10th Excellence in Pediatrics Conference—2018 Book of Abstracts

Introduction: Depression is a major cause of morbidity and disability worldwide, and according to the World Health Organization, it is the fourth leading cause of disease burden. Depression is a co ...

Introduction: Headache with neurological deficits and cerebrospinal fluid lymphocytosis (HaNDL) is an uncommon headache syndrome described as "non-infectious inflammatory intracranial disease", presumably related to a transient immune-mediated central nervous system inflammation. Probably post infectious, etiology and pathophysiology are incompletely understood, with cerebrospinal fluid (CSF) investigations for an infectious agent almost consistently negative.
Case Report: Fifteen-year old male with a previous history of an episodic headache with clinical features of migraine was referred with a suspected diagnosis of acute confusional state. He presented with severe periorbital pain and left-sided frontal headache associated with hypoesthesia and paraesthesia in his right upper limb and difficulty to speak. The patient had a paraphasic speech consistent with motor aphasia and no problems of language comprehension. He had a questionable deviation of the tongue to the left and slight gait imbalance without any preponderant direction. He had no other abnormal findings on examination. MRI was normal and the CSF demonstrated a pleocytosis (194/μL) with predominant lymphocytes, normal glucose levels and mildly elevated protein levels (53 mg/dL). Unexpectedly, PCR was positive for Borrelia burgdorferis sensu lato (s.l.) and the sequence revealed the presence of DNA of Borrelia lusitaniae. The patient was treated with 21-day course of ceftriaxone with a full recovery from headache, aphasia and sensory symptoms within less than 24 h and remains asymptomatic with normal neurological examination.
Discussion: The isolation of Borrelia lusitaniae was concomitant with CSF lymphocytosis and clinical presentation compatible with HaNDL. Borrelia lusitaniae is prevalent in Mediterranean countries, with only few cases reported implicated human disease. But would untreated disease continue to meet HaNDL criteria? Because the favorable outcome and consequently symptomatic treatment of HaNDL, it is imperious to consider other diagnosis, especially serious and/or treatable entities. hours his condition deteriorated, with a GCS of 11, only responding to noxious stimuli and required intensive care. Electroencephalography showed slow and poorly differentiated activity, etiologically nonspecific. Ciprofloxacin and oseltamivir were associated to his therapy and he was also given immunoglobulin 1 g/kg for 2 days and methylprednisolone 30 mg/kg/day for 5 days. Magnetic resonance imaging showed bilateral thalamic lesions suggesting ANE. Because metabolic etiologies such as biotin-responsive basal ganglia disease could not be excluded, he also was started on biotin and thiamine. PCR search for respiratory virus was positive for adenovirus and parainfluenza 3, and negative for Influenza A and B. The remaining work-up was negative, and oseltamivir, ciprofloxacin and acyclovir were suspended. The patient's mother had a history of acute encephalopathy in childhood, and her CT scan showed thalamic lesions. The child gradually improved and was discharged after 9 days with no neurologic sequelae.
Conclusion: ANE is an immune-mediated disease with a potentially devastating course. ANE should be included in the differential diagnosis of encephalopathy with a rapid evolution. Its pathogenesis is not completely understood. This case shows that less frequent viral agents may be involved, and family history should also be valued as some forms of ANE seem to be familial.
Introduction: Social history (SH) provides a significant opportunity for health advocacy in child health. Social determinants of health (SDH) can be excellently tied to current practices as well as educational curricula through SH. However, SH remains underappreciated with its limited utilization in clinical practice. Little is known about pediatricans' views on SH and screening for SDH through SH.
Purpose: The purpose of this study was to evaluate the SH in the light of pediatricians' experiences, and to develop a deeper insight into the reasons limiting the use of SH.
Materials and Methods: A qualitative research method with an interpretivist approach was used. In-depth interviews were conducted with 12 physicians, 11 of whom were pediatricians (residents and specialists from different urban-suburban working settings in Ankara). Additionally a focus group study was conducted with six pediatric residents. Interviews and the focus group were audio-recorded, transcribed verbatim and reviewed for themes with content analysis.
Results: SH has broad definitions in pediatricians' statements and a narrow scope in clinical practice. Analysis has shown three mainstream topics of SH; child's relationships, child's daily life and socioeconomic status. Although all pediatricians stated that socioeconomic conditions have vital influence on child health, most of the participants reported hesitation to ask questions related socioeconomic status. SH is generally associated with an "ideal" history by the participants. It is widely accepted that SH taking improves patient-physician relationships. Most of the participants are not aware of existing screening tools for SH. Few are positive towards screening for SDH while more than half of the participants are distant with various causes; mainly, doubts on necessity for each patient and time concerns. The analysis of participants' statements interestingly has indicated that principal objective of SH is mainly diagnosis and treatment, rather than health advocacy.
Conclusion: Even though pediatricians describe the SH as part of an "ideal" history, clinical practice is limited. There is variation in opinions regarding screening. The study demonstrates that it will be important to take into account that it requires a mindset shift from "diagnostic" to "advocative" when adopting SH as a screening tool for SDH. Medical education and residency training seems to be the key for that shift. Aim: Parents experience high levels of illness uncertainty, which is defined as a sense of loss of control and a perceptual state of doubt that changes over time. This study aimed to evaluate psychometric properties of the Turkish version of Parent Perception of Uncertainty Scale (PPUS).
Methods: It was a methodological study. Data were obtained from parents of 312 hospitalized children by using socio-demographic data collection form, PPUS (31 items and 4 factors), and Spielbergers Permanent and Situational Anxiety Level Inventory. SPSS 22 and AMOS programs were used for analysis (mean, standard deviation, t-test, correlation, etc.).
Results: Content validity index was 1.00, intraclass correlation coefficient was .94 (p < 0.05) and item total correlation point was found enough (between .27 and .59) for PPUS according to literature. The relationship between item scores and subscale scores and correlation of PPUS sub-dimensions with total scale score were found statistically significant (p < 0.001). Cronbach alpha reliability coefficient was found .86 for total scale and between .60 and .80 for subscales. Chi-square/SD (1.84), RMSEA/p (065/p < .05), SRMR (.80), CFI (.92), NNFI (.91) were analysed for confirmatory factor analysis and found acceptable. There were no significant difference between the mean scores of PPUS for test and re-test period which showed PPUS was consistent and reliable. When the relation between the scores was examined, the intraclass correlation coefficient was .98 for the total scale, from .88 to .96 for subscales which was found highly statistically significant (p < 0.05).
Conclusion: Turkish version of PPUS was found valid and reliable.

Role of Viral Pathogen in Hospitalized Children with Community-Acquired Pneumonia in Qatar
Manasik kamil Hassan 1 , Amal Al-Naimi 2 , Aji Varughese 1 , Magda Youssef 2 , Ahmed Alhammadi 2 1 Hamad Medical Corporation, Qatar; 2 Sidra Medical & Research Centre Introduction: Community-acquired pneumonia (CAP) is the leading cause of childhood morbidity and mortality globally. Although the etiology of CAP varies by age, viruses remain the most etiologic agent and may lead to severe disease especially in children with comorbidities. Data on CAP in children were found to be limited in Qatar.
Purpose: This study aimed to determine common virus associated with CAP in hospitalized children and to identify risk factor for pediatric intensive care unit (PICU) admission.

Methods:
A cross-sectional single institutional retrospective descriptive study was performed at Hamad Medical Corporation, the only tertiary and academic medical center in the State of Qatar. The study included children admitted with CAP from December 2017 to June 2018; details of demographic and respiratory viral as detected by molecular assays were analyzed.
Result: A total of 59 hospitalized children with diagnosis of CAP between 3 months and 14 years were included, mean age at diagnosis 3 years, (49%) were male. A total of 43 patients (73%) had positive PCR nasal swab, single virus isolated in 31 cases and multiple viruses in 12 cases. The most isolated virus was rhinovirus (21%), human metapneumovirus (HMP; 17%), bocavirus (15%), H1N1 influenza virus (8%), respiratory syncytial virus and corona viruses were the least common with (7%) each. Nearly 20/59 (33%) of children were admitted to PICU, 15(25%) of them had positive viruses in which the most frequent were H1N1 influenza and rhinovirus with longer PICU stay (median 10 days). Common risk factor associated with PICU hospitalization; History of prematurity and bronchial asthma.
Conclusion: Our study revealed that rhinovirus and HMP virus were the most common causative agents in hospitalized children with CAP. This finding contrasts with a previous report from WHO in which RSV was the most frequently isolated virus. H1N1 influenza virus plays a major role in PICU admission, increase public and healthcare providers' knowledge, and awareness of adherence to annual influenza vaccine will reduce CAP complication and serious morbidity.
ID: 120 Introduction: The American Academy of Pediatrics recommends exclusive breast milk for at least 6 months. However, many parents administer some sort of herbal drinks to their infants. The reasons for herbal introduction might be associated with the ethnic background of parents.
Purpose: The aims of our study were to assess the frequency of supplementing young infants with herbal drinks and to delineate parental factors leading to the administration of such drinks to their little ones. This study has been conducted in the State of Qatar, a country with a diverse ethnic population.

Materials and Methods:
A cross-sectional study using an interview questionnaire was conducted at Hamad General Hospital, the major tertiary and academic center in the State of Qatar. Parents of young infants (<6 months of age) were included in the study.
Results: A total of 400 questionnaires were completed (response rate 98%). Participants of 35 nations living in the State of Qatar were included. Approximately 55% of participants were from the Middle East, 81% were females and 53% were college graduates or higher. Our study has shown that almost 1 in 2 parents gave their children fluids other than milk at an age younger than 6 months. The most commonly given herbal drink was Anise (44%) followed by mint (13%), Chamomile (10%), multi-herbal drinks (6.6%), fennel (4.8%), thyme (1.7%) and cardamom (1.3%). When asked about the reason for giving such herbal drinks, 63% of families hoped it would relieve colic. Around 65% of families reported that herbal drinks have, in fact, helped relieve colic and calm their baby, and 14% stated that the supplements improved their child's general health. Moreover, 6% of participants believed that herbal drinks relieve constipation. Only 2% of participants reported side effects in the form of diarrhea and increased reflux. We investigated the source of parental information regarding herbal drinks, and we found that the most frequent source of information for initiating such drinks was friends and family (67%), tradition (24%) and health care professionals (21%). We asked these families whether they would recommend the same to their friends and relatives, and 57% answered with yes. The practice of administering herbal drinks differed among the participants' ethnic backgrounds. More than 55% of Middle Eastern families were administering their infants such drinks compared to almost 37% of parents from Asian descent (p = 0.003). We also noticed a difference in the age of initiation of such drinks. As high as 30% of Middle Eastern families started at an age of less than 1 month while almost 50% Asian families started at the age of 5-6 months (p = 0.018).
Conclusion: A substantial number of residents in the State of Qatar are administering herbal drinks to their young infants. This might lead to delay in growth and perhaps inducing harm as the safety of such drinks has not been sufficiently studied in this young age group. The role of clinical care providers, including pediatricians, is crucial in counseling families about the uncertainty of herbal drinks.

Cogent Medicine
Validating process of an Electronic Integrated Text, Visual and Audio Questionnaire (EITVAQ) to assess quality of life among children with hydrocephalus Joy Ewenn Tan, Alf Nicholson, John Caird

RCSI, Ireland
Background: To date, children with hydrocephalus continue to have a considerable impact on the long-term outcome. However, current literature on health-related quality of life (HRQOL) among children with hydrocephalus are limited. To date, there is a lack of a child-centred, disease-specific quality of life questionnaire among children with hydrocephalus. This serves a call for research to validate a suitable HRQOL to assess the quality of life among children with hydrocephalus?
Aims: To adapt EITVAQ (Electronic Integrated Text, Visual, Audio Questionnaire) into a phone/ tablet application to gain widespread usage of EITVAQ by multidisciplinary teams. To validate EITVAQ as a tool to measure the quality of life status of children with hydrocephalus from the patient perspective.
Methods: The Validating Process of EITVAQ includes: (1) Content Validity using the nominal group technique.
(2) Feasibility-Comparing the response rate, completion rate and time of completion with a validated HRQOL questionnaire.
(3) Reliability-measuring using Cronbach-Alpha. (4) Concurrent Validity-compare reliability score with a validated HRQOL questionnaire Results: This study reports the result of the validation process. Content validity is achieved by the nominal group technique after three iterations. In this study, EITVAQ has proven to be feasible having a high satisfaction rate of 78%, response rate of 76.5%, an average completion time of 4 min and 26 s. EITVAQ achieved an overall completion rate of 42.2% in comparison to the control (29.5%). EITVAQ has a score of 0.92 (Cronbach Alpha) showing a high internal consistency, which supports the reliability of this questionnaire. Further analysis is done by adding a validated questionnaire as control. EITVAQ (0.928) and the control (0.91) achieved a similar result which supports the concurrent validity.
Conclusions: EITVAQ, an interactive and child-friendly tool to assess quality of life is now validated. It aims to be used widely among children with hydrocephalus, providing a baseline assessment to allow smooth transition and integration to adult health services and community. By introducing a new skill (music-making using technology), we hope to improve executive function skill and overall quality of life.

Cogent Medicine
The Potential Importance of Hypercobalaminemia as a Possible Early Marker in the Working

Diagnosis of Malignancy and Blood Disorders
Abdou Shafik Deyab

Al Hayat International Hospital
Introduction: Hypercobalaminemia is defined by a rate of vitamin B12 above 950 pg/ml. The most obvious cause of hypercobalaminemia is taking too much of the vitamin in the form of supplements. Vitamin B12 is generally not considered toxic in high levels, but it is important to determine if the elevation due to excess vitamin supplements since the other causes of a high vitamin B12 level are usually serious such as solid tumors, blood diseases, liver diseases and kidney diseases.
Aim: The aim of this article is to review the association between hypercobalaminemia and malignancy and hematological disorders. The association of hypercobalaminemia and solid tumors was first described and documented by Carmel et al. in 1975 andin 1977. In ancient literature, hypercobalaminemia is an anomaly frequently observed in malignant blood diseases including chronic myelomonocytic leukemia, primary hypereosinophilic syndrome, myelodysplastic syndromes and acute leukemias. In the series of Chiche et al., 23% of patients with high serum cobalamin had a solid cancer, which was previously unknown in 73% of cases and still at a nonmetastatic stage in 80% of cases. In their work, Chiche et al. found a statistically significant association between vitamin B12 levels > 1275 pg/ml and the existence of a malignant blood disease.
Results: According to a September 2012 study in PLoS One, people with high vitamin B12 had a 4to 18-times higher risk of having a blood disease. Table 1 summarizes the key data in the literature regarding high serum cobalamin observed in malignancy and hematological disorders.
Conclusion: Based on the above, we can conclude that: it is possible to depend on hypercobalaminemia as nonspecific early marker in the working diagnosis of malignancy and hematological disorders. Introduction: Vaccination is one of the most important prophylactic tools for prevention of infectious diseases. The side effects reported with some vaccines are the source of many misconceptions and of rejection of vaccines among both physicians and patients. This study aims to survey the attitudes of Lebanese physicians towards vaccines and the vaccination protocols that they use in their private practice.

ID: 260
Materials and Methods: It is a longitudinal survey according to a stratified sample covering the five governorates of the country. Pediatricians were recruited via email along with direct phone calls. The questionnaire contained general questions about vaccines, their side effects and the vaccination protocols adopted by pediatricians in their private clinics and their preferred reference for these protocols. Subjective opinions and remarks about vaccines among these pediatricians were noted.
Results: Out of 234 pediatricians practicing vaccinations, male to female ratio was 134:100. Age distribution 27.4% of physicians<40yo, 38.5% 40-50 yo and 33.8% above 50 y.o. Years of practice: 38.9% 10-20 years, 22.6% 20-30 years and 10.7% more than 30 years. The majority see 10-25 consultations per day (61.1% = 143) versus more than 25 consultations per day (18.4%). As for the vaccination protocols, most physicians follow the one issued by the Lebanese ministry of health consisting of 10 vaccines only. The updated schedule was issued 2 years ago in collaboration with the Lebanese Pediatric Society and Ministry of Health that includes all vaccines even HPV and Meningitis ACWY. Most of the pediatricians trust vaccines and believe in their advantages. Regarding risks, 74.3% reported fever as the sole side effect of vaccination;10.7% reported severe diarrhea and 7.3% intussusception post vaccination. As high as 44.5% of physicians refer to international vaccination programs; 26.9% use international recommendations to supplement the local protocols.

Results:
The attitudes and knowledge about vaccination and vaccines of 56.7% of students of medicine were based on undergraduate classes, 34.5% on informal sources, and 8.9% on information from the Internet and social networks. The sources of information about vaccination and vaccines which students of medicine use have a significant effect on their prejudices regarding the link between vaccination and the occurrence of autism, allergies and allergic diseases; the opinion that the continuation of vaccination against diphtheria, poliomyelitis and tuberculosis is unnecessary because they are exotic and forgotten diseases, and that the subject of vaccination is sufficiently represented at the Medical Faculty. Croatian and foreign students of medicine differ significantly in their use of sources of information about vaccination, but also in their opinions about vaccination. Personal experience of participation in programmes of mandatory and recommended vaccination correlates with the choice of sources of information on the basis of which students of medicine form their attitudes about vaccination.
Conclusion: Almost half the cohort of students of medicine covered by the survey base their attitudes and knowledge of vaccination and vaccines on informal sources and social networks. The consensus of doctors, regardless whether they are directly involved in the vaccination programme or not, is the foundation of the success of its implementation. At the FMUS, as at most other medical faculties in Croatia and the world, there is no separate course in vaccinology within the undergraduate course, but the issue of vaccination is dealt with sporadically as part of different pre-clinical and clinical subjects. At a time when vaccination coverage is falling and there is a rise in vaccine hesitancy, a change in the curriculum of undergraduate courses is vital since students of medicine as future doctors require more systematic education in vaccinology.
Methods: A quantitative retrospective cohort study. A total of 1000 outpatient cards were analyzed. Age, origin of pain (trauma or disease related), pain characteristics, pain medication (calculated pro kg), pain score and its dynamics after painkiller were collected. Randomly selected cases were divided into two groups as following: group A-patient records from 2017, group B-patient records of 2018. Patients with chronic diseases, chronic pain cases, hospitalized patients or treatment refusal were excluded from the study. Additionally, patients in each group were divided into: trauma and non-trauma patients and subdivided into four different age groups. Statistical analysis was performed using Microsoft Excel and IBM SPSS Statistics version 21.0 software for Windows. Descriptive statistical methods were applied, Kolmogorov-Smirnov test, T criterion for calculating pairs of samples, Mann-Whitney U test and Chi-square test. A p value of <0.05 was considered significant.
Results: We compared 500 pain cases per group A and B. There were 154 (30.8%) traumatic patients in group A versus 116 traumatic patients in group B (23.2%). Pain scoring was performed in 420 (84%) children in group A and it was statistically significantly less than in group B (94.4% of all 500 cases, p < 0.001). Moreover, in all age groups of group B children received pain assessment more frequently (see Fig. 1) and were prescribed pain medication more often (see Table 1) compared to group A. We did not observe any difference in the pain assessment between trauma and non-traumatic cases in general (p = 0.254). However, there was tendency to assess pain more often in non-traumatic patients in group A (p = 0.054). We found that children in 2018 (group B) were medicated better (according to initial pain strength in documentation, painkiller type and dose counted pro kilogram of weight; p < 0.001), but pain reduction (regarding pain strength dynamics) in group A was superior to group B. However, in group A traumatic patients experienced less pain relief compared to non-traumatic. Meanwhile, non-traumatic patients in group B received proper pain reliever more commonly (p < 0.001). Group B patients experienced better pain reduction. However, pain relief in traumatic patients was less adequate compared to non-traumatic Conclusion: Our analysis showed that pain evaluation differed in both groups. In group B, pain was evaluated more frequently and received pain-medication more often than group A. However, teenagers are still less likely to be given analgesics than toddlers. The tendency remains to give less painkiller to trauma patients compared to non-traumatic children.

Cogent Medicine
Big Bites and Pearly Whites: A Public Health Initiative to Improve Children's Oral Health in North-West London Ifeyinwa Blessing Amamilo, Vikram Palit, Ghaida Al-jaddir

Chelsea and Westminster NHS Foundation Trust, United Kingdom
Background: Dental caries in childhood is a public health problem in the United Kingdom. Prevalence in North-West London (NWL) is significantly higher than the national average. Poor parental oral health knowledge and practices have been associated with paediatric caries. Evidence for use of brief intervention to promote paediatric dental health is limited.
Aims/Objectives: This study aimed to describe and explore associations between socio-demographics, parental oral health knowledge and practice and caries. It also aimed to assess change in parental oral health knowledge following dental brief intervention (DBI).
Methods: This is a preliminary analysis of an ongoing 3-year prospective study at Chelsea and Westminster Hospital. Parents of children ≤ 10 years attending the facility were recruited. Data about their children's socio-demographics, parental oral health knowledge and practice for their children were collected using a pre-intervention questionnaire. A cohort of participants received 10-15 min DBI and post-intervention assessment was done. Associations between variables were tested. Logistic regression was used to estimate odds ratio (OR), 95% confidence intervals and pvalues.
Conclusion: Socio-demographic factors, poor parental oral health knowledge and practice contribute to caries among children in NWL. DBI shows early evidence for improving children's oral health within this region. Background: Viral hepatitis is a major health problem endemic in all parts of the world including India. Fulminant hepatic failure occurs in about 1% of patients hospitalized with acute viral hepatitis. In children, the predominant causative agent appears to be hepatitis A virus alone or in combination with other infectious agents. Keeping such patients in intensive care units has achieved survival rates upto 30-40%. There is a paucity of literature describing spectrum of fulminant hepatic failure in Indian children. Hence the present study was conducted to determine the pattern of fulminant hepatic failure in children of Punjab region.

Aims and Objectives:
To determine the pattern of viral markers in children with fulminant hepatic failure of viral etiology and to correlate the clinical and biochemical profile with etiological agents.

Materials and Methods:
This study was conducted on children aged 1-15 years admitted in a tertiary care hospital in north Indian province of Punjab. This was a prospective study conducted over a time period of one and half year. Children of fulminant hepatic failure of viral etiology were only included.
Observations: In this study, a total of 30 children with fulminant hepatic failure of viral etiology were studied. Male to female ratio was 2.3:1. Hepatitis A was the commonest virus associated with fulminant hepatic failure. The prolonged jaundice at admission and greater time interval between onset of jaundice and onset of encephalopathy indicated poor prognosis. Mortality rate was 26.6% in our study. Non-survivors as a group had significantly lower platelet counts. Majority of children were not vaccinated against hepatitis A.
Conclusions: Hepatitis A was the most common etiological agent in the cases of fulminant hepatic failure in children. As it is transmitted by feco-oral route, hand washing and proper hygiene especially while cooking will go a long way in keeping this virus away. Most importantly all children must be vaccinated against hepatitis A virus and this vaccine should be included in national immunization schedule. Timely ICU care will also save many a children with fulminant hepatic failure.

Materials and Methods:
The authors reviewed the medical records of all neonates and infants referred to perform spinal ultrasonography from January 2013 through July 2018, at an academic hospital.
Conclusion: Similar to previous studies, the most common cutaneous stigmata was the simple middle line dimple and was not associated with high risk for spinal dysraphism. The combination of sacral dimples with overlying cutaneous abnormality or the existence of atypical dimples is associated with higher risk for CNTD. Recognition of suspicious lesions is important for an early referral and to reduce the risk of neurological, urological or orthopedic complications. Background: Rheumatic fever (RF) and rheumatic heart disease (RHD) are important causes of acquired cardiovascular disease in children that are still main public health problems and can affect various aspects of health such as physical, psychosocial, and academic. The assessment of the quality of life in children with RF and RHD, as well as the factors that affect their quality of life, are important for the identification of problems and the monitoring of responses of therapy for a comprehensive management.
Purpose: (1)To identify the quality of life children with RF and RHD (2) To analyze socio-demographic and clinical factors that affect quality of life in children with RF and RHD.

Materials and Methods:
A cross-sectional study was conducted on RF and RHD patients aged 5-18 years old and their parents using PedsQL TM 3.0 Cardiac Module questionnaire and retrospective medical records from April 2017 until August 2017. A convenient sample of 100 patients was selected from an outpatient clinic of the pediatric cardiology department in 3 teaching hospitals in Jakarta, Indonesia. Factors that proved to be significant on the univariate analysis were subsequently tested using multivariate analysis.
Results: High quality of life was found in 53% (child-report) and 52% (parent-report) of subjects. Median score from children's reports and parents' reports are, 79.70 (29.7-100) and 77.31 (45.03-99.40), respectively. Clinical factors affecting quality of life included the route of antibiotic administration, and there were no socio-demographic factors. By child-report, children with RF and RHD who received intramuscular antibiotics were 3.2 times more likely to have higher quality of life than children who received oral antibiotics (p < 0.05, OR 3.208 and 95% IK 1.391-7396).
Conclusion: More than half of children with RF and RHD had a high quality of life. The route of antibiotic administration was the only factor affecting quality of life. Those who received intramuscular administration of antibiotics had a higher chance of having high quality of life compared to those who received oral antibiotics.

ID: 275
Cogent Medicine Purpose: We aim to identify the prevalence, gender distribution and characterization of pain experience in children of the Generation XXI birth cohort (G21) at the age of 10 years.
Materials and Methods: Retrospective descriptive study of G21 participants assessed at the age of 10 years who answered questions related to pain (Portuguese version of the Luebeck Pain Screening Questionnaire, applied to parents and children), between 2015 and 2017. It was also used a face scale from 1 to 6 (no pain to severe pain) to try to quantify the intensity of pain among children.
Results: Of the 6392 participants, 55% had pain throughout their lives and 42.7% reported pain in the previous 3 months. Pain was more frequent among girls (58% of girls vs. 51% of boys) (p < 0.001). The reported pain in the previous 3 months had also higher frequencies among girls (45.4% of girls and 40.7% of boys) (p = 0.013). In general, the main anatomical regions were head (20%), abdomen (17%) and legs (12%). The location of pain differs by gender (p < 0.001): headache and abdominal pain were the most implicated locations of pain among both gender, but girls implied pelvic pain more frequently (12%) and boys presented more pain complain in legs (15%). We did not identify statistical differences in frequency and intensity of pain by gender distribution (p = 0.3 and p = 0.7, respectively). More than 65% reported pain lasting more than 3 months of evolution and 39% reported duration longer than 12 months. In 20% of the children, the pain occurred more than once a week, in 23% once a month and in 25% occurred 2-3 times a month. Concerning the intensity, 9% of the participants reported pain intensity of 6 in face scale (maximum) and 61% mentioned pain intensity between face 3 and 4. There were no significant differences by sex in the intensity or frequency of reported pain. The majority of the participants (51.1%) reported never having taken medication or having consulted the doctor as a consequence of the pain (51.1% and 56.3%, respectively). However, 15% of children missed school due to pain. In 44.2%, the pain appeared for no apparent reason and 68% had no associated medical diagnosis. A family history of pain was reported in 50% of the children.

Conclusion:
In this population-based study in Portugal, the overall prevalence of pain was higher in girls. The location of pain differs by gender too. We did not identify statistical differences in frequency and intensity of pain by gender. Although the regions most frequently referred to in G21 are those described in other studies, the frequency of chronic and severe pain was higher in our cohort.
Introduction: Acute rheumatic fever (ARF) is a multisystemic non-suppurative disease resulting from an autoimmune reaction usually caused by group A streptococcal (GAS) pharyngitis. It mostly affects children aged 5-14 years. After the acute phase, all the clinical features of ARF resolve completely apart from valvular lesions that can become chronic and are known as rheumatic heart disease (RHD). Italy is a high-income country (HIC), but the incidence from different reports is above the threshold value for low-risk populations of 2 out of 100.000/year, defined by the 2015 revision of Jones Criteria.
Purpose: Describe the clinical presentation of ARF and the presence and characteristics of carditis at the time of diagnosis in a pediatric population living in a HIC over a 12-year period. Results: A total of 98 patients (male/female rate 1.7) were included with mean age at diagnosis of 8.81 ± SD 3.04 years. Carditis was the second most frequent finding (57.1%), following arthritis (69%). Mitral regurgitation was detected in 87.5%, aortic regurgitation in 64.3% and mitral plus aortic regurgitation in 51.8%; valve stenosis was absent as major cardiovascular complication. Carditis was clinically silent in 25% of patients. Only 60.2% of patients reported a positive history of pharyngotonsillitis; among these, 81% had received antibiotic treatment for pharyngotonsillitis: 58.3% of them had carditis at the diagnosis of ARF.

Materials and
Conclusion: ARF has not disappeared from HICs and pediatricians must be aware of it, especially after GAS pharyngitis. Diagnosis and treatment of GAS pharyngitis is pivotal to stop the development of ARF, but unfortunately our data show that streptococcal pharyngitis can be silent and ARF can develop despite antibiotic treatment. Carditis is present in about 60% of patients at the diagnosis and mitral regurgitation is the most frequent finding. Echocardiography plays a crucial role in the diagnosis since 25% of carditis was clinically silent in our cohort. In contrast to lowincome countries, in our cohort valve regurgitation was the only presentation of rheumatic carditis and no cases of valve stenosis occurred, probably because of an earlier diagnosis. Introduction: Children who are unable to swallow safely, have gastric problems or neurological difficulties may be unable to gain sufficient calories and nutrients by oral intake alone. Such children may require tube feeding via a gastrostomy to meet their nutritional requirements. Usually commercial formula feeds are used to feed these children. However, more families are opting to use blended diets, that is, everyday family meals or food that is blended to a smooth consistency and then passed down the feeding tube; these diets are known as blended diet. The use of blended diet is an area of controversy; many parents "extol the virtues" of blended diets whist dieticians may be unsupportive and advise against the practice. NHS policy strives to achieve patient-centred care through joint, planning and decision-making; the findings of the study indicate that this is not being achieved with regards to blended diet.
Method: A mixed methodology was used in the study, with three phases, the first two being qualitative using thematic analysis with data collected from in-depth interviews and blog posts. The information from phases 1 and 2 informed the content of the survey used in phase 3. The third phase of the research is the quantitative phase. A survey was designed and distributed to families who are and are not using blended diet. This enabled the researcher to gauge the prevalence of the viewpoints/themes from the interviews. The strength of the relationship/ correlation between these views and other variables such as parental age and level of education were also analysed.

Results:
The study revealed a mismatch between the priorities of families and those of clinicians, which was also identified in the literature. A change in the locus of control was noted, with parents being reluctant to "admit" to clinicians that they were using blended diets, combined with the sense that dieticians had less control over the intake of a child who was being fed a blended diet. The quantitative phase indicates that parents who opt to use blended diet have a significantly higher level of concerns about commercial formula and see less need for it. These parents also have more misgivings about the overuse of medicines in general. The qualitative phases reveal anecdotal evidence suggesting blended diets have physiological benefits, some of which are reinforced by the quantitative data. However, these data are all patient (parent) reported and more large scale and objective studies are required.
Introduction and Purpose: Abdominal ultrasound is noninvasive, easily accessible and can open unexpected doors into a varied pathology.

Materials and Methods:
We present three cases from the Pediatrics Department of "Grigore Alexandrescu" Hospital, patients with minimal/no symptomatology with suspected hepatic mass on a random abdominal ultrasound.
Case description: Case 1: 3-year-old boy admitted for investigation after a heterogeneous lesion was described in the right hepatic lobe. He had a hard epigastric mass. Abdominal ultrasound showed a giant, polycyclic tumor passing over the midline. CT localized it in the retroperitoneum. Neuron-specific enolase was 70× normal. There was bone marrow invasion. Pathology confirmed neuroblastoma. Case 2: 4-year-old boy presented with abdominal pain. On inspection there was bulging of the right hypochondrium, collateral circulation. A hard liver could be felt. Ultrasound showed an extensive mass in the right hepatic lobe. CT confirmed the hepatic tumor invading the inferior vena cava up to the right atrium and described secondary neo formations in the lungs. The alpha-fetoprotein was 105× normal. Pathology confirmed hepatoblastoma. Case 3: 9-year-old boy admitted with vomiting, diffuse abdominal pain and fever. Four months before he was treated for pneumonia with pleurisy. Lab tests showed leukocytosis, neutrophilia and marked inflammatory syndrome. Ultrasound and CT described heterogeneous hepatic masses and hilar adenopathy. The diagnosis of multiple liver abscesses was confirmed surgically.
Conclusion: Abdominal ultrasound doubled with CT will set a complete diagnosis on "hepatic" masses. The clinician should be aware that not everything is what it seems at first sight. Introduction: Bilious vomiting within first days of age should be considered as a sign of bowel obstruction until proven otherwise. The gold standard investigation is an upper gastrointestinal (UGI) contrast and most of the babies will have it performed as it is difficult to exclude intestinal obstruction/malrotation clinically or with plain abdominal radiographs.

