Further evidence for the rising incidence of childhood Type 1 diabetes in Kuwait.

AIMS: To provide age-gender standardized incidence rate, temporal trend and seasonal variation of Type 1 diabetes in Kuwaiti children aged < or = 14 years. METHODS: Data were prospectively collected over a period of 6 years (1992-1997) according to the DiaMond Project protocol using the capture-recapture method of ascertainment. RESULTS: Data ascertainment varied between 90% and 96%. The incidence rate of Type 1 diabetes was 20.1 per 100,000 children 0-14 years (95% confidence interval (CI) 18.0-22.1); age-standardized incidence rate 20.9 (95% CI 18.8-23.0). The incidence rate among boys, 21.1 per 100,000 (95% CI 18.1-24.1) was slightly higher than that among girls, 19.0 per 100,000 (95% CI 16.1-21.8). The age-standardized incidence rate was 21.9 (95% CI 18.9-24.8) in boys, and 19.9 (95 CI 17.1-22.8) in girls. Incidence rates increased with age in both sexes (boys chi(2) for linear trend = 13.5, P < 0.001; and for girls chi(2) = 27.8, P < 0.0001). There was a significant trend towards increase in overall incidence during the 6-year period (chi(2) = 6.210, P = 0.013), and in age group 5-9 (chi(2) = 10.8, P = 0.001). Seasonality was demonstrated overall, in boys and girls (P < 0.001). CONCLUSION: The incidence of Type 1 diabetes in Kuwait is high compared with the neighbouring Arab countries, and it appears to be increasing as in many European populations.

Kenny-Caffey syndrome: an Arab variant?

We describe 2 unrelated Bedouin girls who met the criteria for the diagnosis of Kenny-Caffey syndrome. The girls had some unusual features--microcephaly and psychomotor retardation--that distinguish the Kenny-Caffey syndrome profile in Arab children from the classical Kenny-Caffey syndrome phenotype characterized by macrocephaly and normal intelligence. The 2 girls did not harbor the 22q11 microdeletion (the hallmark of the DiGeorge cluster of diseases) that we previously reported in another Bedouin family with the Kenny-Caffey syndrome (Sabry et al. J Med Genet 1998: 35(1): 31-36). This indicates considerable genetic heterogeneity for this syndrome. We also review previously reported 44 Arab/Bedouin patients with the same profile of hypoparathyroidism, short stature, seizures, mental retardation and microcephaly. Our results suggest that these patients represent an Arab variant of Kenny-Caffey syndrome with characteristic microcephaly and psychomotor retardation. We suggest that all patients with Kenny-Caffey syndrome should be investigated for the 22q11 microdeletion. Other possible genetic causes for the Kenny-Caffey syndrome or its Arab variant include chromosome 10p abnormalities.

Factors associated with obesity in Kuwaiti children.

The prevalence of adult obesity in Kuwait is among the highest in the Arab peninsula, and cardiovascular disease, for which obesity is a risk factor, is the leading cause of death. This study reports familial and environmental factors associated with childhood obesity; in addition to adverse effects of obesity on children's serum lipids, lipoproteins, apolipoproteins, insulin, and blood pressure profiles. The authors carried out a pair-matched case-control study including 460 obese (body mass index >90th percentile of the age/sex specific reference value of the National Center for Health Statistics), school children 6 to 13 years old matched by age and gender to 460 normal weight controls. We ascertained obese children in a cross-sectional survey of a representative sample of 2400 school children selected from 20 schools by multistage stratified random sampling. Biochemical variables and blood pressure were adversely affected in obese children. The conditional logistic regression analysis showed that family history of obesity, and diabetes mellitus, respiratory and bone diseases in child were significant associated factors with obesity after adjusting for social and behavioural factors. Physical activity and parental social class were not significant. We recommend early preventive measures with emphasis on families in which one or both parents are overweight.

Opportunistic intestinal protozoal infections in immunocompromised children.

