Supplementation of Lactobacillus acidophilus in prevention of necrotizing enterocolitis in preterm newborns Sonia G Al Sharkawy, Amany M El-Kelany, Mohamed A Al Said Alexandria Journal of Pediatrics 2019 32(1):1-5 Background Necrotizing enterocolitis (NEC) is a serious worldwide health problem in preterm neonates, especially those with very low birth weight. Probiotics may play a role in prevention of NEC and NEC-related mortality. Aim The aim of this study was to evaluate the possible role of Lactobacillus acidophilus in reducing the incidence of NEC (Bell’s stage≥2) and NEC-related mortality. Patients and methods A prospective, blinded, randomized controlled trial was conducted at NICU of Suez Canal University Hospital, Egypt. We studied 100 preterm (≤34 weeks of gestational age) neonates who survived to feed, and they were assigned randomly into two equal groups. The intervention group received L. acidophilus at the first feeding twice daily for 6 weeks or discharge from NICU and the control group did not. Clinicians responsible for the neonates were blinded to the group assignment. Results Probiotic supplementation was associated with significant reduction in incidence of NEC (P<0.05) but did not reduce NEC-related mortality (P=1). Infants in the probiotic group had less gastrointestinal intolerance manifestations than the control group (P=0.027). Conclusion Oral L. acidophilus can reduce the occurrence of NEC (Bell’s stage≥2) and gastrointestinal intolerance manifestations in preterm neonates.

Effect of health education about proper inhaler technique among asthmatic children/caregivers Nihal M El Rifai, Hoda I Rizk Alexandria Journal of Pediatrics 2019 32(1):6-11 Background Inhalation therapy is the cornerstone for asthma management, and it has been reported by several studies that a correct inhalation technique is required for achievement of proper disease control. Objective This study attempted to assess the inhaler technique in Egyptian children with asthma, identify the factors affecting improper technique, and evaluate the effect of educational intervention in improving the technique and asthma control. Patients and methods This pre–post clinical trial included a random sample of 350 asthmatic children aged 2–12 years, following up at the Allergy Clinic, Faculty of Medicine, Cairo University. They were diagnosed as having asthma according to GINA guidelines and were on inhaled corticosteroids using metered-dose inhaler (MDI) or dry-powder inhaler (DPI) for at least 3 months. Children’s inhalation technique was observed and assessed by the study researcher formerly, and then educational intervention was given, which was then followed by reassessment during the next follow-up visit, and the patient’s level of control was determined during each visit. The study was carried out from 30 June to 31 December 2018. Results Longer duration of inhaler use, regular follow-up, maternal education, and receiving education from a qualified trainer were significantly associated with a proper educational technique (P<0.001). Patients with correct inhalation technique were found to be more controlled compared with incorrect users (P<0.001). The most frequent incorrect step for children using a MDI with spacer was shaking the inhaler, MDI without spacer was coordinating the actuation-slow deep inhalation (53.8%), and DPI was loading the dose properly before each use (65%). After educational training, significant improvement for most of the steps was found (P<0.001) and a significant better asthma control was reached (P<0.001). Conclusion Repeated education, checking, and correction of the inhaler steps are required to reach a proper reliable inhalation technique and better asthma control.

Use of inhaler devices in the asthma clinic of Alexandria University Children’s Hospital Maged M Eissa, Ghada M El-Deriny, Fares A Koretam Alexandria Journal of Pediatrics 2019 32(1):12-18 Background Asthma is the most common chronic noncommunicable disease among children. High rates of incorrect inhaler use among children with asthma have been reported and are associated with worse outcomes. Aim This study was designed to state the types of inhaler devices and to evaluate inhalation techniques and their relation to control of asthma Patients and methods The study was conducted on 130 asthmatic children on inhaled corticosteroids at the age between 1 and 14 years attending the asthma clinic of Alexandria University Children’s Hospital, Egypt. The cases were subjected to detailed history. A preprepared questionnaire about the type of inhaler device and their correct use by the caregivers or older children was conducted. Correlation between inhaler techniques and asthma control according to Global Initiative for Asthma guidelines was done. Results The number of patients who used meter dose inhaler (MDI)-spacer, turbuhaler, and aerolizer was 115, 8, and 7, respectively. The percentage of children having wrong inhalational techniques was 21.74, 25, and 14.28% for MDI-spacer, turbuhaler, and aerolizer, respectively.Wrong technique has a significant relation with asthma control in the three devices (P<0.05).There was a significant relation between the control of asthma and all MDI-spacer parameters except for the spacer type. Presence of cracks, absence of valves, wrong method of cleaning of spacer, and not counting doses are all associated with poor asthma control (P<0.05) while the type of spacer has no effect on control of asthma. Conclusion Poor inhalational technique is associated with poor asthma control and regular assessment of inhalational technique in asthmatic children is recommended.

