Journal of Tropical Pediatrics - Advance Access

High Prevalence of Infantile Encephalitic Beriberi with Overlapping Features of Leigh's Disease

Rao, S. N., Mani, S., Madap, K., Kumar, M. V. K., Singh, L., Chandak, G. R. — 2008-05-08

Infantile encephalitic beriberi (IEBB) is a rare form of thiamine deficiency and is poorly described. A proportion of Leigh's disease (LD) patients have similar clinical picture and response to thiamine as beriberi, leading to confusion in diagnosis and management. Data on IEBB and LD is scarce and status of thiamine deficiency in India is controversial. We report several infants with life-threatening respiratory and central nervous system symptoms that overlap between IEBB and LD. Majority had low erythrocyte transketolase levels and responded dramatically to thiamine supplementation suggesting a diagnosis of IEBB. However, presence of characteristic lesions on brain imaging and residual damage in several patients on follow-up does not rule out LD completely. Our study highlights the importance of thiamine deficiency in India, especially in the breast-feds and its overlapping features with LD. Awareness of this common mode of presentation may save patients’ lives by early diagnosis and timely thiamine supplementation.

Antibody Responses and Resistance against Ascaris lumbricoides Infection among Venezuelan Rural Children: The Influence of Ethnicity

2008-05-03

We studied the production of anti parasite antibodies and the resistance against A. lumbricoides infection among the school population of three different Venezuelan ethnic groups: Warao Amerindians, Afro- Americans and white ‘Creole’ descendents. The prevalence and intensity of A. lumbricoides were determined before and after 1 year of anthelminthic treatment. Parasitic loads were associated to pre-treatment serum levels of anti A. lumbricoides IgE and IgG4 antibodies. The intensity of the infection and the proportion of re-infected children were significantly lower (p < 0.0001) among the Warao Amerindians, exhibiting higher levels of IgE (p < 0.0001) and lower levels of IgG4 (p < 0.0001) compared to their non-Amerindian counterparts. IgE levels correlated inversely with the proportion of re-infected children, whereas the levels of IgG4 were positively associated. These results suggest that ethnicity may influence the balance of IgE/IgG4 levels, modulating the intensity of A. lumbricoides and the resistance to the infection.

Linear Growth, Growth-Hormone Secretion and IGF-I Generation in Children with Neglected Hypothyroidism Before and After Thyroxine Replacement

2008-05-01

We studied growth hormone (GH) stimulation and insulin-like growth factor -I (IGF-I) generation tests in 15 children with neglected congenital hypothyroidism (CH) (age = 6.4 ± 4.2 years) and measured their growth parameters for >1 years after starting thyroxine (T4) replacement. One year after treatment, height SDS (HtSDS) increased from –4.3 ± 2.5 to –2.7 ± 2.3. Peak GH response to clonidine increased from 3.2 ± 1.2 ng ml^–1 to 7.62 ± 1.38 ng ml^–1 after treatments. Basal and peak IGF-I response to GH increased from (34.66 ± 17.3 ng ml^–1 and 58.4 ± 36.99 ng ml^–1, respectively) before treatment to (130.6 ± 97.8 ng ml^–1 and 193.75 ± 122.5 ng ml^–1, respectively). HtSDS increments were correlated significantly with basal free T4 concentrations (r = 0.622, P < 0.01). In summary, after long period of hypothyroidism, T4 replacement produced significant, although incomplete, catch-up growth through a partial recovery of GH- IGF-I axis.

Improving the Management of Severe Acute Malnutrition in an Area of High HIV Prevalence

Sadler, K., Kerac, M., Collins, S., Khengere, H., Nesbitt, A. — 2008-05-01

Aim: To assess the clinical outcomes of a combined approach to the treatment of severe acute malnutrition in an area of high HIV prevalence using: (i) an initial inpatient phase, based on WHO guidelines and (ii) an outpatient recovery phase using ready-to-use therapeutic food.

Methods: An operational prospective cohort study implemented in a referral hospital in Southern Malawi between May 2003 and 2004. Patient outcomes were compared with international standards and with audits carried out during the year preceding the study.

Results: Inpatient mortality was 18% compared to 29% the previous year. Programme recovery rate was 58.1% compared to 45% the previous year. The overall programme mortality rate was 25.7%. Of the total known HIV seropositive children, 49.5% died.

Conclusions: Inpatient mortality and cure rates improved compared to pre-study data but the overall mortality rate did not meet international standards. Additional interventions will be needed if these standards are to be achieved.

Factors Associated with Immunization Coverage of Children in Assam, India: Over the First Year of Life

Phukan, R. K., Barman, M. P., Mahanta, J. — 2008-05-01

The children of Assam in the North-East Region of India have consistently evidenced low rates for routine childhood immunizations. This study has been conducted to evaluate the factors affecting the immunization coverage in the first year of life of the children. About 62.2% of the children were fully immunized. Lack of information among the parents was one of the major causes of drop out of vaccinations. The children from urban areas and mother's education level showed significant role in immunization coverage. Improvement in female literacy coupled with the reduction in the drop out rate would add to achieve a higher target of immunization among children in the study area.

Seroprevalence of Helicobacter pylori Infection in Children in Northwest Region of Turkey: Relationship with Iron Deficiency Anemia

Kaya, A. D., Gencay, E., Ozturk, C. E., Yavuz, T. — 2008-04-27

Birth Interval and Risk of Stillbirth or Neonatal Death: Findings from Rural North India

2008-04-27

Short birth intervals have been associated with adverse birth outcomes. This study examines the association between preceding interval and risk of stillbirth or neonatal death in rural north India (n = 80 164). Adjusted odds ratios (OR) and 95% confidence interval (CI) of stillbirth and neonatal mortality were calculated. The odds of stillbirth were significantly greater among birth intervals of <18 months (OR 3.10; CI: 2.69–3.57), 18–35 months (OR 1.47; CI 1.30–1.68) and >59 months (OR 1.44; CI 1.19–1.73), compared with intervals of 36–59 months. Neonatal death was associated with birth intervals of <18 months (OR 4.12; CI 3.74–4.55) and 18–35 months (OR 1.78; CI 1.63–1.94), compared to births spaced 36–59 months. Previous history of either stillbirth or neonatal death was significantly associated with risk of stillbirth and neonatal death, respectively, as were multiple births.

