Neonatal hypoxic-ischemic encephalopathy after acute carbon monoxide intoxication during pregnancy. A case report and brief review of the literature

Carbon monoxide (CO) poisoning during pregnancy is a rare occurrence, associated with high maternal and fetal mortality rates. As CO can cross the placenta, leading to intrauterine hypoxia, CO intoxication can result in neurological sequelae and neurologic complications in fetuses who survive. We report a case of a preterm newborn acutely exposed to CO in-utero and delivered by emergent cesarean section at the 31st week of gestation due to the severe burns suffered by the mother following an indoor boiler explosion. As CO has serious adverse effects both on the mother and fetus, it is important to recognize and treat poisoning in a timely manner. Despite maternal blood CO levels, CO intoxication at critical stage of central nervous system development can lead to hypoxic-ischemic lesions, thus interdisciplinary care and follow up for these patients are mandatory.

The Clinical Impact of Methotrexate-Induced Stroke-Like Neurotoxicity in Paediatric Departments: An Italian Multi-Centre Case-Series

Introduction

Stroke-like syndrome (SLS) is a rare subacute neurological complication of intrathecal or high-dose (≥500 mg) Methotrexate (MTX) administration. Its clinical features, evoking acute cerebral ischaemia with fluctuating course symptoms and a possible spontaneous resolution, have elicited interest among the scientific community. However, many issues are still open on the underlying pathogenesis, clinical, and therapeutic management and long-term outcome.

Materials and Methods

We retrospectively analyzed clinical, radiological and laboratory records of all patients diagnosed with SLS between 2011 and 2021 at 4 National referral centers for Pediatric Onco-Hematology. Patients with a latency period that was longer than 3 weeks between the last MTX administration of MTX and SLS onset were excluded from the analysis, as were those with unclear etiologies. We assessed symptom severity using a dedicated arbitrary scoring system. Eleven patients were included in the study.

Results

The underlying disease was acute lymphoblastic leukemia type B in 10/11 patients, while fibroblastic osteosarcoma was present in a single subject. The median age at diagnosis was 11 years (range 4-34), and 64% of the patients were women. Symptoms occurred after a mean of 9.45 days (± 0.75) since the last MTX administration and lasted between 1 and 96 h. Clinical features included hemiplegia and/or cranial nerves palsy, paraesthesia, movement or speech disorders, and seizure. All patients underwent neuroimaging studies (CT and/or MRI) and EEG. The scoring system revealed an average of 4.9 points (± 2.3), with a median of 5 points (maximum 20 points). We detected a linear correlation between the severity of the disease and age in male patients.

Conclusions

SLS is a rare, well-characterized complication of MTX administration. Despite the small sample, we have been able to confirm some of the previous findings in literature. We also identified a linear correlation between age and severity of the disease, which could improve the future clinical management.

The weaning practices: A new challenge for pediatricians?

Introduction of complementary feeding, or weaning, is the period where infants are gradually introduced to solid foods, with a progressive reduction of breastfeeding or bottle-feeding. Weaning represents a crucial nutritional moment in the growth and development of infants, and it can also affect future health. Throughout the years, various weaning strategies have been proposed, ranging from classic to baby-led weaning. Recently, vegetarian-/vegan-based approaches are also being increasingly adopted by young parents. This rostrum aims to critically address the safety profiles of current weaning practices for infants and to highlight the important role of pediatricians in choosing the most advisable weaning approach for their patients.

Nutraceuticals in Viral Infections: An Overview of the Immunomodulating Properties

Nutraceuticals, including vitamin D, vitamin A, zinc, lactoferrin, polyphenols coenzyme Q, magnesium, and selenium, are implicated in the modulation of the complex molecular pathways involved in the immune response against viral pathogens. A common element of the activity of nutraceuticals is their ability to enhance the innate immune response against pathogens by acting on the major cellular subsets and inducing the release of pro-inflammatory cytokines and antimicrobial peptides. In some cases, this action is accompanied by a direct antimicrobial effect, as evidenced in the specific case of lactoferrin. Furthermore, nutraceuticals act through complex molecular mechanisms to minimize the damage caused by the activation of the immune system against pathogens, reducing the oxidative damage, influencing the antigen presentation, enhancing the differentiation and proliferation of regulatory T cells, driving the differentiation of lymphocyte subsets, and modulating the production of pro-inflammatory cytokines. In this paper, we review the main molecular mechanisms responsible for the immunomodulatory function of nutraceuticals, focusing on the most relevant aspects for the prevention and treatment of viral infections.

