Introduction: Autoimmune hemolytic anemia (AIHA) is rare in childhood, with an estimated annual incidence of 1 per 80,000 people in the general population. Anemia is usually moderate, well tolerated by the patient. Red blood cell transfusions are usually not indicated, except in situations of vital risk.

Clinical case: We present the case of a patient with warm-reactive AIHA. After the diagnosis, she iniciated treatment with glucocorticoids. She needed 2 red cell units, and 3 doses of immunoglobulins as adjuvant treatment.

Conclusions: Usually, transfusion of red cells units in AIHA should be avoided, except in situations of vital risk. Transfusion may intensify haemolysis. However, in some of these patients the disease could be presented as an emergency, that advises the immediate transfusion despite the risks involved, in the presence of signs of cerebral, cardiac or renal hypoxia. Each case must be individualized, and it must be considered in the benefit-risk equation.

Fibrous hamartoma of infancy is a rare benign subcutaneous proliferation, predominantly in males younger than 2 years. Its anatomical location is variable, highlighting the axilla and upper limb. It rarely occurs in the genital region. Diagnosis is difficult, due to its limited symptoms, and should be considered in the differential diagnosis of malignant soft tissue masses. Complete excision is curative and prevents recurrences. We report a case of fibrous hamartoma of infancy located in the scrotum. Clinical, histological characteristics and management are discussed, focus on the uncommon cases of genital involvement reported in the literature.

Introduction: With an overall prevalence of 0,13 to 1,9% in pediatric patients, gallstone disease differs from adult.
Aim: To analyzed several epidemiological, clinical, diagnostic, etiologic and therapeutic aspects of this disease in our area and revise available casuistry.
Method: Retrospective review of gallstone disease recorded at Jerez de la Frontera Hospital (Cádiz, Spain) between 1994 to 2011 in patients <14 years of age. Patients ≤24 months of age were analyzed separately.
Results: Fifty-one patients with cholelithiasis were diagnosed in our department between 1994 and 2011 (29 male and 22 female). Idiophatic gallstone were found in 39.2%, infectious disease with or without antibiotic use in 35.2%, hemolytic disease, obesity, dyslipidemia or family history in 5.8% respectively. 64.7% were symptomatic and 13.7% had complicated disease (choledocholithiasis with cholestasis as more often).
Conclusions: The therapeutic strategies were extremely heterogeneous. It depends on age, lithogenic disease, symptomatic and/or complicated disease associated.

Changes in gait are a common reason for consultation in pediatric emergencies, however cases of true gait ataxia are rare in pediatric patients. The main concern of professional emergency lies in the exclusion of serious causes of this clinical syndrome, fortunately in most cases the origin in childhood is usually benign and self-limiting process.
Among the acquired ataxias, the most common form of presentation in the pediatric emergency is usually that of acute ataxia, which are those whose evolution is less than 72 hours in a previously healthy child. In this review we have analyzed the cases of acquired ataxia evaluated in our pediatric emergency department during a period of 11 years and what was the diagnostic approach. In our series of cases the most common cause of acute ataxia was postinfectious (39.13% of total), followed by the tumoral origin (17.39%) and secondary to ingestion of toxic agents (13.04%).

Obesity and metabolic syndrome are two of the major child health problems in Western society. During the last years, it has been also noticed a decline in sleeping hours among children. Since 1992, many epidemiological studies, both cross-sectional and longitudinal, have shown that chronic sleep deprivation in children relates to an increasing risk of developing overweight-obesity and/or metabolic syndrome (hypertension, increasing resistance to insulin and dyslipidemia). Although precise proccess that make obesity leads to a reduction of sleeping hours are currently unknown, a number of proccess that seem to be somehow involved have been identified. Among others, we may mention the alterations in the hypothalamic-pituitary (several neuropeptides such as leptin and ghrelin), an increasing appetite with special foods high avidity energy, a greater sense of fatigue with consequent reduction in physical activity, and changes in sleep-wake cycle (melatonin rhythm disturbances). This work contains a review of current evidence on the relationship between sleep and obesity within the pediatric population. It is now accepted that children who sleep less hours are more likely to develop overweight and metabolic syndrome, but it has not been possible to demonstrate a clear causality yet. It is necessary to promote adequate sleep among children, not only due to the many beneficial effects already known (cognitive, immunological, behavioral, metabolic and even decrease mortality), but also given its potential ability to prevent obesity and metabolic syndrome.

