The preventive Effectiveness of Rituximab in Pediatric Autoimmune and Inflammatory CNS Diseases Relapse: an Iranian Experience

ObjectivesTo determine the effectiveness of Rituximab (RTX) therapy as the first therapeutic choice for the long-term prevention of secondary relapse in children with Autoimmue Neurological Disease (AIND) had relapse after primary treatment with immunosuppressive agents other than RTX.Materials & Methods We conducted a single-center retrospective study of 9 consecutive pediatric patients (≤ 18 years old) registered on Autoimmune and Demyelinating Disorders Database (ADDD) of Mofid Children Hospital, from 2012 to 2016 and experienced relapse following therapeutic interventions with immunosuppressive agents other than RTX.ResultA remarkable reduction of 94.13% (p=0.015) occurred in annualized relapse rate (ARR) as a clinical indicator of therapeutic efficacy comparing before and after initiating RTX therapy.ConclusionRituximab is an effective drug in relapse prevention of AIND whenadministrated to patients for whom initial treatment with other immunosuppressive agents fail. POWER OF EVIDENCE: This study represents Class IV evidence that RTX therapy significantly reduces ARR in pediatric AIND including DDCNS. &nbsp

The Relative Frequency of Iron Deficiency Anemia and its Correlation with Pulmonary Function in Children with Cystic Fibrosis

Background and Aims: The prevalence of iron deficiency is increasing in the population of cystic fibrosis patient (CF). The aim of this study was to determine the prevalence of iron deficiency anemia and its correlation with pulmonary function in cystic fibrosis patients.Materials and Methods: This descriptive-analytic study was done on the patients with cystic fibrosis who were referred to the Mofid Children Hospital, Tehran, Iran during 2015-2016. Complete blood counting and iron indices were evaluated; furthermore, Pulmonary function test was performed in ≥5 years old patients to determine the forced expiratory volume in first second (FEV1), forced vital capacity (FVC), FEV1/FVC and forced expiratory flow (FEF25-75). The data were analyzed by SPSS software. Pearson correlation coefficient, t-test, Fisher's exact test and χ2 were used for analyzing data. Results: Among 30 patients who were able to perform spirometry, Spirometric findings were normal in 12 patients (40%) which 72% of them were female. There was a statistically significant correlation between the spirometric findings and the gender of the patients (P<0.05), but the correlation between the gender and iron indices was not significant (P>0.05). Moreover, there was no statistically significant correlation between spirometric findings and iron indices (P> 0.05).Conclusion: There was no significant correlation between iron deficiency and pulmonary function in cystic fibrosis patients

A Study of Urodynamic Findings in Children Presenting with Urinary Tract Infection with and Without Reflux

Introduction: Urinary Tract Infections (UTIs) are common in childhood and are frequently associated with abnormalities of the urinary tract. UTIs are the leading cause of morbidity in patients with neurologic bladder; this causes recurrent UTIs and Chronic Kidney Injury& Disease (CKD) that affects their quality of life. Children with UTIs are mostly neurologically intact, but may have infections as a result of a voiding dysfunction. The present study aimed to examine the relationship between occult bladder dysfunction and recurrent UTIs in our patients.Material and Methods: A cross-sectional study was done on 210 children aged 10 months to 15 years presenting with UTI with/without reflux who were admitted to the Nephrology Ward of Mofid Children’s Hospital between April 2011 and September 2013 using convenient sampling. Statistic analyses were conducted using descriptive statistics, Kolmogorov-Smirnov test, Mann Whitney test, Fisher’s Exact test, and odds ratio, and p values <0.05 were considered significant.Results: Of 210 Children 74% were female and 26% were male. 25% had one, 25% had two, 31% had 3, and 19% had more than 3 episodes of UTI. Eighty percent of the female and 56% of the male children had recurrent UTI (P: 0.004, odds ratio: 0.361). Fifty eight percent of the patients had Vesicoureteral Reflux which was bilateral in 34% of them. There was no correlation between UTI and Urinary Reflux (P=0.152, odds ratio=1.591) and also no correlation was detected between urodynamic findings and urinary reflux(P=0.243, odds ratio=1.485). Seventy six percent of the children with recurrent UTI had abnormal urodynamic results.Conclusions: Since many children with recurrent UTI and multiple renal scars have bladder dysfunction, it is recommended that urodynamic studies should be included in the evaluation of every child with recurrent UTI and renal scar.Keywords: Urinary Tract Infections; urodynamics; Vesico-Ureteral Reflux; Chil