Breastfeeding and Allergic Diseases: What's New?

Asthma and other allergic disorders, such as atopic dermatitis and food allergies, are common chronic health problems in childhood. The rapid rise in the prevalence of these conditions registered over the last few decades has stressed the need to identify the modifiable risk factors associated with the development of these diseases. Breast milk, recognized as the gold standard for healthy growth and development of the newborn, is one of the major factors associated with a lower incidence of allergic and infectious diseases in childhood and young adulthood. Although the underlying mechanisms for these effects are not well understood, breastfeeding leads to immune system maturation. In this narrative review, we summarize existing evidence on breastfeeding and human milk composition in relation to allergic disease prevention or development.

Breast milk: more than just nutrition!

From an evolutionary and nutritional standpoint, exclusive human milk feeding for the first 6 months of life, with continued breastfeeding for 1 to 2 years of life, is recognized as the gold standard nourishment for the infant: it is a species-specific food, with a composition designed by nature to better respond to the biological and psychological needs of the newborn/infant. Human milk contains many hundreds of bioactive molecules that protect newborn against infection and inflammation and contribute to immune maturation, organ development, and healthy microbial colonization. Compared with formula feeding, breastfeeding has been associated with decreased morbidity and mortality in infants and to lower incidence of gastrointestinal infections and inflammatory, respiratory and allergic disease. Here, we briefly review the nutritional and functional composition of human milk and provide an overview of its varied bioactive factors.

Structural and functional development in airways throughout childhood: Children are not small adults

Children are not small adults and this fact is particularly true when we consider the respiratory tract. The anatomic peculiarities of the upper airway make infants preferential nasal breathers between 2 and 6 months of life. The pediatric larynx has a more complex shape than previously believed, with the narrowest point located anatomically at the subglottic level and functionally at the cricoid cartilage. Alveolarization of the distal airways starts conventionally at 36-37 weeks of gestation, but occurs mainly after birth, continuing until adolescence. The pediatric chest wall has unique features that are particularly pronounced in infants. Neonates, infants, and toddlers have a higher metabolic rate, and consequently, their oxygen consumption at rest is more than double that of adults. The main anatomical and functional differences between pediatric and adult airways contribute to the understanding of various respiratory symptoms and disease conditions in childhood. Knowing the peculiarities of pediatric airways is helpful in the prevention, management, and treatment of acute and chronic diseases of the respiratory tract. Developmental modifications in the structure of the respiratory tract, in addition to immunological and neurological maturation, should be taken into consideration during childhood.

Use of Soy-Based Formulas and Cow's Milk Allergy: Lights and Shadows

Soybean (Glycine max) is a species of legume native to East Asia and used in childhood diet for over 2,000 years in the East. Soy protein formulas have been available for almost a century. Nowadays, the increase in cow's milk allergy and vegetarian dietary preferences are driving consumers toward cow's milk alternatives. In this paper, we reviewed the nutritional composition of soy-based infant formula and discussed their possible use in pediatric age, mainly focusing on prevention and treatment of cow's milk allergy. Protein quality is determined by digestibility and amino acid content. Purified or concentrated vegetable proteins (e.g., soy protein and gluten) have high digestibility (>95%), similar to those of animal ones. For some intact vegetable products (e.g., whole cereals and pulses), protein digestibility is lower (80-90%). Food processing and heat treatment also influence protein digestibility. Considering these data, we tried to evaluate the possible use of soybean and derivatives in pediatric age, including the nutritional composition of soy formulas and the clinical indications for their use. Moreover, since plant-based beverages are being perceived as healthy by consumers and their use is growing on the market, we recommend that soy drink should not be used as a substitute for infant formulas or cow's milk in children younger than 24 months.

