Anisocoria often raises concerns about potential underlying conditions such as intracranial hemorrhage, brain tumor, or Horner syndrome. However, iatrogenic exposures may also lead to unilateral mydriasis. A six-month-old infant was hospitalized due to acute bronchiolitis with a history of prematurity, bronchopulmonary dysplasia, and periventricular leukomalacia (PVL). He received non-invasive respiratory support, salbutamol, and ipratropium bromide by inhalation. Four days after admission, the infant exhibited an episode of sudden unilateral mydriasis with no other new signs or symptoms. Ophthalmological examination disclosed no abnormalities besides the dilated pupil, and brain CT scan showed PVL similar to the previous imaging without new pathological findings. There are several case reports of ipratropium bromide given by inhalation causing mydriasis by leakage through the inhalation mask. Ipratropium bromide is an antagonist of the muscarinic receptors. It induces bronchodilation and inhibits mucus production. One of the possible side effects of antimuscarinic drugs is mydriasis. Our patient did not exhibit any systemic signs, thus suggesting a local effect by direct contact between the eye and the offending agent. Treatment with ipratropium bromide was stopped, and within 24 h, the pupil size returned to normal. Conclusion : This case underscores the importance of recognizing the side effects of medications, particularly in young patients with complex medical conditions. What is Known: • Unilateral mydriasis refers to unequal pupil sizes, where the abnormal pupil is dilated.• Unilateral mydriasis can result from a variety of causes, ranging from benign to serious conditions, including iatrogenic factors such as medications. What is New: • The occurrence of unilateral mydriasis induced by ipratropium bromide has been rarely reported in pediatric patients.• If unilateral mydriasis is an isolated abnormal finding and there is a history of ipratropium bromide exposure, themydriasis could be due to the ipratropium exposure.

Staphylococcus aureus (SA) is an important pathogen in the pediatric population. Community-acquired SA bacteremia (SAB) may also occur in healthy individuals, yet literature on this matter is scarce. Our study aims to describe patient characteristics, clinical course, and outcomes of healthy children with SAB. This retrospective cohort study included all healthy patients aged 3 months—18 years, with a positive SA blood culture taken during the first 72 hours of hospitalization between 2009 and 2021. Demographic, laboratory, and clinical data were collected. Analysis was performed to assess factors associated with complicated disease. Fifty-seven patients aged 8.5 ± 4.5 years were included. Forty-one (71.9

Immune -mediated or autoimmune encephalitis (AE) is a relatively new, rare and elusive form of encephalitis in children. We retrospectively collected seropositive children (0-18 years old) with well characterized antibodies through 3 reference laboratories in Israel. Clinical symptoms, MRI and EEG findings and treatment courses were described. A total of 16 patients were included in the study, with 10 females. Anti NMDA encephalitis was most common followed by anti HU and anti mGLuR1. Psychiatric symptoms, abnormal movements, seizures and behavioral changes were the most common presentation. Pathological MRI and EEG findings were described in 37% and 56% of children, respectively. Treatment with corticosteroids, Intravenous immunoglobulins (IVIG) was first line in most children. Following inadequate response children were treated with plasmapheresis and/or rituximab. Two patients relapsed following both first and second line protocols. In terms of long term prognosis, 9 children (56%) had one or more residual behavioral, psychiatric or neurologic findings. Three children required hospitalization for rehabilitation. AE remains a rare diagnosis with variable presenting symptoms, requiring a high index of suspicion. Consensus recommended treatment is generally effective in the pediatric population. Female gender was associated with a higher chance of severe disease. Larger cohorts would be needed to identify prognostic factors in the pediatric population.

