Search

Introduction: Competence in neonatal care is especially important for military pediatricians because military pediatricians can be asked to serve in remote duty locations with limited resources. We sought to understand how this competence is defined, developed, and assessed by military pediatric training programs., Materials and Methods: After Institutional Review Board approval was obtained, we interviewed educators and recent graduates from every pediatric military training program to construct a shared definition of competence. We then used Kern's Six Steps for curriculum development to understand how competence is taught and assessed., Results: Participants felt that competence for military pediatricians in the neonatal setting meant that learners should be able to provide a full spectrum of newborn care in any military setting. Participants confirmed that this competence was particularly important for military pediatricians because of the possibility of remote duty locations. Participants felt that specific knowledge, skills, and attitudes supported competence. Knowledge domains include distinguishing normal newborns from abnormal newborns, managing normal newborn care, managing common newborn abnormalities, and creating a safe escalation plan for complicated or uncommon newborn abnormalities. Specific skills that support competence are newborn resuscitation, delivery of effective ventilation, and neonatal circumcision. Specific attitudes that support competence are, understanding the personal limits of knowledge and understanding the resources for escalation of care. Educators use a variety of modalities to teach toward competence, including the structured curricula, bedside teaching, and simulation. According to participants, the assessment of learners occurs primarily through narrative assessment and feedback but would ideally occur through direct observation., Conclusions: Competence in the neonatal setting is particularly important for military pediatricians. Essential skills undergo differential assessment and current assessment methods differ from ideal assessment methods. Future work should focus on how these facets can support a unified curriculum in newborn medicine., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Despite stewardship efforts, laboratory testing overuse persists across medicine., Objectives: To understand laboratory stewardship perceptions and testing patterns at a tertiary care pediatric hospital so that we could identify potential improvement opportunities., Methods: An electronic survey exploring laboratory stewardship was sent to all pediatric medicine resident and staff physicians. Laboratory testing data were also assessed for patterns of testing and overuse., Results: The survey response rate was 54% (43/80). The results indicated good familiarity with stewardship but poor familiarity with testing specifics (eg, cost). A mobile reference application was the most preferred quality improvement intervention, and online modules were the least desired. Overuse was apparent, with as many as 53% of laboratory tests being repeated within 7 days and only half of repeated tests subsequently yielding abnormal results., Conclusions: Altogether, the data we collated demonstrated poor understanding of laboratory stewardship and substantial repeat testing with few abnormal results. These study findings suggest that laboratory stewardship is lacking at our center, and that multiple improvement opportunities exist., (© The Author(s) 2024. Published by Oxford University Press on behalf of American Society for Clinical Pathology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Quality criteria and certification possibilities for paediatric oncology centres vary between countries and are not widely used. An overview of the type and how quality criteria and certifications are used in countries with highly developed healthcare systems is missing. This international cross-sectional survey investigated the use of quality criteria for paediatric oncology centres and whether certification is possible. We sent an online survey to paediatric oncologists from 32 countries worldwide and analysed the survey results and provided regional or national documents on quality criteria and certification possibilities descriptively. Paediatric oncologists from 28 (88%) countries replied. In most countries, the paediatric oncology centres were partly or completely grown historically (75%), followed by the development based on predefined criteria (29%), and due to political reason (25%), with more than one reason in some countries. Quality criteria are available in 20 countries (71%). We newly identified or specified five quality criteria, in addition to those from a previously performed systematic review. Certification of paediatric oncology centres is possible in 13 countries (46%), with a specific certification for paediatric oncology in seven, and a mandatory certification in three of them. The use of quality criteria and certification possibilities are heterogeneous, with quality criteria being more frequently used than certifications. Our study provides an overview of country-specific documents and links with quality criteria, and centre certification possibilities. It can serve as a reference document for stakeholders and may inform an international harmonization of quality criteria and centre certification between countries with similar healthcare systems., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Quality in Health Care.)

This document has been developed to provide a guide for basic and advanced reporting in paediatric echocardiography. Furthermore, it aims to help clinicians in the interpretation of echocardiographic measurements and functional data for estimating the severity of disease in different paediatric age groups. The following topics will be reviewed and discussed in the present document: (i) the general principle in constructing a paediatric echocardiographic report, (ii) the basic elements to be included, and (iii) the potential and limitation of currently employed tools used for disease severity quantification during paediatric reporting. A guide for the interpretation of Z-scores will be provided. Use and interpretation of parameters employed for quantification of ventricular systolic function will be discussed. Difficulties in the adoption of adult parameters for the study of diastolic function and valve defects at different ages and pressure and loading conditions will be outlined, with pitfalls for the assessment listed. A guide for careful use of prediction scores for complex congenital heart disease will be provided. Examples of basic and advanced (disease-specific) formats for reporting in paediatric echocardiography will be provided. This document should serve as a comprehensive guide to (i) structure a comprehensive paediatric echocardiographic report; (ii) identify the basic morphological details, measures, and functional parameters to be included during echocardiographic reporting; and (iii) correctly interpret measurements and functional data for estimating disease severity., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objective: High demand for pediatric neuropsychological care has highlighted the time- and resource-intensive nature of traditional comprehensive evaluations. Emerging care models address these constraints by facilitating tiered neuropsychological services provided in various contexts, including multidisciplinary clinics (MDCs). We aim to demonstrate feasibility and acceptability of tiered neuropsychological care in MDCs through examples from a single institution., Methods: A review of all current MDC practices at a tertiary pediatric care center was conducted to describe clinic workflow, services provided, and triage strategies. Pediatric neuropsychologists (n = 5) and other health care providers (n = 31) completed a survey focused on experience with neuropsychology consultation in MDCs., Results: Neuropsychologists provided care in 11 MDCs, including universal monitoring with consultative interviews and questionnaires, as well as targeted screening. Neuropsychologists (89%) and other health professionals (100%) reported that tiered neuropsychological services improved patient care within MDCs. Other health professionals reported utilizing results from neuropsychology MDC care to inform their clinical approach (48-90%), referrals (58%), and treatment or surveillance decisions (55-71%)., Conclusion: Tiered neuropsychological care in pediatric MDCs is feasible, and provider experience ratings indicate high acceptability. Practical steps for development of MDCs are provided, including identifying teams, clinic goals and outcomes, operational logistics, and billing., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Metabolic syndrome is a cluster of cardio-metabolic risk factors associated with an increased risk of cardiovascular disease and type 2 diabetes. In the last two decades, several definitions of metabolic syndrome have been proposed for the pediatric population; all of them agree on the defining components but differ in the suggested criteria for diagnosis. This review aims to analyze the current diagnostic criteria of metabolic syndrome in pediatrics with reference to their feasibility and reliability in clinical practice., Methods: The systematic research was conducted from January 2003 to June 2020 through MEDLINE via PubMed, Cochrane Library and EMBASE databases., Results: After the selection phase, a total of 15 studies (182 screened) met the inclusion criteria and are reported in the present review. Twelve studies were cross-sectional, two were longitudinal and one was a consensus report. The sample population consisted of multiethnic group or single ethnic group, including Turkish, European, Asian and Hispanic subjects., Conclusions: To date, there is not a univocal, internationally accepted pediatric definition of metabolic syndrome, which guarantees a high sensitivity and stability of the diagnosis. The definition proposed by IDF results the most straightforward and easy to use in clinical practice, having the unquestionable advantage of requiring measurements quickly accessible in clinical practice, without the adoption of multiple reference tables. Further research is needed to validate a new version of such definition which includes the diagnostic cut-off points recently suggested by published guidelines.

