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Background We conducted a trial in Nigeria to assess the immunogenicity of the new bivalent oral poliovirus vaccine + inactivated poliovirus vaccine (bOPV+IPV) immunization schedule and gains in type 2 immunity with addition of second dose of IPV. The trial was conducted in August 2016–March 2017, well past the trivalent OPV-bOPV switch in April 2016. Methods This was an open-label, 2-arm, noninferiority, multicenter, randomized, controlled trial. We enrolled 572 infants aged ≤14 days and randomized them into 2 arms. Arm A received bOPV at birth, 6, and 10 weeks, bOPV+IPV at week 14, and IPV at week 18. Arm B received IPV each at 6, 10, and 14 weeks and bOPV at 18 weeks of age. Results Seroconversion rates for poliovirus types 1 and 3, respectively, were 98.9% (95% confidence interval [CI], 96.7–99.8) and 98.1% (95% CI, 88.2–94.8) in Arm A and 89.6% (95% CI, 85.4–93.0) and 98.5% (95% CI, 96.3–99.6) in Arm B. Type 2 seroconversion with 1 dose IPV in Arm A was 72.0% (95% CI, 66.2–77.3), which increased significantly with addition of second dose to 95.9% (95% CI, 92.8–97.9). Conclusions This first trial on the new Expanded Program on Immunization (EPI) schedule in a sub-Saharan African country demonstrated excellent immunogenicity against poliovirus types 1 and 3 and substantial/enhanced immunogenicity against poliovirus type 2 after 1 to 2 doses of IPV, respectively.

Despite the implementation of effective conjugate vaccines against the three main bacterial pathogens that cause meningitis, Streptococcus pneumoniae, Haemophilus influenzae type b (Hib), and Neisseria meningitidis serogroup A, the burden of meningitis in West Africa remains high. The relative importance of other bacterial, viral, and parasitic pathogens in central nervous system infections is poorly characterized. Cerebrospinal fluid (CSF) specimens were collected from children younger than 5 years with suspected meningitis, presenting at pediatric teaching hospitals across West Africa in five countries including Senegal, Ghana, Togo, Nigeria, and Niger. Cerebrospinal fluid specimens were initially tested using bacteriologic culture and a triplex real-time polymerase chain reaction (PCR) assay for N. meningitidis, S. pneumoniae, and H. influenzae used in routine meningitis surveillance. A custom TaqMan Array Card (TAC) assay was later used to detect 35 pathogens including 15 bacteria, 17 viruses, one fungus, and two protozoans. Among 711 CSF specimens tested, the pathogen positivity rates were 2% and 20% by the triplex real-time PCR (three pathogens) and TAC (35 pathogens), respectively. TAC detected 10 bacterial pathogens, eight viral pathogens, and Plasmodium. Overall, Escherichia coli was the most prevalent (4.8%), followed by S. pneumoniae (3.5%) and Plasmodium (3.5%). Multiple pathogens were detected in 4.4% of the specimens. Children with human immunodeficiency virus (HIV) and Plasmodium detected in CSF had high mortality. Among 220 neonates, 17% had at least one pathogen detected, dominated by gram-negative bacteria. The meningitis TAC enhanced the detection of pathogens in children with meningitis and may be useful for case-based meningitis surveillance.

Background Historically, Nigeria has experienced large bacterial meningitis outbreaks with high mortality in children. Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus), and Haemophilus influenzae are major causes of this invasive disease. In collaboration with the World Health Organization, we conducted longitudinal surveillance in sentinel hospitals within Nigeria to establish the burden of pediatric bacterial meningitis (PBM). Methods From 2010 to 2016, cerebrospinal fluid was collected from children Results A total of 5134 children with suspected meningitis were enrolled at the participating hospitals; of these 153 (2.9%) were confirmed PBM cases. The mortality rate for those infected was 15.0% (23/153). The dominant pathogen was pneumococcus (46.4%: 71/153) followed by meningococcus (34.6%: 53/153) and H. influenzae (19.0%: 29/153). Nearly half the pneumococcal meningitis cases successfully serotyped (46.4%: 13/28) were caused by serotypes that are included in the 10-valent pneumococcal conjugate vaccine. The most prevalent meningococcal and H. influenzae strains were serogroup W and serotype b, respectively. Conclusions Vaccine-type bacterial meningitis continues to be common among children

