School Based Adolescent Care Services: A District Model

Objective

To study the perceived problems of higher secondary school students in a district and to document the effect of a family life and life skill education package.

Methods

A survey was conducted among 11501 adolescents belonging to 103 higher secondary schools in Thiruvananthapuram district, using Teenage Screening Questionnaire-Trivandrum (TSQ-T). Family life and life skill education package was given to class XI students and post intervention evaluation of improvement in knowledge level was assessed after 6 months by a structured pre-tested self-administered questionnaire.

Results

61.2% adolescents reported scholastic problem, 22.1% family related problems, 31.9% personal problems and 15.2% adjustment problems, with boys reporting higher percentage. 65.8% reported body image related problems, 26.4% had dental, 21.3% ENT and 16.2% had dermatological complaints. Among girls 50.2% reported menstrual problems. 506 adolescents volunteered for medical check-up and 1247 for detailed psychological assessment. Family life and life skill education package showed consistent improvement in knowledge even after a gap of 6 months.

Conclusions

The study results showed that a school based adolescent care service programme is effective and feasible.

     

ARSH 8: Family Life Education and Counseling: A School Based Model

Objectives

To understand the problems of school going adolescents in selected schools in the first phase and to provide class based family life education in the second phase.

Methods

Step 1: Identification of the study sample, Step 2: Each adolescent was individually administered TSQ-T by trained project staff , Step 3: ‘Family life education’ sessions were held for the whole class together, Step 4: Queries were collected on a slip of paper without writing their names, Step 5: Those needing medical attention was seen by a medical doctor and psychologist Step 6: Preparation of a guide book named “101 questions”, Step 7: Upscaling the project as a service component to Government schools.

Results

4.6 % of school going boys and 2.5 % of girls were underweight and 4.4 % of boys and 7.8 % of girls were obese. Less than 5 % of adolescents had symptoms suggestive of various mental health disorders, 2.6–8.3 % for attention def-icit hyperactivity disorder (ADHD), 3 % for eliminating disorder, 0.9–2.2 % for conduct disorder, 0.9–3.3 % for anxiety disorders, 1.7–4.4 % for depression and 0.8–1.1 % for psychosis. Adolescent school going girls had a mean age of menarche at 12.7 y and 46 % of girls did not receive any prior information about menarche.

Conclusions

Screening of adolescents using TSQ-T developed at CDC, Kerala and used extensively in community projects, was found to be useful in identifying adolescents with nutrition and lifestyle issues, scholastic problems, mental health problems and reproductive health problems.

     

Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children

Background

Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome.

Aims

To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery.

Methods

We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients’ Visick score assessed parents’ perspective.

Results

Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents’ perspectives were excellent or good in 85 %.

Conclusions

A significant positive impact of redo Nissen intervention on the patient’s outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.

     

Congenital diaphragmatic hernia in neonates: factors related to failure of thoracoscopic repair

Purpose

To evaluate factors related to conversion to open repair (OR) during thoracoscopic repair (TR) in congenital diaphragmatic hernia (CDH).

Methods

CDH subjects who were diagnosed prenatally or within 6 h of birth and underwent TR at our institution from 2007 to 2015 were reviewed. Two groups were defined: Group A, subjects who tolerated TR; and Group B, subjects who required conversion to OR.

Results

Twenty-nine subjects (Group A, 20; Group B, 9) underwent TR. Patients’ demographics were not significantly different between the two groups. In Group A, pre-operative arterial blood gas analysis showed mean PaCO₂ 37.4 mmHg, mean pH 7.45, and mean PaO₂ 201.6 mmHg, which were not significantly different from those of Group B (PaCO₂ 40.6 mmHg, pH 7.43, and PaO₂ 251.1 mmHg). Two Group B cases required conversion due to cardiopulmonary instability. The remaining seven cases were converted for technical reasons (large defect in two, anterior location of the defect in two, bleeding from short gastric vessels or spleen in two, and insufficient operative view in one).

