Israel Medical Association Journal

Background: Pediatric patients with newly diagnosed type 1 diabetes mellitus (T1DM) are commonly treated with daily multiple insulin injections or an insulin pump. They tend to have higher body mass index-standard deviation scores (BMI-SDS) than non-diabetic children.

Objectives: To identify patterns in the changes in BMI in the 3 years after T1DM diagnosis, and to discover factors that relate to excessive weight gain.

Methods: This retrospective study included clinical and laboratory data for 194 boys and girls aged 2–18 years at the time of diagnosis and at 1, 2, and 3 years after. Their BMI values were compared to non-diabetic children using BMI percentile and z-score (standard deviation) based on the U.S. Centers for Disease Control and Prevention (CDC) growth charts.

Results: Both males and females had low mean BMI-SDS at diagnosis (-0.4499 ± 1.38743 male, 0.3050 ± 1.29887 female) that increased after 1 year (-0.0449 ± 1.14772 male, 0.1451 ± 0.98893 female). Lower glycated hemoglobin (HbA1c) at 1 year correlated with higher BMI-SDS (r = -0.215, P = 0.011). No such correlation was found in the following 2 years. The daily dose of basal insulin correlated with higher BMI-SDS at 1 year (r = 0.183, P = 0.026) and 3 years (r = 0.297, P < 0.01). No association was found between the use of an insulin pump or continuous glucose monitoring and higher BMI-SDS.

Conclusions: BMI-SDS of children with T1DM was lower than average at the time of diagnosis and rose higher than average in the 3 years following. Higher BMI-SDS was not significantly associated with sex or ethnicity. The most prominent increase happened in the first year.

Background: School closures due to the coronavirus disease 2019 (COVID-19) outbreak affected students physically, socially, and psychologically with an increase in the number of children and adolescent presenting with anxiety, depression, and drug abuse.

Objectives: To examine the impact of COVID-19 and lockdown on the mental health of minors during the pandemic period and to characterize the type and number of referrals to a regional psychiatric outpatient clinic.

Methods: This study included 380 children evaluated in an outpatient child psychiatric clinic. They were divided into two groups: before the lockdowns (BLD) (n=248), from January 2019 to February 2020, and during the lockdowns (LD) (n=132), from March 2020 to April 2021.

Results: When comparing the LD to BLD, there was increase in suicide attempts (9.8% vs. 2.8%) and in the use of psychotherapy (81% vs. 56%). There was a decrease in the diagnoses of behavior disorders (29.5% vs. 44.8%) and ADHD (29.5% vs. 50%); as well as a decrease in stimulant usage (22.7% vs. 38%). There was a statistically non-significant increase in the number of children with depression, anxiety, and drug-use disorder.

Conclusions: Many children developed educational, social, emotional, and behavioral gaps during LD, and they lost skills to deal with everyday problems due to social isolation. It is important to follow the long-term impact of the lockdowns and social isolation.

Background: Blood pressure (BP) is routinely measured while triaging children presenting to the pediatric emergency department (PED).

Objectives: To determine whether a medical clown shortens the time to acquire a BP measurement among children undergoing triage in the PED.

Methods: The study comprised 133 children. Patients were assigned to one of two groups: with a medical clown or without a medical clown.

Results: The presence of a medical clown led to a significantly shorter time to acquire a blood pressure measurement (60 ± 23 seconds vs. 81 ± 43.5 seconds, P < 0.001. Clowns had a significant effect on shortening total triage length among children of Jewish ethnicity compared to Arab ethnicity (113 ± 353.6 seconds vs. 154 ± 418 seconds, P = 0.012).

Conclusions: Using medical clowns while measuring BP during triage when used in a culturally appropriate manner shortens time.

Background: Rare incidence cases are part of the routine work of pediatric surgeons. Cecal anomalies in children are an example of such cases.

Objectives: To describe the presentation, workup, management and outcome of rare cecal anomalies in children and to analyze the skills needed for their successful treatment.

Methods: A retrospective chart review was conducted of all cases of cecal anomalies managed by the pediatric surgical service at a tertiary hospital from June 2017 to January 2020. Data regarding demographics, clinical presentation, radiological studies, surgical treatment, pathology, complications, and outcome were collected.