Cardiac complications are a major concern in patients with anorexia nervosa (AN) which contribute to morbidity and mortality. However, limited information exists regarding risk factors for the development of these complications. Our objective was to investigate the prevalence and associated risk factors of cardiac involvement among children and adolescents with AN admitted to a tertiary pediatric hospital. We collected demographic, clinical, and laboratory data from individuals with AN hospitalized between 2011 and 2020 in Schneider Children's Medical Center in Israel. Diagnosis was based on established criteria (DSM-5). Patients with other co-morbidities were excluded. Cardiac investigations included electrocardiograms (ECG) and echocardiograms. We conducted correlation tests between cardiac findings and clinical and laboratory indicators. A total of 403 AN patients (81.4% were females) with a median age of 15 +/- 2 years were included in the study. Sinus bradycardia was the most common abnormality, observed in 155 (38%) participants. Echocardiogram was performed in 170 (42.2%) patients, of whom 37 (22%) demonstrated mild cardiac aberrations. Among those aberrations, 94.6% could be attributed to the current metabolic state, including pericardial effusion (15.3%) and valve dysfunction (8.8%). Systolic or diastolic cardiac dysfunction, tachyarrhythmias, or conduction disorders were not observed. Patients with new echocardiographic aberration had significantly lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension was higher in this group.Conclusions: The prevalence of cardiac involvement, except for sinus bradycardia, was notably low in our cohort. The presence of cardiac aberrations is correlated with several clinical variables: lower body mass index (BMI) and the presence of amenorrhea and hypotension at admission. Patients presenting with these variables may be at high risk for cardiac findings per echocardiography. Dividing the patients into high and low risk groups may enable targeted evaluation, while avoiding unnecessary cardiac investigations in low-risk patients.What is Known:center dot Cardiac involvement in anorexia nervosa (AN) patients is a major concern, which contributes to morbidity and mortality.center dot It is unknown which patients are prone to develop this complication.What is New:center dot Cardiac complications in our cohort are less frequent compared to previous studies, and it is correlated with lower body mass index (BMI) at admission, and the prevalence of amenorrhea and hypotension.

Candida lusitaniae fungemia is a serious infection that is rarely reported in children. The aim of this study is to describe a case series of C. lusitaniae fungemia and review previous publications regarding this rare pathogen. This is a multicenter case series of children diagnosed with C. lusitaniae fungemia. A total of 18 cases that occurred over a 15-year period in five tertiary hospitals were included. Additionally, a review of the literature regarding C. lusitaniae fungemia in children was performed. A total of 18 cases were enrolled; 11/18 (61%) were males, with a mean age of 2.3 years. All patients had severe underlying diseases and risk factors for opportunistic infection, most commonly prematurity and malignancies. More than one-third of cases occurred during the last 2 years of the study period. All isolates were susceptible to all tested antifungals. The survival rate following the acute infection was 94%, whereas the survival rate of 14 previously published cases was 71%, with the most common underlying diseases being CGD and malignancies. Candida lusitaniae fungemia is not a common event in the pediatric population, occurring exclusively in children with severe underlying diseases and significant risk factors. This cohort revealed better clinical outcomes than previously reported. All tested isolates were susceptible to all antifungal agents; variability in susceptibility as previously reported was not found in this study. The allegedly higher rate of infection in recent years is in need of further investigation in larger prospective studies in order to conclude if a real trend is at play.

BACKGROUND:Solid organ transplantation has evolved in recent decades, resulting in a rise in patient and graft survival. Frequent hospitalizations affect graft function, patients' health, and quality of life. This study characterizes the frequency and causes of post-transplant hospitalizations among pediatric recipients. METHODS:This is a retrospective observational study evaluating pediatric kidney transplant recipients (KTR) and liver transplant recipients (LTR) aged 0-21 years, followed at a tertiary pediatric center in Israel from 2012 to 2017. Data were collected starting at 60 days post-transplantation. Diagnoses of admissions were based on clinical, laboratory, and radiographic findings. RESULTS:Forty-nine KTR experienced 199 all-cause re-hospitalizations (median number of re-hospitalizations per patient - 3 (IQR [interquartile range] 1-5.5), while 351 re-hospitalizations were recorded in 56 LTR (median - 5 [IQR 2-8.8]). Median follow-up time was 2.2 years for KTR (IQR 1-3.9) and 3 years for LTR (IQR 2.1-4.1). The most common cause for hospitalization for both cohorts was infection (50.8% and 62%, respectively). Gram-negative bacteria were the most common pathogens identified in KTR, while viral pathogens were more common in LTR (51% and 57% of pathogen-identified cases, respectively). CONCLUSIONS:This is the largest study to describe rehospitalizations for pediatric solid organ recipients. The hospital admission rate was higher in LTR in comparison to KTR. Infections were the most common cause of hospitalization throughout the whole study period in both populations. Frequent hospitalizations impose a heavy burden on patients and their families; better understanding of hospitalization causes may help to minimize their frequency.

