Phenotype and molecular characterization of Wilson's disease in Morocco

BACKGROUND AND STUDY AIMS

In Morocco the prevalence of Wilson disease (WD) and the spectrum of mutations are not known. The aim of the present study was to estimate the prevalence of WD in Morocco, to evaluate the phenotype among a large cohort of WD patients, and to characterize ATP7B variants in a subgroup of WD patients.

PATIENTS AND METHODS

We collected data from 226 patients admitted to five university hospital centers in Morocco between 2008 and 2020. The diagnosis was based on clinical manifestations, function tests and biochemical parameters. The genotype was characterized in 18 families diagnosed at the University Hospital Center of Marrakesh, by next generation sequencing.

RESULTS

The mean annual prevalence in Morocco was 3.88 per 100,000 and the allele frequency was 0.15 %. Among the 226 patients included (121 males and 105 females), 196 were referred for a hepatic or neurological involvement and 30 were asymptomatic. The mean age at diagnosis was 13 ± 5.1 years (range: 5 - 42 years). Consanguinity was found in 63.3 % of patients. The mean duration of illness was 2.8 ± 1.9 years. Kayser-Fleischer rings were found in 131 (67.9 %) of 193 patients. Among the 196 symptomatic patients, 141/159 (88.7 %) had low serum ceruloplasmin (<0.2 g/L) and a high 24-hours urinary copper (>100 μg/day) was found in 173/182 (95.1 %) patients. The initial treatment was D-penicillamine in 207 patients, zinc acetate in five, zinc sulfate in five, and nine patients were not treated; 60/207 (29 %) patients have stopped treatment. A total of 72 patients died; the mortality rate was 31.9 %. Eight different ATP7B variants were identified among the 18 patients studied, of which two were novel (p.Cys1104Arg and p.Gln1277Hisfs*52), and six previously published (p.Gln289Ter, p.Cys305Ter, p.Thr1232Pro, p.Lys1020Arg, p.Glu583ArgfsTer25 and c.51+4A>T). All informative patients were homozygous for the disease-causing mutation.

CONCLUSION

In Morocco, a high prevalence due to consanguinity and a high mortality rate due to the difficulty of diagnosis and lack of treatment were observed in WD patients. NGS sequencing identified new ATP7B variants in WD patients from Morocco.

An international multidisciplinary consensus on pediatric metabolic dysfunction-associated fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in children and adolescents, particularly those with obesity. NAFLD is considered a hepatic manifestation of the metabolic syndrome due to its close associations with abdominal obesity, insulin resistance, and atherogenic dyslipidemia. Experts have proposed an alternative terminology, metabolic dysfunction-associated fatty liver disease (MAFLD), to better reflect its pathophysiology. This study aimed to develop consensus statements and recommendations for pediatric MAFLD through collaboration among international experts.

METHODS

A group of 65 experts from 35 countries and six continents, including pediatricians, hepatologists, and endocrinologists, participated in a consensus development process. The process encompassed various aspects of pediatric MAFLD, including epidemiology, mechanisms, screening, and management.

FINDINGS

In round 1, we received 65 surveys from 35 countries and analyzed these results, which informed us that 73.3% of respondents agreed with 20 draft statements while 23.8% agreed somewhat. The mean percentage of agreement or somewhat agreement increased to 80.85% and 15.75%, respectively, in round 2. The final statements covered a wide range of topics related to epidemiology, pathophysiology, and strategies for screening and managing pediatric MAFLD.

CONCLUSIONS

The consensus statements and recommendations developed by an international expert panel serve to optimize clinical outcomes and improve the quality of life for children and adolescents with MAFLD. These findings emphasize the need for standardized approaches in diagnosing and treating pediatric MAFLD.

FUNDING

This work was funded by the National Natural Science Foundation of China (82070588, 82370577), the National Key R&D Program of China (2023YFA1800801), National High Level Hospital Clinical Research Funding (2022-PUMCH-C-014), the Wuxi Taihu Talent Plan (DJTD202106), and the Medical Key Discipline Program of Wuxi Health Commission (ZDXK2021007).

Role of Pediatricians in Promoting and Supporting Breastfeeding: A Position Paper of the International Pediatric Association Strategic Advisory Group on Infant, Child, and Adolescent Nutrition

BACKGROUND

Promoting and supporting breastfeeding is an important public health intervention with multiple benefits for both infants and mothers. Even modest increases in the prevalence and duration of breastfeeding could significantly reduce healthcare costs and improve maternal and child health outcomes. However, widespread adoption of breastfeeding recommendations remains poor in most settings, which contributes to widening health and social inequalities. Pediatricians have a duty to advocate for improving child health, including promoting and supporting breastfeeding.

SUMMARY

This paper, from the International Pediatric Association Special Advisory Group on Nutrition, considers common barriers to breastfeeding and addresses how pediatricians can better promote and support breastfeeding, both at an individual level and by influencing practice and policy. All pediatricians need to understand the basics of breastfeeding, including lactation physiology, recognize common breastfeeding problems, and advise mothers or refer them for appropriate support; training curricula for general pediatricians and all pediatric subspecialties should reflect this. Even in the situation where their day-to-day work does not involve direct contact with mothers and infants, pediatricians can have an important influence on policy and practice. They should support colleagues who work directly with mothers and infants, ensuring that systems and environments are conducive to breastfeeding and, where appropriate, milk expression. Pediatricians and pediatric organizations should also promote policies aimed at promoting and supporting breastfeeding at local, regional, national, and international levels.

