Scurvy in children - A neglected disease?

BACKGROUND: The incidences of pediatric scurvy has decreased substantially, particularly in developed countries, but there are still reports of it from developing countries. Unusual manifestations have led to delays in diagnosis and treatment. Nevertheless, there are few publications regarding misdiagnosis of scurvy. The objective is to determine dietary factors, clinical manifestations, laboratory and radiologic findings, treatment, and outcomes of scurvy cases. The occurrence of misdiagnosis and its associated factors are also explored. METHOD: The medical records of 0-18 year-old children from 2003 to 2016, diagnosed with scurvy, were included and reviewed. Clinical data, and data regarding feeding history, nutritional status, laboratory and radiologic findings, and misdiagnosis were collected. Univariate and logistic regression analysis were used for identification of the independent associated factors. RESULTS: The study consisted of 106 children. The boys-to-girls ratio was 2.2:1, and their mean age was 44.65 months ± 30.50 months. The common manifestations were refusal to walk, tenderness, and swelling at the lower extremities. Four participants had unusual manifestations including proptosis and scalp hematoma. Low serum vitamin C level and abnormal radiologic findings were detected in most patients. All of them fully recovered after receiving vitamin C supplementation. Misdiagnosis was identified in 74 cases (69%). Logistic regression analysis revealed that temperature higher than or equal to 38 °C, participants aged 3 years or below, and swelling at lower extremities were independently associated with misdiagnosis (adjusted OR 5.91, 3.78, and 3.56 respectively). CONCLUSIONS: Scurvy still exists, and misdiagnosis often occurs. Taking a careful medical history and conducting a physical examination are still the best way to diagnose scurvy.

Vitamin supplementation and related nutritional status in Thai children, aged 1-5 years.

OBJECTIVE: To evaluate the prevalence of vitamin supplementation in Thai children aged 1-5 years at Queen Sirikit National Institute of Child Health (QSNICH), parental knowledge of vitamins, practices, and related factors such as nutritional status in vitamin supplementation. MATERIAL AND METHOD: A cross-sectional study was performed at the Well Child Clinic, QSNICH, from 1-31 May 2005. Five hundred parents of young children, aged 1-5 years were interviewed by using the questionnaire to obtain information regarding knowledge and practices of vitamin supplementation. Weight and length/height were measured and nutritional status was assessed using the Thai growth reference. The relationships among vitamin supplement, nutritional status, and other related factors were analyzed using Chi-square test. The p-value < 0.05 was considered statistically significant. RESULTS: Prevalence of vitamin supplementation was 76%, including vitamin C 62%, multi-vitamin (MTV) 35%, and cod-liver oil 20%. Regarding parental knowledge of vitamins, 57% of them knew the health benefits but 74% did not know the toxic effects of vitamins. The reasons for vitamin supplementation were poor feeding 63%, under-weight 23% and unhealthy status 14%. Vitamins were obtained from over-the-counter 59%, health services 40%, and friends 1%. Vitamin supplementation was significantly higher in children over 2 years of age, whose parents knew the benefits of vitamins, and in those children with malnutrition. CONCLUSION: The prevalence of vitamin supplementation was high in malnourished children, over 2 years of age whose parents had knowledge about benefits of vitamins. Parents should be warned about the dangers of high dose of vitamin consumption.

Effect of folic acid supplementation on plasma homocysteine in obese children: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Obese children tend to consume less dietary folate, which is an important cofactor in remethylation of homocysteine to methionine. The deficiency of folate can lead to hyperhomocysteinemia. OBJECTIVE: To determine whether folic acid supplementation could reduce plasma homocysteine in obese children. MATERIAL AND METHOD: Obese children, aged 9-15 years with body mass index > median plus 2 SD according to WHO reference, were randomly assigned to 2 groups: receiving either 5 mg folic acid or placebo for 2 months. Fasting homocysteine, creatinine, folate, vitamin B12, insulin, glucose and lipid profiles were taken at baseline and the end of the study. Dietary vitamin B12, folate intake and physical activity were assessed using validated questionnaires. RESULTS: Fifty obese children (31 boys and 19 girls) took part in the study. Their mean age was 10.9 ± 1.6 years and mean BMI Z-score was 3.41 ± 0.69. After the intervention, plasma homocysteine decreased by 15.75% and 6.99% in the folic acid and placebo group, respectively (mean difference 8.76%; 95% CI: 0.26%, 17.25%, p = 0.044). This divergence was more pronounced in boys and it remained significant after adjusting for baseline homocysteine and other confounders. Subgroup analysis showed a larger magnitude of plasma homocysteine reduction in the low folate group (mean difference 12.24%; 95% CI: 1.39%, 23.09%). CONCLUSION: The homocysteine lowering effect of folic acid supplementation was found in obese children, especially in boys and those with low serum folate. Further long-term interventional studies are needed to determine the effects of the lowered plasma homocysteine on the cardiovascular outcomes of obese children. This trial was registered on clinicaltrials.gov (NCT01766310).

