E-ISSN 1858-8360 | ISSN 0256-4408
 

Original Research (Original Article) 


SUDANESE JOURNAL OF PAEDIATRICS

2019; Vol 19, Issue No. 1

ORIGINAL ARTICLE

Renal scarring following urinary tract infections in children

Balakrishna Bandari (1), Seema Pavaman Sindgikar (1), Soma Santosh Kumar (1), Mangalapady Shenoy Vijaya (1), Raghu Shankar (2)

(1) Department of Pediatrics, K. S. Hegde Medical Academy, Mangalore, NITTE University, Mangalore, India

(2) Department of Pediatric Surgery, K. S. Hegde Medical Academy, Mangalore, NITTE University, Mangalore, India

Correspondence to:

Seema Pavaman Sindgikar

Associate Professor, Department of Pediatrics, K. S. Hegde Medical Academy, NITTE University, Mangalore, India

Email: seemapavaman [at] nitte.edu.in

Received: 09 April 2019 | Accepted: 22 April 2019

How to cite this article:

Bandari B, Sindgikar SP, Kumar SS, Vijaya MS, Shankar R. Renal scarring following urinary tract infections in children. Sudan J Paediatr. 2019;19(1):25–30.

https://doi.org/ 10.24911/SJP.106-1554791193


ABSTRACT

Urinary tract infection (UTI) is the most common bacterial infection seen in younger age group children. The most common risk factor for renal scarring in children with post-UTI is vesicoureteral reflux (VUR). This study looked at renal scarring following UTI in children by dimercaptosuccinic acid (DMSA) scan. It is a cross-sectional time bound study done among 40 infants and children with UTI for a period of 24 months. Their clinical presentation and laboratory data, including micturating cystourethrogram, were documented. DMSA scan, done during the follow-up, established the presence of renal scars if any. UTI was more common in males. Children with history of recurrent UTI had renal scarring. Statistical significance was noted when first and recurrent attacks of UTI were compared for clinical and diagnostic characteristics like Escherichia coli UTI (p = 0.007), increasing grades of VUR (p = 0.006) and renal scar formation (p = 0.041). The study concluded that the high grades of antenatal hydroureteronephrosis (100%), febrile UTI (34%), younger age group (67.5%) and E. coli UTI (86%) were more associated with recurrent attacks of UTI and renal scarring. DMSA, being the non-invasive test, is better proven to be an investigation of choice than other invasive modalities for follow-up of children with recurrent attacks of UTI.


KEYWORDS

Renal scar; Dimercaptosuccinic acid scan; Escherichia coli; Hydroureteronephrosis; Vesicoureteric reflux.


INTRODUCTION

Urinary tract infection (UTI) is the most common bacterial infection seen in younger age group, Escherichia coli being the frequently isolated organism [1]. UTI is defined as the presence of a pure bacterial growth of single species more than 105 colony-forming units (cfu) per millilitre of urine. Recurrent UTI is defined as three or more episodes of UTI with cystitis/lower UTI [2]. In a male infant, an attack of UTI and its recurrence warrants urogenital evaluation for congenital abnormalities. Analysis of such urinary infections includes urine culture sensitivity, ultrasonography (US), micturating cystourethrogram (MCUG), cystoscopy and dimercaptosuccinic acid (DMSA) renal scan for a complete evaluation. Renal scarring following an attack of UTI can be diagnosed by DMSA scan, which is the gold standard [3]. Generally, during the first attack of UTI, the formation of renal scarring is absent to minimal in the absence of coexisting anomalies [4]. However, there are studies which have reported renal scarring even after first febrile UTI [5]. MCUG is an invasive procedure for the diagnosis of vesicoureteral reflux (VUR). Renal scarring generally correlates with severe grade of VUR [6,7]. Prenatal ultrasonograms can detect urogenital anomalies and such neonates can be followed up for the presence of VUR. In the absence of anomaly, VUR can be missed, until, and unless, there is an episode of UTI. DMSA, as a non-invasive modality to test the renal parenchymal involvement, can be included to detect renal scars during follow-up of infants after the first attack of UTI. Such children also need follow-up for development of hypertension, proteinuria and end-stage renal disease. Hence, this study was carried out to look for renal scarring tendencies in children who had UTI.


