Journal of Tropical Pediatrics - current issue

In this Issue October 2009

Sun, 11 Oct 2009 23:34:43 PDT

Diagnostic Challenges of Cystic Fibrosis in Patients of African Origin

Mutesa, L., Bours, V. — Sun, 11 Oct 2009 23:34:43 PDT

Evidence Behind the WHO Guidelines: Hospital Care for Children: What is the Efficacy of Sublingual, Oral and Intravenous Glucose in the Treatment of Hypoglycaemia?

Ganeshalingam, R., O'Connor, M. — Sun, 11 Oct 2009 23:34:43 PDT

Patterns and Predictors of CD4 T-cell Counts Among Children Born to HIV-infected Women in Tanzania

Kupka, R., Msamanga, G. I., Aboud, S., Manji, K. P., Duggan, C., Fawzi, W. W. — Sun, 11 Oct 2009 23:34:43 PDT

We assessed age-specific CD4 T-cell counts and their determinants among Tanzanian children born to HIV-infected mothers to address a major research gap. A total of 474 HIV-uninfected and 69 HIV-infected children were followed until age of 12 months. Maternal predictors were measured during pregnancy and child predictors at birth and throughout the follow up. Child CD4 T-cell counts were evaluated at the age of 3 months and subsequent 3-month intervals; they decreased linearly among HIV-infected (β = –8 cells per week; 95% CI –12 to –4; P = 0.0003) and increased linearly among HIV-uninfected children (β = 4 cells/week; 95% CI 2–7; P = 0.0008). Decreased child counts were predicted by low child anthropometry, maternal HIV stage ≥2, and maternal mid-upper arm circumference <27 cm among HIV-infected children; and by weight-for-height <–2 z-score, maternal HIV stage ≥2, maternal erythrocyte sedimentation rate <81 mm/h and maternal haemoglobin <8.5 g/dl among HIV-uninfected children. The maternal and child predictors described may serve as intervention targets among HIV-exposed children.

Dose-dependent effect of Lactobacillus rhamnosus on quantitative reduction of faecal rotavirus shedding in children

Fang, S.-B., Lee, H.-C., Hu, J.-J., Hou, S.-Y., Liu, H.-L., Fang, H.-W. — Sun, 11 Oct 2009 23:34:43 PDT

Beneficial effects of probiotics in acute infectious diarrhoea in children are mainly seen in watery diarrhoea and viral gastroenteritis. Lactobacillus rhamnosus, one the most extensively studied probiotic strains, is effective in shortening courses of acute diarrhoea in children. However, the dose-dependent effect of Lactobacillus upon quantification of faecal rotavirus shedding in humans remains little known. Thus, an open-label randomized trial in 23 children with acute rotaviral gastroenteritis was undertaken by randomly allocating patients to receive one of the three regimens for 3 days: daily Lactobacillus rhamnosus 35 (Lcr35) with 0 CFU/day to six patients in the control group, 2 x 10⁸ CFU/day to nine patients in the low-dose group, and 6 x 10⁸ CFU/day to eight patients in the high-dose group. Faecal samples were collected before and after the 3-day regimen for measurements of rotavirus concentrations by ELISA. There was no statistically significant change in faecal rotavirus concentrations in either the control group (119.2 x 10⁵ particles/ml vs. 23.7 x 10⁵ particles/ml, p = 0.075) or the low-dose group (36.1 x 10⁵ particles/ml vs. 73.5 x 10⁵ particles/ml, p = 0.859). However, the high-dose group had a significant reduction of faecal rotavirus concentration (64.2 x 10⁵ particles/ml vs. 9.0 x 10⁵ particles/ml, p = 0.012). Without any exception, the faecal rotavirus concentrations of all eight patients in the high-dose Lcr35 group declined by 86% after 3 days when compared with those before Lcr35 administration. In conclusion, this is the first report to provide quantitative evidence of the dose-dependent effect of Lactobacillus rhamnosus, a minimal effective dose of 6 x 10⁸ CFU for 3 days, upon the faecal rotavirus shedding in paediatric patients.

