WARNAKULASURIYA WADUMESTHRIGE SHIRANTHA DEVAN MENDIS
A BIRDS EYE VIEW OF PAEDIATRIC PROBLEMS
IN SRI LANKA
The Democratic Socialist Republic of Sri Lanka or "Ceylon" as it was known for many centuries, is an Island of approximately 65,610 sq. kilometers in area. It is located in the centre of Indian Ocean. The estimated population of Sri Lanka is 17.6 million. Out of this, 33.25 falls to the paediatric age group.
The vital statistics include crude birth rate 20.1, crude death rate 5.6, maternal mortality rate 0.4, infant mortality rate 17.2, neonatal mortality rate 13,0 still births rate 18.1/per 1000 live births.
The cause for paediatric morbidity and mortality is multifactorial. These include congenital, inherited and environmental causes. The environmental cause plays the major role in the causation of paediatric morbidity and mortality. The respiratory diseases and diarrhoeal diseases cause the main paediatric morbidity in the country. It also contributes to the major percentage of paediatric mortality directly or indirectly.
Poverty, poor knowledge about diseases, poor housing facilities, overcrowding, poor sanitation, unavailability of clean water, and poor personal hygiene contribute to the bulk of pediatric problems in Sri Lanka,
Lady Ridgeway Childrens Hospital is the only Children's Hospital in Sri Lanka. It is a teritiary referral center and an Undergraduate and Post graduate Training Centre. It is a hospital with 650 beds. The out patients department caters to 600,000 patients per year.
As indoor patients 45,000 are treated annually. Diseases of the respiratory system 49%, infections and parasite diseases 25.7%. disease of digestive system 6%, disease of the nervous system 3.8%.
The neonatal services in Sri Lanka are not adequate to cope with the demand. We have got only four neonatal intensive care units for the whole island. They are also mainly situated close to the capital city. The still birth rate being 18.1/per 1000 live births. The average neonatal mortality rate being 13.0/per 1000 live births. In the provisional regions it ranges from 5-30/per 1000 live births. The regional statistics indicates the low birth weight rate as (2.5 kg birth weight) 27% of the total births.
Septicaemia causes the highest morbidity among neonates, congenital abnormalities is the second most common. Birth asphyxia, meconium aspiration and respiratory distress syndrome are the third most common causes of neonatal morbidity.
The expanded programme of immunization is to control six vaccines preventable diseases. They are Tuberculosis, Diphtheria, Pertussis, Tetanus, Poliomyelitis and Measles. All these six diseases have come down significantly over the past 10 years.
BCG vaccination that is performed for the prevention of tuberculosis continued to be part of the expanded programme of immunization. The national coverage for BCG immunization is about 78.9%. Tuberculosis has become one of the most important preventable communicable diseases in the world today, being very much in the limelight due to its close association with HIV/AIDS. The incidence of tuberculosis in Sri Lanka has come down to 38 cases per 100,000 population, from 88 cases per 100,000 population in 1962. The age wise pattern of tuberculosis remained unchanged. The incidence of all forms of tuberculosis was lowest in the age group 0 - 14 years with 3.5 cases per 100,000 population. However, considering the age groups 0 - 4 and 5 - 9 years separately, the rate appears to be still low and this shows that BCG vaccination has been very effective against T.B. in children.
The national coverage with three doses for Diphtheria, Tetanus, Pertussis vaccine had risen to 90,2% in 1994. Diphtheria is almost not seen in Sri Lanka today. One case was reported in 1993. The incidence of tetanus is declining out of 196 cases reported 12% falls to the paediatric age group. The incidence of pertussis has gone down to very low levels, only 18 cases were reported last year.
The Poliomyelitis rate has come down dramatically. Twelve cases were reported. Poliomyelitis is a dreaded and crippling disease which caused high morbidity in Sri Lankan children three decades ago. Sri Lanka, too, has joined in the war against Poliomyelitis with an eradication plan also aimed at the year 2000 A.D.
Neonatal tetanus is second only to measles as a leading killer of children. It is endemic in over 90 countries. Even with treatment the case fatality rates can approach 90%. Neonatal tetanus claimed many infant lives before immunization and clean delivery practices. Immunization of pregnant mothers to prevent tetanus in the new born commenced in Sri Lanka in 1969. The quality of clean deliveries remained high, and at least 80% deliveries conducted by trained health workers. These practices have reduced the incidence of neonatal tetanus dramatically.
Total of 847 cases were reported in 1970, only five cases were reported in 1994, Of the five cases reported only one case was delivered at a government hospital. The rest were delivered at home, by untrained staff.
Measles has been gradually decreasing in Sri Lanka, since immunization against the disease was introduced in 1984. In 1993, 558 cases of measles and four deaths were reported. In the pre-immunization era 5000-6000 cases of measles were reported annually.
Dysentery or bloody diarrhoea account for 10% of diarrheal episodes in children under five years of age and these cause about 15% of diarrhoea associated deaths in this age group. Shigella are responsible for more than 50% dysentery in Sri Lankan children. Others include enteroinvasive escherichia coli, enterohaemorrhagis E. coli and campylobacter jejuni.