KEY MESSAGES

Pediatricians have a duty to promote and support breastfeeding, regardless of their day-to-day role and responsibilities. Pediatric training curricula should ensure that all trainees acquire a good understanding of breastfeeding so they are able to effectively support mothers in their personal practice but also influence breastfeeding practice and policy at a local, regional, national, and international level.

Levels of mercury in Moroccan breast milk and the affecting factors: CONTAMILK study

This study aims to evaluate the level of mercury in the breast milk of Moroccan mothers and its association with several maternal parameters and habits, and to estimate the daily intake of the newborns. Inductively coupled plasma mass spectrometry (ICP-MS) was used to determine the concentrations of mercury in 70 colostrum samples. Indeed, a structured questionnaire was administrated during milk collection to report data concerning the maternal socioeconomic and anthropometric parameters, as well as dietary habits and smoking habits in the family, etc. The median of mercury in breast milk was 3,56 μg/L (range 1.64-124 μg/L) and exceeded normal levels of 1.7 μg/l, suggested by the World health organization in 99% of milk samples. Significant associations were found between mercury levels and the occurrence of previous miscarriages, anemia before pregnancy and vitamin & mineral supplementation during pregnancy, as well the frequency of consumption of cereals and the use of lipstick. The estimated daily intake was higher than the tolerable daily intake of the World health organization and the European food safety authority in 30% of newborns. These results need to be confirmed by multicenter studies to investigate the levels of mercury in the breast milk of the Moroccan population.

Defining paediatric metabolic (dysfunction)-associated fatty liver disease: an international expert consensus statement

The term non-alcoholic fatty liver disease (NAFLD), and its definition, have limitations for both adults and children. The definition is most problematic for children, for whom alcohol consumption is usually not a concern. This problematic definition has prompted a consensus to rename and redefine adult NAFLD associated with metabolic dysregulation to metabolic (dysfunction)-associated fatty liver disease (MAFLD). Similarities, distinctions, and differences exist in the causes, natural history, and prognosis of fatty liver diseases in children compared with adults. In this Viewpoint we, an international panel, propose an overarching framework for paediatric fatty liver diseases and an age-appropriate MAFLD definition based on sex and age percentiles. The framework recognises the possibility of other coexisting systemic fatty liver diseases in children. The new MAFLD diagnostic criteria provide paediatricians with a conceptual scaffold for disease diagnosis, risk stratification, and improved clinical and multidisciplinary care, and they align with a definition that is valid across the lifespan.

Lead concentrations in breast milk of Moroccan nursing mothers and associated factors of exposure: CONTAMILK STUDY

The aim of CONTAMILK study was to estimate levels of contamination of breast milk (BM) of Moroccan nursing mothers by some xenobiotics including, lead (Pb), to identify associated factors of exposure and to determine the daily intake of newborns. Lead concentrations were determined in 70 samples of colostrum by ICPMS and a structured questionnaire was filled during milk collection to report participants' data. The median lead concentration was 908 μg/L (range 1.38-515,39 μg/L) and in 79 % of samples, levels were higher than the normal range reported by the World Health Organization (WHO) in BM (2-5 μg/L). Indeed, preterm delivery, frequency of use of cosmetic powders and lipsticks were significantly associated with the level of lead in BM. The estimated daily intake was greater than the tolerable daily intake (TDI) of the European food safety authority (0.5 μg/kg/day) for 39 babies and 6 babies according to the WHO (3.6 μg/kg/day).

Ochratoxin a in breast milk in Morocco: the affecting dietary habits of the lactating mothers and the degree of exposure of newborns "CONTAMILK study"

The aim of the present study is to evaluate the level of contamination of breast milk (BM) by ochratoxin A, among Moroccan lactating mothers in the city of Rabat, and to identify the associated factors of exposure, also to estimate the degree of exposure of the breastfeed infant. The analysis of ochratoxin A (OTA) was accomplished by ELISA method on 82 colostrum samples. OTA was detectable (>0.08 ng/mL) in 55% of samples with a maximum concentration of 10.04 ng/mL, and the levels exceeded 0.5 ng /mL in 50 % of the samples. In addition, several factors and dietary habits affect significantly the level of OTA in the analyzed samples of breast milk including, the consumption of industrial dairy products, the frequency of consumption of canned foods, dried fruits and legumes, also the period of breast milk collection. Besides, OTA was higher than the tolerable daily intake for 49% newborns. However, these results need to be confirmed by multicenter studies to more broadly estimate the levels of exposition of Moroccan population to OTA. Furthermore, awareness campaigns are recommended to inform the public, especially pregnant women and lactating women about appropriate preventive measures to limit exposure to this mycotoxin.

