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Introduction: As a result of the emergence of the SARS-CoV-2 respiratory virus in Wuhan in December 2019, the Spanish Government declared the state of emergency with restrictions such as stay-at-home lockdown. The objective of this study was to analyze emergency activity at a referral pediatric surgery unit in its territory and determine whether surgical pathologies had decreased or not., Methods: A retrospective study of pediatric patients presenting at the emergency department and referred to the pediatric surgery unit from March 14, 2020 to April 20, 2020 was carried out. The results were compared with those from the same dates of the previous year. Demographic variables, pathologies, and management strategies were studied for each case. The number of patients with abdominal pain requiring surgical assessment was also analyzed., Results: 161 patients were included - 91 from 2019 and 70 from 2020. Of the 2020 patients, 62 (88.6%) underwent surgery and 8 (11.4%) were admitted, whereas in 2019, patient distribution was 67 (73.6%) and 24 (26.4%), which means there were fewer admissions in 2020 (p= 0.018). There were no differences in terms of hours to emergency department consultation - just an increase in the case of appendicular pathologies in the 2020 period, with 24 [23-48] hours vs. 24 [12-30] hours (p =  0.045)., Conclusion: The current pandemic has not caused emergency surgeries to decrease. It has only increased time to consultation in patients with appendicular pathologies.

Since 2009, the use of off-label and unlicensed drugs has been regulated in Spain. In pediatrics, this exceptional use is more common than in other medical specialties. It varies from 10% to 90% of all prescriptions in children. This variability is due to differences in methodology, classification and sources of information used, and also to the different pediatrics subspecialties. In addition, the knowledge of several pediatricians on this issue is limited and more than half do not comply with the law, in many cases due to ignorance. However, the use of off-label and unlicensed drugs is legal and necessary. The Medicines Committee of the Spanish Association of Pediatrics (CM-AEP) considers that it is necessary to improve the existing information on medicines in the pediatric population. Therefore, the CM-AEP works out a document where suggestions and actions are proposed to achieve it, because children's health deserves it., (Copyright © 2020. Publicado por Elsevier España, S.L.U.)

On 31 December 2019, the Wuhan Municipal Committee of Health and Healthcare (Hubei Province, China) reported that there were 27 cases of pneumonia of unknown origin with symptoms starting on the 8 December. There were 7 serious cases with common exposure in market with shellfish, fish, and live animals, in the city of Wuhan. On 7 January 2020, the Chinese authorities identified that the agent causing the outbreak was a new type of virus of the Coronaviridae family, temporarily called «new coronavirus», 2019-nCoV. On January 30th, 2020, the World Health Organisation (WHO) declared the outbreak an International Emergency. On 11 February 2020 the WHO assigned it the name of SARS-CoV2 and COVID-19 (SARS-CoV2 and COVID-19). The Ministry of Health summoned the Specialties Societies to prepare a clinical protocol for the management of COVID-19. The Spanish Paediatric Association appointed a Working Group of the Societies of Paediatric Infectious Diseases and Paediatric Intensive Care to prepare the present recommendations with the evidence available at the time of preparing them., (Copyright © 2020 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.)

Here, two papers are presented, which constitute the first reports of surgical procedures in Mexican children performed at the 19 th century. The two publications refer to surgical operations for the extraction of bladder stones. At that time, there was no anesthesia, so part of the description alludes to the suffering of the patients and the operative difficulties. The first case, is referred to as a lithotomy in a 17-year-old girl, performed by surgeon José Victoriano Guerrero in Guadalajara in 1822. The publication is not an academic report, but a pamphlet written as a gift to Emperor Augustin I to celebrate his ascension to the throne. The second work, is a lateral lithotomy in a 5-year-old boy, published by Dr. Luis Jecker in the first issue of the Periódico de la Academia de Medicina de Mégico in 1836., (Copyright: © 2018 Permanyer.)

Objectives: This summary of the European guidelines for pediatric cardiopulmonary resuscitation (CPR) emphasizes the main changes and encourages health care professionals to keep their pediatric CPR knowledge and skills up to date. Basic and advanced pediatric CPR follow the same algorithm in the 2015 guidelines. The main changes affect the prevention of cardiac arrest and the use of fluids. Fluid expansion should not be used routinely in children with fever in the abuse of signs of shock because too high a volume can worsen prognosis. Rescue breaths should last around 1 second in basic CPR, making pediatric recommendations consistent with those for adults. Chest compressions should be at least as deep as one-third the anteroposterior diameter of the thorax. Most children in cardiac arrest lack a shockable rhythm, and in such cases a coordinated sequence of breaths, chest compressions, and administration of adrenalin is essential. An intraosseous canula may be the first choice for introducing fluids and medications, especially in young infants. In treating supraventricular tachycardia with cardioversion, an initial dose of 1 J/kg is currently recommended (vs the dose of 0.5 J/kg previously recommended). After spontaneous circulation is recovered, measures to control fever should be taken. The goal is to reach a normal temperature even before arrival to the hospital.

Objectives: To determine the level of knowledge of pediatricians and parents from Andalucía (southern Spain) about early-onset tooth decay, and to assess if pediatricians provide information to parents about pediatric oral care and visits to the pediatric dentist., Material and Method: A random sample of 113 pediatricians and 112 parents with children under 3 years of age received an anonymous questionnaire comprising 14 items for pediatricians and 16 items for parents, grouped into five blocks: visits to the dentist, oral hygiene, caries, nutritional habits, and treatment of caries. The chi-squared test was used to assess differences between groups., Results: Pediatricians showed deficiencies in their knowledge about visits to the dentist and treatment of caries, however their level of knowledge on oral hygiene, tooth decay and nutritional habits were adequate. Parents showed a low level of knowledge in all aspects of the study, mainly about the treatment of tooth decay. There were no significant differences between pediatricians and parents in the knowledge about visits to the dentist, however pediatricians had more knowledge than the parents about hygiene, tooth decay, nutritional habits and treatment (P<0.001). Most of the parents indicated that pediatricians did not provide them detailed information on oral care, and about the possibility of visiting a pediatric dentist., Conclusions: Andalusian pediatricians should improve their knowledge about early-onset tooth decay, and provide more information to parents about the oral care and the possibility of visiting a pediatric dentist. Parents have a very low level of knowledge about early-onset tooth decay, and particularly about treatment., (Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.)

In 2011, the Spanish Association of Pediatrics decided to support the most ambitious project of its newly created Committee for Medicinal Products: Pediamécum. This is the first free on-line database with information on medicinal products for pediatric use in Spain. The web page http://pediamecum.es/ started on December 17 December 2012. One year later, Pediamécum includes 580 registered drugs. The website achieved more than one million page views by the end of 2013. Because of the first anniversary of Pediamécum, a survey was performed to request the feeling of users. Four hundred eighty-three responses were obtained. Ninety-five percent believed that it is easy to navigate through the web, and 74% said that their doubts about the use of medicines in children were always resolved. The overall rating of Pediamécum is 7.5/10. The aims of Pediamécum are being accomplished; which is reflected essentially due to it becoming a useful tool for all professionals who care for children in their daily clinical practice., (Copyright © 2014 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.)

Introduction: Off-label drug use is a common practice in paediatrics. The aim of the present study was to estimate the knowledge of Spaniard paediatricians on off-label use., Material and Methods: Cross-sectional, multicentre, descriptive and national study from July 2012 to March 2013 using an on-line questionnaire on off-label use in children. An e-mail was sent to paediatricians who were members of the Spanish Association of Paediatrics (AEP) or its Regional or Paediatric Specialties Societies., Results: Out of 673 responses were received, 75.1% of Spanish paediatricians knew the meaning of off-label use, 61% of them prescribed medicines outside the conditions authorised in their Summary of Product Characteristics (SPC) and 47% knew of the importance of noting the off-label use in the medical record. However, just under half of paediatricians informed parents, and only 22% wrote it down in the medical record., Conclusions: Most Spanish paediatricians do not meet current regulations regarding off-label use. This regulation demands: justifying the decisions when off-label use is needed, and to write down in the medical record that, at least an oral consent from the parents has been obtained. This study reveals a fact that Spanish paediatricians must change. Meanwhile, it is a priority to continue with the implementation of consensus and clinical guidelines, to obtain more data on the efficacy and safety of off-label drug use in children, and to incorporate them into the SPC., (Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.)

Resumen: Introducción: La tasa de reingreso hospitalario a 30 días del alta es una medida de calidad de la atención médica. Los pacientes pediátricos con enfermedades crónicas complejas tienen altas tasas de reingreso. La falla en la transición entre el cuidado hospitalario y domiciliario podría explicar este fenómeno. Objetivos: Estimar la tasa de incidencia de reingreso hospitalario a 30 días en pacientes pediátricos con enfermedades crónicas complejas, estimar cuántos son potencialmente prevenibles y explorar posibles factores asociados a reingreso. Materiales y método: Estudio de cohorte prospectivo incluyendo pacientes hospitalizados con enfermedades crónicas complejas de un mes a 18 años de edad. Se excluyeron pacientes con enfermedad oncológica y cardiopatías congénitas. Se evaluaron el reingreso a 30 días y el reingreso potencialmente prevenible. Se valoraron características sociodemográficas, geográficas, clínicas y de la transición hacia el cuidado domiciliario. Resultados: Se incluyeron 171 hospitalizaciones; dentro de los 30 días reingresaron 28 pacientes (16,4%; IC95% 11,6-22,7). De los 28 reingresos, 23 (82,1%; IC95% 64,4-92,1) fueron potencialmente prevenibles. La enfermedad respiratoria se asoció con mayor probabilidad de reingreso. No se encontró asociación entre el reingreso a 30 días y los factores de la transición al cuidado domiciliario evaluados. Conclusiones: La tasa de reingreso a 30 días en pacientes con enfermedad crónica compleja fue del 16,4%, y el 82,1% fueron potencialmente prevenibles. Únicamente la enfermedad respiratoria se comportó como factor de riesgo para reingreso a 30 días. Abstract: Introduction: The rate of hospital readmission within 30 days of discharge is a quality indicator in health care. Paediatric patients with complex chronic conditions have high readmission rates. Failure in the transition between hospital and home care could explain this phenomenon. Objectives: To estimate the incidence rate of 30-day hospital readmission in paediatric patients with complex chronic conditions, estimate how many are potentially preventable and explore factors associated with readmission. Materials and method: Cohort study including hospitalized patients with complex chronic conditions aged one month to 18 years. Patients with cancer or with congenital heart disease requiring surgical correction were excluded. The outcomes assessed were 30-day readmission rate and potentially preventable readmissions. We analysed sociodemographic, geographic, clinical and transition to home care characteristics as factors potentially associated with readmission. Results: The study included 171 hospitalizations, and 28 patients were readmitted within 30 days (16.4%; 95% CI, 11.6–22.7). Of the 28 readmissions, 23 were potentially preventable (82.1%; 95% CI, 64.4–92.1). Respiratory disease was associated with a higher probability of readmission. There was no association between 30-day readmission and the characteristics of the transition to home care. Conclusions: The 30-day readmission rate in patients with complex chronic disease was 16.4%, and 82.1% of readmissions were potentially preventable. Respiratory disease was the only identified risk factor for 30-day readmission.

