Iranian Journal of Pediatrics
Volume:28 Issue: 1, Feb 2018

Context: Children’s health is one of the priorities in most societies. Nevertheless, the highest prevalence rate of malnutrition occurs among under five-year-old children worldwide.
The aim of this study was to estimate the rate of malnutrition in Iranian children through a systematic review and meta-analysis. Also we tried to identify the most prevalent factors causing malnutrition.
Data Sources: The required data were collected by searching the keywords of nutrition, malnutrition, under-nutrition, prevalence, epidemiology, etiology, occurrence and Iran in PubMed, Google Scholar, Scopus, Index Copernicus, DOAJ, EBSCO-CINAHL, SID, Magiran and Iranmedex.
Twenty studies were selected for the final analysis stage, dating from 1999 to 2014. Number of children investigated for wasting, stunting and underweight was 53612, 54312 and 55012 respectively. The results showed that the prevalence of each type of malnutrition, in terms of wasting, stunting and underweight were 7.8% (95% CI: 4.8% - 12.6%), 12.4% (95% CI: 8.3% - 18.5%) and 10.5% (95% CI: 7.1% - 15.4%), respectively. Parents’ educational level, in particular mothers’, gender, birth weight, the place of residence, and mother’s occupation were mentioned as important factors causing malnutrition.
The rate of malnutrition in Iran’s under five-year-old children is lower than the average of that in world and the Eastern Mediterranean region. Breastfeeding, the proper use of complementary feeding, and the principled spacing between births and improving the quality of maternal care have important role in prevention of malnutrition.

The neonatal mortality rate (NMR) is considered amongst the most important socioeconomic and health indicators of a community development. Globally, it has been reported that the daily mortality rate during the neonatal period is much higher (30-fold) than the post-neonatal period. In the Eastern Mediterranean Region, about 40% of the under-5 mortality occurs in the neonatal period. This study aimed to explore the association between the socio-economic, demographic and perinatal care related factors, and the neonatal mortality in the Eastern Mediterranean Region.
The secondary data for the 1990 to 2013 on neonatal mortality rates, socio-demographic, socio-economic and health factors were extracted from official websites, including united nations children’s fund (UNICEF), world health organization (WHO), and united nations educational, scientific and cultural organization (UNESCO). Data were collected using the following keywords: ‘neonatal mortality’, ‘perinatal deaths’, ‘child health, education’, ‘expenditure on health’, ‘safe water’, ‘sanitation’ and ‘health indicators’. We used secondary data analysis to explore the relationship between the possible explanatory variables and neonatal mortality using correlation coefficient analysis.
There was a noticeable decline in neonatal mortality rates (NMR) among the Eastern Mediterranean countries from 1990 to 2013. The neonatal mortality rate had a negative and significant association with literacy status of both sexes, annual growth rates, antenatal care coverage, birth attendance by skilled health personnel, Gross National Income (GNI), total health expenditure per capita, safe drinking water and adequate sanitation facilities. However, the neonatal mortality rate had significant and positive relationships with maternal mortality ratio, total fertility rate, population size, total births and low birth weight.
Despite the fall in the neonatal mortality rate, it remains high in the Eastern Mediterranean countries. Socioeconomic and other related factors appear to play a major role in determining neonatal mortality and there is an inverse relationship between socioeconomic status and the neonatal mortality rate. Neonatal health in Eastern Mediterranean countries needs a more effective and innovative approach to sustain the rapid progress in the overall reduction of child mortality.

