Chickenpox complications, incidence and financial burden in previously healthy children and those with an underlying disease in Ankara in the pre-vaccination period

The aim of this study was to determine the complications, financial burden and mortality caused by chickenpox using the data of Ankara, Turkey in the pre-vaccination period. The study was conducted as a retrospective sectional study. Of the 65 patients admitted to our hospital, 34 (52.3%) had been previously healthy, 10 (15.4%) had previous chronic disease and 21 (32.3%) were immunocompromised. The most common complications of chickenpox in those patient groups were skin and soft tissue infections (41.2%), hematological complications (50%) and gastrointestinal complications (38.1%), respectively. We found 10.6/100,000 and 8.7/100,000 rates of hospitalization due to chickenpox in Ankara for all children and for previously healthy children, respectively. The chickenpox-related mortality rate for the 0-17 age group was 3.03/1,000,000 in Ankara. In conclusion, we feel that a national vaccination program for chickenpox will lead to a significant decrease in the overall cost to our country.     

Severe complications of chickenpox in hospitalised children in the UK and Ireland.

AIMS: To estimate the annual incidence of hospitalisations due to severe complications of varicella, describe the complications and estimate annual mortality. METHODS: Active surveillance throughout the UK and Ireland for 13 months by paediatricians notifying cases to the British Paediatric Surveillance Unit and completing a questionnaire. The case definition was any child aged <16 years hospitalised with complicated varicella, as defined by a list of conditions, or admitted to ICU/HDU with varicella. RESULTS: 188 cases were notified for the surveillance period, of which 112 (0.82/100 000 children/year) met the case definition and were not duplicates. Confirmed cases had a median age of 3 years (range 0-14). The complications were: bacteraemia/septic shock (n = 30), pneumonia (n = 30), encephalitis (n = 26), ataxia (n = 25), toxic shock syndrome/toxin-mediated disease (n = 14), necrotising fasciitis (n = 7), purpura fulminans/disseminated coagulopathy (n = 5), fulminant varicella (n = 5) and neonatal varicella (n = 3). 52 children (46%) had additional bacterial infections. Six deaths were due, or possibly due, to varicella, including one intrauterine death. Four of the other five children who died (ages 2-14 years) had a pre-existing medical condition. Sequelae on discharge were reported for 41 cases (40%), most frequently ataxia or skin scarring. The median length of hospital stay was 7 days (range 1-68). CONCLUSIONS: This study provides a minimum estimate of severe complications and death resulting from varicella in children in the UK and Ireland. Most complications, excluding deaths, occur in otherwise healthy children and thus would be preventable only through a universal childhood immunisation programme.     

Transient and chronic neutropenias detected in children with different viral and bacterial infections

Aim: The aim of the study was to identify the relationship of acquired neutropenias with infections in childhood and to assess their course, complications, short and long-term outcome. Method: During a two-year period, all children admitted to the pediatric ward with neutropenia were investigated for underlying infections with indices of infection, cultures of body fluids and serological tests. Results: Sixty-seven previously healthy children, aged (median, 25-75%) 0.7 years (0.2-1.5), were identified with neutropenia (frequency: 2.0%). An infectious agent was identified in 34/67 cases (50.7%) (viral infection: n=24, bacterial: n=10). In 50/67 (74.6%) children, neutropenia recovered within 2 months (transient neutropenia, TN), while in 17/67 (25.4%) of them it persisted for more than two months. Two years after diagnosis 50/67 children (74.6%) accepted to be reassessed. Of these children, 8/50 (16%) remained neutropenic (neutropenic children, NC), while 42/50 had recovered completely. Conclusion: Neutropenia during childhood is usually transient, often following viral and common bacterial infections, does not present serious complications and in the majority, it resolves spontaneously. However, in a significant percentage of patients, neutropenia is discovered during the course of an infection, on a ground of a preceding chronic neutropenic status.     

Serious neurological disorders in children with chronic headache.

