Iranian Journal of Pediatrics
Volume:23 Issue: 3, jun 2013

Flatfoot constitutes the major cause of clinic visits for pediatric foot problems. The reported prevalence of flatfoot varies widely due to numerous factors. It can be divided into flexible and rigid flatfoot. Diagnosis and management of pediatric flatfoot has long been the matter of controversy. Common assessment tools include visual inspection, anthropometric values, footprint parameters and radiographic evaluation. Most flexible flatfeet are physiologic, asymptomatic, and require no treatment. Otherwise, the physician should treat symptomatic flexible flatfeet. Initial treatment options include activity modification, proper shoe and orthoses, exercises and medication. Furthermore, comorbidities such as obesity and ligamenous laxity should be identified and managed, if applicable. When all nonsurgical treatment options faile, surgery can be considered. Our purpose in this article is to present a clinical algorithmic approach to pediatric flatfoot.

Apnea is one of the most common problems in premature newborns. The present study aimed to determine the effect of olfactory stimulation by vanillin on prevention of apnea in premature newborns. In this randomized controlled trial, 36 premature newborns with the postnatal age of 2 days and weight under 2500 grams referred to the hospitals affiliated to Shiraz University of Medical Sciences, were selected through simple random sampling and allocated into control and experimental groups. The experimental group received olfactory stimulation by saturated vanillin solution, while the control group received no interventions. The newborns of both groups were continuously monitored for presence/absence of apnea and number of episodes of apnea as well as arterial blood oxygen saturation and heart rate for 5 days. The data were analyzed by independent Student t-test and repeat measure ANCOVA. The presence of apnea revealed to be significantly different between the two groups in the first, second, and fourth day of the study (P<0.05). The number of episodes of apnea during five days was also significantly different between the study groups (t=8.32, P<0.05). Using olfactory stimulation by vanillin caused a 3.1-fold decrease in apnea and the effect size was 0.72. Moreover, the two groups were significantly different regarding the arterial blood oxygen and heart rate during the study period (P<0.05). This study indicated the beneficial effect of saturated vanillin solution on apnea; therefore, it may be used for prevention and treatment of apnea in premature infants. Further studies are needed to improve evidence-based practice in this regard.

The objectives of the current study were to translate and adapt Autism Treatment Evaluation Checklist (ATEC) into Persian language and to investigate its reliability and validity in an Iranian autistic sample. A total sample of 134 children with autism spectrum disorders aged 6-15 years were assigned to the study. The process of cross-cultural adaptation was performed according to international methodological steps as following: translation, back-translation, revision by an expert committee and pretest. A sample of 20 primary caregivers of autistic children were pretested. The content validity of the ATEC was reviewed by the expert committee all through the stages. The construct quality of the questionnaire was evaluated by comparison of the adapted version of the instrument with similar tests assessed similar factors. Moreover, the reliability of the questionnaire was evaluated through stability and homogeneity assessments. The results showed good content validity and internal consistency (Cronbach''s alpha: 0.86-0.93). In relation to construct validity, there was significant correlation between ATEC subscales and raw data obtained from Autism Diagnostic Interview-Revised (ADI-R) (r=0.38-0.79). The Intraclass Correlation Coefficient for the test–retest reliability was excellent for all the subscales and also for total scores (ICC: 0.79 - 0.93). Cross-cultural adaptation of ATEC was successful. The psychometric properties were verified and indicated that the adapted questionnaire is valid and reliable to use in Iranian culture.

This study was designed to determine the current age-related hepatitis A virus (HAV) seroprevalance, vaccination status of children and to evaluate the epidemiological shift in HAV serostatus living in Tekirdağ, which is located in Thrace region, the European part of Turkey. Children 6 months-12 years of age with simple health problems were included. Blood samples were studied for HAV IgM and IgG collectively. A questionnaire addressing several characteristics of subjects was administered to obtain basic descriptive data on HAV epidemiology. Vaccination status of the children was recorded according to the immunization cards. The overall anti-HAV IgM and anti-HAV IgG prevalance in children aged 6 months – 12 years was 3.3% and 25.4% respectively. Maximum hepatitis A IgM positivity was in the 7-12 years age group 4.8% (n= 12; P<0.001) and maximum hepatitis A IgG positivity in the same age group was 34% (n=85; P<0.001). HAV vaccination rate among patients aged more than 2 years was 11.03%. HAV IgG seroprevalance was higher in children of low monthly income families (36.1%, n=78; P<0.001) than in the intermediate (17%, n=31) and high income families (11.1%, n=6). These results indicate a shift in Hepatitis A seroprevalance when compared with the previous studies. As HAV infection in childhood is decreasing, the pool of susceptible adolescents and young adults is increasing. Introduction of hepatitis A vaccination into the national immunization schedule of Turkey should be considered.

