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Case presentation: A 20 month-old hypotonic boy with a history of preterm labor at 32 weeks of gestational age, secondary generalized seizures in infancy, hypothyroidism (T4: 2, TSH: 14); motor and speech developmental delay, mild  ataxia and renal failure (chronic kidney disease: CKD) was presented to the clinic of Taleghani pediatric hospital in Gorgan, Northern Iran during 2015. In further evaluation, the patient did not have fix and follow occularly and the head of the left optic nerve was atrophic and congenitally malformed although it seemed the visual prognosis for the right eye was even good with just a slightly pale nerve. The renal ultrasonography showed an increase of general echo which was suggestive for congenital or parenchymal abnormalities. Dialysis was ordered but the patient's family declined. The Image of the infant brain in axial cut using MRI 1.5 Tesla marked molar tooth sign (MTS). The schematic view is also given. Conservative treatment including Scholl, anti-convulsant solution, (30 cc daily), ferrous sulfate (20 drops), calcium tablets carbonate (2 per day) and phenobarbital (5 mg/kg/bw divided in two parts) was administered for the patient.

Diagnosis: Classic Joubert syndrome subtype: CORS (11q12.2 TMEM216)

Joubert syndrome is a rare autosomal recessive disorder affecting the cerebellum and characterized by abnormal respiratory pattern and eye movements, hypotonia, ataxia, developmental retardation with neuropathological defects of cerebellum and brainstem comprising inherited hypoplasia or aplasia of vermis. This clinical entity is possibly under-reported with a prevalence of less than 1 per 100,000. This syndrome is prototype of congenital vermian hypoplasia. Treatment for Joubert syndrome is symptomatic and supportive. Infant stimulation and physical, occupational, speech and hearing therapy may benefit some patients. Infants with abnormal breathing patterns must be monitored.

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Background and Objective: Several methods are available for measuring fever in children. This study was done to compare the accuracy of three method of measuring body temperature using left and right tympanic, axillary and rectal methods in three months to five years old children.

Methods: This descriptive-analytic study was done on 126 children (63 without fever and 63 children with fever) with 3 months to 5 years age in Mofid hospital, Tehran, Iran. Rectal temperature lower than 38°C was considered as Gold standard to determine fever. Body temperature was also recorded for subjects through right and left tympanic and axilary methods.

Results: Body temperature was recorded in axillary method 37.1°C (sensitivity: 92.1%, specificity: 90.5%), right tympanic 36.9°C (sensitivity: 74.6%, specificity: 84.13%) and left tympanic 37.3°C (sensitivity: 93.65%, specificity: 84.13%). The mean temperature in the axillary method 0.77°C, right tympanic 1.02°C and left tympanic 0.48°C was lower than the mean rectal method (P<0.05). The correlation between right, left tympanic and axillary with rectal method was 0.84, 0.894 and 0.925, respectively (P<0.05). The area under the receiver operating characteristic (ROC) curve for left and right tympanic and axillary were 0.95, 0.87, 0.965, respectively.

Conclusion: The difference between rectal and left tympanic method was at the lowest level due to the ease of measuring temperature through tympanic membrane in three months to five years old children.

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Background and Objective: Varicella zoster virus (VZV) can cause a moderate disease in children, but with high risk of serious disease or death in children with acute lymphoblastic leukemia (ALL) Vaccination from infection can be safe, immunogenic, and effective in children with leukemia. This study was done to evaluate the IgG and IgM antibodies against VZV in children with acute lymphoblastic leukemia.

Methods: The descriptive-analytic study was performed on 66 children who were on chemotherapy in Dr Shigh hospital in Mashhad, Iran during 2012. Patients were receivied VZV vaccine. The title negative or positive serum sample for IgG-anti-VZV avidity was determined by using a test kit before and after injection of vaccines VZV for considering the efficacy of vaccines on pediatric patients.

Results: Title serum sample IgG were positive in 32.6% patients, these children have history of chicken pox disease and to be safe against of VZV. 78.3% of the patients were negative for IgG antibody and sensitive against of VZV.

Conclusion: Children with ALL receiving chemotherapy are sensitive to chicken pox disease according to negative IgG titer against VZV.

