Iranian Journal of Pediatrics
Volume:17 Issue: 3, 2007

Objective: To describe sleep patterns and sleep problems among preschool and school aged group children in a primary care setting in Iran.
Material & Methods: This cross sectional study was conducted in two primary care pediatric clinics in Tehran from March 2006 to September 2006.
Findings: Sleep patterns of 215 children studied (101 were in preschool age group; 2-6 years old، and 114 were in primary school age group; 7-12 years old). Sleep problems were common in study group، as follows: bedtime problems 21.05%-56.44%، excessive daytime sleepiness 26.73%-42.98%، awakening during the night 13.86%-32.46%، regularity and duration of sleep 17.54%-27.72%، sleep-disordered breathing 10.53%-17.82%.
Conclusion: These high frequencies of sleep problems in children explains the importance and burden of sleep disorders in children which unfortunately are not noticed by primary care providers in Iran and inadequate attention to them may have negative consequences on a host of functional domains، including mood، behavior، school performance، and health outcomes.

Objective: Excessive crying of infancy; a single continuous episode of crying more than 2 hours; is a common and often serious problem for parents. The objective of this study was to determine the incidence and etiology of acute episodes of excessive infant crying and to propose an approach for taking care of them.
Material & Methods: In this cross sectional study all patients less than 2 years old presented to the Emergency Department (ED) with ≥2 hours of crying with an unapparent cause for their parents were included in this study. Patients with fever، chronic disease and any disease 72 hours proceeding the crying were excluded.
Findings: The incidence of excessive crying was 200 (1.74%) among the 13600 ED visits in 2 consecutive years. The three most common causes were colic (29.5%)، acute otitis media (15.5%) and constipation (5.5%). History and physical examination led to diagnosis in 86% of cases.
Conclusion: Many conditions and diseases may cause excessive crying in infants. Complete history and physical examination of all parts of the body provide clues for the diagnosis in most cases and help the physician to avoid over diagnosis and over treatment.

Objective: Nutritional status directly affects the growing up of children in terms of physical and mental development. In the urban slums the underprivileged children lag behind the basic necessary amount of food and nutrition which is likely to lead to their ill development. This study was undertaken to investigate the dietary food intake pattern among urban slum dwelling children attending schools Dhaka city and to examine the association with various social factors.
Material & Methods: This study is a cross-sectional study among 396 school going children who are residents of slums in different parts of Dhaka Metropolitan city.
Findings: The age of the children were categorized into three age groups; Mean age for the children of age group-1 was 6.51 (±1.01) years، for the age group-2 was 9.24 (±1.09) years and for the age group-3 was 12.5 (±0.91) years. In 77.8 % of the cases the child gets three meals per day but inadequate in amount. In most of the cases the common foods were rice، lentil، potato and green leafy vegetables. The food frequencies reported by the children were; eggs: 1.4 times per week، milk: 1.2 times per week، meat: 0.4 times per week، fish: 2.8 times per week and fruits 2.9 times per week. Those children from families with lower incomes and less educated parents had a dietary pattern which tended to be poor regarding egg، milk، meat and fruit.
Conclusion: The diets of these urban slum school children were inadequate for macronutrients and micronutrient، which is a danger for significant nutritional and health implications. The need to develop healthy food supply and habits should be emphasized.

Objective: Recurrent abdominal pain (RAP) affects a significant number of children each year. It can be defined as experience of at least three episodes of pain، severe enough to affect activities، over a period of three months. The purpose of this study was to determine the organic and non-organic causes of RAP. Also، evaluate different variables of RAP such as age، sex، location and duration of pain، accompanying symptoms and stressful life events in two groups.
Material & Methods: During one year period from October 2003 to September 2004، 70 children (aged 4-12 years)، were investigated in a referral Children''s Center in Tehran. All patients underwent a thorough interview and complete physical examination and an initial sample of blood، urine، and stool evaluation. If any evidence of alarm symptoms (such as vomiting and night pain) were observed، additional studies were performed including abdominal ultrasonography، radiography، and/ or upper gastrointestinal Endoscopy.
Findings: An organic cause was found in 21 (30%) patients and non-organic cause was identified in 49 (70%) cases. Main observations in non-organic groups were: more periumblical pain location، positive history for stressful life events in child and their family. Also، gastrointestinal problems were the most common organic causes in 60% of children. Other organic causes were urinary tract infections 10%، kidney stone 10%، cholelitiasis (5%)، Giardiasis (15%)، and abdominal migraine (5%). Endoscopy seems to be a safe and reliable method in diagnosis of a number of organic lesions otherwise not detected by ordinary investigations. Our data suggest that among the children with RAP، non-organic causes are more commons (70%) than organic causes (30%).
Conclusion: This study showed that in spite of accessing to better instruments in medical sciences in recent decades، the percentage of nonorganic RAP in children is still high.

