Practice Gaps
Cough is a common presenting chief complaint in the pediatric population. Characteristics of cough that are revealed in either the history or physical examination can facilitate diagnosis and management.

Objectives
After completing this article, readers should be able to:

Manage the common causes of cough, recognizing the underlying mechanics of coughing.

Discuss effective and efficient management options based on gathered clinical evidence.

Review existing guidelines for the management of chronic cough.

Identify when subspecialty referral is appropriate.

Clinical Case
A 12-year-old boy with autism spectrum disorder presents with concerns of progressively worsening wet-sounding cough for 3 weeks that is worse at night and clears throughout the day. He was initially evaluated 2 weeks earlier and given albuterol for possible reactive airway disease. He denies fevers, exercise limitation, or viral prodrome. On examination he is afebrile, with a respiratory rate of 18 breaths/min, heart rate of 100 beats/min, blood pressure of 100/67 mm Hg, and pulse oxygen saturation of 100% on room air. He appears comfortable. Physical examination is remarkable for bilateral upper lobe faint expiratory wheezing and right-sided neck swelling. What is the next step in the management of this patient?

Background: Placement of gastric tubes is commonly performed in infants and children but malpositioning is common and is associated with significant complications.

Objective: The aim of this systematic review is to identify the evidence on the use of ultrasound to verify correct gastric tube placement in infants and children and gaps in the research.

Methods: This review was performed using CINAHL, PUBMED, EMBASE and Web of Science databases. Studies were included if they used an empirical study design, were published in English, included infants or children, and evaluated the use of ultrasound to verify correct gastric tube placement compared to radiograph. Sensitivity, specificity, positive and negative predictive values were evaluated.

Results: Four articles were included in the review. Sensitivity estimates were 0.88 to 1.00 and a positive predictive value of 0.99 was reported in one study. Specificity was not reported in any of the included studies. Ultrasound may be an important method to correctly identify gastric tube placement in infants and children with less radiation exposure and cost.

Implications for Practice: Ultrasound could be a used to verify gastric tube positioning in infants and children for both initial placement and continued verification leading to reduced radiation exposure and cost.

Implications for Research: Research should focus on evaluating ultrasound specificity and the clinical feasibility of using ultrasound as a standard practice, including cost and time required to complete the exam, as well as the ability of ultrasound to verify gastric tube placement in infants weighing less than 1500 grams.

Purpose of review: This review summarizes the most current information on cause, evaluation and treatment of dizziness in children.

Recent findings: There has been an increased understanding of the multifactorial cause of dizziness in the paediatric population. Quantitative vestibular testing is increasingly used and valuable as a diagnostic adjunct. Vestibular rehabilitation, migraine hygiene, psychological therapies, pharmaceuticals and/or surgery can be used as well tolerated and effective treatments for vertigo in children and adolescents when tailored to cause.

Summary: Paediatric vertigo can be effectively evaluated through careful history taking and physical examination along with adjunctive tests, such as vestibular testing and audiometry, when appropriate. Options for treatment of vestibular disorders in children and adolescents have greatly expanded in recent years allowing for the effective management of nearly all cases of paediatric vertigo, though a multimodal and/or multidisciplinary approach is often needed.

Purpose of review: Cardiovascular damage could begin early in life. Our aim was to examine the current state of the art related to micronutrient supplementation on vascular health in obese and overweight children. We considered only the studies performed over the past few years.

Recent findings: Vitamin D supplementation in the obese pediatric population with vitamin D deficiency could improve the vascular health of these subjects. The evidence is less clear on supplementation with other micronutrients. Zinc supplementation is currently the most supported by the literature.

Summary: As of today, we can only speculate that supplementation with other micronutrients could improve the vascular health of obese and overweight children. Strong limitations are the different instrumental methods used to assess vascular health in obese children and adolescents under micronutrients supplementation. Actually, indirect indicators more reliable to evaluate vascular health seem to be lipid profile and insulin sensitivity. Furthermore, there is a particular lack of studies in this area in recent years, especially in the pediatric population. Additional studies performed in this population should be pursued to clarify significant relationships between micronutrients and vascular health.

Background: Patients with pediatric leukemia and sickle cell disease are at risk for developing osteonecrosis (ON), a disease that can result in pain, loss of function, and disability. Hip core decompression surgery is an option aimed to prevent femoral head collapse and avoid future arthroplasty.