AIMS: To determine the prevalence of serious neurological disorders among children with chronic headache. METHODS: All children presenting to a specialist headache clinic over seven years with headache as their main complaint were assessed by clinical history, physical and neurological examination, neuroimaging where indicated, and by follow up using prospective headache diaries. RESULTS: A total of 815 children and adolescents (1.25-18.75 years of age, mean 10.8 years (SD 2.9); 432 male) were assessed. Mean duration of headache was 21.2 months (SD 21.2). Neuroimaging (brain CT or MRI) was carried out on 142 (17.5%) children. The vast majority of patients had idiopathic headache (migraine, tension, or unclassified headaches). Fifty one children (6.3%) had other chronic neurological disorders that were unrelated to the headache. The headache in three children (0.37%, 95% CI 0.08% to 1.1%) was related to active intracranial pathology which was predictable on clinical findings in two children but was unexpected until a later stage in one child (0.12%, 95% CI 0.006% to 0.68%). CONCLUSIONS: Chronic headache in childhood is rarely due to serious intracranial pathology. Careful history and thorough clinical examination will identify most patients with serious underlying brain abnormalities. Change in headache symptomatology or personality change should lower the threshold for imaging.     

Risk factors for adverse outcomes of bacterial meningitis

Objective : To identify risk factors for adverse outcomes from bacterial meningitis.
Methodology : From a cohort of 166 children with bacterial meningitis who were studied prospectively, 130/158 (82%) survivors underwent neurological, neuropsychological, audiological and behaviour assessments 5–9 years following their illness.
Results : Major adverse outcomes included 8/166 (4.8%) deaths and severe neurological, intellectual or audiological sequelae in 11/130 (8.5%) children followed. Another 24 (18.5%) had cognitive, auditory or behaviour disorders. Bivariate analysis found age ≤12 months, tertiary referral, symptoms >24 h before diagnosis, seizures, focal neurological signs, deteriorating conscious state in hospital, Streptococcus pneumoniae infection and serum sodium concentration < 130 mmol/L were associated with adverse outcomes. Multivariate analysis showed age ≤12 months, symptoms >24 h, seizures after 72 h in hospital and focal neurological signs as independent risk factors. These were present in 18/19 (95%) children with major sequelae, but absent in 9/24 (37.5%) children with minor disabilities.
Conclusions : As minor disabilities following meningitis cannot be predicted, all survivors require assessment during their early school years.     

Human herpesviruses-6 and -7 each cause significant neurological morbidity in Britain and Ireland.

BACKGROUND: Primary human herpesvirus-6 and -7 (HHV-6/-7) infections cause febrile illness sometimes complicated by convulsions and rarely encephalopathy. AIMS: To explore the extent of such HHV-6 and -7 induced disease in young children. METHODS: In a three year prospective study in Britain and Ireland, 205 children (2-35 months old) hospitalised with suspected encephalitis and/or severe illness with fever and convulsions were reported via the British Paediatric Surveillance Unit network. Blood samples were tested for primary HHV-6 and -7 infections. RESULTS: 26/156 (17%) of children aged 2-23 months had primary infection (11 HHV-6; 13 HHV-7; two with both viruses) coinciding with the acute illness; this was much higher than the about three cases expected by chance. All 26 were pyrexial; 25 had convulsions (18 status epilepticus), 11 requiring ventilation. Median hospital stay was 7.5 days. For HHV-6 primary infection the median age was 53 weeks (range 42-94) and the distribution differed from that of uninfected children; for HHV-7, the median was 60 weeks (range 17-102) and the distribution did not differ for the uninfected. Fewer (5/15) children with primary HHV-7 infection had previously been infected with HHV-6 than expected. CONCLUSIONS: Primary HHV-6 and HHV-7 infections accounted for a significant proportion of cases in those <2 years old of severe illness with fever and convulsions requiring hospital admission; each virus contributed equally. Predisposing factors are age for HHV-6 and no previous infection with HHV-6 for HHV-7. Children with such neurological disease should be investigated for primary HHV-6/-7 infections, especially in rare cases coinciding by chance with immunisation to exclude misdiagnosis as vaccine reactions.     

Epidemiology and cost analysis of varicella in Italy: results of a sentinel study in the pediatric practice. Italian Sentinel Group on Pediatric Infectious Diseases.

