maliheh kadivar

Physiological jaundice of the newborn is a complex benign disease that rarely persists in the second week of life. Neonatal cholestasis (NC) is caused by a disorder in the formation of bile by liver cells or obstruction of the flow of bile through the intrahepatic or extrahepatic biliary tree, which leads to the accumulation of bile substances in the liver, blood, and extrahepatic tissues. This state may continue until the first six months of infancy, and its vulnerability to other cholestatic agents increases. This fact makes NC an uncommon feature of neonatal liver disease rather than a late manifestation. The aim of this paper is to review the definitions, etiologies, clinical manifestations, treatment, and management strategies for NC infants.

Social skills refer to socially acceptable behaviors that enable a person to interact effectively with others, and avoid socially unacceptable reactions. Social skills developed in childhood often form the basis of success in later stages of life. The purpose of this study is to review studies which have assessed social skills and empowerment developed in childhood and further influence the future life stages.

This narrative review was conducted using the keywords such as; social skills, social empowerment and child education. We searched English and Farsi scientific databases. Out of 512 articles, 86 were extracted.

The importance of social skills and empowerment during childhood were categorized in eight dimensions: definitions, various components of social skills, necessity of acquiring these skills, different methods of education, factors influencing child empowerment, role of games in social skills education and methods of evaluating social skills in children. Any deficiency in these skills may lead to many undesirable consequences such as behavioral disorders, poor academic performance, isolation and psychological disorders in adolescence. Various factors are influential in acquiring social skills, the most important of which are the role of age and gender, parents and teachers, and the cultural level of the family.

Education, especially in the preschool period, plays a significant role in empowering children with social skills. One of the best training programs in this domain is cognitive behavioral training (CB Training) program.

Widespread use of smartphones among health care professionals, and increasing audiovisual recording of patients with the aim of clinical and non-clinical purposes has emerged serious ethical, legal and social issues. To address such issues several guidelines have been developed in many countries. However, providing a practical and easily accessible ethical guideline with respect to national values seems necessary. Therefore, we developed an ethical guideline for making and using audiovisual recordings of patients with special attention to Iranian culture, social principles and Islamic commands.

This study was conducted at Tehran University of Medical Sciences in 2017-2019 and the guideline was developed through four phases:  Literature review, focused group discussions, Expert panels, Assessing stakeholders’ views.

The final draft of this guideline consisted of 43 items of "General Regulations" and 25 items of "Specific Regulations". The "General Regulations Section" covered the considerations before, during and after audiovisual recordings of patients. The "Specific Regulations Section" included ethical principles on audiovisual recordings of children and adolescents, cadavers, and patients with impaired decision making capacity as well as the ethical issues on broadcasting the recordings on public media.

Developing an ethical guideline for making and using audiovisual recordings of patients with respect to social, cultural and religious considerations will be helpful to address the emerging ethical, legal and social issues in this regard.

Altered concentrations of cerebrospinal fluid (CSF) and blood amino acids may be related to epilepsy or the severity of the seizure. In the present study, we assessed the concentrations of amino acids in CSF and plasma in neonates with refractory seizures.

In this prospective cohort study, 27 neonates aged 1 to 56 days with refractory seizures were included. Blood and CSF samples were collected from each neonate within 24 hours after receiving 2nd antiseizure medications. All plasma and CSF samples were sent to the laboratory to measure amino acid concentrations. The associations between CSF and plasma amino acid levels with different variables were evaluated.

Except for leucine (P=0.15) and isoleucine (P=0.07), the levels of all amino acids were significantly higher in plasma than CSF. Significant associations were observed between types of seizure and plasma citrulline (P=0.008) and leucine concentrations (P=0.04). The mean of CSF glutamic acid was also statistically different among neonates with different EEG results (P=0.02).

Our findings indicate that several plasma and CSF amino acids could be candidate biomarkers for neonatal refractory seizures. Further studies with larger sample size are to confirm our findings.