Objective: Kawasaki disease (KD) is an intense life-threatening vasculitis. The diagnosis of Kawasaki disease is made by clinical criteria. This disease is a common rheumatologic disease in Iran. The aim of this study was describe the demographics and clinical features of KD in Iranian patients.
Material & Methods: A review was conducted for all cases of KD treated at Pediatric rheumatology department in Children''s Medical Center between January 1994 and July 2004. The diagnostic criteria for typical Kawasaki were based on the criteria of the Japan Kawasaki Disease Research Committee. Atypical or incomplete KD has been described in which patients not strictly meeting the diagnostic criteria but have coronary artery changes. Color doppler echocardiograms were done at the time of diagnosis، 14 to 21 days، 60 days، and 1 year after treatment.
Findings: One hundred fifty nine patients were identified. One hundred twenty five children (78.6%) fulfilled criteria for typical KD. Echocardiographic abnormalities were found in 30 cases (18.9%)، including 9.6% with typical and 46.1% with atypical Kawasaki. The incidence of atypical Kawasaki in our study was about 22%. Coronary arteries aneurysms found in 66.7% and 33.3% was other abnormalities. Male to female ratio was more in patients with cardiac complication (2.3:1).
Conclusion: Kawasaki disease should be considered in any infants or child (especially less than 2 years old) with a prolonged febrile illness. Demographic features of our patients were similar to reports from other country. The incidence of atypical Kawasaki in our study was about 22%.

Objective: Cryptosporidium parvum is a common protozoan pathogen with worldwide distribution. It localizes on the intestinal cells and prolonged diarrhea in immunocompromised patients. The aim of this study was to estimate the prevalence and the clinical features of enteric cryptosporidiosis in pediatric patients with lymphohematopoietic malignancies.
Material & Methods: In this cross-sectional study stool samples were collected from 100 children (67 boys، 33girls) with lymphohematopoietic malignancies who underwent chemotherapy between the ages of 6 months and 17 years (mean age 7.5 years). All of the specimens were examined for the oocysts of C. parvum by modified Ziehl Neelsen (MZN) staining technique and coproantigens of C. parvum by ELISA.
Findings: Cryptosporidium infection was detected in 22 patients. 16 (72.7%) of the infected patients were male and 6 (27.3) female. 7 (31.8%) patients were <5 years، 8 (36.4%) 5-10 years and 7(31.8) >10 years old. Parasites were detected in 19/85 (86.4%) patients with ALL، 2 of 5 (9.1%) with AML، and 1 of 10 (4.5%) with NHL. Clinical symptoms were found in 11 (50%) of the patients. We found longer duration of chemotherapy in patients who were positive for cryptosporidium infection (Mean=2067 days) in comparison to negative group (Mean=258.5 days) (ANOVA، f=2.82، P=0.04).
Conclusion: The incidence of cryptosporidium infection was 22% among pediatric patients with lymphohematopoietic malignancies. We recommend evaluation of these patients with at least two different diagnostic methods in order to prevent possible life threatening outcomes.

Objective: Diabetic nephropathy is one of the major complications and a leading cause of mortality and morbidity in diabetes mellitus. Microalbuminuria is the earliest sign of diabetic nephropathy and it is highly related to glycemic control. Progression of diabetic nephropathy is mostly asymptomatic until advanced stages of renal failure. In this study microalbuminuria and its correlation with duration of diabetes and quality of diabetes control (HbA1c level) is evaluated in 50 children with type 1 diabetes mellitus.
Material & Methods: Fifty children 4 to 6 years following the onset of type 1 diabetes، below 20 years of age، were enrolled in this study. Twenty four hrs urine was checked twice within 3 to 6 months period for microalbuminuria by nephelometry method and values >30 mg/24hrs were considered abnormal. Also HbA1c level and FBS level assessed simultaneously. Mean FBS level during the years of diabetes and number of attacks of DKA wereFindings: Fifty children، 4 to 19 years old with mean age of 14.54 ± 3.62 years، 28 (56%) males completed the study. Nineteen (38%)، 14 (28%) and 17 (34%) children enrolled in this study 4، 5، 6 years after the onset of their diabetes respectively. At 1st evaluation microalbuminuria was detected in 5 (26.3%)، 4 (28.6%) and 6 (35.3%) children، 4، 5، 6 years after diabetes respectively. At 2nd evaluation these values were 4 (21.1%)، 6 (42.9%) and 7 (41.2%) respectively. There was no significant correlation between HbA1c level، FBS level، and mean FBS level during the years of diabetes in microalbuminuric and non-microalbuminuric children.
Conclusion: Despite small sample size of this study، microalbuminuria was detected in children even 4 years after the onset of diabetes and its frequency increased in children with 5 and 6 years of diabetes. We recommend earlier than usual recommendations for microalbuminuria screening in diabetic children.

