Prenatal vitamin D levels and infant cognitive, motor, language and social-emotional development at 6 and 9 months of age.

AIM: Vitamin D is involved in several processes related to the development of neuronal and non-neuronal cells. There is a possible link between maternal vitamin D status in pregnancy and delayed neurocognitive development in the offspring. The aim of the study was to explore the association of maternal and cord blood vitamin D levels with infants' neurodevelopment at 6 and 9 months of age. METHODOLOGY: A cohort study was conducted in western Rajasthan, India. Maternal and cord blood samples were collected at the time of delivery. Serum 25(OH)-vitamin D levels were measured in both. Infant neurodevelopment was assessed at 6 and 9 months of age in six domains namely cognitive, receptive language, expressive language, fine motor, gross motor and social-emotional using the Bayley Scale of Infant Development- III (BSID-III). RESULTS: A total of 175 mother-child pairs were enrolled. Among the mothers taking part in this study, 7.3% had deficient and 59.09% had insufficient levels of serum 25(OH) vitamin D during the third trimester of their pregnancy. Maternal and cord blood serum 25-OH vitamin D levels were 18.86 ± 8.53 ng/mL and 17.39 ± 8.87 ng/mL, respectively, and there was a significant correlation (r = 0.9778, p = 0.000) between levels of vitamin D. Based on the repeated measures ANOVA, post hoc Tukey's HSD test, maternal vitamin D levels had a significant relationship (p = 0.047) to the cognitive development of infants at 6 months of age. Furthermore, cord serum vitamin D levels showed a significant association (p = 0.023 and p = 0.010) with the social-emotional development of the infant at the age of 6 and 9 months. CONCLUSION: Maternal and cord serum 25-OH vitamin D deficiency was significantly associated with the cognitive and social-emotional development of infants.

Quality Assessment of Interactive Mobile Application - Maternal and Infant Care for Tribal Birth Attendants.

Digital health interventions can overcome geographical barriers and prepare health-care providers for better health outcomes in rural and remote tribal areas, however, it has not been explored among traditional birth attendants (TBAs). A mobile application, "maternal and infant care" (MAI) for capacity building of tribal birth attendants was developed and its quality was evaluated using the Mobile Application Rating Scale for user's interest in and satisfaction with the esthetics, information, and functionality. Thirteen Android user TBAs with the MAI application were piloted with the MARS checklist. Engagement, functionality, esthetics, and information quality; and one subjective quality scale having 29 items were used. The application was found to be entertaining excellent rating (mean score ± standard deviation) (4.00 ± 0.58), and scored high on performance (3.77 ± 0.93); layout design (3.85 ± 0.90); subjective quality (4.23 ± 0.93), however, scored minimum on interest; gestural design; visual appeal, etc. MAI is a user-friendly, culturally acceptable Android app that can be used for the capacity building of frontline workers.

Rare Variant of PTH1R Mutation in an Indian Family.

INTRODUCTION: Murk Jansen metaphyseal chondrodysplasia is an extremely rare form of skeletal dysplasia. It is caused by the mutation in PTH1R gene (1). MATERIALS: A 13 year old boy presented with history of progressive bowing of both legs since 5 years of age. He had no history of development delay, seizures, renal stones or abdominal distension. On examination, he was having prominent upper face, prominent tip of nose, long philtrum, small mandible and severe bowing of legs with deformed knee joint. His bone mineral profile came out to be normal. His skeletal survey showed severe metaphyseal dysplasia of long bones of lower limb. His genetic testing revealed heterozygous mutation in PTH1R gene, c.1562G>A variant in exon 16. On extended evaluation, his father and paternal grandmother were also having similar phenotype, however not as severely affected as the index case. RESULT: Murk Jansen metaphyseal chondrodysplasia is characterized by severe short stature, short bowed limbs, clinodactyly and dysmorphic facies with metabolic derangement of hypercalcemia and hypophosphatemia (2). The variant present in our patient has not been reported anywhere yet, hence revealing a new molecular mechanism to an already known rare disease. CONCLUSION: Molecular diagnosis of skeletal dysplasia is of paramount importance as they are a clinically heterogenous group with varied presentation with non-specific radiological findings, however with different treatment and prognostic implications. References Nampoothiri S, Fernández-Rebollo E, Yesodharan D, et al. Jansen metaphyseal chondrodysplasia due to heterozygous H223R PTH1R mutations with or without overt hypercalcemia. J Clin Endocrinol Metab 2016;101(11):4283-4289. Schipani E, Langman CB, Parfitt AM, et al. Constitutively activated receptors for parathyroid hormone and parathyroid hormone- related peptide in Jansen's metaphyseal chondrodysplasia. N Engl J Med 1996;335(10):708-714.