Peripherally inserted central catheters (PICCs) have long been used to provide intravenous therapy to premature neonates. The advantages of PICCs for neonates include avoidance of the pain and handling associated with repeated peripheral intravenous cannulation as well as the ability to safely deliver concentrated parenteral fluid or nutrients. Malpositioned PICC line tips can cause life-threatening complications. There are different intra- or post-procedural techniques to confirm line-tip placement to decrease the potential complications. These include plain radiographs, fluoroscopy, ultrasonographic detection, digital imaging, computed radiography, and intra-cavitary/ trans-esophageal/ and thoracic electrocardiographic monitoring. Each method has advantages and disadvantages and some methods have benefits in specific situations. The present study provides a literature review of common methods developed for detection of PICC tip positions over the last two decades.

Seizure is a common sign in neonates hospitalized in the neonatal intensive care units (NICU) that may lead to morbidity and mortality. Most neonatal seizures are subclinical. Conventional EEG (cEEG) is the gold standard for detecting and monitoring seizures but is not widely available. Amplitude-integrated electroencephalography (aEEG) has been used for over a decade to evaluate infants with seizures. In this study, we tried to determine the efficacy of aEEG as
a widely available diagnostic tool in diagnosing seizures.

All cases with seizures or suspicious seizures were admitted to the NICU of the Children’s Medical Center for one year. cEEG and aEEG were performed for these infants. aEEG was recorded for at least six hours with a description of the tracing. Clinical information, outcomes, and questionnaires (patient information) were recorded in detail. The obtained data were analyzed with the SPSS version 24 software.

Eleven out of twenty-five aEEG recordings were abnormal; other patients showed normal aEEGs. The most common clinical and neurological manifestations were seizure (68%) and hypotonia (28%); the mortality rate was 12%. No significant correlation was observed between aEEG findings and gender, age, familial relation, outcome, ultrasound result, type of seizure, and underlying disease.

Caustic ingestion in the pediatric population usually occurs accidentally in children under five years due to insufficient care or negligent household depositing of caustic substances. Neglectful behavior of parents while preparing formula for a neonate can lead to this rare condition in newborns.

We are reporting the case of a four-day-old newborn that was accidentally given house cleaning liquid mixed with formula by his mother, who mistook it for water to dilute the milk. This led to the development of extensive oral and esophageal lesions. 

This report highlights the importance of providing education for parents on how to prevent such accidents and avoid neglectful behaviors while caring for their children.

 Patent ductus arteriosus (PDA) is a disease presenting on the first days of birth, associated with unpleasant complications such as exaggerated respiratory distress and increased mortality, requiring prompt treatment.

 This study evaluated the relationship between perfusion index and the recovery of patients diagnosed with PDA.

 In this cross-sectional study, 22 neonates with PDA (as the case group) and 22 healthy neonates (as the control group) were selected. The difference in perfusion index (PI) before and after arterial duct closing was determined, and also the relationship between pre-ductal and post-ductal PI in the case and control groups was evaluated. Data were analyzed by SPSS version 21.

 The results showed a significant difference in the mean scores of pre-ductal and post-ductal PI before and after arterial duct closure (P = 0.004). Also, pre-ductal and post-ductal PI scores were significantly lower in the case group than in the control group (P < 0.001)

 According to our findings, PI in infants with PDA is low at presentation and increases after treatment. Therefore, PI can be used as an indicator to evaluate response to treatment during follow-up, particularly when repeated echocardiography is not accessible.

Echocardiography (ECHO) is a non-radiation real-time technique for evaluating Peripherally Inserted Central Catheter (PICC) tips that could overcome the limitations of plain radiographs, including the static and single image and exposing neonates to radiation. This study compared the accuracy of ECHO and radiography for PICC tip positioning in neonates.

This cross-sectional pilot study was conducted in the neonatal intensive care unit (NICU) of the Children's Medical Center in Tehran, Iran. Ultrasonography was used to visualize the end of the catheter in the vessels. After insertion of the catheter, a chest x-ray along with the ECHO was performed by a pediatric cardiologist blinded to the preliminary radiographic reports, and the results were compared and interpreted.