Nutritional status of pediatric patients with congenital heart disease: pre- and post cardiac surgery.

BACKGROUND: Malnutrition is common in infants and children with congenital heart disease (CHD). Cardiac surgery has improved patient survival and nutritional status. OBJECTIVE: To evaluate the impact of cardiac surgery on nutritional status of pediatric patients with CHD. MATERIAL AND METHOD: A prospective cohort study was conducted in pediatric patients with CHD, admitted for cardiac surgery at Queen Sirikit National Institute of Child Health (QSNICH), Bangkok, from August 1st, 2002 to 2003. Demographic data, cardiac and related problems were obtained before operation. Anthropometry was performed at the presentation and post cardiac surgery. Nutritional status was assessed by Z-score of weight for age (ZWA), weight for height (ZWH) and height for age (ZHA). Malnutrition was defined as Z-score <- 2 and compared pre- and post-operation using Chi-square. Paired t-test was used to compare mean Z-score and p-value < 0.05 was statistically significant. RESULTS: All of 161 pediatric patients with CHD undergoing cardiac surgery were 41% males and 59% females. Patients' age ranged from 1 month to 15 years. The related problems included low birth weight (28%) and feeding problem (58%). The most common CHD was ventricular septal defect (29%). The nutritional status of the patients before surgery was defined as normal 57%, malnutrition 40% and over-nutrition 3%. Malnutrition included underweight 28%, wasting 22% and stunting 16%. Post cardiac surgery, the means of ZWA, ZWH and ZHA were significantly increased and the prevalence of underweight and wasting were decreased to 17% and 6% respectively, with statistically significant from the baseline (p < 0.05). CONCLUSION: Malnutrition was found in 40% of pediatric patients with CHD and cardiac surgery has a significant positive effect on weight gain and nutritional status.

The effect of teacher education on the prevalence of obesity in kindergarten children.

BACKGROUND: Childhood obesity is increasing worldwide and becoming an important health problem in both the children's current life and their later years. Providing kindergarten teachers with the knowledge should reduce the severity of obesity and prevent childhood obesity. OBJECTIVE: To monitor the prevalence of over-nutrition and obesity in kindergarten children for 3 years, and to evaluate the effects of teacher education on the prevalence of over-nutrition and obesity. MATERIAL AND METHOD: Kindergarten children from 7 schools in Bangkok were enrolled in this cohort study for 3 years (2005-2007). Three school groups were classified according to the number of informed teachers in the school. The children's weight and height were measured yearly using standard instruments. Nutritional status was assessed by% weight for height (%W/H), using the Thai Growth Reference, 1999. After the second measurement, all teachers were informed directly at the schools. The prevalence of over-nutrition and obesity was assessed and compared among the 3 years, and the 3 groups, using Chi-square (chi 2) test. RESULTS: In the year 2005, 1,232 kindergarten children from 7 schools were enrolled. The prevalence of over-nutrition and obesity was 33% and 17.4% in 2005; 32.8% and 17.2% in 2006; 28.8% and 15.3% in 2007. In the 3rd year the prevalence of over-nutrition decreased statistically significantly from the first 2 years. The prevalence of over-nutrition and obesity in 3 years decreased insignificantly in each group. This showed the positive effects of the teacher education. CONCLUSION: Teacher education has effects in reducing the prevalence of over-nutrition and obesity in the kindergarten children.

Effects of multivitamin and folic acid supplementation in malnourished children.