Linear Growth in Relation to the Circulating Concentration of Insulin-like Growth Factor-I and Free Thyroxine in Infants and Children with Congenital Cyanotic Heart Disease Before vs. After Surgical Intervention

El-Sisi, A., Khella, A., Numan, M., Dilwar, M., Bhat, A., Soliman, A. — Sun, 11 Oct 2009 23:34:43 PDT

This prospective controlled study recorded the anthropometric data and measured the circulating insulin-like growth factor-I (IGF-I) in 16 children with congenital cyanotic heart disease before and a year after surgical intervention. At presentation patients were significantly shorter [length SD scores (LSDS) = –2.44 ± 1.31], vs. controls (LSDS = –0.25 ± 0.18). After surgical treatment the LSDS and growth velocity SD scores (GVSDS) increased significantly to (–) 0.25 ± 0.95 and 3.7 ± 2.1, respectively. IGF-I increased from 45.7 ± 26.3 ng ml^–1 to 67.7 ± 16.4 ng ml^–1. The GVSDS after treatment was correlated with the body mass index (BMI) (r = 0.339, p < 0.05) and negatively with the LSDS before surgery (r = –0.461, p < 0.05). The percentage increase of IGF-I after operation was correlated significantly with the BMI after surgical intervention (r = 0.82, p < 0.001). It appears that the postoperative growth spurt in infants with cyanotic congenital heart disease (CHD) is mediated through activation of the GH/IGF-I system and improved nutrition.

Ghrelin Levels in Children with Congenital Heart Disease

Kandil, M. E., Elwan, A., Hussein, Y., Kandeel, W., Rasheed, M. — Sun, 11 Oct 2009 23:34:43 PDT

Background: Ghrelin is a novel growth hormone-releasing peptide that causes a positive energy balance by stimulating food intake and inducing adiposity and has effects on growth. Many children with congenital heart disease (CHD) present with growth retardation and malnutrition owing to multifactorial reasons.

Aim: To evaluate the circulating level of ghrelin in Egyptian children with congenital cyanotic and acyanotic heart disease and its relation to anthropometric measurements.

Materials and methods: The study included 40 patients with cyanotic and acyanotic CHD (18 cyanotic and 22 acyanotic) and 18 age- and sex-matched healthy control children. All children were subjected to measurement of height, weight, body mass index (BMI) and serum ghrelin was measured using ELISA technique.

Results: Weight, height and BMI were significantly lower in cyanotic and acyanotic patients compared to the control group (p = 0.0001). Serum ghrelin levels were significantly higher in children with cyanotic and acyanotic CHD in comparison to the controls (p = 0.0001). There was a significant negative correlation between ghrelin and BMI in the three groups (r = –0.534, p = 0.023; r = –0.558, p = 0.007; r = –0.608, p = 0.007 respectively for cyanotic, acyanotic and the control groups).

Conclusion: Circulating ghrelin level was elevated in children with congenital cyanotic and acyanotic heart disease, and was associated with a decrease in BMI. This elevation in ghrelin level may represent malnutrition and growth retardation in those patients as obvious by anthropometric measures too. This may suggest that ghrelin may have an important role as a compensatory mechanism in the regulation of the metabolic balance in them.

The Relationship of Body Mass Index and Blood Pressure in Iranian Children <7 Years Old

Ataei, N., Hosseini, M., Iranmanesh, M. — Sun, 11 Oct 2009 23:34:43 PDT

The objective of this study was to evaluate the association between the body mass index (BMI), in healthy young children with their blood pressure (BP). The study included 3186 healthy children aged 1–6 years who were studied between March 2004 and March 2007 in different kindergartens and health centers in Tehran. Each child was classified on the basis of age- and sex-specific BMI percentile as normal weight (BMI <85th percentile), at risk for overweight (BMI >85th and <95th percentile), or overweight (BMI ≥95th percentile). Systolic BP (SBP) and diastolic BP (DBP) was compared among age–sex–BMI groups. Among children aged below 7 years in kindergartens and health centers in Tehran, 7.2% were at risk of overweight and 12.2% were overweight. These proportions were similar for boys and girls and were as follows: 6.9%, 13.9% and 7.5%, 10.5%, respectively. Analysis of variance showed that mean SBP significantly increased according to age (p < 0.0001) and BMI group (p = 0.001). Analysis of variance also showed that mean DBP significantly increased as age increased (p < 0.0001), but no significant difference was found between boys and girls in different age and BMI groups (p = 0.37). Our survey identified a high prevalence of overweight that was associated with elevated SBP among preschool-aged children in Iran. The effect of higher BMI on mean SBP is present in childhood and can be used as a predictor of high SBP even in children as young as 1–6 years.

