Indian Academy of Pediatrics Consensus Guidelines for Probiotic Use in Childhood Diarrhea.

JUSTIFICATION: Several probiotic species and strains, single or combined, have been evaluated in childhood diarrheal disorders, and recommendations have ever been changing as newer trials are published. Therefore, there is a need to develop a guideline for Indian children describing the current role of probiotics in clinical practice. OBJECTIVES: To develop a guideline for the use of probiotics in children with diarrhea. PROCESS: A national consultative group (NCG) was constituted by the Indian Academy of Pediatrics (IAP), consisting of subjects experts. Sub-topics were allotted to various experts as paired groups for detailed review. Members reviewed the international and Indian literature for existing guidelines, systematic reviews, meta-analyses and trials. Thereafter, two virtual structured meetings of the group were held on 2nd and 22nd August, 2020. The management guidelines were formulated by the group and circulated to the participants for comments. The final guidelines were approved by all experts, and adopted by the IAP executive board. RECOMMENDATIONS: The NCG suggests Lactobacillus GG as a conditional recommendation with low-to-moderate level evidence or Saccharomyces boulardii as a conditional recommendation with very low-to-low level evidence as adjuvant therapy in acute diarrhea. The NCG also recommends the use of combination probiotics in neonatal necrotizing enterocolitis (NEC), as these reduce the risk of NEC stage II and above, late-onset sepsis, mortality and also time to achieve full feeds. The NCG does not recommend the use of any kind of probiotics in the therapy of acute dysentery, persistent diarrhea, Clostridium difficile diarrhea and chronic diarrheal conditions such as celiac disease, diarrhea-predominant irritable bowel syndrome and inflammatory bowel disease in children. Risk of antibiotic-associated diarrhea (AAD) is high with some antibiotics and most of these cases present as mild diarrhea. The NCG recommends probiotics only in special situations of AAD. L. rhamnoses GG or S. boulardii may be used for the prevention of AAD. VSL#3, a combination probiotic, may be used as an adjuvant in active pouchitis, prevention of recurrences and maintenance of remission in pouchitis.

Vaccination in preterm and low birth weight infants in India.

In India, the high neonatal and infant mortality rate is due in part to an increasing number of preterm and low birth weight (LBW) infants. Given the immaturity of immune system, these infants are at an increased risk of hospitalization and mortality from vaccine-preventable diseases (VPDs). In this narrative review, we screened the scientific literature for data on the risk of VPDs, vaccination delay and factors related to it in Indian preterm and LBW infants. Although routine childhood vaccinations are recommended regardless of gestational age or birth weight, vaccination is often delayed. It exposes these infants to a higher risk of infections, their associated complications, and death. After-birth complications, lack of awareness of recommendations, vaccine efficacy and effectiveness and concerns related to safety are some of the common barriers to vaccination. Awareness campaigns might help substantiate the need for (and value of) vaccination in preterm and LBW infants.

PLAIN LANGUAGE SUMMARYWhat is the context?In India, the high neonatal mortality rate is due in part to an increasing number of pretern and low birth weight intants.Affected infants have a poorly developed inmune system and are more susceptible to contracting vaccine-preventable diseases.The Indian Academy of Pediatrics recommends vaccination according to the same schedule used for full term infants, following chronological (not gestational) age.Delays in vaccinations increase the risk of preventable infections.What is new?Our review of the scientific literature shows that, in India:infections have more serious conseuences in preterm and low birth weight infantsdelays to vaccinate affected infants are common, mostly due to safety and effectiveness concerns from parents and healthcare pracitionrs.What is the impact?Improving mternal nutritional status and immunization, and perinatal care could help reduce the number of preterm and low birth weight infants.Combining maternal immunization with vaccination of affected infants can confer safe and effective protection.Awareness campaigns for parents and healthcare practitioners could address the issue of vaccination delay in pretern and low birth weight infants in India.

Indian Academy of Pediatrics Guidelines for Pediatric Skin Care.

OBJECTIVE: To develop standard recommendations for skin care in neonates, infants and children to aid the pediatrician to provide quality skin care to infants and children. JUSTIFICATION: Though skin is the largest organ in the body with vital functions, skin care in children especially in newborns and infants, is not given the due attention that is required. There is a need for evidence-based recommendations for the care of skin of newborn babies and infants in India. PROCESS: A committee was formed under the auspices of Indian Academy of Pediatrics in August, 2018 for preparing guidelines on pediatric skin care. Three meetings were held during which we reviewed the existing guidelines/ recommendations/review articles and held detailed discussions, to arrive at recommendations that will help to fill up the knowledge gaps in current practice in India. The initial draft of the manuscript based on the available evidence and experience, was sent to all members for their inputs, after which it was finalized. RECOMMENDATIONS: Vernix caseosa should not be removed. First bath should be delayed until 24 hours after birth, but not before 6 hours, if it is not practically possible to delay owing to cultural reasons. Duration of bath should not exceed 5-10 minutes. Liquid cleanser with acidic or neutral pH is preferred, as it will not affect the skin barrier function or the acid mantle. Cord stump must be kept clean without any application. Diaper area should be kept clean and dry with frequent change of diapers. Application of emollient in newborns born in families with high risk of atopy tends to reduce the risk of developing atopic dermatitis. Oil massage has multiple benefits and is recommended. Massage with sunflower oil, coconut oil or mineral oil are preferred over vegetable oils such as olive oil and mustard oil, which have been found to be detrimental to barrier function.