Frequency of Massive Proteinuria in Childhood Pyelonephritis and the Response to Antibiotic Therapy

Introduction: Urinary tract infection (UTI) is one of the most common bacterial infections in childhood which can contribute to high blood pressure and renal failure later in life. There are diffident methods for evaluation of a child with UTI for differentiation of cystitis from acute pyelonephritis. One of which is measuring protein in urine. The aim of this study is to investigate the role of UTI in provoking proteinuria.Material and Methods: This is Quasi- experimental study, before and after, in patients with acute pyelonephritis in Mofid Children's Hospital during 2004-2006. All pyelonephritic patients were treated by intravenous ceftriaxone for at least for 10 days. Random urine samples were taken from all patients at the onset of admission before starting the antibiotic and at the ninth day of treatment for the evaluation of urine protein and creatinine.Results: 152 children between 1 to 2 years of age entered the study. The prevalence of proteinuria in the acute phase of pyelonephritis was 94.8%. According to our study the prevalence of proteinuria during pyelonephritis is higher in children less than 2 years old (97.3%) and 20% of patients showed nephrotic range of proteinuria. In all cases random urine samples were normal after completion of treatment (p<0.005). Conclusions: the results of this study illustrate that proteinuria has a high frequency during UTI and acute pyelonephritis. Proteinuria during pyelonephritis may be massive and in the nephrotic range but should not be the cause of concern because in the majority of cases it disappears following treatment. Keywords: Pyelonephritis; Proteinuria; Antibiotics; Child

Use of Complementary and Alternative Medicine for Epileptic Children in Tehran: A Cross-Sectional Study (2009-2011)

How to Cite This Article: Tonekaboni Sh, Jafari Naeini S, Khajeh A, Yaghini O, Ghazavi A, Abdollah Gorji F. Use of Complementary and Alternative Medicine for Epileptic Children in Tehran: A Cross-Sectional Study (2009-2011). Iran J Child Neurol. 2014 Winter; 8(1):26-31.ObjectiveAlthough the use of Complementary and Alternative Medicine (CAM) has been evaluated globally, there are few studies in our country on this subject. The purpose of this study was to determine the prevalence, pattern of use, parental sources of information, and benefits of CAM in epileptic children in Tehran.Materials & MethodsOne hundred thirty-three parents or relatives of epileptic children who were referred to outpatient clinics or admitted in neurologic ward of four major hospitals in Tehran, were interviewed by our researcher based on a structured questionnaire; from 2009 to 2010. The information obtained comprised the demographic data of patients and their parents, frequency and morphology of convulsions, the type and sources of CAM and finally, the benefits and adverseeffects of this practice.ResultsForty-four percent of the respondents had used CAM methods either alone or in combination with other methods. The most frequently used CAM was written prayers followed by oral herbs and special diets. CAM was mainly introduced to them by relatives. Only 16.7% of these parents had discussed this matter with their children’s physicians. No efficacy to control seizure was observed for most of these methods.ConclusionThis study showed that use of CAM in our study group is relatively common and may have a potentially hazardous role in the treatment process. So, it is necessary for physicians to have enough information about CAM practice in their patients. References:National Institutes of health. More than one third of US adults use complementary and alternative medicine, according to new government survey. [Serial online] 2004 (cited 2004 May 27). Available from: http://nccam. nih.gov/news/2004/052704.htm.Traditional Medicine: The Fifty-Sixth World Health Assembly WHO, 2003. World Health Organization, 2011. Available from: http://apps.who.int/gb/archive/ pdf_files/WHA56/ea56r31.pdfMichi CA. The use of herbal remedies in Jamaica. Ann Trop Paediatr 1992;12(1):31-6.Ricotti V, Delanty N. Use of complementary and alternative medicine in epilepsy. Curr Neurol Neurosci Rep 2006;6(4):347-53.Aburahma SK, Khader YS, Alzoubi k, Sawalha N. Complemetary and alternative medicine use in a pediatric neurology clinic. Complement Ther Chin Pract 2010;16(3):117-20.Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280(18):1569-75.Khonsari A, Gorji K, Abdollahpur F, Dehestani S, Mousavi A, Delfan B et al. Study of international approaches on treatment of common diseases using different methods of complementary medicine. J Ilam Uni Med Sci 2009;4:37-45. (Full text in Persian)Kwan P, Brodie MJ. Early identification of refractory epilepsy. N Engl J Med 20003;342(5):314-9.Oshikoya KA, Senbanjo IO, Njokanma OF, Soipe A. Use of complementary and alternative medicine for children with chronic health conditions in Lagos, Nigeria. BMC Complement Altern Med 2008;8:66.Liow K, Ablah E, Nguyen JC, Sadler T, Wolfe D, Tran KD et al. Pattern and frequency of use of complementary and alternative medicine among patients with epilepsy in the mid western United States. Epilepsy Behav 2007;10(4):576-82.Tehrani Banihashemi SA, Asgharifard H, Haghdoost AA, Barghamdi M, Mohammadhosseini N. The use of complementary/ Alternative medicine among the general population in Tehran /Iran. Payesh 2008;7(4):355-62.(Full text in Persian)Ekici B, That B, Abah S, Aydinli N, Ozmen M. Application of complementary and alternative medicine in epileptic children at a tertiary pediatric neurology center in Turkey. Eur J Integr Med 2011;4:e71-5.Soo I, Mah JK, Barlow K, Hamiwka L, Wirrell E. Use of complementary and alternative medical therapies in pediatric neurology clinic. Can J Neurol Sci 2005;32(4):524-28.Cuzzolin L, Zaffani S, Murgia V, Gangemi M, Meneghelli G, Chiamenti G, et al. Patterns and perceptions of complementary/alternative medicine among paediatricians and patients’ mothers: a review of the literature. Eur J Pediatr 2003;162(12):820-7