Conclusions

TR can be performed safely in selected cases of CDH. CDH with a large defect and/or an unusual location of the defect remains a challenge for pediatric surgeons.

     

Chronic Kidney Disease (CKD): An Observational Study of Etiology,Severity and Burden of Comorbidities

Objectives

To study the etiology and burden of comorbidities across stages of chronic kidney disease (CKD).

Methods

Children, 2–16 y of age with CKD Stages II- IV were recruited over 12 mo. The etiology, clinical presentation and severity of complications were studied.

Results

Among 78 children [Stage II (n = 21), Stage III (n = 26), Stage IV (n = 31)], congenital anomalies of the kidney and urinary tract (CAKUT) was the commonest etiology and 28 were newly diagnosed in Stage III /IV. High prevalence of comorbidities was observed with growth retardation (65%), hypertension (59%), hyperphosphatemia (32%), vitamin D deficiency (92%), dyslipidemia (64%), left ventricular hypertrophy (45%) and hyperparathyroidism (56%). While most comorbidities correlated with the estimated glomerular filtration rate and severity of CKD, hypertension, vitamin D deficiency and cardiovascular morbidity were prevalent even in early stages.

Conclusions

CAKUT was the commonest cause of CKD. Late detection and high prevalence of comorbidities even in early stages of CKD were observed.

     

Effect of timing of cannulation on outcome for pediatric extracorporeal life support

Purpose

Literature reports worse outcomes for operations performed during off-hours. As this has not been studied in pediatric extracorporeal life support (ECLS), we compared complications based on the timing of cannulation..

Methods

This is a retrospective review of 176 pediatric ECLS patients between 2004 and 2015. Patients cannulated during daytime hours (7:00 A.M. to 7:00 P.M., M-F) were compared to off-hours (nighttime or weekend) using t-test and Chi-square.

Results

The most common indications for ECLS were congenital diaphragmatic hernia (33 %) and persistent pulmonary hypertension (23 %). When comparing regular hours (40 %) to off-hours cannulation (60 %), there were no significant differences in central nervous system complications, hemorrhage (extra-cranial), cannula repositioning, conversion from venovenous to venoarterial, mortality on ECLS, or survival-to-discharge. The overall complication rate was slightly lower in the off-hours group (45.7 % versus 61.9 %, P = 0.034).

Conclusion

Outcomes were not significantly worse for patients undergoing ELCS cannulation during off-hours compared to normal weekday working hours.

     

Effect of delayed cord clamping on hematocrit,and thermal and hemodynamic stability in preterm neonates: <Emphasis Type="Italic">A randomized controlled trial</Emphasis>

Objective

To evaluate the short term clinical effects of delayed cord clamping in preterm neonates.

Design

Randomized controlled trial.

Setting

A tertiary care neonatal unit from October 2013 to September 2014.

Participants

78 mothers with preterm labor between 27 to 31^6/7 weeks gestation.

Intervention

Early cord clamping (10 s), delayed cord clamping (60 s) or delayed cord clamping (60 s) along with intramuscular ergometrine (500 μg) administered to the mother.

Main outcome measures

Primary: hematocrit at 4 h after birth; Secondary: temperature on admission in neonatal intensive care unit, blood pressure (non-invasive) at 12 h, and urinary output for initial 72 h.

Results

Mean (SD) hematocrit at 4 h of birth was 58.9 (2.4)% in delayed cord clamping group, and 58.7 (2.1)% in delayed cord clamping with ergometrine group as compared to 47.6 (1.3)% in early cord clamping group. Mean (SD) temperature on admission in NICU was 35.8 (0.2)ºC, 35.8 (0.3)ºC, and 35.5 (0.3)ºC, respectively in these three groups. The mean (SD) non-invasive blood pressure at 12 h of birth was 45.8 (7.0) mmHg, 45.8 (9.0) mmHg, and 35.5 (8.6) mmHg, respectively in these three groups. Mean (SD) urinary output on day 1 of life was 1.1 (0.2) mL/kg/h, 1.1 (0.2) mL/kg/hr and 0.9 (0.2) ml/kg/h, respectively.

