Septum In Children Research Articles

Spontaneous abscess of the nasal septum in children: a 10-year series.

This paper reports a 10-year series of spontaneous nasal septal abscesses in immune-competent children, with suggestions for optimal management. A retrospective case note review was conducted of children undergoing an operation for incision and drainage of nasal septal abscesses between 2013 and 2023. Six children were identified via electronic hospital records during the 10-year review period, five with a spontaneous abscess. The children were aged 10-14 years. All were immunocompetent and none had active sinus infection. The most common presenting features were nasal swelling, facial swelling, headache, nasal congestion and fever. The most common bacterial isolate was Staphylococcus aureus. All children received prompt surgical drainage and intravenous antibiotic therapy. Complications were seen in three children, with one child developing significant intracranial complications. To our knowledge, this is the first series of spontaneous nasal septal abscesses in immunocompetent children. The high prevalence of Staphylococcus aureus suggests spread from the nasal mucosa or vestibule. Early recognition, computed tomography scanning, surgical drainage and antibiotic therapy are the mainstays of treatment, to prevent potentially life-threatening complications.

Quantitative study of Artemisia pollens deposition in the upper airways of children with adenoidal hypertrophy

Studies regarding the pollen transport and deposition in children nasal airways are still scarce, especially the regional deposition doses, which is difficult to provide guidance for precise application of pollen blockers and nasal administration. In addition, most previous investigations included only one child case, which lacked statistical significance. To this end, we used computational fluid particle dynamics (CFPD) modeling approach to calculate the deposition pattern of Artemisia pollen at various anatomical sites in the upper airway of 12 children with adenoid hypertrophy (AH), and analyzed the effects of respiratory flow rate and pollen density on the deposition distribution. Adult nasal airways from our previous study were included for data comparison. We found that nasal cavities of children with AH aged 4–6 years had a greater area/volume ratio than adults did, and the area and volume of the turbinate region were less than half that of adults. The physical diameter of Artemisia pollen was set to 21.0 μm, with a shape of ellipsoid. Its average density is 1080 kg/m3 in the humid state and 550 kg/m3 in the dry state. In resting state, children with AH had higher deposition rates of wet Artemisia pollen in the nasal septum and nasopharynx, and lower deposition rates in the nasal vestibule and middle turbinate compared with adults. Under exercising conditions, wet pollen was deposited mainly in the nasal vestibule and the anterior part of the nasal septum in children. Compared to wet pollen, the deposition rate of dry Artemisia pollen in resting state was approximately halved and the pollen entering the lower respiratory tract rose approximately 47-fold. The findings suggest that nasal cavities of children are not simply scaled-down version of adults. Notable differences in deposition hotspots and deposition patterns have been discovered between the two. The deposition hotspots shifted significantly forward as the respiratory flow rate increased. Dry Artemisia pollen has a low density and is more likely to enter the lower respiratory airways, which may put children at a higher risk of developing asthma.

Morphology of the myocardium of the interventricular septum in children with hypertrophic cardiomyopathy

To carry out a comparative analysis of the morphology of the interventricular septum (IVS) myocardium in children with hypertrophic cardiomyopathy (HCM) and without cardiovascular pathology. A study of myocardial biopsies of the IVS in children with HCM (n=18, 1.2-17 years) and children without cardiovascular pathology (n=11, 1-16 years) was carried out. The volume of interstitial tissue in the IVS myocardium was determined, a morphometric study of the size of cardiomyocytes (CMCs), the myofibrillogenesis level and the ploidy of CMCs was carried out, the ultrastructure of the CMCs was studied, and the localization of the gap junction protein, connexin43 (Cx43), was revealed by immunohistochemistry. The proportion of interstitial tissue in the myocardium of children with HCM was 9-10% and did not differ from its proportion in the myocardium of children in the control group. The diameter of the CMCs of the IVS in children with HCM reached the limit of ontogenetic growth and exceeded the parameters of the control group (average 18.9±5.7 µm vs 9.3±4.4 µm). CMCs ploidy in children with HCM was 2 times higher than CMCs ploidy in control patients (5.3c vs 2.7c). In the myocardium of children with HCM, the assembly of myofibrils most actively occurred in small CMCs. At the ultrastructural level, signs of immaturity of the contractile apparatus and intercalated discs of the CMC in HCM were demonstrated. In the myocardium of children with HCM, Cx43-containing gap junctions were more often located on the lateral surfaces of the CMC than in the myocardium of the control group. In children with HCM, a morphological picture of an increase in the size of the CMCs and their ploidy during accelerated ontogenetic development was demonstrated in combination with ultrastructural signs of immaturity of the contractile apparatus and intercalated discs and the lack of growth of interstitial tissue of the IVS myocardium compared with patients in the control group.

