Incidence and Outcome of Acute Cardiorenal Syndrome in Hospitalized Children

Objectives

To determine the incidence, etiology and outcome of Cardiorenal syndrome (CRS) in hospitalized children.

Methods

A prospective cohort study was carried out in 242 children between 6 mo to 18 y of age hospitalized with primary cardiac, renal or any systemic disorder at a tertiary care center in India. The primary outcome was the development of CRS. Univariate and multivariate logistic regression analysis were performed to determine the risk of mortality secondary to CRS.

Results

Among 242 children, 67 (27.7%) children developed CRS and the rest 175 (72.3%) did not. Among those with CRS, 40.3%, 20.9%, and 38.8% had CRS-1, 3 and 5, respectively. Cardiac diseases leading to CRS were myocarditis (40.7%) followed by congenital heart disease (25.9%), rheumatic heart disease (18.5%), and dilated cardiomyopathy (7.4%); renal disease associated with CRS was acute glomerulonephritis (100%) and major systemic disorders leading to CRS were septicemia (53.8%), malaria (23.1%), scrub typhus (7.7%), and acute gastroenteritis (3.8%). The occurrence of CRS was associated with an increased risk of mortality (OR 6.3, 95% CI: 2.8, 14.1; p 0.000). A subgroup analysis revealed that children with CRS having acute kidney injury stage 2 and 3 also had a higher risk of mortality (p 0.001).

Conclusions

The incidence of CRS is quite high in children with cardiac, renal or systemic diseases and is associated with a significant risk of mortality. Children presenting with these illnesses should be monitored for the occurrence of CRS so that early intervention may reduce mortality.

     

Early Neurodevelopmental Outcomes After Corrective Cardiac Surgery In Infants

Objective

To assess neurodevelopmental status in Indian infants undergoing corrective surgery for congenital heart disease (CHD) and to analyze factors associated with neurodevelopmental delay.

Design

Cross-sectional study.

Setting

Tertiary-care pediatric cardiology facility.

Participants

Consecutive infants undergoing corrective surgery for CHD (January 2013–December 2014). Palliative procedures, and patients with known genetic syndromes were excluded.

Main outcome measures

Neurodevelopmental evaluation 3 months, and one year after surgery using Developmental Assessment Scales for Indian Infants (DASII); scores were categorized as delayed if ≤70.

Results

Of the 162 children enrolled, delayed PDI and MDI scores were observed in 33.5% and 19.6% of patients at 3 months, respectively; this reduced to 14.5 % on 1-year follow-up. On multivariate analysis, delayed PDI outcome at one year was predicted by early term birth and one-year postoperative head circumference Z-score <–2. Delayed MDI was associated with higher mean perfusion pressure on cardiopulmonary bypass. Cardiac diagnosis and peri-operative factors did not impact neurodevelopmental outcomes.

Conclusions

Neurodevelopmental status is delayed in 14.5% of infants one year after corrective infant heart surgery.

     

Hotspots in <Emphasis Type="Italic">PTPN11</Emphasis> gene among Indian children with Noonan syndrome

Objectives

To test for PTPN11 mutations in clinically diagnosed cases of Noonan syndrome.

Methods

17 individuals with clinical diagnosis of Noonan syndrome were included in the study. Sanger sequencing of all the 15 exons of PTPN11 was done. A genotype-phenotype correlation was attempted.

Results

Mutation in PTPN11 was detected in 11 out of 17 (64.7 %) patients with Noonan syndrome; 72% had mutation in exon 3 and 27 % had mutation in exon 13.

Conclusion

PTPN11 mutation accounts for 64.7% of cases with clinical features of Noonan syndrome in India. Majority of the mutations are in exon 3 and exon 13 of PTPN11, making them the hotspots in Indian population.

     

Pediatric Appropriate Evaluation Protocol for India (PAEP-India): Tool for Assessing Appropriateness of Pediatric Hospitalization

Objectives

To develop and assess Pediatric Appropriateness Evaluation Protocol for India (PAEP-India) for inter-rater reliability and appropriateness of hospitalization.