Hundred immunocompromised children and 100 house contact controls were chosen. Patients included: 52 nephrotic syndrome children receiving corticosteroids for more than one month (age 5.28 +/- 2.32 years), 14 protein-calorie malnutrition (PCM) patients (8 cases of marasmus aged 6 +/- 2.27 months and 6 cases of marasmic kwashiorkor aged 1.39 +/- 0.88 years) and 34 lymphomas patients (22 cases of Hodgkin's disease and 12 cases of non-Hodgkin's lymphoma; age 4.5 +/- 3.54 years). Examination of concentrated stool was done using iodine stain of fresh mounts and modified Ziehl-Neelsen (cold acid-fast) to fixed smears. T-cell subsets were counted after staining with mouse monoclonal antibodies against CD4 and CD8 labeled with fluorescein. Both nephrotic syndrome and lymphomas groups showed affection of cellular immunity in the form of significant decrease in T-helper and H/S ratio and significant increase in suppressor T-cell subsets. Giardia lamblia, Entamoeba histolytica, Cryptosporidium parvum and Blastocystis hominis were the most frequent in patients group and were significantly more prevalent among patients than controls. No significant difference in the prevalence of Entamoeba coli and Chylomastix mesnili between the two groups. C. parvum infection were strictly confined to groups with T-cell subsets abnormalities i.e. nephrotic syndrome and lymphomas groups.

Apolipoproteins A-I and B in Kuwaiti children.

To assess the relation of apolipoproteins (Apos) A-I and B (the carrier proteins for high and low density lipoprotein cholesterol, respectively) with the degree of obesity, body fat distribution, serum lipids, glucose and insulin levels, a case-control study was carried out and included 460 Kuwaiti obese children, 6-13 years old, matched by age and sex to 460 normal-weight controls. Obese children were ascertained in a representative cross-sectional study of 2,400 school children. The Apo A-I levels were not different between obese and non-obese boys, while they were significantly lower in obese girls (p < 0.01). The Apo B mean concentrations were significantly higher in obese boys and girls (p < 0.001), while the Apo A-I:B ratio was significantly lower in obese children (p < 0.001). Apo A-I levels were positively correlated with total cholesterol, high- and low-density lipoprotein cholesterol, but were not correlated with very low-density lipoprotein cholesterol, triglycerides, insulin, glucose or insulin:glucose ratio. Apo B levels were negatively correlated with high-density lipoprotein cholesterol and positively correlated with insulin and insulin:glucose ratio (p < 0.01) in obese children. The study documented an adverse Apo profile in obese Kuwaiti children. Since Apo changes are correctable through management of obesity, their identification in childhood offers prospects for prevention of early onset atherogenesis in adulthood.

Anti-schistosomal IgE and its relation to gastrointestinal allergy in breast-fed infants of Schistosoma mansoni infected mothers.

To study the relationship between presence of gastrointestinal allergic manifestations in breast-fed infants and presence of IgE against Schistosoma mansoni antigens, sixty breast-fed infants of S. mansoni infected mothers were selected. Of them, thirty infants were suffering from manifestations of gastrointestinal allergy (patients) and the other thirty were not suffering from such manifestations (controls). Levels of IgE against S. mansoni adult worm antigen (AWA), soluble egg antigen (SEA) and cercarial antigen (CA) were determined, by ELISA, in sera of these infants. There was significant association between presence of allergic manifestations and presence of IgE against AWA (P = 0.018), SEA (P < 0.001) and CA (P = 0.002). Also, concentration of IgE against AWA was significantly higher in patients group than the control group (P = 0.024). IgE against AWA showed significant negative correlation with haemoglobin concentration (P = 0.009) and serum albumin level (P = 021) and significant positive correlation with absolute eosinophilic count (P = 0.005). Also, IgE against CA showed significant negative correlation with haemoglobin concentration (p = 0.047) and serum albumin level (0 = 0.036). It was concluded that gastrointestinal allergy in breast-fed infants of S. mansoni infected mothers may be due to hypersensitivity of Schistosoma mansoni antigens present in mothers' milk. Schistosoma mansoni should be investigated and treated in mothers from endemic localities when their breast-fed infants are suffering from manifestations suggestive of gastrointestinal allergy.