The aim of this study was to examine the differences in the health related quality of life and the self care and social function in daily life of children with different disabilities. One hundred and two children with physical, emotional and cognitive disabilities (cerebral palsy, mental retardation, and hearing loss) and 28 children age matched as a control group were included in this study for the comparison. The Pediatric Evaluation of Disability Inventory (PEDI) was used to evaluate the independence and participation of children in daily life activities. The Turkish version of the Child Health Questionnaire-Parent form (CHQ - PF50) was used to evaluate the health related quality of life. All 3 groups were different from the control group in terms of self-care and the social domains according to the PEDI results (P<0.05). Children with cerebral palsy (CP) were more dependent in the areas of self-care and mobility activities (P<0.05). The main difference was found in global general health (GGH), physical functioning (PF), the emotional impact on the parent (PE) subsections of the CHQ-PF50 between the CP and the hearing loss groups; the role of the physical (RP) and emotional behavior (BE) subsections between the mental retardation (MR) and the CP groups, and the BE and mental health (MH) subsections between the MR and the hearing loss (HL) groups (P<0.05). All the children with disabilities were different from the control group in their quality of life, self care and social function. However the status of the children with MR and HL were parallel between each other in their health related quality of life, self care and social function. On the other hand, the most affected and dependent group was children with CP. The results will provide guidelines for healthcare professionals in implementing effective rehabilitation programs, especially to those with cerebral palsy, to reduce the level of strain and increase the health related quality of life, self care and social function of children with different disabilities.

Low Birth Weight [LBW] (1500gr≤Birth Weight≤2499 gr) is one of the most serious health problems in neonates. These neonates need complementary interventions (e.g. tactile-kinesthetic stimulation) to promote development. This study was conducted to determine the effect of Tactile-Kinesthetic Stimulation (TKS) on physical and behavioral development of Low Birth Weight neonates. This was a randomized controlled trial with equal randomization (1:1 for two groups) and parallel group design. Forty LBW neonates were randomly allocated into test (n=20) and control (n=20) groups. TKS was provided for three 15 minute periods per day for 10 consecutive days to the test group, with the massages consisting of moderate pressure strokes in supine and prone position and kinesthetic exercises consisting of flexion and extension of limbs. All measurements were taken before and after completion of the study with the same equipment (Philips electronic weighing scale with an accuracy of ±5 grams and Brazelton Neonatal Behavioral Assessment) and by the same person. There was a trend towards increased daily weight gain, but without statistical significance. On the Brazelton scale, the test group showed statistically significant improved scores on the ‘motor’ (P-value <0.001) and ‘regulation of state’ (P-value=0.039) clusters after the 10 days TKS. TKS has no adverse effects on physiologic parameters and gives better adaptive behavior of LBW neonates compared to those without TKS.

Adiponectin is secreted from adipose tissue. This hormone has a fundamental role in pathogenesis of insulin resistance, and has anti-inflammatory and anti-atherogenic effects. The objectives of this study were to compare serum adiponectin level between type 1 diabetics and healthy people and to assess its related factors, and also to determine the relationship between adiponectin and metabolic state. This was a case control study involving 60 diabetics (25 good and 35 poor metabolic controlled) and 28 healthy persons (younger than 18 years old). The data about demographic (age and sex), clinical and paraclinical characteristics [body mass index (BMI), duration of disease, puberty state, and glycosylated hemoglobin (HbA1c) and adiponectin level in serum] were collected. Determinants of adiponectin were assessed using univariate and multiple linear regression analyses. Mean (±SD) serum adiponectin level in healthy persons, good-controlled and poor-controlled type 1 diabetes mellitus patients were 9.16 (±4.2) μg/cc, 10.89 (±4.48)μg/cc, and 15.92 (±8.26)μg/cc, respectively. Post hoc analysis revealed that differences of adiponectin between poor- and good-controlled type 1 diabetes mellitus patients (P=0.01) and between healthy persons and poor controlled type 1 diabetes mellitus (P<0.0001) were statistically significant. Adiponectin level was associated with puberty state and BMI in healthy persons. It was associated with puberty state and HbA1c in type 1 diabetic persons. Serum level of adiponectin was higher in type 1 diabetics than in healthy persons and it can be used as a good marker for metabolic control state among diabetics.

