Leptospirosis in children in Mumbai slums

Objective : There is limited data available on symptomatic leptospirosis in Indian children. We report an outbreak of leptospirosis that occurred in children living in slums following heavy rainfall and flooding. This hospital — based prospective study was conducted from July to August 2001.Methods : Diagnosis of acute leptospirosis was suspected by following the Indian Leptospirosis Society working definition for leptospirosis. Diagnosis was confirmed by detecting anti —Leptospira antibodies, using either aLeptospira genus — specific latex agglutination assay or a dipstick assay or by a macroscopic slide agglutination test.Result : Thirty (32%) out of 93 children admitted had acute leptospirosis. Fever, bodyache, chills, abdominal pain, headache, vomiting, cough, hepatosplenomegaly, edema and crepitations were the common presenting signs and symptoms. Twenty — two children had anicteric leptospirosis and 8 had Weil disease. Response to penicillin treatment was good in all except in one child with Weil disease who died of renal failure within 3 hours of admission.Conclusion : Leptospirosis has emerged as an infectious disease in Mumbai. During monsoon, parents should ensure that their child does not have contact with the contaminated flood water.     

Indoor air pollution and respiratory health of children in the developing world

Indoor air pollution (IAP) is a key contributor to the global burden of disease mainly in developing countries. The use of solid fuel for cooking and heating is the main source of IAP in developing countries, accounting for an estimated 3.5 million deaths and 4.5% of Disability-Adjusted Life Years in 2010. Other sources of IAP include indoor smoking, infiltration of pollutants from outdoor sources and substances emitted from an array of human utilities and biological materials. Children are among the most vulnerable groups for adverse effects of IAP. The respiratory system is a primary target of air pollutants resulting in a wide range of acute and chronic effects. The spectrum of respiratory adverse effects ranges from mild subclinical changes and mild symptoms to life threatening conditions and even death. However, IAP is a modifiable risk factor having potential mitigating interventions. Possible interventions range from simple behavior change to structural changes and from shifting of unclean cooking fuel to clean cooking fuel. Shifting from use of solid fuel to clean fuel invariably reduces household air pollution in developing countries, but such a change is challenging. This review aims to summarize the available information on IAP exposure during childhood and its effects on respiratory health in developing countries. It specifically discusses the common sources of IAP, susceptibility of children to air pollution, mechanisms of action, common respiratory conditions, preventive and mitigating strategies.     

Clinical profile of Saudi children with bronchiectasis

Objective This study represents the experience of a tertiary care center in Saudi Arabia on non-cystic fibrosis bronchiectasis. Methods A retrospective review of all patients with confirmed Non-Cystic Fibrosis (Non-CF) bronchiectasis by chest X-ray and or CT chest in a pulmonary clinic for the period 1993–2005 at a tertiary care center in Riyadh. Results A total of 151 cases were diagnosed as Non-CF bronchiectasis. Siventy-five (49.7%) were males, 76(50.3%) were females. One hundred forty-eight (98%) are alive and 3(2%) died. The southwestern regions constituted 72(50%) of the cases. There is a period (5±3.2) years between the start of symptoms and the diagnosis of bronchiectasis. More than 2/3 of the patients had cough, tachypnea, wheezing, sputum production and failure to thrive. Ninety one (60%) had associated disease: Pulmonary diseases in 48(32%), immunodefficiency in 27(18%), CNS in 18(12%), cardiac in 12(8%), and asthma in 103(68%) of the patients. Left lower lobes were commonly involved in 114(76%) cases. Sixty-eight (67%) were found to have sinusitis. Forty-nine (32%) developed gastroesophgeal reflux (GER). Hemophilus influenza was cultured in 56(37%), Strept pneumoniae in 25(17%), and Pseudomonas aeruginosa in 24(16%) of the patients. 80% of the patients who had pulmonary function test had abnormal changes. Disease progression was related to development of symptoms before 5 years of age, persistent atelectasis, and right lower lobe involvement (p < 0.05). Conclusion Non-CF bronchiectasis is a common problem in Saudi Arabia. Early recognition and institution of treatment with proper vaccination of available anti-bacterial and anti-viral vaccines are encouraged to prevent progression of the disease.     