Medicines Acceptability in Hospitalized Children: An Ongoing Need for Age-Appropriate Formulations

Although knowledge on medicine acceptability remains fragmented, this multi-faceted concept has emerged as a key factor for compliance in pediatrics. In order to investigate the acceptability of medicines used in the University Medical Centre Ibn Sina (CHIS) of Rabat, Morocco, an observational study was conducted. Using a multivariate approach integrating the many aspects of acceptability, standardized observer reports were collected for 570 medicine intakes in patients up to the age of 16, then analyzed on a reference framework. Tablets appeared to be well accepted in children greater than 6 years old, but were crushed/dissolved for 90% of the 40 children aged from 3 to 5, and 100% of the 38 patients younger than 3. Moreover, the prescribed dose was fully taken for only 52% and 16% of these younger children, respectively. Despite this, tablets represented 24% of evaluations in children from 3 to 5 and 20% in infants and toddlers. Oral liquid preparations appeared to be better accepted than tablets in preschoolers, but not for those under 3. Overall, these findings highlight the lack of suitable alternatives for the younger children, especially for formulations of antiepileptics, antithrombotic, and psycholeptic agents in the local context.

Cadmium Contamination in Breast Milk of Moroccan Lactating Women and the Associated Factors: CONTAMILK Study

The objectives of this study were to assess levels of contamination of breast milk (BM) by cadmium (Cd) among lactating mothers from Rabat, Morocco, and to investigate its association with several maternal habits, parameters, and factors. In addition, to estimate the daily intake of the newborns. Cd concentrations were measured by inductively coupled plasma-mass spectrometry (ICP-MS) in 70 human milk samples collected between the 2nd and 5th day postpartum. Accuracy of the analysis was checked by various methods including the use of reference material. A structured questionnaire was filled during the collection of milk reporting data concerning anthropometric, sociodemographic parameters, dietary and cosmetic habits, etc. The median (range) of Cd in human milk was 0.49 μg/L (range 0.013-95.19 μg/L) respectively. In 21 (30%) of 70 samples, Cd levels were higher than the normal reported by the World Health Organization (WHO) in BM (< 1 μg/L). Indeed, several factors affect significantly Cd levels in BM of the mothers such as low maternal education level, preterm delivery, cesarean delivery, and area of residence. Also, the frequency of consumption of milk and dairy products as well dried fruits and wheat bread and the frequency of use of cosmetic powders. However, the daily intake of cadmium by the newborns was lower than tolerable daily intake of the WHO for 97% of them. Our results revealed low cadmium concentrations in human milk samples from Moroccan lactating mothers living in Rabat, also the association of some factors with the levels of contamination found in this population.

Systematic Review of the Literature of Factors Affecting the Exposure and the Levels of Lead in Human Breast Milk

Human milk may sometimes contain chemical contaminants, which could have adverse effects on neonates or nursing infants. Lead (Pb) is of considerable interest due to its toxicity and occurrence. Furthermore, it has been suggested that human milk is a significant potential source of lead exposure to nursing infants. A systematic literature search in PubMed, Science Direct, and Google Scholar databases was performed to identify relevant studies, published in English until 2017, that investigated and explored common factors affecting the level of lead in human milk among lactating women around the world. Forty-nine papers were rated and explored the effect of one or several factors on the level of lead in human milk from 28 countries and carried out over a wide time frame from 1983 to 2017 and through Europe, Asia, America, and Africa, reviewing more than 5,000 subjects. Place of residence, maternal age, stage of lactation, smoking habits, maternal dietary intakes, and parity were the mostly assessed factors among the studies and considered as the main factors affecting Pb levels in BM. Other factors were not studied well enough and considered minor because few surveys evaluated their impacts. However, the literature findings are very controversial.

[Weber-Christian's disease: a preleukemic disorder?]

La maladie de Weber-Christian ou panniculite idiopathique est une affection rare, caractérisée par une inflammation du tissu adipeux sous-cutané; il s'agit d'une entité pathologique non spécifique qui reste toujours un sujet de débat et dont l'évolution est imprévisible. Nous rapportons dans cet article le cas d'un nourrisson de sexe féminin de 9 mois, admise dans un tableau de sepsis précédé d'une symptomatologie respiratoire et suivi de l'apparition de nodosités sous cutanées érythémateuses, de petite taille, dures, sensibles, asymétriques et situées au niveau des bras et des membres inférieurs, la biopsie cutanée a montré une hypodermite lobulaire avec infiltration des polynucléaires neutrophiles. La maladie de Weber-Christian a été retenue après avoir éliminé les autres diagnostics différentiels. Notre patiente a été traitée par la prednisone avec une bonne évolution initiale. Durant le suivi et au cours de la dégression, le diagnostic d'une leucémie aigue lymphoblastique type B a été posé. Cette évolution atypique à notre connaissance n'a jamais été décrite dans la littérature. Nous allons discuter à travers ce cas les différentes situations similaires où un autre diagnostic a été fait après avoir pris en charge les malades comme ayant une panniculite lobulaire idiopathique, en concluant de la nécessité d'une enquête étiologique exhaustive et d'une surveillance prolongée afin de rechercher une éventuelle pathologie associée.

