Distinctive Clinico-electrographic and Radiological Profile of Childhood and Adolescent Seizures.

AIM: Electroencephalogram (EEG) is specific, but not sensitive, for the diagnosis of epilepsy. This study aimed to correlate the clinico-electrographic and radiological features of seizure disorders in children attending a tertiary care centre in northern India. METHODS: Children aged between one to 18 years with seizure episodes were included. Clinical details, including historical as well as physical findings, were evaluated along with EEG and neuroimaging (Magnetic resonance imaging). Details were noted on pre-designed proforma. Variables were analysed by using appropriate statistical methods. RESULTS: A total of 110 children with seizures were enrolled in the study. Male to female ratio was 1.6: 1, and the mean age of the study children was 8 years. The majority of the children were symptomatic for more than one year. The most common seizure type was Generalised Tonic Clonic Seizure (GTCS), and Hypoxic-ischemic Encephalopathy (HIE) sequelae was the most commonly attributed etiology, followed by neurocysticercosis. EEG and neuroimaging findings were found to correlate well with seizure semiology from history. The incidence of febrile seizures was 10% in this study, with nearly three-fourths of them being simple febrile seizures. CONCLUSION: Microcephaly and developmental delay were the most distinctive clinical correlates in children with seizures. There was a fair agreement between the types of seizures described in history and depicted on EEG with Cohen's kappa of 0.4. Also, there was a significant association between the type of seizures on EEG and the duration of symptoms.

Short Stature for Age in Children of 5 to 16 Years: The First Research from the Northern Himalayan Region of India.

Introduction: Anthropometric parameters play vital role in monitoring growth in pediatrics. Many etiological factors lead to short stature. So, before assessing the etiological factors short stature needs to be addressed. This study aimed to screen short stature for age in school-going children aged 5 to 16 years in Uttarakhand. Material and Methods: In this cross-sectional observational study, the height (through stadiometer) and weight (through weight machine) of 4189 students of government and private school in Rishikesh (Uttarakhand) aged 5-16 years were measured after the verbal assent of the students and individual's height is in the 3rd percentile for the mean height of a given age, sex, and population group and was considered short stature. The data collection was performed from October 2019 to July 2021. The data were categorized according to different age groups to 5-8 years, 9-12 years, and 13-16 years. The data were recorded in Microsoft (MS) Excel spreadsheet program. Statistical Package for the Social Sciences (SPSS) v23 (IBM Corp.) was used for data analysis. Descriptive statistics were elaborated in the form of means or standard deviations and medians or Interquartile range IQRs for continuous variables and frequencies and percentages for categorical variables. The Chi-square test was used for group comparisons for categorical data. Results: 7.1% of children were short stature (height 143.16 ± 15.09 cm) in the Himalayan belt, and males were more prone to short stature at age of 9-12 years. Conclusion: In the growing phase of children, the etiology of short stature has to be rectified, so the children can achieve such proper growth. Parents and physicians have to assess and monitor the growth of children timely. This study can be a stepping stone for further epidemiological studies.

Perinatal Exposure to Trace Elements: The Dubious Culprit of Autistic Spectrum Disorder in Children.

There is evidence that few trace elements in the environment work as hazardous materials in terms of their exposure in the perinatal period, causing autistic spectrum disorder (ASD) in children, and avoiding these exposures in the environment can reduce the number of new cases. This perspective study provides preliminary evidence to consider a few trace elements as culprits for ASD. More studies with larger cohorts are needed, but meanwhile, as per available evidence, exposure to these hazardous materials must be warranted during pregnancy and early stages of life.

Malaria in newborn: A missed entity for primary care physician.

Neonatal malaria and congenital malaria, though thought to be a rare entity in non-endemic areas but incidences from epidemic countries are eye openers. It is still thought by primary care physicians that its existence among neonates is not common even in endemic areas due to a low index of suspicion. In order to attain the objective set out in the global technical strategy against malaria 2016-2030, it is important to have a gravity of this disease in all age groups, especially in children and neonates in which misconception of low burden of infection results in underestimation of its morbidity and mortality in these age groups. This disease is only the tip of the iceberg due to unidentified, underreported and neglected illness and being a pointer towards higher circulation among society and pregnant women. So this review article highlights pathophysiology, epidemiology, clinical features, complications, prognosis, treatment and prevention of malaria in newborns and intends to bring awareness among the caregivers to understand the need for attention towards this neglected disease of neonates so that they should be able to identify and manage the disease in this vulnerable age group.

