Paediatrica Indonesiana

Association between vitamin D deficiency and otitis media with effusion in children: a systematic review and meta-analysis

Mon, 21 Oct 2024 00:00:00 +0700

Background Vitamin D plays a crucial role in the regulation of inflammation. However, its effect on the development of otitis media effusion (OME), an inflammatory disease of the middle ear without signs of infection, remains largely unknown.

Objective To assess the association between vitamin D deficiency and OME in children by systematic review and meta-analysis of the literature.

Methods Eligible studies retrieved from PubMed, ProQuest, Embase, Cochrane databases and trial registries published up to 30 October 2022 were included in this review. The risk of bias of the included articles was assessed with the JBI Critical Appraisal Checklist for observational studies. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation framework.

Results We included eight studies (six case-control and two cross-sectional studies) involving 1,114 children, of which four studies were eligible for meta-analysis due to the significant clinical heterogeneity. We found that vitamin D deficiency (defined as vitamin D concentration of 20 ng/mL or less, i.e., ?50 nmol/L) might increase the odds of developing OME by 66.0% (n=514; OR 1.66; 95%CI 1.09 to 2.54; I²=20%), albeit with a very low certainty of evidence.

Conclusion There is a very low quality of evidence indicating that vitamin D deficiency is associated with the development of OME in children. Further large, high-quality cohorts and adjusting for confounding factors are warranted to confirm our findings, ideally by exploring the dose-response relationship between vitamin D concentration and the development of OME.

Risk factors of speech and language disorders in children

Mon, 21 Oct 2024 00:00:00 +0700

Background Speech and language problems are developmental disorders often observed in children. Risk factors for speech and language disorders can occur prenatally, perinatally, or postnatally. Recognizing the risk factors for speech and language problems is essential for early diagnosis and intervention.

Objective To identify risk and protective factors of speech and language disorders in children.

Methods This case-control study was conducted in the Growth and Development Clinic at
Dr. Soetomo Hospital, Siloam Hospital, Kendangsari Merr Hospital, and Darmo Hospital, Surabaya, East Java. Subjects with normal development were included in the control group, subjects with speech-language development disorders with no additional problems were included in the primary case group, and subjects with speech-language disorders and additional problems were included in the secondary case group. Subjects underwent history-taking and developmental examinations to assess for risk factors and types of speech-language disorders.

Results During March – July 2023, 162 subjects aged 2-6 years met the inclusion criteria. The significant risk factors in the primary group were male sex (P=0.000), age 2-3 years (P=0.01), and maternal age 19-35 years (P=0.018). The protective factor identified was not bilingual (P=0.046). In the secondary group, the significant risk factor was male gender (P=0.002). The protective factors obtained were absence of seizures (P=0.028) and not being bilingual (P=0.045).

Conclusion Male gender is a risk factor while non-bilingual is protective for speech-language disorders in children.

Performance of WHO mid-upper arm circumference cut-off to diagnose severe acute malnutrition in under-fives

Fahreza Aditya Neldy, Klara Yuliarti, Murti Andriastuti — Tue, 22 Oct 2024 00:00:00 +0700

Background Many studies indicate that the current WHO recommendation of cut-off value mid-upper arm circumference (MUAC) is not sensitive to detect severe acute malnutrition (SAM) in under-fives cases. Various new cut-off values have been proposed with better diagnostic values but have a wide interval, 12.1 cm—14.5 cm, which may be due to different races or habitus.

Objective To evaluate the diagnostic value of MUAC in diagnosing SAM compared to the weight for height Z score (WFZ) index, to evaluate sensitivity, specificity, positive and negative predictive value of MUAC with 11.5 cm as standard cut-off, and to find an alternative cut-off value that may offer better diagnostic performance.

Methods We collected 421 subjects consecutively in January-February 2020 in Cipto Mangunkusumo Hospital and Puskesmas Cengkareng. We performed brief conversations for demographic data and did the measurement of physical examination and anthropometric measurement by trained researchers and research assistants.

Results Mid-upper arm circumference has excellent diagnostic value to assess SAM in under-fives with area under curve 0,939 (CI95% 0,903-0,974). Diagnostic values MUAC using cut off 11.5 cm were 21% sensitivity (Se) 21%, 99.7% spesificity (Sp)and Youden Index (YI) of 0.20. By using 13.3 cm as a new cut-off value, MUAC has Se 89%, Sp 87%, and YI of 0.76.

Conclusion We conclude that WHO MUAC cut-off using 11.5 cm has lower performance to detect SAM cases than the proposed new cut-off value of 13.3 cm. New MUAC cut-off should be considered to detect more SAM cases among under-fives.

