Prevalence and Predictors of Incomplete Immunization among Children Residing in the Slums of Kathmandu Valley: A Community Based Door-to-Door Survey.

Background Expanded program on immunization is one of the most cost-effective and widely applied public health interventions in worldwide. It is priority program for government of Nepal. Objective To estimate the incomplete immunization and identify predictors of incomplete immunization among age of 12-60 months children residing in the slum areas of Kathmandu Valley. Method This cross sectional, community based door-to-door survey was carried out in slum areas of Kathmandu Valley in months of January to February, 2017. Among nine squatters; having more than 100 households, five were selected by using stratified random sampling. The total 505 children age of 12-60 months was included for study. The face-to-face interview with selected mothers was performed using the structured questionnaire. Mean and standard deviation was calculated for continuous variables and proportions with 95% confidence interval level for categorical variables. The chi-square analyses were used to evaluate association between selected variables with incomplete immunization. The p-value <0.05 was considered as statistically significant. Result The mean age of children was 34.7±17.8 months. Nearly half of the children (43.6%) were within age of 12-24 months. The mean age of mothers was 27.1±5.3 years and more than three quarters (82.2%) were literate. The incomplete immunization was 13.0%; it was found higher among female (14.7%) than male children (11.4%). The incomplete immunization was highly associated with poor knowledge on immunization schedule of mothers (p=0.001). Conclusion The incomplete immunization was higher than national mean. It was found association with poor knowledge on immunization schedule of mothers. So, the immunization program should be more strengthen in slum areas and need to expand the education program focusing on immunization schedule.

Hemiconvulsion-Hemiplegia-Epilepsy Syndrome in a Girl Presented with Complex Partial Seizures.

The mechanisms underlying the Hemiconvulsion-Hemiplegia-Epilepsy syndrome remains unclear. The current proposed pathogenic mechanism is a neuronal injury induced by venous thrombosis and/or hypoxia. Children develop hemispheric brain atrophy with contralateral hemiplegia, epilepsy, and a variable degree of cognitive deficit. We report a 33 months old female child a case of hemiconvulsion-hemiplegia-epilepsy syndrome with right hemisphere unilateral brain edema and left sided hemiplegia and aphasia who presented with left upper extremities complex partial seizures with generalization to tonic clonic seizures and developed status epilepticus that posed diagnostic and therapeutic challenges. Progressive atrophy of the right cerebral hemisphere was noted after 3 months of follow up. Hemiconvulsion-Hemiplegia-Epilepsy syndrome should be suspected in a child with unilateral cerebral hemisphere brain edema and hemiplegia with cognitive deficit following status epilepticus to provide patients and families with an accurate prognosis regarding the subsequent development of epilepsy.

Stress Induced Gastric Ulcers: Presenting as Massive Rectal Bleeding in a Newborn.

Severe gastrointestinal bleeding in newborn period is a serious but uncommon phenomenon that has a broad differential diagnosis. Primary duodenal ulcers are rare in children but stress induced ulceration in stomach occurs more often in neonatal period due to birth asphyxia, prolonged labour, cesarean deliveries, instrumentations, respiratory distress syndrome and sepsis. These present as acute onset of gastrointestinal bleeding commonly as altered gastric aspirate, hematemesis or malena. We report a case of a neonate with stress induced gastric bleeding following birth asphyxia who presented with massive gastrointestinal bleed manifesting as hematemesis and massive rectal bleeding. Resuscitation with multiple blood transfusion and parenteral use of ranitidine controlled the bleeding. Stress induced gastric ulcers should be suspected in a neonate presenting with massive gastrointestinal bleeding after difficult delivery and birth asphyxia.

Clinical Profile and Electroencephalogram Findings in Children with Seizure Presenting to Dhulikhel Hospital.

Background Seizure disorder is the most common childhood neurologic condition and a major public health concern. Identification of the underlying seizure etiology helps to identify appropriate treatment options and the prognosis for the child. Objective This study was conducted to investigate the clinical profile, causes and electroencephalogram findings in children with seizure presenting to a tertiary center in Kavre district. Method This was a hospital based prospective study carried out in the Department of Pediatrics, Dhulikhel Hospital, Kavre from 1st April 2015 to 31st March 2016. Variables collected were demographics, clinical presentations, laboratory tests, brain imaging studies, electroencephalography, diagnosis and outcome. Result Study included 120 (age 1 month to 16 years) children attending Dhulikhel Hospital. Majority of the patients were male (60.84%). Age at first seizure was less than 5 years in 75.83% of children. Seizure was generalized in 62.50%, focal in 31.67% and unclassified in 5.83%. Common causes of seizure were - Primary generalized epilepsy (26.66%), neurocysticercosis (10%) and hypoxic injury (6.6%) which was diagnosed in the perinatal period. Febrile seizure (26.66%) was the most common cause of seizure in children between 6 months to 5 years of age. Neurological examination, electroencephalography and Computed Tomography were abnormal in 71.66%, 68.92% and 58.14% cases respectively. Seizure was controlled by monotherapy in 69.16% cases and was resistant in 7.50% of the cases. Conclusion Primary generalized epilepsy and febrile seizure were the most common causes of seizures in children attending Dhulikhel Hospital. Electroencephalogram findings help to know the pattern of neuronal activity. Response to monotherapy was good and valproic acid was the most commonly used drug.

