Journal of Tropical Pediatrics - current issue

In this Issue June 2009

2009-06-04

Neglected Tropical Diseases

Ebrahim, G. J. — 2009-06-04

Evidence behind the WHO Guidelines: Hospital Care for Children: What Treatments are Effective for the Management of Shock in Severe Dengue?

Smart, K., Safitri, I. — 2009-06-04

Home-based Treatment of Childhood Neurotuberculosis

Schoeman, J., Malan, G., van Toorn, R., Springer, P., Parker, F., Booysen, J. — 2009-06-04

Introduction: In-hospital treatment is widely recognized as the gold standard of treatment for children with neurotuberculosis due to the complexity of care and serious consequences of non-compliance. The continuous rise in the incidence of tuberculosis (TB), fuelled by an HIV-pandemic, has resulted in severe bed shortages in tertiary, secondary and TB hospitals in the Western Cape.

Objective: To evaluate the feasibility of home-based directly observed therapy (DOT) in TBM.

Method: Suitability screening by social workers, in-hospital monitoring of mother–child interaction, medication side effects and intolerance followed by a supervised outpatient surveillance program.

Results: Forty of the 52 children screened were approved for home-based treatment. Thirty-four of these 40 patients (85%) completed TBM treatment successfully at home, and no patient defaulted treatment.

Conclusion: Home-based treatment of childhood neurotuberculosis is feasible in selected patients under close supervision. Mothers could be considered as primary DOT supporters.

Safety, Tolerability and Effectiveness of Generic HAART in HIV-Infected Children in South India

2009-06-04

HIV-infected children in resource-limited settings are increasingly gaining greater access to highly active antiretroviral therapy (HAART) but documented longitudinal data remains limited. We aimed to study the clinical and immunological outcomes among 67 South Indian HIV-infected children with >18 months of follow-up on HAART at a tertiary HIV care program. The median CD4 cell count at enrolment was 290 cells µl^–1 and at treatment initiation was 225 cells µl^–1. Patients demonstrated a significant rise in their CD4 cell counts between treatment initiation and after 6 months (701 cells µl^–1; p = 0.007), 12 months (741 cells µl^–1; p = 0.037), and 18 months of therapy (718 cells µl^–1; p = 0.005). The most common adverse events to therapy were nausea (20.9%) and rash (25.4%). Over one-fifth of patients (25.4%) substituted therapy due to toxicities and 19.4% of patients switched to second-line protease inhibitor-containing regimens. In this South Indian pediatric cohort, generic HAART was safe, effective and relatively well tolerated.

Health-related Quality of Life of Children with Newly Diagnosed Specific Learning Disability

Karande, S., Bhosrekar, K., Kulkarni, M., Thakker, A. — 2009-06-04

The objective of this study was to measure health-related quality of life (HRQL) of children with newly diagnosed specific learning disability (SpLD) using the Child Health Questionnaire-Parent Form 50®. We detected clinically significant deficits (effect size ≥ –0.5) in 9 out of 12 domains: limitations in family activities, emotional impact on parents, social limitations as a result of emotional–behavioral problems, time impact on parents, general behavior, physical functioning, social limitations as a result of physical health, general health perceptions and mental health; and in both summary scores (psychosocial > physical). Multivariate analysis revealed having ≥ 1 non-academic problem(s) (p < 0.0001), attention-deficit hyperactivity disorder (p = 0.005) or first-born status (p = 0.009) predicted a poor psychosocial summary score; and having ≥1 non-academic problem(s) (p = 0.006) or first-born status (p = 0.035) predicted a poor physical summary score. HRQL is significantly compromised in children having newly diagnosed SpLD.

Morbidity in HIV-1-Infected Children Treated or Not Treated with Highly Active Antiretroviral Therapy (HAART), Abidjan, Cote d'Ivoire, 2000-04

Walenda, C., Kouakoussui, A., Rouet, F., Wemin, L., Anaky, M.-F., Msellati, P. — 2009-06-04

Background: In the 2008 UNAIDS epidemic update, 33 million people worldwide were estimated infected with HIV, including 2.2 million children. In Côte d’Ivoire, 480 000 adults and 60 000 children were HIV-infected. Studies in developed countries have shown an improvement of children's morbidity under HAART treatment.

Objective: The objective of this study is to describe and compare morbidity in relation to evolution of the disease in HIV-1-infected children in Côte d’Ivoire, according to symptoms and the presence or absence of HAART treatment.

Methodology: A total of 273 HIV-1-infected children from age 18 months to 18 years were included from October 2000 until December 2003. Follow-up was continued until 30 September 2004. The study population was divided in three groups. Group 1 included symptomatic children treated under HAART. Group 2 included asymptomatic children who did not need HAART treatment. Group 3 included children who met criteria to be treated at inclusion but were not treated.