Conclusion

In preterm neonates delayed cord clamping along with lowering the infant below perineum or incision site and administration of ergometrine to mother has significant benefits in terms of increase in hematocrit, higher temperature on admission, and higher blood pressure and urinary output during perinatal transition.

     

ARSH 4: Parental Understanding of Adolescent Issues: Parent-Adolescent Dyad Agreement

Objective

To elicit areas of discordance between the parent-adolescent dyad with regard to reproductive sexual health issues using the same questions to both and to elicit the gender sensitivity of the parents.

Methods

This study was conducted using similar questions for both adolescents and young adults and their parents in three districts of Kerala. Data analysis was done comparing unmarried adolescents and young adults’ response to reproductive and sexual health issues and the parental agreement status with their ward’s responses.

Results

There were a total of 3,625 parent-unmarried young adults dyads. Parental attitudinal difference towards their sons and daughters on selected parenting issues was observed. With regard to the following reproductive and sexual health problems, (i) knew about menstruation before menarche (64.1 %), (ii) got information on hygiene practices from home (80.8 %), (iii) have menstrual problems (66.4 %), agreement with adolescent response was high, whereas with regard to (i) anxious about adolescent physical and mental changes (29.2 %), (ii) received information on reproductive sexual health (RSH) from mother (26.7 %), (iii) do not have any abnormal vaginal discharge (46.7 %), (iv) parents taken precautions to prevent sexual abuse (17.5 %), (v) have been sexually abused (15.6 %), agreement with unmarried young adults’ response was low and all these differences were statistically significant.

Conclusions

The results of 3,625 parent-unmarried adolescents and young adults dyad data showed poor agreement on vital issues like sexual abuse apart from gender inequality favouring sons.

     

Analysis of the prognostic factors of long-term native liver survival in survivors of biliary atresia

Purpose

Long-term survivors of biliary atresia (BA) sometimes experience liver dysfunction. We evaluated the prognostic factors for long-term native liver survival (NLS) in BA patients after the Kasai procedure.

Methods

This study included 67 patients with jaundice disappearance after the Kasai procedure performed between 1972 and 1995, and NLS for over 10 years. We retrospectively evaluated the clinical parameters, including the type of BA, age at the Kasai procedure, medical conditions, and treatments. The adjusted odds ratios (aOR) were obtained for 20-year NLS using logistic regression analysis.

Results

The median age of the patients at the Kasai procedure was 63 days. Of the 67 study patients, 62 patients (92.5 %) had jaundice-free NLS at the age of 20 years, 4 patients died before the age of 20 years from liver failure, and 1 patient underwent living related liver transplantation. The presence of gastro-esophageal varices requiring endoscopic injection sclerotherapy was a significant factor (aOR 33.8; p = 0.0033), while hypersplenism and cholangitis were not identified as significant factors.

Conclusions

The existence of symptomatic portal hypertension would influence long-term NLS in BA patients after the Kasai procedure. In such patients, accurate evaluation of hepatic function and adequate treatment for sequelae are needed.

     

Onset ages of hepatopulmonary syndrome and pulmonary hypertension in patients with biliary atresia

Purpose

Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) are extrahepatic complications of biliary atresia (BA). Their detection is sometimes delayed, which may result in missed opportunities for liver transplantation. The aim of this study was to determine the onset ages of HPS and PoPH in BA patients.

Methods

BA patients followed at our institution were identified. Patients visited our clinic for routine blood work, as well as regular electrocardiography, chest X-rays, and arterial blood gas tests. Lung perfusion scintigraphy and cardiac ultrasound were performed to diagnose HPS. Cardiac catheterization was conducted to diagnose PoPH.

Results

The study population consisted of 88 BA patients. The median follow-up duration was 11.6 years (range 0.8–26.0 years). Six patients (6.8%) developed HPS and three patients (3.4%) developed PoPH. The median age of onset of HPS was significantly younger than that of PoPH (HPS: 4 years, PoPH: 15 years, P < 0.019). Two patients (66%) with PoPH died, while all patients with HPS survivied.

