Iranian Journal of Pediatrics
Volume:19 Issue: 4, 2009

The aim of this study was to determine the ultrasonographic (US) bladder wall thickness (BWT) in normal children. In 106 children (54 boys and 52 girls، aged 8 months to 15 years) without any history and laboratory findings of bladder dysfunction or infection، US measurement of bladder points was performed with bladder filled to at least 50% of its expected capacity. The mean thickness of four bladder wall points was 1. 79±0. 28 mm. The mean anterior wall thickness was 1. 5±0. 31 mm (range 0. 9-2. 2 mm)، posterior 2±0. 36 mm (range 1. 2-3. 1 mm)، right lateral 1. 8±0. 34 mm (ranges 0. 8-3mm) and left lateral 1. 8±0. 36mm (range 1-3mm). There was a significant difference between bladder sites (P<0. 05) except between lateral sites. We recommend after measurement of four points، to compare these values with normal±2SD curves according to age.

Neonatal Hydronephrosis is a common abnormality diagnosed ante- or postnatally. The aim of this study was to determine the prevalence and severity of vesicoureteral reflux (VUR) in neonates with antenatal or postnatal hydronephrosis and the value of ultrasono­graphy as a noninvasive tool for VUR prediction. In a prospective study، 202 infants with neonatal hydronephrosis were studied. Two successive renal ultrasound examinations were performed at 1 and 4-6 weeks after birth in neonates with antenatal hydronephrosis or immediately after presentation. Voiding cysto­urethrography (VCUG) was performed in all infants. The incidence of VUR was 29. 7%، of which 17. 8% had severe (grade IV-V) reflux. 27% of 133 neonates with unilateral and 34. 8% of 69 cases with bilateral hydronephrosis had VUR. Although a significant association was observed between severity of hydronephrosis and VUR، 5. 9% of normal appearing and 7. 8% of grade 1 hydronephrotic neonates had high-grade reflux. VUR was observed significantly in hydronephrotic neonates. A normal or mildly hydronephrotic urinary tract on ultrasound scan cannot exclude presence of severe VUR. We recommend performing VCUG in all hydronephrotic newborns.

Insufficient lactation is the most common complaint of nursing mothers in a first few months after delivery; this is known to be partly due to the mothers'' deficient knowledge of proper breastfeeding. The goal of this study was to find out whether training of nursing mothers for proper lactation can enhance their lactation. During one year from May 20، 2007 to June 20، 2008 we consecutively enrolled 63 nursing mothers who had been referred to the clinic of Tabriz children''s hospital for counselling and prescription of infant formula because of insufficient lactation during 30 to 60 days after parturition. At first all infants were weighed under similar controlled condition. Their weight was then compared with recorded data in their nursery discharge sheet and growth surveillance card. Term infants with weight gain of less than 500 g/month were consecutively enrolled in the study. All mothers passed a short training course on nutritional and immunological benefits of mother milk for growth of their baby as well as latch and positioning techniques of breast feeding. After 15 days we weighed the infants again and compared the two recorded weights to assess the sufficiency of breastfeeding and effect of training. Statistical analysis was done with independent sample test and paired t- test using SPSS software. In 63 breastfed infants with an age of 30 to 60 days، before training course of mothers، minimum، maximum and mean weight gain was 8. 3، 16 and 12. 5 (±3. 8) g/day respectively; 15 days after training of mothers these figures were 7. 6، 34. 6 and 21. 1 (±13. 5) g/day respectively. Results showed that weight gain in 54 (85. 7%) infants was satisfactory which was statistically meaningful (P<0. 001). This study showed that counseling nursing mothers for proper lactation is the main clinical pathway toward a successful and sustained breastfeeding and must be considered in obstetrics and medical centers.

