Iranian Journal of Pediatrics
Volume:20 Issue: 4, 2010

Constipation is a common problem in children. There is some clinical evidence for the role of probiotics and prebiotics in the treatment of constipated children. This is the first study on the therapeutic effect of synbiotics (combination of probiotics and prebiotic) in treatment of childhood constipation. In a double-blind randomized placebo controlled study 102 children aged 4-12 years with functional constipation were assessed according to Rome III criteria for 4 weeks. They were divided into 3 groups: Group A, received 1.5 ml/kg/day oral liquid paraffin plus placebo, group B, 1 sachet synbiotic per day plus placebo and group C, 1.5 ml/kg/day oral liquid paraffin plus 1 sachet synbiotic per day. Frequency of bowel movements (BMs), stool consistency, number of fecal incontinence episodes, abdominal pain, painful defecation per week, success of treatment and side effects were determined in each group before and after treatment. The frequency of BMs per week increased in all groups (P<0.001), but it differed between groups and was higher in group C (P=0.03). Stool consistency increased and number of fecal incontinence episodes, abdominal pain and painful defecation per week decreased in all groups similarly and there was statistically no difference between them. No side effects were reported in group B; the main side effect in group A and C was seepage of oil (P<0.001). Treatment success was similar in all groups without any significant difference between them (P=0.6). This study showed that synbiotics have positive effects on symptoms of childhood constipation without any side effects.

Human metapneumovirus (hMPV) is a respiratory pathogen responsible for disease and subsequent hospitalizations in young children around the world. The disease pathology, including how viral load correlates with respiratory disease severity, remains unclear. This study investigated the correlation between viral load and clinical characteristics of hMPV infections. Nasopharyngeal aspirate (NPA) samples collected from 18 infants hospitalized for lower respiratory tract infections (LRTIs) in winter were tested for hMPV by reverse transcriptase polymerase chain reaction (RT-PCR) and real-time RT-PCR. Their NPA samples were collected every-other-day to monitor changes in hMPV viral load during hospitalization. Also all these 18 patients were monitored to characterize clinically their illness. hMPV load was not correlated with infection severity (P=0.5，0.9，0.5). In contrast, the log10 of hMPV viral load was significantly different between those lasted for 6-11 days and those for less than 5 days (P=0.01), also the significant difference was shown between those of 6-11 days duration and those of more than 11 days (P=0.006), but there was no significant difference between those lasted for less than 5 days and those for more than 11 days (P=0.4495). Additionally, high hMPV viral shedding occured between 6 and 11days. hMPV load was significantly correlated with the course of illness. The association between hMPV viral load and the course of disease suggested that hMPV is an important pathogen in lower respiratory tract infection in children. But hMPV did not always lead to more severe respiratory illness.

The Apgar score as a proven useful tool for rapid assessment of the neonate is often poorly correlated with other indicators of intrapartum neonatal well-being. This study was carried out to determine the correlation between umbilical cord pH and Apgar score in high-risk pregnancies. This is a prospective cross-sectional, analytic study performed on 96 mother-fetal pairs during 2004-2005 at Shahid Yahyanejad hospital, which is affiliated to Babol University of Medical Sciences. Apgar score at 1 and 5 minutes after birth was taken and an umbilical cord blood gas analysis was done immediately after birth in both groups. Mothers came with a labor pain and were divided into high-risk and low risk if they have had any perinatal risk factors. Other data like gestational age, birth weight, need for resuscitation and admission to the newborn ward or NICU was gathered by a questionnaire for comparison between the two groups. P-value less than 0.05 was considered being significant. The gestational age and birth weight were the same in high-risk and low risk mothers. Mean umbilical artery blood pH in high-risk mothers was significantly lower than in low risk mothers (P=0.004). Mean Apgar scores at 1 and 5 minutes were significantly lower in high-risk mothers than in low risk mothers (P<0.05). According to the Kendal correlation coefficient there was no significant correlation between Apgar score at 1 and 5 minutes and umbilical cord pH in low risk group (r=0.212, P=0.1). But in high-risk group there was significant correlation between Apgar score at 1st and 5th minute and the umbilical cord pH (r=0.01, P=0.036 and r=0.176, P=0.146, respectively). Combination of Apgar score and umbilical cord pH measurement in high-risk pregnant mother could better detect jeopardized baby.