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Background and Objective: Nonalcoholic fatty liver disease is the most common cause of liver disease worldwide and it is defined as a disorder of excess fat accumulation in the liver. This study was done to determine the prevalence of fatty liver among overweight, obese and normal children.
Methods: This historical cohort study was conducted on 90 children ages 5 to 13 years old in Taleghani pediatric theching hospital in Gorgan, north of Iran during 2014. Subjects according to Body Mass Index (BMI) classified into obese (95%>BMI), over weight (85-95% BMI) and normal (5-85% BMI). Childern were matched for age and sex. Liver enzymes (ALT Alanine aminotransferase and AST (Aspartate aminotransferase) and lipid profile includingTriglyceride: TG (High Density Lipoprotein: HDL and (Low Density Lipoprotein: LDL were measured and fatty liver evaluated based on sonographic parameters by a radiologist who didnot know children's BMI.
Results: The prevalence of fatty liver was 23.3% in obese children that was non- significantly higher than normal (16.7%) and over weight (16.7%) children. The prevalence of fatty liver was not significantly different between two sexes. AST was significantly higher in children with normal BMI in compared to obese and over weight children (P<0.05). The highest and lowest level of cholesterol was seen in obese and normal children (P<0.05).
Conclusion: This study showed that the prevalence of fatty liver non-significantly was higher in obese children in comparision with normal and over weight children.

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Arachnoid cysts have primary and secondary types. The prevalence of Arachnoid cysts is about 1% of all tumors in cranial cavity. Based on anatomic position, arachnoid cyst can cause different clinical manifestations including hemiparesis, increase intracranial pressure, macrocephaly and isolated headache and stop body growth. The natural course of the disease is not exactly clear. Some of patients have no symptoms during life and some of them may show some symptoms after a while. This case report is about a 10 years boy who had no sign except generalized headache. Anatomic position of the cyst was in right temporal lobe of the brain on the temporal, parietal and the great wing of sphenoid bones. Arachnoid cyst diagnosed through MRI and CT-Scan. Patient treated with ibuprofen for three days and then patient followed up to treat with surgery method when other clinical symptoms appeare in the patient.

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Background and Objective: Irrational consumption of blood products leads to unwanted side effects in patients and imposes additional financial burdens on society and patients. This study was done to determine the pattern of consumption of packed red blood cells (PRBC) in hospitalized newborns and children.
Methods: This prospective descriptive-analytic study was conducted on 80 newborn (less than 4 months age) 36 children (more than 4 months to 16 years old) who used PRBC in Sari Bu-Ali Sina hospital, north of Iran. Demographic characteristics of patients and parameters of blood product were recorded and compared with standard guideline.
Results: During the study period, administration of 116 units of PRBC (28.5%) was studied. Totally, in 24 % of cases PRBC consumption did not follow the guideline. PRBC consumption was inappropriately prescribed for patients with hemoglobin higher than 12 g/dL (12%) and for patients with hemoglobin higher than 10 g/dL (12%). Both of the consumption volume to weight ratio (P<0.05) and rate of infusion (P<0.05) were significantly higher in children less than or equal to 4 months, than in children older than 4 months. The most commonly indications were respiratory distress syndrome in neonates (62.1%) and bone marrow suppression (14.7%).
Conclusion: A significant percentage of patients were received PRBC out of guideline recommendations.  It seems, for rational use of PRBC in children and neonates the existing guidelines should be more considered to reduce the cost and side effects.
 

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Background and Objective: Chronic and recurrent abdominal pain affect about 7-20% of children in school age, and it is responsible for 2-4% of children's medical referrals. Helicobacter pylori infection in children can cause gastrointestinal problems in childhood, and the lack of treatment and eradication can lead to serious complications. This study was done to evaluate the prevalence of Helicobacter pylori ELISA stool antigen in children with chronic abdominal pain.

Methods: In this case control study, 33 children with chronic abdominal pain and 30 normal children were evaluated. The stool was tested by ELISA method to evaluate Helicobacter pylori antigen.

Results: 15.2% of chidern in the chronic abdominal pain group were positive for Helicobacter pylori. No positive case was found among control group. This difference between case and control groups was significant (P<0.05).