Autoimmune hepatitis (AIH) is a necroinflammatory liver disease of unknown etiology that occurs in the children of all ages. The present study aimed to evaluate the clinical and paraclinical presentations, including pattern of autoantibodies, response to treatment, mortality, and liver transplantation outcome in the Iranian children with AIH. The medical records of 87 children (56 girls and 31 boy) diagnosed with AIH between 2001 and 2010 were retrospectively analyzed for clinical and paraclinical profiles and also treatment outcome. The mean age of the patients was 10.1±4.5 years (64.4% females). The most common clinical findings were jaundice (70.1%), splenomegaly (67.8%), and hepatomegaly (51.7%). Antinuclear, anti-smooth muscle, and anti LKM antibodies were positive in 14/62, 22/53 and 6/40 patients, respectively (36 patients had type 1 AIH, 6 patients had type 2 AIH, 26 patients were seronegative, and autoantibodies were not available in 19 cases). The most common histological finding in the liver biopsies was chronic hepatitis with interface activity that was seen in 65 (74.7%) patients. The complete response was seen in 52 (59.8%) patients and 24 (27.6%) patients underwent liver transplantation. One-year and five-year survival rates were 87.5% and 80% in the transplanted patients. AIH should be kept in mind in the differential diagnosis of both acute and chronic liver diseases in the children and treatment with combination of corticosteroids and azathioprine is a good treatment option. In the patients with end stage liver cirrhosis that did not respond to medical therapy, liver transplantation is the treatment of choice.

The aim of this study was investigating and comparing two components of executive functioning in children with high function autism with normal children. this study was correlation descriptive (causal-comparative). There were two groups, one consisted of 15 participants of children with high function autism disorder (Intelligence quotient [IQ]>80) and the other consisted of 15 normal children, all age and education matched. They were compared with two neuro-cognitive tests, Color Word Stroop and Wisconsin Card Sorting, and one IQ test called Ravens Progressive Matrices test. Analysis of data showed significant difference in both executive functionings, response inhibition (Stroop) and flexibility (Wisconsin Card Sorting) between normal children and children with autism disorder, but there was no significant relation between age and IQ and executive functioning in children with autism. The results showed that children with autism disorder have deficits in executive functions regardless of their IQ level and it can be attributed to the symptoms of autism spectrum disorders.

To evaluate the diagnostic value of provocative test by insulin combined with clonidine for growth hormone deficiency (GHD) during childhood Eighty children underwent a provocative test with insulin(0.075U/Kg, intravenous) combined with clonidine (4μg/kg, orally). Among them, 40 children underwent clonidine provocative test, 40 children underwent insulin tolerance test (ITT) in another day. The specificity of ITT+clonidine test (74%, 88%) was remarkably higher than that of ITT (48%) or clonidine test (65%). ITT+clonidine test had a better accuracy (75%, 85%) than that of ITT (63%) or clonidine test (73%) We conclude that the combined clonidine+insulin test is a feasible, reliable, convenient, time saving, and safe tool for evaluation of the growth hormone (GH) axes than the clonidine test or ITT.

To evaluate the incidence, etiology, outcome, and predictors of mortality in neonates with Acute Renal Failure (ARF) in an out born Neonatal Intensive Care Unit (NICU) of India. A retrospective analysis of case records of out born neonates, who had ARF at admission or developed ARF during NICU stay, from January to December 2011 (one year) was done. Out of the total 456 neonates admitted during the study period, 44 (9.6%) neonates with ARF (32 males, 12 females) were studied. Their mean gestational age, weight, and age at admission was 34.7±3.9 weeks, 2100±630 grams, and 2.1±6.3 respectively. Causes of ARF were pre-renal in 22 (50%), intrinsic renal failure in 16 (36.3%), and post-renal in six (13.6 %). Oliguria was present in 29 neonates. Neonatal sepsis was the commonest cause of ARF, followed by perinatal asphyxia, respiratory distress syndrome, and genitourinary anomalies. ARF was present at admission in 37 neonates. The mortality rate was 15.9% (7/44). Thirty-seven (84%) were discharged with complete recovery of renal functions and followed for six months. Shock, oliguria, need for mechanical ventilation, and presence of disseminated intravascular coagulopathy (DIC) emerged as predictors of mortality in neonates with ARF. The incidence and mortality rate of neonatal ARF were 9.6% and 15.9% respectively in our out born NICU. Neonatal sepsis was the commonest cause of ARF followed by perinatal asphyxia. Shock, oliguria, need for mechanical ventilation, and presence of DIC were associated with poor outcome.

