Disordered eating behaviors, body dissatisfaction and their determinants in Indian adolescents: A cross-sectional observational study.

Objective: Although the prevalence of disordered eating is maximum in high-income countries, the most significant rise occurred in East Asia and South Asia over the last three decades. Body dissatisfaction and disordered eating behaviors (DEBs) are more common than full-blown eating disorders. The cognitive distortion leading to these manifestations mainly occurs during adolescence and early adulthood. In this study, we assess the burden of DEBs in a cohort of Indian adolescents and determine their correlation with body dissatisfaction, calorie intake, and clinicosocial determinants. Methods: The study was conducted from November 2016 to November 2020 and enrolled 180 adolescents of 10-18 years attending the outpatient department of a tertiary-care hospital. Subjects were screened for DEBs, using a 15-item Screening Questionnaire for Eating Distress Syndromes, and for body dissatisfaction, using Photographic-Figure-Rating-Scale. Clinicosocial interviews, dietary and anthropometric evaluation, and psychiatric screening using a Mini-International Neuropsychiatric Interview (MINI-KIDS screen) were conducted. Results: DEB was present in 17.2% of adolescents, while 81.1% had body dissatisfaction and 32.2% had some psychiatric symptoms. The prevalence of DEBs in females was much higher than in males (OR = 7.89, 95%CI: 2.25-27.75, P = 0.001). More males (84.1%) reported body dissatisfaction than females (76.7%) [χ² =9.2, P = 0.010]. However, while females wished to lose weight, males desired weight gain, as measured by body dissatisfaction score (t = 2.9, P = 0.004). Apart from sex, other factors found significant in predicting DEBs in multivariate analysis were education, body dissatisfaction, BMI, and the number of siblings. Conclusion: We conclude that, unlike overt eating disorders, DEBs are common in Indian adolescents. The development of DEBs is influenced by gender, education, body dissatisfaction, BMI, and the number of siblings.

Modified Atkins diet versus levetiracetam for non-surgical drug-resistant epilepsy in children: A randomized open-label study.

BACKGROUND: This study was undertaken to compare the efficacy of modified Atkins diet (MAD) among children with non-surgical drug-resistant epilepsy (DRE) to levetiracetam, when added to on-going anti-seizure medications. METHODS: An open-label, randomized controlled trial among children aged 2-12 years with non-surgical DRE was conducted. Eligible children were randomized in a 1:1 ratio to receive add-on MAD or levetiracetam. Baseline and post-intervention seizure frequency at 12 weeks was determined from seizure logs maintained by parents. The primary outcome was the proportion of responders, i.e., patients who achieved > 50% seizure reduction from baseline. Adverse events were compared. Analysis was intention-to-treat. (NCT04172311) RESULTS: One hundred and one children were enrolled (MAD-51, levetiracetam-50). The majority of the enrolled children had generalized seizures of mixed types secondary to structural brain lesions and Lennox-Gastaut syndrome was the most common electroclinical syndrome (46%). The proportion of children with >50% seizure reduction at 12 weeks was significantly higher in the MAD arm compared to the levetiracetam arm (27/51(52.9%) vs 11/50(22%); p < 0.001). At 12-weeks post-intervention, the change in mean seizure frequency compared to baseline was -47.33 ± 39.57% in the MAD arm and -31.15 ± 32.18% in the levetiracetam arm (p = 0.03). Constipation (41.1%) was the most frequent adverse effect with MAD. Sedation/lethargy (18%) and anxiety and irritability (14%) were the most frequent adverse effects in the levetiracetam group. CONCLUSION: Addition of MAD was found to be superior to levetiracetam among children with non-surgical DRE with predominant generalized seizures in achieving seizure reduction at 12 weeks. Both treatments were well tolerated. Adverse effects, although higher with MAD, were expected side effects.

Stepped Care Model for Developing Pathways of Screening, Referral, and Brief Intervention for Depression in Pregnancy: A Mixed-Method Study from Development Phase.

