Obesity in Thai adolescents: lifestyles, health attitudes and psychosocial concerns.

Objective: To determine the dietary pattern, lifestyle factors, and psychosocial concerns in Thai obese adolescents. Methods: Students’ school health records under the Siriraj School Health Network was reviewed during the academic year of 2005. Those with body mass indices (BMI) ³25 kg/m2 were asked to complete a self-administered questionnaire divided into three parts; 1) health attitudes and psychosocial concerns; 2) dieting lifestyle; 3) physical activity lifestyle. Results: The prevalence of overweight and obesity among 718 from 5,071 students from Siriraj School Health Network was different between genders (7.7% and 2.5 % in male vs. 2.9% and 1% in female). Of those, 403 voluntarily answered the self-administered questionnaires. The majority of students (87.9%) were not satisfied with their actual weight, and tried to lose weight (94.2%). Concerning their lifestyles, 79.4% and 49.6% had taken high calorie food mostly fast food and dined buffet-style at least once a week respectively, while half disliked fruits and vegetables, and 15.4% skipped breakfast. Also, the majority of students exercised less than the standard recommendation of at least three days a week, with more than two thirds, excusing not having enough time to practice while 48% spending at least three hours a day watching television and playing computer. Importantly, more than half of them had weight- related psychosocial problems presenting as poor self image, low self esteem and self confidence. Conclusion: Unhealthy lifestyles, poor health attitudes and negative psychosocial concerns were reported among Thai obese adolescents. Strategies for successful obesity prevention are discussed in this article.

Theophylline overdose in premature neonate: A case report and review of pharmacokinetics.

Theophylline is well-accepted in neonatal medicine for its efficacy in treating apneas of prematurity. However, due to its narrow therapeutic index, decreased drug elimination capacity and limitations of enhanced elimination methods in premature newborns, inadvertent overdoses in this age group can be difficult to manage. We report a case of therapeutic misadventure of a 30-week-old infant who received and overdose of aminophylline for apnea of prematurity. The patient was symptomatic with tachycardia, agitation, vomiting, hyperglycemia and diuresis. He received an exchange transfusion 9 hours after the overdose and had progressive resolution of symptoms. The pharmacokinetics of theophylline in cases of overdose in the neonates is reviewed.

Added efficacy of paracetamol in tepid sponging for fever reduction.

Objective: Fever is one of the most common presenting symptoms in children receiving care at the outpatient walk-in clinic or emergency room. At the Pediatric Department of Siriraj Hospital, detecting and managing febrile children has become a routine practice due, in part, to the implementation of nursing triage. Such measure has brought about a significant reduction in the occurrence of febrile convulsion in the waiting room. However, different nurses employ different or a combination of methods to achieve fever reduction, leading to questions regarding their efficacy in reducing fever in the pediatric outpatient department. Methods: This is a prospective observational study of children presenting to the outpatient clinic at the Department of Pediatrics, Siriraj Hospital, between January and December 2003. The children were taken to the treatment room if they were found at triage to have body temperature of > 38.5ºC. There, the nurses are free to administer either tepid sponging alone or in combination with paracetamol syrup 10 mg/kg/dose. A second temperature was taken before they were released into the waiting room. The data regarding their age, initial and follow-up temperatures, time intervals between the two readings, and whether or not they received paracetamol was collected. The data was then stratified into 2 groups: those who received tepid sponging alone (TS alone) and those who received tepid sponging and paracetamol (TS/Para). Data analysis was done using Sigmastat™2.03. Both two-tailed t-test and a Mann-Whitney Rank Sum Test were employed to analyze the differences between the two groups. Multiple linear regressions were used to correct for the differences that age and time interval between measurements might have on temperature reduction of both groups. Results: There were 995 children who received fever-reduction measures at the outpatient department over the 12-month period. The TS/Para group achieves a statistically significant lower average body temperature than the TS only group at the end of the treatment period (0.647 + 0.675 vs. 0.543 + 0.560; p<0.05) and multiple linear regression analysis shows a statistically significant trend in fever reduction with the TS/Para method when correcting for the effect of patient’s age and time interval between measurements. Discussion: From our study, it is shown that the administration of tepid sponging together with paracetamol can reduce more effectively the body temperature than when tepid sponging is employed alone. However, further study is needed to ascertain the sustainability of fever reduction with these two methods and whether paracetamol administration alone, without tepid sponging, can also achieve the same goal in fever reduction.

Sexual attitudes of adolescent girls after an interactive seminar on sexuality.

