Electrocardiographic features in children with severe falciparum malaria at the University College Hospital, Ibadan.

Introduction: The high burden of Malaria morbidity and mortality in children is due to its potential to cause multi-organ dysfunction. There is however limited information on the specific electrocardiographic features in falciparum malaria in paediatric age group. Aim: To investigate the electrocardiographic (ECG) features in children with (complicated) severe falciparum malaria (SM) and acute uncomplicated malaria (AUM) at the University College Hospital, Ibadan. Methods: This was a comparative cross-sectional study conducted among 398 children with symptomatic and confirmed Plasmodium falciparum malaria and apparently healthy controls. The frequencies of ECG features were described and compared among these children. Results: The prevalence of ECG abnormality was 79.7% and 63.2% in Severe Malaria SM and Acute uncomplicated malaria AUM patients, respectively. Sinus tachycardia was significantly more frequent in SM than AUM and control groups (p <0.001). The risk of an ECG abnormality was about three times higher in SM than healthy children (p<0.001; OR=2.89;95%CI[1.68,4.99). Conclusion: Severe malaria patients had significant ECG abnormalities (Sinus Tachycardia).

Introduction: Le fardeau élevé de la morbidité et de la mortalité du paludisme chez les enfants est dû à son potentiel de provoquer un dysfonctionnement de plusieurs organes. Il existe cependant des informations limitées sur les caractéristiques électro cardiographiques spécifiques du paludisme à falciparum dans le groupe d'âge pédiatrique. Objectif de l'étude: Étudier les caractéristiques électro cardiographiques (ECG) chez les enfants atteints de paludisme à falciparum sévère (compliqué) et de paludisme aigu non compliqué (AUM) dans l'hôpital du collège universitaire d'Ibadan. Méthode de l'étude: Il s'agissait d'une étude transversale comparative menée auprès de 398 enfants atteints de paludisme à plasmodium falciparum symptomatique et confirmé et de témoins apparemment sains. Les fréquences des caractéristiques ECG ont été décrites et comparées chez ces enfants. Résultat de l'étude: La prévalence des anomalies de l'ECG était de 79,7 % et 63,2 % chez les patients atteints de paludisme grave SM et de paludisme aigu non compliqué AUM, respectivement. La tachycardie sinusale était significativement plus fréquente dans les groupes SM que dans les groupes AUM et témoin (p <0,001). Le risque d'anomalie de l'ECG était environ trois fois plus élevé chez les SM que chez les enfants sains (p<0,001; OR=2,89; IC95 %[1,68, 4,99]). Conclusion: les patients atteints de paludisme grave présentaient des anomalies significatives de l'ECG (tachycardie sinusale).

The Paediatric Long Case Examination in the West African College of Physicians - Past, Present and Future.

The Faculty of Paediatrics of the West African College of Physicians has been using the long case as a major clinical examination for Membership candidates since the early 1980s. Many training institutions also retain the long case examination. Over the years, the Faculty made far-reaching changes in this method of examination geared towards the improvement of its performance indices of reliability, validity and fairness. The current paper traces the modifications that have taken place so far including the use of a structured, weighted grading format. It also discusses the need for further modifications including observation of the candidate during the "clerking" period and the practicality of video recording. Use of formats like that of the West African College is recommended for institutions still using the long case. Each institution should weigh the practicability of specific suggested modifications in the light of its circumstances.

La Faculté de pédiatrie du Collège ouest-africain des médecins utilise le cas long comme examen clinique majeur pour les candidats à l'adhésion depuis le début des années 1980. De nombreux établissements de formation conservent également le long examen des cas. Au fil des ans, la Faculté a apporté des changements profonds à cette méthode d'examen visant à améliorer ses indices de performance de fiabilité, de validité et d'équité. Le document actuel retrace les modifications qui ont eu lieu jusqu'à présent, y compris l'utilisation d'un format de notation structuré et pondéré. Il discute également de la nécessité d'apporter d'autres modifications, y compris l'observation du candidat pendant la période de "clerking" et l'aspect pratique de l'enregistrement vidéo. L'utilisation de formats comme celui du West African College est recommandée pour les institutions utilisant encore le cas long. Chaque institution devrait évaluer la faisabilité des modifications spécifiques suggérées à la lumière de ses circonstances.

Accuracy of nelson and best guess formulae in estimation of weights in nigerian children population.

