Journal of Tropical Pediatrics - current issue

In this Issue August 2008

2008-07-25

Brazil's Progress in Achieving the Millennium Development Goals

Rondo, P. H. C — 2008-07-25

Evidence Behind the WHO Guidelines: Hospital Care for Children: What is the Most Appropriate Anti-microbial Treatment for Tuberculous Meningitis?

Woodfield, J., Argent, A. — 2008-07-25

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

Le, C. T., Vu, T. T., Luu, M. C., Do, T. N., Dinh, T.-H., Kamb, M. L. — 2008-07-25

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

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

Van Biljon, G. — 2008-07-25

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

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

2008-07-25

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

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

2008-07-25

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

Serum Retinol Concentrations in Hospitalized Severe Protein-energy Malnourished Children

2008-07-25

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

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

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

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

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

2008-07-25

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

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

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

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

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

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

Shah, I. — 2008-07-25

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

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

Guglani, L., Lodha, R. — 2008-07-25

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

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

Thapa, S. — 2008-07-25

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

Biliary Cirrhosis in a Child with Inherited Interleukin-12 Deficiency

2008-07-25

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

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

Tikare, N. V., Mantur, B. G., Bidari, L. H. — 2008-07-25

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

Guillain-Barre Syndrome Associated with Legionnella Infection

2008-07-25

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

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

Ahn, Y. — 2008-07-25

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

Wang, A., Fan, S., Shen, X. — 2008-07-25

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

Adebayo, K. J., Madu, E. F., Adebayo-Kay, V. C. — 2008-07-25

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

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

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

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

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

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

Ebrahim, G. J. — 2008-07-25

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

Ebrahim, G. J. — 2008-07-25