Total, organic, and inorganic mercury in human breast milk: levels and maternal factors of exposure, systematic literature review, 1976-2017

This systematic review summarizes the finding of 58 studies from 33 countries, which assessed mercury concentrations in breast milk and the factors related to the level of contamination. We performed a literature search in Pubmed, Science Direct, and Google Scholar databases for studies published between 1976 and 2017 that are monitoring and measuring mercury in human breast milk and investigating the associated factors. Then, we extracted more information about the aim of the study, the country, samples size, time of lactation, mercury concentration, and other data. Most of the studies used mature milk or colostrum for analysis and in about 60% of them, the concentrations exceed significantly the limit set by the World Health Organization (WHO) of 1.7 µg/l; In addition, many factors and parameters were related to the level of mercury contamination in breast milk. Periodic monitoring surveys are recommended in each country to evaluate the level of mercury in milk of lactating women and to estimate the level of exposure of newborns.

Clinical and molecular report of c.1331 + 1G > A mutation of the AAAS gene in a Moroccan family with Allgrove syndrome: a case report

BACKGROUND

Allgrove syndrome is a rare autosomal recessive disorder characterized by the triad of achalasia, alacrimia and adrenal insufficiency. It is caused by the mutations of the AAAS gene located on chromosome 12q13. The c.1331 + 1G > A mutation is one of the most common described in North Africa including Tunisia, Algeria and Libya. We report here the clinical and genetic profile of a Moroccan family with Allgrove syndrome.

CASE PRESENTATION

A Moroccan sister and brother born to consanguineous parents were found, at the ages of twelve and fifteen months old respectively, to have alacrimia and isolated glucocorticoid deficiency. Later, they developed achalasia whereupon Allgrove syndrome was diagnosed clinically and confirmed by DNA sequencing which revealed a c.1331 + 1G > A mutation in the AAAS gene.

CONCLUSION

This finding reinforces previous studies in demonstrating the geographic expansion of the ancestral mutation c.1331 + 1G > A in North African patients and thus enabling targeted genetic counseling. To the best of our knowledge, this is the first report of the AAAS gene mutation in Moroccan patients.

Consommation des produits lactés chez l’enfant et l’adolescent marocain de 2 à 16 ans: une étude monocentrique

Introduction

Evaluer la consommation quotidienne des produits laitiers dans une population d’enfants marocains et déterminer les facteurs associés pouvant influencer cette consommation.

Méthodes

Etude prospective du 1^er octobre 2013 au 31 avril 2014. Les enfants âgés entre 2 et 16 ans ont été inclus. Le recrutement a eu lieu dans la ville de Fès. Le recueil des données s’est fait à l’aide d’un questionnaire fréquentiel. Les parents et les enfants inclus ont été interrogés sur la consommation des produits laitiers et les facteurs socio-démographiques avec une évaluation anthropométrique des enfants. L’association des variables à la consommation des produits laitiers a été analysée en analyse univariée et multivariée par un modèle de régression logistique.

Résultats

L’enquête alimentaire avait intéressé 286 enfants dont 151 filles (52,8 %) et 131 garçons (45,8%). Les enfants âgés de 2 à 3 ans représentaient 26,4 %, ceux âgés de 4 à 7 ans 28,9 %, ceux âgés de 7 à 9 ans 18,3 % et les adolescents âgés de 10 à 16 ans 26,4 %. Les enfants consommaient en moyenne 2.5±1 produits laitiers par jour. Les enfants consommaient au moins 3 produits laitiers par jour dans 57,8% chez les enfants âgés de 2 à 3 ans, 53,6% chez les enfants âgés de 4 à 6 ans, 40% chez les enfants âgés de 7 à 9 ans et 41.2% chez les enfants âgés de 10 à 16 ans. Les facteurs associés à la consommation de trois produits laitiers minimum par jour en analyse univariée étaient le niveau d’instruction maternel analphabète p < 0.001 OR = 0.1 et primaire p = 0.002 OR = 0.1, le niveau socioéconomique familial moyen p < 0.001 OR = 3, l’âge p= 0.01 OR = 0.9 et l’indice de masse corporelle normal p = 0.01 OR = 2.5 et > 90° percentiles p < 0.001 OR = 6. Il existe un lien positif entre l’indice de masse corporelle > 90° percentiles p = 0.01 OR = 3.9 est et la quantité consommée des produits laitiers et négatif avec le faible niveau de scolarité maternel analphabète p = 0.008 OR = 0.1 et primaire p = 0.009 OR = 0.1.

Conclusion

La consommation du lait et des autres produits laitiers était inappropriée en particulier chez l’enfant âgé de 7 à 9 ans et l’adolescent de 10 à 16 ans. Le faible niveau d’éducation maternel et un indice de masse corporelle supérieur au 90° percentiles était des facteurs indépendamment associés à la consommation de moins de 3 produits laitiers par jour. La sensibilisation des parents et des enfants sur l’intérêt du lait et de ses dérivés dans l’alimentation de l’enfant est indispensable.

Assessment of cadmium levels in human breast milk and the affecting factors: A systematic review, 1971-2014

BACKGROUND

This is a first systematic review summarizing 43 years of research from 36 countries for the assessment of cadmium in breast milk, a suitable matrix in human biomonitoring.

OBJECTIVES

To report from the published literature the levels of cadmium in breast milk, and the affecting factors causing increase in cadmium concentrations. In addition, to gather several quantitative data that might be useful to evaluate the international degrees of maternal and infant exposure.

