Congenital diaphragmatic hernia in a 2-month old infant: a case report

Congenital diaphragmatic hernia (CDH) in young infants is easily misdiagnosed as bronchopneumonia yet survival of such patients lies in prompt diagnosis and surgical treatment. The report aimed to increase awareness among Paediatricians and Paediatric Surgeons of the need for high index of suspicion for this condition to allow for early diagnosis and management. A two-month old infant presented with a five-week history of cough of sudden onset and a week history of difficulty in breathing. He had been managed in several hospitals for bronchopneumonia. Examination findings showed features of respiratory distress, widespread coarse crepitations and bowel sounds in the lung fields. Chest radiograph showed `loops of bowel in the mediastinum. He had surgical reduction and repair of the hernia, made excellent recovery post-op and was discharged home. CDH is an uncommon anomaly but a high index of suspicion will allow early diagnosis and treatment with favourable outcome when picked early

Environmental factors that determine visual skill development of under-fives in a developing country.

INTRODUCTION: During the early years of life, children get most of their information by relying on their visual observation. Knowledge of visual skill development and environmental risk factors influencing it provides useful guide for early identification of children who may develop some form of visual impairment. AIM: The aim of this study is to describe the visual developmental pattern and determine the environmental risk factors associated with delay in the visual skill area of under-five children. SUBJECTS AND METHODS: This was a cross-sectional study of 415 preschoolers aged 6-59 months. Visual function and visual comprehension were assessed using the Schedule of Growing Skills II tool (GL Assessment Ltd., London). Delay in the visual skill was defined as a developmental quotient in visual skill area below threshold point of 85%. Data were analyzed using descriptive statistics and logistic regression analysis with adjusted odds ratio (AOR) and 95% confidence interval (CI) (95% CI). Alpha value was set at P < 0.05. RESULTS: Mean age of the children studied was 32.6 ± 15.9 months. The prevalence of delay in visual skill area was 17.1%. The odds of delay in visual skill were higher among children of first birth order (AOR 1.83; 95% CI 1.05-3.30), those who lived in large households (AOR 2.34; 95% CI 1.32-3.14), children whose mothers had secondary level education and below (AOR 2.21; 95% CI 1.31-3.83), and those whose fathers earned ≤$100 per month (AOR 1.75; 95% CI 1.01-3.03). CONCLUSION: Identification and management of environmental factors negatively affecting visual skill development will help improve on the visual skill area and invariably child development.

Exercise-induced bronchospasm among school children in Gusau, Nigeria.

BACKGROUND: Childhood asthma was said to be rare in Northern Nigeria three decades ago. However, since then, there has been rapid industrial development with increase in especially textile and quarry factories. Hyperresponsiveness of the bronchi of asthmatic children to various challenge tests differentiate them from non-asthmatic children. One of these, the Exercise-Induced Bronchospasm (EIB) which is a reduction in post exercise Peak Expiratory Flow Rate (PEFR), is widely used to define childhood asthma in epidemiological studies. To determine the current prevalence of asthma in childhood in a Northwestern Nigerian town, pupils aged 5-14 years were enrolled in the study. METHODS: A modified ISAAC questionnaire was administered and the subjects trained to use the peak flow meter. Pre exercise PEFR was obtained thereafter they were subjected to a six minute free running exercise challenge test and the best of three post exercise PEFR taken at intervals was obtained. EIB was taken as 15% reduction or more in post-exercise compared to pre-exercise PEFR. RESULTS: The prevalence of EIB was 6.0% (64/1067 subjects) while 12.7% (136/1067) had a history of wheeze. History of wheeze was found to be a sensitive (96.3%) but nonspecific (22.2%) indicator of childhood asthma. The highest prevalence of EIB was among children aged 10-14 years with male: female ratio 1.9:1. The location of the residence of the pupils did not significantly affect the prevalence of EIB. CONCLUSION: The prevalence of childhood asthma in this region is on the increase compared to earlier studies and there should be a high index of suspicion in children with suggestive symptoms who should then undergo further screening tests.

Lack of association between some risk factors and hepatitis B surface antigenaemia in children with sickle cell anaemia.