Nasal obstruction is a frequent symptom of consultation in pediatric otolaryngology, and its most common etiology is adenoidal hypertrophy. Antrochoanal polyps are an uncommon clinical entity that represents 28-33% of the sinonasal polyposis in children. We report the case of an 8-year-old child, with previous adenoidectomy, with symptoms of nasal obstruction, purulent rhinorrhea, headache frontoorbitarias without epistaxis. The nasal endoscopy and imaging tests diagnosed the presence of a polypoid lesion occupying both nostrils and choanae, being treated by endoscopic sinus surgery. Histology disclosed an antrochoanal polyp and allergy study by prick-test ruled out the existence of allergies. Today, we have not yet sufficient histological and/or allergological evidence to determine the etiology of polyps antrochoanal.

Angiokeratomas are vascular malformations characterized by vascular ectasia in the papillary dermis with reactive epithelial hyperplasia and hyperkeratosis, which can occur in isolation or as widespread systemic form associated with metabolic diseases. The solitary angiokeratoma of the oral mucosa is a rare injury, which to Sipponen communication in 2006, always believed typical of systemic forms and very rare in localized. Its occurrence in childhood is likewise rare, having been described to date only 5 cases in children under 18, although some authors suggest that this may be an underdiagnosed disease, hence the importance of adequate study and diagnosis. We report a 7 years with a reddish lesion on the dorsum of the tongue, no pain, no history of trauma, in which physical examination showed a lesion of 14 mm in diameter in right right edge of the tongue with multiple erythematous papules, showing no other changes in the oral mucosa. Excision was performed under general anesthesia and the diagnosis was verified by histopathological examination of the resected specimen.

In recent decades there have been imposing new forms of food consistent with a social model based on consumption and in which the idea of healthy eating has become a huge commercial interests. Often referring to fast food and the Mediterranean diet, both media and professionals make some general assessments, inaccurates and which ignore the cultural and economic system in which both concepts have been established. In this article we do a recap of various technical information on the subject and offer an overview of these two modes of feeding and its main determinants. We also note the critical importance of education from early childhood intervention and the role of the primary care pediatrician in the prevention of diet-related diseases.

Acute pancreatitis (AP) in childhood is used to present with high levels of amylase, although in certain situations it usually occurs with normal values.

We present the case of a patient who was admitted with a nonspecific symptom of fever, irritability and drowsiness, whose diagnosis of pancreatitis was an intraoperative finding. Serum amylase levels were normal, remaining high, however, levels of lipase.

From this case, we reviewed the literature of the elevation of amylase ad lipase levels in the context of AP in pediatric age.

Introduction and aim: We have perceived an increased frequency and earlier onset of child overweight and obesity. Our objetive is to prove this hypothesis by identifying the age of higher risk of child obesity onset and by studying its association to gender and birth weight.

Material and methods: Birth weight was expressed as z-score and yearly Body Mass Index (BMI) from the first year to the age of eight were collected from all clinical records of 660 children of three Primary Health Centers of Tenerife. Data were classified into three cohorts by their birth year (1989, 1997 and 2000). BMI progression plots were done by gender and cohort. BMI evolution by gender, so intra as among cohorts, has been tested using a multivariate generalized linear model for iterated measurements. ANOVA test was used to estimate at which age the cohorts show a different BMI. The independent predictive power of birth year, birth weight z-score and gender on BMI at the age of eight was evaluated using multiple linear regression models, whereas the influence of these variables on the risk of obesity at eight years old was evaluated using binary multivariable logistic regression models.

Results: Birth year, birth weight z-score and gender show predictive power on BMI at eight years of age, being the former which implies as significant risk of obesity at that age. Obesity onset is more frequent at the age of four years.

Conclusions: a) obesity onset occur at earlier age in our children; b) obesity begins at four years of age in average and is more frequent in boys, and c) a higher birth weight is associated with an increased BMI, at least until the age of eight.

Nutritional rickets has re-emerged in our country because of increased immigration in recent decades, concentrating risk factors in children and adolescents. With the aim of warning about the diversity of presentation of this entity are presented four cases of rickets and recall the main clinical, biochemical and radiological as well as its treatment and prevention.

