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THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY
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Vol.125, No.7, July 2021
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Review
Title
Coronavirus Disease 2019 and Childhood Bronchial Asthma
Author
Seigo Korematsu and Miwa Sawaki
Nakatsu Municipal Hospital
Abstract
The world is now facing the coronavirus disease 2019 (COVID-19) pandemic. This outbreak started in or around December, 2019, in Wuhan, China, and the World Health Organization declared COVID-19 a pandemic health emergency on January 30, 2020. Most respiratory infections exacerbate bronchial asthma. Thus, there is great concern for children with bronchial asthma who may be susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), or become more severely if infected by COVID-19, in addition to exacerbation of bronchial asthma due to COVID-19.
Because of the small number of children infected with COVID-19, whether bronchial asthma and its medication increases the risk of COVID-19 infection and induces exacerbation has not yet been fully understood. However, there is no current information suggesting that patients with childhood bronchial asthma are susceptible to SARS-CoV-2 infection or that bronchial asthma patients who become infected with SARS-CoV-2 are likely to develop severe disease. Rather, it has been suggested that its pathology and treatment act protectively.
SARS-CoV-2 uses angiotensin-converting enzyme 2 for cell entry. The gene expression of angiotensin-converting enzyme 2 in the airway cells of children and patients with bronchial asthma is low.
Although the pathology has not been fully elucidated, we would like to review the progress up to December 2020.
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Original Article
Title
Clinical Features of Neonatal Respiratory Inhibition Using Continuous Monitoring Analysis Via Pulse Oximetry
Author
Hideki Minowa Ayako Ogitani Reiko Ebisu and Hajime Yasuhara
Department of Neonatal Intensive Care Unit, Nara Prefecture General Medical Center
Abstract
The goal of this study was to verify the details of neonatal respiratory inhibition (NRI) using continuous monitoring analysis in healthy infants. We screened for respiratory inhibition in 1,231 infants who weighed at least 2,000 g and were born at a gestational age of at least 36 weeks. NRI was defined as severe hypoxemia, accompanied by clinical manifestations of central cyanosis and a decrease in SpO2 to less than 70%. NRI consists of respiratory inhibition during feeding, and respiratory inhibition after crying or vomiting. The subjects were monitored continuously via pulse oximetry from birth until discharge. NRI was observed in 599 (48.7%) infants (during feeding in 516 (41.9%); after crying in 263 (21.4%); and after vomiting in 32 (2.6%)). Among perinatal factors, NRI was related to twin pregnancy, multiparous women, and short gestational week using multiple logistic regression analysis. Almost all infants with respiratory inhibition after crying recovered until discharge. However, 228 infants with respiratory inhibition during feeding needed additional feeding control after being discharged. The more frequently the infants experienced NRI, the severer the degree of both the minimum SpO2 values and the maximum durations of SpO2 under 70% became. NRI is very common and occurs in many infants. Medical staff caring for infants should note the presence of NRI. Careful nursing guidance should be recommended to the mothers of infants with repeated respiratory inhibition during feeding.
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Original Article
Title
Trends in Pediatric Consultations Based on Data from Public Funding for Infant Medical Expenses
Author
Tomohiro Iwasaki1) and Seigo Korematsu2)
1)Department of Pediatrics, Kunisaki City Hospital
2)Department of Pediatrics, Nakatsu Municipal Hospital
Abstract
The trends in pediatric consultations based on data from public funding for infant medical expenses in Oita prefecture from 2008-2015 was examined.
The average number of annual outpatient visits per infant was 9.40, while the average number of hospitalizations was 0.15 per year. An annual average of approximately 6 billion yen on outpatient expenses and approximately 2.3 billion yen on hospitalization expenses were fully covered through public expenditures. The number of outpatient consultations, number of hospitalizations, outpatient expenses, and hospitalization expenses per person varied among primary medical area, with the number of outpatients exhibiting a positive correlation with the number of pediatricians engaged in primary care.
Furthermore, the payment rate of outpatient expenses to medical institutions, in their own medical areas, exceeded 80% in only five cities, while the median rate in the other 13 cities was 20-66%. The outpatient payment rates were positively correlated with the number of pediatricians engaged in primary care. The payment rate of hospitalization expenses to medical institutions, within secondary medical areas, exceeded 80% in only two medical areas, while the median rate of the other four medical areas was 32-63%.