The risk factors for transmission of Hepatitis B virus (HBV) as well as the relationship between HBs Antigeneamia and some socio-cultural factors including socio-economic status of the families of the children, tribe, religion, rural or urban domicile and the number of persons per bedroom, were studied among 507 children with sickle cell anaemia (SCA) and 501 controls at the Jos University Teaching Hospital (JUTH). Twenty-three percent (22.7%) of the children with SCA were HBsAg positive compared with 19.6% among the control group. None of the risk factors studied, including blood transfusion, parenteral injections, intravenous infusions, hospitalization, ulcers, traditional uvulectomy, surgery, contact with case of known hepatitis, mass immunizations, circumcision, ear piercing and traditional scarifications was significantly associated with HBV infection in both children with SCA and control group and also between children with SCA compared with controls. There was also no association between HBs Antigenaemia and the number of blood transfusions, intravenous infusion or hospitalization in both children with SCA and controls. Similarly, there was no association between the socio-cultural factors studied and HBs Antigenaemia. The result of this study suggests that HBV infection is common in children in this environment and other factors yet to, be identified may play a very important role in the transmission of HBV infection. The high prevalence of HBsAg obtained in both children with SCA and controls, and the lack of identifiable association between the risk factos studied and HBsAntigenaemia suggest that these children may have equally been exposed earlier in life.

Neonatal jaundice with reference to aflatoxins: an aetiological study in Zaria, northern Nigeria.

Two prospective studies were undertaken to determine a possible relationship between perinatal aflatoxin exposure and neonatal jaundice. First, cord blood samples from 37 neonates who subsequently developed jaundice and from 40 non-jaundiced (control) babies were analysed for six major aflatoxins and aflatoxicol. Peripheral blood samples of both groups were also analysed postnatally for aflatoxins. In a second study, serum aflatoxin levels of 64 jaundiced neonates admitted from outside the hospital were compared with levels in 60 non-jaundiced control babies. Aflatoxins were detected in 14 (37.8%) cord blood samples of jaundiced neonates and in nine (22.5%) of the controls. The mean cord aflatoxin concentration was highest in jaundiced neonates with septicaemia, but the difference was not statistically significant. The frequency of detection of aflatoxins in peripheral blood was not significantly different in jaundiced and non-jaundiced babies. Aflatoxins were detected in the blood of over 50% of neonates with jaundice of 'unknown' aetiology. There was no correlation between severity of hyperbilirubinaemia and serum aflatoxin levels. Further studies are needed to determine the extent of pre- and postnatal exposure to aflatoxin in Nigerian infants and the effects of such exposure on fetal and neonatal health.

Munchausen syndrome by proxy: an experience from Nigeria.

We report here on a child who over a period of 8 years was admitted several times to hospitals in different states of Nigeria based on fictitious illnesses described by his mother. The child had various unnecessary, expensive and invasive investigations followed by treatment with harmful drugs. The evolution of this case of Munchausen syndrome by proxy is described in order to alert paediatricians in developing countries to a problem which is described frequently in more affluent societies. We believe this is the first such case to be recorded in West Africa.

