Risk factors predicting early in-hospital mortality among underfive children and need for decentralization of pediatric emergency care services.

Background: Lack of pediatric triage and emergency care system in peripheral healthcare centers leads to unnecessary referral of low- and medium-risk patients. This study was conducted to study the risk factors predicting mortality within 48 h of admission in neonates and under-five children referred to the pediatric emergency of a tertiary care hospital in India. Methods: This prospective study was conducted on children (0-5 years) referred to the pediatric emergency who were enrolled and followed up. The outcome was defined as "survival" or "death" at 48 hours. Logistic regression analysis was conducted to assess the predictors of early in-hospital mortality. Results: A total of 246 consecutive pediatric (62 neonates, 52 young infants, and 132 children aged 1-5 years) referral cases were enrolled; mortality within 48 hours was 20%. Lack of pediatric intensive care (odds ratio [OR] 4.07, 95% confidence interval [CI] 2.0, 8.32, P = 0.02), lack of neonatal intensive care (OR 2.10, 95% CI 1.01,4.28, P ≤ 0.001), distance from referral center >20 km (OR 4.61, 95% CI 2.01, 10.58, P = 0.0003), >1 h taken during transport (OR 7.75, 95% CI 2.93, 20.46, P < 0.001), lack of ambulance facility (OR 0.04, 95% CI 0.009, 0.143, P < 0.0001), very sick condition on arrival (OR 210.1, 95% CI 12.1, 3643.41, P = 0.0002), and unstable temperature-oxygenation-perfusion-sugar on arrival were the independent risk factors predicting in early in-hospital mortality. Conclusion: Developing a pediatric triage and monitoring system, tele-pediatric intensive care unit, regionalizing referral-back-referral services with robust interhospital communication, and strengthening pediatric emergency services are the need of the hour to reduce early in-hospital mortality.

Mortality in paediatric acute myeloid leukaemia.

OBJECTIVE: To analyse the common causes of death in paediatric acute myeloid leukaemia cases at a tertiary care facility. METHODOLOGY: The retrospective study was conducted at the Paediatric Oncology Department of the Combined Military Hospital, Rawalpindi, Pakistan, and comprised newly-registered cases of acute myeloid leukaemia aged <18 years from January 1, 2012, onwards and who completed their treatment before January 31, 2019. Data was retrieved from medical records and was analysed using SPSS 23. RESULTS: Of the 206 cases, 130(63.1%) were males and 76(36.9%) were females. Overall mean age at diagnosis was 5.96±3.57 years (range: 9 months to 15 years). Of the total, 6(2.9%) patients died before the start of treatment. Of the remaining, 43(21.5%) patients died during 1st induction chemotherapy, and 16(8%) during the post-induction period, with overall treatment-related mortality being 65(31.5%). The main cause of death during the first two weeks of induction was infection, while infection followed by multi-organ failure was the main cause of mortality in the second phase. A total of 130(63%) patients completed the treatment. Overall survival was 81(62.3%) while disease-free survival was 77 (59.2%). CONCLUSIONS: Overall treatment-related mortality rate in paediatric acute myeloid leukaemia cases was found to be high. Pregnancies achieved by IVF/ICSI, being complicated with severe OHSS could be related to gestational hypertension.

Diagnostic Accuracy of Waist Circumference and Waist-to-Height Ratio for Moderate and Severe Acute Malnutrition in Under-5 Children.