ID: 232
Purpose: To determine the frequency of surgical diagnoses with UGI contrast as mode of investigation for babies presenting with bilious vomit predominantly.
Materials and Methods: Infants more than 35 weeks gestation presenting with predominantly bilious vomits within 7 days of birth and having had a UGI contrast were included. UGI contrast study reports were recorded and correlated to incidence of surgery and surgical findings.
Results: A total of 172 infants admitted or transferred to our neonatal unit in view of bilious vomiting were investigated with an UGI contrast study between December 2011 and December 2016. Four different symptoms at presentation suggestive of surgical pathologies were noted as shown in Table 1 but mostly with bilious vomit and none were intubated and ventilated. There were 13 (7.5%) abnormal UGI contrast images and all of them underwent laparotomies. Of these babies, 11(6%) had abdominal surgical pathologies and 2 had normal findings. (Table 2) Out of a total of 13 infants who had laparotomies, 7 babies had diagnosis of malrotation (5 with volvulus), 1 ileum atresia, 1 Hirschsprung's disease, 2 other findings (enlarged bladder compression, resulting in symptoms of bowel obstruction and aberrant mesenteric vessels crossing D3, causing compression) while 2 were normal. Positive predictive value for UGI contrast studies was 84%. The sensitivity of UGI contrast study to detect bowel obstruction was 100%, while the specificity was 98%.
Conclusion: In our study, very few babies with bilious vomiting are shown to be associated with malrotation ± volvulus. However, UGI contrast study in view of its high sensitivity and good positive predictive value is a crucial mode of investigation and should always be performed in order for intestinal obstruction not to be missed. The numbers reported can be useful for clinicians and pediatric radiologists to triage time critical transfer or urgency of investigation. Introduction: Globally, pneumonia is the most common cause of death in children younger than 5 years of age. Discrimination of the cases with severe and mild pneumonia is crucial due to the requirement of hospitalization, as well as additional management and treatment protocols. In case of tissue inflammation, endothelial adhesion molecules are expressed on the endothelium and released into blood stream.

INFECTIOUS
Purpose: In this study, we aimed to analyze the role of inerleukin (IL) 6, IL8, IL10, soluble vascular cell adhesion molecule (VCAM-1) and soluble E-Selectin (sSELE) in the diagnosis and prognostic evaluation of pneumonia.

Methods:
The study was conducted in Hacettepe University Ihsan Dogramacı Children's Hospital between January 2016 and January 2018. Patients who were between 1 month and 18 years of age and admitted to outpatient clinics and emergency department with clinical signs of pneumonia were involved in the study and classified as mild and severe disease. Patients with severe pneumonia (SP) were hospitalized and patients with mild disease (MP) were treated in the community. IL6, IL8, IL10, VCAM-1 and sSELE levels of the patients were investigated and compared with the age-and gender-matched healthy subjects.
Results: A total of 113 patients fulfilling the criteria for a diagnosis of community-acquired pneumonia were enrolled in the study, 62 (54.8%) of which had SP and 51 (45%) had MP. Control group consisted of 61 healthy controls. MP and SP groups were significantly different in terms of IL8, IL10 and sSELE levels (p = 0.019, p = 0.013 and p = 0.02, respectively). Patients with SP and MP had significantly different WBC, ESR and CRP values (p < 0.001, p = < 0.001 and p = < 0.001 respectively), as well.
Conclusions: Besides classical acute phase parameters, inflammatory response parameters such as IL6 and VCAM-1 levels may be helpful in diagnosis of pneumonia. In terms of determination of disease severity in pediatric pneumonia, systemic inflammatory markers like IL8 and IL10 and adhesion molecules like sSELE seem useful in clinical settings.

Factors Associated with Delayed Vaccination in Children
Saleh Al, Saleh Abdullah

King Abdualziz Medical City, Saudi Arabia
Background: Complete and timely childhood vaccination is one of the most cost-effective interventions in improving child survival. Delay in receipt of vaccination might result in a child being susceptible to vaccine-preventable diseases. Identification of factors which contribute to delay in receipt of vaccination will help in developing targeted interventions.
Objective: The present study was conducted to assess the reasons for the delay in vaccination in children below 6 years and to determine the factors influencing the timeliness of vaccination.

Method:
A cross-sectional study was conducted at the National Guard Comprehensive Specialized Clinic in Riyadh, Saudi Arabia. The study population consisted of 1000 mother-child pairs attending the Well Baby Clinic. Data was collected by direct interview using a predesigned questionnaire.
Results: Out of the 1000 study subjects, 224 (22.4%) had presented late for vaccination. The most common reason for the late presentation was that the child was ill on the scheduled day of vaccination. The higher level of maternal education and working mother were found to be statistically significantly associated with delayed vaccination.

Conclusion:
The higher level of maternal education and working mother are significantly associated with delayed vaccination. These mothers need more health education on the importance of timely commencement of vaccination to ensure timeliness of receipt of doses of vaccines. Introduction: Our practice sees women of all ages. In this retrospective analysis, we looked at our population of adolescents, including ages 12-17. All patients received gonorrhea and chlamydia testing on at least one occasion. In a retrospective chart review, we reviewed 25 charts of children in this age group and compared the incidence, demographics and frequency of Azithromycinresistant chlamydia in a randomized matched subset of "control" adult charts.

ID: 110
Purpose: We set out to see if adolescent women in our practice were at higher risk of contracting gonorrhea and chlamydia, and when they do contract these diseases, we sought out to see if they would be at higher risk than our adult population of acquiring strains that were resistant to common treatments, most notably azithromycin.

Materials and Methods:
We performed a randomized retrospective chart review of 42 pediatric patients seen at our offices. All of these patients received gonorrhea and chlamydia testing one at least one occasion in our offices. We then matched this group with an equal number of adult patients that were seen in our offices during the same time period, for similar symptomology (or lack thereof.) We compared gonorrhea and chlamydia rates in the two populations and the difference in rates of drug resistance in those with positive tests.
Results: We found a slightly decreased rate of infection with gonorrhea and chlamydia in our test population of pediatric patients (2% vs. 4%). We also found a zero percent rate of resistance to antibiotics in our pediatric population, compared to a low, but statistically significant higher rate in our matched adult cohort group.
Conclusion: Our data sample is small, but initial evidence suggests that the infection rate of adolescents with gonorrhea and chlamydia may be lower than the adult population when presenting to an urban Obgyn practice with similar symptomatology. When they are positive, there may also be a lower rate of drug-resistant strains. Logically, this follows that fewer and less virulent strains may be associated with the adolescent population as opposed to the adult population. This data in no way compromises the value of sexual education counseling provided to pediatric populations, but useful when counseling young women who may be concerned that adolescent experimentation may have affected their fertility. We plan to continue our analysis with a prospective cohort study to achieve higher quality data on the subject.

ID: 102
Cogent Medicine Introduction: Encephalitis is an inflammation of the brain that can have numerous etiologies, both infectious and non-infectious, with similar presentation. Mycoplasma pneumoniae is a frequent agent for respiratory disease, although extrapulmonary complications are not uncommon, but encephalitis is rare in children. Many of these nonrespiratory disorders are postulated to be the result of immune reactions, as well as of direct lesions.
Case Description: A previously healthy 15-year-old male, presented with odynophagia, headache, vomiting and fever 7 days before evolving to altered mental status (Glasgow 13) and worsening of his general condition. He was admitted with the clinical diagnosis of meningoencephalitis, under acyclovir, ceftriaxone and ciprofloxacin. The EEG and Head-CT scan were normal, but the cerebrospinal fluid demonstrated a pleocytosis (53.0/µL) with predominant mononuclear cells, normal glucose levels and mildly elevated protein levels (50.5 mg/dL). The lumbar puncture opening pressure was 23 cmH 2 O. There was intrathecal synthesis of immunoglobulins (Link-Tibbling index elevated for IgG and IgM). Positive PCR in respiratory secretions and serology for Mycoplasma pneumoniae in serum (IgM and IgG) were positive in blood, but negative in cerebrospinal fluid. Ten days after the onset of this disease, he developed a paralysis of the VI cranial nerve, with convergent strabismus of the right eye and diplopia. The Head-MRI demonstrated a T2 and FLAIR hypersignal of the pyramidal tracts bilaterally and of the parietal and cerebellar white matter, which evoked a demyelinating disease. He underwent treatment with daily pulses of methylprednisolone for 5 days, and evolved favorably, with complete resolution of clinical symptoms and signs.
Conclusion: Mycoplasma pneumoniae is able to invade the central nervous system; however, failure to detect it from cerebrospinal fluid by serology or PCR in the diagnosis of mycoplasma encephalitis has been reported. This opens the discussion about the direct pathogen invasion versus immune-mediated lesions that has implications in treatment options.
Objective: There is a crucial balance between oxidant and antioxidant defense mechanisms. We aimed to evaluate the role of the balance of these systems in the pathogenesis and prognosis of community-acquired pneumonia (CAP) in children.

Methods:
We analyzed oxidant and antioxidant stress parameters from serum samples with clinical and demographic data of children with CAP and also compared with age-and gendermatched healthy controls between 2016 and 2017. Serum levels of the total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index, ischemia-modified albumin (IMA) and plasma thiol levels were evaluated and compared among groups.
Results: A total of 160 children were evaluated; 106 of them had pneumonia with 2 groups, including 54 outpatients and 52 inpatients and the remaining 54 were healthy subjects (third group). White blood cell (WBC) and C-reactive protein (CRP) levels were significantly higher in inpatient group than the others (p = 0.02 and p = 0.001, respectively). The mean TAS values were 1.6 ± 0.2, 1.6 ± 0.3 and 1.3 ± 0.2 mmol Trolox equiv./L in outpatients, inpatients and healthy subjects, respectively, with a significant increase in patients (p = 0.001). However, there was no statistically significant difference in TOS values between patients and healthy controls (p = 0.06). The mean serum IMA levels were 0.5 ± 0.1 ABSU in outpatients, 0.7 ± 0.1 ABSU in inpatients and 0.6 ± 0.08 ABSU in control group and the difference among those three groups was statistically significant (p = 0.001). The native thiol levels (NTL) were 410, 346 and 361 µmol/L in outpatient, inpatient, and control groups, respectively. The total thiol levels (TTL) were 450, 392 and 411 µmol/L in outpatient, inpatient and control groups, respectively. The TTL and NTL were significantly lower in inpatients group as compared with the control and outpatient groups (p = 0.004 and p = 0.005, respectively). Catalase (CAT), myeloperoxidase (MPO) and ferroxidase enzyme activities of patients were higher in patients with pneumonia than controls (p = 0.003, p = 0.02 and p = 0.02, respectively).

Conclusion:
Parameters that give an idea regarding with antioxidant capacity including TAS, CAT, MPO and ferroxidase may be useful for the diagnosis of pneumonia. Acute phase reactants including WBC and CRP are still important conventional parameters to predict the disease severity. Both thiol homeostasis parameters and IMA level seem likely to be influenced by disease severity. Our results suggest that plasma thiol levels and IMA may be good candidate biomarkers to predict the severity of pneumonia in children. Introduction: Fever is a common complaint in pediatric age and sometimes requires the performance of blood cultures. With the introduction of new vaccines, the most frequently isolated organisms have changed throughout the years.
Purpose:: To identify positive blood cultures obtained in our Pediatrics department between June 2007 and December 2016, to describe the most significant pathogenic agents and to correlate these findings with the patient's age, vaccine status, diagnosis and prognosis.
Materials and Methods: A list of positive blood cultures in children aged 29 days to 17 years and 364 days during the study period was obtained from our laboratory. The results were classified as likely contaminants, likely pathogens or potential pathogens, based on species, number of positive blood cultures in the episode and patient's medical history. Data was collected retrospectively for patients with likely and potential pathogens. Statistical analysis was conducted using IBM SPSS Statistics 24.
Results: A total 659 positive blood cultures were identified -518 contaminants, 132 likely pathogens (113 disease episodes) and 9 potential pathogens (7 episodes). The most frequently isolated pathogens were Streptococcus pneumoniae (31.0%), Staphylococcus aureus (20.4%), Escherichia coli (12.4%) and Neisseria meningitidis (8.8%). All potential pathogens were coagulase negative Staphylococci; in 2 cases the organism was isolated twice in the same episode, 3 occurred in immunocompromised children and 2 in children with medical devices. The median age at diagnosis was 22 months, 56.6% of cases occurring before 36 months of age. The most frequent diagnosis were pneumonia (29.4%), occult bacteremia (22.9%), urinary tract infection (11.0%) and meningitis (11.0%). Approximately 59% of patients had at least one dose of any pneumococcal conjugate vaccine and 2.7% at least one dose of meningococcal group B vaccine. No antibiotics were prescribed in 17 cases, all with favorable outcomes. Only 1 patient died (occult bacteremia due to Enterococcus faecalis).

Conclusion:
The most frequently isolated pathogen was Streptococcus pneumoniae. This may be explained by the fact that pneumonia was the most frequent diagnosis, 70.6% of cases of pneumococcal bacteremia occurring in that setting. Also, most cases occurred before the 13valent pneumococcal conjugate vaccine became available in Portugal (2010). We describe 7 cases of possible coagulase negative Staphylococci bacteremia. Most studies have chosen to consider such cases as contaminants. However, the fact that they were isolated more than once in the same episode or in children with relevant medical history may indicate a pathogenic role, as described by other authors.

Microbiological Flora Different Biotopes Monitoring in Oncohematological Patients and Analysis of Antibiotic Resistance
Minira Bulegenova, Aizada Arinova, Arai Rakhmanova Scientific Center of Pediatrics and Children Surgery, Kazakhstan Introduction: At present, the resistance of microorganisms is confirmed for different classes of antibiotics applied for various infectious diseases treatment. This problem affects both highly developed and industrialized countries and developing countries alike, as multiple resistance may ultimately lead to fatal consequences. In this regard, the description of the microflora taxonomic structure of different biotopes in oncohematological patients during the period of 2017 with the detection of the resistance to the antibacterial drugs used is of particular relevance. The taxonomic structure of various biotopes microflora in oncohematological patients is presented in the article.

Conclusion:
Received data indicate that the main causative agent of infectious complications in patients was Gram positive bacteria. All types of isolated microorganisms revealed the greatest sensitivity to antibiotics of the carbapenem class and high sensitivity to the third generation cephalosporins and fluoroquinolones. Dynamic monitoring of the microbial environment provides the opportunity to create our own base of antibiotic resistance, which will allow to control the level of the main pathogens resistance to the antibiotics used.

Cogent Medicine
Human Papillomavirus (HPV) and the HPV Vaccination in Teenage Boys: Parental Knowledge and Acceptance Introduction: Currently, in Portugal, the Human Papillomavirus (HPV) vaccine is available in National Vaccination Programme (NVP) free of charge only for girls. However, the vaccine is effective in boys and is recommended by the Portuguese Society of Paediatrics. The present study aims to explore parents and guardians of teenage boy's knowledge about HPV and the HPV vaccine. A self-reported questionnaire was applied on parents and guardians of boys aged 8-18 years old, attending to pediatric medical appointments or pediatric emergency department of a Portuguese local hospital. The questionnaire asked for basic socio-demographic information, attitudes towards and knowledge about HPV and HPV vaccination. Statistical Package for Social Sciences (SPSS) version 24 was used for statistical analysis.
Results: The questionnaire was answered by 105 parents and guardians, aged between 26 and 57 years (M = 42.27; SD = 5.479). As high as 69.5% had heard about HPV, of these 43.8% only knew that HPV can cause cervix cancer, although 64.3% recognized that HPV could affected both genders. As high as 58.9% answered that HPV was sexually transmitted and 68.5% said the best way to prevent infection was vaccination. Overall, 84.5% of participants had heard about HPV vaccination and 56.2% considered the vaccine safe. As for the will to vaccinate their sons, 41% of participants "willing without doubt" for their son to receive HPV vaccine, 51% "willing only if the doctor recommends" and 3.8% "not willing". Mothers had shown to know more about HPV vaccine (heard about HPV vaccine (p < 0.01) knew the vaccine is on the NVP only for girls (p = 0.001), knew the correct time for vaccination (p = 0.018) and considered vaccine safe (p = 0.033), when compared with fathers. Parents with higher education had shown to know more about the best time for vaccination (p < 0.01) and had heard more about HPV (p = 0.014)).
Conclusions: Most of the parents in our study reported having heard of HPV, and for those, their knowledge about the health sequelae of HPV for men was poor compared to their knowledge of its impact in women. However, most parents considered vaccinate their sons. It is necessary to improve public education about the potential impact of HPV on male health to facilitate acceptance and decision for vaccination.

Results of Monitoring of Infection Caused by Group B Streptococcus in Newborn infants and Pregnant Women in 2012-2018 Years
Iryna Maliovanaya Maliovanaya Mogilev Regional Children's Hospital, Belarus, Belarus Introduction: The Streptococcus of Group B (SGB) is found in 10-35% of healthy men and women. The main representative of this group is S. аgalactiae. Today in the developed countries SGB enters into the three of leaders causing infections in newborns.
Purpose: To study the frequency of SGB infection at pregnant women in area, timing of disease manifestation, clinical symptoms and outcomes at newborns. To estimate in general efficiency of the monitoring and then compare with data in other countries.

Materials and Methods:
We analyzed results of screening from 2012-6 months 2018. Bacteriological screening of pregnant women included: rectal and vaginal smear, analysis of urine in the term of 35-37 weeks of pregnancy. Examination of children: contents of the stomach, peripheral blood and skin. We used the cultural and an express bacteriological methods. In total for this period 58,619 pregnant women were examined. Frequency of positive results annually fluctuated and made from 228 in 2012 to 576 in 2016.
Results: SGB colonization in the urogenital path at pregnant women averaged 7%, clinical forms were diagnosed for 29 newborns (64% among all positive cases). In a half (52%) of cases infection at the child, mothers were SGB and pregnancy problems (55%), in 15% of children the delay of prenatal development was registered. Girls and boys made approximately identical quantity-52% and 48%, average body weight at the birth made 3175 g. The SGB early forms made 59%, late forms-41%. Structure of pathology: encephalomeningitis and bacteremia-31% each, sepsis-21%, 17% there was a clinic of pneumonia. The SGB early forms were presented mainly by sepsis and pneumonia, among the late form-encephalomeningitis. In blood tests of children with early forms the combination of a leukopenia, a neutropenia and thrombocytopenia was characteristic, the grows of level of C-protein was registered by 3rd days of a disease. Positive bacteriological results in 41% of cases were received from cerebral fluid, in 59%-from blood, from urine in 45% of cases, 10% of children had positive cultures from both biological environments, 55%-from skin, from a stomach-in 48% of cases. In the disease outcome three children died (10%), 38% of children still had neurological symptoms.
Conclusion: Our monitoring suggested, that SGB colonization of pregnant women in our area made 7% that below, than in other countries, frequency of development of the SGB clinical forms in newborns made 0.5 on 1000 that is similar in Germany, but below than in the USA and other countries of Europe. Clinical forms among SGB carriers of an infection made 64%, that is, slightly higher in comparison with other countries. Most of sick children were full-term, early and the late forms of an infection made almost equal shares. Early manifestations of SGB infection were presented by pneumonia and sepsis, late manifestations at most of children were by clinic of a meningoencephalitis. Level of a mortality was comparable with results of other authors, made 10%.

Elmuntasir Salah
The National Ribat University, Sudan Background: According to the latest World Malaria Report, released in November 2017, there were 216 million cases of malaria in 2016, and 445,000 deaths worldwide. Africa accounts for 91% of cases and 93% of deaths (WMR, 2017). In Sudan, malaria represents 9.3% of outpatient clinic visits and approximately 8.7% of hospital admission. The estimated number of cases ranged between 855,000 and 2,222,000 (average of 1,305,000) and the estimated deaths ranged between 130 and 8000 in 2016 (average of 4000).
Purpose: To identify the progress in malaria case management and the main challenges facing malaria treatment in Sudan.
Methods: Information and data tackled were collected from: Published studies from Sudan through search of online database, published data that not online were collected from authors when possible. Official unpublished documents were copied from Ministry of Health. Other sources were from Sudan Malaria Indicator Survey MIS 2016, WHO World Malaria Report 2017 and WHO Malaria Program Review data.
Results: In Sudan, chloroquine was the most frequently used drug for falciparum malaria for more than 40 years. Since 2004, treatment of uncomplicated malaria in Sudan has changed from monotherapy to artemisinin-based combination therapy (ACT), using the co-blister of artesunate + sulfadoxine/pyrimethamine (AS + SP) and artemether + lumefantrine (Al), as first-and second-line, respectively. By end of 2016, evidence from antimalarial drugs efficacy studies through 2011-2015(Adeel et al., 2015FMOH, 2015;Mohamed et al., 2017;WWARAN 2015) showed declining efficacy of AS + SP. This leads to shift from AS + SP to AL as first line for treatment of uncomplicated malaria and introduction of Dihydroartesiminine-Piperaquine as second line for treatment of uncomplicated malaria. Regarding severe malaria, artemether was used for management for many years but due to the irrational use of artemether injections for treatment of uncomplicated malaria (Mannan AA et al.), introduction of Artesunate injection for treatment of severe malaria side by side with Quinine injection and banning use of artemether injection was recommended since 2017.

Conclusion:
The persistent challenges to malaria treatment in Sudan are the decreasing drug efficacy and irrational use of drugs resulting from non-adherence to treatment guidelines and possibly non-compliance of patients. Matteo Riccò 1 , Luigi Vezzosi 2 , Giovanni Gualerzi 3 , Carlo Signorelli 3,4 1 IRCCS-USL di Reggio Emilia, Italy; 2 University of Naples "Luigi Vanvitelli", Italy; 3 University of Parma, Italy; 4 University "Vita e Salute", San Raffaele Hospital, Italy Introduction: Despite its effectiveness in preventing invasive meningococcal disease (IMD), paediatric uptake of recombinant meningococcal vaccination for MenB and/or MenC is low in Italy.

ID
Purpose: This study aimed to investigate knowledge, attitudes and practice (KAP) about IMD and the relative vaccines in a sample of Italian parents.

Materials and Methods:
A cross-sectional study was conducted from June to July 2017 among a sample of 607 subjects participating to a Facebook discussion group on paediatric vaccinations. A selfadministered anonymous web-based questionnaire was used to collect demographics, KAP and preventive measures, perceived risk for contracting meningitis, attitude towards the utility of meningococcal vaccine, and willingness to receive/perform a meningococcal vaccine. Questionnaire included a specifically designed knowledge test (18 items) on IMD and vaccine-related issues. Factors asso- Introduction: International guidelines recommend exclusive breast milk feeding during the first 6 months of life and to continue its use complimented with other food types until the end of the second year of life. Some studies report that the use of milk formula in maternity wards may influence the nutritional attitudes of parents regarding their children.
Purpose: To determine if the type of milk used during newborn maternity ward stay at a Portuguese University Hospital influences the type of milk use in neonates after discharge.
Materials and Methods: Retrospective analysis of medical records of babies born during 2017 at this hospital. Demographic data were analyzed and a comparison was made between the type of milk feeding done during maternity ward stay and the neonatal feeding done after hospital discharge, reported at the first outpatient visit at the age of 2-3 weeks of life. The sample selection was based on newborns with outpatient visits scheduled on Tuesdays and Thursdays. Conclusion: The type of milk used during the maternity stay influences the short-term parental attitude regarding newborn nutrition, being exclusive breastfeeding more prevalent during ward stay and after discharge. There was an association between vaginal delivery and exclusive breastfeeding nutrition. Staff training and parental encouragement regarding breastfeeding is the key for successfully establishing breastfeeding which is of major importance and influence on future nutrition. Introduction: Children who are in need of palliative care present changing challenges in nutritional care as their disease progresses. Regular nutritional assessment, the child's underlying condition, the stage of disease progression, and treatment and associated complications, as well as the child's anticipated energy and nutritional requirements, should be undertaken. The aim of the study is the assessment of the nutritional status in children with life-limiting diseases.

Materials and Methods:
There are 41 children aged 3-15 years under care of the Kyiv outpatient mobile pediatrics palliative care team. We have assessed the severity of malnutrition in underweight children by weight for age chart, pathology of gastrointestinal tract, behavior, oromotor dysfunction and food's satisfaction.
The chronic constipation (25%), oromotor dysfunction (12.5%) and behavior problem (25%) were identified among children with rare diseases. The 25% of them have special diet and 25% have additional nutrients support. Half of them do not eat by themselves. One child has gastric tube. Satisfaction during feeding was demonstrated in 62.5%. There were malabsorption (3%), chronic constipation (33%), oromotor dysfunction (67%, p = 0.008), gastroesophageal reflux disease (9%), behavior problem (64%, p = 0.05), mental refusal to eat (36%, p = 0.05) among children with paralytic syndromes. As high as 15% children have additional nutrients support and 85% do not eat by themselves (p = 0.459). As high as 21% children with paralytic syndrome intake feeding by gastric tube and only 54.5% of them have satisfaction.
Conclusion: Authors declare about important aspect of the feeding history in children who need palliative care and malnutrition in progressing life-limiting diseases. Further development of close relationship between caregivers and parents concerning parenting skills, knowledge about nutritional needs and ways out of difficulties is crucial for children with life-limiting states in developing country.

Cogent Medicine
Provision of Early and High Amount of Parental Amino Acids to Low Birth Weight Neonated at ICU i

Mohammed Abusabika
AlAzhar University, Palestinian Territories Introduction: Several studies have demonstrated that administration of amino acids (AAs) in the first days of life decreases protein loses and maintains a positive nitrogen balance. This study aimed to determine whether higher and early doses of intravenous amino acids would improve postnatal weight gain and metabolic control in low birth weight neonates. The researcher used an experimental design, clinical randomized controlled trial. The study was conducted in Neonatal Intensive Care Unit (NICU) at Nasser Hospital in Khanyounis. Stratified randomized sampling techniques based on birth weight (less than 2500 g), gestational age (less than 37 weeks) and gender, followed by random allocation of neonates into control and intervention groups. The intervention group consisted of 34 neonates who received high doses of AAs (2 g/kg) in the first day, increased by 0.5 g/kg every other day until maximum dose of 3.5 g/kg/day, and the control group consisted of 32 neonates who received standard dose of AAs (1 g/kg) in the first day increased by 0.5 g/kg every other day until maximum dose of 2 g/kg/day. For data collection, the researcher used medical records, anthropometric measures (weight, length and head circumference), biochemical measurements (CBC, electrolytes, serum albumin, total protein, blood sugar, serum iron and ferritin, and kidney function test). Data were collected at 3 intervals: on admission to NICU, on day 3 and on day 7. Statistical analysis included frequencies, means, t-test, repeated measures and odds ratio. Mean gestational age of neonates in control group and intervention group was 32.25 and 32.35 weeks, respectively, 50% of neonates in both groups were very low birth weight (VLBW) (>1500 g). Mean length of neonates was 39.72 and 39.81 cm, respectively. Mean head circumference was 29.22 and 29.74 cm, respectively.
Results: After the intervention trial showed that there was statistically nonsignificant differences in weight (p = 0.789), height (p = 0.914) and head circumference (p = 0.359) between case group and control group, while the results within groups showed that within the control group, the mean weight decreased by 94.40 g between admission and 3rd day, decreased by 78 g between admission and 7th day, and increased by 16.40 g between 3rd day and 7th day, and for the intervention group, the mean weight decreased by 128.79 g between admission and 3rd day, decreased by 83.9 g between admission and 7th day, and increased by 44.88 g between 3rd day and 7th day, which reflected that neonates in the intervention group who received high dose of AA (2 g/kg/d) gained more weight compared to neonates in the control group who received standard dose of AA (1 g/kg/d). The results also showed that neonates from the intervention group had significantly higher levels of hemoglobin, serum iron, serum ferritin, total protein, but there were no significant differences in serum albumin, random blood sugar.

Conclusion:
The study concluded that administering of early and high intravenous protein to premature/LBW and extreme low birth weight (ELBW) newborns in early postnatal life can improve protein balance, increase protein accretion and can reduce the duration of hospitalization. Introduction: Preterm formulas containing greater protein:energy ratio are beneficial for nonbreastfed infants, since protein is critical for promoting catch-up growth and synthesis of lean body mass. Additionally, formulas containing enriched sn-2 palmitate (sn-2) and reduced mediumchain triglycerides (MCTs) may support better feeding tolerance and nutrient utilization.

ID: 255
Purpose: To evaluate growth, nutritional status and feeding tolerance of low birth weight preterm infants fed with either experimental formula (EF) containing 3.4 g protein/100 kcal, 12.5% of total fat as MCTs, and 40.2% of total palmitic acid esterified in sn-2 position, or control formula (CF) containing 2.9 g protein/100 kcal, 30% fat as MCTs, and without enriched sn-2.
Materials and Methods: Male and female preterm infants with birth weight ≤ 2000 g and gestational age ≤ 33 weeks were recruited from a Neonatal Intensive Care Unit (NICU) at one hospital in Vietnam and randomized in double-blind manner to receive EF (n = 80) or CF (n = 80) until reaching 3 kg body weight. Differences between groups in weight gain (primary endpoint) from day 1 (D1) of full enteral feeding (FEF) until D21 were evaluated for non-inferiority (margin = −2.5 g/d) and superiority (margin = 0 g/d). Stool consistency was rated on a 5-point scale with higher scores indicating harder stool. Feeding tolerance (including gastrointestinal symptoms and time to reach FEF) and blood/urine biochemistries related to nutritional status were assessed.
Results: Adjusted mean weight gain was 3.1 g/d greater in EF than CF; the lower limit of the 95% CI (0.31 g/d) exceeded both non-inferiority (p = 0.0001) and superiority margins (p = 0.030). The difference in weight gain was larger among infants < 1500 g (5.6 g/d; 95% CI = 2. 16, 9.11). Faster weight gain in EF (vs. CF) was sustained into the post-discharge phase until D79 (mean difference up to 2.07 g/d). Differences in length-for-age and head circumference-for-age z-scores at D21  (1.1-7.5 mmol/L). There were no differences between groups in the incidence of abnormal serum creatinine or urinary urea values.
Conclusions: EF containing greater protein:energy ratio, enriched sn-2 and reduced MCTs (vs. CF) is safe, nutritionally suitable, well-tolerated and improves weight gain of preterm infants, especially those with very low birth weight.

