Practice of general pediatrics in Saudi Arabia: current status, challenges, and opportunities.

BACKGROUND: In Saudi Arabia, general pediatrics serves children until they are 14 years old. It has contributed to improving the health of Saudi children. METHOD: This study adopted a qualitative method and recruited pediatric physicians to investigate status, successes, challenges, and opportunities. Later, data were analyzed using thematic analysis and hermeneutic phenomenology. RESULTS: This study attracted 13 pediatric physicians for interviews. All participants appreciated the role of general pediatricians, but the trainees had a negative attitude regarding the general pediatrics specialty. They all agreed on providing primary care for all children and recommended that their first visit should occur earlier. Shortage of pediatricians, lack of community pediatricians, busy clinics, limited Arabic resources, and poor communication skills are significant barriers to children receiving adequate care. The majority of pediatricians favor extending the pediatric age to 18 years old. One pediatrician stated, "Youths between ages 14-18 years are lost, adults and we refuse to care for them…" Additionally, pediatricians have concerns about managing developmental delays and behavioral issues. They believe the current pediatric residency provides many opportunities for a brighter future. CONCLUSION: General pediatrics is well established in Saudi Arabia. To continue thriving, we need to address some challenges that pediatricians face and attract more residency graduates. The current pediatric residency programs can provide opportunities to address deficit areas.

Preferential and Increased Uptake of Hydroxyl-Terminated PAMAM Dendrimers by Activated Microglia in Rabbit Brain Mixed Glial Culture.

Polyamidoamine (PAMAM) dendrimers are multifunctional nanoparticles with tunable physicochemical features, making them promising candidates for targeted drug delivery in the central nervous system (CNS). Systemically administered dendrimers have been shown to localize in activated glial cells, which mediate neuroinflammation in the CNS. These dendrimers delivered drugs specifically to activated microglia, producing significant neurological improvements in multiple brain injury models, including in a neonatal rabbit model of cerebral palsy. To gain further insight into the mechanism of dendrimer cell uptake, we utilized an in vitro model of primary glial cells isolated from newborn rabbits to assess the differences in hydroxyl-terminated generation 4 PAMAM dendrimer (D4-OH) uptake by activated and non-activated glial cells. We used fluorescently-labelled D4-OH (D-Cy5) as a tool for investigating the mechanism of dendrimer uptake. D4-OH PAMAM dendrimer uptake was determined by fluorescence quantification using confocal microscopy and flow cytometry. Our results indicate that although microglial cells in the mixed cell population demonstrate early uptake of dendrimers in this in vitro system, activated microglia take up more dendrimer compared to resting microglia. Astrocytes showed delayed and limited uptake. We also illustrated the differences in mechanism of uptake between resting and activated microglia using different pathway inhibitors. Both resting and activated microglia primarily employed endocytotic pathways, which are enhanced in activated microglial cells. Additionally, we demonstrated that hydroxyl terminated dendrimers are taken up by primary microglia using other mechanisms including pinocytosis, caveolae, and aquaporin channels for dendrimer uptake.

Microglial migration and interactions with dendrimer nanoparticles are altered in the presence of neuroinflammation.

BACKGROUND: Microglial cells have been implicated in neuroinflammation-mediated injury in the brain, including neurodevelopmental disorders such as cerebral palsy (CP) and autism. Pro-inflammatory activation of microglial cells results in the impairment of their neuroprotective functions, leading to an exaggerated, ongoing immune dysregulation that can persist long after the initial insult. We have previously shown that dendrimer-mediated delivery of an anti-inflammatory agent can attenuate inflammation in a rabbit model of maternal inflammation-induced CP and significantly improve the motor phenotype, due to the ability of the dendrimer to selectively localize in activated microglia. METHODS: To elucidate the interactions between dendrimers and microglia, we created an organotypic whole-hemisphere brain slice culture model from newborn rabbits with and without exposure to inflammation in utero. We then used this model to analyze the dynamics of microglial migration and their interactions with dendrimers in the presence of neuroinflammation. RESULTS: Microglial cells in animals with CP had an amoeboid morphology and impaired cell migration, demonstrated by decreased migration distance and velocity when compared to cells in healthy, age-matched controls. However, this decreased migration was associated with a greater, more rapid dendrimer uptake compared to microglial cells from healthy controls. CONCLUSIONS: This study demonstrates that maternal intrauterine inflammation is associated with impaired microglial function and movement in the newborn brain. This microglial impairment may play a role in the development of ongoing brain injury and CP in the offspring. Increased uptake of dendrimers by the "impaired" microglia can be exploited to deliver drugs specifically to these cells and modulate their functions. Host tissue and target cell characteristics are important aspects to be considered in the design and evaluation of targeted dendrimer-based nanotherapeutics for improved and sustained efficacy. This ex vivo model also provides a rapid screening tool for evaluation of the effects of various therapies on microglial function.

