Currently, organ donation rates are insufficient to cover the transplant needs in our population. This has led to the design of a hospital program of organ donation after circulatory determination of death (Maastricht type III donation). Potential donors for this program are those whose vital support is decided to withdraw due to their very severe vital prognosis, given that there is not medical contraindication and the family is not opposed to the donation. These patients will die within 2 hours of withdrawing their ventilatory and circulatory support.
Although the main source of organ recovery for transplantation must still be patients with brain death, organ donation after circulatory determination of death offers more chances for obtaining organs (especially kidneys) and tissues. This situation requires a multidisciplinary team, specific techniques and hospital guidelines and protocols for this donation process. This must be protocoled following the guidelines of the ONT (Organización Nacional de Trasplantes) and the OCATT (Organització Catalana de Trasplantaments).
We report the case of a patient treated in the paediatric ICU for acute intracranial hypertension related to cerebral venous thrombosis in the setting of an acute middle ear infection. The severe clinical situation evolved to withdrawal of life support. She became donor as a type III in the Maastricht donor classification. To the best of our knowledge, this is the first case of asystole donation in a paediatric ICU in Catalonia.

Introduction: Acute confusional state (ACS), also called delirium, is a transient organic mental syndrome in which cognitive functions are altered in a variable way, especially attention. It is more frequent in the elderly and children, although about children literature is still scarce. The causes of ACS can be classified into three main groups: systemic processes, drug intake and neurological diseases. Intoxication, epilepsy, traumatic brain injury (TBI) and central nervous system infections are the most common causes in children. Before an ACS in the pediatric age, a correct history and an adequate differential diagnosis should always be made. Before an abnormal or aggressive behavior with an abrupt onset, it´s important to always rule out the possibility of an organic pathology and not attribute it to behavioral disorders or psychiatric pathology.

Clinical cases: We present four clinical cases of ACS of different etiologies that occurred in the Pediatric Emergency Department of a secondary hospital.

Conclusions: Although ACS is more frequent in adults, pediatricians must be prepared to identify it, treat its symptoms and find out the underlying cause in order to establish early treatment.

La enuresis es un importante problema clínico, familiar y social. Es un trastorno de origen multifactorial en el que los determinantes neurológicos, hormonales y vesicales están claramente influidos por el contexto psicosocial del individuo. Es una condición infradiagnosticada, en la que no se valora de manera suficiente su repercusión emocional y sobre la calidad de vida del niño. También está deficientemente tratada a pesar de las recomendaciones recogidas en las guías disponibles. Un tratamiento óptimo debe iniciarse a partir de los 5 años con un diagnóstico correcto y teniendo en cuenta para cada caso el factor subyacente que condiciona la fisiopatología de la enfermedad. Desde nuestro grupo queremos destacar algunos aspectos clave de esta entidad y resaltar la importancia de su detección en las consultas de pediatría de Atención Primaria y su manejo correcto.

Correspondencia: V. Martínez. Centro de Salud El Llano. c/Juan Alvargonzález, 95. 33209 Gijón. Correo electrónico: martinezvenancio@uniovi.es

Medullary thyroid carcinoma (MTC) is a malignant tumor of the parafollicular C cells of the thyroid, which produces calcitonin (CT). It’s very infrequent in children and adolescents. CT is a well-recognized tool in the diagnosis and the follow up of these tumors. However, few cases of CT-negative MTCs have been reported in literature. This fact makes more difficult to manage these patients.

We present a patient with a moderate risk mutation in RET protoncogene, according to the ATA classification of 2015 who develops a MCT. This case is more precocious and aggressive than what we would normally expect, and it has the peculiarity that tumor markers were between normal limits. We review the literature and analyze possible causes for this event. We also show alternative ways to manage these kind of patients.

M.M. Martínez López. Hospital Doce de Octubre. Avda. de Córdoba, s/n. 28041 Madrid. Correo electrónico: mariamar.martinez.lopez@salud.madrid.org

Introduction: In 1980, Schmitt was the first to coin the term "fever phobia" to describe parents’ unrealistic fears about fever. More than 35 years later, this unfounded fear remains. A survey is conducted in Spain to the workers of four public hospitals. Knowledge about fever in children is analyzed, being the main aim of the study.

Patients and methods: A descriptive, cross-sectional and multicenter study was conducted from 15th September 2015 to 15th October 2015. 4,830 anonymous surveys were sent by e-mail. A sample size of 450 replies was estimated as sufficient, with a miscalculation <4.4% and a confidence interval of 95% (50% heterogeneity). SPSS v22.0 was used for statistical data analysis.

Results: Out of 462 responses were received. Seventy five per cent were women, 56% were under 35 years old, 81% were healthcare professionals and 60% were parents. Results concerning fever knowledge were: 83% affirm that physical methods should be used (not recommended), 60% think that seizures could be prevented with early treatment of fever (false), 56% support that fever should always be treated, even if the child is healthy (wrong) and 41% encourage that antipyretics should be alternated (incorrect). Eighty six per cent of the workers recognized that the fever phobia exists. There are significant differences in responses depending on healthcare and non-healthcare professionals, on being parents or not, and even on gender.

Conclusions: A significant percentage of hospital workers, including doctors and pediatricians, are unaware of the existing recommendations on fever in children. This ignorance favors the persistence of fever-phobia, an infectious fear that leads to unnecessary treatments. Adequate transmission of information to families is needed, but every effort will be arduous while healthcare professionals do not believe their own recommendations.

Parasitic brain cyst is a frequent pathology in endemic areas, but in recent years this disease is increasing in other regions as a result of immigration. Two of the most common diseases that cause brain parasites are hydatidosis and neurocysticercosis. The clinical picture is similar in both entities, for that reason, imaging tests and serology are useful for differential diagnosis. We describe the clinical course of a 9-year-old boy with symptoms of cerebral expansive process. The imaging tests are compatible with parasitic cyst. We initiate antiparasitic treatment and after several months of development, we got the gradual remission of symptoms and the size of the cyst was decreasing.

Herpetic meningoencephalitis and tuberculous meningitis are two severe infectious diseases affecting the central nervous system. In both cases, prognosis depends on early treatment. A four years old girl is presented as a complex clinical case. Symptoms and complementary tools were not enough to differentiate both infections. Only herpes simplex virus type 1 was confirmed in cerebrospinal fluid. However, to complete TB treatment was the final therapy decision. The case was nationally discussed with the Spanish Pediatric TB Research Network (pTBred). No unanimous agreement on whether or not to remove the TB medication was reached.

Langerhans cell histiocytosis (LCH) is a rare disease in children and in a few cases has been described associated to some malignancies like Hodgkin’s disease (HD). Central nervous system (CNS) involvement in HD has been observed in few cases with systemic and recurrent diseases. We report a case of a child who developed these two rare clinical conditions, the coexistence of HD and LCH and the relapse of HD in CNS.

Hypofibrinogenemia is an uncommon but well-recognized complication of acute leukaemia. In most instances, it has been associated with disseminated intravascular coagulation, although other causes as liver injury or treatment with L-asparraginase could exist. The literature includes rare cases in which this coagulation disorder is induced by prednisone as our report. We report the case of a child diagnosed of acute lymphoblastic leukemia with hypofibrinogenemia during the course of treatment with prednisone and we have reviewed the literature concerning the case.

The mucopolysaccharidoses (MPS) are a heterogeneous group of lysosomal diseases caused by the enzymatic deficiency of glycosaminoglycans (GAG) degradation.
Due to recent treatment advances and the fact that early diagnosis and treatment implicate a better clinical outcome, we have started the FIND project. This project is a selective screening to detect possible MPS cases in children using urine and blood samples impregnated in analytical paper, easily obtained in the Pediatrician consultation and supplied in the FIND kit.
We carry out the GAG determination on urine sample. Over those urine samples with an elevated GAG concentration; we can perform the enzymatic activity on the blood sample, in order to identify the possible enzyme defect.