Magnetic resonance imaging brain yield in developmental delay: A developing country perspective.

BACKGROUND: Developmental delay (DD) is an important neuro-morbidity in children affecting the quality of life. MRI plays a crucial role by delineating the underlying structural, metabolic, and genetic abnormalities. AIM: To determine the yield of MRI brain in delineating the various underlying abnormalities and etiological factors in children with DD and to correlate these findings with the clinical presentation. METHODS: This cross-sectional study enrolled 50 children with the developmental delay between 6 months to 6 years of age. OUTCOMES AND RESULTS: The mean age was 31.32 ± 20.56 months. The sensitivity of MRI was 72%. 81.3% of the children with microcephaly had abnormal MRI. The most common underlying etiology was hypoxic-ischemic encephalopathy (42%), followed by congenital/developmental defects and metabolic diseases (10% each). The most commonly involved region of the cerebral cortex was the occipital lobe (44%) because of the high occurrence of coexisting hypoglycemic brain injury, which is extremely common in developing countries and rare in developed countries, with 80% of them having visual abnormalities. Frontal lobe involvement was significantly more in children with abnormal motor findings and behavioral changes. Cortical grey matter abnormalities were significantly more in children with seizures. CONCLUSION AND IMPLICATIONS: It is to be emphasized that children with developmental delays should be evaluated with MRI whenever possible. Apart from hypoxic-ischemic encephalopathy, other etiologies should also be looked for.

Clinico-Microbiological Profile and Clinical Predictor of Urinary Tract Infection in Children: A Single-Center Study From Himalayan Foothills.

BACKGROUND:  Urinary tract infection (UTI) in children is one of the commonest bacterial infections seen in the pediatric population. Clinical presentation ranges from fever with or without focus and isolation of microbiological agents streamline the treatment. Moreover, local/regional microbial profiles are helpful in antibiotic selection, we conducted a study to assess the prevalence of urine culture positivity in a suspected case of UTI. In addition, antibiotic susceptibility patterns and ultrasonography (USG) finding in culture-positive patients were also studied. METHODS AND MATERIALS: It is a prospective observational study comprising symptomatic children aged one month to 18 years presenting to the outpatient department (OPD), inpatient department (IPD), and the emergency department of Pediatrics with UTI during the period of September 2019 to September 2020. The recorded variables were demographic, clinical presentation, anthropometry, physical examination, blood biochemistry, and outcome. Urine samples were collected and processed as per standard protocols. USG was done for all culture-positive children. Data were presented as frequency, mean (SD) and parametric and non-parametric data were analyzed by Wilcoxon-Mann-Whitney U Test, Chi-Squared Test, or Fisher's Exact Test.  Results: Of the total 354 children, 202 (57.1%) were male and the prevalence of UTI was 64 (18.1%). E. coli (70.3%) was the commonest isolated organism followed by Klebsiella spp (15.6%) and Pseudomonas spp (7%) respectively. The mean (SD) age (months) of presentation of symptoms was significantly lower in culture-positive children as compared to [ 83.49 (58.96) vs 110.10 (58.60); p=0.001] culture-negative children. Fever (96.6%) followed by dysuria (20.1%) were the most common symptoms presented for UTI however dysuria (p=0.003), pus cells (p<0.0001), and RBCs (p=0.002) were significantly present in culture positive children. This study shows increased resistance to third generation of cephalosporins. This study revealed significant differences among various groups (organism growth in positive culture) and the Antibiotic susceptibility test (AST) with a p-value of <0.001.  Conclusion: The prevalence of culture-positive UTI was similar to the reported literature and the presence of fever, dysuria, pus cells, and RBC in urine were commonly observed in the lower age group. Amikacin can be used in suspected UTIs with cephalosporin as empirical antibiotics in the Himalayan Foothills region.

