Relationships between Ascaris infection and growth of malnourished preschool children in Kenya.

A longitudinal study in Ascaris-infected and noninfected children was conducted in two Kenyan villages. Anthropometric, clinical, and stool exams were performed three times at 14-week intervals. All children received an anthelmintic drug (levamisole) at the second examination. In the 14 weeks before deworming, children with Ascaris (n = 61) did not differ from controls (n = 125) in percentage expected weight gain. In the 14 weeks after deworming, previously infected children showed higher percentage expected weight gain than controls. Before deworming, there was a statistically significant (P less than 0.0005) decrease in triceps skinfold thickness in Ascaris-infected children versus controls. After deworming, skinfold increased significantly (P less than 0.0005) in previously infected children versus controls. Multiple regression analysis showed that Ascaris infection was by far the most important variable of those studied explaining decrease in skinfold thickness before and increase after deworming. It appears that even light Ascaris infections might adversely influence nutritional status, and deworming might enhance growth.

Perinatal death in ethnic minorities in The Netherlands.

OBJECTIVES: To investigate differences in perinatal death rate and associated obstetric risk factors between ethnic groups in the Netherlands. DESIGN: Retrospective cohort study based on the 1990-1993 birth cohorts in the National Obstetric Registry. SUBJECTS: 569,743 births of which 85,527 were for women belonging to ethnic minorities. MAIN OUTCOME MEASURES: Perinatal death occurring between 16th week of pregnancy and 24 hours after birth. METHOD: Bivariate and multivariate analysis of perinatal death rate per ethnic group. A total of 42,282 women living in the three main cities of the Netherlands were classified on the basis of postal code districts into four socioeconomic (SES) classes for analysis of the relation between SES, perinatal death, and preterm birth. RESULTS: Black mothers had the highest perinatal death rate compared with indigenous Dutch (odds ratio 2.2, 95% CI 1.9, 2.4) followed by a group "others", consisting of women of mixed or unknown ethnicity (odds ratio 1.8, 95% CI 1.5, 2.0), Hindustani (odds ratio 1.4, 95% CI 1.2, 1.6), and Mediterraneans (odds ratio 1.3, 95% CI 1.2, 1.4). Asians (excluding West Indian Asians) and non-Dutch Europeans did not have higher rates than Dutch women. The increased rates of black and Hindustani women could be explained fully and that of the group "others" partially by higher rates of preterm birth. Controlling for age and parity lowered the odds ratio of the Mediterraneans slightly. The risk of ethnicity was independent of SES. CONCLUSION: Ethnic minorities in the Netherlands except immigrants from Asia and other European countries have higher rates of perinatal death than indigenous Dutch women. With a twofold increase, black women had the highest rate, which was related to an equally large increased rate of preterm birth.

Intercultural training of medical students.

Until recently the Utrecht Medical School had a traditional curriculum with a predominantly biomedical orientation and strong emphasis on curative medicine. In 1997 an experimental 'Multi-cultural Family Attachment Course' started at the Utrecht Medical School with 20 second-year medical students. Each student was attached to a native Dutch and an ethnic minority family with a newborn or chronically ill child. In a period of 1.5 years students had to visit each family at home four times. The students monitored growth and development of the child and discussed several aspects of health and disease with the parents according to a structured schedule. In regular group sessions students reported back their experiences. In this way, the influence of socioeconomic circumstances, culture and environment on health becomes a real-life experience. This paper aims to describe some aspects of this pilot-course and the reactions of the students.

Results of group-circumcision of Muslim boys in Malaysia with a new type of disposable clamp.

This study evaluates the safety and results of surgery usingTaraKlamp Circumcision Device during a group circumcision. Atotal of 64 circumcisions of Muslim boys were performed by Medical Assistants supervised by Medical Doctors in a hall in Kuala Lumpur, Malaysia. A new type disposable clamp was used, which was removed 4 days after the operation. No major complications occurred and the boys experienced in general mild pain postoperatively. Mostly good cosmetic results were obtained and 90% of the parents would recommend this new clamp to others. Group circumcisions withTaraKlamp Circumcision Device (Kuala Lumpur, Malaysia) are safe, although proper patient selection and adequate training in using the device are mandatory.