The Brain Atlas: A Visual Guide to the Human Central Nervous System (3rd Edn). T.A. Woolsey, J. Hanaway and M.H. Gado

Ebrahim, G. J. — 2008-04-27

Attitudes Towards End-of-life Issues Amongst Pediatricians in a Tertiary Hospital in a Developing Country

Guglani, L., Lodha, R. — 2008-04-27

To describe the perspectives of pediatricians from a tertiary care center from India on end-of-life (EOL) care issues, a standardized anonymous questionnaire was administered, which included questions regarding attitudes towards withdrawal/withholding of life-sustaining treatment in children and neonates at the EOL, and responses to an EOL case scenario. The questionnaire was administered to 40 pediatricians, of whom 31 (22 males, mean age 34.5 ± 7.7 years) responded. None of the participants had ever instructed withdrawal of support. The most common modes of life-support limitation practiced were withholding new treatments (17/31; 54.8%) and ‘do-not-resuscitate orders’ (14/31; 45.2%). 51.6% respondents believed that withholding treatment and withdrawal of support were ethically the same. There is wide variation in responses and there were significant differences from findings of similar studies from the developed countries, the most important being the complete lack of use of withdrawal of support.

Serum Retinol Concentrations in Hospitalized Severe Protein-energy Malnourished Children

2008-04-01

Background: Vitamin A deficiency (VAD) is a major nutritional problem in many developing countries. Vitamin A status has been reported to be adversely affected in protein-energy malnutrition (PEM). Objective: to assess and compare serum retinol concentrations in hospitalized children with severe PEM and normal ones.

Methods: a prospective series of 34 malnourished and 29 normal control children, <60 months old, hospitalized at IMIP, Recife-PE were recruited for the study between August 2004 and May 2005. Serum retinol level was assayed by high performance liquid chromatography and concentrations adjusted for presence of inflammation as evidenced by levels of C-reactive protein. Blood retinol level was compared according to nutritional status (severe PEM versus normal), gender, age, maternal schooling, family income, breastfeeding practice, residence and perceived morbidity.

Results: the prevalence of low serum retinol (<0.70 µmol l^–1) was 41.2% in children with severe PEM and 24.1% in normal children. Serum retinol concentrations were lower in children whose mothers had low schooling (p = 0.025) and families with low per capita income (p = 0.049), regardless of their nutritional status. Serum retinol concentrations had similar distribution between children with severe PEM and normal, when adjusted for gender (p > 0.05), age (p > 0.05), maternal schooling (p > 0.05), family income (p > 0.05), breastfeeding practice (p > 0.05) and residence (p > 0.05). However, malnourished children with diarrhoea showed lower serum retinol concentrations (p = 0.021) compared to those without diarrhoea.

Conclusion: VAD was prevalent in hospitalized children with severe PEM and also among normal ones although in lesser magnitude. Intervention for prevention and control of deficiency of vitamin A are recommended in settings where diarrhea is endemic and there are unfavorable socio-economical conditions.

Possible Risk Factors for Congenital Malaria at a Tertiary Care Hospital in Sagamu, Ogun State, South-West Nigeria

2008-03-29

Congenital malaria, defined as the presence of malaria parasites in the erythrocytes of newborns aged <7 days, was considered rare in endemic areas until recent studies started reporting high prevalence rates. Various theories have been postulated to explain this phenomenon, but they are not proven conclusively from research. Against this background, a prospective study was designed with the following objectives. To determine the prevalence of congenital malaria parasitaemia and identify possible risk factors amongst newborns delivered in O.O.U.T.H Sagamu, Ogun State. Over a 6-month period, 192 live newborns and their mothers were consecutively recruited into the study. Within 3 days of life, neonatal peripheral blood samples were collected for malaria screening by blood film microscopy and detection of plasmodium lactate dehydrogenase (pLDH) with the OptiMAL® Rapid Malaria Test kit. Maternal peripheral blood samples were taken simultaneously, to check for malaria infestation by blood film microscopy, and questionnaires were administered on the mothers to identify possible factors associated with the development of neonatal parasitaemia. Neonatal clinical and laboratory data were recorded in a proforma designed for the study. Data analysis was done with Epi-info version 6 software and level of significance set at <5%. Twenty-one of 192 newborns delivered in O.O.U.T.H within the study period were diagnosed as having congenital malaria by blood film microscopy, giving a prevalence rate of 10.9%. The main identified innate neonatal risk factor for congenital malaria parasitaemia was prematurity. First-order pregnancy, history of fever within 3 months of delivery and peripheral parasitaemia at delivery (p < 0.001) were the variables that were significantly higher in the mothers of the parasitaemic newborns. We conclude that congenital malaria parasitaemia in tropical endemic areas is not rare. Pre-term neonates, infants of primigravidae, women with history of fever within 3 months of delivery and women with post-partum peripheral parasitaemia may benefit from routine screening for malaria.

Variation in Clinical Presentation of Childhood Group A Streptococcal Pharyngitis in Four Countries

2008-03-29

We conducted a cross-sectional study from September 2001 to August 2003 during which children between 2 and 12 years of age presenting with complaint of sore throat were recruited from urban pediatric clinics in Brazil, Croatia, Egypt and Latvia. The objective of the study was to compare clinical signs and symptoms of children presenting to urban pediatric clinics with sore throat in and between countries and to identify common clinical criteria predicting group A beta hemolytic streptococcal (GAS) pharyngitis. Using a single standard protocol in all four sites, clinical data were recorded and throat swabs obtained for standard GAS culture in 2040 children. Signs and symptoms were tested for statistical association with GAS positive/negative pharyngitis, and were compared using ² tests, ANOVA and Odds Ratios. Clinical signs of GAS pharyngitis in children presenting to clinics varied significantly between countries, and there were few signs or symptom that could statistically be associated with GAS pharyngitis in all four countries, though several were useful in two or three countries. Our results indicate that the clinical manifestations of pharyngitis in clinics may vary by region. It is therefore critical that clinical decision rules for management of pharyngitis should have local validation.

