Showing papers in "Indian Pediatrics in 2019"

Screen Time in Under-five Children.

Abstract: Screen-viewing in childhood is primarily a mean of entertainment, during the unstructured time. We aimed to review the burden of the problem, delineate the associated factors and correlates, evaluate the impact of screen-time on the overall health of under-five children, and the interventions to reduce screen-time. Published articles from January 2009 to June 2018 were searched through PubMed, Clinical Key, Scopus, Embase, and Google Scholar using key Medical Subject Heading words. The burden of screen-time varied from 21% to 98% in the middle-income, and 10% to 93.7% in the high-income countries. The social ecological model was used to illustrate associated factors and correlates including child, caregiver, micro and macro digital-media environment related factors. The interventions included increase in the physical activity, reduction in the body mass index, improving sleep and dietary behaviors etc. The effectiveness of these interventions ranged from 0.3 minutes (standard error 13.3) to −47.16 minutes (standard error 2.01). Clinicians should obtain history of screen-time in children, and advise limiting the screen exposure according to the child’s age. There is a need to generate evidence on burden and effectiveness of interventions among children in the Indian settings, owing to the limited data.

Massive Open Online Courses: Concept and Implications.

Abstract: Massive open online courses (MOOCs) are currently the buzz word in the field of e-learning. By definition, MOOCs are massive courses considering the number of participants enrolled across the globe per course, are open accessed, and are available online. MOOCs have evolved along the trajectory of correspondence courses, radio- and television-broadcasts, and e-learning. Though various taxonomies to classify MOCCs exit, two types - Connectivist Massive Open Online Course (cMOOC) and Extended Massive Open Online Course (xMOOC) have distinctly emerged. cMOOC promotes creativity and interaction among participants, while xMOOC is used merely for knowledge dispersion. With increased and unrestricted use of internet, and with ease of developing new online platforms, MOOCs are proving to be an evolutionary phenomenon. Many universities and institutes of higher learning are using MOOCs for knowledge dispersion and skill development. Their role in faculty development, capacity and capability building in medical education arena is unequivocal. Potential of MOOCs can be well-tapped for conduct of continuing medical education programs, and programs for improving soft-skills and research skills in medical field for faculty development. This review details the concepts of MOOCs and their application in education field, particularly in medical education, and feasibility of developing MOOCs in India.

Comparison of Open and Laparoscopic Appendectomy in Children: A 5-year Single Center Experience.

Abstract: OBJECTIVE To compare the outcomes of treatment in children with acute appendicitis between laparoscopic and open surgical approaches. Design Retrospective study. SETTING Division of Pediatric Surgery at a tertiary-care hospital in Croatia between January 2012 to December 2016. PATIENTS 834 children [median (IQR) age 13 (11,15)] who underwent appendectomy; 301 in the laparoscopic group and 533 in the open group. MAIN OUTCOME MEASURES Postoperative complications, duration of hospitalization, re-operation, and the quantity of analgesics used. RESULTS The median length of hospital stay was 3 days in laparoscopic group compared to 6 days in open group (P<0.001). The amount of analgesics used was lower in patients with laparoscopic appendectomy compared to patients who underwent open procedure (P=0.042). Significantly higher number of wound infections was recorded in the open group (n=21; 3.9%) compared to laparoscopic group (n=3; 1%) (P=0.014). The frequency of re-operation in both groups was equal (1.3%). The median duration of surgery was shorter in the group of patients with laparoscopic appendectomy compared to the open approach (30 vs. 45 min; P<0.001). In five-year period, the proportion of laparoscopic appendectomies increased by 21.5%. CONCLUSIONS Laparoscopic appendectomy was safe and effective in children. Advantages of laparoscopic approach were shorter hospital stay, lower number of wound infections and lower usage of analgesics.

Levetiracetam versus Phenobarbitone in Neonatal Seizures - A Randomized Controlled Trial.

