Organophosphate poisoning in a 12-day-old infant: case report.

A 12-day-old infant girl was admitted with increasing lethargy and respiratory distress. Initial treatment was for pneumonia but deterioration despite appropriate treatment prompted review of her diagnosis and consideration of organophosphate poisoning. There was a brisk response to atropine. To our knowledge, this is the youngest infant reported to have been exposed to poisoning by organophosphates.

Introduction of bubble CPAP in a teaching hospital in Malawi.

BACKGROUND: Continuous positive airway pressure (CPAP) is relatively inexpensive and can be easily taught; it therefore has the potential to be the optimal respiratory support device for neonates in developing countries. OBJECTIVE: The possibility of implementing bubble CPAP in a teaching hospital with a large neonatology unit but very limited resources was investigated. METHODS: A CPAP system was developed consisting of a compressor, oxygen concentrator, water bottle to control the pressure and binasal prongs. Neonates with birthweights between 1 and 2·5 kg with persistent respiratory distress 4 hours after birth were eligible for bubble CPAP. RESULTS: In the 7-week introduction period from 11 March until 27 April 2008, 11 neonates were treated with CPAP. Five of these neonates met the inclusion criteria and six neonates did not meet these criteria. Of the five neonates who received CPAP and met the inclusion criteria, three survived. The six infants who did not meet the inclusion criteria included three preterm infants with apnoea (all died), two with birthweights <1 kg (both died) and a firstborn twin (1.2 kg) who survived. No major complications of CPAP occurred. Bubble CPAP could be used independently by nurses after a short training period. CONCLUSION: Successful long-term implementation of CPAP depends on the availability of sufficient trained nursing staff.

Severe pernicious anaemia in an 8-year-old African girl.

An 8-year-old girl presented with severe muscular weakness, peripheral neuropathy, ataxia, fever and macrocytic anaemia. Clinically, vitamin B(12) (cobalamin) deficiency was considered. Despite the lack of pre-treatment laboratory confirmation of the diagnosis, a therapeutic trial of hydroxocobalamin injections was begun. After several days, a partial clinical response was seen. Within 5 months all symptoms had resolved. After treatment was initiated, laboratory analysis of pre-treatment blood samples confirmed the presence of vitamin B(12) deficiency. Auto-antibodies to intrinsic factor and parietal cells, pathognomonic for pernicious anaemia, were confirmed. Vitamin B(12) deficiency owing to dietary deficiency is not uncommon in children in developing countries. Although nutritional deficiency might have played a role in our patient, this case illustrates that the neurological manifestations of pernicious anaemia can present at a young age in African populations.

MECP2 mutation in a boy with severe neonatal encephalopathy: clinical, neuropathological and molecular findings.

We describe the clinical and neuropathological presentation of a male with an MECP2 mutation whose sister has Rett syndrome (RS). He presented with severe neonatal encephalopathy and died at the age of 13 months. Mutation analysis of the MECP2 gene demonstrated a 488 - 489 del mutation in his and his sister's copies of the gene. Post mortem examination revealed bilateral polymicrogyria in the perisylvian region. This malformation was visibly more severe than previously described in females with RS and another male with an MECP2 mutation. As bilateral polymicrogyria was described in congenital perisylvian syndrome, the presented patient could be regarded as having suffered from a severe form of this syndrome. We conclude that MECP2 screening should be considered in males with severe neonatal encephalopathy and in males and females with a bilateral polymicrogyria syndrome.

Long-stay versus short-stay hospital treatment of children suffering from severe protein-energy malnutrition.

OBJECTIVE: To contrast early discharge versus attempted full nutritional rehabilitation in hospital of children suffering from severe protein-energy malnutrition (PEM). DESIGN: Field experiment, two-way analysis of variance with one between group (short- versus long-stay) and one repeated measures factor (admission, then 12, 18, 24, 30 and 36 months post-admission). Covariates introduced. SETTING: Primary health care, Kingston, Jamaica. SUBJECTS: n = 81; mean age 11 months; 79 contribute longitudinal data; 44 every measurement. INTERVENTIONS: When concurrent illnesses had been treated and normal feeding re-established (weight gain 5 g/kg.day-1), subjects were randomly allocated to short-stay (SS) or long-stay (LS) group. LS retained in hospital for full nutritional rehabilitation mean 40 days). SS discharged immediately (mean 18 days) for standard Health Service care at home for 6 months plus high-energy supplement (3.31 MJ with 20.6 g protein daily) for first 3 months. After discharge LS received 6 months home care, but without supplementation. RESULTS: Significant advantages for LS group on NCHS weight & length for age at discharge, and at 12, 18, 24 and for length also 30 months (P < 0.05 to P < 0.001). Weight advantage peaked at 12 and 18 months, length later at 18 and 24 months. CONCLUSIONS: Contrary to earlier reports, full nutritional rehabilitation can be achieved in hospital for children suffering from PEM. Although in the long-term both groups move towards expected levels in their home community, a significant advantage maintained for approximately 2 years is developmentally advantageous during the critical time after weaning.