MATERIALS AND METHODS

This was a cross-sectional time-bound study done in tertiary care centre, over a period of 2 years. Infants and children less than 13 years who presented as out or inpatient in the Departments of Pediatrics and Pediatric Surgery with the diagnosis of culture-positive UTI were included. Clinical presentation of urinary manifestations like dysuria, increased frequency of micturition, urgency with or without fever were evaluated for UTI. Urine sample was collected in a sterile urine collection bag in younger children <2 years of age after disinfecting the perineum and as midstream clean catch sample in >2 years of age [2]. They were classified to have either first or recurrent episodes. A detailed history of clinical features suggesting UTI, including antenatal history if any, systemic examination and lab data were documented in a structured questionnaire. Blood pressure (BP) was recorded using appropriate sized cuff. Hypertension is defined as average systolic BP and/or diastolic BP that is greater than or equal to the 95th percentile for gender, age and height on three or more occasions [8]. Investigations included renal function tests (urea and creatinine), routine urinalysis and microscopy, urine culture and sensitivity and ultrasound abdomen at the time of presentation. The diagnosis was confirmed by proven positive urine culture test of >105 cfu/ml as per the NICE guidelines [2]. During follow-up between 3 and 6 months MCUG, cystoscopy (as indicated) and DMSA scans were performed. US abnormalities were documented by a consultant radiologist. VUR grading was done after MCUG procedure as per the standards [9]. DMSA scan was done by nuclear medicine specialist. Renal scars were identified and graded as per the standard classification [10]. The types were classified as type 1: no more than two scars, type 2: more than two scars with some normal parenchyma between them, type 3: generalized damage to the whole kidney and type 4: end stage “shrunken” (kidney with little or no uptake of DMSA, i.e., <10% of the overall function). Those with existing renal diseases, such as chronic kidney disease, acute kidney injury and UTI following urethral catheterization and surgical procedures were excluded from the study. Ethical clearance and approval of the study were granted by the Institutional Ethics Committee. Signed informed consent for participation and publication of medical details were obtained from the parents. Confidentiality was ensured at all the stages.

Statistical analysis was performed using software packages SPSS 22.0. The data are expressed as numbers and percentages (n %). Bar charts are used to display percentages for categorized variables. Chi-square test was used to find the significance of association between categorized variables for inferential statistics wherein p-value of <0.05 was taken significant.


RESULTS

A total of 40 children with culture-positive UTI were included. The higher occurrence of UTI was in males (male to female ratio 2.6:1). Circumcision was done in seven children. First attack of UTI was observed in 23 (57.5%) children. The occurrence of UTI was more in younger age (<1 year: 12.5%: <5 years: 67.5%). Female children had more incidence of recurrent UTI (54.5%). Clinical features and laboratory data are tabulated in Table 1. Fever was not the presenting feature in 20%, but irritability, dysuria, vomiting and constipation were pointers to diagnose UTI. Prenatal US, as part of anomaly scan, was abnormal for genitourinary system in 11 (27.5%) children. Out of these children, three cases had renal scarring after the first attack of UTI. Moderate-to-severe hydroureteronephrosis (HUN) was the common finding observed. Most predominant organism cultured was E. coli, others were Klebsiella, Proteus, Pseudomonas, Enterococci, Citrobacter and Staphylococcus aureus. During an episode of UTI, 27 children had US abnormalities. The abnormalities noted were hydronephrosis (27.5%), cystitis (12.5%), posterior urethral valve (PUV) (10%), pyelonephritis (10%), pelviureteric junction abnormalities (5%), left duplex kidney (2.5%) and right solitary kidney (2.5%).

Table 1. Clinical features and laboratory data.