OBJECTIVE: To determine the most appropriate cut-off values of Waist Circumference (WC) and Waist-to-Height Ratio (WHtR) for diagnosing moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) in under-five children. METHODS: This cross-sectional diagnostic accuracy study was conducted between January 2021 and August 2022 in the Department of Pediatrics of a tertiary hospital in Delhi. Children aged 6 months to 5 years attending the outpatient or emergency services were included in the study. Detailed clinical evaluation and anthropometry including measurement of WC were done at enrollment. Body mass index (BMI) and WHtR were calculated. Malnutrition was classified as per the WHO criteria. Receiver operating characteristic curves (sensitivity, specificity) for WC and WHtR (absolute values) were drawn against the standard test of WHO definitions for MAM and SAM to determine the most appropriate cut-offs for diagnosing MAM and SAM. RESULTS: 1500 children with a median (IQR) age of 29 (14, 43) months were enrolled; 21% children had MAM and 11% had SAM as per the WHO criteria. WC < 44.5 cm (sensitivity 74.1%, specificity 71.1%) and WHtR < 0.565 (sensitivity 75.6%, specificity 33.7%) were the best cut-offs to identify MAM, whereas WC < 42.3 cm (sensitivity 67.5%, specificity 81.3%) and WHtR < 0.563 (sensitivity 81.3%, specificity 33.4%) were the best cut-offs to diagnose SAM. CONCLUSION: Waist circumference (< 44.5 cm for MAM; < 42.3 cm for SAM) had a reasonably good sensitivity and specificity for diagnosing MAM and SAM, but the same was not true for WHtR.

Parental Education for Limiting Screen Time in Early Childhood: A Randomized Controlled Trial.

OBJECTIVE: To assess the impact of focused parental education on limiting screen time in early childhood. METHODS: An open label randomized controlled trial was conducted in a tertiary care hospital in Delhi wherein 120 healthy children aged 9-10 months of age, born at term gestation and appropriate for gestational age (birth weight ≥ 2500 g), attending the immunization clinic reporting for measles-rubella (MR) vaccination were enrolled. Primary caregivers were randomized to either receive 30 minutes of in-person active counselling with pre-designed content including a printed pamphlet targeted at reduction of screen time (Educational group, n = 61) or to receive routine in-person counseling on general health measures (Control group, n = 61). All caregivers were followed up. Primary caregivers in both groups were reinforced telephonically every month for 6 months. At the end of six months, we assessed the proportion of children with screen-time > 1 hour/day and the median duration of screen-time (minutes /day). We also compared both groups in terms of changes in pre-post intervention developmental and behavioral scores (measured with Ages and Stages questionnaires). RESULTS: After 6 months of follow-up, 3% (2/61) children in the Educational group had screen time > 1 hour/day as compared to 53% (32/61) (P < 0.001) in the Control group. Median (IQR) for total screen duration in the Educational group was 35 (30,49) minutes/day compared to 75 (50,90) minutes/day in the Control group (P < 0.001). Children in the Educational group were also observed to have a significant change in behavioral score and fine motor and adaptive skills as compared to controls. CONCLUSION: Parental education starting in infancy is a promising intervention to reduce screen exposure in children; it may also have a positive impact on their developmental and behavioral skills.

Two Indian families with Greig cephalopolysyndactyly with non-syndromic phenotype.

The Greig cephalopolysyndactyly syndrome (GCPS) is a rare, autosomal dominant, pleiotropic, multiple congenital anomaly syndrome. The typical findings include hypertelorism, macrocephaly with frontal bossing, and polysyndactyly. We present two families, with GCPS with a non-syndromic phenotype, without the characteristic craniofacial anomalies and with the presence of complex digital anomalies including various types of polydactyly and syndactyly of the fingers and toes. The cases were proven to be GCPS by mutational analysis of GL13 gene. Our patients support the fact that the phenotypic spectrum of GL13 mutations is broader than that encompassed by the usual clinical diagnostic criteria. Individuals with features of familial polysyndactyly should be screened for mutations in GL13 even if they do not fulfill clinical criteria.

Electrical injuries in urban children in New Delhi.

