Ankara Bilkent City Hospital, Children’s Hospital
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Response to comments “ Prevalence and clinical predictors of sleep disturbances in children with seasonal allergic rhinitis”
We sincerely thank the authors for their thoughtful comments and for their interest in our article entitled “Prevalence and Clinical Predictors of Sleep Disturbances in Children with Seasonal Allergic Rhinitis.” We appreciate their constructive observations, which provide an opportunity to further clarify the interpretation of our findings. The authors raise an important methodological point regarding the potential conceptual overlap between the Allergic Rhinitis and its Impact on Asthma (ARIA) severity classification and the Sleep Disturbance Scale for Children (SDSC). We agree that impaired sleep is one of the components considered when classifying allergic rhinitis as moderate-to-severe according to the ARIA guidelines, and therefore some degree of overlap between disease severity and sleep outcomes is theoretically possible. Regarding the specific question of how many children fulfilled the moderate-to-severe ARIA classification solely because of sleep impairment, this information was unfortunately not available, as we evaluated only the overall ARIA severity classification and did not record the individual criteria contributing to disease severity separately. We agree that evaluating disease severity after excluding the sleep-related criterion would represent a valuable methodological approach and could further clarify this relationship in future studies. The authors also appropriately emphasize that pediatric sleep health is influenced by multiple biological, behavioral, familial, environmental, and developmental factors. We fully agree with this broader perspective. Variables such as screen exposure, physical activity, bedtime routines, and sleep hygiene were not systematically collected, as they were beyond the predefined scope of our study, which primarily focused on the relationship between allergic disease characteristics and sleep disturbances. We acknowledge that these factors may influence sleep quality independently or interact with allergic symptoms, and their inclusion in future prospective studies would provide a more comprehensive understanding of sleep health in children with seasonal allergic rhinitis. Similarly, we appreciate the authors’ comments regarding the broad age range of our study population. We agree that sleep characteristics and their determinants may differ between school-aged children and adolescents owing to developmental and behavioral changes. Participants aged 6–16 years were included in the study because the assessment tool used has been validated for this age range. Furthermore, 78 of the 115 participants (67.8%) were aged 10 years or older, indicating that the study population predominantly consisted of older children and adolescents. Although age was recorded as a demographic variable, age-stratified analyses were not prespecified in our study, and the age groups were therefore not analyzed separately. We believe that future studies specifically designed to evaluate developmental differences across age groups would provide valuable additional insight into the relationship between allergic rhinitis and sleep disturbances. Once again, we thank the authors for their insightful comments and for highlighting important considerations regarding the interpretation of pediatric sleep research. We believe these observations complement our findings and further emphasize the importance of adopting a comprehensive approach when evaluating sleep health in children with seasonal allergic rhinitis.
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Comment on ‘‘Prevalence and clinical predictors of sleep disturbances in children with seasonal allergic rhinitis’’
In the latest issue of the Turkish Journal of Pediatric Disease, Aytekin Güvenir et al. (1) evaluated the prevalence and clinical predictors of sleep disturbances in children with seasonal allergic rhinitis (SAR). The authors reported that 44.3% of children with SAR had clinically significant sleep disturbances and that the total and subscale scores of the Sleep Disturbance Scale for Children (SDSC) were higher in children with SAR than in healthy controls. In the multivariate analysis, a higher nasal visual analogue scale (VAS) score remained independently associated with sleep disturbances. The study offers useful insight into sleep disturbances among children with SAR. The evaluation of different SDSC subscales also provides valuable information by demonstrating that sleep-related difficulties in these children may extend beyond sleep-related breathing disorders. Apart from the study limitations acknowledged by the authors, we would like to highlight several points that may be relevant when interpreting the findings. The relationship between the ARIA severity classification and sleep outcomes may merit consideration. Since impaired sleep quality is itself one of the criteria used to classify rhinitis as moderate-to-severe, some children may have been assigned to the more severe category partly or solely on the basis of impaired sleep quality. Although the grouping variable in Table III is labelled as “sleep disorders,” the identical number of affected children reported according to the SDSC threshold and in Table III (n=51) suggests that the groups were defined on the basis of SDSC-defined sleep disturbance. This definitional overlap may have contributed to the observed association between rhinitis severity and SDSC-defined sleep disturbance. We would therefore be interested to know how many children met the moderate-to-severe classification because of impaired sleep quality alone or together with other ARIA criteria. It would also be informative to know whether the association was explored after excluding the sleep-related criterion from the severity classification. Clarification of these points would help contextualize the reported association between rhinitis severity and sleep disturbance. Although the SDSC captures different manifestations of sleep disturbance, contemporary pediatric sleep-health frameworks conceptualize sleep as a product of interacting biological, behavioral, developmental, familial, environmental, and social influences. Children’s sleep occurs within a dynamic socioecological system in which the child may have limited control over sleep schedules, routines, environmental conditions, and opportunities for healthy sleep (2, 3). In this context, we would be interested to know whether other factors that may influence pediatric sleep, such as screen exposure, physical activity, sleep schedules and bedtime routines were also considered or recorded during the study (4-6). Such factors may contribute to sleep outcomes independently or may form part of the pathway linking allergic symptoms to sleep; for example, children with more severe symptoms may spend less time outdoors, engage in less physical activity, or experience changes in screen use and bedtime routines. Any available information regarding these variables could provide further context for interpreting the finding that nasal VAS score was the only independently associated factor in the model. The broad age range of 6–16 years may also deserve consideration, as sleep patterns and their determinants differ between school-aged children and adolescents. Age-related differences in circadian timing, bedtime autonomy, school demands, screen use, and pubertal development may influence both baseline sleep characteristics and the association between allergic symptoms and sleep disturbance (7). We would therefore be interested to know whether sleep outcomes and their clinical associations were also explored separately in school-aged children and adolescents. Such information, if available, could provide additional context regarding the consistency of the findings across developmental stages. Irrespective of these considerations, the study provides valuable evidence supporting the routine assessment of sleep health in children with SAR. Following the identification of a sleep concern, extending the clinical evaluation beyond allergic symptoms to include relevant child-, family-, behavioral-, and environmental factors may enable a more comprehensive understanding of the child’s sleep difficulties
Clinical course and prognosis of acute post-streptococcal glomerulonephritis in children: A single-center experience
Objective: This study aimed to evaluate the impact of clinical and laboratory findings at presentation on renal function and their predictive value for long-term complications in children diagnosed with acute post-streptococcal glomerulonephritis (APSGN). Materials and Methods: Retrospective data of 37 APSGN patients aged 2–18 years, who were followed at the Konya City Hospital Pediatric Nephrology Clinic between January 2023 and January 2026, were analyzed. Clinical symptoms, laboratory parameters, ultrasonography findings, and treatment details were recorded. Results: Macroscopic hematuria was present in 73% of the patients and edema in 27%; approximately 70% of cases presented during the autumn and winter seasons. Patients who developed acute kidney injury (AKI) had significantly higher levels of C-reactive protein (CRP), anti-streptolysin O (ASO) and uric acid (p=0.004, p=0.025 and p=0.035, respectively). Increased renal parenchymal echogenicity on urinary system ultrasonography was observed in all patients with AKI (p=0.012). Hemoglobin levels were significantly lower in patients with nephrotic-range proteinuria (p=0.015). A total of 70.3% of the patients required hospitalization with a mean length of stay of 7.5±3.0 days. During follow-up renal function returned to normal in all patients and proteinuria regressed to normal levels in the majority of patients. Conclusion: Elevated inflammatory markers (CRP, ASO), high uric acid levels and increased renal parenchymal echogenicity are valuable early indicators of AKI in APSGN. Careful assessment of these non-invasive parameters at presentation is crucial for the early identification of high-risk patients and for guiding the management of potential complications.