Background: Currently, there are no European recommendations for the management of pediatric thyroid cancer. Other current international guidelines are not completely concordant. In addition, medical regulations differ between, for instance, the US and Europe. We aimed to develop new, easily accessible national recommendations for differentiated thyroid carcinoma (DTC) patients <18 years of age in the Netherlands as a first step toward a harmonized European Recommendation., Methods: A multidisciplinary working group was formed including pediatric and adult endocrinologists, a pediatric radiologist, a pathologist, endocrine surgeons, pediatric surgeons, pediatric oncologists, nuclear medicine physicians, a clinical geneticist and a patient representative. A systematic literature search was conducted for all existing guidelines and review articles for pediatric DTC from 2000 until February 2019. The Appraisal of Guidelines, Research and Evaluation (AGREE) instrument was used for assessing quality of the articles. All were compared to determine dis- and concordances. The American Thyroid Association (ATA) pediatric guideline 2015 was used as framework to develop specific Dutch recommendations. Discussion points based upon expert opinion and current treatment management of DTC in children in the Netherlands were identified and elaborated., Results: Based on the most recent evidence combined with expert opinion, a 2020 Dutch recommendation for pediatric DTC was written and published as an online interactive decision tree (www.oncoguide.nl)., Conclusion: Pediatric DTC requires a multidisciplinary approach. The 2020 Dutch Pediatric DTC Recommendation can be used as a starting point for the development of a collaborative European recommendation for treatment of pediatric DTC.

Objective: The need for personalization of the reference values of thyroid function tests has been previously suggested. We aimed at determining TSH reference values in a large cohort of children according to age, sex, BMI, and ethnicity., Design: A population-based cohort study., Methods: The study cohort included 75 549 healthy children aged 5-18 years. Data analyzed included age, gender, TSH, FT4 levels, BMI and ethnicity. Multivariate logistic regression analysis examined the associations between the study parameters., Results: TSH in the Jewish population is lower than in the non-Jewish population (median: 2.1 IU/L (IQR: 1.5) vs 2.2 IU/L (IQR: 1.5), P < 0.0001). TSH is significantly affected by BMI for children defined as underweight, normal weight, overweight or obese, levels increased as weight diverged from the normal range (median levels: 2.1 IU/L (IQR: 1.4), 2.0 IU/L (IQR: 1.3), 2.1 IU/L (IQR: 1.4), 2.4 (IQR: 1.5), respectively, P < 0.001). The 2.5 percentile is affected by gender and BMI (P < 0.02 and P < 0.001, respectively), while the 97.5 percentile is affected by ethnic origin and BMI (P < 0.001 for both). New TSH reference intervals (RI) adjusted according to BMI and ethnicity are suggested. Comparison of the old and new RI demonstrate the significance of RI personalization: 25.1% of the children with TSH levels above the old RI are within the new RI, while 2.3% of the children who were in the old RI are below the new RI., Conclusions: TSH reference values in children are affected by BMI and ethnicity. Reference values should be individualized accordingly to improve future clinical decision-making and treatment.