ABSTRACT Objective: To characterize the environmental factors of children and adolescents with Cerebral Palsy (CP) in the state of Minas Gerais (MG), Brazil. Methods: This is a cross-sectional study involving 164 caregivers of children/adolescents with CP, aged 1-14 years. The Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS) were used to classify the participants’ functioning, and environmental factors were evaluated by an on-line questionnaire that examined products and technologies, physical environment, services, and systems. A descriptive analysis was performed using percentage and frequency. Results: Most participants had bilateral CP (66.9%) and 45% of them were spastic. Levels II and V of the GMFCS and MACS were the most frequent. About half (49.4%) used anticonvulsants, 27.4% underwent botulinum toxin application, and 29% went through orthopedic surgery in the lower limbs. Among the participants, 71.3% used orthoses in the lower limbs, and 51.8% used the public health care system. Most had access to physiotherapy (91.5%), but found difficulties to access interventions with other professionals, such as psychologists (28%) and nutritionists (37.8%). The school was the most frequently adapted environment (78%), and had the highest level of structural adaptation (42.7%). Conclusions: The results of this study suggest that the barriers to access health services and barriers to the physical environment may impact participation and social inclusion.

ABSTRACT Objective: To investigate the association between sleep duration, nocturnal awakenings, and sleep latency with body mass index (BMI) at six and 12 months of age. Methods: 179 children from a birth cohort were enrolled. At six and 12 months of age, anthropometric data were obtained using standardized techniques and infants’ mothers answered the Brief Infant Sleep Questionnaire for sleep data. The association of BMI with the independent variables (sleep duration, latency, and nocturnal awakenings) was assessed by linear regression models. Analyses were adjusted for potential confounders and a p-value

ABSTRACT Objective: To describe leprosy involvement and physical disability profiles in children and adolescents under 15 years old. Methods: Ecological time series study, based on data from the Brazilian Notifiable Diseases Information System, including new cases of leprosy residing in Palmas (TO), from 2001 to 2020. Results: A total of 471 notified cases in children and adolescents under 15 years of age were evaluated, resulting in a detection coefficient of 26.5 per 100,000 inhabitants. Of these, 52% (n=243) were women, 5% (n=24) corresponded to grade two disability, and 36% (n=168) were diagnosed through spontaneous demand. The temporal trend analysis showed a 0.5% reduction in the detection coefficient. There was a significant decrease in the diagnosis of the undetermined and tuberculoid clinical forms and a significant increase in the dimorphous form. Diagnosis through contact examination increased significantly by 13.1% and that through spontaneous demand decreased by 4.9%. The detection coefficient of cases with grade two disability reduced significantly by 7.4% while those with grade one increased by 16.8%. Conclusions: Despite the downward trend in the detection coefficient in children and adolescents under 15 years of age and in cases with grade two disability, other factors indicate failure in the adequate management of leprosy in Palmas.

ABSTRACT Objective: To evaluate autoinflammatory diseases (AID) according to age at diagnosis and sex, and response to therapy in a large population. Methods: This is a cross-sectional observational study of a Latin American registry using a designed web system for data storage, collected between 2015 and 2018. Any altered findings during follow-up were recorded. The forms were translated into Portuguese and Spanish, including demographic, clinical, laboratory, genetic and treatment characteristics. Results: We included 152 patients, 51.3% male and 75% Caucasian. The median age at disease onset was 2.1 years (0–15.6 years) and median age at diagnosis 6.9 years (0–21.9 years); 111 (73%) were children (0–9 years old), and 41 (27%) were adolescents and young adults (AYA) (10–21 years old). Periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome (PFAPA) occurred in 46/152 (30%), chronic non-bacterial osteomyelitis (CNO) in 32/152 (21%), and familial Mediterranean fever (FMF) in 24/152 (15.7%). PFAPA was significantly higher in young children than in AYA (38.7% vs. 7.3%, p

ABSTRACT Objective: To estimate the prevalence of developmental defects in dental enamel and its possible association with prenatal, neonatal and postnatal conditions in six-year-old schoolchildren in a southern Brazilian municipality. Methods: A cross-sectional study was conducted involving 655 six-year-old schoolchildren. Sociodemographic and health data were collected through interviews with mothers and children’s oral examinations at schools. Multivariate analyses were performed using Poisson regression with robust estimator. Results: The prevalence of developmental defects of enamel was 44.0%. Demarcated opacities were the most prevalent, followed by diffuse opacities. Late pregnancy, maternal schooling less than eight years, female gender and child’s white skin color were independently associated with the prevalence of demarcated opacities. Conclusions: The prevalence of developmental defects in dental enamel was 44.0%. Late pregnancy, maternal schooling less than eight years, female gender and child’s white skin color were associated with the prevalences.

ABSTRACT Objective: To conduct a bibliographic review on tuberculosis (TB) disease in children and adolescents with rheumatic diseases, being managed with biologic therapy. Data source: An integrative review with a search in the U.S. National Library of Medicine and the National Institutes of Health (PubMed) using the following descriptors and Boolean operators: ([“tuberculosis”] AND ([“children”] OR [“adolescent”]) AND [“rheumatic diseases”] AND ([“tumor necrosis factor-alpha”] OR [“etanercept”] OR [“adalimumab”] OR [“infliximab”] OR [“biological drugs”] OR [“rituximab”] OR [“belimumab”] OR [“tocilizumab”] OR [“canakinumab”] OR [“golimumab”] OR [“secukinumab”] OR [“ustekinumab”] OR [“tofacitinib”] OR [“baricitinib”] OR [“anakinra”] OR [“rilonacept”] OR [“abatacept”]), between January 2010 and October 2021. Data synthesis: Thirty-seven articles were included, with the total number of 36,198 patients. There were 81 cases of latent tuberculosis infection (LTBI), 80 cases of pulmonary tuberculosis (PTB), and four of extrapulmonary tuberculosis (EPTB). The main rheumatic disease was juvenile idiopathic arthritis. Among LTBI cases, most were diagnosed at screening and none progressed to TB disease during follow-up. Of the TB cases using biologics, most used tumor necrosis factor-alpha inhibitors (anti-TNFα) drugs. There was only one death. Conclusions: The study revealed a low rate of active TB in pediatric patients using biologic therapy. Screening for LTBI before initiating biologics should be done in all patients, and treatment, in cases of positive screening, plays a critical role in preventing progression to TB disease.

ABSTRACT Objetive: Studies have shown that the practice of self-medicating children occurs worldwide and is independent of the country’s economic level, medication policies, or access to health services. This study aimed to estimate and characterize the prevalence of self-medication in the Brazilian population of children aged up to 12 years. Methods: We analyzed the data of 7528 children aged up to 12 years whose primary caregivers responded to the National Survey on Access, Use and Promotion of Rational Use of Medicines in Brazil (PNAUM), a cross-sectional population-based study conducted in 245 Brazilian municipalities. The prevalence of self-medication was defined as the use of at least one medication without a doctor’s or dentist’s indication 15 days before the interview. Results: The prevalence of self-medication was 22.2% and was more frequent in older children belonging to poorer families and without health insurance. The acute conditions for which there was a higher frequency of self-medication were pain, fever, and cold/allergic rhinitis. Analgesics/antipyretics stood out among the most used medications for self-medication. Conclusions: The prevalence of self-medication to treat acute conditions was high in Brazilian children sampled in PNAUM, emphasizing the management of common symptoms such as pain, fever, and cold/allergic rhinitis in this age group. These findings reinforce the need for educational actions aimed at parents and caregivers.

Resumen: Objetivos: En España, las pruebas diagnósticas de COVID-19 en atención primaria estuvieron disponibles desde mayo de 2020. Previamente la mayoría de los estudios describían pacientes hospitalarios: la fiebre y la tos eran los síntomas más frecuentes. Interesaba conocer la expresión clínica de la COVID-19 pediátrica en la comunidad. Métodos: Estudio descriptivo analítico observacional de casos pediátricos (0-14 años) de 255 pediatras de atención primaria españoles, del 12/5/2020 al 30/4/2021. Los diagnósticos se determinaron por PCR, test rápido de detección de antígeno o serología IgG positiva. Resultados: Se incluyeron 10.021 niños, 48,4% mujeres, con una edad media de 8,04 ± 4,17 años. Se detectó la infección por búsqueda de contactos (70,9%) o síntomas compatibles (18,8%). El hogar familiar fue la principal fuente de contagio (64,9%), seguido por los colegios (10%) o de origen desconocido (9,9%). No hubo diferencias significativas en la incidencia entre temporadas vacacionales o lectivas. El 43,2% fueron asintomáticos. Los síntomas más frecuentemente encontrados fueron rinorrea en menores de 2 años, fiebre entre 3 y 8 años y cefalea en mayores de 9 años. Se describen exhaustivamente los síntomas y signos observados por edad. Se hospitalizaron a 8 pacientes, uno con un síndrome inflamatorio multisistémico. No hubo fallecimientos. Conclusiones: La COVID-19 es una enfermedad leve con un gran número de casos asintomáticos, con pocas hospitalizaciones y fallecimientos. El lugar principal de transmisión es el domicilio y el cierre de colegios debería ser el último recurso para controlar la pandemia. No se pudo describir un cuadro clínico característico de la enfermedad. Abstract: Objectives: In Spain, the tools to diagnose COVID-19 were available in primary care from May 2020. Previously most studies described inpatients, and fever and cough were the most frequent symptoms. This study aims to define the clinical picture of the pediatric COVID-19 in the community. Methods: A descriptive and analytical observational study was performed including pediatric cases (0-14y) from 255 pediatricians, proportionally distributed to its population, from primary health centers in Spain, from 12th May 2020 to 30th April 2021. Diagnostics were made by PCR detection of viral RNA, rapid antigen detection test or positive IgG serology. Results: There were 10,021 positive children included, 48.4% women, mean age 8,04 ± 4.17 years. Infection was detected due to contact tracing (70.9%), compatible symptoms (18.8%). Household was the main source of transmission (64.9%), followed by school setting (10%) or unknown (9.9%). We did not find any significant differences in the incidence between holidays and school terms. 43.2% of the children were asymptomatic. Most frequent symptoms are rhinorrhea in 9 y. An exhaustive description of objective and subjective symptoms by age is made. 18 patients were hospitalized, one with multisystem inflammatory syndrome in children. There were no deaths. Conclusions: Pediatric COVID-19 is a mild disease, with a large number of asymptomatic cases, with very few hospital admissions and deaths. The main setting for transmission is the household, and school closures should be a last resource measure during the COVID-19 pandemic. A specific clinical picture of pediatric COVID-19 was not found.