Efficacy of The Ketogenic Diet as A Therapy for Intractable Epilepsy in Children

ObjectiveTo determine the role of ketogenic diet in the treatment of intractable epilepsy in children.Materials & MethodsSixty six consecutive children (1-16 years old) with intractable epilepsy whose seizure were not neurodegenerative nor febrile in origin were recruited. They received the ketogenic diet and we evaluated its effect on seizure frequency for 3 months. All these children had more than five seizures per week despite adequate therapy with at least 3-4 anticonvulsant medications. Carbohydrates were initially limited to 10 gr/day and fats constituted 75% of the total energy requirement. Response to the diet was categorized as free of seizure, 99%-75%, 50%-75%, 25%-49% and lower than 25% reduction (resistant to therapy).ResultsFifty five patients (84%) out of 66 children initiating the diet continued it after 1 week. After 3 months, 80% of the patients kept the diet. After one week, one month and 3 months, there was a more than 50% decrease in the frequency of the seizures in 40 (60%), 50 (75%) and 39 (59%) of the patients, respectively. Three patients (4.5%) were seizure-free after 1 week, 12 (18%) were seizure-free after one month and 12 (18%) were seizure-free after three months and a significant relationship was found between seizure reduction and the type of epilepsy (p<0.017).ConclusionThe ketogenic diet should be considered as an alternative therapy for children with intractable seizures. It is more effective than many of the new anticonvulsant medications and is well tolerated by children andtheir families

