Iranian Journal of Pediatrics
Volume:17 Issue: 2, 2007

Objective: Protozoa Giardia lambelia is caused to diarrhea in human and other mammals in worldwide. Giardia colonizes in duodenum and earliest jejunum. It can cover the intestinal surface and causes the stateorrhea، malabsorbtion syndrome and absorb disorder of vitamins A، E and D. Investigation the effect of Giardia on the vitamin B12، folic acid and iron of patients were the purpose of this study.
Material & Methods: A total of 30 children with giardiasis، aged between 6-12 years- old، selected from 3000 patients، who were admitted to the Emam Khomeiny hospital and diagnosed by stool examinations (direct and formalin-ether methods). Blood of patients and control were collected. Amount of vitamin B12 and folic acid were evaluated with radioimmunoassay and iron was evaluated with Ferene method.
Findings: According to the data، folic acid in the patient had no significant difference against control but vitamin B12 and iron in the patient with giardiosis was less than control and the differences were significant (P=0.01، P=0.04 respectively).
Conclusion: According to the results diagnosis of giardiosis in the early stage may prohibit intestinal damage and clinical symptoms due to vitamins and mineral elements shortage in the children.

Objective: Haemophilus influenzae type b (Hib) is a most frequent cause of invasive diseases such as meningitis، septic arthritis and pneumonia in children under 5 years old. Asymptomatic oropharyngeal colonization is an origin of distribution of microorganism to others and probable bacteremia in the same child. The aim of this study was to determine antibiotic susceptibility of Hib in Tehran day care centers.
Material & Methods: Hib was isolated from oropharynx of 1000 children visiting 25 day care centers selected randomly in different parts of Tehran city during second half of year 2005. For antibiotic susceptibility determination we used disk diffusion test.
Findings: Ampicillin resistance was 32.3% and Beta lactamase production was seen in 23.6%. Cephalosporins resistance except for cefixime was between 10% to 20% and in cefixime was 58.8%. Rifampin resistance was 17.6%. Resistance to studied macrolids including azythromycin and clarythromycin was 19.6% and 35.3%.
Conclusion: On the base of high antibiotic resistance to Hib in our study and other similar studies in Iran، we recommend to use optimal effective and proper antibiotics to decrease the high rate of antibiotics resistance to Hib colonization and its invasive diseases.

Objective: Recent studies have shown that amoxicillin، taken once a day may be as effective as oral penicillin V، three or four times a day، as an effective choice for treatment of group A β-hemolytic streptococcal (GABHS) pharyngitis. The purpose of this study was to evaluate the effectiveness of once-daily amoxicillin vs intramuscular benzathine penicillin G in the treatment of streptococcal pharyngitis.
Material & Methods: Children 6-15 years of age presenting to a private pediatric clinic with GABHS pharyngitis in the urban population of Mashhad، Iran. Prospective randomized controlled study in which patients were randomly assigned to receive orally amoxicillin (750 mg once daily) for 10 days versus a single shot of intramuscular benzathin penicillin G (600.000-1.200.000IU). They received orally amoxicillin by a health worker and compliance was monitored. After 48 hours if the first throat culture was positive، the patients were reevaluated by the same physician، and a second throat culture was obtained to evaluate bacteriologic response to treatment. Ninety-nine patients had throat swabs that yielded positive results on culture. In the latter group، 31 children were randomly assigned to receive intramuscularly penicillin، and 68 children were randomly assigned to receive once-daily amoxicillin. Outcomes were measured by impact on the clinical course and response، eradication of GABHS within 48 hours and compliance. Eleven of the amoxicillin-treated patients refused to take the drug، were noncompliant، or did not return for the follow-up visit. Three of this group، had residual positive culture 48 hours after treatment، and had bacteriologic failure with intramuscular penicillin. These were excluded as carriers، leaving 54 amoxicillin-treated patients. The children in the two treatment groups were comparable with respect to age and، gender.
Findings: There were no significant differences in the clinical and bacteriological response، bacteriologic failure and residual positive cultures between the two groups after 48 hours. In the amoxicillin group، 18.9% failed to respond to treatment compared to 6.4% in the penicillin group. The difference was not statistically significant (P-value = 0.1).
Conclusion: Our study was in line with two studies comparing oral forms of drugs. These data demonstrate that once-daily therapy with amoxicillin is as effective as intramuscular benzatine penicillin G for the treatment of GABHS pharyngitis.

Objective: As epilepsy and seizure disorders are common in children، antiepileptic drugs are used more commonly in this age group than in adults. This study was carried out in order to determine the vitamin D and calcium status of children receiving antiepileptic drugs and evaluation of effects of these drugs on vitamin D and calcium metabolism.
Material & Methods: Sixty epileptic children and adolescents visiting Children''s Neurology Clinic who were taking antiepileptic drugs and had inclusion criterions were selected as simple sampling from July 2005 to June 2006. Thirty age and sex matched normal children and adolescents were considered as control group. Serum levels of 25OHD3، calcium and alkaline phosphatase is compared between groups.
Findings: Serum levels of 25OHD3 (P<0.001)، calcium (P<0.001) and alkaline phosphatase (P<0.001) were significantly different between groups. Ten percent of patients had serum 25OHD3 level below lower normal limit. There was a reverse correlation between duration of drug therapy and serum level of 25OHD3 (r = - 0.345، P=0.011).
Conclusion: Antiepileptic drug treatment in children results in reducing serum 25OHD3 and calcium levels and increases bone turnover. With longer duration of treatment serum 25OHD3 level decreases more.