PIP: The case is recounted of a child who was admitted to hospitals several times over a period of 8 years on account of fictitious illnesses invented by his mother. The first occurred when he was 3.5 years old in January 1984. His mother, a nurse, gave a history of intermittent fever for 3 months, loss of appetite and weight. He had been treated with ampicillin, chloramphenicol, and procaine penicillin. No abnormality was detected and his weight at 15.5 kg was appropriate for his age. No fever was recorded throughout 2 weeks in hospital, but he was given chloroquine for possible malaria and then discharged. At follow-up 6 months later, the mother complained of his wheezing. On examination he was normal and had gained 3.8 kg since discharge. The possibility of vernal conjunctivitis plus asthma was entertained and he was then placed on ketotiphen prophylaxis. There was an uneventful follow-up for 6 months. 5 years later in March 1990, his mother related that he had been treated from 22 January 1988 to 21 November 1989 for tuberculosis with streptomycin, isoniazid, rifampicin, and ethambutol. He was also treated with digoxin and Esidrex-K for suspected rheumatic carditis, after which at the University Teaching Hospital, Enugu, he was investigated from 11 April 1989 to 10 August 1989 and found to be normal. One year later in August 1991 she went to one of the authors complaining about polydypsia, polyphagia, and polyuria. Examination had revealed nothing of note. A clinical assessment for diabetes mellitus found the urine specific gravity persistently at 1.010. He was therefore put on carbamazepine (Tegretol) 100 mg t.i.d. After review by a pediatric nephrologist, the child was declared normal. During this visit, the mother and child were interviewed separately. He believed he was ill because his mother said so. A diagnosis of Munchausen syndrome by proxy was made. The mother was referred back to her doctor to arrange for psychiatric care. In Munchausen syndrome, patients fabricate a variety of symptoms and evidence of illness that have no organic basis. Munchausen syndrome by proxy is a form of child abuse, difficult to diagnose, that could result in death. It is more prevalent in affluent countries with sophisticated medical facilities. Its rarity in developing countries may contribute to the difficulty of detection.

Extra-hepatic biliary atresia preoperative and surgical assessment in 25; cases seen in Zaira

Admission in a seven year period of 25 infants with biliary atresia. We note that prelaparatomy percutaneous liver established the diagnosis of extrahepatic biliary atresia; which were confirmed at laparatomy. Fifty percent of the patients had liver cirrhosis before surgery. Therefore; bile drainage was not established in any of the 25 patients following hepatic surgery. Six (24 percent) died of hepatic failure during the period of follow-up. Factors responsible for the poor success rate of surgery included late presentation and grossly non correctible lesions

Prevalence of Mycoplasma pneumoniae in children with pneumonia in Zaria, Nigeria.

The prevalence of Mycoplasma pneumoniae in children suffering from pneumonia was investigated, using complement fixation and growth inhibition tests. From the sera of 104 children with pneumonia, 32 (31%) showed a CF titre greater or equal to 1:64, while all the 52 control children of the same age and sex had a CF titre less than 1:16. Children 6-10 years of age had the highest positive titre (41%) while the age groups 3-5 years and 0-2 years had positive titres of 30 and 28%, respectively. Both sexes were equally affected (33% male, 29% female). Mycoplasma pneumoniae was isolated in two children whose CF antibody titres were 1:16. It is concluded that M. pneumoniae plays an important role as an aetiological agent of pneumonia in children in Zaria, Nigeria, and could be included in the routine diagnostic protocol of pneumonia, especially during the dry harmattan months when cases of lobar pneumonia are prevalent.

Mortality pattern in the Emergency Paediatric Unit of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

Three hundred and seven (307) deaths were recorded out of 3,155 admissions into the Emergency Paediatric Unit of Ahmadu Bello University Teaching Hospital Zaria between January 1st and December 31st 1986, giving a percentage mortality of 9.9 percent. 67 percent of the patients who died were aged between one month and twenty four months, and the overall male: female ratio of deaths was 1:1.04. Measles with complications was the commonest cause of death (24.1 percent) closely followed by protein energy malnutrition (23 percent) and respiratory tract infection (18 percent). Over half of the patients (57.6 percent) died less than 24 hours after admission. As most deaths resulted from preventable conditions, the implications of this finding, and suggestions on how to improve the situation are discussed.

PIP: 307 deaths were recorded out of 3155 admissions to the Emergency Pediatric Unit of Ahamdu Bello University Teaching Hospital, Zaira, Nigeria between January 1st and December 31st, 1986. This was 9.9% of the total admissions. The male-female death ratio was 1:1.04 about the same as the total male-female admissions ratio (1:1.02). The least % mortality is in the 4th quarter of the year; it rises to a peak between July and September. 67% of the patients who died were between 1 and 24 months of age. Measles with complications was the most common cause of death (74 deaths, 24.1%), closely followed by protein energy malnutrition (23%), and respiratory tract infection (18%). Over 1/2 the patients died 24 hours after admission. Most deaths resulted from preventable conditions, such as measles which is preventable by vaccination. A need for programs like the Nigerian government's expanded program on immunization and oral rehydration therapy exists. The Nigerian government has set up a directorate of food, roads, and rural infrastructure to improve the living standard of its rural population. 2 of its aims are to provide abundant food and good drinking water. The government has also started a mass mobilization program.