The paper presents a new trend of weight-for-height index of 2397 school children (1268 boys and 1129 girls) aged 6.5-11.5 years by sex in a representative sample from primary schools of Shiraz (Southern Iran) at an interval of 15 years (1988-2003) and its relation to the Center for Disease Control and Prevention (CDC) data (2000). The data relate to a multi-stage random sample of healthy school children in Shiraz, southern Iran, collected in 2002-2003 academic year. The mean±SD age of these children was 9.1±1.4 yaers. The weight and height were estimated as 28.2±6.9 kg and 131.3±9.6 cm, respectively. Cross-sectional weight-for-height curves were constructed for both sexes. Parametric Lambda-Median-Standard Deviation (LMS) method was applied to estimate weight-for-height centiles. Weight-for-height centiles for boys and girls were nearly close to each other, except for the children of older age in which boy's centiles lay below those of girls. Centiles of the present study lay above previous ones. In both sexes CDC weights were greater than those of Iranians for a given height. This discrepancy was more pronounced in extreme high centiles. The necessity for updating local weight-for-height reference data for clinical work in Iran is emphasized. The positive trend in weight-for-height had been influenced by socio-economic development and improvement of health indicators in Iran during the post war reconstruction period.

The aim of the study was to evaluate clinical characteristics of ureteroceles particularly for diagnostic and treatment challenges. Data about patients treated for ureterocele in the two hospital clinics during 1996- 2009 are retrospectively evaluated. There were 12 girls and 7 boys. Symptomatic urinary tract infection was found in twelve cases. Ureterocele was associated with duplex systems in eleven cases. Vesicoureteral reflux was detected in 4 patients. Bladder diverticulum complicated with ureterocele in 1 patient. Ultrasonography diagnosed ureterocele in 12 patients. Renal scarring was detected in 6 patients at the side of ureterocele. Fifteen patients showed varying degrees of hydro-ureteronephrosis. Surgical therapy included upper pole nephrectomy in 3 cases. Bladder level reconstruction was performed in 11 cases. Five patients were treated only by endoscopic incision. In the follow up period 4 patients showed long term urinary tract infections whereas 3 of them were treated endoscopically. Postoperative reflux was still present in two patients who were treated by endoscopic incision. Ureterocele diagnosis and treatment show challenges. Urinary tract infection is important marker for urinary system evaluation. Preoperative management generally depends on a combination of diagnostic methods. Endoscopic incision needs serious follow up for postoperative problems.

To provide a low-cost and simple model of culturally-appropriate and low cost facilities for improvement of physical activity for girls and their mothers through an after-school program and to determine the changes in anthropometric indexes after this trial. This national study was conducted in 2006-2007 in 7 provinces with different socioeconomic situations in Iran. Female students who studied in the 7th through 10th grade and their mothers were selected by random cluster sampling. In each province, 24 sessions of after-school aerobic physical activity were held for 90 minutes, two days a week, and 3 months long at school sites in the afternoon. The study comprised 410 participants (204 mothers and 206 daughters), with a mean age of 15.86±1.01 and 40.71±6.3 years in girls and their mothers, respectively. The results of the focus group discussions showed that in general, both mothers and daughters were satisfied from the program and found it feasible and successful. After the trial, the indexes of generalized and abdominal obesity improved significantly both in girls and in their mothers (P-value <0.0001 for weight, body mass index and waist circumference). Our findings may provide a low-cost and simple effective model of motivation for physical activity with targeted interventions for girls and their mothers. We suggest that the success of this trial might be a result of bonding and accompaniment of mothers and daughters. Such model can be integrated in the existing health and education systems to increase the physical activity level.

To evaluate the frequency of urinary tract infections (UTIs) and degree of renal parenchymal damage as well as the parameters of growth, development and nutritional status in antenatal hydronephrosis cases with vesicoureteral reflux (VUR). Infants, whose antenatal ultrasonography (US) showed a fetal renal pelvic diameter of 5 mm or greater were investigated. Of the 277 infants with antenatal HN, 36 [56 renal units (RUs)] were diagnosed with VUR. All cases with VUR were evaluated in terms of the frequency of UTIs, scars appearing on 99mTechnetium-dimercaptosuccinic acid scan (DMSA), growth and development [height and weight standard deviation scores (HSDS and WSDS)], and nutritional status [relative weight (RW)]. Statistical evaluation was performed using the Chi-squared test. Of these 36 patients with VUR, 25 (69.4%) were males and 11 (30.6%) females. Of the 56 RUs, 48 (85.7%) had severe VUR (≥ Grade III). The mean duration of postnatal follow-up was 37.8±24.50 months. The annual UTI frequency was found to be 1.25±0.83 episodes/year. Of these 36 infants, 32 (88.8%) recovered from VUR following either medical (17 patients, 47.2%) or surgical (15 patients, 41.6%) treatment. The initial DMSA showed parenchymal defects in 16 (44.4%) RUs, and 4 RUs showed recovery in the final DMSA. Although statistically insignificant (P>0.05), initial growth and development (HSDS: -0.17±0.86; WSDS: 0.00±0.14) and nutritional status (RW: 98.19±8.81) values gradually improved (0.05±1.06, 0.06±1.071 and 101.97±14.85, respectively). Postnatal early diagnosis and appropriate management of VUR in infants with antenatal hydronephrosis can prevent the occurrence of frequent UTIs, renal scarring and malnutrition, enabling normal growth and development.