A. Cabot Dalmau. Rocar d'en Serra, 8. 08310 Argentona (Barcelona).
Correo electrónico: annacabot@telefonica.net

Objective: To evaluate parents' knowledge about asthma.

Material and methods: We delivered the Spanish version of the Newcastle Asthma Knowledge Questionnaire to parents of children with an asthma attack.

Results: The questionnaire was administered to 95 parents (average age of 32.1; 77.7% mothers). The mean score was 16/31. We did not find statistically significant between the score and severity of the asthma attack, need to stay in hospital, previous hospitalization or use of preventive treatment.

39.4% of parents identified correctly the symptoms of an asthma exacerbation. The implication of the bronchospasm and bronchial inflammation in this exacerbation was recognized by 76.6% and 63.8%, respectively. Nevertheless, 47.9 % thought that asthma is a "nervous problem", and 91.5% could not name three triggered factors.

68.1% did not know the names of two medicines useful for an asthma exacerbation, and 41.5% answered that short action 2-agonist are "control medications". 31.9% of these parents did not know about "control medications", 73.4% could not name two of these medicines, and 51.1% answered that antibiotics are an important part in the treatment of asthma.

In addition, 63.8% of these parents believed that cow's milk increases the mucosity, and 25.6% that these patients should not consume dairy produce.

Conclusions: The knowledge of these progenitors was poor; they have false beliefs about the pathogenesis of this disease. Nevertheless, we did not find statistically significant between this low knowledge and the severity of the asthma exacerbation, previous hospitalization or use of "control medications".

The antithrombotic therapy in paediatric patients is carried out using guides extrapolated from adults, in spite of their dif¬ferent haemostatic condition. In the treatment with heparins, the unfractionated heparin (UH) is used in a continuous infusion in a dose suitable to the patient's age and body weight (in children under the age of one 28 U/kg/h and in children over the age of two 20 U/kg/h). In low-molecular-weight heparins (LMWH), sometimes alternatives to oral anticoagulants, the dose varies according to the age, body weight and type of heparin with the therapeutic objective of achieving an anti-Xa level of between 0.5-1 U/mL 4 hours after administration. As regards the oral anticoagulant therapy, its application is problematic because of the different haemostatic conditions of children, with serious hemorrhagic complications accounting for 2% of the cases; the duration varies depending on whether it is a thromboembolism because of thrombophilia (6 months) or whether it is secondary to a disease (minimum 3 months). In acute venous thrombosis a therapy with UH must be started followed by an OAT. In the antiplatelet therapy, used in the arterial thromboembolic processes, the most commonly used drug is aspirin (1-5 mg/kg/day), followed by dipiridamol in doses of 2-5 mg/kg/day. The use of thrombolytics requires a detailed evaluation of the potential risks due to the decrease of the total capacity of the fibrinolytic system. The two most commonly used thrombolytics are urokinase and the tissue plasminogen activator.

Objective: To study the epidemiological and clinical characteristics of migraine and tension-type headache in paediatrics, and to analyze the validity of criteria used to diagnose migraine.

Patients and methods: Information on epidemiological and clinical characteristics, physical examination and complementary examinations, when performed, were collected from medical records of 300 children with acute recurrent headache. The criteria defined by the International Headache Society (IHS) were used in the diagnostic. The sensitivity, specificity and likelihood ratio of the Vahlquist, Prensky and IHS criteria for migraine were all calculated.

Results: A total of 98.3% of the patients had primary headache: migraine (50%) and tensional-type headache (48.3%). Thirty two percent of those with migraine had migraine with aura. The mean age at onset was 8.7 years in migraine and 9.7 years in tensional-type headache (p <0.05), with no differences between sexes. Nevertheless, in migraine aura the age of onset (9.8 years) and prevalence of females (63.3%) were significantly higher (p <0.05). Children with tensional-type headache showed a higher prevalence (p <0.05) of female sex, urban origin and excellent academic performance. Children with migraine had a higher prevalence (p <0.05) of positive family history. In migraine, the pain was unilateral (44.4%) or bilateral (55.9%), pulsatile (87.5%), aggravated by physical activity (68.8%), caused lost days at school (65.3%) and were usually accompanied by vomiting (71%) and photophobia/phonophobia (67%). In the tension-type headaches were bilateral (81.8%) and oppressive (85.3%), they were less frequently aggravated by physical activity (22.3%) or inhibited activities (12.1%) and occasionally accompanied by vomiting (7.3%) and photophobia/phonophobia (18.9%). The pulsating quality, vomiting, one-sidedness and moderate to severe intensity were the items that displayed the greatest discriminating capacity and the IHS criteria were those with the highest diagnostic validity. Diagnosis was not altered by the complementary examinations.

