Journal of Tropical Pediatrics - recent issues

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

In this Issue April 2009

2009-03-26

The United Nations Convention on the Rights of the Child and HIV/AIDS

McMillan, A. S., Simkiss, D. — 2009-03-26

Evidence behind the WHO Guidelines: Hospital Care for Children: What is the Role of Prophylactic Antibiotics in the Management of Burns?

Lee, F., Wong, P., Hill, F., Burgner, D., Taylor, R. — 2009-03-26

Evidence behind the WHO Guidelines: Hospital Care for Children: What is the Evidence that BCG Vaccination Should Not be Used in HIV-infected Children?

Bannister, C., Bennett, L., Carville, A., Azzopardi, P. — 2009-03-26

Time-independent Maternal and Infant Factors and Time-dependent Infant Morbidities including HIV Infection, Contribute to Infant Growth Faltering during the First 2 Years of Life

Webb, A. L., Manji, K., Fawzi, W. W., Villamor, E. — 2009-03-26

Studies investigating the predictors of growth in infants born to HIV-infected women in developing countries are limited. Using data from 886 Tanzanian HIV-infected women and their infants, we examined the impact of maternal socioeconomic and immunological status, infant characteristics at birth, and HIV, diarrhea and respiratory infections on infants’ monthly length-for-age (LAZ) and length-for-weight (WLZ) z-scores during the first 2 years of life. We used restricted cubic splines to estimate average adjusted growth curves by categories of each predictor. LAZ decreased significantly during the first 2 years. WLZ increased from birth to 4 months but decreased significantly thereafter. Greater maternal schooling significantly reduced deterioration in LAZ and WLZ scores from birth to 24 months, while maternal CD4 cell counts ≥200 mm^–3 at baseline were associated with reduced deterioration in LAZ scores. Infants born pre-term or with low-birth weight were significantly more stunted and wasted than their reference groups at all time points though their rate of growth faltering was slower. Infant-HIV status was strongly associated with significantly greater deterioration in LAZ and WLZ scores, beginning at about 4 months of age. Episodes of diarrhea or respiratory infections were related to significantly lower WLZ but not LAZ scores, independent of infant-HIV status. In conclusion, maternal schooling, immunological status and infant infections are important predictors of early growth in children born to HIV-positive women.

Sensitivity of Paediatric AIDS Score vs. WHO Case Classification in Indian Children--A Retrospective Study

Banerjee, T., Pensi, T., Banerjee, D. — 2009-03-26

This study was conducted at the Department of Paediatrics, Dr Ram Manohar Lohia Hospital, to test the statistical significance of existing World Health Organization (WHO) clinical case definition (CCD) for diagnosis of AIDS in areas where diagnostic resources are limited. A total of 360 cases between 18 months and 12 years of age satisfying WHO case definitions of AIDS were included in study group. Our study detected 16.66% (60) of HIV incidence in children visiting the paediatrics outpatient clinic. Twenty percent of cases manifested three major and two minor signs, which had sensitivity of 73.33%; specificity, 90.66% and positive predictive value (PPV), 61.11%. Stepwise logistic analysis identified weight loss, chronic fever >1 month and total lymphocyte count <1500 cells mm^–3 as important predictors. Eighty-six cases (23.89%) showed two major and two minor signs with sensitivity and specificity of 86.66 and 88.66%, respectively. Thus a CCD based on 13 clinical signs/symptoms was proposed for paediatric AIDS with better sensitivity and PPV than the WHO case definition but with almost similar specificity.

