A study of race-related distribution of hepatitis B markers was conducted in 458 children admitted consecutively to Singapore General Hospital. The positive rates for hepatitis B surface antigen (HBsAg) in Chinese, Malays and Indians were 11.2, 8.0 and 12.2% respectively and the corresponding figures for anti-HBs were 30.2, 12.0 and 14.6%. In Chinese children HBsAg prevalence was shown to be sex-related, being higher in males than females. The percentages of Chinese children positive for anti-HBs and anti-HBc were also higher than those of the Indians. This study confirmed that Singapore children were exposed to hepatitis B infection from early life. All three races were equally susceptible to this infection.
A retrospective study of 137 patients with blood culture-positive typhoid fever admitted to the paediatric unit of the Hospital Universiti Sains Malaysia was carried out to study epidemiological, clinical, laboratory and treatment aspects of typhoid fever in Kelantanese children in hospital. The male:female ratio was 1:1.1. School-children were the most affected. Cases were seen throughout the year. The five most frequently presenting features were fever, hepatomegaly, diarrhoea, vomiting and cough. Rose spots were seen in only two patients. Complications included gastritis, bronchitis, ileus, psychosis, encephalopathy, gastro-intestinal bleeding and myocarditis. Relative bradycardia was not seen. Blood and stool cultures were positive in the 1st, 2nd and 3rd weeks of illness. There was no significant difference between percentages of elevated O and H titres, whether done during or after the 1st week of illness. A four-fold rise in (O) titres occurred in 50% of cases tested. We would miss 50% of typhoid fever cases if a titre (O) equal to more than 1/160 were relied upon for diagnosis. Altogether, 46% of patients had leucopenia. Chloramphenicol was the most commonly used antibiotic. There were two deaths.
Yaws was detected in a six-member family in the southern Malaysia state of Johor. This stresses the need to be vigilant against a long-forgotten disease of childhood which was of great public health concern in the past.
A 2.5-year retrospective study of pyogenic meningitis in hospitalized children in Kelantan was carried out with regard to aetiology, clinical features, investigation, treatment and outcome. There were 58 children with 43 cases (74.1%) occurring below the age of 1 year. Frequent presenting symptoms included fever (98.3%), fits (77.6%), anorexia (39.7%), vomiting (34.5%) and drowsiness (12.1%). On admission, 37 (63.7%) had neck stiffness, 10 (17.2%) had Kernig's sign and 32 (55.2%) had coma. CSF cultures were positive for Haemophilus influenzae in 29 (50%), Streptococcus pneumonia in 13 (22.4%) and Neisseria meningitidis in 3 (5.2%). The antibiotic sensitivity profiles showed that the three main organisms were 100% sensitive to Chloramphenicol, Streptococcus pneumoniae was 100% sensitive to penicillin, Neisseria meningitidis was 100% sensitive to penicillin and ampicillin, and Haemophilus influenzae was 90% sensitive to penicillin and ampicillin. The total hospital mortality was 18.9%. All but two of the eleven deaths occurred in children younger than 1 year. Nineteen of the 35 (54.3%) survivors attended for at least one follow-up after discharge from hospital. Of these 19 children, 47.4% had neurological sequelae.
A wide variety of skin disorders in children are encountered by doctors practising in tropical countries. While some of them are common and pose little difficulty in their management, a few are uncommon, run a protracted course and cause errors in diagnosis. Two patients--one with cutaneous tuberculosis and the other with chromomycosis--are described and illustrate the importance of early and prompt detection of disease in children.
In a case control study, 70 children consecutively hospitalized for acute ingestion of poisons were compared with 140 other hospitalized children matched for age. Children aged less than 3 years and boys were most often the victims. Univariate analysis identified Indian race, having a parent younger than 21 years, residing at present address for less than 1 year and living in a household with more than five occupants as significant risk factors. Experience of a recent stressful event in the family barely failed to reach the level of significance. Logistic regression analysis confirmed that Indian race, having a parent younger than 21 years and residing less than 1 year at the present address were independent predictors of acute poisoning. Positive interactions were noted between Indian race and duration of residence and between parental age and duration of residence. Knowledge of risk factors and their interactions may be useful in planning preventive measures against childhood poisoning.
Poliomyelitis in Malaysia has not been reported since 1986. We report two cases of poliomyelitis in non-immunized children whose parents, though relatively educated, opted not to vaccinate their children for socio-cultural reasons. This recent trend may interfere with our attempts to eradicate poliomyelitis globally by the year 2000. The clinical features, pathophysiology and differential diagnosis are discussed.
The prevalence of ocular abnormalities was studied in 165 children from a Malaysian school for the deaf. Ninety-five children (57.6%) had one or more ocular abnormalities. Rubella retinopathy was the commonest form of ocular abnormality (35.2%). Refractive errors were found in 23 children (13.9%). Refractive errors in the rubella group were significantly more common than in the non-rubella group of deaf children (p < 0.001) (chi 2 test). Thirteen children had congenital anomalies causing significantly impaired vision. Ophthalmological examination of deaf children helps in the detection of cases with rubella eye signs and thus helps to identify the cause of deafness. Since deaf children are at greater risk of visual and ocular abnormalities, periodical ophthalmological examination should be carried out in these children.