BACKGROUND: Describing the epidemiology of varicella is relevant to the development of specific prevention strategies and to building up of economic models evaluating the cost:efficiency ratios of these strategies. AIM: Our study was designed to describe the epidemiology of chickenpox among Italian children and to assess the resulting economic and health burden on the country. METHODS: Thirty-nine Italian pediatricians participated in a sentinel network on pediatric infectious diseases representing a total pediatric population of 30 168 children. Each case of varicella observed from January through December, 1997, was recorded. Economic analysis was conducted from the societal point of view. All costs were broken down into two groups: direct and indirect costs. RESULTS: A total of 1599 cases of varicella were reported among children 0 to 14 years old. There were 1266 primary cases (mean age, 4.5 +/- 2 years) and 333 secondary cases (mean age, 3.6 +/- 3.2 years). The global incidence of chickenpox was 51.01/1000/year. Complications were seen in 56 cases (3.5%). Drugs were prescribed in 672 cases. A group of adults (364 susceptible and 193 with uncertain status) were exposed to primary cases. Seventy (12.5%) were eventually infected among whom there were 4 pregnant women. For pediatric patients an average cost of $146.90 (250 400 lire) was estimated; this is largely accounted for by indirect costs. CONCLUSIONS: The epidemiology of varicella in Italy is consistent with that found in previous studies in industrialized countries. Severe complications did not occur in our population. We believe that the health arguments in favor of universal vaccination of children > 18 months of age do not differ in our own country from those of other industrialized nations. Our data could now be incorporated into pharmacoeconomic models to establish cost-efficient strategies for Italy.     

Pattern of childhood epilepsies in Sagumu,Nigeria

Objective  To determine the prevalence, aetiology and clinical pattern of childhood epilepsies in a Nigerian tertiary hospital. Methods  A review of hospital records of children managed for epilepsies at the Pediatric Neurology Clinic. Data studied included the age at presentation, sex, socio-economic class, probable aetiology, clinical type of seizure, Electroencephalopgraphic (EEG) pattern and presence of other neurologic disorders co-existing with seizures. Results  Out of 183 children, 138 had epilepsies giving a prevalence of 75.4%. Sixty nine (54.7%) were aged 6 months to 3 years at the first visit and 115 (69.9%) belonged to lower socio-economic classes IV and V. Birth asphyxia 47 (37.3%) and brain infections in 28 (21.9%) were the leading aetiologies. Generalized tonic-clonic seizures, complex partial seizures and rolandic seizures occurred in 55 (76.9%), 8 (6.3%) and 2 (4.8%) children respectively. Inter-ictal EEG abnormalities were recorded among 72/77 children. Seizures co-existed with other neurologic deficits in 86 (68.3%) of all epileptic cases. 95 (75.4%) children had defaulted from the clinic as at the time of the study. 21 (19.6%) had poor response to drug treatment. Presence of other neurological disorders (p = 0.029) and multiple aetiologies (p = 0.0000) were associated with poor response to drug treatment. Conclusion  Most cases of childhood epilepsy in Sagamu, Nigeria are due to preventable perinatal and neonatal conditions. Therefore, improved obstetric and neonatal care may reduce the prevalence of this condition.     

Laparoscopic appendectomy is recommended for the treatment of complicated appendicitis in children

Laparoscopic appendectomy in children is well accepted for the treatment of non complicated appendicitis. An increased risk of postoperative intraabdominal abcess formation has been reported in complicated appendicitis. The puropose of this study was to compare open (OA) versus laparoscopic appendectomies (LA) in complicated appendicitis in children and to assess the safety and feasibility of LA. The hospital records of 118 consecutive patients who underwent appendectomy for complicated appendicitis (perforated/gangrenous) from 2000 to 2006 were retrospectively analysed. Fifty-four patients had LA and 64 underwent OA. There were 74 males and 44 females. The length of hospital stay ranged from 4 to 12 days in the LA group and 4 to 17 days in the OA group. Five patients (9.2%) in the LA group had post operative complications; intraabdominal collections in 3 and wound infections in 2. Ten patients (15.6%) had postoperative complications in the OA group; intraabdominal collections in 5, wound infection in 3, pleural effusion in 1 and prolonged ileus in 1. In complicated appendicitis the complication rate is lower for LA as compared to OA. We recommend laparoscopic approach to all children presenting with complicated appendicitis.     

