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

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

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

Staphylococcal scarlet fever is an unusual entity, an attenuated manifestation of staphylococcal scalded skin syndrome that is caused by the TSST-1 toxin of Staphylococcus aureus. It presents with scarlatiniform rash (micropapular rash with an erythematous base) and hyperalgesia on palpation with evolution to exudative and/or crusted facial lesions. The infection is favored by minor cutaneous traumas.

It must be suspected in scarlatiniform rash with poor evolution and absence of response to amoxicillin or penicillin G, due to the possibility of being a penicillin-resistant S. aureus. In that case, systemic treatment must be initiated, preferably intravenous administration, being cloxacillin the best option and considering adding clindamycin to prevent progression to bacteremia and attenuate effects of toxin production. In case of methicillin-sensitive germs, the response to treatment is fast and favorable. We present a case of scarlatiniform exanthema caused by S. aureus with poor response to amoxicillin.

Myasthenia gravis is an autoimmune disease of neuromuscular transmission caused by the production of antibodies that destroy or change the function of acetylcholine receptors in the postsynaptic membrane. It is characterized by fast fatigability and fluctuating weakness of striated muscle. The disorder has been associated with the presence of other autoimmune diseases and more rarely thymoma. Palpebral ptosis is the most frequent symptom, and ocular myasthenia gravis (OMG) is the most common clinical presentation during childhood. The detection of antibodies against acetylcholine receptors (anti-ACh) ensures the diagnosis; in seronegative cases, the edrophonium testing or electrophysiological studies are usually necessary. Spontaneous remission in cases of OMG is frequent, although there are patients that develope generalized myasthenia gravis throughout their evolution. Pyridostigmine is the first-line treatment in the OMG. Corticosteroids or other immunosuppressants are used in uncontrolled myasthenic patients, worsening of symptoms or generalization. Thymectomy is not usually necessary. Amblyopia should be ruled out and early treatment improves visual prognosis. We present a case of palpebral ptosis secondary to OMG.

Introduction: Although acute mastoiditis is mainly caused by Streptococcus pneumoniae, Staphylococcus aureus and Streptococcus pyogenes, in recent years there has been an increase in the incidence of Fusobacterium necrophorum, especially in infants.

Case report 1: A infant who goes to the emergency department due to fever, decay and refusal of food. He is tachycardic with affectation of the general state, slight cutaneous pallor and neck stiffness, being normal the rest of the physical examination. With the suspicion of sepsis/bacteremia, intravenous cefotaxime is started. After 2 hours, left otorrhea appears and after 36 hours mastoidism. Cranial CT shows bilateral acute otomastoiditis with left subperiosteal abscess, requiring left mastoidectomy and drainage of subperiosteal abscess. In the culture of the subperiosteal abscess, F. necrophorum is isolated.

Case report 2: Infant taken to the emergency due to the persistence of fever and the appearance of otorrhea at 24 hours of receiving oral amoxicillin-clavulanate for acute acute otitis media. It presents good general condition, the constants are normal and physical examination highlights left otorrhea with mastoidism. Cranial CT confirms bilateral otomastoiditis with possible left subperiosteal abscess. Left mastoidectomy and subperiosteal abscess drainage are performed. In the culture of the subperiosteal abscess, F. necrophorum is isolated.

Conclusion: In infants with acute mastoiditis, we must keep in mind the F. necrophorum as a possible etiological agent, associated with worse evolution, greater need for surgical treatment and higher risk of complications than other germs.

Human milk is a complex fluid composed of a wide variety of substances. The data currently available suggest that, under physiological conditions, the number and concentration of these substances can vary depending on many factors (genetic background, ethnicity, geographic location, diet, postpartum time...). In this context, the aim of the INSPIRE project was to know the natural variability in the composition of human milk among healthy women that differ in their geographical location, ethnicity, diet and socio-economic situation. This article shows the general design of the study and the results obtained regarding human milk oligosaccharides (HMOs), one of the major components in this biological fluid and whose biological functions are very relevant to infant health. The results show a clear effect of the cohort (p <0.05) on the concentrations of almost all HMOs. In addition, maternal age, postpartum time, weight and body mass index were correlated with several HMOs. On the other hand, differences were observed in the profile of HMOs between populations that are ethnically similar but live in different places, which suggests that the environment may play a role in the regulation of the biosynthesis of certain HMOs.

Background:Parental alienation syndrome (PAS), described as a form of child psychological abuse, usually emerges in the context of conflicting divorces. The child rejects a parent without justification due to the other parent’s indoctrination and the child own contribution to the vilification of the rejected parent.

Objectives: To determine the prevalence of certain manifestations described in PAS, parental rejection (PR) and allegations of sexual or child abuse towards a parent (Allegations) in pediatrics emergencies and to evaluate their relationship with conflicting divorces.

Patients and method: We retrospectively studied the files of children who went to a pediatric emergency department at our tertiary hospital in a period of 3 years with a miscellany of psychiatric and psychosocial diagnoses at discharge. The correlation between the variables PR and Allegations has been checked with divorce and concurrence of conflict.

Results: 357 children were included. The prevalence of PR was 9% and 11% for Allegations. In both situations the diagnoses at discharge were analyzed and a strong relationship with the situation of conflicting divorce was confirmed. Logistic regression PR/conflict: OR= 5.6 (95% CI: 2-18; p <0.002), and Allegations/conflict: OR= 12 (95% CI: 4-43; p <0.001).

Conclusions: Our study shows a non-negligible PR and Allegations prevalence and their strong correlation with conflicting divorces. These results entail that pediatrician must be aware of the possibility of PAS in order to require a psychosocial evaluation and to avoid to become an innocent accomplice of this form of abuse.

Objective: To compare the risk of hyponatremia using hypotonic saline (HT) versus isotonic solution (IT) and adverse effects.

Methods: Randomized clinical trial, open, non-blind, in patients admitted to Pediatric Intensive Care Unit after elective surgery, from 6 months to 14 years, weight greater than 6 kg, onset natremia between 130-150 mEq/L and signed informed consent, with no oral intake and maintenance intravenous fluid therapy. Patients with ADH secretion abnormalities are excluded. Sodium, calcium, potassium and chlorine plasma levels are measured on admission, 8, 24 and 48 hours. Patients with normonatremia (135-145 mEq/L) are analyzed.

Results: 60 patients received HT solution (glucosaline 1/3: 51 mEq/L sodium) and 70 IT solution (glucosaline 5/0.9%: 154 mEq/L sodium). The incidence of hyponatremia (sodium <135 mEq/L) at 8 h of the HT group was 38.9% and 4.6% of IT (p <0.001) (OR= 13.15; 95% CI: 3.65-47.3), and at 24 hours: 43% in HT group and 11% in IT (p= 0.021) (OR= 6.15; 95% CI: 1.43-26.39). 3 cases of hypernatremia 8 and 24 horas, all in IT (7%), without significant differences (p= 0,2), and no difference in the incidence of hyperchloremic acidosis. Mean values of potassium and calcemia were normal with low incidence of hypokalemia and ionic hypocalcemia.

Conclusions: The use of IT solution in the postoperative period of general surgery protects against hyponatraemia, especially in the first 24 hours, with no significant risk of hypernatremia or hyperchloremic acidosis. Standar commercialized solutions without potassium and calcium supplements could be used in the short-term postoperative period, if are normal at admission.