Characteristics of young foster children in the urban slums of Bangladesh

Aim: To identify the reasons for the fostering of children, and to describe their feeding practices and assess their health and nutritional status. Methods: Forty-six pairs of mothers and their young foster children (up to 24 mo of age) were interviewed in a cross-sectional study in the urban slums of Dhaka, Bangladesh. Another 82 pairs of mothers and their biological children of a similar age group were interviewed for comparison. Results: Sixty-five percent of the children were fostered because of the death of their biological mothers. Eighty-three percent of the biological mothers died because of complications during delivery or the immediate postpartum period and the remainder died after the postpartum period of diseases unrelated to their pregnancies. More than half (52%) of the foster mothers were childless and a quarter (24%) fostered children for reasons of gender preference. Almost a quarter (24%) of the children were placed in foster homes because of extreme parental poverty. Divorce or separation of the biological parents accounted for only 7% of children fostered. Approximately 90% of the foster children were given animal and/or formula milk in their first month of life while all children in the comparison group were given breast milk. Among the foster children, 58% were given semisolid or solid food before completion of 4 mo compared with 14% in the comparison group. Significantly more children in the foster group suffered from diarrhoea and acute respiratory infection than in the comparison group.

Conclusion: Maternal death, poverty and childlessness and child gender preference of foster mothers were important factors in fostering of children in the study group. Inappropriate feeding practices compounded by diseases may have contributed to the poor nutritional status of the foster children.     

Protection, promotion and support of breastfeeding in low-income countries

The rates of exclusive breastfeeding and the duration of breastfeeding fall short of what is recommended by the Global Strategy on Infant and Young Child Feeding worldwide. In low-income countries this is associated with a great excess of avoidable childhood death and disease. A higher degree of protection, promotion and support of breastfeeding has the potential to avert the death of about 1.3 million children per year and to prevent much of the associated individual and social sufferings. This paper presents some evidence about interventions that are effective to protect, promote and support breastfeeding in the health system and in the community. These interventions should not be implemented in isolation, but as part of an integrated and intersectoral programme, with a participatory approach that takes local cultural characteristics into account. Lack of political will is probably the most important factor associated with inadequate protection, promotion and support of breastfeeding.     

Measurement of reticulocyte hemoglobin content to diagnose iron deficiency in Saudi children

Iron deficiency and iron deficiency anemia are common conditions in children, especially in developing countries. It is often difficult for the pediatrician to know which indices should be used in the diagnosis of these conditions in children. Reticulocyte hemoglobin (Hb) content (CHr) has been shown to be an accurate indicator of anemia, however whether its use suits the situation in developing countries or not is unclear. The aim of this study was to evaluate the value and effectiveness of using CHr as a method to diagnose iron deficiency and iron deficiency anemia in Saudi children. The samples for the study were collected from 305 children suspected to have anemia. Complete blood count, transferrin saturation (Tfsat), ferritin, circulating transferrin receptor (TfR) and CHr were measured. Three groups were defined, iron deficiency (Tfsat <20%, Hb >11 g/dL; n=120), iron deficiency anemia (Tfsat <20%, Hb <11 g/dL; (n=73) and controls (Tfsat >20%; n=112). The anemic group had significantly lower macrocytic anemia (MCV), mean corpuscular hemoglobin (MCH) and CHr. All of the variables in the anemia group were significantly lower than those of the control group except for the ferritin level. Compared to the control group, the iron deficiency group also showed significantly lower values except for transferrin receptor and the ferritin levels. CHr levels of <26 pg correlated well with anemic states. CHr together with a complete blood count may provide an alternative to the traditional hematologic or biochemical panel for the diagnosis of iron deficiency and iron deficiency anemia in young children and is cost-effective in developing countries. A CHr cut-off level of 26 pg is considered to be a reasonable indicator of anemic states.     

