[Measles seroprevalence among pediatricians in a teaching hospital]. / Soroprevalência de sarampo entre pediatras de um hospital-escola.

OBJECTIVE: A measles outbreak occurred in S. Paulo state, during 1996 and 1997, resulting in 20,921 cases. Forty seven percent of the cases occurred in people between 20 and 29 years of age, and one of the control strategies of the Department of Health was the vaccination of health care workers. The prevalence of antibodies against measles among the hospital pediatricians was investigated. METHODS: One hundred and fifty samples were taken from volunteer pediatricians to test for measles antibodies using ELISA. A questionnaire about their having had measles and the vaccine was filled out. RESULTS: Of the 150 doctors, 122 (81.4%) were female and 28 (18.6%) male, of between 23 and 46 years of age (mean and median 27 years). The majority (98%-147/150) had protective levels of antibodies against measles (>100 UI/ml); 118 (80.3%-118/147) without and 29 (19.7%-29/147) with a history of measles. Only 3 pediatricians (2%-3/150), had negative serology, 2 without and 1 with a history of measles. Out of the 118 without history of measles, 79 (67%-39/118) in spite of the protective level of antibodies against measles, did not know if they, had been vaccinated. Out of the 79 vaccinated pediatricians, 64 (81%-64/79), had been vaccinated 25 years before, and still maintained protective levels of antibodies. Of the 3 doctors with negative serologies only one declared that he had been vaccinated. CONCLUSIONS: Measles seroprevalence among pediatricians of this hospital is high, especially due to preceding vaccination. On the other hand, the 2% of pediatricians with negative serology, in an epidemic situation could constitute a significant population for the acquisition and dissemination of the disease.

Use of undiluted whole cow's milk is effective for the routine treatment of children with acute diarrhea and severe dehydration.

A comparison is made between two groups of children aged 1-24 months and admitted to a teaching University Hospital due to acute diarrhea and severe dehydration. One group (n = 119) received a diluted cow's milk formula and the other (n = 109) a full-strength formula. Duration of diarrhea was similar: In the group that received full-strength milk weight gain was greater during diarrhea (5.03 vs. 1.80 g/kg/day, P < 0.01) and during the hospital stay (5.39 vs. 2.33 g/kg/day, P < 0.001). Weight for height z-scores and weight for height as percentage of median improved during the hospital stay only in the group that received the full-strength formula. Full-strength cow's milk seems to be an adequate routine regimen even for children with acute diarrhea that must be treated for severe dehydration. In developing countries diarrhea and dehydration are a disease of small children. As rates of exclusive breast feeding are low, mainly in the urban setting, cow's milk is the main and sometimes the only food available. Lactose-free formulae are priced out of reach of the poor people and in Latin America there is no accepted tradition for use of fermented milk products. Our study is an indication that use of undiluted cow's milk may be effective for the routine treatment of acute diarrhea in children that must be treated as inpatients due to severe dehydration.

[Continuous nebulization with terbutaline sulfate under tent inhalation. Evaluation of the efficacy in children 2 to 5 years of age in asthmatic crises]. / Nébulisation continue avec sulfate de terbutaline sous tente d'inhalation. Evaluation de l'efficacité chez l'enfant de 2 á 5 ans en crise d'asthme.

This study investigated the efficacy of a system for continuous nebulization of terbutaline sulphate in the treatment of acute asthmatic crises in children. The equipment consisted of a condensation nebulizer attached to a 40 liter acrylic tent placed around the patient's head. A prospective, randomized and open clinical trial was conducted. Twenty eight children, 2 to 5 year-old, in acute asthmatic crises were selected. Fourteen were nebulized with terbutaline sulphate while in the control group the aerosolization was proceeded only with half diluted physiologic serum. All patients were administered aminophyline intravenously. The parameter used to evaluate the efficacy of the terbutaline sulphate nebulizing system was clinical improvement measured by the Wood-Downes Score. Two additional parameters indicating terbutaline sulphate absorption were used: reduction of potassium seric levels and positive chronotropic effect. The group treated with terbutaline sulphate showed greater clinical improvement than control group at the 12 hour protocol evaluation as well as lower seric potassium level. A positive chronotropic effect was also observed at the final protocol evaluation. The data showed, preliminarily, that (a) the system for continuous nebulization of terbutaline sulphate was effective in treatment of children's acute asthmatic crises, and (b) there was evidence attesting to the absorption of terbutaline sulphate by the children treatment with it.

