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Intussusception is one of the commonest causes of bowel obstruction in infants. Most infants in Low- and Middle-Income Countries (LMICs) undergo an invasive operative intervention. Supported by simulation-based education (SBE), the Air Enema (AE) non-operative technique was introduced in 2016 in Myanmar. This study assesses the long-term outcomes. Mixed methods study design over 4 years including clinical outcomes and surgeon’s attitudes towards the AE technique and SBE. Prospectively collected clinical outcomes and semi-structured interview with reflexive thematic analysis (RTA). Primary outcome measure was a long-term shift to non-operative intervention. Secondary outcomes: Length of Stay (LoS), recurrence rates, intestinal resection rates, compared to the operative group. The data was analysed according to intention to treat. Quantitative data analysis with Mann–Whitney U test, Fisher’s exact test, Student’s T-Test or Wilcoxon Signed-Rank Test utilised. A p-value of

The rate of an accurate diagnosis for pediatric cancer is said to be low in developing countries; furthermore, due to inconvenient medical access and economic reasons, there are restrictions on the selection of treatments. Desmoid fibromatosis (DF) is a locally progressive, non-metastasizing fibroblast soft tissue tumor classified as intermediate type. We made a pathological diagnosis gross total tumor resection by the international collaboration with Myanmar, Cambodia, and Japan. The case was a 5-year-old Burmese boy. A recurrent growing tumor was found in his right buttock, which caused gait disturbance and aesthetic problems. In order to remove this giant DF, the oncologist consulted our department. Because DF had localized outside the pelvic ring, it could be resected with the embolization of the branch of the internal iliac artery. In operation, the sciatic nerve was preserved and a gross total resection was performed with R1 surgery. The patient is alive without any functional disorders and recurrences and is maintaining a good QOL. This is the first report on treating DF in Myanmar by an international collaboration team.

Background Encephalitis is a worldwide public health issue, with a substantially high burden among children in southeast Asia. We aimed to determine the causes of encephalitis in children admitted to hospitals across the Greater Mekong region by implementing a comprehensive state-of-the-art diagnostic procedure harmonised across all centres, and identifying clinical characteristics related to patients’ conditions. Methods In this multicentre, observational, prospective study of childhood encephalitis, four referral hospitals in Cambodia, Vietnam, Laos, and Myanmar recruited children (aged 28 days to 16 years) who presented with altered mental status lasting more than 24 h and two of the following minor criteria: fever (within the 72 h before or after presentation), one or more generalised or partial seizures (excluding febrile seizures), a new-onset focal neurological deficit, cerebrospinal fluid (CSF) white blood cell count of 5 per mL or higher, or brain imaging (CT or MRI) suggestive of lesions of encephalitis. Comprehensive diagnostic procedures were harmonised across all centres, with first-line testing was done on samples taken at inclusion and results delivered within 24 h of inclusion for main treatable causes of disease and second-line testing was done thereafter for mostly non-treatable causes. An independent expert medical panel reviewed the charts and attribution of causes of all the included children. Using multivariate analyses, we assessed risk factors associated with unfavourable outcomes (ie, severe neurological sequelae and death) at discharge using data from baseline and day 2 after inclusion. This study is registered with ClinicalTrials.gov, NCT04089436, and is now complete. Findings Between July 28, 2014, and Dec 31, 2017, 664 children with encephalitis were enrolled. Median age was 4·3 years (1·8–8·8), 295 (44%) children were female, and 369 (56%) were male. A confirmed or probable cause of encephalitis was identified in 425 (64%) patients: 216 (33%) of 664 cases were due to Japanese encephalitis virus, 27 (4%) were due to dengue virus, 26 (4%) were due to influenza virus, 24 (4%) were due to herpes simplex virus 1, 18 (3%) were due to Mycobacterium tuberculosis, 17 (3%) were due to Streptococcus pneumoniae, 17 (3%) were due to enterovirus A71, 74 (9%) were due to other pathogens, and six (1%) were due to autoimmune encephalitis. Diagnosis was made within 24 h of admission to hospital for 83 (13%) of 664 children. 119 (18%) children had treatable conditions and 276 (42%) had conditions that could have been preventable by vaccination. At time of discharge, 153 (23%) of 664 children had severe neurological sequelae and 83 (13%) had died. In multivariate analyses, risk factors for unfavourable outcome were diagnosis of M tuberculosis infection upon admission (odds ratio 3·23 [95% CI 1·04–10·03]), coma on day 2 (2·90 [1·78–4·72]), supplementary oxygen requirement (1·89 [1·25–2·86]), and more than 1 week duration between symptom onset and admission to hospital (3·03 [1·68–5·48]). At 1 year after inclusion, of 432 children who were discharged alive from hospital with follow-up data, 24 (5%) had died, 129 (30%) had neurological sequelae, and 279 (65%) had completely recovered. Interpretation In southeast Asia, most causes of childhood encephalitis are either preventable or treatable, with Japanese encephalitis virus being the most common cause. We provide crucial information that could guide public health policy to improve diagnostic, vaccination, and early therapeutic guidelines on childhood encephalitis in the Greater Mekong region. Funding Institut Pasteur, Institut Pasteur International Network, Fondation Merieux, Aviesan Sud, INSERM, Wellcome Trust, Institut de Recherche pour le Développement (IRD), and Fondation Total. Translations For the Khmer, Lao, Vietnamese and Burmese translation of the abstract see Supplementary Materials section.