Design

Cross-sectional study.

Setting

The available PAEP tools were reviewed and adapted for Indian context by ten experienced pediatricians following semi-Delphi process. Two PAEP-India tools; newborn (≤28 days) and children (>28 days-18 years) were developed. These PAEP-India tools were applied to cases to assess appropriateness of admission and inter-rater reliability between assessors.

Participants

Two sets of case records were used: (i) 274 cases from five medical colleges in Delhi-NCR [≤28 days (n=51); >28 days to 18 years (n=223)]; (ii) 622 infants who were hospitalized in 146 health facilities and were part of a cohort (n= 30688) from two southern Indian states.

Interventions

Each case-record was evaluated by two pediatricians in a blinded manner using the appropriate PAEPIndia tools, and ‘admission criteria’ were categorized as appropriate, inappropriate or indeterminate.

Main outcome measures

The proportion of appropriate hospitalizations and inter-rater reliability between assessors (using kappa statistic) were estimated for the cases.

Results

97.8% hospitalized cases from medical colleges were labelled as appropriate by both reviewers with inter-rater agreement of 98.9% (k=0.66). In the southerm Indian set of infants, both reviewers labelled 80.5% admissions as appropriate with inter-rater agreement of 96.1% (k= 0.89).

Conclusions

PAEP-India (newborn and child) tools are simple, objective and applicable in diverse settings and highly reliable. These tools can potentially be used for deciding admission appropriateness and hospital stay and may be evaluated later for usefulness for cost reimbursements for insurance proposes.

     

Reference centile curves for body fat percentage,fat-free mass,muscle mass and bone mass measured by bioelectrical impedance in Asian Indian children and adolescents

Objectives

To create gender-specific percentile curves for percent body fat (%BF) by Bio electrical Impedance Analysis (BIA) for screening adiposity and risk of hypertension in Indian children and generate reference curves for percent fat-free mass (%FFM), muscle mass (%LM) and bone mineral content (BMC) by using bioelectrical impedance.

Design

Secondary analysis of data from previous multicenter cross-sectional studies.

Setting

Private schools from five regions of India.

Participants

A random sample of 3850 healthy school children (2067 boys) (5-17 yr) from private schools in five major Indian cities.

Methods

Anthropometry, blood pressure (BP) and body composition were measured by bioelectrical impedance. Reference curves were generated by the LMS method.

Main outcome measures

%BF, %FFM, %LM, BMC and BP

Results

Median %BF increased by 6% from 5 to 13 years of age and declined (around 2%) up to 17 years in boys. In girls, %BF increased by 8% from 5 to 14 years and thereafter declined by 3%. Based upon the risk of hypertension, the new cut-offs of 75th and 85th percentile of %BF were proposed for detecting over fatness and excess fatness in children. Median %FFM was 90% at 5 yrs and decreased till 12 years, and then showed a slight increase to 84% at 17 yrs in boys. In girls, it was 86% at 5 yrs and decreased till 15 yrs, and plateaued at 71.8% at 17 yrs.

Conclusions

Reference curves for percent body fat for Indian children would be useful to screen children for health risk in clinical set up.

     

Pediatric rhabdomyosarcoma in India: A single-center experience

Objective

Analyze the profile and outcome of children with rhabdomyosarcoma from a pediatric-oncology unit.

Design

Retrospective analysis of case records over 23 years (1990–2012).

Setting

Government-run, tertiary-care, university hospital in Northern India.

Participants

159 children (<12-years) with a diagnosis of rhabdomyosarcoma were enrolled. The median age was 4 years; 13% were infants.

Main outcome measure

Five-year event free survival.

Results

The median symptom interval was 2-months. Head and neck region was the most frequent site (44%), followed by tumors in the extremity (15.7%). The majority (67%) of the tumors were located at ‘unfavorable’ sites; 68% were >5 cm in size. The most frequent (58%) pathological subtype was embryonal. Treatment was based on the ‘Intergroup Rhabdomyosarcoma Study (IRS) Group’ risk-stratification. 33% were ‘low-risk’ children, 11% were ‘high-risk’. Treatment-refusal (18%) and abandonment (33%) were major impediments. The median ± SE five-year event free survival of those taking treatment was 43.6 ± 6%.