Efficacy of 99mTc-DTPA Lung Clearance Test in the Diagnosis of PCP in HIV-Positive Patients

2009-03-26

The study aims to evaluate the efficacy of technetium-99m diethylenetriaminepentaacetic acid (^99mTc-DTPA) lung clearance test in the diagnosis of pneumocystis carinii pneumonia (PCP) in HIV-positive paediatric patients. Twenty HIV-negative patients with no chest symptoms constituted Group A, 25 HIV antibody positive asymptomatic children formed Group B, while 45 HIV antibody positive children with respiratory infections comprised Group C. Group C was subdivided into C₁ (n = 20, documented PCP on microbiology), C₂ (n = 10, tuberculosis) and C₃ (n = 15, bacterial pneumonias). The mean age group of patients in Group A, Group B and Group C was 4.7 ± 1.9, 4.2 ± 1.5 and 4.8 ± 1.7 years, respectively. All patients were subjected to complete blood count, blood culture, chest radiographs, microscopic staining of sputum (PCP stains, Ziehl-Nielsen staining, Gram staining), ABG and Mantoux test. All these patients underwent dynamic lung scans using ^99mTc-DTPA aerosols and lung clearance was calculated in terms of half-time transfer value (T_1/2) value. T_1/2 was compared between different groups and lung scan findings were correlated with radiological and microbiological results. Patients with PCP had T_1/2 in the range of 9.02 ± 1.35, TB 28.2 ± 3.03 min and other bacterial pneumonias in the range of 20.5 ± 3.1 min (range for normal individuals was 49.8 ± 6.13 min). T_1/2 in patients with PCP was found to be significantly lower when compared with T_1/2 in other groups. Patients with PCP had characteristic biphasic curves while the rest had monophasic curves. Some patients with PCP had low T_1/2 values even when chest radiographs and arterial blood gases were normal. ^99mTc-DTPA lung clearance test is a sensitive, safe and non-invasive diagnostic tool for the early detection of PCP in HIV-positive paediatric patients.

Plasma IP-10 as a Predictor of Serious Bacterial Infection in Infants Less than 4 Months of Age

Chen, H.-L., Hung, C.-H., Tseng, H.-I, Yang, R.-C. — 2009-03-26

Background: Early diagnosis of serious bacterial infection (SBI) in young infants is a difficult problem by clinical symptoms and signs. The goal of this study is to evaluate the predictive value of plasma IP-10 levels for early diagnosis of SBI in young infants <4 months of age.

Methods: We enrolled pediatric patients who were <4 months of age with a clinical suspicion to have SBI admitted in neonatal intensive care unit or complete nursing unit of Pediatric Department of Kaohsiung Medical University Hospital. Blood was drawn for measurement of complete blood counts, C-reactive protein (CRP) and plasma IP-10 levels and microbiological cultures were obtained at the time of admission.

Results: There were 60 patients enrolled in this study. The SBI group (n = 21) have higher plasma IP-10 levels than those infants without SBI (n = 39) [median 104.8 (range 0–1457.1) versus 0 (range 0–129.3) ng ml^–1, P = 0.0161 after adjusting age]. A plasma IP-10 level >48.2 ng ml^–1 had the best diagnostic accuracy for indicating SBI {sensitivity 81.0% [95% confidence interval (CI) 71.1–90.1%]; specificity 94.9% [95% CI 65.4–87.0%]; positive likelihood ratio 15.9, negative likelihood ratio 0.2}.

Conclusion: In infants who were <4 months of age with suspicion of SBI, IP-10 assay might be a good predictor.

A Multilevel Analysis of Individual and Community Effect on Chronic Childhood Malnutrition in Rural Nigeria

Uthman, O. A. — 2009-03-26

Background: Protein energy malnutrition is the second most important cause of childhood morbidity and mortality in Nigeria after infections. The purpose of this article was to develop and test a model of childhood malnutrition that includes individual-level characteristics along with contextual characteristics defined at the community level.

Design: Multilevel logistic regression analysis.

Subjects and setting: A total of 4007 children resident in 96 rural villages in Nigeria.

Main outcome: Stunting: height-for-age that is less than the international reference value by >2 standard deviations (SDs).