Globally, diarrhoea is the second commonest infectious cause of death in children less than 5 years old. It is estimated that more than one billion diarrhoea episodes occur every year causing up to 700,000 deaths among children younger than 5 years of age. Seventy-two percent of these deaths occur in children below two years and enteric viruses have been recognized as a major cause of childhood diarrhoea. This study was undertaken to determine the prevalence of enteric Adenoviruses and Rotaviruses in children with diarrhoea in rural Enugu communities of Enugu State South East Nigeria. Methods: Stool samples were collected from children less than 5 years with diarrhoea seen in any of the participating hospitals in Enugu State. Samples were collected between June 2015 and May 2017. Detection of rotavirus and enteric adenovirus antigens were performed using commercially available ELISA kit (Oxoid-ProspecT®). Demographic data of the children were also collected. Results: Of the 290 stool samples that had sufficient materials for adenovirus and rotavirus ELISA, 14 (4.8%) and 89 (30.7%) were positive for enteric adenovirus and rotavirus respectively. 3 (1%) were co-infected with adenovirus and rotavirus. Rotavirus positive cases were more among hospitalized patients while enteric adenovirus was more among outpatients. Marked peaks of rotavirus positivity were seen in January of each year but no peak was seen among adenovirus positive cases. Higher vomiting frequencies and severe dehydration were more among rotavirus positive cases compared to adenovirus positive cases (p = 0.030 and 0.001 respectively). Conclusion: Many diarrhoea cases among children aged

Background: Breastfeeding is cost effective means towards the realization of some key United Nations Sustainable Development Goals by the year 2030 particularly in resource limited settings. The objectives of the study were to evaluate the predictors of exclusive breastfeeding duration among mother and child pairs utilizing a tertiary immunization clinic facility. Methods: This was a cross-sectional descriptive study. Respondents were mother-and-child pairs who were recruited consecutively. Relevant maternal and child characteristics were collected using a semi-structured questionnaire. Data were analyzed using Statistical Package for Social Sciences version 20.0 (p < 0.05). Results: Four hundred and twenty seven mother-child pairs were studied. Majority of the mothers have at least secondary education, 383 (80.7%). 407 (95.3%) of the mothers fully understood the actual meaning of EBF. 189 (42.7%) reported practicing EBF in their index child for six months. Maternal perception of insufficient milk production, 52/99 (52.5%) was the most common reason for practicing EBF for

Background The high burden of rotavirus acute gastroenteritis (AGE) is well documented among children under 5 years of age, with the majority of mortality occurring in developing countries. Nigeria ranked second worldwide in the number of rotavirus deaths in 2013. As Nigeria plans to introduce rotavirus vaccine soon, a pre-vaccine documentation of rotavirus disease burden is necessary to determine vaccine impact. Methods Routine rotavirus surveillance was conducted during 2011–2016 in 3 sentinel sites in Nigeria using the standard WHO protocol. Children under 5 years of age hospitalized for acute gastroenteritis were enrolled and demographic, clinical and outcome data were collected. A stool sample was subsequently obtained and tested for human rotavirus antigen using the Enzyme-linked immunosorbent assay (ELISA). Results 2694 children with acute gastroenteritis were enrolled during January 2011 to December 2016; of these, 1242 (46%) tested positive for rotavirus. Among the rotavirus positive cases, 66% and 94% were younger than 12 months and 24 months respectively. Marked peaks in rotavirus positivity were seen in January of each year. Vomiting, and use of oral and intravenous fluids occurred more often in rotavirus positive cases as compared to rotavirus negative cases. Conclusion The high prevalence of rotavirus disease highlights the need for urgent introduction of rotavirus vaccine in Nigeria. Additionally, this study provides pre-vaccine introduction disease-burden data that will serve as a baseline for rotavirus vaccine impact-assessment once vaccine has been introduced in the national immunization program.