Forty infants with mean gestational ages of 35.4±3.3 weeks were enrolled in this study which was conducted during 12 months, from 2019 to 2020. The radiography results confirmed the correct PICC location in 29 infants (72.5%), which was simultaneously confirmed by ECHO in 28 infants (70.0%). The ECHO results indicated inappropriate placement in 12 infants (30%), and radiographs indicated correct placement in 11 infants (27.5%). This confirmed the higher accuracy of ECHO compared to radiography. ECHO had a sensitivity of 100%, specificity of 96.55%, PPV of 91.67%, NPV of 100%, and diagnostic accuracy of 97.5%. Both methods were appropriately correlated regardless of the demographics characteristics, sex, birth weight, gestational age, and catheter insertion site.

The findings confirmed that ECHO was more accurate than radiography for visualizing PICCs tip placement. ECHO does not require radiation exposure, has fewer complications, and is faster than radiography; thus, it should be considered as an alternative to standard radiography for line tip confirmation.

Neonatal seizure is a significant problem in this life course, and its timely and effective treatment is crucial. In this study, we compared the efficacy of levetiracetam versus phenytoin for treating the acute phase of neonatal seizures.

In this single-blind case-control study, 60 consecutive children with neonatal seizures referred to the Children’s medical center in Tehran, Iran, in 2018 were studied. Those neonates who had at least 30 minutes of seizure after Phenobarbital treatment were assigned to receive either phenytoin (20 mg/kg) or levetiracetam (initial dose of 40-60 mg/kg) through block randomization. The efficacy and safety of the two drugs were compared between the groups.

The response rate was 83.3% and 86.7% in phenytoin and Levetiracetam groups, respectively, which was not significantly different between groups (P=1.000). Adverse effects were nearly similar between groups (6.7% in the phenytoin group and 3.3% in the Levetiracetam group, P=1.000).

Levetiracetam and phenytoin are both practical and safe for treating neonatal seizures.

Futile medical care is referred to any medical intervention or activity that bring no benefit to patients. The aim of this study was to evaluate the frequency of futile treatment and its cost in neonates with a probable diagnosis of inherited metabolic disorder.

In this cross-sectional study, hospitalization records of all admitted neonates in Children's Medical Center, Tehran were evaluated between 2013 and 2016. Demographic characteristics of the patients, duration of hospitalization, diagnostic and therapeutic management, and costs were investigated.

In the period studied, 1668 neonates were hospitalized of whom 20 (1.2%) died in neonatal intensive care unite with a probable diagnosis of inherited metabolic disorder. Six (30%) cases had deceased siblings. The total duration of hospitalization was 290 day-patient ranging from 20 hours to 37 days. The costs of hospitalization and medical treatments were calculated. Despite disagreement of eight (40%) parents with any futile treatments, the medical team discontinued the futile care in only one case who received palliative care. In other patients futile treatment continued before death.

Futile medical treatments in neonates with inherited metabolic disorders are not uncommon. Lack of a comprehensive guideline about this issue leads to continuation of futile medical care.

The present study aimed to assess the correlation of spiritual well-being with parental stress and coping strategies in mothers with preterm neonates hospitalized in neonatal intensive care units (NICUs).

This prospective cross-sectional study assessed Spiritual Well-Being (SWB), parental stress, and coping strategies in mothers (n=200) of preterm infants admitted to NICUs. Mothers were further divided based on socio-demographic characteristics, such as mother’s age, gestational age, average scores at school, mothers’ literacy level, the birth rank, cesarean or vaginal delivery, number of children, job, and duration of hospital stay.

The results pointed out that 46.6% and 53.4%of mothers had moderate and high levels of SWB, respectively. Moreover, the religion domain (53.30±7.33) had a higher score, in comparison with the existence domain (46.03±7.15). The planful problem-solving was the most frequently used (46.02±11.46) strategy. Religion domain had a significant positive and negative correlation with planful problem-solving strategy (r=0.439**; P≤0/000) and emotional-driven coping strategy (r=-0.420**; P≤0/000), respectively. There was a significant negative correlation (r=-0.322**; P≤.0/000) between the existence domain and the emotional-driven coping strategy.

Regarding the close interrelationship between mothers and NICU nursing staff, it is clear that nurses can help mothers to cope with stress more quickly and efficiently using accurate assessment and appropriate intervention in terms of their spiritual and religious beliefs.

