Clinical Features and Outcome of SARS-CoV-2 Infection in Neonates: A Systematic Review.

OBJECTIVE: The objective of this study is to systematically synthesize the currently available literature on various modes of transmission (congenital, intrapartum, and postpartum), clinical features and outcomes of SARS-CoV-2 infection in neonates. METHODS: We conducted a comprehensive literature search using PubMed, EMBASE, and Web of Science until 9 June 2020. A combination of keywords and MeSH terms, such as COVID-19, coronavirus, SARS-CoV-2, 2019-nCoV, severe acute respiratory syndrome coronavirus 2, neonates, newborn, infant, pregnancy, obstetrics, vertical transmission, maternal-foetal transmission and intrauterine transmission, were used in the search strategy. We included studies reporting neonatal outcomes of SARS-CoV-2 proven pregnancies or neonatal cases diagnosed with SARS-CoV-2 infection. RESULTS: Eighty-six publications (45 case series and 41 case reports) were included in this review. Forty-five case series reported 1992 pregnant women, of which 1125 (56.5%) gave birth to 1141 neonates. A total of 281 (25%) neonates were preterm, and caesarean section (66%) was the preferred mode of delivery. Forty-one case reports describe 43 mother-baby dyads of which 16 were preterm, 9 were low birth weight and 27 were born by caesarean section. Overall, 58 neonates were reported with SARS-CoV-2 infection (4 had a congenital infection), of which 29 (50%) were symptomatic (23 required ICU) with respiratory symptoms being the predominant manifestation (70%). No mortality was reported in SARS-CoV-2-positive neonates. CONCLUSION: The limited low-quality evidence suggests that the risk of SARS-CoV-2 infections in neonates is extremely low. Unlike children, most COVID-positive neonates were symptomatic and required intensive care. Postpartum acquisition was the commonest mode of infection in neonates, although a few cases of congenital infection have also been reported.

Microorganisms Profile and Antimicrobial Resistance Pattern in Outborn Neonates in Northern India: A Hospital-Based Observational Study.

BACKGROUND: Neonates born somewhere else (outborn) and treated in a referral centre have different microbiological profile. We report the microorganism's profile and antimicrobial resistance (AMR) in blood culture proven sepsis in outborn neonates. METHODS: Culture positive neonatal sepsis from a neonatal unit of a referral institute catering to outborn neonates was studied over an 18 months duration. Data from the hospital information system were used to analyse the culture positivity rates, the spectrum of the microorganisms isolated and AMR pattern. RESULTS: Out of 5258 admitted neonates, 3687 blood samples were sent for suspect sepsis. The blood cultures were positive in 537 (14.6%) samples from 514 neonates. Gram-positive cocci (GPC) were the most common [240 (45%)] followed by gram-negative bacilli (GNB) [233 (43.4%)] and fungi [64 (11.9%)]. Coagulase negative staphylococcus (CONS) contributed to two-thirds of GPC followed by Klebsiella [93 (17.3%)] and Acinetobacter species [52 (9.7%)]. In 403 (75%) neonates, organisms grew in the samples sent at or within 24 h of admission. The case fatality rate was significantly higher in those with culture positive sepsis. The resistance to meropenem and imipenem was documented in 57.1% and 49.7%, respectively and 48% of the GNB was multidrug resistant. CONCLUSIONS: CONS followed by Klebsiella species were the most common organisms isolated. Three-fourths of the neonates had organisms grown at or within 24 h from admission. More than half of the GNB were multidrug resistant. The case fatality rate was significantly higher in those with culture positive sepsis.

Sepsis is the third most common cause of neonatal mortality globally. Outborn neonates differ in their microorganisms' profile and antimicrobial resistance (AMR) pattern in comparison to inborn neonates. In this study, we report the microorganisms profile and their AMR pattern in blood culture proven sepsis in a large cohort of outborn (extramural) neonates admitted to the index institute. We have also presented the state-wise profile and have compared their AMR pattern. Out of the 5258 admitted neonates, 3687 blood samples were sent for culture for suspect sepsis. The blood cultures were positive in 537 (14.6%) samples from 514 neonates. Coagulase-negative staphylococcus (CONS) followed by Klebsiella species were the most common organisms isolated from this large cohort of outborn neonates. More than 75% of the neonates grew the organisms within 24 h from admission indicating that many of them harboured the organisms at admission. Case fatality rate was significantly higher in those neonates with culture positive sepsis in comparison to culture negative sepsis. Close to 50% of the gram-negative bacilli isolates were multidrug resistant and half of them were extensively drug resistant. A significant between-state difference in organism profile and their AMR patterns were observed.

Antenatally Detected Multiple Mediastinal Enterogenous Cysts in a Newborn Presenting with Severe Cardio-Respiratory Compromise and Early Life-Saving Management.