To estimate proportion of Myanmar paediatric population at risk of impoverishment and catastrophic expenditure due to emergency surgical intervention. Prospective data were collected at two tertiary surgical centres including income, household expenses, expenses related to surgery. Data analysis was performed to estimate out-of-pocket (OOP) direct medical costs and OOP total costs. Catastrophic expenditure: expense exceeded 10% of household income. Risk of impoverishment: net income drops were below an impoverishment threshold (PPP—purchasing power parity): I$ 2.00 PPP/day, I$ 1.25/day PPP, national poverty line. Distribution of income was estimated using a gamma distribution. Comparison to an adult cohort was performed using Chi-square test with a p value of

Background Down Syndrome children have complex healthcare needs. There was no previous data of Pediatric Down Syndrome (PDS) in Myanmar and little is known about their health status and challenges to seek proper screening tests and health care services. Since there are no established local guidelines for PDS, limited resources and inaccessibility to specialty centers especially for those form remote areas, more health care challenges are encountered throughout the country. Objectives To assess the health status, screening tests and follow up conditions of Myanmar Down Syndrome children Methods One hundred and sixty six children with Down Syndrome less than 16 years were collected from regional hospitals within one year (January to December 2020).We took history, reviewed medical records and performed clinical examination. We analyzed demographic characteristics, attitude and healthcare knowledge of caregivers, screening tests and following up conditions including problems in coping of caring the children with Down Syndrome. Results Results: Of the 166 participants, majority, (53%) were male. A total of 95(57.2%) were from urban area and most of PDS (96.4%) were cared by biological parents. Half of caregivers in this study group were nongraduate (most are middle-school education).Although (80.7%) were born at regional hospitals, some were unaware of Down Syndrome until the child developed clinical symptoms (maximum age up to 9 years) and (45%) have lack of knowledge about associated health problems. The most common medical conditions reported were cardiac (53.01%), thyroid (13.25%), visual (13.25%), hearing problems (8.43%).Screening tests done for cardiac, thyroid, vision and hearing were 72.89%, 40.96%, 25.3% and 26.51% respectively and only (21.38%) have regular follow up after diagnosis. Most of the caregivers have lack of knowledge about how to care their children, importance of screening tests according to age and regular follow up. Conditions such as financial difficulties, social problems and uneasily accessible health specialties especially for those who live in rural areas became barriers to receive proper health care services. Conclusions More data are needed to understand health conditions, caregiver knowledge and explore the barriers in seeking proper health care services. Appropriate policies, feasible local guidelines and more education programmes to address health care challenges for Down Syndrome children are crucial to raise awareness of healthcare personals and reduce the gap to receive proper healthcare services. Screening tests according to age and long-term care programs are vastly underdeveloped in poor countries like Myanmar, it will be essential for complementing the support system and sustaining the major role that families or caregivers currently play.

