EVOLUTION OF DIAGNOSTIC DELAY IN PEDIATRIC INFLAMMATORY BOWEL DISEASE AND THE IMPACT OF THE COVID-19 PANDEMIC.

BACKGROUND: Pediatric inflammatory bowel disease (IBD) is increasingly prevalent, but diagnosis can still be challenging. Diagnostic delay is particularly deleterious in this age group. OBJECTIVE: This study explores the evolution of diagnostic delay in pediatric IBD and the influence of the COVID-19 pandemic. METHODS: Retrospective study including all pediatric IBD patients diagnosed during 2014, 2019 and 2020 in a tertiary hospital. Diagnostic delay, time to first medical visit, time to pediatric gastroenterologist (PG) visit and time to diagnosis were calculated and compared within a gap of five years (2019 and 2014) and with the year of onset of the pandemic (2020 and 2019). RESULTS: A total of 93 participants were included (2014: 32, 2019: 30, 2020: 31). No significant differences were observed in diagnostic delay, time to first medical visit in Crohn's disease (CD), time to PG visit and time to diagnosis when comparing 2019-2014 and 2020-2019. Time to first visit in ulcerative colitis (UC) and Undetermined-IBD increased in 2019 (P=0.03), with new decrease in 2020 (P=0.04). Diagnostic delay was longer in DC compared to UC plus Undetermined-IBD. CONCLUSION: Diagnostic delay is still an important matter in pediatric IBD, with no significant change over the last years. The time to the first PG visit and the time for diagnosis seem to have the greatest impact on diagnostic delay. Thus, strategies to enhance recognition of IBD symptoms among first-line physicians and to improve communication, facilitating referral, are of utmost importance. Despite the restraints in the health care system caused by the pandemic, time to diagnosis in pediatric IBD was not impaired during 2020 in our center.

Prevalence and Predictive Factors of Exclusive Breastfeeding in the First Six Months of Life.

INTRODUCTION: Exclusive breastfeeding (EBF) is currently recommended until six months of age. The Baby-friendly Hospital (BFH) initiative an international program to promote breastfeeding, was launched in Portugal in 1994. The aim of this study was to identify the prevalence and factors influencing breastfeeding in the first six months of life and to compare the results with a study carried out in 1999 including population from the same geographic area. MATERIAL AND METHODS: A prospective, longitudinal and observational study was carried out in two hospitals in the Lisbon metropolitan area, one BFH and another non-BFH. It consisted of different questionnaires answered by mothers at three distinct moments (zero, three and six months). The first questionnaire was applied between February and June 2019. RESULTS: A total of 423 infants were included, 324 from the BFH and 99 from the non-BFH. The breastfeeding rate was 94.3% at discharge, 78.2% at three months and 64.4% at six months, whereas EBF rate was 74.2%, 51.8% and 25.6% respectively. All women on EBF at six months, except one, were breastfeeding on demand. The discontinuation of EBF was associated with delayed skin-to-skin contact, Neonatal Intensive Care Unit admission, pacifier and artificial teats use, mother's return to work earlier and lower education levels. Conversely, factors that promote EBF were older gestational age, adequate birthweight, breastfeeding initiation in the first hour of life, rooming-in practice, shorter hospital stay and absence of infant's illnesses. Compared with 1999, although there was a significant improvement of breastfeeding rates at three and six months, the EBF rate was similar at six months (23%). Both studies identified the mother's lower education level and mother's return to work as contributing factors to breastfeeding discontinuation. CONCLUSION: Our results are in agreement with previously reported causes of breastfeeding discontinuation and emphasize the importance of sociocultural factors. Compared with 1999, the breastfeeding rates in this Portuguese population increased significantly at three and six months. However, it is still necessary to improve in order to achieve the World Health Organization global target.

Evolução do atraso diagnóstico na doença inflamatória intestinal em idade pediátrica e o impacto da pandemia COVID-19 / Evolution of diagnostic delay in pediatric inflammatory bowel disease and the impact of the covid-19 pandemic