Posterior mediastinal enterogenous cyst is a rare entity in neonate. The neonate can present with severe cardio-respiratory compromise in the form of respiratory distress, shock, cardiac failure or arrhythmia soon after birth which may require immediate surgical intervention. Antenatal screening can demonstrate the cystic mass in fetus early and can help in quick postnatal management. Multidisciplinary management with aspiration of the cysts was life-saving in the present case.

Early Predictors of Ventilator Associated Pneumonia in Preterm Neonates Admitted in a Special Newborn Care Unit.

OBJECTIVES: To determine the utility of microscopic examination and culture of endotracheal aspirate (ETA) in the early diagnosis of ventilator-associated pneumonia (VAP) in preterm neonates. METHODS: We enrolled 80 consecutive neonates (both inborn and out-born) with gestational age of < 37 weeks admitted in Special Newborn Care Unit (SNCU) and requiring mechanical ventilation (MV) for ≥ 48 hours. The diagnosis of VAP was made using the criteria laid down by the Centers for Disease Control (CDC). RESULTS: 47 preterm neonates (58.5%) developed VAP; the overall incidence was 74.7/1000 ventilator-days. The mean (SD) time (hours) to ETA culture was less as compared to diagnosis based on CDC criteria [108.9 (8.00 hrs) vs 132.4 (53.24); P = 0.004] with sensitivity and specificity of 80.8% and 72.7%, respectively. Outborn delivery was the single most important risk factor for VAP. Multidrug resistant (MDR) Klebsiella pneumoniae (63.9%) was the most prevalent organism. CONCLUSIONS: We noticed a very high incidence of VAP among preterm neonates in SNCU. ETA culture can aid in early diagnosis.

Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP): Recommended Immunization Schedule (2023) and Update on Immunization for Children Aged 0 Through 18 Years.

JUSTIFICATION: In view of new developments in vaccinology and the availability of new vaccines, there is a need to revise/review the existing immunization recommendations. PROCESS: The Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics (IAP) had a physical meeting on March 25, 2023, at Vaccicon, Kolkata, followed by online meetings to discuss the updates and new recommendations. Opinion of each member was sought on the various recommendations and updates, following which an evidence-based consensus was reached. The contents were finalized on September 8, 2023, during the National Conference of Pediatric - Infectious Diseases (NCPID) at Aurangabad. An online meeting of all members was held on November 15, 2023 and the recommendations were finalized. Objectives: To review and revise the IAP immunization recommendations of 2020-21 and issue recommendations on existing and new vaccines. RECOMMENDATIONS: The major changes include recommendation of HPV vaccine for boys; a 2-dose schedule of 9vHPV for boys and girls aged 9-14 y; a dose of Td vaccine at 16-18 y; guidance for injectable polio vaccine (IPV) for those patients who are changing from National Immunization Program to IAP schedule.

Understanding Clinical Competence: Understanding Student Assessment.

The extent, purpose, and model of performance assessment should be guided by our understanding of clinical competence. We have come a long way from believing that competence is generic, fixed, and transferable across contents; to viewing competence as dynamic, incremental, contextual, and non-transferable. However, our pattern of assessment largely remains what it was many years ago. Contemporary educationists view competency assessment as different from traditional format. They place more emphasis on the role of expert subjective judgment, especially for performance and domain-independent competencies. Such assessments have conclusively shown their validity, reliability, and utility. They; however, require trained assessors, trust between the teachers and the taught, and above all, a political and administrative will for implementation.

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.

Formulation of Research Question and Composing Study Outcomes and Objectives.

Framing an appropriate research question is the most critical and fundamental part of a study. This helps in developing a hypothesis, formulating aims and objectives and methodological execution of the study. Research questions are usually generated by literature backed thorough analysis of the gaps in previous studies and funnelling it to a specific focussed issue. The research question should be framed using the PICO (Population, Intervention/Exposure, Comparator and Outcome) format and should fulfil the FINER (feasible, interesting, novel, ethically sound, and relevant) criteria for practical aspects. Objectives should always be framed in alignment of the research question using SMART (specific, measurable, achievable, realistic and time defined) approach. Outcomes are classified as primary and secondary. It is advisable to have only one primary objective while secondary objectives can be multiple (usually not exceeding five). This paper describes a cascade approach starting from framing the research question and then deciding on the outcomes and study objectives.

Maternal and Neonatal Tetanus Elimination: Where are We Now?