Main results: Independent of other factors, children born to underweight mothers were 1.32-times more likely to be stunted [adjusted odds ratio (aOR) 1.32; 95% confidence interval (CI) 1.07–1.64]. For each additional month of breastfeeding the odds of being stunted increased by 4% (aOR 1.04; 95% CI 1.03–1.06). Each SD increase in the household wealth index and maternal health-seeking behaviour index decreased the odds of being stunted by 16% (aOR 0.84; 95% CI 0.76–0.94) and 29% (aOR 0.71; 95% CI 0.60 –0.82), respectively.

Conclusion: The study has provided evidence that both individual and community characteristics are important predictors of childhood malnutrition in rural Nigeria; and that scholars trying to understand variation in childhood malnutrition should pay attention to the characteristics of both children and place of residence.

Randomised Controlled Study-efficacy of Clonidine versus Carbamazepine in Children with ADHD

Nair, V., Mahadevan, S. — 2009-03-26

Background: Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorder with a prevalance of 8–12%. Even though psychostimulants remain the treatment of choice, its cost and availability in developing countries limits the usage of the drug. In view of free availability and low cost, a Randomized controlled study was carried out using two second line drugs (clonidine and carbamazepine) in a tertiary care hosipital, Pondicherry, South India.

Objective: To compare the efficacy of clonidine and carbamazepine in children with ADHD.

Method: With approval of ethics committee, a prospective, Double-blind, Randomized controlled study of clonidine and carbamazepine was conducted with 50 children with ADHD (age group 4–12 years), over a period of 2 years (2005–07) in a tertiary care hosipital, Pondicherry, South India.

Results: Clonidine was effective in improving the hyperactivity and impulsivity symptoms in children with ADHD as compared to carbamazepine. Statistical significant improvement was not noted with respect to inattention symptoms and other comorbid conditions.

Conclusion: Clonidine can be a safer and cheaper alternative in treatment of children with ADHD, with a predominant effect on their hyperactivity and impulsivity symptoms.

Bacterial Enteropathogens of Neonates Admitted to an Urban Diarrhoeal Hospital in Bangladesh

2009-03-26

Data on the aetiology of diarrhoea in neonates are scarce, especially from developing countries including Bangladesh. A retrospective review of the electronic database of the Microbiology Laboratory of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), was carried out to examine enteropathogens associated with diarrhoea in neonates. Stool specimens of the neonates on admission to the Dhaka Hospital of ICDDR,B were collected and sent to the laboratory for direct plating onto taurocholate tellurite gelatin agar, Salmonella–Shigella agar and MacConkey's agar. Stool specimens of 2511 neonates of either sex were examined. Bacterial pathogens were recovered from the stools of 699 (27.8%) of these neonates—a single bacterial pathogen from 670 neonates and more than one pathogen from 29 neonates. Vibrio cholerae, Shigella, Salmonella, Aeromonas spp. and Plesiomonas shigelloides were isolated from 294, 108, 52, 222 and 19, respectively, of the neonates. The year-wise isolation of these pathogens varied between 4.9–23.4%, 2.7–5.4%, 0–4.7%, 0–19.4% and 0–1.6%, respectively, of the neonates. The results of the study indicate that infection by V. cholerae, Shigella spp., Salmonella spp., Aeromonas and P. shigelloides is common in neonatal diarrhoea in Bangladesh.

Changes in CD4 Count with Antitubercular Therapy in HIV Infected Children with Tuberculosis

Mukherjee, A., Lodha, R., Kabra, S. K. — 2009-03-26

Prophylactic Probiotics for Prevention of Necrotizing Enterocolitis in Very Low Birth Weight Newborns

Samanta, M., Sarkar, M., Ghosh, P., Ghosh, J. k., Sinha, M. k., Chatterjee, S. — 2009-03-26

Our study showed that enteral administration of prophylactic probiotics in neonatal intensive care setup could significantly reduce morbidity due to necrotising enterocolitis in very low birth weight newborn. It also helps in establishing early full enteral feeding and reduces hospital stay.

