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THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY
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Vol.128, No.11, November 2024
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Review
Title
Clinical Prediction Rules for Pediatric Minor Traumatic Head Injuries: Unaddressed Issues in Japan
Author
Haruki Komatsu
Komatsu Children's Clinic
Abstract
Although it is well known that ionizing radiation exposure from computed tomography (CT) examinations increases the risk of leukemia and brain cancer in children, head CT examinations are frequently performed in children with minor head injuries. To avoid unnecessary CT examinations, the U.S., Canada, and the UK have implemented clinical decision rules (CDRs) for pediatric minor head injuries. CDRs are useful to estimate the risks presented by clinically important traumatic head injuries, but there are many differences among individual CDRs regarding the inclusion/exclusion criteria, primary outcomes, and predictive variables. CDRs are diagnostic support tools, but CDRs do not take the place of physicians. A linear skull fracture is detected in 1%-4% of children with minor head injuries. In Japan, most children with linear fractures are hospitalized, but 'linear skull fracture' is not included in the primary outcomes of CDRs. In addition to the application of CDRs, further improvement of the quality of CDRs is indispensable to remove potential barriers to successful implementation. Final decisions regarding the use of head CT for children should be based on discussions between physicians and the patient's parent(s). Shared decision-making (SDM) in which physicians and parents collaboratively discuss potential management strategies based on both the medical evidence and parents' values is used to reach the final decision about the use of head CT. Support tools are also necessary for SDM to help parents to strike the optimal balance between the risks posed by their child's minor head injury and the radiation exposure from CT.
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Original Article
Title
Serum Zinc Level Increases with Zinc Ointment Application to Infants in the NICU
Author
Eriko Sumi1) Hisakazu Majima1) Toshihiko Hattori1) Takaharu Yamada2) Masanori Kowaki2) and Taihei Tanaka2)
1)Department of Pediatrics, Japanese Red Cross Aichi Medical Center Nagoya Daini Hosipital
2)Department of Neonatology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hosipital
Abstract
Background: In our hospital's NICU, some infants who received zinc ointment to manage diaper dermatitis experienced hyperzincemia. This retrospective study aimed to investigate the impact of zinc ointment application on serum zinc levels among patients admitted to our hospital's NICU between April 1, 2016, and March 31, 2023.
Methods: Patients were included if they received zinc ointment to manage dermatitis during hospitalization, and if their serum zinc levels were measured before and after its application. Patients with changes in oral zinc acetate hydrate dosage or the use of central parenteral nutrition were excluded. The primary endpoint was changes in serum zinc levels before and after the period of zinc ointment application. The secondary endpoint was increased frequency of vomiting.
Results: Seventeen cases met the inclusion criteria and were included. Their median serum zinc levels increased significantly from 74.0 μg/dL (IQR 66.0-78.0 μg/dL) immediately before to 123.0 μg/dL (IQR 85.0-292.0 μg/dL) after the zinc application period. Eight patients experienced hyperzincemia (serum zinc levels >130 μg/dL). Two patients experienced increased frequency of vomiting with one showing concomitant hyperzincemia.
Conclusions: This study suggests that zinc ointment application to infants in the NICU substantially elevates serum zinc levels, potentially resulting in hyperzincemia and an increased frequency of vomiting in some cases. Caution is advised when using zinc ointment, with a heightened awareness of the associated risk of hyperzincemia.