BACKGROUND: An alternative method of estimating children's weights, when direct weighing is impracticable is the use of age-based formulae but these formulae have not been validated in Nigeria. This study compares estimated weights from two commonly used formulae against actual weights of healthy children. METHODS: Children aged 1 month to 11 years (n= 2754) were randomly selected in Ibadan, Nigeria using a two-stage sampling procedure. Weight of each child, measured using a standard calibrated scale and determined using Nelson and Best Guess formulae, were compared. Demographic characteristics were also obtained. Mean percentage error (MPE) was calculated and stratified by gender and age. Bland-Altman graphs were used for visual assessment of the agreement between estimated and measured weights. Clinically acceptable MPE was defined as ±5%. Descriptive statistics and paired t test were used to examine the data. Statistical level of significance was set at p = 0.05. RESULTS: There were 1349 males and 1405 females. Nelson and Best Guess formulae overestimated weight by 10.11% (95% CI: -20.44, 40.65) in infants. For 1-5 years group, Nelson formula marginally underestimated weight by -0.59% (95% CI: -5.16, 3.96) while it overestimated weight by 9.87% (95% CI: 24.89, 44.63) in 6-11 years. Best Guess formulae consistently overestimated weight in all age groups with the MPE ranging from 10.11 to 30.67%. CONCLUSION: Nelson and Best Guess formulae are inaccurate for weight estimations in infants and children aged 6-11 years. Development of new formulae or modifications should be considered for use in the Nigerian children population.

Prevalence of dermatological lesions in hospitalized children at the University College Hospital, Ibadan, Nigeria.

OBJECTIVE: Skin disorders constitute a significant proportion of consultations in children's clinics; however, there is a paucity of data on the prevalence of dermatological lesions in hospitalized children in Nigeria. This study determines the prevalence of dermatological lesions in hospitalized children. MATERIALS AND METHODS: In this cross-sectional study, 402 children aged three months to twelve years admitted in the Pediatric wards of the University College Hospital, Ibadan, were enrolled over a six-month period. Examination of the skin and its appendages was done for each patient. Data on the socioeconomic status, hygiene, and health-related factors were also obtained using a structured questionnaire. RESULTS: Over 96% of the children had at least one identifiable skin lesion. The five leading skin lesions were post-inflammatory hyperpigmentation (49.5%), BCG scar (28.4%), Mongolian spots (27.1%), junctional melanocytic nevi (20.1%), and cafι-au-lait macules (18.4%). The leading infectious skin disease was pyoderma (13.4%), followed by tinea capitis (6.7%). Scarification marks (P=0.001), tinea capitis (P=0.014), plantar fissuring (P=0.001), and impetigo (P=0.016) were associated with low socioeconomic classes, while the presence of BCG scar (50.0%) was associated with the high socioeconomic class. CONCLUSIONS: This study shows that dermatologic lesions are common in hospitalized children. Identifying them will provide an opportunity for pediatricians to educate parents on the various causes as well as prevention of lesions.

Knowledge and Views of Paediatricians about Pulse Oximetry: a Nationwide Online Survey in Nigeria

Pulse oximetry is a non-invasive method of measuring oxygen saturation in clinical settings. This study was carried out to determine the level of knowledge and competencies relating to pulse oximetry and the ability to interpret the information.We conducted a nationwide, multi-centre, and questionnaire-based online survey between January and June 2010. A 32-item questionnaire relating to the use of pulse oximetry in children was answered by 224 in-training and 157 qualified paediatricians (median duration of practice 6 years) working in 24 states in Nigeria. Knowledge of pulse oximetry was evaluated on a scale of 0­100%. Data were analysed using Chisquare and t-test statistics at 5% level of significance.The overall mean test score was 36.6±20.8% (range0­76.5%). The mean knowledge score among intraining and qualified paediatricians was 35.4±19.1%and38.3±23.1%,respectively(p>0.05). Only 16.3% of the respondents answered all three questions correctly relating to the relationship between oxygen saturationand partial pressure of oxygen. Pertaining to the accuracy of pulse oximeters, 3.9% of the respondents answered all 14 questions correctly. On indications for use of pulse oximetry, 29% correctly answered all nine questions. Only 18% of respondents correctly answered the seven questions on interpretation of pulse oximeter reading. Some 73% of respondents believed that training in the use of pulse oximetry was inadequate.A significant proportion of the paediatricians were untrained in pulse oximetry, lacked knowledge of basic principles, and made serious errors in interpretation of readings from pulse oximeters. We suggest that medical schools and residency training programmes place more emphasis on teaching the principles and uses of pulse oximetry

Childhood bacterial meningitis in Ibadan, Nigeria--antibiotic sensitivity pattern of pathogens, prognostic indices and outcome.

