Speakers discuss diagnosis and management of MDR TB, Cerebral Palsy, Childhood Cancer and ADHD


 Children’s Hospital Lahore symposium proceedings

Speakers discuss diagnosis and management
of   MDR TB, Cerebral Palsy, Childhood
Cancer and ADHD

LAHORE: Dr. Salman Kirmani from Aga Khan University Hospital Karachi made a presentation on Disorders of Sexual Development at the Children’s Hospital Lahore annual symposium held recently.  DSD, he said, was the new terminology used for Intersex. He discussed clinical presentations of DSDs and opined that one must do the necessary investigations to confirm the diagnosis. He then showed a side wherein the baby had apparent male genitalia but actually it was a female. Children presenting with ambiguous genitalia are a difficult situation to handle. One must ask for family history of DSD, delay in puberty or failure, and palpate the testis and pedicles. He then talked about sex determination and sex differentiation, development of internal and external genitalias.

In clinical approach, history is important. He also referred to family history offemales who arechildless, family history of infantile death, phallus length and appearance, labioscrotalfolds and the basics testing needed.  Incase uterus, gonads are not visible, one might have to ask for MRI, order abdomino pelvic ultrasound, hormone analysis, Karyotyping and electrolytes. He was of the view that 20-50% of diagnosis are possible by specific tests. He also referred to the risk of gonadal tumour and serious complications while managing these children.

This presentation was followed by free paper sessions and the topics which were discussed included cerebral palsy in children, chronic diarrhea,   Down’s syndrome. Dr. Attica Bari in her presentation stated that human errors are common but they are under reported.  Here study findings were that long duty hours, lack of experience were most important causes of medical errors. One hundred thirty out of one hundred fifty questionnaires were returned by the paediatric medicine residents which included 35% third year residents.  About 18% were serious errors and 48% were minor errors. About 21% did not report it because of fear, 57% disclosed it to the senior physicians, some of them had guilt feelings, sorry and were emotionally upset. The important thing was 86% asked for help from seniors and 77% started using evidence base medicine. Over 70% were more careful while 31% started ordering more tests. Inadequate supervision by the seniors, she pointed out, was yet another reason for these medical errors. She suggested close monitoring and regulating the duty hours of these residents to minimize the chances of medical errors.

 This was followed by a panel discussion on immunization. It was pointed out that the EPI coverage has dropped in Sindh and Baluchistan and it was essential to close the immunization gap. Reasons for EPI failure were also discussed in detail like misconceptions, ignorance about its importance in the community besides some administrative issues. There have been more focus on polio and we have been neglecting other diseases. Prof. Waqar Rabbani opined that we have to improve the working conditions of EPI workers besides education of HCWs and the community at large. Dr. Khalid Sharif from UK asked have we done enough as a community as regards immunization. Mega events like PSL should have been used to convey the message and create awareness about the importance of immunization.

Dr. Ali Akbar spoke about MDR TB in children. He pointed out that the children get it from adults hence we need to improve treatment of the adult patients. MDR TB cases should be referred to appropriate treatment centers. In some cases Intravenous antibiotics and treatment have to be administered for which the patients need to be hospitalized for few months. Dr. Marry Taj spoke about advances in ALL and discussed its management. It was pointed out that leukemia children present with bone marrow suppression, infection, bleeding, organ infiltration with bone and joint pains. Age, white count and steroids response were mentioned as some of the prognostic factors in ALL. Treatment protocol for these children are available at SKMT and AKU. These patients have to take life threatening immunosuppressive drugs for two to three years and these drugs have their own side effects. Hence, one has to be careful and ensure that the patient takes the drugs and do not die of drugs side effects and infection. Long term morbidity and mortality is a problem because of long term treatment. One has to be careful of risks of infection and fungal infections which must be detected early and treated properly. Unfortunately no paediatric oncologists are available in many areas of Pakistan. There are a few treatment facilities located in major cities.  Giving details of a study done at AKU which consisted of 646 children,  it was stated that 62% of these children were lost to follow up. Some died before induction of therapy. These children if properly treated can ensure good outcome. It was concluded that 60-70% of ALL patients can be cured. They usually die of infection. Treatment of infections can be improved. Education of parents and children is also important.  Palliative care, Hospice care closer to home is essential as they should not be in a hospital where they will occupy hospital bed as well.