Conclusions: Migraine and tension-type headache are a common cause of recurrent headache in paediatric age. Onset usually occurs in school-age children. The IHS criteria for the differential diagnosis of headache in children are useful, although monitoring its progress would be the gold standard to validate diagnostic criteria.

The incidence of thromboses among the childhood population is 0.07/10,000, in 5.3/10,000 of the cases during the stay in hospital and in 2.4% of the cases of admissions to the Intensive Care Unit. During the first year of life, the prevalence of venous thromboembolism is 40 times higher that at other child¬hood ages. Spontaneous thrombosis, without a justifying etiological cause, requires one or more prothrombotic risk factors for its onset. There are certain congenital risk factors, due to alterations of the haemostasis, that imply a greater risk if they are associated with other genetic factors. The correct diagnosis through a study of the clinical signs and of the non-invasive and invasive diagnostic techniques, as well as the laboratory tests, in which the D-dimer has proven to be highly sensitive, are indispensable before starting any type of antithrombotic treatment.

Introduction: Transient global amnesia (TGA) is a clinical condition characterized by sudden loss of anterograde memory and a varying degree of retrogade amnesia. Immediate memory is preserved and the neurological examination is normal. The memory deficit resolves within a few hours. This condition is frequent in middle-aged or elderly patients.

Case report: A 9-year-old girl developed sudden anterograde amnesia with preserved immediate memory and a certain degree of retrogade memory deficit, associated with a mild headache. The neurological examination was normal. The clinical condition resolved spontaneously in 4 hours. The patient was left with a mild headache and no memory of the attack. As the brain computed tomographic (CT) scan was normal, the clinical condition suggested a case of TGA.

Discussion: The clinical features reported here are characteristic of TGA. This neurological disorder appears spontaneously, but several precipitating factors may exist. The pathogenetic hypotheses include a vascular etiology with transient vertebrobasilar ischemia, an epileptic phenomenon or a migraine-related event. Acute confusional migraine, typical of childhood, presents with clinical manifestations similar to TGA. The diagnosis of this process is based on clinical findings. It has an excellent prognosis and little tendency to recur. Given the fact that TGA is not frequent in childhood, we performed a CT scan to rule out the possibility of a cerebral ischemic attack. The presence of the typical clinical symptoms and a normal neuroimaging study should lead us to consider this diagnosis in childhood as well.

Objectives: emotional and behavioural disorders can interfere with children's performance at school. In this study the differences between the psychological characteristics of children with an educational delay and children without an educational delay are assessed.

Materials and methods: the Strengths and Difficulties Questionnaire (SDQ) is administered to 73 randomly chosen 9-year-old children who attend a primary school. The SDQ detects psychological and psychiatric disturbances in childhood and is made up of 5 scales: prosocial behaviour, hyperactivity, emotional symptoms, conduct problems and peer relationship problems. The SDQ scores of children with and without an educational delay are compared.

Results: differences are found in the scores when considering the variables of educational delay and gender. There are significant differences between the scores of males with and without an educational delay in the scales of prosocial behaviour and behavioural problems (more symptoms are present in males with an educational delay). Differences are found between the scores of females with and without an educational delay in the scales of hyperactivity, emotional symptoms and behavioural problems (more symptoms are present in females with an educational delay).

Conclusions: there is a link between the educational delay and the presence of emotional symptomatology and behavioural problems in the series studied.

The giant congenital melanocytic nevus is a large pigmented lesion that is present at birth. Its incidence ranges between 1/1000-500000 newborns. The most common sites are posterior trunk, face, scalp and extremities. They can have a curious morphology, for example, "bathing trunk" or cape-like.