Robotic-assisted Kasai portoenterostomy in biliary atresia: A case report and technical considerations
Biliary atresia is a rare and fatal cholestatic disorder characterized by progressive obliteration of the extrahepatic and intrahepatic bile ducts, typically presenting during the neonatal period. Ethology remains uncertain, although immune-mediated injury, viral triggers, and developmental anomalies have been implicated. Kasai portoenterostomy is the primary treatment for biliary atresia, with optimal outcomes achieved when performed within the first 60 days of life. Despite early intervention, many patients experience progressive cirrhosis and portal hypertension. Liver transplantation remains the definitive therapeutic option. The timing of liver transplantation in early infancy remains controversial. A primary concern is increased mortality associated with the inability to administer live childhood vaccines to infants transplanted before six months of age, thereby elevating the risk of subsequent life-threatening infections. A 6-kg infant was diagnosed with biliary atresia and underwent surgery 84 days of age. Robotic-assisted Kasai portoenterostomy was performed to maintain bile flow until transplantation and to minimize adhesion formation, both of which are beneficial for subsequent transplantation. This report presents the technical aspects of the procedure.
Comparison of febrile neutropenia episodes and outcomes in Turkish versus refugee children with cancer: A single-center experience
Febrile neutropenia (FN) is a frequent and potentially life-threatening complication of chemotherapy in pediatric oncology. Refugee and immigrant children are often considered to be at higher risk for adverse infectious outcomes due to socioeconomic disadvantage, substandard living conditions, and language barriers. This study aimed to compare FN episodes and short-term clinical outcomes between refugee/immigrant and Turkish pediatric oncology patients managed within a universal healthcare system. Materials and Methods: This retrospective, single-center study analyzed 50 FN episodes, with one episode included per patient, occurring between May and July 2022 at a tertiary pediatric oncology center. Patients were stratified by residency status as Turkish citizens (n=31) or refugee/immigrant children (n=19), primarily Syrian refugees under temporary protection. Comparative analyses included demographic characteristics, clinical presentation, microbiological findings, treatment characteristics, length of hospital stay (LOS), and socioeconomic parameters. Group comparisons were performed using Chi-square and Mann–Whitney U tests. Results: Refugee families demonstrated significantly greater socioeconomic disadvantage, with 94.7% having household incomes at or below the minimum wage compared with 38.7% of Turkish families (p<0.001). Blood culture positivity was higher among refugee patients (26.3% vs. 3.2%, p=0.024). Despite these differences, no significant between-group differences were observed in length of hospital stay (10.42 days for Turkish vs. 12.05 days for refugee patients, p=0.335), treatment intensity, or antifungal therapy requirements. Short-term FN-related clinical outcomes during hospitalization were comparable between groups. Conclusion: Despite marked socioeconomic and housing disadvantages and higher rates of documented bacteremia, refugee and immigrant children experienced short-term FN outcomes comparable to those of Turkish patients when managed in a standardized inpatient setting. These findings suggest that system-level factors—such as universal healthcare access, centralized tertiary care, standardized FN protocols, and language support—may help mitigate the impact of socioeconomic disparities on acute infectious outcomes. However, these results are limited to hospitalized FN episodes and should not be extrapolated to long-term cancer outcomes or outpatient care settings.
Retrospective analysis of child patients diagnosed with scabies, which is frequently confused with atopic dermatitis, in the Şırnak region
Objective: This study examined patients referred to the pediatric and pediatric allergy departments of Şırnak State Hospital with preliminary diagnoses of scabies and atopic dermatitis, who were diagnosed with scabies and underwent treatment, as well as the applied treatment and treatment responses. The aim of this study was to contribute to the literature. Materials and Methods: Data from 77 pediatric patients aged 0–18 years who were referred to the Pediatric Allergy and Immunology and Pediatric Health and Diseases outpatient clinics of Şırnak State Hospital with a preliminary diagnosis of scabies or atopic dermatitis between May 2025 and November 2025 were retrospectively reviewed. Demographic characteristics, household size, bed sharing, nocturnal itching, family history of similar complaints, treatment adherence, treatment use by all individuals in the household, hygiene practices, and clinical treatment response were evaluated. Results: The study included a total of 77 child patients, 29 of whom were girls (37.7%) and 48 were boys (62.3%). The youngest patient was 1 year old and the oldest was 17 years old. A total of 35.1 of the cases were treated with a diagnosis of atopic dermatitis at the initial presentation. Itching that woke the patient from sleep at night was observed in 77.9%, and a family history of similar complaints was observed in 67.5%. Bed sharing was observed in 28.6%, and dormitory living in 9.1%. The rate of patients who achieved clinical benefit from Scabies treatment was 59.7%. While no treatment success was achieved in patients who shared a bed, clinical improvement was observed in 83.6% of those who did not share a bed (p<0.001). Failure to use the treatment together among all individuals in the household and failure to comply with hygiene measures were significantly associated with treatment failure (p<0.001). In the logistic regression analysis, household size and a diagnosis of AD at the initial presentation were significantly associated with treatment failure (B = 3.763, p < 0.001 and B = 8.477, p = 0.022, respectively). Conclusion: The most important determinants of treatment failure in children with scabies are crowded household structure, bed sharing, failure to treat all individuals in the household simultaneously, and inadequate hygiene practices. Cases confused with atopic dermatitis lead to delays in diagnosis. Early diagnosis, correct treatment, and simultaneous treatment of all contacts are critically important in controlling the disease.
