Iranian Journal of Pediatrics
Volume:27 Issue: 1, Feb 2017

The symptoms of attention deficit/hyperactivity disorder (ADHD) may manifest before the child begins elementary school.
To survey preschool teachers’ knowledge and attitudes regarding ADHD.
In this cross-sectional study, 360 preschool teachers were selected via a randomized cluster sampling method from among the teachers working in Tabriz, Iran, during 2013. A self-administered questionnaire concerning the symptoms of ADHD, the method of diagnosis, and their attitudes regarding ADHD was completed by the participants.
The response rate was 96.1%. The teachers’ age was 39.457.66 years. Educational courses (43.6%) constituted their main source of knowledge regardingADHD. The teachers’ knowledge was more accurate regarding the symptoms of ADHD(81.8% correct answers), followed by the treatment (77.82% correct answers). Their knowledge concerning the consequences of having ADHD and the etiology of the condition was relatively low (61.4% and 69.82%, respectively). The teachers’ knowledge was not correlated with their age or years of experience (P = 0.812). The teachers also reported that their typical reaction to inattentionon the part of children with ADHD was to inform the parents (59%), while their typical reaction to hyperactivity was to point out the issue to the student (45.4%). More knowledge regarding the etiology of ADHDand more overall knowledge aboutADHDwere correlated with a healthier attitude on the part of the teachers toward children with ADHD.
This study is the first to evaluate the knowledge of Iranian preschool teachers regarding ADHD. Preschool teachers’ knowledgeabout the consequences of havingADHDas well as the etiology of the disorder needs improvement. Ourresults indicated that increased knowledge would correlate with a healthier attitude on the part of preschool teachers.

The primary purpose of this study was to investigate the effects of phototherapy on antioxidant status of preterm and term infants with hyperbilirubinemia.
Term and preterm infants were divided to three groups; group 1: 28 to It was found that the reduced glutathione levels in group 1 including preterm infants decreased significantly after phototherapy. It was observed that levels of malondialdehyde increased significantly in term infants compared to preterm infants in group 1 and group 2. It was observed that the decreases in bilirubin and superoxide dismutase enzyme were correlated in group 2 preterm infants and group 3 term infants.
Phototherapy did not significantly affect the antioxidant level in the present study. The fact that therewasa significant decrease in glutathione peroxidase levels after phototherapy only in group 1 preterm infants suggests that more attention should be paid when phototherapy is used in this age group.

Untreated dental caries have considerable consequences on the growth and development of children and their quality of life.
The aim of this study was to evaluate the prevalence of clinical consequences of untreated dental caries in a sample of Iranian children based on the pufa/PUFA diagnostic index.
In this descriptive analytical study, 360 students between the ages of 6 - 12 years were selected using cluster sampling. Oral clinical examinations were performed by one pedodontist. DMFT, dmft, PUFA and pufa scores were recorded. The height and weight of children were also measured to calculate body mass index (BMI). Descriptive findings are reported in terms of frequencies and percentages, as well as means and standard deviations. The data were analyzed in the Statistical Package for the Social Sciences (SPSS) version 21 using Fisher’s Exact Test, the Mann Whitney U test, and logistic regression. The level of significance was set at P = 0.05.
The overall caries experience and the overall prevalence of untreated dental caries in the study population was 93.0% (mean value of 4.39 ± 2.78) and 30.0% (mean value of 0.57 ± 1.15), respectively. Components of d/D and p/P had the highest frequencies. Males and females showed no significant differences in terms of prevalence or severity of untreated dental caries (P > 0.05). The prevalence and mean value of pufa score were significantly higher in under-weight subjects than in normal children (P Our results emphasize the need for further attention to public dental care programs and dental care measures.

