Journal of Tropical Pediatrics - recent issues

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

In this Issue August 2009

Tue, 28 Jul 2009 22:49:31 PDT

Global Health Watch 2: The Alternative World Health Report

Waterston, T. — Tue, 28 Jul 2009 22:49:31 PDT

David Morley - In Memoriam

Ebrahim, G. J., Waterston, T. — Tue, 28 Jul 2009 22:49:31 PDT

Evidence behind the WHO Guidelines: Hospital Care for Children: What is the Role of HIV Antigen Testing in Infants <12-months Old?

Finnegan, J., Nobel, K.-A., Lodha, R. — Tue, 28 Jul 2009 22:49:31 PDT

Evidence behind the WHO Guidelines: Hospital Care for Children: What is the Aetiology of Pneumonia in HIV-infected Children in Developing Countries?

Calder, D., Qazi, S. — Tue, 28 Jul 2009 22:49:31 PDT

Efficacy of Antiretroviral Therapy Program in Children in India: Prognostic Factors and Survival Analysis

Tue, 28 Jul 2009 22:49:31 PDT

The objective of this article is to study the survival pattern and the prognostic factors for HIV-infected children on antiretroviral therapy (ART) for two and half years at the Government Hospital of Thoracic Medicine, Tambaram, Chennai, India. We studied 295 children who were initiated on ART from 1 April 2004 to 30 September 2006 at a large, public tertiary care facility in Chennai, India. Weight for age Z-score was calculated. Survival curves and Cox proportional hazard models were used to identify risk factors for mortality. The mean and median follow up was 11 and 10 months, respectively. The cumulative survival probability at 6, 12, 18, 24 and 30 months was 93, 90, 89.7, 89.7 and 89.7%, respectively. Of the children who died, about 50% died within the first month. Nearly 6% of the children had adherence less than 95%. The children who had a baseline CD4 percent less than or equal to 14% had significantly (p < 0.05) higher mortality as compared to children who had 20% or more. The children who had negative or no change in weight for age Z-score and hemoglobin had 18.9 (3.7–95.7) times significantly higher mortality as compared to children who had positive change in both variables (p < 0.001). The sensitivity, specificity and likelihood ratio of the positive test for negative change or no change in HB was 65%, 85% and 4.3, respectively. Similarly, these were 80%, 73% and 3% for negative or no change in Absolute Lymphocyte Count (ALC). These findings indicate the feasibility and effectiveness of implementing an ART program in a large government hospital in India. Simple nutritional variable hemoglobin and immunologic variable ALC could be used to monitor the progression of disease in children.

Cytokine Profiles in Peripheral, Placental and Cord Blood in an Area of Unstable Malaria Transmission in Eastern Sudan

Tue, 28 Jul 2009 22:49:31 PDT

Background: Understanding the cytokine interactions that underlie both control and disease should be helpful when investigating the pathogenesis of malaria during pregnancy. Few data exists concerning pathogenesis of malaria during pregnancy in areas of unstable malaria transmission. Objectives: The study was conducted in New Halfa hospital, eastern Sudan, which is characterized by unstable malaria transmission to investigate the cytokine profiles in peripheral, placental and cord blood in parturient women. Methods: Enzyme-linked immunosorbent assay was used to measure the concentrations of three cytokines, interferon- (IFN-), interleukin-4 (IL-4) and IL-10, in sera from peripheral, placental and cord blood of 87 Sudanese women. Results: The concentrations of these cytokines were significantly higher in peripheral, placental sera from uninfected women than in sera from infected women. IFN- concentrations were significantly lower in the cord sera from uninfected women in comparison to the infected ones. The levels of these cytokines were not significantly different between the primiparae and multipare. Cord sera in all groups showed lower levels of these cytokines. Strong positive correlations were observed between peripheral and placental cytokines. Conclusion: The immune responses that occur in placental, peripheral and cord blood were influenced by the malaria infections, irrespective of the parity. The immune response during Plasmodium falciparum infection is not different in the peripheral and placental compartments, further studies are required.

Endoscopy Findings in HIV-Infected Children from Sub-Saharan Africa

Cooke, M. L., Goddard, E. A., Brown, R. A. — Tue, 28 Jul 2009 22:49:31 PDT

Background: The causes of persistent gastro-intestinal symptoms in HIV-infected children from sub-Saharan Africa remain poorly documented.

Methods: The clinical, radiological and endoscopic findings of all HIV-infected children who underwent upper GI endoscopy at Red Cross Children's Hospital, Cape Town, South Africa, from February 2003 to October 2005 were documented.

Results: Twenty-six HIV-infected children underwent endoscopy; median age 1 year (range: 0.17–10.9 years). The majority had advanced HIV disease; 18 (69%) were WHO Stage 4; median CD4 10.7% (range: 1–39.8%). Presenting symptoms included persistent vomiting (18), dysphagia (4) and GIT bleed (6). Observational and histological findings showed poor correlation. Pathogens were identified in 10 children: cytomegalovirus infection in seven (two with cryptosporidium co-infection), Candida in two, Helicobacter pylori in one. Age and CD4 count were not associated with the pathogens. Endoscopy findings influenced clinical management in 21 (81%) cases.

