malaysian journal of paediatrics and child health

MALAYSIAN JOURNAL OF PAEDIATRICS AND CHILD HEALTH Vol.15 Nos. 1 and 2 June and December 2007

MALAYSIAN JOURNAL OF PAEDIATRICS AND CHILD HEALTH

MALAYSIAN JOURNAL OF PAEDIATRICS AND CHILD HEALTH ANNOTATION

Breastfeeding – A Pivotal Child Survival Strategya Musa MN

ORIGINAL ARTICLES

Rotavirus Infection in Paediatric Community-Acquired Acute Gastroenteritis: A Retrospective Cross-sectional Study in a private hospital in Malaysia. Adele Tan Guat Kean

1

7

Vol. 15 Nos.1 & 2

Prognostic Factors Associated With Survival of Patients With Ventricular Septal Defect. Wong A Rahim, Ibrahim W Pauzi W, Naing NN

16

The USM Human Genome Centre Experience on Molecular Diagnostic Testing of Spinal Muscular Atrophy. BA Zilfalil, H Fatemeh, MS Watihayati, M Marini

24

Epidemiology And Short-term Outcome Of Kawasaki Disease In Malaysian Children Dr. Hung Liang Choo

28

CASE REPORTS

Pages 1-49 June & December 2007

A Pitfall in Diagnosis: Endobronchial Tuberculosis as a cause of acute on chronic stridor. Norlijah O, Abu MN, Mohd Nor A, Yip CW

33

Juvenile Onset Respiratory Papillomatosis : A Theraputic Challenge Irfan M, AH Shibgatullah, Rosdan S

37

Ankyloblepharon Filiforme Adnatum Associated with Cleft Lip and Palate Raihan S, Tg Norina TJ, MN Raja Azmi.

42

Down Syndrome As a Result of De Novo Robertsonian Translocation Involving Chromosome 14 and 21: A Case Report MM Norhasimah, AB Ahmad Tarmizi, BA Azman, BA Zilfalil, R Ankathil,

46

ISSN 1511-4511

9 771511 451001

Official Publication of the MALAYSIAN PAEDIATRIC ASSOCIATION

PP 5800 / 5 / 95


ANNOTATION

BREASTFEEDING – A PIVOTAL CHILD SURVIVAL STRATEGYa Musa MN, FRCP, FAMM Cyberjaya University College of Medical Sciences

Forty thousand children die each day in developing countries; which is approximately 28 dead children every minute. In many of these countries 25% of their children do not even live long enough to celebrate their fifth birthday. These mortality statistics represents a human tragedy affecting our very youngest. The United Nations Children’s Fund (UNICEF) has identified seven simple, practical and cost-effective activities to help save the lives of our children. The acronym GOBI FFF - Child Survival Strategy describes these 7 measures. The B in the acronym represents beastfeeding which is a pivotal and fundamental component of this child survival strategy.

International agencies, notably UNICEF and WHO, horrified at the rapid decline of breastfeeding and its negative impact on the survival of children dclared in 1989 “as a global goal for optimal maternal and child health and nutrition, all women should be enabled to practise exclusive breastfeeding and all infants should be fed exclusively on breastmilk from birth to 4-6 months of age. Thereafter, children should continue to breastfeed, while receiving appropriate and adequate complementary foods, for up to 2 years of age or beyond.” 1

The science of paediatrics has demonstrated that the first two years of childhood is most crucial for physical growth and neurological development. And the various benefits conferred by breastfeeding was vital to achieve optimal growth and development at this critical stage of childhood.

There are at least 4,237 mammals on mother earth and without exception all of them lactate their young. Conception, gestation, parturition and lactation is a complete cycle of events which moves in harmony. Mothers milk is fundamental to the continued survival of their offsprings and every mammal produce their own unique quantity and quality of milk appropriate and species specific for their young.

Currently, 6 million lives are saved each year by the very act of breastfeeding. UNICEF estimates that there is a potential to save an additional 2 million lives if optimal breastfeeding is practised. The bulk of these infant


deaths are due to gastrointestinal and acute respiratory infections. The various antiinfective factors notably immunoglobulins, macrophages, lymphocytes, interferon, lysozyme, lactoferrin and bifidus factor found in abundance in breast milk confers this early and effective prophylaxis against a whole host of microbes.2 Breast milk would effectively be the baby’s first immunization. Colostrum, the first milk, is dense with anti-oxidants in the form of vitamin E and beta carotene which protect the baby’s body tissues from microbial invasion It facilitates the establishment of the bifidus flora hence antagonisng other pathogenic organism and prevents attachment of E. coli and similar bacteria to gut lining. Unfortunately many cultures erroneously considers colostrum, a “pus like” looking fluid as impure, foul and is discarded. Hence depriving the baby a headstart in its defences against a variety of micro-organisms.