Background: Burns are a leading cause of global disease burden, with children in low- and middle-income countries (LMICs) disproportionately affected. Effective management improves outcomes; however, the availability of necessary resources in LMICs remains unclear. We evaluated surgical centres in LMICs using the WHO Surgical Assessment Tool (SAT) to identify opportunities to optimize paediatric burn care., Methods: We reviewed WHO SAT database entries for 2010-2015. A total of 1121 facilities from 57 countries met the inclusion criteria: facilities with surgical capacity in LMICs operating on children. Human resources, equipment and infrastructure relevant to paediatric burn care were analysed by WHO Regional and World Bank Income Classifications and facility type., Results: Facilities had an average of 147 beds and performed 485 paediatric operations annually. Discrepancies existed between procedures performed and resource availability; 86% of facilities performed acute burn care, but only 37% could consistently provide intravenous fluids. Many, particularly tertiary, centres performed contracture release and skin grafting (41%) and amputation (50%)., Conclusions: LMICs have limited resources to provide paediatric burn care but widely perform many interventions necessary to address the burden of burns. The SAT may not capture innovative and traditional approaches to burn care. There remains an opportunity to improve paediatric burn care globally., (© The Author(s) 2019. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Introduction: In 2011, the American Academy of Paediatrics (AAP) published revised health supervision guidelines for children with Down syndrome (DS). In the absence of South African guidelines, we described the health supervision received by children with DS at a rural regional hospital in the Western Cape, South Africa compared with the AAP guidelines., Methods: This was a 5-year retrospective description of the implementation of the 2011 AAP guidelines at the DS clinic at Worcester Provincial Hospital (WPH), specifically related to screening for and management of cardiac, thyroid, hearing and haematological disorders., Results: Sixty-two children received care at WPH DS clinic during the study period. Thirty-six (58%) children lived in Worcester while 26 (42%) children were referred from peripheral hospitals. The median age at first clinic visit was 0.5 years [inter-quartile range (IQR) 0.2-1.2], a total of 177 person-years of follow-up with a median duration of 1.8 years (IQR 0.3-4.8). Two deaths occurred during the study period. Forty-nine (79%) children had a screening echocardiogram performed, the median age at first echocardiogram was 0.8 years (IQR 0.2-1.4). Five (14%) children from WPH compared with no children from the peripheral hospitals received the echocardiogram within the first month of life in keeping with AAP guidance (p = 0.06). Those requiring cardiac surgery were operated on at a median age of 2 years (IQR 0.9-2.3). Compared with the AAP guidelines, within the first month of life 17 (27%) children had a thyroid screen, 20 (32%) children had a full blood count and 7 (11%) children had a hearing assessment., Conclusion: AAP guidelines for health supervision in DS are challenging to achieve within our local health system. The development and advocacy for a South African DS health supervision guideline that can be applied not only in specialist clinics might improve the care of children with DS., (© The Author(s) [2020]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: Patient experience is a core component of quality and service improvement. In the case of child health, it is parents who often report on their experiences of the child's healthcare. However, these parent experiences are rarely used to drive change. Our aim was to develop and implement the systematic collection of parent experience data across a range of cardiothoracic services, using quality improvement methodology to implement change., Design: Plan-Do-Study-Act methodology was used to develop parent-reported experience measures. Setting: Specialist children's hospital., Participants: Parents of children under the care of one of a number of cardiothoracic services at the hospital., Intervention(s): Completion of questionnaires about hospital experience comprising quantitative and qualitative questions., Main Outcome Measure(s): Response rates and completion of a specific-measurable-achievable-realistic-timely (SMART) action plan by the individual clinical teams., Results: During the first cycle 17 surveys were developed for different clinical services and questionnaires sent/given to 1876 parents. The overall response rate was 30% (15-100%). Clinical teams developed SMART plans following eight (47%) surveys; three teams have reviewed and reported back on their progress against their plan and started on the second cycle of questionnaires. Challenges included lack of resources (time, finances and electronic data collection tools) and problems with actioning SMART plans. However, teams engaged positively, recognizing the importance of parent experience and actively seeking solutions to problems., Conclusions: Parent-reported experience measures are practical and acceptable quality improvement tools in healthcare but challenges need to be addressed, primarily related to resources, training and sustainability., (© The Author(s) 2020. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To investigate the rounding of prescribed drug doses for paediatric administration., Methods: A cross-sectional medication chart review was conducted at a UK paediatric hospital. Proposed administration dose volumes were calculated for prescribed doses using available manufactured liquids measured with oral and intravenous syringes. Resulting percentage deviations in doses administered were calculated., Results: Of 2031 doses observed, 524 (25.8%) required rounding. The majority of which were for children aged 1-12 months. Twenty-seven rounded doses deviated from the prescribed dose by more than 10%., Conclusion: This study highlights the impact of dose-rounding in paediatrics and the need for standardisation., (© 2019 Royal Pharmaceutical Society.)

