Determining the burden of missed opportunities for vaccination among children admitted in healthcare facilities in India: a cross-sectional study.

OBJECTIVES: Children accessing healthcare systems represent a vulnerable population with risk factors for poor health outcomes, including vaccine-preventable diseases. We aimed to quantify missed vaccination opportunities among hospitalised children in India, and identify vaccination barriers perceived by caregivers and healthcare providers. DESIGN: Cross-sectional study. SETTING: Two public-sector tertiary-care hospitals in northern India, during November 2018 and March 2019. PARTICIPANTS: We tracked 263 hospitalised children aged 1-59 months through hospital discharge, to assess vaccination status, and document catch-up vaccinations given during the hospital stay. We interviewed caregivers and healthcare providers to assess their perceptions on vaccination. OUTCOMES: Proportion of hospitalised children considered under-vaccinated for their age; proportion of missed opportunities for vaccination among under-vaccinated children who were eligible for vaccination; and vaccine coverage by antigen. RESULTS: We found that 65.4% (172/263) of hospitalised children were under-vaccinated for their age when they presented to the hospital. Among under-vaccinated children, 61.0% were less than 4 months old, and 55.6% reported prior contact with a health facility for a sick visit. The proportion of under-vaccinated children in hospitals were higher compared with the general population as indicated by regional vaccination coverage data. Among under-vaccinated children who were tracked till discharge, 98.1% (158/161) remained incompletely vaccinated at discharge and were considered 'missed opportunities for vaccination'. Perceived vaccination contraindications that are not part of established contraindications included in national and international guidelines was the most common reason for healthcare providers not to vaccinate children during hospital stay. Among caregivers of under-vaccinated children, 90.1% reported being comfortable having their children vaccinated while they were sick, if recommended by the healthcare provider. CONCLUSION: This pilot study confirmed that hospitalised sick children had substantial missed vaccination opportunities. Addressing these opportunities through concerted actions involving caregivers, healthcare providers and healthcare systems can improve overall vaccination coverage.

Comparison of Diagnostic Accuracy of Different Sites for Transcutaneous Bilirubin Measurement in Early Preterm Infants.

OBJECTIVE: To evaluate correlation of transcutaneous bilirubin (TcB) measured at different body sites with serum total bilirubin (TSB) in early preterm infants. METHODS: This hospital based prospective comparative study was carried out in the Department of Pediatrics, SMS Medical College, Jaipur between April 2015 to March 2016. Early preterm infants with gestational age ≤ 34 weeks in whom clinical jaundice was significant mandating TSB measurement were included in the study. Study subjects who met the inclusion criteria were chosen consecutively. Neonates in whom phototherapy was already initiated and those with poor perfusion (capillary refill time > 3 s) were excluded from the study. All the measurements were carried out within first postnatal week. Transcutaneous bilirubin was measured from three sites: forehead, sternum and interscapular region and within 15 min of TcB measurement, blood samples were taken and serum bilirubin level was calculated. RESULTS: Correlation coefficients of transcutaneous bilirubin measured from forehead, sternum and interscapular sites were 0.82, 0.84 and 0.86 respectively. TcB measured from all the three sites correlated significantly with serum bilirubin (p < 0.001), but the correlation was best at interscapular site. Sensitivity, specificity and false negative rates were calculated with respect to starting phototherapy. Interscapular site had the highest sensitivity and lowest false negative rate (87.6 and 12.4% respectively) as compared to forehead (79.2 and 20.8% respectively) and sternum (87.1 and 12.9% respectively). CONCLUSIONS: Transcutaneous bilirubin measurement is an acceptable method for identification of hyperbilirubinemia requiring treatment in early preterm newborns. The authors recommend interscapular region as a reliable site in infants of gestational age ≤34 wk for measuring transcutaneous bilirubin.

Subjective Global Nutritional Assessment: A Reliable Screening Tool for Nutritional Assessment in Cerebral Palsy Children.