Guillain-Barre Syndrome Associated with Legionnella Infection

2008-03-28

This is the first report of Guillain–Barré syndrome (GBS) related to Legionnella pneumophilia infection. A 13-year-old boy presented with acute dysphagia and dyspnea. He lived in a rural area and had a history of drinking potable deep-hole water. The patient was intubated because of increased respiratory distress. A positive direct fluoresein antigen test confirmed L. pneumophilia infection in BAL. One week after the first admission, acute weakness was noticed including the lower extremities and was more prominent in the distal than the proximal portions. GBS was considered as the initial diagnosis. Tests for all causes known to trigger GBS were negative. Specific serology for L. pneumophilia IgG was positive. He was treated with intravenous immunoglobulins and discharged with minor weakness and difficulty in walking in the second month. On the basis of this case, L. pneumophilia should be included in the etiologic spectrum of GBS.

Longitudinal Study of Prenatal and Postnatal Lead Exposure and Early Cognitive Development in Al-Kharj, Saudi Arabia: A Preliminary Results of Cord Blood Lead Levels

2008-03-18

Extensive data shows a direct link between low-level lead exposure during early development and deficits in neurobehavioral-cognitive performance evident late in childhood through adolescence. Our previous studies confirmed the transfer of lead from the mother to the fetus as well as the effect of low lead exposure on neuropsychological behavior in school children. Such results led us to design a longitudinal survey to evaluate the effect of prenatal and/or postnatal lead exposure on early cognitive development among selected group of children from birth to 2 years of age. During the first stage of this study (between March and July 2004), we measured lead levels in 653 umbilical cord blood samples taken from healthy Saudi mothers delivering at King Khalid Hospital, Al-Kharj. This gave a good opportunity to look at the prevalence of increased blood lead levels in umbilical cord blood and to identify risk factors for prenatal lead exposure. The mean cord lead levels were 2.21 ± 1.691 µg/dl in the range of 0.284–17.276 µg/dl. Only 1.23% of the newborns had blood lead levels >10 µg/dl, the Center for Disease Control level of concern. To investigate risk factors affecting cord blood lead levels, only subjects with lead levels above the 75th percentile (2.475 µg/dl) were selected in the multiple regression models. We observed that cord blood lead levels were significantly influenced by maternal age, the location of residence and intake of prenatal supplements. Controlling for newborn's head circumferences confounders, it was found that cord blood lead levels were significantly and negatively associated with newborn's head circumference (β = –0.158, p = 0.036). The negative association was seen between intake of prenatal supplements and cord blood lead levels emphasizing the role of prenatal supplementations during pregnancy. The significant reductions in newborns, head circumferences due to lead exposure may have serious implications for their future performance and achievement. This study reveals that even at low prenatal lead exposure, all possible measures to inspect lead sources in our environment and reduce lead exposure should be taken.

Epidemiology of Rotavirus Infection in North-western Nigeria

Aminu, M., Ahmad, A. A., Umoh, J. U., Dewar, J., Esona, M. D., Steele, A. D. — 2008-03-15

Rotaviruses (RV) are associated with ~33 000 deaths in children <5 years of age annually in Nigeria. However, limited data exit on RV infection in north-western Nigeria. During July 2002 to July 2004, 1063 (869 diarrhoeic and 194 control) stool samples were collected from children <5 years of age presenting with diarrhoea in north-western Nigeria. The stools were analysed for RV antigen and further characterized by antigenic and genomic methods. RV was detected in 18% of children with diarrhoea and 7.2% of the age-matched case controls. The highest RV burden was detected in children <6-months-old. Long electropherotypes and VP6 subgroup I + II specificity predominated.

Statistical analysis and modelling of spatial point patterns * Illian J., Penttinen A., Stoyan H., Stoyan D. (eds)

Ebrahim, G. J. — 2008-03-13

Causes, Prognostic Factors and Treatment Results of Acute Renal Failure in Children Treated in a Tertiary Hospital in South Africa

Van Biljon, G. — 2008-03-13

The aim of this study was to determine the causes, prognostic factors and treatment results of acute renal failure (ARF) in children admitted to the Pretoria Academic Hospital from 1986 to 2002. A retrospective chart review of 102 children (mean age 37 months) was done. Various factors were analysed including age, sex, causes of ARF, morbidity, mortality, dialysis requirement and outcome. Peritoneal dialysis was the only form of dialysis available. Patients were categorized as those who survived without dialysis or in whom renal function recovered without the need for continuing dialysis (Group I, termed ‘survivors’), and those who died or remained dialysis dependent (Group II, termed ‘non-survivors’). The most common causes of ARF were haemolytic uraemic syndrome (35.3%), acute tubular necrosis (31.4%) and acute glomerulonephritis (15.7%). There were 77 patients in Group I of whom 38 required dialysis, and 25 in Group II of whom 16 were dialysed. Fifteen patients in Group II died and 10 remained dialysis dependent (‘renal deaths’). Only four patients with ‘renal death’ received long-term dialysis. Coma (P < 0.001), liver dysfunction (P < 0.009), a clotting deficiency (P < 0.001), respiratory failure (P < 0.001) and multi-organ failure (P < 0.001) were significantly associated with poor outcome. These factors should be taken into account before initiating dialysis in children in countries where available resources for long-term dialysis are limited.

Clinical proteomics: from diagnosis to therapy Jennifer E. Van Eyk and Michael J. Dunn (eds) Weinheim.

Ebrahim, G. J. — 2008-03-10

Declining Trends of Infant, Child and Under-five Mortality in Nepal

Thapa, S. — 2008-02-29

Demographic and Health Surveys conducted quinquennially in 1996, 2001 and 2006 show that infant, child and under-five mortality in Nepal have declined steadily at least over the past 25 years. Estimates based on exponential-decline regression curves fitted to the 15-year data immediately preceding each survey, aggregated by 5-year period, show the infant, child and under-five mortality rates for the period 1986–1990 to be 106, 58 and 158 per 1000 live births and 52, 17 and 67 per 1000 live births for 2001–2005, respectively. The projected rates, assuming that the policy and program efforts are sustained, for the period 2011–2015 are 32, 7 and 38 per 1000 live births. Nepal is most likely to achieve the Millennium Development Goals (MDG) target of a two-thirds reduction in child mortality by 2015, the end of the MDG countdown.