Malnutrition is one of the important health problems throughout the world, particularly in developing countries, which has undesirable effects on mental and physical health of children. The aim of this study was to find out the prevalence of malnutrition in children under 6 years old in Privince South Khorasan, Iran, in 2007. This cross sectional and descriptive analytical study was conducted on children under 6 years old in South Khorasan Iran, belonging to six urban and rural regions applying multistage cluster sampling methodology. Data were collected through measuring weight and height, structural questionnaires Anthropometric Nutrution Indicators Survey, and face-to-face interviews with mothers. Malnutrition was measured on the basis of the indices underweight, wasting and stunting. The obtained data was analyzed by means of chi-square test in the packages SPSS and EPI-Info 2000, taking α= 0.05 as the significant level. Out of 1807 children 51.7% were males, 52.2% living in urban areas, and 37% were under 24 months old. Weight index was normal in 52.2% children, 34.4% lightly underweight, 11.7% moderately underweight and 1.2% severely underweight. Prevalence of underweight had a significant relationship to habitation, mother's job and parent's education level. According to stunting criteria, 55% were normal, 28.4% lightly stunted 12.7% were moderate, and 3.9% severe stunted. Stunting also had a significant relationship to habitation, age, mother's job, and parent's level of education. Wasting criteria showed that 67.8% were normal 24.7% light, 5.9% moderate and 1.6% had severe wasting. This had a significant relationship to sex and habitation. Prevalence of malnutrition was in children and its relationship to socioeconomic variables, measures such as increasing parent's education - especially mother's knowledge - constancy of breast feeding until the age of 2 years, and promoting nutrition status of children under 6 years are recommended.

FAS and FASL polymorphisms are suggested to play an important role in tubulitis that is a major component of acute rejection. The aim of this study was to investigate the role of FAS-670A/G and FASL-843C/T gene polymorphisms on allograft nephropathy in pediatric renal transplant patients Fifty three patients (22 males 31 females) aged 2 to 20 years (mean 12.3±0.6) who had renal transplantation and fifty healthy control subjects (25 males 25 females) were enrolled in the study. Pearson's Chi Square test was used for the statistical analysis. Survival rates were estimated with the Kaplan Meier method. Age, sex, chronic renal failure etiology, treatment modality and duration and donor type were recorded. FAS-670A/G and FASL-843C/T gene polymorphisms were compared between renal transplant patients and normal healthy population as well as between renal transplant patients with and without acute rejection. FAS-670A/G genotypes or alleles were not significantly different between control and transplant patients and among transplant patients with and without acute rejection (P>0.05 for all). FASL-843C/T genotypes and alleles were not different between transplantation and control groups (P>0.05 for all). However, FASL-843C/T alleles were significantly different between patients with and without AR (P=0.02). The percentages of C allele were higher in children with acute rejection (68.8% vs 44.6%). FASL gene polymorphisms may play a major role in acute rejection while FAS polymorphisms have not been found to be different between patients with and without acute renal graft rejection.

Neonatal sepsis is a common cause of morbidity and mortality among newborns in the developing world. We have investigated the causative agents and their antimicrobial susceptibility of late-onset sepsis (>72 h post-delivery), and determined the possible association between various risk factors and the mortality due to neonatal sepsis in 2008. To view the changes in years, we compared them with the data which we gained in 2004. Medical records of all neonates with late-onset sepsis were reviewed for demographic characteristics (birth weight, gestational age, gender, type of delivery, and mortality rate), positive cultures and risk factors of mortality. One hundred and forty-seven and 227 neonates had been diagnosed as late-onset sepsis in 2004 and 2008, respectively. Coagulase-negative staphylococcus was the most frequent microorganisms. Gram-negative bacilli, particularly Pseudomonas aeruginosa showed a significant increase in years. The mortality rate was 11.5% and 19% in 2004 and 2008, respectively. Birth weight, gestational age, and infection with Klebsiella spp. isolates were found to have significant association with sepsis mortality in our neonatal intensive care unit (NICU). The present study emphasizes the importance of periodic surveys of sepsis encountered in particular neonatal setting to recognize the trend. Increased Gram-negative bacilli rate was possibly related to the widespread use of antibiotics in our NICU.

