Updated growth curves for Turkish children aged 15 days to 60 months.

BACKGROUND: Growth reference values are useful in paediatric health care as a health indicator. Secular changes in height for age values are also known to affect the timing of puberty and brain weight. Different populations may be at different stages of this secular trend. It is, therefore, necessary to periodically update the growth reference values for each population to identify these changes. The aim of this study was to update the growth reference values for Turkish infants and young children. METHODS: Background information and height/length, weight and head circumference measurements on a sample of 2391 boys and 2102 girls were obtained from Well Child Clinic Records. The LMS method was used for the analyses. The percentage of exclusive breastfeeding was 62% at 4 months and 26.6% at 6 months. The continuation rate of breastfeeding at 12 months was 62.5%. RESULTS: Comparison with previous Turkish data showed an increase in height of 0.9 cm for boys and 1.1 cm for girls at age 5 years. The increase in weight was 0.220 kg in girls, while a decrease of 0.160 kg was noted in boys. Comparison with the 2000 US and Swedish values indicated that population differences may exist in pre-pubertal years. CONCLUSION: This study provides an enhanced instrument to evaluate the growth of Turkish infants and young children.

Growth hormone treatment in short children with intrauterine growth retardation.

The aim of this prospective controlled study was to assess the effect of rhGH in short prepubertal children with intrauterine growth retardation and normal growth hormone status. Twenty-six children were randomized into treatment (12F, 4M) and control (6F, 4M) groups. Mean ages were 5.3 (1.3) yr and 4.3 (1.7) yr, respectively. rhGH (Genotropin) was used at a dose of 0.2 IU/kg/day as daily s.c. injections for two years. In the treated group, mean height SDS increased from -3.0 (0.5) to -1.9 (0.7) and height velocity SDS showed a significant increase from -1.3 (2.0) to 3.7 (1.8) in the first year (p < 0.001) and 1.6 (1.8) (p < 0.01) in the second year of treatment. In the controls, height SDS, initially -2.7 (1.4), and height velocity SDS, initially -0.9 (1.1), remained essentially the same during two years of follow-up. Height SDS for bone age changed by 0.6 in the treated group and 0.4 in the control group. Target height SDS--initial height SDS in the treated group improved by 1.1 SD but declined in the control group. IGF-I levels increased from 9.5 (4.2) nmol/l (72 [31.8] ng/ml) to 32.5 (27.0) nmol/l (244.4 [202.8] ng/ml) (p = 0.004) in the treated group while no change was observed in the controls. No adverse effects were encountered during rhGH therapy. It was concluded that rhGH treatment induces a significant increase in growth velocity in the short term. This outcome, as opposed to the unchanged indices in the control group over the same period, may be indicative of an improved height prognosis in short children born with intrauterine growth retardation treated with rhGH.

Ten steps for successful breast-feeding: assessment of hospital performance, its determinants and planning for improvement.

This paper discusses results from a project which aims to document the maternity hospital practices in istanbul within the context of Ten Steps for Successful Breastfeeding. Instruments developed for use in hospital level implementation of the WHO/UNICEF baby friendly hospital initiative were used in five hospitals (two public and three private). No hospital was implementing all Ten Steps. A core hospital team on lactation management and a sufficient number of health personnel skillful in breastfeeding counselling and adequate delivery room conditions are required to implement the Ten Steps. It is very difficult to provide these conditions in public hospitals with an excessive patient load. On the other hand, the fee for service system and the policy of changing practices according to the wishes of the clients can also become barriers to successful breastfeeding, as may occur in some private hospitals.

Analysis of patients admitted to the emergency unit of a university children's hospital in Turkey.

A retrospective analysis of the computerized data of patients admitted to our Emergency Unit Inpatient Service in 1991 was conducted to obtain data about age, sex, referred sources, admission period, monthly admission rates, diagnoses and eventual outcome. More than 47% of patients were younger than one year of age. The most common causes for hospital admission were infectious, respiratory and neurological diseases. The mean hospitalization period was 3.26 days. More than 60% of patients were treated by the Emergency Unit staff. The net mortality rate was 2.9%, infectious diseases being the most common cause of mortality. We conclude that demographic and diagnostic data regarding admissions to the Emergency Unit can be utilized to develop new strategies for patient care and to reorganize education programs for pediatric residents.

Growth and puberty in thalassemia major.