Allgrove syndrome (triple A syndrome) is a rare autosomal recessive condition with adrenal insufficiency, achalasia and alacrima. This syndrome is caused by mutations in AAAS gene. In this article we introduce six patients of Allgrove syndrome, in whom genetic analysis of the triple A gene was used to identify gene mutation, DNA was extracted from blood samples. Exon 1 to 16 and some introns of the AAAS gene were amplified by polymerase chain reaction (PCR). PCR products were evaluated by complete nucleotide sequence analysis. After sequencing, alignment and analysis were carried out. In one patient we identified a IVS14 1 G > A mutation, which is previously reported. In 4 patients, we couldn’t detect any mutation. We determined a new mutation (c.446 87del T) in the AAAS gene in a patient that this deletion causes splicing defect in intron 5 which results in a premature termination and non-functional ALADIN protein. In conclusion, since molecular genetic testing results may influence the therapy and prognosis of Allgrove patients, this paper contributes to understanding of the molecular basis of Allgrove syndrome in Iranian patients.

Despite scientific advances on pain measurement and intervention, pain management for infants has remained a challenge for health teams. This is because infants are not able to talk and defend themselves when they are in pain. Prevention of pain is important, not only because it is an ethical expectation, but also because repeated painful exposures can have harmful consequences. The aim of this study was to explore factors influencing neonatal pain management from the perspectives of nurses and physicians in a neonatal intensive care unit (NICU).
A qualitative content analysis study was carried out. The participants were the nurses and physicians working in the NICU of Alavi medical training center in Ardabil, Iran. Twenty-five nurses took part in focus group discussions and five physicians attended private interviews. Four focus group discussions and five interviews were carried out until data saturation was ensured. Data analysis was performed using conventional content analysis. All the participants were provided with information about the purpose and the nature of the study, and provided informed consent.
Data analyses indicated two effective themes about barriers of implementation of infant pain management, namely “Individual Factors” and “Organizational Factors”. The first theme consisted of the categories “knowledge of the personnel” and “commitment of the personnel”. The second theme included three categories namely “pain control policy”, “work environment condition” and “management issues”.
Our findings indicated that lack of educational courses, absence of an infant pain management policy, and management issues were the main obstacles in the way of implementation of infant pain management by nurses and physicians at the NICU. Therefore, strategies are required to reduce or remove these barriers.

Systemic lupus erythematosus (SLE) is an autoimmune disorder caused by auto-antibodies against self-antigens. Interleukin 37 (IL-37) is a member of IL-1family, and it is a key cytokine in regulating inflammation. We aimed to detect the level of IL-37 in SLE patients and to correlate it with disease activity.
A cross-sectional study included fifty children with SLE following up at the pediatric rheumatology clinic in specialized children’s hospital, Cairo University and chosen randomly; aged up to 16 years and thirty, apparently healthy children with matched age and gender, were assigned as the control group. In all cases and controls, full history was taken, full physical examination performed and laboratory investigations including level of IL-37 were done.
Levels of IL-37 in the 50 cases with SLE were higher than in the 30 controls with statistically significant difference (P = 0.028). Level of IL-37 was higher in active cases than in inactive cases but without statistically significant difference (P = 0.58). Level of IL-37 level in cases with mild activity was lower than in cases with moderate or severe activity but without statistically significant difference (P = 0.23).
level of IL-37 was higher in our SLE patients than in controls and it is higher in active cases than inactive cases. IL-37 is correlated positively with duration between onset and diagnosis of disease and SLEDAI-2K activity score.

Treatment of steroid-resistant nephrotic syndrome (SRNS) remains a huge challenge in pediatric patients. Immunosuppressive agents including cyclosporine A (CsA), tacrolimus (TAC) and mycophenolate mofetil (MMF) are recommended for the management of children with SRNS. The aim of this study was to compare the efficacy of CsA, TAC and MMF in children with SRNS and provide guidance for clinical practice.
This is a retrospective analysis of the records of 70 children with SRNS recruited from a children hospital over a period of seven years. They were treated with CsA, TAC and MMF as initial immunosuppressive therapy in addition to steroids. Complete or partial remission was considered a good response.
Five (41.7%) of 12 children who were on CsA therapy achieved remission at 6 months and 5 (41.7%) at 12 months. Nine (19.1%) of 47 patients treated with TAC achieved remission at 6 months, 20 (42.6%) at 12 months and 6 (12.8%) within or over 24 months. The remission achieved at 6 months and 12 months was 4 (36.4%) and 2 (18.2%) respectively in MMF group. The relapse rates in children who had achieved remission were 30.0%, 45.7% and 50.0% in CsA, TAC and MMF group respectively.
Based on similar baseline characteristics, CsA and TAC as initial therapy for SRNS have a better remission and relapse rates whereas MMF shows a rapid remission effect.

