Iranian Journal of Pediatrics
Volume:23 Issue: 6, Dec 2013

To systematically evaluate therapeutic success of the ketogenic diet (KD) as a treatment option for epilepsy. Using MEDLINE and Google Scholar search, we searched for studies investigating the therapeutic success of ketogenic diet for epilepsy. We estimated therapeutic success rate for ketogenic diet as a treatment option for epilepsy and its 95% CIs using generic inverse variance method. A total of 38 studies met the inclusion criteria. In retrospective studies, the weighted success rate of the patients who take the KD as a treatment option for epilepsy was 58.4% (95% confidence interval (95%CI)=48.7% - 69.9%) at 3 months (n=336); 42.8% (95%CI =36.3% - 50.3%) at 6 months (n=492), and 30.1% (95%CI =24.3% - 37.2%) at 12 months (n=387); in prospective studies, weighted success rate was 53.9% (95%CI 45.5% - 63.8%) at 3 months (n=474); 53.2% (95%CI =44.0% - 64.2%) at 6 months (n=321), and 55.0% (95%CI =45.9% - 65.9%) at 12 months (n=347). This meta-analysis provides formal statistical support for the efficacy of the ketogenic diet in the treatment of epileptic patients.

Obesity in children and adolescents is a hot issue throughout the world. Numerous complications are related to childhood obesity, such as cardiovascular disease, diabetes, insulin resistance and psychological problems. Therefore, identification and treatment of this problem have an important role in the health system. In this clinical approach, we have provided a general overview of the assess­ment and management of obesity in children and adolescents, including definitions, history-taking, physical examinations, and laboratory testing for general practitioners and pediatricians. Furthermore, conventional therapies (physical activity, eating habits and behavioral modification) and non-conventional treatments (drugs and surgery options) have been discussed.

A high incidence of snake bite envenomation has been reported from rural India. Due to inadequate epidemiological data, the incidence is underestimated. This study analyses the pattern of snake bite and their management in children in rural areas of Maharashtra, India. To determine the age, mode of presentation, seasonal variation, clinical profile and outcome of patients with snake bite less than 15 years of age. This study is a retrospective, descriptive study including 162 patients, who presented with history of snake bite. Clinical data about age, sex, clinical manifestations, complications and outcome were obtained from case records and were analyzed. Out of the 162 patients 98 (60.49%) were males. The bites were vasculotoxic in 147 (90.74%) and neuroparalytic in 15 (9.25%) patients. Mainly bites occurred from July to September with 84 (51.85%) bites. Bites were more common in males in age more than 5 years (89%) with bite marks mainly on lower limbs in 120 (74.04%) patients. Deaths were reported in patients who reported late to the hospital with a mortality rate of 1.85%. Snake bite is a life threatening emergency. The key to minimizing mortality and severe morbidity is aggressive management of the ABC`s of resuscitation, and timely and judicious administration of adequate dose of anti-venom.

Shiga toxin-producing E. coli (STEC) is a pathogenic E. coli that may cause hemolytic uremic syndrome (HUS) after diarrheal disease through Shiga toxins. Management of the patients with STEC infection is different from that of other diarrheal diseases due to increase in frequency of HUS after antibiotic administration. Few studies were conducted in Iran and epidemiology of STEC remains obscure; this necessitates examination of stools especially in young children for this bacterium. We determined the frequency of STEC in 947 E. coli strains isolated from diarrheal stools of children less than 14 years in Tehran with conventional culture methods and multiplex-PCR via determining the STX1 and STX2 genes, between October 2008 and September 2009. We also evaluated the association between stool exam findings and presence of STEC. Twenty seven (2.8%) of E. coli isolates were positive for STX1 or STX2 genes, most of which occurred in spring (P<0.05). There was no significant association between STEC positivity and stool exam findings. Eighteen out of 27 (66.7%) Shiga toxin positive samples were isolated from males and the rest from females. The most common STX-positive diarrheal samples showed loose consistency (P<0.017). Although the low frequency of STEC in our population indicates that it is not a major problem in our population, STEC should be regarded as an important infection because of its severe consequences. Further studies with greater sample size are needed to confirm our results.

