impact of maternal iron deficiency and iron deficiency anemia on child's health

Iron deficiency anemia is extremely common, particularly in the developing world, reaching a state of global epidemic. Iron deficiency during pregnancy is one of the leading causes of anemia in infants and young children. Many women go through the entire pregnancy without attaining the minimum required intake of iron. This review aims to determine the impact of maternal iron deficiency and iron deficiency anemia on infants and young children. Extensive literature review revealed that iron deficiency is a global nutritional problem affecting up to 52% of pregnant women. Many of these women are symptomatic. Lack of proper weight gain during pregnancy is an important predictor of iron deficiency

Percutaneous endoscopic gastrostomy tube placement in children with neurodevelopmental disabilities. Parents' perspectives

To study the attitudes of parents toward percutaneous endoscopic gastrostomy [PEG] tube placement and identify contributing factors to their negative attitudes. Thirty consecutive parents were included retrospectively through a single endoscopy unit at the King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia from January to July 2012. A structured 25-item questionnaire was designed to examine their demographics, attitudes, and experience with the PEG procedure. Patients' ages were 3-19 years [mean: 10.2], mostly with severe cerebral palsy [77%]. Their PEG tubes were inserted 2-144 months [mean: 39] prior to the encounter. Only 43% of the parents felt informed and most [73%] had negative attitudes toward the procedure, which was associated with significant delays [p=0.016]. After the procedure, most parents [67%] reported a better-than-expected experience, which was associated with their information levels [p=0.03]. Most parents [80%] regretted not having the PEG tube placed earlier. This depended on their information level, as those who were not informed were more likely to have strong regrets when compared to those informed [82% versus 42%, p=0.008]. Most parents are not well-informed regarding the PEG procedure, which affects their expectations and experiences. Most parents found the experience better than what they expected and regretted not having carried it out earlier

Burnout syndrome in pediatric practice

Burnout is a common work-related syndrome consisting of emotional exhaustion, depersonalization and diminished feelings of personal accomplishment. Burnout influences the performance and efficiency of the healthcare professionals and therefore the quality of the care provided. This study aims to assess the burnout rates and potential determinants in pediatrics. A cross-sectional, descriptive study involving physicians practicing pediatrics in the Jeddah area of Saudi Arabia was conducted utilizing the Maslach Burnout Inventory in addition to questions regarding work-related and lifestyle-related factors. One hundred and thirty pediatricians [55% females] were included with age ranging between 25 and 45 years [mean: 30]. Most [46%] were consultants and 54% practiced in a university based setting. Burnout scores were abnormal in 107 [82%] and in 45 [34%] the syndrome was severe. Males were more likely to reach a severe burnout category compared to females [40% vs. 31%; p=0.012]. Academic pediatricians working in a university setting were much more likely to experience severe burnout compared to their counterparts working in other hospitals [50% vs. 19%; p=0.0005]. Consultants were also more likely to experience severe burnout compared to residents and assistants [46% vs. 27%;p=0.03]. At least one third of practicing pediatricians suffer from burnout syndrome. Specific strategies should be developed and implemented to limit and prevent professional burnout

Meningitis and encephalitis in infants and children

Despite the availability of modern therapies, meningitis and encephalitis remain potentially life-threatening infections in children with mortality rates reaching up to 25%. Treated patients are at a high risk of long term sequelae including epilepsy, learning, and behavioral disorders. The golden rule of early diagnosis and treatment to achieve a good outcome has not yet been challenged by the new, often expensive antibiotics or contemporary critical care. In this article, an updated overview of meningitis and encephalitis in infants and children is presented. It is important to note that routine childhood immunization has significantly decreased the number of serious infections. However, meningitis and encephalitis remain problematic particularly in developing countries where immunization rates are suboptimal. The most common viral etiologies include enteroviruses, herpes simplex virus, and arboviruses. However, the causative virus may not be identified in up to 70% of cases. This is not the case for bacterial infections unless the patient had received prior oral antibiotics. The causative bacterial organisms vary with age, and the less common fungal infections occur mainly in immune compromised patients