Does Exclusive Breastfeeding Confer Protection Against Infantile Hypertrophic Pyloric Stenosis? A 30-year Experience in Benin City, Nigeria

Osifo, D. O., Evbuomwan, I. — 2009-03-26

The incidence of infantile hypertrophic pyloric stenosis has steadily decreased in developing countries, and this study was designed to confirm this and establish any protection conferred by exclusive breastfeeding. A retrospective study was done between July 1978 and June 2008, at the University of Benin Teaching Hospital, Benin City, Nigeria. A total of 57 children aged between 2 and 6 weeks (mean 3.5 ± 1.2 weeks) comprising of 49 males and 8 females with male female ratio 6.1 : 1 were treated. Following the introduction of exclusive breastfeeding in late 1980s and early 1990s in Nigeria, a steady drop in incidence was noticed, with only five cases seen in the last decade and just one case seen in the past 5 years. All were babies who had artificial feeds, with none recorded among babies exclusively breastfed. This decrease in the incidence of infantile hypertrophic pyloric stenosis may have been due to exclusive breastfeeding.

A Visual Dosing Aid for First-line Pediatric Antiretroviral Treatment in Resource-poor Settings

2009-03-26

The visual dosing aid (VDA) was developed to facilitate dosing calculations in response to children's; growth and weight during antiretroviral treatment. The theoretical accuracy of the VDA was assessed using anthropometric data from 55 children receiving care in the USA and 324 children in the Democratic Republic of the Congo. The VDA dose was similar to the WHO recommended dose. A potentially significant relative dosing difference of ≥20% occurred in <3% of children for NVP, AZT and d4T, but was observed in 20% for 3TC, overdosing being more frequent. The VDA compared well with generic pediatric fixed dose combination tablets. Results did not differ between sites. The VDA enables accurate dosing of pediatric ART in distinct populations and could facilitate roll-out of pediatric ART in resource-poor settings.

Lead Levels in Women at Delivery at the Muhimbili National Hospital: A Public Health Problem

Azayo, M. M., Manji, K., Kalokola, F. — 2009-03-26

Lead poisoning is a global health problem but unrecognized in African countries. Umbilical Cord Lead levels can be used to determine community exposure to lead. At delivery, 150 women were recruited for cord blood lead. A prevalence of 10% beyond the accepted range was found. Cord blood levels ranged from 0.1–18.1 µg/dl, with a mean of 4.1 µg/dl. There was no association between lead levels and pregnancy outcomes in terms of low birth weight and pre-term delivery. There was a weak association between lead poisoning and living in a painted house and use of tap water (OR = 1.4). There was no association between lead poisoning and use of facial cosmetics. Living near heavy traffic was more associated with increased cord blood lead levels.

Acquired Methemoglobinemia Due to Contaminated Colours: A Preventable Disaster

Mauskar, A., Karande, S., Kulkarni, M. — 2009-03-26

In this Issue February 2009

2009-02-08

Capacity building for Global Action in Mother and Child Health

Ebrahim, G.J., Heller, R. F., Reynolds, F. — 2009-02-08

Evidence behind the WHO Guidelines: Hospital Care for Children: What is the most appropriate treatment for giardiasis?

Chandy, E., McCarthy, J. — 2009-02-08

The Hypoxic Ischaemic Encephalopathy Score in Predicting Neurodevelopmental Outcomes Among Infants with Birth Asphyxia at the Muhimbili National Hospital, Dar-es-Salaam, Tanzania

