Israel Medical Association Journal

Background: Pepper spray and tear gas are chemical irritants causing ocular, dermal, and respiratory injury. Data specific to pediatric emergency department (PED) presentations remain limited.

Objectives: To characterize the epidemiology, clinical presentation, and short-term outcomes of chemical irritant exposure in children presenting to a tertiary PED.

Methods: We conducted a retrospective cohort study of patients aged 0–18 years of age presenting to a single tertiary PED between 2016 and 2024 following civilian-grade chemical irritant exposure. Cases were identified using ICD-9 codes and free-text electronic medical records search. Demographic characteristics, clinical findings, treatment, and disposition were analyzed using descriptive statistics.

Results: We included 84 pediatric patients (median age 12.5 years, IQR 6.0–15.6; 69.0% male). Exposures occurred most commonly at home (44.0%) and school (36.9%). Ocular involvement was common. Superficial punctate keratitis was identified in 54.5% of patients who underwent fluorescein examination by ophthalmologist (21.5% of the total cohort). Respiratory and dermal symptoms were mild and self-resolving. No severe complications were documented; 96.4% were discharged home.

Conclusions: Civilian-grade chemical irritant exposures in children were predominantly self-limited and managed successfully with conservative ED care, supporting decontamination-based protocols while highlighting home and school settings as priorities for prevention.

Background: Proton pump inhibitors (PPIs) are a common and effective management strategy for eosinophilic esophagitis (EoE) leading to successful remission in most cases. However, there is uncertainty regarding the ideal follow-up pharmacological treatment to maintain remission. We performed a cost-effectiveness and quality-adjusted life year (QALY) analysis.

Objectives: To compare various approaches of pharmacologic treatments for EoE.

Methods: A Markov model was constructed to evaluate the cost-effectiveness and QALY of maintenance therapies for eosinophilic esophagitis, including PPI, topical corticosteroids (tCS), and no treatment strategy, with crossover in treatments for primary and secondary nonresponse. The primary outcomes were incremental cost-effectiveness and QALY at a 5-year time horizon.

Results: In the base-case scenario (5-year time horizon), the average costs were no treatment:₪ 73,075, PPI:₪ 81,455, and tCS:₪ 145,669 as maintenance therapy, with PPI being the dominant strategy (more effective/less costly), and a QALY of 45543, 4.5538, and 4.2283, respectively.

Conclusion: PPI was the most effective/least costly maintenance therapy. PPI is also the most cost-effective pharmacologic strategy. The relatively low adverse effects of this treatment, in addition to its effectiveness and low cost, make it an ideal choice following successful PPI induction treatment.

Background: Mucopolysaccharidosis type II (Hunter syndrome [MPS II]) is a rare, progressive, lysosomal storage disorder, often diagnosed late due to nonspecific early features and limited clinical awareness.

Objectives: To highlight the role of pediatric surgeons in early recognition based on clinical and surgical presentations.

Methods: We retrospectively reviewed patients diagnosed with MPS II at our institution focusing on presenting symptoms, timing of diagnosis, and factors leading to diagnostic suspicion and treatment.

Results: Four boys were diagnosed between 2012 and 2021. Three were diagnosed at 2.5–4 years of age following typical systemic manifestations. The fourth patient was suspected earlier by a pediatric surgeon, whose prior familiarity with similar reported cases enabled recognition of the clinical pattern and led to an earlier diagnosis.

Conclusions: Increased awareness and clinical familiarity among pediatric surgeons are essential for early recognition of MPS II. Recognition of early surgical patterns, such as hernias and recurrent procedures in early childhood, highlights the role of pediatric surgeons in raising diagnostic suspicion, facilitating earlier diagnosis, and enabling earlier initiation of enzyme replacement therapy before disease progression, ultimately improving clinical outcomes.

Background: Trichosporon asahii is an opportunistic fungal pathogen increasingly recognized in immunocompromised patients, including children. Although rare, T. asahii fungemia carries significant morbidity and mortality, particularly in those with hematologic malignancies or prolonged immunosuppression.