Although a lot of interventional studies may be found which have investigated the effects of education on nursing mothers regarding advantages of breast-feeding behavior، but very few studies in developing countries have examined whether mothers are conscious of the risks associated with formula and bottle-feeding on children. Knowing that Breast-feeding Index has decreased in Iran and feeding behaviors are not suitable and adequate in nursing mothers، we studied the effect of education based on PRECEDE Model on improving mothers'' breast-feeding behaviors in Yazd، Iran. Cluster stage sampling was employed to recruit 60 pregnant mothers who had one month to the time of their delivery. Before and 3 months after implementing the educational program through group discussion، lectures and pamphlets، a self-prepared questionnaire was completed by the respondents. Validity and reliability of the scales were approved. SPSS software was used for the purpose of data entry، manipulation، and analysis. Mean age was 25. 9 (±5. 8) years; 96. 6% were housewives. After implementing the educational program، mothers'' knowledge (38%) and attitude (12. 3%) were significantly increased (P=0. 001). After implementing the program، 85% of the mothers fed their children exclusively with mother''s milk and 15%، breast-fed together with formula. The children، who were formula-fed، were breast-fed 4-5 times daily as well. Moreover، none of them was formula-fed from the time of birth and formula-feeding was used as a result of improper weight getting in these children. In order to design effective educational programs، healthcare professionals should better understand the determinants of feeding behaviors in nursing mothers and develop stage-specific interventions، within which، promoting predisposing factors like knowledge and attitude are priorities of the program. The PRECEDE Model، as a basic model for programming، was found to be helpful in addressing the effects of education on formula and bottle-feeding behaviors and their predisposing factors in nursing mothers.

Common variable immunodeficiency (CVID) is a heterogeneous group of disorders، characterized by hypogammaglobulinemia، defective specific antibody responses to pathogens and increased susceptibility to recurrent bacterial infections. Delay in diagnosis and inadequate treatment can lead to irreversible complications and mortality. In order to determine infectious complications among undiagnosed CVID patients، 47 patients diagnosed in the Children''s Medical Center Hospital during a period of 25 years (1984-2009) were enrolled in this study. Patients were divided into two groups including Group 1 (G1) with long diagnostic delay of more than 6 years (24 patients) and Group 2 (G2) with early diagnosis (23 patients). The clinical manifestations were recorded in a period prior to diagnosis in G1 and duration follow up in G2. The number of infections، non infectious complications، hospitalizations، and mortality rate was compared between the two groups. The patients in G1 group had 500 episodes of infections before diagnosis in 256 patient-years (0. 08 per patient per year) and 203 times of hospitalization (0. 03 per patient per year)، which were significantly higher than in G2 patients، who had 75 episodes of infections (0. 015 per patient per year) and 88 hospital admissions (0. 018 per patient per year) during 207 patient follow-up years. Frequency of enteropathies and liver diseases in G1 were also significantly higher than in G2. Lack of awareness about nature of disease، especially among rural and suburban physicians، single organ involvement as a site of clinical presenting، and predomination of non infectious presentation in G1 were the major factors of delayed diagnosis. Diagnostic delay is a major concern in CVID patients، which could result in irreversible complications and mortality، while early diagnosis and proper initial treatment leads to better outcomes and quality of life.

Zinc deficiency is common in children in developing countries due to low intake of animal foods، and high dietary phytate content. Zinc deficiency impairs overall immune function and resistance to infection. The effect of zinc on the common cold is still questionable. To determine whether supplementation of zinc could reduce frequency rate and duration of common cold during cold season in school aged children living in a low socioeconomic suburb of Mashhad (Altimor)، north-east Iran. We designed a randomized double-blind، placebo-controlled efficacy trial. Subjects were 200 grade 2 primary school children who all completed the trial. Intervention supplementation was zinc sulfate tablets (10 mg elemental) and placebo tablets for case and control groups، respectively. Tablets were taken on a daily basis، 6 days a week، for 5 months (November to March). Among the zinc-supplemented group common cold incidence of 1. 37±0. 86 episodes per child during the study period was recorded in comparison to 3. 15±0. 55 cold episodes per child among the placebo group (P<0. 001). Mean overall missing days from school was 0. 55±1. 09 days and 1. 35±1. 79 days for zinc-supplemented and placebo groups، respectively. The need for administration of antibiotics for bacterial infections (pharyngitis، acute otitis media، sinusitis، pneumonia) were 20 and 47 courses for zinc-supplemented and placebo groups، respectively (P<0. 01). This study showed that zinc supplementation has a beneficial impact on the occurrence of common cold.

Urinary tract infection (UTI) is a common disease in children. The distinction between upper and lower UTI in children is associated with some ambiguities. The objective of this study was to determine the sensitivity، specificity، positive predictive value (PPV) and negative predictive value (NPV) of procalcitonin (PCT) compared to C-reactive protein (CRP) in predicting renal involvement. Serum concentrations of PCT and CRP in blood samples of 111 children with UTI were measured. Renal parenchymal involvement was evaluated with 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy. Sensitivity، specificity، PPV and NPV were determined. Out of 111 children، 52 (46. 8%) were shown to have acute renal involvement، 23 (20. 7%) lower UTI، and 36 (32. 5%) refused to be examined by DMSA renal scan. PCT was positive in 36 (69. 2%) patients with upper UTI and 12 (52. 2%) with lower UTI. The sensitivity، specificity، PPV and NPV obtained for PCT and CRP were 70. 6، 45. 5، 75، 40% and 96. 2، 4. 3، 69. 4، and 33. 3%، respectively. No significant correlation was found between renal parenchymal involvement and serum levels of PCT and CRP. However، the results demonstrated that the PCT was a better diagnostic test compared to CRP.