Childhood grief is very different from the adult, showing variable expressivity in each child at each age. Often the information that parents provide the child's death is sparse, late and misleading. They also tend to hide their emotions denying the impact of death in a failed attempt to protect the child from suffering; which prevents the child express their own feelings and encourages present and future psychopathology. Even in schools also addresses the concept of death timidly by teachers.
The primary care paediatricians and school teachers, and professional groups relating closely with the child, can play an important role in advising and supporting bereaved families, minimizing the need for psychological interventions that could induce interpretation and assimilation as a vital disease situation, if handled correctly from the beginning, does not have to become one.
Guidelines for action aimed at parents, other family members and teachers, to educate mental health consultations from primary care pediatrics and from the classrooms are proposed.

Objective: Making a review of the literature and presenting two new cases of traumatic dislocation of the testicle, a rare pathology in the pediatric emergency department. For this reason a study is performed on the publications in journals in spanish and english, with the purpose of bringing us closer to a diagnosis and a management as quickly and efficiently as possible.
Clinical cases: We present 2 clinical cases in young children who went to the Pediatric Emergency Department of the Hospital Torrecárdenas during the years 2010-2012 after suffering two separate accidents. Both of them were diagnosed with dislocation testicular through physical examination with ultrasound confirmation later. Treatment in the 2 cases was surgical (orchidopexy).
Results: In both cases the postoperative evolution was well and subsequent without sequelae.
Conclusion: Testicular dislocation is a rare entity, approximately 1 case/year in our environment, that must be taken into account in the trauma abdomino-pelvic since its early diagnosis and treatment (usually surgical) is of special importance.

Introduction: The introduction of clowns in the day-to-day activities in hospitals is part of the overall work of various professionals seeking to attend to children's emotional states. This paper presents the findings of a survey on the value and repercussions the presence of clowns in the hospital has on the emotional state of children.
Patients and methods: A sample of 182 children between the ages of 4 and 14 was taken from visits and stays at the "Virgen de la Arrixaca" Mothers and Children's Hospital in Murcia. An H-CRIN questionnaire adapted to children was used. Children were interviewed after the performance of a pair of clowns at the hospital.
Results: The children found the clowns' performance amus­ing and stated that they felt happy after the visit. The magic and clowns' routines were the parts they enjoyed most. The majority of the children hope that the clowns will return.
Conclusion: Hospital clowns are a good tool for increasing the positive affect of children in hospital.

Introduction: The objective of the present research is to study the behavior of the faecal calprotectin in the pediatric coeliac disease, comparing its levels while receiving a diet with and without gluten. For the comparison, there were also included healthy children, and patients with diverse non-inflammatory digestive pathologies.
Materials and methods: There have been collected stool samples from de novo coeliac patients (with gluten) and from follow-up coeliac patients (without gluten). As control groups, there were included healthy children without any digestive pathology and others with diverse digestive non-diagnosed disorders from the inflammatory bowel disease.
Results: The faecal calprotectin was significantly higher in the coeliac patients with gluten (119.2 ± 122.6 µg/g) than in the patients with the gluten-free diet (21.5 ± 24.7 µg/g). The later showed similar values to those in the healthy control group.
Conclusions: The faecal calprotectin is higher in the coeliac patients with gluten ingestion than in the coeliac patients with the gluten-free diet and in the healthy group. This could be used as a marker for early detection of gluten ingestion.

Chronic recurrent multifocal osteomyelitis is currently considered a variant of a rare autoinflammatory disorder, which requires a high index of clinic suspicion for suitable diagnostic and therapeutic approach. We present a typical case, providing data on etiopathogenetic hypothesis currently handled in this entity..
The early detection of these malformations can prevent the appearance of chronic lung diseases and can allow for the best therapeutic approach. Although most of the cases do not require treatment, some of them require specific and more aggressive handling.

Objectives: To asses the prevalence and characteristics of voiding and bowel habits in children in our area, and to identify relationships between them, comparing them with results obtained in other populations disparate from ours.
Material and methods: We designed a cross-sectional observational study on voiding and bowel habits in a sample of children in the last year of primary education. After conducting an anonymous survey on these habits, a total of 98 schoolchildren were included in the study. To evaluate its relationship with urinary and bowel habits, groups were created with respect to sex and the presence or absence of urinary incontinence.
Results: The response rate was 70.40%. We analyzed the prevalence rates for urinary and bowel symptoms, showing that the most common abnormal voiding habits were holding maneuvers in 30 (43.3%), urgency in 25 (36.2%), nicturia in 20 (29%), increased urinary frequency in 17 (24.6%), weak stream in 14 (20.3%), any type of incontinence in 10 (14.4%), post void dribbling in 7 (10, 1%), escapes with laughter or effort in 6 (8.7%) and intermittent stream in 5 (7.2%). Four individuals (5.8%) had daytime, nocturnal or mixed incontinence, decreased urinary frequency or delay to initiate urination. Finally, in 2 (2.9%) was noted effort to maintain the voiding, pain with urination or constipation, and only in 1 (1.4%) stool leakage. In addition, urinary incontinence was more common in female individuals.
Conclusions: The survey designed and validated by this study has proven to be an original and useful tool for this purpose, allowing to detect and describe health problems at community level. Female sex favours the presence of urinary incontinence in children. Urinary incontinence has a positive effect on the occurrence of increased voiding frequency, post void dribbling, intermittent urine stream and. These data deserve to be analyzed in future studies more comprehensively.

Introduction: Traumatic brain injury (TBI) is an important pathology in pediatrics due to its frequency and the associated care burden to managing the derivate consequences.
Target: To determinate the epidemiological characteristics of TBI patients treated in the Pediatric Emergency Service of the new "río Hortega" Hospital of Valladolid, after the recent establishment of a new TBI management protocol.
Material and methods: We carried out a longitudinal observational descriptive study which included 127 patients, over a period of six months, who had been diagnosed with TBI, taking the data from a predefined questionnaire.
Results: The average age of the patients was 3.13 years, mostly male (55.9%). The most common cause was the accidental fall. The clinical appearance is more frequent in children older than two years. Most of the cases were classified as mild (94.5%). Only four hospital admissions were prescribed. No deaths were recorded. The CT was performed in 8.9% of the cases.
Conclusion: The results obtained in this study are similar to the one found in the bibliography. Although we get a lower mortality and morbidity rate and a minor indication of diagnostic tests. Initial neurological exploration and the calculation of the Glasgow Score are still the main tools to set the priority in its therapeutic management and prognosis.

Lyme disease is caused by Borrelia burgdorferi, spirochetal bacteria, transmitted to humans by the bite of infected ticks belonging to a few species of the genus Ixodes (Ricinus in Europe, Scapularis and Pacificus in North America and Persulcatus in Eurasia). Disease may involve skin, the joints, central nervous system and the heart. The cardiac affectation is infrequent, especially in children, being limited the published reports.

Objective: The high-flow nasal cannula (HFNC) oxygen therapy is a respiratory support usually used in intensive care units. In our hospital we used it in the pediatric ward (infants and children) since April 2009. Our aim is to test the clinical out­comes, security, and assess the acceptance of its use by the nursing service.
Patients and methods: We reviewed the use of HFNC in acute respiratory failure (ARF) during 2011, establishing three groups: G1, bronchiolitis; G2, children under 2 years with previous episodes, and G3, children over 2 years with previous episodes. Prospectively, we assessed the severity of the ARF, comparing the improvement of the patients, considering the transition of severe distress to moderate distress at 6 respectively 12 hours of the clinical onset. We also realized a survey to all the paediatric ward nurses about their perception of the HFNC (installation and maintenance, interference with medications, diet, side effects, tolerance...).
Results: In our study, 33 patients received HNCF. We saw an improvement in all three groups (p <0.001), without significant differences between them. Taking separately, we found an improvement in each one of them, G1 (p <0.001), G2 (p= 0.003) and G3 (p= 0.006). The perception of nursing about the HFNC is that it's easy to apply, so generally, they had a positive impression about this respiratory support.
Conclusions: The HFNC it's a respiratory support with obvious clinical benefits, easy to use, well accepted by nurses and, as we think, applicable in a hospital ward. Anyway, we mustn't forget that are critically patients requiring maximum vigilance and that not all of them respond favorably.

