Israel Medical Association Journal

Background: Acute renal failure (ARF) is a common complication in critically ill children. It is known as an important predictor of morbidity and mortality in this population. Data on the factors affecting the choice of renal replacement therapy (RRT) modality and its impact on mortality of children with ARF[1] are limited.

Objectives: We retrospectively studied 115 children with ARF necessitating RRT[2] during the period 1995–2005 to evaluate the effect of several prognostic factors as well as RRT type on their immediate outcome.

Methods: The data collected from charts included demographics, primary disease, accompanying medical conditions, use of vasopressor support, indications for dialysis, RRT modality, and complications of dialysis. Categorical variables were analyzed using chi-square or Fisher’s exact tests. Variables associated with mortality (P < 0.1) at the univariable level were studied by a multivariable logistic regression model.

Results: The most common cause of ARF was congenital heart disease (n=75). RRT modalities included peritoneal dialysis (PD) (n=81), hemodialfiltration (HDF) (n=31) and intermittent hemodialysis (IHD) (n=18). Median RRT duration was 4 days (range 1–63 days). Overall mortality was 52.2%. IHD[3] was associated with the best survival rate (P < 0.01 vs. PD[4] and HDF[5]), while children treated with HDF had the worse outcome. Hemodynamic instability and systemic infections were associated with greater mortality, but the rate of these complications did not differ between the study groups.

Conclusions: Our results suggest that IHD[6] when applied to the right patient in an appropriate setting may be a safe and efficient RRT modality in children with ARF. Randomized prospective trials are needed to further evaluate the impact of different RRT modalities on outcome in children with ARF.

Background: Survival in T cell lymphoblastic lymphoma has improved over the past 30 years, largely due to treatment protocols derived from regimens designed for children with acute lymphoblastic leukemia.

Objectives: To assess the outcome of the NHL-BFM-95 protocol in children and adolescents hospitalized during the period 1999–2006.

Methods: We conducted a retrospective multi-institutional, non-randomized study of children and adolescents up to age 21 with T cell lymphoma admitted to pediatric departments in six hospitals in Israel, with regard to prevalence, clinical characteristics, pathological characteristics, prognostic factors, overall survival (OS) and event-free survival (EFS). All patients had a minimal follow-up of one year after diagnosis. The study was based on the NHL[1]-BFM[2]-95 protocol.

Results: At a median follow-up of 4 years (range 1–9 years), OS and EFS for all patients was 86.5% and 83.8%, respectively. OS was 86.7% and 83.3% for patients with stage III and stage IV, respectively, and EFS was 83.3% and 83.3%, respectively. EFS was 62.5% for Arab patients and 89.7% for Jewish patients (P = 0.014). Patients who did not express CD45 antigen showed superior survival (P = 0.028). Five (13.5%) patients relapsed, four of whom died of their disease. Death as a consequence of therapy toxicity was documented in one patient while on the re-induction protocol (protocol IIA).

Conclusions: Our study shows that OS and EFS for all patients was 86.5% and 83.8%, respectively.

Background: For health professionals who interact professionally with children, adequate awareness and training regarding the clinical indicators of child abuse and neglect, as well as subsequent reporting and procedures, are essential.

Objectives: To study Israeli health professionals’ experiences with identification and reporting of suspected cases of child abuse and neglect, and their perceived training needs in this area.

Methods: The study group was a convenience sample comprising 95 Israeli health professionals (physicians, nurses, social workers, psychologists, etc.) attending workshops on medical aspects at a national conference on child abuse and neglect. The study was a cross-sectional survey. The health professionals were asked to complete an anonymous structured questionnaire on their experience with child abuse and neglect and on their training needs.

Results: The participants in the survey had relatively high levels of involvement with child protection. Nevertheless, they strongly expressed their need for training, especially in mastering practice skills. The need for training was greater for professionals with less experience in child protection, and there were different needs according to profession.

Conclusions: Despite their prior extensive experience in dealing with child abuse and neglect, most of the health professionals participating in the conference reported the need for training in various areas.

Background: Data regarding the validity of self-reported weight and height in adolescents are conflicting.

Objectives: To evaluate the validity of self-reported weight and height among 13–14 year old schoolchildren. 

Methods: We conducted a cross-sectional study of 517 schoolchildren aged 13–14 years and compared self-reported and measured weight and height by gender, population group, parental education and crowdedness.

Results: Females under-reported their weight on average by 0.79 ± 5.46 kg (P = 0.03), resulting in underestimation of the body mass index with borderline significance (mean difference 0.28 ± 2.26 kg/m², P = 0.06). Males over-reported their height on average by 0.75 ± 5.81 cm (P = 0.03). Children from less crowded homes (≤ 1 person per room) overestimated their height more than children from more crowded homes, resulting in a significant underestimation of BMI[1] (mean difference between reported BMI and measured values was 0.30 ± 2.36 kg/m², P = 0.04). Measured BMI was a significant predictor of the difference between self-reported and measured BMI, adjusted for gender, population group, parents' education, and crowdedness (β = -0.3, P < 0.0001). As a result of this reporting bias, only 54.9% of children with overweight and obesity (BMI ≥ 85th percentile) were classified correctly, while 6.3% of children were wrongly classified as overweight and obese. The largest difference in BMI was observed in obese females (4.40 ± 4.34) followed by overweight females (2.18 ± 1.95) and underweight females (-1.38 ± 1.75). Similar findings were observed for males, where the largest difference was found among obese males (2.83 ± 3.44).