Association of fasting insulin with serum lipids and blood pressure in Kuwaiti children.

To examine the association of hyperinsulinemia with the atherogenic risk profile in children, we studied the relationships of the fasting plasma insulin level with indices of obesity (body mass index [BMI] and sum of triceps and subscapular skinfold thickness [SFT]), body fat distribution (waist to hip ratio [WHR]), serum lipid, lipoprotein, and apolipoprotein levels, and blood pressure in a case-control study of 460 Kuwaiti prepubertal obese children aged 6 to 13 years matched by age and sex to 460 prepubertal non-obese controls. Obese children were ascertained in a representative cross-sectional study of 2,400 school children. Fasting insulin levels were positively correlated (P < .001) with serum triglyceride (TG) and very-low-density lipoprotein (VLDL) cholesterol levels and negatively correlated with high-density lipoprotein (HDL) cholesterol levels. No significant associations were observed between insulin and total cholesterol (TC), cholesterol, low-density lipoprotein (LDL) or apolipoprotein A-I (apo A-I). Stronger associations of insulin levels with lipoprotein fractions were observed in obese versus non-obese controls. Obese children had a higher concentration of apo B and a lower apo A-I:B ratio (P < .001). Insulin and the insulin to glucose ratio increased with age in obese children, whereas there were slight changes in non-obese children. TG and HDL cholesterol levels and systolic blood pressure (SBP) were significantly different across insulin quartiles in boys and girls. We conclude that the fasting plasma insulin level may be used as a marker for the development of obesity-associated metabolic disorders and elevated blood pressure in children.

The utilization of a paediatric emergency room in a general hospital in Kuwait.

A descriptive study was conducted in Al-Amiri Hospital, Kuwait to evaluate the use of the paediatric emergency room (PER) by children under 12 years of age over an 11-week period. Socio-demographic data on the families, reasons for the visits, the pattern of referral and the diagnoses were reviewed and analyzed. A total of 277 children were enrolled in the study, the majority of whom (81%) were generally well, only 4% requiring admission to hospital. The paediatrician in the emergency room considered that 64% of visits were not emergencies. Some form of treatment and one to two routine investigations were needed in 21% and 21.6%, respectively. Stated reasons for seeking medical care were: symptoms of the child (34%), unavailability of primary clinic at night (22%) and perceived better services in hospital (20%). The median of parental satisfaction at the end of the visit was 95%. We conclude that most visits to the PER at Al-Amiri Hospital are inappropriate and that intensive health education is required to improve use of the PER and to increase public awareness of the difference between primary care and paediatric emergency facilities.

High incidence of childhood-onset IDDM in Kuwait. Kuwait Study Group of Diabetes in Childhood.

OBJECTIVE: To determine the incidence of insulin-dependent diabetes mellitus (IDDM) in children aged 0-14 years in Kuwait, as part of the World Health Organization Multinational Collaborative Study (DIAMOND), and to determine if the incidence rates have increased. RESEARCH DESIGN AND METHODS: All cases of IDDM diagnosed before the child's 15th birthday between 1 January 1992 and 31 December 1993 were recorded. Prospective notification of all children with newly diagnosed diabetes who were admitted to hospitals and periodic review of hospital medical records provided the primary source; notification by physicians working in diabetic clinics, in which registry of all new cases is mandatory, provided the secondary source of ascertainment. RESULTS: The degree of ascertainment was 92.2%. The annual incidence of IDDM for children aged 0-14 years over the 2-year period was 15.4/100,000 (95% confidence interval, 12.4-19), with a male:female ratio of 1.2:1. The age-specific annual incidence rates for the age-groups 0-4, 5-9, and 10-14 years were 12.8, 15.1, and 18.3/100,000, respectively, with a male:female ratio of 1.45:1 in the 0- to 4-year-old age-group and an equal sex ratio in the 5- to 9- and 10- to 14-year-old age-groups. No significant difference was detected between incidence rates of IDDM in boys and girls in the three age-groups. There was no significant linear trend toward an increase in IDDM incidence rates as age advanced. Compared with a previous study by Taha et al. (Taha T, Moussa M, Rashed A, Fenech F: Diabetes mellitus in Kuwait: incidence in the first 29 years of life. Diabetologia 25:306-308, 1983), there was a nearly fourfold increase of IDDM in the age-group 0-14 years, mainly in those children < 5 years old, suggesting a rapid increase in a short period of time. CONCLUSIONS: Kuwait has the highest incidence of IDDM in children in the region, and an apparently increasing incidence has been demonstrated over the last decade.