Objective: To determinate the maternal risk factors in the occurrence of cleft lip and palate in Manzanillo, Cuba.
Method: A case-control study to determinate the maternal risk factors in the occurrence of nonsyndromic cleft lip and palate was done at the "Hermanos Cordové" Paediatric Teaching Hospital in Manzanillo. A consecutive sample of clinical cards of patients attended between 1998 and 2010 was obtained from the Admission Department. Each case was matched with two controls following convenience criteria. The analysis methods were the squared Chi test, odds ratio and its 95% confidence intervals. The Mantel-Haenszel test was used to perform the stratified analysis of variables.
Results: The principal risk factors found, after its magnitude, were: medication during pregnancy (OR= 2.99), mother's age ≤20 years (OR= 2.78), failure in one previous pregnancy (OR= 2.53), mother's age ≥35 years (OR= 2.50), smok­ing (OR= 2.49) and stress (OR= 1.87).
Conclusions: The risk factors obtained in this study agree with literature. Medication during pregnancy was the most important.

Impetigo is a bacterial skin infection, superficial, contagious, usually caused by Staphylococcus aureus, which causes complications such as bone and joint infections, by systemic propagation. Subacute osteomyelitis is a process characterized by nonspecific analytical and radiological symptoms, which often delays the diagnosis especially when it appears on unusual locations. Let us report an 18 month old male patient with symptoms of perioral impetigo who developed a subacute osteomyelitis in the talus and septic arthritis in the ankle. Lab microbiological and radiological test were negative, which delayed diagnosis for 18 days. After failure of two weeks, antibiotic treatment surgical debridement of the abscess and washing of the joint were practiced, associating to it a four weeks parenteral and oral broad spectrum antibiotic therapy against methicillin-resistant S. aureus. We conclude that it is necessary a rough fast diagnosis of hematogenous osteomyelitis in patients with recent history and clinical osteoarticular infections associated. Early diagnosis and careful choice of treatment are essential to prevent relapses and sequelae.

In the first year, the breastfeeding is the gold standard for at least the first 6 months, but there is some dispersion of trends when it reaches the age of introducing complementary feeding. Traditionally, cereals are and have been the first foods that have been recommended as the start of complementary feeding. In recent times there has been a decline that is possibly related to some negative stereotypes so we thought it timely to update its role.

The physiological characteristics of the first years of life are circumstances that are very important to get a good fit in the progression of food in response to the new capabilities will be acquired, in these early years, preferably in their digestive, renal and neuromuscular functions.

Cereals are an excellent source of nutrition, but not everyone has the same properties, so it reviews the composition thereof, to assess the benefits that they have to the health of children, as well as the energy input is needed to cover their needs, and to avoid protected of deficits in vitamins and trace elements. Not only the quantity is important, it is undoubtedly the quality of them and place them in a context of varied and balanced diet that helps compensate the rest of the contributions.

Being important cereals in the diet of our children, we should remember some updated recommendations in different periods of life will have on their use, either in the form of porridge in the early days, as more complex grain more advanced age and highlight the effect that conserve importance in the early years if used correctly.

Disc herniation is a common disorder in adults however, its occurrence in adolescence is much less frequent and extremely rare in children. The etiology and clinical manifestations may be different from disc herniation in adults. Neurological symptoms are infrequent in children and adolescents, and the diagnosis may be delayed for this reason.

We report the case of an obese 11- year old girl with a 1-week history of left-side leg pain and incapacity for walking. Magnetic resonance imaging revealed a posterocentral dics herniation at the L5-S1 level with compression of the S1 nerve root. Surgical intervention was indicated because the conservative treatment failed.

Introduction: Enteric fever (term including typhoid and paratyphoid fever) is a systemic infection caused by Salmonella typhi and Salmonella paratyphi. In developed countries, enteric fever is no longer an endemic disease and has become an infection frequently related to travel to endemic areas.

Patients and methods: Review of cases of enteric fever confirmed by blood culture, during the period from January 1st 2009 to December 31st 2010.

Results: We present four cases: typhoid fever in a 12-year old girl native of Pakistan and in a 13-year old girl from India, who both lived in Barcelona and traveled on vacation to their country of origin; paratyphoid fever in an immigrant child from Senegal and paratyphoid fever in an infant with a turtle as the vector of transmission. In all cases, fever was the main symptom and sign of the disease. All responded well to treatment with amoxicillin-clavulanate. None of the patients had serious complications.

Discussion: Immigrant children who travel to their countries of origin to visit friends and/or relatives are at increased risk of disease. Reptiles, which are common carriers of different Salmonella serovars, may act as potential transmission vector.

Ovarian torsion is an uncommon cause of acute abdominal pain in pediatric patients. Presenting symptoms are nonspecific, requir­ing a high index of suspicion for early diagnosis, essential to increase the viability of the ovary.

We report an 11-year-old, premenarcheal girl, who presented to the emergency department with 4 hours of vomiting and abdominal pain. Upon admission, she experienced initial partial improvement, after 48 hour abdominal pain worsened and fever appeared. Abdominal radiography was performed suggestive of an abdominal mass and abdominal ultrasound and MRI imaging suggestive of ovarian tumor. After surgery it was the final diagnosis of ovarian torsion.

In this case we want to emphasize highly nonspecific clinical presentation of this entity, which together with additional test often inconclusive or misleading, make early diagnosis difficult without a high degree of suspicion.

Strongyloidiasis is a parasitic endemic disease in tropical zones, usually asymptomatic but in immunodepressed patients can induce an hyperinfection and a serious disseminated disease. We report a case of an 18 months old girl from Ethiopia, that comes to consultation with abdominal bloating and diarrhea. Initially was diagnosed and treated as a giardiasis but a clinical improvement was not obtained. Because of the rise of eosinophilia and the persistence of the symptoms, the microbiological studies were repeated and Strongyloides stercoralis larvae were detected in stools. It was treated with albendazole achieving a good result. Strongyloidiasis is a disease that implies diagnostic difficulties, for his symptomatology, for the reliability of the diagnostic tests and for the low incident in our country. The treatment in adults is well established, but in children younger than 2-year-old there is scanty information about the drug of choice.

Trichotillomania is considered, according to DSM-IVR, a disorder of impulse control characterized by recurrent compulsive hair pulling. The age of peak incidence is adolescence, with higher prevalence in women, there are very few reported cases in infants. The etiology appears to be multifactorial; intervening genetic, temperamental and environmental partners. Alopecia of the scalp is the most common clinical manifestation in children. Up to 30% is associated trichophagia and can cause gastrointestinal symptoms and complications such as intestinal obstruction requiring surgical removal trichobezoars. The diagnosis is usually delayed, because adolescents tend to deny and young children is usually not suspected. It forced the differential diagnosis with other organic and psychiatric alopecia. The prognosis depends primarily on age of onset. Current treatments combining behavior therapy with anxiolytic drugs. Given the impact of the trichotillomania in the quality of life and self-esteem, calls for a multidisciplinary approach to this disease, requiring close collaboration of family and school environment. The case of an infant 14 months of age who presents with a plate of alopecia in occipitoparietal region of 4.5 cm in diameter.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) in children is associated with behavioral and learning disorders and failure to thrive. The identification of risk factors may be useful for early diagnosis and management and for the prevention of future serious complications. The diagnosis of OSAHS is based upon data obtained from the medical records, physical examination and laboratory studies.