OBJECTIVE: To determine the prevalence of undernutrition in children with cerebral palsy and to compare subjective and objective methods of nutritional assessment. METHODS: This was a hospital based analytical observational study in which 180 children of cerebral palsy, aged 1-12 y, attending tertiary level hospital, Jaipur from March, 2012 through March, 2013 were included. Subjective assessment was done by questionnaire (Subjective Global Nutritional Assessment; SGNA) in which questions related to nutrition history and physical examination, signs of fat, muscle wasting and edema was done while objective assessment was done by weight, height and triceps skinfold thickness (TSFT) measurements. RESULTS: In this study prevalence of undernutrition by subjective method (SGNA) was 76.67% while by objective measurement (weight, height, TSFT) was 48.89%, 77.78% 35.18% respectively. There was fair to moderate agreement between the SGNA and objective assessments including weight and height (k = 0.341, p = 0.000; k = 0.337, p = 0.000 respectively) while for TSFT agreement between both methods was poor (k = 0.092, p = 0.190). In the index study, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SGNA was for weight was 95%, 37%, 56%, 90%; for height 84%, 50%, 85%, 47%; for TSFT 81%, 30%, 38%, 75% respectively. CONCLUSIONS: The prevalence of undernutrition is high in cerebral palsy children. SGNA can be a reliable tool for assessing nutritional status in children with cerebral palsy and is a simple, comprehensive, noninvasive, and cost-effective tool for screening undernutrition in children of cerebral palsy.

Lactate clearance as the predictor of outcome in pediatric septic shock.

CONTEXT: Septic shock can rapidly evolve into multiple system organ failure and death. In the recent years, hyperlactatemia has been found to be a risk factor for mortality in critically ill adults. AIMS: To evaluate the predictive value of lactate clearance and to determine the optimal cut-off value for predicting outcome in children with septic shock. SETTINGS AND DESIGN: A prospective observational study was performed on children with septic shock admitted to pediatric Intensive Care Unit (PICU). SUBJECTS AND METHODS: Serial lactate levels were measured at PICU admission, 24 and 48 h later. Lactate clearance, percent decrease in lactate level in 24 h, was calculated. The primary outcome measure was survival or nonsurvival at the end of hospital stay. We performed receiver operating characteristic analyses to calculate optimal cut-off values. RESULTS: The mean lactate levels at admission were significantly higher in the nonsurvivors than survivors, 5.12 ± 3.51 versus 3.13 ± 1.71 mmol/L (P = 0.0001). The cut-off for lactate level at admission for the best prediction of mortality was determined as ≥4 mmol/L (odds ratio 5.4; 95% confidence interval [CI] =2.45-12.09). Mean lactate clearance was significantly higher in survivors than nonsurvivors (17.9 ± 39.9 vs. -23.2 ± 62.7; P < 0.0001). A lactate clearance rate of <10% at 24 h had a sensitivity and specificity of 78.7% and 72.2%, respectively and a positive predictive value of 83.1% for death. Failure to achieve a lactate clearance of more than 10% was associated with greater risk of mortality (likelihood ratio + 2.83; 95% CI = 1.82-4.41). CONCLUSIONS: Serial lactate levels can be used to predict outcome in pediatric septic shock. A 24 h lactate clearance cut-off of <10% is a predictor of in-hospital mortality in such patients.

Clinical Spectrum, Comorbidities, and Risk Factor Profile of Cerebral Palsy Children: A Prospective Study.

AIM AND OBJECTIVE: Cerebral palsy (CP) is the most common motor disability in childhood. This study aimed to describe clinical spectrum, comorbidities, and risk factors associated with CP children. MATERIALS AND METHODS: This hospital-based observational study was conducted in tertiary level hospital in Jaipur including 180 CP children aged 1-12 years, attending the Paediatric Neurology Outdoor and Child Development Centre. A detailed history of antenatal, natal, and postnatal events taken and thorough examination was performed to stratify children in proper topographical and physiological classification. RESULTS: Mothers of 47.7% CP children were primigravida and 17.7% mothers had anemia during pregnancy. Among natal factors, asphyxia contributed to maximum cases (52.2%). Seizure in postnatal life was the second most common risk factor for CP after asphyxia. Spastic CP (84.4%) was the most common physiological type, and quadriplegia (56.6%) was the most common topographical type observed in this study. Intellectual disability (47.7%) followed by epilepsy (41.6%) was the most common comorbidity. CONCLUSION: Even with the advancement of health-care system, asphyxia is the most common risk factor, and spastic quadriplegia is the most common type of CP. There is still a need of improving the health facilities to overcome this costly and common neuromotor disability. Widespread knowledge of common risk factors that can predispose to CP can prevent the CP development to some extent and knowledge of clinical spectrum, and comorbidities can improve their targeted treatment which can improve their growth and social participation.

A Neonate with X-linked Lissencephaly with Ambiguous Genitalia.

X-linked lissencephaly with ambiguous genitalia is a rare and recently described syndrome. We report a neonate presenting with the classical features of the syndrome which includes lissencephaly, agenesis of the corpus callosum, intractable epilepsy of neonatal onset, acquired microcephaly, and male genotype with ambiguous genitalia. The baby was managed aggressively with antiepileptics. Early clinical suspicion of the syndrome can prevent future such occurrences in the family through genetic counseling.