Background Since the establishment of pediatric neurology services in 2011, pediatric neurology team has been dealing with increasing numbers of different neurological problems year by year. Developmental, speech and language and behavioral problems are quite common in out-patient clinics. In 2017, UNICEF estimated that 42% to 45% of young Myanmar children need early childhood intervention services. So Child Development Center (CDC) was launched in 2017 as a branch of Pediatric Neurology with services such as developmental screening, assessment and appropriate intervention. Objectives The objective of the study is to evaluate early intervention services for children who were enrolled in CDC. Methods Retrospective study was done on early intervention services in CDC through the review of CDC registration records from 2017 to 2020. The study population included all the children referred for screening, assessment and interventions. After enrollment, thorough history, and relevant general, systemic as well as neurological examinations and necessary investigations were performed for diagnosis and underlying causes. Pediatric neurologists also conducted developmental screening and necessary neurodevelopmental assessments by using instruments such as Schedule of Growing Skills-2, Conner Rating Scale and DSM-5 Diagnostic Criteria. Then, appropriate interventions such as physiotherapy, occupational, speech, behavior and self-care therapies were given by allied professionals in voluntary participation and paraprofessionals. The extracted data from CDC registry to analyze were demographic variables, presenting symptoms, medical history and examination findings, results of developmental assessment and diagnoses and therapy services. Results A total of 138 children with girls (30.43%) and boys (69.57%) were enrolled. The youngest age at enrollment was 1 year, the oldest 15 year with a mean age of 4.558 year. The most common developmental problems were global developmental delay (GDD) (54.35%), autism spectrum disorder (ASD) (17.39%) and speech and language delay (SLD) (16.67%) with male-predominance in GDD (64.81%), ASD (79.17%) and SLD (78.26%) respectively. Speech problems (97.62%), language (97.5%) and adaptive skills (93.33%) delay and behavior problems (37.93%) were the most common presentation in GDD. Youngest age for ASD by DSM-5 was 2 years with a mean age of 3.75 years. Problem-in-making-friends (75%), poor-eye-contact (70.83%), stereotypies (54.17%) and odd-play (41.67%) were the most encountered autism symptoms in children with ASD. Rising trend was found in assessment (36.96% in both 2018 and 2019) and therapy services in comparison with 2017. Conclusions This study explores the promotion of early intervention services for special-needs children as part of pediatric neurology. Scaling up better holistic intervention services in multidisciplinary approach and the study aiming for the outcome of children benefiting from CDC services are further considerations against impact of COVID-19 pandemic in 2020.

Background Simulation-based medical education (SBME) is an integral part of undergraduate and postgraduate training in high-income countries (HICs). Despite potential benefits to low- and middle-income countries (LMICs), it has not been widely applied. Our aim was to use SBME to address some essential paediatric surgery learning needs in a LMIC. Methods Eleven SBME courses were designed, implemented and evaluated over a 4-year period in partnership with local paediatric surgeons and the University of Medicine 1 in Yangon, Myanmar. All courses were simulation-based and different major SBME modalities were utilized. Evaluation included pre- and post-course questionnaires, other evaluation assessments including Likert scale self-rated confidence in different domains, as well as, mixed method evaluation and Kirkpatrick's hierarchy of evaluation. Results Over 4 years, a multidisciplinary team consisting of surgical consultants, fellows, and educational specialists delivered 11 courses at a tertiary LMIC paediatric surgical centre. Attendance varied between 23 and 50 healthcare professionals, with some participants attending all of the educational activities. SBME modalities were utilized to meet each courses' learning objectives. All educational courses scored highly and showed statistically significant differences in all the self-rated pre and post-course confidence Likert scale domains. SBME was accepted and embraced by local participants and faculty, and transition to local delivery of educational content has begun. Level 4 of Kirkpatrick's hierarchy of evaluation was demonstrated. Conclusion SBME can be used to meet essential learning objectives of local staff in a LMIC. Through various modalities, it offers a reliable, proven and affordable means of teaching multiple aspects of paediatric surgical clinical practice. By employing innovative simulation-based solutions, it can be adapted by local faculty to continue meeting ongoing learning needs.

The degree of surveillance data and control strategies for invasive meningococcal disease (IMD) varies across the Asia-Pacific region. IMD cases are often reported throughout the region, but the disease is not notifiable in some countries, including Myanmar, Bangladesh and Malaysia. Although there remains a paucity of data from many countries, specific nations have introduced additional surveillance measures. The incidence of IMD is low and similar across the represented countries (

INTRODUCTION Pediatric intussusception is a common cause of bowel obstruction in infants. Air enema (AE) reduction is routine first-line management in many countries; however, there is a high rate of operative intervention in low- and middle-income countries. The aims of the study were to use simulation-based medical education with an intussusception simulator to introduce AE reduction to Myanmar and to assess its effect on provider behaviors and the resulting clinical care. METHODS Clinical evaluation was conducted by comparing clinical outcomes data for children with intussusception 12 months before implementation with that from 12 months subsequent to implementation. These included the following: AE success rates, recurrence rates, length of stay, intestinal resection, and operative intervention rates. An educational workshop was developed that used a low-cost mannequin to facilitate practice at the reduction of intussusception using AE. Curriculum evaluation was performed through 5-point rating scale self-assessment in several domains. Data analysis was performed with Mann-Whitney U test, Student t test, or Wilcoxon signed-ranks test as appropriate; a P value of less than 0.05 was considered to be significant. RESULTS After implementation, there was a significant reduction in the overall operative intervention rates [82.5% (85/103) vs. 58.7% (44/75), P = 0.006]. Intestinal resection rates increased [15.3% (13/85) vs. 35.9% (14/39), P = 0.02]. The success rate with attempted AE reduction was 94.4% (34/36), with a recurrence rate of 5.6% (2/36). The simulation-based medical education workshop was completed by 25 local participants. There was a significant difference in the confidence of performing (1.9 vs. 3.6, P ≤ 0.0001) or assisting (2.8 vs. 3.7, P = 0.018) an AE reduction before and after the workshop. CONCLUSIONS Simulation-based educational techniques can be successfully applied in a low- and middle-income country to facilitate the safe introduction of new equipment and techniques with significant beneficial impact on provider behaviors and the resulting clinical care.