Indian Academy of Pediatrics Position Paper on Kawasaki Disease.

OBJECTIVE: To formulate practice guidelines on diagnosis and management of Kawasaki disease (KD) for Indian children. JUSTIFICATION: KD is a systemic vasculitis that predominantly affects infants and children less than 5 years of age. Coronary artery abnormalities (CAA) develop in around 15-25% of untreated children with KD. Coronary artery involvement can lead to long-term cardiovascular implications such as development of premature coronary artery disease. Diagnosis of KD is essentially clinical based on recognition of a constellation of characteristic symptoms and signs. Timely diagnosis and initiation of intravenous immunoglobulin (IVIG) therapy is known to produce five-fold reduction in the incidence of CAA. As there is no confirmatory laboratory test for KD, the diagnosis may be missed if one is not familiar with the nuances of clinical diagnosis. PROCESS: A committee was formed under the auspices of Indian Academy of Pediatrics in early 2018 for preparing guidelines on KD in Indian children. A meeting of the consultative committee was held in Mumbai, and a draft protocol was devised. All members scrutinized the recent publications on the subject and an attempt was made to arrive at a broad consensus. Published guidelines on the subject were also reviewed. RECOMMENDATIONS: The diagnosis is clinical and is aided by laboratory and 2D echocardiography. First line of therapy is IVIG, and should be started expeditiously once the diagnosis is made.

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

JUSTIFICATION: 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. OBJECTIVES: 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. CONCLUSIONS: 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 <2y), whereas for children aged 2-5 y and >5-18 y, their intake should be limited to 125 mL/day and 250mL/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.

2019 WACEM - Academic College of Emergency Experts Consensus Recommendations on Admission Criteria to Pediatric Intensive Care Unit from the Emergency Departments in India.

There is a global variation in policies that define clear indications for pediatric intensive care unit (PICU) admissions. In resource-limited countries where PICU service availability is limited, the admission criteria to PICU are urgently needed to optimize the utilization of available intensive care services and to maximize patient benefit. The objective of these consensus recommendations on PICU admission criteria is to provide a framework and reference for future policy development by professional societies and governments. DESIGN: The consensus recommendations were developed by a multidisciplinary consensus task force comprised of international experts in pediatric critical care, emergency medicine, trauma, critical care, and health policy stakeholders during the 2016 annual INDUSEM WORLD CONGRESS in Bengaluru, India. MEASUREMENTS AND MAIN RESULTS: A task force steering committee completed a global literature search about PICU admission criteria development, reviewed PICU admission guidelines published by a variety of professional organizations worldwide, and performed a literature review of relevant publications. The objectives of this task force is to provide a framework for validated approach to determine appropriateness of intensive care unit (ICU) admission in India (resource-limited setting) based on (a) prioritization modeling; (b) general clinical criteria; (c) clinical and objective parameters; and (d) other criteria. The expert consensus panel then discussed and ranked proposed criteria according to scientific evidence, the current standard of care, and expert opinion in the context of the Indian health system. The general subject was addressed in sections: admission criteria and benefits of different levels of care. Following the appraisal of the literature, discussion, and consensus, recommendations were written. CONCLUSION: Although these are consensus recommendations, the subjects addressed encompass complex ethical and medicolegal aspects of patient care that affect daily clinical practice. The scarcity of high-quality evidence made it difficult to answer all the questions asked related to ICU admission. Despite these limitations, the members of the task force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission process. This publication is designed to assist in future development of health policies to ensure effective resource allocation, maximize healthcare benefits, and improve access to quality care for children.

A health care delivery model focusing on development of a cadre of primary care physicians-Recommendations of Organized Medicine Academic Guild.

Organized medicine is the academic guild of professional medical organizations in India. It was founded at the annual conference of Indian Academy of Pediatrics (PEDICON) on January 7, 2018. Organized medicine is constituted by leading professional medical organizations and mandated to support the sustainability of health agenda of the Government of India. A group of experts on behalf of Organized Medicine Academic Guild (OMAG) of India was constituted to facilitate adequate theories and models on how to make primary care integral to participation of people and intersectoral collaboration in equitable delivery of health care. A subtle, flexible, and comprehensive approach instead of a "compartmentalized existing in silos" approach is likely to be needed. This paper is a formal recommendation on behalf of OMAG with an aspiration to deliver to the people of India, what they need, focusing on discrete objectives with long-term plans.

Defining the Best Interest of a Child: Who Comes First - The Child or the Fetus?

In 2017, a 10-year-old girl, who was allegedly raped and impregnated, was denied an abortion on the basis of the Medical Termination of Pregnancy Act 1971. This perspective re-examines this issue while prioritizing the best interest of the child. We recommend that boards should be constituted at district-level hospitals, headed by senior pediatricians, and supported by obstetricians, psychologists, neonatologists, medical social workers, and others to decide the course of action - in particular, the outcome, irrespective of the weeks of pregnancy. If not compatible with the child's life, earlier termination of pregnancy should be considered ensuring the availability of state-of-the-art care to the newborn and the young mother.