There are several diagnostic techniques for this syndrome. Screening methods, such as daytime nap polysomnography, tend to be helpful when the results are positive, but have a poor predictive value if the results are negative. Nocturnal polysomnography is the gold standard and is used in selected patients.

Objective: To determine the magnitude of the problem associated with accidents caused by quad-like off-road vehicles.

Design: An observational study based on alerts received from the Google News search engine between December 27 2005 and April 19 2006.

Setting: The Pediatric Service of Hospital General de Elda in Alicante, Spain.

Participants: Not applicable.

Main outcome measures: Number of individuals injured, age, and sites and types of lesions.

Results: There were 21 accidents with 29 injured, 20.68% of whom were minors.

Conclusions: Quad accidents frequently result in injuries, which can be of consideration. Legal and informative measures should be undertaken to reduce their incidence, especially in minors.

Thyroid hemiagenesis is a rare congenital abnormality, with a prevalence of 0.05%, that is characterized by the absence or hypoplasia of one of the thyroid lobes, more frequently the left lobe. It is usually discovered by chance, on thyroid ultrasound performed during the assessment of elevated plasma thyroid-stimulating hormone (TSH) concentrations or because of the presence of unilateral goiter. Compensatory hypertrophy of the existing lobe frequently develops, probably due to thyroid tissue overstimulation by endogenous TSH. Thyroid function remains normal in the majority of cases, but these patients usually have higher levels of TSH. Close long-term follow-up is necessary in all cases of thyroid hemiagenesis to prevent future complications. We review the clinical features and hormonal status of a group of five children diagnosed in our center over the last 15 years.

Introduction: Lumbar disc herniation is uncommon in individuals under 21 years of age, and extremely infrequent before the age of 10. The clinical presentation differs from that observed in the adult, making the diagnosis difficult. We have reviewed the literature to identify the peculiarities of this lesion in children, in order to distinguish it from the presentation in adults and, therefore, increase the index of suspicion to facilitate diagnosis.

Clinical report: We report a case of herniated L5-S1 disc in a girl who was not quite ten years old. She had been complaining of a limp and left knee pain for about one month. We detected limited lumbar mobility, lumbar scoliosis and a markedly positive result in Lasègue's test. The presence of the herniated disc was revealed by magnetic resonance imaging.

Discussion and conclusions: Lumbar disc herniation is an uncommon lesion, with a difficult and late diagnosis. It should be suspected not only when a patient presents with sciatica, but also when pain is noted in the posterior region of the knee, especially when there is a positive result in Lasègue's test or an isolated and severe hamstring tightness. The diagnostic suspicion is increased by the presence of lumbar scoliosis and decreased lumbar motion, and should be kept in mind when gait disturbances of unclear etiology develop.

Measles is a common childhood disease that generally has a favorable outcome, but sometimes requires hospital admission. In this report, we evaluate the causes for admission by means of an observational, retrospective study of hospital stays due to complications of measles. We reviewed all the medical records corresponding to patients under fourteen years of age admitted to our hospital for measles between January 1, 1999, and December 31, 2004. The most frequent complications were bacterial superinfection of the lesions and pneumonia. Systematic vaccination would decrease the incidence of this disease, as well as the rate of complications and admissions, and the indiscriminate use of antibiotics.

The human intestinal microbiota constitutes a complex ecosystem that plays an important role in human health. This has led to a rapid incorporation of bacterial strains that exhibited specific beneficial properties (probiotics) into the market. The protective role of probiotic bacteria against gastrointestinal pathogens and the underlying mechanisms has received special attention. Bifidobacterium strains are predominant inhabitants of the intestinal tract of infants and one of the main sources of probiotic strains. This genus is considered to be essential for maintaining the balance of the intestinal ecosystem. Bifidobacterium strains exert in vitro antagonistic activity against important gastrointestinal pathogens belonging to the genera Listeria, Clostridium, Salmonella, Shigella, Proteus, Escherichia and Candida. Clinical evidences also support a protective role of some probiotic bifidobacteria in acute infectious diarrhea and antibiotic-associated diarrhea in children. There is an increasing body of evidence about the multiple mechanisms (competitive exclusion, immunomodulation, synthesis of antimicrobials, etc.) by which bifidobacteria could promote the immature infant defenses. Moreover, a large number of rigorous clinical trials on well-identified probiotic strains will be required to find general recommendations of probiotic-containing products for specific purposes in the infant population.

Aim: To describe the diagnosis and therapeutic management of childhood diskitis.

Patients and methods: A retrospective review of 19 consecutive cases of diskitis diagnosed in our center over a 16-year period.

Results: Fifty-eight percent of the patients were boys, 74% of them younger than 4 years old. A slight increase in the incidence was observed in summer. The mean delay in diagnosis was 20 days. The clinical findings were refusal to stand (57.9%), fever (42.1%), paraspinal muscle spasm (31.5%), back pain (31.5%), irritability (26.3%), refusal to walk (21%) and abdominal pain (15.7%). The analytical studies revealed an increase in the erythrocyte sedimentation rate in nearly every case. The blood culture was positive in 11.2% of the cases. In the one case in which aspiration of the disk space was performed, Staphylococcus aureus was isolated. Radionuclide bone scan and magnetic resonance imaging were the most sensitive tests (91% and 86.6%, respectively). The most common sites were L4-L5 (31.5%), L5-S1 (21%) and L3-L4 (15.8%). All the patients were treated with immobilization and 89% received antibiotics. The mean hospital stay was 17 days. There was one case of recurrence. Four patients presented sequelae.

Commentaries: Diskitis is more frequent among preschool children. The most common onset symptoms are refusal to stand and fever. The low incidence and lack of specificity of the symptoms explain the diagnostic delay. The lumbar region is the most frequent location. Radionuclide bone scan and magnetic resonance imaging are of great utility in the diagnosis of diskitis. Treatment is based on antibiotics and immobilization.

The metabolic syndrome is a pathology with an increasing prevalence in children and teenagers. Nevertheless, its exact etiopathogeny is unknown, and diagnostic criteria vary depending on authors and experts' committees. Likewise, its prevalence varies depending on whether adult parameters or paediatric parameters are applied, and in case of using the latter it will vary depending on the chosen cut-point. These features, together with current matters of its treatment, are reviewed in the present article.

Psoriasis is a chronic inflammatory skin disorder that affects 2% to 3% of the population. Approximately one-third of the patients note its onset during childhood, and it accounts for 4% of the cutaneous disorders in children. The face and intertriginous areas are often involved, and they are particularly sensitive to the adverse effects of steroid use. Topical calcineurin inhibitors are an effective and safe option for the treatment of inverse psoriasis in children.

Although the majority of the guidelines recommend the use of noseclips for the performance of spirometry, there is no consensus among specialists as to whether it is really necessary. Small children frequently refuse the noseclip, thus making the performance of pulmonary function studies difficult. The purpose of this study was to determine whether there are differences between spirometry performed with and without noseclips in children. We studied 119 children between 4 and 17 years of age. They underwent two sets of measurements (with and without noseclips) in random order. The results obtained in forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and forced expiratory flow (FEF25-75%) were very similar, with no significant differences. Only the peak expiratory flow (PEF) measurement was statistically superior when it was performed without a noseclip. This study has demonstrated that the non-use of noseclips in children during spirometry does not significantly modify the results of the test.

Hydatidosis continues to be an important cause of morbimortality in several parts of the world. The definitive diagnosis of the hepatic disease depends on the combination of imaging techniques and serological studies. Surgery continues to be the preferred treatment, especially in the case of large or complicated cysts.