This is a retrospective study of the epidemiology, clinical features, laboratory findings, treatment and outcome of haemorrhagic disease in 42 Kelantanese infants who were admitted to Hospital Universiti Sains Malaysia during a 2-year period (1987-1988). Classical haemorrhagic disease of the newborn was the commonest presentation (48%), followed by early onset (29%) and late onset (24%) disease. Home deliveries accounted for 81% of the affected infants. Most of these babies were not given vitamin K at birth in contrast to those delivered in hospitals. All except one infant were breastfed. The six commonest presenting clinical features were pallor, jaundice, umbilical cord bleeding, tense fontanelle, convulsions and hepatomegaly. All the infants had prolonged prothrombin and partial thromboplastin times which were corrected by administration of vitamin K. Subdural haemorrhage was the commonest form of intracranial haemorrhage, followed by subarachnoid haemorrhage. The overall case fatality rate was 14%. The results of this study once again emphasize the value of vitamin K prophylaxis in the newborn.
The outcome in 148 inborn meconium-stained neonates was studied prospectively over a 5-month period. Fifty-three infants (38.5%) developed meconium aspiration syndrome (MAS). There was a significantly higher rate of MAS (p < 0.001), mechanical ventilation (p < 0.016) and hospital stay (p < 0.016) in neonates with meconium in the trachea than in neonates with no meconium in the oropharynx. The incidence of MAS was significantly higher and the duration of hospital stay longer in outborn than in inborn infants (p < 0.022).
Eighty-five children who presented with stridor were reviewed in order to determine the aetiology of stridor in these cases. Congenital causes accounted for 57.6% of cases. Laryngomalacia was the commonest congenital abnormality (77.5%). Other common causes of stridor were a foreign body in the airway (acquired) and laryngotracheobronchitis (33.3%) (infective). Tracheostomized children are a problem in developing countries, requiring prolonged hospitalization. We overcome this problem by teaching parents how to maintain the tracheostomy tube at home.
Intracranial haemorrhage is a major cause of severe morbidity and mortality in child abuse cases in developed countries. However, similar data are not available in most developing countries. This study therefore aimed to determine the incidence of intracranial haemorrhage amongst all cases of child physical abuse, the nature of the injuries incurred, and the morbidity and mortality resulting therefrom. Among 369 cases of physical abuse seen over a 4-year period, 41 (11.4%) had intracranial haemorrhage, of whom 37 (90%) were 2 years old or less. A history of trauma was present in only eight (20%), of which only two were compatible with the injuries incurred. Subdural haemorrhages accounted for 80% of the cases, with skull fractures present in only nine cases. Fifty-four per cent of the 37 children aged 2 years of age or less had no external signs of trauma, but 11 of them had retinal haemorrhages. This is in contrast to the children older than 2 years of age who all had external signs of trauma. The overall prognosis was dismal with an early mortality of almost 30% (13 cases) and at least seven cases with severe neurological sequelae. These findings are comparable with studies from developed countries which have established that non-accidental injury must be considered as a cause of intracranial haemorrhage in any young child, despite the absence of external signs of trauma.
Haemophilus influenzae type b (Hib) endocarditis is a rare but potentially lethal condition. Only ten cases have been reported in the English literature. This report describes an 8-month-old Malay child with a ventricular septal defect who developed Hib endocarditis and died after 4 weeks of hospitalization. The literature is reviewed and previously reported cases summarized.
In dengue shock syndrome, an acute increase in capillary permeability results in leakage of plasma into the interstitial space. Pleural effusion is commonly seen in dengue shock syndrome. We report three cases of dengue-associated adult respiratory distress syndrome (ARDS) in children, in all of whom dengue haemorrhagic fever, presenting with grade 3 or grade 4 dengue shock syndrome with disseminated intravascular coagulopathy, was confirmed. The criteria for the diagnosis of ARDS were based on the expanded definition of ARDS by Murray et al. Treatment consisted of fluid resuscitation, correction of coagulopathy and mechanical ventilation. All three children had multi-organ impairment, but it was more severe in the two who died. The one survivor was well at discharge.
We report seven cases of Kawasaki disease (KD) who were admitted to Hospital University Sains Malaysia over a period of 8 years. The average age at the time of admission was 29.4 months and four of the children were boys. Five children had all six criteria for diagnosis. Ileus was present in three, and hydrops of the gall bladder and pneumonia in two each, but coronary artery dilatation was seen in only one patient. We also review all the cases of KD reported so far from Malaysia and compare the epidemiological data, clinical course and laboratory findings of the Malaysian patients with those from other parts of the world. The epidemiological and clinical features of Malaysians with KD differ from those seen in Singapore and Japan, but are similar to those seen in Thailand, Australia and North America. The incidence of cardiac complications is low in Malaysians.