Is maternal anemia among tribal women being neglected? A study from Southern Rajasthan.

Poor birth outcomes have been linked to maternal anemia. Tribal women are at higher risk of malnutrition and disease due to sociocultural barriers and poor educational status. The data on the prevalence of maternal anemia and its associated factors among pregnant tribal women are limited. A community-based cross-sectional study was conducted among 429 pregnant tribal women for maternal anemia from August 2021 to June 2022. A structured questionnaire was employed to collect sociodemographic data. The prevalence of anemia was 85.7%, with a mean hemoglobin level of 9.21 ± 1.3 g/dL. On applying WHO 2011 anemia criteria for pregnant women, 25.0% had mild anemia, 73.4% had moderate anemia, and 1.6% had severe anemia. The significant factors associated with anemic condition were household condition, monthly income, and husband's occupation. The higher prevalence of anemia among pregnant tribal women is alarming that necessitates a rethinking of health infrastructure and outreach in tribal dominant areas.

Epidemiology, etiology and clinical associations of congenital heart disease identified during congenital rubella syndrome surveillance.

BACKGROUND: Congenital heart disease (CHD) is a common congenital malformation. Antenatal rubella infection in the mother and genetic defects are important causes to which CHD are attributed. Exact contribution of antenatal rubella infection or genetic causes to CHD is still unknown. OBJECTIVE: To study the epidemiology, etiology and clinical associations of echocardiographically confirmed congenital heart disease in infants in Western Rajasthan enrolled in the congenital rubella syndrome (CRS) surveillance project. To study the utility of clinical diagnostic criteria in identifying congenital rubella infection. METHOD: This was a prospective observational study, in which 251 patients with echocardiographically confirmed CHD were enrolled. Detailed clinical evaluation was done in all patients. Rubella serology was done in all patients. Genetic and other testing was done as appropriate. RESULT: The hospital-based prevalence of CHD in infants was 1% at our center. Fifty-seven percent of the babies had acyanotic septal heart defects of which ventricular septal defect (VSD) was the most common (35%). Anti-rubella immunoglobulin M (IgM) antibodies were positive in 8.5% of the CHD patients. A clinically identifiable genetic cause was present in 3.6% of the cases. In patients who tested positive for anti-rubella IgM antibodies also, VSD was the most common (33%) CHD followed by Tetralogy of Fallot (13.2%). CONCLUSION: CRS contributes to 8.5% of CHD. CRS is associated with a wide spectrum of CHD. The etiology of a large number of CHD remains elusive. Detailed studies on the cause and mechanism of development of CHD need to be undertaken.

Guardian-Reported Impact of the COVID-19 Pandemic on the Lifestyle of Children with Diabetes Mellitus.

INTRODUCTION: The coronavirus disease-2019 (COVID-19) pandemic has had an unprecedented impact on the lives and lifestyles of people of all ages worldwide. Lifestyle has an essential role in the management of diabetes mellitus in children. METHODS: The study was carried out at a tertiary care centre in India. A telehealth survey was conducted among the parents/guardians of children with diabetes to study the impact of the COVID-19 pandemic. The survey evaluated the effects on lifestyle, diabetes management and challenges in connecting to a new telemedicine programme. RESULTS: The survey was completed by guardians of 91 patients. The mean age of the patients was 13.0 ± 3.8 years in boys and 11.9 ± 4.5 years in girls. Fifty-seven per cent of them were boys, and 63.7% stayed in rural areas. The pandemic has resulted in a significant increase in screen time and sleep duration. The median non-educational screen time has gone up from 1.00 (0.5-2.0) to 2.50 (1.0-4.0) h. The mean sleep duration in children increased from 9.1 ± 1.4 to 9.7 ± 1.4 h. Telemedicine services have been established with minimum resources, but they have limitations, and awareness about them is also limited. CONCLUSION: The COVID-19 pandemic has made the lifestyle of children with diabetes more sedentary. Some of them have also faced challenges with regard to diabetes-related supplies and management. It would be fair to anticipate more complications related to this sedentary lifestyle in the future and work towards identifying and treating them.