AIM: The objective of this study was to analyze the epidemiology, presentation, management, and complications of electrical burn injuries in urban children. METHODS: Data from records and clinical data were collected retrospectively and prospectively during 2008 to 2010. RESULTS: Of 41 children enrolled, the mean age of children enrolled was 8.1 ± 4.5 years. Low-voltage injury was seen in 28 (68.2%), and 13 (31.8%) had high-voltage injuries. Low-voltage injuries were most commonly (52.45%) secondary to direct contact with live wire, whereas high-voltage injuries in 70% were due to direct contact with broken wires lying in fields/rooftops. Fourteen children of the 41 enrolled had associated injuries. Low-voltage injuries were associated with minor burns, seizures, tibial fracture, eyelid burn, scalp hematoma, and speech and visual impairment, whereas high-voltage injuries were associated with cardiac arrest, extradural hematoma, visceral burns, pulmonary hemorrhage and hypoxic encephalopathy, and postelectrocution acute respiratory distress syndrome. Surgical interventions done included split-thickness skin grafting, fasciotomy, and amputation procedures. The mean duration of hospital stay of all the children enrolled was 9.02 days with 35 children discharged, 71.4% of them having low-voltage injuries. Four children died, 75% of them having high-voltage injury, whereas 2 children left without medical advice, both having low-voltage injuries. CONCLUSIONS: Children are a major group susceptible to electrical injuries in our country. Most of the mechanisms leading to them are easily preventable, but occur because of lack or awareness among the children and their guardians. Burn prevention program should be implemented incorporating these epidemiological data.

Antibiotic Susceptibility, Carrier State and Predictors of Outcome of Staphylococcus aureus Infections in Hospitalized Children.

OBJECTIVES: To evaluate the antibiotic resistance pattern, clinical profile and predictors for adverse outcomes in children hospitalized due to staphylococcal infection; and the frequency of nasal and axillary carrier states in these children. METHODS: This descriptive study enrolled 100 symptomatic children (aged 1 month - 12 years) in whom S. aureus was isolated from cultures of blood, pus or cerebrospinal fluid. All samples were processed as per the Clinical and Laboratory Standards Institute (CLSI) standards. Antimicrobial susceptibility was tested using disc diffusion method; minimum inhibitory concentration (MIC) for vancomycin was measured using E strips. Predictors for poor recovery were determined by univariate and multivariable logistic regression analysis. RESULTS: Skin and soft tissue infections were the most common (47%) followed by respiratory infections (37%). Methicillin-resistant Staphylococcus aureus (MRSA) was detected in 62%, out of which 63% (39/62) were multi-drug resistant. Carrier state was present in 49% (93% MRSA); 80% were axillary carriers. High MIC (>1 µg/mL) for vancomycin was seen in 65% of patients, and was the only factor associated with poor recovery [aOR (95%CI) 5.3 (1.6,18.5); P=0.008] on multivariable logistic regression analysis. CONCLUSION: MRSA is the predominant strain in severe staphylococcal infections requiring hospitalization, and majority of them are multidrug resistant. High MIC to vancomycin among S. aureus is an emerging concern.

Prevalence and outcome of hepatobiliary dysfunction in neonatal septicaemia.