Bacterial meningitis remains a major cause of morbidity, mortality and neurodisability in childhood, particularly in the developing world where effective vaccines against the usual pathogens responsible for the disease are not in routine use. To describe the patterns and outcome of bacterial meningitis among children admitted into the University College Hospital (UCH), Ibadan, Nigeria. All children who satisfied the case definition for meningitis, admitted into the paediatric wards of the University College Hospital, UCH, Ibadan over a period of 30 months were prospectively enrolled and blood and CSF samples were taken for bacteriological analyses. A total of 97 children, 62 males and 35 females were studied. Their ages ranged between 2 months and 12 years, mean age 33.0 (SD=41.7) months, with 80.4% of the cases below the age of 5 years. Haemophilus influenzae type b (Hib) was the leading pathogen, found in 16 (55.1%) of the 29 cases of definite meningitis. Other isolates include Streptococcus pneumoniae (24.1%), Klebsiella spp (7.0%), Staphylococcus aureus (7.0%), Escherichia coli (3.4%) and Pseudomonas spp. (3.4%). Hib and pneumococcus showed varying degrees of resistance to chloramphenicol, penicillin and cotrimoxazole. Twenty six (26.8%) of the cases died and 67.6% of the survivors developed significant neurological sequele. Bacterial meningitis remains a major cause of childhood mortality and neurodisability. Hib and pneumococcus remain the major pathogens responsible for this dreadful disease in Ibadan, Nigeria. The increasing emergence of antibiotic resistance calls for institution of adequate control measures, particularly routine childhood immunisation against the disease.

Pattern of chronic diarrhoea in children: a prospective analysis of causes, clinical features and outcome.

OBJECTIVES: To determine the pattern of chronic diarrhoea in children in Oman. STUDY DESIGN: This is a prospective study carried out over a 7 year period at the Sultan Qaboos University Hospital, Muscat, Oman. SUBJECTS: Sixty two children (37 M:25 F), aged 3 months to 13 years who presented with chronic diarrhoea, defined as diarrhoea persisting for more than 4 weeks, were studied. RESULTS: Principal identifiable causes in the study population include post-gastroenteritis syndrome in 50% of cases, enteric infections and infestations in 27%, and coeliac disease in 13%. On presentation 63% were malnourished, 27% were anaemic while 39% were dehydrated. The median duration of hospital admission was 50 days. Majority of the patients responded to conservative therapy with correction of dehydration, and careful nutritional supplementation, in addition to specific therapy where necessary. Mortality was low (1.5%) resulting from immunodeficiency and gram-negative septicaemia. CONCLUSION: Chronic diarrhoea remains an important cause of morbidity especially malnutrition in children and early and adequate nutritional rehabilitation plays a pivotal role in the management.

Choledochal cysts in African infants: a report of 3 cases and a review of the literature.

Choledochal cysts are relatively rare and are an uncommon cause of cholestasis. Early diagnosis and prompt treatment can prevent complications such as cholangitis, cirrhosis and portal hypertension. This article reviews a rarely reported disease in Africans in whom only 3 cases were documented over the 18 year period in Nigeria. The 3 cases were all females with ages between less than a month and 13 months at presentation. All presented with abdominal swelling with or without jaundice or acholic stools. The use of real-time ultrasonography antenatally and postnatally aided the diagnosis in our patients. Two of the patients presented and were operated and both made full recovery confirming the importance of early surgical intervention. The third patient died, and exemplified the consequences of delayed diagnosis and treatment which occur not uncommonly in developing countries mostly because of sparse and or expensive tertiary health care facilities.

Pattern of chronic liver disease in Omani children--a clinicopathological review.