Ceftriaxone is a third-generation cephalosporin which is widely used for treatment of infection in children accompanied by complications like urinary tract lithiasis and gallbladder psudolithiasis or sludge. The aim of this study was to investigate the incidence and predisposing factors that contribute to these complications in children. This quasi-experimental and before- and after-study was conducted in 96 children who were hospitalized for treatment of different bacterial infections and received 50-100 mg/kg/day ceftriaxone divided into two equal doses intravenously under conditions of adequate hydration. Sonographic examinations of urinary tract and gallbladder were carried out before and after treatment for that purpose. Patients with positive sonographic findings after treatment were followed with serial sonographic examinations. Post-treatment sonography demonstrated nephrolithiasis in 6 (6.3%) and gallbladder stone in one (1%), all were asymptomatic. Comparison of the groups with and without nephrolithiasis demonstrated no significant differences with respect to age, body weight, diagnosis, season of hospitalization, dosage of drug and the duration of treatment. Nephrolithiasis had a significant relation with male gender (P=0.02). Our results showed that pediatric patients may develop small sized, asymptomatic renal stones during a 2-6 day course of normal or moderate dose of ceftriaxone therapy. Close monitoring of ceftriaxone treated patients especially on high dose long term therapy for nephrolithiasis and gallbladder psudolithiasis or sludge is recommended.

Temporary vesicostomy is a urinary diversion procedure for patients with upper urinary tract (UUT) dilatation, secondary to bladder outlet obstruction or dysfunction. The aim of this study was to evaluate our experience in children undergoing such diversion, analyzing its efficacy to prevent urinary tract infection (UTI), improve or resolve hydronephrosis, stabilize or improve kidney function and restore the health of UUT. In this retrospective study, patients who had vesicostomy by Blocksom technique due to bladder outlet obstruction or dysfunction were evaluated in Mofid Children''s Hospital (in Tehran) from March 2007 to March 2012. The reason for applying this procedure was failure in clinical treatment. Data regarding gender, age, diagnosis, time of any surgical intervention, associated anomalies, primary/secondary complications and mortality were collected using a questionnaire, and evaluated by giving a grade that ranged from 0 (worst) to 10 (best) based on Lickert''s scale. From a total number of 53 patients, (88.7% male and 11.3% female) with a mean age of 225 days, 66% had posterior urethral valve and 16 (30%) neurogenic bladder. UTI was present in all cases, hydronephrosis in 52 (98.1%), and vesico-ureteral reflux only in 45 (84.9%) patients. Valve ablation was performed in 17 cases, and clean intermittent catheterization in14 patients which were unsuccessful. We performed vesicostomy in all patients. Mortality rate was 7.5%. Vesicostomy was closed in 35 patients. Cure rate was 85% in UTI, 82.7% in hydronephrosis, 80% in VUR, and 86.5% in kidney function. Vesicostomy is a simple procedure that protects upper urinary tract, decreases hydronephrosis, and improves kidney function. The procedure is well tolerated and reversible, with less complication and should be considered in children in whom conservative and medical treatment has failed.

Approximately one-third of all children with epilepsy do not achieve complete seizure improvement. This study evaluated the efficacy of Vigabatrin in children with intractable epilepsy. From November 2011 to October 2012, 73 children with refractory epilepsy (failure of seizure control with the use of two or more anticonvulsant drugs) who were referred to the Children’s Medical Center and Mofid Children’s Hospital were included in the study. The patients were treated with Vigabatrin in addition to their previous medication, and followed-up after three to four weeks to determine the daily frequency, severity, and duration of seizures in addition to any reported side effects. Of the 67 children, 41 (61.2%) were males and 26 (38.8%) females, their age ranging from three months to 13 years with an average of 3.1 [standard deviation (SD), 2.6] years. The mean daily frequency of seizures at baseline was 6.61 (SD, 5.9) seizures per day. Vigabatrin reduced the seizure frequency ≤2.9 (SD, 5.2) (56% decline) and 3.0 (SD, 5.3) (54.5% decline) per day after three and six months of treatment, respectively. A significant difference was observed between seizure frequencies at three (P<0.001) and six months (P<0.001) after Vigabatrin initiation compared with the baseline. Somnolence [3 (4.5%)], horse laugh [1 (1.5%)], urinary stones [1 (1.5%)], increased appetite [1 (1.5%)], and abnormal electroretinographic pattern [3 (4.5%)] were the most common side effects in our patients. This study confirms the short-term efficacy and safety of Vigabatrin in children with refractory epilepsies.