Growth and sexual development were evaluated in 54 (29 female, 25 male) patients with beta-thalassemia major aged 2.7-21.3 years (mean 10.4 yr). Mean pretransfusion hemoglobin concentration was 7.8 +/- 0.7 mg/dl. All patients except 6 were on desferrioxamine. Age of starting of therapy was 6.8 +/- 3.9 years. Mean SDS values for height, weight and sitting height were significantly lower (p < 0.001) than control cases of similar age. Height deficiency exceeded -2 SD in 18 patients and a delay in bone age (> 2 SD below the mean) was observed in 36 out of 54 patients. Among 11 patients over 14 years, 9 showed delay in onset or progression of puberty and 10 had growth retardation. Height SDS were negatively correlated with chronological age, age of onset of desferrioxamine and present serum ferritin levels (p < 0.001). These findings indicate that abnormal growth and delayed puberty are frequent in transfusion dependent thalassemics. These can be partly overcome by early onset of chelating therapy.

Trial of co-trimoxazole versus procaine penicillin G and benzathin penicillin + procaine penicillin G in the treatment of childhood pneumonia.

This study, which aimed to assess the results of three different regimens in the treatment of pneumonia, was carried out at the Pediatric Outpatient Department of Capa Children's Hospital in Istanbul on 151 patients aged between 4 months and 14 years. The first group (n = 46) received co-trimoxazole orally for 10 days and the second group (n = 63) procaine penicillin G in intramuscularly for 10 days. Benzathin penicillin G combined with procaine penicillin G was given to the third group (n = 42) as a single dose intramuscularly. While the best results were obtained with penicillin procaine G, no statistically significant difference was found between this regimen and co-trimoxazole therapy (chi 2 = 0.305023 P = 0.5). We suggest that co-trimoxazole is easy to administer and cost effective in the ambulatory treatment of pneumonia in children.

Carbohydrate malabsorption in acute diarrhea.

A group of 245 well nourished infants with acute diarrhea were screened for carbohydrate malabsorption by evaluating stool pH and reducing substances in the stools. Carbohydrate malabsorption was diagnosed in 28 cases (11%). Clinical features of carbohydrate intolerance were present in only one case. The duration of diarrhea after admission ranged from 1 to 13 days (mean 3.9 days). An oral lactose tolerance test was consistent with lactase deficiency in 32% of all cases. Thin layer chromatography showed many carbohydrates including monosaccharides in the stools, indicating that the defect in intestinal absorption was not specific for lactose.

beta-Endorphin and some hormonal levels in children with acute stress hyperglycaemia.

The levels of beta-endorphin, insulin, cortisol, GH, glucagon, prolactin and TSH were measured in serum samples of 9 hyperglycaemic patients (3 female, 6 male) with a mean age of 4.1 years admitted to the pediatric emergency unit. All patients were in acute stress due to severe diseases (acute gastroenteritis, bronchopneumonia, septicaemia, etc.). Initial and repeat blood samples for hormone determination were taken at admission and in the recovery phase (after 4-6 weeks of treatment). OGTT was also performed in the recovery phase. The hyperglycaemia, monitored hourly following the initial determination, returned to normal in all patients in 1-5 h without specific treatment. Mean serum glucose values at admission and in the recovery phase were 287.0 and 84.1 mg/dl. Concomitant to the hyperglycaemia encountered in these patients in the acute phase of stress, an increase was noted in all hormone levels excluding glucagon and cortisol. All elevated hormone levels fell to normal in 4-6 weeks with significant differences from initial levels for beta-endorphin (P < 0.05) and insulin (P < 0.01). OGTT gave a normal curve. These results indicate that stress hyperglycaemia, despite high insulin levels, is associated with an increase in beta-endorphin levels. The results also show that hyperglycaemia in acute disease does not alter OGTT in short-term follow up.

Thyroid ultrasound in IDDM.