Objective: To cease the increasing damage to the brain neurons following epileptic seizures، natural anti-oxidative systems play the main role. One of the most important detoxifying systems is composed of the trace element selenium and its dependent detoxifying enzyme، glutathione peroxidase. The object of this study was to evaluate serum selenium and red blood cell glutathione peroxidase activity in pediatric epileptics and compare it with that of healthy children.
Material & Methods: Patients suffering from various types of epilepsy were studied during a 15- month period. Control group consisted of healthy children with no history of any neurologic disease. Serum selenium level and RBC Glutathione peroxidase activity was evaluated and the results compared.
Findings: Fifty three epileptic patients with a mean age of 5.5 years and 57 healthy children with a mean age of 5.6 years were enrolled in this study. Statistically significant differences in the mean values for serum selenium level (72.9 vs. 86.0 ng/ml، P=0.017) and also RBC glutathione peroxidase activity (440.6 vs. 801.0 nmol/min/ml، P=0.000) between the two groups were observed. On the other hand، after analyzing the study results، trying to introduce a value for GPx activity، which could be accepted as a reliable indicator for serum selenium deficiency in patients، was not successful.
Conclusion: Findings of the present study strongly support the proposed crucial role for the trace element selenium and deficiency of its dependent enzyme، glutathione peroxidase، in epilepsy pathogenesis.

Objective: Although pediatric pre-hospital emergency medical services (EMS) are a main challenge of health care systems، few data exists over it. Current study of ambulance calls for medical causes relating to children in Tehran was conducted with the following aims: 1) assessment of the frequency of causes of EMS call، 2) assessment of time indices of service providing by EMS، and 3) to assess the correlation between outcomes and time indices.
Material & Methods: In this retrospective study، all calls to Tehran EMS system (Dial 115) for medical causes of children =<15 years old in Tehran between December 2005 and May 2006 were extracted. Demographic variables، accident type، patient outcome before hospital arrival، and ambulance time indices (response time، scene time، total run time، total run time hospital، transport time، round trip time) were registered.
Findings: 1052 (15.5%) calls were for children. From these، 717 (68%) were due to problems of medic problems. The most frequent problem was epilepsy (26.8%)، unconsciousness (18.1%) and respiratory disorders (15.2%). 12 (5. 6%) subjects died before ambulance arrival، but no one died between scene and hospital arrival. Mean (SD) delay time، response time and scene time were 3.8 ± 1.8، 15.1 ± 6.9، and 23.5 ± 10.9، respectively. The pre-hospital mortality was not correlated with any of the time intervals.
Conclusion: One of six ambulance calls in Tehran is related to pediatric patients، most of them with a medical cause. Epilepsy، unconsciousness and respiratory disorders as the most frequent causes for EMS calls for medical problems highlights the need for planning for training of the EMS personnel with these problems. There is still a need for further improvement in time intervals of EMS services، which may be possible by proper management and equipping by more ambulances.

Objective: This study was performed to determine the prevalence and risk factors of low birth weight (LBW) among the live born neonates at the hospitals in Tehran from Sep 2005 till Sep 2006.
Material & Methods: This study was a cross-sectional study. Ten hospitals in Tehran were chosen randomly. During the period of study several days in a month were chosen randomly and all newborns born on those days were assessed. The studied characteristics included sex، gestational age، birth order، the interval to previous birth، existence of congenital anomalies، multiple pregnancy، maternal age، gravidity and parity number، history of maternal fertility (including previous LBW infants، infertility، abortion)، history of recent pregnancy (including smoking، drug consumption، x-ray exposure، weight gain، vaginal bleeding، gestational illness، folate and iron consumption، gestational infection)، chronic illness of the mother، maternal education and maternal job.
Findings: We studied 514 (56.5%) females and 391 (43.5%) males. The LBW prevalence was 8.6% (78 newborns). There was significant statistical relationship between LBW and gestational age، the interval to previous birth، existence of congenital anomalies، multiple pregnancy، maternal age، history of maternal fertility (including previous LBW infants، infertility، abortion)، history of recent pregnancy (including smoking، drug consumption، weight gain، vaginal bleeding، gestational illness، iron consumption، gestational infection)، chronic illness of the mother and maternal education.
Conclusion: Although our results regarding LBW prevalence and risk factors confirm the results of other studies، we recommend perspective studies to reconfirm the LBW risk factors.

