Relationship between immigration fluxes and patterns of small for gestational age in Italy

pulmonary problems. A 2-y-old child diagnosed a year earlier with idiopathic transverse myelitis affecting C5–C6 spinal segments was emergently admitted to Kosair Children’s Hospital for fever and respiratory distress. He was diagnosed with pneumonia; the third consecutive of such episodes in a 5-mo period. Physical examination during this admission revealed a restless child in a wheelchair, with moderate respiratory distress and nasal flaring. Rectal temperature was 39 C, respiratory rate was 48/min, and heart rate was 144/min. Chest auscultation revealed diminished breath sounds over the entire left hemithorax. Supplemental oxygen at 2 l/ min via a nasal cannula maintained oxyhemoglobin saturation levels above 94%. Chest X-rays showed complete left lower lobe (LLL) consolidation with some extension to the lingula and to the left upper lobe. Chest CT scan showed a sharp demarcation of the consolidation, suggesting the presence of LLL atelectasis. Blood and throat cultures were negative. Flexible fiberoptic bronchoscopic evaluation of the airways showed no evidence of mucous plugging, foreign body, or any extraluminal pressure on the bronchial tree. Fluoroscopy did not detect a paradoxical elevation of the left diaphragm, most probably due to the left lower lobe consolidation. Due to the lack of clinical improvement, persistent need for supplemental oxygen, and the radiological findings, unilateral diaphragmatic paresis and/or weakness of the respiratory muscles was considered, and therapy with BPAP via a nasal mask (initial pressures of 10/5 cmH2O in the assist-control mode with a back-up respiratory rate of 15 breaths/min, and an inspiratory time set at 0.6 s) was initiated. Improvement was noticed within 24 h, oxygen requirement was weaned to 0.5l, and chest X-ray 36 h after BPAP therapy revealed noticeable improvements. The child was discharged on nocturnal nasal BPAP, without supplemental oxygen. A month later, the patient had no respiratory complaints, and chest X-rays showed elevation of the left diaphragm, mild left shift of the mediastinum, and narrowing of the intercostal spaces on the left hemithorax, suggesting left unilateral phrenic nerve paresis. An overnight polysomnographic study (without BPAP) revealed chronic hypoventilation (end tidal CO2 of 84 kPa), and BPAP titration polysomnographic study led to adjustment of the ventilator pressures to 8/4 cmH2O, preserving his end tidal CO2 at 44 kPa. Home use of the nocturnal ventilatory support over 1 y was associated with no further recurrences of pulmonary infection. Transverse myelitis is a rare neurological disorder, particularly in children. Therapy is usually nonspecific, and mostly consists of supportive measures [1]. The use of BPAP via a nasal mask in children has been described as beneficial for sleep-disordered breathing in patients with neuromuscular diseases [2] and in complicated cases following adenoidectomy and tonsillectomy [3]. Different modes of therapy and intervention in children with diaphragmatic paresis have included diaphragmatic plication, electrical pacing, negative extra thoracic pressure, and continuous positive airway pressure (CPAP) [4]. Our clinical experience supports this noninvasive ventilatory mode and should therefore be considered as an effective alternative in infants and small children with unilateral diaphragmatic paresis, and may obviate the need for other invasive surgical interventions.