Hospitalization for varicella in central Israel

In order to determine the impact of chickenpox on the general population, we conducted a retrospective study in four medical centres in central Israel. Hospital records of 182 patients discharged with the diagnosis of varicella during a 3-y period were reviewed. The patients' mean age was 7.9 y. A total of 14 patients (8%) were immunocompromised. Bacterial skin or soft tissue infection was the most common complication (32%). Other complications included gastrointestinal manifestations (14%), pneumonia (12%), febrile seizures (10%) and CNS complications (9%). Twenty-one percent of patients were discharged with the diagnosis of uncomplicated varicella. One patient died, one underwent liver transplantation for liver failure and four had persistent neurological sequelae. Forty-four patients (24%) received acyclovir for an average duration of 5.7 d. The mean hospital stay was 4.3 d; it was significantly longer for patients with CNS complications (8 d). We estimate that the hospitalization rate in Israel is 1/285 cases of chickenpox. While mortality from varicella was found to be relatively rare, the economic burden of this infection in Israel is quite substantial.     

Antiviral treatment of varicella in pediatric practice in the Latium region of Italy: results of an observational study

BACKGROUND: The optimal management of chickenpox in children is a controversial issue, at least in Europe. This study was designed to describe chickenpox in children and its reported management by pediatricians working for the National Health Service in the Latium region of Italy. METHODS: A questionnaire collected information on the duration, complications and treatment of the disease between September, 1998, and May, 1999, by participant pediatricians who enrolled 1094 patients in community pediatric practice. RESULTS: Secondary and tertiary cases of the disease in the same household were more severe than the primary cases. Acyclovir was given to 50% of the children, with a tendency to treat more severely ill children. The duration of the disease was significantly less in children receiving acyclovir within the first 24 h of rash (7.6 days 9.0). No complications requiring hospitalization were reported. CONCLUSIONS: The use of antiviral drugs is not consistent among pediatricians. Clear guidelines are needed to minimize the use of drugs and to identify children who are likely to benefit most from antiviral therapy.     

Complication rates of diagnostic cerebral arteriography in children

Background: Cerebral arteriography (CA) remains the gold standard in delineating both intra- and extracranial vascular anatomy. Most data relating to the safety of CA are drawn from studies of adult patients in whom the practicalities of the procedure, range of potential pathologies and comorbid factors are different from those in children. Objective: To evaluate the current local and neurological complication rates of paediatric CA in the setting of a tertiary level childrens hospital in the UK. Materials and methods: Data from patients who had undergone CA between January 1998 and July 2003 were reviewed. The medical, anaesthetic and nursing records, and angiography reports were reviewed for all identified patients. The following parameters were extracted and entered into a proforma: gender, age, ethnicity, diagnosis, cerebrovascular diagnosis, referral source, date of CA, number of vessels catheterized and local and neurological complications. Results: A total of 176 CA studies were undertaken in 150 patients (median age 7.3 years, range neonate to 19 years; 83 males, 67 females) during the 5.5-year study period. The majority of referrals originated from the neurology (58%) and neurosurgery services (27.8%). No neurological complications or deaths occurred. Local complications occurred in eight children (4.5%). Five children had a groin haematoma and two had bleeding at the puncture site. A single child had a reduced pedal pulse distal to the site of catheterization, but Doppler imaging was normal. Conclusions: CA has a continuing role in the evaluation of cerebrovascular pathologies in children. Neurological complications are rare and local complications are not uncommon (around 5%), but are not usually serious.     

Natural history and risk factors in fulminant hepatic failure

Background: Ornithine carbamoyltransferase (OCT) deficiency is the commonest of the inherited urea cycle disorders. Aims: To determine the long term neurological and cognitive outcome of continuously treated surviving patients. Methods: Twenty eight surviving children (five boys) with OCT deficiency who had been treated continuously with a low protein diet and alternative pathway therapy were identified. Those aged 5–16 years had a detailed neurological examination and psychometric testing. Results: Four presented in the neonatal period and four were treated prospectively following antenatal diagnosis. Median (range) age at diagnosis for the later onset group was 19 (2–144) months; median time between onset of symptoms and diagnosis was 10 (2–48) months. Nine children had had less than three episodes of hyperammonaemic encephalopathy, the others more. Seven had focal abnormalities on neurological examination; 14 had global cognitive impairment; four had a normal IQ but specific learning difficulties. Sixteen underwent neuroimaging which was normal in three, showed focal abnormalities of the cerebral hemispheres in six, and global cerebral atrophy in seven. Conclusion: Eighteen of 28 surviving children with OCT deficiency had disabling neurological complications. Plasma ammonia at diagnosis was the only factor that predicted this outcome. While most neurological complications could be attributed to hyperammonaemic encephalopathy, other mechanisms may also contribute to the neurological abnormalities.     