Conclusions

Large sized tumors, tumors at unfavorable locations, and treatment refusal/abandonment contributed to inferior outcome in children with rhabdomyosarcoma.

     

Safety and Immunogenicity of Two Doses of a Quadrivalent Meningococcal Polysaccharide Diphtheria Toxoid Conjugate Vaccine in Indian and Russian Children Aged 9 to 17 Months

Objective

Evaluation of tolerability, safety and immunogenicity of a two-dose series of a quadrivalent meningococcal polysaccharide diptheria toxoid conjugate (ACYW-D) vaccine in Indian and Russian infants/toddlers.

Design

Open-label, single-arm, phase III multi-national trial.

Study participants

300 children aged 9–17 months, previously unvaccinated against meningococcal disease from four sites each in India (n=200) and the Russian Federation (n=100).

Intervention

Two 0.5 mL doses of ACYW-D by intramuscular injection, 3–6 months apart.

Main outcome measures

Meningococcal antibody titers to serogroups A, C, W-135 and Y, determined using a serum bactericidal assay in the presence of human complement before vaccination and 28 days after the second vaccination. Titers ≥1:8 against either/all of the A, C, W-135 or Y were considered seroprotective.

Results

After dose 2, 95.7–99.5% and 92.9–99.0% of infants/ toddlers achieved seroprotection across the four serogroups in India and the Russian Federation, respectively. No immediate adverse events were reported after any dose of ACYW-D. Solicited reactions were reported in 49.2% of participants, and were mainly of Grade 1 severity, and resolved within three days. Unsolicited adverse events were reported in 19.1% of infants: one event (Grade 3 diarrhea, resolving within one day) was considered related to study vaccine. No non-serious adverse events led to premature withdrawal from the study. Four serious adverse events were reported; none were considered related to study vaccine. No deaths occurred during the study.

Conclusions

A two-dose series of ACYW-D vaccine in Indian and Russian children (9-17 month) was well-tolerated with no safety concerns, and induced robust bactericidal antibody responses against the meningococcal serogroups contained in the vaccine.

     

Consensus statement of the Indian Academy of Pediatrics on newborn hearing screening

Justification

Hearing impairment is one of the most critical sensory impairments with significant social and psychological consequences. Evidence-based, standardized national guidelines are needed for professionals to screen for hearing impairment during the neonatal period.

Process

The meeting on formulation of national consensus guidelines on developmental disorders was organized by Indian Academy of Pediatrics in Mumbai, on 18^th and 19^th December, 2015. The invited experts included Pediatricians, Developmental Pediatricians, Pediatric Neurologists and Clinical Psychologists. The participants framed guidelines after extensive discussions.

Objective

To provide guidelines on newborn hearing screening in India.

Recommendations

The first screening should be conducted before the neonate’s discharge from the hospital–if it ‘fails’, then it should be repeated after four weeks, or at first immunization visit. If it ‘fails’ again, then Auditory Brainstem Response (ABR) audiometry should be conducted. All babies admitted to intensive care unit should be screened via ABR. All babies with abnormal ABR should undergo detailed evaluation, hearing aid fitting and auditory rehabilitation, before six months of age. The goal is to screen newborn babies before one month of age, diagnose hearing loss before three months of age and start intervention before six months of age.

     

An Indian family with tyrosine hydroxylase deficiency

Background

Tyrosine Hydroxylase deficiency is a rare neurotransmitter disorder.

Case Characteristics

An Indian family with the disorder.

Observation

Phenotypic variation, elevated serum prolactin, genetic confirmation, and partial treatment-responsiveness.

Messages

Tyrosine Hydroxylase deficiency is a treatable inborn error of metabolism and serum prolactin assists in diagnosis.

