Recurrence Risk of Febrile Seizures in Children

BACKGROUND

Identifying children with febrile seizure who are at risk for recurrence is important so that special attention can be given to them. The objective of this study was to identify the risk factors for recurrence of febrile seizures in children.

METHODS

This prospective hospital based study was conducted from July 2013 to August 2014 'among children of 6 months to 6 years of age at Bishweshwar Prasad Koirala Institute of Health Sciences (BPKIHS), Nepal. Children meeting the selection criteria were enrolled in study. Clinical, investigation, treatment and outcome parameters were analyzed.

RESULTS

A total of 92 children with febrile seizure were enrolled in study. Males accounted for 70% and females 30%. Simple febrile seizure was present in 48% and complex febrile seizures were seen in 52%. Recurrence of seizure was seen in one third of cases. Loss of consciousness was most common post-ictal phenomenon followed by confusion and lethargy. Upper respiratory infection was the most common precipitating factor. Generalized Tonic Clonic Seizure was the most common seizure type present in 79% of cases. Significant risk factors for recurrence occurred in males (p=0.088), age less than 1 year (p=0.003). Most of the recurrence occurred within one year of first seizure.

CONCLUSIONS

Febrile Seizure is common in males. Almost one third of children with febrile seizure are at risk for recurrence. The significant risk factors for recurrences are male gender and age <1year.

Outcome of Twin Deliveries at a Tertiary Care Centre of Eastern Nepal

BACKGROUND

Twins, compared to singletons, have higher perinatal mortality and morbidity. The aim of this study was to describe the twinning rate, epidemiological variables and hospital outcome of twin deliveries and to find out ways of better management of twins in our part.

METHODS

A retrospective evaluation of the outcome of 92 twin pregnancies during one year study period (1st January 2014 to 31st December 2014) was conducted at BPKIHS. Twins delivered within the institution were included but cases less than 28 weeks gestation were excluded. Maternal and neonatal data were retrieved and analysed.

RESULTS

The twinning rate was 9.2/1000 (92/10,031). The mean birth weight was 1636.30 ±339.21 grams and mean gestational age 34.31±2.67 weeks(28 - 40 weeks). One hundred eighty-two babies (98.9%) were low birth weight (LBW) while 32.1% were small for gestational age (SGA). There was mild, moderate and severe growth discordance in 63 (68.5%)22 (23.9%)and 7 (7.6%) respectively. Three (3.26%) of 92 pairs had twin-to-twin transfusion syndrome. The hospital mortality rate was 10.87% (20/184) and 69 (37.5%) babies had complications. The clinical causes of death were hyaline membrane disease in 7 (3.3%), severe birth asphyxia in 5 (2.7%), congenital malformations in 3(1.6%) and sepsis in 3 (1.6%) babies.

CONCLUSIONS

Twin deliveries are common in this hospital and have poor hospital outcome with more complications and mortality. Hence there is a need for further studies with long term follow-ups to plan for better management of twins in our part.