Children and COVID19: Understanding impact on the growth trajectory of an evolving generation.

The COVID19 pandemic has forced the world to be closed in a shell. It has affected large population worldwide, but studies regarding its effect on children very limited. The majority of the children, who may not be able to grasp the entire emergency, are at a bigger risk with other problems lurking behind the attack of SARS-CoV-2 virus. The risk of infection in children was 1.3%, 1.5%, and 1.7% of total confirmed COVID-19 cases in China, Italy and United States respectively which is less compared to 2003 epidemic of severe acute respiratory syndrome (SARS), when 5-7% of the positive cases were children, with no deaths reported while another recent multinational multicentric study from Europe which included 582 PCR (polymerase chain reaction) confirmed children of 0-18 year of age, provide deeper and generalize incite about clinical effects of COVID19 infection in children. According to this study 25% children have some pre-existing illness and 8% required ICU (intensive care unit) admission with 0.69% case fatality among all infected children. Common risk factor for serious illness as per this study are younger age, male sex and pre-existing underlying chronic medical condition. However, we need to be more concerned about possible implications of indirect and parallel psychosocial and mental health damage due to closure of schools, being in confinement and lack of peer interaction due to COVID19 related lockdown and other containment measures. The effects can range from mood swings, depression, anxiety symptoms to Post Traumatic Stress Disorder, while no meaningful impact on COVID19 related mortality reduction is evident with school closure measures. The objective of this paper is to look at both the positive & negative effects in children due to COVID19 related indirect effects following lockdown and other containment measures. There is a need to gear up in advance with psychological strategies to deal with it post the pandemic by involving all stakeholders (parents, teachers, paediatricians, psychologists, psychiatrists, psychiatric social workers, counsellors), proposing an integrated approach to help the children to overcome the pandemic aftermath.

Atypical Presentation of Crimean-Congo Hemorrhagic Fever as Ascending Paralysis with Rhabdomyolysis.

Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne disease caused by a arbovirus. It is asymptomatic in infected animals but a serious threat to the health of individuals. In human, it starts with nonspecific febrile diseases and progresses into severe hemorrhagic syndrome with high-casual fatality. Here, we report a case of CCHF with atypical presentation of ascending paralysis and rhabdomyolysis. HOW TO CITE THIS ARTICLE: Prasad HR, Sharma A, Kothari N, Vyas V, Goyal S. Atypical Presentation of Crimean-Congo Hemorrhagic Fever as Ascending Paralysis with Rhabdomyolysis. Indian J Crit Care Med 2020;24(2):143-144.

Should We Use DSI or not-What does the PADIS 2018 Guidelines Recommend?

How to cite this article: Sharma A, Bhatia P, Vyas V. Should We Use DSI or not-What does the PADIS 2018 Guidelines Recommend? Indian J Crit Care Med 2019;23(10):491.

A new onset drug induced diabetes mellitus presenting with diabetic ketoacidosis in a child undergoing treatment for B cell acute lymphoblastic leukemia. A case report and review of literature.

OBJECTIVES: Hyperglycemia is a known side effect of anticancer chemotherapeutic drugs. This entity known as drug-induced diabetes mellitus usually does not present with the development of diabetic ketoacidosis (DKA). We hereby report a case of drug induced diabetes mellitus in a child with acute leukemia presenting with DKA. CASE PRESENTATION: We report a case of a teenage boy diagnosed with B cell acute lymphoblastic leukemia and was started on induction phase chemotherapy as per the Indian Collaborative Childhood Leukemia group (ICICLe) acute lymphoblastic leukemia-14 protocol. On day 12 of the induction phase, he developed hyperglycemia and presented to us with severe diabetic ketoacidosis (DKA). Serum anti glutamic acid decarboxylase 65 antibody levels were negative with low serum C peptide levels. Initially, the possibility of drug-induced acute pancreatitis was kept which was ruled out. Keeping the possibility of drug-induced hyperglycemia, the child was started on subcutaneous regular insulin which was titrated as per sugar records. Continuation of remaining chemotherapy was done by PEGylated L-asparaginase with titration of insulin as per home-based sugar records. Insulin requirement increased from 0.3 unit/kg/day to a maximum of 1 unit/kg/day during consolidation phase 1 with PEGylated L-asparaginase suggesting drug-induced hyperglycemia but subsequently insulin requirement decreased and insulin was stopped. CONCLUSIONS: Drug induced diabetes mellitus can present as DKA during induction phase of acute lymphoblastic leukemia (ALL) chemotherapy. A high index of suspicion and close monitoring are required. The insulin requirements in these patients can be very fluctuant and may become nil during the course of treatment.