Resumen: Introducción: Las coinfecciones por gripe y otros virus respiratorios (OVR) durante las epidemias gripales son frecuentes. El objetivo de este estudio es examinar las variables demográficas y virológicas relacionadas con las coinfecciones entre la gripe y OVR. Materiales y métodos: En este estudio se analizaron muestras respiratorias de 8 epidemias gripales consecutivas (desde la temporada 2011-2012 hasta la temporada 2018-2019), en las que se había detectado un resultado positivo de gripe mediante test en laboratorio. Analizamos los datos objetivándolos frente a diferentes variables: edad, sexo, tipo de paciente (hospitalizado/centinela) y tipo/subtipo de gripe detectada. Resultados: Las coinfecciones entre gripe y OVR se detectaron en el 17,8% de los casos positivos de gripe. En los niños de entre 0-4 años (OR: 2,7; IC 95%: 2,2-3,4), los niños de entre 5-14 años (OR: 1,6; IC 95%: 1,2-2,1) y los pacientes infectados por el subtipo A(H3N2) (OR: 1,4; IC 95%: 1,14-1,79), se detectó una probabilidad significativamente mayor de detectar estas coinfecciones. Además, observamos que las coinfecciones entre gripe y 2 o más OVR fueron llamativamente más frecuentes en niños de 0-4 años (OR: 0,5; IC 95%: 0,32-0,8), en adultos de entre 40-64 años (OR: 0,5; IC 95%: 0,3-0,9) y en mujeres (OR: 0,7; IC 95%: 0,5-0,9). Discusión: Estos resultados muestran que las coinfecciones entre gripe y OVR son más frecuentes en niños de 0-4 años y de 5-14 años, y en los casos en los que el subtipo A(H3N2) está implicado. Estos datos pueden ser útiles para enfocar el diagnóstico mediante métodos multiplex en aquellos laboratorios que posean pocos recursos económicos y humanos. Abstract: Introduction: Coinfections of influenza and other respiratory viruses (ORVs) are frequent in the epidemic season. The aim of this study was to examine the demographic and virological variables associated with coinfections by influenza and ORVs. Materials and methods: We analysed respiratory samples of patients with laboratory-confirmed influenza using molecular diagnostic methods obtained in 8 consecutive influenza seasons (2011-2012 to 2018-2019). We analysed data focusing on different variables: age, sex, type of patient (hospitalized/sentinel) and detected type/subtype of influenza. Results: Coinfections of influenza and ORVs were detected in 17.8% of influenza-positive samples. The probability of detecting coinfection was significantly higher in young children (0-4 years; OR: 2.7; 95% CI: 2.2-3.4), children (5-14 years; OR: 1.6; 95% CI: 1.2-2.1) and patients infected with the A(H3N2) subtype (OR: 1.4; 95% CI: 1.14-1.79). Also, we found a significantly higher frequency of coinfections involving influenza and 2 or more other respiratory viruses in young children (0-4 years; OR: 0.5; 95% CI: 0.32-0.8), adults (40-64 years; OR: 0.5; 95% CI: 0.3-0.9) and women (OR: 0.7; 95% CI: 0.5-0.9). Discussion: These results show that coinfections of influenza and ORVs are more frequent in young children and children, and in cases involving the A(H3N2) influenza subtype. Our findings can be useful to guide the use of multiplex diagnostic methods in laboratories with limited resources.

Abstract Objective: This study aimed to verify vitamin D concentration in children and adolescents during the seasons of the year and to compare vitamin D concentration between children engaged in outdoor activities and those engaged in indoor activities. Methods: This is a cross-sectional study with a sample of 708 children and adolescents (aged 6–18 years), excluding 109 (16 were over 19 years old; 39 had a disease that required continuous treatment; 20 were on continuous medication; and 34 had no vitamin D data), ending with 599. The plasma concentration of 25-hydroxyvitamin D2 was measured with commercial kits following manufacturer instructions. Results: Participants who engaged in outdoor activities, as well as those who had data collected during summer and spring, had higher levels of vitamin D. According to the Poisson regression, the proportion of participants with inadequate levels of vitamin D was greater in the participants whose vitamin D was measured during spring (PR 1.15, 95%CI 1.03–1.29) and winter (PR 1.18, 95%CI 1.05–1.32). Also, a greater proportion of inadequate vitamin D was observed for those engaged in indoor activities (PR 1.08, 95%CI 1.01–1.15). Conclusions: Participants who measured the vitamin during the summer and autumn had a lower prevalence of hypovitaminosis D. Even in regions with high solar incidence throughout the year, vitamin D levels can vary significantly during the period’s seasons.

Resumen: Introducción: El objetivo del estudio fue determinar los niveles séricos y fecales de plomo en niños con distintos trastornos digestivos funcionales (TDF) en comparación con controles sanos. Pacientes y métodos: La muestra incluyó a 102 niños de 4-18 años con TDF definidos mediante los criterios de Roma IV y a 102 controles sanos emparejados por edad y sexo. Los niños con TDF se dividieron en 3 subgrupos: estreñimiento funcional (EF) (n = 36), dolor abdominal funcional (DAF) (n = 36) y náuseas funcionales (NF) (n = 30). Los niveles de plomo se midieron mediante espectrometría de absorción atómica. Resultados: El nivel de plomo en sangre (NPS) mediano fue significativamente mayor en niños con TDF en comparación con controles (5,12 vs. 1,77 μg/dl). Los NPS superaron los 5 μg/dl en el 51,9% del grupo TDF. Se observó una diferencia estadísticamente significativa en los NPS entre el subgrupo con EF y los otros 2 subgrupos (DAF y NF) (p = 0,003 y p

Resumen: Introducción: Las resistencias antibióticas de Helicobacter pylori (H. pylori) son el principal factor que afecta a la eficacia de los regímenes terapéuticos actuales. El objetivo principal del estudio es describir el patrón de resistencias antibióticas en niños con infección por H. pylori. Pacientes y métodos: Estudio observacional retrospectivo de 2014 a 2019 en el que se incluyen pacientes entre 5-17 años a los que se realizó gastroscopia, con cultivo de biopsia gástrica positivo para H. pylori y estudio de sensibilidad a antibióticos. Los estudios de sensibilidad antibiótica se realizaron mediante E-test. Los puntos de corte para definir las resistencias fueron los propuestos por el EUCAST. El estudio de erradicación se realizó con test del aliento con urea marcada con C 13 o test monoclonal de antígeno de H. pylori en heces a las 6-8 semanas de finalizar el tratamiento. Resultados: Ochenta pacientes (63,8% mujeres). Media de edad 11,9 años (±2,7 DS). Un 38,8% habían recibido tratamiento previo para H. pylori. Un 10% presentaron en la endoscopia lesiones ulcerosas pépticas. El 67,5% presentaba resistencia al menos a un fármaco. Un 16,3% presentaron doble resistencia. Las resistencias primarias fueron: claritromicina 44,9%, metronidazol 16,3%, levofloxacino 7,9% y amoxicilina 2%. Los pacientes que recibieron tratamiento acorde a las nuevas guías ESPGHAN 2017 presentaron tasas de erradicación significativamente superiores en comparación con los que recibieron tratamiento acorde a las guías previas (80% vs. 55,8% p = 0,04). Conclusiones: La alta tasa de resistencias de H. pylori y, en consecuencia, las bajas tasas de erradicación, siguen siendo una preocupación muy importante. El tratamiento de primera línea, cuando esté indicado debe hacerse guiado por estudios de sensibilidad antibiótica y en los casos en el que no se puedan realizar o no estén disponibles, al menos de acuerdo con las tasas regionales de resistencia. La aplicación correcta de las nuevas guías mejora de forma significativa el nivel de erradicación. Abstract: Introduction: The resistance to antibiotics of Helicobacter pylori (H. pylori) is the main factor that affects current therapeutic treatments. The main objective of this study is to describe the pattern of antibiotic resistances in children with an infection due to H. pylori. Patients and methods: An observational, retrospective study was conducted from 2014 to 2019, which included patients between 5 and 17 years old, on whom a gastroscopy, with a gastric biopsy culture positive for H. pylori, and an antibiotic sensitivity study was performed. The antibiotic sensitivity studies were performed using an epsilometer (E-test). The cut-off points to define the resistances were those proposed by the European Committee on Antimicrobial Susceptibility Testing – EUCAST. The eradication study was performed using the 13C-urea breath test or the H. pylori monoclonal test in faeces 6-8 weeks after finalising the treatment. Results: The study included 80 patients (63.8% females), with a mean age of 11.9 years (SD ± 2.7 DS). Over one-third (38.8%) of the patients had received previous treatment for H. pylori. In the endoscopy, peptic ulcer lesions were observed in 10% of patients. More than two-thirds (67.5%) had resistance to at least one drug. 16.3% presented double resistance. The primary resistances were: clarithromycin, 44.9%, metronidazole 16.3%, levofloxacine 7.9%, and amoxicillin 2%. Patients that received treatment according to the new ESPGHAN 2017 guidelines had significantly higher eradication rates compared to those that received treatment according to previous guidelines (80% vs. 55.8%, P = .04). Conclusions: The high rate of H.pylori resistances, and as a result, the low eradication rates, are still a very important cause for concern. The first line treatment, when this is indicated must be given following the antibiotic sensitivity studies, and in the cases where these cannot be done or are not available, at least in accordance with the regional resistance rates. The correct application of the new guidelines significantly improves the eradication rate.