Objective: Describe functional outcomes and gait quality among a young population with hip ON before and after hip core decompression.

Methods: Study included participants with hip ON secondary to treatment for hematologic malignancy or sickle cell disease, between 8 and 29 years of age, requiring hip core decompression surgery. At 1-year follow-up, 13 participants (9 male, median age of 17 years) completed the Functional Mobility Assessment (FMA), range of motion, and GAITRite testing.

Results: The participants demonstrated improved mobility and endurance on the FMA at 1 year postoperatively compared with preoperatively, with higher scores for time on the Timed Up and Go (mean FMA score = 2.92 [SD = 1.32] vs 2.07 [SD = 1.70]), time on the Timed Up and Down Stairs (3.69 [0.85] vs 2.92 [1.66]), and 9-Minute Walk Test scores for distance walked (2.69 [0.63] vs 2.23 [0.93]) and heart rate (4.54 [0.66] vs 3.31 [1.38]). GAITRite analysis also showed improvements in many gait parameters at 1-year follow-up.

Limitations: Cancer treatment complications other than ON could have contributed to results, not all eligible participants agreed to participate, and follow-up was only 1 year.

Conclusions: Young patients with hip ON demonstrated improvements in functional mobility, endurance, and gait quality 1 year following hip core decompression.

The scientific scope of swallowing disorders in the neonatal and pediatric populations is growing exponentially; however, the preponderance of evidence for evaluation protocols has been concentrated in non-instrumental evaluations creating a lack of research about protocols for instrumental swallowing assessment. Thus, the purpose of this study was to systematically review the literature to identify and to report protocols used in instrumental assessments through videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) in the neonatal and pediatric populations to support clinical decision making. The search strategy was applied in five online databases, no filters were applied to restrict languages or publication dates and the gray literature was reviewed. PRISMA statement was used to guide the construction of this review. The studies included validated and unvalidated protocols, the validated protocols had their risk of bias estimated using the QUADAS-2. In total, 13 studies were included in the final review, of these eleven assessed through QUADAS-2, and two classified with low risk of bias. One study is in the process of standardization and validation of an instrumental assessment protocol for swallowing in bottle-fed infants through VFSS. Information about validity and reliability of published protocols for instrumental evaluation in the neonatal and pediatric populations is limited. Therefore, further research is needs to development studies aiming to standardize and validate protocols for instrumental assessments in these populations.

The proper use of intravenous fluids has likely been responsible for saving more lives than any other group of substances. Proper use includes prescribing an appropriate electrolyte and carbohydrate solution, at a calculated rate or volume, for the right child, at the right time. Forming intravenous fluid plans for hospitalized children requires an understanding of water and electrolyte physiology in healthy children and how different pathology deviates from the norm. This review highlights fluid management in several disease types, including liver disease, diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, kidney disease, and intestinal failure as well as in those with nonphysiologic fluid losses. For each disease, the review discusses specific considerations, evaluations, and management strategies to consider when customizing intravenous fluid plans. Ultimately, all hospitalized children should receive an individualized fluid plan with recurrent evaluations and fluid modifications to provide optimal care.

Purpose: Approximately 25% of inflammatory bowel disease (IBD) patients are diagnosed in childhood and the incidence is increasing. Thus, more patients will transition to adult care in the future. Within the literature, transition readiness has been deemed important to achieving a successful transition; however, it is unclear what outcomes define success. This scoping review aims to summarize the literature on outcomes surrounding transition from pediatric to adult care in patients with IBD.

Methods: A scoping review was conducted with the following steps: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarizing, and reporting results, and (6) consultation with an additional researcher. Studies were identified from 5 databases and were included in part if (1) IBD was a disease of interest, (2) referred to transition as the movement and adjustment from pediatric to adult care, and (3) evaluated patient outcomes up to 5 years after first adult appointment and/or defined a successful or unsuccessful transition.

Results: Twenty-six peer-reviewed studies were included. Four studies defined transition success, while 2 studies defined an unsuccessful transition. Transition outcomes were categorized into these 6 themes: being comfortable in adult care (n = 4); health care utilization (n = 19); disease management (n = 15); knowledge (n = 5); quality of life (n = 6); self-efficacy (n = 7).

