Iranian Journal of Pediatrics
Year:2007 | Volume:17 | Issue:2|Papers Count:16

Objective: The purpose of this study was to determine the risk factors which predispose to the development of high grade IVH (grade 3 and 4) in very low birth weight infants.Material & Methods: In a retrospective case control clinical study files of all premature infants with birth weights less than 1500 grams admitted between April 2004 and Oct 2005 to the neonatal intensive care unit of Akbar Abadi hospital in Tehran were reviewed. 39 infants with IVH grade 3 and 4 were identified. A control group of 82 VLBW infants matched for gestational age and birth weight were selected. Prenatal data, delivery characteristics, neonatal course data and reports of cranial ultrasonography were carefully collected for both groups. Those variables that achieved significance (p<0.05) in univariate analysis entered to multivariate logistic regression analysis. Findings: A total of 325 VLBW infants were evaluated. Mortality rate was 21.5%. Of the remaining the incidence of high grade IVH was 15.5%. Multivariate logistic analysis showed that following factors are associated with greater risk of high grade IVH occurrence: Low gestational age (OR: 3.72; 95% CI: 1.65-8.38), low birth weight (OR: 3.42; 95% CI: 1.65-8.38), low Apgar score at 5 minute (OR:1.58; 95% CI:1.59-6.32), hyaline membrane disease (HMD, OR: 3.16; 95% CI: 1.42-7.45) and maternal tocolytic therapy with magnesium sulfate (OR: 4.40; 95% CI: 1.10-24.5).Conclusion: Our results showed that maternal tocolytic therapy, mechanical ventilation, low gestational age, low birth weight, apnea, and low 5 minute Apgar score increased the risk of major IVH.

Objective: This study was performed to determine the effect of low doses (25 mg/Kg) vs. moderate doses (50 mg/Kg) of clofibrate in treatment of non-hemolytic hyperbilirubinemia in healthy term neonates.Material & Methods: A clinical randomized controlled trial was performed in three groups of healthy term neonates. One group was treated with a single low dose of clofibrate (25 mg/Kg) while another group received a single moderate dose (50mg/kg) both orally plus phototherapy; the results were compared with those of a control group that received only phototherapy.Findings: The mean total serum bilirubin (TSB) levels of 12th and 24th hours were significantly lower in the two clofibrate-treated groups as compared with the control group (P=0.002 and P=0.003, respectively). There was no statistically significant difference between the mean of TSB levels in the two clofibrate-treated groups. Treatment with clofibrate also resulted in a shorter duration of jaundice and a decreased use of phototherapy (P=0.01). No side effects were observed.Conclusion: The present study demonstrated that there was no significant difference between a low (25mg/Kg) and moderate (50mg/Kg) doses of clofibrate in reducing TSB levels and also decreased need of phototherapy in healthy breastfed term newborns with marked hyperbilirubinemia (TSB>16 mg/dL).

Objective: Pacifier as a non-nutritive and comforting object instead of mother’s breast is used widespread in civilised societies. The most possible risks of this habit are increased incidence of oral thrush; dental deformities, recurrent acute otitis media and dental caries, but there are still some reports on its beneficial effects. We carried out this study to compare the rate of exclusive breast-feeding during the first six months of life between the pacifier sucker and non-sucker infants.Material & Methods: The study was designed as a case-control study on infants who came to outpatient clinic in a primary health care center, affiliated to Babol University of medical sciences during 2003-4. Inclusion criteria were: infants aged 6-12 months, born at term via normal vaginal delivery with a normal birth weight. We divided them into pacifier suckers as case group (n=100) and non-suckers as control group (n=120) by frequency matching. Pacifier suckers were given by their mothers a pacifier to suck as a soothing object before 2 month of life. Outcome characteristics including exclusive breast-feeding, rate of early weaning and substitution of mother milk with a non-mother milk in infants who were pacifier suckers were compared with those of the infants who were not used to suck a pacifier. A p-value less than 0.05 was considered being significant. Findings: Success rate of exclusive breast-feeding in pacifier suckers was 30% (n=30), in nonsuckers 64% (n=77), (CI: 2.3-7.3; OR=1.24; P<0.001). The rate of early cessation of breastfeeding among pacifier suckers was 16% and non-suckers 0.01% (p<0.001).Conclusion: To promote successful breast-feeding and to reduce early cessation of breastfeeding, the use of pacifiers should be avoided or restricted.