Towards improving care for children with diabetes in Kuwait.

Presents the results of a medical audit of the records of 199 children diagnosed as diabetic and admitted to Al-Amiri Hospital, Kuwait. Uses the measurement of glycosylated haemoglobin (HbA1) to indicate the levels of control achieved. Finds that the degree of glycaemic control compares favourably with studies done in other hospitals, but unfavourably with specialized diabetic clinics. Proposes that glycaemic control could be improved by provision of the services of specialized support staff such as dietitian, educator, psychologist and health visitor.

Morbidity and mortality of bacterial meningitis in Arab children.

Between September 1981 and March 1987, 92 episodes of bacterial meningitis in 90 children were treated in three major hospitals in Kuwait. The diagnosis was bacteriologically confirmed in 80 (87%). Haemophilus influenzae was the most common aetiological organism and accounted for 42 episodes (45.6%) followed by Streptococcus pneumoniae in 21 (22.8%) and Neisseria meningitidis in only three (3.3%). Bacterial meningitis occurred in 53 children (57.6%) below the age of 1 year and in 81 (88%) below 5 years. The overall case fatality rate was 5.4% and ten children (9%) had severe neurological sequelae of their disease. Sequelae were more common following pneumococcal meningitis (28%) than after Haemophilus (7%). All 12 children with unknown pathogen recovered completely.

Erythrocyte protoporphyrin screening for lead poisoning in Bedouin children. A study from Kuwait.

Screening for lead poisoning can be performed by measuring either blood lead (PbB) or a haematological indicator such as erythrocyte protoporphyrin (EP). We have screened 902 infants and children aged from 3 months to 5 years amongst those attending three primary health care centres in AI Jahra governorate of Kuwait. Blood specimens were collected by finger prick on Guthrie filter paper and the dried blood samples were mailed to the Central Laboratory of the Children's Hospital, Buffalo, USA. One hundred and eighty-four (20 per cent) had an elevated EP (greater than 50 micrograms/dl). Of those 11 had values above 159 micrograms/dl; 140 children were further tested for blood lead levels (PbB) haemoglobin, mean cell volumes, and percentage of transferrin saturation; 41 had blood lead levels greater than 25 micrograms/dl which is the current definition of elevated blood lead levels. Two children (2 per cent) were in Class IV, 17 (15 per cent) and 16 (14 per cent) were in Class II and Class III, respectively. There was a significant correlation between EP and PbB (r = 0.686; P = less than 0.001). Of 72 children with elevated EP and normal PbB, 32 were anaemic (Hb less than 11 g/dl) and 20 had iron deficiency. The role of tribal practices using lead contaminated preparations and their contribution to elevated blood lead levels is discussed.

Pattern of protracted diarrhoea among children in Kuwait.

A total of 92 children with protracted diarrhoea were studied over a 3-year period (October 1983 to September 1986). The diagnosis was postgastro-enteritis syndrome in 61 (66.2%), coeliac disease in 17 (18.5%), Giardia lamblia infestation in 5 (5.4%), immune deficiency in 4 (4.4%), congenital chloride diarrhoea in 2 (2.2%), and glucose-galactose malabsorption, Shwachmann syndrome and intestinal lymphangiectasia in one each. Children with the postgastro-enteritis syndrome were young, malnourished and bottle-fed, and suffered a high incidence of antecedent bacterial infections. Six children died, a case fatality ratio of 6.5%.