Risk factors for acute kidney injury in children with critical illness

Mon, 14 Oct 2024 00:00:00 +0700

Background Acute kidney injury (AKI) is an acute functional kidney disorder that increases morbidity and mortality in children. The mortality rate for critically ill patients accompanied by AKI is quite high and is influenced by the degree of AKI, the severity of the disease, and organ function disorders. Understanding the risk factors of developing AKI in children with critical illness can help prevent AKI.

Objective To determine the risk factors for AKI in children with critical illness.

Methods This retrospective cohort study included 255 children aged 1 month to 18 years admitted at the pediatric intensive care unit (PICU) of dr. Zainoel Abidin Regional Public Hospital, Banda Aceh, Aceh, from January to December 2022 using medical record data. Bivariate and multivariate analyses were performed.

Results Acute kidney injury occurred in 68 (26.7%) patients. Based on pRIFLE criteria, 34 (50%) patients had AKI in the failure stage. Risk factors for AKI in children with critical illness were in descending order of RR: sepsis (RR 14.3; 95%CI 11.68 to 18.66; P=0.000), mechanical ventilation (RR 12.13; 95%CI 8.75 to 15.98; P=0.000), respiratory disorders (RR 2.51; 95%CI 2.06 to 4.02; P=0.003), congenital heart disease (RR 2.08; 95%CI 2.00 to 3.05; P=0.004), CNS disorders (RR 1.24; 95%CI 1.02 to 2.49; P=0.048), nephrotoxic drug use (RR 1.41; 95%CI 1.24 to 3.08; P=0.000), and age 1 month to 5 years (RR 0.072; 95%CI 0.16 to 0.32; P=0.010).

Conclusion Sepsis is a risk factor for AKI in children with critical illness, followed by mechanical ventilation use, respiratory disorders, nephrotoxic drug use. Age <5 years is a protective factor.

Hepcidin levels, markers of iron overload, and liver damage in children with beta-thalassemia major

Indah Sari, Dian Puspita Sari, Moretta Damayanti, Hasri Salwan — Mon, 14 Oct 2024 00:00:00 +0700

Background Thalassemia is a hemoglobin synthesis disorder that causes patients to need lifelong blood transfusions, leading to iron overload and alter organ function, including the liver. Hepcidin, produced by the liver, plays a role in iron homeostasis and should be increased in excess iron stores. However, the level decreases in thalassemia due to some factors, such as ineffective erythropoiesis and liver damage. Recent publications revealed that hepcidin could be associated with iron overload and also a marker of liver diseases.

Objective To analyse the correlation between hepcidin level, markers of iron overload, and liver damage in beta-thalassemia major.

Methods This cross-sectional study included all ?-thalassemia major age 2-18 years admitted to Dr. Mohammad Hoesin Hospital, Palembang, South Sumatera, who underwent blood transfusions from March to August 2022. We measured the level of iron overload markers, hepcidin, liver function test (LFT), and performed liver ultrasonography (USG).

Results Of 97 subjects, median hepcidin level was 10.01 ng/mL and 68% of the subjects showed a decrease. The iron overload parameters were evaluated from serum iron levels (P=0.13), ferritin levels (P=0.90), and transferrin saturation (P=0.29) and 24.7% had abnormal liver USG findings. Spearman’s correlation revealed that only direct bilirubin (DB) (r=0.35; P=0.001) and liver USG (r=0.20; P=0.05) had positive correlations with decreased levels of hepcidin. Also, it had 91.7% sensitivity in predicting liver damage from ultrasound.

Conclusion The hepcidin level was not significantly associated with iron overload markers.

Evaluation of anti-diphtheria toxoid antibody persistence in school-age children in Jakarta, Indonesia

Tue, 29 Oct 2024 00:00:00 +0700

Background Diphtheria can be effectively prevented by adequate immunization. A combined vaccine against diphtheria toxoid, pertussis, and tetanus toxoid (DPT) is currently used in routine pediatric immunizations. Outbreaks of diphtheria could emerge in Indonesia as a consequence of declining routine vaccination during the COVID-19 pandemic.

Objective To analyze the impact of the first (administered at 18-24 months of age ) and second diphtheria boosters (administered at 5-7 years of age ) in retaining protective levels of anti-diphtheria toxoid antibodies. We also investigated for relevant factors associated with anti-diphtheria toxoid antibody titers.

Methods This cross-sectional study was conducted in the Senen District of Jakarta, Indonesia. The inclusion criteria were healthy children aged 6 to 7 years with documented history of DPT vaccination. Primary vaccination defined as 3 doses of DPT at age less than 1 year , first booster was DPT vaccination at 18-24 years of age, and second booster was diphtheria-tetanus (DT) vaccination received at 5 to 7 years of age. Peripheral blood specimens were obtained from participating children, after informed consent was provided by their parents. Antibodies against diphtheria in sera specimens were assessed by commercial anti-diphtheria toxoid immunoglobulin G (IgG) enzyme-linked immunosorbent assay.