Comment on “Clinical and laboratory characteristics of nephropathic cystinosis in a resource-limited region”: linear growth retardation as a clinically important signal
I read with great interest the article by Köksoy and Görükmez (1). Longitudinal data on nephropathic cystinosis from regions of high consanguinity, with constrained access to leukocyte cystine monitoring and uninterrupted cysteamine supply, are scarce, and the authors provide a valuable real-world account of presentation, tubular phenotype, genetics, and renal trajectory. The cohort is especially informative because the recurrent CTNS variant c.681G>A was observed in homozygous form in most genotyped patients. A particular strength of this cohort is the early age at diagnosis, at a median of around 11 months, which the authors note compares favorably with other series from developing settings and likely reflects heightened regional awareness of consanguinity-related disease (1). This makes the outcomes all the more thought-provoking: despite early diagnosis, estimated glomerular filtration rate (eGFR) declined significantly (116.66 to 77.40 mL/min/1.73 m², p=0.007) and height SDS fell further over follow-up, from −2.8 to −3.9 (p=0.034), while weight SDS did not change significantly and body bass index (BMI) SDS remained around −2.0 (1). This gap between early diagnosis and subsequent growth and renal outcome suggests that what determines outcome is not only how early cystinosis is recognized, but what is done after diagnosis to protect growth and bone. Growth retardation was in fact the leading presenting complaint in this cohort, and I would like to use this growth signal to draw attention to three areas that the study, by its scope, could not detail but that are central to that question. Before doing so, one nuance on the data should be addressed. The authors appropriately frame the height decline as multifactorial, citing chronic hypokalemia, persistent acidosis, phosphate loss with defective bone mineralization, reduced caloric intake, and hormonal factors (1). I read the magnitude cautiously given the small sample and heterogeneous follow-up, but the direction is informative: weight did not decline and rose numerically, BMI was stable, and only height fell further behind. To the extent that reduced caloric intake is invoked, this dissociation suggests that it is unlikely to be the principal driver of the linear growth deficit, although the absence of detailed nutritional data in a retrospective cohort precludes a firm conclusion. Either way, linear growth deserves attention as an outcome in its own right. First, the bone-mineral observations may be usefully unified under a single framework. The authors discuss rickets in four patients, nephrocalcinosis in six, and the delicate balance between correcting mineral depletion and overtreatment with active vitamin D, calcium, and phosphate (1). These are facets of what is increasingly recognized, though not yet widely familiar in general practice, as a distinct entity: cystinosis-associated metabolic bone disease (CMBD), which differs from conventional chronic kidney disease (CKD)-mineral and bone disorder (2). Mechanistically, tubular phosphate wasting, reduced 1.25-dihydroxyvitamin D, and chronic metabolic acidosis impair growth-plate mineralization and induce relative resistance to the growth hormone and insulin like growth factor-1 (IGF-1) axis (3). The entity also carries a disease-specific mineral signature with a direct monitoring implication: because persistent tubular phosphate leak keeps serum phosphate low, fibroblast growth factor-23 (FGF-23) remains paradoxically low rather than rising as it does early in typical CKD, so secondary hyperparathyroidism tends to appear late and can be missed if sought only on the usual CKD timeline (4). Bone turnover is additionally altered across CKD stages and deteriorates with age (5). Much of this evidence derives from overlapping European cohorts, so independent confirmation in populations such as the one studied here would be genuinely valuable. Second, the growth hormone axis deserves explicit emphasis. The authors note, appropriately, that effects within this axis may become more evident as chronic kidney disease progresses, consistent with the three patients who reached stage 3 CKD and the three requiring replacement therapy (1). I would add that recombinant human growth hormone (rhGH) may be an actionable option in selected patients before advanced CKD develops. International consensus recommends considering rhGH when adequate cysteamine therapy, nutrition, and symptomatic treatment fail to prevent growth retardation, including in selected patients without advanced renal failure; CKD-specific recommendations support its use once treatable risk factors are corrected and growth potential remains (2,6). In nephropathic cystinosis specifically, long-term rhGH has been reported to roughly double height velocity and to raise height SDS by about 1.6 over three years in prepubertal children on conservative treatment (7). Documenting whether eligible children with persistent growth failure were assessed for rhGH, after optimization of Fanconi replacement, nutrition, cysteamine, and thyroid status, would meaningfully enrich the interpretation of growth outcomes in future cohorts. This last point connects to a feature of the cohort worth underlining: the authors themselves link the relatively high incidence of renal failure to adherence shaped by socioeconomic conditions, and report poorer adherence among those who progressed to advanced CKD (1). Extending their reasoning, I would suggest the same treatment and monitoring gap may also bear on linear growth, since initiation of cysteamine is not equivalent to adequate, adherent, cystine-guided treatment: early initiation and lower leukocyte cystine levels are associated with better linear growth, and outcome depends more on early, presymptomatic intervention than on genotype (8,9). As the authors candidly acknowledge that adherence was assessed subjectively and leukocyte cystine could not be measured locally, this is best read as an association rather than established causation, and likely a bidirectional one; even so, it identifies a modifiable target and reframes early diagnosis as a window of opportunity rather than an endpoint (1). Third, standing height alone may underestimate the burden, because growth in this disease is disproportionate. Compared with other pediatric CKD entities, children with nephropathic cystinosis show disproportionate linear growth and reduced upper-arm fat area, pointing to cystinosis-specific contributors beyond reduced glomerular filtration rate (10). In practice, sitting height and the sitting-height-to-total-height ratio, subischial leg length, the upper-to-lower segment ratio, and upper-arm fat area, together with height velocity, bone age, and pubertal staging, would characterize the deficit far better than standing height SDS alone, and would help distinguish disproportionate, rickets-driven leg shortening from the more harmonious growth deficit of other CKD. These observations are intended to complement rather than detract from the authors’ valuable real-world data. Their findings carry a clear message for pediatricians, pediatric nephrologists, endocrinologists, and dietitians: in nephropathic cystinosis, preserving kidney function and preserving growth potential are parallel therapeutic goals, and early diagnosis delivers its benefit only when followed by adherent, cystine-guided treatment and active protection of growth and bone. I would suggest that future cohorts adopt a standardized growth and bone-mineral module, organized under CMBD, capturing standing and sitting height with segmental measurements, height velocity, mineral-bone biochemistry including FGF-23 and parathyroid hormone where feasible, treatment adherence, leukocyte cystine where available, and growth hormone eligibility. Such a framework would help separate the renal, skeletal, endocrine, and nutritional contributors to growth failure and prompt earlier multidisciplinary intervention during the narrow window before loss of height potential becomes difficult to reverse.
Comment on “Clinical and laboratory characteristics of nephropathic cystinosis in a resource-limited region”
In the latest issue of the Turkish Journal of Pediatric Disease, Köksoy et al. (1) found that growth faltering and progression to renal failure were notable challenges for Turkish patients with cystinosis. We herein address a worthy notice. The CTNS gene mutations encoding a protein named cystinosine, which is a lysosomal cystine transporter, are the primary cause of cystinosis and there are approximately over 140 distinct CTNS mutations. The clinical phenotypes of cystinosis are controlled by the functional effects of the various CTNS mutations (2). Accordingly, sequencing the CTNS gene coding exons has been developed in numerous populations for the early cystinosis identification and characterization of the disease spectrum employing molecular diagnostic tests (3-4). Studies on the genetic landscape of cystinosis in Türkiye are scarce in the literature and they primarily involved small size series in localized settings (5-7). The available study that targeted CTNS mutations at national level based on a Turkish pediatric cystinosis registry was released by Topaloglu et al in 2017 (8). The 57-kb deletion, which is most common among Caucasian cystinosis patients, was not identified in any of the patients. However, seven novel mutations were detected. The most common CTNS mutations were c.681G.A (p.Glu227Glu), c.1015G.A (p.Gly339Arg), and c.18_21 del (p.Thr7Phefs*7) identified in 31%, 22%, and 14% of the patients respectively. Compared to other mutations, the above-mentioned three mutations were importantly correlated with the disease’s earlier onset age and patients with severe CTNS mutations tended to develop worse renal outcomes (8). Notably, the identified genetic CTNS variants in Köksoy et al’s study (1), namely c.681G>A (p.Glu227Glu), c.18_21delGACT (p.Thr7Phefs*7), and c.1015G>A (p.Gly339Arg), contribute to those previously addressed by Topaloglu et al (8). Updating national data on the CTNS mutational spectrum among cystinosis patients and genetic counseling where the families in Türkiye tend to be particularly large and display a high consanguinity rate (18.5%, with first cousin marriages accounting for 57.8%) (9) are deemed critical. These interventions together that recommended by by Köksoy et al (1), namely the initiation of cysteamine therapy, supporting access to the specialized healthcare facilities, and regular monitoring, are solicited to deter further breeding of cystinosis cases in Türkiye on one hand and improve patients’ outcomes and quality of life on the other.
Altered heart rate variability and ventricular repolarization in children with mitral valve prolapse
Objective: The aim of this study was to evaluate heart rate variability (HRV) parameters and ventricular repolarization abnormalities in children with mitral valve prolapse (MVP) compared with healthy controls. Materials and Methods: This retrospective single-center study included 78 children with MVP and 92 healthy controls with similar age and gender distributions. Demographic characteristics, 24-hour Holter-derived HRV parameters, and electrocardiographic measurements were analyzed. HRV indices included SDNN, SDANN, SDANNi, rMSSD, pNN50, total power, VLF, LF, HF, LF/HF ratio, and triangular index. Multiple comparisons were adjusted using the Benjamini–Hochberg false discovery rate (FDR) method. Multivariable linear regression analyses adjusted for age and sex were performed for selected representative variables. Results: Children with MVP demonstrated significantly lower SDANNi, rMSSD, total power, LF, HF, and triangular index values compared with controls after FDR correction. Maximum QTc values were significantly higher in the MVP group. In multivariable regression analysis, MVP remained independently associated with lower HF and rMSSD values and higher maximum QTc values after adjustment for age and gender. No significant differences were observed for LF/HF ratio, SDNN, SDANN, or pNN50 after FDR correction. Conclusion: Children with MVP exhibit reduced parasympathetic modulation together with prolonged ventricular repolarization independently of age and gender. These findings suggest that pediatric MVP may be associated with autonomic and electrophysiological alterations.