[Evaluation of the therapeutic efficacy of dexamethasone in meningococcal meningitis] / Avaliação da eficácia terapêutica da dexametasona na meningite meningocócica.

OBJECTIVE: To evaluate the efficacy of dexamethasone as an auxiliary therapeutic tool to the antibiotics in hospitalized children with meningococcal meningitis. METHODS: A retrospective clinical comparative study was undertaken with children from a pediatric ward affected by laboratory proved meningococcal meningitis at a university hospital. Cases of children in state of shock at admission or deceased in the first 24 hours were excluded. During the period from 1987 to 1989 33 children were treated only with antibiotics (group A), while from 1990 to 1993 other 66 children received additionally dexamethasone (12mg/m2/24h) by intravenous route during four days beginning at the admission to the hospital (group B). The two groups were evaluated at baseline through prognostic scores and analysis of their clinical and laboratorial characteristics obtained from data recorded at the admission. The parameters to evaluate dexamethasone efficacy were the comparative number of neurologic and systemic complications detected at the hospital, and the liquoric profile (leukocyte count, glucose and protein content) verified between day 9 and day 11 of hospitalization. RESULTS: The profile of the two groups (A and B) were homogeneously evaluated by the illness severity scores and their clinical and laboratorial characteristics. Nine complications were recognized in group A (27.2%) and 21 (31.8%) among those of group B, difference not significant. Likewise, there were not observed liquoric differences between the two groups related to the chimiocytologic pattern. CONCLUSIONS: No effect of dexamethasone therapy to prevent neurologic and systemic meningococcal meningitis complications was observed during hospitalization. Similarly no favorable effect in relation to the liquoric pattern verified between day 9 and day 11 of hospitalization was recognized.

Prevalence of serotypes and antimicrobial resistance of streptococcus pneumoniae strains isolated from Brazilian children with invasive infections. Pneumococcal Study Group in Brazil for the SIREVA Project. Regional System for Vaccines in Latin America.

A laboratory surveillance study was developed in Brazil in 1993 to determine capsular types and antimicrobial susceptibility of Streptococcus pneumoniae strains. By studying 360 strains isolated from children with invasive infections in three different cities, 8 out of 34 types were identified as being the most prevalent and considered as the reference group for further analyses. This group comprised 77.7% of all strains studied, and includes the types 1, 5, 6A/B, 9V, 14, 19F, 19A, and 23F. The prevalence of this reference group was significantly higher among strains isolated from children with pneumonia than meningitis. Similarly, this group was more prevalent among strains isolated from children 3 to 6 years of age than from children under 2 years of age. Most strains (78.6%) were found to be susceptible to penicillin and only 1.4% showed high resistance to this antibiotic. However, intermediate resistance to penicillin was detected in 20% of the strains. This laboratory surveillance will be maintained and extended to other cities of Brazil to better define and monitor the trends of pneumococcal infections for proper control and prevention.

[Idiopathic primary pulmonary hemosiderosis: treatment with cyclophosphamide and prednisone]. / Hemossiderose pulonmar idiopática tratada com ciclofosfamida e prednisona.

The authors present the case of a child diagnosed as having idiopathic pulmonary hemosiderosis at five years of age who had a good clinical outcome at the age of ten years. Initially the patient was treated with prednisone and chloroquine with poor results. When cyclophosphamide was added to prednisone, the patient demonstrated clinical and radiological remission. To date, the patient has been followed for one year without any medication, and has had only one limited episode of hemosiderosis. The authors also suggest that the therapeutic regimen with cyclophosphamide and prednisone may be useful for some selected cases.

[Treatment of pediatric outpatients with complicated urinary tract infections]. / Tratamento ambulatorial de crianças com infecção urinária complicada.