Background: Infectious complications of war wounds are a significant source of mortality and morbidity. Tactical Combat Casualty Care (TCCC) guidelines recommend prehospital moxifloxacin, ertapenem, or cefotetan for "all open combat wounds." We describe the prehospital administration of antibiotics to pediatric trauma patients., Methods: We queried the Department of Defense Trauma Registry for all pediatric subjects admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016., Results: During this time, there were 3,439 pediatric encounters which represented 8.0% of all admissions. Prehospital providers administered a total of 216 antibiotic doses to 210 subjects. Older children received antibiotics more frequently than younger children, were more likely to be male, located in Afghanistan, and injured by explosive with the majority surviving to hospital discharge. Cefazolin and ceftriaxone were the most frequently utilized antibiotics., Conclusions: The most frequently administered antibiotics were cephalosporins. TCCC recommended agents for adult prehospital wound prophylaxis were infrequently administered to pediatric casualties. Administration rates of pediatric prehospital wound prophylaxis may be improved with pediatric-specific TCCC guidelines recommending cephalosporins as first-line agents, fielding of a TCCC-oriented Broselow tape, and training prehospital providers on administration of antimicrobials., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The Advisory Committee on Immunization Practices (ACIP), a group of medical and public health experts, meets 3 times per year to develop recommendations for vaccine use in the United States. The group usually has 15 voting members, each of whom is appointed to a 4-year term. ACIP members and Centers for Disease Control and Prevention staff discuss the epidemiology of vaccine-preventable diseases and vaccine research, effectiveness, safety data, and clinical trial results. Representatives from the American Academy of Pediatrics (Y. A. M. and D. W. K.) and the Pediatric Infectious Diseases Society (S. T. O.) are present as liaisons to the ACIP. The ACIP met February 27 to 28, 2019, to discuss hepatitis A (HepA) vaccination of human immunodeficiency virus-infected persons, pneumococcal vaccination among adults aged 65 years or older, influenza vaccine effectiveness and safety, anthrax vaccination in the setting of a mass exposure, human papillomavirus vaccine, zoster vaccines, and Japanese encephalitis vaccine., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Estimate the impact on clinical practice of using a mobile device-based electronic clinical decision support (mECDS) tool within a national standardization project., Materials and Methods: An mECDS tool (app) was released as part of a change package to provide febrile infant management guidance to clinicians. App usage was analyzed using 2 measures: metric hits per case (metric-related screen view count divided by site-reported febrile infant cases in each designated market area [DMA] monthly) and cumulative prior metric hits per site (DMA metric hits summed from study month 1 until the month preceding the index, divided by sites in the DMA). For each metric, a mixed logistic regression model was fit to model site performance as a function of app usage., Results: An increase of 200 cumulative prior metric hits per site was associated with increased odds of adherence to 3 metrics: appropriate admission (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.06-1.18), appropriate length of stay (OR, 1.20; 95% CI, 1.12-1.28), and inappropriate chest x-ray (OR, 0.82; 95% CI, 0.75-0.91). Ten additional metric hits per case were also associated: OR were 1.18 (95% CI, 1.02-1.36), 1.36 (95% CI, 1.14-1.62), and 0.74 (95% CI, 0.62-0.89)., Discussion: mECDS tools are increasingly being implemented, but their impact on clinical practice is poorly described. To our knowledge, although ecologic in nature, this report is the first to link clinical practice to mECDS use on a national scale and outside of an electronic health record., Conclusions: mECDS use was associated with changes in adherence to targeted metrics. Future studies should seek to link mECDS usage more directly to clinical practice and assess other site-level factors., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: The European initiative Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) aimed to optimize care for children with rheumatic diseases. Systemic vasculitides are very rare in children. Consequently, despite recent advances, paediatric-specific information is sparse. The lack of evidence-based recommendations is an important, unmet need. This study aimed to provide recommendations for diagnosing and treating children with rare forms of childhood systemic vasculitis., Methods: Recommendations were developed by a consensus process in accordance with the European League Against Rheumatism standard operating procedures. A systematic literature review informed the recommendations, which were devised and evaluated by a panel of experts via an online survey, and two consensus meetings using nominal group technique. Recommendations were accepted when ⩾ 80% of experts agreed., Results: Ninety-three relevant articles were found, and 78 recommendations were accepted in the two consensus meetings. General, cross-cutting recommendations and disease-specific statements regarding the diagnosis and treatment of childhood-onset PAN, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, and Takayasu arteritis are provided., Conclusion: These Single Hub and Access point for paediatric Rheumatology in Europe recommendations were formulated through an evidence-based consensus process to support uniform, high-quality standard of care for children with rare forms of paediatric systemic vasculitis., (© The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: The European Single Hub and Access point for paediatric Rheumatology in Europe initiative aimed to optimize care for children with rheumatic diseases. Kawasaki disease (KD) is the most common cause of acquired heart disease in children and an important cause of long-term cardiac disease into adulthood. Prompt diagnosis and treatment of KD is difficult due to the heterogeneity of the disease but is crucial for improving outcome. To date, there are no European internationally agreed, evidence-based guidelines concerning the diagnosis and treatment of KD in children. Accordingly, treatment regimens differ widely. The aim of this study is to provide consensus-based, European-wide evidence-informed recommendations for diagnosis and treatment of children with KD., Methods: Recommendations were developed using the EULAR's standard operating procedures. An extensive systematic literature search was performed, and evidence-based recommendations were extrapolated from the included papers. These were evaluated by a panel of international experts via online surveys and subsequently discussed in three consensus meetings, using nominal group technique. Recommendations were accepted when ⩾80% agreed., Results: In total, 17 recommendations for diagnosis and 14 for treatment of KD in children were accepted. Diagnostic recommendations included laboratory and imaging workup for complete as well as incomplete KD. Treatment recommendations included the importance of early treatment in both complete and incomplete KD, use of intravenous immunoglobulin, aspirin, corticosteroids for high-risk cases, and other treatment options for those with resistant disease., Conclusion: The Single Hub and Access point for paediatric Rheumatology in Europe initiative provides international evidence-based recommendations for diagnosing and treating KD in children, facilitating improvement and uniformity of care., (© The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To present a guiding framework from the perspective of psychologists and technologists to develop effective mobile health (mHealth) interventions for pediatric populations., Methods: This topical review uses the IDEAS framework as an organizational method to summarize current strategies to conceptualize, design, evaluate, and disseminate mHealth interventions., Results: Incorporating theories of behavior change and feedback from target populations are essential when developing mHealth interventions. Following user-centered approaches that fully incorporate end users into design and development stages increases the likelihood that the intervention will be acceptable. Iterative design cycles and prototyping are important steps to gather user feedback to optimize an mHealth intervention. Broad sharing of knowledge and products generated during intervention development also is recommended. Assessment of behavioral principles, intervention components, or a full intervention package should be conducted to evaluate usability and efficacy., Conclusions: Pediatric health-care researchers and clinicians are increasingly using mHealth technology to target health behaviors and improve related outcomes. Pediatric psychologists should consider applying the design strategies outlined in the IDEAS framework to produce and disseminate mHealth interventions tailored to the specific needs of pediatric populations., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: We aimed to estimate and compare the ability of clinical tools for dengue diagnosis in a pediatric population., Methods: We prospectively evaluated episodes of acute febrile syndrome identified during the follow-up of a population-based cohort of children and adolescents residing in a dengue endemic city. We estimated the area under the receiver operating characteristic curve (AU-ROC) for dengue diagnosis of three clinical tools: the summation of manifestations of the WHO case definition, a predefined clinical scale and a logistic regression model obtained in this study., Results: We compared 219 dengue cases (confirmed by laboratory) and 286 patients with other febrile illnesses. In a multiple model, variables independently associated with dengue included the duration of fever, sleepiness and exanthema. Rhinorrhea, cough and minimal leukocyte count were inversely associated with dengue. This model reached an accuracy of 84.2% (for a cut-off of >0.5, sensitivity: 79.5%, specificity: 87.9%, positive predictive value: 83.7%, negative predictive value: 84.6%). The AU-ROC of this model (89.8%) was significantly higher than that obtained with either the predefined scale (82.1%) or the WHO definition manifestations (77%)., Conclusion: We validated a predefined scale and identified a multiple model suitable for the clinical diagnosis of dengue in the pediatric population., (© The Author(s) 2018. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