Comparison of Nifedipine and Captopril in Children with Pulmonary Hypertension due to Broncopneumonia

Uner, A., Dogan, M., Demirtas, M., Acikgoz, M., Temel, H., Kaya, A., Caksen, H. — 2008-02-26

This study included 40 children, who were diagnosed with pneumonia and pulmonary hypertension (from the radiographic and clinical features), was performed at Yuzuncu Yil University Faculty of Medicine, Department of Pediatrics, from September 2003 to July 2005. Patients who had pneumonia and congenital heart disease or systemic hypertension or renal and liver disease together were excluded from the study. Blood gas analysis and oxygen concentration, measured with pulse oximetry, were performed in all patients. Besides chest X-ray, electrocardiography and echocardiographic search was also carried out. Echocardiographic examination was performed by using M mode, two-dimensional echocardiography and colored Doppler sonotron Vingmed CFM 725. At echocardiographic examination, pulmonary hypertension is defined as above 35 mmHg of pulmonary artery pressure. For echocardiographic examination, patients with pulmonary hypertension were divided into two groups. Captopril (2 mg/kg/day, three doses a day) and nifedipine (0.5 mg/kg/day, three doses a day) were given to the first and the second group, respectively. Echocardiography was performed daily until normal pulmonary artery pressure was achieved. At the beginning of the treatment, the patients were treated with double antibiotics and antibiotic change was carried out in needed cases at the follow up. Digoxin was administered to the cases of respiratory infection with heart failure.

Risk Factors of Childhood Asthma in Sao Jose do Rio Preto, Sao Paulo, Brazil

2008-02-23

Background: Epidemiological studies have shown increased prevalence of asthma over the last decades and a considerable variation in these rates between different countries, mainly developed. Changes in lifestyle of different populations could explain the increasing prevalence of asthma and its different rates in different communities.

Objectives: A case-control study was conducted to investigate some risks factors associated to asthma in schoolchildren in São José do Rio Preto, São Paulo, Brazil.

Casuistic and Methods: A total of 3793 self-administered written questionnaire (WQ) was filled in by parents of 6–7-year-old schoolchildren, applying the International Study of Asthma and Allergies in Childhood (ISAAC) protocol. Additionally, was added a supplementary WQ evaluating risk factors: gender, personal history of rhinitis and atopic eczema, familial history of atopy, older siblings, day care, breastfeeding, and exposure to pets and to cigarette smoking. Children whose parents responded affirmatively to question ‘Has your child had wheezing in the past 12 monthsquest;’ were identified as having current asthma.

Results: The prevalence of current asthma was 18.3%. In multivariate analysis the following risk factors were associated with asthma: rhinitis (OR = 10.6; 95% CI = 8.27–13.56), atopic eczema (OR = 1.54; 95% CI = 1.00–2.35), father with asthma (OR = 3.49; 95% CI = 1.83–6.67), mother with asthma (OR = 1.84; 95% CI = 1.11–3.05), current exposure to pets (OR = 1.83; 95% CI = 1.45–2.32) and passive tobacco smoking exposure (OR = 1.43; 95% CI = 1.12–1.83).

Conclusions: Our results show that genetic background, environmental factors and the presence of co-morbidities such as rhinitis and atopic eczema are associated to the genesis of asthma in Brazilian schoolchildren.

Serum Total Homocysteine Concentrations in Children and Adolescents in Jos, Nigeria

Adebayo, K. J., Madu, E. F., Adebayo-Kay, V. C. — 2008-02-23

Background: Although the elevation of circulating total serum homocysteine (tHcy) concentration in a fasting state is associated with an increased risk of occlusive vascular disease in adults, the levels in children in Nigeria are not known.

Aim: The goals of this study were to describe the distribution of tHcy among a representative sample of children and adolescents in Jos, Nigeria, and to test for differences in tHcy among sex and age categories.

Methods: The sampling scheme, which included persons aged 10 to 19 years, was a stratified, multistage probability design. This cross sectional study involved 182 school children drawn from secondary schools in Jos, Nigeria between January and July 2003. Fasting venous samples were collected and assayed for tHcy, Total protein and Albumin. Anthropometric measurements were taken.

Result: The mean tHcy concentrations were 2.7 ± 2.4 (95% CI 2.4–2.9), 3.5 ± 3.2 (3.3–3.8) and 3.6 ± 3.2 (3.3–4.1), 4.1 ± 3.6 (4.0–4.4) µmol/l for the girls and boys aged 10–14 and 15–19 years, respectively. Albumin levels correlate positively with plasma total homocysteine, tHcy (r = 0.45, P = 0.03).

Conclusion: This study provided age-specific data regarding tHcy concentrations between 10–19 years population in Jos, Nigeria. The tHcy concentration increased as a function of age in both sexes.

Brucellar Meningitis in an Infant--Evidence for Human Breast Milk Transmission

Tikare, N. V., Mantur, B. G., Bidari, L. H. — 2008-02-21

Brucellar meningitis is relatively uncommon, especially in children younger than 1 year. We present another case of meningitis due to Brucella melitensis biotype 1 in a 11-month-old infant transmitted by breast milk. This is the first report of successful isolation of B. melitensis from the breast milk in the literature. Babies of infected nursing mother should be monitored closely for evidence of infection since the breast milk is the source of transmission of brucellosis. It would be prudent to abstain from breast feeding until infection of nursing mother has been eradicated. One should be aware of this in endemic areas.

Nobel Faces: A Gallery of Nobel Prize Winners Peter Badge Weinheim

Ebrahim, G. J. — 2008-02-12

Prevalence of Orphans among HIV Infected Children--a Preliminary Study from a Pediatric HIV Centre in Western India

Shah, I. — 2008-02-11

The aim of this study was to determine the prevalence of orphaned HIV-infected children in Mumbai, India and analyze whether orphanhood affects care of these children. This study is a retrospective analysis of prospectively collected data of 147 HIV-infected children referred to our pediatric HIV clinic at B. J. Wadia Hospital for Children (Mumbai, India). All children underwent a detailed history and clinical examination. Transmission of HIV was determined by parental HIV status, history of blood transfusion or sexual exposure. Orphan status was determined by verbal autopsy of parent death (either mother or father or both). Factors affected by orphan status such as follow up, caregiver, antiretroviral treatment and age of the child when orphaned was determined. Fifty nine (40%) HIV-infected children were orphans. In 28 children (19%), father had died; in 20 children (13.6%), mother had died; in 11 children (7.5%) both parents had died and in 2 children (1.4%), parents death status was not known. Cause of death was AIDS in 19 parents (38%) and TB in 21 parents (42%). The mean age of the child when mother had died was 5.6 ± 2.2 years; when father had died was 7.08 ± 3.5 years and when both parents had died was 10.9 ± 2.4 years (p < 0.0001). There was no statistical difference in follow up (p = 0.48) or initiation of antiretroviral therapy (p = 0.04) in orphaned and nonorphaned children. In orphaned children, grandparents (5.4%) and aunts (4.8%) took responsibility of taking care of the children. Only two children (1.4%) were put in orphanages. Prevalence of HIV-infected orphans is high (40%). However, there is no difference in HIV care between orphans and nonorphans.