Chronic suppurative otitis media in children of Luanda, Angola

Aim: Evaluation of clinical characteristics, bacteriology and hearing in paediatric patients with and without chronic suppurative otitis media (CSOM) in Luanda, Angola. Methods: Interview, clinical examination, ear‐discharge culture, open air pure‐tone audiometry and brainstem auditory‐evoked potentials of 23 outpatients with CSOM and 23 controls in a paediatric hospital. Results: Of the CSOM vs. control children, 35% vs. 26% had running water, 70% vs. 70% electricity, 64% vs. 0% HIV (p < 0.0001) and 36% vs. 0% tuberculosis in history (p = 0.002). Ten (43%) children had bilateral CSOM. The major ear‐discharge pathogens were Proteus spp. (44%) and Pseudomonas (22%). Hearing impairment of >25 dB was present in 52% of CSOM‐affected ears and bilateral hearing loss in 7 (30%) CSOM children vs. zero control child (p = 0.009). Only one hearing‐impaired child’s family had previously detected the handicap. Conclusion: CSOM occurred in children with high co‐morbidity. Persistent otorrhoea was usually caused by Proteus spp. or Pseudomonas, and often suggestive of either HIV or hearing impairment. In the developing countries, prompt diagnosis and treatment of CSOM would enhance the children’s linguistic and academic development.     

Investigation of the nutritional state of children in a Congolese village

The fatty acid status of an unselected group of 84 Congolese children was determined by estimating the fatty acid composition of the plasma phospholipid (PL) and cholesterolester (CE) fractions using capillary gas chromatography. In comparison with North American and European children a wide range of values and low mean percentages (related to the fatty acids of a chain length of 14–24 carbon atoms) were found for the following fatty acids (mean±SD): linoleic acid (LA) (PL: 17.19±3.85; CE: 40.13±7.72); arachidonic acid (AA) (PL: 6.60±2.28; CE 4.32±1.71); dihomo-gammalinolenic acid (DHLA) (PL: 1.80±0.68; CE 0.41±0.22). On average, 3 fatty acids were higher than in reference groups, while similar values were found for the monoenoic and 9 fatty acids. No sample contained eicosatrienoic acid, 20:39 (ETA) which, dependent on analytical methods, may be difficult to separate from behenic acid (22:0). Changes in the relation between the two lipid fractions occurred when the LA content in CE was less than 35%. Also the correlation between LA and AA in CE, which was significant below 35% LA (r=0.84), changed with higher values for LA (r=0.01). These findings may indicate that alterations in fatty acid metabolism occur when LA values in CE — which are supposed to be directly related to the dietary intake of polyunsaturated fatty acids — fall below 35% of all fatty acids in this lipid fraction.Abbreviations AA arachidonic acid, 20:46 - CE cholesterol ester - DHA docosahexaenoic acid, 20:36 - DHLA dihomo--linolenic acid, 20:63 - EFA essential fatty acids - EPA eicosapentaenoic acid, 20:53 - ETA eicosatrienoic acid, 20:39 - FA fatty acids - LA linoleic acid, 18:26 - LLA linolenic acid, 18:33 - OA oleic acid, 18:19 - PL phospholipids - P/S quotient polyunsaturated to saturated fatty acids - PUFA polyunsaturated fatty acids This work was supported by a grant from the Deutsche Forschungsgemeinschaft, Br 282/13-1)     

Falls among children in the developing world: a gap in child health burden estimations?