common cause for clinic visits and hospital admissions. Formula fed infants are 5 times more prone to acquire ARI, their infections tend to be more severe and they are more likely to require hospitalization. The prophylactic effect of breast milk against a whole host of ARI has been demonstrated including RSV bronchiolitis, otitis media and pneumonia. A Brazilian study showed that formula fed infants were four times more likely to die from pneumonia than breast fed infants.4 The benefits of breasfeeding vis a vis mortality is not merely enjoyed by those in developing countries but also extrapolates well into industrialized and first world nations. Risk benefit analysis undertaken in the USA shows that optimal breastfeeding decreases mortality in the first year of life by 4 per 1,000 live births.5 The major cause of deaths in the USA in the first year of life, beyond the neonatal period is sudden infant death syndrome ( SIDS ). The relative risk for SIDS in a Caucasian breast fed infant is 0.2, that is 5 times lower.6 Most health authorities in North America and Europe have advocated breastfeeding as one of the major preventative measures to further reduce this most tragic, unexpected and premature death.

A Phillipines study found that the risk of diarrhea is 17 times higher in the formula fed infant when contrasted with the breastfed infant.3 This vicious cycle of formula feeding, gastrointestinal infections, dehydration and malnutrition is further exaggerated by poor hygiene, inadequate sanitation facilities, contaminated water supply and poor knowledge of milk preparation. These unfavourable health ambience is unfortunately most evident in developing countries and hence the devastating consequences of substituting human milk with cow’s milk.

Breastfeeding offers the optimal nutrition for infants with the best balance of nutrients. The protein component which is the lowest among mammals is an alpha lactalbumin (unlike beta lactoglobulin in cows milk), has a favourable whey/casein ratio and is taurine rich. The osmolar load hence presented to the relatively immature kidneys is therefore low. Fat is the most variable component and

Acute respiratory infections (ARI) contribute to well over 25% of all childhood mortalities in developing countries. It is also the most


is rich in docosahexanoic acid (DHA) and arachidonic acid (AA) which is vital for brain growth and development. Human milk has the highest lactose content in comparison to other mammals. Lactose is a precursor for galactose which is incorporated in brain tissue as galactolipids, a crucial building block for optimal brain growth and development.

relationship between the amount of breast milk fed and the subsequent IQ outcomes. The New Zealand longitudinal study which examined the association between the duration of breastfeeding, childhood cognitive ability and academic ability from the ages of 8 to 18 years showed an increase in cognitive ability and educational achievement which extended into childhood and early adulthood.8

It also helps to promote colonization of the gut with friendly lactobacillus bifidus and facilitates the absorption of calcium and iron. A bountiful of minerals are found in human milk. The calcium-phosphate ration is ideal for calcium absorption and iron though found in small quantities is 70% bioavailable unlike 30% bioavailability of iron in bovine milk and a meager 10% in formula milk (hence fortified with extra iron).

Various allergic syndromes are associated with formula feeds often due to an adverse immunological response to the foreign betalactoglubulin in bovine based formulas. The spectrum ranges from gastrointestinal symptoms of infantile colic, vomiting, diarrhoeal or bloody stools, malabsorption; to skin manifestations of eczema and respiratory complications of allergic rhinitis and bronchial asthma.9,10

Many of these nutritional extras in human milk are not found in milk formulas. Hence the milk industry’s incessant scientific endeavours to “humanise” the bovine milk formulas by adding the likes of beta carotene, taurine, nucleotides, DHA and AA. These various added nutrients are used as marketing gimmicks to outdo their rivals in terms of conferring “brain power” and added “IQ” points to the bottle fed babies and advertised as being closest to breastmilk mimicking all the wonders found in this Cinderella milk” That breastfeeding makes babies brainier is now an undisputed scientific fact. Lucas in his very interesting British follow up study of premature infants reported that children at ages 7.5 to 8 years who received breast milk had an 8.3 point advantage in IQ scores.7 The researchers were also able to show a dose