Microbiome Composition and Its Impact on the Development of Allergic Diseases

Allergic diseases, such as food allergy (FA), atopic dermatitis (AD), and asthma, are heterogeneous inflammatory immune-mediated disorders that currently constitute a public health issue in many developed countries worldwide. The significant increase in the prevalence of allergic diseases reported over the last few years has closely paralleled substantial environmental changes both on a macro and micro scale, which have led to reduced microbial exposure in early life and perturbation of the human microbiome composition. Increasing evidence shows that early life interactions between the human microbiome and the immune cells play a pivotal role in the development of the immune system. Therefore, the process of early colonization by a “healthy” microbiome is emerging as a key determinant of life-long health. In stark contrast, the perturbation of such a process, which results in changes in the host-microbiome biodiversity and metabolic activities, has been associated with greater susceptibility to immune-mediated disorders later in life, including allergic diseases. Here, we outline recent findings on the potential contribution of the microbiome in the gastrointestinal tract, skin, and airways to the development of FA, AD, and asthma. Furthermore, we address how the modulation of the microbiome composition in these different body districts could be a potential strategy for the prevention and treatment of allergic diseases.

Vitamin D in pediatric health and disease

Several scientific societies established that vitamin D (VD), in its metabolized form 25(OH)D, levels higher than 20 ng/mL are sufficient to ensure optimal bone health, while 25(OH)D levels higher than 30 ng/mL are needed to favor VD extraskeletal actions. However, it has been estimated that approximately 30% of children and 60% of adults worldwide are VD deficient and insufficient, respectively. This is the reason why it is important to provide a practical approach to VD supplementation for infants, children, and adolescents. It is the pediatrician's role to evaluate the modifiable lifestyle risk factors for deficiency, particularly a reduced sun exposure, following an evidence-based approach, and to suggest VD supplementation only when there is a rational reason to support its use.

Dietary Interventions and Nutritional Factors in the Prevention of Pediatric Asthma

Asthma is the most frequent chronic disease in children, and its pathogenesis involves genetic, epigenetic, and environmental factors. The rapid rise in the prevalence of asthma registered over the last few decades has stressed the need to identify the environmental and modifiable factors associated with the development of the disease. In particular, there is increasing interest in the role of modifiable nutritional factors specific to both the prenatal and post-natal early life as, during this time, the immune system is particularly vulnerable to exogenous interferences. Several dietary factors, including maternal diet during pregnancy, the duration of breastfeeding, the use of special milk formulas, the timing of the introduction of complementary foods, and prenatal and early life supplementation with vitamins and probiotics/prebiotics, have been addressed as potential targets for the prevention of asthma. In this review, we outline recent findings on the potential role of prenatal and perinatal dietary and nutritional interventions for the primary prevention of pediatric asthma. Moreover, we addressed unmet needs and areas for future research in the prevention of childhood-onset asthma.

The EDAPA Project (Education of self-measurement of blood pressure) in Grottaglie

