Mortalité pédiatrique au Centre Hospitalier Régional de Saint-Louis (Sénégal)

Introduction : La mortalité infantile notamment la mortalité infanto-juvénile demeure encore élevée en Afrique sub-saharienne malgré une baisse considérable. Les objectifs de notre étude étaient d'évaluer la mortalité hospitalière globale et spécifique en fonction des tranches d'âge (nouveau-né, enfants de moins de 5 ans et enfants âgés de 5 ans et plus) et d'identifier les principaux facteurs de mortalité dans ces différents âges. Matériel et méthodes : Il s'agissait d'une étude rétrospective, descriptive et analytique allant du 1er janvier 2015 au 31 décembre 2015. Elle portait sur l'exploitation des registres de consultation, d'hospitalisation et sur l'analyse des dossiers des enfants décédés âgés de 0 à 15 ans Résultats : Durant l'année 2015, le service avait enregistré 6487 consultations et le nombre d'hospitalisations s'élevait à 2458 enfants. Le nombre de décès enregistré était de 212, mais seuls 193 dossiers d'enfants décédés ont été colligés, le reste des dossiers n'a pas été retrouvés. La mortalité hospitalière globale était de 8,6% et la mortalité spécifique en fonction des tranches d'âge montrait une surmortalité néonatale de 13,9%, une mortalité infanto-juvénile de 8,6% et une mortalité chez les enfants de plus de 5 ans de 3,5%. Les facteurs de mortalité chez les nouveau-nés étaient dominés par la prématurité 32,5%, suivie par la Souffrance Néonatale (SNN) 27,1% et les infections néonatales (INN) 22,4%. Chez les enfants d'un mois à 5 ans, les facteurs de mortalité prédominants étaient la Malnutrition Aiguë Sévère (MAS) compliquée 30%, les Infections Respiratoires Aiguës (IRA) 30% et les méningites purulentes 14%. Conclusion : La réduction de la mortalité néonatale et infanto-juvénile dans notre contexte doit passer par le recrutement en personnels qualifiés (pédiatres, obstétriciens, sages-femmes…), la création d'unité de néonatologie au niveau des EPS de niveau 1, le relèvement du plateau technique des structures hospitalières et la lutte contre la pauvreté et l'amélioration du niveau de vie des populations

[Epidemiology and course of splenomegaly in children and adolescents with sickle cell disease in Senegal]. / Aspects épidémiologiques et évolutifs de la splénomégalie chez les enfants et adolescents porteurs de syndromes drépanocytaires majeurs au Sénégal.

Splenomegaly is common in sickle cell disease (SCD) and can lead to complications. In order to evaluate its prevalence and progression in Senegalese children ad adolescents with SCD, we analyzed the records of all patients followed-up at Albert-Royer Children's Hospital in Dakar, Senegal, from January 1991 to December 2005. Age, clinical course specifying size of the spleen beyond the costal margin, and disease progression were the main data recorded. We included 698 patients (94.6% SS, 4.4% SC and 1% S-beta-thalassemia). The subjects' mean age when included in the cohort was 6 years and 11 months. Splenomegaly was observed in 122 patients (17.5 %), measuring 1-17 cm beyond the costal margin (mean, 4.7 cm). Splenomegaly was more frequent in SC patients (32.3 %) compared to SS patients (16.5 %, p=0.025). The frequency was greater in infants aged 0-12 months (25.6 %) and increased from the 1- to 5-year-old age group to the 6- to 10-year-old, before it decreased further. The course of splenomegaly was marked by subsequent reduction in 17.3 % of cases, total reversal in 43.4 %, and no size variation in 39.3 %. Acute splenic sequestration occurred in 3 SS cases aged 27, 29, and 32 months and was managed with blood transfusion. Seven patients (6 SS and 1 SC) aged 4-13 years presented hypersplenism. Splenectomy was performed in 4 of these cases, while the complication reversed after 2 to 3 blood transfusions in the 3 remaining cases. The prevalence of splenomegaly is relatively low in Senegalese children with SCD. The risk of complications requires monitoring the spleen and teaching parents palpation of the baby's abdomen for early management of splenic sequestration.

[Priapism in sickle cell anaemia in Senegal: prevalence, attitudes and knowledge]. / Priapisme chez le drépanocytaire sénégalais: prévalence, attitudes et connaissances.