Various studies have also implicated the consumption of cow’s milk with long term morbidities. Epidemiological data from Denmark suggests an inverse correlation between breastfeeding and Type 1 diabetes mellitus.11 This was thought to be attributable to an antibody against bovine serum albumin (BSA) which selectively destroys pancreatic cells. Breast milk is essential for the normal development of immunological competence of the intestinal mucosa. A total of 826 Crohn’s patients studied against matched controls showed a statistically significant shorter mean length of breastfeeding. Lack of infantile breast feeding was similarly a risk factor for the development of ulcerative colitis.12 There


is a very interesting geographic distribution of multiple sclerosis world wide. It is rarely reported in countries where breastfeeding is prevalent. Paucity of breast feeding in early childhood is associated with a 6 time relative risk of developing lymphomas in later life.13 The exact mechanism leading to these myriad of immunological syndromes is as yet ill understood but there is incontrovertible evidence to suggest that breastfeeding promotes long term health.

benefits to the infant-mother dyad. This instinctive and innate activity at birth bonds the mother and child which has a life long loving and therapeutic effect. Mothers who breastfeed their babies are less likely to abuse or abandon their babies; a social phenomenon which unfortunately is on the climb in recent years. The family, community and nation similarly benefits from a breastfeeding culture. They enjoy better health nutritionally and emotionally. It is an economic plus since breastfeeding cost less than artificial feedings. In some less developed countries milk powders can bite up to 50% of the family budget. Since breastfed babies are relatively healthier babies less is spent on health care costs which includes clinic consultations, medicines, laboratory tests and hospitalizations. It is therefore the most cost effective child health strategy.

The woman who breastfeeds also enjoys various benefits as a consequence. Immediately post-parturition, the oxytocin released during breastfeeding helps to contract the uterus and reduce the incidence of post-partum haemorrhage and later anaemia. Exclusive breastfeeding offers 98% protection against getting pregnant during the first six months This is called the lactational amenorrhoea method (LAM) and universally this is still the most effective form of contraception available to every lactating woman unlike the more costly and less available contraceptive pills and intrauterine devices.14

Despite the numerous benefits of breastfeeding, the status of breastfeeding world wide still leaves much to be desired. This is due to a complex interaction of several phenomena. This includes the availability and aggressive marketing of a substitute, the erroneous belief that a milk substitute is modern and healthier, the widespread belief that breastfeeding and working is incompatible, unsympathetic employers towards employees choice to breastfeed, the absence of extended families to assist new parents to adjust, the lack of commitment, skills and knowledge of nursing and medical professionals in promoting breastfeeding and a hospital environment whose policies and procedures inhibit the

Breastfeeding reduces the risk of breast and ovarian cancers in mothers. A multicentre study in the USA found that the relative risk of breast cancer among pre-menopausal women decreased as the duration of lactation increased. 15 A multinational study from Australia, Chile, China, Israel, Mexico, the Philippines and Thailand found that the relative risk of ovarian cancer decreased as the duration of lactation increased.16 Breastfeeding confers untold psychosocial


initiation and maintenance of successful lactation.

the world’s attention to humanity’s shared responsibility for the survival, protection and development of our children. Only a global effort could empower women once again to give their babies the healthy start they deserve, a world that allows children to survive and thrive - a world that is baby friendly. And since more and more babies start their lives in hospital, the Baby Friendly Hospital Initiative was mooted.

In 1939, Cicely Williams wrote “Milk and Murder” and proclaimed that “misguided propaganda on infant feeding should be punished as the most criminal form of sedition, and that those deaths should be regarded as murder”. D. Jelliffe coined the term “commerciogenic malnutrition” in 1968 to describe “the industry marketing practices on infant health”

A Baby Friendly Hospital focuses on the needs of the newborns and empowers mothers to invest their own natural gifts in their children’s health. In practical terms, a Baby Friendly Hospital will encourage and help women to breastfeed their babies by applying each of the “Ten Steps to Successful Breastfeeding” developed by UNICEF and WHO. This was a global effort to give babies the best possible start in life. Since the early 1990s there has been a resurrection in the numbers of breastfeeding infants universally coinciding with the various collaborative and international efforts to protect, promote and support breastfeeding.

The World Health Assembly during her 24th sitting in 1974 recommended “strongly the encouragement of breastfeeding as the ideal feeding in order to promote harmonious physical and mental development of children”. The International Code of Marketing of Breast-milk Substitutes was introduced in 1981 to monitor the marketing practices and abuses of the multinational milk industries.17 In 1989, the Convention on the Rights of the Child. “made it the legal obligation of nations to provide mothers and families with the knowledge and support needed for breastfeeding.” And in Florence, Italy the following year, the Innocenti Declaration on the Protection, Promotion ad Support of Breastfeeding “.called on all governments to act and create an environment enabling all women to practise exclusive breastfeeding from birth to 4-6 years and to continue breastfeeding with adequate complementary foods up to 2 years”. These powerful international declarations, supported at the highest levels of government, attracted

The Ministry of Health has been exemplary in their pursuit of the BFHI accreditation. All public hospitals in Malaysia are Baby Friendly Hospitals and have been internationally recognised by UNICEF and WHO.18 In fact, most of these public hospitals have been reassessed on 3 separate occasions over the past 10 years to ensure they maintain their standards. Many of the private hospitals are beginning to follow suit. At least 5 private hospitals and 1 university hospital in Malaysia have been awarded the Baby Friendly


Hospital status and more are preparing for this accreditation process. These positive movements would surely augur well for the health system; delivering a best possible start to our newborn babies.