Telemedicine and Pediatric Care in Rural and Remote Areas of Middle-and-Low-Income Countries: Narrative Review.

OBJECTIVES: Caring for children in low- and middle-income countries (LMIC) can be challenging. This review article aims to explore role of telemedicine in supporting pediatric care in LMIC. METHODOLOGY: A narrative review of existing English and Spanish literature was conducted to assess role of telemedicine to support pediatric care in LMIC. RESULTS: Beside medical education and direct pediatric care, telemedicine can provide sub-specialties consultations without extra burden on families. Additionally, telemedicine can help in lowering under-5 mortality by supporting neonatal care, infectious illnesses, and non-communicable diseases (NCDs). Telemedicine can be a gate for universal coverage for all children at a lower cost. For over a decade, it has been implemented successfully and sustained in a few LMIC. However, challenges in implementing telemedicine are enormous. Still, opportunities arise by using simpler technology, low-width band internet, smartphones, instant messaging applications and solar energy. COVID-19 pandemic facilitated acceptance and applicability of telemedicine worldwide including LMIC. Nevertheless, governments must regulate telemedicine by issuing policies and ensuring employment of local experts when possible to meet local resources and cultural competency. CONCLUSION: Telemedicine has proven successful in improving pediatrics care. Many LMIC should take advantage of this innovation to promote equity and access to high quality pediatric care.

Did the National Lockdown in Saudi Arabia Reduce Lower Respiratory Illnesses in Children?

Objectives: This study aims to explore the effect of lockdown and early precautionary measures implemented in Saudi Arabia on number of pediatric hospitalizations due to lower respiratory illnesses (bronchiolitis, asthma, and pneumonia). Methods: This is a retrospective cross-sectional study aims to review patients from four major hospitals in Saudi Arabia. All pediatric hospitalizations secondary to asthma, bronchiolitis, and pneumonia during the months of the lockdown (March, April, and May) in 2020 were documented. Then, they were compared to the previous 2 years. Variables like number of hospitalizations, oxygen requirement, mechanical ventilation, admission to the intensive care unit (ICU), length of stay, and results of viral studies were collected. Results: We included 1,003 children from four different centers. Males were slightly higher than females (55.8% vs. 44.2%). Total number of hospitalizations in 2020 was 201, significantly lower than 399 and 403 hospitalizations in 2019 and 2018, respectively (P < 0.01). The major drop happened on the months of April and May. Although bronchiolitis hospitalizations' dropped by more than half in 2020 compared to the previous 2 years, it was not statistically significant (P = 0.07). But, asthma hospitalizations were significantly less in 2020 compared to the previous 2 years (49-65% reduction, P = 0.003). Number of pneumonia cases were lowered in 2020 compared to the previous 2 years. However, proportion of pneumonia diagnosis to total hospitalizations increased in 2020 (55% compared to 50% and 35%). There was a surge of viral testing during a period of uncertainty in the early phase of the pandemic. This total reduction in hospitalization was not associated with higher oxygen requirements, mechanical ventilation, ICU admissions or longer hospital stay. Conclusions: Lockdown and precautionary measures executed during the early phase of COVID-19 pandemic helped decrease the number of hospitalizations due to lower respiratory illnesses in Saudi Arabia. Reduction in hospitalizations seems less likely to be secondary to hospital avoidance or delayed presentations as number of ICU admission and oxygen requirements did not increase. The post pandemic pattern of respiratory illnesses among children needs further research.

Preparedness of current and future Saudi Pediatricians to face vaccine hesitancy: Cross-sectional study within the capital city of Saudi Arabia, Riyadh.