AGE CORRELATION OF LINEAR PARAMETERS OF THE NASAL SEPTUM IN YAKUT CHILDREN IN EARLY CHILDHOOD ACCORDING TO THE RESULTS OF COMPUTED TOMOGRAPHY

The dynamics of the frequency of otorhinolaryngological pathology, one of the main causes of which is the deformation of the nasal septum, among the child population has a positive growth trend and, according to some authors, is from 56 to 95% of all cases of treatment. Congenital deformities or developmental anomalies leading to deviation of the nasal septum in children, with untimely diagnosis, can lead to chronic inflammatory processes in the mucous membrane of the cavity and paranasal sinuses, which in turn cause a violation of the airway function of the upper respiratory tract and an increase in the development of infectious diseases. Diagnosis of such conditions in children under the age of six will prevent their consequences, as well as reduce the need for their surgical treatment - septoplasty. The purpose of the study is to establish morphometric patterns of development of nasal septum structures, to identify patterns of its development and the minimum necessary anatomical criteria for predicting and determining deviation in young children. We used the results of head studies using multispiral computed tomography in the multiplanar mode in children aged 0 to 4 years, 16 girls and 32 boys, a total of 48 patients. The linear dimensions of the nasal septum were measured, including the length, maximum length and height, as well as the angle of deviation. According to the results of the analysis, statistically significant correlations were revealed between the age of children and the linear parameters of the nasal septum, a positive dynamic of the increase in the size of the nasal septum by the age of 3-4 years was observed. Simultaneously with the growth of linear dimensions, a decrease in the angle of deviation of the nasal septum is observed; no statistically significant sex differences were found. The discovered phenomena are due to the rapid growth of the cartilaginous part of the nasal septum by the third year of life. The data obtained demonstrate the possibilities of computed tomography for assessing deviations in the development of the nasal septum in young children for early prevention and elimination of rhinopathy.

Deviated nasal septum in children: a review

Deviated nasal septum (DNS) is a common clinical entity in human beings. Deviated nasal septum (DNS) may also result in upper respiratory infection, sinusitis, headache, epistaxis, middle ear infection, and hyposmia which increase the morbidity of the child and hamper the quality of life. The common clinical symptoms associated with DNS among children are nasal obstruction and postnasal discharge. The chronic nasal block in DNS has an adverse effect on the development of the child. DNS has an important effect on the faciomaxillary growth and development, particularly in the first decade of life. The treatment of DNS in childhood has received challenges among otolaryngologists because of its concern about the role of the nasal septum in the overall growth of the midface. So, otolaryngologists are often cautious during the correction of the DNS in children. DNS and its impact on nasal breathing impairment in children are often underestimated by clinicians. Clinicians often have little knowledge on the impact of DNS, its clinical manifestations in children, and its appropriate management. Early intervention for DNS in children is helpful to prevent morbid symptoms and their complications. This review article discusses etiopathology, epidemiology, clinical presentations, diagnosis, and current treatment of the DNS in children.

Deviated nasal septum in children

Abstract Background: Nasal obstruction is a common symptom among children with numerous causes. Congenital or acquired nasal septal deviation may cause nasal obstruction in children. Deviated nasal septum (DNS) may also result in sinusitis, headache, epistaxis and hyposmia which increase the morbidity of the child and hamper the quality of life. The present study investigated the clinical details of the DNS among children at a tertiary care teaching hospital. Methods: This is a retrospective study was conducted at a tertiary care teaching hospital between November 2016 and December 2021. History of nasal obstruction, mouth breathing, nasal bleeding and sinusitis among children with DNS was noted. Anterior rhinoscopy, fiberoptic endoscopic examinations of both nostrils and imaging such as computed tomography were done in all participating children with DNS. Results: Out of 652 children who attended the outpatient department of otorhinolaryngology, 128 (19.6%) were diagnosed with DNS. Out of 128 children with DNS, 72 (56.3%) were male; male:female ratio was 1.28:1. Out of 128 children, 54 (42.2%) children showed C-shaped DNS, 27 (21.1%) showed anterior dislocation, 21 (16.4%) showed S-shaped DNS, 15 (11.8%) showed spur and 11 (8.6%) showed nasal septal thickening. Conclusions: DNS and its impact on nasal breathing impairment in children are often underestimated by clinicians. Clinicians often are unaware on the impact of DNS and its clinical manifestations in children and its appropriate management. Early intervention for DNS in children is helpful to prevent morbid symptoms and their complications.