We present the clinical case of a 5-year-old patient in whom, during a routine examination, an abdominal mass located in the right hypochondrium was found. The patient had been in contact with a dog that was properly dewormed. Through an ultrasound scan and abdominal NMR imaging a hepatic cyst measuring 11 cm in diameter was diagnosed. The serology confirms the etiology since it shows a titre of antibodies against Echinococcus of 1/128. In view of the size of the cyst the chosen treatment was surgery consisting of a cystectomy. Both the study of the cystic fluid (Echinococcus granulosus are seen) as well as the histology of the surgical specimen are diagnostic of a hydatid cyst. The patient's clinical evolution was satisfactory, with the antibodies against Echinococcus becoming negative after the patient had been followed up for a year.

Deep venous thrombosis is rarely seen in paediatrics. In recent years an increase has been noted in its incidence, linked to the greater use of central catheters. We report on the case of a previously healthy girl, free of cardiovascular risk factors, who came to the emergency services with reddening, oedema, increased vascular markings and a feeling of tightness in her right arm of 3 weeks of evolution. A haemogram, blood biochemistry analysis and basic coagulation tests were performed, with normal results. The echo-Doppler revealed a thrombosis of the right subclavian vein. An out-patient treatment was prescribed, initially with low-molecular-weight heparin, and a course of oral anticoagulants was maintained for 6 months. Once the treatment was stopped, a thrombophilia study was performed, with normal results. One year later, the girl is asymptomatic and without treatment. This group of patients is treated according to the findings of the studies on series of adults, since very few paediatric studies have been published on the subject.

The prevalence of malnutrition among children admitted to a Pediatric Intensive Care Unit (PICU) is around 15% to 20%, despite the fact that inadequate nutrition can increase morbidity and mortality. We designed this study to evaluate the nutritional support in a PICU and to determine the causes of inadequate nutritional provision over a 6-month period.

Material and methods: The medical records of 40 patients (18 girls, 22 boys), randomly selected from the 238 admissions during the study period, were reviewed. The length of the stay was over 48 hours in every case. The following data were recorded: personal data, anthropometric data, type of nutritional support, time since admission to the PICU, adherence to requirements (Schofield equation) and causes of inadequate nutrient supply. Data are presented as the mean and standard deviation or as a percentage, as appropriate.

Results: The mean age at admission was 10.5  23.5 months (range: 3 days to 10 years). Sixty-four percent of the patients had been admitted after surgical treatment of a congenital heart defect. The mean length of stay in the PICU: 22.6  24.5 days (range: 3 to 112 days). Five patients died during the PICU stay. Type of nutritional support: 2 children received parenteral nutrition (PN) alone; 6, PN plus continuous enteral feeding; 16, continuous drip alone; 6, continuous drip plus bolus feedings; 3, continuous drip plus oral feedings; 3, bolus feedings; and 3, other combinations. On average, NS started 2.17  1.06 days after admission. The percentage of days on which the patients received the estimated requirements ranged between 16% and 65%, depending on the type of NS. Delivery of nutrients was below the prescribed load in 10% of cases. Only 27.5% of the patients received an adequate energy load throughout the entire stay.

Conclusions: Only a small percentage of children admitted to the PICU received adequate nutritional support. Enteral nutrition, alone or in combination with other feeding methods, constitutes the most widely employed feeding technique in the PICU. It is necessary to implement nutritional support algorithms in the PICU to improve these results.

As a whole, viral hepatitides are an important problem on a world level, with high rates of incidence and prevalence, which vary greatly according to the different regions.

Until now five different hepatitis-causing viruses have been characterised, with certain different clinical and epidemiological characteristics. Hepatitides A and E are faecal-orally transmitted and do not produce chronic diseases. Hepatitides B, D and C, on the other hand, are mainly transmitted parenterally and sexually, and can cause chronic diseases, especially among the paediatric population.

The initial study of the immigrant child should include the serologic tests for the HBV infection. Although the vaccination against that virus is universal, the immunoprophylaxis does not tend to be carried out properly in newborns.

Hepatitis A is endemic to developing countries. It tends to affect children who return to their countries to visit family members and friends, which is why it is especially important that the hyperimmune gamma-globulin vaccination/administration is given, as the case may be, before the trip.

In general, the incidence of hepatitis C is low in infancy (

The objective of this study was to determine the rates of infection, hospitalization and complications of varicella on the Island of Mallorca. To study the incidence of varicella, we retrospectively reviewed the cases reported to the National Network of Epidemiologic Surveillance during the period 1982-2005. Rates of hospitalization were obtained from the discharge records of the patients admitted to the three public hospitals of the island during the periods 1995-2000 and 2001-2005. Rates of admission and complications in the reference hospital (Hospital Universitario Son Dureta) were also studied.

The incidence of varicella decreased from 994/100,000 population during the period 1982-1989 to 521 in 2001-2005 (p <0.0001). Overall, the rate of hospitalization for varicella increased significantly from 10.6/100,000 population aged <15 years (or 1.62/1,000 varicella cases) during the period 1995-2000 to 26.4/100,000 (or 3.54/1,000 cases) in 2001-2005 (p <0.0001). The mean age of the patients was 2.8 years and there were no deaths. The most frequent complications among the 147 children admitted to the reference hospital were: cellulitis (13%), impetigo (10.2%), pneumonia (9.5%), seizures (8.8%) and arthritis (4.8%). An increase in the prevalence of sepsis in hospitalized varicella patients was observed (2/45 versus 9/101, p= 0.3).

Although the incidence of varicella infection seems to be decreasing in Mallorca, we have observed an increase in hospital admissions and severe complications due to this infection. Vaccination against varicella at 12-18 months would probably reduce this trend.

The design of probiotics specifically targeted to the infant population is attractive to both the medical community and the industrial sector since they could facilitate the creation of a safe and efficient barrier against pathogenic microorganisms and, in addition, they can contribute to the maturation of the gut-associated lymphoid tissue. At present, there is scientific evidence supporting the beneficial effect of certain probiotic strains on infant health, particularly in relation to the reduction in the duration and/or severity of diarrheal episodes associated with acute infectious gastroenteritis, including those secondary to antibiotic therapy. On the other hand, some strains may exert preventive and therapeutic effects on atopic eczema and other allergic diseases, although additional clinical studies will be required before probiotics can be used for the treatment of such conditions on a widespread basis.

Fever is the most common reason for consultations in hospitals and the second most common reason in primary care. In view of that fact, all paediatricians are obliged to have in-depth knowledge of its treatment. Ibuprofen and paracetamol are the antipyretics most commonly consumed by the paediatric population. The parents of our patients believe that ibuprofen is the most effective option; that fact seems to have been confirmed in recent studies, after many years of controversy. Leading research on antipyretics has reintroduced a practice that has been condemned over the last few years: the alternation of two drugs to reduce the fever. Thus, two recently published clinical trials demonstrate the efficacy and the innocuousness of the alternation, and a third supports the efficacy and the safety of taking two antipyretics simultaneously.

Moreover, this review aims to lay the foundations for a suitable health education programme regarding fever, and to raise questions that should be addressed in the future.

Immune antibodies are of clinical importance because they can produce a hemolytic reaction or hemolytic disease of the newborn. The aim of this study was to detect ABO immune antibodies in children with ascariasis. Serum samples were collected from a population of children with ascariasis and from a control population of healthy children. The ABO group was determined in the sera, and it was recorded if the child had received antiparasitic treatment at the time of the sample collection. The study of anti-A and anti-B antibodies involved a qualitative hemolysis test, mean hemolysis time, agglutination and titration in a saline medium and an enzyme medium, titration before and after 2- mercaptoethanol treatment in an enzyme medium, and a thermal amplitude test. An inhibition test for anti-B antibodies was also carried out in agarose.

The study of ABO antibodies in the population of children with parasitemia showed that 52.63% of the anti-A and 31.03% of the anti-B antibodies had characteristics of immune antibodies. No ABO immune antibodies were found in the control population. The presence of 6 anti-galactose antibodies was demonstrated in the group with ascariasis. All the sera with immune antibodies were collected before or during the specific treatment. The absence of immune antibodies in the children that completed the treatment and in the children of the control population would suggest that ascariasis was the external stimulus for their development. The monitoring of these antibodies would be useful for the evaluation of the course of the infection following treatment.