Pediatricians’ knowledge of pediatric Mycoplasma pneumoniae infection in the post–COVID-19 period: A single-center cross-sectional survey from Türkiye
Objective: Mycoplasma pneumoniae (MP) remains an important cause of respiratory tract infections and community-acquired pneumonia in children and has regained prominence in the post–COVID-19 period. We aimed to evaluate pediatricians’ knowledge of pediatric MP infection across key clinical domains and to compare knowledge according to professional experience. Materials and Methods: This single-center, cross-sectional, questionnaire-based study was conducted in November–December 2025. A literature-based, face-to-face survey with 29 multiple-choice items (single best answer) assessed knowledge in four domains: risk factors (5 items), clinical manifestations/complications (8 items), diagnostic tests (6 items), and treatment (10 items). Participants were stratified by experience (0–5 years vs. ≥6 years). Item-level correct response rates were compared using chi-square/Fisher’s exact tests, and domain scores were compared using the Mann–Whitney U test. Results: A total of 126 physicians participated (0–5 years: n=93; ≥6 years: n=33). Domain-level knowledge scores were comparable between groups across risk factors, clinical manifestations/complications, diagnostic tests, and treatment. However, several item-level differences were observed; these item-level comparisons were exploratory. Physicians with ≥6 years of experience more frequently answered correctly questions related to the incubation period, cutaneous manifestations, limitations of serologic testing, and identification of an antibiotic ineffective against M.pneumoniae infection. In contrast, physicians with 0–5 years of experience more frequently answered correctly items concerning post-infection immunity, the most commonly affected age group, M.pneumoniae-associated CNS disease, hospitalization-related knowledge, and management of MP-associated hemolytic anemia. Conclusion: Overall knowledge of pediatric M.pneumoniae infection was comparable across experience strata at the domain level; however, item-level findings should be interpreted cautiously as exploratory. These findings support an institution-wide, high-yield educational package prioritizing diagnostic test interpretation (particularly serology), recognition of extrapulmonary manifestations, and evidence-based antimicrobial selection in the post–COVID-19 period.
Pediatric benign transient hyperphosphatasemia: Clinical course and inflammatory ratios
Objective: Benign transient hyperphosphatasemia (BTH) is a self-limited condition characterized by marked isolated serum alkaline phosphatase (ALP) elevation in children without evidence of bone or hepatobiliary disease. This study aimed to describe the clinical course of pediatric BTH and to test the hypothesis that Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) differ between children with BTH and healthy controls. Materials and Methods: In this single-center retrospective study, we screened all pediatric ALP measurements (0–18 years) recorded between 2018 and 2025. Children were included if ALP was at least 2 times the age-specific upper reference limit, liver-related biochemical parameters were normal, there was no clinical evidence of bone or hepatobiliary disease, and ALP normalized during follow-up. NLR and PLR were compared with those of age and gender similar healthy controls without known chronic disease, medication use, or evidence of recent or ongoing infection or inflammatory conditions. Results: Thirty-nine children met the inclusion criteria, with a mean age of 51.9±59.7 months (range, 3–166 months). Of these, 69.2% were younger than 3 years and 59.0% were female. Mean ALP at presentation was 1006.2±1061.9 U/L (range 504–6576). ALP normalized spontaneously within 8.5±3.9 week (range 3–17). Compared with controls, the BTH group had significantly lower NLR (0.85 vs 2.66; p<0.001) and PLR (83.76 vs 122.51; p=0.047). Conclusion: BTH should be considered in clinically well children with isolated ALP elevation after exclusion of serious bone and hepatobiliary disorders. Lower NLR and PLR may provide supportive exploratory information, but require confirmation in larger prospective studies before clinical application.
From stomach to liver: The impact of Helicobacter pylori gastritis on pediatric hepatic steatosis
Objective: The purpose of our study was to examine the association between endoscopically diagnosed Helicobacter pylori (HP) gastritis and hepatosteatosis, and to investigate the correlation between the presence of HP and biochemical and anthropometric measurements in children. Materials and Methods: Patients who were followed up in the Pediatric Gastroenterology outpatient clinic of Kayseri City Training and Research Hospital and underwent esophagogastroduodenoscopy performed by the attending gastroenterologist were evaluated. Patients aged between 2 and 18 years, with a histopathological diagnosis of gastritis, both HP positive and negative, were enrolled in the study. Results: In patients with HP-positive gastritis, the incidence of hepatosteatosis was found to be statistically significantly higher compared to those with HP-negative gastritis (χ² = 22.704; p <0.001). A statistically significant weak positive correlation was found between the density of HP and the grade of hepatosteatosis (rho = 0.344; p <0.001). Conclusion: The HP-positive gastritis in children is associated with the development of hepatosteatosis, and the higher grade of hepatosteatosis in patients with HP-positive gastritis suggests that HP gastritis may impact the development of fatty liver.
Pediatric perioperative management: An integrated review of preoperative evaluation, fasting protocols, postoperative nausea and vomiting, and postoperative pain in light of current guidelines
The aim of this review is to present an integrated overview of pediatric perioperative anesthesia care by focusing on its fundamental components—preoperative evaluation, fasting management, prevention of postoperative nausea and vomiting (PONV), and postoperative pain control—based on current guidelines and evidence. The aim is to emphasize the need for individualized, risk-based approaches in pediatric patients. This study is designed as a narrative review based on current international guidelines and relevant literature on pediatric perioperative anesthesia. Key domains including preoperative assessment, fasting protocols, PONV prophylaxis, and postoperative pain management were evaluated within a comprehensive and integrated clinical framework. Emphasis was placed on risk stratification strategies, avoidance of unnecessary routine investigations, and the implementation of multimodal and age-appropriate approaches. Current evidence indicates that pediatric perioperative care differs significantly from adult practice due to limited physiological reserves, developmental variability, and age-related pharmacokinetic and pharmacodynamic differences. Risk-adapted strategies improve patient safety and outcomes. Specifically, shortened and evidence-based fasting protocols reduce metabolic stress; opioid-sparing multimodal analgesia minimizes adverse effects; risk-based antiemetic prophylaxis decreases the incidence of PONV; and age-appropriate pain assessment tools enhance postoperative pain management. Avoiding unnecessary routine tests further contributes to efficient and patient-centered care. Pediatric perioperative anesthesia care should be based on an integrated, individualized, and risk-oriented approach. The effective combination of optimized preoperative evaluation, evidence-based fasting strategies, tailored PONV prevention, and multimodal pain management improves safety and clinical outcomes. Current evidence strongly supports a shift from routine, standardized practices toward patient-specific, guideline-driven perioperative management in children.