Association of serum zinc levels and symptom control of asthma in children and adolescents- a prospective observational study.

Dysregulation of zinc (Zn) homeostasis causes a shift in the Th1/Th2 balance towards a Th2 response, which may lead to a heightened inflammatory response. Asthma is associated with an exaggerated Th2 response to antigens. This study attempts to find the association of serum Zn with the status of symptom control of asthma in children and adolescents with bronchial asthma. A total of 67 asthmatic children, diagnosed as per Global Initiative for Asthma (GINA) 2019 guidelines, were included in the study. Symptom control of asthma was assessed by Asthma Control Test (ACT) and Childhood Asthma Control Test (C-ACT) scores. Spirometry was performed on those participants who were able to perform satisfactorily. Serum Zn was analyzed using the photometric method. Participants were divided into two groups: controlled and uncontrolled groups according to ACT/C-ACT score. Mean age of the participants was 10.78 ± 3.67 years. The mean S. Zn (µg/dL) was 136.97 ± 48.37. This study found a higher mean S. Zn value in the controlled asthma group as compared to the uncontrolled group (158.06 vs 129.23, p = 0.006). At a cutoff of S. Zn (µg/dL) ≥ 126.84, it predicted controlled asthma with a sensitivity of 89% and a specificity of 55%. No significant difference was found between the mean serum Zn levels in terms of age, sex, severity, and CRP levels. CONCLUSION: A significant difference was observed between the mean value of Zn and symptom control of asthma (p = 0.006) with a weak positive correlation between the two which was statistically significant (rho = 0.26, p = 0.031). However, low levels of zinc were not significantly associated with symptom control of asthma. Thus, we conclude that maintaining an adequate zinc level could help in achieving better control of asthma in pediatric populations. WHAT IS KNOWN: • Zinc has a role in immunological response in the pathophysiology of immunological disorders such as bronchial asthma. WHAT IS NEW: • This study adds a significant association of serum zinc levels with symptom control of asthma in pediatric populations. • This study also gives a cut-off value of serum zinc level which predicts adequate symptom control of asthma.

Maternal and Placental Risk Factors for Small Gestational Age and Fetal Malnutrition.

AIMS: This case-control study was conducted to identify maternal and placental risk factors of small-for-gestational-age (SGA) and fetal malnutrition. METHODS: Cases comprised 104 consecutively delivered SGA neonates (determined as per INTERGROWTH- 21st standard). An equal number of next-born gestation and gender-matched appropriatefor- gestational age (AGA) neonates served as controls. Maternal risk factors were enquired, and placentae were evaluated by clinical and histopathological examination. Nutrition of the neonates was assessed by the clinical assessment of nutrition (CAN) score. Univariate and multivariate logistic regression analysis was done to identify the maternal and placental risk factors. RESULTS: The prevalence of SGA in the present study was 23.9%. Maternal fever [adjusted Odds Ratio (aOR), 95% confidence interval (CI), 16.3 (3.5-124.1); p = 0.001], presence of placental syncytial knots [aOR (95% CI), 2.9 (1.1-9.1); p = 0.04] and placental calcifications [aOR (95% CI), 3(1.1- 8.7); p = 0.03], were identified as independent predictors of SGA using multivariate logistic regression analysis. Malnutrition (SCORE <25) affected 64% of SGA and 16.3% of AGA neonates. The only risk factor significantly associated with malnourished SGA was prematurity, whereas malnourished AGA was significantly associated with prematurity and fetal distress. In-hospital morbidities significantly higher in SGA were perinatal asphyxia, respiratory distress, need for respiratory support, polycythemia, hypoglycemia, and feeding intolerance. Mortality before discharge was 4.8% and 3.8% in SGA and AGA population, respectively (p > 0.05). Neonatal outcomes were comparable among well-nourished, malnourished SGA and AGA groups. CONCLUSION: Maternal fever, placental syncytial knots, and calcifications were independent risk factors of SGA, whereas prematurity and fetal distress were responsible for malnutrition.