Placental hormones such as resistin، adiponectin، ghrelin and leptin are known to have considerable role in fetal growth and there are some articles published in this area recently. Nevertheless there is a shortage of data showing association between resistin level and fetal growth; that was why we decided to conduct a study to evaluate this association. This study was approved by ethic committee of pediatric health research center and research vice chancellor of Tabriz University of Medical Sciences. In this case-control study we measured the insulin، glucose and resistin in the cord blood of neonates with gestational age of 37 weeks or more in Al Zahra tertiary hospital from March 2011 to March 2012. Thirty-nine appropriate for gestation age (AGA) neonates and 41 small for gestation age (SGA) neonates were studied. The umbilical cord blood resistin level was not found to have significant correlation with the type of delivery [normal vaginal delivery (NVD) or cesarean-section (C-S)]، neonate''s gender، maternal age or body mass index (BMI). There was no significant difference in the levels of Insulin and glucose between AGA and SGA groups. Resistin level of blood cord in AGA group was 613. 76±180. 10 (range: 132. 6-983. 80 ng/ml) and in SGA group it was 1303. 47±537. 07 (range: 800. 9-3001 ng/ml) (P<0. 001). Neonates’ weight in AGA group was 3162. 82±407. 92 g and in SGA group it was 2425. 85±32. 84 g (P<0. 001). In this study resistin level had reverse correlation with fetal weight in term neonates. The SGA neonates with growth insufficiency have higher resistin levels in their cord blood than AGA neonates with same gestational age. It is recommended to conduct more studies in future with larger population of patients to clarify the resistin role in neonatal birth weight.

In this study we aimed to determine the prevalence of cardiac malformations in fetuses of Iranian diabetic mothers with pre-gestational and gestational diabetes mellitus (GDM) and to find the patterns of different cardiac malformations. One-hundred and seventy diabetic pregnant women (68 preGDM and 102 GDM) (mean age: 32.17±4.8 years) and 85 healthy controls (mean age: 31.35±4.55 years) were recruited from September 2008 to July 2012. Fetal echocardiography was performed to assess cardiac malformation. In order to study major factors that may affect the results, a complete history was obtained. Fetal echocardiography was performed at mean gestational age of 24.7±5.4 and 20.27±3.9 weeks in diabetic patients and control group, respectively. Fifteen (8.8%) fetuses of diabetic mothers were detected to have cardiac malformations compared with 1 (1.17%) fetus in control group (OR: 8.13, 95%CI: 1.1-62.61, P-value=0.02). Hypertrophic cardiomyopathy noted as the most common cardiac malformation occurred in 6 out of 15 (40%) fetuses, and was found significantly more common in pre-GDM compared to GDM group (7.4% vs 1%, P-value =0.04). Despite the higher incidence of cardiac malformation in pre-GDM compared to GDM group, the difference was not significant. Further, no significant association was observed between the variables including; parity, diabetic regimen, parents’ consanguinity, maternal history of hypertension or hypothyroidism and occurring cardiac malformations (P-value >0.05). In this study we detected cardiac malformations in 8.8% of our diabetic referrals. The result of the present study shows that screening diabetic mothers for fetal cardiac malformations could be beneficial.