We assessed the accuracy of the Nelson, Best Guess and Advanced Pediatric Life Support (APLS) formulae in estimating weight in a suburban Cameroonian pediatric population, by conducting a cross-sectional study using 544 children aged 1 month to 12 years. Agreement between measured and estimated weight was poor for Nelson [concordance correlation coefficient (CCC) 0.89 (95% confidence interval (CI) 0.87-0.90)] and Best Guess [CCC 0.88 (95% CI 0.86-0.90)] formulae, and moderate for the APLS formula [CCC 0.92 (95% CI 0.90-0.93)]. On Bland-Altman analysis, all three methods had limits of agreement (APLS -42.2 to -45.6%, Best Guess -42.7 to -55.1%, Nelson -36.4 to -42.4%) above the -10 to -10% set as criteria for clinical agreement. Conclusively, the accuracy of all three formulae was clinically unacceptable in our study population, suggesting the need for studies aimed at deriving more accurate formulae adapted for use in our context.

Background: The use of hypnosis in children has been described more than two centuries ago, with a more recent research and clinical application. There is currently a good level of evidence for the efficacy of clinical hypnosis in children for minor surgery, medical procedures or pain management. The use of clinical hypnosis, in paediatric cardiology, for invasive procedures such as transesophageal echocardiography, has not been reported., Aims: This study evaluated the feasibility of clinical hypnosis in children undergoing transesophageal echocardiography., Method: This prospective, non-randomised, cross-sectional study was carried out over 24 months in a paediatric cardiology referral centre. All children aged 10-18 years requiring a transesophageal echocardiography examination, outside the operating room and the catheterisation laboratory, were eligible for the study. Children and families could choose between transesophageal echocardiography under clinical hypnosis or under general anaesthesia (<15 years) or sedation (⩾15 years)., Results: We included 16 children aged 11-18 years (seven girls, mean age 14.1±2.5 years). The hypnotic state was achieved for 15 out of the 16 participating children (94%). The transesophageal echocardiography examination could be completely achieved with a full diagnosis for 15 out of 16 children (94%). In all cases, a transesophageal echocardiography examination under clinical hypnosis provided a complete diagnosis., Conclusion: This study demonstrated that hypnosis was feasible and effective for transesophageal echocardiography in adolescents and might be a good alternative to general anaesthesia. Further study with larger numbers of subjects and more diverse congenital cardiac conditions are needed to confirm the results in a more diverse sample.

Introduction: This study aims to describe the quantity and satisfaction current residents and experienced pediatricians have with graduate medical education on transitioning medically complex patients to adult care. There is an increasing need for transitioning medically complex adolescents to adult care. Over 90% now live into adulthood and require transition to adult healthcare providers. The 2010 National Survey of Children with Special Health Care Needs found that only 40% of youth 12-17 yr receive the necessary services to appropriately transition to adult care., Materials and Methods: Prospective, descriptive, anonymous, web-based survey of pediatric residents and staff pediatricians at Army pediatric residency training programs was sent in March 2017. Questions focused on assessing knowledge of transition of care, satisfaction with transition training, and amount of education on transition received during graduate medical education training., Results: Of the 145 responders (310 potential responders, 47% response rate), transition was deemed important with a score of 4.3 out of 5. The comfort level with transition was rated 2.6/5 with only 4.2% of participants receiving formal education during residency. The most commonly perceived barriers to implementing a curriculum were time constraints and available resources. Of the five knowledge assessment questions, three had a correct response rate of less than 1/3., Conclusions: The findings show the disparity between the presence of and perceived need for a formal curriculum on transitioning complex pediatric patients to adult care. This study also highlighted the knowledge gap of the transition process for novice and experienced pediatricians alike.

Background: Infantile haemangiomas (IH) are the most common vascular tumours of infancy. Despite their frequency and potential complications, there are currently no unified U.K. guidelines for the treatment of IH with propranolol. There are still uncertainties and diverse opinions regarding indications, pretreatment investigations, its use in PHACES (posterior fossa malformations-haemangiomas-arterial anomalies-cardiac defects-eye abnormalities-sternal cleft and supraumbilical raphe) syndrome and cessation of treatment., Objectives: To provide unified guidelines for the treatment of IH with propranolol., Methods: This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face-to-face multidisciplinary panel meeting and anonymous voting., Results: The expert panel achieved consensus on 47 statements in eight categories, including indications and contraindications for starting propranolol, pretreatment investigations, starting and target dose, monitoring of adverse effects, the use of propranolol in PHACES syndrome and how to stop treatment., Conclusions: These consensus guidelines will help to standardize and simplify the treatment of IH with oral propranolol across the U.K. and assist in clinical decision-making., (© 2018 British Association of Dermatologists.)

Objective: Implementing evidence-based practices requires a multi-faceted approach. Electronic clinical decision support (ECDS) tools may encourage evidence-based practice adoption. However, data regarding the role of mobile ECDS tools in pediatrics is scant. Our objective is to describe the development, distribution, and usage patterns of a smartphone-based ECDS tool within a national practice standardization project., Materials and Methods: We developed a smartphone-based ECDS tool for use in the American Academy of Pediatrics, Value in Inpatient Pediatrics Network project entitled "Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE)." The mobile application (app), PedsGuide, was developed using evidence-based recommendations created by an interdisciplinary panel. App workflow and content were aligned with clinical benchmarks; app interface was adjusted after usability heuristic review. Usage patterns were measured using Google Analytics., Results: Overall, 3805 users across the United States downloaded PedsGuide from December 1, 2016, to July 31, 2017, leading to 14 256 use sessions (average 3.75 sessions per user). Users engaged in 60 442 screen views, including 37 424 (61.8%) screen views that displayed content related to the REVISE clinical practice benchmarks, including hospital admission appropriateness (26.8%), length of hospitalization (14.6%), and diagnostic testing recommendations (17.0%). Median user touch depth was 5 [IQR 5]., Discussion: We observed rapid dissemination and in-depth engagement with PedsGuide, demonstrating feasibility for using smartphone-based ECDS tools within national practice improvement projects., Conclusions: ECDS tools may prove valuable in future national practice standardization initiatives. Work should next focus on developing robust analytics to determine ECDS tools' impact on medical decision making, clinical practice, and health outcomes.

