Hepatitis B in children with leukemia: the role of primary immunization

Background: Children with cancer have a greatly enhanced risk of contracting hepatitis B infection due to immunosuppression secondary to chemotherapy and radiotherapy, frequent blood transfusions, bone and peripheral vein punctures, tissue damage and mucositis. During the past 3 decades, multimodality therapy for childhood leukemia has resulted in markedly improved survival. Inspite of screening and immuno prophylaxis, hepatitis B infection rates in children with leukemia are high. In view of this, we decided to study the prevalence of hepatitis B among children with leukemia in our institution, and the possible risk factors.Methods: This was a cross sectional study carried out at a tertiary pediatric care center in North Kerala among 104 children between 1 and 12 years of age on treatment for leukemia.Results: Among the 104 children, only 17 (16.3%) had received primary immunization against hepatitis B. Of the 87 children who had not received primary immunization, 44.8% (n=39) developed hepatitis B, compared to 11.8% (n=2) in the vaccinated group (p=0.01).Conclusions: This study highlights the importance of primary immunization against hepatitis B in children with leukemia, and the need for universal coverage.

Prevention of Mother to Child Transmission of Hepatitis B Infection.

The likelihood of developing chronic hepatitis B infection and its complications is most when infection is transmitted vertically. Awareness of the current recommendations for managing babies of mothers who are hepatitis B carriers is not universal, resulting in failure of follow up, despite the serious long term implications, including development of hepatic carcinoma. We review the current guidelines of managing babies born to mothers who are Hepatitis B carriers.

Deliberate Self Harm in Children.

Objective: To study the nature of deliberate self-harm (DSH) in children and to identify the associated factors. Setting: Child Guidance Clinic attached to the Department of Pediatrics of a teaching hospital in South India. Subjects: Children with history of deliberate self harm who were referred to the CGC for psychological evaluation during a 10 year period. Methods: Children and parents were interviewed together and separately and details regarding age, sex, family and school environment, stresses and nature of self harm were documented. Psychiatric diagnosis was made based on DSM IV diagnostic criteria. Results: Among the 30 children included in the study, 21 were boys and 9 were girls. Majority of children were between the ages of 11 and 13 years, the youngest being 6 years old. 76% of children had history of acute stressful life events and 62% of them had chronic ongoing stress. 62 % of children had stress in the family and 41% had stress at school. Stress in the family included death of a parent, conflicts with parents or siblings, mental illness in the family, parental alcoholism and parental disharmony. Stress at school included conflicts with classmates, punishment or negative comments by teachers and learning problems. Psychiatric disorders were present in 52% of children, the commonest being depressive disorder. The commonest mode of DSH was self poisoning, and rat poison (zinc phosphide) was the commonest substance used. Conclusions: Deliberate self harm occurs in young children and the risk factors are comparable to those in adolescents.

Management of pain in leukemic children using the WHO analgesic ladder.

Objective. To ascertain the effectiveness of WHO analgesic ladder in pain management in children with leukemia. Methods. Children with leukemia who were referred to a pain and palliative care clinic attached to the Department of Pediatrics of a medical teaching hospital during a period of 6 months, were included in the study. Results. Thirty nine (39) children, who constituted 64% of children on treatment for leukemia, required referral to pain and palliative care services during the study period. Of these 92% had Acute Lymphocytic Leukemia (ALL) and 8% had Acute Non Lymphocytic Leukemia (ANLL). 95% of children had nociceptive pain and 5% had neuropathic pain. Step – 1 analgesia was effective in 12 (31%) children and 21 (54%) could be managed with Step – 2 analgesia. Step – 3 analgesia was required in only 6 (15%) children. Step 3 analgesia was required in children with neuropathic pain and bone pain. Conclusions. WHO analgesic ladder is effective in managing pain in children with leukemia. Majority of cases of cancer pain in children could be managed by the treating physician using non-opioids, weak opioids and adjuvants as per the WHO guidelines. Children with bone pain and neuropathic pain may require referral to specialist services and use of strong opioids like morphine. The study emphasizes the need for establishing specialist pain management services in all centres where children with cancer are treated.

Intrathecal tetanus immunoglobulins in the management of tetanus.

OBJECTIVE: To study the clinical profile, treatment and outcome of tetanus in children treated with intrathecal tetanus immunoglobulin. (TIG) METHODS: Retrospective analysis of hospital records of tetaus cases admitted to the pediatric ICU during the five year period between 1999 to 2004 was done. RESULTS: There were 66 cases of tetanus treated with intrathecal TIG. Children below 5 years formed 53% of cases and 47% were above 5 years. Totally unimmunized children constituted 82% of cases and 18% partially immunized children. The portal of entry was otogenic in 58% of cases and injury in30% of cases. The common complications observed included thrombophlebitis, aspiration pneumonia, laryngospasm and autonomic system involvement. There were no complications specific to intrathecal administration of TIG. The mortality due to tetanus was 9%. DISCUSSION: Mortality and morbidity due to tetanus was less in the present study compared to other centers where TIG is given intramuscularly. CONCLUSION: Intrathecal TIG is effective in the treatment of mild and moderate tetanus. Randomized controlled clinical trials are needed to evaluate the efficacy of intrathecal TIG in the management of severe tetanus.

Clinical profile of depressive disorder in children.

The aim of this retrospective study was to evaluate the risk factors, clinical features and co-morbid disorders of depressive disorder in children below the age of 12 years. Children who attended the child guidance clinic between January 2000 and December 2003 formed the subjects for the study. The diagnosis of depressive disorder was based on DSMIV diagnostic criteria for Major Depressive Disorder, Single episode. There were 26 boys and 19 girls. Stress at school and in the family was significantly associated with depressive disorder. Children with depressive disorder had significantly more family members affected with mental illnesses. The clinical features included diminished interest in play and activities, excessive tiredness, low self- esteem, problems with concentration, multiple somatic complaints, behavior symptoms like anger and aggression, recent deterioration in school performance and suicidal behavior. Majority of children had other associated psychiatric disorders which included dysthymic disorder, anxiety disorders, conduct disorder and conversion disorder.

Effectiveness of individualized education program for slow learners.

OBJECTIVE: To evaluate the effectiveness of an individualized education program for children with scholastic backwardness. METHODS: Among the children attending a Child Guidance Clinic for scholastic backwardness, 12 of them who were diagnosed as slow learners based on current level of academic functioning and IQ and 6 children having mild mental retardation were given individualized education for a period of two months. Independent assessors evaluated the academic functioning at the beginning of the training and at the end. RESULTS: The results showed that the children had significant improvement in their academic functioning and self esteem after the training. CONCLUSION: The present experiment can be a model to set up a resource room in normal schools to provide individualized education to children who are slow learners.

Deliberate self-poisoning in children.

This prospective study was aimed to analyze the nature of and the factors associated with deliberate self-poisoning in children below the age of 12 years. Children referred to the Child Guidance Clinic for evaluation after recovery from the effects of poisoning during the five-year period between 1999 and 2003 formed the subjects of the study. The children were evaluated for stress factors, psychiatric disorders and the nature and mode of deliberate self-poisoning. Deliberate self-poisoning constituted 0.9% of total admissions due to poisoning. There were 10 boys and 2 girls between the ages of 9 and 12 years. Both acute and chronic stress in the family and school were associated with deliberate self-poisoning. Majority of them had psychiatric disorders. Rat poison (zinc phosphide) was the commonest poison used. Two children got the idea from watching TV serials.