Adverse Events of Exchange Transfusion in Neonatal Hyperbilirubinemia

Introduction: Jaundice is an important problem during neonatal period. When total serum bilirubin (TSB) level exceeds a critical limit, it crosses the blood brain barrier and results into bilirubin encephalopathy. The main aim of therapy for neonatal hyperbilirubinemia is prevention of bilirubin encephalopathy by phototherapy and/or exchange transfusion. The aims of this study were to evaluate the efficacy of exchange transfusion (ET) and observe the adverse events during and following three days of ET in neonates with hyperbilirubinemia. Materials and Method: Hospital based cross-sectional descriptive study. All neonates admitted to neonatal intensive care unit and /or paediatric wards of a tertiary- care centre between September 2010 to March 2012, requiring ET were enrolled. Results: A total of 139 ETs were performed in 120 neonates. The common causes were ABO incompatibility (30.8%), prematurity (30.8%), idiopathic (27.5%), Rh isoimmunization (6.7%) and cephalhematoma (4.2%). Mean pre- ET total serum bilirubin (TSB) was 24.2 mg% dL. There was 58% reduction in TSB in post ET and 31% net reduction in 6 hr post ET. Term and preterm neonates showed equal percentage of TSB reduction. Respiratory distress (10.8%) and bradycardia (6.7%) were the common adverse events during, and hypocalcemia (98.3%) and thrombocytopenia (34.2%) in 3 days following ET. The sick neonates had significantly higher incidence of thrombocytopenia (p= 0.031), respiratory distress (p=0.009), apnea (p<0.001) and cardiorespiratory arrest (p<0.001). Overall mortality was 4.2%, and non-survivors were mostly low birth weight, born outside the present hospital and had higher incidence of adverse events. Conclusion: Exchange transfusion is an effective intervention in reducing the serum bilirubin level. However, these neonates require monitoring of ionised calcium and thrombocytopenia. Sick neonates had higher incidence of adverse events than healthy and close clinical monitoring is needed to improve the outcome. DOI: http://dx.doi.org/10.3126/jnps.v34i1.9030   J Nepal Paediatr Soc 2014;34(1):7-13

Risk Factors for Acute Respiratory Infections in Hospitalized Under Five Children in Central Nepal

Introduction: Acute respiratory infection is a leading cause of morbidity and mortality in under 5 children in developing countries. There are various modifiable risk factors associated with Acute Respiratory Tract Infection (ARI). Hence, identification of associated risk factors for ARI may be helpful to reduce the burden of disease. The aims of this study were to study the risk factors for ARI in under five hospitalized children and to correlate risk factors with ARI related morbidity. It was a hospital- based prospective study. Materials and Methods: Children of less than 5 years admitted in ward with diagnosis of ARI were enrolled in the study as cases. Control included children under 5 years of age attending to Well Baby Clinic, Immunization Clinic and siblings or relatives under 5 years who came with patients in the Paediatric outpatient department of the same institution during the same period. Various risk factors, demographic and clinical data of each child were recorded in a pre-designed proforma of both groups. Results: A total of 200 cases and 200 controls were enrolled. The various risk factors associated with ARI on stepwise logistic regression were male gender, rural residency, overcrowding, history of ARI in any family member within two weeks and undernutrition. The statistically insignificant risk factors were infancy, economic status, illiterate parents, cooking fuel other than LPG, low birth weight, prematurity, lack of exclusive breast feeding, vitamin A deficiency and incomplete immunization. Conclusion: The various risk factors for ARI identified in this study were male gender, rural residency, overcrowding, history of ARI in any family member within two weeks and undernutrition. DOI: http://dx.doi.org/10.3126/jnps.v33i1.7358 J Nepal Paediatr Soc. 2013;33(1):39-44

Clinical profile and outcome of children presenting with poisoning or intoxication: a hospital based study

Poisoning is a common preventable cause of morbidity and mortality in children. Most of the poisoning in children less than 5 years of age is accidental. Objective of the study was to study the clinical profile and outcome of childhood poisoning and intoxication. This was a retrospective study done in patients who were admitted in pediatric wards and pediatric intensive care unit (PICU) of BP Koirala Institute of Health Sciences with history of ingestion of poison or intoxication or envenomation firom January 2005 to June 2008. The data collected were analyzed with SPSS 12.0 software. There were 122 children enrolled in study. Male: female ratio was 1.4:1. The mean age of presentation was 5.8 years. Among 122 patients, 43.4% received pre-referral treatment in the form of gastric lavage, atropine etc. Organophosphorus poisoning was the commonest poisoning seen in 55 (45.1%) patients followed by hydrocarbon 12 (9.8%), mushroom 10 (8.2%) and organochlorine 10 (8.2%) poisoning. During treatment, 50.0% received antidotes. 55.7% received antibiotics, gastric lavage and anticonvulsants were required in 43.4% and 13.9% respectively. Overall survival was 87.4%. The time interval between intoxication and presentation to hospital, mean Glasgow Coma Scale (GCS) and presence of coma (GCS <8) were significantly different between survivors and expired cases. In conclusion, organophosphorus is the commonest agent involved in childhood poisoning. Overall, the outcome is good with 87.4% survival in our hospital. The time gap between the poisoning and presentation to hospital and presence of coma predict mortality.