Health-care workers (HCWs) will require Ebola virus vaccine (EVV) when it is introduced because of the high risk of exposure to the disease. Evaluations of factors that facilitate or limit vaccine uptake are critical for a successful vaccine program. Nigerian HCWs were interviewed to evaluate their knowledge, levels of acceptance, determinants of acceptance, and willingness to pay for EVV. The significance level was set at P ≤ 0.05. None of the 193 participating HCWs had correct knowledge of EVV; 34.7% (67/193) of workers thought that EVV was an extract of the serum of Ebola virus patients. About 77.3% (51/66) of workers in a region that reported Ebola cases (Lagos) were willing to be vaccinated, compared with 4.7% (3/61) in Enugu and 13.6% (9/66) in Abia (P = 0.0001). After health education, the proportion of HCWs willing to receive EVV increased (P = 0.006) except for doctors (P < 0.1). The percentage of HCWs willing to pay for EVV was 86.4%, 72.1%, and 59% in Lagos, Enugu, and Abia, respectively. The workers had fears about EVV based on nonfactual assumptions. Therefore, the EVV introduction strategy should include a strong awareness campaign with adequate explanation about the content of EVV.

Background and Introduction: The incidence of Obesity and overweight appears to be on the increase in resource poor nations that previously had to battle infectious disease and undernutrition only. Obesity is a cause of life threatening diseases and a leading cause of death in the developed world. The most effective way of tackling obesity and overweight is by helping the population understand its dangers and have an attitude that allows for healthy trim people. Since family history reflects genetic susceptibility and environmental exposures shared by close relatives, this study assessed the perception of and attitude to obesity among mothers in a tertiary center in a Nigerian city. This is on the background knowledge that children of obese parents who also have

Background: Introduction of inactivated polio vaccine is imminent and may encounter the challenges that face new vaccines especially vaccine hesitancy. The study evaluated factors that may contribute to hesitancy towards IPV. Methods: Questionnaire adapted from the model developed by the Strategic Advisory Group of Experts Working Group (SAGE WG) was used to assess the factors among 408 parents. The evaluation was under the 3 Cs: Confidence, Complacency and Convenience. Questions were scored on Likert 4-unit-scale system. The data were analyzed using SPSS and, multivariate analysis was used to further test individual significant variables. Results: Overall, Complacency (2.29) and Convenience (2.11) domains were more pro-vaccine hesitant, than Confidence (1.83) domain. However, none was significantly associated with likelihood of a parent’s hesitancy towards IPV vaccination. But certain individual questions: competence of vaccinators (p = 0.04), confidence that their child will not to be infected with poliomyelitis even when not vaccinated (p = 0.03) and, willingness to vaccinate with IPV when OPV is still in use (p = 0.01) were significantly associated with vaccine hesitancy. Conclusions: None of the factors can individually influence acceptance of IPV. However, competence of vaccinators, parental belief and availability of close alternative influenced parental decision to vaccinate.

School health services (SHS) have widespread impact on the health of a large number of children with implications on access to primary health care especially in developing countries. The aim of this study was to assess health services in primary schools in Enugu East Nigeria. Thirty-three head teachers of primary schools in Enugu east Nigeria and officials of Ministry of Education were interviewed using a questionnaire adapted from school health evaluation scale. Four private schools had health personnel. Only six private schools had a health room. Two public schools had a functional first aid box. There were no health records available in any of the schools. School lunch was given by only one private school. Of a maximum of 45, public and private schools had a mean score of 10.3 and 12.7 respectively on the school health evaluation scale (P=0.01). Three schools only attained the minimum acceptable score of 19. Health services are at a minimal level in primary schools in Enugu East Nigeria. A state school health policy should be developed through inter-sectoral collaboration of the relevant stakeholders to use the platform provided by schools to ensure access to primary health care and also act as bridge for more formal medical care for school children.

Background/Objectives: Performance of the vaccination programme in Nigeria is lower than the regional average as well the 95% target necessary for sustained control of vaccine preventable diseases. This study is aimed at assessing the vaccination coverage and its associated factors in children aged 11 - 23 months in Enugu Metropolis. Methods: A cross sectional study in which caregivers and their children pair, aged 11 - 23 months attending children’s outpatient clinics in Enugu metropolis was undertaken. Respondents were selected consecutively while data were collected using pretested interviewer administered semi-structured questionnaire. Data were analyzed using SPSS version 20.0 while level of significance was set at p < 0.05. Logistic regression analysis was used to identify independent predictors of full vaccination. Results: Of 351 subjects studied, 84.9% (298) were fully immunized according to the national programme on immunization schedule using both vaccination cards and history. The OPV0, OPV3, pentavalent-1, pentavalent-3 and measles coverage at the time of survey were 100.0%, 97.2%, 98.0%, 98.6%, 96.9% and 95.4%, respectively. On logistic regression: maternal occupation (government employees), children born in government hospitals and knowledge of when to start and complete vaccinations in a child were the likely predictors for completion of full vaccination in the children. Conclusion: The vaccination coverage among the study group was adjudged to be relatively high. Delivery of a child in a government hospital and the knowledge of the age when routine vaccinations should begin and end in a child were the independent predictors of the high vaccination coverage rate observed. Awareness and health education efforts in government tertiary hospitals should be extended to private and other hospitals to improve and sustain national vaccination coverage in Nigeria.

