Sri Lankan Infants Research Articles

Prediction of cerebral palsy and cognitive delay among high-risk children in a developing nation: A successful early detection programme.

To determine the feasibility of combining the Hammersmith Infant Neurological Examination (HINE) and General Movements Assessment (GMA) within a standard follow-up schedule to predict developmental outcomes in infants at risk in low- and middle-income countries (LMICs). A total of 201 Sri Lankan infants (128 male, 73 female) were prospectively assessed with the GMA before 44 weeks (writhing movements) and at 3 to 4 months (fidgeting movements), followed by the HINE at 5 to 6 months. Developmental outcomes were assessed using the Bayley Scales of Infant and Toddler Development, Fourth Edition and clinical assessment after 24 months. The sensitivity of predicting cerebral palsy (CP) was lower with a single GMA assessment (writhing 89.5%, fidgeting 94.7%) or HINE (89.5%) compared to all three assessments combined (sensitivity 100%, 95% confidence interval [CI] = 82.4-100.0). The GMA and HINE were less predictive of non-CP-related developmental delays, particularly when single assessments were used (< 65% for all domains) compared to all three assessments combined (motor sensitivity > 86.9%, 95% CI = 66.4-97.2; cognitive sensitivity > 86.7%, 95% CI = 69.3-96.2; social-emotional sensitivity > 83.3%, 95% CI = 65.3-94.4). Specificity was lower for the prediction of CP-related (40.1%) and non-CP-related developmental delays (< 46.0% for all). In an LMIC such as Sri Lanka, with limited access to specialist care and neuroimaging, combining two GMA measures and the HINE identified most infants with CP-related and non-CP-related developmental delay, thereby allowing targeted early intervention therapies.

Molybdenum Cofactor Deficiency with a Novel Pathogenic Variant in the Molybdenum Cofactor Synthesis 1 (MOCS1): A Case Report

Molybdenum cofactor deficiency (MOCOD) is a rare autosomal recessive disorder associated with a high mortality rate. We report a genetically confirmed MOCOD case of a Sri Lankan infant girl born to a consanguineous family, who presented with refractory neonatal seizures, respiratory distress, and the appearance of global cerebral ischemia on the CT brain. Biochemical investigations revealed hypouricemia, hypouricosuria, and increased urinary xanthine. Genetic analysis revealed a homozygous novel pathogenic variant in the MOCS1 gene, consistent with MOCOD.

A Sri Lankan infant with immunoglobulin resistant incomplete Kawasaki disease with a vesicular psoriasiform rash, hypertension and late onset small joint arthritis: a case report

BackgroundKawasaki disease (KD) is a medium and small vessel vasculitis which usually has a good response to immunoglobulin therapy (IVIG). We present a case of incomplete KD with IVIG resistance associated with an unusual combination of vesicular guttate-psoriasiform rash, hypertension and late onset small joint arthritis.Case presentationA four-month-old male infant from Sri Lanka presented with high fever, conjunctival redness, pedal oedema and skin rash. He was found to have hypertension since admission with a high white cell count and high inflammatory markers. There was poor response to intravenous antibiotics and subsequent 2D echocardiogram revealed coronary artery aneurysms suggestive of KD. In the third week of illness he developed a vesiculo-papular rash involving face, trunk and limbs – which on biopsy revealed features of guttate psoriasis.Fever spikes continued and the coronary arteries showed progressive dilatation despite timely intravenous immunoglobulin administered on day 6 and methylprednisolone administered on day 10-13. Therapeutic response by means of reduction of fever was seen only after initiation of intravenous infliximab on day 28 of illness for which the fever responded within 24 hours. He developed a small joint arthritis of hands and feet on day 40 of illness which responded only after initiating methotrexate therapy. The hypertension persisted for 4 months after the onset of the illness before complete resolution.ConclusionThis case report depicts an unusual presentation of KD with a vesicular guttate-psoriasiform eruption, hypertension and late onset small joint arthritis. It highlights that clinicians should be aware of the fact that KD could present with such atypical manifestations and could develop unusual complications.