Predictive value of neutrophil gelatinase-associated lipocalin and E-selectin in pediatric sepsis Hanan A El-Sattar El-Halaby, Mayada S Zeid, Maysaa E Zaki Alexandria Journal of Pediatrics 2019 32(1):19-26 Background Sepsis is a leading cause of death in infants and children; early prediction could save patients’ lifes. Aim The aim of this study was to explore the role of neutrophil gelatinase-associated lipocalin (NGAL) and E-selectin in measurements in diagnosing and predicting mortality in patients with suspected sepsis and to identify whether their concentrations differ with blood culture results. Patients and methods This is a two-phase study; the first is a comparative and the second is a cross-sectional one, performed in Mansoura University Children’s Hospital from January to December 2017. The study involved100 children with clinically suspected sepsis and 40 healthy children (the control group). NGAL, E-selectin, C-reactive protein, total leukocyte count, and blood culture were assessed. Patient survival was recorded within 30 days of hospital admission. The study was performed after local institutional review board approval. For parametric data, t-test was used and for threshold value detection receiver operating characteristic curves were used. Results Significantly higher NGAL, E-selectin, C-reactive protein, and total leukocyte count levels were recorded in patients with clinically suspected sepsis than healthy participants; also, they were significantly higher in nonsurvivors. receiver operating characteristic curves for 30-day patients’ mortality showed E-selectin was a good discriminator (area under the curve=0.841), whereas area under the curve was 0.667 for NGAL. E-selectin was significantly higher in the culture-positive group (P=0.012), whereas NGAL did not differ significantly (P=0.153). Conclusion E-selectin and NGAL are diagnostic markers for sepsis. E-selectin is a sensitive prognostic biomarker in patients with clinically suspected sepsis whereas NGAL is less sensitive. E-selectin is significantly higher in blood culture-positive patients with sepsis whereas NGAL did not differ significantly.

Prognostic scoring systems in pediatric ICUs: Pediatric Risk of Mortality III versus Pediatric Index of Mortality 2 Ragia A.M Yousef, Fady M El Gendy, Alyaa A Abd El Aziz Alexandria Journal of Pediatrics 2019 32(1):27-32 Background Estimations of disease severity and probability of death are important elements in determining the prognosis of patients in pediatric ICU (PICU), and a more accurate prognostic assessment can lead to more appropriate monitoring, proper management, and family counseling. Objective The aim of the study was to compare the performance of the PRISM III (Pediatric Risk of Mortality III) and the PIM2 (Pediatric Index of Mortality 2) scores at PICU and to investigate the relation between scores and mortality. Patients and methods A prospective observational cohort study was conducted at PICU, Menoufia University Hospital, Egypt, during the period of February to October 2017. The study was approved by the Ethical Committee of Menoufia University Hospital. A total of 50 patients were included during the study period. Within the first hour of admission, PIM2 and PRISM III scores were applied. Patients were followed up for outcome, measured in the form of survivors and nonsurvivors. Results A total 50 patients were included, of whom 35 were survivors and 15 were nonsurvivors. Most survivors and nonsurvivors were females, but there was no statistical significant influence on outcome. The area under the receiver operating characteristic curve was 0.937 (0.863–1.000) for PRISM III and 0.870 (0.759–0.99) for PIM2. There was a positive correlation between the two scores on the day of admission. Conclusion Both PRISM III and PIM2 scores have a good discriminatory performance. PRISM III has better discrimination ability on admission in comparison with PIM2.