This investigation aims to evaluate the validity of a Persian Tanner Stages Self-Assessment Questionnaire In this cross sectional study, 190 male students aged 8-16 years selected from three layers of different regions of Tehran (North, Central and South) were enrolled. A Persian questionnaire illustrated with Tanner stages of puberty (genital development and pubic hair distribution) was prepared. Children were asked to select the illustration that best described their pubertal development. Tanner status of the children was also estimated by an independent physician using physical examination. The degree of agreement between subjects’ judgments with assessments made by the rater was compared through the calculation of the weighted kappa statistic coefficient. We found a substantial agreement between self-assessment of pubertal development made by the children and doctor’s assessment of genital development (kappa=0.63, P<0.0001) and also the pubic hair distribution (kappa= 0.74, P<0.0001). Although a large proportion of subjects in G4 (89.2%) and G5 (85.7%) were capable of accurately or almost accurately identifying their own Tanner sexual stages, some degree of disagreement was observed in G3 Tanner stage (46.9%). Self-assessment of puberty should be used very cautiously and may not be a substitute method for routine evaluation of pubertal state especially for early and mid pubertal groups.

There are different methods for measuring bilirubin concentration; however, it is quite important for practitioners to know which method should be used in certain clinical situations. The present prospective study aimed to compare three different methods for measuring neonatal bilirubin concentrations. All full term neonates who were either brought into emergency departments or admitted to the neonatal wards in Kerman city in 2011 were recruited (n=428). The correlation coefficients were estimated for the routine ways of bilirubin concentrations including «Capillary», «Cutaneous» and «Laboratory» methods. Of 428 recruited neonates, 178 were female. Mean age ±SD was 178±71 hours. The correlation coefficient for «David Icterometer» vs «JM103» was 0. 91, while the corresponding coefficient for «David Icterometer» vs «Capillary» was 0. 96. It was also equivalent to 0. 85 for correlation between «JM103» and «Capillary» methods. The David Icterometer measured an average of 2. 36 mg/dl levels of bilirubin concentration compared to the JM103 method. The Capillary method showed a lower bilirubin level than the venous concentration (0. 91 mg/dl on average). Compared with the «Capillary», the «JM103» measured a slightly higher level of bilirubin with an average 0. 57 mg/dl. Due to low difference (less than 1 mg/dl) between «JM103» and the «Capillary methods» for measurement of neonatal bilirubin concentration, these two methods could alternatively be used instead of usual laboratory method.

Endotracheal tube suctioning (ETS) is a painful and invasive procedure. Studies have shown that the performance of nurses in this procedure is weak, so we conducted a study to evaluate the effect of ETS education for nurses on neonates’ pain in neonatal intensive care units (NICUs). In a quasi-experimental study, performance of 25 nurses working in NICU was assessed before and after ETS education by a checklist. In addition pain score of 50 neonates was measured using pain assessment tool (PIPP) one minute before, during and 5 minutes after ETS. The neonates had a gestational age of less than 37 weeks and were intubated (at least for 8 hours and up to 24 hours). A P. value of less than 0.05 was considered as statistically significant. Mean scores of nurses'' performance were significantly different before and after education (P≤0.001) by Wilcoxon test. Friedman test revealed that PIPPs before, during and after ETS were significantly different before and after education (P≤0.05). Mann-Whitney test showed no significant differences between PIPPs before ETS, before and after education (P=0.25), but PIPPs during and after ETS were significantly different (P≤0.01). ETS causes moderate to severe pain in neonates. Education improved performance of nurses and decreased pain in neonates during and after ETS. Despite education, neonates will experience mild pain during ETS, so other interventions need to be considerate.