     

Neuroschistosomiasis: An Unusual Intracranial Space Occupying Lesion

Background

Neuroschistosomiasis is an uncommonly reported disease.

Case characteristics

An adolescent Indian boy residing in Kenya presented with headache, visual symptoms and seizures, with MRI showing space-occupying lesions in the occipital lobe and cerebellum.

Observation

Brain biopsy was diagnostic of neuro-schistosomiasis; complete recovery was seen with praziquantel and corticosteroid therapy.

Message

This case highlights the importance of considering epidemiology in differential diagnosis and establishing definitive diagnosis even if it is by invasive methods.

     

Validation of Bioelectric Impedance Analysis against Dual-Energy <Emphasis Type="Italic">X</Emphasis>-ray Absorptiometry for assessment of body composition in Indian children aged 5 to 18 years

Objective

To validate body composition measurements by Bioelectric Impedance Analysis (BIA) against Dual-Energy X-ray Absorptiometry (DXA) as the reference method in healthy children and adolescents.

Design

Cross-sectional

Setting

Schools in and around Pune city, India.

Participants

A random sample of 210 (114 boys, 96 girls) apparently healthy Indian children and adolescents (5–18 y).

Methods

Weight, height, Tanner stage (TS) were recorded. Body composition measures: fat-free mass (FFM), fat mass (FM), lean mass (LM), bone mineral content (BMC) and body fat percentage (%BF) were assessed by BIA and DXA on a single day. Agreement between the methods was estimated by Pearson’s correlation, and Bland and Altman analysis.

Main outcome measures

%BF, FM, FFM, LM, BMC.

Results

BIA underestimated %BF by 6.7 (3.7)% as compared to DXA. Mean FFM, BMC and LM by BIA were significantly higher than by DXA (P<0.001). These differences remained similar after adjusting for age, BMI and TS. Mean differences between FFM (?2.32 (1.39) kg), BMC (?0.18 (0.15) kg), and LM (?2.15 (1.34) kg) by DXA and BIA were significant (P<0.01). Correlations between BIA and DXA were 0.92 for %BF, 0.96 for LM and 0.98 for FFM and BMC. Both the methods were similar in identifying normal and overfat children as per their respective cut-offs.

Conclusion

BIA and DXA techniques are not interchangeable for assessment of body composition. However, BIA may be used in the field/clinical setting preferably with ethnicity specific references.

     

Management of Childhood Functional Constipation: Consensus Practice Guidelines of Indian Society of Pediatric Gastroenterology,Hepatology and Nutrition and Pediatric Gastroenterology Chapter of Indian Academy of Pediatrics

Justification

Management practices of functional constipation are far from satisfactory in developing countries like India; available guidelines do not comprehensively address the problems pertinent to our country.

Process

A questionnaire-based survey was conducted among selected practising pediatricians and pediatric gastroenterologists in India, and the respondents agreed on the need for an Indian guideline on the topic. A group of experts were invited to present the published literature under 12 different headings, and a consensus was developed to formulate the practice guidelines, keeping in view the needs in Indian children.

Objective

To formulate practice guidelines for the management of childhood functional constipation that are relevant to Indian children.

Recommendations

Functional constipation should be diagnosed only in the absence of red flags on history and examination. Those with impaction and/or retentive incontinence should be disimpacted with polyethylene glycol (hospital or home-based). Osmotic laxatives (polyethylene glycol more than 1 year of age and lactulose/lactitol less than 1 year of age) are the first line of maintenance therapy. Stimulant laxatives should be reserved only for rescue therapy. Combination therapies of two osmotics, two stimulants or two classes of laxatives are not recommended. Laxatives as maintenance therapy should be given for a prolonged period and should be tapered off gradually, only after a successful outcome. Essential components of therapy for a successful outcome include counselling, dietary changes, toilet-training and regular follow-up.

     

Long-term Seroprotection Rates Following Second Dose of Measles as MMR Vaccine at 15 months in Indian Children

Objective

To find out seropositivity rates at 4-6 and 9-12 years of age; among those who received one-dose measles at 9 months and one-dose MMR at 15 months of age.