Background: The objective was to evaluate the reliability and validity of the self-report Symptom Screening in Pediatrics Tool (SSPedi) from the perspective of children with cancer and pediatric hematopoietic stem cell transplant (HSCT) recipients., Methods: In this multicenter study, respondents were children age eight to 18 years who had cancer or had received HSCT, and their parents. Two different child respondent populations were targeted. More symptomatic respondents were receiving active treatment for cancer, admitted to the hospital, and expected to be in the hospital three days later. Less symptomatic respondents were in maintenance therapy for acute lymphoblastic leukemia or had completed cancer therapy. Children completed SSPedi and then responded to validated self-report measures of mucositis, nausea, pain, and global quality of life. Children in the more symptomatic group repeated SSPedi and a global symptom change scale three days later. Parent proxy-report was optional. Reliability was evaluated using intraclass correlations while convergent validity was evaluated using Spearman correlations., Results: Of 502 children enrolled, 302 were in the more symptomatic group and 200 were in the less symptomatic group. Intraclass correlation coefficients were 0.88 (95% confidence interval [CI] = 0.82 to 0.92) for test-retest reliability and 0.76 (95% CI = 0.71 to 0.80) for inter-rater reliability. The mean difference in SSPedi scores between more and less symptomatic groups was 7.8 (95% CI = 6.4 to 9.2). SSPedi was responsive to change in global symptoms. All hypothesized relationships among measures were observed., Conclusions: SSPedi is a self-report symptom bother tool for children with cancer and HSCT recipients that is reliable, valid, and responsive to change. SSPedi can be used for clinical and research purposes. Future work should focus on integration into care delivery.

Significant strides have been made in the treatment of childhood cancer. Improvements in survival have led to increased attention toward supportive care indications; including the use of traditional and complementary medicine (T&CM). The use of T&CM among children and adolescents with cancer is well documented in both high-income countries (HICs) and low-middle income countries (LMICs). A higher incidence of the use of T&CM has been reported among children undergoing treatment in LMICs, which has elevated concerns related to drug interactions, adherence to therapy, and treatment-related toxicities. These observations have underscored the need for effective models of integrative care that are culturally sensitive yet sustainable in an LMIC setting. We present considerations inclusive of the clinical care, educational opportunities, governmental policy, and research priorities necessary for the development of models of integrative care for pediatric cancer units in an LMIC setting., (© The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Wholesale revision of the Pediatric Infectious Diseases Developmental Screening Test (PIDDST) was imperative, given the sea change that has occurred in academic medicine and subspecialty practice in the last two decades. The PIDDST 2.0 tracks expected milestones along the continuum from fellow to full professor in today's complex health care environment. Effective use of this instrument in training programs and pediatric departments could help shape the future of the field., (© The Author 2016. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

A pilot study of dose indicators in paediatric computed tomography (CT) was conducted to prove the need to establish diagnostic reference levels (DRLs) for the county of Rio de Janeiro. The dose descriptors were estimated from the beam dosimetry by applying the protocols used in each examination. The total patient sample included 279 children. Regarding the comparison of the dose-length product values among the hospitals, the high-resolution chest CT scans were distinguished among the three types of examinations, due to the discrepancies of 1148 % (1-5 y age group) and 2248 % (5-10 y age group) presented in Hospital A's dose-length product values relative to Hospital D's dose-length product values. The results showed that without DRL, the dose variation can be significant between hospitals in the same county for the same age group in the same examination., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Purpose: The development, dissemination, and adoption of standard concentrations for compounded oral liquids for pediatric patients in Michigan are described., Summary: A baseline assessment of current practices in Michigan revealed significant variations in the concentrations of commonly used oral liquid medicines for pediatric patients. A statewide collaborative initiative in Michigan was created to standardize the concentrations of compounded oral liquids for pediatric patients. Standard concentrations were proposed and adopted by key stakeholders. These standards were then disseminated across the state to prescribers and pharmacists, with encouragement to voluntarily adopt the standards as a patient safety measure. A follow-up survey was conducted to evaluate adoption of the standards. A total of 263 pharmacists responded to the survey. Standardization of the concentrations of compounded oral liquids in Michigan was welcomed by most pharmacies and is perceived to have reduced the risk for errors at transitions of care for children receiving compounded oral liquids. Awareness of the standardization initiative was acknowledged by 77% of survey respondents, and adoption of the standards was observed to some degree by 57% of survey respondents. In addition, 70% of survey respondents agreed or strongly agreed that adoption of the standards has improved patient safety in Michigan., Conclusion: Standard drug concentrations for compounded oral liquids were developed for pediatric patients in Michigan. A survey after dissemination of the recommended standards confirmed general awareness of the initiative and adoption of the standards by a substantial proportion of respondents. Most respondents indicated a belief that creation of the standards improved patient safety., (Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Purpose: One hospital's implementation of revised American Academy of Pediatrics (AAP) guidelines for palivizumab prophylaxis of respiratory syncytial virus (RSV) infection is described., Methods: Revised AAP guidelines for RSV prophylaxis in infants and young children at increased risk for RSV infection recommend that up to five doses of palivizumab be administered during the RSV season. The guidelines also recommend that inpatients not receive monthly palivizumab prophylaxis and that infants and young children eligible for prophylaxis during the RSV season receive a dose of palivizumab two or three days before discharge or promptly after discharge. To ensure compliance with the revised AAP guidelines, a 296-bed hospital implemented a quality-improvement project including (1) efforts by the antimicrobial stewardship pharmacist and the chief medical officer to notify and educate healthcare providers regarding institutional adoption of the guidelines, (2) reinforcement of guideline adherence by clinical pharmacists during daily bedside rounds and via prospective review of all palivizumab orders, and (3) a medication-use evaluation (MUE) to assess adherence to the guidelines. The MUE results showed that during the 2014-15 RSV season (after implementation of the practice changes), the number of palivizumab doses administered at the hospital declined by 56% from the previous RSV season, with 97% of doses administered for appropriate indications., Conclusion: Standardized, comprehensive guidelines with defined criteria for palivizumab prophylaxis of RSV infection resulted in $303,227 of cost savings without a discernible change in nosocomial transmission, or morbidity, or mortality. Hospital infection-control practices controlled nosocomial RSV transmission., (Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Recombinant human GH (rhGH) has been in use for 30 years, and over that time its safety and efficacy in children and adults has been subject to considerable scrutiny. In 2001, a statement from the GH Research Society (GRS) concluded that 'for approved indications, GH is safe'; however, the statement highlighted a number of areas for on-going surveillance of long-term safety, including cancer risk, impact on glucose homeostasis, and use of high dose pharmacological rhGH treatment. Over the intervening years, there have been a number of publications addressing the safety of rhGH with regard to mortality, cancer and cardiovascular risk, and the need for long-term surveillance of the increasing number of adults who were treated with rhGH in childhood. Against this backdrop of interest in safety, the European Society of Paediatric Endocrinology (ESPE), the GRS, and the Pediatric Endocrine Society (PES) convened a meeting to reappraise the safety of rhGH. The ouput of the meeting is a concise position statement., (© 2016 The authors.)