BACKGROUND: Cholestatic jaundice and liver enzyme abnormalities have been reported in neonatal septicaemia; the course, pattern, and outcome of such hepatobiliary dysfunction have not been described. METHODS: One hundred fifty-three neonates with blood culture-positive sepsis were recruited from the neonatal intensive care unit of an urban hospital. Liver function tests were done on day 3 and day 10 in all of the cases. In babies with abnormal results (direct bilirubin >20% of total with a minimum level of 2/dL or alanine aminotransferase [ALT] >50  U/L), tests were repeated weekly for 1 month and then fortnightly for 3 months or until normalization of values. Anthropometry was recorded at all of these visits. RESULTS: Klebsiella pneumoniae was the commonest organism, isolated in 95.4% of subjects. Eighty-three (54.2%) subjects had hepatobiliary dysfunction in the form of either cholestatic jaundice (n = 65 [42.5%]) or derangement in ALT (n = 57 [37.3%]). The onset of cholestasis was seen by day 3 of sepsis in 80% (n = 52), with maximum value of direct bilirubin seen by the 10th day in 90% (n = 58). Only 15% (n = 10) continued to have cholestatic jaundice beyond 30 days of onset of sepsis, and it resolved by 60 days. Hepatic enzyme abnormalities followed a more protracted course: onset by day 10 in 95%, peak value by day 38 in 90%, and normalisation by 60 days in 82% of subjects. The prevalence of any hepatobiliary dysfunction was found less frequently in babies who died as compared with survivors (43.4% vs 56.7%; P < 0.01). The weight, length, and head circumference during follow-up visits were comparable between neonates with or without hepatobiliary dysfunction. CONCLUSIONS: Hepatobiliary dysfunction is common in Gram-negative neonatal septicaemia. The onset of abnormalities is early in most cases but ultimately resolve within 2 to 3 months after sepsis. The presence of conjugated hyperbilirubinemia in neonatal sepsis may carry a better prognosis in terms of survival and has no significant effect on growth during early infancy.

Short-term outcomes of acute fulminant myocarditis in children.

Data on the clinical profile, echocardiographic findings, and outcome of acute fulminant myocarditis (AFM) in children from resource limited countries are limited. To study the clinical profile and short-term outcomes of children aged 2 months to 17 years with AFM managed with only supportive care. We enrolled all children admitted with AFM in our hospital from January 2009 to October 2010. Although the information on patients admitted from January 2009 to March 2010 were retrieved from the case records, data of children admitted from April 2010 were recorded prospectively. AFM was diagnosed based on clinical and echocardiographic criteria. We collected information regarding clinical course, treatment details, and echocardiography findings using a structured performa. All of the children, including those for whom baseline information was collected from the records, were followed-up prospectively to determine short-term outcomes. A total of 10 children, of whom 6 were male, presented with AFM. Their median age was 7.5 (interquartile range [IQR] 2 to 13) years, and the mean left-ventricular ejection fraction (LVEF) was 26% (SD 11.5). Of the 10 children, 9 were discharged, and 1 child died. At discharge, all children showed improvement in the symptoms, but only 4 had improvement in LV function on echocardiography. Factors associated with poor recovery of LV function at discharge were anasarca, low LVEF, and increased serum glutamate pyruvate transaminase levels at admission. One child had died at 2-month follow-up, and another child developed dilated cardiomyopathy at 15 months after discharge. Children with AFM had good immediate- and short-term outcomes even without the use of mechanical assist devices. Decreased LVEF at admission was found to be one of the most important determinants of poor immediate outcomes in these children.

Efficacy And Tolerability Of Oral Iron Chelator, Deferasirox.

BACKGROUND: Thalassemia major is the severe form of ß thalassemia characterized by severe anaemia, hepatosplenomegaly and facioskeletal changes due to increased haemolysis of defective red blood cells. In iron overload states, high levels of iron exceed the iron-carrying capacity of transferrin within the plasma, leading to the formation of nontransferrin-bound iron form. These nontransferrin-bound iron forms can be taken up into cells, including liver, heart, and endocrine cells leading to organ damage. To prevent complications associated with hemosiderosis, iron chelation therapy remains one of the main objectives of clinical management of the patients affected by Thalassemia Major. METHODS: Thirty-seven patients were enrolled using non randomized convenience sampling technique after the written consent from patients. Patients age 2-30 years were enrolled in this study. Serum Ferritin, ALT, Serum Creatinine were checked at the start of the study, 3 months, 6months and then at the end of the study, i.e., at 9 months of the commencement of the study. They were also assessed for other side effects pertaining to oral tolerability of the drug like vomiting, nausea, GI upset, diarrhoea, urinary complaints or any other subjective complaint. RESULTS: Of the 37 patients, 20 were male (54.1%) and 17 were female (45.9%). Mean age of the patients was 10.2 years (Min. 3 years, Max 21 years). The average serum Ferritin at baseline was noted as 3440 which increased after a period of 3 months, 6 months and 9 months with average of 3359, 3677 and 4394 respectively. After the period of 9 months largest 95% confidence interval of serum Ferritin levels was observed in the range of 3420.17 to 5368.63. In our study, 17 patients required alternative chelation (46%). These patients needed IV Deferioxamine because of the rising trend of Serum Ferritin after the study. CONCLUSIONS: From the results of our study, we infer that oral Deferasirox is not an effective iron chelator. If the patients are taking oral deferasirox, their Serum Ferritin should be checked 3 monthlies. The drug is effective only in maintaining Serum Ferritin levels with levels less than 1500ng/ml. Intravenous Deferioxamine still should be preferred over oral iron chelators for effective control of iron overload and its complications.