Functional constipation in infancy and early childhood: epidemiology, risk factors, and healthcare consultation

BackgroundFunctional constipation (FC) is a pediatric problem that is seen frequently. However, its prevalence in Asia remains undetermined. In this study we attempted to determine the prevalence, risk factors and therapeutic modalities of FC in infants and toddlers in Sri Lanka.MethodsChildren aged 6.5 months to 4 years were selected from 14 well-baby and vaccination clinics in the Gampaha District of Sri Lanka. A questionnaire with questions regarding the socio-demographic characteristics, child’s bowel habits, psycho-social risk factors and treatment modalities were filled by the mothers. FC was diagnosed according to ROME III criteria.ResultsA total of 1113 children were analyzed [(female n = 560 (50.3%) with a mean age of 20.7 months, standard deviation [SD] 11.2 months. FC was found in 89 (8.0%). FC was significantly and independently associated with underweight (14.3% vs 7.2%, p = 0.008. [OR and 95% CI: 2,3 (CI; 1.3–4.2)] and residence in an urban area (9.6% vs 5.6%, p = 0.013). [OR and 95% CI: 0.592 (CI; 0.396–0.95)]. Children subjected to violence showed a significantly higher prevalence of FC (20.0 vs 7.8%, p = 0.046). Children being overweight and children living with mothers subjected to violence showed a higher, though not statistically significant, tendency to develop FC. Children with FC visited healthcare clinics more frequently when compared to controls (19.6% vs 6.0%, p < 0.0001). However, only 24% of infants and toddlers with FC were treated specifically for the condition by a doctor.ConclusionsFC occurred in 8% of this cohort of Sri Lankan infants and toddlers. It is significantly associated with underweight and living in an urban area. Only a quarter of them received medical attention for their constipation.Trial registrationSLCP/ERC/2014/12, December 2014.

Factors associated with growth faltering in Sri Lankan infants: A case-control study in selected child welfare clinics in Sri Lanka

Background Growth faltering during later infancy is common in Sri Lanka. While retarding the physical and mental development of the infant, its burden on the social and economic aspects of the family, society and country is immense. Methods A case-control study, involving 150 controls and 75 cases (Total 225), was conducted in two randomly selected Child Welfare Clinics. Infants with failure to thrive were identified from Child Health Development Records and a pre-tested, interviewer administered questionnaire was used for data collection. Data was analyzed using SPSS 17.0. Results Sex distribution was almost equal (Males=52.4%, Females=47.6%). The mean age of mothers was 26 years (SD=4.7) and only 26.2% (n=59) were employed although over 90% had secondary education. Lower segment caesarean section, low birth weight, intra-uterine growth restriction and presence of acute illnesses had a significant association with growth faltering with odds ratios (OR) of 3.3 (95% CI=1.8-5.8), 3.0 (95% CI=1.6-5.6), 3.5 (95% CI=1.3-9.5) and 2.3 (95% CI=1.3-4.1) respectively. Significant factors pertaining to feeding were, non-exclusive breast feeding (OR=2.8 and 95% CI=1.5-5.3), inadequate duration of breast feeding per feed (OR=3.8 and 95% CI= 2.1-6.9), formula feeding (OR=2.1 and 95% CI=1.2-3.7) and inadequate diet (OR=2.7 and 95% CI=1.5-5.0). Parental and household factors such as young maternal age, inadequate maternal education, increased number of children and non-availability of domestic help were not statistically significant. However, low monthly income was a significant factor associated with growth faltering (OR=3.3 and 95% CI=1.8-6.2). Conclusion: Infant and dietary factors were of paramount importance while parental and household factors played a minor role in growth faltering.

Cystic fibrosis in a Sri Lankan infant, confirmed by genotyping: implications for future diagnosis and service provision

Cystic fibrosis (CF) is an autosomal recessive condition caused by a mutation in the cystic fibrosis transmembrane regulator gene (CFTR) on chromosome 7(7q31.2). The diagnosis is usually made clinically, supported by raised sweat chloride, although genotyping provides definitive confirmation and enables genetic counselling. Journal of the Postgraduate Institute of Medicine 2015;2:E17:1-3

The Deuterium Oxide-to-the-Mother Method Documents Adequate Breast-Milk Intake among Sri Lankan Infants1–4

Background: The WHO recommends that exclusive breastfeeding should last up to 6 mo. However, human milk intake of Sri Lankan infants has not been quantified scientifically.Objectives: The objectives of this study were to measure the human milk intake of Sri Lankan infants during the first 6 mo of age and to document the breastfeeding practices of their mothers.Methods: Forty-eight healthy mother-infant dyads were randomly recruited for this cross-sectional study at well-baby clinics. Milk intake was measured using the deuterium oxide–to-the-mother technique over a period of 2 wk. Information on breastfeeding practice and living standards of the participants were gathered using an interviewer-administered questionnaire.Results: Human milk intake was 672 ± 123 g⋅d−1 (mean ± SD), 776 ± 212 g⋅d−1, and 801 ± 51 g⋅d−1 for infants <2 mo, 2 to <4 mo, and 4–6 mo of age, respectively. The milk intakes were not different among the age groups. Maternal body composition, age, or parity had no effects on milk intake of the infants. However, mother’s education (P < 0.05, r = 0.35), infant’s age (P < 0.05, r = 0.30), and body mass index (P < 0.05, r = 0.41) positively correlated with the milk intake. Over 63% of mothers had commenced breastfeeding within 30 min of delivery. About 60% of the mothers were feeding the baby 6–10 times during the daytime and >81% intended to continue exclusive breastfeeding until 6 mo of age.Conclusion: This study, for the first time, documented the adequacy of breast-milk intake among Sri Lankan infants and the nutrition status of the mothers.