Conclusion

The onset of HPS was significantly earlier than that of PoPH. The mortality rate was high in patients with PoPH. Teenagers with BA should receive routine cardiac echocardiograms to detect PH in its early stages.

     

ADad 2: The Validation of the Screen for Child Anxiety Related Emotional Disorders for Anxiety Disorders Among Adolescents in a Rural Community Population in India

Objective

Screen for Child Anxiety Related Emotional Disorders (SCARED), a measure found useful in different settings and cultures has not been validated in the subcontinent. This study validated this measure for identifying Anxiety Disorder (AD) among adolescents in an Indian community context.

Methods

Five hundred adolescents were assessed with SCARED and DSM-IV-TR reference standard for diagnosis of AD. The interviewers were experienced raters who were further trained to interview participants using Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version (K-SADS-PL). Sensitivity, specificity, likelihood ratios and predictive values for various SCARED cut-off scores were calculated. Test-retest reliability and inter-rater reliability of SCARED were examined. The dichotomized SCARED score was correlated with the DSM-IV-TR clinical diagnosis of AD to establish the criterion validity of SCARED as a measure of AD.

Results

A SCARED total score of ≥21(Sn?=?84.62 %, Sp?=?87.36 %; AUC?=?90 %) is suggested for diagnostic use in Indian population. Specific threshold scores were identified for the Panic Disorder, Generalized Anxiety Disorder, Separation Anxiety Disorder and Social Anxiety Disorder subscales. The inter-rater reliability (ICC?=?0.87) and test-retest reliability (ICC?=?0.90) for SCARED is good. Besides the adequate face and content validity, SCARED demonstrates good internal consistency (Cronbach’s α?=?0.89) and item-total correlation. There is a high concordance rate with the reference standard, DSM-IV-TR diagnosis [81 %; Cohen’s κ?=?0.42 (95 % CI?=?0.31 to 0.52); P?=?0.001] in classifying AD.

Conclusions

SCARED has adequate psychometric properties and is now available for clinical and research work in India.

     

Dose optimisation for intraoperative cone-beam flat-detector CT in paediatric spinal surgery

Background

During surgery for spinal deformities, accurate placement of pedicle screws may be guided by intraoperative cone-beam flat-detector CT.

Objective

The purpose of this study was to identify appropriate paediatric imaging protocols aiming to reduce the radiation dose in line with the ALARA principle.

Materials and methods

Using O-arm® (Medtronic, Inc.), three paediatric phantoms were employed to measure CTDI_w doses with default and lowered exposure settings. Images from 126 scans were evaluated by two spinal surgeons and scores were compared (Kappa statistics). Effective doses were calculated. The recommended new low-dose 3-D spine protocols were then used in 15 children.

Results

The lowest acceptable exposure as judged by image quality for intraoperative use was 70 kVp/40 mAs, 70 kVp/80 mAs and 80 kVp/40 mAs for the 1-, 5- and 12-year-old-equivalent phantoms respectively (kappa = 0,70). Optimised dose settings reduced CTDI_w doses 89–93%. The effective dose was 0.5 mSv (91–94,5% reduction). The optimised protocols were used clinically without problems.

Conclusions

Radiation doses for intraoperative 3-D CT using a cone-beam flat-detector scanner could be reduced at least 89% compared to manufacturer settings and still be used to safely navigate pedicle screws.

     

Behavioral,emotional and social functioning in children born with congenital diaphragmatic hernia

Purpose

The aim was to investigate social competence and behavioral and emotional problems in children and adolescents born with CDH.

Methods

All children born with CDH, treated in Stockholm 1990–2009, were invited to participate. After written consent, the Child Behavior Checklist or Adult Self-Report questionnaires were sent to participants. Of the 145 long-term survivors, 51% returned a completed questionnaire. Both the syndrome and competence scales were used and open-ended questions were analyzed with manifest content analysis.