University of Pretoria, South Africa
Introduction: Thyroid hormone resistance (THR) is a syndrome of impaired tissue responsiveness to thyroid hormone. It is classified into three groups, namely generalised, pituitary and peripheral THR. It is usually dominantly inherited; however, de novo mutations occur in approximately 22.5%. Patients have elevated serum thyroid hormone (both free thyroxine [fT4] and free triiodothyronine [fT3]) with a slightly elevated or normal thyroid-stimulating hormone [TSH] in the absence of any medication use, illness, circulating autoantibodies or hormone metabolism or transport defect. The clinical features are variable and both diagnosis and management of these patients remains cumbersome.
Purpose: To highlight the need for repeating thyroid function tests and confirming a diagnosis prior to the initiation of treatment as well as the difficulty in making a diagnosis in resource limited environments.
Case Description: An 11-year 8-month-old female was referred from a peripheral hospital complaining of flu-like symptoms and vomiting. She had no fever, loss of weight, sweating, tremors, headaches nor constipation or diarrhoea. She was doing well at school however on probing was noted to have palpitations daily that worsened during exam time. She had a normal birth history. She had grommets inserted and an adenotonsillectomy done at age 8 years. On clinical examination, she had a thin muscular build with no goitre, lymphadenopathy or eye signs. She hand a mild tremor of both hands but normal reflexes and visual fields. She was tachycardic with a regular pulse and normal blood pressure. No other abnormalities were noted.
Results: Electrocardiogram confirmed a sinus tachycardia. Her thyroid function tests were all elevated (TSH 3.82 mIU/L, fT4 34.5 pmol/L, fT3 23.1 pmol/L). Investigations revealed no abnormalities in the rest of the pituitary axis. Thyroid autoantibodies were all negative. Thyroid ultrasound showed a normal sized gland with increased vascularity but no nodules. The thyroid function tests were repeated using different assays, they remained elevated. A brain magnetic resonance scan revealed no evidence of a pituitary microadenoma or other pathology. Unfortunately thyrotropin releasing hormone is unavailable in our setting (for a stimulation test) as are genetics, thus the diagnosis of THR is based on one of exclusion. The patient's symptoms improved markedly on Atenolol.
Conclusion: THR is problematic to diagnosis and the management is equally as complex. The variable resistance makes it difficult to maintain euthyroidism in all tissues. Conventional antithyroid drugs may be harmful and symptomatic management for the clinically hyperthyroid group remains the mainstay of treatment.

ID: 206
Cogent Medicine Introduction: Childhood obesity is still an important public health problem in Spain and worldwide. Apart from the effects during growth, childhood obesity has been associated with increasing the risk of suffering from chronic diseases during adulthood. Among others, data support increased rates of cardiovascular disease (CVD) and metabolic syndrome. On the other hand, school has been identified as the best place to reach children for screening and intervention studies.

Design of the PESCA Study on Cardiovascular Health in School-Aged Children in Spain
Purpose: To develop a protocol in which pediatricians and teachers collaborate in the prevention, early identification and treatment of cardiovascular (CV) risk factors in school children. Dietary habits. Parents will sign an informed written consent and all ethical aspects will be considered. In order to guarantee the confidentiality, personal data will be taken on a separate sheet and will be kept by the main researcher of the study. Each child will get a random code which will make identification impossible.

Material and Methods
Results: After presenting the aim and protocol of the study, 3 schools from Madrid and Toledo have accepted to participate, with a total number of 1500 children (ages 3-16). Children will not be randomly selected, as parents have to agree upon participation. This could introduce some bias in the socioeconomic background of the family, but will not have an influence on the methodological approach of the study and results. A pilot study will be performed in order to assure feasibility of the study. Nurses will give support to pediatricians at schools, so that exploration does not exceed 1-h time per classroom. Physical fitness will be evaluated during Physical Education (PE) classes in collaboration with PE teachers.

Conclusion:
The importance of the collaboration between primary care pediatricians and teachers has not been sufficiently exploited. PESCA study will try to fill in this gap and to develop tools and algorithms to facilitate early identification of CV risk factors, in order to contribute to children's current and future health.

Effects of Growth Hormone Replacement Therapy on Thyroid Function of Children and Adolescents with Idiopathic Growth Hormone Deficiency
Vicente Introduction: Growth hormone replacement therapy (GHRT) constitutes the treatment of choice for patients with idiopathic growth hormone deficiency (IGHD). Some studies have shown that GHRT decreases the levels of free thyroxine (FT4) in these patients, even though the mechanism behind this phenomenon is not clear.

Purpose:
To evaluate the effect of GHRT on FT4 and thyrotropin (TSH) levels of IGHD patients during the first 12-18 months of therapy. To determine the need for thyroid hormone substitution during the entirety of GHRT and its impact on height outcomes.

Methods: Retrospective analysis of IGHD cases under GHRT in a Pediatric Endocrinology Reference
Center from 2006 to 2018. We collected data on body mass index, height and growth velocity, and standard deviation score (SDS) before therapy onset and after 12-18 months and data on IGF1 SDS, FT4 and TSH before treatment, after 6 and after 12-18 months. Data on those same parameters was collected for patients that needed LT4 substitution (at any point of GHRT) before and after its introduction.
Results: Of the 60 patients included in the analysis, 61.7% were male and the median age of GHRT start was 10 years and 9 months. We verified a statistically significant decrease in FT4 levels after 6 months of treatment, which did not persist in the following 6-12 months. Progressive TSH decrease was found in both evaluations. Of the 34 patients that had concluded GHRT before data collection, 10 (29.4%) presented, at some point during treatment, values of FT4 that were under the reference range for age and L-thyroxine substitution was introduced after a median 1 year and 3 months of treatment. A statistically significant increase in height was seen in these patients after the beginning of LT4 substitution. When comparing post-treatment final height SDS, no statistically significant difference was found between patients that required LT4 therapy and others.
Conclusions: While, generally, GHRT caused a decrease in FT4 levels in the first 6 months of therapy but not at 12-18 months, TSH decrease was progressive through both test periods. A significant percentage of patients needed L-thyroxine substitution at some point during GHRT and after its introduction, a height improvement was verified. In these patients, when appropriate thyroid hormone replacement therapy is established, final stature is not affected.

Neonatal Hypoglycemia in Newborns Without Risk Factors
Georges Nicolas, Riham Chaaban, Marie-Claude Faddous Khalifeh, Juliana Souaiby, Yara Salemeh Centre Hospitalier Universitaire Notre Dame des Secours, Byblos, Jbeil, Lebanon (Lebanese Republic) Introduction: Hypoglycemia is a common problem in neonatal period associated with adverse neurological outcome and brain injury if treatment was not provided. AAP and PES recommended screening for hypoglycemia only in newborns with risk factors, but many other neonates may present episodes of asymptomatic hypoglycemia without any known risk factor.
Objectives: To assess the incidence of hypoglycemia in healthy full term neonates without any risk factors in our medical center and to correlate it with mother's body mass index, the initiating time of feeding and the difference between breastfeeding and formula. To prove the benefit of universal neonatal screening of hypoglycemia in saving many full term newborns without any risk factors.

Materials and Methods:
A hospital based, prospective longitudinal study involving 282 healthy full term asymptomatic neonates. Blood glucose level was measured at 60 and 90 min of life using reagent strips and glucometer independent of feeding time.
Results: According to the definition of hypoglycemia by the AAP (glycemia < 40 mg/dL) and PES (glycemia < 50 mg/dL), the overall incidence of hypoglycemia in asymptomatic healthy full term newborns was 12.1% and 30.9% at 60 min, respectively, while it was 1.1% and 17% at 90 min, respectively. There was no significant statistical association between BMI of the mother and hypoglycemia in neonates. However, the frequency of hypoglycemic episode in babies born at 37 weeks of gestation was higher than those born at 38 weeks and above with a significant P value of 0.0001. Neonates who were breastfed presented much less hypoglycemia than formula fed neonates with statistically significant p value of 0.0001. There was a higher incidence rate of hypoglycemia when feeding was initiated above 1 h after delivery.
Conclusion: Delayed initiation of feeding, gestational age below 38 weeks and bottle fed infants were significantly associated with hypoglycemia. It is preferable to do a universal glycemic screening for all newborns to prevent transient neonatal hypoglycemia, which could have some deleterious consequences on the central nervous system and to start breastfeeding within 1 h after delivery.

General Sir John Kotelawala Defence University, Sri Lanka
Introduction: Growth monitoring is a standard component of community child health services throughout the world. It consists of routine measurements of growth parameters such as weight and height and plotting these measurements on appropriate charts. Weight is the most often used parameter. In Sri Lanka, growth measurements are recorded in the "Child Health Development Record" (CHDR) which contains color coded charts for better comprehension. Accurate understanding and interpretation of growth patterns will enable early detection of problems and timely intervention. Incorrect interpretation can cause anxiety in the carer.
Purpose: The objective was to assess knowledge, understanding and interpretation of growth patterns in the CHDR and the psychological impact of perceived or real growth faltering among mothers of infants in a suburban area of Colombo.
Methods: A descriptive cross-sectional study was conducted at selected child welfare clinics in Piliyandala MOH area. Mothers of infants 6-12 months comprised the study population. An interviewer administered questionnaire with a series of growth charts were used to assess comprehension and interpretation of growth patterns. A focus group discussion was conducted with a group of mothers whose infants had perceived (by health care workers) or real growth faltering to determine the psychological impact.
Results: Out of the total number of mothers (n = 189) interviewed, approximately half (52.4%) had satisfactory knowledge about the weight for age chart identifying color coding correctly. Twothirds (67.7%) of mothers identified growth pattern parallel to the median line as healthy growth (pattern 2) and the pattern showing growth faltering as unacceptable (pattern 3). However, only 21.2% identified weight gain of a low birth weight baby parallel but at the −2SD line as an acceptable growth pattern (pattern 6). About one-third of the mothers misinterpreted rapid weight gain of a normal or low birth weight as healthy patterns (patterns 1, 4 and 5). Mothers of infants with perceived or real growth faltering felt humiliated when they were confronted in the clinic and confessed to feeling helpless, guilty, frustrated and angry.
Conclusion: Although a majority of mothers had satisfactory knowledge about the color zones in the growth chart, their interpretation of growth patterns was not satisfactory. With the recent global trend in increasing childhood obesity, of particular concern is the misinterpretation that rapid weight gain in infancy is healthy. The psychological impact of perceived or real growth faltering on mothers was significant and might adversely impact growth monitoring programs in the community. Introduction: Primary adrenal insufficiency (PAI) is rare in children, being congenital adrenal hyperplasia the most common cause. However, in about 1% of cases, the aetiology may be related to adrenal hypoplasia congenita (AHC), due to defects in adrenocortical cells differentiation. The Xlinked form results from mutations in the DAX-1/NR0B1 gene, on the short arm of X chromosome (Xp21).

ID: 271
Case Presentation: A 2-year-old male was admitted at 14 days of life with lethargy and vomiting, associated with hyponatremic dehydration (sodium 115 mEq/L) and hyperkalemia (potassium 8.5 mEq/L). Because of suspected adrenal crisis, hydrocortisone (HC) and fludrocortisone (FC) were initiated, with good clinical response. Additional investigation revealed normal 17-OHP levels, elevated ACTH (908 pg/mL) and renin and hypocortisolism. He had a brother with history of suspected adrenal crisis at 32 days of life, in the context of failure to thrive, hyponatremic dehydration, hyperkalemia and metabolic acidosis; the hormonal study showed normal 17-OHP, aldosterone and cortisol levels, with ACTH elevation (317 pg/mL). He was under HC and FC medication until he was 2 months old. He maintained paediatric follow-up, with emphasis on feeding difficulties with need of enteric nasogastric tube feeding until he was 4 months old; height evolution above the 95th percentile, and discrete but persistent elevation of the creatine phosphokinase (296-526 U/L), without apparent muscle weakness. At the age of 5, he was referred to Paediatric Endocrinologic Consultation because of noticeable hyperpigmented skin. Investigation demonstrated ACTH elevation (3755 pg/mL) with diminished cortisol (3.7 μg/dL), and normal 17-OHP (0.2 ng/mL), being the diagnosis of PAI confirmed. Genetic study of both brothers showed the presence of a hemizygote variant c.543del (p.Gly183Valfs*81) in the DAX1/NR0B1 gene, confirming the diagnosis of AHC.
Discussion: Diagnosis of AHC requires a high level of suspicion, given the clinical non-specificity and variability of age at presentation, manifestations and associated severity. Early recognition is essential for prompt hormonal replacement and genetic study contributes for genetic counselling, and also for better etiologic characterization. The authors aim to emphasize that genetic alterations in this location might extend to contiguous genes, as the DMD gene, responsible for Duchenne's muscular dystrophy, and so this condition should be thought of during these children's follow-up.

ID: 290
Cogent Medicine The First Growth Hormone Treatment in a Prader-Willi Syndrome Patient in Indonesia: A Case Report Dwi Lestari Pramesti, Aman B. Pulungan

Department of Child Health, Faculty of Medicine-University of Indonesia, Cipto Mangunkusumo National Hospital
Introduction: Prader-Willi syndrome (PWS) is a genetic disorder caused by lack of paternally inherited gene expression in the 15q11-q13 chromosome region. Clinical manifestations of PWS include obesity, hyperphagia, intellectual disability and hypogonadism. The benefits of growth hormone (GH) therapy in PWS patients include improved oxygenation, cardiovascular, motoric and cognitive function; normal adult height; increased IGF-1 levels and HDL levels. Nevertheless, there were no PWS patients treated with GH in Indonesia up to this case, due to lack of funding and awareness.
Purpose: To raise awareness by reporting the benefits and constraints of GH treatment in a PWS patient in Indonesia.
Case Description: A 3-year-old male came to Cipto Mangunkusumo National Hospital with shortness of breath. He was obese and his development was delayed. He was 106 cm tall (WHO z-score 0-1 SD) and weighed 46 kg (WHO z-score >3SD). His BMI was 41.7 kg/m 2 (CDC > P95). He had hypertension (>P95), dysmorphic face features, buried penis, cryptorchidism and brachydactyly. His DNA methylation test confirmed the diagnosis of PWS. His polysomnographic examination showed mild obstructive sleep apnea with apnea hypopnea index (AHI) 5. His IGF-1 level was 77 ng/mL and his HDL level was 10 mg/dL. His IQ score was 61 with delayed mental age (2 year). He started GH therapy since 31 March 2018.
Results: Improvements that could be seen after the patient received GH therapy were increment of height from 106 cm to 115 cm (z-score 2-3SD), decrement of the BMI from 41.7 to 40, lowered blood pressure from >P95 to P50-90, increased IGF-1 level from 77 to 192 ng/mL, increased HDL level from 10 to 22 mg/dL, and improved AHI from 5 to 2.3. The IQ score has not been reevaluated, but there are progresses in his development, he speaks more sentences and can stand without support. The patient was burdened by the high cost of GH that was not covered by national health insurance. The estimated cost until the patient reaches his adult height is $894,722. To date, only a tenth of the cost has been gathered from local crowdfunding platform; therefore, the patient's likelihood of dropping out from the treatment is high.
Conclusion: Benefits are obtained from GH treatment in the PWS patient in Indonesia. Sustainable solutions are needed to increase awareness and to receive funds for GH treatment in PWS patients in Indonesia.

Primary Hypothyroidism in Children: Unusual Clinical Presentation
Ser Yee Soh, Rashida Farhad Vasanwala

Ministry of Health Holdings, Singapore
Introduction: Primary hypothyroidism in children is not uncommon and has an incidence of 1 in 4000. Presentation of acquired hypothyroidism is subtle as the symptom complex is generalized and non-specific. Pleural and pericardial effusion is a rare complication of severe hypothyroidism in children but can be present in 10-30% of adults. It may be a frequent manifestation in myxedema, but rarely associated with mild hypothyroidism, reported incidence of 3-6%. The pathophysiology of edema in hypothyroidism has been studied extensively. Myxedema refers to the deposition of hydrophilic mucopolysaccharides in the dermis, which results in swelling of the affected area. When the pericardial volume expands, it causes the pericardial pressure to increase, resulting in accumulation of pericardial fluid in the pericardial space.
Clinical Case: A seven-and-a-half-year-old girl presented with cough for 1 month and generalized edema for 3 weeks. She was previously well, with no history of cardiac or renal problems. She gained 7 kg in 5 months and her weight plotted between the 75th and 90th centile while the height was at 3rd centile. The swelling involved the eyes, legs, abdomen and was worst at the end of the day. Also noted to have poor appetite, constipation and cold intolerance for the past 6-8 months. The child was otherwise doing well in school and reached her milestones appropriately. There is a positive family history of hypothyroidism-the child's mother has hypothyroidism that was diagnosed 10-15 years ago and is on levothyroxine replacement. On examination, she appeared dull with sallow look and generalized edema. There were no signs of congestive cardiac failure and cardiovascular examination including blood pressure was normal. There was a small palpable goiter and rest of the examination was normal. In view of the symptoms of prolonged cough and generalized edema, a chest-radiograph was done. It showed a globular cardiac silhouette raising suspicion of pericardial effusion and echocardiogram revealed pericardial effusion with echogenic pericardium, and mild bilateral pleural effusion. Other chemical biochemistry showed acute renal impairment, mild transaminitis, elevated total and LDL cholesterol and mild anemia. Autoimmune screen was normal. Thyroid functions showed a markedly raised thyroid stimulating hormone with low FT4 and raised thyroid peroxidase antibody which clinched the diagnosis of autoimmune primary hypothyroidism. Thyroid ultrasound showed a heterogeneous gland with slightly increased vascularity. Thyroxine was started as a low dose and increased slowly to achieve biochemical and clinical euthyroid state. The pericardial effusion resolved in 3 months and metabolic derangements normalized with thyroxine replacement.

Conclusion:
In patients presenting with chronic non-specific clinical symptoms with generalized edema, hypothyroidism must be considered in the differential diagnosis. Also, once diagnosis is established it is good to look for complications like pericardial and pleural effusion especially in cases of severe hypothyroidism. Conversely in patients presenting with unexplained pericardial or pleural effusion, hypothyroidism must be considered in the diagnosis. Early recognition and treatment with thyroxine could eliminate the need for unnecessary diagnostic procedures and invasive measures and reduce the risk of progression to cardiac tamponade.

Biochemical Effects of High Dose Vitamin D Treatment in Preterm Infants
Chun Lim, Sasha Thambapillai, Michael Eisenhut, Claudia Chetcuti-Ganado

Luton and Dunstable Hospital NHS Foundation Trust, United Kingdom
Aims: Our neonatal unit currently supplements all neonates with vitamin D levels of <70 mmol/l with 1500 IU cholecalciferol for 6 weeks. We aimed to determine the incidence of Vitamin D deficiency in extremely low birthweight infants (ELBW) and the influence of ethnicity. Vitamin D supplementation of ELBW infants is debated. We investigated whether 1500 IU of cholecalciferol was safe and effective and the correlation of Vitamin D levels with bone health markers namely corrected calcium, phosphate and alkaline phosphatase levels.
Results: A total of 57 babies born between August 2015 and May 2017 were treated as per local protocol. The median gestational age was 27.0 weeks and median birth weight 855 g. Thirty babies (52%) were Vitamin D deficient (Vitamin D level < 50 mmol/L). There was no statistically significant difference in the incidence between Caucasian and non-Caucasian infants. The correlation of ALP and Vitamin D levels before treatment was 0.463, (p = 0.001). The correlation between the day of life of rise of ALP to >400 and the Vitamin D level was −0.282 (p = 0.049). There was no statistically significant difference between the corrected calcium and phosphate levels and Vitamin D levels before and after treatment. The mean Vitamin D before supplementation was 48 and increase to 78.5 (p = 0.001) after supplementation. The mean ALP before and after supplementation was 601 and 462 respectively (p = 0.0003). There were no babies who developed Hypervitaminosis D. The proportion of babies that remained deficient after treatment was 37%.
Conclusion: The incidence of Vitamin D deficiency is high in ELBW infants and measurement of Vitamin D levels in this cohort is essential. While the current ESPHAN recommendations may be sufficient in Vitamin D-replete infants, higher doses are required in infants who are deficient. Factors other than cholecalciferol may be more significant in affecting bone health in the early days after preterm delivery. We hypothesise that treatment with 1500 IU units of cholecalciferol in ELBW infants is safe. We have shown that Vitamin D treatment improves alkaline phosphatase levels and may promote preterm infant bone health in the longer term.
Internet addicted (OR 1.4, p < 0.05). Adolescents with a single-parent family structure were more prone to be addicted (p < 0.05). Parental control over Internet use (OR 0.73; p < 0.05), over total amount of time spent online (OR 0.69, p < 0.05) and over visited content (OR 0.59; p < 0.001) was associated with lower probability of Internet addiction. Conversely, using Internet during family mealtime was greatly associated with addiction (OR 2.83; p < 0.001).
Conclusion: Internet addiction in adolescents was a significant problem in our study, with a prevalence comparable to other reports. Traits such as grade retention, online activities at bed time, single-parent family structure and Internet use during mealtime were greatly associated with addiction. On the other hand, parental control over Internet use was related to lesser probability of addiction. As such, this study helps to enlighten the importance of parental strategies and behavioural changes on managing with Internet addiction.

ID: 254
Cogent Medicine Introduction: Internet has become part of our daily routine and reality, with a growing interest amidst adolescents. Concerns have risen regarding its excessive use and long-term effects on their health. Few studies have addressed this subject in regards to overweight, lack of sleep and healthrelated problems, especially in Europe. Therefore, we aimed to study the relationship between Internet addiction and health status among Portuguese adolescents.

Methodology:
A cross-sectional community study was conducted by applying a questionnaire that assessed psychosocial factors, health status, Internet addiction (Youth's Internet Addiction Test) and wellbeing of adolescents (WHO-5 Wellbeing Index). Local Portuguese elementary and secondary-school students, from 7th to 12th grade, were asked to participate. A descriptive and bivariate analysis for Internet Addiction was performed, and a logistic regression model was used. STATA v.14 was used for statistical calculations, with a significant p value < 0.05.
Results: This study included 1916 participants with an average age of 15 ± 2 years and a slight female predominance (53.3%). Although most adolescents said they had previously talked about Internet addiction and thought it was an important health-related problem, as much as 16.5% were considered Internet dependent. Health problems were reported by 24% of participants and a poorer status of wellbeing was seen in little over 22%. At bedtime, almost half (45%) admitted to have online activities, with about 41% not sleeping an adequate amount of time. Girls were found to be 28% less addicted to Internet (OR 0.72, p < 0.05). Those who had online activities at bedtime (OR 1.40, p < 0.05) and who lacked sleep (OR 1.55, p < 0.05) were more likely to be addicted. Similarly, a poorer wellbeing status was associated to addiction (OR 1.44, p < 0.05). Chronic health problems related to weight, sight, atopy, anxiety or attention-deficit and hyperactivity disorder were, however, not found to be significantly related to Internet addiction.
Conclusion: Internet addiction was a significant problem in our study sample. Traits such as poorer well-being and lack of sleep year were greatly associated with addiction, concurring with previous studies. On the contrary, though the literature seems to indicate that excessive Internet use has a negative effect in adolescents' chronic health problems, this was not clearly shown in our study and warrants further investigation. Since Internet addiction has important implications on adolescent's health status, clinicians should routinely screen for it within their practice. Conclusions: Almost 40% of overweight and obese adolescents had MHD as a comorbidity. From these, half were diagnosed with depression, a MHD known to have a bidirectional relationship with obesity. Adolescents with MHD had higher levels of excess weight and worse clinical outcomes, with less ability to maintain or reduce weight. These findings suggest that the presence of MHD may be an important indicator of a more persistent and treatment-refractory course of obesity. Adolescents with obesity are at a particular high risk and should be regularly screened for mental health problems. Future research focusing on the psychosocial consequences of excess weight should provide further insights on targets for effective interventions to reduce adolescence obesity and its disease burden.

ID: 262
Introduction: Suicide is one of the leading causes of death of young people and as such, screening for suicidal ideation is a major public health concern. However, there is fear that exposure to suicide-related content would encourage suicide attempt. This false idea is a great barrier to effectively screen. Hence, the need for tools without suicide content.
Purpose: The goal of this study is to present a short tool that could be helpful for suicide screening and prevention.

Gender Differences in Risk Factors for Suicidal Behaviours in Adolescents
Claire Martine van Duin; Carolina Catunda, Andreas Heinz, Helmut Willems

University of Luxembourg, Luxembourg
Introduction: As the second leading cause of death among young people suicide is a severe public health problem. Previous studies have indicated that risk factors for suicidal behaviours differ for males and females, although it remains uncertain whether gender predicts suicidal behaviors. The 2014 HBSC study in Luxembourg has gathered data on the suicidal ideation sequence in adolescents and can contribute to these issues.
Purpose: The objective of this study was to examine gender differences within the risk factors for suicidal behaviours within the adolescent population of Luxembourg.
Materials and Methods: Data on suicidal ideation among adolescents was collected through written survey. Data from secondary school students aged 12-18 were used (N = 5595). Bivariate logistic regressions were conducted in order to identify risk factors for the dependent variables of "sadness", "considering suicide", "planning suicide" and "suicide attempt" in the last 12 months. Subsequently, multivariate logistic regressions were performed split by gender. Twenty-four independent variables were included in the models.

Results:
The three significant variables that added most to the models for "sadness" and "suicide attempt" are named. For boys, the odds for sadness were impacted by the number of health complaints Conclusion: This study has indicated that differences in risk factors between the genders increase as the severity of suicidal behaviour increases. This highlights the need for distinct strategies for the prevention of suicide behaviours that are suitable for the different genders, and their respective risk factors.

ID: 276
Cogent Medicine Introduction: Anxiety arises in anticipation of a future threat. Fear is a response to an imminent threat. They are usually adaptive responses. However, when they interfere with the normal functioning of the individual, they become pathological and are called anxiety disorders. Adolescence is a risk age period for the development of these disorders, which can lead to poor developmental and academic outcomes.

Anxiety and Academic Performance in Adolescents
Purpose: Identify and characterize a population of adolescents with anxiety disorder at the Adolescent Medicine Outpatient Clinic of a Tertiary Hospital and its correlation with academic performance.
Methods: A retrospective study was conducted through the analysis of the clinical processes of adolescents with anxiety disorder followed at the Adolescent Medicine Clinic between 2016 and 2017.
Results: A total of 128 patients were identified, most of whom (n = 95, 74%) were female, with an age comprised between 10 and 21 years. Eighty of those patients (62.5%) were referred from the Emergency Department and 96 (75%) had a first time consultation during school time. The complaints that most frequently motivated a referral were thoracalgia, dyspnea or hyperventilation, and syncope or lipothymia. In 69 patients (54%), diagnostic exams were requested to rule out an organic disease. The most frequently diagnosed anxiety disorder subtypes were social anxiety (33), panic (32) and generalized anxiety (17). Fifty-eight patients (44%), had a decreased school performance and 27 (21%) had a history of grade retention; 91 (71%) were on regular curriculum; around 10% reported having been bullied. The incidence of family dysfunction was 40.6%. After having started pharmacological therapy and/or psychotherapy, 29% of patients improved their grades at school. From those who did not improve their grades, 42 (46%) dropped out from the Clinic.
Conclusion: Poor school results are prevalent among adolescents with anxiety. Every adolescent attending a clinical appointment should undergo a routine structured biopsychosocial assessment for a timely identification of anxiety and early intervention. Training of health professionals in the provision of comprehensive health care to adolescents will reduce health costs in the long run. Introduction: Immigrant adolescents' view of their own well-being is an important indicator of inclusion. Immigrant status has often been postulated as a risk factor for mental health problems among adolescents, but few systematic patterns have been reported in previous studies, especially those that took into account differences between first-and second-generation immigrants.

ID: 148
Method: Using the Italian 2013/14 Health Behaviour in School-aged Children sample, we investigated perceived well-being in a representative sample of 47 799 students aged 11, 13 and 15 years recruited throughout all Italian regions. Well-being was measured as internalising problems (health complaints and life satisfaction) and externalising behaviours (bullying behaviours and physical fights).

Results:
The SES distribution and ethnic background of first-and second-generation immigrants revealed two major patterns: a Western countries pattern and a different pattern, which encompassed people from Eastern European and non-Western/non-European countries. Adolescent immigrants from the Eastern European and non-Western/non-European countries pattern had a higher occurrence of health complaints and more frequently reported low life satisfaction when compared to their counterparts from the host population, and these differences became more marked among second-generation immigrants.
Conclusion: The risk of reporting bullying behaviours and physical fights was evident in firstgeneration immigrants and decreased among second-generation immigrants, independent of ethnic background. Welfare provisions directed to families and children, as well as educational policies, may play a role in the adolescent well-being and mental health, particularly in the immigrant population. Methods: Data (n = 214,283) from the 2013/2014 Health Behaviour in School-aged Children (HBSC) study were used including nationally representative samples of 11-, 13-and 15-year-olds from general schools in 42 participating countries. The self-reported weekly pain during the previous 6 months was studied. Localized "single-site" pain (pain reported at only one site-either head, or stomach, or backache, by excluding other sites) and "multi-site pain" (pain reported in at least two sites) were analysed separately. Multilevel logistic regression analyses for studying country-level effects and log-linear analysis for studying associations between the studied types of pain were used.

ID: 238
Results: Overall, significant cross-country variations in the chronic pain prevalence and chronic pain patterns among adolescents exist. In general, the prevalence of localized specific pain types reported in this study was 11.3% for headache, 7.7% for backache and 4.6% for stomach ache. The prevalence of multi-site pain was more common varying from 13.2% in Armenia to 33.8% in Israel. The log-linear analysis showed that the two-way and three-way interactions among studied pain were all significant (p < 0.001). The strongest effect was found for the co-occurrence of headache and stomach ache, but the weakest for the co-occurrence of all three types of pain.
Conclusions: Although the international heterogeneity of chronic pain prevalence across countries exist, internationally comparable data show that experience of chronic pain among adolescents is common. Chronic pain in adolescents should be managed using a multidisciplinary approach by taking into account the multidimensionality of chronic pain, as adolescents with chronic pain are not a homogeneous group. Introduction: From the Italian prescription data emerges an increase of the consumption of inhaled steroids (IS) in the age group 0−14 years and an increase in ADRs related to them, making it evident of a non-rational use of them that are not always based on scientific evidence. Despite the prevalence of Asthma (9.5%-10.5% in 6−11 years), it has been particularly noted that IS are used inappropriately in children with an "over prescription" for conditions that do not require their use, specially for colds, coughs and sore throats. IS have also a modest effectiveness in preventing both recurrent wheezing viral and bronchiolitis (many times IS are used improperly by pediatricians in these conditions too). In the Enbe Study (Effectiveness of Beclomethasone versus placebo in the treatment of preventing viral wheezing in the preschool age group), Beclomethasone reduced the risk of viral wheezing by 4% (from 11% to 7%), but the difference was not statistically significant.
Purpose: From these considerations, there is a necessity for a Phase IV research project to be conducted by Family Pediatricians (FPs) that can foresee both training courses for FPs and informational for families regarding the correct use of IS and any iatrogenic illness caused by their improper use and a survey on prescriptive appropriateness and safety in children aimed at evaluating the risk-benefit balance on usage. The aim of the study is monitoring the use of IS with careful analysis of the risk/benefit factor of the therapy, through the accuracy of diagnosis, the therapeutic appropriateness and the safe use of medication.

Materials and Methods:
In this epidemiological/observational (case-control) and active surveillance project, the prescribing data for children (0-14 years) were collected and processed by Family Pediatricians (FPs). There have been three time steps: (1)   Introduction: Birth asphyxia, defined as the failure to establish breathing at birth, accounts for an estimated 813,000 deaths each year and is the third largest cause of neonatal mortality. Delivery at a facility where newborn resuscitation is available lends itself to being one of the most effective life-saving public health intervention. However, effective newborn resuscitation requires skill that is unavailable at most birth facilities in low resource countries. One of the key challenges faced by care providers in effective resuscitation is the formation of an effective face mask seal, lack of which leads to high and variable leakage, causing wide variability of tidal volumes even in the hands of experts. NeoBreathe Foot Operated Resuscitator addresses this issue by freeing one hand of the operator from the task of bag-compression, as it employs the operator's foot for powering resuscitation.
Purpose: Comparing efficacy of a novel foot operated resuscitator versus bag and mask ventilation in a manikin.
Method: A controlled trial was conducted at a level III neonatal intensive care unit (NICU) of a tertiary care hospital, among 117 participants, using an infant manikin Baby Anne. Mass flow and pressure sensors were fitted to measure tidal volume (Vt) delivered and volume propelled. Pressure and volume data were recorded in real time. Participants were given study set-up orientation, device usage training and practice time before data capture. Each participant was asked to deliver 60 breaths/min, using each device while targeting adequate chest-rise corresponding to a targeted 15-21 ml Vt. Vt, peak inspiratory pressure (PIP), leak percentage (%), inspiratory time (Ti, ms) and other parameters were recorded using a Notebook PC (Dell®, Windows® 10) on a specially developed application (LabViewTM 2014 platform National Instruments®, USA). Percentage breaths that achieved target range Vt, other key ventilator parameters and their variability were assessed and compared between the two devices. Background and Aims: Parents of children with cystic fibrosis (CF) experience high levels of stress and problems. Family empowerment interventions provide important support for many patients with CF and their families. The present study aimed to assess the effect of a family empowerment program-based nursing intervention on parents coping with stress and problem solving, and quality of life children with CF.