Protein S deficiency in an adolescent female with disseminated tuberculosis presenting as deep vein thrombosis: confounder or correlation?

Tuberculosis remains as an infectious disease with a very high prevalence in the Indian subcontinent. Deep vein thrombosis in tuberculosis is due to the increased fibrinogen levels, release of inflammatory cytokines and decreased synthesis of anticoagulant proteins. We present a case of deep venous thrombosis of bilateral lower limbs in association with pulmonary tuberculosis and protein S deficiency.

Severity of Vitamin D Deficiency in Children with Nephrotic Syndrome: A Study from Tertiary Care Center in Northern India.

In nephrotic syndrome (NS) due to podocytopathies, loss of vitamin D binding globulin along with albumin in urine leads to Vitamin D deficient state. We aimed to study the severity of vitamin D deficiency and its clinical correlation in children with NS. We performed a cross-sectional study at a tertiary care hospital in Northern India. Enrolment of children aged 1-18 years was done. Patient's detailed history, numbers of relapse, treatment details, and data regarding various immunomodulatory drugs treatment. Vitamin D level was estimated, and its status was further classified as deficiency <20 ng/mL and insufficiency 20-30 ng/mL as per Global Consensus Recommendations on evaluation, treatment, and prevention of vitamin D deficiency. Continuous variables were compared using tests such as unpaired t-test, Kruskal-Wallis test, and Wilcoxon rank sum test depending on the distribution of parameters. Categorical variables were compared using Chi-squared tests or Fisher's exact test. A total of 96 children with NS were screened, of which 77.1% had vitamin D deficiency. The mean serum vitamin D level was 14.393 ± 8.52 ng/mL. Among the 48 children of the first episode of NS 36 were deficient (36/48 = 75%). Whereas in the relapse category, 30 patients had infrequently relapsing NS (deficient 24/30 = 80%). Eleven children had frequently relapsing NS; among them, 10 were vitamin D deficient (10/11 = 90.9%), and there was a negative correlation between vitamin D level and duration of illness. Vitamin D deficiency is a common comorbidity in children with NS. Given the putative immunomodulatory property of vitamin D, this deficiency should be identified and treated routinely in all cases of NS.

Congenital Malaria in Newborns Delivered to Malaria-infected Mothers in the Hilly Region of Northern India: Is it Deadly?

BACKGROUND: Malaria is endemic in many states of India. Though there are reports of maternal and congenital malaria from endemic areas, however, there remains a paucity of data from hilly terrains. The present study evaluated the prevalence, clinical and microbiological spectrum of maternal and congenital malaria at a tertiary health care facility in Northern India over a period of 18 months. METHODS: In this observational study, mothers along with their newborns were evaluated for malaria by maternal, placental, and cord blood smear examination and rapid point-of-care diagnostic serological tests. Positive cases were confirmed by polymerase chain reaction. Mother-newborn duos were followed up till discharge from the hospital. RESULTS: A total of 843 mothers delivered during the study period and were screened along with their newborns and placentae. A total of Ten (1.18%) mothers had evidence of malarial parasitemia (Plasmodium vivax, n=7 and Pl. falciparum, n=3), however, none of the placental and cord blood samples were positive for malaria. Overall, 127 (15.1%) neonates required admission in neonatal intensive care unit for various morbidities. Incidence of small for gestational age (SGA) was high (n=210; 24.9%). Multivariate logistic regression analysis demonstrated maternal malaria to be an independent contributor for SGA [Odds Ratio (95% Confidence Interval), 10.7 (2.06 - 49.72)]. However, only 2% variance of SGA could be explained by maternal malaria alone. CONCLUSION: We report an encouragingly lower incidence of maternal malaria in mothers attending for delivery and a 'Zero' incidence for placental and congenital malaria during the study period as compared to national data (upto 7.4% in non-immune mothers), although maternal malaria could be a causative factor for SGA.

Pyridoxine in isoniazid-induced psychosis.