Child Abuse and Neglect (CAN) is a major health problem with serious consequences. Since health care professionals play an important role in identification, management, and reporting CAN cases, they should have precise knowledge on this subject. The aim of this study is to investigate the level of knowledge, attitude and practice of the pediatricians, pediatric residents, and nurses regarding CAN issues as well as their possible needs for any educational programs in this regard.
130 pediatric nurses and physicians working at two pediatric tertiary centers, in Tehran, Iran participated in this descriptive cross-sectional study. An anonymous validated and standardized self-report questionnaire was used as the study instrument. The questionnaire consisted of five sections on demographic information, knowledge, attitude, practice and needs assessment. Analytical statistical tests including t-test, Kruskal–Wallis and Mann-Whitney tests were used to analyze the data.
The level of the participants’ knowledge was moderate (mean score: 16.6±3.17) and their attitude towards child abuse and neglect was at a good level (mean score: 45.72 ±4.25). The results of this study revealed that the overall performance of the participants in dealing with a suspicious case of child abuse and neglect was moderate. Almost all participants (95.5%) indicated the need for educational programs on child abuse both for nurses and physicians.
Results of our study revealed that the overall knowledge, attitude, and practice of the health care professionals in the field of pediatrics regarding child abuse and neglect are not satisfactory and training programs on this issue are mandatory for pediatricians, pediatric residents, and nurses due to their serious role in caring for children.

Child abuse is a significant global concern, with short-term and long-term consequences for the lives of children who are victims of violence. For effective action by decision-makers, the information and analysis obtained from surveillance systems must be used to determine the problem, the magnitude of maltreatment, its relationship with other issues, and the likelihood of preventing maltreatment. Due to the importance of child abuse and the management and control of this event, this study was conducted to design and evaluate a child abuse surveillance system. The system was designed in Visual Studio version 2017 using the C# programming language and ASP.NET framework. SQL Server was used to store the data. The design of the child abuse surveillance system was evaluated according to the usability evaluation. The minimum data set was indexed to collect and store data on abused children by the standard format. Web-based child abuse surveillance system (CASS) has 3 types of users. The system evaluation results showed that the highest number of problems were related to the principle of "help and documentation". Designing a CASS is a practical step in managing and controlling the data of abused children. This system and registration of information will help professionals, managers, and decision-makers make the right decisions to take care of injured children with up-to-date information

The present study aimed to compile and develop a professional guideline for health-care providers in Iran regarding cyberspace usage. This was a mixed-methods study, conducted in three phases. In the first phase, the principles of ethics in cyberspace were collected through a review of the literature and available documents, and were then subjected to content analysis. In the second phase, the views of experts on medical ethics, virtual education, information technology and medical education, as well as clinical sciences experts and representatives of medical students and graduates were evaluated using the focus group method. In the third phase, the draft was evaluated by various stakeholders. Finally, after receiving the comments, the necessary modifications were applied to the guideline.The professional guideline for the use of cyberspace by health-care professionals comprised 30 codes in 5 domains, including the general regulations domain, care and treatment, research, education, and personal development.This guideline presents the various ways professionalism can be maintained in cyberspace interactions. Adherence to the principles of professionalism in cyberspace is required to protect and preserve the public trust in health-care professionals.

This is a new case, affecting a twin that both with Hirschsprung’s disease, one was suffering from long-segment Hirschsprung’s disease with skip segmented. Our surgeon suspected the absence of abnormal vessel tortuosity in the transitional zone; thus, the appendix was sent for permanent pathology. There were ganglion cells in the colostomy site but no ganglion was found in the appendix. Complete biopsies from different parts of the intestine demonstrated positive ganglion cells in the transverse colon, ascending colon, and the distal ileum, jejunum, and duodenum, and negative ganglion cells in the rectum, sigmoid, descending colon, appendix, and 5 cm far from the ileocecal valve were observed. Therefore, the Kimura procedure was done. The most important key in such cases is the surgeons’ observation during operation.