Aim: To investigate the clinical impact of BioFire FilmArray Gastrointestinal Panel (FGP) testing in real-life diarrhoeal episodes of hospitalised paediatric patients. Methods: Children hospitalised between October 2018 and September 2020 for whom stool specimens for FGP were submitted at the clinician's discretion were retrospectively observed. For each episode, demographics, clinical information and stool tests were collected. Results: The clinical impact for each case was evaluated by changing the antibiotic prescription, following the result of the FGP testing. Out of 140 diarrhoeal episodes, 25 pathogens were found in 24 cases using conventional methods, whereas, FGP testing identified 75 pathogens in 56 cases (p <0.05). The pathogens more frequently identified by FGP testing were Campylobacter, Shigelia, Rotavirus, Giardia lambhia and Cryptosporidium. The clinical impact of FGP testing was observed in 17/140 (12%) diarrhoeal episodes, and higher rates in previously healthy (19%) and solid organ-transplanted children (15%). Conclusion: We found that using FGP testing for hospitalised children with diarrhoeal episodes could increase pathogen identification and impact clinical decisions, especially in healthy and transplant patients.

Citrin deficiency is an autosomal recessive disorder associated with SLC25A13 gene pathogenic variants, with more than a hundred known at present. It manifests in neonates as failure to thrive and acute liver insufficiency. We herein describe a case of a 4-week-old infant who presented with insufficient weight gain and liver failure accompanied by hyperammonemia. She was diagnosed with Citrin deficiency after a thorough biochemical and molecular analysis including amino acid profile, DNA sequencing of genes of interest and RNA splice site evaluation, to reveal a yet unknown damaging variant of the SLC25A13 gene.

To investigate the clinical impact of BioFire FilmArray Gastrointestinal Panel (FGP) testing in real-life diarrhoeal episodes of hospitalised paediatric patients. Children hospitalised between October 2018 and September 2020 for whom stool specimens for FGP were submitted at the clinician's discretion were retrospectively observed. For each episode, demographics, clinical information and stool tests were collected. The clinical impact for each case was evaluated by changing the antibiotic prescription, following the result of the FGP testing. Out of 140 diarrhoeal episodes, 25 pathogens were found in 24 cases using conventional methods, whereas, FGP testing identified 75 pathogens in 56 cases ( p  < 0.05). The pathogens more frequently identified by FGP testing were Campylobacter , Shigella , Rotavirus , Giardia lamblia and Cryptosporidium . The clinical impact of FGP testing was observed in 17/140 (12%) diarrhoeal episodes, and higher rates in previously healthy (19%) and solid organ–transplanted children (15%). We found that using FGP testing for hospitalised children with diarrhoeal episodes could increase pathogen identification and impact clinical decisions, especially in healthy and transplant patients.

Bronchiolitis is an infectious disease, with no effective treatment. Music and Mozart's works specifically are known to have a positive effect on physiological parameters, while noise is considered harmful. We aim to evaluate the short-term effect of environmental noise detachment and/or music listening on the course of bronchiolitis in hospitalised children . This is a prospective, double-blinded randomised controlled trial. Patients were divided into three intervention groups: 1-Mozart's Sonata, 2-instrumental music, 3-silence. Music was heard via media players and soundproof headphones. Disease severity was evaluated before and after intervention using the Modified Tal score. Seventy music sessions were included in the analysis (Mozart n  = 23, instrumental n  = 22, silence n  = 25). A one-point drop in the average bronchiolitis severity score was observed in all three groups from 7.1 (CI 95%, 5 to 9.2) to 6.1 (CI 95%, 4.3 to 7.9), p  < 0.001. No significant difference was found between the three groups with respect to change in the severity score before and after the intervention. Isolation from disturbing sounds heard in paediatric departments could be considered a simple non-invasive intervention in children hospitalised with bronchiolitis. Further studies are warranted to evaluate long-term effects of this intervention and the specific effect of music.

Bronchiolitis is an infectious disease, with no effective treatment. Music and Mozart's works specifically are known to have a positive effect on physiological parameters, while noise is considered harmful. We aim to evaluate the short‐term effect of environmental noise detachment and/or music listening on the course of bronchiolitis in hospitalised children.

(Abstracted from Lancet 2020;396:779–785) Cytomegalovirus (CMV) is a congenital infection that has a high rate of maternal morbidity after infection. There is a relatively high rate of vertical transmission to the fetus following a maternal infection of 30% to 40%.