Results
Methods: In this randomized clinical trial, 44 parents of children with CF were randomly assigned into experimental and control groups. Data were collected through coping with stress, problemsolving skills, and quality of life scales from both groups, before, immediately before, and 1 month after the intervention. Family empowerment interventions were held for 10 weeks. The data were analyzed using SPSS, the Wilcoxon signed-rank test and the Mann-Whitney U test.
Results: There was a significant difference between the experimental and control groups after the intervention in the submissive approach dimension of the coping with stress scale in parents (p < .05). The total score level of problem-solving skills of preintervention and postintervention parents of the experimental group was statistically significant (p < .001). There was a significant difference between the mean children's quality of life score in the experimental and control groups after the intervention, and the mean scores of emotional, social, treatment load, and respiratory subscale (p < .01), and mean physical subscale points (p < .05).
Conclusions: Family empowerment interventions applied to the parents of children with CF increase the quality of life of children and their parents' ability to solve problems and cope with stress.

Conclusion:
In our study, non-IgE manifestations were the most frequent; however, we found a relevant number of IgE manifestations with corresponding documented sensitization. In this series, oral provocation tests were performed mainly for tolerance assessment, which reflects the most common practice of using elimination diet as a diagnostic tool. Taking into account the number of suspected cases in our study, there was a high number of cases in which the suspicion was not confirmed. The diagnosis of CMPA in the neonatal period is challenging; a rigorous and timely approach is needed not only to institute early eviction but also to prevent unnecessary (and sometimes prolonged) food restrictions. Objectives: Assessing the potential association between atopy and MpEPDs, as we recently observed a significant elevation of serum IgE in a small group of pediatric patients.

Methods:
We carried out a cross-sectional observational study, including 162 hospitalized children admitted to the hospital (because of respiratory infections or different types of extra-pulmonary diseases with probable immune-mediated pathogenesis) and tested for M. pneumoniae by serology tests.

Results:
We identified three groups of children: (I) with respiratory diseases unrelated to M. pneunoniae (n = 61); (II) with respiratory diseases due M. pneumoniae (n = 56); III) with extrapulmonary diseases related to M. pneumoniae infection (n = 18). MpEDs included in the group III patients were: vasculitic urticaria (n = 4), erythema multiforme (n = 4), myopericarditis (n = 2), myositis (n = 2) nephritis (n = 1), reactive arthritis (n = 1) and meningoencephalitis (n = 1). There was no significant difference in total serum IgE between children with M. pneumoniae respiratory infections and those with respiratory infections unrelated to M. pneumoniae (253.52 ± 56.8 UI/ml vs. 164.37 ± 48.3 UI/ml, respectively). On the contrary, patients developing MpEPDs showed significantly higher levels of IgE than both previous groups (402.15 ± 94.7 UI/ml; p < 0.001 vs. group I; p < 0.01 vs. group II). Such an interesting finding was confirmed also by normalizing the IgE levels for the normal values, according to age.
Conclusions: Hospitalized children diagnosed with different MpEPDs seem to have significantly increased serum IgE compared to children developing respiratory illnesses only. We might speculate that atopy might be a biological marker of predisposition to develop extra-pulmonary complications during M. pneumoniae infection, also according to some recent observations, that seem to support some potential and concomitant immunologic mechanisms in autoimmune diseases, such as basophil-dependent (self-reactive) IgE and IL-17 production. Probably, IgE plays no direct role in the pathophysiology of these clinical manifestations, but the immune imprinting to produce IgE and, particularly, the cellular processes and cytokine environment underlying the individual atopic constitution might trigger a number of different mechanisms, leading to several and heterogeneous clinical disorders described in association to M. pneumoniae infection, as a final result.

Cogent Medicine
Recording and Investigation of the Annual Incidence of the Respiratory Infections which were found under the Tongue of the Hospitalised Children in a General Hospital (2017) Conclusions: The prevalence of both admissions for hospitalization and the incidence of morbidity, but also in the transfers due to respiratory disease and mainly infection are the males, with a particularly high risk during infancy, especially in RSV and rhinitis epidemics, and the greater seasonal incidence and distribution of the hospitalized children is mainly related to winter and spring, events that are consistent with Greek and international bibliographic data. The medical and nursing staff members of our clinic have adequately coped with cases of respiratory problems and have minimized the transfers to tertiary-hospitals, to the most urgent cases. Methods: Based on request from a local charitable foundation, dental age estimation was conducted for 22 children whose ages were disputed. The claimed age of the children was provided by the parents or legal guardian and it ranged from 6 to 18 years. The children mostly originate from Somalia, Bangladesh and Myanmar. Using panoramic radiograph, all the upper and lower teeth on the left side of the arch were scored according to Anglo-Canadian classification system and dental age was estimated using population specific reference data sets developed by dental age research group at King's College London Dental Institute. Paired t-test was used to calculate the difference between the claimed chronological age (CA) and the dental age (DA).

Results:
The overall difference between CA and DA was −0.31 years and the difference was not statistically significant (p > 0.05) indicating that the method employed was fairly accurate. Agewise comparison could not be performed due to less number of children in each age range.
Conclusion: This case series analysis emphasize the importance of utilizing appropriate method of age estimation taking into account of gender and ethnicity of the subjects of concern. The countryspecific ages of legal importance and the legality of registering the date of birth based on age reports will be discussed in this presentation. Purpose: In this study, we tried to estimate the cardiac function of SGA by ultrasonography and clear the mechanism of its change.

Materials and Methods:
We examined retrospectively the medical records of 53 SGA newborn infants who were admitted to NICU of our hospital for past 5 years. For control group, 53 appropriate for gestational age newborn infants were recruited. Infants with congenital malformations, chromosomal abnormalities and signs of intrauterine infection were excluded. Symmetrical SGA were also excluded. The instrument used was a Philips Model iE33 Color Flow Imaging System. Recordings were obtained while the infants were asleep or resting quietly with stable heart rates. Left ventricular dimensions for fractional shortening or ejection fraction were measured using M-mode from a parasternal long-axis view at the level just distal to the mitral valve leaflet tips. The dimensions divided body surface area (BSA) were calculated. Left ventricular diastolic function was evaluated from pulsed wave Doppler interrogation of transmitral flow. The peak velocities of the early passive wave (E wave) and the late active wave (A wave) were measured and calculated the E/A ratio. To estimate ventricular wall motion using tissue Doppler method, the sample volume was placed at the lateral margin of the mitral annulus on the septum. Peak systolic (S'), peak early diastolic (E') and late diastolic (A') myocardial velocities were determined. Statistical analysis was performed using t-test and p < 0.05 was significant.
Results: SGA groups had significantly lower IVSd, LVPWd and LVPWs than the control group. However, SGA groups had significantly higher IVSs/BSA, LVPWs/BSA and LVDd/BSA than the control group. No difference was noted in EF between the two groups. SGA group had lower E, A and E/E' than the control group.
Conclusion: These data indicate low early diastolic function and low atrial systolic function in SGA infants.

ID: 156
Cogent Medicine Introduction: Acute kidney injury (AKI) was the primary cause of neonatal morbidity and mortality. To diagnose AKI in neonate was difficult due to the lack of specific signs, symptoms and or biomarkers. Detecting AKI in critically ill neonates was crucial to decide appropriate management and prevent complications. Cystatin C (Cys-C) was previously recognized as one of renal biomarkers that reflects renal function in neonates population and it was superior compared to others.
Purpose: The aim of the study was to determine diagnostic value of Cys-C in identifying AKI in critically ill neonates.
Materials and Method: Diagnostic test of AKI with eGFR-Creatinine as gold-standard and eGFR-Cys-C as index in critically ill neonates who were treated in Cipto Mangunkusumo Hospital during July to November 2017. Background and Aims: The aim of this study was to determine the effect of education on practices supportive oral feeding of premature infants among healthcare professionals in neonatal intensive care unit (NICU).

Methods:
The study was a nonexperimental pretest-posttest self-report survey design conducted at a medical faculty hospital in Turkey. A sample of 44 NICU healthcare professionals (nurse, midwife and physician) participated in an education course. Data were collected using the Demographic Characteristics and Premature Infant Feeding Questionnaire Form. Participants were split into groups of 8-10 people and the education course was completed in average one and a half hours per day for 5 days. Prior to the education presentation, participants completed the pretest. The posttest was completed 2 weeks after completion of the education course. Data were analyzed using IBM SPSS Statistics 22.0 and paired t-tests were used.
Results: The average age of the participants is 26.14 ± 4.81. Of the 44 participants, 84.1% were nurse, 13.6% physicians, 2.3% were midwives and 88.6% were female. While 63.6% of the healthcare professionals had NRP certification, 70.5% of them did not have the neonatal intensive care unit nursing certificate. It was determined that 40.9% of the participants were not educated about premature infant feeding, while those who participated in the training were found to receive breast milk training in the context of in-service training. The mean rate of correct pretest answers was 58.69%, whereas the mean rate of correct posttest answers was 78% (p < 0.001) Conclusion: It has been determined that the education given on practices supportive oral feeding improves knowledge the healthcare professionals'.

Evaluation of Maternal-Baby Attachment Level of Mothers Applied to Primary Health Care Center
Hazal Özdemir, Fatma Taş Arslan

Selçuk University Health Science Faculty, Turkey
Background and Aims: Maternal-baby attachment is of great importance for the children's physical, psychological and intellectual development and it provides that well-being throughout the life of the child. In this research article, it is aimed to evaluate maternal-baby attachment levels of the mothers who applied to a primary health care center in Konya when their baby was 1 month old.

Method:
The study was performed as a descriptive relational study. The population of research was constituted by 100 mothers who were apply to primary health care center. The data were collected from mothers who agreed to participate in this study. The data were collected by "Identifying Information Form'' that consisted of 25 questions and "Maternal Attachment Inventory". For data analysis, descriptive statistics (number, percentage, mean, standard deviation) was used. Independent t-test, Mann-Whitney U, one-way ANOVA and Kruskal-Wallis variance tests were used for data statistics in independent groups (p < 0.05 meaning level).

Results:
The mothers of 58% were in the age range of 25-34 years. The mean Maternal-Baby Attachment score was 96.81± (7.33). The relation between Maternal-Baby Attachment Inventory score and type of family, type of birth, pregnancy rate, planned pregnancy, being primiparous mother and intended sex of baby were found significant (p < 0.05).

Conclusion:
Research article showed that the nurses, especially pediatric nurses, who have an important responsibilities this subject. Pediatric nurses have a professional nursing approach in the context of family centered care who are the most influential people in starting and maintaining the maternal-baby attachment process. At the same time, nurse trainers should closely follow current knowledge and there is a need for more randomized controlled studies to improve the level of evidence of new nursing approaches in this subject.

ID: 231
Cogent Medicine Introduction: Sucrose has consistently been found to be a safe and effective analgesic in neonates. However, it is frequently underused and poorly documented. In addition, studies suggest that repeated exposure to pain as a neonate can heighten responses to pain later in life and have long-term implications in psychosomatic response to pain.

Methods:
We collected data on 51 babies discharged from the Neonatal Unit in Wishaw in January 2018. Data were collected on demographics including gestation, length of stay, number of painful procedures and use of analgesia. Painful procedures included heel pricks, venous cannulation, lumbar punctures and intramuscular injections. We also distributed 30 questionnaires to staff in the unit to ascertain their views on the use of sucrose in our department. We performed two interventions from February to March 2018. The first was staff education sessions: one for medical staff and six smaller sessions for nursing staff. The second intervention was the introduction of a sucrose documentation sheet to prompt staff to administer sucrose prior to painful procedures as well as to promote more reliable documentation of its use.
We then re-audited our use of sucrose in 36 babies admitted to the unit in May 2018 postintervention.
Results: Questionnaire results showed that 73% of staff felt sucrose should be used as analgesia in all babies regardless of gestation or respiratory support. As high as 60% of staff felt that sucrose was being used less than 50% of the time prior to painful procedures; 100% of staff felt sucrose was an effective painkiller and 97% of staff felt we could provide better analgesia by increasing our use of sucrose. Demographics between the January and May baby cohorts were similar, 67% of babies in both cohort were >37 weeks and 28% of babies in both cohort were 32-37 weeks. Babies in January underwent an average of 12 painful procedures with a cumulative 627 procedures in all 51 babies. Babies in May underwent an average of 10 painful procedures with a cumulative 349 procedures in all 36 babies. Prior to interventions, sucrose was documented as given in 1/51 babies in January 2018, in a total of 1/627 procedures. Following staff education and the introduction of the sucrose sheet, 27/36 (75%) babies had documented use of sucrose during admission, in a total of 78/349 (22%) painful procedures (0.16% pre-intervention, 22% post, p < 0.0001). Introduction: Late preterm (LP) infants are defined as those born at 34 to 36-6 weeks gestational age; these newborns are not fully mature and the last 6 weeks of gestation represent a critical period of growth and development for them. The increase of premature newborns with lower gestational ages means that the stable LP are not admitted to the NICU. These newborns need specific care and monitoring from medical professionals. The LP, compared with term neonates, are at increased risk for feeding difficulty, jaundice, hypoglycemia, temperature instability and respiratory distress, leading to an increase in the number of days of hospitalization.

Discussion
Purpose: The aim of this study was to evaluate the incidence of LP in the regular newborn service, their characteristics, problems during hospitalization and their follow-up.
Material and Methods: A retrospective study was conducted based on the medical records of the LP admitted to the regular newborn service of Centro Hospitalar São João (Portugal) between January 2016 and December 2017. We excluded babies admitted at birth to the NICU and those who did not meet the service's protocol of admission to the regular nursery (birth weight < 2000 g or <34 + 5/7 weeks).
Results: A total of 267 LP were included in this study with an incidence of 5.2% of births. The mean maternal age was 32 years. As high as 51% were male; 50% were born by cesarean section; 28% were twins. The LP were distributed: 34 and 0/7 weeks 3 newborns, 35 and 0/7 weeks 78 newborns and between 36 and 0/6 weeks 186 LP. The average weight was 2560 g and 20% were small for gestational age. As high as 82% LP had some problem related to their prematurity, among which: 167 had feeding difficulty, 141 jaundice, 73 hypoglycemia, 34 LP had respiratory distress and 28 temperature instability. Approximately 10% of these newborns were admitted to NICU because of these problems. As high as 51% increased the number of days of hospitalization, regardless of the type of delivery, with an average increase of 2.6 days. Seventy-nine percent LP had at least one follow-up consultation.
Conclusion: Preterm birth is an important public health matter. The LP are increasing, being a problem in hospitals, due to the morbidity associated with their prematurity. LP need to have a strict monitoring system in the nursery, (most of them do not need to be in the NICU) with a highly qualified, specialized and adequate staff number. Introduction: Despite the paediatric emergency department being home to a vast array of transmissible infectious pathogens, this is the first place many caregivers choose to bring their unwell newborn.

ID: 205
Purpose: Our main focus was to characterize this group and analyse the motives behind parents' decisions to take their children to a paediatric emergency department. We believe that the information collected might be useful for strategizing the risk mitigation and optimization.

Materials and Methods:
We conducted a retrospective analysis of all newborn admissions to the paediatric emergency department of our level II hospital during the 2016 and 2017 years. Unrepresentative admissions (e.g. inter-hospital transfers) and cases with unusable data (e.g. dropouts) were excluded from analysis.
Results: A total of 855 newborn admissions on the paediatric emergency department were accounted, of which 50 cases were excluded. The mean newborn age was 15.2 days old and the mean mother's age was 29.8 years (range 14-46 years). The majority (72.9%) of cases were prompted by the caregiver's initiative, 20.9% were referred by other health professionals and 6.2% were the result of scheduled re-evaluations. The most reported cause by the caregivers was crying or irritability followed by nasal obstruction, coughing and rhinorrhoea. The most commonly observed diagnosis was acute nasopharyngitis, followed by colic. Diagnostic tests were requested in 44.7% of cases. The mean emergency department length of stay was 1.98 h. Newborns referred by other health professionals had a higher rate of hospitalization and diagnostic tests requirement compared to the other newborns (32.1% vs. 15.7% and 76.8% vs. 35.7%, respectively). The global rate of hospitalization was 18.8%.

Conclusion:
The majority of visits to the emergency department in this period may have been solved in a primary healthcare setting. The high count of re-evaluations demonstrates the high degree of suspicion required for this age group, although it is uncertain whether the emergency department is the most adequate place for a re-evaluation. Nevertheless, we could not find an alternative to this daily and accessible service. Further awareness programs directed to the caregivers, as well as providing training to the primary healthcare services are fundamental to guarantee an overall better quality of healthcare services provided to the newborns, reducing the risk of exposure to the environment of paediatric emergency departments.

Association Of Pediatric Tuberculosis With Second Hand Smoke Among 112 Years Old Children In Karachi, Pakistan: A Case Control Study
Ambreen Aziz Sahito 1 , Masood Kadir 2 , Zafar Fatmi 2 , Fahmina Arif 3 1 Isra University, Pakistan; 2 Aga Khan University, Pakistan; 3 Civil HospitalKarachi Introduction: Tuberculosis (TB) is ancient infectious disease, but it still remains a substantial global health problem. TB is the most common cause of infectionrelated death worldwide. Childhood TB is neglected public health issue.
Objectives:: To determine the association between childhood TB and second hand smoke (SHS) among children aged 1 to 12 years in Karachi. Study design: Hospital based, age matched case control study Setting: Civil hospital Karachi and Sindh government hospital New Karachi Duration of study with dates: The study took one year for completion. Data collection was completed in nine months, data entry analysis 2 months and one month for write up.
Subjects and methods: 174 cases and and 343 age matched controls were recruited. Physician diagnosed cases of TB based on Pakistan Paediatric Association Scoring Chart for Diagnosis of Tuberculosis (PPASCT) and children aged 112 years coming to the same hospital with diseases diagnosed other than tuberculosis were enrolled as controls.
Conclusions: Childhood TB was associated with contact to TB patient, not child not vaccinated for measles, and female sex. Exposure to SHS at home in under 5 children while SHS outside home for older children contributed to development of TB. So we need to focus on smoke free environment for our healthier future generation. Introduction: Toxic Epidermal Necrolysis (TEN) is a variation of Stevens-Johnson's disease that encompass widespread epidermal necrosis of the skin and mucosa. Classification is based on affected body surface area (BSA). TEN occurs when >30% of BSA is implicated and is oftentimes related to a severe adverse reaction to a medication. Though rare, with an incidence of 1-2 cases per million, TEN is a potentially life-threatening condition. SCORTEN scale is frequently used to assess disease severity. Reports on child mortality go up to 7%. In sub-Saharan Africa, epidemiological data on TEN is lacking, although it is thought to contribute to a substantial burden in children healthcare and welfare.

POSTER
Clinical Case: An 8-year-old boy living in a rural site in São Tomé and Príncipe islands was diagnosed with tonsillitis at a local Health-Centre and was given amoxicillin oral tablets.
Five days later a quickly spreading blistering rash and acute conjunctivitis started, with no associated fever. Upon examination at the Pediatric Emergency Department, the patient presented with tender erythematous lesions with a necrotic base, large painful erosions and flaccid bullae mainly spread across the face, abdomen, trunk and limbs, largely surpassing 30% of BSA. Oral mucosa and periorbital oedema were also observed. The patient was admitted with intravenous fluid replacement and broad-spectrum antibiotics. Blood tests and hemodynamic monitoring were not readily available, but the patient remained stable. Referral to Dermatology was made, and in collaboration, a presumptive diagnosis of TEN was established, even though skin biopsy was not available. SCORTEN was not assessed due to lack of data. Together with the previous treatment plan, cleansing, regular dressings and skin care were provided, resulting in a steady recovery with no further complications. The patient was discharged after 25 days with widespread skin depigmentation and minimal scarring. Advice against use of amoxicillin or similar antibiotics was given, though the patient did not comply with recommended follow-up.
Discussion: Clinical assessment of TEN is difficult due to overlapping differential diagnosis. However, it should always be considered when a great BSA is involved. In developing countries, lack of clinical resources is often found and further complicate management of disease. Thus, a thorough history and clinical exam are fundamental to assess severity and point to available treatment options. When addressing TEN, supportive measures may increase survival and expedite recovery. This case shows the importance of early recognition of symptoms and management to prevent further complications.

A Case of Catastrophic Antiphospholipid Syndrome in a Previously Healthy 14-Year-Old Emirati Male
Fatima Salem Al Jaberi

Sheikh Khalifa Medical City, United Arab Emirates
Background: Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by venous or arterial thrombosis in the presence of persistent laboratory evidence of antiphospholipid antibodies. APS occurs as a primary condition, or in the presence of systemic lupus erythematosus or another autoimmune disease. Catastrophic APL is the development of thrombotic disease with multiorgan failure, which has its diagnostic criteria. It occurs in 0.8% of patient with APL, with mortality rate of 50% despite treatment with anticoagulants and immune suppressants. Survival rate decreases by 90% in 5 years.
Case Summary: A 14-year-old previously healthy boy presented with abdominal pain and headache for 1 day. On arrival he was noted to have high blood pressure readings, which were persistent through the day. Headache and abdominal pain both were dull and worsening. He was shifted to a secondary level hospital, in which CT head was done, reported to be normal. US kidneys done showed hypo-echoic R kidney with normal vessels bilaterally. Abdominal MRI done showed R renal infarct. Due to failure to relieve the headache and to control the BP despite IV labetalol, he was shifted to PICU. On arrival, he was still having headache, high BP readings with high creatinine, other investigations were unremarkable. Investigate for thrombophilia, brain MRI & fundus exam by Ophthalmology. MRI brain showed multiple aneurysms with massive sinus venous thrombosis. Thrombophilia workup showed prolonged aPPT not corrected with mixing study, but correcting when mixed with phospholipid, ESR was elevated, Antiphospholipid antibodies (anticardiolipin & Anti-beta2-GP) were both positive. During his stay, he was treated with 4 antihypertensive which barely controlling the BP. Also was on Paracetamol, ibuprofen & morphine for the headache. No antibiotics were started, as the history, examination and labs were not suggestive for infection. Once diagnosis of antiphospholipid was confirmed, heparin was started and then shifted to warfarin when the condition of the patient was stabilized. He stayed in the PICU for around 10 days and then 3 weeks in the general pediatric ward for treatment adjustment and rehabilitations. He was discharged home with no neurological sequel; his renal function was improving gradually over time. This is the second case to be diagnosed in our center SKMC in duration of almost more than 12 years.
Conclusion: Antiphospholipid syndrome is an uncommon disorder especially in pediatric population and moreover in males. Also, presenting and being diagnosed in a "Catastrophic state" is also very rare and is associated with high morbidity and mortality. Quick action, diagnosis and starting treatment on time gave the patient the chance to survive the catastrophic state with considerable good recovery.

A Tender Migratory Rash-Sweet Syndrome in a Paediatric Patient
Nikki Petrakis 1 , Navid Adib 2 , Michalis Yiallourides 3 1 James Cook University, Australia; 2 Queensland Paediatric Rheumatology Services; 3 Townsville Hospital and Health Service Introduction: Paediatric Sweet Syndrome (acute febrile neutrophilic dermatosis) is a rare systemic, autoinflammatory condition characterised by the abrupt onset of tender erythematous plaques and nodules on the skin. Sweet syndrome is a rare diagnosis in the paediatric population, with fewer than 100 childhood cases documented in medical literature (1). We would like to present a case of a boy with this condition who presented with a tender migratory rash.
Objective: To give prominence to the consideration of Sweet Syndrome as a differential diagnosis of a tender rash in the paediatric population.
Methods: This case study will utilise retrospective analysis of the patient's electronic medical records, in conjunction with parental consent. The patient's clinical, laboratory and pathological data will be analysed.
Case Description: A 12-year-old boy presented with a tender macular, non-pruritic, "burning" rash that commenced on the left side of his face before progressing to the right side of his face and left arm. For 2 weeks prior, he had a history of headaches, fever and lethargy. The child had a background of long-standing hypertension. Systemic examination was unremarkable other than a mucosal ulcer. Despite no vasculitis, infectious or autoimmune causes found after extensive investigation, he was prophylactically treated for bacterial meningitis with antibiotics. His ASOT titres also returned elevated. During admission, the lesions had crossed dermatomes and formed localised groups in both arms and legs. A punch biopsy revealed neutrophilic infiltration and a working diagnosis of Sweet's syndrome was established. He was treated with systemic corticosteroids and colchicine whilst they were tapered.
Conclusion: Due to its rarity, the presentation of Sweet syndrome in the paediatric population is varied. Patients with this condition may present with numerous extracutaneous manifestations (2). Given the high recurrence rate of this disorder in children and its potential association with an underlying hematological malignancy, Sweet syndrome should be considered an important differential in a child presenting with a tender migratory rash.

Nutritional Disorders and its Correction in Children with Juvenile Idiopathic Arthritis (JIA)
Anna Krasnopolskaya 1 , Larisa Balykova 1 , Ekaterina Akashkina 1 , Oleg Soldatov 2 1 Ogarev Mordovia State University, Russian Federation; 2 Mordovian Republican Clinical Children's Hospital Introduction: Disturbance of alimentary status represents a serious problem for patients with chronic diseases; however, nutrition condition in children with JIA is underestimated.
Purpose: To study nutritional status and its correction expediency in patients with JIА. A total of 50 children with severe JIA 2-18 years of age and 50 healthy children of similar gender, growth and age (control group) were examined using clinical, anthropometric, biochemical and bioimpedance methods. Five children had systemic variant of JIA, 28-poly-and 17-oligoarthritis. All patients received basic therapy, 12 children received corticosteroids, 10-TNF-α inhibitors. For nutrition disturbance correction 10 children received Peptamen (or-Peptamenjunior)-serum-peptides formula in addition to usual diet (10-20 ml/kg/day or 200-600 kkal/ day in 4-6 intakes).
Results: In 12% of patients body mass index (BMI) was less than 5th and in 14% more than 95th percentile. Eight percent of patients had rheumatoid cachexia. The low BMI was represented in cases of high disease activity, the high BMI was associated with corticosteroids administration. As high as 18% of patients had mild, 6%-average and 2%-severe protein-energy deficiency, which was typical for children with systemic and seropositive polyarticular variants of JIА with high level of disease activity. These patients had the low presence of muscular tissue and normal or high body fat mass in bioimpedance. Nutrition disturbances (ND) in 7 (14%) of children were combined with of waist circumference enlargement, dyslipidemia and hyperuricemia. Insulin-resistance and metabolic syndrome diagnosed in 12%. In patients with mild ND transferrin level depression (2.12 + 0.14 vs. 2.97 + 0.21 g/l in control group) was noted, while with average and severe NDin addition hypoalbuminemia and lymphopenia. Both reduction of shoulder muscles circumference and of skeleton-muscular mass share were revealed in JIA patients compared to healthy children. Within 20 days, Peptamen administration has normalized visceral protein concentration in all children with average and one-with severe ND, contributed to general condition improvement and urinary acid level normalization in all patients.

Conclusion:
In systemic and severe polyarticular variants of JIА alimentary disorders take place, which can be successfully corrected by peptides formula.
Introduction and Purpose: When looking at a patient with recurrent abdominal pain, an organic cause should always be considered. Delayed diagnosis has a significant impact on the clinical and nutritional status of the patient, thus affecting the long-term prognosis.

Materials and Methods:
We present the case of a 6-year old patient who was admitted in the Paediatric Gastroenterology Department of "Grigore Alexandrescu" Emergency Children's Hospital with chronic abdominal pain, constipation and important abdominal distension. After a complete work-up, a congenital intestinal malformation was diagnosed.
Case Description: The medical history of the patient revealed constipation with onset at 2 years. The patient had no previous history of abdominal surgery or trauma. She was evaluated for Hirschsprung disease with contrast enema and the diagnosis was excluded. The patient received various treatments for constipation. There was an improvement in the stool consistency, but she continued to present repeatedly with abdominal pain and loss of appetite. The repeated paraclinical work-ups she underwent both in out-patient clinics and during hospital stays excluded frequent causes of chronic abdominal pain and malnutrition: coeliac disease (serology and biopsy), food allergies, inflammation and infections. Functional pain remained the suspected diagnosis. Mother continued to self-medicate using homeopathic treatment. The nutritional status of the patient worsened; she associated weight loss, marked abdominal distension and recurrent abdominal pain.

Results:
The clinical exam at admission revealed altered general state and severe malnutrition W = 12.5 BMI 12, percentile 0.1, Z score = −3.8, diffuse abdominal pain, abdominal distension with important peristaltic waves. Abdominal ultrasound revealed an enlarged intestine. This result was confirmed by abdominal computed tomography. At this point, a decision to perform a laparoscopy was made. The intraoperative finding was jejunal obstruction at 120 cm from the duodenojejunal junction due to congenital adhesion band. After resection, the clinical status improved remarkably and the child soon resumed growth.
Conclusion: Congenital adhesion band is a very rare condition among children. Small bowel obstruction due to congenital adhesion band can be a challenging diagnosis. There is no imaging study that can establish the positive diagnosis, and exploratory laparotomy or laparoscopy are the only means for diagnosis and treatment. Optimal management (diagnosis and treatment) will have a positive impact on the clinical status and also on long-term development and growth.

A Case of Iron-Deficiency Anemia and Pica: What Happened First?
Joana Brandão Silva 1 , Márcia Cordeiro 1 , Sandra Borges 2 , Cristina Costa 1 , Rui Pinto 1 1 Department of Pediatrics, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal; 2 Department of Psychiatry, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal Introduction: Pica is defined as compulsive ingestion of non-nutritive substances, observed especially in children and pregnant women. The etiology is poorly understood, probably multifactorial, but its association with iron deficiency is widely recognized. Besides social stigmatization, pica may evolve with adverse outcomes.
Purpose: To describe a case of allotriophagy in children and the investigations for potential causes and complications.
Case Description: A 9-year-old girl was observed in the emergency department (ED) for chest pain and palpitations in the previous days, which began after school return after the holidays. She was already accompanied at the child-psychiatry outpatient clinic for a history of pica and stuttering since 6 years of age. She started eating styrofoam initially, then thread in clothes and elastic hair bands, with progressive worsening in recent months. She related these behaviors to periods when she felt more anxious, with no other depressive symptoms. She initiated psychotherapy, speech therapy and a few weeks later, fluvoxamine. She was referred to pediatrics consultation after ED visit, where she complained of constipation and output of textile threads in the stool. Her growth charts showed adequate evolution (weight and height in P50-75 and P90, respectively). She had pallor and angular cheilitis, remaining physical examination was normal. Her laboratory tests revealed microcytic hypochromic anemia (hemoglobin 8.4 g/dL, mean corpuscular volume 58.9 fL) and severe iron deficiency (ferritin 3.9 ng/mL).
Results: Oral iron supplementation was initiated; after 2 months of treatment she maintained irondeficiency anemia: hemoglobin 9.9 g/dL, ferritin 7.8 ng/mL. Meanwhile, fluvoxamine doses were increased and she initiated alprazolam, because there was no clinical improvement of pica. Since there was a poor response with oral treatment, it was decided to switch to intravenous iron. The investigation of refractory iron-deficiency anemia showed celiac antibodies, fecal occult blood test and H. pylori antigen in the stool negatives. Abdominal ultrasound, requested for investigation of bezoar, showed no major changes. The patient's family reported cessation of pica episodes coincident with the time of the first infusion of iron, and subsequent resolution of constipation. Hemogram and iron stores normalized; she remains asymptomatic after 5 months.
Conclusions: In our case, no cause to iron-deficiency anemia was identified. Therefore, it is difficult to establish if iron deficiency contributed to pica, or if it was the result of the accumulation of fibers in gastrointestinal tract with consequent malabsorption. A multidisciplinary team approach is preferred, particularly when a concomitant anxiety disorder is present. Introduction: Listeriosis is a severe and uncommon infection which can invade tissues normally resistant to infection, such as the central nervous system, leading to life-threatening meningitis and encephalitis. Cellular immune response plays an important role in protective immunity.

