Israel Medical Association Journal

Objectives: To determine whether children with multiple siblings are at increased risk for accidents, to assess whether quality of child supervision varies with family size, and to evaluate the relationship of family size with the rapidity of seeking medical care after an accident.

Methods: We prospectively studied 333 childhood accidents treated at TEREM (emergency care station) or Shaare Zedek Medical Center. Details on family composition and the accident were obtained through parental interview. Family size of the study population was compared with that of the Jerusalem population. Families with one to three children (Group 1) and four or more children (Group 2) were compared with regard to type of supervision and different "Gap times" – the time interval from when the accident occurred until medical assistance was sought ("Gap 1"), the time from that medical contact until arrival at Shaare Zedek ("Gap 2"), and the time from the accident until arrival at Shaare Zedek for those children for whom interim medical assistance either was ("Gap 3A") or was not ("Gap 3B") sought.

Results: Children from families with 1, 2, 3, 4 and ≥5 children comprised 7.2%, 18.3%, 14.4%, 18.6% and 41.4% of our sample compared to 20.4%, 21.8%, 18.4%, 14.7% and 24.7% in the general population respectively. Children from Group 2 were less often attended to by an adult (44.5% vs. 62.0%) and more often were in the presence only of other children at the time of the accident (27.0% vs. 10.5%). Gaps 1, 2 and 3A in Group 2 (6.3 hours, 16.5 hours, 27.8 hours respectively) were longer than for Group 1 (2.7, 10.7, 13.3 hours respectively).

Conclusions: The risk for accidents is increased among children from families with four or more children. The adequacy of child supervision in large families is impaired. There is a relative delay from the time of the accident until these children are brought for treatment. 

Objectives: To review the current status of MAS[1] in a pediatric tertiary care center in Israel, in terms of feasibility, safety, and effect on standard practices.

Methods: We reviewed the files of all children who underwent a MAS procedure in our department during the period April 2002 to July 2004, and compared the findings with those of children treated by standard practices.

Results: A total of 301 procedures were performed in 271 patients: 107 thoracoscopic and 194 laparoscopic. There were no major intraoperative complications. The total conversion rate was 3.65%: 0 for thoracoscopy and 5.6% for laparoscopy (11/194). Twenty-four types of procedures were performed during the study period. The thoracoscopies accounted for 92.24% of all thoracic procedures in the department (107/116), and routine abdominal laparoscopic procedures replaced open surgery in 30–100% of cases (total 44.8%, 194/433).

Conclusions: MAS procedures appear to be safe for a wide range of indications in children. In our center they currently account for a significant percentage of pediatric surgeries. We suggest that the integration of MAS training in the residency programs of pediatric surgeons be made a major long-term goal. The creation of a pediatric MAS study group, which would allow for multi-institutional studies, is especially important in Israel where a relatively large number of pediatric surgery departments handle a small annual number of patients.

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[1] MAS = minimal access surgery

Objectives: To compare the seasonality of children with T1DM in different populations around the world for which data were available.

Methods: We analyzed large cohorts of T1DM patients with a clinical disease onset before age 14 or 18 years.

Results: We found a seasonality pattern only in ethnically homogenous populations (such as Ashkenazi Jews, Israeli Arabs, individuals in Sardinia and Canterbury, New Zealand, and Afro-Americans) but not in heterogeneous populations (such as in Sydney, Pittsburgh and Denver).

Conclusions: Our findings attempt to explain the controversial data in the literature by showing that ethnically heterogeneous populations with a mixture of patients with various genetic backgrounds and environmental exposures mask the different seasonality pattern of month of birth that many children with diabetes present when compared to the general population.

Objective: To analyze the clinical features of cutaneous mastocytosis in a large series of children.

Methods: We conducted a file review of all children clinically diagnosed with cutaneous mastocytosis in our department over the last 20 years. We evaluated gender, age at onset, character and distribution of the lesions, associated symptoms, and course of the disease.

Results: Altogether, 180 patients with cutaneous mastocytosis were identified. The male to female ratio was 1.5:1. About one-third of patients had a mastocytoma, which was present at birth in over 40% and appeared during the first year of life in most of the remainder. Urticaria pigmentosa was noted in 65% of the patients, presenting at birth in 20% and during the first year in most of the remainder. The majority of lesions was distributed over the trunk and limbs. Different kinds of associated symptoms were noted. Prognosis, in general, was good. Only 11% of the cases, all urticaria pigmentosa, were familial.

Conclusions: Most cases of pediatric mastocytosis are sporadic and appear during the first 2 years of life, especially on the trunk. Urticaria pigmentosa is the most frequent variant. The prognosis of pediatric mastocytosis, in general, is good. 

Background: An estimated 10% of all children are subject to recurrent attacks of abdominal pain of unknown origin. When no organic cause is found, the working diagnosis is usually functional abdominal pain.

Objectives: To investigate the possible causative role of occult constipation.

Methods: We defined occult constipation as the absence of complaints of constipation on initial medical history or of symptoms to indicate the presence of constipation. The diagnosis was made by rectal examination and/or plain abdominal X-ray.

Results: Occult constipation was found to be the cause of RAP[1] in 42.6% of children examined. Treatment consisted of paraffin oil and phosphate enema. In 82.84% of cases the abdominal pain subsided considerably or disappeared within 2 weeks to 3 months of treatment. On telephone interview of the parents at 1–1.5 years after discharge, 96.5% reported that both the abdominal pain and constipation had subsided or disappeared.

