Current Pediatric Reviews (v.11, #4)

Meet Our Editorial Board Member by Yong Poovorawan (233-233).

In recent years due to the technological advances in imaging techniques, which have undoubtedly improved diagnostic accuracy and resulted in improved patient care, the utilization of ionizing radiation in diagnostic imaging has significantly increased. Computed tomography is the major contributor to the radiation burden, but fluoroscopy continues to be a mainstay in paediatric radiology. The rise in the use of ionizing radiation is of particular concern with regard to the paediatric population, as they are up to 10 times more sensitive to the effects of radiation than adults, due to their increased tissue radiosensitivity, increased cumulative lifetime radiation dose and longer lifetime in which to manifest the effects. This article will review the estimated radiation risk to the child from diagnostic imaging and summarise the various methods through which both the paediatrician and radiologist can practice the ALARA (As Low As Reasonably Achievable) principle, which underpins the safe practice of radiology. Emphasis is on the justification for an examination, i.e. weighing of benefits versus radiation risk, on the appropriate utilization of other, non-ionizing imaging modalities such as ultrasound and magnetic resonance imaging, and on optimisation of a clinically indicated examination. It is essential that the paediatrician and radiologist work together in this decision making process for the mutual benefit of the patient. The appropriate practical application of ALARA in the workplace is crucial to the radiation safety of our paediatric patients.

Current Gastrointestinal Imaging in Children by Haran Jogeesvaran, Mohamed Elsayad, Ramiya Kirupananthan (243-250).
Gastrointestinal (GI) pathologies in children present with overlapping symptoms and signs. Radiological imaging is assuming a more prominent role in the diagnostic pathway. This article is aimed primarily at paediatricians, helping them to understand and thereby better utilise radiological imaging.
The strengths and weaknesses of the various imaging modalities are outlined in a concise manner. Illustrative conditions are discussed with an emphasis on key diagnostic features along with several, high quality annotated images. Emerging concepts are introduced throughout the article. These are referenced by the latest research to give the reader an update of current GI imaging in children.

Imaging of Chest and Abdominal Trauma in Children by Susie J. Goodwin, Sean G. Flanagan, Kirsteen McDonald (251-261).
Trauma is the commonest cause of death in children over a year old. The injuries sustained and management of these children differs to adults, due to differences in anatomy and physiology. Careful thought must also be given to exposing children to radiation, and CT scans should be performed only in select patients. This article reviews these important points and explains the imaging findings in chest and abdominal trauma.

Neuroimaging of Non-Accidental Injury by Amit A. Roy, Kshitij Mankad, W. K. Chong, Dawn Saunders (262-277).
Deliberate inflicted trauma to children has irrefutably occurred for centuries but the notion of non-accidental injury (NAI) as a distinct clinical entity has only relatively recently been described. Awareness and understanding of this syndrome of abuse has increased greatly in recent decades, although many alternative names have been given to the condition and uncertainty remains as to what exactly comprises the syndrome.
What is not in question, however, is the role of imaging; the radiologist is often at the front line in terms of raising the spectre of NAI and in assessing the probability given the objective imaging features available.
Non-accidental head injury (NAHI) encompasses a broad spectrum of manifestations, ranging from trivial superficial injuries to potentially fatal severe brain trauma. In this review, we aim to introduce the epidemiological, historical and legal aspects of NAI. Focussing specifically on NAHI, current biomechanical theories and neuropathological aspects will be discussed. Finally, the patterns of injury and prognosticating features with respect to the various imaging modalities will be covered, with careful consideration given to differential diagnoses and syndrome mimics.

Interventional Radiology in Paediatrics by Samantha J. Chippington, Susie J. Goodwin (278-292).
As in adult practice, there is a growing role for paediatric interventional radiology expertise in the management of paediatric pathologies. This review is targeted for clinicians who may refer their patients to paediatric interventional radiology services, or who are responsible for patients who are undergoing paediatric interventional radiology procedures. The article includes a brief overview of the indications for intervention, techniques involved and the commonest complications. Although some of the procedures described are most commonly performed in a tertiary paediatric centre, many are performed in most Children's hospitals.

Symptoms, Diagnosis, and Treatment of Cow';s Milk Allergy by Yvan Vandenplas, Johan Marchand, Lien Meyns (293-297).
Introduction: The diagnosis and management of cow's milk allergy (CMA) is a topic of debate because there are no specific symptoms and reliable diagnostic tests.
Method: Literature was searched using databases to find original papers and reviews on this topic.
Results: A "challenge test" is still recommended as the most specific and sensitive diagnostic test, although a positive challenge test does not proof the involvement of the immune system. Only in the rare case of anaphylaxis, the challenge tests is not recommended.
The Cow's Milk Symptom Score (CoMiSS) is an awareness tool for health care professionals to better recognize symptoms caused by the ingestion of cow's milk, but still needs validation. Today, the recommended diagnostic approach consists of an elimination diet with an extensive cow's milk based hydrolysate, followed by a challenge test. Amino acid based formula is reserved for the severe cases. Rice hydrolysates are gaining popularity, because they have been shown to be effective, have a better acceptability, and to be cheaper than the extensive cow's milk based hydrolysates. Soy infant formula may offer an additional alternative option as reviews concluded that about 10-15% of infants allergic to cow's milk will also react to soy.
Gastro-intestinal microbiota manipulation may be of additional benefit in the treatment of CMA.
Conclusion: The development of rice hydrolysates challenge the use of Today, extensive cow's milk based extensive hydrolysates remain the first option for the majority of patients and amino acid formula for the most severe cases. Rice hydrolysates and soy infant formula are considered as second choice options.

The iron requirement for breastfed infants remains controversial. Given the impact of iron on neurodevelopmental outcomes and the questionable impact of iron supplements after iron deficiency has occurred, its importance as a nutrient in this population cannot be down played. Infants are born with relatively large body stores of iron that are marginally related to maternal iron status in developed countries. Delayed cord clamping may increase these fetal stores, but at the present time this is only recommended for preterm infants who are born with low iron stores. The diagnosis of iron deficiency (ID) and iron deficiency anemia (IDA) remains problematic though new laboratory tests (measures of reticulocyte hemoglobin concentration and serum transferrin receptor) hold promise in developed countries. The present evidence supports the potential benefits of iron supplementation of exclusively breastfed infants after 4 months of age, by which time the iron stores present at birth are depleted. This deficit cannot be made up even if the small amounts of iron in human milk are completely absorbed.