Mild Hypophosphatemia-Associated Conditions in Children: The Need for a Comprehensive Approach.

To better understand the causes of hypophosphatemia in children, we evaluated all serum phosphate tests performed in a tertiary hospital with unexpected but persistent temporary or isolated hypophosphatemia over an 18 year period. We collected 29,279 phosphate tests from 21,398 patients, of which 268 (1.2%) had at least one result showing hypophosphatemia. We found that endocrinopathies (n = 60), tumors (n = 10), and vitamin D deficiency (n = 3) were the medical conditions most commonly associated with mild hypophosphatemia, but in many patients the cause was unclear. Among patients with endocrinopathies, those with diabetes mellitus were found to have lower mean serum phosphate levels (mean 3.4 mg/dL) than those with short stature (3.7 mg/dL) or thyroid disorders (3.7 mg/dL). In addition, we found a correlation between glycemia and phosphatemia in patients with diabetes. However, despite the potential relevance of monitoring phosphate homeostasis and the underlying etiologic mechanisms, renal phosphate losses were estimated in less than 5% of patients with hypophosphatemia. In the pediatric age group, malignancies, hypovitaminosis D, and endocrine disorders, mostly diabetes, were the most common causes of hypophosphatemia. This real-world study also shows that hypophosphatemia is frequently neglected and inadequately evaluated by pediatricians, which emphasizes the need for more education and awareness about this condition to prevent its potentially deleterious consequences.

[Infections in early life as risk factor for coeliac disease]. / Infecciones en la primera infancia como factor de riesgo de enfermedad celiaca.

INTRODUCTION: Among the environmental factors that can affect the pathological response to gluten in coeliac disease (CD), the factors that influence the immune response, such as infections and use of antibiotics, are proposed. Our objective is to determine the relationship between infections in early life and the risk of CD. PATIENTS AND METHODS: A retrospective case-control study, including patients aged 0-16 years with a diagnosis of CD was performed between the years 2014-2018. An analysis was made of documented infections in the first 6 months of life, types of infection (respiratory, gastrointestinal, urinary, others), microorganisms involved, and antibiotic therapy used. RESULTS: A total of 93 coeliac patients, 93 controls, and 237 infectious episodes were registered. Documented infections affected 67.7% of coeliac patients and 50.5% of controls (P = .017), with a mean of 1.49 ± 1.53 episodes in the coeliac group and 1.05 ± 1.5 in the controls (P = .016). Documented infections in the first 6 months of life doubles the risk of developing CD (OR 2.05; 95% CI; 1.13-3.73), with this risk being higher for respiratory infections, which multiply the risk by 2.3 (OR 2.30, 95% CI; 1.28-4.14). Also, having 3 or more respiratory infections in the first 6 months of life multiplied the risk by 2.8 (OR 2.79, 95% CI; 1.03-7.54). No differences were found related to the types of involved microorganism or regarding the use of antibiotics. CONCLUSIONS: Infections in the first 6 months of life increase the risk of developing CD, especially for respiratory infections and, to a greater extent, if 3 or more episodes occur. The use of antibiotics in this period of life has not been related to an increased risk of CD.

Modified Serum ALP Values and Timing of Apparition of Knee Epiphyseal Ossification Centers in Preterm Infants with Cholestasis and Risk of Concomitant Metabolic Bone Disease of Prematurity.

The usefulness of serum alkaline phosphatase (ALP) and phosphorous in screening and monitoring of metabolic bone disease of prematurity (MBDP) still has some limitations, especially in preterm infants with concomitant conditions such as cholestasis. We aimed to assess a modification of serum ALP (M-ALP) as a biomarker for MBDP in preterm infants, and the use of ultrasound monitoring for the apparition of knee ossification centers as marker of bone mineralization. Biochemical and clinical registers were taken from 94 preterm newborns <32 weeks. A significant correlation existed between serum ALP and direct bilirubin (DB), expressed by the regression equation: M-ALP (IU/L) = 302.1 + 96.9 (DB (mg/dL)). The ratio ALP/M-ALP > 1 was demonstrated to be more specific (87.5%) in the diagnosis of MBDP than the cut-off value of serum ALP > 500 IU/L (62.5%). ALP/M-ALP > 1 showed 100% sensitivity and specificity for the diagnosis of MBDP, and a good correlation with specific bone ALP (B-ALP). Patients with the knee nucleus by post-menstrual week 37 had lower B-ALP compared to patients with no nucleus, and no patients with MBDP presented the nucleus by the 40th week. In the absence of reliable specific B-ALP, reinterpreting serum ALP values by M-ALP plus monitoring of knee ossification centers contribute to better management of MBDP in preterm infants with cholestasis.

Manejo diagnóstico y terapéutico actual de la fractura de los primeros pasos / Current diagnosis and management of toddler's fracture