Background: Assessment of the safety profile of the new rotavirus vaccines in Africa requires base-line epidemiological data on intussusception. Hence, this study was aimed at describing the prevalence and associated factors of intussusception in under-five children in Enugu, Southeast, Nigeria. Methods: This was a retrospective descriptive study involving the sixty reported cases of intussusception in under-five children admitted in a hospital in Enugu between 2007 and 2012. Cases of intussusception were selected using the Brighton collaboration intussusception working group level I diagnostic criteria. Information sought from the patients’ folders included demographic characteristics and clinical manifestations including history of previous rotavirus vaccination, duration of illness prior to presentation, diarrhoea, vomiting, passage of red currant jelly-like stool, abdominal mass and distension, method of diagnosis, treatment option(s) employed and their outcomes. The data was analyzed using SPSS version 17.0. Results: The majority of the cases were aged less than one year (53; 88.3%) while the average incidence of intussusception was 0.1 per 1000. None of the cases had received rotavirus vaccinations. The common clinical presentations were vomiting, 55 (17.2%), passage of red currant stool 50 (15.6%), fever 50 (15.6%) and abnormal/absent bowel sound 43 (15.9%). Diagnosis was essentially with the aid of abdominal ultrasonography, 38 (63.3%) while surgery (laparotomy) was the treatment of choice in most cases 48 (80.0%). The case fatality rate was 3 (5.0%). Conclusion: None of the cases studied could be directly linked to rotavirus vaccinations. But seasonal peak incidence coincided with rotavirus diarrhea peak incidence. Efforts should be made to institute post-rotavirus vaccine licensure prospective surveillance study in order to fully determine any relationship between rotavirus vaccination and intussusception in Enugu, South east, Nigeria.

Background Ebola virus disease is a highly virulent and transmissible disease. The largest recorded fatality from Ebola virus disease epidemic is ongoing in a few countries in West Africa, and this poses a health risk to the entire population of the world because arresting the transmission has been challenging. Vaccination is considered a key intervention that is capable of arresting further spread of the disease and preventing future outbreak. However, no vaccine has yet been approved for public use, although various recombinant vaccines are undergoing trials and approval for public use is imminent. Therefore, this study aimed to determine the acceptability of and willingness-to-pay for Ebola virus vaccine by the public. Methods The study was a community-based cross-sectional qualitative and quantitative interventional study conducted in two communities, each in two states in Nigeria. An interviewer-administered questionnaire was used to collect information on respondents’ knowledge of the Ebola virus, the ways to prevent the disease, and their preventive practices, as well as their acceptability of and willingness-to-pay for a hypothetical vaccine against Ebola virus disease. The association between acceptability of the vaccine and other independent variables were evaluated using multivariate regression analysis. Results Ebola virus disease was considered to be a very serious disease by 38.5% of the 582 respondents (224/582), prior to receiving health education on Ebola virus and its vaccine. Eighty percent (80%) accepted to be vaccinated with Ebola vaccine. However, among those that accepted to be vaccinated, most would only accept after observing the outcome on others who have received the vaccine. More than 87.5% was willing to pay for the vaccine, although 55.2% was of the opinion that the vaccine should be provided free of charge. Conclusion The level of acceptability of Ebola virus vaccine among respondents was impressive (though conditional), as well as their willingness to pay for it if the vaccine is not publicly funded. In order to achieve a high uptake of the vaccine, information and education on the vaccine should be extensively shared with the public prior to the introduction of the vaccine, and the vaccine should be provided free of charge by government., Author Summary Ebola virus disease (EVD) is highly virulent and transmissible. The transmission is mostly by direct contact with an infected person or indirectly through contact with material contaminated with the secretions or body fluids of an infected person. Currently there is no vaccine or drug for EVD. Maintaining good personal and environmental hygiene remains the only control strategy, and its implementation was a challenge in West Africa countries. Ebola virus vaccine (EVV) is being developed and may soon be deployed; thus a need to evaluate factors that can improve or discourage the uptake of the vaccine when it becomes approved for public administration. This study highlights the acceptability and willingness-to-pay for EVV. Majority of the respondents were willing to accept the vaccine and pay for it if it is not publicly funded. Of interest was that among those that accepted to be vaccinated, most would only accept to do so after they had observed the outcome on others that had received the vaccine. There is need for early dissemination of correct information and education on EVV to the populace so as to prevent any misinformation and misperception about the vaccine. This will improve universal coverage with the vaccine when deployed.