A Retrospective Study of Nosocomial Infections in a Pediatric Hospital: A Seven-Year Experience at Beijing Children's Hospital

Wang, A., Fan, S., Shen, X. — 2008-02-07

WHO child growth standards: head circumference-for-age, arm circumference-for-age, triceps skin fold-for-age and sub scapular skin fold-for-age.

Ebrahim, G. J. — 2008-01-25

Assessment of Gestational Age Using an Extended New Ballard Examination in Korean Newborns

Ahn, Y. — 2008-01-25

Five-year Surveillance of Antimicrobial use in Chinese Pediatric Intensive Care Units

2008-01-25

In order to demonstrate antibiotic usage in Chinese Pediatric Intensive Care Units (PICUs), and provide some data to further study on relation of antimicrobial use and resistance. We reviewed the use of antibiotics in Chinese PICUs from 2002 to 2006. All data, including general data and antibiotic use data, were obtained from five PICUs of pediatric teaching hospitals in China. The results of antibiotic use were expressed as defined daily doses (DDDs) per 100 patient-days by WHO in this study. All 12 743 patients were included from the five PICUs in this study. Length of stay in PICUs was essentially unchanged, but the percentage of antimicrobial costs vs. drug costs dramatically decreased in this study period (p < 0.01). The percentage of empiric treatment decreased by year (from 82.2% to 70.2%). while the percentage of therapeutic treatment increased by year (from 11.2% to 24.2%) from 2002 to 2006. Total antibiotic usage decreased from 72.1 DDDs per 100 patient-days to 35.5 DDDs per 100 patient-days from 2002 to 2006 (p < 0.05). The significant increase was found in the DDDs per 100 patient-days of second generation cephalosporins in this study (p < 0.05). While usages of the some antibiotics decreased, for example penicillins, third-generation cephalosporins, and macrolides in this study period. The data of antimicrobial use were obtained from five PICUs of biggest pediatric teaching hospital in this 5-year period, which could serve as a basis of antibiotic treatment and a benchmark in future study of antibiotic use.

Preventing Mother-to-Child Transmission of HIV in Vietnam: An Assessment of Progress and Future Directions

Le, C. T., Vu, T. T., Luu, M. C., Do, T. N., Dinh, T.-H., Kamb, M. L. — 2008-01-22

Preliminary to the development a new program supporting perinatal HIV prevention, this assessment was conducted to evaluate Vietnam's national prevention of mother-to-child HIV transmission (PMTCT) program by estimating HIV prevalence among prenatal women and analyzing the healthcare system capacity to deliver services. In 2002–03, a technical team reviewed existing national and local surveillance and program data and conducted on-site interviews and observations at maternal-child health (MCH) programs in the seven provinces with highest HIV rates. The team found that despite high (85%) prenatal service utilization and widespread availability of HIV testing and dissemination of prevention protocols, few HIV-infected mothers were identified in time to allow effective perinatal HIV prevention. Program deficits clustered around the general areas of provider misunderstanding of occupational HIV risk and MTCT, impractical PMTCT policies, and practices hampering effective use of prevention and treatment protocols. Existing problems were significant but modifiable, and will require implementation of practical and appropriate guidelines, enhanced clinical and laboratory capacity, and continued program management and monitoring.

In-Hospital Risk Estimation in Children with Malaria--Early Predictors of Morbidity and Mortality

2008-01-22

Background: Rapid diagnosis and adequate therapy are crucial to prevent development of severe disease and death in children suffering from malaria. A reliable but easy system for disease severity assessment would help to fast track seriously ill children and provide suitable therapies for different patient groups.

Objectives: To examine risk factors and appropriate scoring systems in children suffering from malaria for outcome in terms of morbidity and mortality.

Methods: A prospective, consecutive study in children admitted to the Muhimbili Medical Centre in Dar es Salaam was conducted to evaluate risk factors and test appropriate scoring systems. The simplified Multi-Organ Dysfunction Score (sMODS), a severity of disease classification consisting mainly of clinical data, was applied. Chosen outcome parameters were morbidity and mortality. Results were compared to those obtained from the World Health Organisation (WHO) classification of severe malaria, the Blantyre Coma Scale (BCS) and selected single clinical parameters.

Results: Seventy-five children were recruited into the study. Mean age was 28 months ranging from 6 months to 8 years. ‘Severe Malaria’, according to WHO criteria was evident in 57 patients (76%). Mean sMODS on admission was 15.6 ± 2. Seven patients (9%) died. Among single symptoms, impaired consciousness and respiratory distress predicted both, fatal outcome and morbidity. In terms of scoring systems, the sMODS correlated with both outcome parameters. In comparison, the WHO criteria did not correlate with any of the two parameters, the BCS correlated with mortality only.

Conclusion: In our study, sMODS has been shown to represent a useful quantitative approach towards disease severity classification in resource poor settings and can be used for risk estimation in children suffering from malaria in terms of both morbidity and mortality.