The Kingston Project. II. The effects of high energy supplement and metronidazole on malnourished children rehabilitated in the community: anthropometry.

Malnourished children (mean age 1.2 years) referred from public health clinics to a paediatric metabolic ward in Kingston, Jamaica, were enrolled for treatment in a community-based health care project and were randomly allocated to one of two groups. The first group was treated at home with metronidazole and then for 6 months using the standard health care provided from local clinics by community health aides. The second group was given the same drug and home treatment, but in addition received a high energy supplement of 3.31 MJ daily for 3 months. We have previously shown a significant advantage in both weight and height gain for a group given the same supplement in contrast with standard health care controls (Heikens et al., 1989, Eur. J. Clin. Nutr. 43, 145-160), and in this study test the addition of a drug treatment aimed at reducing malabsorbtion due to a possible microbial overgrowth of the small bowel in malnourished children. This paper reports anthropometric findings showing significant benefits from both the drug and nutritional treatments. Greatest gains were by the group given both treatments, but the group given the antibiotic treatment, without energy supplementation, also made better growth recovery than did controls. Only 8% of the children treated with metronidazole failed to respond to community-based intervention and were admitted to hospital, compared with 19% for the other groups (P < 0.05). These findings support targetted high-energy supplementation for the rehabilitation of moderately malnourished children receiving health clinic care, and suggest further that such programs should include antibiotic treatment directed at SBBO.

PIP: In 1985-86 in Jamaica, a community-based health care project randomly allocated 81 3-36 month old malnourished children from the slums of metropolitan Kingston to either a group receiving home health care/clinic-based care and a 5-day course of a broad spectrum antibiotic, metronidazole (20 mg/kg/day), for 6 months or a group receiving these same interventions and a high energy supplement (HES) (790 kcal) containing 20.6 gm protein for 3 months to test the effect of these interventions on anthropometric measures of growth. The researchers also wanted to determine whether metronidazole would overcome malabsorption of nutrients due to small bowel bacterial overgrowth. Children of both groups benefited considerably from the interventions. For example, significant improvements in weight occurred almost immediately followed by improvements in length, resulting in a significant improvement in the body mass index (BMI) (p = .0001). Children receiving both HES and metronidazole made significantly greater gains than those who only received HES (weight, p = .02; length, p = .0002; and BMI, p = .0001). A significantly greater proportion of children did not respond to treatment and had to be hospitalized for infections, especially respiratory infections, in the HES only group than did those in the HES and metronidazole group (19% vs. 8%; p .05). None of the children receiving metronidazole died. Reduced morbidity, absence of case fatalities, and anthropometric improvements support the belief that home visits by community health aides in combination with clinic-based health services providing HES and antibiotic treatment to moderately malnourished children can indeed rehabilitate them.

The Kingston Project. III. The effects of high energy supplement and metronidazole on malnourished children rehabilitated in the community: morbidity and growth.

In the Kingston Project malnourished children referred from public health clinics to a metabolic ward were treated at home using community health aides within the existing health service. We have previously provided anthropometric results showing significantly greater gains in weight and length for groups given a high energy supplement (3.31 MJ daily) for 3 months during treatment, and greatest gains for a group treated with metronidazole at the beginning of supplementation [Heikens et al., Eur. J. Clin. Nutr. 43, 145-160 (1989); 47, 160-173 (1993)]. We now present findings on morbidity and relate these to the separate interventions and to growth velocities. Although referral was solely on nutritional criteria, 65% of the sample were found to have additional illnesses at enrollment. During the study period (6 months) upper respiratory tract infections (URTI) were the commonest illness in all groups; there were significantly more gastroenteric infections in the group given the supplement, but not the antibiotic, treatment; the children who received only the standard health service care were ill more often and for longer periods than children in the other groups. Diarrhoea, fever and dysentery prevalences were all found to relate significantly to weight velocity, and although prevalences differed between treatment groups, the detrimental effect on velocity was similar whichever the group.

PIP: In 1985-86 in Jamaica, a community-based health care project randomly allocated 163 malnourished children (mean age 1.2 years) from the slums of greater Kingston to 1 of 4 groups: group visited at home by community health aides within the existing health service (HC); group receiving HC and a high energy supplement (HES) (790 kcal); group receiving HC and a 5-day course of abroad spectrum antibiotic, metronidazole, for 3 months; or group receiving HC, HES, and metronidazole. The researchers wanted to examine morbidity and to relate morbidity to the various interventions and growth velocity. 65% of all the children at enrollment suffered from an illness in addition to malnutrition, especially upper respiratory tract infections (URTIs). URTIs continued to be the most frequent illness in all groups throughout the 6-month study. Children receiving HES had significantly more gastroenteric infections, but this was not the case for those receiving metronidazole. Children receiving just HC suffered from morbidity more frequently and were ill for longer durations than the children in the other 3 groups (at 0-3 months, 96.2% vs. 74.3-92.9%, p .04; at 4-6 months, 96.2% vs. 74.3-82.1%, p .06; and 4-7 days, 46.2% vs. 2.9-5.7%, p .0001). Significant covariates of weight velocity were fever (p .0001), mucoid diarrhea (p .0001), and dysentery (p .0003). These illnesses had the same effect on weight velocity, even though their prevalences were different between treatment groups. The effect of cold and cough on weight velocity approached significance (p .052 and P .094, respectively). These findings showed that some illnesses greatly slowed weight gain in malnourished children. They also indicated that antibiotic use reduced the risk of gastroenteric infections in malnourished children, these infections having the most detrimental effect on weight gain.

