Vol 20, No 3 (2024)

Background:Acute bronchiolitis is a viral infection of the lower respiratory tract affect- ing infants aged under 12 months, variably presenting with respiratory distress, diffuse crackles and inflammatory wheezing. The main causative agent is Respiratory Syncytial Virus (RSV). The diagnosis is clinical and treatment mainly supportive. Despite the availability of more than 30 in- ternational guidelines, consistent management recommendations are lacking and considerable vari- ability in patients’ care persists among different providers.

Objective:To review and describe current knowledge about epidemiology, physiopathology, clin- ic, diagnosis and management of acute bronchiolitis, with particular emphasis on updated evidence and future perspectives in terms of treatment and prevention.

Methods and Results:We searched Cochrane for systematic reviews and PubMed for scientific ar- ticles published in the last 10 years, using a combination of the following search terms: "bronchi- olitis", "respiratory syncytial virus", "epidemiology", "risk factors", "severity", "diagnosis", "clin- ic", "diagnostic imaging", "management", "asthma", "wheezing", "bronchodilator", "steroids", "hypertonic saline", "oxygen", "blood gas analysis", "HHHFNC", "rehydration", "enteral feed- ing", "parenteral hydration", "prevention", "vaccine" and "COVID-19 or SARS-CoV2". We ac- cordingly performed a deep and extensive selection of the most updated and considerable litera- ture on the matter, summarizing the most significant evidence concerning all aspects of acute bron- chiolitis (epidemiology, clinic, diagnosis, management and prevention). Furthermore, we ex- amined references and available guidelines from UK, USA, Canada, Italy and Spain. Results are extensively discussed below.

Conclusion:Although acute bronchiolitis has been a widely known disease for decades, its thera- peutic approach remained unchanged and essentially limited to respiratory and metabolic support. Despite the abundance of studies, there is no significant evidence concerning therapeutic alterna- tives (e.g. steroids, inhaled hypertonic solution), which are therefore not recommended. Accord- ing to most recent data, "acute bronchiolitis" definition encompasses a plethora of different clini- cal entities related to each subject’s genetic and immune predisposition. Therefore, future research should focus on the precise characterization of such subcategories in order to individualize thera- peutic management and ensure the most appropriate evidence-based care.

Atopic dermatitis (AD) is the most frequent chronic-recurrent inflammatory skin disease in the pediatric age. It has a complex and multifactorial pathogenesis: the two key actors are im- paired skin barrier function and immune system dysregulation, which represent the main targets of AD therapy. Monoclonal antibodies have revolutionized the management of moderate-to-severe AD, by selective inhibition of key cytokines in the pathogenetic process. For this reason, there is great interest in exploring AD pathogenetic mechanisms to develop new therapeutic strategies. This review aims to summarize the most recent scientific evidence on available and future biologi- cal therapies for the treatment of pediatric AD, emphasizing the molecular mechanisms underlying their action.

The introduction of biological drugs for the treatment of severe allergic asthma in chil- dren, almost twenty years ago, had a substantial impact on both the pathology's clinical course and the quality of life of the patients who receive treatment. Over the years, several molecules have been developed that inhibit molecular targets involved in the pathogenesis of the asthmatic disease. Biological drugs demonstrate a significant improvement in several key clinical parameters in patients with severe asthma. In this review, we provide a concise summary of the evidence on biological therapy for children and adolescents with severe asthma.

Lower gastrointestinal bleeding is an alarming symptom in pediatrics, especially in in- fancy. However, it is commonly secondary to benign and self-limiting conditions, such as anal fis- sures, infections, and allergies; more rarely it is caused by more serious disorders, such as necrotiz- ing enterocolitis, very early onset inflammatory bowel diseases, and vascular malformations. The present review aims at summarizing the different clinical conditions presenting with rectal bleeding in infancy and provides an evidence-based diagnostic work-up for the clinical management of patients with this occurrence.

Background:Infectious mononucleosis is common among adolescents and young adults. Although the majority of cases resolve spontaneously, life-threatening manifestations, and compli- cations have been recognised.

Objective:The purpose of this article is to familiarize clinicians with the clinical manifestations, evaluation, diagnosis, and management of infectious mononucleosis.