Objective: The purpose of this study is to assess the effect of an interactive seminar in sex education on the sexual attitude of adolescent girls in the 9th grade in an all-girl school near Siriraj Hospital, Bangkok, Thailand. Sexual activities in Thai teenagers have emerged as a popular subject of interest in the news media. Government officials, together with schools have been promoting sex education in schools as the means of reducing the adolescents’ tendency to experiment with sex prematurely and inappropriately. As part of an adolescent outreach program at Siriraj Hospital, pediatricians were asked to participate in an interactive sex-education seminar with teenage girls from an all-girl school in the community. Methods: All girls attending the 9th grade were recruited for the one-day interactive seminar. The attendees were divided among the two identical seminar sessions. The seminar took an average of 50 minutes per group. During the didactic portion of the seminar, students were encouraged to participate actively by asking as many questions as possible. Afterwards, the students were asked to fill out an anonymous questionnaire regarding their own sexual attitudes, beliefs and practices. Results: There were 350 attendees; all were between the ages of 12-14 years. Over all, 70.7 % of girls had attitudes that promote the practice of abstinence; 13.8% viewed that sex was an acceptable part of a loving relationship; and 23.9% of the girls had mixed feelings and attitudes towards becoming sexually active at their age. The greatest area of uncertainty was in the area of using sex to maintain a loving relationship, while 8.6% of girls felt that withholding sex from their partners would result in a break up and 30.9% were uncertain whether sex would help intensify love in a relationship. In addition, 3.4% of girls felt they had no right to reject sexual advances while 5.1% did not recognize that being alone with a boy could lead to unplanned sexual intercourse. Discussion: While the prevalence of attitude leading to abstinence in our study was encouraging, the large proportion of students who remained uncertain and undecided about their practice and believed to uphold in the face of increasing pressure to have sex was alarming. As pediatricians who work primarily with teenagers, our challenge is to convert those who are undecided as to which path to take into those who are adamant about maintaining celibacy and abstaining from a sexual relationship until they are older and more equipped to handle its complications and consequences.

Predictors of elevated blood lead level in Thai children: a pilot study using risk assessment questionnaire.

INTRODUCTION: In the era post leaded-gasoline use, the risk of exposure to environmental lead in Thai children is not well described. This is a pilot study using a risk assessment questionnaire to identify children with elevated blood lead level. MATERIAL AND METHOD: Children from 4 communities, 2 in the Bangkok metropolitan area and 2 in Kanchanaburi province, were recruited during their well child visits. Blood lead levels were obtained in all children and parents are asked to fill out a 25-item risk assessment questionnaire. STATISTICAL ANALYSIS: The relationship between the blood lead level and dependent variables were tested using linear regression and one-way analysis of variance (ANOVA) as appropriate. RESULTS: There were 296 children included in the study; 33 from Klong Toey and 114 from Siriraj community in Bangkok while 149 were from two different communities in Kanchanaburi province. The average blood lead level was 5.65 +/- 3.05 mcg/dL. The overall prevalence of children with blood lead level > 10 mcg/dL was 8.1%, while that of the Klong Toey community was 12.5%. The questionnaire identified 3 independent predictors of elevated blood lead levels; the presence of peeling paint in or outside the house, eating paints chips, and the geographic location of children. CONCLUSION: Using a risk assessment questionnaire, together with obtaining blood lead level has proven effective in identifying key environmental features associated with elevated blood lead level in children from sampled Thai communities. The challenge now is to conduct a larger epidemiological study of a similar type in order to guide the screening and preventive efforts.

Dextromethorphan abuse in Thai adolescents: A report of two cases and review of literature.

INTRODUCTION: Dextromethorphan is an opiod-derived, easily available cough remedy that, when used in large quantities, can have stimulatory effects which mimic that of amphetamine and other psychedelic drugs. Due to its easy availability, dextromethorphan is gaining widespread popularity as a recreational drug among Thai youths. Symptoms of overdose are directly related to its pharmacodynamic and pharmacokinetic properties. Dextromethorphan is metabolized by cytochrome p450 2D6, an isoenzyme that exhibit polymorphism in Asians. The drug is also a serotonin-reuptake inhibitor and has significant interactions with other drugs that exert their effects through the serotonin pathway such as the amphetamines, cocaine, and Lysergic Acid (LSD). CASE REPORT: We report here two cases of dextromethorphan overdose that presented to the Pediatric Toxicology Service at Siriraj Hospital, Bangkok, Thailand. Both cases presented with hyper-agitation, confusion, with signs of sympathomimetic overdose. Both patients were treated with supportive care and fully recovered within 24 hours without sequalae. CONCLUSION: Although the acute toxicity of dextromethorphan is abated within 24 hours, its pharmacological properties still render it a dangerous drug to use alone or in combination with other drugs.