Resumen: Introducción y objetivos: El control glucémico postprandial es fundamental para conseguir los objetivos metabólicos en pacientes con diabetes mellitus tipo 1 (DM1). La nueva insulina faster aspart presenta un perfil farmacológico caracterizado por una absorción e inicio de acción más rápidos, mayor disponibilidad precoz y menor incremento de la glucosa postprandial. El objetivo principal del estudio fue analizar su eficacia en pacientes con DM1 tratados con un sistema integrado. Pacientes y métodos: Estudio analítico, longitudinal, prospectivo y multicéntrico, evaluando el empleo de faster aspart durante tres meses en pacientes en edad pediátrica con DM1 con sistema integrado MiniMed640G® tratados previamente con insulina aspart. Al inicio y final del estudio se analizaron para posterior comparación: glucosa media, porcentajes de tiempo en objetivo, tiempo en hipoglucemia e hiperglucemia, área bajo la curva (AUC) 180 mg/dL, glucosa media pre y postprandial en comidas principales, necesidades diarias de insulina, porcentaje basal/bolo y HbA1c. Se registraron complicaciones agudas y eventos adversos, y se evaluó grado de satisfacción mediante encuesta. Resultados: Se incluyeron 31 pacientes de 13,49 ± 2,42 años de edad con DM1 de 7,0 ± 3,67 años de evolución. Faster aspart se asoció con menor porcentaje de tiempo en hiperglucemia > 180 mg/dL (25,8 ± 11,3 vs. 22,4 ± 9,5; p = 0,011) y > 250 mg/dL (5,2 ± 4,9 vs. 4,0 ± 3,6; p = 0,04) y AUC > 180 mg/dL (10,8 ± 6,5 vs. 9,3 ± 6,1; p = 0,03), incrementándose el tiempo en objetivo (71,4 ± 10,0 vs. 74,3 ± 9,2; p = 0,03) sin aumentar hipoglucemias. Las necesidades de insulina, porcentajes basal/bolo y HbA1c no se modificaron significativamente. Faster aspart fue bien tolerada y valorada por los participantes. Conclusiones: Faster aspart consigue un mejor control glucémico, aumentando el tiempo de glucosa en objetivo en niños y adolescentes con DM1 en tratamiento con un sistema integrado. Abstract: Background and aims: Post-prandial glucose control is essential to achieve metabolic goals in patients with type 1 diabetes mellitus (T1DM). The new «faster aspart» insulin has a pharmacological profile noted for its faster absorption and onset of action, and increased early availability, resulting in improved blood glucose control after meals. The main objective of the study was to analyse the efficacy of «faster aspart» vs. «insulin aspart» in children and adolescents with DM1 on sensor-augmented pump treatment. Patients and methods: Multicentre, longitudinal and prospective analytical trial evaluating the use of faster aspart insulin for three months in children with T1DM with MiniMed640G® sensor-augmented pumps previously treated with aspart insulin. At the beginning and end of the study the following variables were analysed for subsequent comparison: mean sensor glucose, percentage of time in range, hypoglycaemia and hyperglycaemia, area under the curve (AUC) 180 mg/dL, mean sensor glucose pre and postprandial in main meals, daily insulin requirements, basal/bolus percentage, and HbA1c. Acute complications, adverse events and satisfaction survey were assessed. Results: The study included 31 patients with a mean of 13.49 ± 2.42 years of age and with T1DM of 7.0 ± 3.67 years of onset. The use of faster aspart was associated with lower time in hyperglycaemia > 180 mg/dL (25.8 ± 11.3 vs. 22.4 ± 9.5; p = 0.011) and > 250 mg/dL (5.2 ± 4.9 vs. 4.0 ± 3.6; p = 0.04), lower AUC > 180 mg/dL (10.8 ± 6.5 vs. 9.3 ± 6.1; p = 0.03), and increased time in range (71.4 ± 10.0 vs. 74.3 ± 9.2; p = 0.03). No significant changes in hypoglycaemia, HbA1c, insulin requirements, and basal/bolus percentages were detected. Faster aspart was safe and well-evaluated by patients and caregivers. Conclusions: Faster aspart achieves better glycaemic control by increasing glucose time in range in children and adolescents with T1DM on treatment with sensor-augmented pumps.

Resumen: Introducción: La neumonía necrotizante (NN) es una complicación grave de la neumonía adquirida en la comunidad caracterizada por la destrucción del parénquima pulmonar normal. Ningún estudio ha evaluado las consecuencias de este daño pulmonar en los años posteriores al episodio. El objetivo es investigar el impacto a largo plazo sobre la función pulmonar y los síntomas respiratorios en niños ingresados por NN. Métodos: Seguimiento de niños diagnosticados de NN desde enero-2003 hasta abril-2016. Se seleccionó a los mayores de 4 años, capaces de realizar una función pulmonar, y un seguimiento durante más de 2 años. Los pacientes recibieron un cuestionario respiratorio y completaron una prueba de función pulmonar. Resultados: Se incluyeron 24 pacientes (12 hombres). La edad mediana en el momento del diagnóstico fue de 26 meses, 15 días de hospitalización y 18 pacientes necesitaron drenaje pleural. Los pacientes fueron seguidos durante un promedio de 8,75 años después de la NN. Durante la evaluación, ningún paciente tuvo asma, tos o sintomatología inducida por el ejercicio. Tres niños sufrieron una segunda neumonía, que no requirió hospitalización. Los resultados de la espirometría fueron (media ± desviación estándar): Z-score FEV1 −0,47 ± 0,65, Z-score FVC −0,56 ± 0,73, Z-score FEV1/FVC 0,19 ± 0,98. No hubo evidencia de enfermedad pulmonar obstructiva o patrones restrictivos. Conclusiones: Los resultados a largo plazo de la NN pediátrica son buenos. Sin embargo, los pacientes tienen una función pulmonar ligeramente disminuida varios años después del episodio. Es aconsejable hacer un seguimiento de estos pacientes debido a la posible disminución de la función pulmonar en edad adulta. Abstract: Introduction: Necrotizing pneumonia (NP) is a serious complication of community-acquired pneumonia characterised by the destruction of normal lung parenchyma. No study has evaluated the repercussions of the lung damage in the years following the episode. The aim of this study was to assess the long-term impact on lung function and respiratory symptoms in children hospitalised due to NP. Methods: We analysed outcomes in children given a diagnosis of NP between January 2003 and April 2016. We selected patients aged more than 4 years capable of undergoing a lung function test, that had been followed up for at least 2 years. The patients completed a respiratory questionnaire and underwent a lung function test. Results: We included a total of 24 patients (12 male). The median age at the time of diagnosis was 28 months, the median length of stay was 15 days, and 18 patients required pleural drainage. The mean duration of follow-up after NP was 8.75 years. During the evaluation, none of the patients exhibited asthma, cough, or exercise-induced symptoms. Three children had a second episode of pneumonia that did not require hospital admission. The spirometry results were the following (given as mean ± standard deviation): FEV1 z-score, −0.47 ± 0.65; FVC z-score, −0.56 ± 0.73; and FEV1/FVC z-score, 0.19 ± 0.98. We found no evidence of obstructive pulmonary disease or restrictive patterns. Conclusions: The long-term outcomes of paediatric NP are good. However, patients exhibited mildly impaired lung function several years after the episode. We recommend follow-up of these patients due to potential impairments in lung function in adulthood.

Resumen: Introducción: El dolor abdominal crónico (DAC) en la infancia es un motivo de consulta frecuente que afecta a la vida familiar, y en ocasiones precisa realización de pruebas complementarias. El objetivo fue realizar el análisis cualitativo, cuantitativo y económico de las pruebas que se solicitan. Pacientes y métodos: Estudio observacional, prospectivo y multicéntrico, incluyendo pacientes entre 4-15 años con DAC. Se diferenciaron 2 grupos: orgánico y funcional. Se recogieron las siguientes variables: clínicas, pruebas complementarias y su coste. Resultados: Se incluyeron 235 niños con DAC (edad media 9,7 ± 2,7 años). Un 79% resultaron trastornos funcionales y un 21% orgánicos. Casi la mitad de los pacientes presentaba algún tipo de síntoma o signo de alarma, pero solo la clínica miccional se asoció con organicidad. La ecografía abdominal, estudio de parásitos en heces, test de hidrógeno espirado y gastroscopia son las que más se asociaron con enfermedad orgánica. Existía una diferencia apreciable entre el coste de las pruebas según cada centro. El gasto económico total fue de 52.490,8 euros, siendo 195 euros por paciente para los funcionales y 306 euros para los orgánicos. Conclusiones: Los síntomas y signos de alarma en el DAC son frecuentes, pero poco específicos. La ecografía abdominal y el estudio de parásitos podrían ser pruebas útiles de primer nivel por su inocuidad para diferenciar TO de TDAF. La gastroscopia y el test de hidrógeno espirado fueron las pruebas más discriminativas de organicidad. El coste económico invertido en pruebas para la orientación diagnóstica del DAC de origen funcional es elevado. Abstract: Introduction: Chronic abdominal pain (CAP) in children is a symptom that frequently leads to a visit to the paediatrician, which affects family life and occasionally requires the need to perform diagnostic studies (DS). The objective was to carry out a qualitative, quantitative, and economic analysis on the tests requested. Patients and methods: An observational, prospective and multicentre study was conducted that included children between 4-15 years old affected by CAP. The difference between organic and functional disorders was taken into account. The following variables were collected: history, warning signs and symptoms, DS, and the cost of these. Results: The study included 235 children with CAP (Age; mean 9.7 ± 2.7 SD). The large majority (79%) were functional disorders and 21% organic disorders. Almost half of the patients had some warning sign or symptom, but urinary symptoms were only associated with organic disorders. The abdominal ultrasound, faecal parasites, breath test, and endoscopy were the most associated with organic disorders. There was a difference between the costs of the DS according to each centre. The total economic cost was 52,490.80 euros, with 195 euros per patient for functional disorders and 306 euros for organic disorders. Conclusion: Signs and symptoms of alarm in CAP were very frequent, but had low discriminative capacity. The abdominal ultrasound and faecal parasites are innocuous DS, and could be useful as a first level study. The endoscopy and the breath test were the most discriminative of organic disease. The economic cost of DS arising from the diagnosis of exclusion in CAP was high.