Background The introduction of inactivated polio vaccines (IPV) is imminent. In view of the Polio Eradication and Endgame Strategic Plan 2013–2018, parental acceptance of IPV will be important for achieving universal coverage. In view of the imminent introduction of IPV, it is only reasonable to assess the awareness and acceptance of IPV, so that necessary socio-anthropological measures would be put in place. This study is aimed at determining the level of awareness and acceptance of IPV by parents. Methods A cross-sectional study involving 408 parents that brought their children for immunization. Structured-questionnaire was to collect data on the parent's demographic characteristics, awareness and acceptance of IPV. The independent factors that may affect parental acceptability of IPV were evaluated using linear regression analysis. Results About 53% of the parents had no knowledge of vaccine content and 84.1% had not heard of IPV, and 40.2% were willing to accept IPV. However, with post-intervention (IPV) health education, the level of acceptance of IPV increased to 95.6% and the difference was statistically significant ( p = 0.0001). 35.3% expressed fear for IPV, and 61.8% cited fear for pain (61.8%). In the rating scale of 1 to 5, doctors (4.7), Nurses (4.0) and staff of the Ministry of Health (4.0) were rated high as reliable media to inform them about a new vaccine. The logistic regression revealed only educational level of mothers ( p -value = 0.048) was the only significant factor associated with acceptability of IPV. Conclusion The parents’ knowledge on vaccine was poor, as well as IPV acceptability (pre health education). But the acceptability was improved with provision of extra information. Although most still preferred OPV, and with improvement in pain management, acceptability of IPV can be improved further. Clear policies and strategies should be immediately developed and implementation of pre-introduction awareness/sensitization on IPV should be commenced.

Severe rotavirus diarrhea in children is a major cause of morbidity globally and mortality in developing countries. It is estimated to be responsible for453,000 deaths in children5 years of age globally and 232,000 in the African region. The aim of the current study was to determine the prevalence of rotavirus gastroenteritis among hospitalized children5 years of age in Enugu and to support awareness and advocacy efforts for the introduction of rotavirus vaccines in Nigeria.World Health Organization-standardized case forms were used to collect data from eligible children with non-bloody diarrhea from October 2010 to September 2012. Data collected included socio-demographic and clinical information. Stool samples were obtained from recruited children and tested for rotavirus antigen using the Oxoid Prospect ELISA Kit (Basingstoke, United Kingdom).Of the 615 diarrhea stool samples collected, 344 (56%) were positive for human rotavirus. Of the 344 positive samples, 329 (96%) were children2 years of age, while 247 (77%) were1 year of age. Peak rotavirus season occurred during the cold dry months of December to April during which 95% of all cases occurred.This study found a relatively high incidence of severe rotavirus-associated diarrhea disease in Nigeria and infants were the most affected. It highlights the urgent need for introduction of rotavirus vaccine into the national immunization program and the need to adequately equip health facilities to enable them administer intravenous fluids to severe diarrhea patients to reduce morbidity and mortality.

The Global polio eradication initiative was launched in 1988 by the international community. Since then, tremendous progress has been made (99%). However, the last 1% of the journey has experienced several setbacks and rate of progress has slowed down in the last few years. Nigeria is one of the remaining 3 endemic countries in the world that has never interrupted the transmission of the poliovirus compared to more than 125 countries in 1988. What are the prospects and challenges to polio eradication in Nigeria? This paper discusses these and other relevant issues regarding polio eradication in Nigeria.