Providing care for terminally ill neonates is an important issue in NICUs. This research aimed to determine nurses’ attitudes toward providing care for terminally ill neonates and their families. A total of 138 nurses working in neonatal intensive care units (NICUs) affiliated to Tehran University of Medical Sciences participated in this cross-sectional study via convenience sampling in 2019. The Data collection tool was the Frommelt attitudes toward caring for terminally ill persons and their families scale. The nurses in this study had the most positive attitudes toward the items “nursing care should include the family of the terminally ill patient, too” (4.2 ± 0.6) and “the care provider can prepare the patient or his/her family for death” (4.1 ± 0.7). The nurses had the least positive attitude toward the item “the time spent on caring for terminally ill patients creates a sense of frustration in me” (1.06 ± 1). The mean score of the attitudes of NICU nurses toward caring for terminally ill neonates and their families indicates the necessity of improving this attitude.

Medical professionalism has a crucial role in educating medical students. The role of professionalism in the clinical environment is therefore an important factor in medical education. This study attempts to evaluate the opinions of medical students in the teaching hospitals of Tehran University of Medical Sciences (TUMS) about the professionalism environment in this university. A sample of 165 students filled out the Persian translation of UMKC-SOM (Climate of Professionalism Survey) questionnaire. This instrument evaluates students’ perspectives on the degree of adherence to professionalism by faculty, residents and other students. The results of the study revealed that the total score of professionalism climate was 53.9 for faculty, 42.09 for residents, and 50.76 for students and the difference between these three groups was statistically significant (p-value < 0.01). Results of further analysis through post-hoc tests for multiple comparisons among the groups revealed that the students found their fellow students and faculty more professional than residents. The study also showed that the medical ethics course had no impact on perceptions observations (p-values > 0.05).The study results also revealed that the students found their fellow students and faculty more professional than residents. This finding demonstrates the importance of teaching professionalism to residents since they serve as role models for students.Further multicenter studies are needed to improve the professionalism climate in the medical teaching environment.

Due to the unique nature of the neonatal intensive care unit (NICU) and its moral distress, this study aimed to investigate moral distress in the NICU. This cross-sectional study was conducted on 234 physicians and nurses working in the neonatal wards of eight hospitals. The Corley’s Moral Distress Scale was used to collect data. Findings showed that 25 of the participants were physicians and 209 were nurses. The intensity and frequency of distress among physicians and nurses were assessed as moderate. The mean intensity and frequency of moral distress among nurses and physicians were 48.3%, 41.5% and 46.46%, 15.62% respectively. The results showed that the mean intensity and frequency of distress were higher, however not significantly, among nurses. The intensity and frequency of moral distress had a statistically significant and direct correlation with the intention to leave and the number of staff in each working shift among the nurses. Moral distress in the NICU practitioners was moderate, so addressing this issue and trying to alleviate it was important. Identifying the causes behind moral distress can help adopt appropriate measures to prevent and reduce them.

 The prevalence of asthma is higher in icteric babies. It is thought that eosinophilia and asthma are complications of phototherapy rather than hyperbilirubinemia.

 Since there is little data in this regard, we evaluated the relationship between phototherapy and the level of eosinophils in this study.

 In this cross-sectional prospective study, we assessed icteric neonates admitted to the neonatal and intensive care unit of Children’s Medical Center of Tehran during 2017 - 2018. Laboratory data including serum bilirubin and count of blood cell differentiation for eosinophils, before, during, and after phototherapy besides demographic data like age, gender, gestational age, and duration of phototherapy were collected.

 Totally, 163 neonates (52.1% male and 47.9% female) with a mean age of 5.49 ± 4.01 days, enrolled in the study. The prevalence of term neonates was 81% and 19% were preterm. The mean of serum total bilirubin was 17.91 ± 3.37 mg/dL. Compared to the mean value of eosinophils before phototherapy, this value in the first (P = 0.001) and second (P < 0.001) days were significantly higher. In female neonates, there was a significant increase in eosinophils in the first (P = 0.001) and second (P < 0.001) day of the post-treatment period. However, in male subjects, this increase was significant only in the second day after phototherapy (P = 0.001). In neonates less than one week of age, this count was significantly increased on the first (P = 0.003) and second (P < 0.001) day after phototherapy. In cases with hemolytic hyperbilirubinemia, eosinophils count before phototherapy and the second day was significant (P = 0.006). The mean of eosinophils in first and second days after phototherapy was not correlated with the severity of hyperbilirubinemia but there is a significant negative correlation between the mean total bilirubin of patients with mean eosinophils before phototherapy.