We examined the impact of the COVID-19 pandemic on how many children were admitted to Israel's largest tertiary paediatric hospital and why they were admitted. Israel declared COVID-19 a national emergency on 19 March 2020. This study examined daily hospital admissions to our three general paediatric wards during the COVID-19 lockdown period from 20 March to 18 April 2020. These 258 admissions were compared with the 4217 admissions from the period immediately before this, 1 February to 19 March 2020, plus 1 February to 18 April in 2018 and 2019. We also compared why patients were admitted during the study period, and any pre-existing conditions, with 638 children hospitalised during the same period in 2019. The mean number of daily hospitalisations during the COVID-19 lockdown period was 8.6, which was 59% lower than the 20.9 recorded during the other three periods before COVID-19. There was a significant decrease in the number of patients admitted with infectious (74%) and non-infectious (44%) aetiologies from 2019 to 2020, and these occurred among patients with (58%), and without (55%), pre-existing medical conditions. The Israeli COVID-19 lockdown had a dramatic effect on admissions to the paediatric wards of a tertiary hospital.

AIM:We examined the impact of the COVID-19 pandemic on how many children were admitted to Israel's largest tertiary paediatric hospital and why they were admitted.METHODS:Israel declared COVID-19 a national emergency on 19 March 2020. This study examined daily hospital admissions to our three general paediatric wards during the COVID-19 lockdown period from 20 March to 18 April 2020. These 258 admissions were compared with the 4217 admissions from the period immediately before this, 1 February to 19 March 2020, plus 1 February to 18 April in 2018 and 2019. We also compared why patients were admitted during the study period, and any pre-existing conditions, with 638 children hospitalised during the same period in 2019.RESULTS:The mean number of daily hospitalisations during the COVID-19 lockdown period was 8.6, which was 59% lower than the 20.9 recorded during the other three periods before COVID-19. There was a significant decrease in the number of patients admitted with infectious (74%) and non-infectious (44%) aetiologies from 2019 to 2020, and these occurred among patients with (58%), and without (55%), pre-existing medical conditions.CONCLUSION:The Israeli COVID-19 lockdown had a dramatic effect on admissions to the paediatric wards of a tertiary hospital.

To present seven paediatric patients with appendicitis, all with late diagnosis resulting from different aspects of the fear from the current global COVID-19 pandemic. Cases were collected from three paediatric surgical wards. Comparison between complicated appendicitis rates in the COVID-19 era and similar period in previous year was performed. All seven children presented with complicated appendicitis. Main reasons for the delayed diagnosis during the COVID-19 era were parental concern, telemedicine use and insufficient evaluation. Higher complication rates were found during the COVID-19 era compared to similar period in previous year (22% vs 11%, P -value .06). The fear from COVID-19 pandemic may result in delayed diagnosis and higher complication rates in common paediatric medical conditions. We believe caregivers and healthcare providers should not withhold necessary medical care since delay in diagnosis and treatment in these routinely seen medical emergencies may become as big of a threat as COVID-19 itself.

A significant drop was found in the number of hospitalizations due to bacterial infections among children during the first peak period of COVID-19 in Israel. There was a 77% decrease in serious bacterial infections, and ≥50% decrease in most types of bacterial infections, especially osteoarticular and skin infections, followed by pneumonia and ENT infections.

AIM:To present seven paediatric patients with appendicitis, all with late diagnosis resulting from different aspects of the fear from the current global COVID-19 pandemic.METHODS:Cases were collected from three paediatric surgical wards. Comparison between complicated appendicitis rates in the COVID-19 era and similar period in previous year was performed.RESULTS:All seven children presented with complicated appendicitis. Main reasons for the delayed diagnosis during the COVID-19 era were parental concern, telemedicine use and insufficient evaluation. Higher complication rates were found during the COVID-19 era compared to similar period in previous year (22% vs 11%, P-value .06).CONCLUSION:The fear from COVID-19 pandemic may result in delayed diagnosis and higher complication rates in common paediatric medical conditions. We believe caregivers and healthcare providers should not withhold necessary medical care since delay in diagnosis and treatment in these routinely seen medical emergencies may become as big of a threat as COVID-19 itself.