Abstract: To compare the efficacy and safety of intravenous Levetiracetam and Phenobarbitone in the treatment of neonatal seizures. Open labelled, Randomized controlled trial. Level III Neonatal Intensive Care Unit (NICU). 100 neonates (0–28 days) with clinical seizures. If seizures persisted even after correction of hypoglycemia and hypocalcemia, participants were randomized to receive either Levetiracetam (20 mg/kg) or Phenobarbitone (20 mg/kg) intravenously. The dose of same drug was repeated if seizures persisted (20 mg/kg of Levetiracetam or 10 mg/kg of Phenobarbitone) and changeover to other drug occurred if the seizures persisted even after second dose of same drug. Cessation of seizures with one or two doses of the first drug, and remaining seizure-free for the next 24 hours. Seizures stoped in 43 (86%) and 31 (62%) neonates in Levetiracetam and Phenobarbitone group, respectively (RR 0.37; 95%CI 0.17, 0.80, P<0.01). 10 neonates had adverse reactions in the phenobarbitone group (hypotension in 5, bradycardia in 3 and requirement of mechanical ventilation in 2 neonates) while none had any adverse reaction in Levetiracatam group. Levetiracetam achieves better control than Phenobarbitone for neonatal seizures when used as first-line antiepileptic drug, and is not associated with adverse drug reactions.

Profile of Pediatric Scrub Typhus in Odisha, India.

Abstract: Objective To investigate the distribution and clinical profile of scrub typhus infection among children with acute febrile illness in Odisha. Methods Children ( 5 days) in 4 agro-climatic zones from June to November 2017 were evaluated. Patients were screened for malaria, leptospira, dengue, typhoid and scrub typhus. Scrub typhus was confirmed by IgM ELISA and PCR. Results Out of 413 cases examined, 48.7% were positive for scrub typhus, and 5.5% of them developed systemic complications. Eschar was found in 17.9% of cases. Five days treatment of Doxycycline and/or Azithromycin was clinically effective against scrub typhus. Conclusions Our study highlights that scrub typhus is one of the causes of high morbidity in children during rainy months in Odisha.

Height Velocity Percentiles in Indian Children Aged 5-17 Years.

Abstract: To assess height velocity and develop height velocity percentiles in 5-17-year-old Indian children; and to study the magnitude and age at peak height velocity. Mixed longitudinal study. Private schools at Pune and Delhi. 2949 children (1681 boys) belonging to affluent class aged 5–17 years (1473-Pune, 1476-Delhi). Annual height and weight measurements from 2007 to 2013. Total 13214 height velocity measurements (7724 on boys). Height velocity percentiles (3rd, 10th, 25th, 50th, 75th, 90th and 97th) constructed using LMS chart maker. Age- and gender-specific height velocity percentiles were generated. Median height velocity in girls decreased from 5 to 8 years, increased to a peak of 6.6 cm at 10.5 years and then declined to 0.3 cm at 17.5 years. In boys, median height velocity reduced till 10.5, increased to a peak of 6.8 cms at 13.5 years and then declined to 1cm by 18 years. Height velocity percentiles in 5-17-year-old urban Indian children were constructed.

Indian Academy of Pediatrics Guidelines on the Fast and Junk Foods, Sugar Sweetened Beverages, Fruit Juices, and Energy Drinks.

Abstract: In view of easy availability and increasing trend of consumption of fast foods and sugar sweetened beverages (fruit juices and drinks, carbonated drinks, energy drinks) in Indian children, and their association with increasing obesity and related non-communicable diseases, there is a need to develop guidelines related to consumption of foods and drinks that have the potential to increase this problem in children and adolescents. To review the evidence and formulate consensus statements related to terminology, magnitude of problem and possible ill effects of junk foods, fast foods, sugar-sweetened beverages and carbonated drinks; and to formulate recommendations for limiting consumption of these foods and beverages in Indian children and adolescents. Process: A National Consultative group constituted by the Nutrition Chapter of the Indian Academy of Pediatrics (IAP), consisting of various stakeholders in private and public sector, reviewed the literature and existing guidelines and policy regulations. Detailed review of literature was circulated to the members, and the Group met on 11th March 2019 at New Delhi for a day-long deliberation on framing the guidelines. The consensus statements and recommendations formulated by the Group were circulated to the participants and a consensus document was finalized. The Group suggests a new acronym ‘JUNCS’ foods, to cover a wide variety of concepts related to unhealthy foods (Junk foods, Ultra-processed foods, Nutritionally inappropriate foods, Caffeinated/colored/carbonated foods/beverages, and Sugar-sweetened beverages). The Group concludes that consumption of these foods and beverages is associated with higher free sugar and energy intake; and is associated with higher body mass index (and possibly with adverse cardiometabolic consequences) in children and adolescents. Intake of caffeinated drinks may be associated with cardiac and sleep disturbances. The Group recommends avoiding consumption of the JUNCS by all children and adolescents as far as possible and limit their consumption to not more than one serving per week. The Group recommends intake of regional and seasonal whole fruits over fruit juices in children and adolescents, and advises no fruit juices/drinks to infants and young children (age 5–18 y, their intake should be limited to 125 mL/day and 250 mL/day, respectively. The Group recommends that caffeinated energy drinks should not be consumed by children and adolescents. The Group supports recommendations of ban on sale of JUNCS foods in school canteens and in near vicinity, and suggests efforts to ensure availability and affordability of healthy snacks and foods. The Group supports traffic light coding of food available in school canteens and recommends legal ban of screen/print/digital advertisements of all the JUNCS foods for channels/magazines/websites/social media catering to children and adolescents. The Group further suggests communication, marketing and policy/taxation strategies to promote consumption of healthy foods, and limit availability and consumption of the JUNCS foods.