Results There were 154 children included in the study, with a female majority (61%). Overall, specific humoral immunity against diphtheria was observed in 113 children (73.4%). There was no statistical difference in immunity level between genders. Importantly, children who received the first and second diphtheria booster had significantly higher anti-diphtheria antibody level than those who did not receive both diphtheria booster (P<0.001).

Conclusion Booster vaccinations are crucial among school-age children in Indonesia to improve their anti-diphtheria immunity and to minimize a risk of diphtheria outbreaks.

Prevalence and factors associated with extrauterine growth restriction in premature infants

Mon, 14 Oct 2024 00:00:00 +0700

Background Extrauterine growth restriction (EUGR) is common in preterm infants and has been shown to affect their neurodevelopment. Significant variability exists in the criteria used to define EUGR and a standard definition has not yet been established. Several factors associated with EUGR have been identified, yet EUGR remains a problem in preterm infants. There is still much to be explored regarding risk factors associated with EUGR.

Objective To determine the prevalence and factors associated with EUGR in preterm infants.

Methods This cross-sectional study included randomly selected premature infants (<37 weeks gestational age) who were admitted to levels II and III Neonatal Ward at Prof. Dr. I.G.N.G. Ngoerah Hospital from May 2022 to August 2023.

Results Of 185 subjects, the prevalence of EUGR in preterm infants was 47% and there were significant associations between EUGR and birth weight <1500 g (PR 8.814; 95%CI: 3.943 to 19.7; P=0.000), small for gestational age/SGA (PR 28.95; 95%CI: 3.79 to 220.1; P=0.000), neonatal sepsis (PR 4.29; 95%CI: 2.21 to 8.31; P=0.000), hyaline membrane disease/HMD (PR 2.12; 95%CI: 1.16 to 3.88; P=0.021), use of respiratory support (PR 2.57; 95%CI: 1.35 to 4.92; P=0.005), initiation of enteral nutrition at >48 hours (PR 2.23; 95%CI: 1.21 to 4.09; P=0.014) and length of stay/LOS >14 days (PR 8.11; 95%CI: 4.13 to 15.9; P=0.000). Multivariate analysis revealed birth weight <1500 g (aPR 5.14; 95%CI: 1.55 to 17.06; P=0.007), SGA (aPR 24.26; 95%CI: 2.64 to 222.6; P=0.005), presence of sepsis (aPR 2.35; 95%CI: 1.00 to 5.5; P=0.049), and length of hospital stay >14 days (aPR 4.93; 95%CI: 2.15 to 11.31; P=0.000) maintained positive significant associations with EUGR.

Conclusion The prevalence of EUGR in preterm infants is 47%. Birth weight <1500 g, small for gestational age, sepsis, and length of stay >14 days are associated with EUGR in preterm infants.

Hematology scoring model to predict sepsis in preterm neonates

Yani Dewi Suryani, Tetty Yuniati, Fiva Aprilia Kadi, Aris Primadi — Mon, 14 Oct 2024 00:00:00 +0700

Background Neonatal sepsis is a major cause of neonatal morbidity and mortality, especially in developing countries. Atypical clinical symptoms lead to delays in diagnosis and treatment. Scoring a combination of routine hematology parameters may be able to predict the occurrence of sepsis in preterm neonates.

Objective To formulate a new model for neonatal sepsis scoring from various complete blood count parameters to predict sepsis in preterm neonates.

Methods This analytical cross sectional study using secondary data from the Registry of the Neonatology Division was conducted at the RSUP Dr. Hasan Sadikin, Bandung, West Java. Subjects were neonates diagnosed with sepsis, of gestational age 28–36 weeks, who were born at the RSUP Dr. Hasan Sadikin from January to December 2021. Laboratory results of patients who met the inclusion criteria were recorded. Subjects were divided into either proven sepsis and probable sepsis groups, based on blood culture results.

Results Of 112 subjects, 35.7% had proven sepsis and 64.3% probable sepsis. In the proven sepsis group, 52.5% of subjects were male, median birth weight was 1,490 grams, median gestational age was 32 weeks, 90% were small for gestational age, and 60% were delivered normally. Multivariable analysis by multiple logistic regression revealed that the parameters associated with the incidence of neonatal sepsis were c-reactive protein (CRP) > 0.18 mg/dL (score 6), hematocrit <40% (score 4), platelet-to-lymphocyte ratio (PLR) < 19.623 (score 4); monocyte-lymphocyte ratio (MLR) < 0.461 (score 2); and mean platelet volume (MPV) value >10 (score 2). Score >8 had a sensitivity of 85% and specificity of 70.8%, with area under the ROC curve of 0.865 (P<0.001). Scoring accuracy was 75.8%, with a positive predictive value of 61.8%, a negative predictive value of 89.5%, and Kappa index of 51.5% with moderate agreement.