Results

All parents of children aged 1.5–5 years and 90% of parents of children aged 6–18 years reported a normal range on the syndrome scale. Five parents indicated internalizing, but none externalizing behavior. All young adults achieved a normal score on the syndrome scale. Eighty-five percent had normal school achievement, 79% had normal social scores and 40% had normal activity levels. Significantly fewer boys (23%) were in the normal activity range compared with 67% of girls.

Conclusions

The vast majority of all parents of children born with CDH scored no behavioral or emotional problems, furthermore, they reported normal social and school competence. However, the activity levels seemed to be reduced in children born with CDH.

     

Wachstum bei Störungen der Schilddrüsenfunktion im Kindes- und Jugendalter

Background

Disorders of the thyroid function of mother and child can not only irreversibly inhibit maturation of the central nervous system, but may also affect growth and puberty.

Objectives

Review of the consequences of thyroid function disorders on the growth of children and adolescents and the relevance of adequate treatment.

Materials and Methods

This article summarises the current literature concerning the effect of thyroid hormone disorders of mother and child and their therapy on growth.

Results

Every untreated manifestation of congenital or acquired hypothyroidism is associated with a delay of growth and skeletal maturation. In children presenting with acquired hyperthyroidism, height is shifted towards higher values and skeletal maturation is accelerated. Approximately 20?% of children and adolescents with Down syndrome develop primary hypothyroidism, frequently manifesting within the first months of life (approximately 5.5?%). Adequate treatment of the thyroid disorder can normalise growth disorders. About 6?% of children with growth hormone deficiency develop abnormally low free thyroxin (fT4) levels in serum during growth hormone treatment due to increased conversion of T4 to T3. There is no indication for treatment after excluding secondary hypothyroidism.

Conclusions

Early diagnosis and timely, adequate treatment of thyroid function disorders of mother and child are essential to achieving growth that is as age-appropriate as possible in affected children and adolescents

     

Outcomes of congenital diaphragmatic hernia repair on extracorporeal life support

Purpose

Extracorporeal life support (ECLS) is applied to refractory pulmonary hypertension in congenital diaphragmatic hernia (CDH). We evaluate the single-center outcomes of infants with CDH to determine the utility of late repair on ECLS versus repair post-decannulation.

Methods

Records of infants with CDH (2004–2014) were retrospectively reviewed.

Results

CDH was diagnosed in 177 infants. Sixty six (37%) underwent ECLS, of which, 11 died prior to repair, 33 were repaired post-decannulation, and 22 were repaired on ECLS. Repair was delayed in patients on ECLS (19 versus 10 days, p < 0.001). Patients repaired on ECLS had longer ECLS runs (22 versus 12 days, p < 0.001) and higher rates of bleeding and mortality than those repaired post-decannulation. Survival was 54% in infants undergoing ECLS, 65% in those who underwent repair, 36% in those repaired during ECLS, and 85% in those who were decannulated prior to repair. Eighteen percent (N = 4) of deaths after repair on ECLS were attributable to surgical bleeding. The remainder was due to pulmonary hypertension or sepsis.

Conclusion

Infants who underwent CDH repair post-decannulation had excellent outcomes and no mortalities attributable to repair. Neonates who underwent repair on ECLS late on bypass had the lowest survival rate with only 18% of mortality in this cohort attributable to surgical bleeding.

     

Incidence and Risk Factors for Hypertension During Childhood Acute Lymphoblastic Leukemia Therapy

Objective

To determine the incidence of hypertension among children during the induction and re-induction phases of acute lymphoblastic leukemia (ALL) therapy and association with possible risk factors.

Methods

A retrospective analysis of 208 consecutive pediatric (age <18 y) ALL patients, treated per BFM-95 protocol between January 2009 and December 2013. Data were analyzed to determine the incidence of hypertension and risk factors for its development.

Results

Incidence of hypertension requiring antihypertensive medication, was 29% (61/208) during induction and 17% (33/198) during re-induction (P=0.003). Median (range) age of patients developing hypertension was 4 y (4 mo to 8 y). Age <10 y and presence of constipation were independently predictive of hypertension by multivariate analysis.