Windows of achievement for development milestones of Sri Lankan infants and toddlers: estimation through statistical modelling.

The normative age ranges during which cohorts of children achieve milestones are called windows of achievement. The patterns of these windows of achievement are known to be both genetically and environmentally dependent. This study aimed to determine the windows of achievement for motor, social emotional, language and cognitive development milestones for infants and toddlers in Sri Lanka. A set of 293 milestones identified through a literature review were subjected to content validation using parent and expert reviews, which resulted in the selection of a revised set of 277 milestones. Thereafter, a sample of 1036 children from 2 months to 30 months was examined to see whether or not they had attained the selected milestones. Percentile ages of attaining milestone were determined using a rearranged closed form equation related to the logistic regression. The parameters required for calculations were derived through the logistic regression of milestone achievement statuses against ages of children. These percentile ages were used to define the respective windows of achievement. A set of 178 robust indicators that represent motor, socio emotional, language and cognitive development skills and their windows of achievement relevant to 2 to 24 months of age were determined. Windows of achievement for six gross motor milestones determined in the study were shown to closely overlap a similar set of windows of achievement published by the World Health Organization indicating the validity of some findings. A methodology combining the content validation based on qualitative techniques and age validation based on regression modelling found to be effective for determining age percentiles for realizing milestones and determining respective windows of achievement.

Body composition among Sri Lankan infants by ¹⁸O dilution method and the validity of anthropometric equations to predict body fat against ¹⁸O dilution.

BackgroundBody composition indicators provide a better guidance for growth and nutritional status of the infants. This study was designed to (1) measure the body composition of the Sri Lankan infants using a reference method, the 18O dilution method; (2) calculate the body fat content of the infants using published skinfold prediction equations; and (3) evaluate the applicability of the skinfold equations to predict body fat among Sri Lankan infants against the 18O dilution method.MethodsTwenty five healthy, exclusively breast-fed infants were randomly recruited at well-baby clinics, for this cross-sectional study. Body composition was measured using 18O dilution. Infant body weight, length, skinfold thicknesses and mid upper-arm circumference were measured using standard procedures. The Bland and Atlman pair-wise comparison method was used to evaluate the agreement of body fat generated using the anthropometric prediction equations against the 18O dilution values as the reference.ResultsMean (SD) body weight and length of the infants were 6.5 kg (0.9) and 64.7 cm (2.8) respectively. Mean total body water, fat free mass, fat mass and % fat mass as measured by 18O dilution method were 58.8% (5.0), 4.6 kg (0.8), 1.9 (0.5) and 29.5% (6.1). Total body water and fat free mass were significantly higher in boys when compared to girls. With the exception of three prediction equations (Bandana et al., Goran et al. and Durnin and Wormsley), most of the other commonly used anthropometry-based prediction equations yielded a bias which was not constant but a function of the % fat mass.ConclusionsBody composition of Sri Lankan infants is comparable to the normative data available from the industrialized countries. Most of the commonly used anthropometric prediction equations generated a bias which varies with the size of the body fat. Only three prediction equations (Bandana, Goran, Durnin & Wormsley) yield a constant bias. The Durnin & Wormsely equation showed the smallest bias when compared to the 18O dilution values with the narrowest limits of agreement. Accuracy of some of the prediction equations is a function of gender.Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-015-0371-2) contains supplementary material, which is available to authorized users.

10 p deletion in a Sri Lankan infant with partial DiGeorge syndrome

Sri Lanka Journal of Child Health , 2014; 43 (3): 171-173 (Key words: 10p deletion; partial DiGeorge syndrome; Sri Lankan infant) DOI: http://dx.doi.org/10.4038/sljch.v43i3.7381

Reactogenicity and safety of the human rotavirus vaccine, Rotarix™ in The Philippines, Sri Lanka, and India: A post-marketing surveillance study