In an open and prospective study involving outpatient children with complicated urinary tract infections (UTI), we evaluated the therapeutic efficacy of ceftriaxone administered intramuscularly, once-daily--50 to 70 mg/kg, during 8 to 10 days. Initially, the selected patients exhibited at least two of the following clinical criteria: age below 6 months, any degree of toxicity, fever, strong suspicion or proved abnormalities of their urinary tracts and lumbar pain in children older than 4 years. Significant bacteriuria was demonstrated by urine culture in 40 patients (21 boys, 19 girls), whose ages ranged from 15 days to 6 years 9 months (median 3 months). The radiological studies revealed vesicoureteral reflux in 6 patients, urethral posterior valve in 1, and neurogenic bladder in 4. The main causative agents were Escherichia coli isolated in 30 patients, Klebsiella (4) and Proteus (4). The treatment was found to be effective in 38 patients (95%). There was failure of treatment in 1 patient and a symptomatic reinfection in another one. It was concluded that children with complicated UTI could be treated alternatively by once daily ceftriaxone.

Oral palatine ulcers of a traumatic nature in infants: Bednar's aphthae.

The authors present five cases of large palatine ulcers of a traumatic nature in infants, with duration from two weeks to four months. Causal diagnosis was difficult at first until the possibility of trauma caused by non-orthodontic nipples (all cases) and dummies (4)--Bednar's aphthae--was considered. Other problems related to sucking were observed: a horizontal position for nursing (all) and very narrow nipple hole (4). The infants' mothers were advised to enlarge the orifice in the nipple and correct the position for nursing (3 cases) and, in addition, to suspend use of a dummy (1 case) and discontinue use of a bottle and dummy (1 case). All of the ulcers healed within a period from one to four weeks. Small scars remained in two of the children.

Aerobic bacteria, Chlamydia trachomatis, Pneumocystis carinii and Cytomegalovirus as agents of severe pneumonia in small infants.

The authors studied 58 infants hospitalized for pneumonia in a semi-intensive care unit. Age ranged from 1 complete to 6 incomplete months. The infants were sent from another hospital in 20 cases and from home in a further 38. Pulmonary involvement, which was alveolar in 46 cases and interstitial in 12, was bilateral in 31 children. The investigation was carried out prospectively on the etiological agents associated with respiratory infection to look for evidence of aerobic bacteria (blood cultures), Chlamydia trachomatis and Cytomegalovirus (serology), and Pneumocystis carinii (direct microscopy of tracheal aspirated material). The following infectious agents were diagnosed in 21 children (36.2%): Aerobic bacteria (8), Chlamydia trachomatis (5), Pneumocystis carinii (3), Cytomegalovirus (3), Cytomegalovirus and Chlamydia trachomatis (1), Aerobic bacteria and Cytomegalovirus (1). Seven cases of infection by Chlamydia trachomatis and/or Cytomegalovirus were diagnosed out of the 12 cases with pulmonary interstitial involvement.

PIP: This paper reports the results of a prospective study designed to evaluate the occurrence of potential pulmonary pathogens in a group of socioeconomically deprived infants hospitalized in a semi-intensive care unit for severe pneumonia. The study was conducted over a 2-year period and included infants ranging in age from 1 complete to 6 incomplete months. Inclusion criteria for this study were: a) history of acute respiratory disease; b) respiratory rate over 60 times/minute; and c) radiographic exam revealing alveolar or interstitial pulmonary alteration. A total of 58 infants were selected for the study, of which 33 (56.9%) were male and the 25 (43.1%) were female. Mean age was 2.3 months. Pulmonary involvement, which was alveolar in 46 (79.3%) patients and interstitial in 12 (20.7%) patients, was bilateral in 31 (53.4%) infants. The investigation of etiological agents associated with respiratory infection sought evidence of aerobic bacteria (blood cultures), Chlamydia trachomatis and Cytomegalovirus (serology), and Pneumocystis carinii (direct microscopic exam of tracheal aspirate). The following infectious agents were diagnosed in 21 (36.2%) patients: aerobic bacteria (8), C. trachomatis (5), P. carinii (3), Cytomegalovirus (3), Cytomegalovirus and C. trachomatis (1), aerobic bacteria and Cytomegalovirus (1). 7 of 12 (58.3%) cases with pulmonary interstitial involvement were infections by C. trachomatis and/or Cytomegalovirus. The authors recommend that the investigation of the role of other infectious agents for this age bracket should continue.

[Management of febrile infants younger than 2 months of age at the Emergency Care Unit: diagnosis aspects and therapeutics]. / Febre no lactente jovem atendido em Serviço de Emergência: aspectos diagnósticos e terapêuticos.