Comparison between nasal continuous positive airway pressure and mechanical ventilation after surfactant administration in preterm neonates with respiratory distress syndrome Hesham A Ghazal, Hassan H Hassan, Mohammed E.A El-Khouly Alexandria Journal of Pediatrics 2019 32(1):33-40 Background Preterm birth continues to be one of the major challenges in perinatal medicine. Prematurity and its associated complications are associated with high morbidity and mortality. Respiratory distress (RD) is the single major cause of illness and death in preterm infants. Aim The aim of this study was to evaluate the outcomes of the use of nasal continuous positive airway pressure (NCPAP) compared with invasive mechanical ventilation (MV) after surfactant administration in preterm neonates with RD syndrome. Patients and methods This randomized controlled clinical study was conducted on 82 preterm neonates with gestational age 28–34 weeks with RD secondary to RD syndrome. Patients were randomized into two groups: 41 received NCPAP and 41 received MV following surfactant administration. The primary outcome was improvement of oxygenation parameters and the need for MV between study enrollment till hospital discharge. Secondary outcomes included incidence of pneumothorax, intraventricular hemorrhage (IVH), patent ductus arteriosus, late-onset sepsis, bronchopulmonary dysplasia, days of oxygen therapy, days of MV, and length of hospital stay. Results Only 26.8% of neonates who received NCPAP needed MV. The application of NCPAP immediately after surfactant administration was significantly associated with a lower incidence of complications, namely, pneumothorax (7.3 vs. 36.6%) and IVH (17.1 vs. 41.5%). There was no significant difference between studied groups regarding the duration of hospital stay, incidence of late onset sepsis, ventilator-associated pneumonia, and patent ductus arteriosus. Conclusion The application of NCPAP immediately after surfactant administration reduces the need for MV, with a resulting lower incidence of complications such as pneumothorax and IVH.

Behavioral problems in children with epilepsy: a case–control study Noha T El Tantawi, Ibrahim Hamdey Alexandria Journal of Pediatrics 2019 32(1):41-45 Background Epilepsy is a disease that is not inclusive of seizures only, as there are behavioral, psychiatric, and cognitive disorders linked to it. Objective This study aims to compare the frequency and type of behavioral problems in children with epilepsy less than 5 years old versus healthy controls. Patients and methods This study is a case–control study conducted from April 2016 to April 2018 in the Neurology Clinic of Mansoura University Children Hospital. Inclusion criteria were age between 1.6 and 5 years old, diagnosis of epilepsy for 1 year at least, and regular follow-up. Excluded were children with cerebral palsy, developmental delay, mental retardation, and neurodegenerative and metabolic disorders. For matching by age and sex, the healthy group was sampled after the epilepsy group. The parents of both groups were interviewed to complete the child behavior checklist. Results The patients with epilepsy had higher child behavior checklist scores when compared with healthy children in different domains of withdrawal (P=0.001), sleep problems (P=0.02), attention-deficit problems (P<0.001), and aggressive behavior (P<0.001). Patients with epilepsy had lower intelligence quotient scores than healthy children (84.06±4.9 versus 97.6±13.7, respectively). Epileptic patients with duration of epilepsy more than 3 years, those who have multiple seizure types, and those who were on polytherapy were affected more. Conclusion Childhood epilepsy can be associated with behavioral problems, which could be related to the age of onset, type of seizure, antiepileptic drugs, and duration of epilepsy.

Study of pulmonary artery banding surgery in children with congenital heart disease in Alexandria, Egypt Ibrahim Elkhadragi, Mostafa Kamal ElHamamy, Hani M Adel, Amr Elgarhy Alexandria Journal of Pediatrics 2019 32(1):46-50 Background The technique of pulmonary artery banding (PAB) was described in 1952 by Muller and Dammann for protecting the lungs in large ventricular septal defect. Subsequently, it was used also in congenital heart diseases with unprotected pulmonary blood flow. The main problem in performing PAB is the optimal intraoperative adjustment of band tightness, which is based mainly on the invasive measurement of pulmonary artery pressure (PAP) and systemic blood pressure. Objective To study the efficiency of a simple and reproducible surgical protocol, based primarily on intraoperative systemic oxygen saturation (SaO2) monitoring using pulse oximetry, to achieve effective PAB in infants with congenital heart diseases, presenting to the Cardiothoracic Surgery Department of Alexandria University. Patients and methods The study included 20 infants with congenital cardiac anomalies referred to the Cardiothoracic Surgery Department of the Alexandria University for PAB. They were operated upon in the period from January 2012 till August 2013. The preliminary band length was calculated by Trusler’s formula. Adjustment of the band was based on the SaO2% at fraction of inspired oxygen (FiO2) 50%. Intraoperative invasive PAP and systemic arterial blood pressure were measured for study purpose. Echo-Doppler gradient across the band was determined on the operative day and after 1 month to assess the immediate and short-term efficacy of the studied surgical protocol. Results The age of the patients ranged from 1.5 to 9 months and their weight ranged from 2.2 to 5 kg. Four infants had Down syndrome. Based on systemic SaO2 at FiO2 of 50%, the PAB had to be readjusted in 10 (50%) infants, in the form of tightening of the band in seven (35%) infants and loosening of the band in three (15%) infants. No readjustment of the band was required in the other ten infants. There was a significant increase of mean arterial blood pressure and a significant decrease of PAP after PAB. The mean PAP/mean arterial blood pressure ratio was 74.38±10.72% before banding and 32.10±8.16% after banding. The mean echo-Doppler gradient across the band was 54.45±4.88 mmHg on the operative day and 66.78±7.61 mmHg after 1 month. Conclusion Intraoperative systemic SaO2 measurement using pulse oximetry at FiO2 of 50%, proved to be an efficient tool to calibrate the degree of tightness of the PAB.