Effect of Long-term Inhaled Corticosteroids on the Hypothalamic-Pituitary-Adrenal Axis in Children with Asthma.

OBJECTIVES: To assess the effect of the long-term use of inhaled corticosteroids (ICS) on the hypothalamic-pituitary-adrenal (HPA) axis. METHODS: Children (5-18 y) diagnosed with asthma and on ICS therapy for ≥6 mo were included. In the first step, screening with fasting at 8 AM, cortisol level was measured; a value <15 mcg/dl was considered low. Children with low fasting cortisol levels were subjected to adreno-corticotropic hormone (ACTH) stimulation test in the second step. Post-ACTH stimulation, cortisol level <18 mcg/dl was considered to have HPA axis suppression. RESULTS: A total of 78 children (males 55, 70.5%) diagnosed with asthma, with a median age of 11.5 (8, 14) y, were enrolled. The median duration of ICS use was 12 (12-24) mo. The median value of post-ACTH stimulation cortisol level was 22.5 (20.6, 25.5) mcg/dl, and a value <18 mcg/dl was observed in 4 (5.1%; 95% CI 0.2-10%) children. There was statistically no significant correlation between low post-ACTH stimulation cortisol level with ICS dose (p = 0.23) and asthma control (p = 0.67). None of the children had clinical features of adrenal insufficiency. CONCLUSIONS: In this study, a few children had low post-ACTH stimulation cortisol values; however, none had clinical evidence of HPA axis suppression. Therefore, ICS is a safe drug in children for treating asthma, even for long-term use.

Down-Klinefelter Syndrome With Concurrent Double Aneuploidy in an Indian Child.

The genetics of Down syndrome (DS) and Klinefelter syndrome (KS) are a nondisjunction of autosomal and sex chromosomes, respectively, resulting in aneuploidies. Less than 70 cases of concurrent Down-Klinefelter syndrome (DS-KS) have been reported in the literature. We report the case of a five-month-old Indian child with a rare double aneuploidy resulting in DS-KS. A five-month-old boy born to non-consanguineously married parents presented with failure to thrive and dysmorphic facies. The family history was unremarkable. On examination, he had an upward eye slant, a depressed nasal bridge, a horizontal crease in the left hand, and a sandal gap. A clinical diagnosis of the Down phenotype was considered. Karyotype analysis revealed the presence of double aneuploidy (48, XXY,+21) suggestive of DS-KS. Down-Klinefelter syndrome presents with the DS phenotype at birth, and the characteristic KS phenotype develops in early infancy and apparently manifests during puberty only. Early diagnosis is required for parental counseling and planning for future pregnancies. In children with a typical Down syndrome phenotype, chromosomal analysis is highly recommended. The diagnosis of DS-KS at the earliest has implications for these children's short-term and long-term outcomes. It helps in planning the subsequent pregnancy with appropriate genetic testing and counseling to avoid the risk of another child with trisomy.

Going the extra mile: Developing an interactive mobile application for maternal and infant care for tribal birth attendants.