AIM: To estimate the incidence and mortality rates for unintentional fall injuries in children under 5 years of age in three developing regions of the world. METHODS: This is a systematic review of literature on unintentional childhood fall injuries. A computerized PUBMED search of literature published between 1980 and 2006 was conducted and a manual search of journals was also completed. RESULTS: Over 140,000 injuries to children under 19 years were reported in 56 studies (21 from Asia, 20 from Africa and 15 from South America); on an average 36% of injuries (52 575) were due to falls. The median incidence is estimated at 137.5 fall injuries per 100,000 children. The incidence of falls specific to the under-5 age group was reported in 16 studies with a median incidence of 40.6 falls per 100,000. The overall average incidence rate for childhood falls is highest in South America at 1315 followed by Asia at 1036 and Africa at 786 per 100,000, respectively. Average mortality rates were highest for Asia at 27 followed by Africa at 13.2 per 100,000, respectively. CONCLUSION: This review demonstrates that the burden of falls on children has not been well documented, and is most likely under-reported. With the large and growing population of children in developing countries, the public health implications of the observed results are tremendous. Appropriate prevention relies on accurate statistics.     

Resistance to implementing Kangaroo Mother Care in developing countries, and proposed solutions

BACKGROUND: Randomized clinical trials have shown that Kangaroo Mother Care (KMC) can decrease morbidity and mortality due to low birthweight. Between 1994 and 2004, 44 teams in 25 developing countries were trained in KMC in Bogotá, Colombia; however, not all the teams were successful in initiating their own programmes and, of those that started, not all replicated the validated model. AIM: To identify factors involved in unsuccessful KMC implementation and find solutions. METHODS: A study was conducted in which 17 open-ended questionnaires were sent by e-mail to the coordinators of functioning KMC programmes in 15 countries, and 15 site visits were made to institutes that reported problems in starting programmes. The information was classified according to the perceived obstacle and the KMC model component involved. RESULTS: The early-discharge component (including ambulatory follow-up) was that found most difficult to implement. Resistance from health professionals, mothers and families was often related to local cultural practices. CONCLUSION: Active surveillance for and appropriate identification of obstacles usually indicated the appropriate solution. Some of the obstacles were common to many second-generation KMC programmes, making this information valuable for the implementation of programmes.     

Iodine deficiency in urban slums of Bhubaneswar

Objective The present study aimed at assessing the population prevalence of goiter and iodine deficiency in school children of 6–12 yr living in urban slums of Bhubaneswer, the capital city of Orissa. Methods A cross-sectional study was performed using the 30-cluster sampling methodology and surveillance methods for iodine deficiency as recommended by WHO/ICCIDD/UNICEF. The total goitre rate (n=1248), urinary iodine concentration (UIC) (n=411) and iodine content of edible salt (n=368) were measured. Results The goitre prevalence was 23.6% (grade 1=18.9%, grade 2=4.7%) with no significant gender variation. Goitre prevalence was significantly higher in children of 10–12 yr (P=0.012) and scheduled caste and tribe (P=0.003). Median urinary iodine concentration was 50.0 μg/l with 85.7% of children having values less than 100 μg/l, indicating as biochemical iodine deficiency. Median UIC was inversely in association with gradations of goitre. Children of 10–12 yr and scheduled caste/tribe communities had significantly higher median UIC (P=0.001) than their counterpart peers. About 51% of children were consuming salt having stipulated iodine content of 15 ppm. Conclusion The study indicates moderate iodine deficiency in the population, despite a mandatory salt iodization programme in Orissa that has been in force since 1989. There is a need to improve the situation through enforcing monitoring of salt iodization to ensure quality and increasing the level of awareness about the iodized salt for sustainable prevention and control of iodine deficiency.     

Scaling up child and adolescent mental health services in South Africa: Human resource requirements and costs