Approximately 60% of term and 80% of premature infants are hospitalized for hyperbilirubinemia in the first week of life. Hyperbilirubinemia is the most common cause of infant hospitalization and readmission. Due to the high frequency of hyperbilirubinemia in infants and the high costs of treatment, it is necessary to find a way to decrease hospitalization duration.
The aim of this study is to assess the adjunctive effect of probiotics on decreasing hospitalization time for infants with hyperbilirubinemia.
In this randomized, controlled clinical trial, 92 term infants with hyperbilirubinemia who met the inclusion criteria were randomly assigned to either the probiotic or control group. Patients in both groups underwent common phototherapy. Once a day, those in the probiotic group were also given half of a capsule of Prokid probiotic, while those in the control group received half of a placebo capsule. The duration of phototherapy and hospitalization, the blood groups of mothers and infants, and each patient’s bilirubin levels before and after phototherapy, direct Coombs test results, and levels of hemoglobin, G6PD, and reticulocytes were recorded.
Data from 92 patients with a mean age of 5.25 ± 2.35 days underwent analysis. The control group had 47 (51.1%) patients with a mean age of 5.19 ±2 .51 days and the probiotic group had 45 (48.9%) patients with a mean age of 5.31 ± 2.19 days (P = 0.81). The 92 patients had a mean bilirubin level of 16.70 ± 3.07 mg/dL, with a mean of 16.42 ± 3.53 mg/dL in the control group and 17.00 ± 2.49 mg/dL in the probiotic group (P = 0.37). The duration of hospitalization averaged 3.34 ± 0.70 days overall, with an average of 3.55 ± 0.74 days for the control group and 3.13 ± 0.70 days for the probiotic group. The probiotic group had a significantly lower hospitalization stay in comparison to the control group (P = 0.004).
Our findings suggest that probiotics may be beneficial as an adjunct treatment for infants with hyperbilirubinemia by reducing the duration of hospitalization.

Congenital hypothyroidism (CH) is one of the major causes of physical and mental disabilities, which are preventable and treatable. This study aimed to investigate physical growth and to evaluate the effectiveness of performed therapeutic interventions on normality of serum T4 and TSH levels in children with CH of Yazd city.
This retrospective cohort study was performed on all neonates with CH, who were born during years 2006 and 2008. The growth pattern of height, weight and head circumference during the first five years of children with CH and the effectiveness of performed therapeutic interventions on normality of serum T4 and TSH levels were evaluated. The collected data were analyzed using the 22nd version of the SPSS software.
The pattern of height, weight, and head circumference of the girls with CH was comparable with the growth pattern of NCHS of healthy individuals. The pattern of height and weight growth of boys with CH gradually became similar to the growth pattern of NCHS of healthy boys. However, there was a decline in their head circumference growth trend after six months of age. Also it was revealed that therapeutic interventions had an appropriate effect on normalization of serum TSH, T4 levels and growth pattern in CH children under treatment.
After treatment and care for these patients, the growth patterns and serum T4 and TSH levels of these children reached a normal and desirable range.

The effect of fentanyl and morphine, two most frequently used drugs for premedication in general anesthesia, on gallbladder of newborns, has not been sufficiently investigated. Intubation and mechanical ventilation in a neonatal respiratory distress syndrome are stressful procedures, in which these two drugs are used to reduce stress and pain. We studied the effect of these drugs on neonatal bile system during these procedures
The present study aimed at determining the effect of fentanyl and morphine on gallbladder dimensions among newborns admitted to the neonatal intensive care unit (NICU).
Thirty-two newborns with the gestational age between 26 and 38 weeks, undergoing intubation and mechanical ventilation, were selected for this randomized, double-blinded, clinical trial study. They were randomly divided into two groups; group 1 received morphine and group 2 received fentanyl. Gallbladder measurements (width, depth, length and volume) were compared between the two groups by ultrasound evaluation. The data were collected between Nov 2012 and Oct 2013 at the NICU of the Children’s hospital in Bandar Abbas, Iran.
There were no significant differences between the two groups in the evaluated parameters when demographic variables were compared. We found statistically differences between width, depth and volume of the newborns’ gallbladders. However, there was no significant differences with regard to gallbladder length (P = 0.19).
Morphine caused gallbladder dilatation more than fentanyl. However, it should be considered that total parenteral nutrition (TPN) which is common in NICU leads to gallbladder dilatation. Therefore, it seems that fentanyl could be considered as a preferred short-term analgesic with less adverse effects than morphine. A larger study is needed to confirm these results.

