multiplex PCR amplification and DHPLC analysis. a, b, and c demonstrate all exons of the DMD, GK, and NROB1 genes were heterozygous deletions in samples of this boy’s mother. While d, e, and f reveal deletions of DMD, GK, and NROB1 genes of this boy
Background Xp21 contiguous gene deletion syndrome is a rare genetic metabolic disorder with poor prognosis in infants, involving deletions of one or more genes in Xp21. When deletions of adrenal hypoplasia (AHC), Duchenne muscular dystrophy (DMD), and chronic granulomatosis (CGD) loci are included, complex glycerol kinase deficiency (CGKD) can be diagnosed. We present a case of CGKD that was initially misdiagnosed and died during treatment in our hospital in terms of improving our understanding of the clinical features and diagnosis of this disease, as well as highlighting the need for more precise dosing of corticosteroid replacement therapy. Case presentation A 48-day-old full-term male infant was transferred to our medical center with global growth delay and persistent vomiting. Routine laboratory tests revealed hyperkalemia, hyponatremia, and a high level of creatine kinase. The initial diagnosis was adrenal cortical hyperplasia (ACH), then revised to adrenocortical insufficiency with a normal level of ACTH detected. After supplementing the routine lipid test and urinary glycerol test, CGKD was diagnosed clinically due to positive triglyceridemia and urinary glycerol, and the follow-up gene screening further confirmed the diagnosis. The boy kept thriving after corticosteroid replacement and salt supplementation. While levels of serum ACTH and cortisol decreased and remained low after corticosteroid replacement was administered. The patient died of acute type 2 respiratory failure and hypoglycemia after an acute upper respiratory tract infection, which may be the result of adrenal crisis after infection. Infants with CGKD have a poor prognosis, so physicians should administer regular follow-ups, and parents counseling during treatment to improve the survival of patients. Conclusions Overall, CGKD, although rare, cannot be easily excluded in children with persistent vomiting. Extensive blood tests can help to detect abnormal indicators. Adrenal crisis needs to be avoided as much as possible during corticosteroid replacement therapy.
 
Hierarchical theoretical model of factors associated with osteopenia of prematurity
(continued)
Bivariate analyses related to characteristics of preterm newborns (Blocks 2, 3 and 4)
Background Preterm newborn nutrition affects postnatal skeletal growth and bone mineralization, but studies have not yet fully concluded the relationship between nutrition and osteopenia. This study was intended to investigate the impact of nutritional factors on osteopenia in preterm newborns. Methods This is a case–control study with babies born with gestational age ≤ 32 weeks in a high-risk maternity hospital, between 2018 and 2019. The population consisted of 115 newborns, being 46 cases (40%) and 69 controls (60%). Disease outcome was based on serum alkaline phosphatase levels > 900UL/l and hypophosphatemia < 4 mg/dl. Gestational data at birth and clinical and nutritional follow-up data during 8 weeks postnatally were assessed. Variables were assessed using regressive logistic models. Findings Preterm infants who were fed pasteurized fresh human milk with acidity ≥ 4 ºDornic are 5.36 times more likely to develop osteopenia ( p = 0.035). Higher calcium intake, compared to controls, also increased the probability of disease occurrence [OR 1.05 (CI 1.006–1.1); p = 0.025], while the presence of a partner [OR 0.10 (CI 0.02–0.59); p = 0.038] and the shortest time using sedatives [OR 0.89 (CI 0.83–0.98); p = 0.010] were protective factors associated with osteopenia. Extremely low birth weight [OR 5.49 (CI 1.20–25.1); p = 0.028], sepsis [OR 5.71 (CI 1.35–24.2); p = 0.018] and invasive ventilatory support [OR 1.09 (CI 1.03–1.18); p = 0.007] were risk factors. Conclusions Acidity and high calcium intake are the main nutritional factors associated with osteopenia of prematurity. Further studies on the use of human milk with lower acidity, recommendation and nutritional supplementation of calcium should be accomplished to guide prevention strategies in newborns at risk for osteopenia during hospital stay.
 
Type of antibiotic self medicating. TMP-SMX: Trimethoprim/sulfamethoxazole
Others* Ampicillin, Ciprofloxacin, Clarithromycin, Clindamycin, Dicloxacillin, Nifuroxazide, Norfloxacin, Trimethoprim Sulfadiazine (1% each)
Introduction Antibiotic self-medication is a common practice in pediatric caregivers in low-income countries with limited resources and represents a public health problem. Our study sought to determine what factors are associated with this practice, including differences in knowledge or attitudes of caregivers who attend a pediatric emergency service. Methods Case-control study based on surveys of caregivers of pediatric patients brought to the emergency room with clinical symptoms suggestive of acute infection. Cases were defined as those caregivers who reported self-medication of antibiotics for the current illness and controls where those who did not report self-medication. Information was collected through a self-administered questionnaire that inquired about demographic and family characteristics, attitudes and knowledge toward self-medication of antibiotics. Data were compared using logistic regression and are presented with odd ratios and confidence intervals. Results A total of 728 caregivers, 182 cases and 546 controls were included. We found that higher parental education, both in mothers (OR 0.56, 95% CI 0.40-0.79) and fathers (OR 0.62, 95% CI 0.43-0.89) was associated with less self-medication. Attitudes such as always requesting antibiotics from their doctors (OR 3.92, 95% CI 1.59-9.66), frequently buying antibiotics without a prescription (OR 23.66, 95% CI 11.76-47.59) and giving advice on antibiotics among family members (OR 2.90, 95% CI 1.75-4.82) resulted in an increased likelihood of self-medication. There was also a higher probability of antibiotic self-medication in older children (OR 1.13, 95% CI 1.09-1.17), those with a greater number of siblings (OR 1.25, 95% CI 1.09-1.43) and in those cases that received antibiotics within the last 3 months (OR 6.27, 95% CI 4.35-9.04). Overall knowledge of risk of antibiotic self-medication was low. Conclusions Some patient and family characteristics such as age, number of siblings, recent antibiotic usage and inappropriate attitudes are strongly related to antibiotic self-medication. These findings will inform future interventions to reduce self-medication in children.
 
Top-cited authors
Tanis R Fenton
  • The University of Calgary
Jae H. Kim
  • University of California, San Diego
James Tumwine
  • Kabale University
Thorkild Tylleskär
  • University of Bergen
Ken P Kleinman
  • University of Massachusetts Amherst