Congenital chloride diarrhoea in Kuwaiti children.

Congenital chloride diarrhoea was diagnosed in 16 Kuwaiti children over a 7 year period (1980-1986) with an estimated incidence of 7.6 per 100,000 live births. The mean age at diagnosis was 3.2 months (range 1 week to 5 months). There were 9 boys and 7 girls with a mean age of 3 years 10 months (range 10 months to 7 years). All children had a shortened gestational period, abdominal distension and chronic diarrhoea. The serum electrolytes in all patients prior to treatment showed hyponatraemia, hypokalaemia, hypochloraemia and metabolic alkalosis. The diagnosis was confirmed by a stool chloride content that exceeded the sum of faecal sodium and potassium. Fifteen patients survived and showed catch-up growth with adequate replacement therapy and 1 died with renal failure.

Acute gastroenteritis: clinical features according to etiologic agents.

The clinical manifestations in 595 children hospitalized with gastroenteritis during a 15-month time frame were studied. They were divided into eight groups according to etiologic agent: rotavirus (203 patients); Salmonellae (98); Escherichia coli (55); Campylobacter (36); Shigella (22); combined rotavirus and salmonellae (44); combined rotavirus and other bacteria (26); and no pathogen (111). The mean duration of diarrhea was shortest in the rotavirus and "no pathogen" groups (4.8 and 5.6 days, respectively) and longest with pure and mixed salmonella infections (12.3 and 12.9 days, respectively). Associated manifestations were most frequent with salmonellae and least frequent with rotavirus and E. coli infections. Malnutrition also was most common with salmonellae and lowest with rotavirus and E. coli. There were no differences in the frequency of hypernatremia. Hyponatremia was most frequently encountered with salmonella (25% compared to 9% in the rest of the patients). Evidence of septicemia was found in 22 patients, 21 of whom were in the salmonella groups. The four deaths in this series (0.7%) also were in the salmonellae groups. The clinical severity of salmonella infection in developing countries, particularly in young and malnourished children, warrants attention to more intensive management. The selective use of antibiotics may help reduce the mortality and morbidity of gastroenteritis.

Coeliac disease among children in Kuwait: difficulties in diagnosis and management.

Twenty children with coeliac disease were diagnosed over a five year period in an area with 10,000-12,000 births per year. The average annual incidence was 1:3000 births. All children presented with severe symptoms and rickets was not uncommon (25%). Mean age at onset of symptoms was 38 months (range 6-120) and 72 months at the time of diagnosis (range 13-192), with a mean delay of 34 months. No cases were diagnosed during infancy. The difficulties in the differentiation of coeliac disease from the more common causes of chronic diarrhoea, and problems with diagnosis and management are discussed.

High incidence of lead poisoning revealed by erythrocyte protoporphyrin (EPP) screening in Arabian children.

The measurement of erythrocyte protoporphyrin (EPP) has been used in screening infants for undue exposure to lead. The infants were from a high risk area, Al Jahra in Kuwait, and were selected from those attending the emergency department of Al Jahra District Hospital. Dried spots of blood on Guthrie filter paper were mailed to the Central Laboratory of the Children's Hospital in Buffalo, New York. Elevated EPP values (greater than 50 micrograms/dl) were present in 63 (66%) out of 96 tests. Forty-four of the infants with elevated values were investigated further: 16 had blood lead levels above 30 micrograms/dl (1.45 mmol/l) and 12 had evidence of iron deficiency anaemia. Five infants with blood lead levels above 80 micrograms/dl (3.9 mmol/l) needed urgent chelation and in addition an 8-month-old infant with the highest EPP value (478 micrograms/dl) died of acute lead encephalopathy. We conclude that lead poisoning is a serious problem in Al Jahra, Kuwait, and that a comprehensive programme for screening and health education are urgently needed to avoid the irreversible effects of lead toxicity.