We interviewed 108 sickle cell anaemia patients aged 5 years older on priapism, and 113 healthy subjects in a control group. They were recruited in the out-patient consultation of the two sickle cell anemia care units of the Fann teaching hospital in Dakar. Ten cases of priapism were identified, all in the group of sickle cell patients (the difference is significant, p = 0.004). Prevalence of priapism was 9.3%. Actuarial probability of having priapism was 8.3% by 10 years of age, and 38.9% +/- 5.7 by 20 years of age. Before the interview, only 10.2% of the sickle cell patients and 8% in the control group knew about priapism, and most of them were unaware of its association with sickle cell disease (75% of sickle cell anaemia patients and 80% of control subjects). This lack of information should be improved by an educational program.

[Pédiatric haemophilus influenzae b meningitis in Dakar]. / Méningite pédiatrique à haemophilus influenzae b à Dakar.

OBJECTIVE: This study had for aim to determine the etiology of Haemophilus b pediatric meningitis. DESIGN: A retrospective study of 216 biologically confirmed cases was carried out during 6 years (January 1995- December 2000) on children 0 to 15 years of age, hospitalized at the Albert Royer Children Hospital Center. RESULTS: Haemophilus influenzae b is the first cause of pediatric meningitis (19.7%) followed by Nesseria meningitidis (14.5%), and Streptococcus pneumoniae (13.6%). The Haemophilus influenzae b meningitis cases are distributed all year round with a peak between January and March, that is to say, during the dry and cool season. They affect children at an average age of 11.7 months, with a sex ratio of 1.1 for boys. Almost all of the patients live in the low-socio-economic areas of the Dakar suburbs (92.8%). More than 90% of the H. influenzae b isolates are sensitive to ceftriaxone (96%) chloramphenicol (93%), and to ampicillin (91%). Clinical evolution is marked by death (17.8%) and recovery with psychological, sensory, and motor sequels (19.9%). CONCLUSION: This report should help to include the combined vaccine Antihaemophilus influenzae b in the Senegalese Broad Vaccination Program. The final aim is the reduction of morbidity and mortality of infections due to Haemophilus influenzae b.

[Evaluation of gingival condition in homozygous children and adolescents with sickle cell anemia in Senegal]. / Evaluation de l'etat gingival chez l'enfant et l'adolescent drepanocytaires homozygotes au Senegal.

Sickle cell anaemia is an inherited disorder of haemoglobin synthesis leading to haemolytic anaemia. It touches more than 50 million people in the world and 10% of the population in Senegal. Only the homozygous form is symptomatic and appears by painful crises of vaso-occlusive type. There is a lack of works carried out or published in Senegal about potential link between periodontal conditions and sickle-cell anaemia. The main objective of this study is to assess the gingival conditions in Senegalese children and adolescents homozygous sickle cell anaemic. Secondary, the gingival state is correlated with oral hygiene and rate of reticulocytes to determine their relationship. Fifty homozygous attending the Albert Royer Paediatric Hospital of Dakar and unscathed of other systemic pathologies, were examined. The patients are old between 3 and 16 years with an average age 9.4 years +/- 3.8. The gingival state is assessed by measurement of the gingival index (GI) and index of sulculary bleeding (SBI). Partial correlation is performed between the two indexes and average of reticulocytes. The gingival index mean is 1.7 +/- 0.6 and 66% of the patients present a severe inflammation, which is more frequent in the age bracket from 3 to 12 years. The SBI mean is 1 +/- 1.1 and 68% of the patients present gingival bleeding, which is moderate to severe in 18%, with a greater frequency in the age bracket from 13 to 16 years. Strong correlation is found between plaque index, GI and SBI. Damage of gingival state seems not to be linked to the high average of reticulocytes controlling for oral hygiene. Children and adolescent homozygous have an inflammatory periodontium associated to poor oral hygiene, which highlights their needs in periodontal treatments. Early tracking and preventive treatment of periodontal diseases during systematic oral visits must be required.

[Epidemiological and clinical aspects of paediatric HIV infections in Albert-Royer Paediatric Hospital (Dakar, Senegal)]. / Aspects épidémiologiques et cliniques de l'infection à VIH de l'enfant au centre hospitalier national d'enfants Albert-Royer à Dakar.

UNLABELLED: Human Immunodeficiency Virus (HIV) infection prevalence rate is estimated at 1.4% in Senegal, and about 3,000 children could be infected. HIV positive children are followed up since 2000 in Albert Royer Hospital (Dakar, Senegal). OBJECTIVES: To describe clinical and epidemiological aspects of HIV paediatric infection, and to evaluate the implementation of high active antiretroviral therapy in HIV positive children in our country. POPULATION AND METHODS: Over a period of three years, the medical reports of 98 infected patients have been collected, 96% with HIV 1 infection. RESULTS: Most of the patients had a maternally transmitted HIV infection (99%). At their enrollment, the median age was 60 months; malnutrition (79%), persistent lymphadenopathy (65%) and skin lesions (64%) were the common clinical manifestations. Thirty-nine percent of the patients were in class C (CDC) and 81% had CD4 cell count< or =25%. Median viral load were 421,852 copies/ml at presentation. Seven infants had a rapid progressive disease with encephalopathy. Thirty-six patients received high active antiretroviral therapy with high observance and good tolerance. CONCLUSION: This study allowed to define clinical and biological profile of paediatric HIV infection in our country and to update the implementation of high active antiretroviral therapy.