Conclusion: Considering the high prevalence of Helicobacter pylori antigen in children with chronic abdominal pain, it is suggested that children with chronic abdominal pain without a definite cause screened for Helicobacter pylori infection.

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Background and Objective: Perinatal mortality rate (PMR) is one of the main indicators in evaluation of health community and healthcare systems. This study was performed to determine the perinatal mortality rate in the referral third level of maternal and infant care center affiliated to Babol University of Medical Sciences.
Methods: This descriptive-analytical study was performed on by cross-sectional method and 19234 births (9751 male and 9483 female) from 22 weeks gestation to 29 days after delivery Ayatollah Rouhani Hospital in Babol, northern Iran during 2011-18. Data on the cause of neonatal death, maternal age, type of delivery, malformations, maternal underlying disease, maternal pregnancy-related conditions, and diseases at the time of death in neonate were collected from website of the Ministry of Health. Then each of the indicators was calculated per 1000 live births.
Results: In this study, the PMR was calculated per 1000 live births which was 29.01 (boys 16.17 and girls 12.84). The portion of vaginal delivery was 9.67 and cesarean section was 19.34. Out of 558 perinatal deaths, 59.9% died due to intrauterine death with an index of 17.37 and 40.1% of deaths were due to infant death with an index of 11.63. Most neonatal deaths (74%) occurred within the first 24 hours of birth and in terms of gestational age 86.02% were <37 weeks of gestation with an index of 24.95, and low birth weight were 83.8% with an index of 24.31. Underlying disease was found in 25.6% of mothers and pregnancy-related conditions in 74.4% of cases. Fetal distress in 14.4% with an index of 4.20 was the most common disease associated with infant death or cause of death in preterm infants. Other causes of perinatal death were specific disorders of perinatal origin, birth defects, chromosomal abnormalities, and accidents were 10.09, 4.06, and 0.58 per 1000 live births, respectively.
Conclusion: The most and important factors of prenatal mortality wrer prematurity and low birth weight that major causes include maternal pregnancy-related conditions and maternal underlying disease, Therefore, emphasis on adequate prenatal care, identification and follow-up of mothers with underlying diseases can be effective in reducing perinatal mortality.

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Background and Objective: Infantile colic which can cause nervousness and anxiety in parents by fussing and restlessness in babies. This study was done to determine the prevalence and associated risk factors of infantile colic in Babol, the North of IRAN.
Methods: This descriptive-analytical study was done on 591 breastfeeding babies (321 females, 270 males) born with birth weight 2500-4000 grams and gestational age ≥37 weeks without any medical problem during 2016-18. They visited in age 2, 4, 8, 12 weeks by neonatologist. On the basis of parents complain and Wessel's criteria babies were divided into three groups: Cramp with crying (colicky group), Cramp without crying and normal group. Then possible risk factors of infantile colic have been compared in three groups.
Results: 45.5% of babies presented cramp with crying as colic group. Time of restlessness was significantly more than morning during night and afternoon (P<0.05). Colic was higher in infants born by cesarean section (P<0.05), and in the first-born child (P<0.05). However, there was not significant relation with gender, mothers’ education, parents smoking and taking dairy product.
Conclusion: According to this study’s findings, nearly half of infants had the symptoms of colic, which was higher in first children, infants born by cesarean section and during night.

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Background and Objective: Congenital anomalies are one of the major causes of neonatal mortality. Congenital heart disease (CHD) is the most common birth defect world wide, and recent studies about CHD have reported congenital heart disease approximately is about one percent of all live births. This study was done to determine the frequency of congenital heart disease using ecocardiography in patients with extra-cardiac anomalies in Gorgan peadiatric center in north of Iran.
Methods: In this descriptive study, 55 girls, 84 boys a total of 139 patients were in the age range of birth to 12 years of age whom have referred to Taleghani Teaching and Medical Center in Gorgan during 2012-17. 139 cases of congenital heart disorders with echocardiographic report sheet in their medical record were evaluated. Information of patients including age, sex, ethnicity, type of extra-cardiac, anomalies, cardiac anomalies (simple, complex and ductal anomalies), cardiac murmur status, and clinical symptoms were extracted from their medical records.
Results: From of total of echocardiography, 139 patients (88.5%) were affected by congenital heart disease. The anomalies were included of 88 cases (56.05%), 48 cases (31.21%), 2 cases (1.27%) simple, complex anomaly and ductal dependent anomaly respectively. The other disorders accompanied with congenital heart diseases were 17 cases (12.2%) with cleft palate, 4 cases (2.9%) with congenital diaphragmatic hernia, 8 cases (5.8%) with closed anus, 52 cases (37.4%) with Down syndrome, 4 cases (2.9%) with Turner syndrome, 4 cases (2.9%) with ileum atresia, 11 cases (7.9%) with Esophageal atresia, 7 cases (5%) with Hirschsprung's disease, 6 cases (4.3%) with urogenital anomalies and 26 cases (18.7%) with other extra-cardiac abnormalities.
Conclusion: Down syndrome and cleft palate are among the highest prevalant anomalies with congenital heart diseases.