The pattern and prognosis of speech disorders among children in Enugu, Nigeria.

Of 965 children with neurological disorders seen in the Child Neurology Clinic of the University of Nigeria Teaching Hospital, Enugu over a 3-year period (1985-87), 80 (8.3%; 41 boys and 39 girls) had speech problems. The most common speech disorder was dyslalia. Twenty-six (32.5%) of the 80 children were mentally retarded. Besides speech problems, some of the children had other neurological disorders such as hyperactivity, recurrent seizures, microcephaly and deafness. Varying degrees of improvement in speech were observed in only eight girls and four boys, amounting to 24% of the 50 who were followed up for a period ranging from 3 months to 3 years (mean follow-up period 12.26 months). Eight of those who improved (66.6%) did so within the first 18 months of follow-up. There was a disturbingly high rate of default from follow-up, 30 of the patients (37.5%) failing to keep appointments at the clinic after the first assessment. Also, there was a long delay between onset of symptoms and presentation to hospital (mean delay 45.3 months). With the recent acquisition of the services of a speech therapist by the hospital, it is hoped that the prognosis for children with speech problems will be considerably improved.     

Neurological complications of childhood leukaemia.

We have reviewed the neurological complications not directly attributable to leukaemic infiltration in a group of 438 children with leukaemia or lymphoma. 61 children had one or more complications due chiefly to bleeding, infection, or drug toxicity. Early death from intracranial haemorrhage occurred in 1% of children with lymphoblastic leukaemia and 7% of children with myeloblastic leukaemia. Measles and chicken pox were the most serious infective complications; one child remains severely retarded after presumed measles encephalitis, one child with chicken pox died, and a second remains disabled. 2 additional cases of measles encephalitis and one of progressive multifocal leucoencephalopathy are described. Drugs which caused neurotoxicity included vincristine, cytosine arabinoside, L-asparaginase, and phenothiazines, but most problems were caused by methotrexate. Methotrexate toxicity was more prevalent and more serious in children who had had previous central nervous system leukaemia. We conclude that viral infections and methotrexate pose the greatest neurological hazards to children with leukaemia.     

The Immunization Monitoring Program Active (IMPACT) prospective five year study of Canadian children hospitalized for chickenpox or an associated complication

BACKGROUND: Varicella vaccine was approved for use in Canada in 1998. A major goal of universal varicella vaccine programs is to reduce severe infection and associated complications. Baseline data are essential against which to judge the effectiveness of routine childhood immunization. OBJECTIVE: To describe morbidity and mortality among children hospitalized for chickenpox. Methods. From January 1, 1991, to March 31, 1996, chickenpox admissions to 11 pediatric referral centers were actively identified. Patient and illness characteristics were compared for 3 subgroups defined by prior health: healthy; unhealthy but immunocompetent; immunocompromised. RESULTS: Of 861 cases 488 (56.7%) were healthy, 75(8.7%) were unhealthy and 298 (34.6%) were immunocompromised. The immunocompromised children differed from healthy/unhealthy cases in mean age (6.4 vs. 4.0/4.6 years, respectively, P < 0.0001); median interval from rash onset to admission (2 vs. 5/5 days, P < 0.0001); complication rate (20% vs. 90%/79%; P = 0.001); and rate of acyclovir therapy (98% vs. 24%/39%; P = 0.001). Unhealthy vs. healthy cases had a higher frequency (P < 0.01) of intensive care (13.3% vs. 4.7%), ventilation (9.3% vs. 2.0%) and death (4% vs. 0.2%). CONCLUSION: These data provide a baseline for morbidity/mortality resulting from chickenpox before varicella vaccine use in Canada.     