Flexible Bronchoscopic Removal of Foreign Bodies from Airway of Children: Single Center Experience Over 12 Years.

Abstract: To report our experience of tracheobronchial foreign body removal in children using flexible bronchoscopy as the primary mode. Hospital records of tracheobronchial foreign body extractions between January, 2006 and January, 2018 were reviewed. Clinical presentations, radiological findings, location and types of tracheobronchial foreign bodies, types of bronchoscopes, complications and outcome of the procedures were analyzed. 283 extractions in children with median (range) age of 18 (5–168) months were reviewed. Extraction by flexible bronchoscope, using wire baskets or grasping forceps, was successful in 260 cases. No major complications were encountered. Mean (SD) time for the procedure was 31 (6.3) minutes. Airway foreign bodies can safely be removed by flexible bronchoscopy with minimal complications. This procedure can be considered the primary mode for removal of airway foreign bodies by a trained and experienced person.

Infantile Thiamine Deficiency: New Insights into an Old Disease.

Abstract: The wide spectrum of clinical presentation in infantile thiamine deficiency is difficult to recognize, and the diagnosis is frequently missed due to the lack of widespread awareness, and non-availability of costly and technically demanding investigations. The topic was searched by two independent researchers using online databases of Google scholar and PubMed. We considered the related studies published in the last 20 years. The terms used for the search were ‘thiamine’, ‘thiamine deficiency’, ‘beriberi’, ‘B-vitamins’, ‘micronutrients’, ‘malnutrition’, ‘infant mortality’. ‘Wernicke’s syndrome’, ‘Wernicke’s encephalopathy’, and ‘lactic acidosis’. In the absence of specific diagnostic tests, a low threshold for a therapeutic thiamine challenge is currently the best approach to diagnose infantile thiamine deficiency in severe acute conditions. The practical approach is to consider thiamine injection as a complementary resuscitation tool in infants with severe acute conditions; more so in presence of underlying risk factors, clinically evident malnutrition or where a dextrose-based fluid is used for resuscitation. Further, as persistent subclinical thiamine deficiency during infancy can have long-term neuro-developmental effects, reasonable strategy is to treat pregnant women suspected of having the deficiency, and to supplement thiamine in both mother and the baby during breastfeeding. Health care professionals in the country need to be sensitized to adopt a high level of clinical suspicion for thiamine deficiency and a low threshold for the administration of thiamine, particularly when infantile thiamine deficiency is suspected.

Early Aggressive Enteral Feeding in Neonates Weighing 750-1250 Grams: A Randomized Controlled Trial.

Abstract: BACKGROUND In preterm neonates, enteral feeding is advanced slowly, considering the risk of necrotizing enterocolitis. Prolonged intravenous alimentation in these neonates, however, may increase the risk of sepsis-related morbidity and mortality, particularly in low resource settings. OBJECTIVES Objective of this was study to evaluate impact of aggressive enteral feeding on mortality and morbidities among preterm neonates. DESIGN Randomized controlled trial. PARTICIPANTS Neonates with birthweight 750-1250 g. INTERVENTIONS 131 preterm neonates with birth weight 750-1250 g, admitted to neonatal intensive care unit between April 2012 and June 2014, were randomized to aggressive feeding or conservative feeding regimen. OUTCOMES The primary outcome of the study was all-cause mortality during hospital stay. The secondary outcomes included proportion of sepsis (blood culture proven), necrotizing enterocolitis, feed intolerance, survival without major morbidity at discharge, time to reach full enteral feed (180 mL/kg/d), duration of hospitalization, and average daily weight gain (g/kg). RESULTS All-cause mortality was 33.3% in aggressive regimen and 43.1% in conservative regimen, [RR (95%) CI 0.77 (0.49, 1.20)]. Neonates with aggressive feeding regimen reached full enteral feed earlier; median (IQR) 7 (6, 8) days compared to conservative regimen, 10 (9, 14) days; P <0.001. There was no difference in culture positive sepsis rate, survival without major morbidities, feed intolerance, necrotizing enterocolitis, duration of hospitalization and average daily weight gain. CONCLUSIONS In neonates with birth weight 750-1250 g, early aggressive feeding regimen is feasible but not associated with significant reduction in all-cause mortality, culture positive sepsis or survival without major morbidities during hospital stay. Neonates with aggressive regimen have fewer days on IV fluids and reach full feed earlier.