These results suggest that there are more than just a few areas in which outpatient clinics in primary areas, along with hospitalization in secondary areas, are not functioning completely.
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Original Article
Title
A Survey on Illness Disclosure and Involvement in Medical Decision-making among Japanese Adolescent Patients
Author
Megumi Tsuji1)2) Naoko Takenouchi1)3) Noriko Sho1)4) and Hiroyuki Nagafuchi1)5)
1)Clinical Ethics Consult Team, Kanagawa Children's Medical Center
2)Department of Neurology, Kanagawa Children's Medical Center
3)Cancer Center, Kanagawa Children's Medical Center
4)Department of Child and Adolescent Psychiatry, Kanagawa Children's Medical Center
5)Department of Critical Care Medicine, Kanagawa Children's Medical Center
Abstract
【Introduction】When a child receives medical treatment, it is recommended that the medical condition be explained according to his/her developmental stage. However, to the best of our knowledge, there is no study in Japan investigating to what extent children want to know the name of their disease and condition, or their desire to participate in determining treatment strategies. We conducted a survey to clarify the current situation.
【Subjects and Methods】The survey was conducted using a questionnaire presented to 369 junior high school students who visited the hospital for an initial consultation (excluding emergency hospitalization) between April 1, 2018 and March 31, 2019.
【Results】Valid responses were obtained from 185 subjects who visited 17 clinical departments for the initial consultation. The Department of Child and Adolescent Psychiatry had the highest number of patients at 28.0%, followed by the Department of Orthopedics at 21.5%, and the Department of General Medicine at 13.9%. To the question "Do you want to know the name of the disease?" 80.5%, 16.8%, and 2.7% of subjects responded "I want to know,""Neither," and "I do not want to know," respectively. Regarding the selection of treatment, more than 40% had the intention of self-determination, including 10.8% and 34.9% who responded "I definitely want to determine it by myself" and "Generally, I want to determine it by myself," respectively.
【Conclusion】It became clear that junior high school students in Japan are interested in learning the name of their disease and condition, as well as determining treatment strategies for themselves. Additionally, in Japan, to support pediatric patients' self-determination, it is necessary to create a system that promotes explaining the child's medical condition according to his/her preference and developmental stage.
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Case Report
Title
ECMO for Persistent Pulmonary Hypertension in a Newborn Conducted at a Local Hospital
Author
Yoshikazu Otsubo1) Munenori Matsudaira2) Mari Yokokawa1) Takuya Hayashida1) Hiroyuki Esaki1) Mariko Kinoshita1) Atsushi Shimasaki1) Risa Koizumi1) Yuriko Matsuo1) and Muneichiro Sumi1)
1)Department of Pediatrics, Sasebo City General Hospital
2)Department of Intensive Care Medicine, Sasebo City General Hospital
Abstract
We herein report the first neonatal case of ECMO treatment in Nagasaki prefecture. Our hospital is one of 3 tertiary care hospitals in our prefecture. We have always conducted pediatric intensive care without the assistance of an intensivist at ICU. Taking this situation into consideration, we developed a new system of pediatric intensive care with the incorporation of both an intensivist and pediatric nurse specialist. In particular, we requested the cooperation of a pediatric surgeon and clinical engineer when performing the ECMO procedures.
During the COVID-19 pandemic in 2020, the usefulness of ECMO for severe respiratory disorders has been established even in the pediatric field and a network for pediatric COVID-19 treatment has also been established in the Kyusyu-Okinawa area. However, facilities where ECMO, especially for neonates, can be conducted are extremely limited in Japan. Discussions of centralization of ECMO cases are underway, but this network and transferring system remains insufficient. When requiring emergent ECMO treatment, if it is difficult to organize an ECMO team at a single facility, ECMO can be performed by assembling medical practitioners who are familiar with this treatment. Countermeasures are thus needed until a centralized system of neonatal and infant ECMO cases can be fully established.
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Case Report
Title
Dramatic Improvement Following Additional Calcium Channel Blocker Treatment of a Child with Idiopathic Pulmonary Arterial Hypertension - A Case Report
Author
Toru Iwasa Kimiko Nakajima Dai Suzuki Heima Sakaguchi Hideo Ohuchi Etsuko Tsuda Isao Shiraishi and Ken-ichi Kurosaki
Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
Abstract
A 6-year-old girl developed fatigue, chest pain, and palpitation during exercise. She was diagnosed with severe idiopathic pulmonary arterial hypertension and was referred to our hospital at the age of 9, following 2 years of exacerbation.