BACKGROUND: Vaccines have helped in eradicating many communicable diseases. They are considered major players in preserving children's health. However, concerns about vaccines' ingredients and safety became hot topics globally. With doubt, some parents became hesitant to vaccinate their children. A recent study documented high prevalence of vaccine hesitancy among Saudi parents. OBJECTIVES: This study aims to explore preparedness of current and future pediatricians to face vaccine hesitancy, a growing public health issue in Saudi Arabia. METHODS: This study adopted non-interventional cross-sectional online questionnaire specifically designed to encompass general vaccine hesitancy related questions including Covid-19's vaccines. RESULTS: The study recruited 119 participants form three main tertiary centers in Riyadh. Trainees were the majority with pediatric consultants representing 22%. Females were more than half of total participants (53%). Although familiarity with the term "vaccine hesitancy" was common, it was affected by training level. Among participants, 66% heard about it from social media. Furthermore, only 32% received designated training. Knowledge was suboptimal among all levels except for those who received formal training. Despite 80% encountered vaccine hesitancy, only 55% consider it a common public health issue. Attitude toward vaccine hesitant parents was negative among male physicians (odds ratio of 2.3, P value 0.045). Additionally, majority consider it a form of child neglect (95%). In regard to COVID19's vaccine, 31% were reluctant to get vaccinated themselves. CONCLUSION: Pediatric workforce in Saudi Arabia commonly encounters vaccine hesitancy. The strong stand against vaccine hesitant parents might affect rapport with families. Sub-optimal knowledge, negative attitude and emerging COVID19 vaccine hesitancy might negatively impact future efforts. Tailored training and innovative educational platforms are essentials to address vaccine hesitancy in Saudi Arabia.

The impact of vitamin D food fortification and health outcomes in children: a systematic review and meta-regression.

OBJECTIVE: Vitamin D (vitD) deficiency is a global childhood health problem. Food fortification is a promising strategy to curb vitD deficiency. We aimed to assess the effectiveness of utilizing vitD fortification in staple foods to improve 25hydroxyvitamin D (25(OH)D) concentration and to reduce the prevalence of vitD deficiency among healthy children. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating the use of vitD fortified food products compared to no fortification among healthy children aged 1-18 years old. We searched Medline, Embase, Global Health, and Cochrane (CENTRAL) databases from database inception until May 2019. Independently, six reviewers in pairs screened titles and abstracts, assessed the full text for eligibility, and performed data extraction and quality assessment. The primary outcome is the impact of fortification on 25(OH)D concentration. The secondary outcomes included the impact of fortification on the prevalence of vitD deficiency, school performance, cognitive function, school absences, infection rate, hospital admission length, and compliance with fortified food product consumption. RESULTS: We identified 2229 articles. After assessing eligibility, 20 RCTs met the inclusion criteria. The eligible RCTs assessed the fortification of milk, cereal, juice, bread, yogurt, and cheese compared with no fortification. All RCTs, except for three, had a low risk of bias. Food fortification improved 25(OH)D concentration by a mean difference (MD) of 15.51 nmol/L (95% confidence interval (CI) 6.28, 24.74; I2 = 99%), which resulted in a mean increase of 3 nmol/l for every 100 IU of vitD, when adjusted for baseline 25(OH)D concentration and country latitude. Additionally, the prevalence of vitD deficiency decreased by a risk ratio of 0.53 (95% CI 0.41, 0.69; I2 = 95%), and cognitive function improved by a MD of 1.22 intelligence quotient (IQ) points (95% CI 0.65, 1.79; I2 = 0%). The overall evidence quality was high. CONCLUSION: VitD food fortification is an effective way to improve 25(OH)D concentration, prevent vitD deficiency, and improve IQ levels. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017057631.

Anti-MSP-10 IgG indicates recent exposure to Plasmodium vivax infection in the Peruvian Amazon.

BACKGROUNDSerological tools for the accurate detection of recent malaria exposure are needed to guide and monitor malaria control efforts. IgG responses against Plasmodium vivax and P. falciparum merozoite surface protein-10 (MSP10) were measured as a potential way to identify recent malaria exposure in the Peruvian Amazon.METHODSA field-based study included 470 participants in a longitudinal cohort who completed a comprehensive evaluation: light microscopy and PCR on enrollment, at least 1 monthly follow-up by light microscopy, a second PCR, and serum and dried blood spots for serological analysis at the end of the follow-up. IgG titers against novel mammalian cell-produced recombinant PvMSP10 and PfMSP10 were determined by ELISA.RESULTSDuring the follow-up period, 205 participants were infected, including 171 with P. vivax, 26 with P. falciparum, 6 with infections by both species but at different times, and 2 with mixed infections. Exposure to P. vivax was more accurately identified when serological responses to PvMSP10 were obtained from serum (sensitivity, 58.1%; specificity, 81.8%; AUC: 0.76) than from dried blood spots (sensitivity, 35.2; specificity, 83.5%; AUC: 0.64) (PAUC < 0.001). Sensitivity was highest (serum, 82.9%; dried blood spot, 45.7%) with confirmed P. vivax infections occurring 7-30 days before sample collection; sensitivity decreased significantly in relation to time since last documented infection. PvMSP10 serological data did not show evidence of interspecies cross-reactivity. Anti-PfMSP10 responses poorly discriminated between P. falciparum-exposed and nonexposed individuals (AUC = 0.59; P > 0.05).CONCLUSIONAnti-PvMSP10 IgG indicates recent exposure to P. vivax at the population level in the Amazon region. Serum, not dried blood spots, should be used for such serological tests.FUNDINGCooperative agreement U19AI089681 from the United States Public Health Service, NIH/National Institute of Allergy and Infectious Diseases, as the Amazonian International Center of Excellence in Malaria Research.