Resumen: Introducción: El consumo de productos ultraprocesados (UP) se relaciona con múltiples enfermedades en el adulto, como hipertensión arterial, diabetes o asma. Objetivo: estudiar si el consumo de UP en niños se asocia con enfermedades respiratorias sibilantes (asma o bronquitis/sibilancias de repetición). Material y métodos: Estudio transversal dentro del proyecto SEguimiento del Niño para un Desarrollo Óptimo (SENDO), una cohorte abierta, multidisciplinar y multipropósito de niños españoles. El consumo de UP se calculó mediante cuestionarios semicuantitativos de frecuencia de consumo de alimentos. Los alimentos se agruparon según la clasificación NOVA y se estimó el consumo diario y el porcentaje de kilocalorías procedentes de UP. Dividimos la exposición en «alto» y «bajo» a partir de la mediana de consumo. Se calcularon las odds ratio y los intervalos de confianza al 95% para las enfermedades respiratorias sibilantes asociadas al consumo alto de UP, usando como referencia el bajo consumo. Se calcularon estimadores brutos y multiajustados y se utilizaron modelos de regresión mixtos para tener en cuenta la correlación entre hermanos. Resultados: En los 513 niños estudiados (51,8% varones, edad media de 5,2 años), el consumo medio de UP fue de 446,76 g/día, representando un 39,9% de la ingesta calórica total. Un alto consumo de UP se asoció a un incremento del 87% de la prevalencia de enfermedades respiratorias sibilantes (OR 1,87; IC 95% 1,01-3,45). Encontramos que un mayor consumo de UP multiplica por 2,12 (IC 95% 1,10-4,05) la prevalencia de bronquitis/sibilancias de repetición. Conclusiones: Nuestros resultados muestran una asociación directa entre el consumo de UP y la prevalencia de enfermedades sibilantes en niños. Abstract: Introduction: The consumption of ultra-processed products (UP) is associated with many diseases in the adult, such as arterial hypertension, diabetes, or asthma. Objective: To determine whether the consumption of UP in children is associated with wheezing respiratory diseases (asthma or bronchitis/recurrent wheezing). Material and methods: A cross-sectional study was conducted within the Follow-up of the Child for Optimal Development ?SENDO? project (an open, multidisciplinary and multiple outcome study of Spanish children). The consumption of UP was calculated using semi-quantitative questionnaires on the frequency of food consumption. The foods were grouped according the NOVA classification, and the daily consumption was estimated along with the percentage of kilocalories from the UP. The exposure was grouped into “high” and “low” from the median consumption. Odds ratios and 95% confidence intervals were calculated for wheezing respiratory diseases associated with the high consumption UP, using low consumption as a reference. Crude and multi-adjusted estimators were calculated, and mixed regression models were used to take into account the correlation between siblings. Results: In the 513 children studied (51.8% males, mean age 5.2 years), the mean consumption of UP was 446.76 g/day, representing 39.9% of the total calories ingested. A high consumption of UP was associated with an increase of 87% in the prevalence of wheezing respiratory diseases (OR 1.87; 95% CI 1.01-3.45). It was found that a higher consumption of UP multiplied by 2.12 (95% CI 1.10-4.05) the prevalence of bronchitis/recurrent wheezing. Conclusions: The results of this study show a direct relationship between UP consumption and the prevalence of wheezing diseases in children.

Resumen: Introducción: La infección por VIH era el principal factor de riesgo para presentar neumonía por Pneumocystis jirovecii (NPJ). En la actualidad, las características clínico-epidemiológicas de la NPJ en niños han cambiado, existiendo pocos estudios en este sentido. Métodos: Realizamos un estudio observacional retrospectivo en pacientes pediátricos diagnosticados de NPJ durante 17 años en un hospital de tercer nivel en España. Resultados: Se recogió a 23 pacientes, de los que 11/23 (47,8%) presentaban enfermedad hematológica, 5/23 (21,7%) inmunodeficiencia primaria y 4/23 (17,4%) infección por VIH. Recibían profilaxis con trimetoprima-sulfametoxazol (TMP-SMX) 11/23 pacientes (47,8%). Todos recibieron tratamiento con TMP-SMX y 18/23 (78,3%), glucocorticoides sistémicos. Fallecieron 6/23 pacientes (26,1%), de los que 1/6 (16,7%) presentaba infección por VIH. En los pacientes no VIH con mayor leucocitosis, mayor retención de CO2 y mayor frecuencia cardíaca al inicio, se evidenció mayor mortalidad, diferencias no objetivadas en pacientes con VIH. No se encontraron diferencias en mortalidad en relación con el factor predisponente, empleo de TMP-SMX ni tratamiento con glucocorticoides. Conclusiones: En la actualidad, los pacientes pediátricos con neoplasias hematológicas constituyen el principal grupo de riesgo de desarrollar NPJ en este grupo etario. No hemos encontrado diferencias de mortalidad entre pacientes con o sin infección por VIH como factor predisponente. Entre los pacientes no VIH la mortalidad fue mayor en aquellos que presentaron mayor leucocitosis, mayor retención de CO2 y mayor frecuencia cardíaca al inicio. No se objetivó mejor pronóstico en pacientes que recibían profilaxis con TMP-SMX previamente al desarrollo de la NPJ ni en los que recibieron glucocorticoides sistémicos como parte del tratamiento. Abstract: Introduction: HIV infection was the main risk of suffering Pneumocystis jirovecii pneumonia (PJP). The clinical-epidemiological characteristics of PJP have currently changed, with there being few studies on this. Methods: A retrospective observational study was carried out on paediatric patients diagnosed with PJP over a 17 year period in a third level hospital in Spain. Results: A total of 23 patients were included, of whom 7/23 (47.8%) suffered a haematological disease, 5/23 (21.7%) a primary immunodeficiency, and 4/23 (17.4%) an HIV infection. Prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) was received by 11/23 (47.8%) patients. All were treated with TMP-SMX and 18/23 (78.3%) with systemic glucocorticoids. There were 6 (26.1%) deaths, of which one of them (16.7%) suffered an HIV infection. A higher mortality was seen in the non-HIV patients with greater leucocytosis, greater CO2 retention, and a higher heart rate at onset, differences not observed in HIV patients. No differences were found in mortality in relation to the predisposing factor, use of pTMP-SMX, or treatment with glucocorticoids. Conclusions: Paediatric patients with haematological cancers are currently the main risk group of developing PJP in this age group. No differences were found in mortality between patients with or without HIV infection as predisposing factor. The mortality among non-HIV patients was higher in those that had greater leucocytosis, greater CO2 retention, and increased heart rate at onset. A better prognosis was not seen in patients that received prophylaxis with TMP-SMX prior to the development of the PJP, or in those that received glucocorticoids as part of the treatment.

Resumen: Objetivo: Mostrar el proceso de elaboración, dentro del Grupo de Trabajo de Intoxicaciones de la Sociedad Española de Urgencias de Pediatría (GTI-SEUP), de la lista de recomendaciones de «no hacer» ante un paciente pediátrico que ha contactado con una sustancia potencialmente tóxica. Método: El proceso de elaboración de la lista se realizó en tres fases. Primera: «Lluvia de ideas» abierta a todos los miembros del GTI-SEUP. Segunda: Selección de las recomendaciones, siguiendo una metodología Delphi-modificada. Se solicitó a todos los participantes que puntuasen las propuestas (del 1 = totalmente en desacuerdo al 9 = totalmente de acuerdo). Se aceptaron aquellas con una puntuación media superior a 8 (siempre que al menos 2/3 de los participantes le hubieran otorgado una puntuación ≥ 7) y se realizó una segunda consulta para las recomendaciones con una puntuación media entre 6 y 8. Tercera: Redacción y consenso del documento final. Resultado: Inicialmente se obtuvieron 11 propuestas; 32 de los 57 participantes del GTI-SEUP respondieron al cuestionario de puntuación. En la primera consulta, fueron aceptadas siete recomendaciones de «no hacer» y cuatro obtuvieron una puntuación media dudosa (entre 6 y 8). Tras la segunda consulta, la lista quedó formada por ocho recomendaciones. Dos hacen referencia al manejo general, cuatro a técnicas de descontaminación digestiva y dos a la administración de antídotos. Conclusión: La lista de acciones que no hay que hacer ante un niño que ha contactado con un posible tóxico es una herramienta consensuada, dentro del GTI-SEUP, para promover una mejora de la calidad asistencial ofrecida a estos pacientes. Dicha mejora se basa en evitar medidas innecesarias, que en ocasiones pueden resultar nocivas para el niño. Abstract: Objective: To show the preparation process by the Poisoning Working Group of the Spanish Society of Paediatric Emergencies (GTI-SEUP), of the list of things «not to do» for a paediatric patient who has been exposed to a potentially toxic substance. Method: The preparation process of the list was carried out in three phases. First: «Brainstorming» that was open to all members of the GTI-SEUP. Second: Recommendations were selected by following modified-Delphi methodology. All participants were asked to rate the proposals (from 1 = strongly disagree to 9 = strongly agree). Those with an average score greater than 8 were accepted (provided that at least two-thirds of the participants had given them a score ≥ 7), and a second consultation was made for the recommendations with an average score between 6 and 8. Third: Writing and creating a consensus of the final document was done. Result: A total of 11 proposals were initially obtained. Thirty-two of the 57 GTI-SEUP participants completed the scoring questionnaire. In the first consultation, seven «not to do» recommendations were accepted, and four obtained a doubtful average score (between 6 and 8). After the second consultation, the list was made up of eight recommendations. Two refer to general management, four to gastrointestinal decontamination techniques, and two to the administration of antidotes. Conclusion: The list of actions that should not be taken with a child that has been exposed to a possible poison is a consensus tool, within the GTI-SEUP, to promote improvement in the quality of care offered to these patients. This improvement is based on avoiding unnecessary measures, which can sometimes be harmful to the child.

Resumen: Objetivo: Validar el contenido y la adecuación del material desplegable «Rescube» con la información adaptada de la «cadena de supervivencia». Material y métodos: La investigación fue realizada en tres etapas: 1) desarrollo del material desplegable por 7 profesionales, utilizando los pasos de un método Delphi; 2) evaluación del material desplegable por 11 expertos mediante una escala Likert y posterior cálculo de índices de validez de contenido, y 3) estudio piloto en dos grupos de niños entre 5 y 8 años: grupo Rescube (GR; n = 60) y grupo Tradicional (GT; n = 60). El GR recibió la formación con el Rescube y un peluche, mientras que en el GT se utilizó un maniquí pediátrico. Los participantes fueron evaluados individualmente antes de la formación, y una semana y un mes después. Resultados: Todos los índices calculados de validez de contenido superan el punto de corte aconsejado para los análisis con más de 9 expertos (≥ 0,80). Los resultados de aprendizaje de los niños fueron positivos, observándose porcentajes iguales o superiores al 80% en todas las variables registradas tras una semana e iguales o superiores al 67% tras un mes. No se observaron diferencias significativas entre los grupos. Conclusión: La herramienta docente basada en imágenes infantiles en un cubo desplegable Rescube es válida y útil para formar a los escolares más jóvenes en la «cadena de supervivencia». Abstract: Purpose: To validate the content and adequacy of the «Rescube» training material that includes adapted information from the chain of survival. Material and methods: The study included three steps: (i) material development by 7 experts, following Delphi method; (ii) assessment of training material by 11 experts by means of a Likert score and calculation of content validity; and (iii) pilot study in two groups of 5 to 8 years-old: Rescube group (GR; n = 60) and Traditional group (GT; n = 60). GR was trained with Rescube and a Teddy bear, while GT was traditionally trained with a pediatric manikin. Participants were individually assessed at baseline, and one week and one month after training. Results: All content validity indexes calculated are above the recommended cut-off for analysis with more than 9 experts (≥ 0,80). Children's learning results were positive, with percentages equal or higher than 80% in all registered variables at the first (one week) evaluation and equal or higher than 67% when evaluated one month after training. No significant differences were detected between groups. Conclusion: The Rescube training tool based on infantile pictures is valid and useful to train young schoolchildren in the chain of survival.

