Original Article Indian J Pediatr 1999; 66 : 863~865

i i,

U r o l i t h i a s i s : A Tribal S c e n a r i o

B.C. Bakane ~, S~.B. Nagtilak 2 and Bhaidas PatiP

Departments of Surgery~ and Biochemistry2, JMF's, A.C.P.M. Medical College,

Dhule, Maharashtra

Abstract. Urolithiasis is quite prevalent in Satpura belt of Central India. Forty five children with
urolithiasis were studied in Jawahar Medical Foundations Hospital, Dhule, Maharashtra over a pe-
riod of three years. The mean age was 7.1 • 3.2 (range 18 months - 15 years). The chief presenting
complaints were dysuria and lower abdominal pain. The physical, laboratory and radiographic find-
ings were evaluated. Calculi were located in the bladder (80%), urethra (9%), kidney (6.6%) and
ureter (4.4%). Calculi were mainly composed of calcium oxalate (65.7%) and calcium phosphate
(34.3%).
The predominant urinary tract stones in the tribal Satpura belt are bladder stones and may be
related to poor nutrition, low socioeconomic status and consumption of bajra (millet) as staple food
as found in this region (93.5%). (Indian J Pediatr 1999; 66 : 863-865)

Key words : Urolithiasis; Tribal children; Millet.

The geographical variations in the inci-
dence and pattern of paediatric urolithiasis
are well known 1. Reports from Europe 2 and
America 3 have shown a steady decrease in
the incidence of calculus disease in chil-
dren which has been due to decrease in the
incidence of bladder stones, which contin-
ue to be endemic in developing countries.
Although bladder stones are chiefly related
to diet, genetic and metabolic abnormali-
ties are considered important in the etiolo-
gy of renal stones. The treatment is direct-
ed towards the correction and elimination
of possible etiological factors and preven-
tion of recurrence.
Urolithiasis is quite prevalent (7.6%) in
Satpura mountain range*. D u e to lack of
health awareness, health infrastructure and
Reprint requests : Bhausaheb Bakane,
Associate Professor of Surgery, Village
Nandora, P.O. Sevagram, Tal. & Dist. Wardha-
442 102, Maharashtra.
research facilities in this remote area, so far
no etiological studies on urolithiasis have
been carried out. This study was undertak-
en to determine the clinical profile and
chemical composition of urinary calculi in
children residing in this region.
MATERIALS A N D M E T H O D S
The study was carried out at Jawahar Med-
ical Foundation's Annasaheb C h u d a m a n
Patil Memorial Medical College, Hospital
Dhule, which is a tertiary health center sit-
uated in the foothills of Satpura mountain
range of Central India and providing
health services to the tribal community.
Forty five children upto 15 years of age
with urinary calculi were operated be-
tween January 1993 and December 1995.
The records of these patients were re-
v i e w e d with regards to age, sex, history,
physical, laboratory and radiographic find-
864 B.C. BAKANEETA/.
ings. Intravenous p y e l o g r a p h y and sono-
graphy were performed whenever indicat-
ed. The chemical composition of calculi
was analyzed as per the method suggested
by W'mers.
RESULTS
Forty five children with urolithiasis were
studied (40 males and 5 females) (M : F = 8
: 1). The majority of patients were below six
years with 29% below three years of age.
The mean age at presentation was 7.1 • 3.2
years (range 18 m o n t h s - 15 years). The
chief presenting complaints were dysuria
and lower abdominal pain. Gross hematu-
ria occurred in five cases and complete ob-
struction to urine flow due to impacted
stone in urethra in two cases. None of the
cases h a d renal failure. Values of serum
calcium and phosphate were within the
normal range. Crystals of calcium oxalate
in urine were seen in 20 cases (44.4%).
The majority of patients (93.5%) con-
s u m e d bajra (millet) (Pennisetum typhode-
urn) with negligible consumption of green
leafy vegetables and legumes g r o w n in
wild conditions. The m a x i m u m calculi
were in lower urinary tract : urinary blad-
der (80%), urethra (9%), renal pelvis (6.6%)
and ureter (4.4%). One child had bilateral
ureteric stones. The biochemical analysis of
the stones revealed calcium phosphate in
65.7% and calcium oxalate in 34.3%. Calci-
u m carbonate, triple phosphate, cystine
and uric acid were not detected in any of
the calculi in the study group.
DISCUSSION
Urolithiasis is an age old problem affecting
population of all ages. There is a steady de-
crease in the incidence of urolithiasis in
Vol. 66, No. 6, 1999
children in developed countries, b a t the
d i s e a s e c o n t i n u e s to be endemic in some
parts of South East Asia. This is due to de-
dine in bladder stone disease in developed
countries which continues to be prevalent
in developing countries. Studies 6 from de-
veloped countries have shown that the up-
per u r i n a r y tract calculi are c o m m o n e r
than the lower u r i n a r y tract calculi. The
present study reports more calculi in the
lower urinary tract i.e. bladder (~0%). Ma-
jority of the patients in this studY were
boys and presented in first six years of life
which is consistent with other reports on
bladder stones in children7. The analysis of
the stones revealed mainly calcium phos-
phate and calcium oxalate. The triple phos-
phate, cystine and uric acid were not de-
tected in any of the calculi, although other
studies 7 have shown that more than half of
bladder calculi are composed of uric acid
and calcium oxalate.
Earlier study on analysis of, drinking
water from available sources in the study
area revealed that hardness and a!kalinity
are significantly high. On analysis the sta-
ple food bajra (millet) showed significantly
higher content of calcium and phosphate
which m a y explain the composition of the
calculi in the present study 8.
The study demonstrates that the pre-
dominant site of urolithiasis in tribal chil-
dren of Satpura region continues to be uri-
nary bladder, which is in contrast to the
dramatic change in the pattern of urinary
calculus disease in developed countries.
This may be due to malnutrition, low soci-
oeconomic status, hard drinking water and
consumption of staple food bajra which is
rich in calcium and phosphate.
The proportion of cases with renal and
ureteric stones was low in this study. This
may be due to the fact that the formation of
Vol. 66, No. 6,1999 UROLITHIASI$