Background Rotavirus vaccine was planned to be introduced in the National Immunization Program of Myanmar in 2020. Reported potential association of a small increased risk of intussusception after rotavirus vaccination in some countries is a major safety concern and it is mandatory to collect baseline information before vaccine introduction. Methods Retrospective study reviewed medical records of intussusception cases for past 3 years (2015–2018) and prospective, active study was conducted from August 2018 to January 2020 at three tertiary children hospitals where pediatric surgical facility is present. Brighton Level 1 Criteria was used for confirmation of intussusception among children 3days after onset) is significantly associated with requirement of surgery (61/85, 71.8%), which in turn is significantly associated with longer hospital stay (296/452, 65.5%) (p < 0.05). Conclusions Intussusception occurrence is most frequent between 5-7 months age group which is old enough to be vaccinated under the schedule that has now been introduced in Myanmar. More than half of the cases were treated by surgery and late arrival to hospital enhances requirement of surgery and poor outcome. Findings of this baseline surveillance provide important facts for public health officials in balancing risks and benefits of rotavirus vaccine introduction, defining targeted age and dosage scheduling and facilitate monitoring system in post-vaccination., Intussusception, baseline surveillance, rotavirus vaccination, Myanmar.

Penetrating craniocerebral injuries are not uncommon in children, however, it can be obscured if history or examination is missed.

We report a case of neonatal herpes simplex virus (HSV)-1 central nervous system disease with bilateral acute retinal necrosis (ARN). An infant was presented at 17 days of age with focal seizures. Cerebrospinal fluid polymerase chain reaction was positive for HSV-1 and brain magnetic resonance imaging showed cerebritis. While receiving intravenous acyclovir therapy, the infant developed ARN with vitreous fluid polymerase chain reaction positive for HSV-1 necessitating intravitreal foscarnet therapy. This is the first reported neonatal ARN secondary to HSV-1 and the first ARN case presenting without external ocular or cutaneous signs. Our report highlights that infants with neonatal HSV central nervous system disease should undergo a thorough ophthalmological evaluation to facilitate prompt diagnosis and immediate treatment of this rapidly progressive sight-threatening disease.

BACKGROUND Combined vaccines containing diphtheria-tetanus-pertussis whole-cell (DTPw), Haemophilus influenzae type b (Hib), and hepatitis-B vaccines are essential for the continuing success of vaccination programs in developing nations. This randomized, dose-ranging study assessed the immunogenicity and reactogenicity of primary and booster vaccination with pentavalent DTPw-HBV/Hib vaccines containing 10, 5 or 2.5 microg of polyribosylribitol phosphate (PRP) conjugated to tetanus toxoid (trials Hib-052/064). METHODS Six hundred eighty infants were randomized to receive one of 5 vaccine combinations at 6, 10, and 14 weeks of age. Of these, 351 received the same vaccine at 15-24 months of age. The immune response was evaluated on blood samples collected 1 month after the 3-dose primary course and before and 6 weeks after the booster dose. Reactogenicity was assessed during a 4-day period after each vaccine dose using diary cards. RESULTS After primary vaccination, all subjects had seroprotective anti-PRP antibody concentrations (> or = 0.15 microg/mL) and > 95% had concentrations > or = 1.0 microg/mL, irrespective of the PRP dose administered. Anti-PRP antibody avidity after primary vaccination and antibody persistence until the second year of life were similar among groups. The booster dose induced marked increases in anti-PRP antibody GMCs and antibody avidity, indicative of effective priming and the presence of immune memory. All vaccination regimens elicited good immune responses and comparable antibody persistence to the other vaccine antigens, with significant increases in all antibody concentrations observed after boosting. All vaccination regimens were safe, with similar overall reactogenicity profiles. CONCLUSION Hib conjugate vaccines containing reduced amounts of PRP can be effectively combined with the licensed DTPw-HBV vaccine to provide protection against 5 major childhood pathogens in a single injection.