Chronic diarrhoea in Nigerian children.

PIP: To study the etiology of chronic childhood diarrhea among Nigerian children, 142 patients, aged 6 months to 5 years, with diarrhea for at least 1 month, were evaluated; the study took place during January-December 1983 at the Ahmadu Bello University Teaching Hospital, Zaria, Northern Nigeria. Enteropathogenic agents were identified in stools of 90 (63%) patients. Giardia lamblia and Entamoeba histolytica were most commonly detected, representing 41% and 23%, respectively, of all parasitic pathogens. In children with negative stool microscopy, chronic diarrhea was associated with primary lactose intolerance (2 cases), abdominal tuberculosis (2 cases), hyponatremia, low serum albumin, anemia due to sickle cell disease, or Staphylococcus aureus infection. In contrast with chronic diarrhea etiologies reported among children in Europe and North America, infections were the major cause of chronic childhood diarrhea among these children. In general, it is accepted that intestinal infection usually produces acute diarrhea--and that, if the host fails to mount a competent immune response, if there is repeated exposure to infectious agents, or if severe infection damages a substantial proportion of absorptive cells, then severe, protracted diarrhea may result. The high case fatality rate of 9% in this series was associated with specific infectious complications of septicemia, bronchopneumonia, lobar pneumonia and measles. Severe malnutrition also worsened the prognosis in chronic diarrhea. The results indicate that early detection and treatment of amebiasis and giardiasis is a useful approach in the treatment of chronic diarrhea cases among children.^ieng

Juvenile tropical pancreatitis syndrome in northern Nigeria: a case report.

A six-year-old boy with abdominal pain since the age of two years is described. Physical examination revealed no abnormality but under general anaesthesia a mass could be felt in the left upper abdominal quadrant. An X-ray showed calcification in that quadrant, anterior to the vertebrae and an IVP revealed incomplete duplication of the left ureter. At laparotomy, small multiple calculi were removed from the pancreatic duct and pancreatico-jejunostomy was performed. Following surgery, his crippling abdominal pain ceased dramatically and he has remained symptom-free.

Renal masses in neonates: report of eight cases.

Palpable renal masses presenting in eight newly born babies are described. Three of the masses were primary renal tumours, namely renal dysplasia in two and congenital mesoblastic nephroma in one, while in three neonates the masses were secondary to obstruction, in two in the 'prune belly' anomaly and in one caused by posterior urethral valves. In two of the babies the masses were thought to be renal because of their location and in one following an abnormal intravenous pyelogram. Firm diagnoses were not possible in all our patients because some parents defaulted before investigation was complete. While surgical exploration is often crucial in establishing the diagnosis of an abdominal mass it is possible in certain cases to make a correct diagnosis without surgery.

Secretory IgA in nasal secretions of children with acute gastroenteritis and kwashiorkor.

Secretory immunoglobulin A (IgA) was quantitated using the Mancini technique in the nasal washings of children with acute gastroenteritis and in children with kwashiorkor but without gut symptoms. The total immunoglobulin was expressed as a percentage of total protein in nasal secretion measured by biuret method. The IgA level was slightly lower in the kwashiorkor group than in the control group, and there was no statistical difference between IgA level in the acute gastroenteritis and the control group. An explanation for these observations is offered.

Unusual presentation of Burkitt's tumour in childhood. Case reports.

Five cases of unusual presentation of Burkitt's lymphoma are reported; three of these, had localised scalp tumours or peripheral lymph nodes. Another case presented with paraplegia and rectal bleeding which disappeared on our standard chemotherapy consisting cyclophosphamide, vincristine and methotrexate (COM). The fifth case who developed pleural effusion during chemotherapy initially presented with abdominal tumour. These five cases illustrate the protean presentation of Burkitt's lymphoma.