Conclusion: Upper-GI endoscopy identified a diverse spectrum of disease and provided information that would be clinically relevant to most HIV-infected children with upper gastro-intestinal symptoms.

Safety, Effectiveness and Barriers to Follow-up Using an 'Early Discharge' Kangaroo Care Policy in a Resource Poor Setting

Blencowe, H., Kerac, M., Molyneux, E. — Tue, 28 Jul 2009 22:49:31 PDT

Aim: To describe the outcomes of low-birth-weight babies using an ‘early discharge’ Kangaroo care policy and to identify barriers to their follow-up.

Methods: Prospective descriptive study of all 272 babies admitted to a Kangaroo Care Ward in Malawi from November 2003 to May 2004. Infants were discharged to outpatient care once weighing over 1300 g and gaining weight. Follow-up was carried out until 2500 g.

Results: Infants [201 of 272 (73.9%)] reached a weight >2500 g; 46 out of 272 (16.9%) died; outcome was unknown in 25 of 272 (9.2%). Outpatient mortality was higher amongst discharges weighing under 1500 g [RR = 2.41(1.25–4.63) P = 0.01]. Discharge below birth weight did not affect mortality [RR = 0.77(0.40–1.46) P = 0.42]. Barriers identified to seeking healthcare post-discharge included transport problems and late recognition of illness.

Conclusions: Early discharge is safe and feasible, but issues regarding access to healthcare need to be addressed. Future research is needed to determine how best high mortality can be reduced in specific subgroups: notably infants <1500 g.

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

Phukan, R. K., Barman, M. P., Mahanta, J. — Tue, 28 Jul 2009 22:49:31 PDT

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.

Two Doses of Measles Vaccine: Are Some States in India Ready for It?

John, S., Sanghi, S., Prasad, S., Bose, A., George, K. — Tue, 28 Jul 2009 22:49:31 PDT

We present the results of two surveys of measles outbreaks near Vellore, which perhaps supports the cause for introduction of a second dose of measles vaccine. Survey one had 590 under 10-year olds. The attack rate was 15.1, 11.7 and 5.7% in the unimmunized, among those vaccinated at 6 months and at 9 months, respectively. The overall vaccine efficacy (VE) was 28% if vaccinated at 6 months and 66% if at 9 months. Second survey had 1702 children and adolescents. There were 59 cases of measles of which 49 were over 5 years of age, the mean age being 8.8 years. The VE was 66% for children up to 6 years and 48.4% for those aged 7–15. The data suggests that measles vaccine is better given at 9 months. The low VE in school age children could be improved by introducing a second dose of measles vaccine.

Clinical Notations on Bacteremic Cavitating Pneumococcal Pneumonia in Nonvaccinated Immunocompetent Children

Tue, 28 Jul 2009 22:49:31 PDT

We describe 10 children who developed lung cavitation during the treatment of bacteremic pneumococcal lobar pneumonia. Chest CT scan showed extensive consolidation with several small lucencies and air-filled cavities. Invasive procedures like aggressive pleural intervention were not needed and the children recovered attaining normal lung function on long-term follow-up.

The Economic Burden of Preterm/Very Low Birth Weight Care in Nigeria

Tongo, O. O., Orimadegun, A. E., Ajayi, S. O., Akinyinka, O. O. — Tue, 28 Jul 2009 22:49:31 PDT

The care of very low birth weight (VLBW) neonates may impose an enormous burden on professional resources and finances of caregivers. This study seeks to evaluate the immediate cost of care of VLBW babies in a developing economy. Twenty-four hospital case records VLBW babies who survived till discharge over a 1 year period at the University College Hospital, Ibadan, Nigeria were reviewed. Estimates of the out of pocket costs of managing these babies were calculated. The overall cost of hospital care ranged from US$211.1 to US$1573.9. The direct (median) and indirect (median) cost of care ranged from US$80 to US$1055 (US$247.3) and US$101.0 to US$1128.1 (US$257.2), respectively. These constituted 22.8% and 3966.3% (median 133.4%) of the combined family income. In conclusion, the cost of care of the VLBW deliveries in Nigeria is very high for the level of the economy and constitutes a major financial burden on the family.

A Novel Mutation in the SLC19A2 Gene in a Turkish Female with Thiamine-responsive Megaloblastic Anemia Syndrome

Tue, 28 Jul 2009 22:49:31 PDT

Reported here is a 2-year-old girl who was diagnosed to have thiamine-responsive megaloblastic anemia during evaluations for her bilateral neurosensorial deafness. Besides reporting a new mutation on the gene SLC19A2 for the first time in the literature, we highlight the recognition of this syndrome—when megaloblastic anemia and diabetes mellitus coexists—and the role of thiamine replacement for the treatment of both disorders.