Principal Findings: The three most common diseases in Group 1 before treatment were bronchitis, diarrhoea and ear nose and throat (ENT) diseases. Under treatment, the three most common diseases in Group 1 were bronchitis, ENT diseases and diarrhoea. The three most occurring diseases in Group 2 were bronchitis, ENT diseases and skin infectious diseases. The three most occurring diseases in Group 3 were bronchitis, diarrhoea and ENT diseases.

Conclusions: The incidence of diseases was significantly lower among asymptomatic children than among symptomatic untreated children (p < 0.0001). The morbidity found in symptomatic children who received treatment was similar to that encountered in asymptomatic children. The main reason for death in all of the groups was tuberculosis.

Behaviour Problems in Young Children in Rural Bangladesh

Khan, N. Z., Ferdous, S., Islam, R., Sultana, A., Durkin, M., McConachie, H. — 2009-06-04

Objective: To determine the prevalence of child behaviour problems reported by parents in rural Bangladesh.

Methods: A total of 4003 children aged 2–9 years were identified during a population-based survey of 2231 households. A predetermined sample of 499 was selected, of which health professionals saw 453 (90.8%) for structured physical and neurological examination, standardized testing of cognition and adaptive behaviour and parent report of developmental history and behaviour problems.

Results: The prevalence of behaviour impairments was 14.6% (95% CI 11.4, 17.9). The majority involved somatic complaints, including nocturnal enuresis and pica. Problems such as aggression or restlessness were infrequently reported. Behaviour impairments were significantly associated with malnutrition (prevalence ratio 2.1, 95% CI 1.2, 3.6, p < 0.01) and cognitive, motor or seizure disabilities (prevalence ratio 1.8, 95% CI 1.1, 2.9, p < 0.05).

Conclusions: The prevalence and nature of reported behaviour impairments in rural Bangladesh have implications for public health planning and delivery of health services.

Breastfeeding Knowledge and Practices amongst Mothers in a Rural Population of North India: A Community-based Study

Kishore, M. S. S., Kumar, P., Aggarwal, A. K. — 2009-06-04

Background: National family health survey-3 of India has revealed startling lower exclusive breastfeeding (EBF) rates (16.9%) in the state of Haryana compared with national data (46%). The barriers to breastfeeding in this population are not clearly known. Therefore, a study was conducted in a rural population of the state to study their breastfeeding practices, knowledge regarding usefulness of breastfeeding and factors influencing the breastfeeding practices.

Methods: In six villages of Panchkula district of Haryana, all the mothers of infants between 0–6 months were interviewed using a pretested semi-structured questionnaire. Time at initiation of breastfeeding, duration of EBF and their understanding about the usefulness of breastfeeding were assessed. Position of the baby during breastfeeding and attachment of the baby's mouth to the breast were assessed by direct observation while feeding. Breastfeeding knowledge of the mother was evaluated.

Results: Out of the 77 mothers, 30% and 10% exclusively breastfed their infants till 4 and 6 months of age, respectively. There was ‘good attachment’ in 42% mother–infant pairs and infants were held in ‘correct position’ by 60% mothers. Thirty-nine percent of the mothers had ‘satisfactory’ breastfeeding knowledge. On multivariate logistic regression analysis, lack of breastfeeding counseling was significantly associated with decreased rates of EBF at 4 months and 6 months (p-value 0.01 and 0.002, respectively) and ‘full’ breastfeeding (FBF) at 6 months of age (p-value 0.002).

Conclusions: EBF/FBF practices and breastfeeding knowledge are suboptimal among the rural North Indian mothers. Breastfeeding counseling with emphasis on correct technique can improve the EBF/FBF rates.

Vitamin D Insufficiency among Children and Adolescents Living in Tehran, Iran

2009-06-04

Vitamin D is important for calcium absorption and skeletal growth. Vitamin D insufficiency (VDI) is a prevalent health problem in children. A study was performed to determine the prevalence of VDI in healthy children living in Tehran, Iran. In a cross-sectional study, 963 students (424 boys and 539 girls) aged 7–18 years were selected by random sampling. Serum 25-hydroxyvitamin D (25-OHD), calcium, alkaline phosphatase and phosphorus were measured. VDI was defined as serum 25-OHD <20 ng/ml. Prevalence of VDI was 53.6% in girls and 11.3% in boys. VDI in female students was about five times more common than males (p < 0.000001). VDI in children and adolescent girls is a health problem not only for these age-groups but also for the next generation to come. Encouraging girls to have more sun exposure, fortification of foods and prescription of supplemental vitamin D are recommended.