OBJECTIVE: To determine the pattern of chronic liver disease in Omani children. STUDY DESIGN: Seventy six children [43M : 33F] aged 4 days to 10 years, referred to the Paediatric Gastroenterology clinic of the Sultan Qaboos University Hospital, Muscat, Oman, between 1995--2000 for evaluation of liver disease were studied. Liver biopsies were performed in all and tissues obtained processed and examined for histological lesions. RESULT: The main histological diagnoses were neonatal hepatitis (22) biliary atresia (9) biliary hypoplasia (7), cirrhosis (7) and congenital hepatic fibrosis (5). Hepatomegaly with or without jaundice was the indication for liver biopsy in the majority of patients studied. CONCLUSION: The study has provided background information on the occurrence of specific liver diseases in Omani children. Neonatal hepatitis syndrome was the most common diagnosis before the age of 2 years.

Malnutrition in children with congenital heart defects.

OBJECTIVE: To assess the frequency of malnutrition in children with congenital heart defects in a hospital outpatient setting. METHODS: One hundred and fifty-two children with congenital heart defects (patients), and an equal number of children with innocent cardiac murmurs (controls) attending the Pediatric Cardiology Outpatient Clinic at Sultan Qaboos University Hospital, Muscat, Oman from 1997 to 1998 were prospectively studied. Weight, height and head circumference were used for evaluation of nutritional status. Patients and controls were categorized into acute malnutrition (weight <3rd percentile for age, and height >3rd centile), and chronic malnutrition (weight and height <3rd centile), based on the National Centre for Health Statistics standards. Children with symptomatic congenital heart defects (Group I, number = 73) were also compared with those without symptoms (Group II, number = 79). RESULTS: The study patients showed a higher frequency of both acute (27%) and chronic (24%) malnutrition (p<0.01). Children in Group I had a significant reduction in weight (p<0.01), height (p=0.02) and head circumference (p<0.01) compared to controls, however for those in Group II the differences were not significant. Acute malnutrition was higher in both groups, 31% (p<0.01) and 16% (p=0.04), whilst chronic malnutrition was significantly higher only in Group I, 31% (p<0.01). Infants in Group I were more frequently affected (33/45) compared to older children (13/28; p=0.02). CONCLUSION: Malnutrition remains a problem among children with congenital heart defects, especially in those with either heart failure or cyanosis, and symptomatic infants are the worst affected. Greater attention is required in the dietary management, early diagnosis and intervention to restore normal growth.

Visceral leishmaniasis in Omani children: a review.

A retrospective study was undertaken of 33 children with visceral leishmaniasis admitted to Sultan Qaboos University Hospital (SQUH), Oman between 1993 and 1999. The aim was to study the epidemiological and clinical characteristics of visceral leishmaniasis in children in Oman. All presented with fever, anaemia and splenomegaly. Hepatomegaly and lymphadenopathy were present in 88% and 39% of children, respectively. All had iron deficiency anaemia. Hypertriglyceridaemia is a new observation. Diagnosis in all cases was confirmed by histological demonstration of Leishmania amastigotes in bone marrrow (32 subjects) or splenic aspirate (one subject). All children were treated with sodium stibogluconate, 14 needed blood transfusion or blood products and all but two responded well. There were two deaths from associated complications (6% mortality).

Endocarditis with a large thrombus complicating a central venous access device.

A 12-month-old child on total parenteral nutrition via a central venous access device developed an infected thrombus and endocarditis. The vegetation disappeared on conservative management. The device was left in place.

Improved prognosis of heart failure due to idiopathic dilated cardiomyopathy in children.

We analyzed the outcome of 18 children with idiopathic dilated cardiomyopathy (IDC). There was a striking female preponderance (M:F = 1:3.5) and 15 (83%) presented below the age of 2 years. Follow up for a mean duration of 3.5 years revealed complete recovery in seven (43%) and an additional three (19%) became asymptomatic. Three (19%) died and another three (19%) continued to be symptomatic but in controlled heart failure. Two were lost to follow up. Among those who improved, the majority (75%) did so in 1.5 years. Three of five patients who received periodic dobutamine infusion showed improvement in quality of life. The survivals of 94% at 1 year and 87% at 3 years are significantly better than those previously reported. This is the first such study of IDC in children from the Arab peninsula.

Defaecation pattern and intestinal transit in Nigerian children.

The defaecation pattern and intestinal transit time of 410 apparently healthy children aged between 6 months and 5 years were studied by questionnaire and carmine red marker. The majority of the children ate a predominantly high residue diet. Stool frequency varied from once every other day to 5 times a day, with 95% of the children opening their bowels one to three times a day. There was a gradual decline in mean stool frequency with increasing age. The stool produced was usually soft and between 50 and 75 ml in size. Mean mouth to anus transit time in 98 randomly selected children from the study group was 18.3 hours. The information obtained from this study should facilitate early identification of diarrhoea and constipation in the Nigerian pre-school child.