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Original Article
Title
Adolescents' Interest in HPV Vaccination and Effect of Educational Intervention on Their Vaccination Intention at a Junior High School in Japan
Author
Yo Murata Yuya Saito Chinami Miyamoto and Toshimasa Obonai
Department of Pediatrics, Tokyo Metropolitan Tama-Hokubu Medical Center, Higashimurayama
Abstract
Human papillomavirus (HPV) vaccine is provided by a national routine immunization in Japan. However, the vaccination rate remains extremely low, posing a significant public health challenge. We examined the knowledge of the HPV vaccine and vaccination intention among second-year junior high school students (aged 13-14 years) and assessed the effectiveness of providing information about the vaccine through school classes. Information was provided during a cancer education class, and we compared the students' responses to a questionnaire about the HPV vaccine before and after attending the class. Questionnaires were collected from 278 girls and 224 boys. Before the class, awareness of the effectiveness of the HPV vaccine among girls was 53%, with only 34% recognizing that junior high school girls were the main target for routine immunization. For boys, the corresponding figures were 19% and 8%, respectively. The primary sources of information about the HPV vaccine for girls were parents/family, followed by television and radio. After the class, 89% of girls and 86% of boys expressed a desire for HPV vaccine education at junior high schools. The proportion of girls interested in HPV vaccination increased from 53% before the class to 89% after it, while for boys, it increased from 31% to 75%. This study reveals that junior high school students have insufficient information about HPV immunization but that using school classes for information delivery is effective in enhancing knowledge and changing their awareness. Information provided during school classes holds the potential to improve HPV vaccination rates.
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Case Report
Title
Newly Treatable Lysosomal Storage Disease: Acid Sphingomyelinase Deficiency
Author
Kenji Inoue Masato Kusumoto Eisuke Terasaki Mariko Ishihara and Takeo Kato
Shiga Medical Center for Children
Abstract
Acid sphingomyelinase deficiency (ASMD) is a lysosomal storage disorder characterized by deficient activity of acid sphingomyelinase (ASM), an enzyme that hydrolyzes sphingomyelin to ceramide and phosphocholine, resulting in accumulation of sphingomyelin in cells throughout the body, especially in the liver, spleen, bone marrow, brain, and alveoli. ASMD is classified as infantile neurovisceral type that is the most severe form and uniformly fetal within 3 years of childhood due to neurological symptoms and hepatosplenomegaly, chronic visceral type that has a variable onset of age ranging from infant from adulthood and slowly progressive visceral disease manifestations such as hepatosplenomegaly without neurological symptoms, and chronic neurovisceral type that is intermediate form of these two phenotypes. The treatment for ASMD has previously been symptomatic therapy, but enzyme replacement therapy is available as a disease-specific treatment from 2022. An eleven-year-old Nepalese boy was diagnosed with ASMD due to left hypochondrium discomfort and pain, and was referred to our center for enzyme replacement therapy. He was diagnosed with chronic visceral ASMD without neurological symptoms, and had stunted growth, hepatosplenomegaly, pulmonary interstitial shadows, liver dysfunction, and dyslipidemia including hypo-HDL cholesterolemia. A 31-week enzyme replacement therapy with olipidase alfa improved his symptoms and findings with no adverse events. Early treatment with enzyme replacement therapy is particularly effective. Suspicion of ASMD based on the findings such as hepatosplenomegaly and low HDL cholesterol, will lead to early diagnosis of ASMD. We need to recognize that ASMD is now a treatable disease.
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Case Report
Title
Vitamin D Intoxication in a School-aged Child Caused by the Misuse of an Imported Supplement by a Caregiver
Author
Takaharu Nishijima Yuki Nishihasi Serina Majima Hisano Nakatsubo and Kazuhiro Watanabe
Department of Pediatrics, Kurobe City Hospital
Abstract
Vitamin D accumulation can cause toxicity and result in hypercalcemia. In adults, intoxication due to the prescription of vitamin D, especially in the elderly, and the risk of toxicity due to impaired renal function have been reported. In children, we found 26 cases of intoxication caused by imported supplements, between 2019 and 2023. In contrast, in Japan, only four cases have been reported at medical facilities.
We report the case of a seven-year-old child with vitamin D intoxication caused by an imported supplement, purchased by a family member via the Internet, and administered to their child at 250 times the standard intake. When the child presented to the hospital with fatigue and nausea, hypercalcemia (serum calcium 14.0 mg/dL) and increased 25-hydroxyvitamin D levels (701 ng/mL) were detected. Hypercalcemia improved, but it was two months until the toxic level of vitamin D normalized. The patient was followed-up after discharge because of the possibility of recurrence.