9. Lucas et al. Early diet of preterm infants and development of allergy or atopic disease: randomized prospective study. BMJ 1990; 300:837-40 10. Kramer MS. Does breastfeeding protect help protect against atopic disease? Biology, methodology and a golden jubilee of controversy. J Pediatrics 1988; 112:181-90 11. Mayer et al. Reduced risk of IDDM among breastfed children. Diabetes 1988; 37:1625-32 12. W h o r w e l l P J e t a l . B o t t l e f e e d i n g , e a r l y gastroenteritis and inflammatory bowel disease. BMJ 1989; 298:1617-8 13. Davis et al. Infant feeding and childhood cancer. Lancet 1988; (ii):356-8 14. Soodeh R & Benbouzid B. Breastfeeding and child spacing. Importance of information collection to public health policy. Bulletin of the WHO 1990; 68(5):625-31 15. Newcomb DA et al. Lactation and a reduced risk of pre-menopausal breast cancer. New Engl J Med 1994; 330:81-87 16. Rosenblatt K et al. Lactation and the risk of epithelial ovarian cancer. Int J Epidemiol 1993; 22:192-7 17. State of the Code by country and by company. IBFAN/IOCU 1991. Code of Documentation Centre, Penang, Malaysia 18. P r o t e c t i n g , P r o m o t i n g a n d S u p p o r t i n g Breastfeeding. The special role of maternity services. A Joint WHO/UNICEF Statement 1989.

References

1. Innocenti Declaration on the Protection, Promotion and Support of Breatsfeeding. UNICEF (1990) 2. Goldman AS. The immune system of human milk : antimicrobial, anti- inflammatory and immunomodulatory properties. Pediatric Infectious Diseases Journal 1993; 12:664-71 3. Popkin et al. Breastfeeding and diarrhoeal morbidity. Pediatrics 1990; 86(6):874-82 4. Victoria CG et al. Risk factors for death due to respiratory infections among Brazilian infants. Int J Epidemiol 1989; 18:918-25 5. Rogan WJ et al. Cancer from PCBs in breast milk? A risk benefit analysis. Pediatric Research 1989; 25:105A 6. Damus K et al. Sudden Infant Death Syndrome: Risk factors and basic mechanisms. New York; PMA Publishing Corp. 1988; 187-201 7. Lucas et al. Breast milk and subsequent intelligence quotient in children born premature. Lancet 1992; 339:261-4 8. Horwood CJ et al. Breastfeeding and later cognitive development and academic outcomes. Pediatrics 1998; 101(i):99


ORIGINAL ARTICLE

ROTAVIRUS INFECTION IN PAEDIATRIC COMMUNITYACQUIRED ACUTE GASTROENTERITIS: A RETROSPECTIVE CROSS-SECTIONAL STUDY IN A PRIVATE HOSPITAL IN MALAYSIA Adele Tan Guat Kean* (F.R.C.P Glasg.) Department of Paediatrics, Lam Wah Ee Hospital.

ABSTRACT Objectives: 1) To establish the incidence of rotavirus infection in paediatric patients admitted to a private hospital in Malaysia with a diagnosis of community-acquired acute gastroenteritis. 2) To determine whether patients with rotaviral acute gastroenteritis have greater disease severity. Design Retrospective cross-sectional study. Setting An urban private hospital in Malaysia. Participants All paediatric patients with a discharge diagnosis of acute gastroenteritis (AGE) admitted to the hospital between September 2005 and March 2006. A total of 261 patients were included in the study. Results Rotavirus infection contributed to 54% of paediatric hospital admissions with discharge diagnoses of acute gastroenteritis. 74% of children with rotavirus infection were aged 5 years and below. This study demonstrated that patients with rotaviral

gastroenteritis had greater disease severity, as measured by two indicators. Firstly, the average length of hospital stay was longer in patients who were rotavirus positive (5.14 days) compared to those who were rotavirus negative (4.81 days). These results were statistically significant (p