[International and intercultural aspects of pediatrics and adolescent health care]. / Internationale en interculturele aspecten van kindergeneeskunde en jeugdgezondheidszorg.

PIP: Population statistics of Amsterdam between the 17th and 19th centuries indicate that 20-30% of young married people had been born in foreign lands. At the present time, 6% of the country's population, nearly 1 million people, are direct descendants of foreign parents: 240,000 Surinamese, 210,000 Turks, 170,000 Moroccans, and 80,000 from the Antilles. 40% of foreigners live in the four large cities, and there they make up about 15% of the population; 30-50% of children in these cities have foreign born parents. Among health concerns affecting these people are parasitic diseases, tuberculosis, salmonellosis, and the importation of infections such as viral B hepatitis, which so far has been successfully controlled. About 4% of the foreigners (30,000 people) carry a defective gene, and when two such people marry, in 25% of cases a child can be born with a severe defect as well as thalassemia major (mainly children of Moroccans and Turks) and sickle cell anemia (Surinamese and Antillans). 20-40% of children from tropical or subtropical areas also have lactase enzyme deficiency, which gives them stomach complaints because of incomplete metabolism of milk sugar. In recent years it has been reported that asthma and respiratory infections with longer hospitalizations occur more frequently among foreign children. Infant mortality is also 2-3 times higher among them. Intercultural aspects affecting Turkish and Moroccans immigrants include communication problems, primarily those of the first generation, which should be facilitated by language centers and educational materials. Generation conflicts arise from contrasts between homelife and the outside world as well as from the fact that many of the parents are illiterate. Cultural difference are rooted in Islam, which requires loyalty to the group with traditional role patterns. Other problems pertain to the social isolation of the mother and the lower position of women, and the uncertain legal position of foreigners, which can result in sometimes unwarranted feelings of discrimination.^ieng

[Medical care of underage refugees]. / De medische zorg voor jeugdige asielzoekers.

The growing number of people seeking asylum in the Netherlands compromises the provision of adequate medical services to all. This development may have a negative impact on refugee children especially. International literature indicates that many children, especially the ones coming from tropical areas or the ones who resided in refugee camps, are suffering from diseases such as tuberculosis, hepatitis B, anaemia, parasitic diseases, caries, malnutrition, hearing and seeing impairments. Many children have psychosocial problems due to traumatic experiences in their country of origin and/or during their flight. These problems lead to a diversity of complaints such as difficulty to sleep, enuresis, feeding problems and hyperactivity. Both the somatic and the psychosocial problems may impede the growth and development of these children. It is therefore imperative to identify the children at risk and to formulate guidelines for providing medical care to refugee children. Special care should also be given to the housing, the living conditions and the provision of specialised personnel and to limiting the duration of the asylum procedure in the case of families with children and other minors.

[Ethical shortcomings of skeletal age determination to establish minority for single young asylum seekers]. / Ethische tekortkomingen van het leeftijdsonderzoek ter beoordeling van minderjarigheid van alleenstaande asielzoekers.

Each year tens of thousands of asylum seekers from all over the world come to the Netherlands. Amongst them are minors who come alone. They are eligible for a separate, less severe, admittance procedure than for adults and their under-age children. Because of abuse of this procedure by adults an X-ray age examination of the claviculae and hand-wrist has been introduced to determine minority. A person who claims to be a minor but appears to be an adult is invited to submit to the examination on a 'voluntary' basis. The selection procedure, the informed consent, the voluntariness and the technical aspects of the age measurement suffer from ethical shortcomings. An ethical committee should ensure that the procedures conform to the generally accepted Dutch ethical principles laid down in the Dutch Medical Treatment Act. In addition, the selection of asylum seekers for age determination should be carried out by specialized officials (an alternative would be to subject all single minor asylum seekers to age measurement). The waiting time for age measurement should be reduced to prevent the medial clavicular epiphyseal disc from closing during the waiting time. Age should not be judged on the basis of a partially closed epiphyseal disc, as this is controversial. It is recommended that the age for the single minor asylum seeker regulation be reduced from 18 to 16 years.