With the easy accessibility of supplements, including imported products, via the Internet, we should consider the possibility that people taking supplements at home can become intoxicated. Although interest in the efficacy of vitamin D is increasing, interest in the dangers of vitamin D intoxication is low. Appropriate information should be provided, and continuous evaluation is essential when recommending vitamin D intake. Social awareness regarding the dangers of fat-soluble vitamin intoxication caused by supplemental overdoses should be increased to prevent recurrence. Family members should be given support according to their circumstances to ensure and protect the trust in parent-child relationships.
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Case Report
Title
Buruli Ulcer with Cellulitis-like Symptoms in a Japanese Girl
Author
Yasuhisa Sakakibara1) Mayu Iwata1) Keiko Yamada1) Yo Hayashi2) Takeshi Ebisawa2) Teruo Ueno2) and Michio Konishi1)
1)Department of Pediatrics, Tonami General Hospital
2)Department of Plastic and Reconstructive Surgery, Tonami General Hospital
Abstract
Although Buruli ulcer ranks as the third most prevalent mycobacterial infection, it remains underrecognized in Japan, often requiring surgical intervention for extensive lesions. Herein, we report a pediatric Buruli ulcer arising from a post-sting ulcer with cellulitis-like symptoms.
In November, a 7-year-old girl was bitten on her left forearm by an insect resembling a mosquito. The bite area remained red and transformed into a black crust by the end of the month. In January of the following year, the black crust ulcerated, and the emergence of cellulitis-like symptoms after failed antibacterial therapy prompted her transfer to our hospital. Skin biopsy revealed extensive necrosis without inflammation or granulomatous lesions. Thus, an acid-fast bacilli stain was initially omitted. Because of Buruli ulcer suspicion, staining was immediately conducted, revealing acid-fast bacilli in the subcutaneous tissue. Similarly, the acid-fast bacilli were detected in stamp specimens obtained from minimal exudate of the ulcerative lesion. Buruli ulcer was clinically diagnosed and treated with three antimycobacterial drugs. An additional incubation temperature of 30°C yielded a positive culture at 8 weeks. Mass spectrometry misidentified the agent as Mycobacterium marinum. Five weeks after antimycobacterial therapy, surgery was performed, and the diagnosis was confirmed by polymerase chain reaction analysis of the excised tissue.
For a persistent subcutaneous nodule, a painless skin ulcer, or cellulitis after an insect bite that was unresponsive to antimicrobial therapy, early suspicion of Buruli ulcer is crucial. Each department should be notified about the need for unconventional testing to detect Mycobacterium ulcerans.
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Case Report
Title
Diphenhydramine Overdose Resembling Limbic Encephalitis in a 15-year-old Male Patient
Author
Tasuku Tamai1) Osamu Kobayashi2) Atsuhiko Haigo1) Tomoki Maeda2) and Kenji Ihara2)
1)Department of Pediatrics, Bungoono City Hospital
2)Department of Pediatrics, Oita University Faculty of Medicine
Abstract
We report a case of an overdose of diphenhydramine (DPH) that mimicked limbic encephalitis. The patient was a 15-year-old male adolescent. Immediately after waking up, the patient exhibited abnormal behavior. His parents brought him to our hospital. We suspected limbic encephalitis because of abnormal mental status and unusual behavior in the febrile state, and he was transferred to a tertiary care facility. A cerebrospinal fluid examination revealed normal findings, while MRI revealed a swollen lesion in the left hippocampus. Urine drug test results were positive for tricyclic antidepressants. Seven hours after admission, he regained consciousness and later admitted to consuming a large amount of DPH. A DPH overdose can trigger non-specific symptoms due to central nervous system dysfunction caused by its anticholinergic effects, whereas no symptoms or physical findings specific to DPH have been reported. Furthermore, DPH cannot be detected through routine screening tests using urine. These factors make it difficult for primary care physicians to accurately diagnose DPH overdose without sufficient patient information. In recent years, there has been an increase in both suicidal and recreational abuse of DPH due to the overflow of information about illegal drugs on social media platforms. Pediatricians should be aware of the increasing prevalence of DPH poisoning among youths. When young patients with neurological symptoms and imaging findings suggestive of acute limbic encephalitis are encountered, a differential diagnosis of DPH overdose should be considered. Urine and blood sampling and storage during the acute phase are essential for confirming the diagnosis of DPH overdose.
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