Brain tumours in children

A 10 years old, female patient presented with symptoms of abnormal movement of the body for 5 years, deviation of mouth to left side for 12 days and difficulty in walking for 12 days. We report a very rare case of Brain Stem gliomas. Clinical and imaging findings were suggestive of brain stem gliomas.

Incidence of congenital heart disease in tertiary care hospital

AIMS AND OBJECTIVES

The present study was under taken to determine the spectrum, clinical profile and outcome of patients with congenital heart disease (CHD) admitted to a tertiary care hospital.

MATERIALS AND METHODS

This is a retrospective, observational hospital based study conducted during January 2006 to December 2006. Out of 14461 admissions, 84 were cases of CHD. Only patients with echocardiographic proof of CHD were included in the study. Detailed clinical and laboratory findings and outcome of all cases were noted in pre-structured formats. Data were entered in MS-excel. Data was analyzed by software SPSS version 10.

RESULTS

The incidence of CHD was 5.8 per 1000 hospitalized patients. Out of 84 CHD cases, 51 were males and 33 females; with a male to female ratio of 1.5:1. CHD presented more frequently during infancy (46 %). Acyanotic heart disease was detected in 58 (69 %) cases while cyanotic heart disease was detected in 26 (31%) cases. Among acyanotic heart disease, ventricular septal defect (VSD) was found in 49 (58.3%), atrial septal defect (ASD) in 4 patients (4.8%), endocardial cushion defect (ECD) in 2 patients (2.4%) and dextrocardia was found in 3 patients (3.6%). Among cyanotic heart disease, Tetralogy of Fallot (TOF) accounted for 13.1%, total anomalous pulmonary venous connection (TAPVC) 3.6%, transposition of great arteries (TGA) with VSD 1.2% and unspecified cases of heart disease was found in 13.1%. VSD and TOF were the most common lesions while other CHD like ASD, dextrocardia, TAPVC, ECD, TGA with VSD were encountered less frequently. The most common clinical presentations were failure to thrive (FTT) and developmental delay (86.9%), breathlessness (69%), lower respiratory tract infection (LRTI) (52%), congestive cardiac failure (CCF) (46%), cyanosis (20.2%), cyanotic spell (9.5%) and infective endocarditis (9.5%). The mortality rate was 20 %.

CONCLUSION

The incidence of CHD was 5.8 per thousand hospitalized children. VSD, TOF were the most common congenital cardiac lesion. VSD was observed either isolated or associated with other lesions like TGA. The mortality rate was 20 %. The mortality usually occurred in those patients complicated with congestive cardiac failure, lower respiratory tract infection and infective endocarditis.

Acid base and electrolyte disturbance in diarrhoea

OBJECTIVE

The present study was undertaken to study the frequency of electrolyte imbalance in children with diarrhoea and the relationship between electrolyte abnormalities and mortality.

MATERIALS AND METHODS

This is a retrospective, observational hospital based study. Fifty seven children admitted to paediatric ward with diarrhoea and dehydration was evaluated for electrolyte and acid base status at presentation. The variables were analyzed using chi-square and student t- test.