Conclusions: Most studies evaluated transition outcomes by themes of health care utilization (n = 19) and disease management (n = 15). Future research should focus on engaging patients along with providers in order to create a consensus on indicators of transition success.

Objective: The present study aims to explore the relative effectiveness of two group-based cognitive rehabilitation programs for reducing fatigue in pediatric acquired brain injury (pABI). Method: This is an exploratory study of secondary endpoints in a blinded, parallel-randomized controlled trial with children and adolescents (ages 10-17 years) with pABI and reported executive dysfunction. It investigates the effectiveness of a metacognitive program (pediatric goal management training, n = 36) compared to a psychoeducational program (pediatric brain health workshop, n = 37) for reducing fatigue (Pediatric Quality of Life Inventory, Multidimensional Fatigue Scale), 8 weeks and 6 months postintervention. Results: Seventy-three participants completed the allocated interventions, and 71 attended the 6-month follow-up. The results showed a significant decrease in parent-reported fatigue for both interventions from baseline to the 6-month follow-up. Forty percent of the total sample had a reliable change. There was no significant difference between the intervention groups, but a tendency in favor of the psychoeducational approach. Only subscales cognitive and sleep/rest fatigue showed significant reductions. In regression analyses, several factors predicted fatigue at 6 months follow-up, but only better global outcome and executive attention predicted a decrease in fatigue symptoms after 6 months. Conclusions: Group-based cognitive rehabilitation in the chronic phase of pABI, including education of parents and teachers, may be helpful in reducing fatigue. Global outcome and executive attention at baseline predicted fatigue improvement. Developmental factors are important to consider when tailoring pediatric interventions, as well as modifiable factors associated with fatigue.

Learning objectives: After completing this activity, practitioners will be better able to:

* Discuss and better understand the recently adopted screening standards for adolescents with depression and the potential advantages of using "lifestyle medicine"

* Set up a process for providing effective interventions for the increased number of patients with adolescent depression

* Design or update their toolbox of treatment options for adolescents with depression based on the new literature and increased demand

Abstract: Recently adopted quality standards recommend that pediatricians screen adolescents for depression and that they document follow-up plans for those who screen positive. As a result of these new recommendations, pediatricians and other pediatric providers, as well as psychiatrists and other mental health professionals, may face an increasing number of referrals and a growing need for effective interventions for adolescent depression. Given the widely acknowledged scarcity of traditional mental health resources, the current study reviewed the rapidly expanding array of evidence-based, but nontraditional, interventions applicable to outpatient pediatric and mental health care settings. Many of these interventions come from a lifestyle medicine framework. Lifestyle medicine interventions are congruent with the cultures of pediatrics and outpatient psychiatry, and offer additional evidence-based tools for providers managing adolescent depression. These interventions can be implemented individually or within group or community settings, and may be used in conjunction with more common interventions such as psychotherapy or psychotropic medications.

Abstract: Children and adolescents with high-risk (metastatic and relapsed) solid tumors have poor outcomes despite intensive multimodal therapy, and there is a pressing need for novel therapeutic strategies. Adoptive cellular therapy (ACT) has demonstrated activity in multiple adult cancer types, and opportunity exists to expand the use of this therapy in children. Employment of immunotherapy in the pediatric population has realized only modest overall clinical trial results, with success thus far restricted mainly to antibody-based therapies and chimeric antigen receptor T-cell therapies for lymphoid malignancy. As we improve our understanding of the orchestrated cellular and molecular mechanisms involved in ACT, this will provide biologic insight and improved ACT strategies for pediatric malignancies. This review focuses on ACT strategies outside of chimeric antigen receptor T-cell therapy, including completed and ongoing clinical trials, and highlights promising preclinical data in tumor-infiltrating lymphocytes that enhance the clinical efficacy of ACT for high-risk pediatric solid tumors.