Coagulase-negative staphylococcal bacteremia in severely malnourished Jamaican children.

Immunosuppression increases the susceptibility to infection and changes the inflammatory response in children with severe protein-energy malnutrition. In this 5-year prospective study bacteremia was documented in 16% of 336 severely malnourished children, 2 to 34 months of age, who were hospitalized consecutively in the Tropical Metabolism Research Unit, Kingston, Jamaica. The 53 children had 60 episodes of nosocomial and community-acquired bacteremia with 69 blood isolates. Community-acquired bacteremia accounted for 72% (43 of 60) of bacteremic episodes. Thirty-five percent (24 of 69) of the strains were coagulase-negative staphylococci, 19% (13 of 69) were Staphylococcus aureus and 11% (8 of 69) were Streptococcus Group D. Seventeen episodes of coagulase-negative staphylococcal bacteremia were acquired in the community and 7 were nosocomial. These patients were more likely to have pneumonic consolidation than children with all other bacteremias combined (P < 0.02, Fisher's exact test). The bacteremia-related case fatality rate was 8% (5 of 60). Polymicrobial and Gram-negative septicemia were independent positive predictive factors for mortality when compared with single-agent and Gram-positive sepsis (P < 0.02). This 71% (49 of 69) prevalence of Gram-positive organisms suggests a change in the epidemiology from the predominant Gram-negative etiologies (76%) described in previous reports.

Acute respiratory infections in ambulatory malnourished children: a serological study.

We studied the aetiological agents of acute respiratory infections occurring in an ambulatory population of 83 malnourished Jamaican-born children aged 6 to 32 months using serological methods for diagnosis. In 60% (38/63) of symptomatic children and in 25% (5/20) of those without reported disease the following microorganisms were observed: parainfluenza viruses in 15 children, influenza viruses in 12, adenovirus in 10, respiratory syncitial virus in 7 and Mycoplasma pneumoniae in 7 children. The prevalence of the viral infections apparently increased with the severity of malnutrition.

The Kingston project. I. Growth of malnourished children during rehabilitation in the community, given a high energy supplement.

Moderate and severely malnourished children referred from public health clinics in Kingston, Jamaica, to a metabolic ward were treated at home for 6 months using community health aides and standard health care similar to that offered by the local health service. A randomly selected subgroup of these children received in addition a daily high energy food supplement of 3.31 MJ for the first 3 months of the 6-month intervention period. Both groups received full nutritional and medical surveillance and care. The supplemented gained significantly more in weight than the unsupplemented children, but the advantage was lost once supplementation ceased. They also gained significantly more in length and this gain was maintained at the end of the intervention period. However, this increase in length, without continuing superior weight gain, left the supplemented children significantly more wasted than the unsupplemented, as measured by a body mass index (weight divided by height squared). These findings remained stable after interactions with morbidity measures had been taken into account. It is concluded that (1) high-energy supplementation assists rehabilitation of malnourished children brought to public health service clinics and treated in the community, and (2) supplementation should be continued until there is catch-up growth to within an acceptable distance from expected length for age.

Nosocomial and community-acquired infections in malnourished children.

A total of 206 community-acquired and 73 nosocomial infections in 50 malnourished Jamaican children were studied prospectively. Predominant community-acquired infections in the 50 children, included gastroenteritis (68%), otitis media (60%), rhinopharyngitis (60%), oral candidiasis (46%), skin infections (40%), pneumonia (28%), bacteraemia (24%) and bacteriuria (18%). The most frequent nosocomial infections were rhinopharyngitis (34%), lower respiratory tract infections (24%) and septicaemia (18%). In those infections where an aetiological agent was identified, Giardia lamblia was the commonest enteric pathogen, Staphylococcus epidermidis, the most frequent blood culture isolate and Klebsiella sp. were recovered from the majority of urines. The lack of clinical signs and symptoms and atypical clinical presentation in some infected malnourished children were attributed to impairment of the acute inflammatory response. Diagnosis of infection in these children required a high index of suspicion and a comprehensive screening system. Nasal, throat and axilla swabs taken on admission revealed significant colonization with coliforms and pneumococcus; however, these swabs were not useful as indicators of potentially infective organisms. Four of the 50 children died and two of these deaths were attributed to infection.