Gomez-Lopez-Hernández syndrome: First reported case from the Indian subcontinent.

Gomez-Lopez-Hernández syndrome (GLHS) is a rare neurocutaneous syndrome characterized by a triad of findings: partial alopecia of the scalp, trigeminal anaesthesia, and rhombencephalosynapsis. GLHS is also known as cerebello-trigeminal-dermal dysplasia. Besides this triad, a number of varying traits have been described in 35 previously reported cases. Reported here is a case of a four-year-old boy, born out of consanguineous marriage, presenting with the classic triad of findings, i.e. partial alopecia of the scalp, trigeminal anaesthesia, and rhombencephalosynapsis. To the extent known, this is the first case of GLHS reported from India. If a child presents with alopecia and rhom-bencephalosynapsis, GLHS should be considered in the differential diagnosis. A host of studies can be used to determine the exact pathogenesis, and confirming the diagnosis of GLHS is an important step in prenatal testing for at-risk pregnancies.

Griscelli syndrome subtype 2 with hemophagocytic lympho-histiocytosis: A case report and review of literature.

Griscelli syndrome (GS) is a rare autosomal recessive disorder resulting in pigmentary dilution of the skin and hair with variable phenotypes depending upon subtypes. Mutations in 3 distinct genes MYO5A, RAB27A, MLPH are responsible for 3 subtypes (GS1, GS2, and GS3) of GS respectively. GS subtype 2 commonly develops hemophagocytic lymphohistiocytosis (HLH) and recurrent infections due to immunodeficiency. We hereby report a 20 month old male child presenting with silvery gray hair, hypomelanosis and features of hemophagocytosis. The diagnosis of a type 2 GS was made in response to a set of clinical features: hypopigmentation of skin and the silvered reflection of the hair, absence of psychomotor retardation, the occurrence of an accelerated phase (hemophagocytosis) and, above all, a pathognomonic appearance by microscopic examination of a hair. The absence of giant granules in the nucleated cells made it possible to eliminate Chediak-Higashi syndrome, which shares a close clinical spectrum with GS. This case promotes awareness about this rare case of GS as a high indicator of suspicion about this potentially fatal condition and aids in prompt diagnosis and foresees complications. Early bone marrow transplant is the only curative treatment for GS-2.

Proteus Syndrome with Neurological Manifestations: A Rare Presentation.

Proteus syndrome (PS) is an extremely rare and complex disorder. Approximately 200 cases have been reported, and it seems to affect people of all ethnic and racial groups. PS is characterized by segmental overgrowth of multiple tissues and organs including vascular malformations, lipomatous overgrowth, hyperpigmentation, and various types of nevi. We hereby present a 7-year-old boy who presented with seizures and overgrowth of one-half of the body. Although classical physical features have been described, epilepsy and other neurological manifestations are rarely reported features of PS. Early detection of association of epilepsy and hemimegalencephaly with PS can prevent/minimize the neurological complications, disability, morbidity, and mortality.

Skeletal Maturation and Mineralisation of Children with Moderate to Severe Spastic Quadriplegia.

INTRODUCTION: Diminished bone mineral density and delayed skeletal maturation are common in children with spastic quadriplegia. AIM: The purpose of our study was to evaluate the Bone Mineral Density (BMD) of children with moderate to severe spastic quadriplegia and its relationship with other variables like nutrition and growth. MATERIALS AND METHODS: This was a hospital based, cross- sectional, case-control study. Forty-two (28 males, 14 females) children with spastic quadriplegia and 42 (24 males, 18 females) healthy children were included in the study. BMD of cases and control were measured by Dual Energy X-ray Absorptiometry (DEXA). Radiographs of left hand and wrist of cases and controls were taken and bone age was determined. RESULTS: BMD values of upper extremity, lower extremity, thoraco-lumbar spine and pelvis in cases were lower than those of controls (p <0.0001). In children with non severe malnutrition, 75% of the cases had lower bone age than chronological age, whereas all cases with severe malnutrition had lower bone age than chronological age. Step wise regression analysis showed that nutritional status independently contributed to lower BMD values but the BMD values did not correlate significantly with the use of anticonvulsant drugs and presence of physical therapy. CONCLUSION: Decreased BMD and delayed bone age is prevalent in children with spastic quadriplegia and nutritional status is an important contributing factor.