Conclusion A hematological score >8 can be used as a predictor of sepsis in preterm neonates.

The School Years Screening Test for Evaluation of Mental Status-Revised (SYSTEMS-R) as a cognitive function screening tool in children with epilepsy

Mon, 14 Oct 2024 00:00:00 +0700

Background Children with epilepsy are at high risk of cognitive impairment that can affect quality of life. Intelligence quotient (IQ) measurement using the Wechsler Intelligence Scale for Children (WISC) is the gold standard test of cognitive function, but it is time-consuming and costly. The School Years Screening Test for Evaluation of Mental Status-Revised (SYSTEMS-R) is a potential cognitive function screening tool that can be used in children with epilepsy.

Objective To assess the performance of SYSTEMS-R as a cognitive function screening tool in children aged 6-15 years with epilepsy.

Methods This cross-sectional diagnostic test study was conducted in children aged 6-15 years with epilepsy. All subjects were assessed using both SYSTEMS-R and WISC 4^th edition. The sensitivity, specificity, positive and negative predictive value, likelihood ratios of the positive and negative tests, and accuracy of SYSTEMS-R was calculated, with WISC as the gold standard test.

Results Based on the SYSTEMS-R, the prevalence of cognitive impairment in children aged 6-15 years with epilepsy in our population was 86.4%. With WISC as the gold SYSTEMS-R had 84% sensitivity, 91% specificity, 98% positive predictive value, and 47% negative predictive value. The likelihood ratio of a positive SYSTEMS-R test was 10.11 and the likelihood ratio of a negative test was 0.17. The overall accuracy of SYSTEMS-R to detect cognitive impairment was 85%.

Conclusion SYSTEMS-R has good sensitivity and specificity to assess cognitive function in children 6-15 years with epilepsy. It can be considered for widespread use in the early detection of cognitive impairment in pediatric epilepsy patients aged 6-15 years.

Measurement of leak volume as a diagnostic predictor of post-extubation stridor in pediatric patients

Pravit Jetanachai, Jariya Pojthaveekiet — Mon, 14 Oct 2024 00:00:00 +0700

Background Endotracheal intubation can cause post-extubation stridor (PES). The PES may prolong the length of stay in the hospital and be associated with increased morbidity and mortality, particularly if re-intubation is necessary. The leak volume (LV) test is a simple method to detect airway edema.

Objective To evaluate the efficacy of LV and percent leak volume (PLV) in predicting PES.

Methods Inspired tidal volume (VTi) and expired tidal volume (VTe) were observed for six respiratory cycles during positive pressure ventilation before extubation. The average of the six VTi and six VTe values were recorded. The LV was the difference between average VTi and average VTe. The conversion of the ratio of LV to average VTi into percentage was defined as PLV. Both LV and PLV were analyzed to determine cut-off values in predicting PES.

Results Among 77 patients, 39 patients (50.6%) developed PES. Both LV and PLV showed a significant decrease in patients with PES.The ROC analysis showed that LV at a cut-off point of < 18.34 ml gave a sensitivity of 82.1% and specificity of 57.9%, whereas PLV < 13.83% yielded 79.5% sensitivity and 57.9% specificity for predicting PES. The LV and PLV had an area under the ROC curve of 0.770 (95%CI 0.665 to 0.874; P<0.001) and 0.706 (95%CI 0.59 to 0.821; P=0.01) respectively.

Conclusion Leak volume and percent leak volume can be used as markers to predict PES in pediatric patients.

A serial case of Japanese encephalitis in West Kalimantan

Nathania Thedra, Evelyn Phangkawira — Mon, 14 Oct 2024 00:00:00 +0700

Japanese encephalitis (JE) is an important, vaccine-preventable cause of viral encephalitis in Asia. This medical condition has a high morbidity and mortality rate, remains an under-recognized cause of encephalitis, with high rate of mortality and severe sequelae in children, especially in West Kalimantan. However, poor surveillance has made the burden difficult to quantify, hindering decisions about subsidized vaccine introduction.

In this serial case, the most common clinical presentations of JE were fever, altered mental status, seizures, vomiting, and positive meningeal irritation signs or pathologic reflexes. The JE mortality rate was as high as 40%. These highlight the need of disease surveillance, diagnostic kits supply, and health education to increase public disease awareness.

Undetected Takayasu arteritis presenting as severe hypertension in children: a report of two cases

Mon, 21 Oct 2024 00:00:00 +0700

Takayasu arteritis (TA) is a rare chronic granulomatous vasculitis mainly affecting the aorta and its main branches. Clinical presentations of TA are non-specific, especially in the initial phase, which likely contributes to delayed diagnosis besides the rarity of the disorder. Childhood-onset of TA is associated with significant morbidity and mortality. This case report aimed to present two rare cases of acute symptomatic severe hypertension in children due to TA.