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Background and Objective: Foreign body aspiration is the cause of death in 7% of children under two year’s olds. Children’ molars teeth do not erupt and under devedoled ability to swallow food and generally likely to be distracted, playing or ambulatory while eating. This study was performed to determine the frequency of foreign body aspiration in children under ten years old in north of Iran.
Methods: This descriptive study was done on 50 children (21 boys, 29 girls) less than ten years old with the final detection of foreign body aspiration hospitalized in Taleghani hospital in Gorgan, north of Iran during 2016-17. Demographic characteristics, results of physical examination, radiography and bronchoscopy recorded in the file and the radiology report was collected by a pulmonologist and radiologist.
Results: The common age of foreign body aspiration was between 1-3 years (58%) followed by over 3 years (24%) and under 1 years old (18%). Symptoms of patients with foreign body aspiration were including cough (64%), rhonchi (52%), respiratory distress (32%), wheezing (32%), choking (30%). Common physical examination findings were wheezing (40%), unilateral pulmonary sound (34%), stridor (20%), and rhonchi (6%). The most common findings in Chest X-Rays were unilateral air trapping (48%) in right lung, left mediastan shift (30%), right lung atelectasia (20%), pneumonia (16%). Just in one case (2%) was found the body of radio opac in right lung and in 32% of cases, the graghs were normal. In 70% of patients less 24 hours, in 26% between 1-15 Dayes and in 4% of cases more than 15 Dayes were taken to medical centers. The most common foreign body was nuts (32%) followed by plastic objects (26%), aspiration by sunflower seeds (14%) and beens (10%) and other foreign objects (18%).
Conclusion: The most common clinical signs of foreign body aspiration were cough, wheezing and right lung pneumonia.

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Background and Objective: Poisoning is one of the most common causes of emergency room visits. Opioids and methadone are the causes of unintentional poisoning, especially in children, who have a high burden of emergency referrals in children's hospitals. This study was performed to evaluate methadone poisoning in the pediatric emergency department in Gorgan, North of Iran.
Methods: This cross-sectional study was performed on the records of patients admitted (85 boys and 70 girls) cases due to methadone poisoning in Taleghani Hospital in Gorgan, North of Iran during 2001-19 .The symptoms of patients and the costs of treatment and care of patients were analyzed.
Results: A total of 258 cases of poisoning were registered, of which 155 (60%) were methadone poisoning. Poisoning occurred for 136 cases (87.8%) with methadone syrup and for 19 cases (12.2%) with methadone tablets. The mean of age and age range was 47.94±36.25 months and 4-156 months, respectively. The mean and standard deviation of the time interval from consumption to the time of admission was 164.84±160.11 minutes and the maximum and minimum time interval were 720 and 15 minutes, respectively. 34 cases (22%) were conscious, 110 cases (71.5%) had impaired level of consciousness, seven cases (4.5%) presented with cardio respiratory arrest and three patients (1.9%) presented with seizures and one child (0.1%) was dead. Moises, bradypnea and apnea were seen in 78 (51.3%), 62 (40%) and 7 (4.5%) children, respectively. Six children had a history of hospitalization due to methadone poisoning, of which 2 were the day before, 3 were the month before, and 1 was 2 years ago. Two children were addicted. The mean±SD of the number of hospitalization days were 2.39±1.57 and the minimum and the maximum were 1 and 9 days. The mean±SD of hospitalization cost was 7642249±5341725 Rials. The average consumption of naloxone was 6.83± 10.41mg and the minimum and the maximum were one and 68 milligrams.
Conclusion: The results of this study showed that meiosis is not observed in half of children with methadone poisoning. Therefore, it is recommended that in the case of children with impaired level of consciousness or seizures without a specific reason; methadone poisoning should be concerned as a differential diagnosis by medical staff and this diagnosis should not be ignored only in the absence of meiosis or respiratory dysfunction.