Comment on “Levetiracetam in childhood epilepsy: Expanding the evidence base”
We read with genuine interest the article by Toksöz and Teber recently published in the Turkish Journal of Pediatric Disease, which presents long-term efficacy and safety data on levetiracetam (LEV) monotherapy in 101 children managed at a tertiary pediatric neurology centre (1). The reported seizure-response rate of 72.3%, with complete seizure freedom in 38.0% of patients, positions this study squarely within the broader real-world evidence base and confirms LEV’s standing as a first-line antiseizure medication (ASM) in childhood epilepsy. Particularly clinically useful is the identification of age over four years and low pre-treatment seizure frequency as independent predictors of a favourable response—two stratification criteria that translate directly into day-to-day prescribing decisions. Yet, precisely because this paper contributes to a growing corpus of retrospective evidence on LEV, it also highlights several dimensions that deserve more rigorous prospective investigation. To begin with, situating the results of Toksöz and Teber within the comparative effectiveness literature raises questions that a single-arm retrospective design cannot resolve. A systematic review and meta-analysis of four randomised controlled trials including 381 children demonstrated that LEV monotherapy was associated with a significantly lower frequency of at least one seizure and a 76% reduction in dermatological adverse events relative to carbamazepine (CBZ), while seizure-freedom rates did not differ significantly between the two agents (2). This context matters: an overall response rate of 72.3% is meaningful, but without a comparator arm—whether historical or concurrent—it remains difficult to determine whether this figure reflects a drug effect, a patient-selection effect, or an institutional effect. A large Turkish tertiary centre cohort of 281 children treated with LEV monotherapy across a decade found seizure reduction rates that, while broadly consistent with the current paper, varied substantially by epilepsy aetiology—ranging from idiopathic to symptomatic and cryptogenic forms (3). Heterogeneity in patient mix is therefore a critical variable, and its underreporting limits how far the findings of Toksöz and Teber can be generalised to other settings, Table I summarises the efficacy and adverse-event profiles across the major cohorts and meta-analyses cited in this commentary, placing the index study in comparative perspective. A closely related limitation concerns the absence of structured epilepsy syndrome classification in the cohort. The International League Against Epilepsy (ILAE) 2017 framework —distinguishing focal, generalised, combined generalised-and-focal, and unknown epilepsies—is not a bureaucratic formality; it carries direct and differential therapeutic implications (4). LEV holds regulatory approval as adjunctive therapy for focal-onset seizures and juvenile myoclonic epilepsy, but its behaviour across syndrome subtypes diverges in ways that aggregate response rates flatten into invisibility. A head-to-head systematic review and meta-analysis comparing LEV versus oxcarbazepine in children found that focal epilepsy subgroups drove most of the seizure-free advantage observed with LEV, while outcomes in other syndromic categories were considerably narrower (5). The clinical decision that a practitioner makes when initiating LEV in a child with Rolandic epilepsy—a syndrome with a favourable natural history regardless of treatment—should not be conflated with the decision made for a child with drug-resistant generalised epilepsy. Disaggregating outcomes by ILAE-classified syndrome type is not merely a methodological nicety; it is the minimum granularity needed to transform observational data into actionable prescribing evidence. Future work from this group should prioritise syndrome classification at enrolment. The adverse-event profile documented by Toksöz and Teber —45.5% of patients affected, with drowsiness, irritability, and fatigue predominating—is numerically consistent with prior series (6). The published literature, however, draws attention to a dimension of LEV toxicity that chart-based retrospective ascertainment systematically underestimates: the neuropsychiatric spectrum. Behavioural dysregulation under LEV, encompassing irritability, emotional lability, hyperactivity, and, in a minority of cases, frank psychotic symptoms, has been documented in up to 37.6% of pediatric patients in series that used structured ascertainment methods (7). A systematic review specifically examining behavioural side effects in children on LEV confirmed a statistically significant relative risk of 2.18 for total behavioural adverse events compared to placebo—hostility, nervousness, and aggression being the most frequently reported domains (8). These reactions are not trivial. A child whose seizures are controlled but who becomes aggressive, oppositional, or emotionally dysregulated has not simply ‘tolerated’ the drug; the family’s quality of life has been exchanged for seizure freedom, which is a different clinical outcome entirely. Neurodevelopmental comorbidities magnify this risk: children with pre-existing cognitive or psychiatric vulnerabilities are disproportionately susceptible to LEV-related behavioural deterioration, a factor impossible to fully control for in retrospective designs (9). Integrating standardised tools—the Child Behavior Checklist (CBCL) or the Strengths and Difficulties Questionnaire (SDQ)—at baseline and at each scheduled visit would allow future studies to detect these effects early and systematically, before they become reasons for treatment discontinuation rather than data points in the record. A dimension not discussed by Toksöz and Teber, yet central to understanding long-term LEV performance in children, is the concept of treatment retention as an integrated measure of efficacy and tolerability. In a real-world European pediatric cohort, the one-year LEV continuation rate was estimated at 72%, with insufficient efficacy—rather than adverse events— accounting for the majority of discontinuations. This architecture of drug attrition carries a practical message: achieving initial seizure control is necessary but not sufficient; sustaining it without accumulated tolerability burden is the harder clinical problem. Age-specific pharmacokinetic variability compounds this challenge. LEV clearance in young children is substantially faster than in adults, resulting in lower plasma concentrations at standard weight-based doses and potentially explaining some of the apparent efficacy ceiling observed in younger age groups —a finding that aligns with the age-related predictor identified by Toksöz and Teber (10). Prospective designs incorporating therapeutic drug monitoring would allow disentanglement of pharmacokinetic from pharmacodynamic sources of treatment failure, a distinction with direct therapeutic implications for dose adjustment strategies in the under-four age group. A final perspective, critical from a global pediatric neurology standpoint, concerns the generalisability of these findings beyond well-resourced tertiary settings. A systematic review and meta-analysis estimated the prevalence of childhood epilepsy in sub-Saharan Africa at 7.8 per 1000 population, with treatment gaps exceeding 80% in several regions (11). The recent inclusion of LEV on the WHO Essential Medicines List was a meaningful step, yet access remains constrained in low-and middle-income countries (LMICs) by drug cost, cold-chain logistics, and the scarcity of trained pediatric neurologists (12). A scoping review of epilepsy care outcomes in LMICs underscored that real-world effectiveness data generated in Turkish or European tertiary centres cannot be uncritically transposed to contexts where EEG is unavailable, neuroimaging is sporadic, and the interval between seizure onset and specialist consultation may span years (13). The cohort of Toksöz and Teber does not report on diagnostic delays, socioeconomic stratification, or access-related variables—all of which shape LEV outcomes in resource-limited settings in ways that standard efficacy metrics do not capture. Collaborative networks linking high-income and LMIC centres could help establish globally representative benchmarks and identify which elements of current management protocols are feasibly exportable, Figure 1 proposes a syndrome-stratified, neurobehaviourally monitored prospective framework that could serve as a blueprint for such collaborative efforts. In summary, the study by Toksöz and Teber makes a genuine and valuable contribution: it provides real-world evidence of LEV’s efficacy in a sizeable pediatric cohort, documents the adverse-event landscape with clinical honesty, and offers two stratification criteria with immediate utility at the point of prescribing. The path to a more complete understanding of LEV in childhood epilepsy runs through syndrome-specific prospective designs, standardised neurobehavioural monitoring incorporated from enrolment, retention and therapeutic drug monitoring analyses, and deliberate cross-centre collaboration that places these findings within a global epidemiological frame. Levetiracetam has more than justified its first-line status; the question of for whom, at what dose, and at what neuropsychiatric cost remains, in meaningful ways, open.