To investigate T-cell immunoglobulin domain and mucin domain-containing molecule-3 (Tim-3) and its ligand galectin-9 mRNA expression in peripheral blood mononuclear cells (PBMCs) from Henoch-Schoenlein Purpura (HSP) patients. Quantitative real-time reverse transcription-polymerase chain reaction (PCR) was used to examine the mRNA expression of Tim-3 and its ligand galectin-9 in PBMCs from HSP patients. ELISA methods were used to examine the levels of serum IFN-γ and immunoglobulin A1 (IgA1). The Spearman rank test was used for correlation analysis between Tim-3, galectin-9 mRNA expression and serum IFN-γ and IgA1 levels, respectively. The results showed that Tim-3 and galectin-9 mRNA expression was obviously higher in patients, which was closely correlated with serum IFN-γ and IgA1, respectively. The results suggested that Tim-3/Tim-3L may be related to the pathogenesis of HSP.

Permanent congenital hearing loss, a common congenital anomaly, may affect speech and language acquisition, academic achievement and social development. Current standards emphasize early recognition of congenital hearing loss. This study was conducted to find the prevalence of hearing impairment in term newborns in Yazd, Iran. This was a descriptive-analytic study conducted in Yazd on 7250 term newborns. Otoacoustic emissions (OAEs) test was performed in all newborns during the first 24 hours after birth. Those who failed to respond at the first step were retested 15 days later. Those who failed to respond at the second step too, were tested by acoustic brainstem responses (ABR) test. Chi square test was used for data analysis. From 7250 newborns in the first step 598 (8.2%) and 682 (9.4%) ears (right and left, respectively) failed. In the second step 51 (0.7%) and 58 (0.8%) ears (right and left, respectively) failed. Consanguinity and route of delivery had significant effect on the frequency of hearing loss. The overall frequency of congenital hearing loss in this study was found high.

We aimed to evaluate clinical features and follow-up data of children with functional and secondary constipation. Hospital records of 335 constipated children were evaluated. Children were divided into 2 groups as functional and secondary, and were compared with regard to clinical and anthropometric data. Of 335 children (M/F 167/168, mean age 4.3±3.5 years) 91% had functional constipation (group 1). Family history of constipation was significantly higher in group 1. Malnutrition was found in 18% of group 1, 56% in group 2 (p<0.001). If a constipated child has a family history of constipation but does not have failure to thrive and constipation begins at an older age, functional constipation is more probable.

Congenital chyloperitoneum is an uncommon clinical condition. A few numbers of cases of congenital chyloperitoneum in children have been described who were treated in a variety of methods. A 5 days old baby boy with a significant abdominal distension was diagnosed with congenital chyloperitoneum. Due to the failed conservative managements by medium-chain triglyceride (MCT) enriched milk and partial parenteral nutrition (PPN), the authors tried platelet rich fibrin glue (PRFG) as an alternative choice which was applied in through an already inserted intra-abdominal catheter. PRFG successfully stopped the lymph leakage from all over the small intestinal mesentery; thereby PRFG may be considered as an effective alternative treatment before surgical intervention. Applying PRFG is an easy, safe, and effective alternative option that may be used to close the chylous ascites lymph leakage in children if conservative management with PPN fails.

Spontaneous kidney rupture could develop in the course of posterior urethral valve (PUV), the most common cause of outflow urinary tract obstruction in male infants. However, urinary extravasation is a rare complication among this group of children. Our case report presents diagnostic difficulties connected with spontaneous kidney rupture due to PUV in a 6 week-old infant. Due to not equivocal images, thundery course of disease and rapid deterioration in the infant`s condition, the patient required an urgent laparatomy. This case showed that the investigation of renal abnormalities during early neonatal period, is very important specifically in PUV that can lead to kidney rupture.

Insulin resistance syndromes are a heterogeneous group of disorders with variable clinical phenotypes, associated with increased blood glucose and insulin levels. Herein, a 10-year old girl with abnormal face and dentition is presented. She has suffered from diabetes mellitus type I since she was 6 years old. Hyperglycemia did not respond to age appropriate insulin dosage; therefore, insulin dosage was increased, but did not lead to appropriate glycemic control. Twenty two exons of insulin receptor gene (INSR), on short arm of chromosome 19, were sequenced, but no identifiable disease causing mutation was detected. Although a rare mutation within the intronic or promoter region has not been excluded in this case, further molecular studies on patients with insulin resistance syndromes associated with certain features are needed.