Objective: Hyperbilirubinemia in the healthy، term neonate is the most common cause of rehospitalization. Expense، risk of nosocomial infections، separation from mother''s nursing، imparting a sense of illness to the infant، and disrupting of parents'' and family relationship with neonate are all unhappy drawbacks to in-hospital phototherapy. Because home phototherapy is being used in different regions of Iran، evaluation of effectiveness، benefits and complications of this method can help the physicians and parents to use home phototherapy for management of neonatal icterus.
Material & Methods: This prospective study has been done from April 2005 to February 2006 on 108 healthy full-term newborns with jaundice that visited the emergency room of the Children''s Medical Center in Tehran. These newborns that had full criteria of home phototherapy are treated by standard four lamp home phototherapy after parents'' acceptance.
Findings: All 108 patients 48 (44%) male and 60 (56%) female with an average age of 7.1 days and average weight of 3170 gram were treated with home phototherapy in average for 33 hours. Average serum bilirubin value on entry into home phototherapy was 16.4 (14.2-18) mg/dl and 10.1 mg/dl when discontinued. The average daily decrement in bilirubin was 3.2 mg/dl/day. Parental satisfaction has been nearly 94 percent. Phototherapy-related complications were noted only in one patient hospitalized due to hyperthermia. Poor compliance was identified in five families (4.6%) who could not continue home phototherapy due to their anxiety. Hyperbilirubinemia in 2 (1.9%) patients did not respond to phototherapy due to G6PD deficiency and hypothyroidism.
Conclusion: Home phototherapy is an effective alternative to in-hospital phototherapy for healthy full-term jaundiced newborns if performed by an expert medical team. Benefits such as low expense، continuation of mother''s nursing and not imparting a sense of illness to the infant were major causes for parents'' content.

Objective: Erythropoietin (Epo) is an essential hormone for erythropoiesis. Parenterral recombinant erythropoietin (rEpo) is effective for prevention of anemia of prematurity (AOP). The aim of this study was to determine the effect of enteral rEpo on erythropoiesis in preterm infants.
Material & Methods: This is a randomized clinical trial (RCT) study performed on preterm infants (£1800gr birth weight and £34 weeks gestational age [GA]). Two groups of infants were randomly included in the study by sequential admissions. One group (n=7) received Epo (CIMBA. Cuba) 1200U/kg per week (3 days a week) plus ferrous sulfate (3-6 mg/kg/day). The control group (n=7) received only ferrous solfate. Hemoglobin (HB)، Hematocrit (Hct) reticulocyte count، serum Epo and ferritin level were measured at baseline، after 10 days and on discharge. Collected data were tested by T-test and repeated measurement and analyzed by SPSS software.
Findings: Mean (SD) GA of control group (n=7) were 30.3 (0.9) weeks and Epo group (n=7) were 30.7 (2.56) (P=0.7). The mean (SD) body weight of control group was 1392 (196) gr and Epo group 1328 (267) gr. Reticulocytes count at the end of study in Epo group was significantly more than in control groups [2.99 (1.45) vs 1.36 (0.96)] (P<0.009). Serum mean erythropoietin level in Epo group was significantly more than in control group [18 (11) vs 8.7 (4)] (P=0.006). Mean serum ferritin level in Epo group was lower than in control group although statically not significant [238 (78.59) vs 340 (166.51)] (P=0.4). There was no significant difference in Hb and Hct between the two groups (P=0.3).
Conclusion: Oral administration of rEpo increased significantly serum Epo and reticulocytes count (stimulated erythropoiesis) but did not increase Hb and Hct in preterm infants.

Objective: Accidental caustic ingestion can result in severe gastrointestinal injury، especially in esophagus، that has thinnest and most sensitive tissue with most contact in caustic ingestion. Endoscopy is the most direct equipment in evaluation of patients. The aim of this study was to evaluate the severity of esophageal injury due to different substances in children aged 1-6 yr at the Children''s Medical Center in Tehran.
Material & Methods: In a prospective study (Oct 2002 - Apr2003)، 100 children were admitted because of accidental caustic ingestion. The ingested materials، their quantities، early symptoms and endoscopic findings were prospectively analyzed.
Findings: Forty-two of 100 patients had ingested stronger materials، of these، 37 had esophageal burns higher than grade I; 58 patients ingested weaker materials، which had none or only grade I burn. Of 44 symptomatic patients، 37 had important burns. Between substance property and quantity and early symptoms with esophageal burns was coherence (P<0.05). Totally 76/100 patients were symptomatic، and 39 patients had grade I، 17 grade IIa، 12 grade IIb، 4 grade IIIa، and 4 grade IIIb burns. Seventeen (17%) patients that developed esophageal stricture had all grade IIb burns.
Conclusion: Esophageal injury happens after caustic ingestion with different severity. The stronger the ingested material، the severer the damage to esophagus and the more long time sequelae (stricture) is to expect.