In an attempt to overcome ethnic and racial differences in skeletal maturation, the use of ethnic-specific standards has been suggested. Do we need such standards? Based on a fundamental understanding of phenotypic plasticity and an individual's ability to respond to environmental cues, the author argues that we do not need ethnic-specific standards for bone maturity. I suggest that we use a unified international standard of bone maturity for comparing the health, nutrition, and quality of life of all children, regardless of their race, nationality, and ethnicity., (© 2016 European Society of Endocrinology.)

The exposure of paediatric patients during X-ray examinations in St Petersburg hospitals was investigated. Data about radiography examinations were collected, and mean patient effective doses and entrance surface air kerma for each X-ray unit were estimated. The results of the study were compared with other countries practice. This data will be used to optimise paediatric conventional X-ray examinations in Russia., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Paediatric patients are recognised to be at higher risk of developing radiation-induced cancer than adults. The purpose of this pilot study was to evaluate the radiation doses to paediatric patients during computed tomography (CT) procedures in order to propose local diagnostic reference levels (DRLs). A total of 296 patients (aged 6-10 y) were investigated in 8 hospitals equipped with 64-, 16- and dual-slice CT machines. The mean dose length product values were 772, 446 and 178 mGy cm for head, abdomen and chest, respectively. Imaging protocols were not adapted to the patient's weight in certain CT machines. The results confirmed that paediatric patients are exposed to an unnecessary radiation dose. The established DRLs were higher than those available in other countries. This study showed the need for harmonisation of the practice in CT departments and radiation dose optimisation., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The article reports results from the largest international dose survey in paediatric computed tomography (CT) in 32 countries and proposes international diagnostic reference levels (DRLs) in terms of computed tomography dose index (CTDI vol) and dose length product (DLP). It also assesses whether mean or median values of individual facilities should be used. A total of 6115 individual patient data were recorded among four age groups: <1 y, >1-5 y, >5-10 y and >10-15 y. CTDIw, CTDI vol and DLP from the CT console were recorded in dedicated forms together with patient data and technical parameters. Statistical analysis was performed, and international DRLs were established at rounded 75th percentile values of distribution of median values from all CT facilities. The study presents evidence in favour of using median rather than mean of patient dose indices as the representative of typical local dose in a facility, and for establishing DRLs as third quartile of median values. International DRLs were established for paediatric CT examinations for routine head, chest and abdomen in the four age groups. DRLs for CTDI vol are similar to the reference values from other published reports, with some differences for chest and abdomen CT. Higher variations were observed between DLP values, based on a survey of whole multi-phase exams. It may be noted that other studies in literature were based on single phase only. DRLs reported in this article can be used in countries without sufficient medical physics support to identify non-optimised practice. Recommendations to improve the accuracy and importance of future surveys are provided., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Indication-based national diagnostic reference levels (DRLs) for a few most common paediatric computed tomography (CT) examinations are proposed. Patient dose data (CTDI vol and dose length product) were collected for over 1000 patients in 4 university hospitals with best experiences in paediatric CT. Four indications for chest CT and two for abdomen (abdomen + pelvis), chest + abdomen and head CT were considered. The DRLs for the body examinations are proposed as exponential DRL-curves, where CTDI vol and dose length product are presented as a function of patient weight. The same DRL curve applies to all the indications studied. The basic 75 % level curve is supplemented by 50 % level curve to enable considerations on varying levels of technology. For head CT, DRLs are proposed for a few age groups (1, 1-5, 5-10 and 10-15 y), separately for routine CT and CT for ventricular size. The proposed DRLs are generally lower than the few published DRLs in other countries., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

A structured Web-based search was performed to identify online educational programs on the optimal use of antibiotics in children. Identified Web sites of interest were classified using predefined quality criteria for educational Web resources. Of 10 Web sites identified, only 2 met all the quality criteria: APUA and Getsmart., (© The Author 2013. Published by Oxford University Press on behalf of the Pediatric Infectious Diseases Society. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Association of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results., Aims: The purpose of this review is to draw attention to the gaps within the circumcision literature that need to be addressed before significant changes to public policy regarding neonatal circumcision are made within North America., Methods: A literature review of peer-reviewed journal articles was performed., Main Outcome Measures: The main outcome measure was the state of circumcision research, especially with regard to new developments in the field, as it applies to North American populations., Results: This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on men's sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes., Conclusion: Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America., (© 2014 International Society for Sexual Medicine.)