[Congenital syphilis as an imported disease]. / Congenitale lues als importziekte.

Two infants, a two-month-old boy and a two-month-old girl adopted from Sri Lanka, were diagnosed as having congenital syphilis and treated accordingly. The girl presented with only skin symptoms and a developing pseudoparalysis of Parrot. The boy was in quite a bad condition, having rhinitis, an oedematous appearance, skin symptoms, severe anaemia and hepatosplenomegaly. In both patients serological blood tests and cerebrospinal fluid tests for lues were positive. Both children showed osteochondritis and periostitis of the long bones on X-rays. This disease is rare in the Netherlands, but it is important to diagnose it early, because early adequate treatment may result in complete cure.

[Bedwetting by Dutch, Surinam, Moroccan and Turkish 3-4, 5-6, and 11-12-year-old children]. / Bedplassen bij Nederlandse, Surinaamse, Marokkaanse en Turkse kinderen van 3-4, 5-6 en 11-12 jaar.

OBJECTIVE: To investigate whether ethnic origin is related to the prevalence of bedwetting among children and how parents handle bedwetters. DESIGN: Descriptive study. SETTING: Department of Youth Health Care in Amsterdam, the Netherlands. METHOD: Parents of children who attended a child health centre in 1992/1993 were interviewed using a questionnaire. A total of 1506 children aged 3-4, 2422 aged 5-6 and 2081 aged 11-12 years participated in the study. RESULTS: The prevalences of bedwetting were 24.6%, 15.7% and 5.4% at 3-4, 5-6 and 11-12 years of age respectively. Moroccan and Turkish 3-4-year-olds wet their beds just as often as Dutch children, Surinamese 3-4-year-olds less often. However, Surinamese, Moroccan and Turkish school children wet their beds more often than their Dutch classmates. For Dutch children the prevalence of bedwetting at the age of 5-6 was clearly lower than at the age of 3-4, in contrast with Surinamese, Moroccan and Turkish children. Non-Dutch bedwetters were rewarded less often for a dry night and punished more often for a wet night than Dutch bedwetters, even at the age of 3-4. CONCLUSION: Bedwetting by school children still occurs often, and more often among non-Dutch than among Dutch children. Possibly, differences between Dutch and non-Dutch parents in the ways they deal with bedwetting plays a part. Appropriate information and support of (especially non-Dutch) parents of young children can perhaps reduce the prevalence of bedwetting at later ages.

[Missed infections in immigrant children]. / Gemiste pathogenen bij immigrerende kinderen.

Three African children who migrated to the Netherlands developed serious infections after they arrived. The first patient, a girl of 3 years adopted from the Zaire, was discovered to be a chronic hepatitis B carrier. Advice to vaccinate her whole adoption family was not followed. Her adoptive mother became infected with hepatitis B. The second patient, an Ethiopian girl of 13 years, was not adequately screened for infections on arrival. She was a chronic hepatitis B carrier and infected her adoptive mother. Seven years later she developed pulmonary tuberculosis with cavity formation and infected four contacts. The third patient, a 15-year-old political refugee from Zaire, who developed paediatric aids and later died of it, was not screened according to the screening protocol advised for immigrating children. All immigrating children should be fully and adequately screened for infectious diseases upon arrival in the Netherlands.

[Treatment of persistent nocturnal enuresis in children of Turkish and Moroccan migrants requires extra attention for the family]. / Behandeling van hardnekkige enuresis nocturna bij kinderen van Turkse en Marokkaanse migranten vraagt extra aandacht voor het gezin.