Response to the Letter entitled “Comment on Hypertension in children with congenital adrenal hyperplasia: Prevalence and associated factors”
Parental broader autism phenotype and its association with adolescent social anxiety
Objective: Social anxiety disorder (SAD) and autism spectrum disorder (ASD) share overlapping social-cognitive features. The broader autism phenotype (BAP), reflecting subclinical autistic traits in parents, may be relevant in understanding adolescent social anxiety within a family context. This study aimed to examine the association between parental BAP traits and social anxiety severity in adolescents. Materials and Methods: In this study, 109 adolescents with SAD (aged 11–17 years, 79.8% female) and their parents (109 mothers and 109 fathers) were included. Adolescents completed the Social Anxiety Disorder Severity Scale–Child Version, while parents completed the Autism Spectrum Quotient (AQ) and the Social Responsiveness Scale (SRS), used as a secondary exploratory measure of social functioning. Non-parametric analyses and binary logistic regression were performed. Results: Greater SAD severity was associated with lower paternal AQ scores (ρ=–0.29, p=0.002). In addition, adolescents in the higher-severity SAD group had significantly higher SRS scores compared to those in the lower-severity group (p=0.003). Conclusion: Parental BAP traits, particularly paternal autistic traits, may be associated with social anxiety severity in adolescents. However, due to the cross-sectional design, reliance on questionnaire-based measures, and potential shared-informant bias, these findings should be interpreted cautiously and considered hypothesis-generating rather than confirmatory.
Assessing the training needs of pediatric healthcare professionals in communication, risk management, and psychosocial resilience
Objective: The quality of pediatric healthcare is closely tied to the communicative and psychosocial capacities of healthcare professionals. This study aimed to quantitatively determine the training needs of staff working in a tertiary pediatric hospital focusing on communication, management of violence-related risks, and psychosocial resilience. Materials and Methods: A cross-sectional descriptive design was employed using the Hennessy-Hicks Training Needs Analysis approach. Data were collected via an online questionnaire from 133 healthcare professionals. The training need for each specific skill was calculated using discrepancy scores, which represent the difference between the perceived importance of the skill for professional duties and the participant’s self-assessed current competence. Results: Positive discrepancy scores were observed across all 16 items, although the magnitude of these differences was modest in absolute terms. At the domain level, relatively higher training needs were identified in the management of violence-related risks (M=0.44) and the psychosocial resilience/organizational dimension (M=0.42). Communication skills presented a relatively lower but still positive need (M=0.24). The training topics ranked highest included recognizing and coping with burnout, achieving competency in “White Code” (a national emergency response protocol for workplace violence) procedures, and exhibiting safe behaviors during threats. Conclusion: Training needs in pediatric hospital settings extend beyond individual knowledge gaps to represent structural requirements driven by professional roles and high-stress environments. In-service training policies should prioritize risk management and psychosocial resilience as core components, embedding communication skills as a foundational layer rather than an isolated module. Training designs must be sensitive to specific professional roles, unit intensities, and shift schedules.
Family relationships in the digital age: The impact of problematic screen use on parent–adolescent relationships
Objective: Problematic screen use (PSU) in adolescence has been linked to impaired well-being, but its associations with parent–adolescent relationship quality remain insufficiently characterized. This study examined whether PSU levels were associated with positive relationship, negative relationship, and openness dimensions in mother– and father–adolescent relationships. Materials and Methods: This cross-sectional study included 196 adolescents aged 11–18 years who presented to a pediatric outpatient clinic. Data were collected using a Sociodemographic Information Form, the Child–Adolescent Digital Addiction Scale, and the Parent–Adolescent Relationship Quality Scale. Group differences were evaluated using appropriate non-parametric statistical methods. Results: The mean age of the participants was 14.29±2.21 years, and 59.7% were female. Positive relationship with mother scores differed significantly across PSU groups (p=0.029), with post hoc analysis indicating a difference primarily between healthy users and adolescents in the digital addiction group. Negative relationship with mother scores also differed significantly (p<0.001), with healthy users scoring lower than those in the excessive use and digital addiction groups. Paternal openness (p=0.007), positive relationship with father (p = 0.038), and negative relationship with father (p=0.012) also varied significantly across groups, whereas maternal openness showed a borderline association (p=0.055). Conclusion: Higher PSU was associated with poorer parent–adolescent relationship quality, particularly in the domains of conflict and positive relational functioning. These findings suggest that assessment of adolescent PSU should incorporate family relational processes, especially trust-based communication and parent–adolescent conflict.
Psychosocial outcomes in healthy siblings of children with celiac disease: A controlled cross-sectional study
Objective: The aim of this study was to compare health-related quality of life (QoL) and anxiety/depressive symptoms in healthy siblings of children with celiac disease (CD) with age- and gender-similar healthy siblings of children without chronic illness. Materials and Methods: This controlled cross-sectional study, conducted in a pediatric gastroenterology and child psychiatry setting at a tertiary-care hospital, enrolled healthy siblings aged 8–17 years into a CD-sibling group (n=70) and a control group (n=70). Sociodemographic data were collected using a standardized form, QoL was assessed using the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales, and psychiatric symptoms were assessed using the Revised Child Anxiety and Depression Scale (RCADS). Between-group comparisons and Spearman rank correlations were used, and predictors of total anxiety and psychosocial QoL were examined using univariable and multivariable linear regression. Results: Sociodemographic and familial characteristics were largely comparable between groups. Compared with controls, the CD-sibling group had higher total anxiety scores (p=0.007), whereas depressive symptoms were similar between groups (p=0.758). Psychosocial and total QoL were lower in the CD-sibling group (both p<0.001), while physical QoL did not differ between groups (p=0.201). In multivariable models within the CD-sibling group, longer time since diagnosis and maternal psychiatric disorder independently predicted higher anxiety and poorer psychosocial QoL, whereas a greater number of siblings predicted lower anxiety and better psychosocial QoL. Conclusion: Healthy siblings of children with CD experience increased anxiety and reduced psychosocial/total QoL, underscoring the importance of family-centered monitoring that includes sibling well-being and maternal mental health.
Hematological markers of systemic inflammation potentially associated with migraine in pediatric patients
Objective: The aim of this study was to evaluate potential neuroinflammatory processes in pediatric migraine using hematological inflammatory indices and to examine their associations with age and gender. Materials and Methods: This retrospective cross-sectional study included 90 children diagnosed with migraine and healthy control group, conducted between August 1, 2019, and August 1, 2025. Complete blood count parameters were analyzed for all participants. The neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and other hematological inflammatory markers were calculated. Comparisons were made between the migraine and control groups. Additionally, the migraine group was subdivided according to age, gender, and treatment status, and subgroup analyses were performed. Results: Platelet-to-lymphocyte ratio values were significantly higher in the migraine group than in the control group. In gender-based comparisons, a statistically significant difference was observed only in red blood cell (RBC) counts, whereas no gender-related differences were detected in other inflammatory parameters. Within the migraine group, lymphocyte counts decreased in the older age subgroup, while platelet counts and NLR values showed a significant increase. Among patients receiving flunarizine treatment, no significant differences were observed in inflammatory markers, except for mean corpuscular volume (MCV). Conclusion: Platelet-to-lymphocyte ratio may serve as a marker of increased inflammatory burden in pediatric patients with migraine. The age-related increase in inflammatory indices may reflect neuroinflammatory processes involved in migraine pathophysiology. These findings highlight the importance of considering age in the clinical evaluation of pediatric migraine patients.