In two groups of children with and without the history of LBW، Intelligence Quotient (IQ) and growth indices including weight and height are compared. In this historical cohort study performed in Zanjan City (Iran)، 130 six-year-old children of both sexes in two equal groups، 65 with LBW history and 65 with normal birth weight (NBW)، were selected randomly to be assessed for IQ، utilizing Wechsler Intelligence Scale for Children-Revised (WISC-R) and physical growth indices، including weight and height. The results were analyzed statistically and P-values less than 0. 05 were considered as significant. Verbal، non-verbal and total IQ، all were significantly different between LBW and NBW groups (P=0. 02، P=0. 04 and P=0. 01، respectively). Mean total IQ was 93. 66±8. 27 and 99. 32±11. 05، respectively. Weight and height between case and control groups showed significant differences، too (P=0. 001 and P= 0. 005، respectively). The results of this study and similar studies emphasize paying special attention to the problem of low birth weight deliveries، recognizing related risk factors and trying to reduce them.

Non-traumatic coma is a relatively common condition in children that may cause considerable mortality and morbidity. The purpose of this study was to determine clinical presentation، etiology and outcome of non-traumatic coma in children. In a retrospective cross sectional study over a period of 5 years، files of 150 children aged between 1 month and 14 years admitted with non-traumatic coma to pediatric intensive care unit of Rasool Akram hospital were reviewed. Historical، presenting symptoms، clinical and laboratory data were collected. Etiology of coma was determined on the basis of clinical history and relevant investigations. The outcome was recorded as died or neurological condition at discharge as normal، mild or sever disability. Chi-square test was used to test the differences in categorical variables. There were 63 (42%) boys and 87 (58%) girls. The mean±SD age of patients was 2. 7±2. 35 years. Systemic presentations including nausea، vomiting، fever، lethargy and poor feeding were more prominent in children under 2 years. Etiology of coma in 49 patients (32. 7%) was infectious (meningitis، encephalitis، respiratory and systemic). Other causes were status epilepticus 44 (29. 4%)، metabolic (diabetic ketoacidosis، inborn errors of metabolism) 11 (7. 3%)، intoxications 10 (6. 7%)، accidental (drowning، electrical shock، suffocation) 9 (6%)، shunt dysfunction (secondary to congenital brain malformations) 7 (4. 6%)، others (acute disseminated encephalomyelitis، vasculitis، hypertensive encephalopathy) 11 (7. 3%)، unknown 9 (6%). Infection occurred significantly (P=0. 002) in children under 2 years of age، whereas accidents and intoxications were more prominent (P=0. 004) in those between 2 and 6 years. Overall 25 children (16. 6%) died. Of those survived 16 became severely disabled. Accidents and infections had higher mortality compared to other groups (P<0. 001 and P=0. 02 respectively). Our results showed that infection was the most common cause of non-traumatic coma in childhood. Accidents and infection had higher mortality than other causes.

Substance abuse in adolescents may also be a marker to other harmful life styles. This study aims to find out the prevalence، pattern and sociodemographic risk factors of substance abuse in male adolescents. This study examined 390 male school children aged 10-19 years in the rural and urban areas of district Aligarh، Uttar Pradesh، India. Data was analyzed by SPSS -10. Substance abuse was prevalent in 13. 3% of adolescents of whom 96. 1% were using various forms of tobacco and 3. 8% were taking alcohol. While there was statistically significant association between the substance abuse and the age group of adolescents and size of their families، variables such as religion، socioeconomic status، place of residence were not associated with substance use. Most of the students reported initiation of substance use at 14 yrs of age due to peer pressure. Peer educators would be a useful strategy for communication with adolescents to counter peer pressure. The prevention and control measures should be started at primary education level.