OBJECTIVE: To study the effect of multivitamin and folic acid supplementation on serum folate level and weight gain. MATERIAL AND METHOD: A prospective randomized controlled study was conducted in malnourished children at the Nutrition Clinic, Queen Sirikit National Institute of Child Health from February to June 2000. History taking, weight-height measurement, and blood testing for complete blood count (CBC) and serum folate level were done. Patients were randomly by assigned into 2 groups. The study group was supplemented daily with multivitamins (MVD) along with a folic acid tablet while the control group was supplemented daily with MVD only, for 6 weeks. RESULTS: Twenty-nine malnourished children were enrolled in the present study. They were randomly by assigned into 2 groups, 14 children in the study group and 15 children in the control group. There were 11 boys (38%) and 18 girls (62%). Mean age was 36.3 months. Anemia and low serum folate level were found in 24 per cent and 21 per cent respectively. There was no significant difference in the data of both groups, except that anemia was more common in the study group (p = 0.018). After 6 weeks of supplementation, increases in weight and serum folate level were significantly higher in the study group, but there was no significant difference in weight increased between both groups. CONCLUSION: Folate deficiency may be found in malnourished children. Efficacy of folic acid supplement is good. Folic acid needs to be supplemented in malnourished children.

The nutritional status of outpatients at Queen Sirikit National Institute of Child Health.

OBJECTIVE: To study the nutritional status and prevalence of malnutrition in outpatients at Queen Sirikit National Institute of Child Health (QSNICH). MATERIAL AND METHOD: A cross-sectional study was done in outpatients at the Well-baby Clinic (WBC) and Outpatient Department (OPD), in May 1999. Patient sex, age, weight and length or height were recorded. Per cent weight for age (%W/A), per cent height for age (%H/A) and per cent weight for height (%W/H) were determined, using Thai standard growth data (1999). RESULT: A total of 3,667 children were included in the study including 1,903 well children from the WBC and 1,764 sick-children from the OPD. The gender distribution was 49 per cent girls and 51 per cent boys. Their ages ranged from 10 days to 16 years. Nutritional status was classified as normal in 49.4 per cent, underweight in 19.8 per cent, wasting in 12.4 per cent, stunting in 12.8 per cent, overweight in 15.4 per cent and obesity in 10.4 per cent. The prevalence of normal, underweight and wasting status at the OPD were significantly higher; whereas, the prevalence of stunting, overweight and obesity status were significantly higher at WBC. There were no gender differences, except for a higher prevalence of stunting in males (p < 0.05). CONCLUSION: Malnutrition is still a health problem in Thai children, both undernutrition and overnutrition. Good nutrition must be promoted to prevent malnutrition and early detection of malnutrition should be a major concern of health care personal with introduction of early intervention.

Scurvy in pediatric patients: a review of 28 cases.

OBJECTIVE: To study the dietary factors, clinical findings, plasma vitamin C level and post-treatment outcome of scurvy in pediatric patients at Queen Sirikit National Institute of Child Health. STUDY DESIGN: A retrospective study. METHOD: The medical and radiographic records of pediatric patients, diagnosed with scurvy at Queen Sirikit National Institute of Child Health from 1995 to 2002 were reviewed. RESULTS: Twenty-eight pediatric patients were diagnosed with scurvy. Their ages ranged between 10 months-9 years 7 months (median age of 29 months). 93 per cent of the cases were between 1-4 years of age. All were fed with well-cooked foods and small amounts or no vegetables and fruits. Supplementation with ultra heat temperature (UHT) milk was found in 89 per cent, average 5.8 boxes/day and 14.3 months in duration. Eighty-six per cent of cases were misdiagnosed previously. Clinical manifestations involved limp or inability to walk (96%), tenderness of lower limbs (86%), bleeding per gum (36%), fever (18%), and petechial hemorrhage (3.6%). All cases had abnormal radiographic findings compatible with scurvy and 2 cases had epiphyseal separation. All had clinical improvement within the first week after vitamin C supplementation. CONCLUSION: Vitamin C deficiency was found in the children's intake of small amounts or no vegetables and fruits together with UHT-milk. Frequent manifestations were limping and inability to walk and pain in the lower limbs. Response to vitamin C treatment was dramatic.