The role of fetuin-A in adolescent obesity: Association with anthropometric and metabolic parameters
Objective: Childhood obesity is a growing global health problem linked to chronic inflammation and metabolic complications, including dyslipidemia, insulin resistance, type 2 diabetes mellitus, nonalcoholic fatty liver disease, and hypertension. Fetuin-A, a hepatokine involved in insulin signaling and inflammation, has been studied in adults, but its role in pediatric obesity is unclear. This study evaluated fetuin-A levels in obese adolescents and their association with anthropometric and metabolic parameters. Materials and Methods: This cross-sectional study included 40 obese adolescents (BMI > 95th percentile) and 30 healthy controls (BMI between the 15th and 85th percentiles) who had no additional systemic diseases and were not receiving any medication. Anthropometric measurements and fasting glucose, insulin, high-sensitivity C-reactive protein, and fetuin-A were assessed. The presence of dyslipidemia, hepatic steatosis, and hypertension was evaluated. Results: Hs-CRP levels were significantly higher in obese patients than in controls (p=0.015) However, fetuin-A levels did not differ significantly between the groups. Fetuin-A showed no correlation with insulin resistance, lipid parameters, hepatic steatosis, or hypertension. Conclusion: Obesity-related complications (insulin resistance, dyslipidemia, fatty liver, and hypertension) were observed in more than half of our group. Although hs-CRP levels of obese cases were high, fetuin-A concentrations were observed to be similar in all cases and in subgroup analyzes. It may be due to factors affecting fetuin-A levels or its posttranslational modification. Further large-scale longitudinal studies are required to elucidate its contribution to metabolic inflammation in children.
Beyond the threshold of viability: Mortality, morbidity, and critical prognostic cut-offs in infants born at 22–26 weeks of gestation
Objective: The aim of this study was to evaluate mortality, early morbidities, and critical prognostic thresholds in extremely preterm infants born at 22–26 weeks of gestation at the limit of periviability. Materials and Methods: This retrospective single-center study included live-born infants between 22+0 and 26+6 weeks of gestation who were admitted to a tertiary 194-bed neonatal intensive care unit between June 1, 2021, and March 31, 2023. Prenatal, natal, and postnatal characteristics were analyzed. The primary outcome was mortality. Receiver operating characteristic (ROC) analysis was performed to determine optimal gestational age and birth weight cut-off values for predicting mortality. Results: Among 11038 neonatal admissions during the study period, 263 (2.38%) were extremely preterm infants within the specified gestational age range. Overall mortality was 70.7%. Gestational age and birth weight were identified as the strongest independent predictors of survival. ROC analysis demonstrated significant cut-off values of 24.2 weeks for gestational age and 740 g for birth weight in predicting mortality. The most common early morbidities were patent ductus arteriosus (54.6%), culture-proven sepsis (38.7%), and osteopenia (28%). Survival improved markedly beyond 24 weeks of gestation, highlighting the critical prognostic importance of even small increments in maturity. Conclusion: Biological immaturity remains the principal determinant of outcome in infants born at the threshold of viability. However, identification of clinically relevant gestational age and birth weight thresholds may guide prenatal counseling, individualized resuscitation decisions, and intensive care strategies to improve survival in this vulnerable population. Ultimately, achieving “quality survival” – survival without major disability – requires long-term neurodevelopmental follow-up beyond hospital discharge.
Diagnostic accuracy of ultrasonography versus Tc-99m DMSA for detecting renal parenchymal damage in children with recurrent urinary fltract infections and vesicoureteral reflux: Patient-level and regression-based analyses
Objective: We aimed to assess the diagnostic performance of renal ultrasonography (USG) compared with technetium-99m dimercaptosuccinic acid renal cortical scintigraphy (DMSA scintigraphy) in detecting renal parenchymal damage in paediatric patients with vesicoureteral reflux (VUR) and/or recurrent urinary tract infection (rUTI). Materials and Methods: We retrospectively analysed 181 paediatric patients who underwent both renal USG and DMSA scintigraphy. Kidneys coded as absent were excluded. Diagnostic accuracy indices (sensitivity, specificity, PPV, NPV, accuracy, and AUC with 95% confidence intervals) were calculated at kidney and patient levels. Logistic regression was performed to evaluate the impact of age, gender, and renal uptake. Results: In comparison to DMSA scintigraphy as the reference standard, USG identified parenchymal damage with a sensitivity of 50.9% for the left kidney and 44.7% for the right kidney, while demonstrating exceptional specificity (>99%). At the patient level (n=162), USG achieved a sensitivity of 49.4%, specificity of 100%, accuracy of 76%, and AUC of 0.75. DMSA scintigraphy identified significantly more kidneys with parenchymal injury than USG in all age cohorts. Logistic regression further indicated that advancing age and diminished renal uptake on DMSA scintigraphy were independent predictors of parenchymal damage, while sex was not significant. Conclusion: Ultrasonography demonstrated excellent specificity but limited sensitivity compared with DMSA scintigraphy. These findings indicate that USG alone is inadequate for the early detection of renal parenchymal damage in children with VUR and/or rUTI. DMSA scintigraphy remains essential in this high-risk population.
Surgical management of ductal origin of the right pulmonary artery in an infant
This clinical case report describes a 1.5-month-old infant with ductal origin of the right pulmonary artery. The surgical management included reconstruction of the right ventricular outflow tract and reimplantation of the right pulmonary artery using a 6‑mm ringed expanded polytetrafluoroethylene (ePTFE) graft.
Diagnostic discrimination of C-reactive protein and blood count-derived indices for concurrent urinary tract infection in pediatric urolithiasis
Objective: The aim of this study was to evaluate the diagnostic discrimination of CRP and CBC-derived inflammatory indices for identifying concurrent culture-confirmed UTI in children with urolithiasis during early clinical assessment. Materials and Methods: This single-center retrospective observational study included 77 children with imaging-confirmed urolithiasis and 45 healthy controls. Concurrent UTI was defined by compatible symptoms together with urine culture growth of ≥10⁵ colony-forming units/mL. Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), monocyte-to-platelet ratio (MPR), mean platelet volume (MPV), white blood cell count, and CRP were compared across study groups. Receiver operating characteristic analyses were used to assess diagnostic discrimination for culture-confirmed UTI. Results: Among 77 children with urolithiasis, 46 (59.7%) had concurrent culture-confirmed UTI. Compared with both healthy controls and stone/UTI-negative patients, those with concurrent UTI had significantly higher NLR, MLR, MPR, white blood cell count, and CRP levels, whereas MPV showed poor discriminatory performance. CRP demonstrated the highest diagnostic discrimination for concurrent UTI (AUC 0.996), with a cutoff of ≥5 mg/L yielding 98.0% sensitivity and 100% specificity. Among the complete blood count–derived indices, NLR performed best (AUC 0.838), followed by MLR (AUC 0.827) and MPR (AUC 0.779). Secondary exploratory analyses suggested declining inflammatory markers after infection control and stone clearance in the surgical cohort, whereas a very small subgroup with culture-negative postoperative fever showed descriptive marker re-elevation in exploratory analyses. Conclusion: In pediatric urolithiasis, CRP demonstrated the strongest diagnostic discrimination for concurrent culture-confirmed UTI, whereas NLR was the most informative supportive complete blood count–derived index. Secondary exploratory observations should be interpreted cautiously and require confirmation in larger cohorts. Overall, the present findings remain preliminary and require prospective validation before any routine clinical application.