Resumen: Introducción: La anemia hemolítica autoinmune (AHAI) es una enfermedad rara en niños, generalmente autolimitada. Material y métodos: Estudio descriptivo transversal en menores de 18 años diagnosticados de AHAI desde enero de 1997 a julio de 2019. Se recogieron variables clínicas y se clasificaron según el test de Coombs directo (TCD) en AHAI por anticuerpos calientes (IgG+/-C3d) y fríos (C3d). Se analizó la respuesta al tratamiento y su evolución. Resultados: Se incluyeron 25 pacientes, siendo el 72% varones. La media de edad al diagnóstico fue de dos años (rango 0,4-9). Los síntomas predominantes fueron fiebre (72%), palidez (68%), ictericia (64%), hepatoesplenomegalia y coluria (48%). La mediana de hemoglobina al diagnóstico fue 5,4 g/dL. En el 96% el TCD fue positivo, con detección de anticuerpos IgG en el 76%. Un solo caso presentó TCD negativo. Un 20% asociaron otra citopenia, uno de ellos fue diagnosticado posteriormente de inmunodeficiencia variable común. En un 32% se sospechó o documentó una infección viral concomitante. La mayoría de los casos fueron autolimitados y respondieron a tratamiento con corticoides (72%). Aquellos con respuesta parcial (24%), principalmente los que asociaban otras citopenias, precisaron otras líneas de tratamiento (rituximab, micofenolato, inmunoglobulinas). Se detectaron complicaciones (32%) y recaídas (26%) únicamente en AHAI por anticuerpos calientes. Conclusiones: Nuestra serie confirma que la AHAI es una enfermedad muy poco frecuente en la infancia. La mayoría de los casos evolucionan favorablemente, aunque hasta una cuarta parte precisan segundas líneas de tratamiento y casos excepcionales tratamientos muy agresivos. Estos últimos suelen corresponder a pacientes con más de una citopenia en la evolución de la enfermedad. Abstract: Introduction: Autoimmune hemolytic anemia (AIHA) is a rare and generally self-limiting disease in children. Material and methods: A descriptive cross-sectional study was performed in children under 18 years diagnosed with AIHA from January/1997 to July/2019. Clinical variables were collected and AIHA was classified according to the direct antiglobulin test (DAT) in warm AIHA (IgG+/-C3d) and cold AIHA (C3d). Response to treatment and evolution were analyzed. Results: 25 patients were included and 72% were males. The median age at diagnosis was 2 years (range 0.4 to 9). Fever (72%), pallor (68%), jaundice (64%), hepatosplenomegaly and coluria (48%) were the most common presenting symptoms. The median hemoglobin at diagnosis was 5.4 g/dl. DAT was positive in 96%, with detection of IgG antibodies in 76%. A single case presented negative DAT. 20% of the patients associated another cytopenia, one of which was subsequently diagnosed with common variable immunodeficiency. Concomitant viral infection was suspected or documented in 32%. Most of the cases were self-limiting and responded to corticosteroid treatment (72%). Those with partial response (24%), mainly those associated with other cytopenias, required other lines of treatment (rituximab, mycophenolate, immunoglobulins). Complications (32%) and relapses (26%) were detected only in warm AIHA. Conclusions: Our case series confirms that AIHA is a very rare disease in childhood. Most cases evolve favorably, although up to a quarter of them require second lines of treatment and, in exceptional cases, they need very aggressive treatments. These latter cases generally correspond to patients who present more than one cytopenia in the course of the disease.

Exclusive breastfeeding (BF) is the best feeding option for infants under 6 months of age. After this age, complementary feeding with other solid foods and liquids is advised for 1 to 2 years in addition to breast milk or formula. It is well established that BF has physical and emotional health benefits for both mother and child, as it has been demonstrated that it improves long-term neurological development, decreases the incidence of chronic diseases such as obesity, and stimulates the immune system function in children, while also reducing sleep deprivation in mothers and strengthening the mother-child relationship.1

ABSTRACT Objective: The aim of this study was to evaluate the coronavirus disease 2019 (COVID-19) cutaneous manifestations described in pediatric patients and discuss their relevance for early diagnosis. Data source: The study consisted of a systematic review of original articles indexed in PubMed and Embase databases, as well as gray literature articles found through Google Scholar. A search strategy, based on PICO (Patient, Intervention, Comparison, Outcome) Tool, with the terms “child,” “infant,” “childhood,” “adolescents,” “teenagers,” “COVID-19,” “SARS-CoV-2,” and “skin manifestations,” was performed to optimize the findings. The study did not restrict any article regarding language. Data synthesis: Out of the 310 articles that initially met the inclusion criteria, 35 were selected for review, totalizing 369 patients. The most common COVID-19 cutaneous manifestations in children and adolescents were Chilblain-like lesions, presented in 67.5% of the cases, followed by erythema multiforme-like (31.7%) and varicella-like lesions (0.8%). The Chilblain-like lesions appeared 7.6 days (95%CI 7.4–7.8) after the viral infection and lasted for 17.5 days (95%CI 16.5–18.5), erythema multiforme-like lesions appeared in 9.5 days (95%CI 9–10) and lasted for 10.3 days (95%CI 9.1–11.5), and varicella-like lesions appeared in 12.3 days (95%CI 4–20.6) and lasted for 7 days. Conclusions: Knowledge of the different skin manifestations in children and adolescents with COVID-19 is essential for an early diagnosis and, consequently, the possibility of promptly care adoption as well as to interrupt the new coronavirus transmission chains in the current pandemic context.

Resumen: La hipertensión arterial es el principal factor de riesgo modificable para la enfermedad cardiovascular, ocupando el primer lugar entre las causas de pérdida de años de vida ajustados por discapacidad. En los últimos años la hipertensión arterial en niños y adolescentes ha ganado terreno en la medicina cardiovascular gracias a los avances en diversas áreas de la investigación fundamentalmente fisiopatológica y clínica. A pesar de los avances que se han llevado a cabo en los últimos años, la prevención, diagnóstico y tratamiento de la hipertensión arterial en niños y adolescentes todavía son susceptibles de mejorar. En este sentido cobra especial relevancia la medida correcta de la presión arterial que contempla una serie de elementos indispensables como son los dispositivos de medición, el procedimiento reglado y la interpretación de los resultados con base en percentiles según edad, sexo y talla. La disponibilidad de una calculadora de acceso libre facilita el diagnóstico y seguimiento de la hipertensión arterial https://hyperchildnet.eu/ Abstract: Arterial hypertension is the main modifiable risk factor for cardiovascular disease, occupying the first place among the causes of loss of life years adjusted for disability. In recent years, arterial hypertension in children and adolescents has gained ground in cardiovascular medicine thanks to progress made in several areas, fundamentally in pathophysiological and clinical research. Despite the advances that have been made in recent years, the prevention, diagnosis and treatment of high blood pressure in children and adolescents still have room for improvement. In this sense, the correct measurement of blood pressure is especially important, since it includes a series of essential elements such as the measurement devices, the regulated procedure and the interpretation of the results based on percentiles according to age, gender and height. The availability of a free access calculator facilitates the diagnosis and monitoring of arterial hypertension https://hyperchildnet.eu/.

Abstract Objective: To evaluate the quality of children’s menus in restaurants located in shopping malls. Methods: To select the sample, restaurants from 30% of shopping malls in each region of the city of São Paulo were included and, after considering only one restaurant per chain, the total was limited to 151 restaurants, 30.2% of which (n=35) presented a children’s menu. Data were collected through a form on Google Forms. Results: Of the restaurants with children’s menu, 60% (n=21) were conventional restaurants and 40% (n=14) takeaway/fast-food. The large number of chains present in most visited malls showed a democratization of the way of eating, with popular and accessible menus, regardless of social status. Most of the analyzed foods were cooked (41.5%). Most preparations did not use grease in their preparation and there was a notable lack of fruit and vegetables (FV) (4%). Sweet desserts were offered in 11.4% of the places and 20% included gifts with meals. Conclusions: The scarce offer of children’s menus, few options and low FV offer indicate the need for a new look at the development of children’s menus and a greater integration between the possibilities of restaurants and the expectations of parents and children, in the challenge of integrating the relationship between the supply of new foods that promote healthier habits and their consumption.

Abstract Objective: This study aims to present standard reference for values of maximum respiratory pressures of healthy schoolchildren, according to gender. Methods: This is a cross-sectional study involving healthy children aged 7–10 years. Data of body mass and height were evaluated to calculate body mass index (BMI). In addition, forced expiratory volume in 1 second (FEV1) and maximal expiratory pressure values were evaluated according to the American Thoracic Society. The maximal inspiratory pressure (MIP) and data of maximal expiratory pressure (MEP) obtained in the study showed normal distribution and curves were built by the Lambda–Mu–Sigma (LMS) method, as well as the values of MIP and MEP percentiles 3, 10, 25, 50, 75, 90, and 97 for each gender. Results: MIP and MEP data were collected from 399 schoolchildren. All schoolchildren in the sample had adequate FEV1 and BMI. The study showed an increase in respiratory pressure values with age progression. The MIP and MEP values of girls were of 53.4±11.0 and 61.8±12.5cmH2O, respectively, and those of boys were 59.9±13.6 and 69.6±15.7cmH2O, respectively. Conclusions: Normal curves and percentiles were developed for MIP and MEP values of healthy schoolchildren. The extreme percentiles (3rd and 97th) were determined, and a specific graph was elaborated for each group. These graphs may help clinical follow-up and therapeutic monitoring of different pediatric populations.