Temporary conchotomy for plastic closure of perforation of the nasal septum in children

Temporary conchotomy for plastic closure of perforation of the nasal septum in children

Влияние сопутствующего искривления носовой перегородки на показатели мукоцилиарного транспорта в послеоперационном периоде у детей с хроническим риносинуситом

Objective. To analyze the effect of concomitant deviated nasal septum in children with chronic rhinosinusitis (CRS) on the effectiveness of functional endoscopic sinus surgery (FESS), the state of the ciliary apparatus, and the morphology of the nasal mucosa in the postoperative period. Patients and methods. A comprehensive examination was performed in 124 patients with CRS without nasal septum deviation as well as 66 patients with CRS and concomitant nasal septum deviation who underwent FESS. Results. A statistically significant improvement in the condition of the subjects after surgery was found in both groups. At the same time, patients with CRS and nasal septum deviation had a higher number of complications and the need for revision surgery. The subjective evaluation of the results of FESS was significantly higher in the group of children with CRS without nasal septum deviation. According to the results of video cytomorphometry in children with CRS without deviated nasal septum, by 6 and 12 months of the postoperative period, there was a close to significant and significant increase in the survival of epithelial cells, the number of cells with mobile cilia, the length of cilia, and the frequency of cilia beating. A year after the operation, this group of subjects also showed a statistically significant decrease in epithelial dystrophy, the number of neutrophils and lymphocytes, and a tendency to arrange cells in layers. In contrast, in patients with CRS and nasal septum deviation, a significant increase in the length of cilia was noted only by 12 months after surgery, while other parameters only tended to normalize. Synchronicity of cilia beat increased significantly by 12 months in both groups. Thus, the obtained results indicate a delayed recovery of the ciliary apparatus and the morphology of the ciliated epithelium mucosa after FESS in children with CRS and concomitant nasal septum deviation, which may be associated with persistent inflammation, causing a less favorable course of the postoperative period.

Efficacy of staging surgery in pulmonary atresia with intact ventricular septum

Objective: To assess the feasibility and efficacy of a staged invasive treatment strategy for the treatment of pulmonary atresia with intact ventricular septum, in the first stage using a catheter-based stent placement, second-stage surgery, and three-stage atrial septal occlusion. Methods: Totally 19 children with pulmonary atresia with intact ventricular septum were enrolled at Department of Cardiovascular Surgery, the Children's Hospital of Zhejiang University School of Medicine from January 2009 to December 2017, including 11 male and 8 female patients. The age was (13.8±7.7) days (ranging from 3 to 35 days). The weight was (3.4±0.5) kg (ranging from 2.8 to 4.1 kg). Among them, there were 13 cases of type Ⅱ and 6 cases of type Ⅲ. Regular follow-up visits for patients with stage Ⅰ arterial duct stenting after 1, 3, and 6 months; and routine follow-ups for 1, 3, and 6 months after stage Ⅱ surgery.The t test was used to compare the oxygen saturation between pre-operation and post-operation. Results: All 19 patients underwent arterial catheterization. The preoperative peripheral oxygen saturation was (64.4±5.3)%, while increased to (86.0±3.0)% after operation (t=16.353, P=0.000). One patient died during follow-up and 2 patients lost follow-up. One patient received stent balloon dilatation due to oxygen saturation decrease.Twelve patients completed the second-stage surgery and 1 case died after surgery. The rest were alive, including 2 cases of double-ventricular correction and 9 cases of semi-ventricular treatment in one room; 2 cases had completed three-stage atrial septal occlusion. Conclusions: Stage Ⅰ arterial duct stent, stage Ⅱ surgery, and stage Ⅲ atrial septal occlusion to treat pulmonary atresia with intact ventricular septum in children is feasible and effective. The method can be used as the important treatment direction for pulmonary atresia with intact ventricular septum.