[Transferrine soluble receptors' contribution to the assessment of iron status in homozygous drepanocytic anemia]. / Apport des récepteurs solubles de la transferrine dans l'évaluation du statut en fer au cours de la drépanocytose homozygote.

Sickle cell anemia does not cause martial deprivation per se, but may worsen when iron deficiency exists, notably in tropical zone where infectious diseases and malnutrition are endemic mainly during childhood. This study was aimed to assess iron deficiency prevalence among children with sickle cell disease (SCD) and to determine the best parameters for its diagnosis. In addition to classical parameters, we measured transferrine's soluble receptors which can reveal an iron deficiency, either isolated or associated to another condition since its level is not influenced by chronic anemia. Assays were carried out in 40 homozygous SCD patients, aged 3 to 18 years, having an hemoglobin level < 11 g/dL and in 30 age-paired controls assumed to be healthy and having a negative Emmel test and an hemoglobin level < 11 g/dL. The results showed hyposideremia (serum iron < 60 microg/dL) in 17.5% of the patients. Ferritinemia, transferrinemia as well as total iron fixation capacity were in the normal range for the majority of SCD patients in spite of the frequency of hyposideremia and microcytic anemia (20%). Transferrine's saturation coefficient was low in 22.5% of patients, which can be due to martial deprivation or to inflammatory status. These results confirm the limitations of usual biochemical parameters in the diagnosis of iron deficiency in homozygous drepanocytosis. Soluble receptors' levels were increased in 60% of controls; that proves that iron deficiency prevalence is high in our countries. Higher levels were found in 97.5% of patients. However, receptors' levels are increased during haemolysis, thus it is difficult to ascertain the origin of the increase, but taking into account its index value can reduces misinterpretation. In addition, considering simultaneously microcytosis, hypochromia, transferrine's soluble receptor level and its index, we can speculate that martial deficiency occurs in 20% of SCD patients, a percentage close to the 17.1% obtained by other authors using only the combination of microcytosis and hypochromia. It results from this study that associating microcytosis and hypochromia could validly assess iron deficiency during drepanocytosis.

[Prevalence of antiphospholipid antibodies in patients with sickle cell disease]. / Prévalence des anticorps antiphospholipides au cours de la drépanocytose homozygote.

Structural abnormalities in erythrocyte membrane are more and more claimed as a determinant factor in the sickle cell disease pathogenesis. This being would have been provided by a new anionic phospholipids distribution and conformation. Phosphatidyl-serine exposing and phosphatidic acid enhancing would induce specific immunoglobulins synthesis. In this study, assessment of antiphospholipid antibodies prevalence was carried out among sickle cell trait patients (n = 35) and homozygous patients (n = 59) as compared to healthy subjects (n = 39). Antiphospholipid antibodies, assayed by ELISA procedure, were significantly higher among the homozygous patients than the sickle cell trait patients ones and highlighted as compared to healthy subjects. Pathologic data were only observed among homozygous patients. These specific antibodies, associated with thrombosis and haemolysis, would have constitute a morbid link and a therapeutic target of this sickness, dominated by homodynamic troubles.

[Neonatal mortality associated with transfer of low birth weight newborns. Assessment of a neonatal care unit of Dakar]. / Mortalité néonatale associée au transfert des nouveau-nés de petit poids. Bilan d'une unité de néonatologie de Dakar.

The aim of this study is to assess mortality rate of low birth weight newborns admitted to a neonatal care unit of Dakar after transfer. This retrospective study include all newborns weighing less than 2500 g transferred to Abass Ndao neonatal care unit between January 1st,1998 and December 31, 1999. Maternal, newborns and transfer related parameters were studied. Data of 180 new-borns were recorded from a sample of 247 babies transferred. The mean weight of these babies were 1452.5 +/- 432 g. An ambulance was used for transport in only 10% of cases. The median time of admission after birth was 3 hours. Median delay of admission and methods of transfer, maternal age and parity, apgar score at 1st and 5th minute were comparable between the newborns deceased and survivors (p > 0.05). To reduce mortality associated with newborns transfer, we insist on a better organisation of neonatal transport in under developed countries by promoting obstetricians and paediatricians collaboration and prevention of low birth weight.