Pattern of Cardiac Diseases in Children Attended at Dhulikhel Hospital, Nepal.

Background Congenital Heart Disease and Rheumatic Heart Disease are the most common childhood cardiac disease encountered in developing countries. Objective To study the pattern and the prevalence of cardiac diseases, its age wise distribution and to determine their risk factors for mortality in children presented to Dhulikhel Hospital, Kathmandu University Hospital. Method A study of cardiac diseases in children, since birth to 16 years of age attending the department of pediatrics in Dhulikhel Hospital, Kathmandu University Hospital was done over a period of 30 months (Jan 2014 to June 2016). The pattern of disease was studied. Detailed clinical examination of all cases was done followed by the necessary relevant investigations including electrocardiography, chest x-ray, echocardiography and supportive laboratory investigations. Result In this study period, 218 pediatric cardiac cases were encountered, among which 144 cases (66.05%) were Congenital Heart Disease, 57 cases (26.14%) were Rheumatic Heart Disease, 14 cases (6.42%) were Pericardial Disease and 3 cases (1.37%) were classified as Dilated Cardiomyopathy. Majority of Congenital Heart Disease were of isolated Ventricular Septal Defect (25%) and isolated Atrial Septal Defect (20.13%) followed by Patent Ductus Arteriosus (9.02%), Tetralogy of Fallot (6.94%) and Complex Congenital Heart Disease (6.25%). All of the Rheumatic Heart Disease primarily involved the Mitral Valve; however combined Aortic Valve involvement was seen in 26.31% of cases. All the 14 cases of pericardial disease presented with pericardial effusion and two cases presented with constrictive pericarditis. All the cases of pericardial disease were investigated to be of tubercular in origin. Conclusion Septal defects are the most common Congenital Heart Disease encountered in children. Although the prevalence of Rheumatic Heart Disease is decreasing worldwide, it is still a big burden in our community. Tubercular pericardial effusion is still not uncommon and should be suspected with a child presenting with pericardial effusion. Increased level of cardiac care and corrective surgeries are needed for children with cardiac disease in Dhulikhel Hospital, Kathmandu University Hospital.

Sydenham's Chorea as Presentation of Rheumatic Heart Disease.

Sydenham's chorea is the most common type of acquired chorea in childhood which is a major neurological manifestation of rheumatic fever. We describe a 13 years old girl who presented with weakness and purposeless involuntary movements of upper and lower limbs. The symptoms slightly affected the child's daily activities and had an unstable gait on walking which was aggravated during stress. Grade II ejection systolic murmur was noticed on cardiovascular examination. Echocardiography evaluation showed thickened aortic and mitral valve leaflets with mild to moderate degree of mitral regurgitation. Anti-streptolysin O titer was positive (≥200 IU/ml). CT scan of brain was normal. Subsequently child was diagnosed as Rheumatic heart disease with Sydenham's chorea and kept on regular Benzathine penicillin prophylaxis. Symptoms subsided spontaneously after 3 months without any further complications. Although decreasing, early diagnosis and management of Sydenham's chorea and Rheumatic heart disease are very crucial and should be considered with such presentation.

Bacterial isolates and its antibiotic susceptibility pattern in NICU.

BACKGROUND: Neonatal sepsis is one of the major causes of morbidity and mortality among the newborns in the developing world. OBJECTIVES: To determine the common bacterial isolates causing sepsis in neonatal intensive care unit and its antibiotic susceptibility pattern. METHODS: A one year discriptive prospective study was conducted in neonatal intensive care unit to analyse the results of blood culture and to look into the sensitivity of the commonly used antibiotics. RESULTS: The blood culture yield by conventional method was 44.13% with nosocomial sepsis accounting for 10.79%. 84.08% were culture proven early onset sepsis and 15.95% were late onset sepsis. Klebsiella infection was the commonest organism isolated in early, late and nosocomial sepsis but statistically not significant. Gram positive organisms were 39.36% in which Staphylococcus aureus was the leading microorganism followed by coagulase negative staphylococcus areus. Gram negative organisms were 60.64% amongst them Klebsiella was the most often encountered followed by Pseudomonas. The most common organism Klebsiella was 87.5% and 78.3% resistance to ampicillin and gentamycin respectively. Among gram negative isolates 87.5% and 77.2% were resistance to ampicillin and gentamycin respectively. Among gram positive isolates 58.5% and 31.5% resistance were noted to ampicillin and gentamycin respectively. Resistance to cefotaxim to gram negative and gram positive isolates were 87.34% and 59.35% respectively. CONCLUSION: Klebsiella is most common organism which is almost resistance to first line antibiotics. Resistance to both gram negative and gram positive isolates among firstline antibiotics and even with cefotaxim is emerging and is a major concern in neonatal intensive care unit.