Children at Work, Child Labor and Modern Slavery in India: An Overview.

Abstract: There is a large child work force in India reported to be about 40 million. Child labor is being regarded as a form of modern slavery, as children are forced to work or have no choice to refuse work. Children are employed in a variety of occupations, many of which are hazardous. Exposure to machinery, pesticides, dust in agricultural work and fumes, chemicals, acids, cotton and wool fiber in other forms of work is detrimental to health. A large number are held in bonded servitude. In urban areas, children are employed as domestic helpers and engaged in eateries and auto-repair work. Trafficking and trading of children for work and sexual slavery are also major concerns. Poverty and illiteracy are root causes of child labor, but iniquitous societal attitudes are responsible for abuse and exploitation. Working children are deprived of proper health care and education, and lose their childhood and dignity. Several legal measures exist to prevent child labor and protect them from harm, but are thwarted by the distressing socioeconomic conditions. Although child labor would be difficult to abolish, exploitation can be prevented with concerted efforts of the government agencies, professional bodies and the civil society.

Prevention of Micronutrient Deficiencies in Young Children: Consensus Statement from Infant and Young Child Feeding Chapter of Indian Academy of Pediatrics.

Abstract: Micronutrient deficiencies have significant impact on the overall health and well-being of society and potential targets for supplementations. It is important to formulate a consensus statement in view of current evidence, and put in place strategies to meet targets. To formulate by endorsement or adoption and disseminate a consensus statement for prevention of micronutrients deficiencies in young children for office practices from an Indian perspective. A National Consultative Meeting was convened by Infant and Young Child Feeding Chapter (IYCF) of Indian Academy of Pediatrics (IAP) on 17 December, 2016 at Mumbai. IYCF chapter, IAP, United Nations Children Fund, National Institute of Nutrition and Government of India were the participating agencies; and participants representing different parts of India were included. Micronutrient deficiencies are widespread. For its prevention proper maternal and infant-young child feeding strategies need to be practiced. Encourage delayed cord clamping, dietary diversification, germinated foods, soaking and fermentation processes. Existing Iron, Vitamin A, Zinc supplementation and universal salt iodization programs need to be scaled up, especially in high risk groups. Universal vitamin D supplementation need to be in place; though, the dose needs more research. Vitamin B12 deficiency screening and supplementation should be practiced only in high-risk groups. Availability of appropriately fortified foods needs to be addressed urgently.

What is New in Management of Pediatric Tuberculosis

Abstract: Tuberculosis continues to haunt mankind since its discovery more than a century ago. Although commendable advancements have been made in the diagnosis as well as treatment, especially in the last couple of decades, the healthcare burden of this disease worldwide is immense. Continuously evolving medical science has provided recent changes in national guidelines along with discovery of newer anti-tubercular drugs after many decades. In view of WHO declaring tuberculosis as a global health emergency and strong commitment being reflected by Government of India whereby National Strategic Plan aims to eliminate tuberculosis by 2025, it is high time that we work collectively on the goal of tuberculosis elimination. This article sums up the updates on newer anti-tubercular drugs as well as the recent changes adopted in Revised National Tuberculosis Control Program.

Intussusception: Single Center Experience of 10 Years.

Abstract: To analyze the association between the clinical presentation, clinical course, management and outcome in intussusception with emphasis on safety of saline hydrostatic reduction. This retrospective study included 375 patients of intussusception diagnosed between March 2007 to February 2017. Symptoms at presentation, mode of reduction of intussusception and associated complications were recorded. 336 (89.6%) patients were aged below 3 years. Classical triad of abdominal pain, vomiting and red stools was present in 111 (29.6%) patients. While 64 (17.1 %) patients had spontaneous resolution, hydrostatic reduction and surgery cured 283 (75.5 %) and 28 (7.4 %) patients, respectively; overall recurrence rate was 13.1%. Among the patients who underwent operative reduction, blood in stools was present in 15 (53.6%) patients. Hydrostatic reduction of intussusception is effective irrespective of duration of symptoms and number of recurrences.