Evaluating the child with unsteady gait

Unsteady gait is a relatively common presentation to the pediatric emergency and neurology services. Unsteadiness can be due to a wide variety of causes, however, the primary concern on initial assessment is to exclude serious disorders such as meningitis, encephalitis, or brain tumors. Recognizing benign and non-neurological causes of unsteady gait is essential to avoid unnecessary investigations and hospital admission. In this review, a clinical approach to the unsteady child is presented with discussion of diagnostic considerations, approach to investigation, treatment, and prognosis. Ataxia can be cerebellar or sensory. Cerebellar ataxia can be acute, chronic, progressive, or episodic. It may result from trauma, infections, metabolic, degenerative disease, space occupying lesions, or congenital anomalies. Sensory ataxia is due to peripheral neuropathy involving large myelinated fibers that carry vibration and position sense, or due to posterior spinal column dysfunction. Accurate assessment depends on detailed history, examination, and then formulation of a differential diagnosis list to guide laboratory investigations

Dandy walker malformation and hypertrophic cardiomyopathy. Unusual fatal association

Dandy Walker malformation [DWM] is a rare congenital brain anomaly characterized by cystic dilation of the fourth ventricle and hypoplasia of the cerebellar vermis. Other extracranial anomalies can be associated, including cardiac defects. We report a rare patient with DWM associated with progressive heart failure secondary to hypertrophic cardiomyopathy. He was diagnosed at 2 months of age and died 5 months later. We conclude that hypertrophic cardiomyopathy can be associated with DWM with poor prognosis. A careful cardiac evaluation is needed in all infants with DWM for early recognition of such potentially serious associated cardiac malformations

use of complementary and alternative therapies in Western Saudi Arabia

To examine the use of complementary and alternative therapies [CAT] in our region, particularly for children with chronic conditions, and explore contributing factors to their use. A prospective random sample of mothers visiting the out patient department of King Abdulaziz University Hospital in Jeddah, Saudi Arabia were identified from the 1st of June, 2006 to the 31st of May, 2008. A survey using a structured 50-item questionnaire was used to examine their demographics, child's medical problem, and the use of CAT. Seventy-nine mothers were interviewed, and their child's condition was acute in 47%, chronic, or recurrent in 53%, and treatable in 84%. Neurological complaints were reported in 25%. Thirty-three [42%] families used CAT in their child, mostly [57%] before seeking medical help. Religious and spiritual healing was used in 82%, oral, or topical preparations or herbs in 30%, and physical interventions in 21%. Factors associated with using CAT included child's age < 1 year [p = 0.008], less than high school education of the fathers [p = 0.01], chronic medical condition [p = 0.00008] or neurological disorder [p = 0009], and positive family history of using CAT [p < 0.0001]. Many parents refer to CAT typically before seeking medical help. Pediatricians should counsel and caution parents regarding the lack of studies demonstrating efficacy and safety of CAT in young children

value of seizure semiology in lateralizing and localizing partially originating seizures

Diagnosis epilepsy depends heavily on a detailed, and accurate description of the abnormal transient neurological manifestations. Observing the seizures yields important semiologic features that characterize epilepsy. Video-EEG monitoring allows the identification of important lateralizing [left versus right], and localizing [involved brain region] semiologic features. This information is vital for identifying the seizure origin for possible surgical interventions. The aim of this review is to present a summary of important semiologic characteristics of various seizures that are important for accurate seizure lateralization and localization. This would most likely help during reviewing video-EEG recorded seizures of intractable patients for possible epilepsy surgery. Semiologic features of partial and secondarily generalized seizures can be grouped into one of 4 categories including; automatism, speech, motor, and autonomic features. These features will be discussed in detail in this review. However, seizure semiology should be correlated with EEG and MRI findings. Accurate identification of the seizure origin is more likely if focal EEG onset and MRI findings were concordant with the clinical semiology