A Succesful Treatment of Avian Influenza Infection in Turkey

Dogan, N., Ozkan, B., Boga, I., Kizilkaya, M., Altindag, H. — Tue, 28 Jul 2009 22:49:31 PDT

Avian influenza is a disease characterized with severe pneumonia caused by virus influenza A. Birds and poultry are vectors for spread of this disease. It is diagnosed by clinical evidence and reverse transcription-polymerase chain reaction. Here, we discuss the treatment procedures of a child diagnosed as avian influenza.

Mycoplasma pneumoniae--Associated Cerebral Infarction in a Child

Lee, C.-Y., Huang, Y.-Y., Huang, F.-L., Liu, F.-C., Chen, P.-Y. — Tue, 28 Jul 2009 22:49:31 PDT

The central nervous system's involvement is the most common reported extra-pulmonary manifestations of Mycoplasma pneumoniae infection, and stroke was one of the most special situations. We presented a 4-year-old child who presented with acute stroke on the third day of the onset of Mycoplasma respiratory tract infection. Brain magnetic resonance angiography demonstrated that occlusion of bilateral internal carotid arteries and vertebral arteries above the level of the first cervical vertebrate which is not been reported previously.

The Relationship between Glucagon-Like Peptide 2 and Feeding Intolerance in Preterm Infants

Ozer, E. A., Holst, J. J., Duman, N., Kumral, A., Ozkan, H. — Tue, 28 Jul 2009 22:49:31 PDT

Glucagon-like peptide 2 (GLP-2) is a hormone produced primarily in the distal intestine, stimulated by enteral nutrients, and playing diverse roles in the intestinal adaptation and growth. We aimed to investigate whether GLP-2 may play a role in the development of feeding intolerance which is a common problem in preterm newborns resulting from the intestinal immaturity. The study included 20 term and 28 preterm neonates. Of preterm babies, 13 showed feeding intolerance fulfilling at least one of the following criteria: abdominal distension, increased gastric residual volume and presence of bile in the gastric aspirate. The plasma GLP-2 levels measured prior to enteral feeding (fasting level) and at 60 min after the beginning of the feeding (post-pradial level) were correlated with of clinical parameters. There was no statistical difference between GLP-2 levels of overall preterm babies and those of term newborns. However, preterm neonates with feeding intolerance showed significantly lower levels of GLP-2 and increased duration to achieve full enteral feeding and hospitalization. It is suggested that GLP-2 plays a significant role in the regulation of feeding in newborns and that preterm babies with low levels of GLP-2 carry a risk for development of feeding intolerance. It may, therefore, be of relevance to investigate the therapeutic and prophylactic effects of GLP-2 administration in the preterm babies.

Medical Microbiology for the New Curriculum: A Case-Based Approach, Carey R. B., Schuster M. and McGowan K. L.

Ebrahim, G. J. — Tue, 28 Jul 2009 22:49:31 PDT

Medical Statistics from Scratch, 2nd Edition * David Bowers

Ebrahim, G. J. — Tue, 28 Jul 2009 22:49:31 PDT

Evidence-based Emergency Care: Diagnostic Testing and Clinical Decision Rules. Pines J. M. and Everett W. W.

Ebrahim, G. J. — Tue, 28 Jul 2009 22:49:31 PDT

In this Issue June 2009

Thu, 04 Jun 2009 00:47:20 PDT

Neglected Tropical Diseases

Ebrahim, G. J. — Thu, 04 Jun 2009 00:47:20 PDT

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. — Thu, 04 Jun 2009 00:47:20 PDT

Home-based Treatment of Childhood Neurotuberculosis

Schoeman, J., Malan, G., van Toorn, R., Springer, P., Parker, F., Booysen, J. — Thu, 04 Jun 2009 00:47:20 PDT

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

Thu, 04 Jun 2009 00:47:20 PDT

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. — Thu, 04 Jun 2009 00:47:20 PDT

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. — Thu, 04 Jun 2009 00:47:20 PDT

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. — Thu, 04 Jun 2009 00:47:20 PDT

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. — Thu, 04 Jun 2009 00:47:21 PDT

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

Thu, 04 Jun 2009 00:47:21 PDT

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. — Thu, 04 Jun 2009 00:47:21 PDT

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. — Thu, 04 Jun 2009 00:47:21 PDT

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

Alves da Cunha, A. J. L., Alves Galvao, M. G., Santos, M. — Thu, 04 Jun 2009 00:47:21 PDT

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. — Thu, 04 Jun 2009 00:47:21 PDT

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

Thu, 04 Jun 2009 00:47:21 PDT

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. — Thu, 04 Jun 2009 00:47:21 PDT

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

Ebrahim, G. J. — Thu, 04 Jun 2009 00:47:21 PDT