ID: 126
Case Report: A 10-year-old girl, from Sao Tome and Principe, with hepatic cirrhosis due to autoimmune hepatitis, under steroid treatment for the past 3 months, presented with a 4-day fever, headache, myalgias, cough, abdominal pain and diarrhea. The next day her condition worsened with altered mental status and meningeal signs. Blood culture was positive for Listeria monocytogenes and she was treated with ampicillin plus gentamicin, while maintaining steroid treatment. Lumbar puncture was not performed due to thrombocytopenia (27 × 10 9 /L). EEG and Head-CT scan were normal, while MRI showed an enhancing micronodular lesion, in mammillary bodies with peripheral reinforcement and perilesional edema that was interpreted as a small abscess. She evolved favorably, with complete resolution of clinical and radiological signs and symptoms, having completed 31 days of IV ampicillin and 18 days of gentamicin. She was discharged on oral amoxicillin and maintained an outpatient follow-up.
Discussion: Listeriosis should be investigated in all patients with cellular immunosuppression who present febrile symptoms. The central nervous system may be the only area of the body infected and patients may present with focal neurological signs or disturbed states of consciousness. While brain abscess is rarely found, rhombencephalitis composes a rare but characteristic form of neurolisteriosis, as in our patient. The duration of therapy depends on the clinical syndrome, the presence of underlying disease and the response to treatment. Establishing suitable treatment as early as possible can improve the prognosis.

Ya-Lei Chen
National Kaohsiung Normal University, Taiwan Introduction: Incidence of children with autism is related to gene expression, immune response and changes of neurotransmitters; however, the molecular mechanism is unknown. The murine maternal immune activation (MIA) offspring model enables longitudinal studies exploring aberrant social behaviors similar to those observed in humans.
Purpose: This study aimed to investigate the changes of expression of cerebral genes, cytokines, chemokines and neurotransmitters at newborn and adolescence, observed by MIA offspring model.
Materials and Methods: MIA was induced using the following lipopolysaccharide subcutaneous injection conditions: 25 μg/kg on gestational day 15, 25 μg/kg on day 16 and 50 μg/kg on day 17. As controls, pregnant mice were injected with 500 μL phosphate-buffered saline (PBS) on day 15, 16 and 17. The brains of the offspring (n = 6-10) at newborn and adolescence were excised and evaluated their gene, cytokine, chemokine and neurotransmitter expressions. The social behaviors (n = 30) were estimated using elevated plus maze, three-chambered and home-caged behavioral tests at adolescent stages.

Results:
The social deficit behaviors on elevated plus maze, three-chambered and home-caged behavioral tests were appeared at MIA adolescent offspring. As compared to PBS-treated controls, the gene expression of interferon-stimulated (gbp3, irgm1, ifi44) was upregulated and serotonin synthesizing enzyme (tph 1) was downregulated at newborn while, at adolescent stage, immunodevelopmental transcription factor (egr2) and hormones (pomc, hcrt) were upregulated and serotonin synthesizing enzyme (tph2) and serotonin transporter (slc6a4) were downregulated. The cerebral IL-6 levels were endogenously upregulated, but L-selectin levels were downregulated at adolescent stages. Moreover, the cerebral serotonin concentration was significantly decreased at adolescence.

Conclusion:
We concluded that MIA induced by exposure to LPS decreased cerebral serotonin levels in parallel to the downregulation of the tph2 and slc6a4 genes and in conjunction with social deficit behaviors similar to autism in offspring. Potentially, the social deficit behaviors were induced via the interplay among immune response, neurotransmitters and developmental genes for a long term.

Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bezmıalem Vakıf University, Turkey
Introduction: Polyneuropathy (PNP) is damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body. PNP can present with many differing symptoms, including numbness, muscle weakness, poor bladder control or respiratory problems, depending on the type of nerve involved. Whole-body vibration (WBV) has been used in different populations as a new and effective intervention method to improve balance, postural control and muscle strength. The immediate effect of WBV on respiratory muscle strength has not been studied yet.
Purpose: The purpose of this study was to investigate the effect of one session WBV on respiratory muscle strength and functions in a case with polyneuropathy.
Case Description: A 12-year-old male child with chronic demyelinating polyneuropathy received five bouts of 3 min of WBV therapy with 2 min of rest between bouts (total 15 minutes WBV) at 20 Hz in a standing position. Before and after the WBV, maximal inspiratory (MIP) and expiratory pressure (MEP) measurements and pulmonary function test measurements were done. Results: Out of a total of 116 children studied with CMA, 64% were male and the average age at the time of the test was 10.7 ± 3.8 years. Children frequently had more than one clinical indication for CMA: 85% had intellectual disability, 60% had development delay and 43% had dysmorphisms. Previous genetic investigation was done in 97% children. Of those, 93% had molecular analysis of Fragile X syndrome, 70% had done karyotype analysis and 22% underwent phenotype directed tests. Abnormal CMA results were reported in 41%, with a total of 63 copy number variations (CNV), 1-4 per individual. Deletions comprised 62% of all abnormalities, duplications 32% and loss of heterozygosity events 5%. To assess the clinical significance of the CMA, patient's direct family testing was done in 51% of children. In 36% of the abnormal results, the clinical significance of findings remained unknown; 26% were classified as non-etiological; 21% were defined as pathogenic or likely pathogenic and 15% had polymorphisms present in the normal population. The overall diagnostic rate (percentage of total patients with pathogenic CNV) was 9%. Further genetic investigation was conducted in 17% of children with abnormal CMA and in 19% of children with normal CMA.
Conclusion: Although CMA is one of the genetic analysis with better diagnostic yield, in our study variants of unknown clinical significance were high (36%), family tests were needed in half of those with altered results and further genetic investigation was requested for 18% of the total sample. Deciphering the clinical significance of CMA can be challenging, as the capacity to detect abnormalities is greater than clinician's ability to interpret their role in ID and DD.

National Medical Research Center for Children's Health, Russian Federation
Introduction: Childhood epilepsies a heterogeneous group of disorders and syndromes with different severity, prognosis and treatment. The purpose of study was to recognise the possible reason of failed AED treatment and to find the ways to overcome it.
Methods: A total of 36 patients with different forms of epilepsy aged from 3 months to 16 years not the candidate for surgical treatment have been studied. The long duration EEG, high-resolution MRI, biochemical, lactate level, genetic investigation were performed to these children.

Results:
In 11 children, the respiratory chain disorders confirmed by mtDNA sequence were found. Metabolic diseases were discovered in patients: two glutaric aciduria type1, one glutaric aciduria type2, one propionic aciduria, one methylmalonic aciduria, one Gaucher type3, two patient with glycogenosis type9, two patients with ceroid lipofuscinosis type 2 and 6. Genetic epilepsies with mutation in genes SCN8A (two patients), GRIN2A, KCNMA1 and duplication 15q11.2q13.3, c.1312G>A in SRPX2 were revealed. In other cases with normal MRI, the reason of pharmacoresistant seizures was not discover yet. In children with metabolic disorders and energy metabolism disorders, we use the specific therapy (diet, L-carnitine, vitamins, enzyme replacement therapy, etc.) in cases which it possible, avoid valproic acid in treatment, as well we use the phenytoin in patient with potassium channel mutation. These treatment management leads to reduction in seizures frequency or even to seizures remission in some cases.

Conclusions:
The recognition and diagnostic of underlying the etiologies of intractable seizures improve the treatment management in many cases.

Laura E. Castañeda-Ramirez Hospiten Los Cabos, Mexico
Introduction: Febrile seizures have an incidence of 4-5% of the pediatric population from 0 to 6 years. Incidence in males than in females 1.5:1. Simple 3-15 min and complex 15-30 min. Its physiopathology is unknown, associated factors such as increased circulation of toxins, myelination deficit in immature brain, immaturity of thermoregulation mechanisms, increased oxygen consumption, in any febrile process.
Objective: To describe the etiology and evolution of the case treated in a second level private hospital in Mexico.
Clinical Case: Male, son of 30-year-old healthy mother, 35-year-old healthy father, second pregnancy, weight 3.2 kg, size 49 cm, Apgar 8-9 term, obtained by scheduled cesarean section, exclusively breastfed 6 months, complete immunizations, normal psychomotor development. Parents deny history of febrile seizures or epilepsy. 7-months-old, simple febrile seizures began as myoclonic spasms on left arm, 3 min last accompanied by loss of consciousness, first 24 h evolving into complex 3-5 per day of 3-30 min last associated with body temperature 37.9°C-38.3°P C, changes in evacuation characteristics. Recurrences of convulsive seizures, same characteristic, more atonic in intervals of 30-60 days the following 5 months associated with febrile process of 38.3°C. When 13-months-old, head movements are added without loss of consciousness, 1-3 per day called "Head Drops". Results: We have applied diazepam 0.3-0.5mg/kg/dose, phenytoin 20 mg/kg/day, metronidazole 30 mg/kg/day, metamizole 10 mg/kg/day, paracetamol 20 mg/kg/day, and with valproic acid 25-40 mg/kg/day, levetiracetam 30 mg/kg dose and clobazam 0.1-0.3 mg/kg/day oral the crisis has been controlled. Psychomotor development has been normal. The etiology of the crises in this case is cryptogenic.

Discussion and Conclusions:
Children under 12-months-old with febrile convulsive seizures have a 50% risk of recurrence with body temperature below 38°C at the time of the crisis and recurrence in the same febrile outbreak. The seizures were refractory to antiepileptic drugs, behaving as a Syndrome of Epilepsy with myoclonic-atonic crisis; as described by Doose in 1970; children are previously normal, with a history of febrile seizures in 11-28%, the evolution of this syndrome is variable, 50-89% stops having crisis after 3 years, 58% with a normal IQ.

Cogent Medicine
The Concept of Self-Reference in Autism Amalia Megremi 1 , John Darzentas 1,2 1 University of Aegean, Greece; 2 University of York, United Kingdom Introduction: Autism is a disorder in the individual's communication with others. But, what is the relationship of the autistic person with his/herself? How is the autistic person self-referred? Does communication disorder in autism not only related to interpersonal relationships but also to the intrapersonal self-referential relationship of the individual with himself/herself? Purpose: Investigation of self-reference in autism.

Materials and Methods: Literature review.
Results: Main finding in autism is the disorder of mirror neurons. Mirror neurons are activated when the individual observes someone else's actions and when the individual performs the same actions him/herself. Mirror neurons teach me empathy and sympathy for the other individual, but also for myself. Consequently, in autism, there is a deficit both in the interpersonal social interaction of the individual with others but also in the intrapersonal self-referential relationship of the individual with himself/herself. Clinical features of autism related to the way an autistic individual refers to himself/herself are: (1) Sensory disorders: Sensory disorders occur in 90% of autistics: they look for intense stimuli (intense music, intense skin pressure), they do not tolerate sensory overload (they cannot wear certain fabrics, eat particular foods) or they do not respond at all to normal sensory stimuli (while the acoustic pathway is intact, they do not respond to the call of their name). (2) Reaction to pain: Autistic children often have an increased pain threshold. (3) Selfinjuries: Self-injuries occur in 25-50% of autistics. The more limited the ability of the autistic individual to communicate (and hence interpersonal skills), the greater the likelihood of such behaviors, suggesting indirectly that there is a correlation between interpersonal relationships and the relationship of one's self, and that a disorder at one level implies a disorder at the other one. The above clinical features suggest that in autism the relationship with the self is deficient, and that is why the individual performs actions (sensory disorders, self-injuries, low reaction to pain) that could enhance it.
Conclusions: In autism it is not only the relationship between the individual and the others which is disturbed, but also the relationship with himself/herself. The absence of activation of mirror neurons in autistic people is a major finding suggesting this dual disorder, while the clinical features mentioned support this finding. Finally, the disturbed relationship to others comes from, or ends up in, a disturbed relationship with the self (bidirectional correlation). Expanding the rationale, does love/compassion towards the self reflects love/compassion towards others and vice-versa?

Queen's University, Canada
Purpose: Human-Centred Design (HCD) is an approach to research and problem-solving that actively seeks human perspective at each stage of the problem-solving process-whether that is defining or observing the problem, brainstorming possible solutions, conceptualizing a chosen action, developing a plan of action or implementing the solution. It emphasizes dignity, access and cultural appropriateness. Although the UN Convention on the Rights of the Child states that when young people are the focus of research, they have the right to be consulted, this is not always standard practice among health researchers and development professionals doing monitoring and evaluation. The purpose of this poster is to highlight the concept of adolescent-focused HCD, providing positive examples including from our work at the Queen's University Child Health 2.0 initiative (www.childhealth2.com), and to emphasize the opportunities of this approach for paediatrics more broadly.
Focus: Adolescent-focused HCD specifically applied in the area of adolescent medicine aims to actively and very intentionally engage youth in problem-solving. It recognizes that children and adolescents have a unique, and non-adult, perspective that-although not necessarily more or less valued than an adult perspective-should be specifically sought. This is particularly true because HCD principles emphasize that in order for solutions to be effective, the population of focus should be involved in the problem-solving at all stages. Adolescent-focused HCD has five main iterative stages (empathize, define, ideate, create prototypes, testing). HCD has many similarities with participatory action research and integrated knowledge translation, but focuses more specifically on the creation and testing of effective solutions. Adolescent-focused HCD has been previously used to inform interventions for reduction of sexually transmitted infections, gender-based violence, injuries and substance abuse as well as to increase use of health care services by young people. Yet, it is still relatively unknown as a mainstream approach.
Significance: Adolescents represent important stakeholders and collaborators in health programming, health system research and development work that involves them. In many contexts, this is a new idea. Adolescent-focused HCD provides a structure through which meaningful engagement of young people can occur for problem-solving related to health promotion, health protection, disease prevention and effective treatments.
Target Audience: The audience for this poster will be researchers and practitioners interested in finding effective ways to address adolescent health issues. It will be of specific interest to those with interest in, and possible opportunity for application of, this innovative, practical and structured way to meaningfully engage youth.

Cogent Medicine
Anorexia Nervosa and the Silent Heart Injury Alfonso Ortigado, Francisco José Martín, Gonzalo Galicia, Pilar Sevilla, Isabel Miras, Laura Montes Department of Pediatrics, University Guadalajara Hospital, Guadalajara, Spain Introduction: Anorexia nervosa (AN) is a disorder characterized by fear of weight gain, and a distorted self image that can have devastating health consequences. AN is associated with cardiovascular complications: bradycardia, hypotension, prolonged QTc interval, increased QTc dispersion, atherosclerotic vascular disease, myocardial fibrosis and pericardial effusion (PE). Some of these cardiovascular changes are mild and reversible, but some may be life-threatening. The lesser-known association with PE has been increasingly described in the literature and may progress to cardiac tamponade in rare cases. The etiology of PE remains uncertain, malnutrition itself may promote effusions, but low serum T3 levels (low T3 syndrome) and increased brain natriuretic peptide (BNP) serum levels may also be associated with PE.
Purpose: To describe a case of anorexia nervosa with cardiac complications.
Case Description: We report the case of a previously healthy 14-year-old female diagnosed with AN (DSM-V), with an 8-month history of a 10 kg weight loss. Parental consent was obtained. She was referred to pediatric cardiology due to asymptomatic bradycardia. Physical examination: weight 35 kg (−1.80 SD), height 153 cm (−1.12 SD), BMI 14.95 kg/m 2 (−1.59 SD), heart rate 45 bpm, blood pressure 95/ 55 mmHg, body temperature 36ºC, oxygen saturation 98%, she was vitally stable with normal respiration, there was no edema or signs of heart failure observed, on auscultation she had bradycardia with regular rhythm. Laboratory blood tests revealed normal studies with complete blood count, liver and kidney functions, serum electrolytes, glucose, proteins, prealbumin, cholesterol, creatine kinase, iron, ferritin, vitamins A-D-E-B12, folate, calcium, phosphorus, zinc and cardiac troponin-I. Endocrine tests were also normal (FSH, LH, estradiol, prolactin, cortisol, ACTH, insulin-like growth factor 1-3). However, thyroid function presented an abnormal feature with low serum TSH and free T3 concentration, normal T4 concentration and serum antithyroid antibodies were undetectable. Chest radiography was normal. Electrocardiography revealed sinus bradycardia, 45 bpm, without remarkable changes. Echocardiography demonstrated a silent moderate pericardial effusion, without collapse of the right atrium in late diastole or compression of the free right ventricular wall. The refeeding regimen achieved a healthy BMI 19.5 kg/m 2 . Pericardial effusion and bradycardia were reversible with weight recovery.
Results: Low BMI is associated with bradycardia and pericardial effusion.
Conclusions: (1) Energy deprivation and starvation associated with anorexia nervosa have consequences on the cardiovascular system. (2) Pericardial effusion and bradycardia are correlated with low BMI and are reversible with refeeding.
(3) Cardiac evaluation should be recommended for patients with anorexia nervosa.

Inna Yakovleva
Institute of Children and Adolescents Health Care of the Ukrainian National Academy of Medical Sciences, Ukraine Introduction: Progression of arterial hypertension (AH) and development of complications occurs under the influence of various aggressive factors that impact both directly and indirectly through the formation of endothelial dysfunction, which is a marker of cardiovascular complications. The prevalence of childhood hypertension is rising in parallel with global increases in the prevalence of overweight and obesity, which is associated with premature cardiovascular complications.
Purpose: This study aimed to evaluate the significance of risk factors leading to stabilization and progressive development of AH in adolescents depending on body weight.
Materials and Methods: AH was studied in 120 adolescents 13-18 years of age, who were divided into 3 groups according to body mass index (BMI). The first group included 43 teenagers with hypertension and normal weight (BMI not greater than 85‰), the second-25 peers with overweight (BMI ranged from 85-97‰), and the third group-52 teenagers with obesity (BMI greater than 97‰). We assessed: serum level of endothelin-I, inflammatory markers (C-reactive protein [CRP], interleukin-6 (IL-6), TNF-α), microalbuminuria (MAU), as well as resting and 24-h blood pressure monitoring, cardiac ultrasound. Endothelial function was evaluated according to the method of D.S. Celermajer, (1992).
Results: In patients with normal body weight, AH was recorded from 38.7% to 35.6% of the time of day, significantly exceeds its density as adolescents with excessive body weight (from 27.4% to 24.4%) and with obesity (from 28.1% to 26.6%, prevailing at night; p < 0,001). It was revealed that in adolescents with hypertension, as the body weight increases, myocardium is restructured with the involvement of the left and right heart ventricles and left atrium, with the development of myocardial hypertrophy (eccentric, concentric remodeling). Indicators of endothelial dysfunction showed that the gain of brachial artery diameter was below 10% in 41.0% adolescents 1st group, in 48.6% patients 2nd group, and in 70.0% patients with obesity (p < 0.01). We found that the average of endothelin-I was significantly higher in adolescents with obesity 0.95 ± 0.12 pmol/l compared with healthy peers 0.69 ± 0.03 (p < 0.001). Values of interleukin-6 and TNF-α in adolescents with hypertension in the presence of overweight and obesity were higher as compared with the control group, but did not reach the level of reliability and showed no significant difference depending on the body weight. CRP indicators in adolescents with hypertension increased significantly from the group with normal body weight 1.26 ± 0.22 mg/l to the group with excess weight (2.73 ± 0.66; p < 0,01) and obesity (7.45 ± 1.62; p < 0.001). The level of MAU was significantly higher in adolescents with normal body weight compared with obese peers (33.59 ± 4.53 vs. 24,464,13 mg\l; p < 0.01).
Conclusion: Consequently, in adolescents with AH and overweight, but especially in those with obesity, we found an increase in the level of the most powerful factor vasoconstriction-endothelin-1, as well as systemic factors of subclinical inflammation CRP. This fact determines the formation of endothelial dysfunction in this category of adolescents, promoting stabilization and progression of the AH with development of maladaptive myocardial remodeling (hypertrophy).

Cannabis Use during Adolescence: An Overview in Luxembourg and in Comparison to Other European Countries
Carolina Catunda, Andreas Heinz, Claire van Duin, Helmut Willems

University of Luxembourg, France
Introduction: Cannabis is the most widely consumed illegal drug worldwide. The use of cannabis is a risk factor for mental illnesses, but also for social problems such as lower educational attainment and the use of other drugs. Consumption is considered particularly harmful if it starts early in adolescence, if in a high-dose and if it continues on a regular basis.
Purpose: This study aims to give an overview on adolescents' cannabis consumption in Luxembourg (how often and when they started consuming cannabis) and in comparison with other European countries.

Materials and Methods:
In 2014, 3461 students in secondary school took part in the HBSC study. The questionnaire was translated to both French and German. They answered, among other health-related questions, about their cannabis use (30 days and lifetime prevalence), as well as when they started consuming it.
Results: Two groups were formed: 15-16 and 17-18 years old. In the 15-16 group, 11.2% used cannabis in the past 30 days and 21.7% tried it at least once in their lives. In the age group of 17-18, 15.2% started using it in the last month and 38% in lifetime. Regarding the use in the past 30 days split by gender, the prevalence for girls is 8.9% and 13.8% for boys (15-16 age group) and 10.6% and 20.1%, respectively (17-18 year-olds). The lifetime prevalence for 15-16 years old is 18% for both girls and boys, higher than the 13% HBSC participant countries (mostly European) mean for girls and 17% for boys. Finally, about the age they first tried cannabis, 6.8% of boys and 5.3% of girls responded the age of 12 (or younger), a similar ascendant curve is found and the prevalence of 25% for boys is reached at the age of 14 years, as for girls it is at 14.2 years old.
Conclusion: First, our results highlight the differences between the 30-day versus lifetime consumption, indicating the latter is much more widespread than the regular consumption. Second, the older the students are, the higher the proportion of cannabis users, for both boys and girls, with regular consumption being more frequent among boys. In addition, consumption in a lifetime in Luxembourg is higher than other European countries. Finally, a quarter of consumers started at the age of 14 or younger. This data indicate not only that prevention programs still are in need, but they should start early.

Marina Melkumova, Yeva Movsesyan, Sergey Sargsyan
Arabkir Medical Centre-Institute of Child and Adolescent Health, Armenia Introduction: Communication with parents is an essential component of parent-child relationships and strong determinant of health and well-being among adolescents. Ease of communication with father is associated with emotional well-being, self-esteem, reduced engagement with health compromising behavior especially for girls. Psychosomatic health complaints may result in injures, suicide, mental health problems.
Purpose: The aim of the study was to explore the association between some psychosomatic complaints and communication difficulties with father in Armenian adolescents.

Materials and Methods:
The analyses was based on data from the Armenian HBSC cross-sectional study conducted in 2013/2014 with representative sample consisted of 3679 pupils among 11-15 years old (mean age = 13.2 + 1.6 years, 48% of boys, 52% of girls) and 1436 pupils of 17 years old (40% of boys, 60% of girls). According to HBSC methodology, standardized anonymous questionnaires were used.
Results: About 35.5% of boys and 46.6% of girls aged 11-15 who had difficulties in communication with father reported feeling low more than once a week. Feeling nervous more than once a week were reported by 17.2% of boys and 46.6% of girls who recognized their communications with father as difficult. Analyses showed that psychosomatic complaints and ease of communication are worsening with the age. Among 17-year-old students who found communication with father as difficult, 62% of girls and 47% of boys feel low and 50% of girls and 36% of boys feel nervous more than once a week. Good communication with father correlates with low rate of psychosomatic complaints especially among girls: only 16% of boys and 20% of girls who reported ease of communication with father feeling nervous more than once a week Conclusion: Survey data indicates to an essential and significant correlation between communication with father and psychosomatic health and well-being among Armenian adolescents. Boys and girls who better communicate with father are more likely to report low psychosomatic complaints than those with difficult communication with fathers. Gender-related differences are significant both for good and bad communication. Purpose: The aim of the paper is to evaluate the association between problematic social media use and adolescent well-being, taking into account socioeconomic and demographic factors and relation with significant persons.

Material and Methods:
A nationally representative sample of 5225 school children (mean age = 13.59 ± 1.66) were collected within the 2018 Health Behavior in School-aged Children (HBSC) study conducted in Poland. The WHO-5 index was considered as a main outcome variable. It consists of 5 items rated on 6-point Likert scale (range 0-25) and refers to positive mood, vitality and general meaning of life. Social connectedness was measured using the Multidimensional Scale of Perceived Social Support (MSPSS). The scale is composed of a total of 12 items, with 4 items for each subscale relating to family, peers and significant others. Only first two dimension of MSPSS were included in the HBSC protocol, both ranged 0-24. Social media addiction symptoms was measured with the nine-item Social Media Disorder Scale (SMD-scale), using a dichotomous (No/Yes) responses. The 6item Family Affluence Scale (FAS) was used to assess socioeconomic disparities. Series of multivariate linear regression models were estimated.

Results:
The overall well-being WHO-5 index was 13.82 ± 5.47. Two-thirds of students reported at least one symptom of excessive social media use (on average 1.95 symptoms ± 2.16). Girls reported lower well-being and more symptoms of the Internet addiction than boys. Adolescents with many symptoms of the Internet addiction achieved much lower WHO-5 index than those without such problems, 11.14 ± 5.44 versus 15.15 ± 5.39 in marginal categories, respectively. Problematic social media use had a greater negative impact on family relationships than on relationships with peers. In the multivariate linear regression model, five factors under study (age, gender, family support, peers support, social media use), but not FAS, explained 27.8% variability of the WHO-5 index. Family support was found as the main predictor of WHO-5. On the contrary, 21.9% of variability in family support index was explained by age, gender, peer support, social media abuse and FAS.
Conclusion: Excessive social media use represents a serious risk to adolescent health and their social bonds. More complex mechanisms of this association should be the subject of further research.

Prevalence and Association of Depressive Symptoms with the Consumption of Analgesics among Adolescents
Momota Hena 1 , Cherry Leung 2 , Eva K. Clausson 3 , Pernilla Garmy 1,3 1 Clinical Health Promotion Centre, Lund University, Sweden; 2 Community Health Systems, University of California, San Francisco, USA; 3 Faculty of Health Sciences, Kristianstad University, Sweden Introduction: Depression is a major cause of morbidity and disability worldwide, and according to the World Health Organization, it is the fourth leading cause of disease burden. Depression is a complex condition that can have disabling effects on an individual's personal relationships, productivity and general health. A large group of youths are at risk for depression, which is more pervasive than normal teenage mood swings. The worldwide prevalence rate of depression among adolescents is approximately 4-8%. Depressive symptoms have a significant association with how physiological pain is perceived. In Sweden, non-prescribed over-the-counter (OTC) drugs have seen permitted since 2009. Therefore, analgesics like paracetamol and ibuprofen are available from retail shops for all customers, including adolescents. Studies on the use of OTC drugs in Sweden have revealed how Swedish teenagers can be vulnerable as new customers due to gaps in knowledge and misconceptions about OTC drugs.
Purpose: The aim of this study is to investigate the prevalence of depressive symptoms, physiological pain and the consumption of analgesics, as well as the association between depressive symptoms and the consumption of analgesics among Swedish adolescents between 13 and 15 years old. The hypothesis of this study is that there is a correlation between depressive symptoms and analgesic intake among Swedish adolescents.

Materials and Methods:
This study was conducted in six municipalities in southern Sweden from 2012 to 2014. All schools with students in grade 8 were asked to participate in the study, and 21 of the 23 eligible schools agreed to participate. Questionnaires were distributed among the students, and consent responses were obtained. Depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale (CES-D), scores ≥16.
Results: The prevalence of depressive symptoms was 37% among girls and 13% among boys. The prevalence rate of consuming analgesics during the last weeks was 57% among girls and 29% among boys. A multivariate logistic regression showed that depressive symptoms are significantly associated with the consumption of analgesics among teenagers.
Conclusion: This paper could contribute to the wider research scope in the global community in terms of how increasing use of OTC analgesics among adolescents might be a sign that the health care system should focus on their complex psychosocial problems. Further research should be done on what to target when supporting adolescents who are struggling with pain and higher consumption of analgesics to educate them about pain-management strategies.

Stoilka Koleva Mandadzhieva, Blagoi Ivanov Marinov, Stefan Stoilov Kostianev
Medical University of Plovdiv, Bulgaria, Bulgaria Introduction: The main determinants of lung functions are gender, age, height and weight and they contribute to calculating the predicted normal values. The complex assessment of respiratory functions among healthy children includes comprehensive measurements of anthropometric parameters. There is increasing evidence on the effect of obesity on lung function in children with and without respiratory diseases.
Purpose: The aim of the present study was to evaluate the prevalence of overweight and obesity among healthy children and its impact on lung function parameters.
Materials and Methods: Six hundred and seventy-one healthy Bulgarian school children (339 males) in the age span 7-18 years took part in the study. All participants completed anthropometric measurements-standing height, weight and BMI. Studied group underwent comprehensive pulmonary function assessment-(MasterScreen Diffusion, Jaeger, Wuerzburg, Germany) in a certified laboratory applying the ATS and ERS criteria to ensure quality. (2000) reference values to evaluate the prevalence of overweight and obesity. The overweight and obese children group consisted 131: overweight-97 and obese-34, so that was 19.5% or every fifth child. The highest prevalence of overweight was at the age of 10, 11, 12 and 17 and obesity-at 7, 10 and 14 years, respectively. We compared children with normal weight and overweight and obesity in every age group and found that the increase in weight is combined with height growth and the same increase in lung function parameters-FVC, FEV1, PEF and FEF50. As an example at the age of 10, children with normal weight had a mean height of 142.1 ± 6.6 vs. 147.8 ± 6.1 (p < 0.05) in overweight and 151.6 ± 11.1 (p < 0.05) in obese children. The same pattern was found in FEV1(L): children with normal weight had mean value 2.16 ± 0.31 vs. 2.37 ± 0.28 (p < 0.05) in overweight and 2.71 ± 0.54 (p < 0.05) in obese children. In order to overcome the effect of height we compared the normal weight and overweight and obese children in height groups and found nonsignificant differences for the spirometric indices. Only in the group 130-139 cm, the obese children had lower values-FEV1(L): 1.78 ± 0.13 vs. 1.91 ± 0.19 (NS) in children with normal weight.

Conclusions:
The prevalence of overweight and obesity in healthy Bulgarian children was 19.5%. The increase of weight is combined with height growth and same pattern in the mean spirometry indices. Lower values were found only in obese 7-year-old children.