Background: Depression in pregnancy affects nearly one in five women in low- and middle-income countries and is associated with adverse obstetric and neonatal outcome. Burden of morbidity is high, but specialized mental health resources are meager. Effective low intensity psychosocial interventions hold promise to fill the treatment gap for maternal depression. In this paper, we aim to describe the process of development of a stepped care model incorporating screening, providing brief intervention, and referral pathways developed for managing depression in pregnancy in antenatal care health facilities in India. Methodology: Using complex intervention development and evaluation method of Medical Research Council, United Kingdom, we searched evidence-based strategies from preexisting manuals, conducted formative research for need assessment and stakeholder engagement, and developed the intervention following an expert review panel. We conducted pilot testing to assess the feasibility and acceptability of intervention supplemented by three focused group discussions. Results: Manual review identified psychoeducation, empathetic listening, behavior activation, and supportive counseling as important elements. Need assessment revealed huge gap in perinatal mental health knowledge. Nearly 92% of total 272 perinatal women had poor awareness and 35%-70% of total 62 health-care providers had poor knowledge. In qualitative interview, women reported depressive symptoms as a normal part of pregnancy and had poor help seeking, behavior symptoms of depression were more prominent. A stepped care algorithm was developed for screening all expectant mothers in each trimester for depression using Patient Health Questionnaire-9 (PHQ-9). Women with PHQ-9 score >19 or reporting self-harm ideation were urgently referred to psychiatrist. Women with PHQ-9 score 5-19 were given brief intervention for depression in pregnancy intervention by antenatal nurse. The intervention developed consists of three sessions of psychoeducation, relaxation exercise, and mental health promotion, each lasting 20 min and at gap of 2 weeks each. Service providers and mothers reported good acceptability of psychosocial intervention and reported satisfaction with content and delivery of intervention. Conclusion: Low intensity brief psychosocial interventions can be adapted for implementation if relevant stakeholders are engaged at each step right from development of such as screening, intervention pathway to delivery, and effectiveness study.

Coronavirus Disease 2019 (COVID-19) Vaccination for Children: Position Statement of Indian Academy of Pediatrics Advisory Committee on Vaccination and Immunization Practices.

JUSTIFICATION: Data generated after the first wave has revealed that some children with coronavirus 19 (COVID-19) can become seriously ill. Multi-inflammatory syndrome in children (MIS-C) and long COVID cause significant morbidity in children. Prolonged school closures and quarantine have played havoc with the psychosocial health of children. Many countries in the world have issued emergency use authorisation (EUA) of selected Covid-19 vaccines for use in children. In India, a Subject Expert Committee (SEC) has recommended the use of Covaxin (Bharat Biotech) for children from the ages of 2-18 years. The recommendation has been given to the Drugs Controller General of India (DCGI) for final approval. OBJECTIVE: To provide an evidence-based document to guide the pediatricians on the recommendation to administer COVID vaccines to children, as and when they are available for use. PROCESS: Formulation of key questions was done by the committee, followed by review of literature on epidemiology and burden of Covid-19 in children, review of the studies on COVID vaccines in children, and the IAP stand on Covid-19 vaccination in children. The available data was discussed in the ACVIP focused WhatsApp group followed by an online meeting on 24 October, 2021, wherein the document was discussed in detail and finalized. RECOMMENDATIONS: The IAP supports the Government of India's decision to extend the COVID-19 vaccination program to children between 2-18 years of age. Children with high-risk conditions may be immunized on a priority basis. The IAP and its members should be a partner with the Government of India, in the implementation of this program and the surveillance that is necessary following the roll-out.

Pediatric Residency Training for Integration of Behavior Health: Indian Perspective.

Behaviour disorders are common in children. Various studies in children and Adolescents in India have found that 6% to 30% of study participants had one or other behaviour This calls for emphasis on integration of behavioral health (IBH) in the training programs for medical undergraduates and postgraduates in paediatrics. This article examines the current medical training programs for IBH of children and adolescents in curriculum of these programs in India. Pediatrics residency programs are described. The impact of Indian culture on IBH issues is also discussed. Ideas for integrating behavioral health in Medical education in India are given.

Intravenous Methylprednisolone Versus Oral Prednisolone for West Syndrome: A Randomized Open-Label Trial.

OBJECTIVE: To compare intravenous methylprednisolone (IVMP) with oral prednisolone (OP) for the treatment of West syndrome. METHODS: In this randomized, open-label trial, children aged 2 to 30 mo presenting with epileptic spasms with hypsarrhythmia or its variants on EEG were randomized to receive either IVMP (30 mg/kg/d for 3 d followed by oral prednisolone taper) or OP (4 mg/kg/d for two weeks followed by taper). The primary outcome measure was spasms cessation on day 14. Secondary outcomes included time to response, electroclinical remission at 2 and 6 wk, and frequency of adverse effects. ( ClinicalTrials.gov Identifier: NCT03876444). RESULTS: Sixty children were enrolled; 31 in the IVMP and 29 in the OP arm. Proportion of children achieving spasms cessation at day 14 was similar in both groups (54.8% versus 68.9%, p = 0.26). Time to achieve remission was lower in the IVMP group (mean 5.4 ± 0.9 versus 9.5 ± 2.6 d, p < 0.0001). Electroclinical remission at 2 wk was similar in both groups (51.6% versus 44.8%, p = 0.59) but lower at 6 wk in the IVMP group (45.2% versus 75.9%, p < 0.015). Adverse effects like sleep disturbance, irritability and hypertension were more common in IVMP group whereas weight gain was more common in the OP group. CONCLUSIONS: There was no significant difference in spasms cessation between the groups on day 14 although remission was higher at 6 wk in OP group. Our study suggests that OP was better than IVMP in efficacy and sustained remission with fewer adverse effects.