upper urinary tract stones is largely unre-
lated to diet mad other environmental fac-
tors. Half the cases of renal stones have an
underlying metabolic etiology, of which id-
iopathic hypercalciuria is the commonest 9.
However, the etiology in significant pro-
portion of cases remains obscure.
The most important factor in the
formation of bladder stone is consumption
of a predominantly cereal based diet with
very little animal proteins. Uric acid stones
form in urine with low pH, which probably
results from a diet of high acid ash but with
a low phosphate content. Repeated attacks
of diarrhoea and d e h y d r a t i o n leading to
the passage of a concentrated acidic urine
could also be the contributing factors I~
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FAILURE TO DIAGNOSE CONGENITAL H E A R T DISEASE I N INFANCY

Infant characteristics (birth weight, gestational age, intrauterine growth retardation, and
chromosomal anomaly) are associated with death o f infants with congenital cardiovascular
malformations and with death of such infants before diagnosis. Diagnosis of coarctation of
the aorta, Ebstein's anomaly, atrial septal defect, and truncus arteriosus are over-represented
in infants found by community search, particularly in those infants without associated mal-
formations. Paternal education is associated with failureto diagnose congenital heart disease
in lifebut other sociodcmographic characteristicsof the infant'sfamily are not.
Diagnosis of congcnital cardiovascular malformations requires close observation in the
nconatal period. Analysis of age at death of infants with undiagnosed congenital cardiovas-
cular malformation suggests thatsuch infantsmay be at risk ifdischarged within the firsttwo
days of life.
Abstracted from : Pediatrics 1999; 103 : 743-747