We wish to present a challenging case, which required us to “think out of the box.” Its solution is applicable to all children dealing with a similar challenge and may help to significantly improve compliance to a common medication. We present a 4-year-old child diagnosed with an autistic spectrum disorder and global developmental delay, limiting his communication skills. In addition, he is very selective to foods—and especially to their texture—and therefore has a very limited and routine diet. The child presented to our hospital with acute kidney injury and anuria following an episode of acute gastroenteritis. After extensive workup, he was diagnosed with atypical hemolytic uremic syndrome, necessitating dialysis, plasmapheresis, and numerous medications—including Eculizumab, anti-hypertensives, and daily medications to maintain his electrolyte balance (mainly Sevelamer, Calcium carbonate, and Kayexalate). Due to decreased glomerular filtration rate (eGFR) as low as 9 mL/min, the child had persistent hyperkalaemia (levels as high as 5.8 meq/L), requiring daily sodium polystyrene sulfonate (Kayexalate) treatment. Due to its sand-like texture and the patient's extreme selectivity to foods, this medication was the most difficult for him to take. Various attempts to mix the Kayexalate into different foods did not succeed—the child still noticed the texture and rejected the medication. In such cases, Kayexalate may be administered rectally—but as this experience was very traumatic for him, his parents refused to continue this form of intake. As the patient was oliguric, renal clearance of potassium was impaired, leading to elevated potassium levels which frequently required dialysis. Kayexalate is a cation-exchange resin well accepted to treat hyperkalaemia. It releases sodium ions from the resin and binds potassium ions within the intestinal lumen, increasing fecal potassium excretion. Although unpredictable and variable, this in vivo exchange capacity is approximately 1 mEq of potassium per 1 g of Kayexalate. Kayexalate can be administered rectally; however, rectal administration is less effective, unpleasant, and even traumatic.1, 2 Frustrated by the persistent hyperkalaemia, we tasted the drug—and searched for a tasty food that can mask the its texture. Reviewing the patients' limited diet, we thought of ice cream—which he loves. The preparation for oral use of Kayexalate requires each dose to be suspended in water or syrup. Any vehicle may be compatible for use in order to improve the taste, except for significant amounts of potassium-containing products (such as fruit juice) as it may impair the medications' action. Usually, sweetened water, any syrup, or sweetened paste (such as jam or honey) are well accepted.1 In addition, palatability may be improved by cooling the prepared mixture. Kayexalate added into infant formula or expressed breast milk is an acceptable common practice, despite its low water solubility.3, 4 This extemporaneous formulation should be refrigerated for 60 minutes and used within 24 hours. Moreover, the stability of frozen sodium polystyrene sulfonate at 20°C for at least 6 weeks was demonstrated by Johnson et al as an extemporaneous formulation of sodium polystyrene sulfonate candy (fudge) in order to increase tolerability.5, 6 The candy is a mixture of Kayexalate with margarine, maple extract (or any other flavoring), cream, and sugar—and may be served frozen (like ice cream). As this formulation is not safe and carries a choking hazard under the age of 5, it was not attempted in this case. Kayexalate should be stored below 30°C, allowing refrigeration. To our knowledge, the sodium polystyrene sulfonate candy is the only evidence in the literature of the stability of the powdered resin in temperatures as low as −20°C (similar to a household freezer). The drugs' stability in different vehicles and food ingredients below 30°C as well as under freezing temperatures allowed us to mix it in melted ice cream. We melted the ice cream, mixed it with 15 g of Kayexalate, and froze it again—in order to maintain its texture. Our patient consumed the ice cream in a bowl, once daily. His compliance was amazingly high! It seemed that he did not notice the sand-like texture of the drug and was able to finish the whole dose of 15 g at one take. Serum potassium levels decreased significantly, as shown in Table 1. Many children have a hard time taking medications in general, and those that are not palatable in particular, making palatability a challenging factor of paediatric formulation development.7 Palatability—described as the overall acceptance of the taste, flavour, smell, dose, volume or size, and texture of a medication to be administered by mouth or to be swallowed—is essential for adherence in this population and influences the choice of dosage form and its design.7 As a consequence, caregivers usually attempt to achieve compliance by mixing the dose with different foods or drinks.8-10 These manipulations may affect the biopharmaceutical characteristics of the drug—including its chemical stability, solubility, and oral bioavailability—and therefore influence its safety and efficacy.10-12 The manipulation on Kayexalate presented in this report improved compliance to the oral route of administration, eliminating the need for rectal administration as well as the need for dialysis. This form of intake may assist other children to reduce the rate of complications of hyperkalaemia, decrease the need for dialysis, and shorten hospitalization days. There are no competing interests to declare.