Electroclinical spectrum of childhood epilepsy secondary to neonatal hypoglycemic brain injury in a low resource setting: A 10-year experience.

PURPOSE: Neonatal hypoglycemic brain injury (NHBI) is being increasingly recognized as an important cause of drug resistant childhood epilepsy in low resource settings. We report the electro-clinical spectrum of children with epilepsy secondary to NHBI. METHODS: This was a retrospective study of children enrolled in the Epilepsy Clinic from January 2009 to August 2019. Data of children who had developed epilepsy after documented symptomatic neonatal hypoglycemia was collected. Details of clinical profile, seizure types, neurodevelopmental co-morbidities, EEG, neuroimaging findings and seizure outcomes were noted. RESULTS: One hundred and seventy children were enrolled. The mean age at seizure onset was 10.3 months (SD 0.5 months). The seizures types were epileptic spasms (76.5%), focal with visual auras (11.2%), bilateral tonic clonic (7.1%), myoclonic (3.5%) and atonic seizures (1.8%). The EEG findings included classical hypsarrhythmia (49.4%), hypsarrhythmia variant (27.1%), focal occipital or temporo-occipital spike wave discharges (10.6%), multifocal discharges (4.7%), diffuse slow spike and wave with bursts of fast rhythms (2.4%), continuous spike waves during sleep (1.2%) and normal EEG (4.7%). MRI showed gliosis with or without encephalomalacia in the occipital lobe with or without parietal lobe in 96.5% of the patients. Co-morbidities included global developmental delay (91.2%), cerebral palsy (48.7%), vision impairment (48.2%), microcephaly (38.2%), hearing impairment (19.4%), and behavioural problems (16.5%). Drug resistant childhood epilepsy was seen in 116 (68.2%) patients. CONCLUSIONS: Our study highlights the varied electroclinical and radiological spectrum and the adverse epilepsy and neurodevelopmental outcomes associated with NHBI.

Normative Data for IVC Diameter and its Correlation with the Somatic Parameters in Healthy Indian Children.

OBJECTIVE: To determine the normative data for inferior vena cava (IVC) diameter in children and its correlation with various somatic parameters like height, weight and body surface area in Indian children. Readily available baseline data of IVC diameter in normal children shall be of great help in rapid assessment of variations in sick children. METHODS: Total 475 healthy children aged one month to 12 y visiting out patient clinics (OPD's) were enrolled in this study. Weight, height and body surface area were calculated at the time of examination. The maximum and minimum diameters of IVC were measured during the expiratory and inspiratory phase of the respiratory cycle respectively using M mode ultrasonography. Collapsibility Index was also calculated for each subject by measuring difference between the maximum (expiratory) and minimum (inspiratory) IVC diameters divided by the maximum diameter. RESULTS: The mean age of study subjects was 4.72 ± 3.72 y. Out of 475 subjects, 285 (60%) were boys and 190 (40%) were girls. Mean weight for age (%) of subjects was 89.18 ± 13.26%. Correlation was studied between physical parameters and IVC diameter which revealed a positive correlation of age, height and weight with both maximum and minimum IVC diameter. Regression analysis was also performed to derive the equations for maximum and minimum diameters of children from 1 y to 12 y. CONCLUSIONS: This study provides reference values of IVC diameters for Indian children of different age groups.

Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP) Recommended Immunization Schedule (2018-19) and Update on Immunization for Children Aged 0 Through 18 Years.