Clinical features Number (%) Investigations Number (%)
Symptoms E. coli 14 (35%)
Fever 31 (78%) Abnormal US 27 (67.5%)
Vomiting 5 (12.5%) VUR Positive 23 (57.5%)
Dysuria 24 (60%) VUR Absent 17 (42.5%)
Frequency 10 (25%) Grade 1 VUR 6 (15%)
Poor feeding 12 (30%) Grade 2 VUR 3 (7.5%)
Constipation 12 (30%) Grade 3 VUR 5 (12.5%)
Hypertension 4 (10%) Grade 4 VUR 4 (10%)
Grade 5 VUR 5 (12.5%)
Renal scar present (DMSA) 14 (35%)
Type 1 8 (57.1%)
Type 2 5 (35.7%)
Type 3 1 (7.14%)
Type 4 0

These findings were more seen in recurrent UTI (82.4%). Positive reflux was noted in 23 cases, majority in recurrent UTI (82.4%). Grade 5 VUR was present in five children. Five children with constipation were noted to have Grade 1 VUR, amounting to secondary VUR.

All the children underwent DMSA scan during the follow-up period. The significance of E. coli UTI, US abnormalities, positive VUR and renal scarring comparison between first and recurrent attacks is shown in Table 2. The significance was noted for all except US. Renal scars were present in 14 children, 21.7% in the first episode of UTI. Scarring was more common in males (78.5%). Febrile UTI had more risk of scarring (34.3%). Among the E. coli UTI, scarring was observed in 86% of cases (Figure 1). All the children with abnormal prenatal US of moderate-to-severe HUN had renal scarring during the follow-up. DMSA scan was abnormal in three children (23%) with normal US findings. Two of them had recurrent UTI and one child was diagnosed with pyelonephritis (S. aureus UTI). Positive VUR contributed to 47.8% of renal scarring. Renal scar was formed in four children who had Grade 5 VUR. During the first attack of UTI, nine (39%) children had positive reflux and three (33%) among them had renal scarring. These children were diagnosed to have posterior urethral valve. In absence of reflux, type 1 renal scar was formed in three children during the follow-up, probably because of recurrent attacks.

Table 2. Comparison of Escherichia coli UTI, abnormal US, positive MCUG and DMSA scan with first and recurrent attacks of UTI.

Characteristics First attack Recurrent attack p value
Escherichia coli UTI 4 (17.4%) 10 (58.8%) 0.007
Abnormal US 13 (56.5%) 14 (82.4%) 0.085
Positive MCUG 9 (39.1%) 14 (82.4%) 0.006
Renal scar (DMSA scan) 5 (21.7%) 9 (52.9%) 0.041

Figure 1. Bar diagram representing the relation between renal scarring and E. coli and non E. coli UTI, MCUG, and US kidneys, ureters and bladder (KUB).


DISCUSSION

This study was done with the intention to assess renal scarring tendency in children who also have underlying genitourinary abnormalities. Younger children are more prone to develop scarring. Several studies report that renal scars are common in younger age (less than 2 years) of onset for UTI [10]. NICE guidelines recommend that male infants and children with recurrent UTI need to be worked for any renal malformations and need a close follow-up. Atypical UTI and recurrent UTI need to be worked up with an US during an episode of acute infection, DMSA 4–6 months and MCUG following the acute event [2].