Inflammatory Myofibroblastic Tumor: A Rare Presentation and an Effective Treatment with Crizotinib.

Inflammatory myofibroblastic tumor (IMT) is a rare entity of neoplastic origin. It usually occurs in children and adolescents and most commonly involves pulmonary and gastrointestinal sites. Here, the authors present two cases; one is the nine months old boy with a subcutaneous IMT in the left temporal region that was treated successfully with surgical resection. To the best of our knowledge, this is the first reported case of a subcutaneous IMT in this particular region. The second is an eight years old girl with an IMT of the right hemi-pelvis. The mass had complete surgical excision with clear margins and no residual disease. She was kept on regular follow-up with ultrasound abdomen. However, her disease relapsed with the appearance of lesions in right iliac fossa, right ovary, and liver. Biopsy of the relapsed abdominal mass confirmed ALK-positive IMT. She was treated with ALK inhibitor Crizotinib. She was monitored with regular blood complete picture, hepatic and renal function test, and ultrasound abdomen. Her lesions started regressing within one month, and she achieved complete remission after 6 months of treatment.

Optimum Induction Chemotherapy for Pediatric Acute Myeloid Leukemia: Experience From A Developing Country.

OBJECTIVES: Treatment outcome in children with acute myeloid leukemia (AML) has improved in the developed world but remains poor in developing countries. We assessed the role of etoposide in induction chemotherapy in pediatric AML. METHODS: This analysis retrospectively compared 2 induction chemotherapy regimens consisting of daunorubicin and cytarabine with etoposide (ADE) and without etoposide (AD). All newly diagnosed cases of AML younger than 18 years from January 1, 2012, onwards who completed their treatment before January 31, 2019, were included. Data of 186 cases, including 117 males (62.9%) and 69 females (37.1%), were analyzed. Demographic, initial presentation blood counts, and AML subtypes were almost identical in both groups. RESULTS: Complete remission rates were almost identical for the ADE versus the AD group (78.8% vs 80.0%, p = 0.980). Treatment-related mortality was higher, albeit not significantly, in the ADE (25 of 105; 23.8%) versus the AD (16 of 81; 19.8%) group (p = 0.508). Overall survival was 32 of 105 (30.5%) in the ADE and 43 of 81 (53.1%) in the AD group (p = 0.079), and disease-free survival was 29 of 105 (27.6%) and 39 of 81 (48.1%) in ADE and AD groups (p = 0.056), respectively. CONCLUSIONS: Etoposide in induction treatment of pediatric AML is associated with increased episodes of bacterial and fungal infections and high treatment-related mortality. Moreover, it does not offer any survival benefit. In low- and middle-income countries like Pakistan, it should not be used in the induction treatment protocol.

Impact of Malnutrition on Treatment Outcome of Paediatric Acute Myeloid Leukemia.