Computer-aided Facial Analysis in Diagnosing Dysmorphic Syndromes in Indian Children.

Abstract: To assess the utility of computer-aided facial analysis in identifying dysmorphic syndromes in Indian children. Fifty-one patients with a definite molecular or cytogenetic diagnosis and recognizable facial dysmorphism were enrolled in the study and their facial photographs were uploaded in the Face2Gene software. The results provided by the software were compared with the molecular diagnosis. Of the 51 patients, the software predicted the correct diagnosis in 37 patients (72.5%); predicted as the first in the top ten suggestions in 26 (70.2%). In 14 patients, the software did not suggest a correct diagnosis. Computer-aided facial analysis is a method that can aid in diagnosis of genetic syndromes in Indian children. As more clinicians start to use this software, its accuracy is expected to improve.

Glycemic Control and Long-term Complications in Pediatric Onset Type 1 Diabetes Mellitus: A Single-center Experience from Northern India.

Abstract: To study glycemic control, mortality and long-term complications in children with type 1 diabetes (T1D). Cross-sectional study. Referral centre at a government teaching hospital. Patients with T1D with age ≤18 years at onset. We retrospectively collected demographic data from computer records from 1991 to 2015. Prospective study for outcomes was conducted between 2012 and 2016. Mortality rate, glycosylated hemoglobin (HbA1c), and microvascular complication rate. The proportion of T1D patients (n=512) 100 mg/dL in 34% patients. The mortality rate and prevalence of hypertension were high, given the short duration of diabetes of the patients. The proportion of patients with age ≤5 years at onset of diabetes has increased at our center.

Gallbladder Disease in Children: A 20-year Single-center Experience.

Abstract: Aim of this study was to examine the changes in incidence of pediatric cholecystectomies. Based on a review of hospital-records, children were divided into two groups regarding year of surgery (Group I: 1998–2007; Group II: 2008–2017) and their characteristics were compared. Number of cholecystecomies increased from 11 to 34. Median age increased from 11 to 15.5 years and mean BMI increased from 19.2 kg/m2 to 23.0 kg/m2. Hereditary spherocytosis decreased from 63.6% to 11.8% (P=0.001) of indications for cholecystectomy, while proportion of cholesterol stones increased from 27.3% to 70.6% (P=0.006). Frequency of laparoscopic cholecystectomy increased from 36.4% to 85.3% (P=0.001). Duration of hospital stay shortened from 8to 4 days (P=0.008). Number of pediatric cholecystectomies has significantly increased in the last 20 years, as well as average BMI of the observed population This probably signifies a correlation between rising obesity rates and increase in frequency of symptomatic cholelithiasis in children.

Prediction of Severe Acute Kidney Injury using Renal Angina Index in a Pediatric Intensive Care Unit.

Abstract: To determi ne the proportion of children in a pediatric intensive care unit with a positive Day 0 Renal angina index who develop severe acute kidney injury (AKI) on Day 3; and to compare the predictive ability of the index with that of individual markers of renal injury, for the development of severe acute kidney injury. Observational study. Pediatric intensive care unit of a tertiary-care hospital. Consecutive children, 1 month to 12 years, admitted in Level 3 pediatric intensive care unit for a minimum of 8 hours, having weight and intake-output records, were eligible. Children known to have chronic kidney disease or already in stage 2/3 acute kidney injury/dialysis were excluded. Day 0 Renal angina index was calculated from the product of Risk Group score (Pediatric intensive care admission/Ventilation and inotropy) and Renal Injury score (fluid overload over previous 8 hours or the % fall in estimated creatinine clearance from baseline). Renal angina index ≥8 was considered positive. The proportion of children with positive Day 0 Renal angina index who develop severe AKI (Kidney Disease Improving Global Outcomes (KDIGO) ≥Stage 2) on Day 3. Of 162 enrolled children (median (IQR) age 10.5 (3,39) months), 86 (53%) had positive Renal angina index. On Day 3, a higher proportion of children with positive index developed severe AKI, compared to negative group (RR 95.5; 95% CI 21.7,420.5; P<.001). Day 0 positive Renal angina index had a sensitivity, specificity, positive predictive value and negative predictive value of 96.9%, 75.5%, 72% and 97.4% respectively, for predicting severe AKI on Day 3. The Receiver Operating Characteristic curve of Day 0 renal angina scores showed AUC of 0.90 (95% CI 0.85, 0.95), better than the AUC obtained from either Day 0 serum creatinine or Day 0 percent fall in estimated creatinine clearance from baseline. Day 0 Renal angina index positivity is a promising tool to identify critically ill children with impending severe AKI.