Improving time to antibiotic administration in febrile neutropenia: A quality improvement initiative in a pediatric oncology inpatient unit
Objective: Febrile neutropenia (FN) is a medical emergency requiring prompt initiation of empirical antibiotic therapy. We aimed to evaluate the impact of a structured, unit-based quality improvement intervention on time to antibiotic administration (TTA) in hospitalized pediatric oncology patients. Materials and Methods: This single-center quality improvement study was conducted in a pediatric oncology inpatient unit. The intervention consisted of a structured educational program targeting healthcare professionals, including physicians and nurses. FN episodes were analyzed across pre-intervention, intervention, and post-intervention phases, and TTA was compared between these periods. Results: A total of 73 FN episodes in 40 patients were included. Median TTA decreased from 38 minutes in the pre-intervention phase to 32 minutes during the intervention phase and to 18 minutes in the post-intervention phase (p<0.001). The proportion of patients receiving antibiotics within 60 minutes increased from 77% to 100% (p=0.010). Conclusion: A structured, unit-based quality improvement intervention significantly reduced TTA in hospitalized pediatric oncology patients. These findings highlight the importance of system-level strategies in improving time-sensitive clinical processes in high-risk patient populations.
Germinal Matrix-intraventricular hemorrhage in very preterm infants: Frequency, associated factors, and the role of postnatal clinical course
Objective: Germinal matrix-intraventricular hemorrhage (GMH-IVH) remains one of the most important complications associated with prematurity and is a major cause of neonatal morbidity and mortality. This study aimed to determine the frequency of GMH-IVH and to evaluate prenatal, natal, and postnatal factors associated with its development in preterm infants. Materials and Methods: This retrospective study included preterm infants with a gestational age between 24 and 32 weeks and a birth weight ≤1500 g who were followed in the neonatal intensive care unit of a tertiary referral center. Cranial ultrasonography, performed within the first 72 hours of life and repeated at the end of the first week, was used to diagnose and grade GMH-IVH according to the Volpe classification. Demographic characteristics, maternal factors, delivery characteristics, and early postnatal clinical and laboratory parameters were analyzed. Infants were grouped according to the presence of GMH-IVH and the severity of hemorrhage. Results: A total of 312 preterm infants were included in the study. GMH-IVH was detected in 49.7% of the infants. Among these, 83 (53.5%) had mild hemorrhage (Grade 1–2) and 72 (46.5%) had severe hemorrhage (Grade 3–4). Lower gestational age, lower birth weight, absence of antenatal steroid use, lower Apgar scores, requirement for invasive mechanical ventilation, presence of patent ductus arteriosus, and abnormalities in coagulation parameters were significantly associated with GMH-IVH. Conclusion: GMH-IVH in preterm infants is a multifactorial condition associated with several prenatal and postnatal factors. However, the retrospective design precludes establishing causality. Our findings highlight the strong association with postnatal clinical instability, particularly invasive mechanical ventilation and PDA treatment, suggesting that these are critical markers of illness severity. Identification of modifiable factors and optimization of perinatal and neonatal care may contribute to reducing the incidence and severity of GMH-IVH in this vulnerable population.
Bone health assessment in children with osteogenesis imperfecta from a pediatric endocrinology perspective
Objective: Osteogenesis imperfecta (OI) is an uncommon hereditary disorder of connective tissue that results in fragile bones due to abnormalities in collagen structure. This study aimed to evaluate bone health in children with OI who were hospitalized for fracture treatment. Materials and Methods: This retrospective observational study reviewed the records of children aged 3–18 years and diagnosed with OI and hospitalized in the pediatric orthopedics ward for fractures between May 1, 2023, and January 31, 2026. The patients’ demographic characteristics, biochemical parameters, bone mineral density (BMD) Z-scores, vertebral radiographs, vitamin D levels, sun exposure, and treatment status were evaluated. Results: A total of 37 patients participated in the study. The average age of the patients was 10.35±3.82 years, and 78.4% were male. Mean BMD Z-score was -1.44±1.61. Vertebral fractures were present in 27% of the patients. Significant differences were observed between groups stratified by vitamin D levels for age (p = 0.020), serum calcium (p = 0.003), phosphorus (p = 0.005), alkaline phosphatase (p = 0.027), parathyroid hormone (p = 0.018), and BMD Z-score (p = 0.023). Patients with vitamin D deficiency showed lower serum calcium levels and BMD Z-scores. Additionally, a statistically significant positive correlation was identified between BMD Z-score and serum calcium levels (r=0.343; p=0.038). Conclusion: Evaluation of skeletal health in children with OI should not rely solely on BMD measurements; vertebral fractures, biochemical markers, growth, and environmental factors should also be considered. Collaboration between pediatric orthopedics and pediatric endocrinology is vital for better long-term outcomes.
The RAS/Mitogen-Activated Protein Kinase (MAPK) pathway is a core developmental signaling cascade that regulates proliferation, differentiation, survival, and tissue growth across multiple organ systems. Germline dysregulation of this pathway results in RASopathies. Although the causal variants affect different components of the pathway, they converge on abnormal downstream signaling. This explains why these disorders share a recognizable clinical core despite clear syndrome-specific differences. The most prevalent and well-known entity is Noonan syndrome, while other major subtypes include cardiofaciocutaneous syndrome, Costello syndrome, and Noonan syndrome with multiple lentigines. RASopathies are characterized by distinctive craniofacial features and multisystem involvement. Congenital heart disease is a significant cause of morbidity. Neurodevelopmental difficulties are common across the spectrum and may be particularly pronounced in Cardiofaciocutaneous and Costello syndromes. Short stature, pectus anomalies, scoliosis, and other musculoskeletal findings are also recurrent features. Another important concern is the malignancy risk, which varies significantly by genotype. Although these disorders share a common pathway, genotype-phenotype correlations are increasingly relevant in daily practice. Molecular findings now directly inform risk assessment and long-term follow-up. In parallel, early experience with pathway-directed therapies is beginning to influence the management of selected complications. MEK inhibitors have shown promising results in selected manifestations, particularly hypertrophic cardiomyopathy and refractory lymphatic complications. In this review, we discuss the biological organization of the RAS/MAPK pathway and relate it to the clinical spectrum of RASopathies. We focus on shared and distinguishing phenotypic features, clinically relevant genotype-phenotype correlations, and the emerging role of targeted therapies.
Hepatosplenomegaly in children: A gateway to inherited metabolic disorders
Objective: Hepatomegaly and/or splenomegaly (HSM) are common clinical findings with a broad differential diagnosis, including infectious, hematologic, malignant, and inherited metabolic diseases. Although inborn errors of metabolism (IEM) are rare, they constitute critical and often treatable causes of HSM. This study aimed to evaluate pediatric patients presenting with hepatomegaly and/or splenomegaly for underlying metabolic disorders and to identify diagnostic indicators that may facilitate early recognition and appropriate management of IEM. Materials and Methods: This retrospective study evaluated 223 children presenting with hepatomegaly, splenomegaly, or hepatosplenomegaly between June 2023 and October 2025 at a pediatric metabolic clinic. Only those with genetically confirmed diagnoses of IEM were included in the final cohort. Clinical features and laboratory findings were evaluated. Results: Twenty-seven patients (15.4%) received a confirmed IEM diagnosis. The most frequent disorders were glycogen storage diseases (n=13, 7.4%), followed by Gaucher disease (n=6, 3.4%), acid sphingomyelinase deficiency (n=3, 1.7%), and single cases of Niemann-Pick type C, Mucopolysaccharidosis type II, GM1 gangliosidosis, hereditary fructose intolerance, and galactosemia. Consanguinity was present in 84.6%, and characteristic systemic findings such as hypoglycemia, hyperlipidemia, cytopenias, cholestasis, neurological involvement, or coarse facies served as critical diagnostic clues. Conclusion: Inborn errors of metabolism should be considered in children presenting with hepatomegaly and/or splenomegaly, particularly in the presence of accompanying systemic findings, especially in regions with high consanguinity rates. Recognition of diagnostic clues may facilitate earlier referral, reduce diagnostic delays, and enable timely initiation of disease specific treatments, including enzyme replacement therapy or dietary modification.