OBJECTIVE: To analyse the distribution of malnutrition in paediatric acute myeloid leukaemia (AML) and its effect on treatment outcome and survival in Pakistani children. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Department of Paediatric Oncology, Combined Military Hospital (CMH), Rawalpindi, Pakistan from January 2012 to January 2019. METHODOLOGY: Data of all newly registered cases of paediatric AML was analysed to see the association of nutritional status according to Z-score classification and treatment outcome. The outcome was divided into disease-free and overall survival. RESULTS: A total of 206 cases, including 130 (63.1%) boys and 76 (36.9%) girls were evaluated. The mean age at diagnosis was 5.96 ± 3.58 years. Pallor was the most common clinical feature in 172 (83.5%) followed by fever in 158 (76.7%) cases. AML M-2 was the most frequent French-American-British (FAB) subtype in 94 (45.6%) cases. Majority of the patients (n = 128, 62.1%) were well nourished; and 46 (22.3%) and 32 (15.5%) were moderately and severely malnourished, respectively. Disease-free survival (DFS) was 43.0%, 32.6% and 21.9% in well nourished, moderately malnourished and severely malnourished patients, respectively (p=0.022). Overall survival (OS) was 43.8%, 39.1% and 21.9% in well nourished, moderately malnourished and severely malnourished patients, respectively (p=0.012). CONCLUSION: Malnutrition adversely affects the treatment outcome in paediatric AML. It is significantly associated with increased treatment-related mortality, mainly due to infection and decreased disease-free and overall survival. Key Words: Paediatric acute myeloid leukaemia, Mortality, Nutritional status, Weight-for-age, Z score, Pakistan.

Cytogenetic Abnormalities and Their Impact on Treatment Outcome in Paediatric Acute Myeloid Leukaemia in Pakistan.

OBJECTIVE: To determine the impact of cytogenetic abnormalities on the treatment outcome of paediatric acute myeloid leukaemia (AML) at a tertiary care facility of Pakistan. STUDY DESIGN: Retrospective Observational study. PLACE AND DURATION OF STUDY: Paediatric Oncology Ward, Combined Military Hospital, Rawalpindi, from January 2012 to September 2019. METHODOLOGY: All registered cases of AML under 18 years of age, admitted to paediatric oncology ward in Combined Military Hospital, Rawalpindi, who had completed their treatment before 30th September 2019 were included. Their demographic and clinical data including WBC counts, immunophenotyping, cytogenetic abnormalities and impact of cytogenetics on disease outcome was assessed. Data was analysed for descriptive statistics and association of proportions. RESULTS: Data of 138 cases of de novo AML including 90 (65.2%) males and 48 (34.8%) females were analysed. The mean age was 6.37 ±3.51 years. Initial WBC of more than 50x109/L was seen in 43 (31.2%) patients. The most common FAB subtype was M-2 in 74 (53.6%), followed by M-4 in 20 (14.5%) cases. The majority of cases 81 (58.7%) had normal cytogenetics followed by 42 (30.4%) favourable and 15 (10.8%) unfavourable abnormalities. Five-year overall survival was 82.4%, 56.5% and 55.6% for favourable, intermediate and unfavourable risk cytogenetics, respectively (p=0.039). Disease-free survival was 82.4%, 51.6% and 44.4% for favourable, intermediate and unfavourable risk cytogenetics (p=0.008). CONCLUSIONS: Identification of cytogenetic aberrations at diagnosis will help in risk stratification and predicting prognosis in AML. This will further assist in improving treatment strategies for different cytogenetic risk groups. Key Words: Paediatric acute myeloid leukaemia, Cytogenetics, Treatment outcome.

Prognostic Factors in Childhood Acute Myeloid Leukemia; Experience from A Developing Country.