[Laparoscopic cholecystectomy in sickle cell disease]. / La cholécystectomie laparoscopique dans la drépanocytose.

STUDY AIM: Sickle cell affection is a public health problem in Africa. The aims of this prospective study were to evaluate the early results of laparoscopic cholecystectomy in sickle cell patients in Senegal. METHOD: From January 1998 to June 2002 all the sickle cell patients undergoing a laparoscopic cholecystectomy were included. Intra- and post-operative protocol (blood transfusion if Hb < 9 g/dl, rehydration, oxygenotherapy) was standardized. RESULTS: Forty-two patients with sickle cell of types SS-33 and AS9 were operated upon by same surgeon. One case of conversion due to an effraction of biliary junction was reported. One homozygote patient died post-operatively because of peritonitis. Two acute thoracic syndromes, three vaso-occlusive crisis, and two cases of wound infection constituted the post-operative morbidity. No case of complication was noted in those who underwent pre-operative transfusion. CONCLUSION: Laparoscopic cholecystectomy can be carried out in sickle cell patients with biliary lithiasis provided that general anaesthetic rules are respected.

[Management of children with sickle cell disease in Africa: experience in a cohort of children at the Royal Albert Hospital in Dakar]. / Prise en charge de la drépanocytose chez l'enfant en Afrique: expérience de la cohorte de l'Hôpital d'enfants Albert Royer de Dakar.

Management of major sickle hemoglobinopathies in industrialized countries has improved significantly over the last few years thanks to strict application of the preventive and curative measures developed as a result of a better understanding of the underlying pathophysiological mechanisms. However patients in Africa have benefited little from progress in the field due to the lack of human and physical resources in sharp contrast with the high prevalence of the disease. The purpose of this study was to analyze problems involved in management of childhood sickle cell disease in Africa based on our experience in a cohort of 556 cases treated over a period of 12 years. The main problems were the same as those encountered in other black African nations, i.e., delayed diagnosis due to a lack of routine neonatal diagnostic screening, difficulty implementing anti-infectious prophylaxis due not only to the high cost of recommended vaccinations not covered by the Expanded Program on Immunization but also to poor compliance with antiobioprophylaxis, and insufficient transfusion facilities hindering application of long-term transfusion protocols when indicated. In addition the high prevalence of digestive-tract parasitosis and malaria raise the need to combine standard preventive measures with routine parasiticidal treatment and malarial prophylaxis adapted to each geographical area. The high frequency of associated iron deficiency requires systematic laboratory testing to identify and treat resulting manifestations during follow-up. An important prerequisite for widespread implementation of appropriate preventive and curative measures in Africa is recognition of sickle cell disease as a priority in public health care policy.

[Epidemiology and prognosis of childhood injuries in Dakar, Senegal]. / Epidémiologie et pronostic des accidents de l'enfant à Dakar, Sénégal.

The impact of accidental injury on childhood morbidity and mortality in Africa is underestimated. The frequency and severity of accidents is high. This retrospective study includes 381 children (3% of admission) between the ages of 0 and 15 years hospitalized for accidental injury at the Principal Hospital in Dakar, Senegal, between January 1, 1997 and December 31, 2000. The annual incidence of childhood injury doubled over the 4-year study period. Mean age was 48 months and the M/F sex ratio was 1.7. The causes were trauma (n = 184) due to domestic accidents (n = 109 including 91 falls) or road accidents (n = 75), poisoning (n = 129 including 38 caustic soda burns), foreign body aspiration or ingestion (n = 30), burns (n = 18), and miscellaneous accidents (n = 20). Most fatalities (9%) were due to road accidents and falls. Rapid uncontrolled urbanization and problems of displaced rural populations in adapting to city living may account for the high frequency of falls from high buildings and road accidents. As in industrialized countries road accidents, though not the most frequent, are the most lethal. Lack of emergency services accounts for severity. Vigorous information campaigns and prevention action will be needed to lower the high morbidity and mortality of childhood injury in developing countries.

[Progressive spinal amyotrophy type I or Werdnig-Hoffman disease. Apropos of 5 cases in Dakar (Senegal)]. / L'amyotrophie spinale progressive de type I ou maladie de Werdnig-Hoffmann. A propos de 5 cas dakarois (Sénégal).