Objectives: This case series aimed to describe the clinical characteristics, risk factors, microbiological profiles, and treatment outcomes of pediatric patients diagnosed with T. asahii fungemia over a 13-year period at a tertiary care children’s hospital.

Methods: A retrospective review was conducted of all cases of T. asahii fungemia diagnosed between 2010 and 2023 in patients under 18 years of age. Data collected included patient demographics, underlying conditions, immunosuppressive status, presence of central venous catheters (CVCs), neutrophil counts, antifungal susceptibility profiles, treatments administered, and clinical outcomes.

Results: Most cases occurred in immunocompromised patients, mainly those with neutropenia and a CVC. Half of the patients died. T. asahii isolates were generally susceptible to voriconazole and other azoles but showed partial resistance to amphotericin B. Clinical improvement was mainly associated with early antifungal treatment (particularly voriconazole) and supportive measures, including immunosuppression reduction, neutrophil recovery, and CVC removal.

Conclusions: Voriconazole appears to be a reasonable empiric treatment option for pediatric T. asahii fungemia, a condition associated with a very poor prognosis. Successful management may also require early recognition of risk factors and interventions aimed at reversing immunosuppression and eliminating potential sources of infection such as CVCs.

Background: Gangrenous appendicitis falls to the midpoint of the continuum between uncomplicated and complicated appendicitis. We present an eight-year single-center retrospective review of uncomplicated, complicated and gangrenous appendicitis.

Objectives: To analyze the presentation of gangrenous appendicitis in our population.

Methods: We reviewed the presentation, as well as the laboratory, surgical, and pathological findings for complicated, uncomplicated, and gangrenous appendicitis. Logistic regression analysis was conducted to identify predictors of gangrenous and of complicated appendicitis.

Results: During the study period, 865 children had uncomplicated appendicitis and 134 had complicated appendicitis. Younger age, duration of illness as well as vomiting, diarrhea, and fever were more common in complicated than uncomplicated appendicitis. White blood cell count, neutrophil count and C-reactive protein were higher in complicated appendicitis. Logistic regression showed that vomiting and presence of fever occurred more frequently in children with non-perforated gangrenous appendicitis than with other uncomplicated appendicitis. Laboratory results for non-perforated gangrenous appendicitis were comparable to those of complicated appendicitis, as was usage of radiography and computed tomography.

Conclusion: Gangrenous appendicitis shares similar historical elements with complicated appendicitis and has a similar laboratory. These children, like those with complicated appendicitis, may not be optimal candidates for non-operative management.

Neck masses are a common yet challenging presentation in pediatric patients. They may be caused by congenital, inflammatory, neoplastic, or vascular issues. The diverse nature of these masses can make definitive diagnosis difficult for clinicians. Several classification systems exist to categorize neck masses, considering factors such as age at presentation, anatomical location, imaging characteristics, and underlying etiology [1].

These masses often reflect benign infectious, inflammatory, or congenital etiologies. However, in certain cases, lymphadenopathy or other neck masses may indicate an underlying malignancy, thereby serving as a significant source of anxiety for patients and their families.

Fibromatosis colli (FMC) is characterized by a diffuse enlargement of the sternocleidomastoid muscle (SCM), usually in infancy. FMC, initially described as SCM tumors in childhood, is detected in 0.4% of live births but is among the most frequent perinatal neck masses [2].

Background: Recent guidelines have emphasized the importance of the diagnosis and treatment of obesity in all healthcare settings. However, obesity rarely appears as a chronic diagnosis during hospitalization, and there are few reports of targeted interventions.

Objective: To assess obesity-related diagnoses and interventions during pediatric acute hospitalization.

Methods: A retrospective cohort study was conducted in a pediatric ward. Hospitalization records of all patients aged 2–18 years were retrieved during a 30-month period. Weight percentile for patient age was calculated using the U.S. Centers for Disease Control and Prevention (CDC) age- and sex-adjusted charts. Patients with a weight-percentile-for-age of ≥ 95% were classified as suspected obesity. The characteristics of obesity-diagnosed patients were compared to obesity-overlooked patients.