Patients with cystic fibrosis (CF) usually have abnormal intestinal microbiota and dysregulated immune mediators due to massive exposure to antibiotics. Probiotics as immunomodulatory and anti-inflammatory substances are considered to improve both clinical and biochemical intestinal and pulmonary function in CF patients. We decided to investigate the effects of probiotics on quality of life and pulmonary exacerbations in children with cystic fibrosis. In a prospective, randomized, controlled clinical trial, 37 CF patients (2-12 years old) were randomly divided into two groups. 20 patients of probiotic group took probiotics (2×109CFU/d) for one month while 17 patients of control group took placebo capsules. Quality of life was determined using PedsQLTM4.0 questionnaire at the beginning, then three and six months after completing the treatment period. Rate of pulmonary exacerbation in probiotic group patients was also evaluated during three months after intervention and compared to the same three months of the previous year. Results were analyzed using SPSS (11.5). P<0.05 was considered statistically significant. Significant improvement was observed in the mean total score of parent reported quality of life among probiotic group patients in comparison with placebo group at 3rd month (P=0.01), but this was not significant at 6th month of probiotic treatment. Rate of pulmonary exacerbation was significantly reduced among probiotic group (P<0.01). Probiotics are considered as useful nutritional supplements on reducing number of pulmonary exacerbations and improving quality of life in patients with cystic fibrosis. Effects of probiotics seem to be temporary and probably continuous ingestion might have more stable improving effects on quality of life.

Timely identification and prompt resuscitation of newborns in the delivery room may cause a decline in neonatal morbidity and mortality. We try to identify risk factors in mother and fetus that result in birth of newborns needing resuscitation at birth. Case notes of all deliveries and neonates born from April 2010 to March 2011 in Mahdieh Medical Center (Tehran, Iran), a Level III Neonatal Intensive Care Unit, were reviewed; relevant maternal, fetal and perinatal data was extracted and analyzed. During the study period, 4692 neonates were delivered; 4522 (97.7%) did not require respiratory assistance. One-hundred seven (2.3%) newborns needed resuscitation with bag and mask ventilation in the delivery unit, of whom 77 (1.6%) babies responded to bag and mask ventilation while 30 (0.65%) neonates needed endotracheal intubation and 15 (0.3%) were given chest compressions. Epinephrine/volume expander was administered to 10 (0.2%) newborns. In 17 patients resuscitation was continued for >10 mins. There was a positive correlation between the need for resuscitation and following risk factors: low birth weight, preterm labor, chorioamnionitis, pre-eclampsia, prolonged rupture of membranes, abruptio placentae, prolonged labor, meconium staining of amniotic fluid, multiple pregnancy and fetal distress. On multiple regression; low birth weight, meconium stained liquor and chorioamnionitis revealed as independent risk factors that made endotracheal intubation necessary. Accurate identification of risk factors and anticipation at the birth of a high-risk neonate would result in adequate preparation and prompt resuscitation of neonates who need some level of intervention and thus, reducing neonatal morbidity and mortality.

ETV6/RUNX1 (also known as TEL/AML1) is the most frequent gene fusion in childhood acute lymphoblastic leukemia (ALL). Sixty-three patients were enrolled in this study to explore the distribution of this gene in Iranian population. This study used 63 peripheral blood and bone marrow (PB/BM) samples from children with ALL. Immunophenotyping of PB and BM samples were performed using flow cytometry to illustrate the lineage. Moreover, reverse transcriptase polymerase chain reaction (RT-PCR) technique was used to amplify transcripts of leukemia-specific chromosome fusion gene ETV6/RUNX1 and to monitor the expression levels of the ETV6/RUNX1 in patients according to Van Dongen et al protocol. On the basis of French-American-British (FAB) classification, 47 individuals had ALL-L1. The incidence of ETV6/RUNX1 fusion gene in this study was 34.9%. The laboratory and clinical features of twenty two ETV6/RUNX1 positive ALL cases were similar to those of other studies. The most positive cases of ETV6/RUNX1 fusion gene had the early pre B ALL and pre B ALL immunophenotypes. The ETV6/RUNX1 fusion gene is a common genetic anomaly in Iranian childhood ALL patients and the prevalence of the ETV6/RUNX1 fusion gene is similar to that of ALL patients in other countries. However early pre B cells were the most common type in studied patients.