82 febrile young infants were studied, prospectively, at the Emergency Service in Hospital Universitário-University of São Paulo. All the children were kept at the Emergency ward for 24 hours. Clinical and laboratory investigations were performed and when necessary, administration of antibiotic agents were started. 18 infants exhibited potentially severe bacterial infections (21.9%). Several important disorders were recognized in 40 infants (48.8%). All infants were followed until the end of the febrile episode: 20 children as inpatients and 62 as outpatients. 38 infants received antibiotic therapy (46.3%). Evolution was satisfactory in all patients. The authors detected in young febrile infants potentially dangerous clinical conditions that need close observation, laboratorial investigation and frequently antimicrobial therapy. The observation period at the Emergency ward was important to allow these procedures and to decide about hospitalization need.

[Serotypes of pneumococci isolated from children with pneumonia: implication of pneumococcal specific immunization]. / Sorotipos de pneumococos isolados de crianças com pneumonia: implicação com a imunização específica anti-pneumocócica.

For the 15 years from 1978 to 1992 serologic typing was performed on 124 pneumococcus isolates from children with acute pneumonia. The source of bacteria was material obtained by aspirative pulmonary punction, pleural fluid or blood; 122 capsular antigens representing groups and types could be determined. Of the 122 isolates serogrouped 14, 1, 6, 5, 4, 7, 23, 19 and 4, accounted for 25.4%; 23.8%; 13.1%; 9.0%; 4.9%; 4.9%; 4.1%; 4.1%; 4.1%; respectively, of cases. The currently available 23-valent vaccine would provide protection against 89.3% of identified pneumococci in our study, but because of its poor immunogenicity in children less than 2 years old (73.0%) they would have received reduced protection by the use of this vaccine. The distribution of pneumococci serogroups found in our study has an intermediary pattern in relation to those found at develop countries (6, 14, 18, 19, 23) and developing ones (1, 2, 3, 5, 7, 12, 46). The new conjugate vaccines, with limited number of pneumococcal groups/types, should be analysed before the introduction in different geographic areas.

Adenovirus genome types isolated from stools of children with gastroenteritis in São Paulo, Brazil.

In a prospective one-year study of acute gastroenteritis in hospitalized children less than 2 years of age, in São Paulo (Brazil), adenoviruses were detected by specific enzyme immunoassay (El-ARA) in 7 of 67 (10%) ill children and in 9 of 79 (11.4%) controls. They were the sole recognizable agent of diarrhea in 6 ill children. In another child these viruses were detected in a dual infection with astrovirus. Enteric adenoviruses (Ad40/41) were the most common serotypes detected in children with diarrhea (3/7) and Ad7 the serotype most detected in the controls (5/9), associated with lower respiratory tract infection. Thirteen adenovirus strains, isolated in HEp2 or HEK-293 cells, were characterized by seroneutralization and restriction enzyme analysis. The established adenoviruses were typed as AV-7-D5 (five associated to lower respiratory tract infection and one to diarrhea), AV-1-D10 (one diarrhea case), AV-31-D2 (two controls with respiratory infection), and two isolates as AV-12-D7, a new genome type. One subgenus D isolate, serotype 28, with restriction patterns different from those of the prototype, remained untyped. Only one enteric adenovirus could be typed. The restriction patterns of this isolated were similar to those of the prototype AV-41-D1. The genome type of the other three enteric adenoviruses could not be determined.

Septicemia por Staphylococcus aureus em crianças: tolerância bacteriana à vancomicina e poder bactericida do soro / Staphylococcus aureus septicemia in children: bacterial tolerance to vancomycin and serum bactericidal test