Role of Astrovirus in Intussusception in Nigerian infants

Aminu, M., Ameh, E. A., Geyer, A., Esona, M. D., Taylor, M. B., Steele, A. D. — 2009-06-04

Intussusception (IS) is a form of intestinal obstruction in which a segment of the bowel prolapses into a more distal segment. Viral infections, mostly adenovirus, enteroviruses, human herpesvirus and Epstein–Barr virus are reported in 20–50% of childhood cases of IS. Between January and July 2004, six stool specimens collected from infants 0- to 8-months old diagnosed and admitted for IS were investigated for the presence of rotavirus, astrovirus and adenovirus antigens. Astrovirus antigen was detected in three of the six stool specimens by enzyme immune assay (EIA) and confirmed in two specimens by reverse transcription–polymerase chain reaction (RT–PCR). Rotavirus, non-enteric adenovirus and astrovirus were detected by EIA, as mixed infections in a single specimen. The rotavirus strain revealed a SGI+II, mixed G1G2G8P[6] genotype and had no visible electrophoretic profile. A larger study is needed to determine the extent of involvement of astroviruses in IS in infants and the virus should be included in studies investigating the aetiology of IS.

Acute lower respiratory tract infection due to Chlamydia and Mycoplasma spp. in Egyptian children under 5 years of age

Elkholy, A., Elkaraksy, H., Fattouh, A., Bazaraa, H., Hegazy, R., AbdElhalim, M. — 2009-06-04

Wheezing and Respiratory Infections in Brazilian Children: Does a Standard Management Work?

Alves da Cunha, A. J. L., Alves Galvao, M. G., Santos, M. — 2009-06-04

Background: Wheezing associated with acute respiratory infections (ARI) is responsible for unnecessary use of antibiotics.

Objectives: To evaluate the response of children with ARI and wheezing managed according to the World Health Organization (WHO) protocol.

Methods: Cross-sectional study of children aged 2–59 months conducted in a Brazilian pediatric public hospital. Children showing fast breathing received inhalations of bronchodilator. Those who persisted with fast breathing had chest radiographs taken. When appropriate, oral antibiotics were prescribed for pneumonia. Audible wheezing was also registered.

Results: We included 217 children: mean age 25.7 months (SD = 17.5) with 54.4% (118/217) being males. Audible wheezing was detected in 18.6% (40/217). In 87.6% (190/217) of children normal respiratory rates were reached after inhalations. In cases of pneumonia, 26% (7/27) persisted with fast breathing.

Conclusion: A good response using WHO protocol suggests its usefulness in emergency rooms, although few cases will continue to receive antibiotics unnecessarily.

Gangrenous Retrocolic Appendix Masquerading as Incarcerated Umbilical Hernia in a 13-month-old Boy

David, O. O. — 2009-06-04

The diagnosis of appendicitis is challenging in neonates and infants due to the unspecific clinical signs and symptoms, presence of many differentials and inability to elicit history from a preverbal child. Gangrenous retrocolic appendix mimicking incarcerated umbilical hernia is rare. Consequently, the correct diagnosis of a gangrenous retrocolic appendix in a 13-month-old boy who presented with features highly suggestive of incarceration of proboscoid congenital umbilical hernia was very challenging. This case is presented to highlight the diagnostic challenge and increase the suspicion of appendicitis in infants with non-classical clinical features.

Psychotic Disorder and Extrapyramidal Symptoms Associated with Vitamin B12 and Folate Deficiency

2009-06-04

Vitamin B12 and folate deficiency causing neuropsychiatric and thrombotic manifestations, such as peripheral neuropathy, subacute combined degeneration of cord, dementia, ataxia, optic atrophy, catatonia, psychosis, mood disturbances, myocardial infarction and portal vein thrombosis are well known. This present report highlights an unusual presentation of vitamin B12 deficiency—psychotic disorder, extrapyramidal symptoms in a 12-year-old boy. His symptoms responded to parenteral vitamin B12 therapy. So with this report we emphasized that serum vitamin B12 and folate levels should be measured, especially in those patients who present with other known neuropsychiatric features of vitamin B12 and folate deficiency.

Severity of Sickle Cell Disease in Yemeni Children

Al-Saqladi, A.-W. M., Delpisheh, A., Bin-Gadeem, H. A., Brabin, B. J. — 2009-06-04

Evidence-based Hematology * Crowther M. A., Ginsberg J., Schunemann H. J., Meyer R. M., Chichester L. R. (eds)

Ebrahim, G. J. — 2009-06-04