BACKGROUND: In the developed world, 5-years survival of childhood acute myeloid leukaemia (AML) has improved to 70%. However, the survival rates in the developing world are below 40%. The main contributing factors to these reduced survival rates are a late presentation, malnutrition and high treatment-related mortality. AIM: To document the factors affecting treatment outcome of childhood AML at a tertiary care facility of Pakistan. METHODS AND RESULTS: All newly registered cases of AML under 18 years of age from January 1, 2012 onwards who completed their treatment before November 30, 2019 were included. Data of 219 cases of AML containing 140 (63.9%) males and 79 (36.1%) females was analyzed. The mean age was 6.30 ± 3.66 years. Pallor was the commonest presenting features in 180 (82.2%) and M2 was the commonest French American-British (FAB) subtype in 103 (47.0%) cases. In univariate analysis, high white blood cells (WBC) count at presentation (P = .006), poor nutritional status (P = .005), unfavourable cytogenetics (P = .019), certain types of FAB AML subtype (P = .005), and use of etoposide in induction chemotherapy (P = .042) significantly adversely affected overall survival (OS). Neutropenic sepsis and bleeding were the major causes of treatment-related mortality. Response to induction chemotherapy was the most significant prognostic factor in the multivariate analysis (P = <.001). After a median follow-up of 40.96 ± 26.23 months, 5-year OS and DFS of the cohort were 40.6% and 38.3% respectively. CONCLUSIONS: In this largest cohort of childhood AML from Pakistan, high WBC count at presentation, malnutrition, unfavourable cytogenetics and use of etoposide during induction chemotherapy were associated with decreased OS and DFS rates. Response to the induction chemotherapy was the most significant prognostic factor.

Predictors of treatment outcome of Wilms Tumour in low-income country; single centre experience from Pakistan.

BACKGROUND: Wilms tumor (WT) represents around 85% of pediatric renal tumors. In high-income countries, 5-years survival of WT is above 90% but survival in developing countries is inferior. OBJECTIVE: To identify the predictors of treatment outcome of WT in a developing country. METHODS: A retrospective study conducted at the pediatric oncology department, Combined Military Hospital Rawalpindi, Pakistan. All newly diagnosed WT cases from 1st January 2012 who completed their treatment before 31st August 2019 were evaluated. Treatment was based on SIOP Wilms Tumour 2001/UK version 5. Patients presenting before nephrectomy received pre-operative chemotherapy. The postoperative chemotherapy regimen was decided according to the stage, risk stratification and metastatic status of the patient. RESULTS: Data of 84 cases, including 40 (47.6%) males and 44 (52.4%) females was analyzed. The mean diagnostic age was 38.87 ± 28.66 months and 68 (81%) cases were less than five years of age. The commonest presenting features were abdominal mass in 75 (89.3%) cases. The right kidney was affected in 43 (51.2%) cases. Stage I disease was documented in 27 (32.1%) cases, stage II in 25 (29.8%), stage III in 13 (15.5%), and stage IV in 17 (20.2%) cases. In univariate analysis, advanced stage (P = < 0.001) and metastatic disease (P=< 0.001) adversely affected the treatment outcome. Multivariate analysis demonstrated that advanced stage WT was associated with the worst outcome (P= < 0.05). Four (4.8%) cases had treatment-related mortality (TRM). With a median follow-up time of 28.26 ± 23.03 months, OS and EFS were 66 (78.6%) and 63 (75.0%) respectively. DISCUSSION: Delayed presentation with advanced-stage metastatic disease is quite common in the developing courtiers and is the major contributor to decreased EFS and OS. In the present study, 20.2% cases had metastatic disease, which is similar to reported from other developing countries. OS decreased from 92.6% in stage I to 47.1% in stage IV disease (P=< 0.001) and EFS decreased from 92.6% in stage I to 43.8% in stage IV disease (P=< 0.001). Very similar results are reported by a regional study [17]. Results in stage I and II disease are comparable to documented in the western world and inferior in advanced-stage disease. The strength of the present study is that multiple factors, affecting the treatment outcome of WT over almost seven years period were evaluated. CONCLUSIONS: Stage of the disease is the most important prognostic factor. Delayed presentation with metastatic disease has a poor outcome.

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.