Social Media Use and Physical Appearance Social Comparison and their Relation with Body Image in Adolescence
Anna Maria Dzielska 1 , Joanna Mazur 1 , Anna Oblacińska 1 , Dorota Kleszczewska 2 , Agnieszka Malkowska-Szkutnik 3 1 Institute of Mother and Child, Poland; 2 Foundation of the Institute of Mother and Child, Poland; 3 Faculty of Pedagogy, Warsaw University Introduction: Social comparison theory has been increasingly used in cases to understand the processes through which societal messages about appearance influence adolescents' body image. Along with the rapid development of new technologies, social media is becoming an extremely important media channel influencing the various spheres of teenagers' lives. Research suggests that the use of social media can negatively affect the body image of teenagers through the social comparisons of appearance and internalization of body standards.
Purpose: The main purpose of the study was to show how social media use and physical appearance social comparison affects body image of adolescents.
Materials and Methods: Data from the Polish Health Behaviour in School-aged Children (HBSC) 2017/18 survey for students aged 13-15 years (14.57 ± 1.05) were used. The sample totaled 3501 participants (48.3% boys). An exploratory factor analysis was conducted along with an analysis of scale reliability using Cronbach's alpha to evaluate psychometric properties of the Physical Appearance Comparison Scale (PACS), Social Media Disorder Scale (SMD) and Body Image Scale (BIS). Differences in PACS, SMD and BIS scores according age groups and gender were checked. Linear regression models adjusted on age and gender were estimated with BIS as a dependent variable. Simple path model was estimated and Sobel's mediation test was used. The data was analysed using IBM SPSS v.21 (PS Imago).
Results: SMU was higher in the 13 than 15 year-olds. PACS scores were significantly higher in the older age group. The younger group had significantly better body image. Girls were more likely to show worse body image and presented higher mean score of SMU and boys made social comparisons of appearance to a lesser extent than girls. The model adjusted on gender explained 21.6% of BIS variability and showed that SMD as well as PACS significantly lower BIS among studied adolescents. Partial mediation of the PACS in relation with SMD and BIS was investigated, confirmed by Sobel's test, Z = −15.27, p < 0.001. Introduction: Nowadays, every age group experiences stress. It has an impact on our well-being and health. Adolescents are particularly vulnerable to stress which is associated with their entering into adulthood and the changes that affect their health and social bonds.
Purpose: The aims of this study were to assess the mechanism of relationship between physical activity, stress and subjective complaints.
Material and Methods: The research was a carried out in 2018 as last round of the Health Behaviour in School Aged Children (HBSC) in Poland. Questions about stress were asked to 3498 students aged 13 and 15. Cohen stress scale was used in the questionnaire. The main dependent variable was the scale of eight subjective complaints (subjective complaints checklist [SCL]). Independent variables were the sex, age, family affluence-determined by FAS scale and moderate-to-vigorous physical activity of young people-MVPA.
Results: In a simple correlation analysis, attention should be paid to strong relationship between stress and subjective complaints. MVPA is more strongly correlated with stress than with SCL. In more affluent families, adolescents are more physically active and there are less stress.
In the multivariate linear regression model, adjusted for age, sex and FAS-MVPA remains an important predictor of SCL (p = 0.001). If we include stress in the analysis, the impact of MVPA becomes irrelevant (p = 0.359). But if stress is considered as dependent variable, MVPA becomes important. Mediation effect was confirmed by Sobel test.
Conclusion: When analyzing the relationship between physical activity (PA) and subjective health of school children, it is worth to consider intermediate relationships. PA can act indirectly by reducing stress.

Three Cases of Hypokalemic Periodic Paralysis
Rita Moita 1 , Ruben Rocha 2 , João Luís Barreira 1 1 Department of Pediatrics, Centro Hospitalar São João, Portugal; 2 Department of Pediatrics, Centro Materno Infantil do Norte, Portugal Introduction: Hypokalemic periodic paralysis (HPP) is a group of muscular diseases and the diagnosis is based in the consensus diagnostic criteria: a history of recurrent attacks of muscle weakness associated with documented serum potassium <3.5 mmol/L during attacks and/or the identification of a heterozygous pathogenic variant in CACNA1S or SCN4A gene. Approximately 30% do not have a pathogenic variant identified in either of these known genes.
Case Report: The first case is a 17-year-old boy, previously healthy, admitted to the emergency department with generalized and intense myalgias and weakness after a football practice. No history of previous episodes, recent infections or medications. He was pale and had generalized weakness with paralysis of lower limbs. Laboratory results were normal except for potassium 1.7 mEq/L. The electrocardiogram (EKG) presented U waves and flattening of T wave. He improved symptomatically and normalized EKG after intravenous potassium. He was discharged with potassium supplements, nutritional counseling and restriction of intense physical activity. Seven weeks after he had a second episode during a respiratory infection. His family history revealed similar episodes in three maternal relatives. On genetic test, we found the mutation c1583G>A at exon 11 of the CACNA1S gene. Recently, his 13-year-old sister had her first episode of marked asthenia and weakness after a long walk the day before. She presented with tetraparesis. Her serum potassium was 1.7 mEq/L. The EKG presented a prolonged QT interval, U waves in DII and flattening of T wave. She improved clinically after intravenous and oral potassium supplements. The third case is a healthy 11-year-old with 4 episodes of generalized and transitory muscular weakness after physical exercise. In one of them, he displayed extreme fatigue, generalized muscular weakness in four limbs, dizziness and dyspnea. He had no family history of periodic paralysis. He had a normal creatine kinase and thyroid function. He had mild hypokalaemia (3.2 mEq/L). The exercise stress test affected predominantly the lower limbs, with motor deficit and inability to walk. The findings during the electromyogram test could translate an ion channel dysfunction in the context of periodic paralysis. The genetic tests so far were all negative.

Conclusion:
We present three different cases of HPP, with and without family history, with and without the identification of a pathogenic variant, showing the heterogeneity of this condition and the challenges that the clinician was to deal with, regarding diagnosis and treatment.

A Rare Cause of Upper Gastrointestinal Tract Obstruction in a Patient with Marfanoid Phenotype
Livia Elena Brezeanu 1 , Oana Maria Guta 1 , Raluca Vlad 1,2 , Anatolie Nidelcu 1 , Daniela Pacurar 1,2 1 "Grigore Alexandrescu"Emergency Hospital for Children, Bucharest, Romania; 2 "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania Purpose: The purpose of this case report is to highlight the importance of a rigorous differential diagnosis in a pediatric patient with recurrent vomiting.

Materials and Methods:
We present the case of a 17-year-old adolescent, admitted in the Pediatrics Department of "Grigore Alexandrescu" Hospital in July 2018 for recurrent episodes of vomiting associated with epigastric pain.
Results: (Case Description): The patient started presenting abdominal pain 5 years before, apparently after an appendectomy. In the last year, he associated heartburn, dysgeusia, recurrent food vomiting and postprandial plenitude. A diagnosis of H. pylori acute gastritis was initially set and he received triple therapy with temporary relief. Later on, gastroesophageal reflux disease and esophageal motility disorders were taken into account for the differential diagnosis. Due to chronic digestive symptoms, the adolescent presents anxiety related to food intake with extremely reduced appetite, food selectivity and lack of weight gain. The clinical examination reveals marfanoid phenotype, ligamentous hyperlaxity, low weight, chest deformity, excavated abdomen, painful in the epigastrum and clapotage. Laboratory investigations are within normal limits. Esogastroduodenal barium examination shows an important gastric stasis with an elongated stomach, its inferior pole located distally to the iliac crest, dilation of the second part of the duodenum with delayed distal passage. Abdominal ultrasound reveals reduced aortomesenteric distance at the third part of the duodenum. Upper gastrointestinal endoscopy shows barium residue in the stomach 24 h after the contrast study was performed, important gastric stasis and a spastic pylorus which does not allow the passage of the endoscopy tube in the duodenum. Abdominal computed tomography confirms the obstruction by vascular compression of the third part of the duodenum at the aortomesenteric angle, a specific image for superior mesenteric artery syndrome. Surgical treatment is recommended, but the parents refuse.
Conclusion: Although a rare entity, duodenal obstruction by aorto-mesenteric clamp must be taken into account in the differential diagnosis of recurrent vomiting. An early radiologic diagnostic spares the patient of chronic digestive disease with negative impact on nutritional status and quality of life.

ID: 214
Cogent Medicine Introduction: Henoch Schonlein Purpura (HSP) is a common systemic vasculitis in children. The annual incidence is 6-20 cases per 100,000 in the UK. It often follows a short mild febrile illness and is triggered by infections, vaccinations or environmental exposures. It commonly causes a macular rash that evolves into symmetrical purpuric lesions over lower limbs, buttocks and ulnar surface of the arms. It can cause joint pain and swelling, particularly in the knee and ankle joints, along with colicky abdominal pain, bloody diarrhoea and kidney involvement.
Purpose: To present the rare feature of a lumbar subcutaneous swelling in a case of HSP.
Case Description: A 4-year-old girl presented to the paediatric assessment unit with left ankle swelling and purpura over her ankles. She was observed and felt to have evolving HSP. Her blood pressure was within normal limits for her age and height and there was no proteinuria. She was noted to have microcytic anaemia following a Full Blood Count and was commenced on iron supplementation. She was discharged with follow-up arranged to monitor blood pressure, urinalysis as per local guidelines and repeat a full blood count in 3 months time. She re-presented the following day with a subcutaneous swelling over the lumbar region of her back. The rest of her systemic examination was normal. A CT scan showed a well-defined paraspinal subcutaneous fluid collection 12 cm × 1 cm × 12 cm superficial to the spinous process. She was discharged and followed up by her GP who noted complete resolution of the swelling within 7 days. She had no further complications.

Results:
We have presented a case of a rare finding of a lumbar-sacral swelling associated with HSP.
Conclusion: HSP is a common paediatric presentation and can have systemic complications to include kidneys, joints and cutaneous involvement with facial, scalp, peno-scrotal and labial oedema. This is however only the third case found within the literature of lumbar-sacral swelling and oedema associated with HSP. Schaefer et al presented the first case in a 5-year-old boy whose lumbar-sacral swelling occurred prior to the development of the typical purpuric rash. Duman et al. presented the second case of a 4-year-old boy who developed a lumbar-sacral swelling 3 days after the development of the rash. This case demonstrates an uncommonly reported feature of HSP and highlights the possible atypical nature with which it could present.

Centro Hospitalar Tondela-Viseu, Portugal
Introduction: Primary spontaneous pneumomediastinum (SPM) is defined as air in the mediastinum of unknown cause. SPM is a rare clinical entity, even more so in pediatric patients, occasionally associated with pneumothorax, pneumopericardium or, rarely, pneumorrhachis. Many pathological and physiological events can cause SPM, such as repetitive Valsalva maneuvers, asthma, foreign body ingestion and/or aspiration, esophageal perforation, inhalation of illicit drugs, among others. Its association with bronchopulmonary infection by Mycoplasma pneumoniae and respiratory syncytial virus is also well established. Diagnosis can be confirmed by chest radiography. Clinical presentation usually includes acute chest pain and dyspnea, although symptoms such as neck pain, dysphonia or dysphagia may also occur. SPM is a benign and self-limiting condition, with only supportive care needed. Hospitalization is considered because of the risk for complications (such as hypertensive pneumomediastinum and pneumothorax).
Case Report: A previously healthy 9-year-old girl went to the emergency department (ED) after 3 days of productive cough, low grade fever and sore throat. On clinical examination, palpable subcutaneous crackles, crepitus and anterior cervical pain suggested subcutaneous emphysema, without respiratory distress and with normal respiratory sounds on auscultation. Chest radiography revealed subcutaneous emphysema, retropharyngeal air-trapping and extraluminal air in the mediastinum. Diagnosis was confirmed by computerized tomography, which also showed signs of pneumorrhachis. She was admitted under supportive care (oxygen, bed rest and analgesics) with good clinical evolution. There was no recurrence during follow-up. Assessment of precipitating events excluded most frequent etiologies.
Conclusion: Clinical signs of subcutaneous emphysema require radiological investigation to evaluate its extension and the location of the air source, and as differential diagnosis, one must always consider SPM. This case highlights a rare disease at this age, with an uncommon presentation and without a known trigger event.
Introduction: Effective communication between clinicians is critical to the functioning of a successful and safe health care system. The comprehensive, safe and efficient transfer of patient information from one healthcare professional to another is crucial to ensure patient wellbeing and to minimise adverse events. The ISBAR3 is a structured clinical handover template. ISBAR3 provides a simple and effective framework in which to plan and structure communication that can significantly improve patient outcomes.
Aims: (1) To raise awareness of the usage of ISBAR3 as a tool of communication among medical staff.
(2) To evaluate the use of ISBAR3 in clinical handover in a tertiary children's hospital. (3) To raise awareness of the usage of ISBAR3 as a tool of communication among medical students.
Methods: All relevant staff are informed of and educated on the ISBAR3 framework on clinical handover. Over a period of 5 weeks, a team of fourth year medical students attended the morning handover meeting, observed and collected data on the implementation of ISBAR3. Points were assigned to each component of the ISBAR3 framework that was implemented. This data were entered into a clinical audit data excel template for analysis. The handovers included all medical admissions that presented through the Accident and Emergency Department. Intensive Care Unit admissions and patients transferred from other clinical centres were omitted from the dataset. The data set was completely anonymised.
Results: During the 5-week period, there were a total of 39 medical admission clinical handovers. There was only one case that had a perfect handover and touched on all aspects-Epilepsy. All other cases had flaws. The top 3 components implemented were Identification (Name & Age) and Situation (Presenting Complaint), scoring 97%, 89% and 97%, respectively. The three commonly omitted aspects were within Risk (Infection Control, Child Protection and Safety for Discharge), scoring 7.6%, 10.2% and 7.7%, respectively.
Conclusion: While the impact these findings have on patient care cannot be directly evaluated, it is evident that the ISBAR3 tool is not being used as standard procedure at our centre. This identifies an area of clinical practice with room for improvement. A re-audit is planned following dissemination of information to complete the audit cycle.

Cogent Medicine
Care Burden for Adolescent Whose Family Members Need Palliative Care: Nursing Students' Opinion Sevil Özkan, Fatma Taş Arslan

Faculty of Health Sciences, Selcuk University, Turkey
Aim: Palliative care patients need assistance and support of the caregiver in many areas, such as their daily lives, medicines, etc., and sometimes caregiver can be children. This study aimed to evaluate nursing students' opinions on care burden of adolescent.
Method: This study was carried out with total 106 last year nursing students in a university, who chose palliative care in spring term in 2017-2018. The study aimed to determine nursing students' opinion on burden care of adolescent care giver. First an education about burden care of palliative care was given to students and after it video was played. Video was about a family that mother, grandmother and younger brother needed palliative care. Father was working all the time to support family expenses. And a teenage boy had to take care of all his family members needs. Video was translated Turkish simultaneously. After watching it, students discussed the burden care for him and made a common decision report.
Findings: "Unhappiness, insomnia, feeling alone, tiredness, failure at school" determined as subjective aspect of burden care. "Time is not enough for anything, money problems" were determined as objective aspects of burden care. They also expressed negative reaction for burden care (such as future is black, I do not want to have a family, etc.) or positive reaction for burden care (such as I am a strong boy so I can do anything. etc.).
Conclusion: Burden care can affect children's lives, whose family members are palliative care patients, in different ways.

Cogan´s Syndrome-A Case Report
Ana Margarida Leite 1 , Tiago Branco 1 , Sofia Pimenta 1 , Joana Soares 1 , Conceição Fernandes 1 , Carla Fraga 3 , Natália Oliveira 2 , António Marinho 2 , Sónia Lira 1 1 CHTS; 2 HGSA; 3 CMIN Introduction: Cogan's syndrome is a chronic inflammatory disorder that most commonly affects young adults of both sexes, with a mean age of 30 years. There are a few cases reported in children starting from 4 years old. The pathogenesis is unknown, but is probably the results of an autoimmune mechanism. Clinical hallmarks are interstitial keratitis and vestibulo auditory dysfunction, and associations between Cogan's syndrome and systemic vasculitis, as well as aortitis, also exist. The interstitial keratitis typically causes eye redness, pain, photophobia and blurred vision. The inner ear manifestations consisting of vertigo, ataxia, nausea, vomiting, tinnitus and hearing loss. The diagnosis of Cogan's syndrome is mainly clinical and based upon characteristic involvement of both the eye and the inner ear. The differential diagnosis includes sarcoidosis, polyarteritis nodosa, granulomatosis with polyangiitis and rheumatoid arthritis. Other diagnostic possibilities include the infectious causes of interstitial keratitis and subacute encephalopathy syndrome. Medical treatment of Cogan's syndrome depends on how extensive the disease is at the time of diagnosis. In cases with only mild eye involvement, the treatment is the application of topical glucocorticoids. When there is evidence of an inner ear pathology, a severe infection of the eye or systemic vasculitis, immunosuppressive therapy is used. The first choice is glucocorticoids.
Case Report: We describe a case of a 17-year-old boy, with a history of juvenile myoclonic epilepsy (single episode). He went to the emergency department for fever, oral thrush and odynophagia, which were associated with increased inflammatory markers, anemia, lymphopenia and hepatosplenomegaly. The etiologic study conducted on that date was inconclusive, and it was referenced for general pediatric consultation to pursue study. Three months later, tinnitus and severe neurosensory hearing loss was added to the previous condition and 1 month later a bilateral red eye was added. Ophthalmologic examination referred to red eye without uveitis. Otologic examination established the presence of hearing loss and started treatment with oral corticosteroids. He completed an etiological study and faced the most probable diagnosis of Cogan's syndrome with central involvement and severe hearing loss, being treated with methylprednisolone. Currently being treated with prednisolone, esomeprazole, supplemental calcium and vitamin D. It has presented good response to corticotherapy, with progressive improvement of hearing loss, without new episodes of red eye.
Conclusion: Cogan's syndrome is an infrequent disease. Corticosteroids are the first line of treatment, and they can aid in the recovery of hearing if given early in the disease course. Patients without systemics disease generally have a good prognosis. Therefore, early assessment and treatment for systemic inflammation are needed to prevent life-threatening complications.
Introduction: Down syndrome is the most common cause of intellectual disability worldwide. This syndrome is caused by a genetic abnormality-triplication of chromosome 21. It occurs in about 1 per 1000 babies born each year and involves numerous physical features and comorbidities. Among these, congenital heart defects, blood and immune system disorders, atlantoaxial instability and others are known to be frequent and can be associated with a worse outcome.
Purpose: To acknowledge the characteristics and needs of the children with Down syndrome with follow-up in a tertiary referral hospital and establish an adjusted protocol.
Material and Methods: Retrospective study of the medical records of 128 children with Down syndrome diagnosis, who had multidisciplinary follow-up, from January 2007 through December 2017.
Results: Our sample included 128 children with Down syndrome (51% were male; median age was 10 years). 97% (n = 124) of these children had at least one complication associated with the syndrome. Congenital heart disease occurred in 69.5% (n = 89). Half (n = 64) had otorrinolaringologic comorbidities. Ophthalmological complications were present in 47.7% (n = 61). Gastroenterologic (24.2%), endocrine (23.4%) and orthopedic (25%) problems also affect a significant group of children. Due to these comorbidities, 77% (n = 99) had one or more surgeries during the last 10 years and up to 40.6% were submitted to at least one cardiac intervention. Smaller percentages were found for otorrinolaringologic (32%), ophthalmological (7.8%) and orthopedic (4.7%) surgeries. If we consider exclusively the children with cardiac defects, more than half (58.4%) required one or more cardiac surgeries. A higher percentage of surgical intervention (61%) was found in the group of children with an otorrinolaringologic compilation. The vast majority of the children (86%) had at least one hospitalization, with the number being as high as 22 hospitalizations in one of the cases.
Conclusion: As medicine evolves, the follow-up of children with Down syndrome is improving, which manifests through better development and clinical outcomes as well as an improvement in their life expectancy. Their health management requires an organized approach with regular evaluation and monitoring for associated abnormalities and prevention of common disorders. We have established recommendations for medical evaluation in our hospital and hope to improve our methods as we learn more about these children profile.

Scientific Center of Pediatrics and Children Surgery, Kazakhstan
Introduction: The article describes a non-typical clinical case of cytomegalovirus infection in a child suffering esophageal stenosis, manifested by unusual localization of cell transformation in the form of multilayered squamous esophagus epithelium lesion, that allowed to determine diagnosis with plucked biopsy. Сhild B, girl, 1 year 5 months old.
Complaints on Admission: Vomiting, dysphagic phenomena, impaired food passability. Аnamnesis: birth weight 1500 g, up to 1.5 month feeding through the probe because of morphofunctional immaturity of the internal organs and prematurity. Later the child was transferred for "per os" feeding, which was digested according to the age norm. At the age of 11 months, the regurgitation after each meal has occurred, the composition of which corresponded to undigested food. Regurgitation was preceded by coughing, with the increase of the distant oral crepitus. For the last 2-3 months, the baby was fed by small portions. The child's condition was complicated by bilateral pneumonia, which was repeatedly treated by antibacterial therapy.
Results: Results of esophagogastroduodenoscopy (EGDS): esophagus passable, widened in diameter. Mucous pale, with the false pockets. There was a stenosis at the level of the distal part (possibly the cardia) up to 1.0-1.5 mm, making impossible for the endoscope to pass. Conclusion: cicatricial stenosis of cardiac, decompensated form. Histological study: esophagus mucosa biopsy was presented by a fragment of a multilayer squamous non-keratinizing epithelium with lymphocytic and plasmacytic infiltration. Also the transformation of squamous non-keratinizing epithelium was noted: cells were enlarged, there was a light rim ("owl eye") in the perinuclear area. The cytoplasm of these cells was unevenly mesh.
Conclusion: Cytomegalovirus esophagitis. PCR (blood): CMV-positive, PCR (urine): CMV-positive, PCR (saliva): CMV-positive. Thus, this clinical case revealed activation of CMV esophagitis as a result of decreased immune protection, which have been evidenced by the results of immune status investigation. The entrance gate to the virus could be the upper segments of the respiratory and digestive tract. Most obvious is that newborn prematurity and morphological immaturity of the internal organs appeared to be risk factors in the development of the disease. It is not excluded that case of pneumonia in the anamnesis was also the result of CMV infection. The presented clinical case is interesting by unusual localization of cell transformation, particularly lesion of multilayered squamous epithelium of the esophagus, which allowed to establish the diagnosis in a pinch biopsy. So, as the conclusion, it is necessary to keep in the mind that cases of esophageal stenosis in children may occur as possible complications of CMV-esophagitis.

Figen Turk Dudukcu, Fatma Tas Arslan Selcuk University, Turkey
Background and Aims: Attachment is a strong and emotional attachment to the person associated with the birth of the infant. This study was planned to determine the status of paternal infant attachment and the factors that affect the attachment of 6-to 12-month-old infant to a family health center.

Methods:
The study was conducted with 179 fathers, who had children between 6 and 12 months, who were referred to a public hospital child polyclinic. Data were collected from March-June 2017 using the "Personal Information Form" and the "Paternal Infant Attachment Scale". The data are presented as number, percentages, mean and standard deviation, and the groups were compared using the Student's t test, ANOVA (F), Mann-Whitney U and Kruskal-Wallis tests (p < 0.05).

Results:
The "Paternal Infant Attachment Scale" (PİAS) levels of the fathers participating in the study are 84.67 ± 9.00. According to the parents who had two or more children of the father who had a child in the study, the score of PİAS was higher than that of the parents who received university education (p < 0.05). According to the parents whose monthly income was middleearner's BBBÖ score was low and their father's relationship with their father was good, the father's score was found to be statistically significantly higher than that of the father (p < 0.05). There was no significant relationship between father's gender and age, father's age and occupation, father's first marriage, family type and father's PIAS score (p < 0.05).
Conclusions: As a result of the study, it was seen that the number of children, education and income status, and the level of father relationship were related to paternal infant attachment.
Introduction: Acute bacterial parotitis is mainly caused by Staphylococcus aureus. It is rare in neonates and infants without identified risk factors. It is even more rare when the cause is group b Streptococcus (GBS). The diagnosis is essentially clinical with parotid swelling associated with local inflammatory signs and outflow of pus through the Stensen's duct. This latter is the pathognomonic sign of this pathology. Sometimes systemic signs are presentation such as fever, irritability and refusal to eat. Ultrasound scans not only corroborates the previous diagnosis, but it also excludes local complications. The treatment consists of an initial phase of large spectrum empirical endovenous antibiotic and subsequent therapeutic adjustment for the identified microorganism. Surgical intervention is rarely needed.
Case Description: 36 days, female, observed in the emergency due to fever and irritability with 5 h of evolution. In physical examination painful swelling with flushing of parotid region is observed. Perinatal antecedents include gestation without intercurrences, positive GBS screening with complete prophylaxis, eutocic delivery at 37 weeks and 5 days, birth weight of 2280 g. Complementary diagnostic: leucocytes 4900/µl, elevation of C-reactive protein 53 mg/L, normal amylase and ultrasound suggestive of parotitis. He initiated intravenous antibiotic therapy (Ceftriaxone + Flucloxacillin) after collection of blood culture and exudate of the Stensen's duct. Isolated SGB in Stensen's duct exudate, suspended Flucloxacillin and complete 10 days of Ceftriaxone. Observed in ambulatory at 5 months with normal physical examination and without new episodes of parotitis.
Conclusion: GBS is an important cause of infection in neonates and small infants with a high mortality and morbidity rate. Since the implementation of GBS prophylaxis, the incidence of early infection by GBS has declined dramatically. However, the incidence of late infection, between the eighth and the ninetieth day, remained stable, which fully strengthens the various transmission paths. Although most times the late GBS infection occurs as bacteraemia, it can also manifest as a localized infection, such as parotitis. In conclusion, with this clinical case, the authors seek to demonstrate a rare form of late GBS infection.

Assessment of the Nutritional Status of Primary School Children in Fako Division, South West Region, Cameroon
Nvonako Tsasse Hildegarde 1 , Paul Koki 2 , Lawrence Mbuagbaw 3 1 University of Nairobi, Kenya; 2 Mother and Child Centre (Chantal Biya Foundation) Yaounde-Cameroon; 3 Buea Regional Hospital, Cameroon Prevention (CDC) 2000 Z scores and percentiles were computed for anthropometric indices and body mass index (BMI), respectively.

Results:
The overall prevalence of undernutrition obtained was 16.9%, while the prevalence of underweight, stunting and wasting was 4.4%, 11.4% and 1.4%, respectively. The overall prevalence of overnutrition obtained was 38.8%, while the prevalence of overweight and obesity was 24.0% and 14.8%, respectively.
Conclusion: Overnutrition in primary school children is rising at a more alarming rate as compared to undernutrition.

ID: 296
Cogent Medicine Introduction: A walk is undoubtedly of great importance for human functioning at all stages of his life, hence the need for constant research on his cognition. Most analyses show that in typically developing children, the variability of gait decreases with age to reach about 7 years of age. Depending on the parameters observed, some authors, however, pay attention to the further development of walking after crossing this age. Factors that determine gait parameters may include gender. Available analyses indicating intersexual differences in this respect concern mainly adults or older people. There are no studies on children, in what is the key maturing period for them Purpose: The aim of the study was to compare individual gait parameters in boys and girls aged 10-13 years.

Materials and Methods:
The study involved 87 girls and 52 boys aged 10-13. The height and weight of the subjects were measured, the BMI index was calculated and the body mass status was determined. With G-Walk, the symmetry and range of pelvic movements were assessed in all three planes. The collected information has been subjected to statistical analysis.
Results: The girls examined, in proportion to the height of the body, did considerably longer steps during the walk than the boys, but there was no gender differentiation in the symmetry of the pelvic movements in any of the planes. All children were characterized by the highest pelvic mobility in the transverse plane, the smallest in sagittal, although a larger range of pelvic movement in the walking, both in the frontal and transverse plane, was demonstrated in boys. Observed differences were significant only for the right side of the pelvis. In the sagittal plane, however, significant differences in the position and range of motion of both the right and left sides of the pelvis were noted.

Conclusions:
The movement of the pelvis during gait in girls and boys aged 10-13 years is significantly different. In boys, a significantly larger range of motion and a slightly higher symmetry index are observed.

Cogent Medicine
The Influence of Excessive Body Weight in Children on the Range and Symmetry of Pelvic Movement in a Walk Agnieszka Jankowicz-Szymanska 1 , Eliza Smoła 1 , Edyta Mikołajczyk 2 1 Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland; 2 Department of Physiotherapy, University of Physical Education in Krakow, Poland Introduction: A walk is undoubtedly of great importance for human functioning at all stages of his life, hence the need for constant research on his cognition. Most analyses show that in typically developing children, the variability of gait decreases with age to reach about 7 years of age. Depending on the parameters observed, some authors, however, pay attention to the further development of walking after crossing this age. Factors that determine gait parameters may include gender. Available analyses indicating intersexual differences in this respect concern mainly adults or older people. There are no studies on children, in what is the key maturing period for them.
Purpose: The aim of the study was to compare individual gait parameters in boys and girls aged 10-13 years.
Materials and Methods: The study involved 87 girls and 52 boys aged 10-13. The height and weight of the subjects were measured, the BMI index was calculated and the body mass status was determined. With G-Walk, the symmetry and range of pelvic movements were assessed in all three planes. The collected information has been subjected to statistical analysis.
Results: The girls examined, in proportion to the height of the body, did considerably longer steps during the walk than the boys, but there was no gender differentiation in the symmetry of the pelvic movements in any of the planes. All children were characterized by the highest pelvic mobility in the transverse plane, the smallest in sagittal, although a larger range of pelvic movement in the walking, both in the frontal and transverse plane, was demonstrated in boys. Observed differences were significant only for the right side of the pelvis. In the sagittal plane, however, significant differences in the position and range of motion of both the right and left sides of the pelvis were noted.
Conclusions: The movement of the pelvis during gait in girls and boys aged 10-13 years is significantly different. In boys, a significantly larger range of motion and a slightly higher symmetry index are observed.

Antioxidants in Correction of Autonomic Cardioneuropathy in Children and Adolescents with Diabetes Mellitus
Larisa Balykova 1 , Elena Samoshkina 1 , Yuriy Soldatov 2 , Tatiana Zolnikova 1 1 Ogarev Mordovia State University, Russian Federation; 2 Mordovian Republican Clinical Children's Hospital Introduction: Clinical efficiency of antioxidants (AO) in diabetes mellitus (DM) and its complications has been proved by the evidence-based medicine in adult patients, while in pediatric population, it has not been thoroughly studied.
Aim: To estimate AO efficacy in correcting the signs of autonomic cardiac neuropathy in children with type I DM.
Methods: A total of 98 patients with DM aged 5-18 years and 40 healthy children and adolescents were included in open clinical trial, conducted with Local Ethic Committee approval. Written informed consent was obtained. The inclusion criteria were: DM experience more than 5 years, disturbances of autonomous heart rhythm regulation (signs of autonomic cardioneuropathy). The exclusion criteria were: structural heart diseases, QTc interval prolongation ≥ 480 on rest electrocardiogram (ECG), left ventricle ejection fraction < 50%. Children were examined by clinical, biochemical methods, 12-lead ECG, cardiovascular tests and Holter monitoring with heart rate variability (HRV) evaluation. The patients were randomized into four groups. Group 1 was treated by combination of ultra-short and long-lasting insulins without AO, groups 2-4 additionally took Lcarnitine, α-lipoic acid and methylethyl-3-oxypyridinum succinate (MEOS), respectively. AO were administered for 1 month 4 times per year.
Results: MEOS and α-lipoic acid decreased the mean daily and (slightly less) mean nocturnal heart rate as well as frequency of revealing pathological circadian index values (mean daily to mean nocturnal heart rate ratio) to 20-26% versus 42% in group 1. АO contributed to optimization orthostatic, Valsalva and 30:15 test results. The use of АO diminished heart rhythm concentration (rMSSD and pNN50% increase by 23-69%), but normalized SDNNi only in group 4, probably due to metabolic control and glycosylated hemoglobin level optimization. Long-term use of АO, especially MEOS and α-lipoic acid increased the capacity of all heart rhythm spectrum components (especially high frequency HF), approaching low-to high-frequency ratio LH/HF to healthy-control level, while in group 1 a tendency for worsening both sympathico-vagal balance and cardiovascular test results was noted.
Conclusion: AO, especially MEOS was noted to slow down the rates of diabetic autonomic cardiac neuropathy progression in children with type 1 DM. Introduction: Congenital primary hypothyroidism (CH) occurs in approximately 1:2000-1:4000 newborns and is one of the most common preventable and treatable causes of intellectual disability. Inadequate thyroid hormone production leading to primary hypothyroidism is more commonly caused by thyroid dysgenesis, but in 15% of cases inborn errors of thyroid hormone synthesis are present (Dyshormonogenesis). Mutations in the peroxidase thyroid (TPO) gene are the most frequent.

ID: 273
Methods: We included children followed in our tertiary center for CH with clinical and echographic characteristics compatible with dyshormonogenesis. Genetic testing for dyshormonogenesis was performed-in our center only the peroxidase thyroid (TPO) gene-was analyzed, through direct sequence for the presence of mutations.
Results: Nine patients were included in the study, 55% males (n = 5). Eight patients (n = 8) were diagnosed through the endocrine-metabolic neonatal screening and one was diagnosed after detection of goiter on the prenatal ultrasound. Mean value of TSH at diagnosis was 208 uUI/mL (min. value 35.9; max. 393). All patients initiated treatment with levothyroxine in the first month of life. One-third of the patients had positive family history of thyroid disease. Mutations in the TPO gene were found in two patients-one with two biallelic variants c.1472G>A and c.1993C>T and another with a biallelic variant c.1769-1G>A. Neither had family history of thyroid disease.