Tissue Doppler imaging evaluates the ventricular function in both systolic and diastolic assessments.
This study aimed to determine the level of cardiac function in children with Down syndrome without structural cardiac lesions using conventional and tissue Doppler echocardiography.
From September 2013 to August 2014 in Mashhad, Iran, a group of 36 children with Down syndrome aged between 4 months and 19 years without anatomic heart disease had their ventricular function assessed by both 2D echocardiography and tissue Doppler imaging. The following were measured: velocity of systolic waves (S), traditional Doppler imaging of early diastolic waves (E), traditional Doppler imaging of late diastolic waves (A), tissue Doppler imaging early diastolic waves (E’), and tissue Doppler imaging late diastolic waves (A’) at the mitral and tricuspid valve levels. Other data, such as fractional shortening, heart rate, and ejection fraction, were also measured.
At the time of the examination, the mean age of the participants was 6.4 ± 5.5 years. An association was found between children’s age and the tricuspid A-wave. The A-wave velocity of the tricuspid annulus increased when the body surface area decreased. In addition, compared with the normal subjects, the large age group presented with considerable differences in wave speed, including E, A, and E/E’, at the mitral and tricuspid annulus levels.
Despite the Down syndrome children having an apparently normally structured heart, tissue Doppler imaging reveals different findings than those of normal children. The findings of this modality can be used to explain the reason behind the limited physical functioning of children with Down syndrome and may be considered as predictive factors for future cardiac events in these children.

Persistent pulmonary hypertension of the newborn (PPHN) occurs in post-term neonates with an incidence of 1 in 500 - 1,500 live births. The survival rate is approximately 69% after conventional management of infants suffering from PPHN. Extracorporeal membrane oxygenation (ECMO) therapy improves survival up to 86%.
A total of 32 neonates with PPHN participated in this study. These neonates were randomly assigned into two 16-case groups: group A received tadalafil while group B received sildenafil. A random simple sampling method was used for the selection of subjects. The severity of tricuspid regurgitation (TR), main pulmonary artery (MPA) diameter, mean pulmonary artery pressure (MPAP), and right ventricular end-diastolic diameter (RVEDD) were assessed by echocardiography before and 6 months after treatment.
MPAP decreased after treatment in both groups, but the mean of changes in PAP in the two groups was not significantly different (P = 0.48). Both tadalafil and sildenafil significantly reduced the TR severity, RVEDD, and MPA diameter (P Tadalafil and sildenafil can similarly reduce MPAP, TR severity, RVEDD, and MPA diameter.

Neonatal intensive care unit (NICU) developmental care refers to interventions in the infant’s environment in neonatal intensive care unit to reduce environmental stresses and provide greater family-infant compatibility.
The aim of this study was to assess current developmental care performance and factors influencing implementation of this care at NICUs in Tehran, Iran.
This cross-sectional study as part of a larger mixed method study assessed the quality of developmental care in Tehran NICUs. The study was performed on 400 nurses working in level III NICUs in 27 hospitals of Tehran during years 2014 and 2015. Data were collected using two scales, «NICU developmental care assessment (NDCA) scale » and «NICU developmental care structural (NDCS) checklist». The scales validity was detected by content, face and construct and reliability by internal consistency and test-retest. The overall and each domain score were calculated in percentages. Data were analyzed using the SPSS-21 software using descriptive statistics tests and regression analysis.
The total score of quality of providing developmental care was 74. 84%. Among all domains, «daily routine care» had the highest score (85. 67%) and «sleep and pain care» had the lowest score (66. 63%). Total score of structure was 43. 06%. The number of neonates admitted per day (B -0. 328, P = 0. 019) and number of infants managed by each nurse (B -2. 543, P = 0. 019) were significant predictor variables for better quality of total developmental care.
The number of infants cared and admitted were the only significant factors contributing to high quality of developmental care. Therefore, it is reasonable to assume that in case of Tehran, work-load and structure of services should receive greater attention.