Objective: The purpose of this study was to examine prevalence of three subtypes of attention deficit hyperactivity disorder (ADHD) including attention deficit type، hyperactivity type، and combined type in a group of elementary school children in Shiraz.
Material & Methods: For this purpose 1311 students (644 boys and 667 girls) aged 7-12 years were recruited using cluster random sampling. The instrument used in this study was the SWAN questionnaire (Swanson، Schuck، Mann، Carlson، Hartman & Sergeant، 2004).
Findings: The results revealed that 5% to 8.5% of elementary school children show symptoms of one of the subtypes of ADHD. The results also revealed that the prevalence of hyperactivity disorder decreased with age while the prevalence of attention deficit increased with age. The prevalence of hyperactivity and attention deficit disorder in boys was not significantly different than in girls. However، the prevalence of combined type of disorder was significantly higher in boys than in girls. In addition، mean scores of the attention deficit، hyperactivity and combined type of disorder were significantly different in different socio-economic groups.
Conclusion: Prevalence of the subtypes of the disorder was different across age and gender and children with lower socio-economic status are in danger of higher mean scores in all subtypes of the disorder.

Objective: Several case reports and epidemiologic studies have reported a relation between different vaccines including measles، rubella، and mumps and Guillain-Barre syndrome (GBS). In this study we investigated relation between receiving measles and/or rubella vaccines and occurrence of Guillain- Barre syndrome after national immunization campaign in 2003 in Iran.
Material & Methods: In this study we used National Surveillance system for acute flaccid paralysis data from the beginning of 2002 to the end of 2004. We studied 5-14 year-old children. Three-year time span of the study was divided into fifteen 10 weeks periods، and number of reported and approved cases of Guillain-Barre syndrome in each time period has been analyzed supposing their distribution was according to Poisson distribution. One of time periods has been chosen in a manner that its first 4 weeks included embedded National Immunization and following 6 weeks were designated for covering incubation period of Guillin- Barre syndrome.
Findings: Of total 553 reported flaccid paralysis cases in 5-15 year-old children 370 were approved to be Guillain- Barre (~67%). Estimated average incidence of Guillain-Barre syndrome in <15 year-olds is 1/100،000/year (95% CI: 0.88-13)، and in 5-15 year-old children is 0.6/100،000/year (95% CI: 0.58-083). Thus، number of expected cases in 25 cases each 10 weeks time period was 23.8 of GBS that were reported in the time period which coincided with immunization campaign. Probability of occurring ≥25 cases of GBS in that time period according to Poison distribution with expected case numbers of 23.8 is equal to 0.43 (P=0.43).
Conclusion: Yearly incidence rate of GBS in this study was similar to other studies. According to our results، there was no increase in GBS incidence in the 4 weeks national Immunization Campaign and 6 weeks after it in comparison to other 10 weeks periods before or after this time period.

Objective: Approximately 50% of newborn develop jaundice، however only 6% of them have significant hyperbilirubinemia that need more evaluation. Actually، most of sampling (50-90%) for detection of hyperbilirubinemia is not necessary and cause some problems such as infection، tissue injury، pain، discomfort، wasting time and money. So non-invasive methods is desirable to decrease unnecessary sampling.
Material & Methods: This study performed on neonates who referred to Shiraz University of Medical Science affiliated Nemazee hospital neonatal emergency room due to jaundice. Initially 92 neonates were selected. After taking digital images and calculating mean and 95 percentile yellow wave''s lengths of forehead skin and detection of total serum bilirubin، the correlation between wave''s lengths and serum total bilirubin were determined. 95 percentile of skin yellow wave lengths that determined bilirubin level of 5، 10، 15 and 20 mg/dl were used for making 4 yellow strips of the icterometer. This icterometer was used for screening of 209 neonates who referred for evaluation of jaundice.
Findings: Using icterometer in evaluation of 209 neonates with jaundice demonstrated sensitivity 94.7%، specificity 55.2%، positive predictive value of 85%، negative predictive value of 95% and accuracy 87%.
Conclusion: This Icterometer can be applied as a screening tool in neonatal hyperbilirubinemia to detect less significant degree of hyperbilirubinemia that doesn''t need sampling in Shiraz and even other regions of Iran with the same skin color.

Objective: Pneumonia causes about three million deaths a year in young children; nearly all of them are in developing countries. Most of pneumonias are caused by microorganisms but a number of non-infectious agents could be the etiologic agent. The aim of this study was to determine the epidemiological، clinical and laboratory characteristics of pediatric patients admitted to Amirkola Children''s Hospital، Babol/Iran because of pneumonia.
Material & Methods: This cross-sectional study was done on pediatric patients، aged 1 month to 12 years who were hospitalized with a final diagnosis of pneumonia. From 2003 to 2005 a total of 404 cases with a diagnosis of pneumonia were recorded. The diagnosis was based on physical examination، result of chest radiography and laboratory findings. The epidemiologic، clinical and laboratory characteristics were recorded and analyzed by SPSS 10 software.
Findings: Sex distribution showed male 58.6%، female 41.4%. The mean age of boys was significantly less than girls (P=0.02). Admissions more than once because of pneumonia were seen in 10% of the patients. The most common clinical signs and symptoms were positive pulmonary auscultation، cough and increased respiratory rate. ESR and CRP were elevated in 66% and 65.8% respectively. The blood culture was positive in 3.5% of cases and the predominant bacteria isolated was Haemophilus influenzae type b. The mortality rate of pneumonia in this study was 1.2%.
Conclusion: Although cases of positive culture for bacterial infection in our study population seem to be low، the predominance of Haemophilus influenzae type b in comparison to the similar studies in developed countries necessitates the vaccination of target population against this microorganism.

