Foreign body (FB) injury from aspiration or ingestion is a common pediatric health problem. Diagnosis relies on clinical judgment plus medical history, physical examination, and radiographic evaluation. A multi-institutional review of 1269 FB events revealed that 85% were correctly diagnosed following a single physician encounter. However, 15% of the children had an elusive diagnosis (>1 week), despite previous evaluation. Delays in diagnosis were seven times more likely to occur in aspirations than in ingestions. Secondary injuries (e.g., pneumonia and atelectasis) occurred in 13% of airway FBs but in only 1.7% of esophageal FBs. Plain radiographs were used in 82% of children, and special studies (e.g., fluoroscopy) in only 7%. We conclude that diagnosis of FB injury in children is frequently achieved at the initial evaluation but that continued surveillance by follow-up visits to health care facilities from parents and other caretakers is important, to reduce pulmonary injuries.

immediate resuscitation. Clinical examination showed pallor and microcephaly without organomegaly. A neonatal cranial ultrasound performed on day 2 demonstrated bilaterally enlarged ventricles with thalamic calcification (Fig. 1). He had pancytopenia and raised liver enzymes. Congenital infection was considered: TORCH serology, metabolic screening, full septic screening, lumbar puncture and fundoscopy were all normal. The patient had a prolonged NICU stay for management of developed congestive cardiac failure in the first week of life requiring neonatal intensive care; echocardiography showed concentric left ventricular hypertrophy with low ejection fraction. No cause for this infantile hypertrophic cardiomyopathy was identified, including by an extensive familial cardiomyopathy genetic panel. On follow-up, the child had global developmental delay and intermittent hospital admissions for lower respiratory tract infections and seizures. Brain magnetic resonance imaging performed at 3 months of age showed marked dilation of the lateral and third ventricles, cerebral atrophy, reduced myelination and abnormal cerebral white matter with subcortical cysts. Genetic testing identified a homozygous c.172G>A (p.Gly58Arg) mutation in the RNASEH2C Aicardi-Goutieres syndrome (AGS) gene in the child, and the parents were heterozygous for the variant. Currently, the child is bedridden, tracheostomy dependent on home oxygen and has intractable epilepsy.AGS is an autosomal recessive progressive encephalopathy with features mimicking congenital infections like TORCH with microcephaly, haematological abnormalities and organomegaly. 1,2 It is a result of mutations in TREX1 and the RNASEH2 complex, the dysfunctional proteins in AGS that act as nuclease enzymes breaking down DNA and RNA. Failure of nuclease activity probably results in an inappropriate innate immune response to retained selfnucleic acids involved in cellular repair and immune system regulation. 3 Brain imaging, CSF chemistry and genetic testing are the key investigations. AGS is considered an interferonopathyin other words, it is a pathological condition caused by the overproduction of IFNα. 4 The main laboratory findings are increased CSF and serum interferon alpha levels. The primary treatment is supportive. It is especially important to recognise genetic disorders that mimic congenital infection because of the risk of recurrence in subsequent pregnancies.

Non-specialist professionals should have greater awareness of the existence of this uncommon complication of diabetes in the hope that earlier diagnosis will lead to lesser degrees of deformity.

Median age was 5.5 months (interquartile range [IQR], 0.7-46.5 mo), and congenital heart disease was the most common diagnosis. Overall, by day 7 of admission, the median maximum cumulative FA, as a percentage of estimated admission weight, was 7.5% (IQR, 3.3-15.1) occurring at a median of 4 days after admission. Overall, higher FA was associated with greater duration of mechanical ventilation (MV) (mean difference, 1.17 [95% CI, 1.13-1.22]; p < 0.001]), longer intensive care length of stay (LOS) (mean difference, 1.16 [95% CI, 1.12-1.21]; p < 0.001]), longer hospital LOS (mean difference, 1.19 [95% CI, 1.13-1.26]; p < 0.001]), and increased mortality (odds ratio, 1.31 [95% CI, 1.08-1.59]; p = 0.005). However, these associations depended on the effects of children with extreme values, and there was no increase in risk up to 20% FA, overall, in children following cardiopulmonary bypass and in children in the general ICU. When excluding children with maximum FA of >10%, there was no association with duration of MV (mean difference, 0.99 [95% CI, 0.94-1.04]; p = 0.64) and intensive care or hospital LOS (mean difference, 1.01 [95% CI, 0.96-1.06]; p = 0.70 and 1.01 [95% CI, 0.95-1.08]; 0.79, respectively) but an association with reduced mortality 0.71 (95% CI, 0.53-0.97; p = 0.03). CONCLUSIONS:In mechanically ventilated critically ill children, greater maximum FA was associated with longer duration of MV, intensive care LOS, hospital LOS, and mortality. However, these findings were driven by extreme values of FA of greater than 20%, and up to 10%, there was reduced mortality and no signal of harm.

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