Introduction: Mycoplasma pneumoniae is one of the main causes of pneumonia in children.

Objectives: To study cases of pneumonia caused by Mycoplasma pneumoniae in children less than 15 years of age in a hospital in Barcelona, to establish the epidemiological, clinical, radiological and analytic characteristics. Another aim was to establish whether there are differences between children under and over 5 years of age and in cases of coinfections.

Methods: A retrospective study was carried out in which the authors reviewed the clinical histories of children under 15 years of age who, from 2000 to 2006, were brought to the Hospital del Mar in Barcelona and who were positive for Mycoplasma IgM. The statistical analysis of the findings was performed using a SPSS software package.

Results: Sixty-three cases of mycoplasma pneumonia were diagnosed, 35 in girls and 28 in boys. The mean age was 5.9 years, and 46% were less than 5 years old. There was a higher incidence during 2002 and 2004, but there was no seasonal prevalence. The most common clinical manifestations were fever (n=57) and cough (n=53), as well as pharyngitis or vomiting, while the great majority of the children were in good general health. Abnormal lung sounds were detected on auscultation in 57 cases; in the majority they were unilateral and involved crackles. Radiographic changes, mainly unilateral, were observed in 59 cases. The results of laboratory analyses revealed no significant alterations. Treatment consisted of penicillin or macrolides. There were 16 cases of coinfection with Adenovirus, six with Chlamydia pneumoniae and one with Enterovirus.

Conclusions: Mycoplasma should be considered as the possible causal agent of pediatric pneumonia. The difficulty in the differential diagnosis with respect to other types of pneumonia, the clinical similarities of this disease in children under and over 5 years of age and the substantial incidence of coinfections are stressed.

Toxic shock syndrome and toxic shock-like syndrome are diseases caused by superantigens that trigger a systemic inflammatory response, which is responsible for the clinical manifestations. We report two cases treated at our institution that meet the diagnostic criteria for toxic shock syndrome: body temperature ≥38.9 ºC, rash with subsequent desquamation, hypotension and involvement of three or more organ systems. The first patient developed multisystem failure with negative cultures, sug¬gesting a probable staphylococcal etiology. The patient experienced a progressive deterioration with no response to supportive care, and finally died. The second case presented as necrotising fasciitis of the abdominal wall, requiring surgical debridement. Streptococcus pyogenes was grown in the samples obtained from the pharynx and from the surgical wound. This patient had a favorable clinical course with tracheal stenosis as the only sequela at the discharge from hospital.

High clinical suspicion is extremely important in this syndrome for the early initiation of antibiotic therapy and intensive care.

Pyomyositis is an infectious disease of the skeletal muscles in which the most common etiologic agent is Staphylococcus aureus. Given the low incidence and the nonspecific clinical symptoms of this disease, a high index of suspicion is necessary in order for the proper studies to be carried out (ultrasound, magnetic resonance imaging, etc.). The treatment is medical and surgical, and long-term antibiotic therapy is generally required.

We present three cases diagnosed in our hospital between October 2001 and June 2004 in children of different ages.

Mucopolysaccharidosis type I is an inherited lysosomal storage disease caused by deficiency of the enzyme a-L-iduronidase that leads to a progressive accumulation of dermatan sulfate and heparan sulfato glycosaminoglycans in organs and tissues and to increased urinary excretion.

There are three clinical syndromes in decreasing order of severity: Hurler (MPS IH), Hurler-Scheie (MPS IHS) and Scheie (MPS IS). Mucopolysaccharidosis I is a chronic, progressive, multisystemic disease. Respiratory insufficiency and sleep apnea-hypopnea syndrome, together with cardiovascular compromise and joint problems, are the main causes of morbidity and mortality.

Bone marrow or hematopoietic stem cell transplantation and enzyme replacement therapy (ERT) are the mainstays of treatment of these patients.

We report the clinical courses of two patients who have been treated with recombinant human a-L-iduronidase (laronidase) for 30 months and a third patient who began ERT 3 months ago. None of these patients has presented adverse events related to ERT.

The high rate of neurological processes with a catastrophic evolution demands the comprehensive, active and continuous care of patients and their families by a multi-professional team, with the prime objective of achieving the best possible quality of life for the child and the child's family.

The neurological disorder must be characterised by maximum diagnostic certainty, a lack of response to the treatment, a progressive evolution, incurability and irreversibility and a fatal prognosis in a relatively short period of time. With these premises, the aim is to provide the patient with total care to die with dignity, limiting therapeutic measures and maintaining the cost-benefit ratio through objectives agreed with the patient, the family and the multidisciplinary team of professionals. The objective of this programme is to combine resources and adapt the care structure to the patient's needs through the application of protocols for comprehensive care, involving information, communication and support provided in the home and/or hospital.

Introduction: One of the most frequent reasons for a visit to the neuropediatrician is related to cranial morphology as regards the uni or bilateral occipital flattening of the child's head. It is important to distinguish between the real posterior plagiocephaly due to the closure of the lambdoidal suture and the occipital flattening without suture closure, with the purpose of guiding on the most appropriate therapeutic measures in each case.

Objective: To assess the existence or not of real posterior plagiocephaly in children with occipital flattening.

Patients and methods: During 4 years, 42 children under a year of age attended the consultation with problems related to the head; nine showed an occipital flattening. All nine cases were requested to undergo a cranial CT scan, recommending the most adequate treatment for each case.

Results: Only one case showed a posterior plagiocephaly. They were all recommended postural measures and physiotherapy, and in three cases the use of helmets. The remodelling of the skull was adequate and both the children as the families tolerated the helmet.

Conclusions: Most of children with occipital flattening do not show a pagliocephaly. In these cases the postural measures, the physiotherapy and in some cases the placement of a helmet is enough to improve and even to normalize the cranial morphology of the unweaned baby.

Proposal for a protocol for the comprehensive care of patients with neurological disorders in the terminal phase, with procedures for their short-term and medium-term care, with dietary and therapeutic measures that bring wellbeing and comfort to patients and their families: hydration and nutrition through a nasogastric or duodenal tube, percutaneous endoscopic gastrostomy, central venous route; control of the vesical and intestinal rhythm; adaptation of the sleep-wake rhythm; physical, psychological and social care; treatment of pain, digestive, orthopaedic and infectious problems; specific therapies for the disease; anti-epileptic drugs; physical rehabilitation; psychological support. In addition, the provision of (current and proactive) information to, and communication with, the patient, the patient's family, health care staff. Continuous care through the control of weight, temperature, cardiac and respiratory frequency, blood pressure, O2 and CO2 saturation, intracranial pressure, blood count, coagulation, biochemistry, proteinogram, urine density and osmolarity.

Introduction: Helicobacter pylori infection is often acquired during childhood. Our objective was to determine the effectiveness and reliability of a rapid antigen test of H. pylori in faeces as an alternative to the breath test in children (criteria of non-invasive reference).

Patients and methods: The patients enrolled where children with suggestive symptoms of H. pylori infection who were attended in our service from June 2006 to April 2007. Tests of rapid detection of antibodies of immunoglobulin G versus H. pylori had been performed, breath test and rapid antigen test of H. pylori in faeces.

Results: Our sample included a total of 94 children, 57% female; mean age 10.4 ± 2.9 years (2-16). By means of a breath test 39 (41.5%) of the children were infected with H. pylori. The faeces test diagnosed 28 (30%) infected children and serology showed 40 (42.5%). The overall sensitivity and specificity of the faeces test were of 54% and 87% and 74% and 80% for the serology test. The children were arranged in different groups of age 8 children less than 6 years old, 61 with ages between 7-12 years of age and 25 children above 12 years old. For the faeces test sensitivity it was 75, 57 and 29% and specificity was 100, 81 and 94%, for these three age groups respectively. Serology sensitivity was 50, 82 and 57%, respectively, and the specificity was 50, 82 and 83%.