Conclusions:
We found a novel variant c. 1769-1G>A in the TPO gene, not described in the literature, that is probably pathologic, but we need further evaluation to confirm. In our center, only the TPO gene was tested, but other gene mutations, as DUOX2, TG and TSHR are also common genetic defects associated with CH patients, that we could have found in these patients, if analyzed. The authors would like to reinforce that patients in whom CH is proven to be permanent, as in dyshormonogenesis, genetic counselling and thyroid hormone replacement throughout life is required.

Low Level of Vitamin D Increases the Risk of Low Energy Fractures in Children
Georges Nicolas, Fady Hoyek, Elias Assaf, Simon Akiki Centre Hospitalier Universitaire Notre Dame des Secours, Byblos, Jbeil, Lebanon (Lebanese Republic) Introduction: The physiological process by which vitamin D regulates calcium and phosphorus metabolism, the major mineral constituents of bone tissue, is by far very well understood. However, the clinical implementation of vitamin D deficiency on bone fragility in childhood remains controversial.
Objective: The aim of this case-control study is to investigate the prevalence of vitamin D deficiency among Lebanese children who experienced a "low-energy" fracture in our center.
Materials and Methods: A total of 37 cases and 70 control patients were included in this study. All healthy children admitted to the emergency department between 1 and 15 years of age were potential candidate for this study. Fracture was confirmed by conventional X-ray radiography and 25-HydroxyVitamin D level of the same candidates was measured.
Results: A total of 19 patients out of the 37 cases were suffering from vitamin D deficiency (25-hydroxyVitamin D < 20 ng/ml), whereas only 13 out of the 70 control candidates were found to have deficiency in vitamin D. A statistically significant relationship between D hypovitaminosis and low energy fractures has been noticed among children between 1 and 15 years of age who presented to the emergency department of Notre-Dame des Secours University Medical Center (OR: 4.63; 95% CI: 1.92-11.18; X2: 12.41, p-value: 0.000428).
Conclusion: A relation has been established between vitamin D deficiency and low energy fractures in Lebanese children. However, the reasons behind D hypovitaminosis, despite sufficient amount of sunlight exposure, in Lebanese pediatric population are still to be considered. Furthermore, a larger sample and multicenter study will be needed to determine if a relationship exists between the severity of vitamin D deficiency and the frequency of fractures and their complications.

Primary Hypothyroidism in Children: Unusual Clinical Presentation
Ser Yee Soh, Rashida Farhad Vasanwala

Ministry of Health Holdings, Singapore
Introduction: Primary hypothyroidism in children is not uncommon and has an incidence of 1 in 4000. Presentation of acquired hypothyroidism is subtle as the symptom complex is generalized and non-specific. Pleural and pericardial effusion is a rare complication of severe hypothyroidism in children but can be present in 10-30% of adults. It may be a frequent manifestation in myxedema, but rarely associated with mild hypothyroidism, reported incidence of 3-6%. The pathophysiology of edema in hypothyroidism has been studied extensively. Myxedema refers to the deposition of hydrophilic mucopolysaccharides in the dermis, which results in swelling of the affected area. When the pericardial volume expands, it causes the pericardial pressure to increase, resulting in accumulation of pericardial fluid in the pericardial space.
Clinical Case: A seven-and-a-half-year-old girl, presented with cough for 1 month and generalized edema for 3 weeks. She was previously well, with no history of cardiac or renal problems. She gained 7 kg in 5 months and her weight plotted between the 75th and 90th centile while the height was at 3rd centile. The swelling involved the eyes, legs, abdomen and was worst at the end of the day. Also noted to have poor appetite, constipation and cold intolerance for the past 6-8 months. The child was otherwise doing well in school and reached her milestones appropriately. There is a positive family history of hypothyroidism-the child's mother has hypothyroidism that was diagnosed 10-15 years ago and is on levothyroxine replacement. On examination, she appeared dull with sallow look and generalized edema. There were no signs of congestive cardiac failure and cardiovascular examination including blood pressure was normal. There was a small palpable goiter and rest of the examination was normal. In view of the symptoms of prolonged cough and generalized edema, a chest-radiograph was done. It showed a globular cardiac silhouette raising suspicion of pericardial effusion and echocardiogram revealed pericardial effusion with echogenic pericardium, and mild bilateral pleural effusion. Other chemical biochemistry showed acute renal impairment, mild transaminitis, elevated total and LDL cholesterol and mild anemia. Autoimmune screen was normal. Thyroid functions showed a markedly raised thyroid stimulating hormone with low FT4 and raised thyroid peroxidase antibody which clinched the diagnosis of autoimmune primary hypothyroidism. Thyroid ultrasound showed a heterogeneous gland with slightly increased vascularity. Thyroxine was started as a low dose and increased slowly to achieve biochemical and clinical euthyroid state. The pericardial effusion resolved in 3 months and metabolic derangements normalized with thyroxine replacement.
Conclusion: In patients presenting with chronic non-specific clinical symptoms with generalized edema, hypothyroidism must be considered in the differential diagnosis. Also, once diagnosis is established it is good to look for complications like pericardial and pleural effusion especially in cases of severe hypothyroidism. Conversely in patients presenting with unexplained pericardial or pleural effusion, hypothyroidism must be considered in the diagnosis. Early recognition and treatment with thyroxine could eliminate the need for unnecessary diagnostic procedures and invasive measures and reduce the risk of progression to cardiac tamponade. Introduction: Tuberculosis is an important cause of morbidity and mortality in children worldwide. Diagnosing this condition is especially challenging in infants and young children due to non-specific clinical manifestations and its overlap with several other diseases, including pneumonia.

ID: 243
Case Description: A previously healthy 13-month-old male toddler was brought to our emergency department (ED) due to fever in the previous 12 days and productive cough and rhinorrhea in the previous 3 days. He was on the third day of treatment with amoxicillin for an acute medial otitis. When observed in the ED, he had a good general appearance, bilateral tympanic membrane erythema and normal, clear and symmetric breathing sounds in the pulmonary auscultation. The blood analysis revealed elevated white cell count and C-reactive protein. The chest radiography revealed a density in the right upper lobe. Given this workup, he was diagnosed with pneumonia, admitted and treated with ampicillin. Despite being well-appearing, active and having adequate food intake, the fever persisted during the first week of hospital stay. On the eighth day, the toddler's family was informed that his grandmother, with whom he had daily contact during the previous month, had just been diagnosed with pulmonary tuberculosis. A lung computed tomography was performed, revealing upper right lobe atelectasis and several hilar and mediastinal adenopathies compressing the right upper bronchus. The bronchoscopy confirmed the external compression of the same bronchus. Gastric aspirate was collected and tested with nucleic acid detection through polymerase chain reaction amplification for Mycobacterium Tuberculosis Complex, which was positive. Acid-fast direct smear and Interferon-γ release assay were also positive. Cultures revealed the same microorganism, confirming the diagnosis. He started antituberculosis treatment with good clinical evolution.
Conclusion: In children less than 5 years of age, primary pulmonary disease is more frequent, presenting as several days of low-grade fever and mild cough. The most common radiographic feature is hilar and mediastinal adenopathy and small parenchymal focus. In some cases, and especially in infants, the enlarged lymph nodes may compress nearby bronchus causing external stenosis and subsequent complications including necrosis, emphysema, atelectasis or a segmental lesion mimicking lobar pneumonia. This clinical case highlights the challenge of diagnosing tuberculosis in young children, being an example of a clinical overlap with another potentially severe disease. Introduction: Kawasaki disease ("mucocutaneous lymph node syndrome") consists of various clinical symptoms and signs, mainly high fever (lasting over 5 days), that usually occurs in children under 5 years old. It is a systemic vasculitis often accompanied by cardiac complications such as coronary arteries' aneurysms. Its characteristics point to an infectious origin, although genetic predisposition cannot be excluded.

ID: 294
Purpose: Sensitization of hospital and private pediatricians about the significance of early diagnosis and treatment of Kawasaki disease since it is the most common cause of acquired heart disease in childhood.
Case Description: A 2.5-year-old male toddler referred from a private pediatrician to our Pediatric Clinic, due to a 2-day high fever (following vaccination against meningitis B) accompanied by diarrheas and diffuse maculopapular erythematous rash on face, trunk, genital area and extremities, including palms and soles (edematous).
Results: His lips were reddish, cracked and edematous. Gingivitis, conjunctivitis, blepharitis were present and two days after his admission to our clinic, cervical lymphadenopathy was noted. He had received treatment with antihistamines and amoxicillin-clavulanic acid, prescribed by the private pediatrician (was discontinued after hospital admission), and we started treating him with cefuroxime. His laboratory tests revealed gradual elevation of WBCs, transaminases and inflammatory markers (WBC: 15970, 17800, 20600;N: 67%, 78.80%, 70.7%;ESR (mm/h): 30, 41, 2;CRP(mg/L): 68, 80, 66, 74, 91). Thrombocytosis occurred the 7th day of the disease (458,000/μl) and platelet count reached over 1,000,000 two weeks after initiation of fever. Also, serum albumin levels gradually decreased 10 days after initiation of fever. Blood and pharyngeal cultures were negative. Virological and serological tests for EBV, CMV and HSV were negative, but the ones for Adenovirus were found positive. Cardiological assessment was performed on the sixth day of fever (normal findings), followed by initiation of therapy with aspirin (80 mg/kg/24 h divided into 4 doses) and intravenous immunoglobulin (2 g/kg/24 h). Reduction of fever was noted within the first day of IVIG therapy and on the ninth day of the therapy (after heart ultrasound and reassessment, which were between normal parameters), the toddler was discharged continuing therapy with lowdose (anticoagulant) aspirin 5 mg/kg/24 h. On the seventh day of hospitalization (10 days after onset of fever), palms exfoliation began and after a few days soles exfoliation began as well. One month after discharge from hospital, cardiological assessment and heart ultrasound were repeated (no pathological findings).
Conclusions: Early diagnosis and appropriate treatment of the situation contributed to avoidance of disastrous consequences to our little patient's health (such as coronary arteries' aneurysms). It is assumed that a combination of an infectious (viral) factor, genetic predisposal or/and maybe the recent vaccination have triggered immune system's response and caused the described manifestation of Kawasaki disease. Introduction: Malaria is a frequent but potentially fatal disease in tropical countries. According to published data, in Mozambique, malaria can reach prevalences between 40% and 80% in children 2-9 years. The presence of complications aggravates the prognosis.
Purpose: We aim to describe a case of complicated malaria in the pediatric age.
Case description: LN, 7 years old, previously healthy, got admitted in the emergency service (ES) with 7 days of evolution of fever and general malaise. Observed at the beginning of illness by alternative medicine. He made paracetamol in fixed scheme, without improvement during this period. On the eve of admission, he had two episodes of tonic-clonic-generalized seizures. Observed at the local Health Center, rapid test for malaria performed was positive. At the physical examination, he presented Score Glasgow (SG) 10/15. He was given artesunate and was referred to the general hospital. He repeated convulsive crisis, requiring mannitol and phenytoin to control it. The blood count showed hemoglobin 8.9 g/dL, leukocytes 6800/µL (76.3% neutrophils). A diagnosis of cerebral malaria with moderate anemia was assumed. LN initially manifested macroscopic hematuria in relation to malarial nephritis, and then progressed favorably. He was discharged after eight doses of intravenous artesunate, with negative slide search for plasmodium and completed artemether + lumefantrine treatment during three more days. From the neurological point of view with important recovery, although with limitations in speech and swallowing. Now maintains follow up in consultation of general Pediatrics, speech therapy and physiatry.
Conclusion: Malaria is an unavoidable reality in endemic countries. However, early diagnosis and timely therapy prevent many complications and improve the prognosis. We must be attentive to this diagnostic hypothesis, especially when we observe children who have contacted or been in countries endemic to the disease in the previous 6 months.

Cogent Medicine
Febrile Splenomegaly: Presentation of Two Cases Gabriela Tavchioska 1 , Aleksandra Hristova 2 1 General Hospital Prilep, Macedonia, Former Yugoslav Republic of; 2 General Hospital Kumanovo, Macedonia, Former Yugoslav Republic of Introduction: Spleen enlargement or splenomegaly is defined as a palpable splenic edge felt more than 2 cm below the left costal margin. A palpable spleen tip may be a normal finding in up to 30% of newborns and 10% in healthy school-age children. Splenomegaly is associated with many different acute and chronic diseases.
Purpose: To present the diagnostic approach to the febrile child whose spleen is enlarged.
Cases Description: The first case concerns a 2-year-old male child admitted to hospital due to a temperature of 3 days and splenomegaly. The second case concerns a 2-year-old male child with a temperature of 5 days and splenomegaly that was outpatient investigated. In both cases biochemical, microbial and ultrasonographic investigations were performed. In the first case, according to the results, infectious mononucleosis was diagnosed. The disease had a favorable course and, with appropriate therapy, the child was discharged from hospital for a week. The child in the second case after the investigations due to prolonged fever and the finding of pancytopenia was sent to the University Children's Clinic where leishmaniasis was diagnosed.
Conclusion: The appropriate diagnostic approach in a child with temperature and splenomegaly is very important for a timely diagnosis, appropriate treatment and timely referral to an institution that provides a higher level of health care. Introduction: Neisseria meningitidis is the bacterium that causes meningococcal disease, one of the leading sources of community-acquired sepsis and meningitis among children. Thirteen serogroups of Neisseria meningitidis have been identified, but six of these serogroups (A, B, C, W135, X and Y) are responsible for majority of the infections worldwide. Meningococcal disease still is associated with a high mortality rate and persistent neurologic defects, particularly among infants and young children. The epidemiology of Meningococcal disease is extensively described and reviewed elsewhere, with serogroups B currently causing the majority of disease in Europe.

ID: 272
Case Description: An 8-month-old boy, previously healthy fully vaccinated according to the Portuguese programme and 1 dose of serogroup B meningococcal vaccine (Bexsero), was brought to Emergency Department with high fever, vomiting and irritability developing in the previous 24 h On physical examination he was irritable and pale. Lab tests revealed leukocytosis (21,220/µL), elevated C-reactive protein (246.3 mg/L), prolonged PT and INR. Venous blood gas analysis revealed pH: 7.42, pCO 2 :45 mmHg, lactate levels: 2.2 mmol/L and HCO 3 -: 20.1 mmol/L. He started treatment with ceftriaxone, vancomycin and fluid resuscitation. Lumbar puncture showed pleocytosis, hyperproteinorraquia and hypoglycorrhachia. Blood cultures and polymerase chain reaction (PCR) analysis were positive for group B meningococcus and vancomycin was discontinued. The patient started showing clinical improvement within a few hours but was discharged after 10 days because of prolonged fever. Further investigation was conducted on an outpatient basis with immunological study and auditory evoked potentials.
Conclusion: Clinical presentation of meningococcal disease is varied and the concerns about this are valid, given the rapid onset of illness and the high morbidity and mortality. In the reported case, the patient was clinically stable with nonspecific signs on admission. It is important to consider this diagnosis even in the absence of suggestive symptoms or signs in order to provide an appropriate treatment and improve the outcome. Case Report: Nine-year old girl with sickle cell disease admitted in Luanda´s hospital with osteomyelitis and weight loss (7 kg). She started cefazolin and ciprofloxacin, followed by chloramphenicol and clindamycin, and after 22 days, she was admitted in our hospital with multifocal osteomyelitis. MRI showed osteomyelitis of humerus and radius bilaterally (with abscesses), bilateral arthritis of the elbows with left-handed effusion, synovitis/arthritis of the shoulders and spondylodiscitis of L4-S2. She was twice subjected to an orthopedic surgery for drainage of abscesses and joint decompression. The biopsies of bone and synovial liquid identified multiresistant Serratia marcescens, so she was medicated with meropenem and amikacin. Because there is no clinical improvement she received also hyperbaric oxygen therapy (20 sessions), with good evolution. After 32 days, she developed fever, leukopenia and neutropenia therefore vancomycin and amphotericin B were prescribed. Amphotericin B led to severe hypokalemia (1.7 mEq/L) and has been discontinued. He also presented tuberculin test and IGRA T-SPOT positives and considering spondylodiscitis, it was assumed bone tuberculosis and started isoniazid, rifampicin, pyrazinamide and ethambutol. After 1 month, she had toxic hepatitis requiring the interruption of tuberculostatic therapy and replacement of isoniazid with levofloxacin. She was discharged after 90 days and today still has some limitations: a slight one on right arm's extension; on extension and supination of the left arm; and an abduction, anterior flexion and external rotation of her left shoulder.
Discussion: Osteomyelitis complications can be severe causing significant impairment on bone development and quality of life. An early diagnosis and appropriate therapy can greatly improve long-term outcome. Besides antibiotic, adjuvant therapies such as bone decompression surgery or hyperbaric oxygen may be required on chronic and recurrent cases. As this case points out, when facing chronic osteomyelitis, not responding to usual therapy, clinicians should be aware of bone tuberculosis, particularly when treating patients from endemic areas.

Hospital de Dona Estefânia-CHCL.EPE Lisbon Portugal, Portugal
Introduction: Orbital myositis is an inflammatory disease of extraocular muscles. It is quite rare in children and may be oligosymptomatic or severe (in this case with ptosis and proptosis). Although the majority are idiopathic, it may be associated with systemic disorders, and some forms have been associated with infectious diseases, such as streptococcal pharyngitis.
Case Report: A 14-year-old boy was admitted with pain on the right eye, diplopia, proptosis and ptosis with 1-week evolution and progressive deterioration. He had no fever or other symptoms. Two years prior he had a similar episode, treated with steroids. He had a history of recurrent episodes of tonsillitis. CT showed enlargement of the rectus superior and right eyelid and enlargement of the orbital muscles on the left eye. His complete blood count was normal, CRP 0.8 g/L, ASO titer 1200 UI/ml and Anti-DNase B Ab 824 UI/ml. The remaining work-up was normal. Eleven months later he presented with periorbital swelling of the left eye, pain with eye movements and diplopia. The throat was hyperemic. CT showed enlargement of the inferior obliquus muscle. Rapid antigen detection for group A streptococcus was positive and he was given with intramuscular penicillin injections (1,200,000 UI) and methylprednisolone pulses. He started monthly penicillin prophylaxis without new episodes of myositis. Additionally, tonsillectomy was performed in July 2018 with pathology report of the tonsils revealing bacterial aggregates in the tonsillar crypts.
Comments: We describe a recurrent orbital myositis associated with serological evidence of recent streptococcal infection. This case suggests a possible post-streptococcal immune mechanism for this disease. As other manifestations of the post-streptococcal syndrome, orbital myositis appears to have an immune mechanism of lesion an, as such, could be explained in this context. Case Description: Female newborn, 18 days old, previously healthy, admitted to emergency room (ER) due to hematuria and refusal to feed with 24 h of evolution. The physical examination was normal. Urinalysis showed leukocyturia and newborn was hospitalized under ampicillin and gentamicin, completing 10 days. Urine culture was inconclusive (10 4 CFU/ml, 2 types of colonies). At D10, fever was reported for the first time associated with leukocyturia and worsening of serum inflammatory parameters. At that time, urine culture revealed Enterococcus faecalis, sensitive to ampicillin. The patient performed ampicillin and amikacin for 10 days and then cefuroxime. Renal ultrasound (D19) showed a heterogeneous lesion in the middle third of the left kidney, with a subsequent increase in size, which justified renal MRI (D23): "nodular lesions in the left kidney (19 and 25 mm) with apparent peripheral enhancement after contrast (renal abscess? neoplastic lesion?)". Given the suspected diagnosis, the patient was transferred to our hospital on D27. Determination of tumor markers and urinary catecholamines were normal. Percutaneous kidney biopsy confirmed a xanthogranulomatous inflammatory process. The evolution was favorable under systemic antibiotic therapy (ampicillin and cefotaxime) with progressive reduction of lesion size and posterior calcification. The patient was discharged under antibiotic prophylaxis, with no new episodes of urinary tract infection after 6 months of follow-up. The lipid profile and study of neutrophil function (Phagotest and Burst-test) were normal. VCUG excluded vesicoureteral reflux.

ID: 235
Conclusion: Xanthogranulomatous pyelonephritis is rare in the neonatal period. Histopathological examination is essential to confirm clinical suspicion and exclude other entities mimicked by focal and unilateral progressive disease. Treatment includes surgery and/or antibiotic therapy. There are few cases described in the literature with favorable evolution only under prolonged systemic antibiotics, but their use allows a greater preservation of renal function. Introduction: Malnutrition has been consistently reported as being common in children with congenital heart diseases (CHD) with prevalence varying from 25% to 90%. Studies in developed countries have shown that malnutrition at the time of surgical intervention was associated with poorer outcomes postoperatively. Data from developing countries are lacking.

ID: 244
Purpose: To determine the prevalence of preoperative malnutrition in children with CHD undergoing surgical repair and to evaluate its effect on postoperative outcomes: length of hospital stay, length of stay in the intensive care (ICU), duration of mechanical ventilation, duration of use of ionotropic support and rate of infections, in a tertiary healthcare center in Lebanon.

Materials and Methods:
We conducted a retrospective cohort study in a single tertiary healthcare center in Lebanon. Children aged between 1 month and 5 years with CHD, undergoing surgical repair between January 2015 and January 2017 were included in the study. Anthropometric measurements were recorded and z-score for weight for height (if <2 years of age) and BMI (if >2 years of age) were calculated. We adjusted for the severity of the cardiac condition using the RASH-1 score model. Outcomes recorded were length of hospital stay, length of stay in the ICU, duration of use of ionotropic support and rate of infections.
Results: A total of 143 patients fulfilled the inclusion criteria. Thirty-five patients (27%) showed malnutrition on admission and it was more common in those under 2 years of age (34.1% vs. 13.2%). Using regression on the bivariate level: height for age z score, weight for age z score and BMI for age z score were statistically associated with the length of ICU stay. On the multivariate level when the predictors were adjusted for RACHS score, and type of heart disease (acyanotic/ cyanotic), height for age z score and weight for age z score were significantly inversely associated with length of ICU stay (beta coefficient −5.97; CI (−10.2, -1.91) and −6.07; CI (−9.8, -2.3), respectively.

Conclusion:
The prevalence of malnutrition in our cohort was 27% and it was more common in those <2 years of age. Furthermore, it is in this age group that we found a significant inverse correlation between anthropometrics defining the nutritional status and one of the outcomes: length of ICU stay. This may prompt physicians taking care of patients with CHD to develop tools to define and optimize their nutritional status especially if they are in the younger age group before scheduling their surgical repair.

Cogent Medicine
High-Protein Diet in Hepatic Lipid Accumulation Management of Non-alcoholic Fatty Liver Disease. A Literature Review Anh Hoang Nguyen 1,2 1 Child Nutrition Foundation; 2 University of Worcester, United Kingdom Introduction: Hepatic steatosis is the simplest stage in non-alcoholic fatty liver disease (NAFLD), which could precede a more severe stage of hepatocellular inflammation and damage, such as non-alcoholic steatohepatitis (NASH) and cirrhosis, caused by the accumulated fat. Some studies on the effect of high protein (HP) intake to reduced accumulation of hepatic lipids have been published recently, but its long-term effect and the responses of gene expression to HP remain to be fully unexplored.
Aims: To assess the effects of protein supplementation against increased intrahepatocellular lipids (IHCL) in long-term intervention studies on humans. Moreover, the author considers studies on humans and rodents, which investigated mechanisms of the regulation of gene expression underlying IHCL reduction in response to HP.
Method: A literature search on PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) using the following search terms: hepatic steatosis, HP and gene expression, for relevant articles. Eligible publications are consistent with published intervention studies in English language on adult and rodents (mice or rats).
Result: Energy intake total, BMI, body weight and insulin resistance remained unchanged in longterm response to an HP, compared with baseline. Protein intake increased significantly whereas carbohydrate and fat consumption decreased. The IHCL reduction was strongly associated with added protein consumption after 4 weeks, although the evidence was weaker for longer intervention periods. Evidence from studies on humans and rodents demonstrated that increased fatty acid beta oxidation activity through increased uptake of free fatty acids into the mitochondria due to upregulated expressions of Cpt1, CD36, but inhibition of lipogenesis genes when responding to an HP diet.

Conclusion:
The results of the present review cannot confirm the long-term effect of increased protein intake on IHCL reduction, due to the lack of enough strong evidence in these intervention studies on humans. However, the long-term effect of HP consumption and a spontaneous reduction in carbohydrate and fat intake to maintain caloric balance were strongly linked. There was a strong correlation between beta-fatty acid oxidation and upregulation of translocate protein on outer mitochondrial membrane (Cpt1 and CD36) in response to a HP diet. Cpt1: Carnitine palmitoyltransferase ID: 137 Introduction: The development of medical technologies and rising of frequency of survival of children with critical anomalies or illnesses during recent years have led to an increase in the proportion of children who are in need of a complete palliative care system, including a range of nutritional support. A separate problem is the provision of necessary nutrients to orphans which are in the children's facilities. A separate problem is the provision of necessary nutrients to orphans which are in the children's facilities. Unfortunately, the "empirical" approach is the reality of most orphanages.
Aim: The aim of study is the evaluation of the degree of nutritive deficiency in the child with Larsen syndrome and working out individual nutritional support.

Materials and Methods:
The anthropometric methods of diagnosing the degree of protein-energy insufficiency (Brock 2, Piney, Z-score indices) are used. The energy requirement was calculated with Schofield (WH) equation. Identification of foodstuff worked out.
Case Description and Results: A boy I., 1 year 2 months weighs 4 kg, height 66 cm, entered the hospital from an orphanage. The main diagnosis of the child is Larsen syndrome. He is fed a semicustomized milk formula with conventional feed. The actual intake of energy at a dose of 600 ml/ day was 100.5 kcal/kg, protein-2.2 g/kg/day. An increase in body weight over the last 6 months is 250 g. Brock 2 index was 40%. The Z-score WtA was "-" 6, a Z-score HtA-"-" 12, the Z-score WtHt -"-"3.5. The Piney index was 19. That is, with a symmetric delay in all indices of physical development, the assessment may be normotrophy, while the child has a severe form of malnutrition. The obtained data testify in favor of the extreme degree of nutritional insufficiency. The physiological energy requirement according to Schofield (WH) equation-384.55 kcal/day. The energy expenditure taking into account all coefficients is 460.92 kcal/day on the actual body weight. Considering the impossibility of a sharp load, the energy demand was estimated at 115 kcal/kg during the adaptation period. The needs in proteins for children are set at 1.2-1.5 g/ kg per day. Since ESPGHAN recommendations, it was decided to add the product of clinical nutrition (Infatrini, N.V.Nutricia, Netherlands). At the end of the week, the child assimilated 70 ml of food, of which: 20 ml of anti-reflux formula, 50 ml Infatrini, 10 times a day. Thus, 480 kcal/day and 16.2 g per day protein was hold in the volume of the enteric substrate, which the child tolerates well. During 10 days, the child increased body weight by 100 g and became calmer, showed an interest in environment.
Conclusions: Deep protein-energy insufficiency in children with combined neurosomatic pathology can be corrected by carefully calculating the actual energy needs and the appointment of specialized clinical nutrition. The usage of standardized indexes of physical development to determine the degree of nutritional deficiency and products for establishing energy needs in the practice of nutritional support for children of the palliative group can contribute the establishing of the adequate nutrition. Introduction: Good nutrition in children is essential for satisfactory physical and emotional growth, intellectual development and productivity. Nutritional deficiency in children therefore, not only has implications on health, but on the socioeconomic development of the country. The diet for a child should provide all macro and micro nutrients needed in correct proportions. Diet of Sri Lankan children is rice based. Although a wide variety of vegetables and fruits are available locally at a reasonable price, rice is considered the most important item in a child's diet. Hence, children's diets are of poor quality. Since mothers play a main role in feeding children, providing them with a practical method of providing a palatable, high-quality meal at affordable cost using local food might help to improve their diets. "Myplate" for preschoolers is a method developed by the United States Department of Agriculture, to ensure a nutritious diet to preschool children. We developed a colorful poster using locally available vegetables, fruits, grains, proteins and dairy food based on the Myplate method to be used by local mothers.
Purpose: This study was performed to evaluate the effectiveness of the locally adapted plate method in improving the quality of mid-day meal offered to preschool children.

Materials and Methods:
A cluster randomized interventional study was conducted among 60 mothers of children aged 2-5 years in a suburban area in Colombo. Mothers in both control (n = 30) and intervention (n = 30) groups were provided with a standardized plate and were and asked to photograph the mid day meal of the child for 1 week (baseline). Both groups were given nutrition education including correct food groups and proportions, while the intervention group was taught the plate method and given the poster. They were asked to photograph the child's meal immediately and 2 months afterwards, for a week. The quality of the food plate was assessed using a numerical score (total 10) giving 1 mark for the correct food group and 1 mark for the correct proportion. Each food group was also scored separately.
Results: The quality of the food plate improved significantly in both groups (p < 0.5) which was sustained at 2 months, with a bigger effect in the intervention group. The most striking change was a reduction of the carbohydrate and increase in vegetables and fruits offered. Introduction: Inflammatory myofibroblastic tumor (IMT) of the lung is a rare benign tumor accounting for 20% of pediatric lung tumors. Histologically, it is composed of fascicles of spindle cells with a prominent inflammatory infiltrate. IMT is now considered as a real neoplasm because of the proliferation of myofibroblastic cells and the malignant behavior with a high potential for recurrence. The differential diagnosis includes other benign or malignant lung tumors, congenital lung malformations and inflammatory diseases, such as tuberculosis (TB). The definite diagnosis of IMT is usually feasible after surgical resection due to the nonspecific clinical and radiological features of the tumor.

ID: 112
Purpose: We present the case of a 12-year-old asymptomatic boy with a lung mass that coexists with chronic endobronchial infection. Although radiologic and laboratory findings were compatible with pulmonary TB, right lower lobectomy was performed and histological examination revealed a pulmonary IMT.
Case Description: A 12-year-old boy presented for further evaluation of a lung mass incidentally detected on a chest X-ray. Personal and familiar history was uneventful. The boy was fully immunized for age including Bacille Calmette-Guerin vaccine. Chest computed tomography (CT) scan showed a right lower lobe tumor with intense calcification associated with bilateral bronchiectatic lesions. Radiological images did not reveal protrusion of the mass into the bronchi lumen.
Magnetic resonance imaging showed similar findings suggestive of TB or histoplasmosis. Flexible bronchoscopy showed diffuse inflammation of the bronchial mucosa and profuse mucopurulent secretions. Bronchoscopic picture was compatible with chronic endobronchial infection. Tuberculin skin test was marginally positive and Quantiferon-TB Gold positive, whereas Histoplasma antibodies were negative. Cultures in the sputum twice performed showed Haemophilus and Pseudomonas species, respectively. The clinical history of the child was indicative of a different diagnosis other than TB. Thus, right lower lobectomy was performed. Histopathological examination revealed the diagnosis of a pulmonary IMT. The patient was discharged in good general condition without any signs of relapse 14 months after surgery (clinical examination, CT).
Discussion: Although IMT is no longer considered as a reaction to an inflammatory insult, children with IMT may exhibit symptoms of chronic inflammation as did our patient. The precise etiology of the disease remains unclear. Children may show nonspecific and variable symptoms. Radiological imaging is useful in suspected lesions, but the diagnosis is usually confirmed only by histopathological assessment.
Conclusion: Pulmonary IMT is an uncommon disease, but with significant morbidity among the pediatric population. Because of the potential malignant behavior of this tumor, raised awareness and close follow-up are vital of this potentially misdiagnosed and lethal disorder.