Tropical pulmonary eosinophilia (TPE) is considered to be a variant of human filarial infection. The pulmonary manifestations of TPE have been well described. Extra-pulmonary features of the disease, although not commonly seen, have been reported previously. A 9-year-old Malay girl with a history of recurrent cough and wheezing was admitted because of cardiac failure. Physical examination revealed a very sick girl with tachypnoea, central cyanosis, finger clubbing, elevated jugular venous pulse, generalized crackles and rhonchi in the chest, a loud second heart sound and hepatosplenomegaly. A chest radiograph showed cardiomegaly and right pleural effusion. Laboratory investigations revealed hypochromic, microcytic anaemia with persistent blood eosinophilia (absolute eosinophil counts varied from 1.9 to 5.5 x 10(9)/1). The ELISA test for antifilarial IgG antibodies was strongly positive. She responded promptly to treatment with diethylcarbamazine. In summary, this is a patient with TPE who presented with cor pulmonale, probably due to late-stage interstitial pulmonary fibrosis. In order to prevent the long term morbidity of cardiorespiratory disability, the early signs of TPE should be recognized and the infection treated.
A prospective study was carried out to (i) compare head growth patterns of 103 very low birthweight (VLBW, < 1500 g) Malaysian infants and 98 normal birthweight (NBW, 2500- < 4500 g) controls during the 1st year of life; and (ii) examine the relationship between neurodevelopmental outcome at 1 year of age and occipito-frontal head circumferences (OFC) at birth and at 1 year of age in VLBW babies. When compared with those of NBW infants at birth, mid-infancy and 1 year of age, the mean OFC ratios (observed/expected OFC at 50th percentile) of VLBW infants were significantly lower (p < 0.001). Small-for-gestational-age (SGA) VLBW babies had significantly lower mean OFC ratios than their appropriate-for-gestational-age (AGA) VLBW counterparts at birth (p < 0.001), but this difference was no longer seen at mid-infancy or at 1 year of age. Logistic regression analysis showed that abnormal late neonatal cranial ultrasound findings (odds ratio 8.5, 95% confidence interval 4.12-22.07; p < 0.001) and each additional day of oxygen therapy (odds ratio 1.15, 95% confidence interval 1.00-4.45; p = 0.045) were significant risk factors associated with neurodevelopmental disability at 1 year of age, while mean OFC ratios at birth or at 1 year of age were not. Poor postnatal head growth per se did not predict disability, but probably reflected the consequences of "brain injury" as evidenced by abnormal brain scans.
All post-neonatal children with acute non-traumatic coma admitted over an 8-month period were analysed and followed up for 18-24 months to determine the aetiology and outcome of their coma. One hundred and sixteen children, 72 boys and 44 girls, were recruited. Half the children were under 1 year of age and only 16 (14%) were more than 6 years of age. Eighty cases (69%) were due to infection, 15 (13%) to toxic metabolic causes, six (5%) to hypoxic ischaemic insults, four (3.5%) had intracranial haemorrhage, nine (7.8%) were due to miscellaneous causes and in two (1.7%) the cause was unknown. Seven cases were lost to follow-up. Of the remainder, 39 (35.7%) died, 32 (29.3%) developed permanent neurological deficit, and 38 (35%) were discharged well. The outcome was worst in the infectious group. Age of onset and sex did not significantly affect outcome. Our findings are similar to experience in Japan, where infection accounts for 74% of non-traumatic coma, but differ considerably from Western data on childhood coma where only a third of cases are due to infection.
We describe a Malay girl with disseminated cryptococcosis affecting the lungs, liver, lymph nodes and bones. The diagnosis was made by culture of the bone marrow. Tests of immune function showed that she was HIV-negative but the CD4 percentage was persistently low. Idiopathic CD4+ T-lymphocytopenia was diagnosed. The child died despite two courses of anti-fungal therapy.
Despite concerns about adverse effects, chloramphenicol (CMC) continues to be used in certain situations and, due to its low therapeutic index and variable pharmacokinetics, therapeutic drug monitoring (TDM) is often recommended. At our centre, CMC finds applications in typhoid and meningitis and TDM is routinely performed. Elsewhere in Malaysia, however, CMC is used without TDM. We therefore decided to evaluate our TDM for CMC in relation to its roles in CMC therapy in children, who constitute most of our patients. Our objective was also to develop strategies to improve our TDM for CMC use. Data were collected from 168 children given CMC for various indications and monitored by the TDM service. Plasma CMC was determined by HPLC and used to adjust doses to maintain concentrations within a range of 10-25 micrograms/ml. Outcomes measured included daily temperatures and haematological indices. Daily doses and plasma CMC varied greatly. Doses averaged 40.5 mg/kg for neonates and 75.5 for older children. Average peak concentrations were therapeutic in 60% and trough in 42%. Average duration of fever was 6.3 days and it was unaffected by plasma CMC. Typhoid was eradicated in 97% but nine children with other diagnoses died. Side-effects were confined to mild reversible haematological abnormalities which developed in 11% of children at plasma concentrations which tended to be high. We conclude that CMC remains useful in children with typhoid. Its use for other indications, however, should be reviewed. Routine TDM for CMC is probably not warranted, at least until a clearer role is defined by well designed prospective studies.