Correlations between selected parameters of nasal cavity in neonates and young infants - computed tomography study.

Correlations between selected metric parameters of the nasal cavity and nasopharynx in children without atresia may be useful for anticipating probable dimensions of this region in living subjects, in terms of changes with age. One hundred and eighty children, age range 0-3 years, were divided into five age groups, and measurements of 18 distances between structures of nasal cavity and nosopharynx were performed on computed tomography scans. Correlation coefficients and relations between parameters have been determined. Our study confirmed the existence of statistically significant correlations between linear dimensions within nasal cavity in children. The analysis demon-strated that for the values of following indexes: nasal septum length/piriform aperture width, and maximum length of the nasal septum/posterior nares width no statistically significant differences have been noted between age groups of children. All correlations have been positive. No statistically significant differences have been noted between the maximum width of the vomer and osseous parameters measured, both in the anterior and posterior part of the nasal cavity, and nasal septum length. The size of posterior nares changed with age in children by a constant value. So far, no such an analysis has been carried out assessing potential correlations between linear dimensions for the entire nasal cavity, nasopharynx, length of the nasal septum in children, as well as proportions of individual linear dimensions of the anatomical structures analysed, in various age groups.

A Novel Bilayer Approach to Ventricular Septal Deformation Analysis by Speckle Tracking Imaging in Children with Right Ventricular Overload

The aim of this study was to evaluate functional differences between the left and right sides of the ventricular septum in children with right ventricular overload. Radial, longitudinal, and circumferential strain on both sides of the ventricular septum were compared using speckle-tracking echocardiography in patients with preoperative atrial septal defects (n= 22), postoperative tetralogy of Fallot (n= 23) and age-matched normal controls (n= 44). The duration between peak strain of the left and right ventricular septum (TLt-Rt) was also evaluated. Radial and circumferential strain in the control group were significantly higher on the left than the right ventricular septum (41.3 ± 12.8% vs 22.6 ± 6.8% and -28.0 ± 5.4% vs -22.5 ± 4.8%, respectively; P < .0001 for both), whereas longitudinal strain did not significantly differ (-22.0 ± 4.9% and -20.7 ± 5.2%, respectively). TLt-Rt was 52.9 ± 35.6, 33.4 ± 29.0, and 38.7 ± 31.0 msec for radial, longitudinal, and circumferential strain, respectively. Longitudinal and circumferential strain on both sides were significantly increased in patients with atrial septal defects compared with controls (P < .05), although radial strain was similar on both sides. Radial strain on the right side was significantly increased in patients with tetralogy of Fallot compared with controls (P < .05), whereas that on the left side was significantly reduced (P < .001). Longitudinal strain on both sides was significantly decreased (P < .01 and P < .001 for the left and right sides, respectively). In addition, TLt-Rt in patients with tetralogy of Fallot was significantly increased with radial and circumferential deformation (P < .05 for both). Deformation of both sides of the ventricular septum functionally differed. Bilayer analysis of theventricular septum can help in the evaluation of right ventricular performance under volume and pressure overload.

The pathology of visible blood vessels on the nasal septum in children with epistaxis

Objective Epistaxis is common in children, but its cause remains unknown. About half the children who present with epistaxis have prominent vessels on the nasal septum. The aim of this study was to determine the pathological nature of the prominent septal vessels in children with recurrent epistaxis. Methods 4 mm punch biopsies of the nasal septal mucosa were taken from 5 children undergoing nasal cautery under general anaesthesia. Results Histology showed that the prominent vessels were thin-walled arterioles and capillaries with a surrounding inflammatory infiltrate. There was no evidence of venous varicosities or arterial microaneurysms. Conclusion We postulate a mechanism for septal neovascularisation due to chronic low-grade inflammation as a cause for recurrent epistaxis in children.

Safe and rapid approach to the deviated nasal septum in children

Safe and rapid approach to the deviated nasal septum in children

Deformation of the nasal septum in children, adolescents, and adults in Western Pomerania province of Poland.