JUSTIFICATION: There is a need to revise/review recommendations regarding existing vaccines in view of current developments in vaccinology. PROCESS: Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics (IAP) reviewed the new evidence, had two meetings, and representatives of few vaccine manufacturers also presented their data. The recommendations were finalized unanimously. OBJECTIVES: To revise and review the IAP recommendations for 2018-19 and issue recommendations on existing and certain new vaccines. RECOMMENDATIONS: The major changes in the IAP 2018-19 Immunization Timetable include administration of hepatitis B vaccine within 24 hours of age, acceptance of four doses of hepatitis B vaccine if a combination pentavalent or hexavalent vaccine is used, administration of DTwP or DTaP in the primary series, and complete replacement of oral polio vaccine (OPV) by injectable polio vaccine (IPV) as early as possible. In case IPV is not available or feasible, the child should be offered three doses of bivalent OPV. In such cases, the child should be advised to receive two fractional doses of IPV at a Government facility at 6 and 14 weeks or at least one dose of intramuscular IPV, either standalone or as a combination, at 14 weeks. The first dose of monovalent Rotavirus vaccine (RV1) can be administered at 6 weeks and the second at 10 weeks of age in a two-dose schedule. Any of the available rotavirus vaccine may be administered. Inactivated influenza vaccine (either trivalent or quadrivalent) is recommended annually to all children between 6 months to 5 years of age. Measles-containing vaccine (MMR/MR) should be administered after 9 months of age. Additional dose of MR vaccine may be administered during MR campaign for children 9 months to 15 years, irrespective of previous vaccination status. Single dose of Typhoid conjugate vaccine (TCV) is recommended from the age of 6 months and beyond, and can be administered with MMR vaccine if administered at 9 months. Four-dose schedule of anti-rabies vaccine for Post Exposure Prophylaxis as recommended by World Health Organization in 2018, is endorsed, and monoclonal rabies antibody can be administered as an alternative to Rabies immunoglobulin for post-exposure prophylaxis.

Determinants of Nutritional Anemia in Adolescents.

OBJECTIVES: To associate the severity of nutritional anaemia with serum levels of ferritin, vitamin B12 and folate; and to determine demographic, socio-economic and nutritional correlates for nutritional anemia in adolescents. METHODS: Cross-sectional hospital-based study among 200 adolescents (10-18 y) with anemia. Dietary intake (24-h recall), and serum levels of folate, vitamin B12 and ferritin were estimated. RESULTS: Iron, folate and vitamin B12 deficiency was present in 30.5% 79.5% and 50% of adolescents, respectively. Statistically significant association was observed between severity of anemia and serum vitamin B12 levels, iron intake, folate intake, Vitamin B12 intake, vegetarian diet, attainment of menarche and history of worm infestation. CONCLUSIONS: Folate and vitamin B12 deficiencies are more common than iron deficiency in anemic adolescents. Low dietary intake of these nutrients seems to be a significant determinant of their deficiencies.

Quality of Life of Adolescents With Transfusion-dependent Thalassemia and Their Siblings: A Cross-sectional Study.

Transfusion-dependent thalassemia (TDT) and its treatment affect the physical, emotional, and social functioning, impairing the quality of life (QoL). There are few studies on QoL of adolescent with TDT. Its effect on their siblings' QoL has not been studied so far. In this cross-sectional study, 40 adolescents with TDT, 28 siblings, and 40 controls were studied to assess the QoL of adolescents thalassemics, and their siblings using the shorter version of World Health Organization Quality of Life instrument, the WHOQOL-BREF. Thalassemics had poor perception of their general health and scored significantly lower in all the subscales compared with the controls. Lowest mean subscale scores were for physical (57.7 vs. 72.4, P<0.001), and psychological domains (56.7 vs. 72.3, P<0.001). Their siblings also scored significantly less in environment domain. Prevalence of school dropout, short stature, and delayed puberty were significantly higher in thalassemics. Pretransfusion hemoglobin, age at onset of anemia, and chronological age were found to be significant predictors of total summary scores. This study showed that the concept of QoL is a cumulative reflection of individual and disease variables and highlights the negative impact of thalassemia on the patients' QoL and some aspects of their siblings' lives also.

Isotonic intravenous maintenance fluid reduces hospital acquired hyponatremia in young children with central nervous system infections.