Impact of attitude and knowledge on intention to breastfeed: Can mHealth based education influence decision to breastfeed exclusively?

BACKGROUND: Exclusive breastfeeding has been endorsed as the healthiest feeding choice for newborns. This study aims to assess impact of expecting mothers' knowledge and attitude toward intention to breastfeed exclusively. Utilizing mobile health (mHealth) as educational tool can offer a widely distributed and affordable platform to promote exclusive breastfeeding. RESEARCH AIMS AND QUESTIONS: This study aims to assess impact of expecting mothers' knowledge, attitude and beliefs on decision to breastfeed exclusively. Furthermore, it purposes mobile health (mHealth) as educational tool offering a widely distributed, affordable and accessible platform to promote exclusive breastfeeding. METHODS: The study was conducted in prenatal clinics' waiting areas to interview expecting mothers utilizing a translated version of Infant Feeding Practices Survey II (IFPS II, CDC). After completing the survey, an educational video was shown utilizing a tablet and the question was re-asked about intention toward breastfeeding exclusively. RESULTS: Most expecting mothers indicated having some awareness about breastfeeding (67%) but only 46.1% intended to initiate exclusive breastfeeding early in life prior to the intervention. Moreover, only 53.7% believed breastfeeding is the best nutritional choice. Actually, 39.5% of participants considered breastfeeding equal to formula. Most working mothers complained of lack of workplace support to breastfeed. Also, they were not comfortable breastfeeding in front of others except spouse. Additionally, most participants found nurses and media as poor information resources. Resources utilizing social media and Internet were found useful. After watching the educational video, the majority expressed positive intention to breastfeed exclusively (80.8%). Positive intentions were associated with advance maternal age, prior breastfeeding knowledge and willingness to hear experts' opinions. CONCLUSION: Saudi women have limited knowledge about exclusive breastfeeding and early initiation. They feel unprepared, unsupported, lack resources and socially challenged. An educational material utilizing mHealth can alter intentions to breastfeed exclusively.

Developmental delay in the Amazon: The social determinants and prevalence among rural communities in Peru.

The consequences of poor child development are becoming increasingly recognized. Programs are being put in place around the world to improve child development by providing healthy and stimulating environments for children. However, these programs often have limited reach and little is known about the prevalence of developmental delay in under-developed communities. The current study set-out to better understand the prevalence of developmental delay in rural communities in the Amazon region of Peru. Also, it explores social determinants that are associated with any delay. Cross-sectional study by evaluating developmental delay in children under 4 years utilizing Ages and Stages Questionnaire (ASQ-3). Additionally, conducting a social determinants questionnaire answered by caretakers to identify social drivers for developmental delay. The data was analyzed with multi-variant analysis to measure association. The prevalence of developmental delay in the Amazonian communities was 26.7% (19.3% in communication, 11.4% in gross motor skills, 8% in both) (N = 596). The multivariate logistic regression analysis revealed significant associations between developmental delay and; level of education (OR 0.64, p = 0.009), age of mother during child's birth (OR 0.96, p = 0.002), visits by community health agents (OR 0.73, p = 0.013), and river as primary water source (OR 2.39, p = 0.001). The social determinants questionnaire revealed that 39% of the mothers had their first child before the age of 17, nearly half stopped going to school before the age of 12 (52%), 29% gave birth at home, 13% breast fed for less than 7 months, and 50% of the children had diarrhea in the last month. There is still a great need to improve the conditions for child development in the Amazon region of Peru. One-fourth of the children suffer from developmental delay, which will likely impede their potentials for life unless something is done. The impact of education, age of mother at birth of the child, community health agents, and access to clean drinking water were important findings. Improvements can be made in these areas to create a large, cost-effective impact on the well-being of the communities.