Conclusions: The faeces test sensitivity in our study is less than the results of prior publications. In our children population the faeces test is more specific than sensitive and it is more sensitive in younger children. The serological test is more sensitive and specific in children >6 years old.

The use of safe lipid emulsions in pediatric parenteral nutrition represents one of the most remarkable advances in clinical nutrition. For this reason, there is a great interest in optimizing them to enhance their beneficial effects and reduce their risk of complications. Lipids must be part of parenteral nutrition solutions, being a source of essential fatty acids, but also because they are a good source of energy with a low osmolarity. For many years the only lipid emulsions for intravenous administration were those derived from soybean oil with egg phospholipids as an emulsifier. They demonstrated their efficacy and safety, but now, the trend is to use new sources of lipids. Both 50% mixtures of long and medium chain triglycerides and lipids based on olive oil incorporating a small percentage of long chain triglycerides (LCT), have proved their safety in pediatrics and may have some advantages when compared to LCT. Recently, new lipid emulsions containing -3 have appeared in the Spanish market. On the other hand, there seems to be a relation between the administration of intravenous lipids and hepatic failure, but its exact mechanism is not known. Some studies indicate individual factors that would explain the great variability in the risk of hepatic failure related to parenteral nutrition.

The objective of this study is to describe the frequency, morbimortality and treatment of diaphragmatic dysfunction (DD) after pediatric cardiac surgery.

Patients and methods: Series of DD cases identified among the population of children who underwent cardiac surgery at the hospital 12 de Octubre of Madrid from the years1997-2006. Demographic, surgical and postsurgical data have been obtained retrospectively, as well as data on hospital stay and the morbimortality.

Results: A total of 1,063 children underwent cardiac surgery, diagnosing 23 DD cases. A secondary case was excluded due to generalized neuropathy. The global frequency was of 2.1%, the mean age was 14 days (1 d-16 m), being 20 of the cases under 1 year of age. Reefing was performed in 13 patients (62%). The indications for reefing were due to extubation failu¬re (n= 11) and persistent respiratory difficulties (n= 2).

Surgical reefing had to be performed in 9 from the 13 newborns. In the cases of paresis the length of the invasive mechanical ventilation, stay at the PICU and hospital stay was 8, 12 and 20 days (mean) respectively. The paralysis required a longer time of invasive ventilation and hospitalization (19, 34 and 47,5 days).

Conclusions: A diaphragm echography in spontaneous breathing should be performed on any newborn that underwent a complex cardiopathy surgery previous to the extubation in order to determine an early diagnosis and to reduce the length of mechanical ventilation and associated morbidity.

Halitosis is an unpleasant odour emanating from mouth, nose or airway. This is not a usual reason for a direct consultation in pediatrics but is frequently mentioned by the patient´s family. On many occasions, health professionals are not concerned about this type of discomfort. Information about this problem is scarce.

This symptom should be taken into account as it can be the manifestation of several medical and odontological disorders and for the social, economical and psychological implications, mostly in adolescents. The intention of this work is to revise bibliography about etiology, physiopathology, diagnosis and different therapeutic options of halitosis including the newest ones, in order to facilitate the daily practice at a pediatric level. The education of the affected patient is necessary in order to acquire healthy and effective hygienic habits to cope with the halitosis.

Children's diet in our country seems to be deficient in fruits and vegetables and rich in hyper caloric food. The purpose of this study is to access intake frequency of food groups in school children of our environment and the influence gender and ethnicity pose over it as well. We have evaluated the socioeconomic and demographic characteristics, lifestyles and the intake frequency of food groups in a population of 383 2nd, 3rd and 4th grade children from elementary school. Boys consume more daily servings of food rich in carbohydrates (4.38 ± 1.6 vs. 3.97 ± 1.4; p= 0.03) and more dairy products (3.23 ± 1.1 vs. 2.83 ± 1.0; p= 0.002) than girls, and, on the other hand, girls eat more candy than boys (2.81 ± 3.9 vs. 2.01 ± 2.3 servings per week; p= 0.03). A high percentage of children did not meet regular recommended food percentages, both by deficiency: fruits and vegetables (78.1%), dairy products (43.4%) and carbohydrates (42.8%); and by excess: protein food (8.1%), pastries (21.2%), candy (18.9%), and sodas/snacks (8.7%). Children belonging to a certain ethnic group consume significantly less dairy products, protein products and fruits/vegetables; and, at the same time, more pastries, candy and sodas/snacks than children that do not belong to a specific ethnic group. Two significant associations (p <0.01) have been found in the analysis of the relationship between different food groups: 1) fruits and vegetables intake was associated with a higher consumption of carbohydrates and fish, and with a lower consumption of sodas/snacks and time watching TV; and 2) pastry intake was associated with a higher consumption of sodas/snacks and sweets.

The estudy concludes that gender and ethnicity are factors that influence the school children´s diet and they shall be considered as risk factors for malnutrition.

Objectives: Depict the form of the clinical manifestation of the herpetic encephalitis and prove the utility of the different complementary explorations in its use.

Material and methods: Retrospective revision of the herpetic encephalitis cases diagnosed through quantitative PCR which required to be admitted in UCIP (Intensive Care and Pediatric Urgencies). There was a collection of data regarding the clinical evolution and the sensitivity of the different complementary diagnostic methods. In the 7 cases the LCR was reevaluated through DNA quantification by means of PCR and the viral load was correlated with the different clinical data.

Results: 16 cases altogether. Their ages ranged between 19 days and 12 years (mean age: 34 months). The clinical manifestation was undistinguishable of the presented by other encephalitis. Main symptoms were fever (81% of the cases), convulsions (68%), vomiting (62%) and diminished level of consciousness (50%). Imaging tests and neurophysiological studies sensitivity were less than 80% (being less than 50% in the first 24 hours since the symptoms onset). Quantitative PCR is the gold standard for the detection of viral load. Viral load was positively correlated with age, number of leukocytes in CSF and time since beginning of the clinical manifestation. There was no correlation between viral load and disease prognosis.

Conclusions: Neither the clinical presentation or neuroimaging or neurophysiological studies have enough sensitivity for helping diagnosis. On the contrary, we have found that real-time quantitative PCR is useful for the diagnosis of herpetic encephalitis. There was no association between viral load and illness prognosis. The viral load has not been correlated with the clinical picture. However, more studies are needed to evaluate the clinical utility of this technique.

The AIDS pandemic continues to be one of the main problems affecting development and safety throughout the world, in Spain and more specifically in the Community of Madrid (CM). The first to be affected were homosexual/bisexual men, followed by intravenous drug users and infection through heterosexual transmission, a route which affected women, and vertical transmission (VT). VT dominates in children (95.3%). At 31 December 2008, the cohort of children infected via VT in the CM was made up of 261 children. Of those children, 48 had lost their mothers after witnessing their deterioration due to the disease, which had serious repercussions on the children's quality of life and substantially affected their development. Moreover, a change was seen in the route of transmission in mothers as of 2002, with the main route being heterosexual contact versus intravenous drug use. That change was brought about by the increase in the immigrant population and by a change in the socio-environmental paradigm since these mothers did not belong to groups with risk practices, but their sexual practices did involve contact that put them at risk. With regard to VT, there is a significant association between the decrease in HIV-1 infections and the taking of antiretroviral treatments like prophylaxis during pregnancy and birth. Nevertheless, VT has not yet been eradicated, which means it continues to be a relevant public health problem.

