Response from Dilip Dan to Commentary from Inge on CaseReport OBSU-D-09-00159

We would like to thank Professor Inge for his commentary and agree with most of the comments. It has been said that the first step of a journey is usually the most important and often the most difficult. This case was the first in our collective experience and provided an extraordinarily difficult therapeutic challenge. The risk/benefit ratio of bariatric surgery is well established in the morbidly obese adult and is under current investigation in teenagers. The decision to undertake a sleeve gastrectomy in one so young and with such debility as in the current case was the Aristotelian mean of cost, benefit, availability, feasibility, and accessibility of therapeutic options. We agree that our work with this child has just begun!

Bariatric surgery in the management of childhood obesity: should there be an age limit?

We report a case of a 6-year-old girl suffering from morbid obesity, Blount;s disease, and significant social and functional impairment who underwent a laparoscopic sleeve gastrectomy. One year later, she has shown remarkable improvement in all aspects of her health emphasizing the success of the procedure. A follow-up laparoscopic Roux-en-Y gastric bypass or biliopancreatic diversion (BPD) are options if she regains weight as she gets older. This case is noteworthy for several reasons. The age of the patient is younger than any currently on record who has had this treatment. Additionally, the utilization of a sleeve gastrectomy as a first-step procedure, to be followed by Roux-en-Y gastric bypass or BPD, remains a novel treatment for morbid obesity in a pediatric population.

Caregivers' practices, knowledge and beliefs of antibiotics in paediatric upper respiratory tract infections in Trinidad and Tobago: a cross-sectional study

BACKGROUND: Antibiotic overuse and misuse for upper respiratory tract infections in children is widespread and fuelled by public attitudes and expectations. This study assessed knowledge, beliefs, and practices regarding antibiotic use for these paediatric infections among children's caregivers' in Trinidad and Tobago in the English speaking Caribbean. METHODS: In a cross-sectional observational study, by random survey children's adult caregivers gave a telephone interview from November 1998 to January 1999. On a pilot-tested evaluation instrument, respondents provided information about their knowledge and beliefs of antibiotics, and their use of these agents to treat recent episodes (< previous 30 days) of upper respiratory tract infections in children under their care. Caregivers were scored on an antibiotic knowledge test and divided based on their score. Differences between those with high and low scores were compared using the chi-square test. RESULTS: Of the 417 caregivers, 70% were female and between 18-40 years, 77% were educated to high school and beyond and 43% lived in urban areas. Two hundred and forty nine (60%) respondents scored high (>or12) on antibiotic knowledge and 149 (34%) had used antibiotics in the preceding year. More caregivers with a high knowledge score had private health insurance (33%), (p < 0.02), high school education (57%) (p < 0.002), and had used antibiotics in the preceding year (p < 0.008) and within the last 30 days (p < 0.05). Caregivers with high scores were less likely to demand antibiotics (p < 0.05) or keep them at home (p < 0.001), but more likely to self-treat with antibiotics (p < 0.001). Caregivers administered antibiotics in 241/288 (84%) self-assessed severe episodes of infection (p < 0.001) and in 59/126 (43%) cough and cold episodes without visiting a health clinic or private physician (p < 0.05). CONCLUSIONS: In Trinidad and Tobago, caregivers scoring low on antibiotic knowledge have erroneous beliefs and use antibiotics inappropriately. Children in their care receive antibiotics for upper respiratory tract infections without visiting a health clinic or a physician. Educational interventions in the community on the consequences of inappropriate antibiotic use in children are recommended. Our findings emphasise the need to address information, training, legislation and education at all levels of the drug delivery system towards discouraging self-medication with antibiotics in children.

The changing face of paediatrics in the English-speaking Caribbean

Childhood mortality and morbidity patterns in the English-speaking Caribbean have changed significantly over the past 40 years. Acute respiratory illness, physical injury and conditions originating in the perinatal period have replaced malnutrition, gastroenteritis and other infectious diseases as major causes of illness and death in Caribbean children. Although population growth has slowed down, about one-third of the population of the English-speaking Caribbean remains under the age of 15 years. Infant mortality rates have also fallen but the major contributor to this decline has been a reduction in post-neonatal deaths. The decrease in mortality and morbidity from infectious diseases has led to a prominence of disorders originating in the perinatal period, psychosocial problems and chronic childhood disorders. Adverse economic conditions are held culpable for the re-emergence of protein energy malnutrition (PEM) and pulmonary tubercolosis in some territories. There is an urgent need to focus attention on the areas of perinatal and adolescent health, childhood disability, accidental and non-accidental injury, sexual abuse and human immunodeficiency virus (HIV) infection. Immunization programmes also require continuing support and expansion. These tasks cannot be accomplished without meaningful long term investment of financial and human resources in the health and educational services of the region (AU)