Celiac disease is an important cause of chronic diarrhea, failure to thrive, and anemia in children. Mode of presentation of celiac disease has changed in last few years. Study was conducted to determine the mode of clinical presentation of a large group of patients with celiac disease and whether there has been a change in the presentation with the time. A prospective study was conducted on 134 children diagnosed to be having celiac disease in the Pediatric Gastroenterology, PGIMER, Chandigarh, from July 1st 2006 to December 31st 2007. Their detailed clinical profile was recorded on a pretested proforma and all patients underwent hemogram, liver function tests, IgA Anti tTG, and upper GI endoscopy. Major symptoms at presentation were diarrhea (54.5%), failure to thrive (52.2%), abdominal distension (41%), anemia (40%), pain abdomen (19.4%), vomiting (15.7%) and constipation (2.2% of cases). 60.4% of patients had short stature. Anemia was microcytic hypochromic in 79.1% of patients, and dimorphic in 20.9%. Serum transaminases were raised in 38.8 % of cases. The mean serum anti tTG level was 164.24U/ml (Range 0-749 U/ml) and levels correlated with the severity of small intestinal damage on biopsy. 15 patients were negative for the serology but 8 out of them had IgA deficiency and all had histopathology suggestive of celiac disease. Classical presentation of celiac disease is less commonly encountered these days probably related to the more widespread use of serologic testing and early recognition of atypical manifestations of celiac disease.

Acute scrotal conditions are a common clinical setting that present with pain and swelling of the hemiscrotum. The aim of our study has been to evaluate the findings in boys operated on acute scrotum. A descriptive study was conducted on 100 patients with acute scrotum admitted to Mofid Children's Hospital from March 1993 to March 2007. Data included history, age, primary symptoms, definite diagnosis, side involvement, paraclinical tests, imaging modalities, medical or surgical management and type of the surgery. Diagnosis was made mainly by clinical signs and symptoms and surgical exploration. Torsion of testis (n=31) was the most common cause of acute scrotum followed by incarcerated inguinal hernia (n=30), torsion of testicular appendage (n=27), epididymo-orchitis (n=7), idiopathic scrotal edema (n=4) and hematocele (n=1). Most (34%) of the patients were in the first year of life and the mean age was 5.4 years. The commonest signs were pain and swelling (62%) followed by pain, swelling and redness (21%) and pain alone (16%). 83 patients consisting of 31 with torsion of testis, 14 with torsion of testicular appendage, 30 with incarcerated hernia and 7 with epididymo-orchitis underwent surgical exploration after careful physical examination. 10 of 31 patients with torsion of testis had orchiectomy and orchiopexy of contra-lateral testis and the rest had detorsion and bilateral orchiopexy. 80% of patients were referred to the hospital after 12 hours of clinical onset of symptoms. Early exploration of scrotum based on careful physical examination excludes the risk of misdiagnosis by diagnostic procedures and unnecessary delay by diagnostic techniques. Exploration of scrotum is a relatively safe and simple procedure with good cosmetic results, it also allows an accurate diagnosis to be made.

Early and accurate diagnosis of bacterial meningitis is of critical concern. Optimum and rapid laboratory facilities are not routinely available for detecting the etiologic agents of meningitis. The objective of this study was to compare polymerase chain reaction (PCR) assay with culture for detection of bacteria in central nervous system (CNS) samples from patients suspected to have meningitis. One-hundred CSF samples were obtained and divided into two parts. One part of samples was used for standard bacterial culture and gram staining. The remaining was used for DNA extraction. PCR assay was performed with universal primers for 16S rDNA gene of bacteria. Performance characteristics of the test were determined. The PCR method was able to detect bacteria in all 36 culture-positive and in 38 of 64 culture-negative cases showing sensitivity and specificity of 100% and 40.6% respectively. Positive predictive value was 48.6% and negative predictive value 100%, however, Kappa coefficient showed the correlation of the 2 methods to be at 0.33. There are advantages and disadvantages in performance characteristics of the conventional CSF culture and universal CSF 16S rDNA PCR. Therefore, it is recommended to use both methods in clinical practice, particularly in suspicious contaminated samples, with presumable presence of fastidious or slow growing bacteria because of antibiotic consumption.