METHODS

We reviewed the literature published between 1971 and 2014, available on Pubmed, Science Direct, and Google Scholar, reporting quantitative data about cadmium levels in human breast milk. Information about the aim of the study, name of the country, period of collection of samples, size of samples, sampling method, time of lactation, mother's age, area of residence, cadmium concentration, and other data were extracted.

RESULTS

Sixty-seven studies were selected and included in this systematic review. Some concentrations greatly exceed the limit set by the World Health Organization (WHO); however, about 50% of the studies had less than 1 µg/L cadmium concentration (recommended by the WHO); as well as many factors have shown their implication in breast milk contamination.

CONCLUSIONS

Breast milk is a pathway of maternal excretion of cadmium. It is also a biological indicator of the degree of environmental pollution and cadmium exposure of the lactating woman and the nourished infant. Therefore, preventive measures and continuous monitoring are necessary.

Physician practice in food allergy prevention in the Middle East and North Africa

BACKGROUND

A number of scientific organisations have developed guidelines for the primary prevention of allergic disease through nutritional interventions. However, even if the best evidence-based guidelines are available, these guidelines do not necessarily lead to adherence and improved health outcomes.

METHOD

To determine how closely the practice of physicians in select Middle Eastern and North African countries compares with the current recommendations on the primary prevention of allergy a survey study was performed using a structured questionnaire and convenience sampling.

RESULTS

A total of 1481 physicians responded, of which 66.1% were pediatricians. A total of 76.6% of responding physicians routinely identify infants who are at risk for developing allergy. In infants at risk for developing allergy, 89.1% recommend exclusive breastfeeding for at least 4 months. In contrast to current recommendations, 51.6% routinely recommend avoidance of any allergenic food in the lactating mother. In infants at risk of developing allergy who are completely formula fed, standard infant formula was recommended by 22.5% of responders. Of the responding physicians, 50.6% would recommend delaying the introduction of complementary food in infants at risk of allergy compared to those not at risk, whereas 62.5% would recommend postponing the introduction of potentially allergenic foods. Only 6.6% stated they follow all current recommendations on food allergy prevention.

CONCLUSION

The results of this survey suggest that a substantial part of responding physicians from select Middle Eastern and North African (MENA) countries do not follow current recommendations on primary prevention of allergic disease through nutritional interventions.

Early childhood obesity: a survey of knowledge and practices of physicians from the Middle East and North Africa

Background

Childhood obesity is one of the most serious public health issues of the twenty-first century affecting even low- and middle-income countries. Overweight and obese children are more likely to stay obese into adulthood. Due to the paucity of data on local practices, our study aimed to assess the knowledge and practices of physicians from the Middle East and North Africa region with respect to early-onset obesity.

Methods

A specific questionnaire investigating the perception and knowledge on early-onset obesity was circulated to healthcare providers (general physicians, pediatricians, pediatric gastroenterologist, neonatologists) practicing in 17 Middle East and North African countries.

Results

A total of 999/1051 completed forms (95% response) were evaluated. Of all respondents, 28.9% did not consistently use growth charts to monitor growth during every visit and only 25.2% and 46.6% of respondents were aware of the correct cut-off criterion for overweight and obesity, respectively. Of those surveyed, 22.3, 14.0, 36.1, 48.2, and 49.1% of respondents did not consider hypertension, type 2 diabetes, coronary heart disease, fatty liver disease, and decreased life span, respectively, to be a long-term complication of early childhood obesity. Furthermore, only 0.7% of respondents correctly answered all survey questions pertaining to knowledge of early childhood overweight and obesity.

Conclusion

The survey highlights the low use of growth charts in the evaluation of early childhood growth in Middle East and North Africa region, and demonstrated poor knowledge of healthcare providers on the short- and long-term complications of early-onset obesity. This suggests a need for both continued professional education and development, and implementation of guidelines for the prevention and management of early childhood overweight and obesity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0865-1) contains supplementary material, which is available to authorized users.

[Pseudoxanthoma elasticum: A rare cause of gastrointestinal bleeding in children]

INTRODUCTION

Pseudoxanthoma elasticum (PXE) is a rare autosomal recessive connective tissue disorder, characterized by calcification and progressive fragmentation of elastic fibers. Gastrointestinal lesions are rare in children and may be responsible for serious complications. This article reports two pediatric cases of PXE revealed by gastrointestinal bleeding.

CASE REPORTS

An 11-year-old boy and a 12-year-old girl were hospitalized for gastrointestinal bleeding. Digestive endoscopy showed hemorrhagic gastroenteritis bulbitis in the first case and it was normal in the second. Abdominal ultrasound showed diffuse linear calcifications in both cases. The diagnosis of PXE was retained based on the presence of vascular disease in both patients, a skin lesion in the girl, and an ocular lesion in the boy. The genetic study confirmed the diagnosis of PXE identifying two ABCC6 mutations in the composite state in the boy: the c.2263G> A (p.G755R) mutation on exon 18 and the c.3421C> T (pR1141X) mutation on exon 24 and the 4021G> A (R1164Q) mutation in the homozygous state of ABCC6 exon 24 in the girl.