Group B streptococcus (GBS) is a common bacterial pathogen causing nenatal infections. This study aimed to determine the serotypes and genotypes of GBS isolated from neonates and to ascertain the association between the type and the antibiotic resistance of GBS strains.
A total of 26 group B streptococcus (GBS) strains were isolated from neonates in our hospital between January, 2008 and August, 2014. Species identification was conducted with a VITEK system (BioMerieux) and conventional biochemical tests. A latex agglutination test was used to determine the serotypes of the GBS strains. The antibiotic resistance of GBS strains was then evaluated using a Kirby-Bauer disk susceptibility test and an Epsilometer test (E-test). Multilocus sequence typing (MLST) was used to determine the sequence types (STs) of all 26 GBS strains.
and Serotype III and sequence type ST17 were the major GBS strain serotype and genotype causing invasive infections in neonates, respectively. These GBS strains exhibited a high rate of resistance to tetracycline, erythromycin, and clindamycin, confirming that penicillin should remain the first-line antibiotic for the treatment of GBS infection. In addition, we identified an association between serotype III and genotype ST17 with septicaemia, purulent meningitis and pneumonia in GBS infections in neonates.

The majority of infants and children with cow’s milk allergy will grow out of their allergy after a few years. The aim of this study was to identify the natural course of cow’s milk allergy in infants and children during a follow-up of 18 months and also the predictive factors for its outgrowing.
This prospective cross-sectional study included infants and children with IgE- mediated cow’s milk allergy. Demographic data, clinical manifestations and probable predictive factors were recorded. Skin prick tests were done with commercial extracts of cow’s milk, egg, fish, nuts and wheat on arrival. These infants and children were followed for 18 months and resolution was established by successful ingestion of cow’s milk. The collected data were analyzed using SPSS version 22.0. Descriptive statistics, student’s t-test or Mann-Whitney U‑test and Chi- square test were used; a P Forty-nine infants and children (33 boys and 16 girls) with IgE- mediated cow’s milk allergy presentation ranged in age from 3.5 to 48 months with a mean of 17.5 ± 11.7 months enrolled in this study. Skin was the most common site of involvement, followed by gastrointestinal system and respiratory tract. Twenty-three (46%) infants and children developed tolerance to cow's milk during a follow-up of 18 months. There was a significant relationship between parental allergy and atopic dermatitis with the chance of tolerance of cow’s milk.
Our findings showed that about one half of the infants and children with IgE-mediated cow’s milk allergy grew out of it over 18 months of follow-up (mean age 2 years). The follow-up of patients with cow’s milk allergy is important in appropriate timing of re-introduction of cow’s milk to the diet; atopic dermatitis and parental allergy can predict this outcome.

Vesicoureteral reflux is a common problem in young children. The increased risk of urinary tract infection in these patients is the main cause of renal parenchymal damage. The main managements are prophylactic antibiotics and different surgical interventions. In this study, we evaluate the results of surgical intervention in VUR patients.
This is a cross sectional retrospective study of all our patients with primary reflux who have been managed surgically between 2002 and 2016.
Of 420 patients with VUR, 207 were managed surgically. Eighteen (8.7%) patients with bilateral reflux before intervention and persistent reflux (grade II or III) after intervention, progressed to end stage renal disease (ESRD). There was no significant relation between the grade of reflux, the serum level of the creatinine or frequency of positive urine culture, and progression to ESRD, while a significant relation existed between grade of post-operative VUR and post-operative positive urine culture with ESRD (P = 0.000).
It seems that surgery cannot prevent renal damage in some cases of VUR. Close follow up after surgical intervention particularly in those with persistent reflux (of any grade) for prevention of renal damage is recommended.