Mwakyusa, S. D., Manji, K. P., Massawe, A. W. — 2009-02-08

Hypoxic Ischemic Encephalopathy (HIE) score may be used to predict neurodevelopment outcome in infants with birth asphyxia. A total of 140 infants who had a 5 min Apgar score of <7 at birth had detailed motor and neurodevelopment assessment. Outcome measures were grouped as normal or abnormal with morbidity (convulsions, abnormal muscle tone and delayed development) or death. The positive predictive value (PPV) for mortality was 42.3% for moderate HIE and 93.8% for severe HIE. For severe HIE the PPV was 100%. Thirteen infants had delayed development, the score had PPV of 63.6% for moderate HIE and 100% for severe HIE. The best correlation with outcome was the peak score of 15 or higher had a PPV of 100%. Specificity was found to be 100% and sensitivity of 14%. The HIE scoring system is a useful predictor of neurodevelopment outcome at 6 months of age in a resource poor setting.

Short-Term Outcome of Very Low Birth Weight Infants in a Developing Country: Comparison with the Vermont Oxford Network

2009-02-08

Objectives: To determine the outcome of very low birth weight infants (VLBWI) admitted to a level III NICU in UAE and compare the results to percentiles published by the Vermont Oxford Network (VON).

Method: Outcome data were collected retrospectively, using standard definitions, on a cohort of VLBWI 500–1500 g admitted between January 2004 and December 2006.

Results: Of the 173 infants weighing 501–1500 g at birth, 85.6% survived until discharge, which corresponds to the 50th percentile (P50) of VON. Chronic lung disease (CLD) occurred in 12.1% (<P25), death or CLD 26.6%, necrotizing enterocolitis (NEC) 5.8% (<P50), intraventricular hemorrhage (IVH) of any grade 17.5% (P25), grade III or IV IVH in 5% (P25), periventricular leucomalacia (PVL) 2.8% (P50), retinopathy of prematurity stage (ROP) 11.3% (<P10). The mortality and morbidity data for the subgroups of 501–1000 g and 1001–1500 g birth weight are also reported.

Conclusion: We report the outcome of VLBWI born in a developing country with high resources. The rates of CLD, IVH and ROP were ≤25th percentile of the VON and mortality, NEC and PVL were in the 50th percentile.

Factors Related to Lower Adherence Rates to Inhaled Corticosteroids in Children and Adolescents: A Prospective Randomized Cohort Study

Lasmar, L., Camargos, P., Bousquet, J., Goulart, E., Sakurai, E., Carvalhais, M. — 2009-02-08

Asthma morbidity is high, partly due to low adherence to inhaled corticosteroids (ICS). This study aims to assess rates and factors related to low adherence to ICS over time in asthmatic children and adolescents.

Methods: A concurrent cohort study was carried out for 24 months in 168 randomly selected patients suffering from persistent moderate asthma. All of them were given beclomethasone dipropionate (BDP) free of charge. Adherence rates were verified by pharmacy records (doses filled/doses prescribed). A multivariate analysis evaluated factors related with low adherence rates.

Results: Overall adherence rates were 72.5, 58.6 and 61.1% in the 4th, 12th and 24th months of follow-up, respectively. Factors associated to adherence rates <70% were: mother's schooling level (p = 0.03), replacement of the caregiver (p = 0.03), prescription greater than two puffs/day (p = 0.005), absence of rhinosinusitis (p = 0.002) and age under 7 years (p = 0.04). Only the number of consultations lower than two in a 4-month period was associated to a lower adherence rate in all study periods (p = 0.02).

Conclusions: Adherence rates decreased over time, even in patients who had received the medication free of charge, and factors related to lower adherence changed during the follow-up. Results have shown that adherence had a dynamic pattern and its determinants should be re-evaluated continuously. Only the number of consultations was associated to a lower adherence rate in all periods, pointing out that health programs must recognize and facilitate the access of patients needing special care, which can contribute for better adherence and reducing asthma morbidity.

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. — 2009-02-08

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.

Feeding and Nutritional Characteristics of Infants on PMTCT Programs

Magezi, S. R., Kikafunda, J., Whitehead, R. — 2009-02-08

Objectives: To compare feeding and nutritional characteristics of infants born to mothers on the prevention of mother to child transmission (PMTCT) programs with infants not in the program.