Allergy Testing - An Overview.

Abstract: Childhood allergies pose huge economic burden and adverse effects on quality of life. Serum IgE has been considered a surrogate allergy marker for decades. Availability of several over-the-counter allergy tests add to confusion of partially trained caregivers. The present review focuses on current status of allergy testing in Indian scenario. Various in-vitro and in-vivo diagnostic modalities are available for allergy detection. Skin prick tests are useful for aero-allergies whereas oral challenge tests are best for identifying suspected food allergies. An allergy test should be individualized based on clinical features, diagnostic efficacy, and cost-benefit analysis.

Effect of a Formative Objective Structured Clinical Examination on the Clinical Performance of Undergraduate Medical Students in a Summative Examination: A Randomized Controlled Trial.

Abstract: To study the effect of formative Objective structured clinical examination (OSCE) on the undergraduate medical students’ performance in a subsequent summative-OSCE assessment. In a randomized single-blind trial, 130 fifth year medical students at Raparin hospital, Erbil were assigned to intervention (n=61) and control group (n=69). Formative-OSCE was performed for the intervention group in pediatric module with feedback on their performance versus standard pediatric module for the control group. Students’ clinical performance was assessed by a summative-OSCE. Multiple regression was used to predict the summative-OSCE score depending on the participation in formative-OSCE along with the other factors. Eleven students were excluded because of early drop-out, leaving 119 students for analysis. The summative-OSCE mean score (out of a total score of 100) in intervention group 64.6 (10.91) was significantly lower as compared to the control group 69.2 (10.45). Single formative-OSCE does not necessarily lead to better performance in subsequent summative-OSCE.

Implementation of Kangaroo Mother Care — Challenges and Solutions

Abstract: Kangaroo Mother Care (KMC) is an efficient intervention that provides warmth, sensory stimulation, safety, protection against infections, breastfeeding, and bonding between infant and mother. The issues faced in implementing of KMC are highlighted herein, along with a suggestive plan for policy making for better implementation. With this plan, it will be easier to extend the approach to the community, where KMC has the potential to reach numerous LBW babies. Therefore, well-functioning facility-based services should be available before introducing KMC in the community, as community KMC must link with facility-based services for successful implementation. Community health workers and staff in facilities without KMC units should also be trained on KMC benefits and positioning. Each health facility implementing KMC services should have a written policy and guidelines that are based on national documents, and adapted to its specific level of health care.

Profile of Acute Kidney Injury in Hospitalized Children with Idiopathic Nephrotic Syndrome

Abstract: To determine the incidence, risk factors and outcome of acute kidney injury (AKI) in hospitalized children with nephrotic syndrome. All consecutive hospitalized children (aged 1–14 years) with diagnosis of nephrotic syndrome between February 2016 and January 2017 were enrolled for the study. Children (aged 1–14 years) with features of nephritis, underlying secondary causes of nephrotic syndrome as well as children admitted for diagnostic renal biopsy and intravenous cyclophosphamide or rituximab infusion were excluded. A total of 73 children (81 admissions) were enrolled; incidence of AKI was 16% (95% CI, 9-23). On multivariate logistic regression analysis, furosemide infusion was observed as an independent risk factor for acute kidney injury (OR 23; 95% CI, 3-141; P<0.001). Out of 13 children with AKI, three died. Acute kidney injury in hospitalized children with nephrotic syndrome has high risk of mortality. Children receiving furosemide infusion should be closely monitored for occurrence of acute kidney injury.

Hepatitis A Virus-related Pediatric Liver Disease Burden and its Significance in the Indian Subcontinent

Abstract: To study the Hepatitis A virus (HAV) infection-related pediatric liver disease burden. Hospital records of 431 children (age <18 y) diagnosed to be suffering from acute HAV infection during 2011 to 2018 were extracted and analyzed. Additionally, a seroprevalence study was done on 2599 participants (696 children and 1903 adults). HAV infection accounted for about half (48.6% of acute hepatitis and 46.5% (92/198) of acute liver failure cases) of all acute onset icteric illness, with significant morbidity and mortality. As per seroprevalence data, 16.2% of children between 10–18 years of age, and 10.3% of adults aged 18–30 years remained susceptible to HAV infection. HAV infection is the major contributor the overall pediatric liver disease burden. A significant proportion of subjects remain susceptible to HAV infection even after 10 years of age. Population-based studies are required to further delineate the epidemiology of HAV infection in India for deciding introduction of HAV vaccine in the national immunization schedule.