CONCLUSION

Digestive manifestations are unusual ; however, pseudoxanthoma elasticum should be considered in all cases of gastrointestinal bleeding for no apparent reason. Early diagnosis allows prevention and measures to control the risk factors and limit the progression of complications.

Gaucher's disease: report of 11 cases with review of literature

Gaucher's disease (GD) is a lysosomal storage disorder due to glucocerebrosidase deficiency; it's one of the rare genetic diseases for which therapy is now available. The purpose of this work is to study the epidemiological features of the disease and to highlight the diagnostic difficulties. We performed an 11-year retrospective study of 11 patients with GD followed-up in the department of paediatric hepatology gastroenterology and nutrition of Rabat children's Hospital. We observed 11 patients with GD: 6 males and 5 females. Age at onset ranged from 3 months to 10 years with an average of 3.41 years. Mean age at diagnosis was 4 years (range 3months-14years). Parental consanguinity was noted in 85% cases. According to the clinical presentation, we classified our patients into: 9 cases of type 1 (81%) and two cases of type 2 (19%), none of the patients presented GD type 3. GD type 1: The age at diagnosis ranged from 2 years to 14 year with an average of 6 years. Main symptoms were: splenomegaly, hepatomegaly, pallor, haemorrhagic appearance (40%), bone pain (40%). The diagnosis was based on histology showing the Gaucher's cells in various tissues (100%). Enzymatic activity dosage confirmed the diagnosis of GD for 4 patients (44.5%). The treatment was always symptomatic (analgesics, transfusion). A splenectomy was performed in one case presenting with multiple splenic abscesses and high transfusion requirements. None of the patients received a specific treatment (substitutive enzymotherapy). The follow-up period ranged from 3 months to 6 years with an average follow-up of 4 years. We noticed stability in 4 cases, 2 worsening cases with bone and spleen complications. Three patients were lost to follow-up. GD type 2: we observed two cases of GD type 2 diagnosed at 3 and 18 months. The visceral symptoms were serious and the neurological features included seizures, hypertony, squint, physical developmental milestones delay. Both of them died. Gaucher's disease is not exceptional in Morocco. Type 1 is the most common type. We noted through this study some diagnostic difficulties as the diagnosis was delayed and the enzymatic dosage was performed in only 42% of the cases as well as therapeutic difficulty with no prescription of the specific treatment given the high cost of the enzyme.

Malignant infantile osteopetrosis: case report with review of literature

Malignant Infantile Osteopetrosis (MIOP) is a rare genetic disorder due to osteoclast abnormal activity. We report a thirteen month-old male patient, diagnosed as MIOP while investigating the cause of hepatosplenomegaly associated with hydrocephalus. His medical history revealed non consanguineous parents and one brother's death at the same age of unknown etiology (similar symptoms). Systemic examination showed hepatosplenomegaly, growth failure, developmental milestones delay, and rickets features. Ophthalmic exam yielded bilateral optic atrophy. Skeleton radiographs detected generalized dense bone and rickets. Cerebral CT scan revealed hydrocephalus. Histological examination showed hypoplastic bone marrow and extra-medullary hematopoeisis. Diagnosis was confirmed by genetic testing that showed two heterozygote mutations within the TCIRG1 gene. The patient received supportive treatment. He died from an acute respiratory distress. MIOP should be kept in mind as a rare cause of hepatosplenomegaly. Early diagnosis and timely Hematopoietic stem cell transplantation are the only curative approach for an otherwise fatal disease.

Metabolic profil in a group of obese Moroccan children enrolled in schools in the city of Rabat

Introduction

To determine the metabolic profile in a group of obese children in Morocco.

Methods

The BMI, the waist circumference, the blood pressure and metabolic parameters in 73 children (37 obese and 36 normal) were compared.

Results

80% of obese children had abdominal obesity (p <0.0001). For systolic blood pressure among children who have a higher value than the 95th percentile, 85.7% were obese and 14.3% children are normal children. For diastolic blood pressure, 83.34% of obese children had higher diastolic blood pressure values in the 95th percentile and 16.6% of normal children have a higher value than the 95th percentile (p=0.013). No obese child had hyperglycemia. The prevalence of metabolic syndrome was 21.6%.

Conclusion

Obesity is number one risk of cardiovascular disease for children. Early detection can help for an appropriate care.

Growth evaluation of a group of children enrolled in public schools in Rabat, Morocco: the role of socioeconomic factors

OBJECTIVES

The aim of this study was to assess the prevalence of underweight, stunting, and the socioeconomic risk factors among children enrolled in primary public schools in Rabat, Morocco.

METHODS

Twenty-three schools were randomly selected. A cross-sectional study was conducted between April and June 2010. The survey was conducted on the basis of two questionnaires for both parents and children. The references used were from the World Health Organization, 2007.

RESULTS

Our study focused on a sample of 1569 children whose average age was 9.7 ± 0.95 years. The prevalence of underweight among girls and boys was 43.1%, while that of stunting was 18.2%. The majority of the children in our population come from a low socioeconomic level. While 59% of fathers are laborers, 85% of mothers are unemployed.

CONCLUSION

In our study, we demonstrated that child malnutrition is strongly linked to a low socioeconomic level. These observations suggest that besides income, schooling and food quality may also be important factors that can affect growth. Educational programs, whether held in schools or informally, such as literacy or parenting classes, are valuable complements to other nutrition sustaining activities.