Conclusions: Studies based on self-reported weight and height in adolescents may be biased. Attempts should be made to correct this bias, based on the available data for each population.

Background: Poisonings are a significant cause of pediatric morbidity and mortality. The Israel Poison Information Center provides clinical consultations on poisonings and drug information 24 hours a day.

Objective: To evaluate epidemiologic characteristics of pediatric poison exposures in Israel.

Methods: We reviewed computerized queries and performed a descriptive analysis of the Poison Center database pertaining to patients less than 18 years old during 2007.

Results: A total of 15,005 pediatric poison exposures were recorded, 80.3% of them occurring in children under 6 years old. Of the calls to the Poison Center, 78.6% were made by the public, 20.7% by physicians, and in 74.4% the call was within 2 hours of exposure. Most exposures occurred at home (89.3%) and were unintentional (89.5%). Among adolescents, most exposures were intentional (49.3%, 38.2% suicides), the time lapse until consultation was longer (37% > 2 hours), and more physicians (54.8%) consulted the Poison Center. Most cases were asymptomatic or mildly affected (92.3%), 54.4% in adolescents. The commonest substances involved in single poison exposure were detergents, antimicrobials, topical preparations, acetaminophen and scale removers; in adolescents the most common substances were acetaminophen, methylphenidate, non-steroidal anti-inflammatory drugs, atropine and ethanol. Moderate to severe toxicity was commonly associated with organophosphates, alkali, ethanol, Vipera palaestinae and neuroleptics. Most patients could be observed at home (66.6%), while more adolescents were referred to emergency departments (42.2% vs. 9.9%) or hospitalized (14.5% vs. 1.9%).

Conclusions: Pediatric poisonings are a significant health problem. The magnitude of the problem is greater in the young age group but more severe in adolescence, probably due to deliberate self-poisoning. Greater national efforts should be directed towards improved poison prevention, rational management of pediatric poisoning, and creating a national poisoning registry.
 

Immunization coverage is a major health indicator. In Israel, routine childhood immunizations are provided at community public well-baby clinics. Immunization monitoring is an important cornerstone of a national health policy however, data obtained through sampling carries the risk of under-representation of certain population strata, particularly high risk groups. Despite high national average immunization coverage, specific sub-populations are under-immunized, as highlighted by outbreaks of vaccine-preventable diseases. The mean national immunization coverage at age 2 years (2006 data) was: DTaP[1]-IPV[2]-Hib4[3] (all 93%), HBV[4]3 (96%), MMR1[5] (94%), HAV1[6] (90%). These reports are based on a 17% population-based sample in some districts and on cumulative reports in others. A national immunization registry requires data completeness, protection of confidentiality, compulsory reporting by providers, and links to other computerized health records. It should provide individual immunization data from infancy to adulthood and be accessible to both providers and consumers. In 2008 the Israel Ministry of Health launched a national immunization registry based on immunization reporting from well-baby clinics using a web-based computerized system. As of January 2010, 120 well-baby clinics are connected to the nascent registry, which includes the records of some 50,000 children. The implementation of a comprehensive national immunization registry augurs well for the prospect of evidence-based assessment of the health status of children in Israel. 

 
[1] DTaP = diphtheria-tetanus-acellular pertussis

[2] IPV = inactivated polio vaccine

[3] Hib = Haemophilus influenzae b

[4] HBV = hepatitis B virus

[5] MMR = measles-mymps-rubella

[6] HAV = hepatitis B virus

Background: Human parvovirus B19 is a global and common infectious pathogen in humans, primarily in children.

Objectives: To assess the immunoglobulin G seroprevalence of B19 in children in Israel.

Methods: Overall, 128 previously healthy children (1.5–17 years old) hospitalized for various diseases other than acute human parvovirus B19 infection were assessed for IgG[1] to the virus by enzyme-linked immunosorbent assay. 

Results: The IgG seroprevalence increased from 22% in children aged 1.5–9 years to 52% in older children (P = 0.001).

Conclusions: Our data suggest that most acute parvovirus B19 infections in Israel occur in the early school years, and that by 18 years of age 50% of Israeli children have been infected by the virus.

[1] IgG = immunoglobulin G

Background: An outbreak of pertussis occurred in a daycare center with 87.5% vaccination coverage.

Objectives: To assess the effectiveness of the acellular pertussis vaccine and prevention of pertussis after chemoprophylaxis with azithromycin.

Methods: We studied 31 daycare children aged 3–5.5 years exposed to a child with pertussis. Nasopharyngeal swabs were obtained for Bordetella pertussis culture and polymerase chain reaction initially, and at days 21 and 60 of follow-up, in cases exhibiting symptoms.

Results: Of the 31 daycare children 6 (19%) tested positive for B. pertussis by PCR[1], 4 of whom had not been vaccinated against the disease. Of the two vaccinated children who contracted pertussis, one had milder symptoms and the other was asymptomatic. The incidence of pertussis was significantly lower in the vaccinated group (2/27) than in the unvaccinated group (4/4) (P = 0.000), with efficacy of the vaccine calculated to be 92.5%. Azithromycin chemoprophylaxis was taken only by 14 of the 25 exposed children (56%). On day 21 follow-up, there was no further laboratory-diagnosed B. pertussis cases in any of the exposed children, regardless of whether or not chemoprophylaxis was taken.

Conclusions: Based on the children’s clinical manifestations and PCR findings a pertussis outbreak had occurred in the daycare center studied. Our findings support the importance of pertussis vaccination since all the unvaccinated children in the daycare center contracted the infection.