OBJECTIVE: To assess the effect of the clinical dry bed training according to Azrin/Messer for Turkish and Moroccan children with nocturnal enuresis aged 11 years or more, living in the Netherlands, as compared with native Dutch children. SETTING: Overvecht Hospital, Utrecht. DESIGN: Comparative and follow-up study. METHOD: After an admission period of 8 days a home training of two months was given. 40 migrant children and 43 Dutch children were trained. Improvement rates were measured on the day of hospital discharge, after three and after nine months. Several adjustments, based on cultural differences, were needed in the course of the project. RESULTS: On the day of discharge about 90% of both children groups showed improvement. After three months 60% of migrant children and 81% of Dutch children showed improvement, after nine months 61% and 70% respectively. In the end 51% of the Dutch children and 36% of the migrant children remained dry. The parents of migrant children believed their children would alter their micturition behaviour when they met disapproval, punishment and shame. CONCLUSION: The clinical dry bed training is suitable for migrant children if intensive and time consuming support can be given during the follow-up period, especially to the parents (in Dutch children, training of just the child often suffices). Frequent home visits, use of interpreters and active involvement of the parents are needed. A positive approach with emphasis on praise instead of punishment and shame has to be taught to the parents.

[Incidence and prevalence of hemoglobinopathies in children in The Netherlands]. / Incidentie en prevalentie van hemoglobinopathieën bij kinderen in Nederland.

OBJECTIVE: To evaluate the prevalence and incidence of thalassaemia major and sickle-cell disease in children. DESIGN: Descriptive nationwide epidemiological study. SETTING: Clinical Genetic Centre Utrecht. METHOD: Prevalence data were collected by a written survey among all 333 Dutch paediatricians (1992; response rate 99.1%). Incidence data are collected monthly by the Dutch Paediatric Surveillance Unit (1992/'93; response rate: 86%). RESULTS: In September 1992, 128 children were being treated by a paediatrician for sickle-cell disease. Two children had parents born in the Netherlands, but all children were of other ethnic origins, mainly from Surinam, the Dutch Antilles, Turkey and Africa; 50 children were born in the Netherlands. 31 children were under treatment for thalassaemia major, none of them of original Dutch descent; the most frequent ethnic backgrounds were Turkey and Morocco; 20 children were born in the Netherlands. From October 1992 till December 1993 (15 months) 18 children were newly diagnosed with sickle-cell disease, of whom 7 were born in the Netherlands, and 8 children were newly diagnosed with thalassaemia major, of whom 2 were born in the Netherlands. CONCLUSION: Sickle-cell disease and thalassaemia major are (still) rare diseases in the Netherlands. With the present migration and the increase of consanguineous marriage, they are expected to become a more important health issue.

[The treatment of acute gastroenteritis in children in The Netherlands]. / De behandeling van acute gastro-enteritis bij kinderen in Nederland.

A national survey on the treatment of acute gastroenteritis in children was conducted among 10% of the Dutch general practitioners and 10% of the paediatricians. Oral Rehydration Solution was used by less than 40% of the general practitioners, while 95% of the paediatricians used it (nearly) always. About a quarter of the general practitioners used antidiarrhoeal medication in contrast to the paediatricians who hardly or never used these drugs. The refeeding period after the acute rehydration therapy showed great difference. The need for a uniform dietary advice was felt by nearly half the general practitioners. It is concluded that the internationally accepted primary treatment with O.R.S. has insufficient impact on the Dutch general practitioners. Greater knowledge on the unique features of this method is needed. The dietary advice after the primary treatment needs more uniformity.

[Medical education in the Netherlands: little attention paid to the cultural diversity of patients]. / Medisch onderwijs in Nederland: weinig aandacht voor culturele diversiteit van patiënten.