The maternal and neonatal tetanus elimination (MNTE) program was envisaged by the World Health Organization to overcome the mortality and morbidity caused by maternal and neonatal tetanus (MNT). Although preventable by simple cost-effective practices like universal immunization, clean delivery practices, and healthy umbilical cord care, as of date MNT is still prevalent in 12 developing countries of Asia and Africa. Definitive approaches need to be microplanned by these countries to successfully accomplish the three stages of MNTE, ie, achieving, validating, and sustaining. Once a country achieves MNTE, this status is required to be validated and sustained according to the high-risk and low-risk categorization of the districts. The three-pronged strategies for achieving and sustaining MNTE include (a) rigorous immunization of women of reproductive age with tetanus toxoid-containing vaccines, (b) strengthening of clean delivery services for pregnant women, and (c) effective surveillance for MNT. Although the deadlines for achieving MNTE globally have been missed many times, yet there has been a significant progress to date as evident by 80% reduction in countries requiring validation for MNTE (59 countries in 1999 to 12 countries in 2020). Huge strides have been made in the overall coverage of two doses of tetanus toxoid (13.79% to 65.27%), neonates being protected at birth (12% to 88%), global coverage of third-dose DPT (more than doubled), and reduction of 88% estimated deaths due to NT in the last four decades. Identification of the most vulnerable populations, systematic planning at all levels of health care, involvement of local community support, tackling the implementation gap, strong political will, good financial support, and continued robust surveillance will go a long way in achieving MNTE.

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

JUSTIFICATION: In India, till recently, breastfeeding women have been excluded from the coronavirus disease (COVID-19) vaccination program, rendering a significant population of the country, including frontline workers, ineligible to derive the benefits of the COVID-19 vaccine rollout. OBJECTIVE: The objective of this recommendation is production of an evidence-based document to guide the pediatricians to give advice to breastfeeding mothers regarding the safety of COVID-19 vaccines in lactating women. PROCESS: Formulation of key question was done under the chairmanship of president of the IAP. It was followed by review of literature regarding efficacy and safety of COVID-19 vaccines in breastfeeding women. The recommendations of other international and national professional bodies were also deliberated in detail. The available data was discussed in the ACVIP focused WhatsApp group. Opinion of all members was taken and the final document was prepared after achieving consensus. RECOMMENDATIONS: The IAP/ACVIP recommends the administration of COVID-19 vaccines to all breastfeeding women. The IAP/ACVIP endorses the recent recommendation of the Government of India, to consider all breastfeeding women as eligible for COVID-19 vaccination.

Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP): Recommended Immunization Schedule (2020-21) and Update on Immunization for Children Aged 0 Through 18 Years.

JUSTIFICATION: In view of new developments in vaccinology and the availability of new vaccines, there is a need to revise/review the existing immunization recommendations. PROCESS: Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics (IAP) had a physical meeting in March, 2020 followed by online meetings (September-October, 2020), to discuss the updates and new recommendations. Opinion of each member was sought on the various recommendations and updates, following which an evidence-based consensus was reached. OBJECTIVES: To review and revise the IAP recommendations for 2020-21 and issue recommendations on existing and new vaccines. RECOMMENDATIONS: The major changes include recommendation of a booster dose of injectable polio vaccine (IPV) at 4-6 years for children who have received the initial IPV doses as per the ACVIP/IAP schedule, re-emphasis on the importance of IPV in the primary immunization schedule, preferred timing of second dose of varicella vaccine at 3-6 months after the first dose, and uniform dosing recommendation of 0.5 mL (15 µg HA) for inactivated influenza vaccines.

Pediatric Risk of Mortality III Score - Predictor of Mortality and Hospital Stay in Pediatric Intensive Care Unit.

BACKGROUND: Pediatric Risk of Mortality (PRISM) III score is one of the widely used scoring systems to quantify critical illness in the pediatric age group. This study was carried out to find the association of PRISM III score with the outcome (discharge/mortality) and also hospital stay in survivors and nonsurvivors. SETTING: The study was conducted in a tertiary care hospital from January 2014 to June 2015. MATERIALS AND METHODS: A total of 524 patients were admitted, and after excluding the patients who met the exclusion criteria, 486 patients were analyzed. STATISTICAL ANALYSIS: Logistic regression was used to find the association of variables under the PRISM III score with mortality. Linear regression was used to find the association of PRISM III score with length of stay. RESULTS: Mortality was 31%; male: female ratio was 1.5:1. Maximum patients presented with respiratory system involvement (26.3%), and maximum mortality (20.3%) was observed in the patients with respiratory involvement. Discrimination by the model between mortality and survival was excellent (receiver operating characteristic curve [0.903]). Maximum risk of mortality was noticed in mechanically ventilated patients (odds ratio [OR]: 10.87) followed by lower systolic blood pressure (OR: 2.72), deranged prothrombin time, partial thromboplastin time (OR: 1.50), deranged mental status (OR: 1.41), and tachycardia (OR: 1.37). Length of stay (LOS) in patients increased till PRISM III score of 25. Average LOS in survivors was 4.327 days which was not accounted by difference in PRISM III score between different patients. With each unit increase in PRISM III score, LOS increased by 5 h. CONCLUSIONS: PRISM III score has excellent capacity to discriminate between survival and mortality. PRISM III score can be used to predict LOS among survivors.