Abstract Objective: To describe the characteristics of stage-5 chronic kidney disease (CKD) children and adolescents undergoing renal replacement therapy (RRT) in Amazonas, Brazil, estimating the frequencies of current and new cases, describing the presence of anemia and bone metabolism disorders. Methods: Thirty-five patients aged 7 to 19 years-old on hemodialysis (HD) or peritoneal dialysis (PD) were studied between June 2018 and April 2019. The frequencies of current and new cases were estimated based on the 0 to 19 years-old population of Amazonas, in the same period. Data were collected about the underlying cause and diagnosis of CKD, dialysis, and biochemical analysis. Results: The frequencies of current and new cases were 24 and 15 patients per million people of compatible age (pmpca), respectively. The causes of CKD were nephrotic syndrome (22.8%), nephritic syndrome (14.3%), and neurogenic bladder (14.3%); in 48.6%, the cause was unknown/not investigated. Ten patients underwent renal biopsy, seven with segmental and focal glomerulosclerosis. The majority (80%) were on HD, with an average kt/V of 1.4, and in 51.4% the vascular access was the double lumen catheter. Hypocalcemia was found in 82.8% of patients, hyperphosphatemia in 57.2%, vitamin D insufficiency or deficiency in 60%, and altered parathyroid hormone values in 48.6%. Hemoglobin was low in 80%, with absolute/functional iron deficiency in 28.6%. Conclusions: In children and adolescents of Amazonas, Brazil, we found 24 pmpca with stage-5 CKU currently in RRT and 16.3 pmpca per year of new cases requiring RRT. Most patients were adolescents on HD, half without a causal diagnosis of CKD, with a high frequency of anemia and bone metabolism disorder.

Abstract Objective: To systematically review the literature on the instruments used to assess excessive daytime sleepiness (EDS) in Brazilian children and adolescents. Data source: A systematic review of the literature was performed in the databases MEDLINE PubMed, Scopus, Web of Science, LILACS, Scielo and SPORTDiscus, with no time limit for searches. The eligibility criteria were studies published in English and Portuguese, original articles that used questionnaires to assess EDS and whose sample consisted of Brazilian children and/or adolescents. As search strategy, the following terms were combined with Boolean operators “OR” and/or “AND”: drowsiness, disorders of excessive somnolence, excessive daytime sleepiness, day sleepiness, midday sleepiness, daytime sleepiness, adolescents, Brazil, Brazilian adolescents, and children. Data synthesis: Sixteen articles were selected, in which nine different instruments were applied to 8.240 children and adolescents from the South, Southeast, Midwest and Northeast regions of Brazil. The mean of methodological quality of studies was 16.1±1.9 points. The instruments most frequently used were the Pediatric Daytime Sleepiness Scale (PDSS) and Karolinska Sleepiness Scale (KSS), but only PDSS was shown reliable to assess EDS in Brazilian children and adolescents. Conclusions: The PDSS was the only instrument considered reliable to assess EDS in Brazilian children and adolescents. Further research on EDS in children and adolescents are suggested to perform the validation of other instruments for Brazil and present internal consistency values.

Resumen: Introducción: El fenotipo obeso metabólicamente sano (FOMS) define a los pacientes obesos que tienen preservada la sensibilidad a la insulina y que no presentan complicaciones metabólicas. Este fenotipo se asocia a menor riesgo de padecer enfermedad cardiovascular y diabetes tipo 2 en la edad adulta. Objetivos: Determinar la prevalencia del FOMS y del fenotipo obeso con riesgo metabólico (FORM) en una cohorte de niños y adolescentes obesos y establecer la capacidad predictiva del índice de masa triponderal (IMT) y de otros parámetros antropométricos para identificar a estos pacientes. Pacientes y métodos: Estudio transversal de 239 pacientes (125 varones) obesos de 8 a 18 años de edad. El 45,9% presentan obesidad grado 3. Se utilizan las curvas ROC para buscar el mejor punto de corte para: IMT, índice de masa corporal (IMC), valor z-score del IMC (zsIMC) e índice cintura/talla (ICT). Componentes FOMS: glucemia plasmática, triglicéridos plasmáticos, colesterol HDL y presión arterial. Resultados: La prevalencia del FORM en nuestra cohorte es del 62,4%, sin que se observen diferencias entre sexos, incrementándose con la edad y con el grado de obesidad. El IMT tiene una sensibilidad de 75,8 y una especificidad de 42,2 para identificar los pacientes FORM. El mejor punto de corte para el IMT es 18,7 kg/m3, para el IMC 30,4 kg/m2, para el zsIMC +3,5 DE y para el ICT 0,62. Conclusiones: La precisión diagnóstica del IMT para identificar niños y adolescentes con riesgo metabólico es similar al IMC y al ICT. No obstante, su cálculo es más sencillo y además facilita y simplifica la categorización del grado de obesidad en ambos sexos. Abstract: Introduction: The metabolically healthy obese (MHO) phenotype defines obese patients who have preserved insulin sensitivity and absence of metabolic complications. This phenotype is associated with a lower risk of cardiovascular disease and type 2 diabetes in adulthood. Objectives: To determine the prevalence of MHO and the metabolically unhealthy obesity (MUO) phenotype in a cohort of obese children and adolescents and to establish the predictive capacity of the tri-ponderal mass index (TMI) and other anthropometric parameters in order to identify these patients. Patients and methods: A cross-sectional study was conducted on 239 obese patients (125 males) from 8 to 18 years of age. Grade 3 obesity was present in 45.9% of the patients. ROC curves were used to find the best cut-off point for: TMI, body mass index (BMI), BMI z-score (BMIzs), and waist/height index (WHI). MHO components: plasma blood glucose, plasma triglycerides, HDL-cholesterol, and blood pressure. Results: The prevalence of MUO in the study cohort was 62.4%. No differences between genders were observed, and it was increasing with the age and obesity degree. The TMI has a sensitivity of 75.8 and a specificity of 42.2 to identify the MUO patients. The best cut-off point for TMI is 18.7 kg/m3, for BMI it was 30.4 kg/m2, for BMIzs +3.5 SD, and 0.62 for WHI. Conclusions: The diagnostic accuracy of TMI in identifying obese adolescents with metabolic risk was similar to BMI and WHI. However, the TMI is much simpler to use and simplifies the categorization of the obesity in both genders.

Resumen: Introducción: El objetivo de este estudio ha sido analizar el estado de nutrición, la alimentación y las complicaciones digestivas de los niños que precisan técnicas de depuración extrarrenal continua (TDEC). Material y métodos: Estudio retrospectivo realizado sobre una base de datos prospectiva de los niños tratados con TDEC entre 2013 y 2017. Se analizaron las características de los pacientes, la técnica de depuración, el tipo de nutrición, el aporte calórico y proteico, las complicaciones digestivas y la evolución clínica. Resultados: Sesenta y cinco niños (61,5% varones) fueron tratados con TDEC y 24 (37%) precisaron soporte con oxigenación con membrana extracorpórea. Un 27,7% tenían un peso inferior al percentil 3 y un 48,4% una talla inferior al percentil 3. Al inicio de la TDEC 31 niños (47,7%) recibían nutrición enteral y 52 (80%) al final de la misma. La nutrición enteral fue por sonda transpilórica en el 76% de los casos. La mediana de aporte calórico fue de 63 kcal/kg/día y la del aporte proteico de 1,6 g/kg/día. Cuarenta y ocho pacientes (73,8%) presentaron complicaciones digestivas: 29 (44,6%) distensión gástrica o restos gástricos excesivos, 22 (33,8%) estreñimiento, 8 (12,3%) vómitos y 4 (6,1%) diarrea. Un paciente con oxigenación con membrana extracorpórea presentó isquemia intestinal. En 3 pacientes (4,6%) se tuvo que suspender la nutrición enteral por complicaciones. No existió relación entre las complicaciones y el tipo de alimentación o la asistencia en oxigenación con membrana extracorpórea. Conclusiones: Un elevado porcentaje de niños tratados con TDEC presentan malnutrición, pero la mayoría pueden ser alimentados con nutrición enteral. Aunque el porcentaje de complicaciones digestivas es elevado, en pocos pacientes se tiene que suspender la nutrición enteral. Abstract: Introduction: The aim of this study was to analyse the nutritional state, diet and gastrointestinal complications of children that require continuous renal replacement therapy (CRRT). Material and methods: A retrospective analysis of a database, which included the information about patients who required CRRT between the years 2013 and 2017. Data were collected on the replacement technique, type of nutrition, calorie and protein intake, gastrointestinal complications, and clinical course. Results: A total of 65 children (61.5% male) were treated with CRRT, and 24 patients (37%) also needed ECMO support. Just over one-quarter (27.7%) of patients had a weight less than P3, and 48.4% of them a height less than P3. At the beginning of the technique, 31 children (47.7%) received enteral nutrition, at the end, there were 52 patients receiving enteral nutrition (80%). The transpyloric tube was used to provide nutrition in 76% of the cases. The median caloric intake was 63 kcal/kg/day, and the protein intake was 1.6 g/kg/day. There were gastrointestinal difficulties during the process in 48 patients (73.8%), with 29 (44.6%) patients being diagnosed with gastric distension or excessive gastric remains, 22 (33.8%) with constipation, 8 (12.3%) with vomiting, and 4 (6.1%) diarrhoea. One patient treated with ECMO presented with intestinal ischaemia. Enteral nutrition was cancelled in 3 patients (4.6%) due to the complications. There was no relationship between complications and type of diet or ECMO assistance. Conclusions: A high percentage of children treated with CRRT showed undernutrition but they had adequate tolerance to the enteral nutrition. Although the gastrointestinal complications percentage was high in few subjects, these complications are the reason why enteral nutrition was stopped.