Fever and dysuria were common clinical manifestations. Afebrile UTI can also have scar formation if associated anomalies are present [11]. Our study reports 38% afebrile UTI had scarring. Najib et al. [4] reports that between febrile and afebrile UTI, scar formation was more with the former (43.7% and 13.5%). Recurrent attacks of UTI had underlying predisposing factors like constipation, VUR as reported in the literature [12]. Many paediatric studies support that 85%–90% of urine culture isolate is E. coli and has more risk of scarring similar to our study [1,13]. Antenatal scans positive for renal anomalies are prone to develop UTI and consequences in postnatal life. All the children (100%) diagnosed with moderate-to-severe grade HUN in utero had renal scarring. The literature suggests increasing grades of HUN is associated with increased risk of urologic pathologies [14]. Gökaslan et al. [15] reports statistically significant (p = 0.005) correlation between the anomalous prenatal scan and scar formation postnatally. In the present study, cortical scarring was noted in children with posterior urethral valves with VUR, even after the first attack of UTI. Freitas AC et al reports scarring can be seen in 20% of cases after the first episode [16]. Without evidence of VUR, renal scarring can be seen with specific conditions. Shaikh et al. [17] reports 18% of cases had evidence of scar formation without VUR secondary to haematological spread of organisms. In our study, the haematological spread of S. aureus infection and renal anomalies were predisposing conditions in 17.6% cases in the absence of VUR. Statistical significance was noted when first and recurrent attacks of UTI were compared for clinical and diagnostic characteristics, such as E. coli UTI (p = 0.007), increasing grades of VUR (p = 0.006) and renal scar formation (p = 0.041). Mir et al. [18] and Snodgrass et al. [19] report that there is increased incidence of UTI among children with VUR as major risk factor for recurrent UTI. The reason behind VUR to cause recurrent UTI was because it elevates bladder pressure which gets transmitted to the kidney causing reflux nephropathy and scar formation. This study had shown 33%, 33%, 40%, 50% and 80% of renal scarring in children with Grades I, II, III, IV, and V respectively (p ≥ 0.05, not significant statistically). Similar to this, a study proved that increasing grades of VUR has greater chances of renal scarring, i.e., 0%, 30.7%, 50%, 69.5% and 100% in Grades I, II, III, IV and V, respectively (p = 0.001) [20].


CONCLUSIONS

Recurrent UTI is relatively common in young children. Antenatal HUN (high grades), febrile UTI, female gender, children less than 5 years age group, congenital abnormalities (PUV and duplex kidney), increasing grades of VUR, infection with uropathogenic E. coli were the common risk factors associated with recurrent UTI and renal scarring in this study. Hence, the management of children with recurrent UTI depends on the age of presentation and the severity of associated symptom. We also recommend DMSA scan to evaluate children with first episode of UTI who were diagnosed to have high grade HUN by prenatal US, and in recurrent UTI, especially younger age group. Long-term follow-up of these children has to be done for the identification of complications such as renal function deterioration and hypertension. Our study also suggests that incidence of renal scarring was high in recurrent UTI and that absence of VUR is not protective, as renal scarring can occur even without VUR. Early diagnosis and aggressive treatment of these children is required.

CONFLICTS OF INTEREST

None.

FUNDING

None.

ETHICS

Ethical clearance and approval of the study were granted by the Institutional Ethics Committee. Signed informed consent for participation and publication of medical details were obtained from the parents. Confidentiality was ensured at all stages.