The echocardiographic findings in kwashiorkor.

Echocardiography (ECHO), electrocardiography (ECG), and chest radiography (CXR) were performed in 44 children with kwashiorkor, and 44 age- and sex-matched controls. In patients with kwashiorkor, mean values obtained for end diastolic dimension (29.2 +/- 3.8 mm), end systolic dimension (20.9 +/- 2.8 mm), posterior ventricular wall thickness (5.42 +/- 0.57 mm), and shortening fraction (28.2 +/- 4.3%) were significantly smaller than the corresponding values obtained in the controls -38.0 +/- 5.8 mm (P < 0.001), 27.6 +/- 4.5 mm (P < 0.001), 7.07 +/- 0.71 mm (P < 0.001) and 31.4 +/- 4.5% (P < 0.05), respectively. Similarly, mean cardiothoracic ratio (48.6 +/- 3.4%) and QRS amplitude (13.20 +/- 4.85 mm) were significantly (P < 0.001) smaller in subjects than controls, corresponding values being 54 +/- 3.2 per cent and 20.18 +/- 5.12 mm, respectively. In the subjects, there was very good correlation between posterior ventricular wall thickness and cardiothoracic ratio (r = 0.93; P < 0.001) and also between the estimated left ventricular mass and S1 + R6 amplitude (r = 0.89; P < 0.001).

Prognostic factors in severely malnourished hospitalized Nigerian children. Anthropometric and biochemical factors.

To determine the clinical factors that are of prognostic importance in protein-energy malnutrition (PEM), 150 patients admitted into the paediatric wards at the University College Hospital, Ibadan, Nigeria, were studied. Detailed clinical history, anthropometry and biochemical investigations were done immediately on admission. Case fatality rate decreased with age: 75% and 33% in those aged 12 months and below, and 30 to 36 months, respectively. The mortality in marasmus, kwashiorkor and marasmic-kwashiorkor were 35%, 47% and 60%, respectively. Hepatomegaly on admission had no significant impact on prognosis, but mortality increased with increasing hepatomegaly. Growth failure on admission, as measured by weight-for-age, weight-for-height and mid-upper-arm circumference were significantly associated with poor prognosis (p < 0.01, p < 0.01 and p < 0.001, respectively). Hypokalaemia and hyponatraemia were each separately associated with poor prognosis. When both electrolytes were low, more patients died (81%) than when both were normal (24%) (p < 0.001). Similarly, hypoproteinaemia and hypoalbuminaemia were associated with poor prognosis singly and in combination. When both serum proteins and albumin were low, the mortality was 32%, and there were no deaths when both were normal. The outcome in severe PEM is still poor. Good clinical precision in identifying clinical and biochemical prognostic factors, early intervention and good subsequent management are important in reducing mortality in PEM.

The electrocardiographic changes in kwashiorkor.

An electrocardiogram (ECG), serum electrolytes, serum albumin, haematocrit and cardiothoracic ratio were recorded in 90 Nigerian children with kwashiorkor and 90 age- and sex-matched controls. The ECG abnormalities observed among the study group included sinus tachycardia (91%), low QRS amplitude (100%) and prolonged QTc intervals (17%). Other ECG abnormalities noted were short QTc intervals (three children), prolonged PR intervals (four children) and right axis deviation (two children). The mean serum sodium, potassium, calcium, albumin, haematocrit and cardiothoracic ratio were significantly lower in children with kwashiorkor than in the controls (p < 0.001). The correlation between the QRS amplitude and serum potassium and calcium was poor (p > 0.05). Also, there was poor correlation between heart rate and haematocrit (p > 0.05) and between QTc intervals and serum calcium and potassium (p > 0.05). However, the correlation between the QRS amplitude and cardiothoracic ratio was good (r = 0.91, p < 0.001). These findings suggest that the ECG changes in kwashiorkor are due to myocardial atrophy.

Body temperature in apparently healthy African children under 10 years of age.

Body temperature was determined weekly for a period of 3 weeks in 346 healthy children aged 5 months to 10 years. Individual axillary temperatures in the 346 children ranged from 35.05 degrees C to 37.28 degrees C and fell into normal distribution curve. This study has thus determined normal body temperatures in Nigerian children and will serve as reference data for future comparison.