Objective: To determine the prevalence of high blood pressure in a representative sample of children and adolescents from Tehran، Iran، and also to compare our results with those reported by the Second Task Force.
Material & Methods: This cross-sectional study was carried out from March 2004 to September 2005. Individuals between 13 and 18 years of age were selected randomly from the list of schools (grade 6 through 12) in various locations throughout Tehran. All measurements were performed at public and high schools. The size of the sample was defined based on the expected prevalence of hypertension for the age group. After randomization، data were collected through a questionnaire. Blood pressure was measured twice. Weight and height were also measured. High blood pressure was defined as systolic and/or diastolic blood pressure over the 95th percentile in both measures.
Findings: The final sample included 6038 (3280 boys 2758 girls) apparently healthy students. In all students who had a systolic or diastolic blood pressure equal or more than the 95th percentile، blood pressure was measured after 1 and 2 weeks (second and third rescreening). Blood pressure was elevated in 287 students in the initial screening (4.7%)، with a decrease to 1.0% and 0.8% when this group was screened a second and third time respectively. According to the 1987 Task Force Report in United States، systolic hypertension was found in 2.8% and diastolic hypertension in 3.4% in screening. In rescreening، both systolic and diastolic hypertension had fallen to 0.7%. In the third screening systolic hypertension had fallen to 0.6% and diastolic hypertension to 0.5%.
Conclusion: The prevalence of elevated blood pressure was 0.8% in the present study. No statistically significant difference was noted between the prevalence of elevated blood pressure between genders. Additionally، these results confirm the importance of the Task Force recommendation that multiple BP measurements should be obtained before making a diagnosis of hypertension

Objective: Shigella infections are one of the major causes of diarrhea worldwide and especially in developing countries. This study was conducted to investigate clinical symptoms، predisposing factors and effective antibiotic regimens in children hospitalized for clinical dysentery.
Material & Methods: Children older than 6 months admitted for gastroentritis in Bahrami hospital in Tehran from September 1998 to September 2001 with a positive fecal culture for Shigella were included in this study. The data was gathered from patients'' records.
Findings: From 173 patients، 46.2% were females mostly aged 2-5 years. More than 50% of patients were admitted in summer. The frequency of anemia was 31.8% and 34.7% were under the median growth curve. Except diarrhea، the most frequent clinical manifestations of shigellosis were fever (98.2%)، dehydration (87.2%) and convulsion (68.2%). 135 (78%) patients received Nalidixic acid and the rest was treated with ceftriaxone as the first choice because of their poor condition on admission. Nine (5.2%) patients died with Ekiri syndrome and sepsis manifestation despite antimicrobial treatment. Conclusion: The mortality rate in this study was higher than in other studies. Fifty-six percent of mortality cases was due to Ekiri syndrome and the remainder was due to sepsis in children less than 1 year old. We found no specific clinical symptom or sign for shiglosis.

Objective: β-thalassemia is a widespread disease. Long term transfusion is the most important therapy in these patients but the best regimen is controversial yet. In this study two groups of thalassemic patients were compared. Subcutaneous desferal regimen was compared versus subcutaneous in combination with intravenous desferal.
Material & Methods: This clinical trial was done on thalassemic patients in Pediatric Center who were similar in mean age، number of subcutaneous desferal infusions and number of transfusions. This study was done in one year and serum ferritin was measured every 3 months in patients (cases) and at the end of the study (in controls).
Findings: Mean serum ferritin was significantly different in two groups at the end of the study (after one year follow-up)، it was higher in case group than in controls (1.7 times) (P value=0.04).
Conclusion: In this study، combination therapy of intravenous and subcutaneous desferal was more effective to reduce the iron overload. With more accurate management we will achieve a better long term prognosis in these patients.

