Risk factors for fatal diarrhoea among dehydrated malnourished children in a Madagascar hospital.

OBJECTIVE: To examine mortality risk factors during rehydration among 6-35 month malnourished children with diarrhoea. DESIGN: Data collected prospectively during a clinical trial comparing two oral rehydration solutions (ORS). SETTING: Paediatric ward. SUBJECTS: Study children had either a weight-for-age Z-score below -2 or a weight-for-height below 70% of NCHS median. All had diarrhoea for < 5 days. 150 were enrolled and two were excluded for intercurrent infection. INTERVENTION: Children were randomly allocated to receiving 100 ml/kg of standard or rice-based ORS during the 6h following admission. Then they received 420 kJ/kg/day of high energy milk, progressively increased to 840 kJ/kg/day. RESULTS: Mortality rate was 16% and with no difference by ORS group. In univariate analysis, the risk of dying (mean odds ratio; 95% confidence interval) was significantly higher among girls (3.5; 1.4-8.9), in non-breast-fed children (3.7; 1.4-9.6) and in children with a low weight-for-height (5.1; 1.9-14.1). Low weight, moderate or severe dehydration, low plasma specific gravity or total plasma protein and longer duration of diarrhoea before inclusion also were significant risk factors. In multivariate logistic analysis, only absence of breast-feeding was associated with a higher risk of dying among girls with a low weight-for-height. Among them, eight out of nine died, compared to 15 out of 139 for other children. CONCLUSION: Breast-feedings protected severely malnourished girls against death from diarrhoea even when dehydration was corrected. Mechanisms underlying this selective effect are poorly understood.

[The value of anatomo-pathologic examination of the placenta in areas of endemic malaria and low socio-cultural levels]. / Intérêt de l'examen anatomo-pathologique du placenta dans les zones d'endémie palustre et de faible niveau socio-culturel.

OBJECTIVES: Determine the sensitivity of the pathology examination of the placenta as a screening examination for malaria and the consequences of this infection on prematurity and birth-weight. METHODS: Eighty placentas were examined at the Mjunga, Madagascar dispensary at the beginning of the rainy season. The aspect of the placenta was compared with a malaria index and to malaria disease state as a function of parity and anti-malarial prophylaxis used by the mother as well as with the state of the infant. RESULTS: Among the placentas examined, 41.3% were considered normal and abnormal or clearly pathological in 58.7%. Estimating the gestational age on the basis of the histological examination of the amniotic cells was in agreement with the gestational age calculated from the last cycle in 53 cases and in disagreement in 8 cases. The percentage of cases of malaria discovered by the pathology examination (20%) was greater than that after thick swab screening (10%). 75% of the mothers has Plasmodium falciparum infection at the time of delivery and 13.8% of the mothers with negative thick drops had malaria lesions of the placenta. The parity of infected mothers was similar to non infected mothers. All the premature newborns had pathological placentas included 12.5% with malarial lesions. 90% of the hypertrophic newborns had pathological placentas included 50% with malarial lesions. No case of congenital malaria was observed. CONCLUSION: Pathology examination of the placenta is as sensitive as blood drop tests for screening for malaria. The histological examination of amniotic cells can give a good estimation of gestational age in developing countries.

[Aspects of primary tuberculosis infection in children: 27 cases observed at Children's Hospital, Antananarivo]. / Aspects de la primo-infection tuberculeuse de l'enfant: à propos de 27 cas observés à l'Hôpital des Enfants-Antananarivo.

A retrospective study on tubercular primary infection in children was carried-out for 18 months (January 1994--June 1995) at the Child Hospital of Tsaralalana in Antananarivo-City. 27 cases were reported. The sex-ratio was of 1,01/1. The most clinical forms were pulmonary tuberculosis. An associated factor was malnutrition. Contact has been traced back to close family. Short course treatment regimen was the standard applied.

[Influenza in the pediatric hospital unit at Antananarivo]. / Etude de la grippe en milieu hospitalier pédiatrique à Antananarivo.

62 rhinopharingeal samples from malagasy children, aged of 6 days to 14 years old, hospitalized because of acute respiratory infections, with doubtful viral etiology case, during June to August 1992, at the "Hôpital des Enfants" in Antananarivo, were examined by two methods: inoculation by embryonned eggs and inoculation by MDCK cells. 24.1% of the samples were positive. The repartition of the cases by age and by sex were studied. The children aged of 1 to 12 months were the most affected with 65.7% of all cases (male: 60%, female: 40%). One subtype was detected: A(H3N2).

[Evaluation of the management of tuberculosis in children in Madagascar. Results of a multicentric study]. / Evaluation de la prise en charge de la tuberculose infantile à Madagascar. Résultats d'une étude multicentrique.