Cytosorb for Management of Acute Kidney Injury due to Rhabdomyolysis in a Child.

Abstract: A 6-year-old girl presented with rhabdomyolysis following a febrile illness. Polymerase chain reaction (PCR) for Influenza B and enterovirus was positive. Her serum creatine kinase (CK) and myoglobin levels were very high. She developed myoglobinuria with oliguria leading to acute kidney injury. Continuous renal replacement therapy along with Cytosorb filter resulted in good outcome.

Flexible Fiberoptic Bronchoscopy in Pediatric Practice.

Abstract: Flexible fiberoptic bronchoscopy a vital diagnostic and therapeutic procedure for assessing the airway. Its logistics, clinical indications and utility need to be elucidated in pediatric context. Pediatric flexible fibreoptic bronchoscopy is useful for diagnosis of airway anomalies, bronchoalveolar lavage for diagnostic and therapeutic purposes, and interventions like foreign body removal. Newer ultra-thin bronchoscopes can be used to perform this procedure in children of all ages. Pediatric flexible bronchoscopy is a valuable diagnostic and therapeutic tool in the hands of skilled personnel when used judiciously.

Normative Data of Optimally Placed Endotracheal Tube by Point-of-care Ultrasound in Neonates.

Abstract: To derive normative data of the distance between optimally placed endotracheal tube tip and arch of aorta by ultrasound in neonates across different weight and gestation. Cross-sectional study. Tertiary care neonatal intensive care unit from April 2015 to May 2016. All neonates requiring endotracheal intubation were eligible for the study. During intubation, insertional length was determined using weight-based formula. The distance between endotracheal tube tip and arch of aorta was measured by ultrasound. Endotracheal tube position was confirmed by chest radiograph. Out of 133 enrolled infants, 101 (75.9%) had optimally placed endotracheal tubes. The mean (SD) distance between endotracheal tube tip and arch of aorta by ultrasound was 0.78 (0.21) cm in infants <1500 g and 1.04 (0.32) cm in infants ≥1500 g. The regression equation to estimate insertional length from weight, crown heel length (CHL), occipito-frontal circumference (OFC), nasal tragus length (NTL) and sternal length (SL) were Wt(kg)+4.95, 0.15×CHL(cm)+0.57, 0.22×OFC(cm)+0.49, 0.82× NTL(cm)+1.24 and 0752×SL(cm)+2.26, respectively. Our study reports normative data of the distance between optimally placed endotracheal tube tip and arch of aorta by ultrasound in neonates. The distance between endotracheal tube tip and arch of aorta increases with increase in weight and gestation. Insertional length correlates strongly with all the anthropometric parameters.

A Landscape Analysis of Human Milk Banks in India.

Abstract: Objectives To evaluate the existing status of human milk banks in India with reference to infrastructure, human resources, funding mechanisms, operating procedures and quality assurance. Methods A pretested questionnaire was administered to 16 out of 22 human milk banks across India, operational for more than one year prior to commencing the study. Results 11 (69%) milk banks were in government or charitable hospitals; only 2 (12.5%) were established with government funding. 8 (50%) had a dedicated technician and only 1(6%) had more than five lactation counsellors. Milk was collected predominantly from mothers of sick babies and in postnatal care wards followed by pediatric outpatient departments, camps, satellite centers, and homes. 10 (63%) reported gaps between donor milk demand and supply. 12 (75%) used shaker water bath pasteurizer and cooled the milk manually without monitoring temperature, and 4 (25%) pooled milk under the laminar airflow. 10 (63%) tracked donor to recipient and almost all did not collect data on early initiation, exclusive breastfeeding or human milk feeding. Conclusions Our study reports the gaps of milk banking practices in India, which need to be addressed for strengthening them. Gaps include suboptimal financial support from the government, shortage of key human resources, processes and data gaps, and demand supply gap of donor human milk.

Daily Iron Requirements in Healthy Indian Children and Adolescents.