Objective: Delayed puberty is defined as lack of breast development after the age of 13 years in girls، and lack of testes enlargement after the age of 14 years in boys. Considering the importance of delayed puberty، the present study tries to analyze its etiological factors. It is hoped that the study would help developing programs، aiming at drawing the attention of families، health centers and physicians to the necessity of early diagnosis and timely treatment of delayed puberty.
Material & Methods: In this observational descriptive study، we reviewed the etiology of delayed puberty in affected patients، who had been referred to the Institute for Endocrinology and Metabolism in Tehran، during a period of 5 years from 1995 to 1999.
Findings: Patients (32 boys and 16 girls) were divided into 3 groups based on clinical and laboratory information. 24 patients (50%) were categorized in the group of hypogonadotropic hypogonadism (including 18 cases with isolated hypogonadotropic hypogonadism، 2 cases of Kallmann_syndrome، 3 cases with hypopituitarism، 1 case with hypogondism and thalassemia). 14 (29.2%) patients including 13 boys and 1 girl were categorized in the group with constitutional delay of growth and puberty. 10 patients (20.8%) were categorized in the group with hypergonadotropic hypogonadism (including 6 cases with Turner syndrome، 2 cases with Klinefelter syndrome، 2 cases with 46XX pure gonadal dysgensis). The most common cause of hypogonadism in boys was constitutional delay of growth and puberty (40.6%) and hypogonadotropic hypogonadism (40.6%) while in girls it was Turner syndrome (37.5%). The most common cause for patients to be referred was short stature (43/5%) and then non appearance of pubertal signs (37.5%).
Conclusion: When facing patients with delayed puberty، hypergonadotropic hypogonadism in girls، and constitutional delay of growth and puberty as well as hypogonadotropic hypogonadism in boys، should be considered as the first diagnosis. In all patients، who are referred due to short stature، the stage of puberty should be determined and delayed puberty should be considered as differential diagnosis.

Objective: Multiple pregnancies is a high-risk pregnancy since it is associated with increased perinatal and maternal problems. The aim of our study to determine the frequency of multiple pregnancy and its maternal and perinatal complications.
Material & Methods: In a cross -sectional study we assessed 94 multiple pregnancies and 199 neonates in three educational hospitals in Tehran (Baghiyatallah، Najmie and Mahdie) in first half of 2006. The information was collected from hospital registries of mothers and their neonates.
Findings: Of 4584 deliveries، 84(1.8%) were twins، 9(0.19%) were triplets and 1(0.02%) was quadruplets. 59 (62.7%) of mothers had preterm labor and 14 (14.8%) had pre-eclampsia. We found discordant birth weigh ≥ 20% in 24 (25.4%) and TTTS (Twin-To-Twin Transfusion) in 3(3.1%) of mothers. 174 (87.4%) of all neonates were admitted in NICU or pediatric department. The frequency of mortality and respiratory distress in neonates were 27 (13.5%) and 107 (53.7 %)، respectively.39 (19.5%) of neonates had Apgar scores<7 and seizure was not observed in neonates. 65 (32.6%) of neonates were normal weight (> 2500 gram)، 104 (52.4%) LBV، 21(10.5%) VLBV and 9(4.5%) ELBV. Hypocalcaemia، hypoglycemia and anemia detected in 45 (22.6%)، 24 (12%) and 48 (24.1%) of neonates respectively.
Conclusion: Regard to increasing the prevalence of multiple pregnancies، better use of infertility modalities، early diagnosis of the multiple pregnancies، prevention of preterm birth، close fetal surveillance، atraumatic labor and delivery can improve maternal and perinatal outcome.

Objective: The most common cause of lacrimation in children is congenital nasolacrimal duct obstruction. Although there is a belief that the most of them resolve spontaneously، there is no agreement in the time and type of treatment. This study was done to determine the success rate of three approaches to treatment of congenital nasolacrimal duct obstruction in children aged 12-24 months.
Material & Methods: From February 2006 to December 2006، 60 12-24 month-old children with congenital nasolacrimal duct obstruction were enrolled in this study. The parents that agreed to probing were divided accidentally into two groups of probing and irrigation، and probing and air insufflation. The parents that agreed to wait for a month went to conservative management with office massage of the nasolacrimal duct and treatment with antibiotics by ophthalmologist.
Findings: Of 60 children included in this study 27(45%) were females and 33(55%) males. The mean age of children in the group of probing with irrigation was 18.09 months، probing and air insufflation 19.44 months، and in group of conservative management 19.41 months. The success rate was 91.30% in the group of probing and irrigation، 96% in the group of probing and air insufflation، and 100% in the group for conservative treatment.
Conclusion: Congenital nasolacrimal duct obstruction in almost all of children resolved spontaneously or by simple surgical intervention (probing). The persistent cases may have structural abnormality in nasolacrimal duct or nasal anatomy. Our study showed that conservative and surgical approach in children aged 12-24 months have a favorable outcome، therefore the age can not be a relevant factor in selection of the type of treatment in congenital nasolacrimal duct obstruction.

Objective: Post operative vomiting (POV) is one of the most distressing complications after surgery especially in children. Since prophylactic treatment in all patients may be accompanied by many side effects، we conducted a study to evaluate the history of motion sickness (MS) as a risk factor and its predictive value for post operative vomiting in children.
Material & Methods: In a prospective زohort study، a sample of 100 consecutive patients aged 1-16 years scheduled for elective surgery under general anesthesia were questioned، a history of MS was sought and patients were observed during next 24 hours for the subsequent development of POV.
Findings: The overall incidence of POV was 30%. Twenty one patients were MS positive and 79 were negative. MS-positive children were more likely to vomit than those who were MS-negative (P=0.02). Demographic data، type of surgery، technique of anesthesia، duration of fasting and surgery did not differ significantly between the two groups. The sensitivity of MS as a predictor of POV was 51% and the specificity 90%، giving a positive predictive value of 81% and negative predictive value 80%.
Conclusion: Motion sickness is associated with POV in this group of children، and its positive predictive value is high.