AIM OF THE STUDY The EDAPA Project (Education of self-measurement of blood pressure) was conceived to train hypertensive patients in self blood pressure monitoring (SBPM) and to survey their feedback, including patient’ assessment, by recording their related cardiovascular diseases (CVD risks factors) and lifestyle habits. METHODS The project was conducted during the year 2006. Initially we met Grottaglie’s citizens and illustrated to participants the importance of SBPM at home in the overall management of hypertension, that might lead to a better control of BP and cardiovascular outcomes. After explaining the correct technique for SBPM, we distributed semiautomatic devices (OMRON M6) and asked the participants to fill in the Hypertension Questionnaire Form and to record their own blood pressure values in a diary. RESULTS Among almost 3,000 citizens interviewed, 370 (198 M, 172 F; mean age: 60 years) agreed to take part in our study. They were hypertensive for almost 10 years, but waited 3 years before beginning therapy. They measured BP 4 times a month and, in the same sitting, 66% of them carried out only 1 measurement, 29% of them 2 measurements and only 2.5% carried out 3 measurements. Taking as reference BP value of 135/85 mmHg, we registered 28% of the population as normotensive and the remaining 72% as hypertensive. Among the hypertensives, 30% showed a good control, 55% showed a bad one and the remaining 15% was not aware of being hypertensive. Adding non-treated hypertensives to those treated but not controlled, we noticed that 70% of the participants was not properly controlled. Regarding risk factors, almost 64% showed hypercholesterolemia; 18% were smokers; 35% of males and 28% of females showed hyperglicemia and 63% of the latter had a waist line > 88 cm; 32% used to consume alcohol (46% males and 15% females); 26% had a metabolic syndrome; 13% was affected by vascular brain injuries, 30% by peripheral artheriopaty, 35% had heart diseases, 10% was nephropatic and 13% diabetic. CONCLUSIONS By this project we evidenced that, with simple devices and low costs, it is possible to make people understand the importance of self-measurement for a more practical management of the illness, for the follow-up of the BP values and to verify the efficiency of the treatment. A more active and direct role of hypertensive patients in their own medical care could reasonably bring a reduction of expenses in long-term management of the disease, a reduction of inappropriate shifts of therapy and, as seen, an increased reliability of the self-measured pressure values.

Spatial perception in normal and strabismic subjects: role of stereopsis and monocular clues

PURPOSE

To evaluate the roles of binocular vision, monocular clues, and experience in spatial perception in a prospective, nonrandomized, case-control study.

METHODS

A test was created consisting of three wood blocks arranged along the frontal plane inside Panum area. To produce some degrees of horizontal disparity, blocks were moved along a sagittal plane. Thirteen normal subjects (control group) and 13 nonamblyopic strabismic subjects (study group) were asked to identify, both under binocular and monocular vision, the position of the blocks in a series of 12 randomized presentations (phase 1). In phase II of the trial, a letter E in three different sizes, acting as a monocular clue, marked the three blocks. In both phases, the number of correct answers to the test during binocular and monocular vision was recorded.

RESULTS

Binocular normal responses appeared greater than monocular normal responses and strabismic binocular responses in both phases (p < 0.001). Binocular strabismic responses and monocular answers of both groups appeared similar.

CONCLUSIONS

In our experimental model, spatial orientation of strabismic subjects in binocular vision is substantially identical to that of normal subjects in monocular vision. Monocular clues were used in the same manner in both groups of subjects, and experience seemed to play no role in spatial localization of visual objects.

Vitreous hemorrhage following phakic anterior chamber intraocular lens implantation in severe myopia

PURPOSE

To describe two cases of vitreous hemorrhage following phakic anterior chamber lens (AC-IOL) implantation in high myopia.

CASE REPORT

In case 1, hemorrhage developed one month after surgery, without retinal involvement, and visual acuity (VA) resulted 20/200 after pars-plana vitrectomy (PPV). In Case 2, vitreous hemorrhage was complicated by retinal detachment (RD). PPV and silicone oil injection were performed, with AC-IOL removal and cristalline lens extraction. After 2 years the retina was attached and VA was 20/80.

DISCUSSION

Only few cases of RD, posterior uveitis and endophthalmitis are reported following phakic AC-IOL implant. Vitreous hemorrhage could represent an additional posterior segment complication. Intraoperative manoeuvres, hypotony-induced posterior vitreous detachment and/or peripheral retina traction could play a role in engendering this complication in highly myopic eyes.

Older age as risk factor for deviation from emmetropia in pseudophakia

PURPOSE

To find risk factors for deviation from emmetropia after cataract surgery in clinical practice.

METHODS

We evaluated the refractive outcome in 106 patients who had underone phacoemulsification and in-the-bag IOL placement 115 +/- 10 days after surgery. Postoperative optical correction and refractive error (diopters of spherical equivalent--ED) were related to age and sex, pre-operative axial length and keratometric diopter power, and operative incision technique.