Methods:A search was conducted in October 2022 in PubMed Clinical Queries using the key terms \"infectious mononucleosis\" OR "Epstein-Barr virus" OR "EBV". The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the aforementioned search was used in the compilation of the present article.

Results:Infectious mononucleosis, caused by Epstein-Barr virus, most commonly affects adoles- cents and adults aged 15 to 24 years. Epstein-Barr virus is transmitted primarily in saliva. Infectious mononucleosis is characterized by a triad of fever, tonsillar pharyngitis, and lymphadenopathy. Fa- tigue may be profound but tends to resolve within three months. Periorbital and/or palpebral edema, typically bilateral, occurs in one-third of patients. Splenomegaly and hepatomegaly occur in approx- imately 50% and 10% of cases, respectively. A skin rash, which is usually widely scattered, ery- thematous, and maculopapular, occurs in approximately 10 to 45% of cases. Peripheral blood leu- kocytosis is observed in most patients; lymphocytes make up at least 50% of the white blood cell differential count. Atypical lymphocytes constitute more than 10% of the total lymphocyte count. The classic test for infectious mononucleosis is the demonstration of heterophile antibodies. The monospot test is the most widely used method to detect the serum heterophile antibodies of infectious mononucleosis. When confirmation of the diagnosis of infectious mononucleosis is required in patients with mononucleosis-like illness and a negative mono-spot test, serologic testing for anti- bodies to viral capsid antigens is recommended. Infectious mononucleosis is a risk factor for chronic fatigue syndrome. Spontaneous splenic rupture occurs in 0.1 to 0.5% of patients with infectious mononucleosis and is potentially life-threatening. Treatment is mainly supportive. Reduction of activity and bed rest as tolerated are recommended. Patients should be advised to avoid contact sports or strenuous exercise for 8 weeks or while splenomegaly is still present. Most patients have an uneventful recovery.

Conclusion:Infectious mononucleosis is generally a benign and self-limited disease. Prompt diag- nosis is essential to avoid unnecessary investigations and treatments and to minimize complications. Splenic rupture is the most feared complication. As avoiding exposure to EBV is almost impossible, the most effective way to prevent EBV infection and infectious mononucleosis is the development of an effective, safe, and affordable EBV vaccine that can confer life-long immunity.

Background:Worldwide, iron deficiency anemia is the most prevalent nutritional deficiency disorder and the leading cause of anemia in children, especially in developing countries. When present in early childhood, especially if severe and prolonged, iron deficiency anemia can result in neurodevelop- mental and cognitive deficits, which may not always be fully reversible even following the correction of iron deficiency anemia.

Objective:This article aimed to familiarize physicians with the clinical manifestations, diagnosis, evaluation, prevention, and management of children with iron deficiency anemia.

Methods:A PubMed search was conducted in February 2023 in Clinical Queries using the key term \"iron deficiency anemia\". The search strategy included all clinical trials (including open trials, non-randomized controlled trials, and randomized controlled trials), observational studies (including case reports and case series), and reviews (including narrative reviews, clinical guidelines, and meta-analyses) published within the past 10 years. Google, UpToDate, and Wikipedia were also searched to enrich the review. Only pa- pers published in the English literature were included in this review. The information retrieved from the search was used in the compilation of the present article.

Results:Iron deficiency anemia is most common among children aged nine months to three years and during adolescence. Iron deficiency anemia can result from increased demand for iron, inadequate iron intake, decreased iron absorption (malabsorption), increased blood loss, and rarely, defective plasma iron transport. Most children with mild iron deficiency anemia are asymptomatic. Pallor is the most frequent presenting feature. In mild to moderate iron deficiency anemia, poor appetite, fatigability, lassitude, leth- argy, exercise intolerance, irritability, and dizziness may be seen. In severe iron deficiency anemia, tachy- cardia, shortness of breath, diaphoresis, and poor capillary refilling may occur. When present in early childhood, especially if severe and prolonged, iron deficiency anemia can result in neurodevelopmental and cognitive deficits, which may not always be fully reversible even with the correction of iron deficien- cy anemia. A low hemoglobin and a peripheral blood film showing hypochromia, microcytosis, and marked anisocytosis, should arouse suspicion of iron deficiency anemia. A low serum ferritin level may confirm the diagnosis. Oral iron therapy is the first-line treatment for iron deficiency anemia. This can be achieved by oral administration of one of the ferrous preparations, which is the most cost-effective medi- cation for the treatment of iron deficiency anemia. The optimal response can be achieved with a dosage of 3 to 6 mg/kg of elemental iron per day. Parenteral iron therapy or red blood cell transfusion is usually not necessary.