Objective: Bilirubin is the endproduct of heme catabolism. Serum bilirubin level can occationally be the only variable that affects the physician''s decision. Bilirubin test is one of the most sensitive tests in the clinical laboratory. The aim of this research was to compare results of chemical versus direct spectrophotometric measurement of serum bilirubin.
Material & Methods: This cross-sectional study was carried out in 2006 on 119 specimens of serum. Bilirubin levels were determined by four methods: direct spectrophotometric by DAS and clinic II instruments، chemically with dichloroaniline (DCA)، and diazo methods.
Findings: Mean serum bilirubin measured by DAS، clinicII، diazo، and DCA methods was 8.38 (3.59)، 7.80 (3.69)، 9.70 (4.06)، and 8.17 (4.09) mg/dl respectively. Difference of means was significant when examined using ANOVA (P<0.001). The differences between diazo method and the other three methods were significant، while among the latter methods there was no statistically significant difference.
Conclusion: Regarding significant differences between methods، for a better orientation of the physician and more accurate follow up of patients، we recommend to mention the method of measurement in laboratory reports.

Objective: Foreign body aspiration (FBA) is a common cause of respiratory distress in children between 6 months and 3 years old. Early diagnosis and management will decrease complications and mortality.
Material & Methods: A retrospective study was done on records of 140 patients with FBA between 1998- 2003 at Imam Reza hospital a tertiary university hospital of Mashhad University of Medical Sciences.
Findings: From 140 patients، 62% were male and 82.2% were under 6 years old. History of chocking was the most frequent clinical finding (77%)، other clinical findings were wheezing (38.6%)، decreased breathing sounds (42.1%)، cough (20%)، respiratory distress (15.4%)، fever (15.4%) and stridor (6.6%). Chest radiography was normal in 42.1%. The time of diagnosis was the first day in 42.3%. The most common aspirated foreign bodies were seeds (40.7%) and the most common site of FBA was right bronchus. Complications consisted of 27.9 % pneumonia، 17.1% persistent and resistant pneumonia، cardio-respiratory arrest in 2 % and lung abscess in 0.7%. Mean hospital stay was 2 days and mortality rate 2.9%.
Conclusion: Foreign body aspiration can occur at any age especially in children under 6 years in the absence of predisposing factors. Normal auscultation and chest X-ray do not rule out the diagnosis of FBA; high suspicion is the important clue for diagnosis.

Objective: Meningitis is one of the most important causes of sensorineural hearing loss in childhood. Because of the critical situation of patients، proper attention is not usually paid to hearing assessment in meningitis. By early detection and medical intervention at proper time، the retadation of lingual development can be avoided.
Material & Methods: The hearing function of 40 children with meningitis was evaluated at 24-72 hours after diagnosis (acute period) and 24 hours before discharging from hospital (recovery period) with auditory brainstem responses (ABR). All patients 7-14 days after discharge underwent thorough investigation by detecting otoacoustic emissions test (OAE).
Findings: Using the ABR test، during the acute period، 35 (87.5%) patients had normal hearing and in 5 (12.5%) patients severe to profound sensorineural hearing loss was detected. The same results were obtained during recovery period. OAE test showed normal hearing in 37 (92.5%) patients and impaired cochlear function in 3 (7.5%) patients.Conclusion: Early detection of hearing loss in the acute and recovery period of meningitis can be made by ABR and OAE tests.

Objective: The objective of this study was to determine the causes of persistent diarrhea in hospitalized patients at Children''s Medical Center in Tehran.
Material & Methods: Primarily we determined the 41 different etiologies of persistent diarrhea which were recognizable in Iran at the time of study. then we studied all hospitalized patients with these diagnoses between the years 1992 till 1998.
Findings: During the period of study there were 1300 patients who had been hospitalized in children''s hospital. Among these patients 215 had persistent diarrhea. 10 most common etiologies of persistent diarrhea were celiac disease، cystic fibrosis، ulcerative colitis، malnutrition، immune deficiencies، urinary tract infections، giardiasis، gastroenteritis، cow milk allergy، and intestinal lymphangiectasia.
Conclusion: Based on the results of this study، in approaching patients with persistent diarrhea، it is better to consider more common and probable etiologies primarily to avoid unnecessary costs and then perform suitable diagnostic studies