RESULTS

Emmetropia was achieved in 15% of cases; 65% of eyes needed a myopic correction, averaging = 0.46 +/- 0.91 ED. The refractive error was 0.74 +/- 0.61 ED (< or = 1 ED in 77% of cases, < or = 2 ED in 97%). Both optical correction and refractive error were correlated to older age at the time of surgery (p=0.002 and p=0.001, respectively). Astigmatism appeared greater in clear-cornea incision than in limbar incision cases (p=0.05).

CONCLUSIONS

The higher refractive error in patients aged over 73 years suggests that age may be a risk factor for deviation from emmetropia after cataract surgery.

Vitreous fluorophotometry and changes in blood-retinal barrier permeability induced by bendazac lysine

Vitreous fluorophotometry was used to investigate the effect of Bendazac lysine on the blood retinal barrier in 12 insulin-dependent diabetics with mild background retinopathy. The study was a randomized, double blind, cross-over trial, drug versus Placebo. Each treatment period was of 4 months. The vitreous penetration coefficient was reduced by 21% (95% c.i. 12, 30; p = 0.001) by treatment with respect to Placebo.

Second Generation Binocular Polaroid Test

BACKGROUND

The aim of the study was to introduce a new test to detect small areas of suppression in the binocular visual field and to lower the minimum age at which a suppression test could be identified correctly. Two tests were compared: the Binocular Polaroid Test (poltest), introduced in clinical practice a few years ago and used in screening programs for vision impairment; and the Second Generation Binocular Polaroid Test (polstar), more recently designed to have simpler answers than the poltest.

METHODS

One hundred and eighty-two children were examined consecutively. To assess the validity of the two tests, sensitivity, specificity, predictive value, and phi coefficient were calculated. The applicability of the two tests and the speed of the responses was assessed by means of the test of probability of binomial distribution.

RESULTS

The polstar has appeared to be simpler and easier in younger patients (age range 20 to 36 months, P = 0.078), and has shown 100% of specificity with a sensitivity of 84% for the polstar 1 and of 100% for the polstar 2.

CONCLUSION

The results appear to demonstrate that the poltest has been improved, and that the polstar may be considered an interesting investigation device for early detection of monocular visual impairment.

[Etiopathogenetic role of metabolic, circulatory, sex factors and type and duration of diabetes in diabetic retinopathy. Investigation with vitreofluorophotometry]

We have studied metabolic, circulatory and vascular parameters in a group of 57 diabetics (37 affected by IDDM, 20 affected by NIDDM; 35 were males, 22 were females). Goals of present study were: 1) quantitative evaluation of the blood retinal barrier; 2) influence of the metabolic state, blood pressure, sex, type and duration of the diabetes on the ocular conditions; 3) relationship between ophthalmoscopic appearance of the retina and vitreous fluorophotometric recordings. We concluded that: a) ocular alterations depend by lipidic metabolism, blood pressure, sex, type and duration of the diabetes; b) vitreous fluorophotometry has proved a good device for early detection of retinal damages in the diabetic retinopathy.

Binocular Polaroid Test for vision screening of pre-school age children

We report the results obtained with the Binocular Polaroid Test in a large population screening devised to detect vision disturbances in pre-school age children. The Binocular Polaroid Test is a new test for rapid detection of small unilateral scotoma in the binocular visual field. The test was performed on 1566 children age 3 to 6 years in a field examination. The reliability of the test was controlled in a study examination. A complete study examination was performed in 60 of the 96 subjects with a positive response to the test. One hundred subjects selected at random among those with a negative response were used as controls. The study examination disclosed vision disturbances in 41 of the 60 children with a positive response to the Binocular Polaroid Test. The remaining 19 results were normal. No vision disturbances were detected in the control group. The predictive value and the "phi" coefficient were calculated. The results indicate that the Binocular Polaroid Test appears very suitable for vision screening in pre-school age children for whom an early diagnosis is of paramount importance for treatment and prognosis of a vision alteration.