Rotavirus Infections among HIV-Infected Children in Nairobi, Kenya

Sun, 11 Oct 2009 23:34:43 PDT

Human rotaviruses have emerged as a leading cause of acute diarrhea in children <5 years of age worldwide. Although there are previous reports relating to various aspects of rotaviruses, there is limited data on the involvement of rotavirus infection in HIV-infected children. We therefore evaluated the importance of rotavirus infections in HIV-related diarrhea in Kenyan children. Fecal samples were collected from a total of 207 children during the period February 1999 to June 2000 and screened for HRV antigen by enzyme-linked immunosorbent assay (ELISA). Positive samples were analyzed by VP6 subgroup specificity assay, by polyacrylamide gel electrophoresis (PAGE) and reverse transcriptase/polymerase chain reaction (RT–PCR). Fourteen percent (29/207) of the samples were positive. HIV-seropositive children with diarrhea were more likely than their counterparts without diarrhea to have rotaviruses [23.3% (10/43) versus 2.9% (2/70); p = 0.0001]. Rotavirus strain G3P[6] was predominant. These results indicate that rotavirus is an important viral etiological agent causing diarrhea in HIV-seropositive children.

Linear Growth in Children with Iron Deficiency Anemia Before and After Treatment

Sun, 11 Oct 2009 23:34:43 PDT

We measured growth [length (L) standard deviation score (SDS), growth velocity (GV) SDS and body mass index (BMI)] and hematological (hemoglobin, hematocrit, MCV and MCH) parameters in 40 children (aged 17.2 ± 12.4 months) with iron deficiency anemia (IDA) before and after iron therapy. Before treatment children with IDA had LSDS = –1.2 ± 1, GV = 7.5 ± 2.2, GVSDS = –1.42 ± 0.6 and BMI = 13.5 ± 1.2. They were significantly shorter and had reduced growth as compared with age-matched controls. After treatment, their growth parameters significantly increased with LSDS = –0.6 ± –0.9, GV = 13.2 ± 4.4 cm year^–1, GVSDS = 1.7 ± 0.5 and BMI = 14.2 ± 1.1. Their GV correlated significantly with serum ferritin concentration (r = 0.48, p < 0.001) and BMI (r = 0.32, p < 0.1). In summary, IDA during the first 2 years of life significantly impairs growth.

Randomized Clinical Trial Comparing Hepatitis B Vaccine Administered by 0, 6 and 14 Week versus 6, 10 and 14 Week Schedule in Healthy Infants

Das, R. R., Mathew, J. L., Ratho, R. K., Dutta, S. — Sun, 11 Oct 2009 23:34:43 PDT

Objective: This randomized, single-blinded trial was carried out to compare the sero-efficacy of hepatitis B vaccine administered to healthy infants by either of two schedules–birth, 6, 14 weeks or 6, 10 and 14 weeks.

Methods: The 74 infants born to HbsAg-negative mothers were randomized to receive recombinant hepatitis B vaccine at 0, 6 and 14 weeks (Group A) or 6, 10 and 14 weeks (Group B). Serum anti-HBs antibody titer was measured before the first dose and 6 months after the third dose by laboratory personnel blinded to the intervention. All participants received other vaccines as per the national immunization schedule.

Results: At 6 months after the third dose sero-conversion was 100% in both groups. A total of 97.3% of subjects in Group A were sero protected (>10 mIUml^–1) with geometric mean titer (GMT) of 113.78 mIUml^–1 and 94.6% in Group B (GMT 107.04 mIUml^–1) [p = 0.8].

Conclusion: Hepatitis B vaccination by 0, 6 and 14 weeks and 6, 10 and 14 weeks schedules are comparable in terms of sero-efficacy.

Lymphadenovarix of the Head-Neck region--A Rare Presentation of Bancroftian Filariasis

Dwivedi, R. C., Gupta, P., Dwivedi, R. C., Kishore, K., Bhatia, N. — Sun, 11 Oct 2009 23:34:43 PDT

Cystic swellings of the neck in children have limited differential diagnoses, often either lymphatic or vascular malformations. Other cystic inflammations can be the result of tuberculous abscesses, suppurated lymph nodes and actinomycosis. Microfilaria causing lmphadenovarix of head–neck region has not yet been described in the literature. A 10-year-old Indian boy presented with an asymptomatic cystic neck mass of 8 months duration. Aspiration of the swelling demonstrated numerous Wuchereria bancrofti microfilaria and the patient responded well to 6 weeks of daily anti-filarial treatment using diethylcarbamazine citrate (6mg kg^–1 day^–1). This appears to be the first report of microfilariae-associated lymphadenovarix of head–neck region. Though rare, filariasis should be considered as a differential diagnosis for aberrant swellings where lymphatic filarids are endemic.