Type I spinal muscular atrophy or Werdnig-Hoffman disease is rarely described in black populations. We report five such cases diagnosed in a paediatric outpatient clinic in Dakar. We conducted a retrospective study relating to patients examined for hypotonia progressing since birth for whom the electromyogram had made it possible to confirm an involvement of the peripheral nerve without nerve conduction anomaly. Mean age of diagnosis was 12.3 +/- 7.6 months. Respiratory distress was noted for 2 patients. A family background of similar symptomatology was found in 1 case and consanguinity in 2 cases. Only 1 case of death occurred whereas the 4 other patients were lost to follow-up. The diagnosis of spinal muscular atrophy must be considered in the presence of any severe hypotonia in infants.

[Management problems of malignant hemopathies among children in Senegal]. / Problèmes posés par la prise en charge des hémopathies malignes chez l'enfant au Sénégal.

Malignant hemopathies are not considered as public health priority in Senegal because of their infrequency in comparison with infections and malnutrition. However they remain usually lethal instead of a great improvement of their prognosis in suitable therapeutic conditions. The objective of this study was to determine the epidemiologic and evolutionnal profile of these pathologies, and identify practical management problems in a reference public pediatric service in Senegal. We retrospectively analysed hospitals registers and records of all patients followed up in Albert Royer Children Hospital of Dakar from january 1989 to december 1998. During this ten years period 25 cases of malignant hemopathies were diagnosed among 32,789 hospitalised children, representing an hospital prevalence of 0.08 per cent. Mean age at the desease diagnosis was 9.5 years and sex ratio 2.57 (18 boys and 7 girls). The malignant type was acute leukemia (AL) in 11 cases (44%) including 9 cases of of acute lymphoblastic leukemia (ALL) and 2 cases of acute myeloblastic leukemia (AML); chronic myeloid leukemia (CML) in 2 cases (8%), Hodgkin's desease (HD) in 9 cases (36%) and non hodgkinian lymphoma (NHL) in 3 cases. NHLwere Burkitt type in 2casesand lymphoblastic type in 1 case. Their was no maxillary or facial localisation in Burkitt type lymphoma. The mean duration between the first clinical symptomes and the diagnosis of the disease was 4 months and delayed diagnosis was mainly due to delayed transfer from peripheral health services to hospital. Among 19 patients whose records were available, 17 were subjected to chemotherapy. However reference protocols were completely applyed in only 2 cases, one with HD and an other with lymphoblastic lymphoma. Transfusion managementwas not sufficient because of the lack of blood derived products (packed platelets or leucocytes) when needed. Thirteen patients died while followed up and mean survival after first hospitalisation in these cases was 120 days in ALL, 38 days in AML, 2.5 years in HD and 18 months in NHL The other patients were lost of sight and presumed to be dead at home. Eventually, this study showed that, in our hospital, children with malignant hemopathies did not derive benefit of therapeutic progress enregistered long time ago in developed countries, since they remain constantly lethal. The main factors of lethality could be delayed transfer to hospital because of lack of knowledge about these pathologies in the peripheral health services and poor therapeutic conditions in reference hospitals. Creation of specialised clinical haematology department could enable us to improve the prognosis of these affections by an optimal use of available human and material ressources.

[Defects in peroxidation of erythrocyte phospholipids in sickle cell trait]. / Lésions péroxydatives des phospholipides érythrocytaires au cours de la drépanocytose AS.

The sickle cell disease pathophysiology is provided by several events including deoxyhemoglobin S polymerization and hemorrheological troubles. Classically, such disorders have been known to concern only the homozygous SS and heterozygous SC profiles. However, troubles are more and more described since early years in the sickle cell trait patients and the pathogenesis factors are unknown. Our study focussed on phospholipids which are the basic and functional constituent elements of erythrocyte plasmic membrane. Assaying the membrane lipids extracted by Folch method and lipid standards (cholesterol, phosphatidic acid, lysophosphatidyl-choline, phosphatidyl-choline, lysophosphatidyl-ethanolamine, phosphatidyl-ethanolamine, sphingomyelin) was carried out by HPLC among 91 sickle cell trait patients as compared to 78 healthy subjects. The main abnormalities observed were an empoverishement in phosphatidyl-choline contrasting with an accumulation of membrane lysophosphatidyl-choline, lysophosphatidyl-ethanolamine, phosphatidic acid and sphingomyelin in sickle cell patients. These results suggest that sickle cell trait harmlessness is not actual. The accumulation of lysophosphatidyl-choline, by its cytolytic biomembrane perturbing properties, predispose therefore the sickled red cell to the haemolysis phenomena and allow to forecast deeper disturbances among homozygous subjects. These morbid disorders attributable to lipid peroxidation would justify an antioxidant treatment during the sickle cell disease.