OBJECTIVE: To find the appropriate type of intravenous fluid (isotonic vs. hypotonic saline in 5 % dextrose) for empiric maintenance fluid therapy in children with central nervous system (CNS) infections that reduces the incidence of hospital acquired hyponatremia. METHODS: This blinded randomized controlled trial included hospitalized children aged 3 mo to 5 y with suspected CNS infections requiring intravenous maintenance fluid for at least 24 h. The subjects were randomized to receive 0.9 % saline (Group-A), 0.45 % saline (Group-B) and 0.18 % saline (Group-C) at standard maintenance rate. The outcome measures were proportion of patients developing hyponatremia (serum sodium < 135 mmol/L) after 24 h and serum sodium values at 6, 12, 18, 24 h of receiving maintenance fluids. RESULTS: Of the 92 patients enrolled, 31, 30 and 31 patients were randomized to Group A, B and C, respectively. Majority (60.7 %) of the patients in Group-C developed hyponatremia compared with 7.1 % of the children in Group-A and 46.1 % in Group-B. During first 24 h of fluid administration successive fall in the serum sodium values was observed in patients receiving hypotonic fluids. The risk of developing hyponatremia was nearly 6½ (95 % confidence interval (CI) 1.6-26) to 8.5 (95 % CI 2.16-33.39) times more in patients who received hypotonic saline compared to those who received isotonic saline. CONCLUSIONS: Administration of 0.9 % saline in 5 % dextrose as intravenous maintenance fluid in children with CNS infection leads to significantly less incidence of hyponatremia when compared to that with hypotonic fluids.

A case report of nephrogenic diabetes insipidus with idiopathic Fanconi syndrome in a child who presented with vitamin D resistant rickets.

Fanconi syndrome is a complex of multiple tubular dysfunctions of proximal tubular cells, occurring alone or in association with a variety of inherited (primary) or acquired (secondary) disorders. It is characterized by aminoaciduria, normoglycemic glycosuria, tubular proteinuria without hematuria, metabolic acidosis without anion gap and excessive urinary excretion of phosphorous, calcium, uric acid, bicarbonate, sodium, potassium and magnesium. Diabetes insipidus is a disease of collecting tubules and children mainly present with dehydration and hypernatremia. We are reporting the first case of idiopathic Fanconi's syndrome along with nephrogenic diabetes insipidus in a child who presented to us with vitamin D resistant rickets. Medline search did not reveal any case of nephrogenic diabetes insipidus (NDI) associated with idiopathic Fanconi syndrome. We hypothesized that the NDI may be due to to severe hypokalemia induced tubular dysfunction.

Incidence, Pattern, and Severity of Acute Respiratory Infections among Infants and Toddlers of a Peri-Urban Area of Delhi: A 12-Month Prospective Study.

Acute respiratory infections (ARIs) in spite of being the single most important under-five morbidity have not been studied adequately in peri-urban settings in India. We conducted this study prospectively on a cohort of 106 children in a peri-urban area of Delhi. The overall 2-week prevalence of all types of ARI was 34.3%. Annual combined incidence of all types of ARI was 7.9 episodes/100 child-weeks; while that for no pneumonia, cough, and cold, pneumonia, and otitis media was 7.1, 0.85, and 0.09 epi/100 ch-wks, respectively. Incidence of ARI was higher in infancy (9.4 epi/100 ch-wks) as compared to toddlers (7.0 epi/100 ch-wks). Pneumonia incidence was higher among boys (0.9 epi/100 ch-wks as compared to 0.6 for girls) and the highest in infants under 2 months of age (1.09 epi/100 ch-wks; P < 0.01). Incidence of severe pneumonia was roughly one-tenth that of pneumonia. Incidence of both ARI and pneumonia peaked in spring and autumn. Mothers of infants, zespecially those under 2 months of age, need to be made aware of ARI/pneumonia and IEC campaigns may be aired more intensively keeping their peak season in mind.

Idiopathic Fanconi's syndrome with nephrogenic diabetes insipidus in a child who presented as vitamin D resistant rickets--a case report and review of literature.

Fanconi's syndrome is a complex of multiple tubular dysfunctions of proximal tubular cells occurring alone or in association with a variety of inherited (primary) or acquired (secondary) disorders. It is characterized by aminoaciduria, normoglycemic glycosuria, tubular proteinuria without hematuria, metabolic acidosis without anion gap and excessive urinary excretion of phosphorous, calcium, uric acid, bicarbonate, sodium, potassium and magnesium. Diabetes insipidus is a disease of collecting tubules and a child mainly presents with dehydration and hypernatremia. We report the first case of idiopathic Fanconi's syndrome along with nephrogenic diabetes insipidus (NDI) in a child who presented to us as resistant rickets. Medline search did not reveal any case of nephrogenic diabetes insipidus associated with idiopathic Fanconi's syndrome. We hypothesized that the NDI may be due to severe hypokalemia induced tubular dysfunction. The child was treated for hypophosphatemic rickets with severe metabolic acidosis and the treatment for NDI was also given. Now he has healed rickets and normal blood pH, sodium and osmolarity.