Child maltreatment between knowledge, attitude and beliefs among Saudi pediatricians, pediatric residency trainees and medical students.

BACKGROUND: Child maltreatment is not included in Saudi medical schools and pediatric residency curriculums, which might limit knowledge and spread misconceptions. Additionally, physicians might have different attitudes regarding reporting child abuse and neglect. In this study, we hypothesize that medical students and pediatric trainees have limited knowledge, oblivious attitude and misbeliefs regarding child maltreatment in comparison to experienced pediatricians. But, medical students and trainees might hold higher motives and willingness to learn about child maltreatment and their consequences. METHODS: A self reported questionnaire was distributed after a pilot study to include pediatricians, pediatrics trainees and medical students in all main areas of pediatrics services: pediatrics wards, pediatrics outpatient clinics, critical care and pediatrics emergency. RESULTS: In disregard to their level of training, medical students and physicians believed that child maltreatment happens within the kingdom and is common. They were familiar with the child maltreatment definition, although only one third thought it is subject to culture sensitivity. However, experienced physicians were more knowledgeable especially about neglect. Moreover, female participants were more likely to report despite being more skeptical of readiness of Saudi law system to deal with cases of maltreatment. In general, knowledge about reporting was clearly deficit at all levels. Fortunately, all participants requested and were enthusiastic to receive further training. CONCLUSION: Saudi medical students, pediatrics trainees and pediatricians have good basic knowledge, positive attitude and willingness to learn more to provide a safe environment for children in Saudi Arabia. However, knowledge in regards to reporting child maltreatment is a major observed defect. Still, further education and training are needed to combat CAN in Saudi Arabia.

Communication skills between physicians' insights and parents' perceptions in a teaching hospital in KSA.

OBJECTIVES: Communication between physicians and parents is the cornerstone of their relationship to reach a common goal of better child health. To deliver proper communication, a physician needs to learn certain skills that are not included in the curriculum of medical schools or paediatrics residency training in KSA. This study probed the physicians' attitude towards their styles of communication based on the parents' perception. METHODS: The data were collected from a randomly selected sample of physicians and parents from general paediatrics wards at King Saud University Medical City (KSUMC), Riyadh, KSA. We used a validated Criteria Cognitive Aptitude Test (CAT-T) questionnaire and a translated version of the CAT-T questionnaire for the physicians and parents, respectively. The data were then analyzed using variable qualitative and quantitative statistical methods. RESULTS: The data were collected from 63 physicians and 100 parents in the pediatric wards at KSUMC. We observed an increased level of confidence in communication skills (CS) among experienced physicians, while young physicians expressed concerns regarding their communication with parents concerning decision-making. The parents rated the physicians' skill of active listening as poor. However, the parents rated the physicians' introduction as higher than their own self-rating. In addition, the parents' satisfaction with the physicians' CS was inversely related to the parents' level of education. CONCLUSION: Our data suggests a clear discrepancy between the physicians' insights and the parents' perceptions about the CS. This finding emphasizes a need for further training among physicians to satisfy parents and in ultimately improving child health in the KSA.

Correction: Colorimetric Detection of Plasmodium vivax in Urine Using MSP10 Oligonucleotides and Gold Nanoparticles.

[This corrects the article DOI: 10.1371/journal.pntd.0005029.].

Colorimetric Detection of Plasmodium vivax in Urine Using MSP10 Oligonucleotides and Gold Nanoparticles.

Plasmodium vivax is the most prevalent cause of human malaria in the world and can lead to severe disease with high potential for relapse. Its genetic and geographic diversities make it challenging to control. P. vivax is understudied and to achieve control of malaria in endemic areas, a rapid, accurate, and simple diagnostic tool is necessary. In this pilot study, we found that a colorimetric system using AuNPs and MSP10 DNA detection in urine can provide fast, easy, and inexpensive identification of P. vivax. The test exhibited promising sensitivity (84%), high specificity (97%), and only mild cross-reactivity with P. falciparum (21%). It is simple to use, with a visible color change that negates the need for a spectrometer, making it suitable for use in austere conditions. Using urine eliminates the need for finger-prick, increasing both the safety profile and patient acceptance of this model.