Iron Supplementation in Previously Anemic Bolivian Children Normalized Hematologic Parameters, But Not Immunologic Parameters

Sejas, E., Kolsteren, P., Hoeree, T., Roberfroid, D. — 2008-01-22

Iron deficiency anemia (IDA) is considered to be the most prevalent micronutrient deficiency in the world. Estimates indicate that 1.2 billion people suffer mild to severe forms of anemia and that up to 46% of schoolchildren in developing countries are affected. In 2003, ENDSA, the national demographic and health survey of Bolivia showed that 60% of children under five and 72% of children under 2 years old were anemic. Micronutrient deficiency has been suggested to impair cell-mediated immunity. In particular, iron, zinc and vitamin A deficiencies have an impact on the immune system. In vitro and in vivo laboratory studies indicate a link between iron deficiency and impaired T-lymphocyte proliferation. The exact effects or mechanisms of iron deficiency on maturation and proliferation of T-lymphocytes in vivo are, however, not yet known. This study investigated the effects of iron on the maturation of T-lymphocytes in anemic but otherwise healthy schoolchildren (no apparent protein-energy deficiency or other morbidity). Anemic children of a poor peri-urban school of Cochabamba city, Bolivia, were given iron treatment for three consecutive months. We chose to look at CD1a+ lymphocytes, which are immature thymocytes. The proportions of CD1a+ lymphocytes in the peripheral circulation measured at baseline and after treatment were compared with a reference group of age-matched non-anemic children controls from the same school. The immunologic parameters, although improved, did not reach the proportions of the control group. Overall, the proportion of circulating immature T-lymphocytes decreased from 18.3% to 9.2% in the treated following iron supplementation in anemic children, compared with 3.4% in non-anemic children.

Acute rheumatic fever: an important differential diagnosis of septic arthritis

Mataika, R., Carapetis, J. R., Kado, J., Steer, A. C. — 2008-01-21

We present three cases of suspected septic arthritis in which the joint fluid was sterile. Subsequently all three patients were diagnosed with established moderate-severe rheumatic heart disease. In retrospect it is likely that the earlier presentations were in fact episodes of acute rheumatic fever but were not recognized as such. These cases underline the importance of acute rheumatic fever as a differential diagnosis of septic arthritis when the joint fluid is sterile, particularly in regions where there are high rates of acute rheumatic fever and rheumatic heart disease.

Clinically Significant Neonatal Hyperbilirubinemia: An Analysis of 646 Cases in Istanbul

Ipek, I. O., Bozaykut, A. — 2008-01-21

Biliary Cirrhosis in a Child with Inherited Interleukin-12 Deficiency

2008-01-19

Interleukin-12 (IL-12) is a key cytokine in the defense against intracellular bacteria notably Mycobacteria and Salmonella species. We report a case of disseminated mycobacterial infection, following BCG vaccination, in a child who later developed tuberculosis. Functional tests and a novel diagnostic polymerase chain reaction (PCR) assay, revealed a loss-of-function deletion in the IL12 gene. Analysis of samples from the parents and siblings of the patient indicated an autosomal recessive inheritance pattern with varying degrees of phenotypic expression in identical genotypes. Interferon- (IFN-) therapy was associated with marked clinical improvement. Biliary cirrhosis, a hitherto unreported complication of IL-12 deficiency, developed later and required liver transplantation. A defect in the IL-12–IFN- pathway should be suspected in patients presenting with multiple, repeated or persistent infection with intracellular bacteria. The diagnostic work-up and the immuno-genetic assay described here can aid in the quick and reliable diagnosis of IL-12 deficiency resulting from genetic defects and its subsequent management.

Recurrent Abdominal Pain Syndrome in a Cohort of Sri Lankan Children and Adolescents

Devanarayana, N. M., de Silva, D. G. H., de Silva, H. J. — 2008-01-19

Recurrent abdominal pain (RAP) is a common problem among children and adolescents. The epidemiology of RAP among Sri Lankan children is unknown. A self-administered parental questionnaire was distributed to 810 randomly selected school children, aged 5–15 years, and 734 (90.6%) were returned. RAP was diagnosed using Apley criteria. Children who fulfilled the criteria were interviewed. Seventy-seven had RAP (10.5%). Of them, 45 (58.4%) had periumbilical pain. The severity was mild to moderate in 45 (58.4%) and severe in 32 (41.6%). Common associated symptoms were headache (42.9%), anorexia (35.1%), lethargy (23.4%) and joint pain (23.4%). Health care consultation among affected children was 70.1%. RAP was significantly higher in those who were exposed to stressful life events and who had a family history of RAP (p < 0.0001). RAP was not associated with school academic performance and participation in sports (p > 0.05). According to our results, the epidemiology and clinical profile of RAP in Sri Lankan children appears to be similar to that in other parts of the world, except for health care consultation, which is higher than previously reported.

Pharmaceutical biotechnology: concepts and application Gary Walsh (ed)

Ebrahim, G. J. — 2008-01-17

Handbook of statistical genetics - 3rd Edn. Volumes 1 and 2 D. J. Balding, M. Bisho, C. Cannings (eds)

Ebrahim, G. J. — 2008-01-17

Virology: principles and applications J. Carter, V. Saunders (eds)

Ebrahim, G. J. — 2008-01-17

Anemia Reduction in Preschool Children with the Addition of Low Doses of Iron to School Meals

2007-12-21

Background. In developing countries there is high prevalence of iron deficiency anemia, which causes negative impact on growth, development and quality of life for infant population. Currently several strategies are being elaborated and tested to tackle this problem. Objective. To measure anemia prevalence in preschool children. To evaluate fortification effectiveness with 5 or 10 mg of elemental iron/daily added to school meals by increasing hemoglobin levels in anemic children. Methods. Double-blind, cluster randomized intervention study with 728 students from public network. Blood count was taken at beginning of study, to evaluate anemia prevalence, those anemic were selected for intervention, after intervention new blood count was taken to evaluate fortification effectiveness. Ferrous Sulphate was added in individual dosage of 5 or 10 mg of elemental iron/daily to usual school meal. From 35 schools 3 were randomized to receive 5 mg/daily (group A) and 3 to receive 10 mg/daily (group B). Hemoglobin and hematocrit averages before and after intervention were compared in each group and between them. Results. In group A, the anemia prevalence reduced 34.9 to 12.4%, and in group B 39.0 to 18.7%. In both groups a significant increase in hemoglobin was observed: in group A from 10.1 to 11.5 g/dl (p < 0.01) and in group B from 10.0 to 11.0 g/dl (p < 0.01). There was no statistically significant difference in final levels of hemoglobin among groups. Conclusions. Both dosages of elemental iron were equally effective in increasing hemoglobin levels, and reducing anemia prevalence. Fortification of school meals was shown to be an effective, low cost and easy to manage intervention.