To analyze the clinical and laboratory data of neonates diagnosed with Zellweger syndrome and to estimate the incidence of the syndrome.
The databases of four institutions that admitted newborns diagnosed with Zellweger syndrome to intensive care units between January 2013 and December 2016 were examined.
A total of 105,887 live babies were born in the four centers during the study period. Seven were diagnosed with Zellweger syndrome; the incidence was thus 1/15,126. Birth weights were 2,200 - 3,300 g. Six cases were born to consanguineous parents. Dysmorphic findings, respiratory failure, and hypotonia were evident in all patients. Hepatomegaly was apparent in four cases, congenital cardiac defects in four, characteristic cerebral magnetic resonance imaging findings in four, renal cysts in five, hepatic cysts in three, and splenomegaly in one. PEX1 mutations were identified in three patients, and one mutation was novel.
The incidences of Zellweger syndrome and cardiac disease were higher than reported previously, being (to the best of our knowledge) among the highest reported worldwide. This is the first time that such incidences have been calculated in Turkey. The syndrome is more common in regions where consanguineous marriage rates are higher.

Cesarean section deliveries at 37 weeks gestational period are incredibly high in Turkey. In order to determine the antenatal characteristics, respiratory morbidity and mortality cases, we have conducted a retrospective cohort study on this population.
514 infants encountering clinical signs of respiratory distress within 24 hours were enrolled. To compare the differences, infants were categorized into three groups as: late-preterm, early-term and full-term infants. Demographic and clinical data were explored.
Early-term infants represented higher RDS rates (13.1%; P = 0.033 for early-term and full-term infants; P = 0.338 for early-term and late-preterm infants), meconium aspiration syndrome (P Early-term neonates encounter respiratory problems, morbidities and significant respiratory distress syndrome rates similar to the rates of late preterm neonates and seemed to have a tendency to hypoxic deliveries with low Apgar scores. Considering the increasing delivery rate at this period, real estimates should be investigated in large, multi-centered prospective studies in terms of both short and long term outcomes.

Stimulants are not very effective on attention deficit hyperactivity disorder (ADHD) children under 6 years old. The most common medication that is used in this range of age is Risperidone. Evaluating the safety and efficacy of Aripiprazole versus Risperidone for treating children under 6 years suffering from ADHD was the aim of this study.
During this double-blind clinical trial, 34 children aged 3 - 6 years who were diagnosed with ADHD, received treatments with Aripiprazole or Risperidone randomly for 12 weeks. Follow-up measures comprised, CGAS, the ADHD-RS, CPRS and side effect checklist.
The findings revealed that 20 patients in Risperidone group (including 13 boys and 7 girls) and 20 patients in Aripiprazole group (including 13 boys and 7 girls) had at least one follow-up examination. After 12 weeks of the study, both medications showed distinct improvements in ADHD RS (P The findings revealed that both Risperidone and Aripiprazole are effective in treating ADHD children under 6 years old and there was no significant difference between the two drugs. Children can tolerate them well. Aripiprazole effect on children showed itself earlier compared to Risperidone.