Comparision of clinical and laboratory parameters in culture proven and unproven early onset sepsis in NICU.

BACKGROUND: Early onset sepsis remains a major cause for neonatal morbidity and mortality. OBJECTIVES: The aim of this study was to describe and compare the clinical and laboratory characteristics of neonates in neonatal intensive care unit with culture positive and negative early onset sepsis and verify if there were any differences between the groups. METHODS: A one year comparative prospective study was conducted from January 2011 to January 2012 in neonatal intensive care unit (NICU), Dhulikhel Hospital, Kathmandu University Hospital (KUH). RESULTS: Out of 215 cases of suspected neonatal sepsis, 192 (89.30%) cases of early onset sepsis were admitted in neonatal intensive care unit. Out of which 82 cases (42.7%) had blood culture positive and 110( 57.3%) had culture negative but compatible with features of clinical sepsis. There were no cases of culture proven meningitis and urinary tract infections. The clinical characteristic did not show any statistical differences between the study groups except for seizure which was found to be high in culture positive cases (p= 0.041). The hospital stay in neonatal intensive care unit was significantly longer (p=0.02) in culture positive cases. As for the laboratory test there were no differences found between the two study groups except cases of meningitis was more in culture proven early onset sepsis (p=0.00). The overall mortality in early onset sepsis was 36.95%. The higher mortality of 64.7% was seen in culture positive cases but statistically not significant. CONCLUSION: Clinical manifestation and laboratory test were insufficient to distinguish between neonatal infection with blood culture positive and negative sepsis, hence both culture positive and negative cases should be treated promptly and equally.

Clinical and laboratory profile of children with eosinophilia at Dhulikhel hospital.

BACKGROUND: Eosinophilia in children is commonly caused by or parasitic, allergic and immunologic problems. OBJECTIVES: To study clinical and laboratory profile of patients with eosinophilia and to identify possible causes. METHOD: A prospective and descriptive study was conducted from January 2009- December 2011. All the cases of eosinophilia with symptoms and signs of single or multiple organ were included. The known cause of eosinophilia like allergy, asthma and drugs were excluded. RESULTS: During three years period, 84(2.41%) cases had eosinophilia with single or multiple organ involvement. 14.3%, 39.3% and 46.4% had mild, moderate and severe eosinophilia respectively, with cases of hypereosinophilia comprising 85.7%. Eosinophilia was seen predominantly in Tamang caste with overall age ranging from 1-14 years. Most common symptoms and signs were abdominal pain (67.9%) hepatomegaly (59.5%) respectively. Gastrointestinal system was most commonly involved organ followed by respiratory system. Nineteen percent had polyserositis involving pleural, pericardial effusion and ascites at presentation. Out of 84 patients only nine serum samples were able to be sent for parasitological analysis. Sixteen cases had identifiable and/ or possible causes. Serum sample for parasitological analysis revealed fascilosis, filariasis, strongylosis, stercoralis and toxocariasis. CONCLUSION: Eosinophilia is more common among Tamang population in our study. Most common symptoms and signs are abdominal pain and hepatomegaly respectively. Parasitic infection seems to be the most common cause however further study has to be done to reach final conclusion.

Sonographic measurement of fetal pinna length in normal pregnancies.

BACKGROUND: Many studies have emphasized on fetal pinna measurements and morphologic features to use this structure as an additional marker for fetal chromosomal anomaly. OBJECTIVES: To assess relationship between fetal pinna length and gestation age and develop a nomogram. To assess relationship between fetal pinna length and head circumference and biparietal diameter. METHODS: Fetal pinna measurements from the tip of helix to the end of lobe were obtained prospectively in 850 singleton pregnant women between 15 and 40 weeks gestation Normal case was defined as normal sonographic findings during examination and normal infant examination at birth or both. Final study population was 787. The relationship between gestational age in weeks to pinna length in millimeters was analyzed by simple linear regression. Correlation of fetal ear length measurements with gestational age, biparietal diameter and head circumference were also obtained. RESULTS: Linear relationships were found between fetal pinna length and gestational age [Pinna Length (mm)=1.044xGestational age (weeks) -3.857]. A nomogram of normal pinna length was obtained. High correlation was found between pinna length and gestational age (r=0.942; p less than 0.001), pinna length and head circumference (r=0.931; p less than 0.001). Significant correlation was found between pinna length and biparietal diameter (r=0.934; p=0.004) CONCLUSIONS: The results of this study provide a nomogram for fetal pinna. The study also provides relationship and good correlation between pinna length and other biometric measurements.