Resumen: Introducción y objetivos: La cuantificación del tamaño del ventrículo derecho (VD) es crucial en determinadas cardiopatías congénitas. Para su evaluación se recomiendan distintas técnicas de imagen, siendo más accesible la medición de diámetros ventriculares mediante ecocardiografía. En pediatría la normalización de parámetros ecocardiográficos es compleja, escasa y heterogénea. El objetivo de este estudio consistió en establecer Z-score de diámetros de VD fiables y reproducibles capaces de predecir valores de referencia en población pediátrica sana española. Métodos: Estudio multicéntrico prospectivo de 661 pacientes sanos (edades 0-18 años, 43,5% mujeres). Los diámetros ecocardiográficos del VD se relacionaron con variables biométricas mediante distintas ecuaciones de regresión. Para su estandarización se analizaron factores de confusión (sexo, edad y variabilidad inter/intraobservador), heterocedasticidad y residuos (test Saphiro-Wilk y Breusch-Pagan). Resultados: Se obtuvieron curvas de normalidad (Z-score) para cada diámetro del VD que permitieron predecir el valor medio de cada diámetro en función de la edad, peso, talla y distintas superficies corporales. La superficie corporal según fórmula de Haycock ofreció un excelente ajuste para los distintos diámetros basal, medial y longitudinal (R2 0,81; 0,82; 0,9). Los factores de confusión no aportaron cambios significativos, por lo que no fueron incluidos en los modelos finales (variabilidad inter- e intraobservador, CCI > 0,9). Conclusiones: Se brindan valores de referencia de diámetros VD de población pediátrica sana. Las curvas de Z-score ofrecidas cubren una importante carencia en cardiología pediátrica y son aplicables a todos los grupos de edad para evaluar el tamaño del VD, de gran interés clínico en la práctica diaria. Abstract: Introduction and objectives: Right ventricle (RV) measurements are crucial for certain congenital heart diseases and various cardiovascular conditions. Echocardiographic RV diameters are especially useful for its assessment. Paediatric echocardiographic data standardisation in normal subjects is complex, scarce, and heterogeneous. The aim of this study was to establish reliable and reproducible echocardiographic reference values (Z-score) of RV diameters in a healthy Spanish paediatric cohort. Methods: A multicentre study was conducted on 661 healthy subjects (age range 0-18 years, 43.5% female). Several regression models were tested to examine the relationship between RV diameters and biometric variables. Heteroscedasticity and residual associations (Shapiro-Wilk and Breusch-Pagan tests) and confounding factors (gender, age, inter/intraobserver agreement) were considered for an unbiased standardisation. Results: Structured Z-scores were computed for each RV diameter. Predicted mean value for each diameter was determined according to age, weight, height, and different body surface area. The Haycock formula provided the best fit for basal, midcavity, and longitudinal diameters (R2 0.81; 0.82; 0.9). Confounders were not significant, and therefore not included in final models (inter/intraobserver agreement > 0.9). Conclusions: This study reports reference values for echocardiographic RV diameters from a Spanish healthy paediatric cohort using a rigorous statistical design. These Z-scores partly cover a gap in current paediatric cardiology and represent a relevant diagnostic tool for clinical practice, as well as a useful guide to decision making at any paediatric stage.

Resumen: Introducción: En niños, los resultados que muestran asociación entre la presencia de hiperlaxitud articular generalizada (HAG) y trastornos digestivos funcionales (TDF) son limitados y polémicos. Objetivo: Determinar la asociación entre HAG y TDF y la búsqueda de factores de riesgo para la HAG en niñas de una Institución Educativa Pública de Tuluá, Colombia. Pacientes y métodos: Las escolares completaron el Cuestionario de Roma IV para identificar TDF. Cada niña con diagnóstico de algún TDF fue apareado con control sano de la misma edad. La laxitud articular se evaluó según el puntaje de Beighton y se consideró HAG cuando fue ≥ 4. Se comparó la prevalencia de HAG en niñas con y sin TDF. Resultados: En el estudio participaron 921 niñas entre los 10 y 18 años de edad. Doscientas diecinueve (23,8%) niñas presentaron algún TDF. Fueron analizadas 169 niñas con TDF y 169 niñas controles sanas. No hubo diferencias significativas en la HAG entre las niñas con y sin diagnóstico de algún TDF (OR=1,12 IC95%=0,71-1,77 p=0,5838) ni se presentaron factores de riesgo. Conclusión: En este estudio no se logró determinar asociación entre HAG y la presencia de TDF, ni ningún factor de riesgo. Abstract: Introduction: Although results show an association between the presence of generalised joint hypermobility (GJH) and functional gastrointestinal disorders (FGIDs) in children, they are limited and controversial. Objective: To determine the association between GJH and FGIDs and the search for risk factors for GJH in girls from a Public Educational Institution of Tuluá, Colombia. Patients and methods: The students completed the Rome IV Questionnaire to identify FGIDs. Each girl with a diagnosis of some FGIDs was matched with a healthy control of the same age. Joint laxity was assessed according to the Beighton score and was considered as GJH when it was ≥ 4. The prevalence of GJH was compared in girls with and without FGIDs. Results: Out of a total of 921 girls between 10 and 18 years of age that participated in the study, 219 (23.8%) of them had some FGIDs. The analysis was performed on a total of 169 girls with FGIDs and 169 healthy control girls. There were no significant differences in GJH between girls with and without a diagnosis of some FGIDs (OR=1.12: 95% CI; 0.71-1.77, P=.5838), nor were there any risk factors. Conclusion: In this study, no relationship or any risk factor was found between GJH and the presence of FGIDs.

Resumen: Introducción: La lesión hepática inducida por fármacos debida a quimioterapia es una causa importante de morbilidad en enfermos oncológicos aunque sus manifestaciones clínicas son poco conocidas. Objetivo: El objetivo del presente estudio fue determinar las características (formas de presentación, gravedad y tipo de lesión) de la hepatotoxicidad por quimioterapia en niños tratados por cáncer. Pacientes y método: Se incluyó en el estudio a un total de 22 enfermos oncológico en los que, tras descartar otras causas de aumento de transaminasas (infecciosa, metabólica, autoinmune o hereditaria), se concluye, según la escala de causalidad CIOMS, que se trata de un episodio posible, probable o definido de lesión hepática por fármacos. Resultados: Todos los niños tuvieron más de un episodio de hepatotoxicidad, en total se analizan 98 episodios. Metotrexato fue el fármaco implicado con mayor frecuencia. El patrón histológico de daño predominante fue hepatocelular. Solo 2 episodios fueron clasificados de graves. Conclusiones: La hepatotoxicidad idiosincrásica por quimioterapia es frecuente, la tendencia es a la recidiva con la reexposición y, aunque no suele tener consecuencias importantes, la elevada frecuencia hace aconsejable establecer algoritmos de seguridad estandarizados con controles muy estrictos de enzimas hepáticas durante los períodos de alto riesgo de quimioterapia. Abstract: Introduction: Drug-induced liver injury due to chemotherapy is an important cause of morbidity in cancer patients, although its clinical manifestations are poorly understood. Objective: The objective of the present study was to determine the characteristics (forms of presentation, severity, and type of injury) of hepatotoxicity due to chemotherapy in children treated for cancer. Patients and method: A total of 22 oncological patients were included in the study, after ruling out other causes of increased transaminases (infectious, metabolic, autoimmune, or hereditary), according to the CIOMS causality scale, it is concluded that it was a possible, probable or definite episode of hepatic injury by drugs. Results: All children had more than one episode of hepatotoxicity, and a total of 98 episodes are analysed. Methotrexate was the most commonly implicated drug. The histological pattern of predominant damage was hepatocellular. Only 2 episodes were classified as serious. Conclusions: Idiosyncratic hepatotoxicity due to chemotherapy is frequent, with a tendency to relapse with re-exposure. Although it does not usually have important consequences, the high frequency makes it advisable to establish standardised safety algorithms with very strict monitoring of liver enzymes during high periods of risk in chemotherapy.

Resumen: Objetivo: Describir los modos de muerte de los niños en las Unidades de Cuidados Intensivos Pediátricos (UCIP) en España y analizar las características de aquellos que fallecen tras decidir una limitación del esfuerzo terapéutico (LET). Métodos: Estudio retrospectivo multicéntrico mediante revisión de informes de alta de los pacientes fallecidos en 8 UCIPs españolas entre 2011 y 2017. Resultados: Se recogieron 337 fallecimientos, de los cuales 151 (50,7%) ocurrieron durante una decisión de LET, mientras que 114 (33,8%) fueron por reanimación cardiopulmonar indicada pero fallida (FRCP) y 52 (15,4%) por muerte cerebral. Los motivos más frecuentes de ingreso en los niños que luego fallecieron fueron cardíacos (32,6%) y respiratorios (22,6%). El 25,5% (86 casos) habían tenido ingresos previos, 253 (75.1%) padecían enfermedades crónicas y 78 (23,2%) presentaban al ingreso una discapacidad grave. La LET fue más frecuente en estos niños y en aquellos con cáncer. La LET consistió fundamentalmente en no iniciar la RCP en caso de parada cardíaca (45%), retirada de la ventilación mecánica (31.6%) y retirada de fármacos vasoactivos (21.6%). Conclusiones: En el momento actual al menos la mitad de los niños que fallecen en una UCIP en España lo hacen tras una decisión de LET, que es más frecuente en aquellos con ingresos previos, discapacidad grave, enfermedad crónica u oncológica. Los profesionales debemos ser conscientes de esta realidad y prepararnos para compartir las decisiones con las familias y ofrecer la mejor calidad asistencial posible a los niños al final de su vida. Abstract: Objective: To describe the different types of child deaths in Paediatric Intensive Care Units (PICU) in Spain, and to analyse the characteristics of those dying from a limitation of therapeutic efforts (LET). Method: A multicentre retrospective study by conducted by reviewing the hospital discharge reports corresponding to deceased patients in 8 Spanish PICUs between 2011 and 2017. Results: A total of 337 deaths were recorded, of which 151 (50’7%) occurred after a decision of LET, while 114 (33’8%) were due to an indicated, but failed, cardiopulmonary resuscitation, and 52 (15.4%) were due to brain death. The most common causes of hospital admission for those children that finally died were a heart-related problem (32.6%) or a respiratory problem (22.6%).A total of 86 cases (25.5%) had a previous hospital admission, with 253 cases (75%) suffering from some type of chronical illness, and 78 (23%) had a serious disability at the time of the admission.LET cases were more frequent among these children and those suffering from cancer. The predominant LET type consisted in: not starting the CPR in the event of a cardiac arrest (45%), withdrawal of the respiratory support (31.6%), and withdrawal of vasoactive drugs (21.6%). Conclusions: At the present time, at least half of the children dying in a PICU in Spain die after a LET decision, which is more frequent in those patients with previous hospital admissions, with a serious incapacity, and chronic or oncological disease. Health professionals should be aware of this situation, and be prepared to share decisions with the families, and to offer children at the end of their life the best possible caring quality.

Abstract Objective: To analyze factors associated with the incomplete timely vaccination schedule up to 12 months of age, in children born in 2015, in the municipality of Rondonópolis, Mato Grosso. Methods: Population survey, August/2017 to February/2018, which used the method proposed by the World Health Organization to collect information about routine vaccination. For analysis of the associated factors, the recommendations of the National Immunization Program of the Ministry of Health were considered. Univariate analysis was performed, and the factors associated with p