Spain continues to be one of the countries with the highest HIV/AIDS incidence rates in Western Europe. The Community of Madrid is the area most affected by the infection, with a total of 17,667 cases of AIDS until December 2008, accounting for 23.9% of the cases recorded on a nation level. The south and north-eastern districts of the aforementioned Community, and especially Usera, Puente de Vallecas, San Blas and Hortaleza, were identified as basic transmission areas with a higher prevalence of cases of vertical transmission. A change was also observed with regard to the migration flow in the different districts of the city, with the districts with the highest numbers of immigrants coinciding with those with the highest recorded prevalence rates of cases of vertically transmitted HIV. The prevalence of cases of vertically transmitted HIV was significantly correlated with the percentage of migrants (p= –0.544; p= 0.011), people without degrees (p= 0.487; p= 0.025), unemployed women (p= 0.477; p= 0.029) and populations with a low per capita income (p= –0.508; p= 0.019). Moreover, this leads to the thought that these south and north-eastern districts may also be important areas for the spread of other infectious diseases and, therefore, this report may contribute to the development of effective strategies for HIV education as regards the prevention of risk situations.

Methadone is a synthetic opioid, prescribed worldwide in the management of opiate addiction. This wide distribution has increased the risk of methadone poisoning in children. Methadone overdose is dangerous, particularly in children, where the poisoning episodes occur more frequently under 3 years old.

We describe a case of accidental methadone intoxication in a 16-month infant, and we discuss the characteristics of this severe poisoning. We emphasize the clinical features of intoxication, treatment measures and insist in the importance of an adequate prevention.

It has been considered in occasions that breakfast is the most important meal of the day, although paradoxically it is the most missed meal. There is a growing scientific interest in the role of breakfast in weight control, and in factors such as appetite control, dietary quality and the reduction of risk of chronic diseases. The regular consumption of breakfast has been linked with improvement in academic performance and better social abilities'. Breakfast consumption is also considered an important determinant of a healthful lifestyle and this association may have a positive influence in the prevention of childhood obesity. We will review the scientific data on this topic and will propose some suggestions directed to improve the practice of eating breakfast among our youngsters.

Acute lobar nephronia (ALN) is an acute bacterial infection localized in the renal parenchyma, seldom described in paediatric literature. We present three cases of ALN, one of them acquired through the blood stream. In all three cases, the diagnosis was made by renal ultrasonography.

We highlight the utility of renal ultrasonography for early diagnosis and the importance of appropriate antibiotic treatment.

Introduction: After looking carefully into all the clinical information concerning a lawsuit, an expert medical report is done. A judge should decide if lex artis ad hoc was or not carried out, so medical problems must be clearly exposed.

Method: All the reports done between January 1st, 2003 and December 31st, 2010 were analyzed. Measured variables included: gender, age, reason of claim, sued pediatric subspecialties and court rulings. SPSS v14.0 program was used for statistical analysis.

Results: A total of 344 expert reports were done. Children aged

Conclusions: Clinical reports allowed establishing that, in most of the cases, medical interventions were according to lex artis ad hoc. However, in a few instances, there were some details that made the defence more difficult, especially the absence of correct information in clinical reports. Most of the paediatricians do not realize the possibility of lawsuits. Considering that a correct clinical report is the best way to avoid a lawsuit, we reaffirm in the importance to do it well, in order to prevent unpleasant situations. Good clinical practices have to be learnt in the early years of our specialty, and not as a consequence of a legal claim.

The convenience to recommend or not vitamin supplements is an issue that is presented frequently during consultation. The American Academy of Pediatrics recommends these supplements to determined risk groups and recently, they have also modified their vitamin D recommendations. In a small number of dietetic surveys carried out in our unit about a group of patients following general recommendations about a healthy diet, deficiencies in the intake of some micronutrients where observed. Though the promotion of healthy nourishment is the best way to prevent nutritional deficiencies, sometimes the supplementation is necessary. An individual supplementation must be recommended and pediatricians shall know the existing medications in the market as well as their compositions in order to adequate the dosage to the individual needs of each patient.

A cohort study was done with the objective of investigating the hospitalization risk and some related indicators in children with cleft lip and palate (CLP), compared with previously healthy pediatric population. We followed (since 1986) 98 infants with CLP (patients) and 196 previously healthy children (controls) who were first admitted at the "Hermanos Cordové" Pediatric Teaching Hospital in Manzanillo, Cuba, all of them of two years or less, they were included consecutively from their first hospital admission. The data collection finished when they were 14 years old. The relative risk of readmissions, causes of readmissions and average stay at the hospital were estimated in each group. Children with CLP had high risk of readmissions compared with previously health pediatric population. The risk was greater in the first (0-4) years of life, stage of malnutrition (RR= 7.3), acute respiratory diseases (RR= 3.44) and acute digestive diseases (RR= 3.3) were the principal causes of readmissions. The stay average in patients was more than twice the controls average. The study has a special reference in the pediatric importance in the total attention of these patients.

Introduction: The objective of this study was to determine prospectively the viral etiology of acute gastroenteritis (AGE) in hospitalized weaning babies and describe the clinical characteristics of the principal virus detected.

Patients and methods: All children aged 1 to 23 months admitted to 3 hospitals during October 2006-March 2007 were followed for the presence of AGE from the time of hospital admission until 72 hours after hospital discharge. A stool sample of children with AGE was tested for calicivirus (norovirus and sapovirus), rotavirus, adenovirus and astrovirus by RT-PCR.

Results: Of the 1,576 hospitalized children, 1,300 (82.5%) were fully monitored being our study cohort. A total of 242 children had AGE (18.6% of the cohort) and stool samples from 217 children were obtained (89.7%). In 91 cases (42%) were positive to rotavirus, 72 (33.2%) to norovirus, 7 (3.2%) to astrovirus, and in 2 to adenovirus, not detecting sapovirus in any case, 13 children (6%) showed mixed infections by two or more viruses and 32 (14.7%) cases were negative for the analyzed virus. Norovirus AGE have less apathy and weight loss than the cases of rotavirus but a higher percentage of stools with blood.

Conclusions: The viruses are a frequent cause of AGE among the hospitalized children of less than 2 years of age being rotavirus the principal virus found followed by norovirus. Few clinical differences were observed between rotavirus and norovirus and analytical determination is necessary for their differentiation.

Introduction: It is difficult to carry out clinical trials with homeopathy, and therefore the controversy about its efficiency continues. There is no description, so far, about the impact of homeopathy on chicken pox.

Patients and methods: Exploratory prospective cohort study. Follow up on 160 children less than 15 years of age in three groups treated with homeopathy (group 1), conventional treatment (group 3) or both (group 2). The subjects where followed up until the end of convalescence. These were Number of skin lesions on the thorax, and evolution of symptoms as fever, itching, discomfort, sleep disorder, hunger and headache was analyzed.

Results: The group treated with homeopathy had an age older than (5.6 years vs. 4.2 yrs in group 3), with no differences in the presence of children with fever, itching and number of lesions at the first visit.

In the group treated with homeopathy, respect to the one that received symptomatic treatment there was a significant lower duration of fever (1.4 vs. 2.4 days), less length of the scratching lesions (1.4 vs. 1.8 days) and in the duration of the lesions (of 6.6 in the group treated with homeopathy and 9.2 days in the symptomatic group), without any modification in the rest of the variables.

Conclusions: In this exploratory observational study the homeopathic treatment indicates a possible benefit in reducing the symptoms and the duration of the chicken pox.

Polypoid gallbladder lesions (PGL) in children have rarely been reported. They may be primary or secondary, malignant or benign. They can be asymptomatic or be accompanied by biliary colic, unspecific abdominal pain, nausea, vomiting, bloating, cholestasis, and/or pancreatitis. They are diagnosed through abdominal ultrasound. In most centers surgery is considered if the lesion is larger than 10 mm, if it is associated with gallstones, if the polyp is sessile or flat, if there is a rapid increase in size or if the patient is symptomatic. We report the first case of multiple PGL in a pediatric patient and a review of the changes in the management of this disease in the last five years.