Vitreous fluorophotometry in juvenile diabetics after oral fluorescein

Vitreous fluorophotometry was performed in young patients (8 to 19 years old) affected by insulin-dependent diabetes mellitus, with no signs of diabetic retinopathy. Oral fluorescein was administered, and measures were used to prevent hypoglycemia during the examination. The results showed a breakdown of the blood-retinal barrier in nine (43%) of the 21 patients. The oral fluorescein method allows a satisfactory evaluation of ocular fluorescence profiles, with minimal risk of systemic side effects.

Binocular Polaroid test

A test is presented for the detection of small suppression scotomas in strabismic and in anisometropic patients. Three small light-spots (the central is polarized) are viewed through Polaroid filters placed in front of the eyes. This arrangement produces the perception of the central spot only from one eye, but normal fusion provides the perception of three light-spots. Complete suppression of the central light indicates the presence of a scotoma in the binocular visual field. An inhibition scotoma in the non-dominant eye was found in all cases of small angle esotropia and of anisometropic amblyopia.

Unilateral visual agnosia

A case of unilateral visual agnosia for all types of stimuli limited to the left visual hemifield and associated with a right occipital temporal vascular lesion is reported. Questions raised by this case of hemiagnosia as compared to previous ones are discussed.

Binocular disparity in visual evoked responses. Clinical evidence in normal and stereoblind subjects

The authors have utilized a binocular flat or stereoscopic pattern (grating) to record visual evoked responses (VER) in normal and strabismic subjects. The aim was to find an electrophysiological correlate with the degree of binocular interaction in these subjects. The perception of the grating as tridimensional or flat derived from the disparity obtained with Polaroid filters placed in front of the eyes. In normal subjects, the results demonstrated a significant increase of VER amplitude during tridimensional perception of the pattern. In strabismic subjects the electrophysiological response was not correlated with the binocular conditions.

Galactosemic enzyme levels in presenile cataracts

Galactose-1-phosphate uridyl transferase and galactokinase activities have been measured in the red blood cells of a group of patients with "idiopathic" presenile cataract and of a group of nondiabetic patients with senile cataract. The activity of both galactosemic enzymes was found to be within the normal range in all the patients with presenile cataract. In the group of patients with senile cataract, galactokinase activity was normal in all 24 subjects examined, and galactose-1-phosphate uridyl transferase activity was moderately reduced in 3 of 14.

Proximal and accommodative convergence and age

The authors have estimated the phoria for distant and near fixation in two groups of subject (mean age 27. 5+/- 4.4 and 59.2 +/- 8.2 years). Different accommodative stimuli were induced by adding minus lenses for distant fixation and plus lenses for near fixation. Statistical analysis of the experimental data indicates that, for distant fixation, the value of phoria per unit of accommodative stimulus is significantly lower presbyopic than in nonpresbyopic subject. Also, during near fixation, the accommodative convergence (AC/A ratio) is more reliable in the presbyopic subjects when the accommodative stimulus is progressively reduced. This varying behavior indicates in presbyopic subjects that proximal convergence is of greater relative importance in the determination of the fusion-free position. In nonpresbyopic subjects, accommodative convergence is the more important component.

Bilateral papilloedema in long term therapy with lithium carbonate

A 31-year-old white woman developed bilateral papilloedema whilst on lithium carbonate therapy for five years because of manic depressive illness. Oedema of the optic disc disappeared after lithium administration had been discontinued. To our knowledge this is the second case of this kind which has been reported in literature.

Vertical retraction syndrome

A 14-year-old white boy, the second of 5 brothers, showed a congenital deficit of ocular motility in his left eye, characterized by limited elevation, marked retraction of the globe and narrowing of the palpebral fissure during upward gaze. The ocular movements in the other directions of gaze were normal with normal binocular vision and stereopsis. The characteristics of the motility defect and the results of the forced duction test suggest the possibility of an anomaly of superior rectus scleral insertion rather than of an innervational defect or of a muscular fibrosis.