Monitoring of rotavirus vaccination in Morocco: establishing the baseline burden of rotavirus disease

BACKGROUND

Rotavirus is a leading cause of childhood morbidity and mortality worldwide. Clinical trials for two rotavirus vaccines recommended by the WHO for global use since 2009 have successfully demonstrated the safety and efficacy of these vaccines in a wide range of countries. To control the burden of severe and fatal diarrheal disease, the Ministry of Health of Morocco introduced the single strain rotavirus vaccine into their national immunization program in 2010.

METHODS

We employed a standard WHO case definition to identify children under 5 hospitalized with AGE at four hospitals from June 2006 to May 2010 to establish baseline burden of rotavirus disease before introduction of vaccine. Stool samples were collected and tested for rotavirus using a standard enzyme immunoassay.

RESULTS

Overall, 40% (741 of 1841) of the children hospitalized with AGE tested positive for rotavirus, making it the single most common cause of severe gastroenteritis among children in Morocco. Applying this prevalence to the estimates of diarrheal hospitalizations and deaths in Morocco, we estimate that rotavirus annually causes 19,646 hospitalizations and 1604 deaths in children under 5 years of age.

DISCUSSION

On the basis of these surveillance data, we estimate that 1 in 389 Moroccan children died and 1 in 32 was hospitalized due to rotavirus before their fifth birthday. A considerable proportion of these deaths and hospitalizations should be preventable through vaccination, and the 4 years of stable prevaccine surveillance in Morocco will be a tremendously useful platform for assessing potential changes in the epidemiology of rotavirus disease and measuring impact of the new rotavirus vaccine program in Morocco.

Prevalence of obesity and overweight in children: a study in government primary schools in Rabat, Morocco

BACKGROUND AND AIMS

We undertook this study to assess the prevalence of obesity and overweight in children enrolled in government primary schools in the city of Rabat, Morocco.

METHODS

Twenty three schools were randomly selected. A cross-sectional study was conducted between April 2010 and June 2010. The survey was conducted on the basis of two questionnaires for both parents and children. The references used are those of the WHO (2007).

RESULTS

Our study involved a sample of 1570 children with an average age of 9.7 ± 0.95 years. The prevalence of overweight and obesity was 8.7%. Overweight affected 5.1% and obesity affected 3.6%. The majority of our population consisted of children of low socioeconomic status where 59% of fathers are laborers and 85% of mothers are unemployed.

CONCLUSION

Overweight and obesity do not spare the most underprivileged social strata of our country. Therefore, prevention strategies and programs to raise awareness of risks and threats involved must be a public health priority.

[Sclerosing cholangitis revealing Langerhans cell histiocytosis in a 15-month-old child]

INTRODUCTION

Langerhans cell histiocytosis (LCH) is a rare disease that mainly affects young children. Sclerosing cholangitis may occur in 10-15% of patients with the multivisceral form. We report the case of a 15-month-old child who presented sclerosing cholangitis revealing LCH.

OBSERVATION

A 15-month-old child was hospitalized for cholestatic jaundice. He was the son of consanguineous parents and had repeated ear infections. One month before his hospitalization, he developed febrile jaundice. Initial clinical examination showed hepatosplenomegaly, with cholestasis, bicytopenia, and biological inflammatory syndrome. The digestive radiological studies revealed hepatomegaly and a regular thickening of the intestinal wall with an extension to the biliary tree. During his hospitalization, the infant developed stubborn ascites, lymphadenopathy, and skin lesions. Skull radiographs revealed punched-out lesions. The skin biopsy confirmed the diagnosis of histiocytosis X. Chemotherapy was started. The child died after the first course of treatment as a consequence of liver failure.

CONCLUSION

Sclerosing cholangitis may complicate LCH, mainly in its multivisceral form. On average, sclerosing cholangitis develops 2 years after diagnosis in children. It is rarely indicative of the diagnosis, which is mainly based on radiological examinations. Liver involvement is a factor of poor prognosis. It precipitates the occurrence of biliary cirrhosis. Usually, sclerosing cholangitis responds poorly to Langerhans histiocytosis treatment and liver transplantation must be considered.

Child health and survival in the Eastern Mediterranean region

Most child deaths in the region are preventable and occur in just a few of the 22 countries in the region. The interventions are not expensive, but governments need to implement them

Cornstarch thickened formula reduces oesophageal acid exposure time in infants

BACKGROUND

Infant regurgitation is a phenomenon causing worldwide parental distress and anxiety. Parental reassurance and dietary advices regarding feeding techniques and volumes are helpful in the management. Guidelines also recommend the use of thickened formula. However, the impact of thickened feeding on the frequency of acid reflux is still a matter of debate. Therefore, we evaluated the effect of a casein predominant formula thickened with a specifically selected and treated cornstarch on the frequency and duration of acid reflux episodes.

METHODS

Ninety-six formula-fed infants with a mean age of 93 days, presenting with episodes of regurgitation and vomiting occurring more than five times a day and with an abnormal oesophageal pH monitoring, were randomised to a regular infant formula (n = 45) or cornstarch thickened casein predominant formula (n = 51) for 28 days. A second pH monitoring was performed at the end of the study period (26+/-5 days). Symptoms were daily recorded in a diary by the parents for 28 days.