In Madagascar, tuberculosis remains an important cause of morbidity and letality with a Risk of Annual Tubercular Infection about 1% in 1996 in spite of a vaccination rate of 82.6% and tubercular drugs free of charge. In 1995, the National Tubercular Control Program detected 7,000 cases of pulmonary tuberculosis and expected more than 12,000 cases per year. This study was carried out in order to review the management and the treatment of the child tuberculosis in Madagascar. This retrospective study was conducted in four pediatric units of the General hospital of Befelatanana (A and B), Ambohimiandra Hospital and Regional Hospital Centre of Toliara for a twenty four months period from January 1997 to December 1998. All the less than 15-year-old children medical files were consulted. 214 cases were suspected of tuberculosis. 133 of them were treated upon clinical presumption basis and/or radiological exams (33 bacteriological and/or histopathological exams were only realized). 56% of the cases were vaccinated by BCG vaccine. Respiratory diseases with fever motive 46% of hospitalization. The majority of these children are living in poor conditions and 38% of them had malnutrition. Were found as clinical manifestations: 47% of pulmonary tuberculosis (among them 20% were smear-positive pulmonary tuberculosis), 12% had ganglionar tuberculosis, 10% peritoneal tuberculosis, 8% a tubercular meningitis, 5% a Pott-disease and 2% a miliary-disease. Mortality increases with suffocation. 18% of cases died, especially infants and in tubercular meningitis. The authors conclude that management and treatment of tuberculosis need an early diagnosis. But the diagnosis is difficult in front of non specific clinical manifestations in children and due to lack of means and national agreement which settle up diagnosis and therapy. A scoring system based upon clinical signs in agreement with complementary medical tests is desirable.

[Evaluation of the use of antibiotics in the hospital pediatric milieu]. / Evaluation de l'utilisation des antibiotiques en milieu hospitalier pédiatrique.

Excessive and inappropriate use of antibiotics is a world-wide serious problem because it contributes to the development and the spreading of antibiotic resistance. The authors carried out a study for one year by 1998, in order to evaluate antibiotic prescriptions in three childhood diseases: respiratory, digestive and neurological diseases. Patients hospitalized at the unit paediatric of the General hospital of Befelatanana are 0 month to 15 years old. Three antibiotic families were frequently used: cotrimoxazole, penicillins derivatives and aminoglycosides. Results of this study noted that antibiotic precriptions were irrational. Some factors may give explanations to these facts: the insufficiency of biological labs, but also expensive costs of exams. It is desirable that all paediatricians can gather in order to draw up clinical protocols and to assess them by a multicentric survey. Further results may be used as reference for empirical or probabilist antibiotic prescriptions of which efficacy will be checked by an experienced lab.

[Costs directly related to acute lower respiratory tract infections in the pediatric hospital milieu]. / Coût direct lié aux infections respiratoires aiguës basses en milieu hospitalier pédiatrique.

The purpose of this retrospective study carried out by 1997 in two paediatric units of Antananarivo: paediatric unit of the General hospital of Befelatanana (Marfan) and paediatric unit of the Hospital Center of Soavinandriana (CI), was to evaluate direct service costs for an hospitalization of a child affected by lower acute airway diseases. In the first unit, there is partial charge, in the second, there is full charge. Direct services were continued by complementary tests, therapy and meals. The length of the hospitalization changes according to the cause and the severity of diseases. Average direct service costs were of 19 and 38 US$ respectively. Maximum direct service costs were of 77 and 154 US$ respectively. Amounts of direct service costs were crippled especially by inappropriate use of antibiotics.

[Oral rice-based rehydration solution (SRO), alternative of SRO of WHO in acute diarrhea in malnourished patients]. / La solution de réhydratation orale (SRO) à base de riz, alternative de la SRO de l'OMS dans la diarrhée aiguë des malnutris.

BACKGROUND: Although malnutrition is frequently associated with diarrhea, most oral rehydration solutions have been tested in well-nourished children. The study tests efficacy of rice, a traditional treatment for diarrhea in Madagascar. PATIENTS AND METHODS: 150 severely malnourished children, aged 6 months to 3 years, took part in this randomized trial. All the children were given oral rehydration solution, (100 ml/kg) in the first 6 hours. The first group (68 children) was given a solution containing glucose, (20 g/l). The second group (82 children) was given a solution containing rice powder (50 g/l). Treatment was then continued according to WHO recommendations, including feeding after rehydration (mixture of milk, oil and sugar). RESULTS: The age, weight, height, duration of diarrhea before admission, degree of dehydration and pathogens in stools of the two groups were comparable on admission. Only 2 patients were withdrawn from the trial. The percentage of death was the same in both groups: 16% of those given glucose and 15% of those given rice-based rehydration solution. The weight gains were similar in both groups; the duration of diarrhea was 89 +/- 6 hours in the glucose-fed groups and 68 +/- 4 hours for those given the rice-based rehydration solution (p < 0.02). CONCLUSIONS: Both glucose and rice-based rehydration solutions are equally effective for rehydrating severely malnourished children with acute diarrhea. The rice-based rehydration solution also reduces the duration of diarrhea.