OBJETIVO. Analisar a sensibilidade e tolerância das cepas de Staphylococcus aureus isoladas de crianças com septicemia e avaliar o poder bactericida sérico na monitorizaçäo terapêutica desses casos. MÉTODOS. Foram estudados 17 casos de crianças com septicemia por Staphylococcus aureus internadas na Enfermaria de cuidados semi-Intensivos do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo. Foram realizados testes de sensibilidade antimicrobiana pelo método de difusäo em disco e diluiçäo em tubo. Foram realizados 29 testes no pico e 23 no vale dos antibióticos utilizados, determinando o poder bactericida do soro. RESULTADOS. As cepas de Staphylococcus aureus de origem hospitalar mostraram resistência a quase todos os antibióticos, exceto vancomicina e pefloxacina. Observou-se fenômeno de tolerância em cinco (50 por cento) das cepas testadas para vancomicina, sendo que quatro apresentaram má evoluçäo clínica. Os testes para determinaçäo do poder bactericida sérico revelaram títulos no pico ò1/8 em 55,5 por cento das observaç 8es; neste grupo a evoluçäo clínica foi melhor. CONCLUSäO. As cepas de Staphylococcus aureus de origem hospitalar estudadas säo multirresistentes. O fenômeno de tolerância antimicrobiana, assim como o poder bactericida do soro em níveis baixos, pode estar associado a má resposta terapêutica. A valorizaçäo do PBS como critério de avaliaçäo terapêutica em infecçöes graves e o papel da tolerância do Staphylococcus aureus à vancomicina merecem maiores estudos

[Staphylococcus aureus septicemia in children: bacterial tolerance to vancomycin and serum bactericidal activity]. / Septicemia por Staphylococcus aureus em criança: tolerância bacteriana à vancomicina e poder bactericida do soro.

PURPOSE: To evaluate the susceptibility and of strains of Staphylococcus aureus isolated from children with septicemia, and to evaluate the importance of the serum bactericidal test. METHODS: Seventeen children with Staphylococcus aureus septicemia admitted to the Semi Intensive Care Unit of the Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo were studied. Twenty nine tests in the pico and 23 in the nadir of the antibiotics were made. RESULTS: Strains of Staphylococcus aureus from hospital origin were resistant to all the antibiotics but vancomycin and pefloxacin. The phenomenon of tolerance was seen in 5 (50%) of the strains that were tested for vancomycin, and 4 of the children had a bad evolution. The serum bactericidal tests showed titles in the pico > or = 1/8 in 55.5% of the observations; in this group the evolution was better. CONCLUSION: Strain of Staphylococcus aureus from hospital origin are multiresistant. The phenomenon of antimicrobial tolerance, as well as the serum bactericidal test may be related to a bad therapeutic evolution. The increasing value of the serum bactericidal test as a way to evaluate the therapeutic evolution in severe infections, and the role of the tolerance of the Staphylococcus aureus to vancomycin more studies.

[Occurrence of human astrovirus in São Paulo City, Brazil]. / Ocorrência de astrovírus humanos na cidade de São Paulo, Brasil.

Human astrovirus was detected during a 13-month longitudinal study of the incidence of diarrhoea viruses among hospitalized children (less than 2 years of age) in a pediatric clinic of the city of S. Paulo (University Hospital). Serial fecal samples (intervals of 4 days) were collected from 146 children with and without acute diarrhoea at admission and during their stay in the hospital. Two (3%) of the 67 children with diarrhoea were positive at admission to the clinic by the highly sensitive ASTROVIRUS BIOTIN-AVIDIN ELISA, using CDC monoclonal antibodies (MAb SE7). All 79 children without diarrhoea (controls) were negative for astrovirus at admission. However, astrovirus was detected in 7 (4.8%) of the 146 hospitalized children during their stay in the clinic. Three of the positives shed astroviruses in 2 successive stool samples. All children positive for astrovirus were negative for rotavirus, adenovirus and bacterial and parasitic enteric agents. This is the first study of the detection of human astrovirus in Brazil. Astrovirus appears to be a significant cause of infantile gastroenteritis among young children in this country.

[A serological inquiry for the detection of antibodies against human immunodeficiency virus (HIV) in children in a general ward]. / Inquérito sorológico para a detecção de anticorpos contra o vírus da imunodeficiência humana (VIH) em crianças internadas em enfermaria geral.

The results of a serum inquiry for detection of antibodies against the Human Immuno-deficiency Virus in a non selected group of children, patients of a general pediatric ward, are reported. Of the 441 cases, the ELISA test gave a positive result for 1.1% of them. This result was confirmed by the Western-Blot or ImmunoBlot test. None of the five children who tested positive had a previous history of blood transfusion. These children's mothers showed positive results to the ELISA test. Of four cases, at least one of the parents was IV drug addicted. In every case the transmission was vertical. On the basis of these findings, it is suggested that hospital staff should take the necessary precautions when manipulating blood and secretions and it is recommended that serum inquiries be made on the wards of general hospitals in the attempt to establish reliable data on the prevalence of HIV.