Introduction: Immunization has been shown to be the most successful and cost-effective public health intervention in the 20th century. In the developing world, it does not only prevent about three million child deaths annually, but also has the potential to prevent additional two million deaths if coverage improves. However, immunization coverage has remained low in Nigeria although vaccines are provided relatively free by the government. Efforts have focused on the health worker, health system and logistics with little attention being paid to maternal factors like knowledge, perception, beliefs and practice.Objectives: To assess mothers’ knowledge, perception and practice of routine and campaign immunization in Enugu.Methods: A structured questionnaire was administered to 207 mothers who have at least one child less than 5 years of age, attending children outpatient and immunization clinics at the University of Nigeria Teaching Hospital, Enugu.Results: Forty-eight per cent of the mothers had tertiary education, 42% had secondary education, and 9% had primary education while 1% had no formal education. Eighty-two per cent knew that children are immunized to prevent major killer diseases, 14% and 3.4% believed it was to prevent all diseases, and to treat diseases respectively. Most mothers took their children to health facilities for routine immunization (95.2%) and also accepted immunization on immunization campaign days (75.4%). However, 23.6% had never immunized their children during campaigns. On the other hand, 13% (27) of mothers had out-rightly rejected immunization during campaign while 85% (177) had never rejected immunization. The remaining 2% were not immunized due to reasons other than rejection. More mothers significantly rejected campaign immunization than the number that did not go for routine immunization (p=0.000). Maternal highest educational level was significantly associated with knowledge of reason for immunization and acceptance of immunization (p=0.000). Religious denomination was not significantly associated with rejection of campaign immunization (p=0.056).Conclusion: Most mothers studied had good knowledge and positive perception and practice of immunization. However, the Campaign immunization rejection rate was relatively high for the south eastern Nigeria where it is often assumed that non-compliance is not a problem. Similarly, the proportions of mothers with wrong knowledge and poor perception of immunization require policy attention. Maternal education was significantly associated with knowledge and acceptance of immunization. These findings are important in the design and implementation of childhood immunization programmes.

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No Abstract. Nigerian Journal of Paediatrics Vol. 32 (4) 2005: pp. 73-76

Objectives A health-facility survey was done to determine the knowledge and utilization of oral rehydration therapy (ORT) among 400 mothers resident in Enugu. Methods A systematic sample from a list of mothers attending the immunization clinic of the Institute of Child Health (ICH) of the University of Nigeria Teaching Hospital, Enugu was interviewed using a pre-tested structured questionnaire. Results A pre-survey awareness of ORT was noted among 97.5% of the mothers. The beneficial effects of ORT were seen by 57.3% of the mothers as replenishment of lost energy and 37.5% as fluid and salt replacement. Although 77.0% of the respondents could not describe correctly the preparation of salt-sugar solution (SSS)/oral rehydration salt solution (ORS), a high ORT utilization rate of 74.6% was recorded. ORT as a modality of managing childhood diarrhoea remained totally acceptable to 89.5% of the mothers. Conclusion Many Mothers, although they accept and use ORT/SSS, could not accurately describe the methods of preparation of ORS/SSS. It is recommended that maternal perception of the role of ORT should be utilized by health personnel to promote its use, while routine training of caregivers on the preparation of SSS/ORS should be intensified during health education sessions. Key Words: Knowledge of ORT, utilization of ORT, mothers, routine training. Orient Journal of Medicine Vol.15(1&2) 2003: 45-48

We present a rare case of mucopolysaccharidosis (MPS) with a typical presentation of mental retardation and absence of corneal clouding. The purpose of presenting this case report is to highlight the distinctive manifestation of MPS (Hunter’s disease) and to provide a concise report of Hunter’s disease for medical practitioners with the hope that such information will help identify boys earlier in the course of their disease. This report is of a 7-year-old boy who presented to the children outpatient through a referral with a history of inability to grasp objects, inability to express self, and coarse skin, which started 5 years ago. On examination, he was short statured, with a big head, protruding abdomen, coarse skin, swollen wrist joints, and clubbed fingers. There was mild mental retardation. Investigations revealed mucopolysaccharides in urine ad radiographic findings were in keeping with diagnosis. Based on the clinical features and radiological findings, one can diagnose a case of MPS. However, careful and critical approach is necessary to exactly diagnose the type of MPS as enzymatic studies are not available in most centers. Keywords: Mucopolysaccharidosis, Children, Distinctive features