Potentially serious Lamotrigine-related skin rash

To report our experience with lamotrigine [LTG]-related skin rash in children with epilepsy. We identified a series of consecutive children with epilepsy treated with LTG prospectively over a 5-year period ending 1st October 2005 at King Abdul-Aziz University Hospital and King Faisal Specialist Hospital and Research Center, Jeddah, Kingdom of Saudi Arabia. Of 207 children on LTG, 15 [7.2%] developed a skin rash with ages ranging between 3-12 years [mean 7.5]. We used LTG as monotherapy in 3/15 and as add on in 12/15, mostly [10/15] in addition to valproic acid [VPA]. The rash was mild with complete recovery in 7 children [47%]. The remaining 8 [3.9% of the total] had severe rash that necessitated admission to hospital. Seven out of these 8 children were also receiving VPA. One child had superimposed secondary bacterial infection and admitted for intravenous antibiotics. Two children recovered slowly with extensive post-inflammatory hyperpigmentation. We diagnosed Stevens-Johnson syndrome in 5 children [2.4% of the total]. One of these 5 children had progressive symptoms that evolved to toxic epidermal necrolysis. He required prolonged intensive care admission and developed sepsis with disseminated intravascular coagulopathy. He deteriorated despite supportive therapy, and died 5 weeks after the initiation of LTG therapy. Lamotrigine is a novel antiepileptic drug with a favorable therapeutic profile and good tolerability. However, LTG-related skin rash is a potentially serious adverse event that should be carefully monitored. Although the risk is small, one should weigh this against the potential benefits, particularly in children on VPA

unusual case of isolated trochlear nerve palsy

Trochlear nerve palsy is rarely encountered in children and only 5% are truly isolated. Multiple sclerosis [MS] is also extremely uncommon in children. This report describes an otherwise healthy 10-year-old boy who presented with a 5-day history of vertical diplopia with associated dizziness, decreased appetite, and unsteadiness. He had no recent history of infection and no previous history of neurological symptoms. Ophthalmologic assessment revealed full ocular ductions and right hyperdeviation in primary gaze during alternate cover test. This hyperdeviation increased during left gaze, and right head tilt consistent with paresis of the right oblique muscle. Brain MRI revealed multiple well-defined hyperintense T2 lesions in the periventricular and subcortical white matter, and brainstem, suggestive of MS. His symptoms resolved after 2 weeks with no treatment. To conclude, isolated trochlear nerve palsy can be the initial clinical manifestation of childhood MS. Long term follow up is needed to confirm the diagnosis of MS

Updated overview of pediatric headache and migraine

Headache is a common complaint, occurring in >90% of school age children. The frequency increases with increasing age and the etiologies range from tension to life-threatening infections and brain tumors. Migraine is the most frequent cause of acute and recurrent headaches in children. The overall prevalence of non-migraine headaches is 10-25%. A thorough history, physical and neurological examination, and appropriate diagnostic testing [if indicated] will enable the physician to distinguish migraine and tension headaches from those of a secondary etiology. In this review, we present an updated overview of childhood headaches. The recently developed International Classification of Headache Disorders, second edition [ICHD-II] will be summarized. The Quality Standards Subcommittee of the American Academy of Neurology [AAN] and the Practice Committee of Child Neurology Society [CNS] recommendations for neuroimaging of children with recurrent headaches concluded that routine neuroimaging is not indicated if .the neurological examination is normal. Neuroimaging should be considered in children with recent onset of severe headache, change in the headache type, associated focal neurological features, or seizures. Trends in the management guidelines will be highlighted

Ketogenic diet update and application

The ketogenic diet is a high-fat, low-carbohydrate, and adequate-protein diet for the treatment of intractable seizures in children, initially introduced in 1921 to mimic the biochemical changes associated with fasting. The diet is individually calculated and rigidly controlled, requiring a comprehensive medical team approach. Although there are adverse, as well as, beneficial effects, several studies have proved its tolerability and efficacy in children with medically refractory epilepsy. Children must be carefully selected, monitored, and followed, and the parents must be committed. The division of Pediatric Neurology at King Faisal Specialist Hospital and Research Center in Jeddah is one of very few centers that provide this treatment option in the Middle East. Over the last 2 years, 8 children with intractable epilepsy were placed on the ketogenic diet in our center. Overall, 38% [3/8] reached accepted efficacy [>50% seizure reduction], which is lower than the 50% efficacy in published literature. Many issues and problems arose in the provision and compliance with the ketogenic diet, many of which were unique to our culture. It is critical that this treatment is provided to highly selected children with committed parents