Low Body Mass Index, Anaemia and Poor Perinatal Outcome in a Rural Hospital in Eastern Sudan

Adam, I., Babiker, S., Mohmmed, A. A., Salih, M. M., Prins, M. H., Zaki, Z. M. — 2007-12-21

Background: The first step in improving early neonatal survival is to document rate of these deaths, identify the common causes. Objectives: the study was conducted at New Halfa hospital, eastern Sudan to investigate the prevalence and possible risk factors for a poor perinatal outcome, mainly low birth weight (LBW), APGAR score <5 at 1 min, fetal anaemia and perinatal mortality. Results: LBW occurred in 15.3%, the perinatal death was 9.2%. Maternal low body mass index (BMI) was significantly associated with LBW (OR = 1.8, 95% CI = 1.0–3.2; p = 0.02), which was a risk factor for APGAR score <5 at 1 min (OR = 11.5, 95% CI = 5.9–22.5; p < 0.001) and perinatal mortality (OR = 6.5, 95% CI = 2.9–14.8, p < 0.00001). Maternal anaemia was a risk factor for fetal anaemia (OR = 2.1, 95% CI = 1.4–3.1; p < 0.001). Conclusion: More attention to maternal nutrition and in an attempt to prevent anaemia may lead to improvement in the perinatal outcome.

Treatment of Anal Achalasia after Transanal Endorectal Pull-Through for Hirschsprung's Disease with Topical Botulinum Toxin

Jiang, D. P., Li, Z. Z., Zhang, Y. B., Jiang, Z. T. — 2007-12-21

Hypertriglyceridemic Waist Phenotype and Associated Lifestyle Factors in a National Population of Youths: CASPIAN Study

2007-12-21

The objectives of the current study, that is the first of its kind, were to determine the prevalence of the hypertriglyceridemic waist (HW) phenotype in a nationally representative sample of children, as well as the metabolic risk factors identified by HW, and to identify lifestyle habits related to this phenotype. This national survey was conducted on 4811 representative school-students. We assessed the sensitivity and specificity of the HW phenotype for abnormal anthropometric and biochemical factors by using receiver operator characteristic curves. We determined the association of dietary patterns (obtained by factor analysis), physical activity level and some environmental factors with the HW phenotype. Overall, 8.52% of participants had the HW phenotype. Those children with the HW phenotype were more likely to have cardiovascular risk factors, notably for overweight and hypercholesterolemia. The dietary pattern characterized by junk foods increased the odds of having the HW phenotype, OR = 1.426 (95%CI, 1.109, 1.892), whereas the other dietary pattern including healthy foods decreased this odds, OR = 0.874 (95%CI, 0.765, 0.998). The risk of the HW phenotype rose with the consumption of solid hydrogenated fat as well as white-flour bread. Low education of parents and a positive family history of diabetes mellitus, obesity and or premature cardiovascular disease were the other risk factors for the HW phenotype. Low levels of physical activity significantly increased the risk of having the HW phenotype. The HW phenotype can be used as an accurate and easy tool for screening children at metabolic risk in population-based studies.

Early Introduction of Solids and Pneumonia in Young Infants in Papua New Guinea: A Case Control Study

Anga, G., Vince, J. D., Kaupa, M. — 2007-12-21

A prospective case control study to determine the association of early introduction of solids with admission to hospital with pneumonia was undertaken at Mount Hagen General Hospital (MHGH) in the highlands of Papua New Guinea (PNG) over a 3-month period in 2005. Twenty three infants up to 6 months of age admitted with radiologically confirmed pneumonia were compared with 24 infants of similar age attending the well baby clinic for immunization and with 35 infants admitted to the hospital with conditions other than pneumonia or meningitis. There was a highly significant difference in feeding patterns between the groups. Children with pneumonia were much more likely than the control children to have started solids before the age of 2 months [OR = 18.06 (4.8–72.86)]. They were also significantly more likely to have been admitted previously with a diagnosis of pneumonia (P < 0.001). The children in each group were of comparable age and weight and there were no obvious confounding factors. This study provides clear evidence for the association between early introduction of solids and pneumonia in PNG highlands children. The findings are consistent with other international data. While the reasons for the association remain speculative, the association strongly reinforces the need to educate the community on best infant feeding practices and to discourage the early introduction of solids.

Human Touch vs. Axillary Digital Thermometry for Detection of Neonatal Hypothermia at Community Level

Agarwal, S., Sethi, V., Pandey, R. M., Kondal, D. — 2007-12-21

We examined the diagnostic accuracy of human touch (HT) method in assessing hypothermia against axillary digital thermometry (ADT) by a trained non-medical field investigator (who supervised activities of community health volunteers) in seven villages of Agra district, Uttar Pradesh, India. Body temperature of 148 newborns born between March and August 2005 was measured at four points in time for each enrolled newborn (within 48 h and on days 7, 30 and 60) by the field investigator under the axilla using a digital thermometer and by HT method using standard methodology. Total observations were 533. Hypothermia assessed by HT was in agreement with that assessed by ADT (<36.5°C) in 498 observations. Hypothermia assessed by HT showed a high diagnostic accuracy when compared against ADT (kappa 0.65–0.81; sensitivity 74%; specificity 96.7%; positive predictive value 22; negative predictive value 0.26). HT is a simple, quick, inexpensive and programmatically important method. However, being a subjective assessment, its reliability depends on the investigator being adequately trained and competent in making consistently accurate assessments. There is also a need to assess whether with training and supervision even the less literate mothers, traditional birth attendants and community health volunteers can accurately assess mild and moderate hypothermia before promoting HT for early identification of neonatal risk in community-based programs.

Intravenous Magnesium Sulphate vs. Inhaled Nitric Oxide for Moderate, Persistent Pulmonary Hypertension of the Newborn. A Multicentre, Retrospective Study

2007-11-29

We have compared intravenous magnesium sulphate vs. inhaled nitric oxide in the therapy of moderate persistent pulmonary hypertension of the neonate. A retrospective collection of clinical data from 58 neonates was carried out in six neonatal intensive care units of Southern Italy sharing the same operational protocols. In our setting, both drugs were effective in treating moderate persistent pulmonary hypertension of the neonate but nitric oxide (NO) treatment resulted in much faster amelioration of oxygenation index, taken as a marker of the underlying condition. No significant difference was recorded in immediate or long-term complications. We conclude that, wherever NO facilities are not readily available, magnesium sulphate is a safe and cheaper alternative for first-line treatment of moderate persistent pulmonary hypertension of the neonate.