Treatment of paraquat poisoning with cyclophosphamide / dexamethasone combination: The first two years experience at Siriraj Hospital.

While the mortality rate from paraquat is high, a proven treatment for paraquat poisoning is still lacked. In this article, we describe the outcome of the first two years of implementing a treatment protocol containing cyclophosphamide and dexamethasone for paraquat poisoning at Siriraj Hospital. Treatment group was studied by a retrospective review of cases at Siriraj Hospital with significant paraquat poisoning in 2002-2003. Significant ingestion means ingestion of 1gram total or 20 mg/kg or positive urine dithionite test for paraquat. AII patients with significant ingestion received treatments with a regimen consisting of enteral administration of a single dose of Fuller’s earth solution and a 14-day course of intravenous cyclophosphamide plus intravenous dexamethasone plus intravenously vitamin C. Survival rate was compared with historical controls that included searchable cases with significant paraquat poisonings admitted to Siriraj Hospital who were treated only with Fuller’s earth or Bentonite, vitamins B and C and supportive care. From January 2002 to November 2003, there were 6 cases of significant paraquat poisoning presented to Siriraj Hospital. The survival rate of treatment group is 83.3% as judged by presence without life-threatening signs at 4 weeks after the ingestion. Nine cases of significant paraquat poisoning were identified from Siriraj Hospital’s searchable medical records from 1994-1997 and were enrolled as controls. AII control cases died within 12 days, six from fulminant paraquat poisoning and the remaining from moderate to severe poisoning. The use of immunosuppressive agents known for its ability to treat inflammatory lung disease such as cyclophosphamide and dexamethasone presents a viable alternative to an otherwise serious and untreatable poisoning.

Methamphetamine abuse during pregnancy and its health impact on neonates born at Siriraj Hospital, Bangkok, Thailand.

To ascertain the impact of intrauterine methamphetamine exposure on the overall health of newborn infants at Siriraj Hospital, Bangkok, Thailand, birth records of somatic growth parameters and neonatal withdrawal symptoms of 47 infants born to methamphetamine-abusing women during January 2001 to December 2001 were compared to 49 newborns whose mothers did not use methamphetamines during pregnancy. The data on somatic growth was analyzed using linear regression and multiple linear regression. The association between methamphetamine use and withdrawal symptoms was analyzed using the chi-square. Home visitation and maternal interview records were reviewed in order to assess for child-rearing attitude, and psychosocial parameters. Infants of methamphetamine-abusing mothers were found to have a significantly smaller gestational age-adjusted head circumference (regression coefficient = -1.458, p < 0.001) and birth weight (regression coefficient = -217.9, p < or = 0.001) measurements. Methamphetamine exposure was also associated with symptoms of agitation (5/47), vomiting (11/47) and tachypnea (12/47) when compared to the non-exposed group (p < 0r =0.001). Maternal interviews were conducted in 23 cases and showed that: 96% of the cases had inadequate prenatal care (<5 visits), 48% had at least one parent involved in prostitution, 39% of the mothers were unwilling to take their children home, and government or non-government support were provided in only 30% of the cases. In-utero methamphetamine exposure has been shown to adversely effect somatic growth of newborns and cause a variety of withdrawal-like symptoms. These infants are also psychosocially disadvantaged and are at greater risk for abuse and neglect.

The management of environmental lead exposure in the pediatric population: lessons from Clitty Creek, Thailand.