Diabetic nephropathy is a serious complication of type 1 diabetes which involves one third of the patients. The aim of this study was to estimate the frequency of microalbuminuria in type 1 diabetic patients visited in Pediatric Endocrine Clinic in Hamedan، west province of Iran، in 2007. Diabetic patients visited in Pediatric Diabetes Clinic were enrolled in the study. Variable data such as age، sex، duration of the disease، stage of puberty، dose of insulin/kg/day، and blood pressure of the patients were obtained according to history and physical examination. 24h urine samples were collected for protein، creatinine، and microalbumin. Data analysis was assessed using independent t-test and chi-square test. One-hundred five patients (56 females and 49 males) with a mean age of 13. 3±5. 5 years، were evaluated. Fifteen (14. 3%) cases had microalbuminuria. Mean age in microalbuminuric group was 16. 2±2. 8، and in non-microalbuminuric group was 12. 7±5. 6 years (P=0. 024). Mean duration of diabetes was 9. 1±3. 2 yr in microalbuminuric and 4. 5± 3. 9 in non-microalbuminuric group. There was a significant correlation between duration of diabetes and microalbuminuria (P<0. 001). Blood pressure was normal in 95. 5% of the patients while in patients with microalbuminuria 73. 3% had hypertension (P<0. 001). Frequency of micro­albuminuria was higher in patients taking lower doses of insulin corrected to their body weight (P=0. 008). Frequency of microalbuminuria was significant، so regular screening is highly recommended for early detection and timely treatment of diabetic nephropathy in order to prevent progression to end stage renal disease.

There is shortage of knowledge about medical problems in adolescent skiers. This study aimed to determine frequency of medical signs and symptoms during or after ski among adolescent skiers. This cross sectional study was performed in 12 consecutive weekends in winter 2005 at Dizin ski resort in Iran. All adolescent skiers (<16years) who had entered the resort during this time period were enrolled in the study. A questionnaire including demographics، duration of transport to the resort، wearing glasses and contact lenses for medical and non medical applications، duration and frequency of skiing and development of signs and symptoms of ski sickness during or after skiing was filled for each participant. In addition، association of mentioned variables with medical problems was investigated. Of 162 skiers، 111 subjects (68. 5%) were males. The mean age of the participants was 14. 7±2. 1 years. Of them، 127 skiers wore glasses or lens during skiing. Visual disorders including myopia، hyperopia and astigmatism were found in 24 (14. 8%) skiers. Our study showed that the frequency of main ski-related signs and symptoms varies from 0 to 10. 5%. There was significant association between occurrence of signs and symptoms and presence of visual disorder (P=0. 015). Our results showed that development of ski-related signs and symptoms is relatively frequent. These signs and symptoms have association with minor ophthalmologic problems such as myopia or astigmatism.

Myocarditis is inflammation of the cardiac myocytes. In the first 6 months of life، myocarditis is slow-progressing and sudden death is common. It should not be forgotten that these patients can have intrauterine myocarditis. A 4-month-old male patient had fast breathing and cyanosis during crying in the last month. At admission، we found tachypnea and hypoxia in his physical examination، and cardiomegaly on the chest radiogram. Subsequently، dilatation of left ventricle and left atrium، systolic dysfunction of left ventricle، and mitral valve regurgitation were found in echocardiography. The patient was diagnosed with myocarditis. We were informed that he had a twin brother، so we evaluated the second baby too. Similar but less severe findings were obtained in the echocardiographic examination of the twin brother، who had normal findings in physical examination. Infectious and metabolic scanning tests were performed on both patients. The underlying cause could not be spotted. Sizes of ventricles and atria، and left ventricle functions of the patients were found to be normal with treatment at the end of the 6th week. Four-month-old twins were diagnosed and recovered from myocarditis with supportive therapy in a short time. We think that the twins had intrauterine myocarditis

The oculocerebrorenal syndrome of Lowe (OCRL) is a rare x-linked recessive disorder first described in 1952. This syndrome is characterized by ocular involvement، mental retardation and kidney disease. The causative gene is OCRL1. Survival rarely exceeds 40 years. A 13-year-old boy was referred because of short stature. In physical examination his height was 108. 2 cm. He had poor growth، psychomotor retardation، severe hypotonia، congenital cataract which was operated on earlier in life، searching nystagmus، anti social behavior and used foul language. He had been on treatment for renal tubular acidosis (Fanconi syndrome) since 8 month of age. The possibility of OCRL should be considered in boys with cataracts and glumerolar disease. As the condition can be diagnosed in first months of life، early treatment can prevent patients from various complications.