Insulin dependent diabetes mellitus (IDMM) is often associated with autoimmune thyroiditis (AIT) and a high prevalence of thyroid antibodies (TA). Ultrasound imaging of the thyroid may contribute to the evaluation of patients with AIT. We therefore investigated ultrasound findings of the thyroid in 83 IDDM patients (44F, 39M) with an age range of 2.3-22.3 yrs (median 11.1). Thyroid volume (ml) determined by ultrasound ranged between 1.3 and 17.9 (median 5.7). Thyroid volumes of 75 healthy children (32F, 43M) with an age range of 2.0 to 11.8 yrs (median 7.6) ranged between 1.6 and 13.2 ml (median 4.8) and did not show a significant difference from the IDDM group from age 4 to 12. TA were positive in 18.8% of the IDDM group. Thyroid volume was higher in TA (+) diabetics (p = 0.05), a finding which may be attributed to a higher percentage of cases with elevated TSH in the TA (+) group. Two diabetic patients showed non-homogeneous hypoechogenicity in the ultrasound compatible with AIT which was later confirmed in one of these cases by aspiration biopsy. Ultrasound imaging of the thyroid may contribute to the evaluation of patients with AIT in IDDM.

Paraprofessional women as health care facilitators in mother and child health.

The aim of the study was to compare the performance of midwives with that of lady home visitors (LHV; paraprofessionals). The project area was divided into six according to the population map. One midwife or one LHV was assigned to each visiting area. Home visits were carried out to identify and offer guidance on family planning (FP), antenatal care, well-child control, immunizations and other mother and child health related issues to those at high risk. Criteria taken for evaluation were the numbers of pregnant women identified in the last trimester; pregnant women receiving antenatal care; deliveries attended by a health care provider; modern FP users; continuation rate of the new users; pregnancy rate in new users; immunization status of children; well-child visits of the children. No significant differences were found in these health measurements between areas visited by LHV and areas visited by midwives. Response rates to the invitation was also similar in both areas. An important observation was the good performance of the LHV in communicating with the families. Women with limited school attainment from the community can be used effectively and efficiently in community health services.

Growth response to growth hormone-releasing hormone(1-29)-NH2 compared with growth hormone.

To assess the growth-promoting effect of different doses of growth hormone-releasing hormone(1-29)-NH2 (GHRH(1-29)-NH2) in GH deficiency (GHD) of hypothalamic origin, 43 prepubertal children aged between 4.3 and 18.9 years (mean 10.4 +/- 2.9 years) were randomly assigned to three treatment regimens: low-dose GHRH(1-29)-NH2 (LD group; n = 15), high-dose GHRH(1-29)-NH2 (HD group; n = 12) and GH (GH group; n = 16). The LD group received GHRH(1-29)-NH2 at 30 micrograms/kg/day s.c. in three daily doses, the HD group received 60 micrograms/kg/day s.c. in three daily doses and the GH group received GH, 0.1 IU/kg/day s.c. once daily. All children were treated for a period of 6 months. Evaluation included anthropometry, bone age, intravenous and subcutaneous GHRH(1-29)-NH2 tests and determination of insulin-like growth factor I (IGF-I) levels. An increase in height velocity of 2 cm/year or more was observed in all except two children. Height velocity during treatment was lowest in the LD group, but comparable in the HD and GH groups. An increase in height SDS for bone age occurred only in the GH-treated group. GH responses to intravenous GHRH(1-29)-NH2 showed a priming effect of the LD GHRH(1-29)-NH2 treatment, while a decrease in response occurred in the GH-treated group. Following a subcutaneous test dose of one-third of the daily dose of GHRH(1-29)-NH2, GH levels remained unchanged in both the LD and HD groups. There was accumulation of GHRH immunoreactivity over time in the HD group, but there was no correlation between measured GHRH and GH levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Estimation of annual height velocity based on short- versus long-term measurements.

We assessed the relationships between annual height velocity, calculated from two measurements taken at intervals of 6, 12 and 24 months, in 69 healthy prepubertal children (34 male, 35 female) aged 6.5 years (range 6.25-6.75 yrs) who were followed for 2.5 years and measured biannually. Initial height values for age were within normal ranges except for one child with a height SDS of -2.0. Mean annual velocities also conformed to British norms. Significant differences were observed between consecutive six-monthly velocities and these values failed to predict annual velocities calculated from measurements taken at 12- or 24-month intervals. Seasonal effects were thought to have some impact on the six-monthly velocity differences. Height velocity, based on measurements taken at intervals of 12 months, was essentially similar to two-year velocity values. The results indicate that in estimating annual height velocity, six-month intervals between measurements may be misleading while 12-monthly measurements are as reliable as height velocity values based on measurements taken at two-year intervals.

Development of Kasabach-Merritt syndrome following needle aspiration of a hemangioma.