RESULTS

Majority (70%) of patients were below 2 years of age. There were 37 (65%) males and 20(35%) females. Electrolyte disturbance was observed in 46 (80%) patients while acid base disturbance was observed in all (100%) where the estimations were done. The major electrolyte disturbances noted were hyponatremia (56%), which was either isolated (26%) or associated with hypokalemia (26%). The second common abnormality was hypokalemia (46%) which was again either isolated (14%) or associated with hyponatremia (26%). About 10% patient had hypernatremia and about 3% had hyperkalemia. Twenty one (37 %) patients had mixed electrolyte imbalance. ABG analysis was performed only in 16 patients. Arterial blood gas analysis could be performed only in 16 patients. Metabolic acidosis was present in 15 (94%) while one (6%) had metabolic alkalosis. Out of 57, five patients (8.7%) expired. All of them had electrolyte abnormalities. Out of five patients who died one had isolated hyponatremia, 2 had hyponatremia + hypokalemia, while one each had hypernatremia + hypokalemia and hypernatremia+ hyperkalemia. Statistically significant mortality was observed in patients presenting with either hyponatremia or hypokalemia as compared to the group with normal electrolytes.

CONCLUSION

Hyponatremia, hypokalemia and metabolic acidosis are common electrolyte and acid-base abnormalities in children with diarrhoea and dehydration and often responsible for mortality.

Risk factors in early neonatal sepsis

OBJECTIVE

To study the maternal and neonatal risk factors for neonatal sepsis.

MATERIALS AND METHODS

This is prospective case control study, conducted on the neonates up to 7 days of life with a diagnosis of neonatal sepsis. There were 100 cases of neonatal sepsis and 100 control cases. The neonates in the case and control groups were evaluated for various maternal and neonatal risk factors.

RESULTS

The factors which carried a significant risk for development of neonatal sepsis were premature rupture of membrane (PROM), meconium stained amniotic fluid (MSAF), foul smelling liquor, low birth weight, prematurity and low Apgar score at birth. The blood culture was positive in 22% of cases. The commonest organisms isolated were S. aureus and Klebsiella. The overall mortality was 11%. The incidence of risk factors was almost equal in culture positive and culture negative cases.

CONCLUSION

The study identifies PROM, MSAF, foul smelling amniotic fluid, prematurity, low birth weight and low Apgar score at birth as strong risk factors for development of neonatal sepsis. In the presence of above factors, the neonate should be screened and observed for sepsis and considered for early institution of antibiotics.

Clinical and laboratory profile of dengue infection in children

The present work is a prospective, observational, hospital based study on 100 sero positive cases of dengue infection, admitted to Dhaka Children Hospital, Dhaka, Bangladesh during the period 2000 -2001. The patients were in the age group 8 months to 14 years with a mean age of 8.3 years. The serological tests were performed by rapid strip test. Primary dengue infection (only Ig M positive) was observed in 15% cases while rest 85% were secondary dengue infection (either Ig G or both Ig M and Ig G positive). Classical dengue fever (DF) was noted in 11% patients and 89% children presented with dengue hemorrhagic fever / dengue shock syndrome (DHF / DSS). Common clinical presentations were fever, headache, retro- orbital pain, arthralgia / bone pain, vomiting, abdominal pain and bleeding manifestations. Other presentations were tachycardia, bradycardia, hypotension, hepatomegaly, splenomegaly, pleural effusion, ascites, thrombocytopenia and high hematocrit values. The incidences of tachycardia, hypotension, hepatomegaly, high hematocrit and thrombocytopenia were significantly higher in DHF / DSS cases. The tourniquet test was positive in significantly higher percentage of DF cases. The tourniquet test and thrombocytopenia did not correlate well with other bleeding manifestations suggesting alternate pathogenesis for bleeding. In an epidemic setting, if a child presents with fever, vomiting, musculoskeletal pain and bleeding along with hepatomegaly, low platelet count and high hematocrit, a strong possibility of DHF/ DSS should be kept.