During the month of September-October 1997, a depression storm caused massive flooding in the area of western Kanchanaburi province, Thailand, causing lead-contaminated water from a nearby lead refinery plant to spill into the surrounding areas of Clitty Creek; exposing the village downstream to large amounts of lead. The Ministry of Public Health, together with the Ministry of Science, the Ministry of Industry, and officials from the Kanchanaburi Office of Public Health, began measures for environmental deleading and assessment of exposure and health risks of the population. METHOD: This was a retrospective cohort study of the effects that environmental remediation and chelation therapy had on the blood lead levels of children residing in Lower Clitty Creek Village during the period between 1997-2001. Sixty-eight children were followed yearly for their blood lead levels and hematocrit, beginning in early 1998. Simultaneously, programs for environmental remediation had begun. The blood lead levels (BLLs) of children were followed over a 3-year period. The BLLs during the 2 year period of environmental remediation alone were compared. Subsequently, when chelation therapy was instituted, levels pre and post chelation therapy, as well as the efficacy of the two different chelation methods were compared using standard 2-tailed t-test. RESULTS: The initial average BLL was 27.75 +/- 5.4 mg/dl (1998). After environmental remediation began, BLL at one year (1999) was 30.64 +/- 4.49 mg/dl (p = 0.072), and at two years (2000) was 30.30 +/- 5.1 mg/dl (p = 0.537). There were 18 children with BLLs > 25 who were elected to receive chelation therapy with CaNa2EDTA (11) and DMSA (7). Post chelation average BLL was 18.73 +/- 7.50 mg/dl. The difference between pre and post chelation BLL was statistically significant (p < 0.001: paired t-test). The differences in average BLLs between pre and post chelation for the EDTA group was 15.37 mg/dl and for the DMSA group it was 8.91 mg/dl. Children treated with EDTA appeared, on average, to have 6.47 mg/dl (p < 0.05: 95% CI (0.821-12.12)) lower BLL than those treated with DMSA. CONCLUSION: The incident at Clitty Creek serves to illustrate the importance of environmental remediation as a priority to treating lead poisoning in children. Only when effective environmental deleading has taken place can medical intervention in the form of chelation therapy begin.

The accuracy of pediatric nursing triage and its effectiveness in reducing the febrile convulsion rate in the waiting room.

Triage has become an integral part of risk management for patients at the Pediatric OPD. After 12 months of its institution, we evaluate the accuracy of nursing triage and its impact on reducing the rate of Febrile Convulsions (FC)occuring in the waiting room at the Pediatric OPD. Methods : We reviewed the medical records of patients seen in the Pediatric Outpatient Department on 7 random days over a 3-month period. The triage status of the patients was noted and compared to their clinical discharge status. Patients were considered to have "true urgent" discharge status if, during their stay in the OPD, they received emergency interventions such as intravenous hydration, oxygen, or if they were admitted for treatment. The results were entered into contingency table. Records of patients who received treatment for febrile convulsion in the treatment room during the 24-month period from January 2000 to December 2001 were also reviewed. Patients were assigned into the pre or post-triage groups according to if they were seen prior or subsequent to the institution of MTS on May 1, 2001. The episode of FC was considered to have occurred at home if it was noted in the chart or if it was noted that patient had already begun convulsing at the time the patient arrived at the hospital. The difference in febrile convulsion rate occuring in the OPD before and after MTS was instituted was analyzed using a 2 tailed t-test. Results : There were 806 triage records reviewed. Nursing triage's sensitivity at predicting immediate medical interventions or admissions was 0.79 and specificity was 0.98, with a positive predictive value of 0.67 and a negative predictive value of 0.99. The rate of febrile convulsion occuring in the OPD after the instituion of MTS was found to be significantly less than that occuring before institution of MTS ( p = < 0.001). Conclusion : The evaluation of our MTS shows that we are able to predict non-urgent triage cases with good accuracy. And the intervention brought on by the triage system helped to decrease the incidence of febrile convulsion seen in the waiting room at the Pediatric OPD.

The effectiveness of pediatric triage training course for emergency room nurses at Siriraj Hospital.

The recognition of an acutely ill child is considered to be of vital importance in an emergency situation. Fast and timely intervention can prevent significant morbidity from occurring. The skill of assessing ill children in order to identify those that need immediate attention is often the task of experienced pediatric nurses. However, when availability of such personnel is limited, simplified triage criteria may be taught to novice nurses in order that they can quickly and efficiently identify those patients needing urgent care. Method: We conducted a pilot triage training project with 30 volunteer, non-pediatric nurses and assessed the effectiveness of the training course through the use of a pre and post-Pediatric Triage Knowledge Test (PTKT), as well as by the accuracy of the participants' triage performance on 439 pediatric patients. Results: The participants, on average, showed significant improvement on the Pediatric Triage Knowledge Assessment Test (p = 0.01; paired t-test), as well as being able to perform accurate triage after training on 88.3% of patients. Moreover, the existence of triage significantly reduced the waiting time of urgent patients by a total of 7 minutes (p = 0.05; t-test), while the waiting time for non-urgent patients was not affected. Conclusion: The pilot triage training project effectively increased non-pediatric nurses' knowledge of pediatric triage and their performance of triage, and is associated with a significant reduction in the waiting time of urgent pedi.