Immunization During the COVID-19 Pandemic: Recommendations From Indian Academy of Pediatrics Advisory Committee on Vaccines and Immunization Practices.

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, immunization practices of all age groups, especially routine childhood vaccines, have been interrupted. Immunization is considered an essential health activity, which needs to be resumed as early as possible. This pandemic has created several unique issues related to routine immunization of individual children at clinics, which needs to be addressed. In this communication, the Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics addresses the common questions and issues related to SARS-CoV-2 and routine immunization services. This also includes the recommendations for routine immunization of SARS-CoV-2 suspect and positive children, and for the logistics to be followed for immunization services.

E-Learning in Medical Education in India.

E-learning, or learning and teaching facilitated and supported through the application of technology, is presently being used widely in all fields of education, and also being utilized extensively in medical education. This narrative review aims to introduce the concept of e-learning, and discuss its need and scope in medical education in India. Experience shows that students and faculty are mostly in favor of adopting e-learning side-by-side with traditional learning, and the advantages far outweigh the likely discomfort associated with adoption of this new method.

Effect of different phases of menstrual cycle on brainstem auditory evoked response.

INTRODUCTION: The change in the hormonal levels during the three phases of menstrual cycle, namely, menstrual phase (hormonal withdrawal), proliferative phase (estrogen peak), and secretory phase (progesterone peak), influences the conduction velocities in the central auditory pathways. Variable findings of brainstem auditory evoked response (BAER) have been reported during different phases of menstrual cycle by different researchers. AIM: To study the effect of different phases of menstrual cycle on BAER. METHODOLOGY: A prospective observational study on 80 audiometrically normal, healthy, eumenorrheic female students in age group of 18-24 years was done at a medical college of northern India. BAER was recorded across the three phases of the menstrual cycle, i.e., menstrual phase (day 1-3), proliferative phase (day 10-12), and secretory phase (day 20-22). Recordings of peak latencies, interpeak latencies, and amplitude of waves of BAER were taken and statistically analyzed. RESULTS: In this study, significant decrease in the latencies of wave III, wave V, and interpeak latency I-III and a trend of decrease in latencies of wave I and interpeak latency I-V (which was statistically insignificant) were observed in proliferative (estrogen peak) phase as compared to menstrual and secretory phase. However, there was no statistically significant difference found in the amplitude of waves of BAER during all the three phases of menstrual cycle. CONCLUSION: The hormonal changes during different phases of menstrual cycle do seem to influence BAER.

Senior Loken Syndrome.

Senior Loken Syndrome (SLS) is a rare genetic disorder having juvenile nephronophthisis and retinal degeneration progressing to blindness and end stage renal disease. The present case report is about two sisters who presented with decreased visual acuity and end stage renal disease. Both had decreased vision, pallor, deranged renal function test and chronic malnutrition. Investigations revealed anaemia, uraemia, raised creatinine, low Glomerular Filteration Rate (GFR). Ophthalmology examination revealed nystagmus, retinal examination depicted pale optic disc and pigmentary changes in the retina. Renal ultrasound showed grade III renal parenchymal changes and bilateral cortico-medullary cysts. These cases are presented to highlight the importance of timely recognition of renal derangement in patients with retinal disease to delay end stage renal disease.

Impact of self-assessment by students on their learning.

CONTEXT: Tutor assessment is sometimes also considered as an exercise of power by the assessor over assesses. Student self-assessment is the process by which the students gather information about and reflect on their own learning and is considered to be a very important component of learning. AIM: The primary objective of this study was to analyze the impact of self-assessment by undergraduate medical students on their subsequent academic performance. The secondary objective was to obtain the perception of students and faculty about self-assessment as a tool for enhanced learning. MATERIALS AND METHODS: The study was based on the evaluation of two theory tests consisting of both essay type and short answer questions, administered to students of the 1(st) year MBBS (n = 89). They self-assessed their performance after 3 days of the first test followed by marking of faculty and feedback. Then, a nonidentical theory test on the same topic with the same difficulty level was conducted after 7 days and assessed by the teachers. The feedback about the perception of students and faculty about this intervention was obtained. RESULTS: Significant improvement in the academic performance after the process of self-assessment was observed (P < 0.001). There was a significantly positive correlation between student and teacher marking (r = 0.79). Both students and faculty perceived it to be helpful for developing self-directed learning skills. CONCLUSIONS: Self-assessment can increase the interest and motivation level of students for the subjects leading to enhanced learning and better academic performance, helping them in development of critical skills for analysis of their own work.