Results: Of the hospitalized patients, 245/2827 (8.6%) had weight-percentile-for-age of ≥ 95%. Of these, 91/245 (37.4%) had obesity-related references in their medical record; 65/245 (26.5%) had a mean body mass index of 97.66% ± 2.6. Only 38/245 (15.5%) were diagnosed with obesity; weight-related recommendations only appeared in the discharge letter for 44/245 (17.9%). Multivariate analysis indicated that obesity was significantly more overlooked in preschoolers than in adolescents (adjusted odds ratio [OR] 11.78, 95% confidence interval [95%CI] 4.71–29.42), P < 0.001) and in patients, regardless of age, whose chief complaint was not abdominal (OR 7.7, 95%CI 1.92–30.8, P = 0.004).

Conclusions: Low rates of obesity-related diagnoses during pediatric acute hospitalization, especially in younger patients, are frequent. Pediatric staff should note obesity in patients and be trained in non-stigmatizing intervention during hospitalization.

Tracheobronchial injuries (TBI) are rare but potentially fatal complications of blunt thoracic trauma. Recent literature supports conservative management in selected stable cases. In this study, we describe the case of a pediatric patient with a tracheal tear that was managed successfully without surgical intervention.

In hemodynamically stable pediatric patients, even high-grade tracheal injuries may be managed conservatively with close intensive care unit (ICU) monitoring. Early multidisciplinary evaluation is essential.

TBI following blunt trauma is an uncommon but life-threatening condition, particularly in children. Blunt trauma accounts for approximately 94% of TBIs in pediatric cases, in contrast to penetrating trauma which predominates in adults [1]. Management options are typically guided by injury classification, such as the (American Association for the Surgery of Trauma [AAST] Grade III, Cardillo Level IIIA). Non-operative treatment may be appropriate in specific stable cases even in high-grade injuries, as illustrated in former literature [2,3].

Background: Lung transplantation is an advanced medical therapy reserved for patients with end-stage lung disease. Relative to other solid organ transplants, lung transplantation in children is infrequently performed. The most common etiologies for pediatric lung transplantation worldwide are cystic fibrosis, pulmonary hypertension, and children’s interstitial lung disease.

Objectives: To describe our experience in pediatric lung transplants at Israel's largest transplant center.

Methods: We performed a retrospective review of all pediatric lung transplantations conducted in our center since 1997. We recorded demographic characteristics, indication for transplantation, clinical and laboratory parameters, post-transplant complications, and survival rates.

Results: Of 965 lung transplants, 29 (3.0%) were pediatric patients who underwent lung or heart-lung transplants for end-stage lung disease. Age at transplantation ranged from 2 to 18 years, with a median of 14.0 years (IQR 11–15). Primary etiologies for transplantation were cystic fibrosis (44%), pulmonary hypertension (17%), and children’s interstitial lung disease (10%). Survival at 1, 5, 10, and 15 years post-transplant were 90%, 65%, 55%, and 20%, respectively, which is consistent with data reported by pediatric lung transplantation registries. The primary cause of mortality post-transplant was chronic lung allograft dysfunction. Four patients (13.8%) underwent re-transplant. There was no association between survival and transplant indication, nor between survival and type of procedure (lung vs. heart-lung transplant).

Conclusions: The short- and long-term outcomes from our program are consistent with published registry data. These outcomes may reflect the benefits of a centralized pediatric lung transplant program, supported by a multidisciplinary team trained in high-capacity international centers.

Background: Pediatric urinary tract infections (UTIs) are a significant health concern, with rising antibiotic resistance complicating treatment decisions. We investigated pathogen distribution, antibiotic susceptibility patterns, and the cost-effectiveness of treatment options among hospitalized children at a tertiary medical center in Israel.

Objectives: To assess antibiotic susceptibility patterns of UTI pathogens in hospitalized children and evaluate cost-effective alternatives to gentamicin.