Giant cell hepatitis (GCH) is a histological finding in infants with neonatal cholestasis and rarely can be seen after this period. Autoimmune hemolytic anemia (AIHA) which is characterized by massive and acute red blood cell destruction due to antibody production، responds favorably to corticosteroid therapy. The combination of GCH and AIHA is a rare distinct entity that carries poor response to immunosuppressive therapy and often progresses to fatal liver disease. A 13-month-old boy was referred to us with anemia and icterus. Investigations confirmed the diagnosis of GCH which was associated with AIHA. Treatment with steroids and azathioprin failed. We changed to cyclosporine. The anemia improved by steroid and IVIG at the beginning، but few months later anemia relapsed. Finally he recovered with rituximab and now he is 6 years old in suitable condition. The association of AIHA with GCH is an uncommon condition that can be life threatening. Most patients initially respond to immunosuppressive agents، but usually recur and have an aggressive course. In this case liver disease responded to steroid and immunosuppressive therapy، but the AIHA was refractory to immunosuppressive therapy. Rituximab is used in treatment of this condition، and this treatment was well tolerated and resulted in dramatic sustained improvement of anemia.

Megalencephalic leukoencephalopathy with subcortical cysts (MLC) is an autosomal recessive disorder characterized by macrocephaly، and slowly progressive clinical course marked by ataxia، spasticity and mental decline. MLC is caused by mutations in the gene MLC1 which encodes a novel protein، MLC1. A 4-year-old girl with macrocephaly، spasticity، ataxia and abnormal cerebral white matter and subcortical cysts in brain MRI diagnosed with MLC. This is the first report of MLC in an Iranian family. MLC1 should be considered in children with macrocephaly and slowly progressive psychomotor decline. This disease can be prenatally diagnosed and genetic counseling offered for future pregnancies.

Paratesticular rhabdomyosarcoma is the most common pediatric soft-tissue sarcoma، often presenting in the first two decades after birth. Paratesticular embryonal rhabdomyosarcoma (RMS) is a rare tumor arising from the mesenchymal tissues of the spermatic cord، epididymis، testis and testicular tunics. It represents only 7% of all patients entered in the Intergroup Rhabdomyosarcoma Study (IRS) and 17% of all malignant intrascrotal tumors in children less than 15 years old. We report a case of a 14-year-old boy with a left paratesticular tumor، who undergone inguinal surgery and misdiagnosed as being inguinal hernia. During operation، the surgeon realized that the mass was not an inguinal hernia، it seemed like a testicular tumor. A urologist was consulted. The patient underwent left high inguinal orchiectomy. His serum markers for α-fetoprotein، β-human chorionic gonadotropin and lactate dehydrogenase were normal. In the result of further investigation، the patient was diagnosed as having paratesticular embryonal rhabdomyosarcoma with retroperitoneal lymph node mass. We referred him to the oncology department. The patient was followed up post-operatively with chemotherapy. Vincristine، doxorubicin and cyclophosphamide (VAC) regimen was used. One year after completion of chemotherapy there was no evidence of the disease. In the patients with testicular and paratesticular mass، ultrasound should be considered the imaging modality of choice for evaluating intra-scrotal pathologies in adolescents.

Multiple duodenal and jejuno-ileal atresias are extremely uncommon. The familial occurrence of multiple intestinal atresias is even more unusual. Also fetal death with isolated intestinal atresia is very rare، and the combination of recurrent familial intestinal atresias and intra-uterine fetal death has not been reported previously. We report on two cases of intra-uterine fetal death in a 30-year-old woman who is consanguineous with her husband and they have only one boy who carries chromosomal abnormality. To best of our knowledge this is the first reported case of two consecutive pregnancies with multiple intestinal atresias leading to intrauterine fetal death. Multiple and recurrent intestinal atresias are extremely uncommon. These rare cases may contribute to genetic mapping for intestinal atresias.

Dermoid cyst with dermal sinus in occipital region is extremely rare occurrence and still rarer in asterion region. We report a case of dermoid cyst with dermal sinus at the asterion probably the second case of world literature and discuss the findings. 16 year-old female patient with mental retardation and inability to speak since childhood presented with history of progressive increasing swelling since childhood over the left side of occipital region. Local examination and investigations were suggestive of extracranial cystic lesion. The lesion was excised completely. When excision of such lesions is contemplated، careful attention must be paid during exploration. Failure to recognize intracranial communication in such lesions may result in fatal consequences. Pre-operative suspicion of such a connection helped us to identify the underlying defect intra-operatively and facilitated safe excision.