A case of Kasabach-Merritt syndrome that developed following needle aspiration in an infant with hemangioma is presented. Enlargement of the tumor leading to severe respiratory distress accompanied by hemorrhages occurred within six to eight hours after this simple intervention. The symptoms continued despite repeated thrombocyte transfusions and prednisolone therapy. Radiotherapy and local intraarterial corticosteroid therapy were attempted and led to some improvement. It took approximately three months for the platelet count and one year for the clinical state to revert to normal. This case illustrates that minor trauma may lead to life-threatening symptoms in a young infant with congenital hemangioma.

Experiences of a health team working in a new urban settlement area in Istanbul.

A project aiming at creating a model for comprehensive maternal and child health care for urban underdeveloped areas was started in a new settlement area of migrants in the vicinity of Istanbul. The project had an impact on health care status, particularly among infants and children, but the results indicated that more effort was needed to reach the mothers. It was noted that building space and the appearance of the work place influenced the prestige of the team. Absentee problems could be partly surmounted by repeated home visits. Based on this experience, it was concluded that health services in underdeveloped areas need to be supported by non medical personnel to act as home visitors and as mediators between the community and the health team. It was also concluded that an established recording system to include both clinical data and attendance is needed to define the cases who need special care.

PIP: The purpose of this study was to establish a model of comprehensive health care for women and children in slum areas of urban cities in Turkey. The initial startup began in December 1986 with an area population and health survey. Prevention and curative services were initiated in March 1987. Poor attendance was a major problem. Group interviews were conducted in early 1988. In February 1989 a daily computerized record system was set up to identify risk groups and nonattenders. Home visits were conducted with a medically equipped mobile van; new facilities and staff were added. 26% of the district population of 9760 were women of reproductive age. 69% were married and 7.8% pregnant. 1267 infants and children between 0-60 months lived in the area of which 230 were 1 year. The area represented mainly skilled workers in nuclear families in houses that were in good condition. 51% had 5 years of schooling, 26% were illiterate, and 15.4% of husbands were illiterate. 59.6% of children, 20.4% of nonpregnant women, and 25% or pregnant women came for a 1st appointment albeit not at the scheduled date. Those not attending were found to go to private physicians, and believed that a free service cannot be good and criticized the physical accommodations. After home visits, attendance rose to 79.7% for infants, 61.8% for children, and 38.6% for women. Attendance over a 24 month period revealed that visits were higher than expected for infants and children. The program impact was a higher immunization rate/age (87% lacking immunization were immunized) and increased well baby care (83.1%). Maternal health improved and family planning users increased. The baseline survey showed 71.1% receiving antenatal care vs. 93.7% of the 147 currently pregnant women having received at least 1 visit in the 1-year survey. Hospital births also increased from a baseline of 58.8% to 78.3%. Family planning increased from 22.9% to 34.0% which included the preferred IUD. IUD users rose from 12.3% to 19.8% of married women of reproductive age. 47% of nonusers who had been pregnant in the past 2 years were now modern contraceptive users. Clinic utilization was enhanced by regular home visits by health workers, and quality of care. The appearance of the building space and comfortable surroundings also were important. Quality of care improvements are suggested over expansion. Community support is essential. Personnel need strong communication skills. Flexibility is needed to meet people's needs, and reevaluation is required.

An educational intervention on promotion of breast feeding.

This study was designed to search for an effective method to promote exclusive breast feeding among Turkish city women delivering in hospitals. Four hundred and forty-two primiparae with uncomplicated deliveries and with healthy infants with birthweights of greater than 2500 g were exposed to a group educational session on breast feeding after birth, followed by one repeat session at home. Four hundred and ninety-nine women served as controls. All homes were visited monthly for 6 months by independent observers and data relevant to the feeding of the infants were collected. Weight measurements of 176 infants were taken at age 4 months. The study and control mothers were similar in sociodemographic characteristics which reflected a low socio-economic/educational background but relatively good housing conditions. Although significant differences in frequency of exclusive breast feeding were found between the study and control groups, the impact of the intervention was much lower than our expectations and short-lived. Type of feeding was not related to sex or birthweight of the infant, nor to maternal variables. Weight at age 4 months was within normal limits and similar in the study and control groups. It was concluded that lack of up-to-date information on infant feeding was the main obstacle to breast feeding in urban groups in Turkey, and that the impact of an educational intervention limited to the first week after delivery was lost within the first 2 months.