Cardiac catheterization revealed pulmonary arterial hypertension with a pulmonary arterial pressure of 72/40 (50) mmHg and a pulmonary vascular resistance index (PVRI) of 10.68 Wood units × m2. Although she did not experience an improvement in oxygen inhalation, acute vasoreactivity testing with inhalation of nitric oxide (NO) was positive, with significant improvements in pulmonary arterial pressure and PVRI. Accordingly, her medication was changed from tadalafil to riociguat.
Following the change in medication, she showed improvements in pulmonary arterial pressure and PVRI, and even greater improvement in NO inhalation. A calcium channel blocker (nifedipine) was added to her treatment regimen. Cardiac catheterization after the addition of nifedipine revealed a near-normal pulmonary arterial pressure of 34/12 (23) mmHg and a PVRI of 3.45 Wood units × m2.
In conclusion, calcium channel blockers are effective in some pediatric patients with pulmonary arterial hypertension, and careful use in selected cases is advisable.
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Case Report
Title
Growth Inhibition of Neonates Treated with Radiation Therapy for Kasabach-Merritt Phenomenon
Author
Ayumi Horiguchi1)2) Yuki Arakawa1) Masato Yanagi1) Chika Kanno2) Ken Kawabata2) Masaki Shimizu2) and Katsuyoshi Koh1)
1)Department of Hematology/Oncology, Saitama Children's Medical Center
2)Division of Neonatology, Saitama Children's Medical Center
Abstract
Hemangiomas with the Kasabach-Merritt phenomenon (KMP) cause severe thrombocytopenia and coagulopathy, resulting in a high mortality rate. Corticosteroid therapy is generally recommended as the first-line treatment, yet the response rate to corticosteroids is low. Radiation therapy has been proven effective for KMP; however, it can inhibit growth. In this study, we retrospectively reviewed three neonates who received radiation therapy. All cases were also treated with corticosteroids. Vincristine was added to the treatment regimen in one case. The radiation dose was 1 Gy per session with a total of 10 sessions. Radiation was provided by X-ray in two patients and electron beam in the third. Long bones were not irradiated in the two patients receiving X-ray therapy, and they did not suffer growth inhibition. The patient treated with electron beam therapy developed symptoms of growth inhibition at 5 years of age, although there were no signs of growth inhibition at 3 years of age. Long-term follow-up is essential for the evaluation of potential growth inhibition. In conclusion, although radiation therapy is a useful treatment option with rapid effectiveness for patients with KMP, given the risk of late complications, the details of radiation therapy should be deliberately planned and managed.
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Case Report
Title
A Pediatric Patient Who Chose Selective Plasma Exchange Because of a History of Anaphylaxis Due to Fresh Frozen Plasma
Author
Hideki Ban1)2) Katsuki Hirai1) Sayuri Tanaka3) Akinori Kuroda3) Masaki Mori3) Shiro Ozasa4) Toshiyuki Takahashi5) Norio Hanafusa6) Kenichiro Miura2) and Motoshi Hattori2)
1)Department of Pediatrics, Japanese Red Cross Kumamoto Hospital
2)Department of Pediatric Nephrology, Tokyo Women's Medical University
3)Department of Clinical Engineering, Department of Nephrology, Japanese Red Cross Kumamoto Hospital
4)Department of Pediatrics, Kumamoto University Hospital
5)Department of Neurology, Tohoku University Graduate School of Medicine
6)Department of Blood Purification, Tokyo Women's Medical University
Abstract
Apheresis has three therapeutic modalities and comprises simple plasma exchange (PE), double filtration plasmapheresis, and immunoadsorption plasmapheresis. However, these modalities are associated with decreases in coagulation factors. Recently, a membrane-type plasma separator (Evacure Plus®, Kawasumi Laboratories Inc.) was launched, which enabled selective plasma exchange (SePE). However, few studies have reported its use in pediatrics. We describe a 12-year-old boy diagnosed with relapsing myelin oligodendrocyte glycoprotein antibody seropositive neuromyelitis optica with a history of anaphylaxis to fresh frozen plasma (FFP) during a previous PE. Therefore, SePE was employed to circumvent the use of FFP. The target processed plasma volume was 1.5 plasma volume, and SePE was repeated for four consecutive days. The mean elimination rates (range) were 79% (72%—80%) for IgG and 25% (24%—29%) for fibrinogen. Accordingly, SePE averts the use of FFP and can eliminate IgG, which is the causative substance of autoimmune diseases. Hence, SePE should be selected as a candidate treatment for apheresis in pediatrics.