ObjectivesNasal septum deformation (NSD) contributes to the occurrence of upper respiratory tract diseases in around 45-55% of Poland's population. The evaluation of frequency of occurrence and type of nasal septum deformation among randomly chosen representatives of the Szczecin and surrounding area population was the aim of this study.MethodsNSD was assessed in 235 patients (123 male, 112 female) aged 5-60. Mladina's classification system was used for the evaluation.ResultsDeformations of nasal septum were found in 43% of the examined subjects. Type 3 of NSD dominated (12.4%), while types 2 and 1 were found in 10.3% and 4.2% of the subjects, respectively. 9.2% of the patients showed type 5 of deformation, while types 6, 4, and 7 were found in 1.3%, 3.2% and 2.7% of the patients, respectively.ConclusionsStraight nasal septum was found in females more often than in males, mostly on the left side. Associations between NSD, on one side, and age, sex, and traumas, on the other were found. NSD influenced the quality of respiration and frequency of upper respiratory tract diseases in the examined subjects.

Analysis of ventricular septal motion by Doppler tissue imaging in atrial septal defect and normal heart

The aortic root and the upper part of the ventricular septum moves anteriorly in early systole, while the lower part moves posteriorly. The hinge of the counterpart motion of the ventricular septum is called pivot point. Using Doppler tissue imaging (DTI), we attempted to clarify the location of the pivot point of the ventricular septum in children with normal heart and with atrial septal defect (ASD), and to investigate the relation between the degree of the downward shift of the pivot point and that of volume overload of the right ventricle in patients with ASD. Study subjects consisted of 20 healthy children and 36 patients with ASD, aged from 1 to 15 years (mean 5.7 ± 3.4) in the normal group and 6 months to 12 years (mean 4.4 ± 3.2) in the ASD group, respectively. The pivot point was designated as a border of the color signal of DTI of the ventricular septum in early systole. Measurements were then obtained on cross-sectional echocardiography and DTI: septal length in the parasternal long-axis view, distance from aortic valve to pivot point in early systole, diastolic left ventricular internal dimension, and diastolic right ventricular internal dimension. In the normal group, the ratio of distance from aortic valve to pivot point/septal length was 0.13 ± 0.049, whereas it was 0.26 ± 0.168 in the group with ASD (p <0.001). In the ASD group, the distance from aortic valve to pivot point normalized by body surface area (mm/m 2) correlated with the ratio of diastolic right/left ventricular internal dimension and with the ratio of pulmonary to systemic flow (Qp/Qs) (r = 0.63 and 0.50, respectively). The ratio of the distance from aortic valve to pivot point/septal length correlated with the ratio of diastolic right/left ventricular internal dimension and Qp/Qs (r = 0.56 and 0.44, respectively). By DTI, the pivot point was located at the upper 13 ± 5% of the total length of the ventricular septum in normal children, and was located at 26 ± 17% in patients with ASD (p <0.001). The degree of this displacement in ASD correlated with that of volume overload of the right ventricle. The paradoxic motion of the ventricular septum shown in the ASD could be explained by this downward shift of the pivot point.

Hematoma and Abscess of the Nasal Septum in Children

To evaluate the clinical characteristics and treatment outcome of hematoma and abscess of the nasal septum (HANS) in children. Retrospective case series. Pediatric tertiary care facility. Consecutive series of 20 children (age, 2 months to 15 years; mean age, 7 years) who were admitted to the hospital for treatment of HANS after nasal trauma during an 18-year period. In addition to receiving antibiotics, all patients underwent general anesthetic for incision and evacuation of the collection of blood and pus together with nasal packing. All patients had a history of nasal trauma. The HANS was a consequence of child abuse (2 patients younger than 2 years), minor nasal trauma (14 patients aged 1 to 10 years), and sports injury (4 patients older than 10 years). The diagnosis was made 1 to 14 days (mean, 5.9 days) after the episode of trauma. Nasal obstruction was the most common symptom found and was present in all but 1 patient. Pain, rhinorrhea, and fever occurred in 50%, 35%, and 25% of patients, respectively. Nasal fracture was present in 3 children. Abscess was found at surgery in 12 patients and was universally associated with septal cartilage destruction. Hematoma was present in 8 patients and associated with cartilage destruction in 2 patients. Organisms cultured were Staphylococcus aureus, Streptococcus pneumoniae, and group A beta-hemolytic streptococcus and were obtained from all 12 patients with septal abscess and from 1 patient with septal hematoma. Corrective nasal surgery has been performed in 5 patients, 4 of whom had a history of septal abscess. The diagnosis of HANS must be considered in all children who have acute onset of nasal obstruction and a history of recent nasal trauma to minimize the risk of nasal deformity and prevent the development of septic complications.