Pre-exposure Purified Vero Cell Rabies Vaccine and Concomitant Routine Childhood Vaccinations: 5-year Post-vaccination Follow-up Study of an Infant Cohort in Vietnam

Lang, J., Feroldi, E., Vien, N. C. — 2007-11-29

Children have a high risk of exposure to rabies in countries where the disease is endemic. This prospective, 5-year study followed two groups of children who had received diphtheria, tetanus, whole-cell pertussis and inactivated poliomyelitis vaccine (DTP-IPV) at 2, 3, 4 months and 1 year (Group B) or concomitant with three doses of purified Vero cell rabies vaccine (PVRV), given at 2, 4 months and 1 year (Group A). Antibody determinations were made annually for 5 years. Data were available from a total of 72 subjects; 30 in Group A and 32 in Group B. In Group A, the percentage of patients immunized against rabies (anti-rabies ≥ 0.5 IU/ml) decreased from 100% after the third vaccination to 63%, 5 years later. After 5 years, 93.8% in Group A and 96.7% in Group B had seroprotective diphtheria antibody titers ≥ 0.01 IU/ml, and all subjects had anti-polio (type 1, 2 and 3) seroprotective titers ≥ 5 1:dil. We conclude that co-administration of PVRV with DTP-IPV elicited protective antibody concentrations to all antigens that persist for at least 5 years, with continued protection against rabies in over 60% of subjects. These results are consistent with integration of pre-exposure rabies vaccination into the Expanded Program on Immunization (EPI) in countries where rabies is endemic.

Children with Human Immunodeficiency Virus Infection Admitted to a Paediatric Intensive Care Unit in South Africa

Rabie, H., de Boer, A., van den Bos, S., Cotton, M. F., Kling, S., Goussard, P. — 2007-11-25

Background: Early data regarding the outcome of human immunodeficiency virus (HIV)-infected children in paediatric intensive care units (PICUs) suggested mortality as high as 100%. Recent studies report mortality of 38%. Survival depends on the indication for admission. Objectives: The objective of the study is to describe the prevalence, duration of stay and outcome of HIV-infected patients in a single PICU over a 1-year period. Additional objectives included describing the indications for admission as well as the clinical and laboratory characteristics of HIV-infected infants and children requiring PICU admission.

Methods: Retrospective chart review of all children with serological proof of HIV admitted to PICU at Tygerberg Children's Hospital from 1 January–31 December 2003 was studied.

Results: Of 465 patients admitted, 47 (10%) were HIV infected. For HIV-infected children, the median age on admission was 4 months. The median duration of stay was 6 days, significantly longer than for the non-HIV group (p = 0.0001). Fifty-seven percent had advanced clinical and immunological disease. Seventeen died in PICU and 4 shortly afterwards; poor PICU outcome was significantly associated with HIV status (p = 0.001). Lower total lymphocyte count (p = 0.004) and higher gamma globulin level (p = 0.04) were paradoxically, the only findings significantly associated with survival. Acute respiratory failure (ARF) accounted for 76% of admissions, including Pneumocystis jiroveci in 38%. Fifty-one percent had evidence of cytomegalovirus infection. Conclusions: HIV-infected children requiring PICU can survive despite the lack of availability of antiretroviral therapy.

Novel Mutation of Aspartoacylase Gene in a Turkish Patient with Canavan Disease

Unalp, A., Altiok, E., Uran, N., Ozturk, A., Yuksel, S. — 2007-11-12

Canavan disease is a neurodegenerative disease with autosomal recessive inheritance. Although this disease is prevalant among Ashkenazi Jewish population, several cases have been reported from all over the world. Canavan disease is caused by a genetic mutation in aspartoacylase gene. We have identified a novel mutation, a homozygous C432+1G>A mutation, in a 10-month-old boy who has a typical Canavan phenotype (without macrocephaly) accompanied by typical brain magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS) and diffusion magnetic resonance findings. The patient's mother was found to be heterozygous for this mutation. We believe that future studies of aspartoacylase gene in various ethnic groups could lead to a better understanding of Canavan's pathophysiology and gene therapy.

School-Based Deworming Programme in Sanliurfa, Turkey: Changing from Externally Funding Phase to Self-Sufficient Phase

Ulukanligil, M. — 2007-10-15

In Sanliurfa, Turkey, externally funded temporary deworming activities have led to an internally funded self-sufficient programme in 2004–05 academic year. A total of 200 000 doses of mebendazole were distributed to schoolchildren, absentee children and small children and women through both schools and health centres. We interviewed 64 representative teachers, 82 administrative teachers, 112 schoolchildren and 108 parents using questionnaires, department interviews and focus groups discussions. We also collected 162 stool samples from third- and fourth-grade schoolchildren and examined them using the Kato–Katz technique. The evaluation of second year's of deworming program indicated that the programme's methodology of training representative teachers to play a major role in organizing the activities within schools and liaising with health staff was found to be successful by most of the teachers. The results showed that 85.2% of the women had benefited from the extended anthelmintic coverage. A total of 67.4% of them received the drugs from schools and 10.9% obtained them from health centres. The prevalence of helmintic infection had declined from 77 to 35% in shantytown schoolchildren and from 53 to 6.4% in apartment schoolchildren. The prevalence of Ascaris lumbricoides and Trichuris trichiura decreased from 63.2 to 17% and from 16.8 to 1.1%, respectively, in schoolchildren. The results also indicated that 53.5% of the schoolchildren changed over to clean habits and began to use soap after using the toilet. The evaluation of the second year's deworming programme showed that the programme was sustainable and there was no risk of the programme being discontinued. Political commitment was obtained from the local business community, academic sector, the local governmental administrations and the city municipality. These organizations realized the programme's rapid and clear benefits and collaborated in a multipartners’ programme. The cost of treatment per child was $0.05 and in total $11 000 was sufficient to implement a broad-range programme including education of children about cleanliness and treatment of infection to improve their health.