REFERENCES

  1. Kunin CM. Epidemiology and natural history of urinary tract infection in school age children. Pediatr Clin North Am. 1971;18:509–28. https://doi.org/10.1016/S0031-3955(16)32563-9
  2. National Collaborating Centre for Women’s and Children’s Health (Great Britain), Royal College of Obstetricians and Gynaecologists (Great Britain). Urinary tract infection in children: diagnosis, treatment, and long-term management. London, UK: RCOG Press; 2007.
  3. Hains DS, Cohen HL, McCarville MB, Ellison EE, Huffman A, Glass S, et al. Elucidation of renal scars in children with vesicoureteral reflux using contrast-enhanced ultrasound: a pilot study. Kidney Int Rep. 2017;2(3):420–4. https://doi.org/10.1016/j.ekir.2017.01.008
  4. Najib KH, Fallahzadeh E, Fallahzadeh MK, Fallahzadeh MH, Erjaee A. Renal scar formation in children with recurrent urinary tract infections. Iran Red Crescent Med J. 2009;11(1):93–5.
  5. Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med. 2003;348(3):195–202. https://doi.org/10.1056/NEJMoa021698
  6. Orellana P, Baquedano P, Rangarajan V, Zhao JH, Eng ND, Fettich J, et al. Relationship between acute pyelonephritis, renal scarring, and vesicoureteral reflux: results of a coordinated research project. Pediatr Nephrol. 2004;19:1122–6. https://doi.org/10.1007/s00467-004-1501-5
  7. Zaffanello M, Cataldi L, Brugnara M, Franchini M, Bruno C, Fanos V. Hidden high-grade vesicoureteral reflux is the main risk factor for chronic renal damage in children under the age of two years with first urinary tract infection. Scand J Urol Nephrol. 2009;43:494–500. https://doi.org/10.3109/00365590903286663
  8. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114:555–76. https://doi.org/10.1542/peds.114.2.S2.555
  9. Çelebi S, Özaydın S, Baştaş CB, Kuzdan Ö, Erdoğan C, Yazıcı M, et al. Reliability of the grading system for voiding cystourethrograms in the management of vesicoureteral reflux: an interrater comparison. Adv Urol. 2016;2016:1684190. https://doi.org/10.1155/2016/1684190
  10. Beiraghdar F, Panahi Y, Einollahi B, Moharamzad Y, Nemati E, Amirsalari S. Predisposing factors for renal scarring in children with urinary tract infection. Saudi J Kidney Dis Transplant. 2012;23(3):532–37.
  11. Hiraoka M. Medical management of congenital anomalies of the kidney and urinary tract.Pediatr Int. 2003;45(5):624–33.
  12. Keren R, Shaikh N, Pohl H, Gravens-Mueller L, Ivanova A, Zaoutis L, et al. Risk factors for recurrent urinary tract infection and renal scarring. Pediatrics. 2015;136(1):e13–21. https://doi.org/10.1542/peds.2015-0409
  13. Conover MS, Hadjifrangiskou M, Palermo JJ, Hibbing ME, Dodson KW, Hultgren SJ. Metabolic requirements of Escherichia coli in intracellular bacterial communities during urinary tract infection pathogenesis. mBio. 2016;7(2):1–13. https://doi.org/10.1128/mBio.00104-16
  14. Ylinen E, Ala-Houhala M, Wikström S. Risk of renal scarring in vesicoureteral reflux detected either antenatally or during the neonatal period. Urology. 2003;61(6):1238–42. https://doi.org/10.1016/S0090-4295(03)00229-2
  15. Gökaslan F, Yalçınkaya F, Fitöz S, Özçakar ZB. Evaluation and outcome of antenatal hydronephrosis: a prospective study. Renal Failure. 2012;34(6):718–21. https://doi.org/10.3109/0886022X.2012.676492
  16. Freitas AC, Leite J, Matos P, Rocha L, Costa T, Faria S, et al. Risk factors for renal scarring after first febrile urinary tract infection. Nascer e Crescer. 2016;25(1):11–4.
  17. Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics. 2010;126(6):1084–91. https://doi.org/10.1542/peds.2010-0685
  18. Mir S, Ertan P, Ozkayin N. Risk factors for renal scarring in children with primary vesicoureteral reflux disease. Saudi J Kidney Dis Transplant. 2013;24(1):54–9. https://doi.org/10.4103/1319-2442.106241
  19. Snodgrass WT, Shah A, Yang M, Kwon J, Villanueva C, Traylor J, et al. Prevalence and risk factors for renal scars in children with febrile UTI and/or VUR. J Pediatr Urol. 2013;9(6):856–63. https://doi.org/10.1016/j.jpurol.2012.11.019
  20. Park YS. Renal scar formation after urinary tract infection in children. Korean J Pediatr. 2012;55(10):367–70. https://doi.org/10.3345/kjp.2012.55.10.367


How to Cite this Article
Pubmed Style

Shatnawi MS, Alrwala MMa, Ghanma AM, Alquraan ML, Zreiqat EN, Alzoubi MM. Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study. Sudan J Paed. 2019; 19(1): 25-30. doi:10.24911/SJP.106-1546805996


Web Style

Shatnawi MS, Alrwala MMa, Ghanma AM, Alquraan ML, Zreiqat EN, Alzoubi MM. Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study. http://www.sudanjp.com/?mno=24884 [Access: July 19, 2019]. doi:10.24911/SJP.106-1546805996


AMA (American Medical Association) Style

Shatnawi MS, Alrwala MMa, Ghanma AM, Alquraan ML, Zreiqat EN, Alzoubi MM. Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study. Sudan J Paed. 2019; 19(1): 25-30. doi:10.24911/SJP.106-1546805996