Intracranial suppuration

OBJECTIVE: To evaluate prevalence, age, position, predisposing factors, bacteriology, clinical features and outcomes of children with subdural empyema (SDE) and brain abscess (BA). DESIGN: Retrospective hospital-based study in a tertiary children's hospital. METHODS: Clinical data were reviewed on all children classified as having SDE or BA for 10.75 years from 1 January 1992 to 31 August 2003 at the Royal Alexandra Hospital for Children, Sydney, Australia. RESULTS: Forty-six children with intracranial suppuration were identified: 26 had BA, 16 had SDE and four children had both SDE and BA. Significant differences between SDE and BA were that: sinusitis was a predisposing factor for SDE (P = 0.01), Streptococcus milleri was the main organism isolated in SDE (P = 0.02), periorbital oedema (P = 0.005) and photophobia (P = 0.02) were clinical features specifically associated with SDE, and 75% of multiple abscesses were in females (P = 0.005). The age distribution of SDE was biphasic, with peaks at <2 years and >7 years. Cases of BA peaked at age 9-11 years. Forty-eight per cent of all children were between 9 and 13 years old; 20% were <1 year old. All the children with SDE and BA were aged 1 year or less. Three of the 46 children died, all with BA. Eighteen (39.1%) returned to normal and 25 (54.3%) had neurological complications. Neurological complications were more common in the BA group. CONCLUSION: The mortality rate of intracranial suppuration is low, but morbidity remains high. A high degree of suspicion is needed to diagnose and treat intracranial infections early.     

上海市闵行区婴幼儿轻度胃肠功能紊乱的流行病学调查

目的 调查轻度胃肠功能紊乱在中国上海市闵行区婴幼儿中的发病情况.方法 收集并分析2008年4月至6月上海市闵行区12个社区中5030例0-24个月的婴幼儿的问卷调查及营养生长情况.结果 在受调查的5030例中,发生或曾发牛过胃肠功能紊乱的婴幼儿1909例(38.0%),性别差异无统计学意义(P=0.06).5030例受调查婴幼儿中,690例(13.7%)发牛便秘,619例(12.3%)发生腹泻,899例(17.9%)发生溢乳/吐奶,71例(1.4%)发生肠痉挛.不同年龄组胃肠功能紊乱患病率差异有统计学意义,其中便秘及溢乳/吐奶随着年龄的增加患病率显著降低(P<0.01),而腹泻则随着年龄增加发生率递增(P<0.01).胃肠功能紊乱与父母胃肠疾病、辅食的添加、呼吸道感染有一定关系.发生胃肠功能紊乱后,腹泻就诊率62.7%,其他症状就诊率在4.5%～16.9%之间.有胃肠功能紊乱者,尤其是溢乳/吐奶患儿,其营养、生长指标均较无胃肠功能紊乱者低下.结论 婴幼儿胃肠功能紊乱较为常见,就诊率不高,对婴幼儿营养状态、生长有一定的影响.     

Neurological outcome of patients with ornithine carbamoyltransferase deficiency.

BACKGROUND: Ornithine carbamoyltransferase (OCT) deficiency is the commonest of the inherited urea cycle disorders. AIMS: To determine the long term neurological and cognitive outcome of continuously treated surviving patients. METHODS: Twenty eight surviving children (five boys) with OCT deficiency who had been treated continuously with a low protein diet and alternative pathway therapy were identified. Those aged 5-16 years had a detailed neurological examination and psychometric testing. RESULTS: Four presented in the neonatal period and four were treated prospectively following antenatal diagnosis. Median (range) age at diagnosis for the later onset group was 19 (2-144) months; median time between onset of symptoms and diagnosis was 10 (2-48) months. Nine children had had less than three episodes of hyperammonaemic encephalopathy, the others more. Seven had focal abnormalities on neurological examination; 14 had global cognitive impairment; four had a normal IQ but specific learning difficulties. Sixteen underwent neuroimaging which was normal in three, showed focal abnormalities of the cerebral hemispheres in six, and global cerebral atrophy in seven. CONCLUSION: Eighteen of 28 surviving children with OCT deficiency had disabling neurological complications. Plasma ammonia at diagnosis was the only factor that predicted this outcome. While most neurological complications could be attributed to hyperammonaemic encephalopathy, other mechanisms may also contribute to the neurological abnormalities.