Methods

80 healthy children (53 males) at 4-6 or 9-12 years of age, attending outpatient department for vaccination were enrolled. Antibody titers were estimated using commercially available quantitative-IgG ELISA kits.

Results

The seropositivity rates against measles, mumps, rubella were 80% (40/50), 86% (43/50), and 96% (48/50), respectively at 4-6 years, and 83.3% (25/30), 96.7% (29/30) and 96.7% (29/30), respectively at 9-12 years of age.

Conclusion

Single dose of rubella vaccine seems to provide adequate long-term protection; however, measles vaccine requires more doses for similar protection.

     

Physical Activity Patterns Among School Children in India

Objective

To assess the prevalence of physical activity and its relation with socio-demographic variables and eating habits among school-aged children in India.

Methods

The study incorporated secondary analysis of anthropometric measurements and questionnaires on lifestyle and dietary habits of 1,680 school children aged between 3 and 11 y, obtained while carrying out the OBEY-AD project. The inventory contained questions about several variables concerning to physical activity, educational background, lifestyles and eating habits for both children and parents. Questions were organized along specific contents, which could be informative topics, picture choices and multiple answers choices.

Results

Prevalence of inactivity was 21 % and exhibited significant variations between cities. Physical activity was significantly associated to socio-economic status and consumption of fruits and vegetables. No association could be revealed with children’s BMI.

Conclusions

Health-promotion interventions aimed at improving healthy lifestyles in Indian children should focus on population strata with low socio-economic status.

     

Immunogenicity and safety of a liquid hexavalent vaccine in Indian infants

Objective

To evaluate the immunogenicity and safety of a fully liquid, hexavalent diphtheria-tetanus-acellular pertussis–inactivated poliovirus–hepatitis B–Haemophilus influenzae type b (DTaP-IPV-HB-PRP~T) vaccine in Indian infants.

Design

Phase III, single-arm study.

Setting

Two tertiary-care hospitals.

Participants

177 healthy, 6-week-old infants.

Intervention

All participants received hepatitis B vaccine and Oral polio vaccine (OPV) at birth and DTaP-IPV-HB-PRP~T at 6, 10, 14 weeks of age.

Main outcome measures

Serum was analyzed for immune responses to all antigens 1 month post-3rd dose; safety was assessed for 30 minutes post-vaccination, and for 7 days (solicited reactions) and 30 days (unsolicited events).

Results

Seroprotection rates were 100% for anti-HB (≥10 mIU/mL), anti-PRP (≥0.15 μg/mL), anti-T (≥0.01 IU/mL), anti-polio 1, 2, and 3 (≥8 [1/dil]), and 99.3% for diphtheria (≥0.01 IU/mL). For the pertussis antigens, vaccine response rate was 93.8% for anti-PT and 99.3% for anti-FHA. 37.9% and 54.6% of participants experienced at least one solicited injection site and systemic reaction, respectively, and 20.3% of participants experienced at least one unsolicited event (none of which was related to the vaccination). Four serious adverse events (including one death) were reported, but none was related to the vaccination.

Conclusion

The fully liquid DTaP-IPV-HB-PRP~T vaccine is highly immunogenic in infants in India when administered in a 6, 10, 14 week schedule along with HB and OPV administered at birth, and was well tolerated.

     

Nasal Continuous Positive Airway Pressure in Bronchiolitis: <Emphasis Type="Italic">A Randomized Controlled Trial</Emphasis>

Objective

To evaluate the efficacy of nasal continuous positive airway pressure (nCPAP) in decreasing respiratory distress in bronchiolitis.

Design

Randomized controlled trial.

Setting

Tertiary-care hospital in New Delhi, India.

Participants

72 infants (age < 1y) hospitalized with a clinical diagnosis of bronchiolitis were randomized to receive standard care, or nCPAP in addition to standard care, in the first hour after admission. 23 parents refused to give consent for participation. 2 infants did not tolerate nCPAP.

