H. P. Singh

Placental and neonatal outcome in maternal malaria

ObjectivePrimary: To determine the incidence of congenital malaria in a cohort of pregnant women in a hyper-endemic area of central India. Secondary: (1) To find out the placental weight and placental malaria positivity, and to assess fetal and neonatal outcome in terms of survival, mean hemoglobin and mean birth weight.DesignProspective observational study.SettingMaternity and neonatal ward of a tertiary level hospital attached to a medical college located in Rewa, Madhya Pradesh, India.ParticipantsNear term and term pregnant women admitted in the maternity ward with a singleton pregnancy, whose neonates were available for examination till at least 6 hours after birth.MethodsThick and thin blood smear were examined for malarial parasites from mothers prior to delivery. Based on the results of peripheral smear they were divided into ‘exposed group’ (peripheral smear positive for malaria parasite) and unexposed group’ (smear negative for malaria parasite). These groups were then followed prospectively till delivery and subsequently till the mother and the neonates were discharged from the hospital.Outcome variablesPrimary: Presence of asexual parasite in neonate. Secondary: Placental weight, presence of asexual malarial parasite in placenta, still births, early neonatal deaths, mean birth weight and mean hemoglobin.ResultsSeventy-two (35.5%) of 203 blood smears of near term and term pregnant women were found positive for malaria parasite (60 P. vivax and 12 P. falciparum); rest 131 comprised the unexposed group. Six (2.95%) neonates had parasitemia (4 P. vivax and 2 P. falciparum). Of the 203 smears made from placental blood, 24 (11.8%) were positive for malaria parasite. The mean (SD) birth weight [2300 (472) g vs 2430 (322) g; P=0.98], proportion of preterm babies (6.9% vs 8.4%, P=0.71), incidence of still birth (4.2% vs 3.0%, P=1.0) and early neonatal death (2.8% vs 3.0%, P=1.0) were not significantly different between the exposed and unexposed group.ConclusionsThe incidence of congenital malaria is low despite high maternal smear positivity for malaria.

Scurvy: A Common Co-morbid Condition in Severe Acute Malnutrition

To the Editor: Human breast milk has more vitamin C than cow’s milk, and thus, breastfed infants are less prone to develop scurvy [1]. Delay in starting complementary foods, improper dietary habits and recurrent diarrhea predispose to scurvy. The present study was designed to study the prevalence of radiological features of vitamin C deficiency in severe acute malnutrition (SAM) children. This study included SAM children from Severe Malnutrition Treatment unit (SMTU) of Department of Pediatrics, Gandhi Memorial Hospital, Shyam Shah Medical College, Rewa, and nutritional rehabilitation centre (NRC) attached to District Hospital, Rewa, Madhya Pradesh. All SAM children between ages 6mo to 5y admitted during the study period (Sept through Nov 2013) were included. Three children with known genetic disorders involving cartilage or bone were excluded on the basis of clinical examination and previous investigations and radiological examination, viz., achondroplasia, hypo-phosphatemic rickets and osteogenesis imperfecta, one each. Fifty cases of SAM admitted over the study period were enrolled for the study. After taking written informed consent from parents, radiograph of knee joint was done and was examined by the radiologist, who was unaware of the clinical condition of the patients while evaluating the x-rays. Following radiograph features were considered to be diagnostic of vitamin C deficiency [2, 3]—Wimberger sign, Pencil-thin cortex, Trummerfeld zone, Pelkan spur, Frankel line, Subperiosteal hemorrhage, Corner sign and, Ground glass appearance of diaphysis. Because of financial constraints serum level of ascorbic acid was not done. Among 50 SAM children, radiological signs of vitamin C deficiency were found in 48 children (96%) (Table 1). All children from urban area had scurvy as compared to 95% from rural area. The early radiological features of vitamin C deficiency were; generalized osteopenia, Pencil thin cortex, Wimberger’s ring sign and Frankel’s line. The frequency of various radiological features observed were Wimberger sign(41), Frankel line(41), Pencil-thin cortex(36), Corner sign(21), Pelkan spur(12), Trummerfeld zone(2). The clinical features of scurvy found in the study were non-specific, like irritability(7) and limb pain (3). The radiological features manifested earlier than the clinical features, whereas previous studies have shown that radiological signs manifest after 3–6 mo of nutritional deficiency [4]. Ninety three percent of the cases were between 1 and 4y of age [5], but present study shows features of scurvy as early as 7mo of age. This suggests vitamin C deficiency in mothers, consecutively in breastmilk thus leading to scurvy at an early age. There was no association of vitamin C deficiency with gender, socioeconomic status, and literacy level of mothers. The study concludes that SAM children are prone to vitamin C deficiency at an early age. J. Singh : R. K. Verma :H. P. Singh Department of Pediatrics, S. S. Medical College, Rewa, Madhya Pradesh, India

Retinopathy as a prognostic marker in cerebral malaria

ObjectivesTo study the association between fundal changes (malarial retinopathy) and mortality in children with cerebral malaria.Methods50 consecutive children (mean age 8.4 y, 23 males) with cerebral malaria (acute febrile encephalopathy and either peripheral smear or Rapid diagnostic test positive for malaria) were evaluated by a single ophthalmologist for any changes of retinopathy. Children were managed as per standard guidelines for treatment of cerebral malaria.ResultsP. vivax infection was seen in one child, P. falciparum infection in 42 children, and a mixed infection in 7. Retinopathy was present in 48% of the children. 13 children died during hospital stay. The mean interval from admission to fundus examination was 11.6 (4.64) h. Presence of ‘any retinopathy’ (P=0.02), and either of papilledema (P=0.02), hemorrhages (P=0.005) or vessel changes (P=0.01), were associated with a significantly higher risk of death.ConclusionsMalarial retinopathy is significantly associated with mortality in children with cerebral malaria. It may be used for both prognostication, and triaging for optimum utilization of intensive care facilities in these children.

Drowning - An Unnoticed Leader of Childhood Morbidity and Mortality

Drowning is one of the leading causes of childhood morbidity and mortality in developing countries often goes unnoticed as compared to communicable disease deaths. In 1997, drowning was described as “the final frontier of injury prevention”, because of the scarcity of evidence for the effectiveness of intervention strategies. Since that time, though, a certain amount of progress has been made. A 2005 assessment of the data supplied by WHO’s 192 member countries, 114 had either no drowning data available or no data more recent than 1990 to report. It is one of the most tragic condition seen in paediatrics and the fact that most episodes are preventable by simple measures add to the tragedy. Having established that drowning is a significant and preventable cause of death in children, we need to focus on this neglected matter into one that is addressed at national and international levels.