Background:  Children and adolescents with mental health problems have poor service cover in low- and middle-income countries. Little is known about the resources that would be required to provide child and adolescent mental health services (CAMHS) in these countries. The purpose of this study was to calculate the human resources and associated costs required to scale up CAMHS in South Africa.
Methods:  A spreadsheet model was developed to calculate mental health service resources, based on an estimation of the need for services in a given population. The model can be adapted to specific settings by adjusting population size, age distribution, prevalence, comorbidity, levels of coverage, service utilisation rates, workloads, length of consultations and staff profile. Steps in the modelling include population identification; estimates of prevalence, service utilisation and staffing; and costing.
Results:  Using a nominal total population of 100,000 (of which 43,170 would be children and adolescents under 20 years of age), the following full-time equivalent staff are required at minimum coverage level: 5.8 in PHC facilities, .6 in general hospital outpatient departments (OPDs), .1 in general hospital inpatient facilities, 1.1 in specialist CAMHS OPDs, .6 in specialist CAMHS inpatient facilities, .5 in specialist CAMHS day services, and .8 in regional CAMHS teams. This translates into roughly $21.50 and $5.99 per child or adolescent per annum nationally for the full coverage and minimum coverage scenarios respectively. When comparing the results of this model with current realities in South Africa, there remains a substantial shortfall in existing levels of CAMHS provision.
Conclusions:  The model can be used as an advocacy tool to engage with planners and policy makers on a rational basis. It can also be adapted for use in other countries, and is intended to support wider calls for a global scaling up of mental health services.     

Warfare and children

In 2007, 136 million children were born in the world, and 9.2 million died before they were 5 years old; 99.8% of these deaths were in developing countries, and 8.2 million were unnecessary. This is 23 000 unnecessary deaths every day. Approximately 0.2 million children die from the direct effects of war every year, and at least twice as many die from the indirect effects. However, most child deaths are caused by common childhood infections in communities that are not affected by war. In 2007, overseas development aid totalled only $104 billion, and world military expenditure totalled US$1339 billion. The 49 poorest countries in the world have a population of 1.3 billion; they spent only $27 per person on health in 2006, but the world spent $201 per person on military activity. The five permanent members of the United Nations Security Council account for 90% of weapons sales to developing countries, yet they are the very countries that have accepted responsibility for ensuring world security. Unfortunately, many governments in both rich and poor countries do not want to limit military spending – the vested interests that support military activity are too powerful. War is immensely harmful, but not primarily because of the horrible injuries, nor the large number of deaths it causes indirectly from infection, malnutrition, and social and political disruption. By far, the greatest harm comes from the diversion of huge amounts of money that could be used for beneficial development into harmful and destructive military activity.     

Under fives mortality in the urban slums of Lucknow

The main objective of this study was to elicit proportional cause specific mortality in the underfives in the urban slums of Lucknow in North India. The families with under five mortality in the 28 randomly selected slums in 1993 were located from the records of the slum health workers and verbal autopsy was conducted to assign a cause of death. There were 71 deaths among 2796 children. The annual under five mortality was 25.4 and the under five mortality rate was 126.7. After the neonatal period, “high fever” that could not be classified into any other disease incorporated in the verbal autopsy instrument, was the most common symptom associated with death, seen in 21.1% cases (95% C.I.: 15.5–34.4%) followed by these diseases: pheumonia in 19.7%, diarrhea in 18.3% and measles in 11.4%. “High fever” as the leading symptom associated with death is being reported for the first time from the urban slums of India. There is an urgent need to identify the underlying etiologies of death due to “high fever” and the policy implications are that children with fever must receive immediate and continued medical attention till the symptom persists.     

Factors contributing to poor results of treatment of esophageal atresia in developing countries

The results of treatment of 341 consecutive cases of esophageal atresia/tracheoesophageal fistula over an 11-year period have been analyzed to determine the factors resulting in a poorer prognosis of these cases in a developing country; 121 neonates in the first 6-year period are compared with 220 in the last 5 years. In the latter group only 8% were in Waterston's group A; 46% reached the hospital within 24 h of birth, 13% were normothermic on presentation, 70% had a chest infection, and 28% had major associated malformations. This was similar to the preceding 6-year period. In the last 5 years the overall mortality was 58%, compared to 67% in the preceding 6 years. Despite improvement in survival in the last 5 years, the overall survival is far inferior to that reported from the developed countries. The factors resulting in poorer results have been analyzed and remedial actions suggested.     