Design: A hospital-based case–control study was used.

Setting: The study was conducted in Nsambya hospital, Kampala, Uganda.

Subjects: A total of 176 mother/baby pairs were included in the study with 88 from each group. Infants were aged from 3 to 12 months.

Results: The percentage of mothers exclusively breastfeeding was lower in PMTCT mothers (65%) compared to the 98% in non-PMTCT mothers (p < 0.01). The mean duration of breastfeeding was 2.5 months among PMTCT mothers compared to 4.1 months in non-PMTCT mothers (p < 0.01). Dietary diversity score (DDS) was higher among PMTCT babies (4.3) compared to 3.7 among non-PMTCT babies (p < 0.05).

The percentage of babies reported ill in the previous month was much higher among the PMTCT infants (79%) compared to the non-PMTCT infants (69%) and the incidence of diarrhoea was almost twice as high among the PMTCT infants (18.1%) compared to the 9.3% in non-PMTCT infants [risk ratio (RR) = 1.94]. In addition, the incidence of respiratory infections was higher among the PMTCT infants (47.7%) compared to 39.5% in the non-PMTCT infants (RR = 1.2). The mean z-scores: [Weight for age z-score (WAZ)] [height for age z-score (HAZ)] and [weight for height z-score (WHZ)] were significantly lower (p < 0.01) for PMTCT infants. The incidence of stunting among PMTCT infants (11.8%) was twice that of the non-PMTCT ones (5.2%) and incidence of underweight was 8.4% in the PMTCT infants compared to 1.2% in the non-PMTCT ones.

Conclusions: The feeding patterns of the PMTCT infants were significantly different from the non-PMTCT ones both in terms of breastfeeding and DDS. Although DDS was higher among the PMTCT infants it did not translate into better nutritional status. The higher incidence of morbidity combined with the lower incidence of breastfeeding among the PMTCT infants are some of the contributing factors to significantly higher levels of malnutrition.

Effect of Kangaroo Mother Care on Postpartum Depression

de Alencar, A. E. M. A., Arraes, L. C., de Albuquerque, E. C., Alves, J. G. B. — 2009-02-08

Postpartum depression (PPD) is a serious public health issue. Kangaroo mother care (KMC) is widely considered to be the most feasible, readily available and preferred intervention for decreasing neonatal morbidity and mortality in developing countries. We conducted a prospective study to assess the effect of KMC on PPD. The study population included 177 low-income mothers with their preterm infants. We used the validated Portuguese version of the Postpartum Depression Screening Scale for the assessment of maternal depression. The mothers were evaluated twice, at Neonatal Intensive Care Unit admission and at KMC discharge. We found 66 mothers (37.3%) with depression and it decreased to 30 (16.9%) after KMC intervention; p < 0.0001. None developed PPD during the Kangaroo stay. We concluded that KMC may lessen maternal depression. Further studies, may be required to clarify these preliminary findings.

Factors Influencincing Discharge against Medical Advice among Paediatric Patients in Abakaliki, Southeastern Nigeria

Ibekwe, R. C., Muoneke, V. U, Nnebe-Agumadu, U. H, Amadife, M.-A. U — 2009-02-08

Discharge against medical advice (DAMA) has become a major problem in health care delivery in Nigeria. Children are the victims because most of the times they are not the one taking the decision, and may not understand or contribute to it. This retrospective study was undertaken to identify the factors that influence DAMA among paediatric patients in Ebonyi State University Teaching Hospital, Abakaliki in southeastern Nigeria, with a view at curbing it. There were 97 cases of DAMA out of a total admission of 6505 giving a prevalence rate of 1.5%. Infants constituted 52.2% of them, of which 37.8% were neonates. Majority (96.7%) were from lower social classes residing in rural villages (61.1%).Neonatal conditions (36.7%) were the most common condition for which DAMA was sought, followed by severe malaria (22.2%) and road traffic accident with fractures (12.2%). The common reasons given for DAMA were financial constraint (33.3%), resort to native treatment (25%) and hopelessness of the disease condition (15%). DAMA at the study site is closely asssociated with parental poverty and ignorance. Neonates and older children with surgical conditions are the most vulnerable group. Policies should be targeted at protecting these groups.