RESULTS

At inclusion, the pH-metric parameters did not differ between the control and the intervention group. Results of pH monitoring at baseline and at the end of the study did not differ in the control group on the regular infant formula. However, in the group with the casein dominant cornstarch thickened formula, all pH-metric parameters (reflux index (% of the investigation time with a pH < 4.0), number of reflux episodes >5 min, duration of the longest reflux episode) decreased significantly. The frequency of vomiting and regurgitation did not differ between both groups at baseline, remained unchanged in the control group, but decreased significantly in the intervention group.

CONCLUSION

A casein dominant formula thickened with a specifically treated cornstarch reduces oesophageal acid exposure, and reduces the frequency of clinical symptoms.

The effect of fermented milk on interferon production in malnourished children and in anorexia nervosa patients undergoing nutritional care

For several years cytokine production has been associated with infections but it was not suspected that some types of food could also induce cytokines, even in a state of non-infection. Lactic bacteria can induce interferon (IFN) production in human healthy subjects, thus, a better protection against infections would be expected. Therefore, we planned to evaluate the effect of two diets including yoghurt or milk on IFN-gamma production during nutritional recovery in two different situations of malnutrition: (1) children with diarrhoea; and (2) patients with anorexia nervosa (AN). Both the diet including yoghurt of that including milk seemed to increase IFN-gamma production at the end of nutritional recovery in the malnourished children with diarrhoea. The significance of interferon production and the lymphocyte subset increase should be explored to know if a better resistance against pathogens is related to them. Regulation of intestinal absorption and moderate stimulation of interferon production make the yoghurt-based diet a good choice in the nutritional care of children. In the same way, an increase in the IFN-gamma production was observed in AN patients consuming yoghurt. This increase of IFN-gamma production could be considered a biological marker to detect the effect of probiotics on the immune response, especially in the improvement of a deficient nutritional status.

[Mucopolysaccharidosis type I in Morocco: clinical features and genetic profile]

BACKGROUND

Mucopolysaccharidoses (MPS) are inherited metabolic disorders due to lysosomal enzyme deficiencies, leading to glycosaminoglycan accumulation in lysosomes of different tissues. The aim of this study was to characterize MPS types, particularly MPS I, which are difficult to differentiate by clinical features.

PATIENTS AND METHODS

Over a period of three years (June 1996-May 1999), 16 Moroccan patients (3-20 years old) with MPS were investigated. Twelve of them came from the Souss region. In subjects with suspected clinical MPS I or II, the diagnosis was confirmed by biochemical investigations, which included the quantification of total glycosaminoglycans (GAGs) released in urine, their identification, and the assay of alpha-L-iduronidase activity in leucocytes. A molecular analysis was performed in parallel, to provide the genetic proof of the diagnosis.

RESULTS

These 16 patients belonged to 12 families, nine of which were consanguineous (75%). Twelve patients had Hurler syndrome and three had Hurler/Scheie's syndrome; no case of Scheie's syndrome was observed. Short stature, coarse face, organomegaly, hernia, cardiac disease, mental delay and dysostosis were observed in variable degrees. We report three cases without corneal clouding. Increased total urinary GAGs, identified as dermatan sulfate and heparan sulfate by thin-layer chromatography and total deficiency of alpha-L-iduronidase activity, were noted in studied subjects. At the molecular level the P533R mutation was detected in 24 among 26 alleles studied.

CONCLUSION

It is now possible to perform the screening of MPS I and II in Morocco by analysis of clinical, radiologic observations and biological investigation. The predominance of P533R mutation could permit the screening of healthy heterozygotes and genetic counselling for families of Moroccan descent.

[Visceral leishmaniasis and malnutrition: a case report]

BACKGROUND

Visceral leishmaniasis occurring in malnourished subjects can have an uncommon course, which explains difficulties in its diagnosis.

CASE REPORT

A 22-month-old infant was admitted because of malnutrition and prolonged fever. The bacteriological investigation was negative. When his nutritional status improved, he developed a splenomegaly. The medullogram confirmed the diagnosis of visceral leishmaniasis. The course was then favorable with treatment by pentavalent antimonial.

CONCLUSION

Malnutrition constitutes a risk factor of opportunist parasitic disease such as leishmaniasis. Its diagnosis can be very difficult.

[A severe form of urinary tuberculosis in children]

Urinary tuberculosis is a rare disease in children. It poses major diagnostic problems because of clinical symptoms, which are often atypical and misleading. It causes serious lesions which are often multifocal and extensive, requiring complex surgical excision and urinary tract reconstruction. Prevention of this disease is based on generalized vaccination with BCG and adequate treatment of pulmonary tuberculosis. The authors report a case of urinary tuberculosis in a fourteen-year-old child who presented episodes of cystitis and hematuria refractory to treatment. The diagnosis, confirmed by the positive test for AFB in the urine was established late, at the stage of silent kidney and scleroatrophic bladder. The patient was treated with antituberculous chemotherapy (Isoniazid; Rifampicin, PZA) and nephro-ureterectomy with augmentation enterocystoplasty.