ABSTRACT Background: Pediatric inflammatory bowel disease (IBD) is increasingly prevalent, but diagnosis can still be challenging. Diagnostic delay is particularly deleterious in this age group. Objective This study explores the evolution of diagnostic delay in pediatric IBD and the influence of the COVID-19 pandemic. Methods Retrospective study including all pediatric IBD patients diagnosed during 2014, 2019 and 2020 in a tertiary hospital. Diagnostic delay, time to first medical visit, time to pediatric gastroenterologist (PG) visit and time to diagnosis were calculated and compared within a gap of five years (2019 and 2014) and with the year of onset of the pandemic (2020 and 2019). Results A total of 93 participants were included (2014: 32, 2019: 30, 2020: 31). No significant differences were observed in diagnostic delay, time to first medical visit in Crohn's disease (CD), time to PG visit and time to diagnosis when comparing 2019-2014 and 2020-2019. Time to first visit in ulcerative colitis (UC) and Undetermined-IBD increased in 2019 (P=0.03), with new decrease in 2020 (P=0.04). Diagnostic delay was longer in DC compared to UC plus Undetermined-IBD. Conclusion Diagnostic delay is still an important matter in pediatric IBD, with no significant change over the last years. The time to the first PG visit and the time for diagnosis seem to have the greatest impact on diagnostic delay. Thus, strategies to enhance recognition of IBD symptoms among first-line physicians and to improve communication, facilitating referral, are of utmost importance. Despite the restraints in the health care system caused by the pandemic, time to diagnosis in pediatric IBD was not impaired during 2020 in our center.

RESUMO Contexto Apesar da prevalência crescente da doença inflamatória intestinal (DII) em idade pediátrica, o seu diagnóstico pode ser desafiante. Um atraso no diagnóstico é particularmente deletério nesta faixa etária. Objetivo Este estudo investiga a evolução do atraso diagnóstico na DII pediátrica e o impacto da pandemia COVID-19 no mesmo. Métodos Estudo retrospetivo que incluiu todos os doentes em idade pediátrica diagnosticados com DII durante 2014, 2019 e 2020 num hospital terciário. O atraso diagnóstico, o tempo para a primeira visita médica, o tempo para a primeira visita ao gastroenterologista pediátrico (GP) e o tempo para o diagnóstico foram calculados e comparados num intervalo de cinco anos (2019 e 2014) e com o ano marcado pelo surgimento da pandemia COVID-19 (2020 e 2019). Resultados Foram incluídos 93 participantes (2014: 32, 2019: 30, 2020: 31). Não se observou diferença significativa no atraso diagnóstico, no tempo para a primeira visita médica na doença de Crohn (DC), no tempo para a primeira visita ao GP e no tempo para o diagnóstico após comparação entre 2019-2014 e 2020-2019. Na colite ulcerosa e colite indeterminada, o tempo para a primeira visita médica aumentou em 2019 (P=0,03), com nova diminuição em 2020 (P=0,04). O atraso diagnóstico foi superior na DC comparativamente com a colite ulcerosa e colite indeterminada. Conclusão O atraso diagnóstico na DII pediátrica continua a ser um tema importante, que não sofreu alteração significativa ao longo dos últimos anos. O tempo para a primeira visita ao GP e o tempo para o diagnóstico parecem ter maior impacto no atraso diagnóstico, pelo que são necessárias estratégias para aumentar o reconhecimento dos sintomas da DII entre os médicos de primeira linha, bem como melhorar a comunicação e a referenciação. Apesar das restrições causadas pela pandemia no sistema de saúde, o tempo para o diagnóstico na DII pediátrica não foi comprometido no nosso centro em 2020.

Reversible Cerebral Vasoconstriction Syndrome in a Previously Healthy Child: A Case Report.

Objectives: We describe the case of a healthy boy diagnosed with reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES). Methods: He was identified after presenting in the emergency department (ED). A review of the 5 previous cases of RCVS complicated with PRES reported in the literature was performed. Results: A 9-year-old boy was brought to the ED for intense, throbbing headache and vomiting. Physical and neurologic examinations were normal. Brain CT and CSF examination were unremarkable, and he was discharged after symptomatic relief. Five days later, he returned to the ED for generalized tonic-clonic seizures that ceased with levetiracetam. MRI with angiography showed PRES. Systolic hypertension refractory to therapy was documented. New-onset fluctuating right-sided paresis and paresthesia appeared, so MRI was repeated, showing diffuse cerebral vasoconstriction suggesting RCVS. Nimodipine was started with complete resolution of symptoms and normalization of blood pressure. Four weeks after discharge, TD and MRI showed total vasospasm resolution. There was no recurrence in 12-month follow-up. Discussion: This case emphasizes the interconnection between RCVS and PRES, highlighting the need to include both as differential diagnoses for severe headache and the essential role of MR angiography in the investigation.

Impact of COVID-19 in Pediatric Patients and Young Adults with Inflammatory Bowel Disease.