Dr. Mubarak Ali from SZMC Rahimyar Khan in his presentation talked about cardiac complications in children. More than50% of the children in this study were suffering from thalassemia and Bone Marrow Transplant, he said, was too expensive. He also referred to iron overload, cardiac complications. Congestive heart failure is a major complication while arrhythmias also account for 1%. Most of the patients in his study were between the agesof 5-10 years.  He suggested regular cardiac checkup and assessment of the children from the age of five years. Prof. Masood Sadiq pointed out that cardiomegaly was not a complicationof Thalassemia.

In the last session Dr. Nandita De Souza from India talked about ADHD problems and practiceinchildren.  Her center, she said, was a community based child development center and it was a part of primary caring center. They have managed over six thousand children during the last ten years.They also have an outreach programme. All naughty children, she clarified, are not suffering from ADHD. Parents gets lot of blame for this as they cannot discipline their children. She then talked about inattention, hyperactivity which is different in different setting and place and impulsivity because they do not think about the consequences of their actions. It was also important that we should not under diagnose and over diagnose ADHD. In case children between the ages of 4-18 years have behavioural and leering issues, they must be assessed for ADHD. Assessment must be made before twelve years of age and the symptoms must be persistent for more than six months. Symptoms should have effects on functioning. Parents do not complain about these symptoms to schools for fear of their children being turned away from school. Getting ADHD history from schools about the children is extremely difficult. Emotional problems, learning disability ,autism, hearing problems were mentioned as some of the differential diagnosis of ADHD.

We at our center, she said, have developed a management protocol for ADHD patients. She emphasized the importance of starting with a strength which lifts the mood. Strength within the family is important because they interact with the child. Similarly the attitude of neighbors, school teachers and educators was also important in the management of these children suffering from ADHD. Parents to parents sharing their experiences was also very useful. We regularly organize workshops for the teachers.  One needs to be firm, be calm and be fair. In anger management, ensure that anger does not hurt others. The children do not hurt themselves and do not damage property. Talk to the children how do they feel? Class behaviour report should be useful. While managing these children one should try behaviour therapy for 1-5 years old and use medication in children between the ages of 6-14 years. Dr. DeSouza also disclosed that they have started training primary paediatrician in their offices and it can be done. To overcome the problem of poor follow up, use social workers. Drop outs from behavioural therapy and poor availability of services were some of the problems, she added.

Dr. Shehla Fadoo from Aga Khan University Karachi talked about how to improve childhood cancer survival. She pointed out that there are two lac fifty thousand childhood cancers diagnosed each year and 90%of them die most of them in the developing countries. Mortality from childhood cancer is just 5% in developed countries and about 55% in low income countries. More than 70% of these patients, she opined, are curable. In Pakistan about   nine thousand children suffer from cancer each year. Overall survival is less than30%, less than50% are reaching healthcare facilities where treatment is available. Childhood cancer survival has now increased because of combination therapy and multi-disciplinary approach. We in Pakistan have about ten to fifteen centers and about twenty paediatric oncologists. We have very few fully trained paediatric oncologists. Late diagnosis and lack of awareness among doctors and general public are the reasons for late referral. Speaking about failure to complete treatment, Dr. Fadoo said that almost 30% of these paediatric patients are lost to follow up. Treatment is also expensive and there are a very few treatment centers in the public sector.

Continuing she said that childhood cancer is a very rare disease. It has excellent outcome and cost effective treatments are available. It is also preventable by doing screening. Early initiating of treatment and timely referrals reduce the chances of failure and outcome is much better. Most of the diseases these children suffer from are brain tumour, leukemia, and lymphoma. She emphasized the importance of setting up more paediatric oncology centers and paediatric oncology trained nurses. We can also train paediatrician and they can liaisonwith primary paediatric oncologists. It is extremely important that we develop few sate of the art paediatric oncology centers in Pakistan for training.  Multi-disciplinary Tumour Boards should be established. We need dedicated paramedical staff and nurses besides initiating an outreach programme. We must provide standard care, palliative care and ensure long term follow up of these patients. Pain control was extremely important. There is a fear of toxicity but we need to establish adequate pain control facilities. We are also working to establish Pakistan Society of Paediatric Oncology, she remarked. Her conclusions were that almost 70% of children with cancer diagnosis can be cured.

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