Objective: Premature infants often develop significant anemia that requires blood transfusion، this carries significant risks. This study was carried out to determine the effect of recombinant human erythropoietin (r-HuEPO) on prevention of anemia of prematurity.
Material & Methods: From April 2001 to March 2002، 24 neonates in newborn services at Amirkola children''s hospital randomly were assigned to erythropoietin group and control (no treatment) group. Inclusion criteria were birth weight of ≤1750 grams and gestational age ≤34 weeks. Exclusion criteria were problems of hemolytic anemia، congenital infections، congenital malformations، severe asphyxia، intraventricular hemorrhage (grade III and IV)، need for exchange transfusion and death during the first week of life. Erythropoietin group received r-HuEPO400 unit/kg/dose subcutaneously three times a week plus 4 mg/kg/day iron orally. White blood cell، hemoglobin (Hgb)، hematocrit (Hct)، platelet and reticulocyte count were obtained every 2 weeks until the 42nd day of life. Anemia was defined as Hgb≤8gr/dl and Hct≤24%. Student t test and Fisher exact were used to evaluate differences between the two groups.
Findings: Hemoglobin and hematocrit values were significantly higher in erythropoietin group than the control group after the 14th day of the study (P<0.04) and this difference was getting higher until the end of the trial (P<0.001). Five neonates developed anemia; all of them were from control group. One of these neonates required transfusion. None of the erythropoietin group newborns developed anemia.
Conclusion: The results of this study confirm the efficacy of recombinant human erythropoietin in the prevention of anemia of prematurity.

Objective: This study was designed to determine the predisposing factors in children with symptomatic urinary tract infection (UTI) according to age and gender.
Material & Methods: We reviewed prospectively 183 pediatric patients with symptomatic UTI admitted to emergency department or referred to nephrology clinic from November 2002 through July 2005. All patients underwent renal ultrasonography and voiding-cystouretherography or radionuclide cystography. Diuretic renal scan or intravenous pyelography (IVP) was performed in those with urinary system dilatation. Urodynamic studies were done in patients with normal radiologic findings and recurrent infections or urinary-intestinal symptoms.
Findings: Of 183 patients, 130 cases (71%) were female and 53 patients (29%) male. Most of the patients (61.9%) were between 2-24 months old (P=0/001). Vesicoureteral reflux (VUR) was the most common predisposing factor in both genders (46.9% in girls and 48.9% in boys). Voiding dysfunction in girls and urinary obstruction in boys were found with a significant difference (P=0/03 for both). In all age groups, except patients≤1 month, the most common predisposing factor was reflux. Reflux, urinary obstruction and nephrolithiasis were found with a significant difference in 2-24 months age group (P=0/001 for all).
Conclusion: In our study vesicoureteral reflux (VUR) was as common in boys as in girls, and suggested urolithiasis as a significant UTI predisposing factor. This study showed that voiding dysfunction in girls and urinary obstruction in boys are as significant predisposing factors. We suggest urodynamic studies in patients with normal radiologic findings and recurrent infections or urinary-intestinal symptoms.

Objective: Objective: Juvenile dermatomyoistis (JDMS) involves children rarely. Our purpose of this study is to detect clinical and laboratory aspects of this disorder and its treatment in Khorasan Province.
Material & Methods: A 10-years retrospective study performed on medical records of all patients with JDMS in a medical center in Mashhad. Data was analyzed with statistical measures including SPSS and Excel.
Findings: 18 patients had DJMS during 10 years. There was a female to male predominance (1.25/1). The mean age of patients was 12.1 years. Muscular weakness was the most common presenting symptom. Skin involvement including heliotrope rash and Gottron papules were detected in most patients. Elevated muscular enzymes were an important finding in many cases. EMG، and muscle biopsy in those cases performed، showed abnormal results. Seventeen (94.5%) of patients responded to oral prednisolon therapy.
Conclusion: According to clinical manifestations and laboratory findings، in particular muscular enzyme assays، a timely diagnosis and treatment with oral prednisolon can improve the disease dramatically and reduce morbidity and mortality rates as well.