Methods: A retrospective analysis of 1649 pediatric UTI cases (January 2010–May 2022) at Galilee Medical Center examined patient demographics, urine culture results, and antibiotic susceptibility. A cost-effectiveness analysis was performed using incremental cost-effectiveness ratios (ICERs), based on susceptibility rates from the study and antibiotic costs from the Israel Ministry of Health, with gentamicin as the comparator.

Results: Escherichia coli was the most common pathogen (63.7%). High susceptibility rates were observed for carbapenems and amikacin (> 99%), with lower rates for gentamicin (91.7%) and ceftriaxone (87.6%). Treatment costs ranged from US$2.54 (trimethoprim/sulfamethoxazole) to US$307.80 (ertapenem). Fosfomycin demonstrated higher susceptibility than gentamicin (94.2% vs 91.7%) and lower cost (US$3.77 vs US$8.05), dominating gentamicin in cost-effectiveness analysis. Piperacillin/tazobactam and ceftriaxone were dominated by gentamicin in terms of cost-effectiveness.

Conclusions: E. coli was the predominant pathogen in pediatric UTIs among hospitalized children. Carbapenems and amikacin showed high susceptibility but were costly. Fosfomycin demonstrated high susceptibility, favorable cost-effectiveness, and the advantage of oral administration, making it a promising option for empiric treatment. Empiric antibiotic selection should integrate susceptibility patterns, clinical context, and economic considerations.

Background: The Iron Swords war created stressful circumstances that could negatively impact glycemic control in individuals with type 1 diabetes (T1D).

Objectives: To evaluate changes in continuous glucose monitoring (CGM) metrics in pediatric T1D patients during the war.

Methods: This retrospective study included T1D patients monitored by CGM. Metrics from three selected 2-week periods were compared (before the war, after the war outbreak, and 4 months later). Study variables included time-in-range (70–180 mg/dl; 3.9–10 mmol/L), time-in-tight-range (70–140 mg/dl; 3.9–7.8 mmol/L), time-in-marked-hypoglycemia (< 54 mg/dl; < 3 mmol/liter), and time-in-severe-hyperglycemia (> 250 mg/dl; >13.3 mmol/liter). Patients were treated with either a multiple daily insulin (MDI) regimen or insulin pump, with or without an open-source automated insulin delivery (OS-AID) system.

Results: Data of 99 patients were analyzed (mean age 12.2 ± 4.0 years, mean diabetes duration 4.6 ± 3.9 years, 52.5% males). No significant changes in CGM metrics were observed across the entire cohort at any time point. Patients with higher socioeconomic position (SEP; cluster > 7) had better CGM metrics, with an increase in time-in-tight-range in the lower SEP group and in time-in-severe-hyperglycemia in the higher SEP group (P = 0.003). OS-AID users (n=20) had superior pre-war CGM metrics and maintained stable glycemia during the war, MDI users showed increased time-in-severe-hyperglycemia post-outbreak (P = 0.05).

Conclusions: Throughout the war, children and adolescents with T1D treated with insulin pumps maintained relatively stable glycemic control. Susceptibility to change following the onset of war was influenced by SEP and mode of insulin therapy.

Background: Hyponatremia is common among hospitalized children, including those with community acquired pneumonia. The prevalence and severity of hyponatremia were reported to correlate with disease. However, data regarding the association between hyponatremia and causative infectious pathogens are limited and results are inconsistent.

Objectives: To investigate the associations between sodium levels, severity and causative pathogen in children with pneumonia.

Methods: A retrospective study of all children (< 18 years) hospitalized with pneumonia from 1 January 2018 to 31 December 2020. Admission sodium levels were compared to the presumed etiological pathogens, clinical parameters, and inflammatory markers.