Prophylaxis of Childhood Migraine: Topiramate Versus Propranolol

How to Cite this Article: Tonekaboni SH, Ghazavi A, Fayyazi A, Khajeh A, Taghdiri MM, Abdollah Gorji F, Azargashb E. Prophylaxis of Childhood Migraine: Topiramate Versus Propranolol. Iran J Child Neurol. 2013 Winter; 7 (1):9-14. ObjectiveHeadache is a common disabling neurological disorder and migraine comprises more than half the causes of recurrent headaches in children. Despite extended prevalence of this type of headache there is lack of evidence about best drug treatment for migraine. So we aimed to compare the therapeutic effects of these drugs on childhood migraine.Materials & MethodsIn the current study, a randomized clinical trial consisting of 78 patients according to 2004 International Headache Association criteria were randomly assigned to two groups that matched by age and sex. One of these two groups was treated with Topiramate, while the other was given Propranolol. After one and four months, the efficiency of these treatments was measured in terms of frequency, severity and duration of migraine attacks.ResultsResults obtained from the data collected showed that of these 78 studied patients, 38 patients received Topiramate treatment (group A) and the rest (40 patients; group B) was treated with Propranolol. The average age of group A was 8.5± 2.9 years and that of group B was 8.3 ± 2.8 years. No significant difference was observed between these two groups in terms of reduction in frequency, severity and duration of migraine attacks.ConclusionResults showed that both treatments had the same efficiency in healing migraine headaches and there was no significant difference between their treating results. However, further studies are needed to examine medical effects of these two medicines. ReferencesAbu-Arefeh  I,  Russell  G.  Prevalence  of  headache  and migraine in schoolchildren. BMJ 1994 Sep 24; 309 (6957): 765-9.Lipton RB, Silberstein SD, Stewart WF. An update on the epidemiology of migraine. Headache 1994 Jun; 34 (6):319-28.Stewart WF, Linet MS, Celentano DD, Van Natta M, Ziegler D. Age- and sex-specific incidence rates of migraine with and without aura. Am J Epidemiol 1991 Nov; 134 (10): 1111-20.Marcos J. Cruz, Ignacio Valencia, Agustı´n Legido, et al, Efficacy and Tolerability of Topiramate in Pediatric Migraine. Pediatr Neurol 2009; 41: 167-170.Ashrafi  MR,  Shabanian  R,  Zamani  GR,  Mahfelati  F. Sodium valproat versus Propranolol in pediatric migraine prophylaxis. Eur J Pediatr Neurol 2005; 9 (5): 333-8.Hershey AD, Winner PK. Pediatric migraine: recognition and treatment. J Am Osteopath Assoc 2005 Apr; 105:4 ( Supple 2):2S–8S.Lewis DW, Scott D, Rendin V. Treatment of pediatric headache. Expert Opin Pharmacother 2002 Oct;3(10):1433-42.Stewart WF, Lipton RB, Kolodner K, Liberman J, Sawyer J. Reliability of the migraine disability assessment scores in a population-based sample of headache sufferers. Cephalalgia 1999 Mar; 19 (2): 107-14.Hershey AD,  Powers  SW,  Vockell ALB,  LeCates  SL, Kabbouche MA, Maynard MK. PedMIDAS: development of a questionnaire to assess disability of migraines in children. Neurology 2001 Dec; 57(11): 2034-9.Hershey AD, Powers SW, Vockell ALB, LeCates SL, Segers A, Kabbouche MA. Development of a patient- based grading scale for PedMIDAS. Cephalalgia 2004 Oct; 24 (10): 844-9.Ferraro D, Di Trapani G. Topiramate in the prevention of pediatric migraine: literature review. J Headache Pain 2008 Jun; 9 (3): 147-50.J W. Lance and P J. Goadsby. Mechanism and Management of Headache. Butterworth-Heinemann; 7th edition, 2004.Lipton RB, Silberstein SD. Stewart WF. An update on the epidemiology of migraine. Headache 1994 Jun; 34(6):319-28.

Epidemiology of Guillain-BarréSyndrome in Iranian Children Aged 0-15 Years (2008-2013)

Abstract Objective: Guillain-Barre Syndrome (GBS) is an acute inflammatory polyneuropathy characterized by a rapid progressive symmetric weakness. This is the most common cause of Acute Flaccid Paralysis (AFP) in most parts of the world. This study was carried out to investigate the epidemiological features of GBS in Iranian children. Materials & Methods: Data were extracted using the AFP surveillance system: a National screening program to detect all cases of AFP aged 0-15 years, around the country. National Population Statistics data and AFP demographic data during 2008-2013 intervals was obtained from the relevant authorities in ministry of health. GBS cases were then extracted from this data base. Chi-square and Fisher's exact test were used for statistical analysis. Results: 1884 cases of GBS were identified in years of study and average annual incidence rate was 1.72 per 100,000 populations. The highest incidence rate was in the range of 0-5 years. There was no statistically significant relation between the incidence of GBS and the season in the whole country. Conclusion: High costs of GBS treatment, morbidity and occasional mortality and the number of new cases which is estimated to be about 300 people per year, need particular attention of health system