Pediatric injuries presenting to an emergency department in a developing country

PURPOSE: To describe the causes and outcomes of pediatric injuries using the emergency departments (ED) as a surveillance site. METHOD: Prospective, 14-days surveys of all injuries were conducted in the EDs of the two national trauma referral hospitals of Trinidad and Tobago. Data on patient demographics, type, cause, and outcome of injuries were collected. The chi 2 test for significance was was used for categorical variables. RESULTS: Pediatric patients (< 20 years) accounted for 41.5 percent (714/1722) of injury visits. Of these, 62.6 percent were male and 17.4 percent were < four years old, 26.2 percent four to nine years, 31.1 percent 10 to 14 years, and 25.4 percent were 15 to 19 years old. Three patients (0.4 percent) died, 68.6 percent were discharged, and 31.0 percent admitted. Intentional injuries accounted for 13.9 percent of injuries. Of the intentional injuries, the assailant was significantly more likely to be known than not (P < 0.01). The most common causes of all injuries were: falls, 44.4 percent; blunt objects, 12.3 percent sharp objects, 11.8 percent; motor vehicle (including pedestrians), 7.4 percent; poison, 3.6 percent and burns 1.7 percent. Injuries occurring in the home accounted for 46.2 percent in school, 25.5 percent; sports/recreation, 11.1 percent and at work, 4.5 percent. The contusion/abrasions, 26.7 percent fractures, 18.8 percent; and sprains/dislocations, 9.4 percent. CONCLUSION: Pediatric injuries are significant cause of morbidity and mortality in this country, accounting for almost one third of injured patients. Because of the low frequency of pediatric injury deaths, ED surveillance may be a more effective means of identifying high risk groups and activities for injuries. Data from the EDs may be useful in other developing countries to develop injury prevention programs.(AU)

Prevalence of paediatric skin diseases in rural Honduras

Although review of medical literature suggests that skin disease is a common cause of morbidity in developing countries, there have been few prospective primary care studies to document the prevalence of dermatologic conditions. The goal of this study was to determine the prevalence of paediatric skin diseases in rural Honduras. The study was conducted in October 1992, during a medical mission sponsored by the University of Cincinnati, Children's Hospital Medical Center (Cincinnati) and the Honduran Ministry of Health (AU)

Multicultural paediatrics ... Toronto 1993: the new reality - abstract

The new reality of practising paediatrics in Toronto, 1993, is recognition of the city's great ethnic and cultural diversity. The multicultural mix of initial European immigrants and the later influx from the Caribbean, S.E. Asia, Hong Kong, India, Pakistan, Sri Lanka, Africa, South America, the Middle East, Eastern Europe and the former Eastern Block, creates challenges to the practice of medicine and paediatrics. We are now faced with a new medicine - of unusual diseases, homeopathy and herbal medicines of many cultures and of differing concepts of child care and discipline. Language difficulties and distortion from nuances of language, traditional and cultural expectations, adaptation, assimilation and cultural changes, all produce tremendous pressures on children and family. Specifically, the cultural and religious diversity of the new immigrants with differing views on childbirth, child rearing, nutrition

The changing pattern of paediatrics in Barbados: a twenty-year study - abstract

The admissions to a Paediatric Unit during the years 1962, 1965 and 1981 have been analysed and compared, special attention being paid to the number and cause of deaths. In 1962 the Unit was small, inadequate, overcrowed and understaffed. Malnutrition pervaded all admissions, and the mortality rate was high. There was a high admission for preventable infectious disease. During the first year (1965) at the new Queen Elizabeth Hospital, we were still overcrowded and understaffed. Malnutrition and preventable infectious diseases were still common. The incidence of bronchial asthma was rising and occasional cases of diabetes mellitus and noeplastic disease were seen. In 1981 we had a better staffed unit with five consultants, three registrars and five house officers. The department was also responsible for a 25-bed Premature Baby Unit and all neonatal babies. We were not as over crowded as previously. Malnutrition has been all but conquered. Accidental poisoning remains a major preventable disease while preventable infectious diseases, except gastroenteritis, have been controlled. Bronchial asthma has appeared as a major paediatric problem and congenital abnormalities, neoplastic disease and diabetes mellitus are major causes for concern. Congenital malformatioins and overwhelming infections are now the major causes of death in the Unit (AU)