Results: Five cases of cecal anomalies were encountered over a period of 32 months, including a cecal volvulus, cecal duplication, cecal intussusception, and two cecal masses (one ulcerated lipoma and one polyp). All patients, except the patient with cecal duplication, presented acutely and were managed surgically. Long-term follow-up of 17–24 months was unremarkable in all cases.

Conclusions: A wide knowledge base, careful judgment, and creativity enable pediatric surgeons to successfully treat rare conditions such as rare cecal anomalies. These skills should be part of the education of pediatric surgery trainees.

Background: The growing popularity of trampoline jumping in the past years has led to an increase in trampoline-related injuries. The risk is particularly high in large trampoline parks, which are attended by many individuals of various sizes and ages.

Objective: To describe a tertiary pediatric center experience in Israel.

Methods: The database of a tertiary pediatric medical center was retrospectively reviewed for all trampoline-associated admissions to the emergency department in 2015–2018. Data were collected on patient demographics and injury characteristics with an emphasis on type and venue.

Results: Of the 23,248 admissions for orthopedic trauma during the period, 244 children were admitted for 246 trampoline-related injuries. Injuries involved the lower limb in 130 children (53%), upper limb in 87 (36%), spine in 20 (8%), and other sites in 9 (3%). Almost half of the injuries (113/246, 46%) were fractures, 27% required either closed or open reduction in the operating room. Large trampoline centers were responsible for half of the cases.

Conclusions: Trampoline injuries accounted for 1.05% of all emergency department admissions at a tertiary pediatric hospital in 2015–2018. Nearly half of the trampoline-related injuries were fractures. Large trampoline centers pose a potential risk for more serious injuries. We raise awareness of the risks of trampoline jumping, considering increasing popularity of trampoline parks, and encourage the authorities to implement safety regulations.

Background: Adenovirus infections are prevalent in children. They usually cause a mild self-limited disease. However, this infection can be associated with considerable morbidity and mortality in specific populations, especially among immunocompromised children. Children with Down syndrome are susceptible to a higher frequency and increased severity of viral infections. Little is known about the severity and clinical course of adenovirus infections in children with Down syndrome.

Objectives: To characterize hospitalized children diagnosed with Down syndrome and presenting with adenovirus infection.

Methods: We performed a retrospective review of children admitted with adenovirus from January 2005 to August 2014 from a single tertiary pediatric medical center in Israel. Data were compared between patients with and without Down syndrome.

Results: Among the 486 hospitalized children with adenoviral infection, 11 (2.28%) were diagnosed with Down syndrome. We found that children with Down syndrome were more likely to experience a higher incidence of complications (18.2% vs. 2.4%, P = 0.008), a higher rate of admissions to the intensive care unit (36.4% vs. 2.4%, P < 0.001), and more prolonged hospitalizations (17 ± 15.9 days compared to 4.46 ± 3.16, P = 0.025).

Conclusions: Children with Down syndrome who were hospitalized with adenovirus infection represent a high-risk group and warrant close monitoring. If a vaccine for adenovirus becomes available, children with Down syndrome should be considered as candidates

Background: The coronavirus disease-2019 (COVID-19) social-distancing strategy, including 7 weeks of strict lockdown, enabled an extraordinary test of stay-at-home regulations, which forced a sedentary lifestyle on all children and adolescents.

Objectives: To assess the lockdown effect on pediatric weight.

Methods: A retrospective-prospective cohort study at our hospital’s pediatric outpatient clinics following the COVID-19 lockdown. Patients aged 0–18 years visiting the clinic were weighed and previous weight and other clinical data were collected from the medical charts. Weight-percentile-for-age standardization was calculated according to the U.S. Centers for Disease Control and Prevention and the World Health Organization growth tables. Pre- and post-lockdown weight-percentiles-for-age were compared using paired t-test. Multivariate analysis was conducted using linear regression model.

Results: The study was comprised of 229 patients; 117/229 (51.1%) were boys, 60/229 (26.2%) aged under 6 years. Total mean weight-percentile was significantly higher following the lockdown (40.44 vs. 38.82, respectively, P = 0.029). Boys had a significant post-lockdown weight-percentile rise (37.66 vs. 34.42, P = 0.014), whereas girls had higher baseline pre-quarantine weight-percentile of 43.42, which did not change. Patients younger than 6 years had a significant increase in weight-percentiles (39.18 vs. 33.58, P = 0.021). In multivariate analysis these correlations were preserved.