ID: 291
Cogent Medicine Case Description: We present an 8-month-old male with severe persistent respiratory distress present since he was born, without improvement with bronchodilator or inhaled steroids and poor weight and height gain. He was initially observed in his residence area hospital and then referred to a specialized Pediatric Pulmonology consultation. There, he had normal alpha-1 antitrypsin, negative sweat test and negative CMV IgM, with positive IgG. Thoracic CT scan revealed atelectasic densification in the upper lobes and parenchymal changes in "depolished glass". Bronchofibroscopy demonstrated a normal-looking bronchoalveolar lavage and CMV DNA test was strongly positive. The transfontanellar ultrasonography and ophthalmologic and hearing evaluation were normal. It was also performed a blood CMV DNA test and in the Guthrie Filter Paper CMV tests who were negative. The immunological evaluation was normal and the cardiac study was normal too. Hospitalization was decided for intravenous ganciclovir therapy for 21 days, followed by oral valganciclovir therapy for a total of 6 months. During this period, there was a clinical marked improvement and the patient is now perfectly well without any signs of respiratory distress.
Conclusion: Persistent CMV infection may cause a diffuse necrotizing pneumonitis with fibrosis not only in immunocompromised but also in immunocompetent infants. In these patients, CMV infection should be identified and if confirmed specific antiviral therapy may be the only therapeutic option. In this case, the authors want to emphasize the late diagnosis as well as a difficulty in its certainty.

Effect of Probiotic Supplementation (Lactobacillus reuteri) in Patients With Cystic Fibrosis (CF)
Tatjana Jakjovska Institute for Pulmonary Diseases, Macedonia, Former Yugoslav Republic of Introduction: Probiotics are proven to reduce intestinal inflammation in children with cystic fibrosis (CF) and may reduce the duration of respiratory and gastrointestinal diseases.
Aim: We want to determine the effects of the probiotic Lactobacillus reuteri on symptoms of respiratory and gastrointestinal diseases in CF.
Methods: A total of 38 patients with CF (2-24 years, mean age 9.6 ± 4.2) received probiotic Lactobacillus reuteri for 6 months. Main outcome parameters were forced expiratory volume (FEV1), FVC (forced vital capacity) and change in anthropometric parameters.
Results: In the study, FEV1 and FVC were measured in CF patients before and after they received probiotic Lactobacillus reuteri. We found significant difference for FEV1 (p < 0.05) and FVC (p < 0.05), in both children and adolescents. We did not find significant difference for body weight, body height and for BMI, but the patients were heavier after 6 months.
Conclusions: Probiotics may delay respiratory impairment and gastrointestinal inflammation, but further studies are needed.

ID: 283
Cogent Medicine Results: There were 31 patients with the diagnosis of non-cystic fibrosis bronchiectasis, most of them with history of recurrent low respiratory infection, 52% females, with a median age of 12 years. The most common symptoms on presentation were productive cough, breathlessness, wheezing and repeated pneumonia. Diagnosis was based on findings in high resolution computerized tomography of chest; bronchiectasis was found in both lungs in 11 (35.5%) cases, and in 20 (64.5%) cases the location was unilateral. There was association with atelectasis in 15 (48.4%). The underlying cause was identified in 17 (54.8%). Common causes were post-infectious in 11 (35.5%) and confirmed primary ciliary dyskinesia in 3 (9.7%). Complications were observed in 19 (61.3%) patients, being the most common recurrent low respiratory infections (12 cases, 38.7%), and hemoptysis (5 cases, 16.1%). Three children (9.7%) required surgery. The most frequent medical treatment prescribed was respiratory physiotherapy (20 patients, 64.6%), followed by inhaled corticosteroids (11 patients, 35.5%), in wheezing children. Currently, all children are stable.
Conclusion: With this paper we try to remind the existence of non-cystic fibrosis bronchiectasis in pediatric population often without many respiratory symptoms, and the need to be aware of early diagnosis and appropriate therapy (respiratory physiotherapy, vaccines and aggressive treatment of any infection that arises). This can make the change in patient's future quality of life in childhood and adult life.

ID: 152
Cogent Medicine Introduction: Hyperimunoglobulin E syndrome (HIES) is a primary immunodeficiency disease with genetic mutation as its etiology and characterized by extremely high serum IgE levels, accompanied by musculoskeletal, facial and dental abnormality together with recurrent bacterial and/or fungal infections of the subcutaneous tissue, skin, respiratory tracts, lung and bone. Not only, it is difficult to determine HIES in childhood due to its broad-spectrum clinical characteristic, but also the lack of diagnostic tools and resources in developing country play significant role in the postponement of identifying the disease. Therefore, a delay in identifying HIES may cause serious complications. Multiple morbidity and complications in HIES lead to disruption of children's growth and development.
Purpose: This case report was about 2 years observation on a boy with HIES. Difficulty in identifying the disease in limited resources as well as the complexity of HIES comorbidities, resulted in postponement of adequate HIES management. Giant bullae in the patient's lung were the result of HIES complication due to recurrent bacterial and fungal infection in the respiratory tract and lung. This condition affected patient's growth and development; therefore, a long-term follow-up in this patient is necessary.
Case Report: A case of a boy who develop signs and symptoms of primary immunodeficiency disease since his early stage of life; however, due to the lack of ability and resources in identifying the disease, HIES was diagnosed years later. Accompanying the high IgE level (144,136 IU/ml), recurrent infections on his skin, eyes, nails, respiratory tract and oral cavity were the common clinical manifestations. A giant bulla in the left lung was subsequently present and identified at the age of 8 years old. Decision not to perform bullae excision was taken, considering the later effects of the surgery on the patient. He had monthly transfusion of intravenous immunoglobulin and prophylaxis antibiotics as well as antifungals in order to minimize infections. Added with those medical conditions, some non-medical problems were also occurred, such as the lack of parental knowledge and acceptance regarding to the disease. These surely affected patient's quality of life (PedsQL score: 43.3).
Results: There are adequate changes in terms of behavior and acceptance toward HIES. Both parents of the patient had strong willingness to learn about HIES and support their son to have appropriate medical treatment continuously, while the patient learn to accept his disease and try to cope with medical and non-medical instructions.
Conclusion: A 2-years follow-up on a HIES patient with bullae in the lung has been done. There was a progress in term of patient's quality of life despite the serious comorbid. Introduction: We present a 3-day-old girl with laryngomalacia and feeding difficulties caused by a hiatal hernia. Hiatal hernias are characterized by protrusion of the stomach into the thoracic cavity through a widening of the diaphragm. Hiatal hernias have been reported to affect 10-50% of the population.

ID: 209
Case Description: Girl born full term by spontaneous vaginal delivery after an uncomplicated pregnancy. Birth weight was 2760 g (3rd centile); length and head circumference were at the 50th centile. She was admitted to the maternity ward where "noisy breathing" was observed. Initial physical examination was normal, except for bilateral preauricular pits. An otorhinolaryngologist was consulted for persistence of an inspiratory stridor on the third day of life and confirmed the presence of mild laryngomalacia. She was hospitalized at the neonatal medium care for monitoring. Pulse oximetry showed oxygen saturation just below normal ranges. Feeding difficulties were noticed, wherefore placement of a nasogastric feeding tube. Projectile vomiting and desaturation were observed immediately after feeding through nasogastric feeding tube.
Radiography showed an abnormal air structure inside the thoracic cavity suspicious of a congenital diaphragmatic or hiatal hernia. The girl was transferred to the neonatal intensive care, enteral feeding was stopped, total parenteral nutrition and respiratory support with high-flow nasal cannula was started. Upper gastrointestinal contrast study confirmed the diagnosis of a large hiatal hernia with a thoracic stomach. On day 7, a laparotomic repair with Nissen fundoplication and placement of a gastrostomy was performed. Enteral feeding through gastrostomy was started 48 h later. Respiratory support could progressively be diminished. Feeding difficulties (absence of nutritive sucking) were noticed afterwards. A neurologic workup, with electroencephalography and cranial ultrasound was normal. The patient was discharged from hospital on day 40 with home gastrostomy feeding. Genetics showed a large duplication on chromosome 9(9q34). Duplication of 9q34 is a very rare genetic condition associated with characteristic appearance, feeding difficulties, poor growth and related to an increased risk of developmental and speech delay. The COL5A1 gene that encodes a component of type V collagen is imbedded in this duplication, which might explain the large hernia, but up to now it has not been described.
Conclusion: Laryngomalacia in newborns is relatively common and usually innocent, however when associated with feeding difficulties, requests immediate further evaluation. Full diagnostic work-up revealed a rare genetic disorder, which might explain the large hernia, but this association has not been described until now.

Investigate the Maternal-Baby Attachment and the Factors that Affect the Maternal-Baby Attachment
Hazal Özdemir, Fatma Taş Arslan Selçuk University Health Science Faculty, Turkey Background and Aim: Attachment is an important concept for the child's development process. It develops between the mother and the baby, and affects the physical, psychological and intellectual development of the child significantly. In this review article, it is aimed to investigate the maternal-baby attachment and the factors that affect the maternal-baby attachment.
Methods: We could say that the literature, especially over the past 5 years mostly focused on these topics. The discussion paper provided a search of PubMed, CINAHL and Ovid Medline. Search was conducted using the keywords of newborn, maternal and baby attachment, attachment, pediatric nursing, nursing care to explore the attachment relating to factors that affect the attachment. Studies had to meet the following criteria to be included in this manuscript: (a) to be published between 2011 and 2017 and (b) to consist of newborn and maternal baby attachment. Exclusion criteria were as follows: (a) not published as a full article, (b) not published in English.
Results: One of the most important factors that positively affect the attachment process is the intention to breastfeed and breastfeed. İt is important to planned pregnancy, readiness to pregnancy, healthy progress of pregnancy to maternal-baby attachment. On the contrary, postpartum depression which is seen in the postpartum period, effect on maternal-baby attachment negatively. This relationship, which develops between the mother and the baby, continues to be effective throughout life, deeply affecting the child's physical, psychological and intellectual development. On the contrary, unhealthy or periodically interrupted forms of attachment lead to the development of personality, trust and attachment problems in the later stages of the child.
Conclusion: Research reviews showed that attachment is important responsibilities for pediatric nurses who provide services to the mother and baby in the primary health care centers. Pediatric nurses are the most influential people in starting and maintaining a healthy maternal-baby attachment process within a family-centered care in a professional nursing approaches. Pediatric nurses closely follow current knowledge this subject and there is a need for more randomized controlled studies to improve the level of evidence of new nursing approaches.

ID: 287
Purpose: To characterize the cases of NEC in term neonates in a Level III NICU and evaluate the determinants of severity.
Material and Methods: Retrospective study of all term neonates with 37 or more weeks of gestational age admitted at our NICU with the diagnosis of NEC according to Bell's criteria from 1 January 2002 to 31 December 2017.
Results: Thirty-one term neonates were diagnosed with NEC, corresponding to 18% of all NEC cases. The majority of newborns were male (64.5%); median gestational age was 39 weeks (37-41) and median birth weight was 2.78kg (1.72kg-4.19kg); 25 (80.6%) neonates had underlying disease or possible risk factors for NEC. The median onset of the disease was the third day of life. NEC classification was stage I-5 (16%); stage II-14 (45%) and stage III-12 (39%). Surgery was required in 14 (45.2%) neonates. Transfusions (p = 0.020) and use of vasopressors (p = 0.012) were more common in stage III disease as well as low platelet count (p < 0.001) and albumin levels (p = 0.001), and high CRP levels (p = 0.039). No statistical differences were found between enteral feeding and stage of NEC. Conclusion: In our study, we confirmed that the majority of patients had underlying disease or possible risk factors for the development of NEC. Predictors of severity are not well defined, particularly in term neonates. Our study suggests lower platelet count is associated with more severe disease. Successful efforts are needed to prevent NEC in term neonates and to identify those at higher risk for severe disease, mainly in those with known predisposing conditions.

ID: 204
Cogent Medicine Introduction: Neonatal hypernatremia is a potentially serious process that can lead to complications without early detection. While the reported incidence varies widely, studies indicate an incidence increase. Neonatal hypernatremia is generally associated with inadequate fluid intake, particularly due to insufficient lactation in breastfed neonates. Clinical signs and symptoms are often mild and non-specific which can prove difficult to identify.
Purpose: To determine the incidence of hypernatremia in our institution (which is a baby-friendly hospital) and assess its detection and management.
Materials and Methods: A retrospective study was performed in our institution between May 2016 and April 2017 which consisted in revising the charts of all newborns in whom serum sodium was determined for any reason, and selecting every case with a serum sodium level ≥ 150 mEq/L.
Results: During the study period, we observed 1926 live births, of whom 233 newborns were submitted to serum sodium determination. Thirty newborns were included in the study, of which 28 were detected in the postnatal care ward and 2 in the emergency room. The mean age was 3.3 ± 0.9 days (range 2-6 days), mean birth weight was 3509 ± 393 g and mean weight loss was 11.6 ± 1.5% (range 9.6-17.1%). As high as 86.7% newborns were exclusively breastfed. Seventy percent had primiparous mothers, with a mean age of 39.3 ± 5.3 years. As high as 46.7% were delivered by caesarean. All neonates lost over 7% of their birth weight, and 90% lost over 10%.
Other signs and symptoms detected were: feeding difficulties (30%), perception of decreased urine output (16.7%), jaundice requiring phototherapy at time of diagnosis (13.3%), jaundice already in phototherapy (10%) and lethargy (6.7%). The mean serum sodium was 152.1 ± 2.52 mEq/L (range 150-158 mEq/L). In 76.7% of the cases, the correction of the hypernatremia was achieved with oral supplementation, with breast or formula milk, and the rest were treated with intravenous fluid. The mean decline of serum sodium levels in neonates treated with oral supplementation was 0.24 mEq/L/h (range 0.09-0.34 mEq/L/h). In the neonate group treated with intravenous fluids, the mean decline was 0.38 mEq/L/h (range 0.13-0.6 mEq/L/h). No complications or obits were registered.
Conclusion: We estimate a rate incidence of hypernatremia of 156 per 10,000 live births per year. Strategies such as daily weighing, careful medical examination, breastfeeding support in the ward and having the first medical evaluation at primary care in the first week of life allowed the early detection and management of these newborns.

Perinatal Factors that Affect on the Development of RDS in Late Preterm Infants
hypoxia on the background of placental dysfunction, which was more connected with the development of respiratory distress than CS. Among all of LPI born due to urgent CS, 53.8% were in need of respiratory support; however, the indication for the Cs was the state of fetus. The most common indication of the elective CS was premature placental abruption. Among this cohort infants of 34 weeks of GA dominated without the increasing of occurrence of respiratory disorders despite less GA.
Conclusion: LPI with high perinatal risk regardless of GA equally often have respiratory disorders and need of careful monitoring and respiratory support. Frequency of the development and severity flow of respiratory distress depend on the perinatal background of the fetus development rather than on the method of delivery.

Rate of Premature Newborns in General Hospital Kumanovo during the Period 2014-2017
Aleksandra Hristova 1 , Gabriela Tavchioska 2 1 General Hospital Kumanovo, Macedonia, Former Yugoslav Republic of; 2 General Hospital Prilep, Macedonia, Former Yugoslav Republic of Introduction: Thorough pregnancy monitoring and management and increased correlation between primary and secondary health care providers lead to decreasing trend of premature newborns within General Hospital Kumanovo.
Purpose: To present the trend of preterm born newborns during the period of 4 years (2014)(2015)(2016)(2017) in General Hospital Kumanovo and to present the gestational age of premature newborns.
Material and Methods: For this retrospective study, data were collected from the annual reports of the department and medical histories of newborns. Statistical analysis includes estimation of rate of prematurity for each year of the investigated period, creation of linear trend and selection of newborns according the gestational age.
Conclusion: There is a trend of discreet decrease of the rate of premature newborns, mostly in the group of newborns with gestational age from 34.0 to 36.6 GW which is consistent with the improved level of health care provision within the General Hospital Kumanovo.

Health Literacy Level of Mothers and Rational Use of Antibiotics in Children
Raziye Çelen, Fatma Taş Arslan

Selcuk University, Turkey
Background and Aims: Mothers are responsible for the effective management of medication and children's health care. The aim of this study is to determine the relationship between the level of health literacy and the rational use of antibiotic for mothers with children aged 1 month-6 years.

Methods:
The study was a descriptive, cross-sectional and correlational design. The study was conducted between on January-May 2018 on a total of 121 mothers with children who are treated at the pediatric outpatient clinics of a medical faculty hospital in Turkey. Data were collected using the Questionnaire Form and Health Literacy Scale. The data were analyzed using percent, mean, standard deviation and Spearman Correlation.

Results:
The average age of the mothers is 31.20 ± 5.81. As high as 84.3% of children are between 1 and 6 years of age. Children have become sick 3.14 ± 2.91 times and they used antibiotics 2.79 ± 2.64 times within 1 year. As high as 46.3% of the mothers prescribe medication to their children without illness, and it is stated that the majority of these medication analgesics/ antipyretics. As high as 82.6% of mothers did not know use rational of antibiotics. Mean score of health literacy level was 100.85 ± 17.64. There was no significant relationship between the health literacy level and knowing use rational of antibiotic (r = −0.55; p = 0.549). There was a strong and significant relationship between antibiotic use and be sick status in one year (r = 0.64; p < 0.001).
Conclusions: It has been determined that there was no relationship between health literacy and knowing the rational use of antibiotics.

Myeloid Sarcoma Presenting as Irritability and Mild Proptosis in a 6-Month Infant: A Case Report
Erika Alejandra Diaz, Gabriel Vargas, Leslie Uribe, Francisco Rivera-Ortegón

Tecnologico de Monterrey, Mexico
Introduction: Clinical presentation of myeloid sarcoma (MS) is diverse, which makes the diagnosis a real challenge. We report the case of a patient with MS presenting as irritability and mild proptosis without initial bone marrow involvement which appeared 10 days after the first bone marrow was performed.
Purpose: To exemplify the importance of a complete clinical evaluation in a patient with irritability as the only manifestation of cancer.
Case Report: A previously healthy 6-month-old infant presented with a 12-day history of hyporexia, progressive irritability and fever. On examination he was well-appearing, a mild right proptosis was present, no enlarged lymph nodes neither hepatosplenomegaly nor abdominal mass were found. Initial laboratory workup revealed: hemoglobin 10.8 g/dL, platelet count 412 × 103/μL, white blood cells 10.8 × 103/μL with 42% neutrophils, 48% lymphocytes, 3% atypical lymphocytes and an elevated lactate dehydrogenase of 983 U/L. Initial workup for osteomyelitis was performed, with a Technetium Tc 99m medronate bone scanning showing hypercaptation areas at the left proximal humeral and femoral metaphysis, suggestive of malignancy. A whole-body MRI showed involvement of maxillary sinus with orbital extension, multiple medullar lesions at the left humeral diaphysis, and both femoral and tibial diaphysis (Fig. 1).
A bone marrow aspiration showed no blast cells, but suggestive neuroblastoma cells were found by immunophenotyping (strong expression of CD56). Following neuroblastoma workup, a bilateral bone marrow aspiration and biopsy were performed, showing diffuse monoblastic cell infiltration, positive for myeloperoxidase and CD56. Cerebrospinal fluid (CSF) cytology and cytochemistry showed no malignant cells. The patient was diagnosed with MS of the maxillary sinus with orbital extension, bone marrow involvement, and bone and soft tissue infiltration. Treatment was initiated with ADE (Cytarabine, Daunorubicin, Etoposide) and triple intrathecal chemoprophylaxis. He underwent remission after his first cycle of induction chemotherapy and remains so 4 months after the 5th chemotherapy cycle.

Conclusion:
The clinical presentation of this patient represents a diagnostic challenge, considering that there were no specific clinical signs and symptoms. These cases require a meticulous diagnostic evaluation to initiate the treatment as soon as possible, considering that patients with bone marrow involvement have a poor prognosis.

Cogent Medicine
Paediatric Registrar Review Clinic: Improving Efficiency and Attendance Chun Lim, Alexander D. Chesover, Anne Ingram

Luton and Dunstable Hospital NHS Foundation Trust, United Kingdom
Introduction: A quality improvement project was undertaken within a district general hospital's paediatric department focussing on improving the efficiency and attendance rate of the Paediatric Registrar Review Clinic (RRC). Identified issues were high "did not attend" (DNA) rate, inadequate referral information and inappropriate utilisation of the clinic. This resulted in either patients missing their review or attending when a more appropriate follow-up method was preferable, registrars challenged to efficiently run clinics without pertinent clinical information and ineffective utilisation of the department's clinic time. Data were collected through retrospective audit by registrars of nine consecutive RRC (November 2016 to January 2017) and included: number of patients booked, DNA, presence of referral information and feasibility for alternative follow-up.

Results:
The results (tabulated below) highlight high DNA, poor documentation of clinical problem and reason for review, and scope for alternative follow up suggesting inefficient use of clinic time.
In response, four interventions were implemented: (1) RRC guide listing best practices for referring.
(2) RRC appointment letter: reformatted explanation to families of clinic details, location and how to change appointments.
(3) RRC booking form: reformatted with adequate space for required referral information. (4) Administrative changes: (a) Enable ward clerks to rearrange clinic appointments. (b) Automated text message reminder 1 week prior to clinic. A repeat RRC audit of clinics (October 2017 to March 2018) was performed to measure the intervention's impact. Data collection methods were identical. Microsoft Excel was used for analysis by descriptive statistics for comparison between audits.
The significant improvement in referral clinical details, decreased DNA rates and overall suitability of follow-up method allowed more effective clinic preparation and clinical review by registrars and

Before intervention
After intervention improved resource utilisation. This resulted from simple interventions without significant reorganisation of a clinical system. Successful development of a clinical system change requires involvement from the whole department to best understand challenges from different perspectives.

ID: 223
Cogent Medicine They must contain the proper information in order for the specimen to be processed. There is raised concern regarding multiple forms not being correctly completed. This leads to unnecessary added workload for both phlebotomists and medical team members. In some occasions, it leads to unnecessary repeat courses of venepuncture on a child.
Purpose: To raise awareness among medical staff regarding the importance of accuracy in filling out blood form requests. To evaluate the current performance compared to predefined criteria set by the Irish local Health Department. To implement the use of the "plan, do, study, act" (PDSA) model to improve the current situation in our hospital.
Methods: This is a 4-week prospective study during which data are collected on a daily basis to evaluate the current performance of accuracy. During the end of the second week, data were evaluated and action was taken. A medical student made a verbal announcement during Grand Rounds, creating awareness on this audit and highlighting the most commonly omitted components on the blood forms for the previous 2 weeks. Reminders were sent out to medical doctors from all specialties on group chats to inform those who may have been absent at Grand Rounds. Data were again evaluated during the fourth week. All data were anonymised, collated and analysed on Excel.
Results: During the 4 weeks period, a total of 238 venipunctures were performed. During the first 2 weeks, 38/116 (32.65%) forms were not filled out correctly. During the 3rd and 4th week, post verbal action taken, there was a total of 39/122 (31.65%) forms not filled out correctly. The two most commonly omitted components were biography sticker details on the forms and adequate number of stickers for blood bottle samples.
Conclusion: Despite action being taken, there has been no improvement. Leaving out biography sticker details on forms and not putting sufficient stickers for blood bottle samples are serious omissions. During the next PDSA cycle, we plan to design screen savers for hospital computers to create a stronger visual prompt, as well as a laminated card-size checklist reminder to be distributed to all medical staff.
Introduction: Spina bifida is the most common cause of neurogenic bladder in children that may lead to progressive chronic kidney disease (CKD). Early diagnosis and prompt treatment can preserve kidney function.
Purpose: To raise awareness and highlight the importance of early diagnosis, management and referral of neurogenic bladder children with spina bifida to prevent renal damage and progressive CKD.
Case Report: We present a case of an 11-year-old girl, who had a lumbar lump since birth. At 8 months old, she went a surgical lump removal with no further treatment. Since 2 years of age, she had trouble with toilet training and was diaper dependent. Since 6 years old, she often experienced recurrent abdominal pain, vomiting, fever and regularly visited several doctors. Although she has spina bifida with those complaints, the previous doctors never suspected renal disease. At 11 years of age, she came to the hospital with uremic encephalopathy, severe anemia (Hb 3.5 g/dL), proteinuria, underweight and stunted, and CKD stage V (GFR 13.4 mL/min/1.73 m 2 ). A renal ultrasound and voiding cystourethrogram (VCUG) revealed bilateral hydronephrosis grade IV, hydroureter and left vesicoureteral reflux grade IV. These concluded the diagnosis of neurogenic bladder due to spina bifida in this patient. After 7 days of hospitalization and received 1 episode of hemodialysis, she was discharged, and started using clean intermittent catheterization (CIC) and conservative treatment. However, late diagnosis, management and referral have led her to stage V of CKD.

Conclusion:
In a child with history of having a lumbar lump and recurrent urinary tract infections (UTIs), awareness is crucial to prevent renal damage and progressive CKD.

Cogent Medicine
Strengthening of Health Care Capacities to Improve Early Childhood Development in Serbia-

Results and Plans
Vitomir Lozanović Dragana 1 , Bogdanovic, Radovan, Milos 2 ; Milidrag, Marica 2 ; Jovanovic, Ljiljana Sokal 2 1 Institute of Mother and Child Health Care of Serbia "Dr Vukan Čupić", Serbia; 2 Pediatric Association of Serbia Introduction: The National Program for Early Childhood Development Promotion (NECDP), adopted by the Serbian Government in March 2016, highlights the health care system-most notably its primary level-as the point of access to and coordination of multi-sector early intervention measures, designed to support families and children in the first years of life. Supported by the Ministry of Health and UNICEF, over the past 7 years, the Pediatric Association (PAS) has undertaken a mission to spread ideas, strengthen the capacities of all primary care pediatricians and medical staff teams working in Development Counselling Centers (DCC) in Serbia by delivering training programs, equipping the premises, strengthening partner relationships with the parents and linking with other community-based systems.
Purpose: To present the results of 7 years implementation of the projects aimed to health system capacities building for ECD, conducted by PAS and UNICEF, with support of MoH and partners.
Materials and Methods: Analysis of the results using reports of coordinators, statistical analysis of input-output tests of knowledge and satisfaction of course participants, as well as analysis of additional activities in the application of lessons learned in the courses.
Results: Training has been organized separately for pediatricians (84 sessions, 17 interactive courses) and for DCC teams (68 sessions, 14 interactive courses), including in the use of child developmental screening and assessment tools (ASQ, GMCD). More than 160 pediatricians from 24 primary health centers have been trained, which has increased their capacities for early detection of developmental delays and disabilities (pediatricians' knowledge level increased by 33%). Putting theory into practice, the tools have been used for assessing the development of more than 7000

Cogent Medicine
Urachal Anomalies-Case Report and Literature Review Vicente Rey y Formoso 1 , Ana Lia Gonçalo 2 , Sofia Vasconcelos Castro 3 , Maria Garcia Fernandez 3 1 Serviço de Pediatria-Hospital Pediátrico Integrado-Hospital São João; 2 Serviço de Pediatria-Hospital Pedro Hispano; 3 Serviço de Cirurgia Pediátrica-Hospital Pediátrico Integrado-Hospital São João Introduction: Urachal anomalies are congenital malformations that can either be found incidentally on an abdominal imaging exam or present themselves with a wide range of symptoms. Their treatment is currently subject to a lot of controversy.
Purpose: We present a short case report that serves as introduction to a recent literature review.
Although infrequent, these malformations are still important differential diagnosis when investigating abdominal or pelvic symptoms.
Case Report/Materials and Methods: A previously healthy 8-year-old boy entered the Emergency Services with complaints of a severe hypogastric pain in the previous 24 h. He had no other symptoms or findings on physical examination. An ultra-sound (US) was requested and revealed inflammatory signs in a previously unknown vesicourachal diverticulum as the cause for the complaints. The patient had normal urine and blood tests and after the pain resolved under ibuprofen he was discharged. The symptoms remitted after 3 days and he remains asymptomatic after several months of follow-up. This case report shows how even the most rarely detected urachal remnant can present with apparently common symptoms and how these should be considered in certain clinical settings. It also exemplifies the doubt that can arise when treating asymptomatic patients. The literature review was based on articles published on the last 10 years available on PubMed.
Results: The urachus is a tube-shaped embryological structure that extends from the umbilicus to the bladder. Its anomalies arise from a failure in the obliteration of its lumen and can be divided in four categories: Patent urachus-patent connection between the umbilicus and the bladder; Umbilical-urachal sinus-blind focal dilation at the umbilical end; Vesicourachal diverticulumfocal outpouching at the vesical end; Urachal cyst-fluid-filled dilation with no communication with either end. They usually manifest due to infection or other complications, presenting with a wide variety of symptoms and US imaging is very effective in their diagnosis. Those complications (and the risk of malignancy) led to a traditionally surgical approach-however, many authors nowadays defend that excision may not always be necessary, particularly in young patients and the ones that are asymptomatic.
Conclusions: Urachal anomalies are more frequent than previously thought. They can present with a wide range of clinical scenarios, some of which as simple as an acute abdominal pain (as in our case report) and can frequently be diagnosed with an US. There has been a recent paradigm change concerning their management.

Marina Reznik, Philip O. Ozuah
Montefiore Medical Center, USA Introduction: Children spend nearly half of their day in school under the supervision of teachers. However, studies show that many teachers lack confidence in student asthma management.
Purpose: The objective of this study was to evaluate the effectiveness of an educational workshop on school teachers' confidence in asthma management.

Materials and Methods:
We conducted an intervention study of classroom teachers from four schools in the Bronx, NY. Teachers completed a 20-item questionnaire evaluating confidence in school asthma management before and after a 45-min workshop delivered by a community health worker. The workshop reviewed asthma symptoms, triggers, and management of acute attacks as per national guidelines. We asked teachers about confidence managing students with asthma, including symptom recognition, trigger avoidance, assisting with medications, communicating with parents, encouraging participation in activity and responding to emergencies. Teachers rated their confidence on a Likert scale (5 = completely sure, 1 = not at all sure). McNemar test was used to compare pre/post responses.
Results: A total of 64/70 (91%) teachers completed pre/post surveys (mean age 39.7 years; mean years of experience 8.0 years). Fewer teachers reported feeling worried if a student developed an asthma attack in the classroom post-intervention compared to pre-intervention (24.6% vs. 42.9%, p = 0.012). Post-intervention, teachers were more confident on 8 out of 10 asthma management items.
Conclusion: A brief asthma workshop incorporating national guidelines on school asthma management improved teacher confidence in managing asthma. Developing a sustainable model of annual asthma workshop delivery for school personnel may improve their confidence in assisting with asthma management for students.

ID: 297
Cogent Medicine The Problem of Abnormal Body Weight in Children from the Point of View of a School Nurse

Małgorzata Kołpa
Institute of Health Sciences, State Higher Vocational School in Tarnow, Poland Introduction: Obesity has been recognized by the World Health Organization as an epidemic of the 21st century. Over the past four decades, the prevalence of obesity has tripled. Considered a problem of high income countries, overweight and obesity is also currently developing in the medium-and lowincome regions of the world. Excess weight can cause the disorder of many systems in the human body. A large role in this area belongs to the Health Care staff-PHC doctor, but especially to the school nurse, necessarily in cooperation with the educators and parents of students.
Purpose: The aim of the study was to estimate the incidence of abnormal body weight in girls and boys in pre-school and school age and in determining the age at which the greatest risk of developing excessive body weight in each sex is observed.
Materials and Methods: The study was attended by a total of 6589 children aged 4-12 from Tarnów kindergartens and primary sch ools, including 3385 boys and 3204 girls. Evaluation of nutritional status was made using anthropometric measurements-height, body weight and body mass index-BMI. The research was carried out in 2014-2017.
Results: The majority of respondents in Tarnów had a correct BMI index. Excessive body weight affects over 19% of Tarnów children, more often boys, and nearly 30% of them are already obese. Overweight is about 14% of girls and 13% of boys, while obese is, respectively, about 5% of girls and 7% of boys. The largest percentage of children with overweight or obesity is a group of 9-year-olds. In this age, too much weight to body height ratio is more than every third child. Underweight is compared to the occurrence of overweight. It is observed more often in girls aged 4 years. Boys 4-7 years old have a higher body mass compared to girls. Apart from 5-year-olds, the differences show statistical significance.

Conclusions:
In the development of excessive body weight in children, the age at which children start primary school is crucial. Perhaps it is a time when one should conduct more intensive education, especially when children start to make independent nutrition decisions. The school nurse's role would also be a relatively frequent monitoring of weight gain in children from grades I-III.