Shigellosis is the number one cause of Morbidity and mortality following dysentery in Sri Lankan children. Complications of shigellosis seen in Sri Lankan children include Rectal prolapse, Toxic megacolon, Toxemia, Hyponatraemia, Hypoproteinaemia, proctocolitis and Haemolytis-Uraemic Syndrome. We conducted a study at childrens hospital about Shigellosis in Sri Lankan children. Shigella species were isolated from 256 of 2127 cases (12.0%). These 256 comprised 147 (57.45) Shigella Dysentery type-1 105 (41%) "Shigella Flexneri and four (1.6%) Shigella sonnei.
About 85% of these children presented with blood and mucus diarrhoea. More than 20% needed intravenous therapy.
About 20% of isolates were sensitive to Ampicillin, Nalidixic acid and co-trimoxazole. But more than 90% of isolates were sensitive to Gentamycin, Cefotaxime and Ceftazidime.
Complications such as Haemolytic-uraemic syndrome disseminated intravascular coagulation and proctocolitis (one case each) were observed only in Shigella dysentery Type-1 infected children. The three deaths that occurred were also due to the same infection. Shigella dysentery infection causes a serious health problem among Sri Lankan children, especially under five years.
Malnutrition causes a serious health problem to the average Sri Lankan child. Sri Lanka being a developing country and the poor socio-economic situation is the main cause for this. Below the age of five years 35% are malnourished. Malnutrition contributes directly or indirectly to about 40% of all childhood mortality. The malnutrition clinical syndromes of Marusmus and Kwashiorkor are frequently seen in our children's Wards.
A study was done to assess the nutritional status in 1170 children according to three anthropometric indices. Height for age, (stunted) weight for height (wasted) and weight for age (undernutrition) were assessed by background variables. Out of 1170 children weighted 32% were undernourished, 21% were stunted and 15% were wasted.
In the latter half of 1994 chloramphenicol resistant salmonella typhi outbreaks began to emerge in Sri Lanka. A total of 18 cases of resistant typhoid was reported from three different districts of the 38 patients one died before the Abst report was received. Eight cases were in the paediatric age group. The Salmonella Typhi isolates were resistant to Chloramphenical, Co-trimoxazole and Ampicillin, but sensitive to Amikacin, Cefotaxime and Ciprofioxacin.
I will give a short review of the paediatric problems present in the Nuwara Eliya District that I work. It is a Base Hospital in the mid country of Sri Lanka catering for a population of 600,000. Nuwara Eliya is known as the Garden City of Sri Lanka. Unfortunately, it is notorious for its vital statistics. This district has the highest neonatal mortality rate (29 per 1000 live births - National average being 13 per 1000) and the highest infant mortality rate (40 per 1000 live births - National average being 19 per 1000). I have analyzed all the neonatal deaths that occurred in my unit from October 1994 to July 1995. The total admissions were 465, out of which there were 39 deaths. The cause of death in the majority of cases was septicaemia, asphyxia and prematurity were the second most prominent cause.
The high risk factors we identified from this study are gestation 32 weeks, birth weight 1,7 kg, no antenatal care, home deliveries, deliveries done by unqualified people and transfer of babies from peripheral hospitals.
The general paediatric ward in my unit consists of 30 beds. I have analyzed all the patients admitted to this ward from October 1994 to April 1995. The total admissions were 1194. Diseases of the respiratory system 496 (41%), Diaehoeal diseases 175 (14%), diseases of Neryous system 125 (10.4%), Renal diseases 37 (3%), Rheumatic fever 25 (2%), urinary tract infections 23 (1.9%), poisoning 23 (1.9%).
Meningitis seems to cause a major morbidity in the district that I work. I have collected 18 cases of Meningitis over the past 9 months. Majority of the patients were between the ages of one month to one year. Fourteen (77%) the commonest presenting symptoms were fever 11 (61%) and fits 5 (27%). CSF was turbid in 10 (55%) patients, polymorhs 100 in four (22%) patients, more than 500 in two (11%) patients, direct smear was positive in seven (38%) patients. Antibiotics that were used were Penicillin, Chloramphenicol and Cephalosporins. Eight (44%) had antibiotics for more than 20 days. Complications included fits two (11%) cerebral abcess three (16%) and hydrocephalus five (27%). fourteen (77%) patients had permanent sequalae and two (11%) deaths were recorded.
It is interesting to note the high incidence of accidental poisoning admitted to paediatric unit. There were 23 (1.9%) poisoning cases. Ten had ingested organophosphates. Forty percent of the population in Nuwara Eliya district get involved in cultivation, potatoes and other vegetables. Insecticides and pesticides are being used abundantly in this area. At certain instances children do get access to these agrochemicals. They present to the hospital without any history of ingestion, but clinical feature suggestive of organophosphate poisoning. Out of the 10 cases we had one death. In rest of Sri Lanka we hardly ever see agrochemical poisoning in children, the commonest that we do see in Sri Lanka is Kerosene oil ingestion.
A high incidence of neural tube defects is seen in the Nuwara Eliya district. I have seen more than 20 cases over the past 10 months. Tea cultivation which is the main agricultural product in the hill country seems to have an association with neural tube defects. Tanin alkaloid present in tea extracts is envisaged as the causative factor. Further research is necessary in this respect.