Objective: The disorder known as "Auditory neuropathy (AN)" is not new but has recently become more clearly defined and understood. Auditory neuropathy is a form of hearing impairment in which the cochlear function is normal but neural transmission in the auditory pathway is disordered. This condition accounts for approximately 7% of permanent childhood hearing loss and 0.2-4% of high risk neonates.
Case Reports: Four children (three boys and one girl) younger than two years with auditory neuropathy symptoms are presented. Based on audiologic and clinical findings there were high risk factors in two cases. In each case، absent auditory brainstem response (ABR)، absent acoustic reflexes، present cochlear microphonics (CM) and present transient evoked otoacoustic emissions (TEOAE) were shown.
Conclusion: This section discusses the clinical profile of cases regarding etiology (neonatal insults، infectious processes، genetic and syndromic factors)، age of symptom onset، prevalence of AN/AD، outer hair cells function، audiogram، and acoustic reflexes in relation to other studies

Objective: Medullary Thyroid Carcinoma (MTC) is hereditary in 25% of cases، and occurs primarily in an autosomal dominant manner. Thus، siblings and offspring of a patient diagnosed with a germline mutation are at a 50% risk for carrying the same mutation. Germline mutations of RET proto-oncogene is the known cause of almost all hereditary MTCs. Mutation analysis of RET is necessary for all apparently sporadic MTC patients.
Cases Presentation: In this study، three siblings diagnosed with MTC in a family were analyzed for RET mutations. The result of direct DNA sequencing showed Cys634Arg point mutation in all 3 of them. Screening of their offspring and 4th sibling resulted in identification of a 3-year-old boy as a mutation carrier. According to general consensus، he is at second risk level، which qualifies him for prophylactic total thyroidectomy.
Conclusion: Molecular analysis of RET proto-oncogene should be done in a routine manner to differentiate hereditary MTC patients from sporadic ones. In case of finding a germline mutation، all siblings and offspring of the mutation carrier should be screened and asymptomatic carriers referred to total prophylactic thyroidectomy.

Objective: Sirenomelia or Mermaid syndrome is characterized by complete or incomplete fusion of lower extremities with an incidence of 1.5 to 4.2 in 100000 live births. It occurs in gastrulation period (beginning of third gestational week) because of insufficient mesoderm formation in caudal region. Various theories have been postulated to explain the etiology of sirenomelia such as pressure theory which denotes that some intra-uterine force، probably amniotic، acts on the tail of embryo. The aim of this study was to present a rare congenital malformation. In addition we reviewed the pertinent literature in this regard.
Case Presentation: We report a case of sirenomelia with multiple interesting anomalies including bilateral renal agenesis، absent external genitalia، gall bladder agenesis، colorectal agenesis from mid ascending colon، ileosacral dysgenesis، meningocele، caudal tapering of abdominal aorta and single umbilical artery. History، detailed autopsy findings and review of literature are presented in this report.
Conclusion: Sirenomelia is a rare congenital malformation leading to stillbirth or early death after birth due to multiple anomalies، so prompt intra-uterine diagnosis and therapeutic abortion is of utmost importance.

Objective: Leukocyte adhesion deficiency (LAD) disorders، LAD-1 and LAD-2 are rare disease of leukocyte function. LAD-1 results from a lock of leukocyte cell surface expression of b2 integrin molecules (CD11 & CD18) that are essential for leukocyte adhesion to endothelial cells and chemo taxis.
Case Presentationt: Our patient a 23-month-old male infant was brought with recurrent skin infections. On examination، the infant was pale with multiple scars in his body. Investigations revealed persisting leukocytosis، serum Immunoglobulin profile and complement were normal. Flow cytometry showed decreased in CD11 and CD18 marker of PMN a diagnosis of LAD1 was made.
Conclusion: The accompaniment of persistent leukocytosis and recurrent skin infections will guide us to the primary immune deficiency specially leukocyte adhesion deficiency.

Objective: Complete form of androgen insensitivity was first described by Morris and Mahesh in 1960s. This X-linked trait occurs in one of 20،000 to 64،000 male births. Androgen receptor gene is located on the short arm of the X chromosome. 200 mutations are known at this locus. External genital tract is phenotypically feminine with short blind vagina. Uterus، often Fallopian tubes، Mϋllerian and Wolffian remnants are absent. End organ insensitivity leads to sparse pubic and axillary hair. Patients often present as adolescent girls with primary amenorrhea and bilateral inguinal hernia.
Case Report: Third offspring of a first cousin marriage was assessed in routine neonatal examination a few hours after birth. Systemic physical examination was normal، external genital tract had normal female appearance. There was a bilateral direct inguinal hernia containing ovoid masses. Karyotype was 46XY. The first offspring was 15 years old and raised as female، with history of bilateral orchiectomy and herniorrhaphy in early infancy. Recent laparoscopy showed that uterus was absent. Karyotype was 46XY. Other sibling was a normal male with 46XY karyotype and coincidental idiopathic nephrocalcinosis. May be these are same mutations on the same gene locus. DNA analysis and sequencing will clear this dilemma.
Conclusion: Ocurrence of androgen insensitivity has been reported in literature for 3 decades. In the recent decade، authors achieved the ability to clarify the mutations completely. DNA sequencing and assessing 5 alpha reductase activity in genital skin fibroblasts in these two siblings is strongly recommended.