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Case Report
Title
Agenesis of the Dorsal Pancreas with Diabetes in a School-aged Child
Author
Masahiko Joo1) Jun Muneuchi1) Yu Nakajima1) Yuichiro Sugitani1) Hiroshi Hamada2) Tetsuro Kamimura2) and Yasuhiko Takahashi1)
1)Department of Pediatrics, Japan Community Healthcare Organization Kyushu Hospital
2)Department of Pediatric Surgery, Japan Community Healthcare Organization Kyushu Hospital
Abstract
Agenesis of the dorsal pancreas does not generate specific symptoms and is often diagnosed incidentally based on abdominal screening tests or complication-related symptoms. Among the incidental findings, there are some reports of diabetes, but most of these cases occur in adults. We report a case of a boy who developed diabetes mellitus at the young age of 9 years and was rapidly diagnosed based on agenesis of the dorsal pancreas. Thirst, polydipsia, and weight loss of approximately 5 kg were observed from 3 months prior, but he was in good physical condition and under observation. A urine examination at his school revealed a urinary sugar level of 3+. He visited a family doctor and was referred to our department because of a strong suspicion of diabetes with a blood glucose level of 235 mg/dL and glycated hemoglobin level >14%. Despite the apparent polyuria symptoms persisting for 3 months, diabetes mellitus other than acute-onset type 1 diabetes was suspected because acidosis was mild with blood gas and the blood glucose level was in the range of 200 mg/dL, which was not remarkably high. Abdominal computed tomography revealed a pancreatic body tail defect, and a diagnosis of congenital agenesis of the dorsal pancreas was made. As a result of close examination, the patient was confirmed to have insulin dependency. Congenital anomalies are not only associated with pancreatic diabetes but also with diabetes at a young age. Adult-onset diabetes mellitus type V (MODY5), pancreatitis, and pancreatic cancer, among others, have been reported, and it is necessary to accurately diagnose the presence or absence of pancreatic tail defects from the viewpoint of these complications. Therefore, in some cases of childhood-onset diabetes mellitus, it may be preferable to perform an abdominal imaging test.
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Case Report
Title
Pulmonary Tuberculosis That Developed 5 Years after Immigration from the Philippines
Author
Mami Washio Tamaki Ueda Norihiko Uchida and Megumi Takemoto
Department of Pediatrics, Hamanomachi Hospital
Abstract
The incidence of tuberculosis in Japan has been steadily decreasing, with an annual incidence of 50 cases of pediatric tuberculosis at present. We report a case of a boy who developed pulmonary tuberculosis 5 years after immigration from the Philippines. A 14-year-old boy presented with remittent fever and productive cough which lasted for 2 weeks and 3 weeks, respectively. As he had a history of living in the Philippines, pulmonary tuberculosis was suspected.
The tuberculin skin test (TST) and interferon gamma release assay (IGRA) showed positive results, and chest high-resolution computed tomography (HRCT) showed centrilobular nodules at the right lung apex. Although the sputum examination was negative for acid-fast bacilli, his symptoms and imaging findings gradually improved after starting anti-tuberculosis medicines. Therefore, the diagnosis of pulmonary tuberculosis was made.
Adolescents born in tuberculosis-endemic countries are at a risk of developing tuberculosis disease. When teenagers born outside of Japan present with persistent symptoms, we should consider the possibility of imported infectious diseases, such as tuberculosis, and check for tuberculosis incidence at their place of birth. Furthermore, we should promptly perform the sputum test for acid-fast bacilli, the TST and IGRA, and chest HRCT, regardless of the time of immigration.