HLA-B*1502 in Iranian Children with Anticonvulsant Drugs-Induced Skin Reactions

How to Cite This Article: Tonekaboni SH, Jafari N, Mansouri M, Jabbehdari S, Eftekhari R, Chavoshzadeh Z, Abdollah Gorji F, Mesdaghi M. HLA-B*1502 in Iranian Children with Anticonvulsant Drugs-Induced Skin Reactions. Iran J Child Neurol. Spring 2017; 11(2):26-30. AbstractObjectiveAnticonvulsant drugs can cause various forms of skin drug reactions, ranging from exanthema to severe blistering reactions. An association between HLA-B*1502 allele and severe skin reactions have been reported.Materials & Methods Fifteen patients with severe skin reactions following treatment with anticonvulsant drugs (Carbamazepine, lamotrigine, phenobarbital, primidone) and 15 controls (age-matched epileptic patients taking similar anticonvulsants without drug eruption) were included. They were referred to Mofid Children’s Hospital in Tehran, Iran, between Jan 2012 to Jan 2014. Genomic DNA was extracted from peripheral blood of all patients and HLA- B*1502 genotype was detected by real-time PCR.Results None of the patients was positive for HLA- B*1502, but two patients in control group had positive HLA- B*1502.Conclusion The HLA- B*1502 is not correlated with severe anticonvulsant drugs -induced skin reactions in Iranian children. References 1.Roujeau JC. Clinical heterogeneity of drug hypersensitivity. Toxicology 2005; 209: 123 –9.2.McCormack M, Alfirevic A, Bourgeois S, Farrell JJ, Kasperavičiūtė D, Carrington M, et al. HLA-A*3101 and carbamazepine-induced hypersensitivity reactions in Europeans. N Engl J Med 2011; 364(12):1134-43.3.Daly AK, Donaldson PT, Bhatnagar P, Shen Y, Pe’er I, Floratos A, et al. HLA-B*5701 genotype is a major determinant of drug-induced liver injury due to flucloxacillin. Nat Genetic 2009; 41:816–9.4.Amstutz U, Ross CJ, Castro-Pastrana LI, Rieder MJ, Shear NH, Hayden MR, Carleton BC. CPNDS Consortium; HLA-A 31:01 and HLA-B 15:02 as genetic markers for carbamazepine hypersensitivity in children. Clin Pharmacol Ther 2013; 94(1):142-9.5.Man CB, Kwan P, Baum L, Yu E, Lau KM, Cheng AS, Ng MH. Association between HLA-B*1502 allele and antiepileptic drug-induced cutaneous reactions in Han Chinese. Epilepsia 2007; 48(5):1015-8.6.Zeng T, Long YS, Min FL, Liao WP, Shi YW. Association of HLA-B*1502 allele with lamotrigine-induced Stevens– Johnson syndrome and toxic epidermal necrolysis in Han Chinese subjects: a meta-analysis. Int J Dermatol 2015; 54(4):488-93.7.Bastuji-Garin S, Rzany B, Stern RS, Shear NH, Naldi L, Roujeau JC. Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme. Arch Dermatol 1993; 129(1):92-6.8. Hung SI, Chung WH, Jee SH, Chen WC, Chang YT, Lee WR, et al. Genetic susceptibility to carbamazepine-induced cutaneous adverse drug reactions. Pharmacogenet Genomics 2006; 16(4):297-306.9. Wang Q, Zhou JQ, Zhou LM, Chen ZY, Fang ZY, Chen SD, et al. Association between HLA-B*1502 allele and carbamazepine-induced severe cutaneous adverse reactions in Han people of southern China mainlan. Seizure 2011; 20 (6):446-8.10. Li LJ, Hu FY, Wu XT, An DM, Yan B, Zhou D. Predictive markers for carbamazepine and lamotrigine-induced maculopapular exanthema in Han Chinese. Epilepsy Res 2013; 106 (1-2):296-300.11. Kim SH, Lee KW, Song WJ, Kim SH, Jee YK, Lee SM, et al; Adverse Drug Reaction Research Group in Korea. Carbamazepine-induced severe cutaneous adverse reactions and HLA genotypes in Koreans. Epilepsy Res 2011; 97 (1-2):190-7.12. Criado PR, Criado RFJ, Avancini JM, Santi CG. Drug reaction with eosinophilia and systemic symptoms (DRESS)/drug-induced hypersensitivity syndrome (DIHS): a review of current concepts. An Bras Dermatol 2012; 87(3):435–49.13. Chung WH, Hung SI, Hong HS, Hsih MS, Yang LC, Ho HC, et al. Medical genetics: a marker for Stevens– Johnson syndrome. Nature 2004; 428: 486.14. Man CB, Kwan P, Baum L, Yu E, Lau KM, Cheng AS, Ng MH. Association between HLA-B*1502 allele and antiepileptic drug induced cutaneous reactions in Han Chinese. Epilepsia 2007; 48: 1015–8.15. Locharernkul C, Loplumlert J, Limotai C, Korkij W, Desudchit T, Tongkobpetch S, et al. Carbamazepine and phenytoin induced Stevens–Johnson syndrome is associated with HLA-B*1502 allele in Thai population. Epilepsia 2008; 49:2087–91.16. Kaniwa N, Saito Y, Aihara M, Matsunaga K, Tohkin M, Kurose K, et al. HLA-B locus in Japanese patients with anti-epileptics and allopurinol-related Stevens– Johnson syndrome and toxic epidermal necrolysis. Pharmacogenomics 2008; 9: 1617–22.17. Alfirevic A, Jorgensen AL, Williamson PR, Chadwick DW, Park BK, Pirmohamed M. HLA-B locus in Caucasian patients with carbamazepine hypersensitivity. Pharmacogenomics 2006; 7: 813–8.18. Tangamornsuksan W, Chaiyakunapruk N, Somkrua R, Lohitnavy M, Tassaneeyakul W. Relationship between the HLA-B*1502 allele and carbamazepine-induced Stevens- Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis. JAMA Dermatol 2013; 149(9):1025-32