Cerebral Palsy (CP) constitutes a heterogeneous group of developmental disorders resulting from damage to the brain which affects motor system. Cerebrolysin, as a neurotrophic peptide has been used for improving symptoms of patients suffering from neurodegenerative disorders.
Due to the presence of limited information about the usefulness of Cerebrolysin in CP, this study was performed for the evaluation of Cerebrolysin in the management of spasticity in children with CP.
26 Spastic CP patients aged between 2 and 6 years entered this study. At the first visit, Modified Ashworth scale for assessment of spasticity was used. Then Cerebrolysin was administered at a dose of 0.1 cc/kg intramuscularly (IM) for 3 months. In the first month, the medication was injected 5 times per week. In the second month of therapy, injections were performed as follows: 4 injections in the first week, 3 injections in the second week, 2 injections in the third week and a single one in the fourth week. In the third month of therapy, Cerebrolysin was continued as weekly injections. The spasticity of the patients was evaluated at the end of the first and third month of therapy.
Modified Ashworth score at baseline was 20.62 ± 9.65 which reached 15.19 ± 7.30 after 1 month of treatment. This figure was 14.81 ± 3.77 at month 3. Total decline in Modified Ashworth Scale was 5.42 ± 5.33 at the first month and 5.81 ± 2.74 at the third month in comparison to baseline. The difference between Modified Ashworth Scale at baseline and 1 month after therapy was significant (P = 0.000) but there was no significant difference between first month and third month of therapy. (P = 0.755). Also analysis indicates that there was an association between absolute reduction of Modified Ashworth score and the age at beginning of treatment (P = 0.037).
Using Cerebrolysin as a neurotrophic peptide may improve spasticity of children with CP and should be considered as a possible useful treatment in CP cases.

Influenza viruses and human metapneumovirus (HMPV) are among the common causes of acute respiratory tract infections in children worldwide.
The aim of this study was to determine the frequency of HMPV and influenza viruses in children less than 5 years old hospitalized with severe acute respiratory infections (SARI) during 2013 - 2016.
For this study, 770 nasopharyngeal swabs from children with SARIs were tested for detection of influenza viruses by One step real time RT-PCR method in National Influenza Center, Tehran, Iran. Influenza virus negative samples were tested for HMPV using One step RT-PCR kit.
Influenza viruses were detected in 263 of 770 specimens (34%) with influenza A/H1N1 being the prominent subtype. All 507 influenza negative samples were tested for HMPV. HMPV was detected in 7 (1.4%) cases.
In this research two different viruses were detected in 35% of cases, the remaining 65% of the patients might have been infected by other viruses or bacteria. Active surveillance studies with large sample size in different geographical regions and population based studies besides hospitalized patients with SARIs are needed to obtain more data about respiratory infections epidemiology.

Intussusception is a major cause of acute abdomen in childhood. Prompt diagnosis and appropriate treatment of intussusception is of prime importance for preventing morbidity and mortality. In this study, we aimed to investigate the effectivity of ultrasound (USG)-guided hydrostatic reduction of intussusception with saline and to investigate the factors affecting the success of this method.
A total of 100 children with intussusception who were treated by hydrostatic reduction with saline were retrospectively reviewed. The effect of age, gender, duration of symptoms, rectal bleeding, number of reduction attempts performed, and the diameter and length of the invaginated segment measured on USG were evaluated.
Successful reduction was achieved in 88 (88%) patients. Mean age was 24.83 months, with 25.59 months in patients with successful reduction and 20 months in patients with failed reduction. Reduction was successful in 83.9% of the patients with a history of rectal bleeding and in 94.7% of the patients with no history of rectal bleeding (P > 0.05). Mean duration of symptoms was 2.74 days in the patients with successful reduction and 4.33 days in the patients with failed reduction. The mean diameter and length of the invaginated segments measured on USG were 3.5 cm and 5.12 cm in the patients with successful reduction and 4.27 cm and 9.23 cm in the patients with failed reduction, respectively. No significant difference was observed between the patients with successful and failed reduction in terms of rectal bleeding, vomiting, gender, age, and body weight (P > 0.05). It was also found that success rate increased as the number of reduction attempts increased and the success rate decreased as the duration of symptoms and the diameter and the length of the invaginated segment increased (P In conclusion, USG-guided reduction of intussusception with saline is a practical and safe method that yields high success rates. Repeating this method in patients with partial reduction that are clinically stable leads to a significant increase in the success of the procedure. A prolonged duration of symptoms and an increase in the size and the diameter of the invaginated segment may have adverse effects on the success of the procedure.