Peroxisome biogenesis disorders، Zellweger syndrome spectrum (PBD، ZSS) are constituted of three different phenotypically disorders: Zellweger syndrome (ZS)، the most severe; neonatal adrenoleukodystrophy (NALD); and infantile refsum disease (IRD)، the least severe، that have been originally described based on their biochemical and molecular bases of these disorders which had been fully determined. Individuals with PBD، ZSS usually come to clinical attention in the newborn period or later in childhood. The diagnosis of PBD، ZSS can be definitively determined by biochemical assays. Measurement of plasma very-long-chain fatty acid (VLCFA) levels is the most commonly used and most informative initial screen. Mutations in thirteen different PEX genes - those that encode peroxins، the proteins required for normal peroxisome assembly - have been identified in PBD، ZSS. Mutations in PEX1، the most common cause of PBD، ZSS، are observed in about 68% of affected individuals. Sequence analysis is available clinically for the following seven genes: PEX1، PXMP3 (PEX2)، PRXR1 (PEX5)، PEX6، PEX10، PEX12، and PEX26.

Calcium oxalate stones are the most common type of stones in patients with idiopathic nephrolithiasis. A calcium phosphate stones are more typical of patients with renal tubular acidosis، chronic urinary tract infection and primary hyperparathyroidism.
A non-contrast enhanced helical computed tomography (CT) scan of the abdomen is the diagnostic procedure of choice with superior sensitivity and specificity of almost 100% compared to the KUB and abdominal ultrasound. Patients should be instructed to strain their urine and bring in any stone that passes for analysis. Stone identification enables better planning of subsequent therapy. The likelihood of stone passage is 95% for stones up to 5 mm in size. Stones larger than 5 mm in diameter that do not pass in several days merit referral to an urologist for lithotripsy، or lithotomy. No specific work-up or drug therapy is typically provided for patients who have passed a single stone. Long term management of patients who have passed their first stone includes recommendations to avoid a diet high in salt or animal protein and maintenance of a fluid intake greater than 2 liters per day. A low calcium diet is also an important risk factor for calcium nephrolithiasis. A low dietary calcium intake reduces the concentration of calcium in the intestinal lumen which can lead to increase in gastrointestinal absorption and urinary excretion of oxalate. Patient with recurrent disease should receive a complete evaluation to treat the identified risk factors and prevent stone formation.

Objective: Aplasia Cutis Congenita (ACC) is a rare disorder with a complicated pattern of inheritance. Babies are born with the absence of certain layers of skin. It most commonly manifests as a solitary defect on the scalp، but sometimes it may occur as multiple lesions. The affected area is typically covered with a thin، transparent membrane. The skull and/or underlying areas may be visible and be abnormally developed. ACC may be the primary disorder or it may occur in association with other underlying disorders.
Case presentation: This article presents a case of ACC in a newborn whose mother was treated with methimazole due to thyrotoxicosis during the first trimester of pregnancy. He was born term with midline scalp defects. This case report is presented to highlight the steps to successful management and review the relevant literatureConclusion: Management strategies are based on the size and presence of an underlying skull defect. A review of the literature seems to support the hypothesis that methimazole is a potential teratogen. Although the risk of birth defects is low with clinically applied doses of the drug، it cannot be regarded as safe and should therefore be avoided pregnant women. Propylthiouracil should be considered as the first choice drug for hyperthyroid pregnant women until further data on the safety of methimazole are available

Objective: Neonatal subgaleal hemorrhage is a rare but potentially lethal complication of instrumental delivery، particularly vacuum extraction. It is often underreported and underdiagnosed. The prevalence of subgaleal hemorrhages varies from 0.04 to 0.15% of all deliveries. We describe two cases of severe subgaleal hemorrhage (SGH) and review the key elements of identification and treatment.
Case report: The first case was a female neonate with birth weight 2220gr that was born by vacuum assisted vaginal delivery. At birth، the infant was pale، flaccid with no respiratory effort. She was grossly pale with poor perfusion، lethargic، decreased muscle tone، anemia، and hypovolemic shock. On her head a large fluctuant swelling was seen. She died at 20th hours of age. The second case was a full term male neonate that was born with cesarean section after an unsuccessful 2 to 3 time vacuum extraction. At birth the infant was limp، cyanotic with weak respiratory effort. After 7th hours، a severe fluctuant swelling was found on his head with head circumference of 38.5 cm and ecchymosis around his orbits. He developed anemia and seizure. After successful treatment، he was released from hospital.
Conclusion: Increased awareness of SGH should lead to earlier identification، referral and treatment، with resultant improved outcomes.