Kawasaki disease is an acute vasculitis that occurs mainly in children. Cervical lymphadenopathy is one of the major presenting manifestations of Kawasaki disease. We report a case of Kawasaki disease with para aortic lymphadenopathy, as an unusual feature in this disease. This 2.5 year old girl presented with persistent high grade fever, erythematous rash, bilateral non purulent conjunctivitis, red lips, and edema of extremities. Laboratory results included an elevated erythrocyte sedimentation rate, leukocytosis, anemia, and positive C-reactive protein. On second day after admission she developed abdominal pain. Ultrasonography of abdomen revealed multiple lymph nodes around para aortic area, the largest measuring 12mm´6mm. Treatment consisted of aspirin and high dose intravenous γ-globulin. Ultrasonography and CT scan of abdomen performed one week later showed disappearance of the lymph nodes. There are few previous reports of lymphadenopathy in unusual sites such as mediastinum in Kawasaki disease. Para aortic lymph nodes enlargement might be an associated finding with acute phase of Kawasaki disease. In these patients a close observation and ultrasonographic follow up will prevent unnecessary further investigation.

Hepatitis A virus (HAV) infection constitutes an important health problem in developing countries. It is usually a benign self-limiting disease, but may present with atypical clinical findings. A twelve-year-old male with ascites, pleural effusion, and acalculous cholecystitis during the course of HAV infection is reported. He was managed conservatively and clinical improvement was observed with resolution of HAV infection. To our knowledge, this is the first case in which all these three rare complications were observed in a single patient in the early period of disease.

Niemann-Pick disease and β-thalassemia are distinct conditions with specific clinical and morphological manifestations. β-thalassemia is the most common inherited blood disorder in Iran whereas Niemann-Pick disease, a lysosomal storage disorder, is rarely found in this country. This 5-month old girl, a known case of β-thalassemia major was hospitalized for failure to thrive and hepathosplenomegaly. Because of unusual splenomegaly and liver enzymes disturbance that was not compatible with the first diagnosis, further evaluation revealed cherry red spot and high lipid profile suggestive of lysosomal storage disease. Foamy cells in the bone marrow and low activity of the specific enzyme led to the diagnosis of Niemann-Pick disease. This unique case illustrates the importance of looking for a second pathological condition in a patient whose clinical profile does not support the first diagnosis in its entirety.

Chronic granulomatous disease (CGD) is an immunodeficiency affecting phagocytic leukocytes. Defective respiratory burst mechanism renders the affected patients to be susceptible to catalase positive microorganisms. With the great successes in antibacterial prophylaxis and therapy, fungal infections are a persistent problem. Invasive aspergillosis is the most important cause of mortality in CGD. We describe a nine year-old boy with CGD who presented with aspergillus induced skull osteomyelitis. He was successfully treated with voriconazole after initial failure of amphotericin B therapy. Currently, newer triazoles are recommended as initial therapy for invasive aspergillosis in immunodeficiency states such as CGD.

Congenital pouch colon, also known as congenital short colon or "Pouch colon syndrome", is a rare condition that occurs in association with anorectal malformations; colon is either partially or completely replaced by pouch-like dilatation and communicates with the urogenital tract by means of a fistula. This anomaly is exclusively seen in Northern parts of India with only a few cases reported from elsewhere. A 1-day old neonate was presented with abdominal distension due to lack of passage of meconium. Clinical and radiological investigations revealed ano-rectal malformation. Incidental findings were left sided renal agenesis and right sided anorchia. Laparotomy revealed congenital pouch colon which was dealt accordingly. The baby is now healthy and awaiting further reconstructive surgery. Although urogenital anomalies are not uncommon with congenital pouch colon, the finding of renal agenesis with unilateral anorchia is quite rare.

A one and a half years old boy presented with recurrent episodes of respiratory distress, accompanied by dry non spasmodic cough and characterized by appearance of a continuous stridor showing no positional variation. The child was symptomatic since early infancy.Parents also complained of inability to gain weight as compared to other siblings. There was no history of foreign body ingestion or complaints of asthma or tuberculosis in the family. General physical examination revealed tachypnea and biphasic stridor in a malnourished and stunted child in the absence of any significant lymphadenopathy or oral thrush.On systemic examination, bilaterally, stridorous sounds were auscultated. Primary investigations on the child showed minimal reflux on gastro-esophageal reflux isotope scan, a normal chest roentgenogram, negative sweat chloride test and negative serology for HIV (Human immuno­deficiency virus).Echocardiography performed on the child revealed a structurally normal heart. On conducting further investigations, bronchoscopy detected a bulge in the anterior tracheal wall while barium swallow displayed indentation in the upper esophagus. The MRI (magnetic resonance imaging) subsequently conducted clinched the underlying clinical condition. The MRI images are depicted below.