PIP: Between August 1986-December 1988, researchers enrolled at least 941 primiparous women infant pairs at a social security obstetric hospital in Instanbul, Turkey into a study intended to examine an educational model to promote exclusive breast feeding. Neither changes in hospital routine nor a continuing support program accompanied the short term intervention. Cases watched a video on oral rehydration therapy and domestic hygiene geared toward diarrhea prevention while in the hospital. They also watched a video on breast feeding followed by a discussion on breast feeding. On days 5-7, health students made home visits to discuss breast feeding and left a booklet on breast feeding. The controls only watched the film on diarrhea. Their home visits on days 5-7 centered on domestic hygiene and baby care. Health students visited each subject once a month for 6 months. Most mothers intended to breast feed (83.2%). More educated mothers (88%) originally planned to breast feed their infants than mothers with limited (81.5%) or no education (69.7%; p.01). By the end of the 1st week, only 47.1% of the cases and 12.4% of the controls were exclusively breast feeding. Supplements consisted on nonmilk liquids. Many mothers stated that they did not produce enough milk so they had to supplement. MOreover the number of cases exclusively breast feeding fell dramatically so that by the 3rd month almost no mother infant pairs practiced exclusive breast feeding. Still cases were significantly more likely to breast feed in the 1st 2 months than controls. Despite little change in behavior, most case mothers felt that the educational session influenced them and they learned the breast is best. In conclusion, the main obstacle was insufficient up to date information available to mothers, relatives, and health personnel.

An educational intervention on promotion of breast feeding complemented by continuing support.

The study, aiming to document the effect of continued support for mothers on frequency of exclusive breast feeding, was carried out by inclusion of breast feeding counselling in the context of well-baby care. One hundred and forty-six mothers who had been exposed to two educational sessions on breast feeding after delivery were given appointments to bring their baby to the paediatric hospital for well-baby care. The mother-infant pairs were followed by the same two residents for 4 months. Mean number of visits was six. A conscious effort was made during all visits to influence the mothers and their close relatives towards exclusive breast feeding. It was observed that in a large proportion of the infants, breast milk was being supplemented with water at the time of the first visit and no further effort was made to change this traditional behaviour. Comparison of the results with a group of mothers who had been exposed to similar educational sessions after delivery but without further support showed a striking increase in frequency of exclusive breast feeding (breast milk and water) in the supported group.

PIP: Researchers enrolled at least 96 primiparous women infant pairs in Instanbul, Turkey into a study intended to examine the effect of continued support of mothers on an educational model to promote exclusive breast feeding. Both the study group and the control group were exposed to the same educational sessions on breast feeding. The mothers received an appointment card during the 1st home visit for a follow up visit at the University Children's Hospital at 2 weeks. The same physician saw the same group of infants monthly for 4 months. The physicians discussed breast feeding and infant feeding with mother for 5-15 minutes. Further they encouraged mothers to telephone or visit whenever a problem occurred. They also suggested bringing a close family member with them, especially the mother in law. Indeed close relatives accompanied mothers on 90% of the visits. The deeply rooted tradition of supplementing breast milk with water manifested itself in 47.9% of the cases at 1 week. Since this was so deeply rooted, the researchers considered breast milk and water as exclusive breast feeding. 85.4% of the study group practiced exclusive breast feeding at 1 month compared to 60.9% for the control group. Even though the percentage of those in the study group who exclusively breast fed was lower at 4 months (60.9%), it was well above the comparable percentage for the control group (5%). Moreover by 4 months only 4.2% of case infants were completely weaned compared to 34.8% of the control infants. These results indicate that continuing support for mothers who breast feed plays an key role in promotion of breast feeding. Further it is preferable if the continuing support comes from the same health worker.

Oral rehydration therapy: studies on potassium balance.

The clinical response and changes in potassium balance were studied during oral rehydration therapy (ORT) with a solution containing 20 mmol potassium per litre in well-nourished and malnourished infants of 3 to 15 months of age as well as in neonates and young infants less than 2 months old (range 5-60 days). All infants were successfully rehydrated orally. The potassium intake considerably exceeded the potassium output in all groups during the entire rehydration period. The stool and urine potassium output were about the same in the 3 groups of patients. The retention of potassium increased during ORT in all groups at about the same rate. The study thus demonstrates that an oral rehydration solution (ORS) containing 20 mmol potassium per litre provides enough potassium to all patients. An increase in the potassium concentration of the ORT is therefore not recommended.