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Case Report
Title
Two Sibling Cases Treated as Congenital Syphilis Born to a Mother with Untreated Syphilis
Author
Akiko Hirokami Junko Oikawa Kiyotaka Kosugiyama Hikari Saito Shuji Sai Kiyoshi Nagumo and Seido Iwata
Department of Pediatrics, Teine Keijinkai Hospital
Abstract
Here we report two sibling cases of congenital syphilis (CS) born to a mother with untreated syphilis that required antibiotic treatment after birth. The initial maternal screening test was negative for syphilis. The first baby showed blisters on his extremities, later confirmed as syphilitic pemphigus, with increased inflammatory response at birth. Shortly after the birth, the baby and the mother were diagnosed with syphilis by TORCH serology screening. Although antibiotic therapy was initiated, the mother did not take the full course of antibiotics. Her second child was delivered with untreated or incompletely treated syphilis. The baby showed no physical findings suggestive of CS at birth, and the serological examination was insufficient to make a definitive diagnosis of CS. However, the maternal blood tests indicated that she was a patient with potentially active syphilis and the baby had a mild increase in inflammatory reaction. Since we could not rule out the possibility of mother-to-child transmission, we also treated the second baby with antibiotics. For years of follow-up, both babies showed no symptoms of syphilis. Because the number of syphilis patients is increasing, it is likely that we will see more babies born to mothers with syphilis. Pediatricians should have enough information about syphilis to achieve prevention and detection.
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Case Report
Title
Reptile-associated Salmonellosis Transmitted by an Indoor-reared Snake in a 2-month-old Infant
Author
Kaori Kawano1) Yasushi Ito1)2) Eriko Mizoguchi1) and Nozomi Ishii1)
1)Department of Pediatrics, Aiiku Maternal & Child Health Center, Aiiku Hospital
2)Department of Pediatrics, Tokyo Women's Medical University, School of Medicine
Abstract
In recent years, wild animals, such as reptiles, have become increasingly popular as pets. We report a case of a 2-month-old female infant with Salmonella gastroenterocolitis that originated from a ball python, which was reared indoors as a pet. The infant presented with vomiting, fever, inactivity, and sluggish breastfeeding. The urine and cerebrospinal fluid tests were normal, but her CRP level was elevated to 4.00 mg/dL, indicating occult bacteremia. Antibiotic therapy was initiated, which alleviated her fever immediately. The patient was discharged on the sixth day of hospitalization with a good clinical course. Salmonella serogroup O4 was isolated from the fecal culture of the breastfed infant who was considered unlikely to have food poisoning. A subsequent review of history of pet-keeping and animal contact revealed that two snakes were reared inside the house. Furthermore, Salmonella enterica serovar Paratyphi B variant Java, whose drug susceptibility is similar to that of Salmonella O4 of the patient, was identified in the feces of the snake. The sanitary management of snake rearing at home was inadequate. With the diversification of pets, the prevention of reptile-associated salmonellosis remains a significant challenge. Reptiles should be classified as pets that require careful attention in homes with infants. In addition to hygiene measures, reptile owners (especially those with infants) should learn about infection prevention and safety measures.
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Case Report
Title
Central Nervous System Depression from Accidental Ingestion of Over-the-counter Eye Drops in a One-year-old Infant
Author
Haruki Komatsu
Department of Pediatrics, Toho University Sakura Medical Center
Abstract
A 12-month-old girl was brought to the emergency department by her mother with a complaint of abrupt lethargy. Approximately one hour before arrival, she had been found playing with an open bottle of over-the-counter eye drops containing 0.05% of tetrahydrozoline. It was assumed that the child had ingested 6 to 7 mL. The blood pressure was 98/52 mmHg with a heart rate of 94 beats/minute. The respirations were not shallow with a rate of 19 breaths/minute and oxygen saturation was 99% at room air. The child had no fever. A physical examination revealed lethargy, responsive to deep pain. The pupils were constricted. There were no abnormal findings in routine blood examination. The child was previously healthy and there were no sedative anticholinergic and opiate agents in the house. She remained lethargic and was admitted to the pediatric ward for closer observation. After 12 hours of observation, she was awake, alert and active. After 24 hours of ingestion, she was discharged without sequelae. Although she suffered central nervous system (CNS) depression following accidental ingestion of over-the-counter eye drops containing tetrahydrozoline, which has often been reported in the United States, to the best of our knowledge, this report is the first case in Japan. Treatment of poisoning caused by tetrahydrozoline is primarily supportive. Pediatricians must be informed of the possibility of CNS suppression caused by over-the-counter eye drops in young children.
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