Accompagner vers la mort son enfant atteint de cancer et faire le deuil de celui-ci représente une expérience bouleversante et souffrante à laquelle aucun parent ne souhaite être confronté. En Amérique du Nord, plusieurs dizaines de milliers d’enfants vivent avec le cancer (Snaman et al., 2020). Au Canada, 20 % des enfants atteints de cancer ne survivront pas à leur maladie (Société canadienne du cancer, 2021). Les parents de ces enfants sont leurs proches aidants principaux. Toutefois, le processus psychologique et social que traversent les parents ainsi que leurs besoins psychosociaux durant la fin de vie de leur enfant atteint de cancer sont peu documentés. Le présent article présente une synthèse des connaissances sur l’expérience des parents qui accompagnent leur enfant atteint de cancer vers les soins de fin de vie dans une perspective psychosociale. Cette recension permet, dans un premier temps, de caractériser la transition des soins curatifs vers les soins palliatifs d’un enfant atteint de cancer avancé. Dans un deuxième temps, elle décrit les principaux facteurs psychosociaux qui influencent le vécu des parents à travers la trajectoire de soin de l’enfant, de l’annonce de la maladie jusqu’à la période de deuil. Enfin, des recommandations pour améliorer le soutien psychosocial offert aux parents tout au long de la trajectoire de soin de l’enfant malade, incluant la phase palliative et celle du deuil, sont proposées.

Importance: The Mini-Clinical Evaluation Exercise (Mini-CEX) is highly recommended for assessing interns’ performance.

Objective: To develop a pediatric occupational therapy–specific Mini-CEX and examine its psychometrics.

Design: Stage 1 had a retrospective design; Stage 2 had a prospective design.

Setting: Pediatric occupational therapy unit in a hospital in Taiwan.

Participants: Thirty-four occupational therapy interns were evaluated with the Mini-CEX (physician version), and 57 were evaluated with the occupational therapy–specific Mini-CEX.

Outcomes and Measures: The occupational therapy–specific Mini-CEX was developed with seven items on a 9-point scale categorized into three levels (unsatisfactory, satisfactory, highly satisfactory).

Results: In Stage 1, the frequency of Mini-CEX (physician version) items receiving a rating of not applicable ranged from 1.9% to 88.1%. In Stage 2, the frequency of occupational therapy–specific Mini-CEX items receiving a rating of not applicable ranged from 3.5% to 31.6%. With the theme of evaluation taken into consideration, the frequency of not-applicable ratings was 0% to 8.8%. For the occupational therapy–specific Mini-CEX, content validity (item-level content validity index = 1, scale-level content validity index = 1) and internal consistency (Cronbach’s α = .93) were excellent. The interns’ scores on the second evaluation were significantly higher than those on their first evaluation, indicating good discriminant validity.

Conclusions and Relevance: The occupational therapy–specific Mini-CEX appears to be reliable and valid, and it is appropriate for evaluating interns’ skills and attitudes in pediatric occupational therapy practice.

What This Article Adds: The results support the development of the occupational therapy–specific Mini-CEX and its application in pediatric internship training.

Essential Med Notes is a clinical complement and resource for medical trainees. This 37th edition features substantial content revisions to the main text, figures, graphics, and evidence-based medicine boxes of all 31 chapters across the 3 volumes - Primary, Medicine, and Surgery.

Primary:
- Ethical, legal, and organizational medicine
- Anesthesia
- Clinical Pharmacology
- Dermatology
- Emergency medicine
- Family Medicine
- Medical Genetics
- Medical Imaging
- Pediatrics
- Psychiatry
- Public Health and Preventice Medicine

Cet ouvrage aborde pour le pédiatre, le médecin généraliste, ou tout professionnel de la santé de l’enfant, l’ensemble des aspects de la prévention, du diagnostic et du suivi, ainsi que les différentes structures d’orientation et d’accueil à tous les âges de l’enfance (du nouveau-né à l’adolescence). Toutes les pathologies pédiatriques sont abordées et intégrées au sein de véritables monographies autonomes comme l’infectiologie, les urgences, les pathologies respiratoires, digestives ou neurologiques, les spécificités reliées à l’adolescence… L’ouvrage a bénéficié de la coordination d’experts reconnus ayant assuré la cohérence rédactionnelle des différents chapitres par les spécialistes concernés. Cette 7e édition bénéficie d’une profonde refonte des contenus et d’une mise à jour complète des données médicales avec une première partie sous forme d’algorithmes déclinant des symptômes ou des motifs de consultation, facilitant la recherche des informations dans les chapitres de l’ouvrage et ainsi la conduite diagnostique pratique. Une très grande rigueur a marqué la coordination multiple de ce document de référence. L’attention des coordinateurs, à l’échelle de chaque thématique ou de l’ouvrage dans son ensemble, a permis de veiller scrupuleusement au respect des objectifs attendus pour le praticien de terrain.