Conclusion:In spite of a decline in prevalence, iron deficiency anemia remains a common cause of ane- mia in young children and adolescents, especially in developing countries; hence, its prevention is im- portant. Primary prevention can be achieved by supplementary iron or iron fortification of staple foods. The importance of dietary counseling and nutritional education cannot be overemphasized. Secondary prevention involves screening for, diagnosing, and treating iron deficiency anemia. The American Acad- emy of Pediatrics recommends universal laboratory screening for iron deficiency anemia at approximately one year of age for healthy children. Assessment of risk factors associated with iron deficiency anemia should be performed at this time. Selective laboratory screening should be performed at any age when risk factors for iron deficiency anemia have been identified.

The study aims to investigate the presence of TORCH infections in a child with bilateral cataracts and deafness and report the ToRCH-serology screening profile (Toxoplasma gondii (TOX), rubella (RV), cytomegalovirus (CMV), and herpes simplex virus (HSV-I/II)) in pediatric cataract and deafness.

Methods:Cases that had a clear clinical history of congenital cataracts and congenital deafness were included in the study. The study population consisted of 18 bilateral cataracts and 12 bilateral deafness child who was admitted to AIIMS Bhubaneswar for cataract surgery and cochlear implan- tation, respectively. Sera of all children were tested qualitatively and quantitatively for IgG/IgM-antibodies against ToRCH agents in a sequential manner.

Results:Anti-IgG antibodies against the torch panel were detected in all cataract and deafness pa- tients. Anti-CMV IgG was detected in 17 of 18 bilateral cataract children and 11 of 12 bilateral deaf children. The rates of anti-CMV IgG antibody positivity were significantly higher. In the cataract group, 94.44% and in the deafness group, 91.66% of the patient was Anti-CMV IgG positive. Be- sides this, 77.7 % of the patient from the cataract group and 75% from the deafness group was anti- RV IgG antibody positive. In bilateral cataract patients, IgG‑alone seropositive cases were mostly attributed to CMV (94.44%; 17/18), followed by RV (77.70%; 14/18), HSV‑I (27.70%; 5/18), TOX (27.70%; 5/18), and HSV‑II (16.60%; 3/18). In bilateral deafness patients, the spectrum of IgG alone seropositive cases was almost the same except for TOX (0/12).

Conclusion:The current study recommends interpreting ToRCH-screening in pediatric cataracts and deafness with caution. Interpretation should include both serial qualitative and quantitative as- says in tandem with clinical correlation to minimize diagnostic errors. The sero-clinical-positivity needs to be tested in older children who might pose a threat to the spread of infection.

Background:Ovarian torsion in infants can be asymptomatic or may present with ab- dominal mass and malnutrition. It is an uncommon and non-specific condition in children. We re- port a girl who underwent detorsion and ovariopexy for suspected ovarian torsion after a previous oophorectomy. The role of progesterone therapy is determined in reducing the size of adnexal mass.

Case Presentation:The patient was diagnosed with right ovarian torsion and underwent an oopho- rectomy at one year of age. About 18 months later, she was diagnosed with left ovarian torsion and underwent detorsion with lateral pelvic fixation. Despite the pelvic fixation of the ovary, a continu- ous increase in the volume of the ovarian tissue was evident during successive ultrasounds. Proges- terone therapy was started at five years of age in order to prevent retorsion and preserve the ovarian tissue. In successive follow-ups during the therapy, ovarian volume decreased, and its size (27*18 mm) was restored.

Conclusion:The presented case reminds doctors of the possibility of ovarian torsion in young girls with pelvic pain. More research is needed on the use of hormonal drugs, such as progesterone, in similar cases.