 Our findings showed that there was a significant relationship between hyperbilirubinemia and its therapeutic phototherapy with an increasing level of peripheral eosinophils count in neonates.

 Appropriate and accurate easy access tools are necessary to overcome complications from malpositioned line tips of peripherally inserted central catheters (PICCs) in critically ill neonates. Ultrasound is a radiationless, cost-beneficial, and time-saving method that allows medical personnel to manipulate the line and correct possible malposition of this tip. In addition, it reduces the need for a second radiography.

 We compared the effectiveness of sonography with radiography for confirmation of the line tip placement.

 This prospective descriptive-analytical study was conducted in the Neonatal Intensive Care Unit (NICU) in Tehran Children’s Medical Center (tertiary level), Tehran, Iran. Neonates who were candidates for PICC implantation according to the ward’s protocol were enrolled in the study. Radiography and sonography were performed after catheter insertion by a radiologist blinded to the preliminary radiographic reports. The results of both methods were compared and interpreted by statistical analysis using the chi-square and Pearson correlation tests.

 A total of 90 infants, 45 (50%) males and 45 (50%) females, were assessed. We noted that 17 (18.8%) cases had malpositioned tips according to the radiographs. Malpositioning of the line tips were identified in 21.1% of cases by sonography (P ≤ 0.05), which indicated a higher accuracy for sonography compared to radiography. Both methods were appropriately correlated regardless of the underlying variables. Sonography had a sensitivity of 100% and specificity of 89.5%, a positive predictive value (PPV) of 97.3%, and a negative predictive value (NPV) of 100%.

 Our findings show that sonography can be a more accurate, safer bedside tool, with fewer complications compared to radiography in PICC tip placement determination in neonates. Multi-center studies with increased sample sizes should be performed to confirm replacement of radiography by sonography as the gold standard test for confirmation of PICC tip positioning.

Gaucher’s disease (GD) is one of the most common lysosomal diseases in humans. It results from β‑glucosidase deficiency and leads to necrosis, especially in macrophages with the accumulation of glucosylceramidase in cells. Most of the deleterious effects of the disease are seen in the liver, spleen, and bone marrow. The aim of this study was to compare the efficacy of Imiglucerase with Eliglustat in treating patients with GD. PubMed/Medline, Cochrane Library, Scopus, Web of Science, Embase, and Google Scholar were searched from inception to August, 2018. Predefined inclusion criteria for included studies were based on search methodology and are as follows: All randomized, quasi-randomized controlled, and cohort studies about patients with GD Type 1 that Imiglucerase was compared with Eliglustat were included. Two authors independently choose the papers based on the inclusion criteria. From 2979 recognized studies, three studies including two randomized clinical trials and one cohort study were recognized to meet the inclusion criteria. The primary outcomes were hemoglobin level, platelets count, liver, and spleen size, and the secondary outcomes were the immunological side effects of the medicines and bone complications. The results showed that there is no meaningful difference between the two medicines in terms of increasing blood hemoglobin, platelets count, and reducing the liver and spleen size. The findings of this review showed that both medicines are effective in the treatment of GD Type 1 and there is no statistically significant difference between their efficacies.

Infants born with congenital heart disease (CHD) typically present different clinical manifestations which make this condition hard to diagnose. Considering serious complications arising from misdiagnosis, inventing new methods and/or improving traditional diagnostic approaches has always been a research objective.

In this cross-sectional analysis, which took place in Children's Medical Center in Tehran, 150 infants admitted to an intensive care unit were evaluated based on echocardiographic findings from 2015 to 2017. Echocardiography was done due to abnormalities in physical examination and/or oxygen saturation level.

The sensitivity of clinical study value was 82% and the negative predictive value was 20%. The sensitivity of arterial oxygen saturation immediately after admission to the neonatal intensive care was 92%, the specificity was 34%, positive predictive value was 56% and negative predictive value was 25%.

In terms of high sensitivity, clinical symptom including tachypnea, cyanosis, arrhythmias, respiratory distress, cardiac murmur, or arterial oxygen saturation level in newborns may be useful for screening CHD. Among the clinical manifestations, cyanosis and respiratory distress are more valuable.