To determine the risk factors associated with lower respiratory tract infections (LRTI) related hospitalizations in preterm infants receiving palivizumab throughout the high season for respiratory syncytial virus (RSV) infection. Premature infants who were commenced on palivizumab prophylaxis during the RSV season were included in the study following parental consent. Information on demographic, social, prenatal and postnatal clinical characteristics was recorded and risk factors associated with hospitalization were evaluated for each patient. While 234 participants (Group 1, 92.8%) did not require hospitalization during the study period, 18 patients (Group 2, 7.2%) were hospitalized at least once for LRTI during the RSV season. The rate of moderate-severe bronchopulmonary dysplasia (BPD) was significantly higher in group 2 compared to group 1 (38.9% vs 16.2%; P=0.016). Of the 18 infants who were hospitalized, 6 (33.3%) tested positive for RSV while the remaining 12 patients (66.7%) were negative for RSV. Odds ratio (OR) analysis of several risk factors revealed the presence of BPD (OR: 3.28; 95%CI: 1.19-9), being from a family with low socioeconomic status (OR: 3.64; 95%CI 1.08-12.3) to be associated with a higher likelihood of LRTI-related hospitalization. Our data demonstrated that RSV is an important LRTI agent and cause of hospitalization especially in preterm infants with additional risks such as BPD, gestational age of <28 weeks and low socioeconomic status. We suggest that improving care conditions and decreased BPD with prematurity would help in prevention of LRTI hospitalization.

To determine the risk factors associated with lower respiratory tract infections (LRTI) related hospitalizations in preterm infants receiving palivizumab throughout the high season for respiratory syncytial virus (RSV) infection. Premature infants who were commenced on palivizumab prophylaxis during the RSV season were included in the study following parental consent. Information on demographic, social, prenatal and postnatal clinical characteristics was recorded and risk factors associated with hospitalization were evaluated for each patient. While 234 participants (Group 1, 92.8%) did not require hospitalization during the study period, 18 patients (Group 2, 7.2%) were hospitalized at least once for LRTI during the RSV season. The rate of moderate-severe bronchopulmonary dysplasia (BPD) was significantly higher in group 2 compared to group 1 (38.9% vs 16.2%; P=0.016). Of the 18 infants who were hospitalized, 6 (33.3%) tested positive for RSV while the remaining 12 patients (66.7%) were negative for RSV. Odds ratio (OR) analysis of several risk factors revealed the presence of BPD (OR: 3.28; 95%CI: 0.19-9), a GA <28 weeks (OR: 1.6; 95%CI: 0.61-4.18), history of exposure to smoke (OR: 1.51; 95%CI: 0.52-4.38), being from a family with low socioeconomic status (OR: 3.64; 95%CI 1.08-12.3) to be associated with a higher likelihood of LRTI-related hospitalization. Our data demonstrated that RSV is an important LRTI agent and cause of hospitalization especially in preterm infants with additional risks such as BPD, gestational age of <28 weeks and low socioeconomic status. We suggest that improving care conditions and decreased BPD with prematurity would help in prevention of LRTI hospitalization.

This study was conducted to determine the prevalence of low birth weight (LBW) and its related risk factors in an appropriate sample of neonates in Shahroud, northeast Iran. At this study, a random sample of 1000 neonates were selected of which 72 neonates were LBWs. We used univariate and multivariate logistic regression methods to evaluate the LBW risk factors in LBWs compared to normal weight infants. 7.2% of neonates were LBWs and 6.1% born before 37 weeks of gestation. Prematurity, high-risk pregnancy and maternal age have significant statistical association with LBW. Odds Ratio (OR) for prematurity was 42.82 (95%CI; 21.93-83.57), for high risk pregnancy 2.76 (95%CI; 1.47-5.19) and for maternal age group more than 35 years in comparison to 19-35 years age group 0.2 (95%CI; 0.05-0.71). Based on this study; prematurity and high risk pregnancy were the most important risk factors for LBW. There was also a reverse association between maternal age and LBW.