Results: Among 751 (52% males) children, 10 (1%) had sodium levels < 130 mEq/L, 187 (25%) had mildly decreased levels 130–134 mEq/L, and the remaining 554 (74%) had normal levels 135–145 mEq/L. Sodium levels < 130 mEq/L were found in 7/236 (3%) of the patients with presumed bacterial pneumonia, in 0/20 of patients with presumed atypical-bacterial, and in only 3/495 (0.6%) of the patients with a presumed viral infection, P < 0.001. Sodium levels < 135 mEq/L conferred an odds ratio of 3.1 (95% confidence interval [95%CI] 2.1–4.3) and levels < 130 mEq/L an odds ratio of 6.8 (95%CI 1.8–33.0) for bacterial infection, P < 0.001 for both. Hyponatremia was also inversely associated with high white blood cell counts, absolute neutrophil cell counts, and C-reactive protein levels.

Conclusions: Hyponatremia was common among children hospitalized with pneumonia and was associated with elevated inflammatory markers and presumed bacterial pneumonia.

Pediatrics stands at the forefront of medical innovation, from neonatal care to the management of complex acute and chronic conditions. The field continues to evolve, driven by pioneering research. Advances in genetics, technology, and personalized medicine are transforming pediatric care, addressing the diverse needs of children globally, and offering new opportunities to enhance health outcomes and quality of life.

Background: Chest radiograph is a standard procedure for diagnosis of pneumonia; however, interpretation shows considerable variability among observers.

Objectives: To assess the extent of agreement between pediatric residents and board-certified radiologists in interpretation of chest radiography for detection of pneumonia. To evaluate the impact of resident experience, patient age, and signs of infection on this phenomenon.

Methods: The cohort included 935 patients with suspected pneumonia admitted to the pediatric emergency department at a non-tertiary medical center in Israel 2019–2021. All patients had chest radiographs interpreted by a resident and a radiologist. Interobserver agreement was assessed using Κ and prevalence-adjusted bias-adjusted κ (PABAK) with 95% confidence intervals (95%CI). Results were stratified by resident experience (junior or senior), patient age (≤ 3 vs. > 3 years), white blood cells (≤ 15,000 vs. > 15,000 cells/ml), C-reactive protein (≤ 5 vs. > 5.0 mg/dl), and temperature (< 38.0°C vs. ≥ 38.0°C).

Results: Moderate agreement between pediatric residents and radiologists was demonstrated for diagnosis of pneumonia (κ= 0.45). After adjustment for disease prevalence, the extent of agreement increased to near-substantial (PABAK= 0.59, 95% confidence interval 0.54–0.64). The extent of agreement was higher for children over 3 years of age and in patients without clinical or biochemical features of pneumonia, especially when diagnosis of pneumonia was ruled out.

Conclusions: A second reading of chest radiographs by an experienced radiologist should be considered, particularly for patients younger than 3 years of age and in those with signs of infection and an initial diagnosis of pneumonia.

Background: Understanding medical guidelines can be challenging for patients and their families, leading to incorrect use or dosages due to inadequate or unclear explanations. Graphic organizers are tools that can help improve comprehension of medical guidelines.

Objectives: To assess the effectiveness of using designed graphic organizers to enhance comprehension of medical guidelines.

Methods: A prospective randomized controlled study was conducted at Soroka University Medical Center between 2015 and 2017. Parents of children aged 1–7 years, admitted for asthma exacerbation requiring the use of an inhaler with a spacer or for febrile convulsion requiring rectal diazepam, were enrolled. Participants were randomly assigned to receive instructions through a graphic organizer (intervention group) or plain text (control group). An assessment form was administered to evaluate the understanding of the correct steps for using the inhaler with a spacer or administering rectal diazepam. A follow-up telephone assessment was conducted after 30–60 days to evaluate recollection.

Results: Seventy-four parents with similar demographic characteristics were enrolled (intervention group [38], control group [36]). There was no significant difference in comprehension between the two groups when using medical guidelines for the two interventions. However, there was a correlation between maternal education level and long-term recollection, with an average score of 24%, 42%, and 48% among mothers with less than 8 years, 8–12 years, and over 12 years of education, respectively (P = 0.004).

Conclusions: The use of graphic organizers did not improve parent comprehension of pediatric medical guidelines. However, long-term recollection was positively correlated with maternal education level.