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Background and Objective: Iron deficiency anemia lead to a decrease in intelegence question (IQ) and a decrease in learning and mental and physical abilities. This study was done to determine the status of iron intake in infants aged 6 to 24 months under the cover of comprehensive health centers in Miandorood city, Mazandaran province, Iran during 2019.
Methods: This descriptive-analytical study was carried out on 400 infants aged 6-24 months who were enrolled in comprehensive health centers in Miandorood city, Mazandaran province, Iran during 2019. The status of iron drop consumption and mothers' awareness in this field were evaluated.
Results: The mean age of the infants was 13.8±4.8 months. The range of the mother’s age was 28.8±5.6 years. Of these, 274 (68.5%) of infants used iron drops regularly, 106 case (26.5%) often, and 20 case (5.0%) never. The mother's knowledge score was significantly correlated with the type of iron intake, height percentile, and maternal education level (P<0.05). Evaluation of the possible causes of irregular iron intake shows that the most frequent cases were forgetting (28.8%), 9.5% for nausea and vomiting, and ‎‎9.0% for teeth color changing.‎
Conclusion: Mothers' awareness of iron drops consumption was good. The most important barriers to regular iron intake in the present study were forgetfulness, vomiting, and tooth discoloration.
 

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Kawasaki disease is a medium-size vasculitis with peak incidence among infants of 9 to 11 month age. This case report represents a female infant of 18-month age whom was admitted to the Taleghani Pediatric Center of Gorgan, Iran; with referral for admission due to persistent fever for roughly 2 weeks despite various outpatient treatments. Upon the admission, Echocardiographic study was performed to assess whether the patient fulfils cardiac criteria of Kawaski disease which was consistent with the diagnosis and also positive for serious coronary complications in the infant. General condition of the patient improved as the treatment with both IVIG and Corticosteroids was initiated and carditis seemed to vanish in echocardiographic studies but as expected aneurysmal growth can last for over 80 days and in this case serial echocardiographic studies confirmed the formation of giant coronary aneurysms. Diagnosis of Kawasaki disease is based on persistent fever and consistency with clinical criteria and the main purpose of this case report was to emphasize the need to consider this disease in cases of persistent fever to avoid the serious following complications.

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Background and Objective: Poisoning is one of the most common reasons for emergency department visits worldwide. Awareness of poisoning patterns helps identify risk factors and enables early diagnosis. In Iran, narcotics are among the main causes of poisoning in children. The current study aimed to determine the prevalence of narcotics-induced poisoning in children under 18 years old referring to the Al-e-Jalil Educational and Therapeutic Center in Aq Qala, Golestan Province.
Methods: This retrospective descriptive study was conducted on 36 children aged 1 month to 18 years (22 boys and 14 girls; mean age: 51.62±36.25 months) referring to the Al-e-Jalil Educational and Therapeutic Center in Aq Qala due to narcotics-induced poisoning from 2020 to 2022. Samples were included in the study using census. Patients’ medical records were reviewed and recorded in a checklist.
Results: The highest poisoning rate stemmed from the consumption of opium (69.4%), followed by methadone (25%). Decreased level of consciousness upon hospital admission was determined to be 66.7%. The interval between poisoning and hospital admission was 5.60±3.86 hours. The mean length of hospital stay was 1.25±0.80 days, and no patients died. Most children were male (61.1%), Turkmen (69.4%), and rural residents (86.1%). The highest cases of poisoning occurred in the summer (36.1%). The most common route of contact was oral (97.2%).
Conclusion: The poisoning rate with opium is higher compared to other narcotics. However, there is strong evidence of increased opium use among young people and some evidence of increased methadone use.