Introduction: Acute COVID-19 in pediatric and young adult patients tends to be milder in severity compared to adult infection. Recent studies seem to show that inflammatory bowel disease (IBD) patients are at no greater risk than the general population. We aim to describe our experience in the follow-up of pediatric and young adult patients with IBD followed in our center and determine possible risk factors of said population for severe COVID-19. Methods: We performed a retrospective study of all patients aged under 25 years followed for IBD at the Unit of Pediatric Gastroenterology in a tertiary center between December 2019 and April 2021 evaluating the incidence of COVID-19 and characterization of positive cases. Results: Of the 268 participants, 24 had COVID-19: the mean age was 19 years old and gender had an equal distribution; 75% (n = 18) had Crohn's disease, whereas only 25% (n = 6) had ulcerative colitis. Most patients were in clinical remission (n = 21). The majority of patients were under treatment with a tumor necrosis factor (TNF) antagonist (58%, n = 14), mainly infliximab, and most had no comorbidities other than IBD (83%). Regarding COVID-19, 17% of the patients were asymptomatic while the rest had only mild symptoms. There were no reported gastrointestinal complaints, no complications nor hospitalizations. Most patients did not require interruption of their IBD treatment. Conclusions: Our data suggest that pediatric and young adult IBD patients have a low risk for complications and hospitalization, regardless of IBD treatment. We believe that this experience is encouraging and allows for safe counseling regarding treatment options and school attendance in pediatric and young adult IBD patients.

Introdução: Na população pediátrica e de jovens adultos a gravidade da COVID-19 tende a ser moderada quando comparada com os doentes adultos. Os estudos mais recentes sugerem que os doentes com doença inflamatória intestinal (DII) não têm risco acrescido em relação à população geral. O objetivo do presente estudo é a descrição da nossa experiência no follow-up de crianças e jovens adultos com DII a COVID-19 e determinar a existência de possíveis fatores de risco para doença grave na referida população. Métodos: Foi realizado um estudo retrospetivo de todos os doentes com idade inferior a 25 anos, seguidos na Unidade de Gastrenterologia Pediátrico de um centro terciário por DII, com avaliação da incidência de COVID-19 entre dezembro de 2019 e abril de 2021, e caracterização dos casos postivos. Resultados: Entre os 268 participantes, 24 tiveram COVID-19. A idade média foi de 19 anos com uma distribuição por género equiparável. Destes, 75% (n = 18) tinham doença de Crohn, enquanto 25% (6) tinham colite ulcerosa. A maior parte dos doentes apresentavam-se em remissão clínica (n = 21) e, à data da doença COVID-19. A sua maioria, os doentes encontravam-se sob tratamento com antagonistas do fator de necrose tumoral (58%, n = 14), predominantemente o infliximab, e a generalidade dos doentes (83%) não apresentava outras comorbilidades além da DII. Relativamente à COVID-19, 17% eram assintomáticos enquanto os restantes apresentavam apenas sintomas ligeiros. Não houve relato de queixas gastrointestinais, complicações ou necessidade de hospitalização. Na maioria dos casos, não houve necessidade de interromper o tratamento da DII. Conclusão: Os nossos dados sugerem que doentes pediátricos e jovens adultos com DII apresentam um risco baixo de complicações ou hospitalização associados à COVID-19, independentemente do tratamento em curso para a DII. Este estudo apresenta resultados encorajadores e contribui para o aconselhamento adequado e fundamentado aos doentes e respetivos cuidadores, no que diz respeito às opções terapêuticas e frequência escolar dos doentes pediátricos e jovens adultos com DII.

Influence of SARS-CoV-2 pandemic on sleep habits in a pediatric population.

Objective: Assessment of changes in sleep habits at home in children during COVID-19 lockdown. Methods: Retrospective, transversal study in a pediatric ward of a level II hospital. Questionnaires concerning sleep quality, patterns and its modifications during lockdown were distributed from June to August 2020. Comparison with a control sample from previous study (2019). Statistical analysis on SPSS Statistics23. Results: Two groups were compared: during lockdown (n=36, mean age 9.3 years-old) and before lockdown (n=48, mean age 8.8 years-old). 55.6% stated changes in sleep patterns. There was an increase in sleep hours, specifically in school-aged children (p=0.05) and adolescents (p=0.03), with no impact in global subjective sleep quality. Significative increase in screen hours (p=0.02) and its use after dinner (p=0.04). Discussion: Changes in sleep patterns during lockdown were frequent, alongside a higher use of screens. However, these did not affect the subjective sleep quality nor increased the occurrence of sleep disturbances.