Play, particularly pretend play, has a cognitive basis and has been linked to the language and social ability.
The goal of this study was to examine face and content validity, inter-rater, intra-rater and test-retest reliability of the Persian translation of the child-initiated pretend play assessment
Ten occupational therapists consented to be in the content validity study. Face validity was examined by five occupational therapy specialists. For reliability, 31 typically developing children aged 4 - 6 years were chosen from kindergartens of four regions of Tehran, Iran. Two weeks after the initial assessment the children were re-tested for test-retest reliability. Intra-rater and inter-rater reliability was scored from videos of the children’s play assessment.
To be culturally appropriate for Iran, some phrases were changed and the pigs were replaced by dogs. Content validity index (CVI) and content validity ratio (CVR) were acceptable for all items. The Intra-class correlation coefficient was ICC = 0.99 for intra-rater reliability and ICC = 0.98 for inter-rater reliability. For test-retest reliability, the intra-class correlation coefficient for symbolic and combined object substitution scores and all elaborate play scores ranged from ICC = 0.69 to - 0.99. For imitated actions, the majority of children scored 0 on both test and re-test.
The Persian version of child initiated pretend play assessment has appropriate face and content validity. Inter-rater and intra-rater reliability were excellent. PEPA, combined and symbolic NOS showed good to excellent test-retest reliability. Test retest reliability for conventional NOS was moderate and NIA was not stable with more children imitating the examiner in the first test but not the re-test.

To assess serum osteopontin (OPN) concentrations and to evaluate the correlation between OPN levels and insulin resistance (IR) in obese dyslipidemic children.
The study featured 107 obese children with ages ranging between 3 - 17 years. Anthropometrical measurements and biochemical analyses were performed and serum OPN samples were obtained. IR was defined using the homeostasis model assessment-insulin resistance (HOMA-IR) protocol.
Of the 107 obese children that were recruited for the study, 63 were girls (58.9%) and 44 were boys (58.9%), with a mean age of 11.18 ± 3.41 years. Of them, 21 (19.6%) were diagnosed with dyslipidemia. No significant differences in age and gender were identified between the dyslipidemic and non-dyslipidemic groups. The mean body mass index (BMI), fasting blood glucose, insulin, and alanine transaminase levels were similar in both groups (P = 0.74). The average total cholesterol (TC), low-density lipoprotein cholesterol (LDL), and triglyceride (TG) levels were higher, while the high-density lipoprotein (HDL) and cholesterol levels were lower in the dyslipidemic group. Amongst the children with dyslipidemia, 28 (84.84%) had IR. The mean OPN levels in the dyslipidemic group were not found to be higher than the non-dyslipidemic group (46.94 ± 25.64 vs 48.92 ± 24.45; P = 0.70). Multivariate regression analysis confirmed that increased HOMA-IR levels (P = 0.01) are an important risk factor for dyslipidemia.
While serum OPN levels were found to be related to IR in obese children, OPN levels were not associated with dyslipidemia.