Relationship between Intestinal Parasitic Infection in Children and Soil Contamination in an Urban Slum

2009-02-08

Purpose: Urban slums are well known for their high infant mortality and morbidity rates, and parasitic infections seem to be a common problem among these children. The aim of the present study was to determine protozoa and nematodes prevalence among children of a selected community located in São Paulo, Brazil, and access the relation between soil and children infection.

Methods: Soil contamination samples from 15 strategic locations in the slum area as well as stool samples (examined for protozoa and nematodes through five different methods) from 120 children aged 2–14 years (49% M: 51% F, mean ± SD = 7.9 ± 3.8 years) were assessed in a cross-sectional study. Children's domicile locations were determined, and a comparative analysis was undertaken to correlate children and soil infection.

Results: Overall infection rate was 30.8% (n = 37), without difference between genders. The most frequent intestinal protozoa were Endolimax nana (20.8%), Entamoeba coli (15.8%) and Giardia lamblia (16.7%). Frequencies of Ascaris lumbricoides and Enterobius vermicularis in stool samples were 2.5 and 1.7%, respectively. No cases of hookworms, Schistosoma mansoni or Tricuris trichiura were identified. Polyparasitism occurred in 10.8% of the children, while 69.2% were free of parasitic infections. Out of the 15 soil samples analyzed, Ascaris sp. eggs were found in 20% and hookworm eggs in 6.7%.

Conclusion: Helminth infection is not as prevalent as previously reported in urban slums in São Paulo, neither as clinical disease nor in soil samples. Protozoa intestinal infection, however, is still frequent in some marginalized populations in São Paulo. Improvement in living standards, mostly sanitation might decrease the prevalence of these diseases.

Challenges in the Identification and Treatment of PANDAS: A Case Series

Mabrouk, A. A., Eapen, V. — 2009-02-08

Paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS), is characterized by childhood-onset obsessive-compulsive disorder (OCD) and Tic disorder that has been found to have a post infectious autoimmune-mediated etiology, where the onset and subsequent exacerbations of symptoms is temporally related to group A beta-hemolytic streptococci (GABHS) infection. In addition to the use of anti-tic and antiobsessional agents, the use of Penicillin during the acute phase and for prophylaxis, tonsillectomy, immunomodulatory therapies such as plasma exchange and intravenous immunoglobulin, etc. have all been reported to improve the symptoms. We describe five cases of neuropsychiatric symptoms triggered by streptococcal infection in an Arab population and highlight the challenges faced by clinicians in the identification and management of PANDAS.

The Determinants of Exclusive Breast Feeding in Urban Slums: A Community Based Study

Tiwari, R., Mahajan, P. C., Lahariya, C. — 2009-02-08

The actual rate of Exclusive Breast Feeding (EBF) (up to the age of 6 months) is dismally low in urban slums of India. The reasons and determinants of this are debatable. The study was planned to understand the determinants of EBF in the infants in urban slums. A community-based cross sectional study was done in urban slums of Gwalior, India. The data were collected by interviewing the caregivers of 279 infants aged between 6 and 11 months from November 2005 to July 2006. Only 11 (3.8%) mothers knew that EBF should be done till six months and 22 (7.8%) actually practiced EBF. A total of 178 (63.8%) and 212 (76.0%) newborns were given pre- and post-lacteal feeds with 26.2% discarding colostrum. Only 22 (7.8%) practiced EBF. The early breastfeeding (BF) initiation, Ante Natal Clinic (ANC) visits, mothers’ education and immunization visits were significantly associated with higher probability of EBF. There were a number of myths and misconceptions about BF in this urban slum population. The correct information about BF was more common amongst the women who had frequent contacts with health facilities due to any reason or during ANC or immunization visit. Similarly, it is the continuum of good health and feeding practices and the mothers who start early BF or get their child immunized regularly are more likely to EBF their children. Considering the widely prevalent myths and low rate of utilization of health services along with high potential benefits of EBF, every opportunity of mothers’ interaction with the health facility should be utilized for promoting correct and EBF practices.