Clinical review of pediatric epilepsy

Seizure disorders are very common and represent the most common cause of referrals to pediatric neurology. Epilepsy, defined as recurrent unprovoked seizures, is also common with a frequency of 4-8 cases per 1000 children. In Saudi Arabia, inherited neurological disorders, including epilepsy and genetic epilepsy syndromes, are more common because of the high rate of consanguinity. This article attempts to provide an updated overview of pediatric epilepsy and review the most recent diagnostic and therapeutic guidelines. Seizures in children have wide variations in clinical expression with age specific presentation. Although epilepsy is a clinical diagnosis, EEG often provides supportive evidence and helps in seizure classification. Epilepsy syndromes are more common in younger children, and their proper diagnosis provides valuable genetic, therapeutic, and prognostic information. Magnetic resonance imaging is superior in identifying congenital or developmental abnormalities and should be performed in preference to CT. Monotherapy is the best management approach for better compliance and to prevent interactions or side effects. To conclude, epilepsy remains a clinical diagnosis and therefore, careful and detailed history remains the cornerstone of an accurate clinical diagnosis

Impressions and experience of nonneurologists in neurology

Neurological disorders are common in Saudi Arabia and the demand for trained neurologists is strong. We aimed to study the impressions and experiences of general physicians in the neurology field and examine their referral practices. We included attendees of the [neurology for non-neurologists] symposium, which took place from 14-15 October 2004 at King Faisal Specialist Hospital and Research Center in Jeddah, Kingdom of Saudi Arabia. We designed a structured 24-item questionnaire to examine their demographics, training, practice, and referral patterns. One hundred and eight participants registered for the symposium, with 69 [64%] questionnaires returned. Attendee's ages were 23-60 years [mean 35], with 53% being males. There were 46% consultants and specialists, 33.5% trainees, 14.5% students, and 6% other health professionals. Most physicians [62%] practiced in the field of general practice or internal medicine and 62% received a structured neurology rotation during training. Patients with neurological complaints constituted 29.5% of those seen in their practice, and they referred 33.3% to neurology. Only 13.5% and 15.5% were highly confident in diagnosing and treating these patients. Those who reported seeing many patients with neurological complaints [4 on the Likert scale] were 18.8 times more likely to feel highly confident in their diagnoses [95% confidence interval [CI]: 3-195, p=0.0002] and 23 times more likely to feel highly confident in their management [95% CI: 3.6-236, p=0.0005]. Many physicians [20.5%] had no direct access to a neurologist for referrals. Many general physicians were not highly confident in diagnosing and treating neurology patients. Given the limited number of neurologists, we recommend appropriate neurological training of generalists

Pediatric neuro-developmental and behavioral disorders "Practitioners' perspectives"

Developmental and behavioral [DB] disorders are commonly encountered in the general pediatric and neurology practices. There is a strong demand for trained developmental pediatricians and child psychiatrists in our region. In this study, we aimed to study practitioner's experiences in dealing with these disorders and their referral practices. Attendees of an international pediatric symposium on neuro-developmental and behavioral disorders were included. The symposium was conducted by the Department of Neurosciences, King Faisal Specialist Hospital and Research Center in Jeddah from 4-6th March, 2003. A structured 25-item questionnaire was designed to examine their demographics, training, practice and referral patterns. A total of 167 attendees registered for the symposium and 131 [78%] questionnaires were returned. Participant's ages were 23-69 years [mean 36, SD 8.5], with 67% being females. Many participants were practicing general pediatrics [43.5%] and the majority [92%] frequently saw and followed children with DB disorders. However, only 24% felt highly confident in their management. As well, only 35% and 31% of physicians received structured developmental and psychiatry rotations, during their training. Those who received a structured developmental rotation felt more comfortable in making the correct diagnosis [odds ratio [OR] 4, 95% confidence interval [CI] 1.2-14, p=0.01] and in providing appropriate treatment [OR 3.8, 95% CI 1.4-11, p=0.006]. Many participants [32%] had no direct access to a developmental pediatrician or child psychiatrist for referrals. Developmental and behavioral disorders are common in daily pediatric practice. Most practitioners did not receive a structured rotation covering these disorders during their training and were not highly confident in managing affected children. Given the limited number of developmental pediatricians and child psychiatrists, we highly recommend appropriate developmental and psychiatric training for practitioners