[Acute flaccid paralysis after drug injection: a case report in the pediatric service of the Befelatanana Hospital Center in Antananarivo]. / Paralysie flasque aiguë post-injectionnelle de médicament chez l'enfant: à propos d'un cas observé au Service de Pédiatrie du Centre Hospitalier de Befelatanana-Antananarivo.

In the framework of the poliomyelitis program eradication, the World Health Organization suggests two markers to survey the circulation of the poliovirus: notification of all cases of acute flask paralysis (AFP) and etiological research of these AFP from two stool samples. The authors reported the case of a AFP, occurring after a polio vaccination in a 5-year-old boy who had later an acute rhinopharyngitis treated by antibiotics and quinine intramuscular injections. A left lower limb AFP justified his hospitalisation. The isolation of a Sabin type 3 poliovirus was a pitfall because clinical and complementary investigations demonstrate a peripheral neuromuscular paralysis. This demonstrative case shows the need for health staff to be trained to perform correctly an usual act like intramuscular drug injections.

[Diagnostic pitfalls in childhood acute obstructive dyspnea]. / Pièges diagnostiques d'une dyspnée aiguë obstructive de l'enfant.

Diagnosis of an acute obstructive dyspnea is very difficult because there are many possible causes. The authors reported the case of a 3.5-year-old boy with an atopic status who presented iterative asthma attacks which evolute to severity in spite of an appropriate therapy. Then suffocation occurred with a serious infectious context. The cause of the disease was diagnosed by respiratory tract endoscopic exam which allowed to detect a laryngeal papillomatis. The surgical extraction of this tumour cured the patient. Physiopathology of acute obstructive dyspnea in child was discussed. Upper airway obstructions are separated from lower pulmonary diseases. Two syndromes are very difficult to separate among upper airway obstructions: spasmodic laryngitis and subglottal laryngitis. They are considered in fact as different outward signs of the same disease: subglottal laryngitis is the infectious evolutive form of a spasmodic laryngitis in which atopic status exists. Laryngeal papillomatosis would be a favourising factor of infection. The authors conclude that respiratory tract endoscopic exam is very important to diagnose childhood acute obstructive dyspnea.

[Infantile diarrheal diseases in Madagascar: bacterial, parasitologic and viral study]. / Les maladies diarrhéiques infantiles à Madagascar: etude bactérienne, parasitaire et virale.

From November 1988 to October 1989, an etiological study showed off the prevalence and the part of several enteropathogen agents which are not yet studied in MADAGASCAR. 1,523 stool's samples from 884 children with diarrhea and 639 children without diarrhea from 0 to 14 years old have been investigated. A bacterial, parasitical or viral etiology was found from 36.3% of diarrheic children and 11.2% of healthy children. The three agents the most frequently identified from children with diarrhea are EPEC (10.5%), Campylobacter jejuni (10.3%) and rotavirus (10%) and associations of two or three pathogen agents are frequent (6.2%).

[Congenital afibrinogenemia complicated by spontaneous cerebral hemorrhages: a case report]. / Afibrinogénémie congénitale compliquée d'hémorrhagies cérébrales spontanées: à propos d'un cas.

Congenital afibrinogenemia is a rare autosomal recessive disease caused by markedly reduced or absent synthesis of fibrinogen. Consanguinity is common in affected family. Clinical manifestations range to minimal or moderate bleeding to catastrophic haemorrhage. Bleedings are often post-traumatic, sometimes spontaneous. Diagnosis is established by laboratory tests presenting trace or absence of fibrinogen. Substitutive treatment with fibrinogen concentrates or fresh frozen plasma is used. The authors reported the case of a 41-year-old male with congenital afibrinogenemia with fatal spontaneous cerebral haemorrhage. Diagnosis was made upon history, bleeding history, clinical examination, blood coagulation tests and radiography. Cerebral haemorrhage must be suspected in any patient presenting blood coagulation disorders with bleeding history. Drug therapy must be installed immediately and continued before obtention of specific radiology images which are often late in relation to clinical signs.

[Poliomyelitis in Madagascar (1988-1996): current situation in the World Health eradication program by the year 2000]. / La poliomyélite à Madagascar (1988-1996): situation actuelle dans le cadre du programme mondial d'éradication d'ici l'an 2000.

The number of acute flaccid paralysis (AFP) cases reported to World Health Organization (WHO) decreased from 1988 (48 cases) to 1996 (8 cases), but the real endemic situation of poliomyelitis is unknown. Cases are under or misreported. Very often, notifications are delayed; virological investigations of the etiology could not be performed as well as the environment studies and the immunization ripostes. In 1996, only one AFP case was confirmed by isolation of wild poliovirus. The immunization coverage in children under one by OPV (3 doses) was 73.0% in 1996 from the statistics of the Public Health Services but only 54.7% from randomized studies. The eradication of poliomyelitis by the year 2000 has engaged Madagascar in the disease prevention by improving the immunization coverage within the Expanded Immunization Programme in association with the Organization of National Immunization Days in October and November 1997. Likewise, the Virological Unit of the Pasteur Institute was recognized as the National WHO Reference Centre for Polio.