Assessment of corrected QT interval in children with type 1 diabetes mellitus Tarek El-Walili, Hani M Adel, Shaymaa E Abdel Meguid, Asmaa I.K Elsayed Alexandria Journal of Pediatrics 2019 32(1):51-54 Background Type 1 diabetes mellitus (T1DM) is associated with increased risk for cardiovascular complications. It was reported that children and adolescents with T1DM have a six-fold greater risk for prolongation of the QT interval. QT prolongation has been suggested as an independent marker of increased mortality in patients with T1DM. Objective To study the corrected QT (QTc) interval in children attending the Alexandria University Children’s Hospital with T1DM and its relation to the glycemic control and duration of the disease. Patients and methods The study included 60 children with T1DM (aged 4–15 years) compared with 60 healthy matched children. All children were subjected to thorough history taking and clinical examination. The QT interval was measured on 12-lead resting electrocardiogram and the QTc was calculated using Bazett’s formula, in all cases and controls. The glycosylated hemoglobin (HbA1c%) was measured in all cases and controls. Results One-third of the diabetic children had prolonged QTc interval (≥0.45 s), whereas all controls had normal QTc interval (<0.45 s). The great majority (95%) of the patients with prolonged QTc interval had inadequate glycemic control (HbA1c >7.5%). A significant positive correlation was found between the QTc interval and both the HbA1c% and the duration of diabetes. Conclusion Prolongation of the QTc interval is very prevalent among children with T1DM attending the Alexandria University Children’s Hospital. This is tied to the poor glycemic control and duration of diabetes. Therefore, good glycemic control and follow-up of QTc interval are mandatory to minimize the potential for life-threatening events among our diabetic children.

Registry of ocular anomalies among patients with genetic disorders in Alexandria and nearby governorates Iman M Marzouk, Nehal M Elshakankiry, Afaf G Ibrahim, Shimaa A.M Anwar, Shaimaa M Awadallah Alexandria Journal of Pediatrics 2019 32(1):55-60 Background The eye is second only to the brain as an individual organ in its frequency of involvement in genetic disorders. The array of ocular findings associated with developmental disorders, metabolic diseases, and chromosomal anomalies is endless. Aim To determine the prevalence and describe types of ocular malformations among patients with genetic disorders attending the Genetic Clinic of Alexandria University Children’s Hospital from January 2015 to December 2017. Patients and methods In this study, 354 patients were included. Patients’ data were collected from records as follows: the age and sex of the patients, residence, parental consanguinity, family history, pre/perinatal history, and data of general examination and ophthalmic examination. Results Of 354 patients who were enrolled in this study, 83 (23.4%) patients had genetic ocular malformations, 16 cases had corneal clouding, 15 cases of ptosis, 10 cases of strabismus, nine cases of refractive errors, and six cases of microphthalmia. The age variation in the study was between 8 days and 14 years, and 55.4% of cases were below the age of 2 years. Male : female ratio was 1.1 : 1. Overall, 61.4% of cases had positive history of consanguineous marriage, and 9% of cases had a positive prenatal history. Moreover, 4.8% of cases with ocular malformations had chromosomal abnormality, in which 3.6% were numerical (Trisomy 13) and 1.2% were structural (deletion 18q). Genetic diseases associated with ocular malformations could be classified into isolated (nonsyndromic) disorders, which represented 3.6%, and syndromic disorders, which represented the remaining 96.4% of cases. Isolated disorders included primary microcephaly (2.4%) and blepharophimosis, ptosis, and epicanthus disease (1.2%), whereas the syndromic cases included chromosomal disorders (4.8%), metabolic disorders (26.5%), syndromes with primary dermatological abnormalities (7.2%), syndromes with primary skeletal abnormalities (19.2%), syndromes with endocrine/growth retardation (28.6%), syndromes with primary neurologic abnormalities (7.2%), and others (4.2%). Conclusion Overall, 23.4% of patients with genetic syndromes had ocular malformations. The most common anomaly was congenital corneal clouding (19.3%) followed by ptosis (18%), strabismus (12%), refractive errors (10.8%), and microphthalmia (7.2%) in the order of frequency.