Conclusions: A general weight gain among children was noted, especially in boys during the lockdown, with substantial effect under the age of 6 years. This collateral side-effect should be considered in further quarantine regulations

Background: Evaluation of children's anthropometrics poses challenges due to age-related changes. The main focus is on height and weight. However, since weight is height-dependent, body mass index (BMI) is the best surrogate measurement of adiposity. Israel has not developed national growth tables; therefore, researchers and clinicians utilize either World Health Organization (WHO) or U.S. Centers for Disease Control and Prevention (CDC) tables as benchmarks.

Objectives: To evaluate the anthropometrics of Israeli children benchmarked by CDC and WHO tables.

Methods: A retrospective review was conducted of the 1987–2003 birth cohort (age 4–18 years) from Clalit Health Services databases. Anthropometrics were retrieved twice: at study entry and one year later. We evaluated them as separate cohorts. Gender-specific age-matched median height and BMI were compared with CDC and WHO height and BMI tables.

Results: The study consisted of 15,650, mean age at study entry 9.5 years (range 4–18). Gender-specific median heights of the Israeli children were similar to CDC and WHO values at younger ages, but were slightly shorter than the age-matched CDC and WHO toward the age of final height in both cohorts. However, gender-specific median BMI was considerably and statistically significant higher compared to CDC and WHO values consistently along the entire age range in both cohorts.

Conclusions: Israeli children were slightly shorter toward the age of final height, compared to WHO and CDC. However, BMI in Israeli children was significantly higher compared to the CDC and WHO consistently along the age range, which raises an alarm regarding obesity patterns

Germany was a scientifically advanced country in the 19th and early 20th centuries, particularly in medicine, with a major interest in research and the treatment of tuberculosis. From 1933 until 1945, Nazi Germany perverted scientific research through criminal experimentations on captured prisoners of war and on "subhumans" by scientifically untrained, but politically driven, staff. This article exposes a series of failed experiments on tuberculosis in adults, experiments without scientific validity. Nonetheless, Dr. Kurt Heißmeyer repeated the experiment on Jewish children, who were murdered for the sake of personal academic ambition. It is now 75 years since liberation and the murdered children must be remembered. This observational review raises questions of medical and ethical values

Background: Pancreatic trauma is uncommon in pediatric patients and presents diagnostic and therapeutic challenges. While non-operative management (NOM) of minor pancreatic injuries is well accepted, the management of major pancreatic injuries remains controversial.

Objectives: To evaluate management strategies for major blunt pancreatic injury in children.

Methods: Data were retrospectively collected for all children treated for grade III or higher pancreatic injury due to blunt abdominal trauma from 1992 to 2015 at two medical centers. Data included demographics, mechanism of injury, laboratory and imaging studies, management strategy, clinical course, operative findings, and outcome.

Results: The cohort included seven boys and four girls aged 4–15 years old (median 9). Six patients had associated abdominal (mainly liver, n=3) injuries. The main mechanism of injury was bicycle (handlebar) trauma (n=6). Five patients had grade III injury and six had grade IV. The highest mean amylase level was recorded at 48 hours after injury (1418 U/L). Management strategies included conservative (n=5) and operative treatment (n=6): distal (n=3) and central (n=1) pancreatectomy, drainage only (n=2) based on the computed tomography findings and patient hemodynamic stability. Pseudocyst developed in all NOM patients (n=5) and two OM cases, and one patient developed a pancreatic fistula. There were no differences in average length of hospital stay.

Conclusions: NOM of high-grade blunt pancreatic injury in children may pose a higher risk of pseudocyst formation than OM, with a similar hospitalization time. However, pseudocyst is a relatively benign complication with a high rate of spontaneous resolution with no need for surgical intervention.

Background: Vitamin D is essential for skeletal health. Because peak bone mass accrual occurs during childhood and adolescence, vitamin D insufficiency during this period of life could cause adverse health outcomes.

Objectives: To explore the potential sex differences in anthropometric indicators and vitamin D status among primary school-age children.

Methods: A modified food-frequency intake questionnaire was completed by 116 pre-pubertal children (52 girls, 64 boys). Body measurements were recorded and blood was drawn to assess vitamin D status. All children were of Arab-Israeli origin and lived in villages or rural areas in the north-east area of Israel.