OBJECTIVE: To ascertain how much attention is given to cultural diversity in the eight medical faculties in Dutch universities. DESIGN: Interviews. METHOD: In the period January-June 2001 interviews were held with 76 people in medical faculties: policy makers, teachers and students. RESULTS: Medical courses scarcely devoted any attention to the fact that physicians need to deal with a multicultural society. Only the medical courses at the Free University of Amsterdam and Nijmegen University had included a compulsory module in this subject. The other universities were aiming for a more integrated treatment of the subject. However, for the time being, the acquisition of information about cultural diversity (specific diseases in different ethnic groups, different conceptions about health and disease and possibilities for solving communication problems) depended mainly on the personal interest of the teacher and the choices of the medical students. CONCLUSION: Cultural diversity receives little attention in the medical courses at the eight Dutch university medical faculties. A national approach to this problem is therefore recommended, with the setting up of an interfaculty workgroup to develop good teaching material on subjects related to cultural diversity.

[Good results from circumcisions of Muslim boys performed outside the hospital]. / Gunstige resultaten bij circumcisie van moslimjongens buiten het ziekenhuis.

OBJECTIVE: To describe the experience with circumcision of Moslem boys under local anaesthesia outside the hospital. DESIGN: Prospective, descriptive. METHOD: A total of 94 circumcisions under local anaesthesia were performed from April through November 1997 in a Health Centre of the Municipal Health Service, Utrecht, the Netherlands. Pain and unrest of the boys were scored on a scale from 1 to 10 by the operating surgeon (1 = no pain/patient fully calm; 10 = unbearable pain/patient in panic). Postoperative follow-up was only done on request of the parents/fosterers. The reasons for these follow-ups were recorded. One week after the circumcision the parents/fosterers were asked if there were any complications and whether they were satisfied with this method. RESULTS: The median age was 3 years (range: 2-24). The pain during the operation was scored by the surgeon with a median of 1 (1-6) while unrest scored a median of 3 (1-9). Thirteen children were seen again because of bleeding (n = 4), haematoma (n = 2), swelling (n = 7). One week after the operation 89% of 70 parents/fosterers interviewed by telephone were content with the treatment. The social aspect of this way of circumcision was much appreciated. CONCLUSION: Circumcisions under local anaesthesia outside the hospital are feasible. Complications were according to published figures and most parents were content. With this procedure a cost reduction of 70% may be achieved in comparison with clinically performed circumcision under general anaesthesia.

[Genetic carrier screening for hemoglobinopathies in the Netherlands is not opportune]. / Screening op dragerschap van hemoglobinopathieën in Nederland niet opportuun.

OBJECTIVE: To investigate whether screening for carriership of sickle-cell anaemia and thalassaemia is desirable in the Netherlands, given the prevalence of the diseases, the possibilities of a screening test and the knowledge of the population at risk. DESIGN: Descriptive. SETTING: Wilhelmina Children's Hospital, Clinical Genetic Centre, Utrecht, the Netherlands. METHODS: In September 1992 Dutch paediatricians were treating 128 children with sickle-cell anaemia and 31 with thalassaemia major. Between October 1992 and December 1994, sickle-cell anaemia was diagnosed in 40 children and thalassaemia major in 14; of these, 16 and 4, respectively, had been born in the Netherlands. A protocol for the screening for carriership adjusted to the Dutch situation was drawn up in the past, with an estimate of the corresponding costs. Patients with sickle-cell anaemia or thalassaemia major, their families, care givers and persons without disease but originating from Surinam, the Netherlands Antilles, Turkey or Morocco were interviewed about their knowledge of these two diseases. RESULTS: The knowledge of the diseases was low among the Turkish and Moroccan populations, and very global among the Surinamese and Antillian populations. There was more belief in supernatural causes than in a genetic predisposition. CONCLUSION: Given the low number of newly diagnosed haemoglobinopathies in children born in the Netherlands, the poor knowledge of the disease of the population at risk, the difficulty in identifying the best moment in life for screening and the rather complicated screening method, a screening programme for carriership of haemoglobinopathies in the Netherlands is not opportune. Where sickle-cell anaemia is concerned, screening for this disease during the neonatal period might be considered.