Intervention

The outcome was assessed after 60 minutes. If nCPAP was not tolerated or the distress increased, the infant was switched to standard care. Analysis was done on intention-to-treat basis.

Main outcome measures

Change in respiratory rate, Silverman-Anderson score and a Modified Pediatric Society of New Zealand Severity Score.

Results

14 out of 32 in nCPAP group and 5 out of 35 in standard care group had change in respiratory rate ≥10 (P=0.008). The mean (SD) change in respiratory rate[8.0 (5.8) vs 5.1 (4.0), P=0.02] in Silverman-Anderson score [0.78 (0.87) vs 0.39 (0.73), P=0.029] and in Modified Pediatric Society of New Zealand Severity Score [2.5 (3.01) vs. 1.08 (1.3), P=0.012] were significantly different in the nCPAP and standard care groups, respectively.

Conclusion

nCPAP helped reduce respiratory distress significantly compared to standard care.

     

Abnormal systemic venous connection possibly associated with a persistent right umbilical vein; a case report

Background

Abnormal venous connections involving a persistent right umbilical vein are rare. In a minority of cases the liver is entirely bypassed and the condition is associated with multiple congenital malformations.

Case presentation

The described case illustrates a systemic venous drainage that was severely abnormal in a newborn girl with a truncus arteriosus type II congenital heart defect. Injection of contrast medium through the umbilical vein catheter revealed a very peculiar venous connection that passed anterio-laterally through the right hemithorax before crossing in an oblique fashion towards the superior vena cava.

Conclusions

This venous drainage may be the result of a persistent right umbilical vein connecting with the superior vena cava.

     

Vitamin K supplementation to prevent hemorrhagic morbidity and mortality of newborns in India and China

Background

Vitamin K deficiency bleeding (VKDB) can cause prolonged and bleeding (intracranial hemorrhage) among newborns, which can be life-threatening or lead to long-term morbidity. The aim of this review article is to reiterate empirical evidence to support the argument that vitamin K should be mandatory for newborns in India and China, as well as in other countries with a high burden of neonatal deaths.

Data sources

Studies were integrated from the PubMed/MEDLINE database search, as well as related literature available elsewhere.

Results

Both India and China have been slow in adopting an effective program for administering vitamin K injections to newborns to prevent VKDB-related morbidity and mortality. VKDB cases in China and India have shown inadequate attention to routine use of vitamin K by injection.

Conclusions

While no reliable data are publicly available, the issue of VKDB is at last receiving some attention from the Chinese public health system as well as the Indian government. In both countries, routine vitamin K administration to newborns would prove to be a cost-effective intervention to reduce preventable neonatal morbidity and mortality. VKDB is a global neonatal care issue, including countries where parental resistance is preventing babies from defense against this life-threatening condition.

     

Transcutaneous bilirubin nomogram for healthy term and late preterm neonates in first 96 hours of life

Objective

To develop nomogram of Transcutaneous Bilirubin among healthy term and late-preterm neonates during first 96 hours of age.

Design

Longitudinal observational study.

Setting

Neonatal unit of a tertiary care Hospital of Central Gujarat, India.

Participants

1075 healthy term and late preterm neonates (≥35weeks).

Intervention

Six-hourly transcutaneous bilirubin was obtained from birth to 96 hour of life using Drager JM 103 Transcutaneous Bilirubinometer.

Main outcome measures

Nomogram of Transcutaneous Bilirubin with percentile values was obtained, rate of rise of bilirubin was calculated and predictive ability of normative data was analyzed for subsequent need of phototherapy.

Results

The age-specific percentile curves and nomogram were developed from the transcutaneous bilirubin readings of 1,010 neonates. Rate of rise in first 12 hour was 0.2 mg/dL and was 0.17 mg/dL in 12 to 24 hour of life which decreased on second day of life. Neonates who required phototherapy had consistently higher readings of transcutaneous bilirubin and also higher rate of rise in first 48 hrs.

Conclusion

Neonates whose transcutaneous bilirubin is above the 50th percentile should be monitored for the development of significant hyperbilirubinemia.