Neonatal bacterial septicemia in a tropical area. Four-year experience in Guadeloupe (French West Indies)

During a four-year study (1987–1990) at the Neonatal Department, University Hospital Pointe-à-Pitre (French West Indies), blood culture was systematically performed on all admitted newborns. The incidence of septicemia was 48 of 1000 admissions and 8.9 of 1000 inborn live births. Among the 107 neonatal positive blood cultures, group B streptococcus accounted for 37% of blood culture isolates and was the most frequent cause of septicemia. The overall mortality rate was 8.4%. The incidence of neonatal bacterial septicemia was among the high rates reported in the literature. The incidence of neonatal bacterial septicemia is discussed as a public health problem in perinatology in Guadeloupe in spite of good medical care. A review of the literature on bacterial septicemia in tropical or developing countries compared to the Guadeloupean experience allows speculation that this problem might be underestimated in third world countries.     

Catheter Interventions for Congenital Heart Disease in Third World Countries

The term “Third World” loosely encompasses a group of middle- and low-income countries. Considerable differences exist in health care delivery and health indices among these countries. The vast majority of children in the Third World do not have health insurance for congential heart disease (CHD). Catheter interventions for CHD are expensive because of installation costs of expensive biplane equipment, the requirement of dedicated personnel, and the need to stock a large inventory of expensive hardware. As a result, many catheter intervention procedures are beyond the reach of the average patient in the developing world. The following cost-effective strategies have evolved in selected institutions that have attempted to perform catheter interventions for CHD at an affordable cost: sharing of space, equipment, and support personnel with a busy adult cardiology program; use of single plane equipment; the development of sedation protocols to reduce the need for anesthesiologists; strategies to reduce procedure time; reuse of hardware through ethylene oxide sterilization; improvisations to use adult hardware items for CHD interventions; judicious case selection; and improvised alternatives to occlusive devices. These strategies may help reduce costs and allow a larger proportion of patients in developing countries with CHD to undergo interventions. However, the safety of these strategies and the cost savings need to be carefully evaluated prospectively.     

Neonatal bacterial septicemia in a tropical area. Four-year experience in Guadeloupe (French West Indies)

During a four-year study (1987–1990) at the Neonatal Department, University Hospital Pointe-à-Pitre (French West Indies), blood culture was systematically performed on all admitted newborns. The incidence of septicemia was 48 of 1000 admissions and 8.9 of 1000 inborn live births. Among the 107 neonatal positive blood cultures, group B streptococcus accounted for 37% of blood culture isolates and was the most frequent cause of septicemia. The overall mortality rate was 8.4%. The incidence of neonatal bacterial septicemia was among the high rates reported in the literature. The incidence of neonatal bacterial septicemia is discussed as a public health problem in perinatology in Guadeloupe in spite of good medical care. A review of the literature on bacterial septicemia in tropical or developing countries compared to the Guadeloupean experience allows speculation that this problem might be underestimated in third world countries.     

Aquatic leech infestation: a rare cause of severe anaemia in an adolescent Tanzanian girl

We report on a 15-year-old girl who presented with a history of chest pain, coughing, intermittent haemoptysis, fever, pallor and vomiting to a rural hospital in Tanzania. She was severely anaemic with signs of cardiorespiratory distress. Haemoglobin was 4.8 g/dl; the chest X-ray film was normal. She required one unit of blood. After 3 days, she vomited up a small parasite which proved to be an aquatic leech. Oesophagogastroscopy, then performed, revealed four small mucosal lesions in the pharynx and upper oesophagus. No other leeches were seen. Further oesophagogastroscopy 4 days later showed a normal mucosa. The girl was discharged on iron and folic acid supplements. A small lake near her village was identified as the likely source of her infestation. The family had used the water for drinking without any precautions—Terrestrial leeches can cause profound, life-threatening anaemia, but even more so do aquatic leeches. This type is acquired while bathing or drinking unfiltered water. They attach themselves to mucous membranes, having been described in sites like conjunctiva, nose, pharynx/larynx, trachea/bronchi, oesophagus, vagina, and rectum. Especially in the airways, they can cause even fatal bleeding or obstruction. Treatment consists of removal of the leech. Conclusion: in developing countries, even unusual causes like leech infestation have to be considered in the differential diagnosis of severe anaemia in children.