INTRODUCCIÓN: La fractura de los primeros pasos o fractura de toddler es una fractura espiroidea de tibia propia de la primera infancia. El objetivo es analizar su incidencia y el manejo diagnóstico y terapéutico actual. PACIENTES Y MÉTODOS: Estudio descriptivo retrospectivo de los pacientes de 0 a 3 años diagnosticados en un hospital terciario entre los años 2013 y 2017. RESULTADOS: Registrados 53 pacientes (10,6 casos/año), con una mediana de edad de 2 años y ligero predominio masculino. La radiografía inicial resultó normal en el 24,5%. Con la aproximación inicial, el 69,8% de los pacientes se diagnosticaron de fractura, el 11,3% de sospecha de fractura y el 18,9% de contusión. El 22% precisaron prueba de control; 10 radiografía (patológica 90%) y 5 ecografía (patológica 80%, 3 de ellos con radiografía inicial normal). El 80,8% de los pacientes se inmovilizaron con férula frente al 19,2% en los que se realizó inmovilización flexible o no inmovilización. Se encontraron complicaciones en el 21,4% de los pacientes inmovilizados con férula, fundamentalmente úlceras por presión (19%), que fueron más frecuentes en este grupo que en los no inmovilizados (21,4 vs. 0%; p = 0,006), sin diferencias significativas en cuanto a tiempo hasta carga. CONCLUSIONES: La radiografía simple tiene una sensibilidad limitada para el diagnóstico de la fractura de los primeros pasos. En el grupo de pacientes con radiografía normal el uso de ecografía puede contribuir al diagnóstico y a evitar radiación adicional. Aunque el tratamiento más común de esta fractura sigue siendo la inmovilización con férula, la alternativa sin inmovilización rígida no parece obtener peores resultados, incluso parece presentar menor morbilidad asociada al tratamiento

INTRODUCTION: Toddler's fracture is an accidental spiral tibial fracture, characteristic of the early childhood. The objective of this study is to determine the incidence and current diagnosis and management of this disorder. PATIENTS AND METHODS: A retrospective study was conducted on a sample of patients aged 0-3 years diagnosed with a toddler's fracture in a tertiary hospital between years 2013 and 2017. RESULTS: A total of 53 patients were registered (10.6 cases per year). The median age was 2 years, with a slight male predominance. The initial radiograph was normal in 24.5% of patients. With the initial approach, 69.8% of patients were diagnosed with fracture, 11.3% with suspected fracture, and 18.9% with contusion. A follow-up was required in 22% required a control test, using radiographs in 10 patients (pathological 90%), and ultrasound in 5 (pathological 80%, 3 of them with normal initial radiography). The large majority (80.8%) of the patients were immobilised with a cast, while flexible immobilisation or non-immobilisation was used in 19.2%. Complications were found in a 21.4% of patients immobilised with splint, mainly skin injuries (19%). These were more frequent in this group than in those that were not immobilised (21.4% vs. 0%, P = .006); with no significant differences in time to weight-bearing. CONCLUSIONS: Radiography has a limited sensitivity for the diagnosis of toddler's fracture. In the group of patients with normal radiography, the use of ultrasound can be helpful to the diagnosis and avoid additional radiation. Even though the most common treatment continues to be immobilisation with a splint, the alternative without rigid immobilisation does not seem to give worse results, even with lower morbidity associated with the treatment

Dilatación gástrica misteriosa / A misterious stomach dilatation

La ascaridiasis es una de las parasitosis más comunes a nivel mundial. Es especialmente frecuente en países tropicales subdesarrollados, en los que las condiciones higiénicas y socioeconómicas favorecen la transmisión. El ciclo del parásito es entérico-neumoentérico y se inicia con la ingesta oral de huevos de este. La infestación puede ser asintomática o producir clínica gastrointestinal o respiratoria durante su paso pulmonar (neumonitis eosinofílica y síndrome de Loeffler). Durante la fase intestinal puede producir diarrea leve intermitente, dolor abdominal, náuseas y vómitos. En raras ocasiones aparece obstrucción intestinal, apendicitis aguda, invaginación, colecistitis, pancreatitis, absceso hepático o peritonitis. Se presenta un caso que cursó, de manera atípica, con una dilatación gástrica muy marcada

Ascaridiasis is one of the most common parasitosis worldwide. It is especially prevalent in underdeveloped tropical countries where hygienic and socioeconomic conditions favor transmission. The parasite cycle is enteric-pneumo-enteric, and begins with the oral intake of eggs from it. The infestation can be asymptomatic or produce gastrointestinal or respiratory symptoms during pulmonary passage (eosinophilic pneumonitis and Loeffler syndrome). During intestinal phase, it can cause intermittent mild diarrhea, abdominal pain, nausea and vomiting. Rarely, intestinal obstruction, acute appendicitis, invagination, cholecystitis, pancreatitis, liver abscess or peritonitis appear. We report a case, atypically, with a mega-stomach

[Current diagnosis and management of toddler's fracture]. / Manejo diagnóstico y terapéutico actual de la fractura de los primeros pasos.

INTRODUCTION: Toddler's fracture is an accidental spiral tibial fracture, characteristic of the early childhood. The objective of this study is to determine the incidence and current diagnosis and management of this disorder. PATIENTS AND METHODS: A retrospective study was conducted on a sample of patients aged 0-3 years diagnosed with a toddler's fracture in a tertiary hospital between years 2013 and 2017. RESULTS: A total of 53 patients were registered (10.6 cases per year). The median age was 2 years, with a slight male predominance. The initial radiograph was normal in 24.5% of patients. With the initial approach, 69.8% of patients were diagnosed with fracture, 11.3% with suspected fracture, and 18.9% with contusion. A follow-up was required in 22% required a control test, using radiographs in 10 patients (pathological 90%), and ultrasound in 5 (pathological 80%, 3 of them with normal initial radiography). The large majority (80.8%) of the patients were immobilised with a cast, while flexible immobilisation or non-immobilisation was used in 19.2%. Complications were found in a 21.4% of patients immobilised with splint, mainly skin injuries (19%). These were more frequent in this group than in those that were not immobilised (21.4% vs. 0%, P=.006); with no significant differences in time to weight-bearing. CONCLUSIONS: Radiography has a limited sensitivity for the diagnosis of toddler's fracture. In the group of patients with normal radiography, the use of ultrasound can be helpful to the diagnosis and avoid additional radiation. Even though the most common treatment continues to be immobilisation with a splint, the alternative without rigid immobilisation does not seem to give worse results, even with lower morbidity associated with the treatment.