Isoniazid is a first-line drug for the management of tuberculosis. Recent changes in paediatric tuberculosis guidelines have insisted on a higher daily dose of isoniazid. Given the burden of paediatric tuberculosis in developing countries, it is pertinent that paediatricians are well versed with all possible adverse effects associated with isoniazid therapy and not just common ones like hepatotoxicity or peripheral neuropathy. Psychosis is one such rare adverse effect which has a reported incidence of 1%-2%. Here, we report a case of isoniazid-induced psychosis in a 4-year-old girl. The purpose of this report is to sensitise the paediatric healthcare community regarding this rare clinical entity along with highlighting the putative role of pyridoxine supplementation in the management of isoniazid-induced psychosis.

Urinary tract infection in children with Nephrotic syndrome: One of the hurdles for primary care physician and pediatrician towards timely diagnosis and optimum management of the disease.

Background: Urinary tract infection (UTI) is a common infection in children with nephrotic syndrome (NS). Clinical experience suggests that childhood nephrotic syndrome is frequently diagnosed incorrectly and managed inadequately on the top of this existing UTI in the episode becomes an additive obstacle for the primary care physicians or pediatricians towards optimum management, leading to poor outcome. So, we have conducted this clinico- microbiological study of UTI in NS in children to provide the exact picture of UTI with NS so that the primary care providers can be helped in having high index of suspicion of this infection and knowing prevalent organisms and their antimicrobial sensitivity pattern. Aim: The aim of the study was to study clinical features and identify the responsible organisms with its drug sensitivity pattern with response to treatment in various types and stages of NS with UTI in children. Methods: This cross-sectional hospital based study was conducted on 50 children of 2-18 years of age with NS attending nephrology clinic or admitted to the Paediatric ward of AIIMS, Rishikesh. Demographic, clinical, and microbiological data were recorded and details were entered in a predesigned proforma sheet. Results: Out of 50 cases, 8 (16%) had a positive urine culture. Six (75%) out of them had first episode and two (25%) were frequent relapsers of NS. Fever, decreased urine output, and generalized edema were the presenting features. The most common bacteria responsible for UTI was Pseudomonas aeruginosa (in around 25% isolates). Escherichia coli and Citrobacter koseri were the most resistant organisms. Patients were treated with antibiotics according to sensitivity pattern which resulted in resolution of symptoms and repeat urine culture became sterile subsequently. Conclusion: About one-sixth of children with Nephrotic Syndrome had UTI. UTI should be ruled out in every case of NS in active phase to prevent long-term morbidity and mortality.

Comparison of clinical and laboratory profile of pulmonary and extrapulmonary tuberculosis in children: A single-center experience from India.

BACKGROUND: Pediatric tuberculosis (TB) is an indicator of the recent transmission of TB in the community. However, the diagnosis of pediatric TB poses a challenge to clinicians. AIMS: We aimed to evaluate and compare the clinical and laboratory profile of pulmonary TB (PTB) and extra PTB (EPTB) in children and adolescents. METHODS: In this retrospective observational study, children attending the pediatric TB clinic of All India Institute of Medical Sciences, Rishikesh, from August 2015 to July 2017 were included in the study. The medical case records of patients were reviewed for demography, clinical findings, investigations, and diagnosis. The clinical and laboratory characteristics of patients with PTB and EPTB were compared. RESULTS: A total of 58 children included. Out of which, 33 (56.9%) had PTB, and 25 (43.1%) had EPTB. The EPTB cases included 15 (60%) pleural TB, 9 (36%) lymph node TB, and 1 (4%) TB meningitis patient. Fever, cough, and weight loss were the most common symptoms. Hilar lymphadenopathy was the most common radiological abnormality. Microbiological confirmation was possible in 54.5% of patients with PTB. Cough (aOR 70.326; 95% CI: 5.370-921.032) and microbiological confirmation (aOR 46.011; 95% CI: 2.073-1021.201) were more in PTB as compared to EPTB. CONCLUSIONS: PTB and EPTB are common in children and adolescents. The typical clinical manifestations and positive microbiological confirmation are less common in EPTB than PTB. RELEVANCE FOR PATIENTS: TB is one of the common communicable diseases in the developing world. Diagnosis of TB in children is often challenging. Our study results help in better understanding childhood TB and EPTB clinical features and have potential to increase diagnostic yield.