Results: Prevalence of obesity was higher among girls (34%) compared to boys (21.9%, P = 0.018). All the children were vitamin D insufficient, and 80% were deficient. Plasma vitamin D was significantly higher among boys (12.4 ng/ml) compared to girls (9.1 ng/ml, P < 0.01). A significant negative correlation was found between vitamin D status and weight percentile for girls (r = -0.43, P < 0.05) but not for boys. There was a trend toward a statistically significant inverse correlation between vitamin D status and body fat percent in the girls (r = -0.37, P = 0.07). Sex frameworks are important for the understanding of the determinants of health and the development of effective health promotion programs.

Conclusions: Pre-pubertal girls in Arab villages should be provided with tailor-made nutrition and physical activity programs for promoting health.

Background: Methylene blue (MB), an inhibitor of nitric oxide synthesis and its effects is a potentially effective treatment against distributive shock states such as septic shock and vasoplegic syndrome. MB has been shown to alleviate vasoplegia and promote an increase in blood pressure. It may reduce mortality. However, in the pediatric population, there are few case reports and only one controlled study on administration of MB use for vasoplegia, sepsis, or shock in general.

Objectives: To summarize the experience of administering MB for vasoplegic shock in a tertiary care pediatric intensive care unit.

Methods: A retrospective chart review of seven pediatric cases treated with MB for vasoplegic shock was conducted. MB was administered as a bolus followed by continuous infusion. The authors measured blood pressure, vasopressor, and inotropic support. Patient outcome was monitored.

Results: The authors observed a favorable hemodynamic response with an increase in blood pressure and a reduction in vasopressor and inotropic support needed following MB administration in six patients. No side effects were observed. Three patients eventually died one to two days later, secondary to their underlying disease.

Conclusions: This case series adds to the small body of evidence in the pediatric population supporting the use of MB for distributive shock states and emphasizes the need for larger, randomized trials evaluating its role in vasoplegic shock treatment.

Background: Immune thrombocytopenia (ITP) is an autoimmune disorder of variable origin that results in bleeding and decreased platelet count. Autoimmune abnormalities have been described in patients with malignancies including non-Hodgkin's lymphoma but are rarely described in patients with Hodgkin's lymphoma.

Objectives: To describe an unusual presentation of Hodgkin's lymphoma in an unusual age and alarm pediatricians of the challenging diagnosis.  

Methods: We present two cases that highlight an unusual clinical presentation of childhood Hodgkin's lymphoma occurring at an atypical age.

Results: Over a 4-year period, two children aged 5 and 6 years were admitted for suspected ITP, both had cervical lymphadenopathy. Bone marrow examination showed no evidence of tumor or fibrosis. Biopsy of the lymph node was possible only after administration of intravenous immunoglobulins and normalization of the platelet count. Platelet counts increased after initiation of chemotherapy.

Conclusions: The identification of the clinical presentation of ITP as a possible presentation of Hodgkin's lymphoma is important to facilitate timely diagnosis and management.

Background: Urinary tract infection (UTI) is a common bacterial infection in children.

Early treatment may prevent renal damage in pyelonephritis. The choice of empiric antibiotic treatment is based on knowledge of the local susceptibility of urinary bacteria to antibiotics. In Israel the recommended empiric oral antibiotic treatment are First or second generation cephalosporin, trimethoprim-sulfamethoxazole or amoxicillin-clavulanic acid.

Objectives: To describe resistance rates of urine bacteria isolated from children with UTI in the community settings. Identify risk factors for resistance.

Methods: A retrospective cross-sectional study of UTI in children aged 3 months to 18 years diagnosed with UTI and treated as outpatients in a large community clinic between 7/2015 and 7/2017 with a diagnosis of UTI.

Results: A total of 989 urinary samples were isolated, 232 were included in the study. Resistance rates to cephalexin, cefuroxime, ampicillin/clavulanate and Trimethoprim-Sulfamethoxazole were 9.9%, 9.1%, 20.7%, and 16.5%, respectively. Urinary tract abnormalities and recurrent UTI were associated with an increase in antibiotic resistance rates. Other factors such as age, fever, and previous antibiotic treatment were not associated with resistance differences.

Conclusions: Resistance rates to common oral antibiotics were low compared to previous studies performed in Israel in hospital settings. First generation cephalosporins are the preferred empiric antibiotics for febrile UTI for outpatient children. Amoxicillin/clavulanate is not favorable due to resistance of over 20% and the broad spectrum of this antibiotic. Care should be taken in children with renal abnormalities as there is a worrying degree of resistance rates to the oral first line antibiotic therapy.