Objective: In the few cases of acute childhood diarrhea that require antimicrobial therapy, the correct choice of the drug depends on detailed previous knowledge of local strains and pattern of antimicrobial resistance. Shigellosis is one of the most important examples in this group of intestinal infections. In order to establish such parameters in our city this study was carried out to determine the prevalence and pattern of antimicrobial resistance of Shigella species among patients with acute diarrhea admitted to the Amirkola children's hospital, North of Iran.Material & Methods: The study included all patients with acute diarrhea, 6 months to 12 years of age, who were admitted to the Amirkola children's hospital during March 2001 to March 2004. Incidence, phenotypic characteristics and antimicrobial resistance patterns of Shigella strains, isolated from hospitalized children with acute diarrhea, were studied.Findings: We received 260 positive cultures for Shigella out of 1850 stool samples during 3 years (14.05%). Shigella specimens presented a high resistance rate to trimethoprim-sulfamethoxazole (73.84%) and ampicillin (73.84%), and low resistance rate to Ciprofluxacine (2.69%) and cefotaxim (2.69%). S. flexneri (70%) was most frequently isolated, followed by S. Sonnei (30 %). No cases of S. boydii and S. dysenteriae were found. Conclusion: Our results provide data on antimicrobial resistance to choose a proper antibiotic for Shigellosis in our community. According to our findings cefotaxime for pediatric patients and quinolone derivatives for adult patients are the proper drug choices. Systematic monitoring is needed to identify changes in prevalence and antimicrobial resistance pattern.

Objective: Acute lower respiratory infections lead to high morbidity and mortality rates in children from developing countries. The aim of this study was to look into the extent of respiratory syncytial virus infections in children with special reference to the role of specific immunoglobulins in protection against infection as well as the association with bacterial pathogens.Material & Methods: Nasopharyngeal aspirates were tested for respiratory syncytial virus antigen by enzyme immunoassay and IgA antibodies by single radio immunodiffusion test. Viral culture on HEP-2 cell system and bacterial culture was done. Sera were tested for detection of antibodies to respiratory syncytial virus by indirect fluorescent antibody test. Antigens of streptococcus pneumoniae and haemophilus influenzae were detected in serum and urine by latex agglutination assay.Findings: Incidence rates of acute lower respiratory infections were highest in infants; bronchiolitis and bronchopneumonia being the main contributors. Respiratory syncytial virus infection was found in 27.08% of the cases.Conclusion: Secretory IgA antibodies level was found to be a good indicator of respiratory syncytial virus infection as seen by the significantly higher levels in cases as compared to both non respiratory syncytial virus cases and controls.

Objective: Urolithiasis in children although occurring less often than adults, causes considerable morbidity. The main aim of this study is to evaluate clinical features and risk factors of pediatric urolithiasis.Material & Methods: All children with documented urolithiasis who were referred to department of pediatric nephrology between 1999 and 2005, were evaluated from the point of demographic features, family history, clinical symptoms, imaging results and laboratory findings.Findings: We investigated 184 patients (100 females and 84 males) with urolithiasis between 2 months and 14 years of age (mean age 3.66±3.49 years). The stones' diameter was 3-27 mm (mean 8.20±5.36). In 85.8% of cases the stone was located only in kidneys and in 3.3% only in bladder. The most common causes of presentation were urinary tract infection (UTI), restlessness and gross hematuria. Positive family history was detected in 41%, UTI in 40.8%, anatomic abnormality in 13% and sterile pyuria in 18.5% of patients. Metabolic evaluation, which was carried out in 162 patients, revealed that 104 (64%) of them had a metabolic risk factor including normocalcemic hypercalciuria (42%), Hyperuricosuria (10.5%), Cystinuria (7.4%), and Hyperoxaluria (4.3%).Conclusion: All children with urolithiasis should be completely evaluated, as most of them have an anatomic, infectious or metabolic risk factor.