Vancouver/ICMJE Style

Shatnawi MS, Alrwala MMa, Ghanma AM, Alquraan ML, Zreiqat EN, Alzoubi MM. Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study. Sudan J Paed. (2019), [cited July 19, 2019]; 19(1): 25-30. doi:10.24911/SJP.106-1546805996



Harvard Style

Shatnawi, M. S., Alrwala, . M. M. a., Ghanma, . A. M., Alquraan, . M. L., Zreiqat, . E. N. & Alzoubi, . M. M. (2019) Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study. Sudan J Paed, 19 (1), 25-30. doi:10.24911/SJP.106-1546805996



Turabian Style

Shatnawi, Mohammad Salem, Mohammad Mu azi Alrwala, Abdulla Majed Ghanma, Mohammad Lutfi Alquraan, Ehab Nequla Zreiqat, and Manar Mohammad Alzoubi. 2019. Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study. Sudanese Journal of Paediatrics, 19 (1), 25-30. doi:10.24911/SJP.106-1546805996



Chicago Style

Shatnawi, Mohammad Salem, Mohammad Mu azi Alrwala, Abdulla Majed Ghanma, Mohammad Lutfi Alquraan, Ehab Nequla Zreiqat, and Manar Mohammad Alzoubi. "Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study." Sudanese Journal of Paediatrics 19 (2019), 25-30. doi:10.24911/SJP.106-1546805996



MLA (The Modern Language Association) Style

Shatnawi, Mohammad Salem, Mohammad Mu azi Alrwala, Abdulla Majed Ghanma, Mohammad Lutfi Alquraan, Ehab Nequla Zreiqat, and Manar Mohammad Alzoubi. "Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study." Sudanese Journal of Paediatrics 19.1 (2019), 25-30. Print. doi:10.24911/SJP.106-1546805996



APA (American Psychological Association) Style

Shatnawi, M. S., Alrwala, . M. M. a., Ghanma, . A. M., Alquraan, . M. L., Zreiqat, . E. N. & Alzoubi, . M. M. (2019) Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study. Sudanese Journal of Paediatrics, 19 (1), 25-30. doi:10.24911/SJP.106-1546805996





Most Viewed Articles
  • Rheumatic heart disease in North Darfur: an alarmingly high burden and control initiative
    Nagwa Salih, Ishag Eisa, Daresalam Ishag, Intisar Ibrahim, Sulafa Ali
    Sudan J Paed. 2018; 18(1): 24-27
    » Abstract » doi: 10.24911/SJP.2018.1.4

  • Evaluation of Science. [eng]
    Adnan Mahmmood Usmani; Sultan Ayoub Meo
    Sudan J Paed. 2011; 11(1): 6-7
    » Abstract

  • Blood tests are not always helpful in predicting bacterial meningitis in children.
    Taha I Yousif, Katie O'Reilly, Montasser Nadeem
    Sudan J Paed. 2016; 16(2): 77-79
    » Abstract

  • Commitment to the wellbeing of children worldwide. [eng]
    Mustafa Abdalla M Salih; Satti Abdelrahim Satti
    Sudan J Paed. 2011; 11(2): 4-5
    » Abstract

  • X-linked hypophosphatemic rickets (PHEX mutation): A case report and literature review.
    Badi Alenazi, M A Maleque Molla, Abdullah Alshaya, Mahmoud Saleh
    Sudan J Paed. 2017; 17(1): 61-65
    » Abstract

  • About the Cover. [eng]

    Sudan J Paed. 2016; 16(2): i-i
    » Abstract

  • Four decades of the Sudanese Journal of Paediatrics and milstones.
    Mustafa Abdalla M Salih, Mohammed Osman Swar
    Sudan J Paed. 2017; 17(1): 5-9
    » Abstract

  • Bartter syndrome associated with nephropathic cystinosis.
    Nader M Osman, Ali Al Sanosi
    Sudan J Paed. 2016; 16(2): 93-98
    » Abstract