Parvovirus B19-induced Thrombocytopenia and Anemia in a Child with Fatal Fulminant Hepatic Failure Coinfected with Hepatitis A and E Viruses

Kishore, J., Sen, M. — Sun, 11 Oct 2009 23:34:43 PDT

A 5-year-old male, drowsy, jaundiced child presented with fulminant hepatitis and had HAV and HEV infection. He had hepatic encephalopathy grade 1, fever, pallor, hypotension, crepitations in his right lung base and hepatosplenomegaly with dyspnoea. He had highly raised liver enzymes and hypoalbuminemia (2.8 g/dl) but anemia (hemoglobin of 7.7 g/dl and 5.7 g/dl 2 days later), reticulocytopenia and severe thrombocytopenia (44 x 10⁹/l) were unexplained. Parvovirus B19-specific IgM antibodies and B19 DNA were found in the serum of the child. Chest X-ray showed pleural effusion and bronchopneumonia, while blood culture isolated coagulase-negative staphylococci (BACTEC 9120) and he had low oxygen saturation. Hence, he was treated with IV amoxicillin+ clavulinic acid and oxygen inhalation. He had seizures and cardiac arrest but was revived. On the third day his condition worsened and the child died despite intensive care. Hence it is concluded that his anemia and thrombocytopenia were B19 induced and this might have aggravated or caused fulminant hepatitis.

An Unusual Cause of Gastrointestinal Bleeding and Severe Anemia in a Child: Leech Infestation

Taskesen, M., Katar, S., Bascik, H. — Sun, 11 Oct 2009 23:34:43 PDT

A 1-year-old boy with epistaxis, gastrointestinal bleeding and severe anemia that caused cardiorespiratory distress presented to our unit. The results of coagulation tests were normal. An erythrocyte suspension transfusion was given to the patient. On the second day of his hospitalization, a leech was removed from his nose. In developing countries, leech infestation should be considered in cases where epistaxis, hematemesis, gastrointestinal bleeding and severe anemia are of unknown origin.

Prevalence of Thinness and Overweight Among Urban Adolescents of West Bengal, India

Ghosh, J. R., Bandyopadhyay, A. R. — Sun, 11 Oct 2009 23:34:43 PDT

Optimization Strategy to Minimize Wastage of Palivizumab during the 2008 RSV Season in Sao Paulo, Brazil

Sun, 11 Oct 2009 23:34:43 PDT

Palivizumab is currently recommended to high-risk children as a prophylaxis for respiratory syncytial virus (RSV) infection. However, it is still very expensive for developing countries like Brazil. Herein, we describe our strategy to minimize wastage of Palivizumab during the 2008 RSV season. Appointments were fixed for 304 children on 2 days of the week, so that a mean of 19.9 children received Palivizumab per day. That allowed remaining volumes of Palivizumab vials to be pooled and used for other children on the same day within the 6 h period after opening a vial. That strategy saved 26.3% of vials, which represents USD749 143.75.

Endomyocardial Fibrosis: An Under-diagnosed Cause of Cardiomyopathy in Sudanese Children

Ali, S. K. M. — Sun, 11 Oct 2009 23:34:43 PDT

Endomyocardial fibrosis (EMF) is a tropical cardiomyopathy reported in many tropical countries. Patients were seen at the Children's Hospital-Khartoum, Sudan during September 2007–08 where cardiac evaluation was done. Six patients were identified (18% of all children with cardiomyopathy); all were males aged 8–17 years. All patients presented with abdominal distention, stunted growth, raised jugular venous pressure, ascites and hepatosplenomegaly. Electrocardiogram abnormalities included atrial fibrillation, first and third degree AV block and tall P wave. Echocardiography revealed huge right atrium dilatation and right ventricle apex obliteration by fibrous tissue. One patient had left-side affection with moderate mitral regurgitation. Eosinophilia was present in three patients. Two patients received antituberculosis drugs with no improvement, two had history of treated bilharziasis and two had been labeled as having Ebstein disease. EMF is an important cause of cardiomyopathy in Sudan that is often misdiagnosed. Clinical and echocardiographic examinations can lead to the correct diagnosis.

Fluid Needs for Children Made Easy:Simple Formulae for Calculating the Fluid Needs of Children

Dugdale, A. — Sun, 11 Oct 2009 23:34:43 PDT