Conclusion

The present study reports a high incidence of hypertension among children undergoing ALL induction therapy.

     

Airway reconstruction using decellularized tracheal allografts in a porcine model

Purpose

Tracheal cartilage reconstruction is an essential approach for the treatment of tracheal congenital abnormalities or injury. Here, we evaluated the use of allogeneic decellularized tracheas as novel support scaffolds.

Methods

Six weaned pigs (4-week-old domestic males) were transplanted with allogeneic tracheal graft patches (three decellularized and three fresh tracheal scaffolds) onto artificial defects (approximately 15 × 15 mm). After 11 weeks, the tracheas were evaluated by bronchoscopy and histological studies.

Results

No pigs displayed airway symptoms during the observation period. Tracheal lumen restored by fresh graft patches showed more advanced narrowing than that treated with decellularized grafts by bronchoscopy. Histologically, fresh grafts induced typical cellular rejection; this was decreased with decellularized grafts. In addition, immunohistochemistry demonstrated regenerating foci of recipient cartilage along the adjacent surface of decellularized tracheal grafts.

Conclusion

Decellularized allogeneic tracheal scaffolds could be effective materials for restoring impaired trachea.

     

Pediatric Asthma and Food Allergy

Objective

To quantitatively summarize the evidence from observational studies on the relation between pediatric asthma and food allergy.

Methods

A literature search was conducted in Medline and EMBASE (August 2016). Two independent reviewers appraised the studies and extracted the estimates of interest. Methodological quality of the included studies was assessed using National Heart Lung and Blood Institute (NHLBI) Quality Assessment Tools. Data were pooled using random-effects meta-analysis.

Results

A total of 32 relevant studies were identified but only 8 studies met the inclusion criteria. Using random-effect model, food allergy showed strong association with asthma in children (OR = 2.87 [95% CI: 2.05–4.00]; P < 0.0001).

Conclusions

This study suggested that food allergy is associated with an increased risk of asthma in children.

     

Clinical safety of 3-T brain magnetic resonance imaging in newborns

Background

The effects and potential hazards of brain magnetic resonance imaging (MRI) at 3 T in newborns are debated.

Objective

Assess the impact of 3-T MRI in newborns on body temperature and physiological parameters.

Material and methods

Forty-nine newborns, born preterm and at term, underwent 3-T brain MRI at term-corrected age. Rectal and skin temperature, oxygen saturation and heart rate were recorded before, during and after the scan.

Results

A statistically significant increase in skin temperature of 0.6 °C was observed at the end of the MRI scan (P<0.01). There was no significant changes in rectal temperature, heart rate or oxygen saturation.

Conclusion

Core temperature, heart rate and oxygen saturation in newborns were not affected by 3-T brain MR scanning.

     

ARSH 2: Reproductive and Sexual Health Knowledge,Attitude and Practices: Comparison Among Boys and Girls (10–24 y)

Objective

To compare the knowledge, attitude and practice of boys and girls on reproductive sexual health and their perspective on the needs of adolescents on this aspect.

Methods

This comparative study was conducted among boys and girls between 10 and 24 y in three districts of Kerala; through a cross sectional community survey using a pretested structured schedule with additional sexuality related questions for 15–24 y age group.

Results

Higher percentage of boys knew about condoms (95.1 %, p 0.001) whereas higher percentage of girls (56.5 %, p 0.001) knew about copper-T. Girls had a better knowledge on legal age of marriage (91 %, p 0.001), that both the partners are equally responsible for the problem of infertility (89.7 %, p 0.009) and that the gender of the baby is determined by male sperm (60.4 %, p 0.001). Above 90 % of boys and girls demanded adolescent care services and facilities for counseling.

Conclusions

This comparative study on knowledge, attitude and practice of boys and girls between 10 and 24 y has shown that greater proportion of girls had correct knowledge on the legal age of marriage, ideal age of pregnancy, preferred an arranged marriage and felt the need for premarital counseling.