The authors present the case of a newborn girl with a giant congenital "garment" nevus, which occupies the entire genital and inguinal regions and buttocks, as well as the upper thighs and lower thorax. It has a dark brown and black pigmentation and hypertrichosis, and there are three smaller nevi in the left parietal region, the forearm and the chin. Furthermore, there are flat, pigmented lesions in extremities and thorax. The results of laboratory tests, abdominal and cerebral ultrasound, radiography of the bony spine and nuclear magnetic resonance imaging of the spinal column were normal. The biopsy of the affected skin revealed the presence of an intradermal nevus.

The major complication of a giant congenital melanocyte nevus, apart from the cosmetic problem, is its malignant transformation. These nevi can be associated with neurocutaneous melanosis in up to 25% of the cases. It is essential to initiate treatment as soon as possible.

We report a case of serum sickness in a 3-year-old patient who presented urticaria and arthralgias after seven days of treatment with amoxicillin-clavulanic.

Background: Several papers related to the medical mistakes have been published over the past years. The Pediatrics Emergency Services are specially susceptible as regards to the prescription mistake but there are few specific articles.

Objectives: To determine the frequency and variables associated to the deviations of good medical practice in medical prescriptions in our Pediatrics Emergency Service.

Methods: Retrospective observational study. We revised the prescriptions done during fifty eight days on a random basis (from July 2003 to March 2004). From every prescription: legibility, dose assessment, units, intervals and drug allergies were evaluated. The day of the week, shift and level of training of the prescribing physician were documented.

Results: During the revised 58 day, 3,143 prescriptions were made. One or more deviations to the good medical practice were detected in 1,348 (43%) of the prescriptions. None of the mistakes were classified as severe. The variable where more deviations were detected was the legibility and dosage assessment. In 11% at least one of the elements were considered illegible. Statistical significant differences were found when analyzing the day of the week variables (week-end vs. Monday-Friday, p= 0.0036) and to the level of training (resident vs. pediatricians, p

Conclusions: Medical prescription mistakes are very common in our Pediatrics Emergency Service. None of them were severe but limited the good compliance of the treatment. Some characteristics that make deviations more frequent can be identified in order to design interventions to improve the quality.

Cysticercosis is the most common human's CNS (central nervous system) parasitic disease, and the most frequent cause of acquired epilepsy in developing countries. It is a growing problem in developed countries due to the influx of immigrants from endemic areas.

Treatment with praziquantel and albendazole, although at the beginning it was initially promising, it has been questioned by many authors, because of its side effects, and because many of the patients progressed favourably without the need of any antiparasitic treatment. Many randomized controlled trials which support the use of the antiparasitic treatment in patients with cystic lesions and in contrast enhancing ones have been published.

In patients exclusively with calcified lesions the antiparasitary or steroid treatment is not specified.

However, the decision of administering anthelmintics and or corticoids is not always clear, having to individualize its use when appropriate in the cases where a clear symptom is not shown.

Eating disorders (ED) are one of the psychopathologies with more growing incidence and prevalence in recent decades. Moreover, this growth is expanding towards age segments different from the traditional ones. Specifically, ED is being found with more frequently, in adults with absence of prior pathology, and children beginning from 8-9 years. This work focuses on the latter, analyzing the causes of appearance, the role of the family and the new forms of conceptualization of ED, as well as prevention, making a special emphasis on the fundamental role of the pediatrician regarding early detection.

We present the case of an auriculotemporal syndrome or Frey syndrome in an unweaned baby who was delivered with the assistance of forceps. Frey syndrome in childhood is characterized by recurrent episodes of facial erythema along the distribution of the auriculotemporal nerve. It appears to be a mild condition that tends to disappear spontaneously with time and no specific therapy is needed in affected children. It is important for pediatricians to be familiar with this syndrome that can be interpreted as a food allergy and to avoid unnecessary investigations.

The upper respiratory airways infections in childhood have a high incidence and they are a frequent source of consultation whose management sometimes is controversial because of the use of excessive treatment. The Waldeyer's tonsillar ring is the umbrella protector to prevent many times the infection's progress to the whole organism. Sometimes due to less known circumstances this protection can be lost and therefore cause an important pathology in the health of the child.

We show a girl with a very infrequent process during childhood and which is necessary to diagnose rapidly to avoid its progress. The peritonsilar phlegmon is the first step for an abscess and even though the first intention is to hospitalize hospital, intravenous treatment, complex complementary exams, in many cases a a more conservative attitude could be adopted than the one we used in this case.

We review the bibliography to learn the last changes in how to act in the presence of this disease.