Deviated nasal septum in kashmiri children (Incidence and Etiology)

“The study comprised of 4562 children ranging from Birth to 14 years of age. Nasal septal deviation was found in 25 per cent of the cases with 18 per cent in 0–1 Year age group (Newborn & lnfants) and then showing rise in incidence as age advances with maximum of 32.65 percent in 11–14 year age group. Septal deviation in children though found commonly but leads to symptoms only infrequently. 7.35 percent cases were found to be symptomatic indicating that most of the times the deviation of septum is of mild nature. Trauma was found to be an important aetiological factor and it was found that mild nature of trauma (80%) in the form of falling on nose while learning to walk was more common. Various maternal factors like Parity, Gestational period of pregnancy, duration of labour and type of delivery were considered. None of these factors were found to have any significant correlation with deviation of nasal septum in children.”

Total septal reconstruction through decortication (external) approach in children.

Severe posttraumatic deformities of the ventrocaudal and ventrocranial septum in children continue to present a serious challenge to the modern rhinosurgeon. Conservative septoplastic techniques through Cottle's approach produce an untolerably high rate of recurrence or insufficient restoration of the function of the nose. The total septal reconstruction through decortication (external) approach is proposed as a solution for this problem. After temporary elevation of the skin, the nasal septum is approached in between the lower lateral cartilages. The mucoperichondrium is elevated, and the entire septal cartilage is removed. The straight part of the cartilage from the central part is used to reconstruct the ventrocaudal and ventrocranial septum, while the deformed cartilage is straightened by crushing and positioned in the posterior septal space. The cartilage graft is precisely sutured to the upper lateral cartilages and to the fibers of the septospinal ligament. In an eight-year period, five girls and 19 boys, aged 5 to 14 years, were operated on using this technique. Satisfactory functional results were obtained without any major complications in all patients. There were neither serious alterations of the growth of the nose, nor the necessity for reoperation. Total septal reconstruction through decortication (external) approach is useful for correction of severe septal deformities in children.

An approach to the nasal septum in children.

Surgery of the nasal septum has long been discouraged in the pediatric population. Concerns about growth and development of the nose have led surgeons to adopt an extremely cautious attitude toward the correction of nasal septal deformities in childhood. More recently, studies have shown that with proper preservation of septal cartilage, surgery can be safely undertaken in this area. Frequently, however, exposure to the nasal septum is limited in small children due to the size of the nasal vestibule. Sublabial septoplasty has been safely carried out now in ten patients ranging in age from 4 to 9 years. This approach allows for complete access to the nasal septum while avoiding any external cosmetic deformity. The nasal septum has been preserved in all cases through morsalization and repositioning. Growth and development of the nose has been followed for up to 60 months without evidence of deformity or alteration. Sublabial septoplasty would, therefore, appear to be a safe and cosmetically acceptable approach to the correction of severe nasal septal deformities of childhood.

Patency of the interatrial septum in children undergoing cardiac catheterization.

AbstractCatheter passage into the left atrium from the right atrium greatly facilitates invasive cardiovascular evaluation and reduces the risks attendant on cardiac catheterization studies. We reviewed 371 consecutive cardiac catheterizations to establish the presence of natural interatrial communications. Catheter course, pressure equalization, and left‐to‐right atrial shunt on recirculation angiography were considered to determine intact interatrial septum (IIS), patent foramen ovale (PFO) or atrial septal defect (ASD).During the first year of life, 88% of infants had PFO or ASD; in 12%, the interatrial septum was intact. In children 1–10 years old, 49% had IIS, 27% had PFO, and 24% had ASD. In children 10–21 years old, 24% had PFO, or ASD. Though there seems to be a greater likelihood of ISS in those with left heart obstruction, hemodynamic factors did not completely explain the timing of closure of the foramen ovale.Presence of an interatrial communication allows catheter entrance into all left heart structures including the aorta; therefore, in patients with PFO or ASD, retrograde arterial procedure or transseptal puncture technique can be avoided when performing left heart catheterization. This appears possible in 88% of those under 1 year of age, in 51% of those 1–10 years old, and in 24% of children 10–21 years old.