Regulatory bodies in The Philippines, Sri Lanka, and India require post-marketing surveillance to provide additional safety data on Rotarix™ in real-life settings. In such studies conducted in The Philippines (November 2006 to July 2012; NCT00353366), Sri Lanka (November 2008 to August 2009; NCT00779779), and India (August 2009 to April 2010; NCT00938327), 2 doses of Rotarix™ were administered according to the local prescribing information (PI). The occurrence of at least Grade “2”/”3” solicited adverse event (AE) (fever, vomiting, or diarrhea), within 15 days in The Philippines or 8 days in Sri Lanka and India; unsolicited AEs within 31 days and serious adverse events (SAEs) throughout the study were recorded. Of the 1494, 522, and 332 infants enrolled in The Philippines, Sri Lanka, and India, 14.7% 14.9% and 12.7% infants, respectively recorded at least Grade “2”/”3” solicited AEs. The most commonly reported solicited AEs were irritability in The Philippines (32.2% post-Dose-1; 23.5% post-Dose-2) and India (23.0% post-Dose-1; 13.2% post-Dose-2), and fever (18.0% post-Dose-1; 20.2% post-Dose-2) in Sri Lanka. Unsolicited AEs were recorded in 24.5% (The Philippines), 4.8% (Sri Lanka), and 6.9% (India) of infants. Forty-one SAEs were recorded in the Philippines of which 6 (decreased oral intake with increased sleeping time and constipation; pneumonia, urinary tract infection, and intussusception) were considered by the investigators as causally related to vaccination. One vaccine-unrelated SAE occurred in a Sri Lankan infant. All SAEs resolved and the infants recovered. Two doses of Rotarix™, administered to healthy infants according to local PI, were well tolerated in The Philippines, Sri Lanka, and India.

Safety and immunogenicity of live-attenuated Japanese encephalitis SA 14-14-2 vaccine co-administered with measles vaccine in 9-month-old infants in Sri Lanka

IntroductionTo facilitate introduction of live attenuated SA 14-14-2 Japanese encephalitis vaccine (LJEV) into the National Immunization Programme of Sri Lanka, we evaluated the safety and immunogenicity of co-administration of LJEV and measles vaccine at 9 months of age. Serum immune responses were evaluated post-vaccination on days 28, 180, and 365 using JE neutralization test and anti-measles IgG ELISA. Results278 infants received one dose of LJEV and measles vaccine. Of these, 257 were eligible for the per-protocol analysis. On Day 0, 14 infants (5.5%) were seropositive for JE, but none were seropositive for measles. At Day 28, seropositivity rates were 90.7% (95% CI, 86.4–93.9%) for JE and 84.8% (95% CI, 79.8–89.0%) for measles. The geometric mean titer for JE neutralizing antibodies was 111 (95% CI, 90–135), and the geometric mean concentration (GMC) for anti-measles IgG was 375mIU/mL (95% CI, 351–400mIU/mL). Over the next year, JE neutralizing antibody responses declined only slightly, with seropositivity at 87.4% (95% CI, 82.6–91.2%) at Day 365. In contrast, measles antibody levels continued to increase over time. Seropositivity for anti-measles IgG reached 97.2% (95% CI, 94.4–98.9%) at Day 365, and the GMC rose to 1202mIU/mL (95% CI, 1077–1341mIU/mL). Co-administration of LJEV and measles vaccine was also safe. Most adverse reactions were mild, and no serious adverse events were related to study vaccinations. ConclusionThe safety and immunogenicity of LJEV co-administered with measles vaccine in Sri Lankan infants is similar to that seen in other populations, and our results support use of LJEV at 9 months of age. Live SA 14-14-2 vaccine is now prequalified by the WHO for use in infants in Asia, and other countries may wish to introduce LJEV to combat this devastating disease.

Ocular and subcutaneous dirofilariasis in a Sri Lankan infant: an environmental hazard caused by dogs and mosquitoes

An 11-month-old infant presented with a subcutaneous nodule in the right cheek which was found by ultrasonography to be a worm. Following treatment with di-ethylcarbamazine, a worm emerged from the left upper eyelid which was confirmed to be Dirofilaria repens. Dirofilariasis usually manifests as a single lesion and is rare in infants.

A Sri Lankan infant with vaccine associated acute flaccid paralysis

Global incidence of poliomyelitis has reduced by more than 99% since the Global Polio Eradication Initiative was launched in 1988 [1]. In par with the global trend, Sri Lanka has achieved great success with no reported cases since 1993, but still is not declared as a country which has eradicated polio due to prevalence of polioyomyelitis in neighbouring countries [2]. Countries which have eradicated polio use killed injectable polio vaccine (IPV), mainly because oral polio vaccine (OPV) can result in paralytic poliomyelitis. In literature review, we could not find any reported cases of paralytic poliomyelitis following vaccination in Sri Lanka. We report a case of acute flaccid paralysis following immunisation with first dose of OPV.