Unusual Etiology of Hypercalcemia in an Adolescent With Acute Gastroenteritis.

We present the report of an adolescent female who presented with acute gastroenteritis, weight loss, and hypercalcemia. Further evaluation revealed hyperthyroidism to be the cause of hypercalcemia. Treatment of hyperthyroidism successfully corrected the hypercalcemia in our index case.

Rare but not Abdicated: Status of Haemophilia in foothills of Himalaya, Uttarakhand: A cross-sectional study.

BACKGROUND: Haemophilia is one of the bleeding disorders, which is inherited, in an xlinked recessive pattern. The diagnosis is by estimation of factor levels of 8 and 9. Timebound treatment for people living with Haemophilia (PWH) is factor replacement during bleeding manifestation. The prevalence of Haemophilia was mostly underestimated, and it is more so in hilly terrains like the state of Uttarakhand. MATERIALS AND METHOD: This is a crosssectional study by compiling the data of PWH visiting the tertiary care centre for Haemophilia in Uttarakhand. We collected data from the patients with bleeding disorder reporting to the Haemophilia centre from July 2017 to December 2018. In this manuscript, we try to describe the pattern of Haemophilia and the degree of severity and incidence of inhibitors among the sample population of PWH who represent the population of Uttarakhand. The magnitude of problems faced by PWH from this hilly terrain to assess basic treatment in case of emergency is also being depicted. RESULT: We reported Haemophilia A contributing about 80% of the PWH in our centre. Average distance a PWH has to travel to obtain treatment was about 131.5 km (SD ± 83.7 km). Incidence of inhibitors was about 5%. CONCLUSION: We infer from our study that Hemophilia A is more common than Hemophilia B. Through this manuscript we hope to spread awareness of the Haemophilia care that is ongoing, the role of prophylaxis therapy and the future role of primary care physicians that may change the care of PWH in future.

Serum Calcium and Melatonin Levels in Neonates Undergoing Phototherapy.

Phototherapy-induced hypocalcemia has been postulated to result from a decline in serum melatonin levels. The present observational study evaluated the effects of phototherapy on serum calcium and melatonin levels, and assessed their correlation, if any. Eighty-nine neonates with a total serum bilirubin levels of 14.1 ± 2.8 mg/dL were recruited at the mean age of 51.9 ± 21.7 h. After a median interquartile range (IQR) duration of phototherapy for 24.0 (24-25.5) h, serum calcium levels decreased significantly, from 9.6 ± 0.8 to 9.4 ± 0.6 mg/dL; p = 0.02, leading to asymptomatic hypocalcemia in 2.2% of the neonates. Median (IQR) serum melatonin levels also decreased from 187.8 (133.5-227.6) to 176.3 (145.6-202.5) pg/mL after phototherapy, the difference being statistically insignificant. No significant correlation was documented between the duration of phototherapy with calcium and melatonin levels. The authors conclude that phototherapy resulted in a small but significant reduction of serum calcium levels without any significant correlation with serum melatonin.

Magnetic Resonance Spectroscopy in Children With Developmental Delay: Time to Look Beyond Conventional Magnetic Resonance Imaging (MRI).

Developmental delay (DD) is an important long-term neuromorbidity owing to various insults to the developing brain and neuroimaging plays a key role in evaluating these children. Magnetic resonance spectroscopy (MRS) is the only noninvasive method to determine the levels of various metabolites in the brain which aids in delineating the underlying abnormalities. A total of 48 children aged between 6 months to 6 years with developmental delay were included and evaluated with neuroimaging in our study. Sensitivity of MRS in children with DD and DD plus (DD along with seizures, abnormal motor findings, behavior, brainstem evoked response audiometry, visual assessment, and microcephaly) was 81.2% and 89.6% respectively. 86.6% of children with microcephaly had abnormal MRS. MRS detected abnormalities in two-thirds of children with normal magnetic resonance imaging (MRI). Children with behavioral abnormalities had significantly lower N-acetyl aspartate (NAA)-creatine and NAA-choline ratios on MRS. Thus, MRS is additive to MRI in delineating the underlying pathophysiology in children with DD.