Abstract: This study aimed to define the estimated average requirement and the recommended dietary allowance of iron for Indian children and adolescents. The Estimated average requirement was derived for children aged 1–17y, from the mean bioavailability-adjusted daily physiological iron requirement, which in turn was estimated using a factorial method. This consisted of mean daily iron losses from the body and additional iron required for tissue growth and storage, while also defining the variance of each factor to derive the Recommended dietary allowance. The estimated average requirement of iron for children ranged from 5.6 to 11.0 mg/d in children aged 1–9y. For adolescents aged 10–17y, these ranged from 10.8 to 18.4 mg/d and 15.4 to 18.5 mg/d for adolescent boys and girls, respectively. New estimates of estimated average requirement for iron in Indian children are presented, and same may be used to inform iron supplementation and food fortification policies.

Zinc Supplementation for Promoting Growth in Children Under 5 years of age in Low- and Middle-income Countries: A Systematic Review.

Abstract: To study the effect of zinc supplementation in children under 5 years of age from low- and middle-income countries (LMICs) on anthropometry and prevalence of malnutrition. Systematic review of randomized controlled trials and cluster randomized trials. Setting Low- and middle-income countries. 63 trials with zinc supplementation, incorporating data on 27372 children. Trials conducted exclusively in specifically diseased participants and in children with severe acute malnutrition were excluded. Zinc supplementation, provided either as medicinal supplementation or through food fortification. (i)Anthropometry: weight, height, weight-for-height, mid-arm circumference, head circumference; (ii) Prevalence of malnutrition. There was no evidence of effect on height-for-age Z score at the end of supplementation period (25 trials; 9165 participants; MD= 0.00 Z; 95% CI -0.07, 0.07; P=0.98; moderate quality evidence) with significant heterogeneity (I2 = 57%; P<0.001) related to dose and duration of zinc between trials. There was little or no effect on change in height-for-age Z score (13 trials; 8852 participants; MD= 0.11 Z; 95% CI -0.00, 0.21; P=0.05), but the heterogeneity was considerable (I2=94%; P<0.001). There was no evidence of effect on length (6303 participants; MD= 1.18 cm; 95% CI -0.63, 2.99 cm, P=0.20; moderate quality evidence; considerable heterogeneity, I2=99%) but a little positive effect on change in length (19 trials; 10783 participants; MD= 0.43 cm; 95% CI 0.16, 0.70, P=0.002; moderate quality evidence; considerable heterogeneity, I2=93%). There was no evidence of effect on weight-for-age Z score or change in weight-for-age Z score but a little positive effect on weight (19 trials; 8851 study participants; MD= 0.23 kg; 95% CI 0.03, 0.42; P=0.02; considerable heterogeneity, I2=91%) and change in weight (kg) (23 trials; 10143 study participants; MD= 0.11 kg; 95% CI 0.05, 0.17, P<0.001, substantial heterogeneity, I2=80%). There was no evidence of effect on weight-for-height Z score, and mid upper arm circumference at the end of supplementation period, but there was a little positive effect on change in mid-arm circumference from baseline (8 trials; 1724 participants; MD = 0.09 cm; 95% CI 0.01, 0.16; P=0.03; no heterogeneity, I2=0%). Head circumference in zinc supplemented group was marginally higher compared to control (2966 study participants; MD= 0.39 cm; 95% CI 0.03, 0.75; P=0.03; substantial heterogeneity, I2=67%). There was no evidence of benefit in stunting (10 trials; 11838 study participants; RR= 1.0; 95% CI 0.95, 1.06; P=0.89; moderate quality evidence; no significant heterogeneity, I2=11%), wasting (7 trials; 8988 study participants; RR= 0.94; 95% CI 0.82, 1.06; P=0.31; moderate quality evidence; no significant heterogeneity, I2=13%) or underweight (7 trials; 8677 study participants; RR= 1.08; 95% CI 0.96, 1.21; P=0.19; moderate quality evidence; substantial heterogeneity, I2=73%). Available evidence suggests that zinc supplementation probably leads to little or no improvement in anthropometric indices and malnutrition (stunting, underweight and wasting) in children under five years of age in LMICs. Advocating zinc supplementation as a public health measure to improve growth, therefore, appears unjustified in these settings with scarce resources.

ILAE Classification of Seizures and Epilepsies: An Update for the Pediatrician.

Abstract: The International League Against Epilepsy (ILAE) recently published an updated classification of seizures and epilepsy. This updated classification aims to have a better organized classification and ensure better understanding of terms, in addition to including new seizure types. As both seizures and epilepsy are important childhood conditions, we herein list some of the important aspects of the updated classification for the benefit of the general pediatricians. The full classifications are available at the ILAE website.