Objective: Although headache is a common complaint among patients with lupus, no universally accepted explanation was available until the International Headaches Society adopted Lupus headache as a Nomenclature in its classification recently. Few studies indicate that lupus patients with positive anti-nuclear antibody (ANA) and positive antiphospholipid antibodies (aPL) experience more frequent headaches. The aim of this study was to determine the correlation between headache frequencies and ANA, anti-double strand DNA (anti-ds-DNA) and aPL positivity.Material & Methods: In this prospective multicenter study were enrolled 55 children, 45 girls and 10 boys (F/M ratio:4.5), aged 3-16 years (mean 11.5 years), with neuropsychiatric lupus complaining of headache, that where followed-up for 5 years.. Whether lupus headache is a sign of progressive nature of the disease and how it should be treated is not clear yet. Those with active disease, hypertension, or tension headache were not included in this study.Findings: We studied 55 children with definite lupus. Twenty three (43%) of our patients developed new or significantly worse, persistent headaches that sometimes were similar to migraine in the early course of their disease. However their headaches were not accompanied with disease flare up and the headaches were not found to be related to hypertension or use of other medications either. Accordingly, we came to a diagnosis of lupus headache for these patients. Among them 19/55 cases (35%) had a positive aPL and 53/55 cases (96%) had a positive ANA.Conclusion: Lupus headaches are most likely multifactorial, and probably only a small proportion of them truly represent active lupus. The above data highlights probable correlation between aPL, ANA, an anti-ds-DNA and lupus headache. However, more research is required to find better treatments and to establish a definitive correlation among them.

Objective: Wolfram syndrome (WFS) is a rare and complex genetic disorder referred to as DIDMOAD (diabetes insipidus, diabetes mellitus, optic atrophy and deafness).Material & Methods: All insulin dependent diabetic patients presented over a period of 10 years, who had optic atrophy or a positive family history of WFS, were enrolled in the study. Criteria for the diagnosis of WFS were the presence of insulin dependent diabetes mellitus (IDDM) along with optic atrophy unexplained by any other disease and/or some other abnormalities associated with WFS.Findings: WFS has been diagnosed in sixteen patients, 9 males and 7 females aged 5.5 to 22yr (median age of 13.4 yr). Nine patients (more than half) came from consanguineous marriages. The earliest manifestation of WFS was IDDM (at a median age of 5.4yrs). All patients developed non-autoimmune IDDM before the age of 8 years old. Only two cases were ketoacidotic. Common diabetic complications of proliferative retinopathy, glomerulosclerosis and neuropathy were remarkably absent in our patients even with long-lasting diabetes mellitus. Antidiuretic hormone (ADH)-responsive diabetes insipidus was confirmed by water deprivation test in 8 patients (50%). The incidence of diabetes insipidus in our patients was lower compared to other studies. Growth retardation, as short stature and a weight below the 5th percentile for age and gender, was found in 13 (81%) and 5 (31%) patients respectively.Conclusion: Early diagnosis and proper treatment aimed at relieving the symptoms and preventing the future complications are of paramount value and importance.

Objective: Congenital brain tumors are very rare. We review these tumors in patients younger than 2 months diagnosed in our Department.Material & Methods: Seven congenital brain tumors were diagnosed during five years. Clinical and radiological findings and prognosis are analyzed. Findings: The study included 5 female and two male infants. Two cases were diagnosed antenatally by means of ultrasonography. All patients presented with intracranial hypertension. The tumor was non-homogenous with cystic and solid components in all neuroimaging, except for the case with choroid plexus papilloma. Hydrocephalus was evident in all of them. Most findings were infra-tentorial lesions. There were three teratomas, one primitive neuro-ectodermal tumor, one ependymoblastoma and one choroid plexus papilloma. Six patients were operated on, with one intra-operative death. Two passed away postoperatively with aspiration pneumonia. One patient died due to complications of chemotherapy and another one due to tumor recurrence one year after surgery. Only the patient with choroid plexus papilloma is alive after 2 years.Conclusion: Today, the availability of noninvasive imaging procedures such as computerized tomography scan and magnetic resonance imaging has improved the diagnosis of congenital brain tumors. Inspite of development in prenatal diagnosis, appropriate pre and post operative management, the mortality associated with these tumors still remains high. The final prognosis in these patients is still discouraging despite early surgery and operative and anesthetic improvements. Choroid plexus papilloma accompanies the best prognosis, whereas teratoma and primitive neuroectodermal tumors have the worst prognosis.