Background: Mobile health applications are an established tool for healthcare management, patient education, and even capacity building for healthcare providers. However, its use among traditional birth attendants (TBAs) is limited. The aim of this study is to explore the needs and bottlenecks of developing an interactive mobile application for maternal and infant care (MAI) of TBAs. Materials and Methods: It is a qualitative study having in-depth interviews (face-to-face approach) conducted among the seekers of MAI services. Setting: This study is conducted in tribal and rural locations in the district Sirohi, Rajasthan. Participants: TBAs and tribal females of reproductive age in tribal-dominated areas have participated. The development of an interactive mobile application MAI has three phases: (1) a need-based approach to identify the needs on the ground; (2) identifying intervention bottlenecks and possible solutions; (3) design and development of the mobile application. Results: Ninety-six tribal females of reproductive age participated in the needs assessment. Eighty percent of them were ≤ 30 years of age and 40% of them were uneducated. Most participants informed that lack of information (culturally/locally appropriate content), peer advocacy, affordability, lack of transportation, and the influence of TBAs are the significant factors for less uptake of maternity and child health services in the tribal and rural areas. Conclusion: The MAI app has culturally/locally appropriate content and is prepared by the local TBAs and Accredited Social Health Activists, with full local character and clothing. MAI app has videos and audio in the local language (Marwari) with pictorial quizzes. Using the MAI app, TBAs may self-educate and guide tribal pregnant women about maternal hygiene and infant healthcare as needed at various stages of pregnancy and childbirth.

Anesthetic challenges for pheochromocytoma surgery in pediatric patients: A case series.

Pheochromocytoma in children is an exceptionally uncommon cause of hypertension in this age group. These tumors pose a significant threat of adverse cardiovascular events during the perioperative phase. In this article, we describe three cases of pediatric pheochromocytoma to shed light on the difficulties associated with administering anesthesia to patients with this condition. The foundations for successful perioperative outcomes include preoperative blood pressure control, extensive intraoperative hemodynamic evaluation, and appropriate coordination with surgeons.

Medication errors in the practice of paediatric anaesthesia - a narrative review.

Medication error has emerged as a significant problem in healthcare, especially in the past 2 decades. In anaesthesia, the paediatric age group is particularly at risk of such events because of complex age- and weight-based drug calculation, drug formulations, serial dilutions, and often limited staff experience in handling such patients. We searched PubMed, Cochrane, and Google Scholar for literature on medication errors in paediatric anaesthesia in children (< 18 years of age). Two authors searched for the articles independently, and a third author sorted any consensus differences. A total of 2979 articles were retrieved. We studied primary outcomes, the results, and conclusions of the various studies. A total of 21 relevant articles were selected finally. Following preventive strategies like colour coding, accurate dose calculations, verification by a second individual, and checking and encouraging self-reporting can improve perioperative safety in the paediatric population to a significant extent.

Nasogastric tube insertion using conventional versus bubble technique for its confirmation in anesthetized patients: a prospective randomized study.

BACKGROUND: Nasogastric tube insertion and confirmation of its position can be difficult in the anesthetized patient. The purpose of the present study was to compare the bubble technique with the conventional method for confirmation of nasogastric tube placement in these patients. METHODS: Two hundred sixty adult patients, aged between 20...70 years, posted for surgeries requiring general anesthesia, tracheal intubation, and a nasogastric tube were enrolled in this study. Patients were randomized into 2 groups: Group B (Bubble group) and Group C (Control group). In Group C, a conventional technique using a lubricated nasogastric tube was positioned through the nostril with head remained neutral. In Group B, 2% lidocaine jelly was added to the proximal end to form a single bubble. The correct placement of the nasogastric tube in the stomach was confirmed by fluoroscopy by an independent observer intraoperatively. RESULTS: The duration of nasogastric tube insertion was 57.2..13.3seconds in Group B and 59.8..11.9seconds in Group C (p=0.111). The confirmation rate of the bubble technique was 76.8% (95% CI: 68.7...83.3), which was significantly better than the conventional method where the confirmation rate was 59.7% (95% CI 50.9...67.9), p<0.001. When compared to fluoroscopy, bubble technique was found to have a sensitivity of 92.3% (95% CI: 85.6...96.1) with specificity of 81.0% (95% CI: 60.0...92.3), positive predictive value of 96.0% (95% CI: 90.2...98.4), and a moderate negative predictive value of 68.0% (95% CI: 48.4...82.8). CONCLUSIONS: The bubble technique of nasogastric tube insertion has a higher confirmation rate in comparison to the conventional technique. TRIAL REGISTRY NUMBER: Clinical Trial Registry of India (CTRI/2018/09/015864).