Atypical Kawasaki Disease Presenting with Symptoms from the Genitourinary System: An Autopsy Report

2009-02-08

Symptoms from the genitourinary system are unusual in Kawasaki disease (KD). Renal involvement is even rarer and it is confirmed by biopsy when the person is alive. We describe the case of an 11-year-old boy admitted to the hospital complaining about prolonged fever (5 days) and hematuria. His urinalysis showed also pyuria, proteinuria and urinary renal tubular epithelial cells concentrations. During the next days, the patient presented limb edema. After almost 2 weeks of hospitalization the patient was transferred to the intensive care unit because of melena and intense abdominal pain. Upon admission, the patient collapsed and died. The diagnosis of KD was established during autopsy. The macroscopical and histopathological examination of the heart showed increased dimensions and weight and multiple thrombi in the coronary arteries with intramural dense polymorphonuclear inflammatory infiltration and necrosis. Histological examination of the kidneys revealed normal glomerulus, mild expansion of mesangial matrix, interstitial infiltration with lymphocytes, plasmatocytes and eosinophiles, normal vessels and normal immunofluorescence.

Intravenous Magnesium Sulphate Infusion in the Management of Very Severe Tetanus in a Child: A Descriptive Case Report

Puliyel, M. M., Pillai, R., Korula, S. — 2009-02-08

We report a 7-year-old boy with very severe tetanus treated with continuous infusion of magnesium sulphate for the control of spasms and severe autonomic dysfunction which was refractory to deep sedation and mechanical ventilation. The infusion was not associated with any adverse effects and he made an uneventful recovery. We recommend the use of intravenous magnesium sulphate infusion as an inexpensive and highly effective modality in severe tetanus.

Development of Dual-class Antiretroviral Drug Resistance in a Child Coinfected with HIV and Tuberculosis: A Case Report from KwaZulu-Natal, South Africa

2009-02-08

The treatment of concurrent HIV and tuberculosis (TB) in children <3 years of age has not been well-studied and is complicated by potential drug–drug interactions. The recommended antiretroviral therapy (ART) in coinfected children in South Africa consists of full-strength ritonavir, lamivudine and stavudine. We report on a child initiated on this regimen, during concurrent TB treatment, who promptly developed an adverse reaction, virologic failure and dual-class antiretroviral drug resistance, compromising subsequent salvage ART.

Congenital Syphilis and Ventricular Septal Defect

Vasquez-Manzanilla, O., Dickson-Gonzalez, S. M., Rodriguez-Morales, A. J. — 2009-02-08

Association of Mean Platelet Volume between Glucose Regulation in Children with Type 1 Diabetes

Pirgon, O., Asya Tanju, I., Alev Erikci, A. — 2009-02-08

Neuroscience at a Glance, 3rd edn Roger A. Barker and Stephen Barasi (with neuropharmacology by M. J. Neal)

Ebrahim, G. J. — 2009-02-08

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

Ebrahim, G. J. — 2009-02-08

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

Ebrahim, G. J. — 2009-02-08

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

Ebrahim, G. J. — 2009-02-08

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

Ebrahim, G. J. — 2009-02-08

Editorial-India's progress towards achieving the targets set in the Millennium development Goals

Elizabeth, K. E. — 2009-02-08