Objective: Children, due to their great parental dependency, are amongst the cases that should receive preoperatively medication to reduce their fear and anxiety. The objective of this study was to compare the efficacy of rectal diazepam and midazolam for this purpose in pediatric patients scheduled for elective surgery.Material & Methods: 60 children, aged between 1 and 6 years, scheduled for elective surgery, were included in this double blind, randomized controlled trial. Patients were randomly allocated into three equal groups. Patients in midazolam and diazepam groups received the drugs 0.3 mg/kg and 0.5 mg/kg respectively (in normal saline at a final volume of 2.5 ml) and placebo group received only 2.5 ml of normal saline 20 min before arriving operation room through rectal applicator. Sedation and anxiety scores at the time of separation from their parents before arriving operating room were recorded for all groups.Findings: There was a significant reduction in anxiety level in midazolam and diazepam groups as compared to placebo group (P<0.001). Sedation rate was 65% for midazolam, 60% for diazepam, and 15% for placebo group (P=0.007). There were no significant changes in hemodynamic parameters in the three study groups.Conclusion: With respect to effective anxiolytic and sedative activity, rectal midazolam (0.3 mg/Kg) and diazepam (0.5 mg/Kg) can be used as an anesthetic premedicant for children at preoperative period and their use is safe regarding hemodynamic variables and related side-effects.

Although the exact incidence of flatfoot in children is unknown, it is very common and is, in fact, one of the most common conditions seen in pediatric orthopedic practices. All children are born with flat feet, and more than 30% of neonates have a calcaneovalgus deformity of both feet. This condition is not painful and generally resolves without treatment; very rarely is corrective casting necessary. For the pediatrician evaluating flatfoot, it is important to differentiate between flexible and nonflexible (rigid) flatfoot, and to classify the condition as painful or painless. Most children who present to a pediatrician for evaluation of flatfoot will have a flexible flatfoot that does not require treatment. On the other hand, other conditions that do require treatment, such as congenital vertical talus, tarsal coalition, and skew-foot often present as nonflexible flatfoot. Surgical management is rarely indicated for a true flexible flatfoot. The longitudinal arch of the foot is not present at birth and slowly develops during childhood, usually by about age five or six. It is a process that occurs throughout growth and is not affected by the presence or absence of external arch support. Sometimes the arch takes even longer to take shape, but this still usually does not cause any problems. A variety of tendon transfers and reconstructive procedures have been advocated, but none has proved uniformly successful. Nor have any of the various types of supports ever been shown to change the arch architecture. It should be borne in mind that painful flexible flat foot requires treatment, often with several types of shoe inserts and supports and as a last resort by operative procedures. Although parents are often concerned about pediatric flatfoot, the child is usually found to be asymptomatic, and no treatment is indicated. In most instances, the best treatment is simply taking enough time to convince the family that no treatment is necessary.

Patient can present with normal acid-base balance, a single disorder, or multiple combinations of two or three disorders. The pH can be estimated in a patient with a single disturbance using the formulas which describe predicted compensation. Blood gas studies are required for diagnosis and pH estimation when more than one disturbance may be present or when the information is insufficient to allow diagnosis of a single disturbance with confidence (e.g., the patient is unable to give an adequate history). The diagnostic approach to acid-base disorders utilizes information from the history and physical examination, venous blood laboratory studies, and arterial blood gas studies in a stepwise fashion.

Objective: Congenital chloride diarrhea (CCD) is a rare autosomal recessive disorder of intestinal chloride absorption. Pathognomonic features consist of watery diarrhea, failure to thrive, dehydration and hypokalemic hypochloremic metabolic alkalosis.Case Presentation: This is the report on an 8-month old Iranian girl with severe and complicated course of CCD and poor response to current treatment. In addition, she had a renal tubular defect in uric acid handling, resulted in persistent hyperuricosuria and hypouricemia.Conclusion: Specific characteristics of CCD in our population need additional investigation. But, it is recommended to consider CCD in any patient with severe resistant diarrhea to prevent its irreversible and long term organ damage.

Objectives: Attention deficit hyperactivity disorder (ADMD) is a common neuropsychiatric syndrome of childhood and adolescence in which stimulant medications are used to treat it. The evidence clearly indicates a temporary retardation in the rate of growth in weight and stature, with no effect on adult height.Case Presentation: In this article we present a case with ADHD on stimulant therapy that had a catch up growth after the discontinuation of therapy, then review the literature on possible growth, and suppressing effects of these medications in the long term treatment.Conclusion: Most of the previous studies suggest that the stimulant-associated height deficits in ADHD are temporary and early manifestation of ADHD itself and not complication of therapy, and the small risk of lost centimeters may be a price worth paying for many children to gain improved learning and social function.