Background: Simulation is an important educational tool to improve medical training and patient safety. Debriefing after simulation is crucial to maximise learning and to translate the lessons learnt to improve real clinical performance, and thus to reduce medical error. Currently there are few tools to improve performance debriefing and learning after simulations of serious paediatric situations., Purpose: The purpose of this study was to develop a tool to guide and assess debriefings after simulations of serious paediatric situations, applying the current evidence base and user-based research., Study Design: A literature review and semistructured interviews (performed in 2010) to identify important features of a paediatric simulation debriefing. Emergent theme analysis was used to identify key components of an effective debriefing which could be used as a tool for assessing debriefing effectiveness., Results: The literature review identified 34 relevant studies. Interviews were carried out with 16 paediatricians, both debriefing facilitators and learners. In total, 307 features of a debriefing were identified. These were grouped into eight dimensions representing the key components of a paediatric debriefing: the facilitator's approach, learning environment, engagement of learners, reaction, descriptive reflection, analysis, diagnosis and application. These eight dimensions were used to create a tool, the Objective Structured Assessment of Debriefing (OSAD). Each dimension can be scored on a five-point Likert scale containing descriptions for scores 1, 3 and 5 to serve as anchors and aid scoring., Conclusions: The study identified the important features of a paediatric simulation debriefing, which were developed into the OSAD tool. OSAD offers a structured approach to paediatric simulation debriefing, and is based on evidence from published literature and views of simulation facilitators and learners. OSAD may be used as a guide or assessment tool to improve the quality of debriefing after paediatric simulation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose: The development and implementation of a comprehensive and standardized list of pediatric i.v. medication concentrations across a large healthcare system are described., Summary: In accordance with National Patient Safety Goals, facilities affiliated with the Hospital Corporation of America system had independently standardized and limited the number of drug concentrations in use. This resulted in variation among facilities, which prevented the systemwide standardization of drug dictionaries within the computerized pharmacy and prescriber-order-entry systems, complicated the movement of providers among facilities, and contributed to inconsistency in medication prescribing. A team of experts collaborated to create a comprehensive standard list that included 119 medications and 372 concentrations for pediatric i.v. medications. Implementation of this standard list was driven through a financial incentive from the malpractice insurance provider; facilities that completed the required activities for this optional program could apply for a credit of a portion of their malpractice insurance cost. For the standardization of pediatric i.v. medications, required activities included approval of the standard medication list, incorporation of this list into facility pharmacy dictionaries, and update of all smart pump software to include only the new standard medications and concentrations. Of the 145 facilities that were eligible for the implementation of standard pediatric i.v. medication concentrations, 141 (97%) completed all requirements and received the 2% malpractice insurance cost credit., Conclusion: The use of a financial incentive strategy, in the form of a malpractice insurance credit, successfully motivated the implementation of standardized pediatric medication concentrations across a large healthcare system., (Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Context: Cardiovascular disease is a leading cause of morbidity and mortality. Early identification and treatment of risk factors that accelerate this condition are paramount to preventing disease. To this effect, the National Heart Lung and Blood Institute (NHLBI), endorsed by the American Academy of Pediatrics, issued updated pediatric guidelines for cardiovascular risk reduction in 2011. Integration of these guidelines into pediatric practice may lessen cardiovascular morbidity., Evidence Acquisition: In addition to reviewing the NHLBI guidelines, a detailed literature search was performed on PubMed for clinical studies published between 2010 and 2013. Key search terms included "pediatric dyslipidemia/hyperlipidemia," "cardiovascular disease," "atherosclerosis," "familial hypercholesterolemia," "hypertriglyceridemia," and "diabetes." Additional citations from these publications were also reviewed. Final publications were selected for their relevance to the topic., Evidence Synthesis: These guidelines contain several important recommendations relative to lipid management, including screening all children with nonfasting non-high-density lipoprotein-cholesterol at ages 9-11 years, incorporation of aggressive lifestyle changes to meet cholesterol targets, and initiation of statin therapy for those with low-density lipoprotein-cholesterol elevation. In addition, both type 1 and type 2 diabetes are now considered high-risk conditions and have stringent cholesterol targets. The primary aim is early identification of children with familial hypercholesterolemia; however, these recommendations have met with some controversy. The purpose of this update is to summarize these recent lipid guidelines, present the relevant controversies, highlight common cholesterol disorders, and discuss dyslipidemia specific to the pediatric diabetes population., Conclusion: Identification and treatment of youth with dyslipidemia is of paramount importance to the reduction of future cardiovascular disease. Increasing the comprehension and application of the newest NHLBI guidelines is critical to improving cardiovascular outcomes.

In children with structurally normal hearts, the mechanisms of arrhythmias are usually the same as in the adult patient. Some arrhythmias are particularly associated with young age and very rarely seen in adult patients. Arrhythmias in structural heart disease may be associated either with the underlying abnormality or result from surgical intervention. Chronic haemodynamic stress of congenital heart disease (CHD) might create an electrophysiological and anatomic substrate highly favourable for re-entrant arrhythmias. As a general rule, prescription of antiarrhythmic drugs requires a clear diagnosis with electrocardiographic documentation of a given arrhythmia. Risk-benefit analysis of drug therapy should be considered when facing an arrhythmia in a child. Prophylactic antiarrhythmic drug therapy is given only to protect the child from recurrent supraventricular tachycardia during this time span until the disease will eventually cease spontaneously. In the last decades, radiofrequency catheter ablation is progressively used as curative therapy for tachyarrhythmias in children and patients with or without CHD. Even in young children, procedures can be performed with high success rates and low complication rates as shown by several retrospective and prospective paediatric multi-centre studies. Three-dimensional mapping and non-fluoroscopic navigation techniques and enhanced catheter technology have further improved safety and efficacy even in CHD patients with complex arrhythmias. During last decades, cardiac devices (pacemakers and implantable cardiac defibrillator) have developed rapidly. The pacing generator size has diminished and the pacing leads have become progressively thinner. These developments have made application of cardiac pacing in children easier although no dedicated paediatric pacing systems exist.