The aim of this study was to assess the presence of DNA damage in full-term newborns with neonatal sepsis.
Sixty neonates with early onset neonatal sepsis and 45 apparently healthy controls were enrolled in the study. Screening of neonates was done using a modified clinical sepsis score and hematological scoring system, adjusted to the results of blood culture and screening tests. Complete blood count, C-reactive protein (CRP), and DNA studies were done.
Sepsis was likely in 41 (68.3%) patients with scores of 3 or 4 and CRP levels of 12 - 48 mg/L. Sepsis was very likely in 19 (31.7%) patients with scores of ≥ 5 and CRP of 48 - 96 mg/L. Sepsis was unlikely in all controls with scores of ≤ 2. The mean neutrophil count was 9700 ± 4600/µL in patients and 4230 ± 1400/µL in controls. The higher the total polymorphonuclear count and CRP level, the more severe was the sepsis. Twenty-six of 60 (43.3%) sepsis patients and 5 of 45 controls (11%) had DNA damage. There was a highly significant negative correlation between DNA damage, blood culture results, and CRP levels.
DNA damage, demonstrated by clinical and laboratory evidence with a combination of blood cultures, CRP, and hematological scoring system results, can be used as an indicator of both the immune status of the neonate and the severity of the sepsis.

To find out the early neonatal outcome (morbidity and early neonatal mortality) of the babies born by caesarean section (CS) and to compare the outcomes between elective and emergency CS.
A longitudinal study was conducted in a tertiary care hospital. Maternal and neonatal characteristics were noted.
A total of 750 neonates were enrolled and 37% were born by elective CS. Out of 750 children 55% were male newborns and 45% were females. The NICU (neonatal intensive care unit) admission requirement was 24%, whereas 3.33% of neonates died within 7 days of life. Neonatal morbidity was higher in emergency CS, similar to respiratory depression at birth (OR: 6.00, 95% CI 3.06-11.78, P Newborns delivered through emergency CS had a higher morbidity and mortality rate compared to elective CS. Adequate antenatal care and early referral may convert this emergency CS to normal or elective CS and can reduce neonatal morbidity and mortality.

Obesity is the major cause of nonalcoholic fatty liver disease (NAFLD) as the most common form of chronic liver disease. Prevention of obesity can be useful in reducing the incidence of NAFLD.
This study evaluated the prevalence of fatty liver in relation with body mass index (BMI) by means of ultrasound in high school students of Zanjan.
In this cross-sectional study, three hundred high school students aged 12 to 18 years, from Zanjan city were selected randomly and divided to three groups with one hundred children in each group, based on body mass index. Only 240 of them participated in the study. The participants were examined by a pediatrician. Weight, height and waist circumferences were measured at baseline. Liver ultrasound was performed for all children and grade of fatty liver was determined.
There was a significant correlation between grade of fatty liver with BMI, gender and age (P = 0.000, P = 0.000 and P = 0.006, respectively). Boys had higher rates of fatty liver than girls. Our study showed a strong association between BMI and prevalence of fatty liver on ultrasound. However, there was no relation between severity of fatty liver and waist circumference (P = 0.067). The waist circumference was greater in boys, and it increased with age. The mean BMI in children with grade 1 and 2 fatty liver was 26.79 and 30.5, respectively.
According to the study hypothesis, based on BMI, the degree of NAFLD in children was predictable. Ultrasound of liver is one of the assessment methods of fatty liver but it is not a diagnostic method; it is useful for prevention in order to reduce BMI.

Neonatal period is one of the most important critical phases of human life. Intensive care unit has a stressful environment for the infant in which the patient will be under the pressure of factors such as noise, nursing intervention and harsh light; the most important factor in this regard being separation from parents.
This study aimed to investigate the effect of skin-to-skin care by fathers on salivary cortisol of his infant.
This study was a randomized clinical trial on 45 premature infants paired by their fathers at the neonatal intensive care unit (NICU) of Tabriz Alzahra teaching hospital conducted during November 2015. The control group received standard care and the intervention group had 45 minutes of skin to skin care. Saliva samples were collected from infants before, during, and after this intervention to measure the cortisol level. The SPSS 13 statistical software was used to analyze the data with the significance level of P Salivary cortisol in babies in the control group had a mean value of 66.36 (SD = 71.22) and intervention group a mean value of 59.56 (SD = 59.20) (P = 0.56).
Both groups showed decreasing cortisol levels during the study, the reduction in the skin-to-skin care group was more than the control group, but with no significant difference. Thus, making it possible for fathers to take care of their infants in an effective, helpful and secure way.