Outcome of newborns with birth asphyxia

Birth asphyxia is one of the common causes of mortality and morbidity in neonates and the incidence is 2-9 per 1,000 live borns. The present work is a retrospective hospital based observational study. Babies born at B.P. Koirala Institute of Health Sciences, Dharan, Nepal during the period from April 2002 to April 2003 with gestational age >or=37 weeks with Apgar score <or=6 at 5 minutes were included in the study. The aim was to study the clinical profile, the acid base parameters and the outcome of asphyxiated newborns. Babies with congenital defects, evidence of infection and maternal drug addiction were excluded from the study. All babies were resuscitated according to the guidelines of American Heart Association. Data on 50 birth asphyxia cases were tabulated and analysed. There were 10 (20%) cases of severe birth asphyxia (Apgar score: 1-3 ) and 40 (80%) cases of moderate birth asphyxia (Apgar score: 4-6). Staging of hypoxic ischaemic encephalopathy (HIE) was performed according to Sarnat's staging. Thirty percent of these cases presented with various stages of HIE and the incidence was higher in low Apgar score group. The common presentations of HIE cases had depressed neonatal reflexes, seizures, lethargy, and pupillary abnormalities. The common acid base disturbance was metabolic acidosis which was observed only in babies with HIE-3. Two neonates (4%) died during the hospital stay due to multiorgan failure and severe metabolic acidosis.

The management of extensive penile fibrosis: a new technique of 'minimal scar-tissue excision'

OBJECTIVE

To evaluate the results of excising minimal scar tissue in patients undergoing insertion of a penile prosthesis for extensive corporal fibrosis.

PATIENTS AND METHODS

Twelve patients (mean age 58 years, range 44-73) with extensive corporal fibrosis who underwent the insertion of a penile prosthesis were evaluated. Eleven patients had a defect of varying extent after the insertion of the penile prosthesis, and a polytetrafluoroethylene graft was used to cover the area.

RESULTS

All 12 patients tolerated the procedure well and currently have a functioning penile implant.

CONCLUSIONS

Minimal excision of scar tissue provided better results and fewer complications when compared to other studies which used extensive excision.

Clinico- Biochemical Profile of Neonatal Seizure

Objectives: The present study was undertaken to study the incidence, etiological factor, and days of onset, clinical types and biochemical abnormalities in babies having neonatal seizures. Materials and Methods: This is a retrospective, observational hospital based study. Ninety neonates, who developed seizures before 28 days of life and admitted to neonatal intensive care unit and nursery with neonatal seizure, were evaluated for incidence, etiological factor, clinical types and biochemical abnormalities found in neonatal seizure. The variables were analysed using Chi- Square and student t- test. Results: The incidence of neonatal seizure was 10.3/ 1000 live births. The seizures were common in male babies. 65 (72.2%) neonates were born to multiparous women while 35 (38%) were born to primigravidas. In birth asphyxia (n= 40), the most common type of seizure observed was subtle seizure 20 (50%), followed by focal clonic 10 (25%) and multifocal clonic 5 (12.5%). Tonic type of seizure was observed in 3 (7.5%) and myoclonic in 2 (5%). Meningitis and septicaemia was the second most common cause of neonatal seizure observed in our study. Among metabolic abnormalities hypoglycaemia was found in 20 (22%) and hypocalcaemia in 10 (11%). Conclusion: The commonest cause of seizure was birth asphyxia presenting within 72 hours of life. Among infection septicaemia and meningitis was the most common cause leading to neonatal seizure. Among biochemical abnormalities the most common cause of seizure observed in our study was hypoglycaemia and hypocalcaemia. Subtle seizures were the commonest type of seizure observed in this study. Key words: Neonatal seizure, biochemical disturbances in seizure.    DOI = 10.3126/jnps.v28i1.1398   J. Nepal Paediatr. Soc. Vol.28(1) p.7-9

Achondroplasia: Case Report and Review of Literature

A two month old male child presented to emergency of B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan and was admitted to Paediatric ward with history of fever, cough and respiratory distress. On examination the breathing was rapid and shallow. The child was small for age with an upper to lower segment ratio of 1.9. The anteroposterior diameter of thorax was reduced. We report a very rare case of achondroplasia which was recognized in a two month age child who presented with severe pneumonia. Usually the clinically features of achondroplasia is more prominent when the child is growing in height but we diagnosed it in a two months child after performing the skeletal survey.   DOI: http://dx.doi.org/10.3126/jnps.v31i3.5363 J Nep Paedtr Soc 2011;31(3): 216-224-226