  • Article authored by three generations: International lifetime commitment to child health
    Mustafa Abdalla M Salih, Mohammed Osman Swar
    Sudan J Paed. 2017; 17(2): 5-10
    » Abstract » doi: 10.24911/SJP.2017.2.1

  • The Editors of Sudanese Journal of Paediatrics would like to thank. [eng]

    Sudan J Paed. 2016; 16(2): 99-99
    » Abstract

  • Most Downloaded
  • Why mothers are not exclusively breast feeding their babies till 6 months of age? Knowledge and practices data from two large cities of the Kingdom of Saudi Arabia
    Hafsa Raheel, Shabana Tharkar
    Sudan J Paed. 2018; 18(1): 28-38
    » Abstract » doi: 10.24911/SJP.2018.1.5

  • Inborn errors of metabolism associated with hyperglycaemic ketoacidosis and diabetes mellitus: narrative review
    Majid Alfadhel, Amir Babiker
    Sudan J Paed. 2018; 18(1): 10-23
    » Abstract » doi: 10.24911/SJP.2018.1.3

  • Article authored by three generations: International lifetime commitment to child health
    Mustafa Abdalla M Salih, Mohammed Osman Swar
    Sudan J Paed. 2017; 17(2): 5-10
    » Abstract » doi: 10.24911/SJP.2017.2.1

  • Severe desquamation in Kawasaki disease: Is it somehow protective?
    Jubran Theeb Alqanatish, Amir Babiker
    Sudan J Paed. 2017; 17(2): 56-59
    » Abstract » doi: 10.24911/SJP.2017.2.7

  • A journey from being preterm to pediatric neurology
    Rana Abdullah AlSheikh, Rawan Abdullah AlSheikh
    Sudan J Paed. 2018; 18(2): 72-73
    » Abstract » doi: 10.24911/SJP.106-1545214668

  • Ethical considerations about changing parental attitude towards end-of-life care in twins with lethal disease
    Mohamad-Hani Temsah
    Sudan J Paed. 2018; 18(1): 76-82
    » Abstract » doi: 10.24911/SJP.2018.1.11

  • Prevalence of obesity, overweight, underweight, and stunting among school children in Argo city, Northern Sudan
    Mohamed D Hussein, Noufa A Alonazi, Sarar Mohamed Mohamed
    Sudan J Paed. 2018; 18(2): 15-19
    » Abstract » doi: 10.24911/SJP.106-1544799078

  • Presacral Neuroblastoma in an 11 months old infant
    Sunil Malik, Sonal Saran, Annu Kharbanda
    Sudan J Paed. 2018; 18(1): 87-89
    » Abstract » doi: 10.24911/SJP.2018.1.14

  • Intracranial calcification, microcephaly and intrauterine growth restriction: a telltale sign of congenital CMV infection
    Sunil Malik, Sonal Saran, Yash Sharma
    Sudan J Paed. 2018; 18(2): 67-68
    » Abstract » doi: 10.24911/SJP.106-1530897563

  • Burosumab - a new drug to treat hypophosphatemic rickets
    Stepan Kutilek, Amir Babiker, Badi Alenazi
    Sudan J Paed. 2017; 17(2): 71-73
    » Abstract » doi: 10.24911/SJP.2017.2.11

  • Most Cited Articles
  • Commitment to the wellbeing of children worldwide. [eng]
    Mustafa Abdalla M Salih; Satti Abdelrahim Satti
    Sudan J Paed. 2011; 11(2): 4-5
    » Abstract
    Cited : 4 times [Click to see citing articles]

  • Evaluation of Science. [eng]
    Adnan Mahmmood Usmani; Sultan Ayoub Meo
    Sudan J Paed. 2011; 11(1): 6-7
    » Abstract
    Cited : 1 time [Click to see citing article]

  • Burosumab - a new drug to treat hypophosphatemic rickets
    Stepan Kutilek, Amir Babiker, Badi Alenazi
    Sudan J Paed. 2017; 17(2): 71-73
    » Abstract » doi: 10.24911/SJP.2017.2.11
    Cited : 1 time [Click to see citing article]