Conclusions: Occult constipation can be easily identified and treated in a large number of children with RAP who were diagnosed as having functional abdominal pain.

Background: In the developing child the nervous system undergoes a maturation process. The development and organization of any motor ability is the naturally adopted preference among the possibilities and constraints. The motor behavior of children with cerebral palsy is a personal automatic preference based on such constraints. One of the clinical measures designed for measuring the function of children with CP[1] is the Gross Motor Function Measure. Motor development curves for children with CP have been established based on the GMFM[2] instrument and Gross Motor Function Classification System.

Objectives: To examine the change over time in gross motor function for children with CP attending a special education school for handicapped children in Israel.

Method: We conducted a retrospective review of the medical records of children at various ages and with varying degrees of severity who were being treated by a multidisciplinary team. The study population comprised 106 children aged 3–8 years with CP who were attending the school of special education at Assaf Harofeh Medical Center. The GMFM-88 test was performed annually for the study children over a 7 year period (1995–2001).

Results: During the study period the GMFM measures scores improved significantly. The rate of improvement and top achievements over the years differed according to the severity of the motor impairment. The gross motor development reached a plateau at the age of 6–7 years.

Conclusions: The changes in gross motor development of the study population were similar to the profile of changes in the developmental process of children who develop normally. The nature of the curves of gross motor change for the children with CP should be borne in mind when designing individual treatment goals and strategies for a child.

Background: Contralateral exploration of the groin has been common practice among pediatric surgeons for nearly 50 years, based on the high incidence of patent processus vaginalis on the contralateral side with the potential for the subsequent development of a hernia.

Objectives: To evaluate transinguinal laparoscopic examination of the contralateral side during repair of inguinal hernia in children in order to reach a decision regarding exploration of the contralateral side.

Methods: Over a of 21 month period 124 children with unilateral inguinal hernia underwent laparoscopic evaluation of the contralateral groin. The operations were performed under general anesthesia as ambulatory procedures.

Results: Transinguinal contralateral laparoscopic exploration was positive (patent processus vaginalis) in 26 children (21%) and negative (closed processus vaginalis) in 88 (71%). Failure to introduce the telescope occurred in 10 patients (8%) due to a friable or narrow hernia sac. Twenty-five children below 2 years of age were spared exploration of the contralateral side as a result of the negative laparoscopic examination. On the other hand, 15 children aged 2–17 had their contralateral groin explored because of a positive finding at laparoscopy.

Conclusions: Transinguinal laparoscopic examination of the contralateral side during repair of inguinal hernia in children is a simple, safe and quick method to avoid systematic bilateral explorations and should be part of every pediatric surgeon's experience.

The treatment of acute pain and anxiety in children undergoing therapeutic and diagnostic procedures in the emergency department has improved dramatically in recent years. The availability of non-invasive monitoring devices and the use of short-acting sedative and analgesic medications enable physicians to conduct safe and effective sedation and analgesia treatment. In today's practice of pediatric emergency medicine, sedation and analgesia has been considered as the standard of care for procedural pain. In most pediatric emergency departments throughout North America, "procedural sedation and analgesia" treatment is being performed by non-anesthesiologists (qualified emergency physicians and nurses). In 2003, the Israel Ministry of Health published formal guidelines for pediatric sedation by non-anesthesiologists; this important document recognizes for the first time the need for pediatric sedation and analgesia in the operating room. We describe the basic principles of procedural sedation and analgesia in children and urge physicians working in pediatric emergency rooms in Israel to expand their knowledge and be more involved in the treatment of pediatric procedural pain.

Background: The management of diabetes in preschool children poses unique difficulties for both the families and the medical team.

Objective: To test the feasibility and safety of insulin pump therapy in the 1–6 year age group in order to improve quality of life and metabolic control.

Methods: The study group comprised 15 type 1 diabetic children aged 1–6 years old (mean ± SD, 3.8 ± 1.2 years) from three diabetes centers. Insulin pump therapy was applied for 12 months. Data, including insulin dose, hemoglobin A1c, hypoglycemic events, as well as scores on the Diabetes Quality of Life Measure Questionnaire and the Diabetes Treatment Satisfaction Questionnaire, were collected and compared with the multiple daily injections treatment prior to entry into the study.

Results: HbA1c[1] was measured at the beginning of the study and at 2, 4, 8 and 12 months later; the respective levels (mean ± SD) were 8.82 ± 0.98, 8.45 ± 1.05, 8.37 ± 0.85, 8.32 ± 0.71, 8.18 ± 0.90%. HbA1c measurements after 12 months were significantly lower than at the beginning of the study (P < 0.05). There were no significant differences in insulin dose and the total number of hypoglycemic events. In both the DQOL[2] and DTSQ[3] scales there were significant differences in scores in favor of the insulin pump period (43.7 ± 8.0 versus 33.7 ± 7.9, P < 0.001; and 10.9 ± 2.3 versus 14.5 ± 2.3, P < 0.001), respectively.

Conclusions: For very young diabetic children, insulin pump therapy improves quality of life and is feasible and safe. It should be considered as an optional mode of therapy for this age group.