Evaluation of One Hundred Pediatric Muscle Biopsies During A 2-Year Period in Mofid Children And Toos Hospitals

 How to Cite This Article:Nilipor Y, Shariatmadari F, Abdollah gorji F, Rouzrokh M, Ghofrani M, Karimzadeh P, Taghdiri MM,  Delavarkasmaei H, Ahmadabadi F, Bakhshandeh bali MK, Nemati H, Saket S, Jafari N, Yaghini O, Tonekaboni SH.  Evaluation of One Hundred Pediatric Muscle Biopsies During A 2-Year Period in Mofid Children And Toos Hospitals. Iran J Child Neurol. 2013 Spring;7(2):17-21. ObjectiveMuscle biopsy is a very important diagnostic test in the investigation of a child with suspected neuromuscular disorder. The goal of this study was to review and evaluate pediatric muscle biopsies during a 2-year period with focus on histopathology diagnosis and correlations with other paraclinicstudies.Materials & MethodsWe investigated 100 muscle biopsies belonging to patients with clinical impression of neuromuscular disorder. These patients have been visited consecutively by pediatric neurologists during 2010 to 2012. Samples were investigated by standard enzyme histochemical and immunohistochemical techniques.ResultSixty-nine (69%) males and 39 (39%) females with a mean age of 5.7 years were evaluated. Major pathologic diagnoses were Muscular dystrophy (48 cases), Neurogenic atrophy (18 cases), nonspecific myopathic atrophy (12cases), congenital myopathy (6 cases), storage myopathies (4 cases) and in 6 cases there was no specific histochemical pathologic finding. EMG was abnormal in 79 cases. Degree of correlation between EMG and biopsy result was significant in children ≥ 2 years of age.ConclusionThis study confirms the high diagnostic yields of muscle biopsyespecially only if standard and new techniques such as enzyme study and immunohistochemistry are implemented. Also, we report 11 cases of Merosin negative congenital muscular dystrophy. This is the largest documented case series of Merosin deficient congenital muscular dystrophy reported from Iran. References1. Harvey B. Sarnat. Evaluation and Investigation. In:Kliegman. Stanton.Schor. Behrman.Nelson Text Book of Pediatrics.19th edition.Philadelphia: Elsevier,2011. P.2109-2112. 2. Harvey B. Sarnat and John H Menkes. Disease of TheMotore Unit. In: John H Menkes, Harvey B Sarnat, Bernard L Maria. Child Neurology. 7th edition.california: lippincott,2006.p.969-972.3. Marius Kuras Skram, Sasha Gulati, Erik Larrson. Muscle Biopsies In Children-An Evaluation Of Histopathology And Clinical Valueduring A 5-Year Period. Upsala J Med Sci 2009 March:114 (1);41-45.4. Owji M, Modaressi F. Diagnosis of Myopathies Using Histology. Histochemistry, Immunohistochemistry and Electron Microscopy 2010,12 (4):434 -440.5. Dua T, Das M, Kabra M. Spectrum of Floppy Children in Indian Scenario. Indian Pediatric J 2001, 38:1236-1243.6. Rabie M, Jossiphov J, Nevo Y. Electromyography accuracy compared to muscle biopsy in childhood. J Child Neurol 2007 jul; 22(7):803.8.