Efficacy and safety of a live attenuated, cold-adapted influenza vaccine, trivalent against culture-confirmed influenza in young children in Asia.

BACKGROUND: This study was designed to evaluate the efficacy and safety of cold-adapted influenza vaccine, trivalent (CAIV-T) against culture-confirmed influenza in children 12 to <36 months of age during 2 consecutive influenza seasons at multiple sites in Asia. METHODS: In year 1, 3174 children 12 to <36 months of age were randomized to receive 2 doses of CAIV-T (n = 1900) or placebo (n = 1274) intranasally > or =28 days apart. In year 2, 2947 subjects were rerandomized to receive 1 dose of CAIV-T or placebo. RESULTS: Mean age at enrollment was 23.5 +/- 7.4 months. In year 1, efficacy of CAIV-T compared with placebo was 72.9% [95% confidence interval (CI): 62.8-80.5%] against antigenically similar influenza subtypes, and 70.1% (95% CI: 60.9-77.3%) against any strain. In year 2, revaccination with CAIV-T demonstrated significant efficacy against antigenically similar (84.3%; 95% CI: 70.1-92.4%) and any (64.2%; 95% CI: 44.2-77.3%) influenza strains. In year 1, fever, runny nose/nasal congestion, decreased activity and appetite, and use of fever medication were more frequent with CAIV-T after dose 1. Runny nose/nasal congestion after dose 2 (year 1) and dose 3 (year 2) and use of fever medication after dose 3 (year 2) were the only other events reported significantly more frequently in CAIV-T recipients. CONCLUSIONS: CAIV-T was well tolerated and effective in preventing culture-confirmed influenza illness over multiple and complex influenza seasons in young children in Asia.

Efficacy of zinc in the treatment of severe pneumonia in hospitalized children <2 y old.

BACKGROUND: Severe pneumonia remains a leading cause of morbidity and mortality in undernourished young children in developing countries. OBJECTIVE: This study evaluated the effect of adjuvant zinc therapy on recovery from severe pneumonia by hospitalized children in southern India who were receiving standard antibiotic therapy. DESIGN: This randomized, double-blind, placebo-controlled clinical trial was conducted at the Christian Medical College Hospital, an 1800-bed teaching hospital in Tamilnadu, India. Enrollment and follow-up occurred between September 2003 and August 2004. Children aged 2-23 mo (n = 299) who were hospitalized with severe pneumonia were randomly assigned to receive 10-mg tablets of zinc sulfate or placebo twice a day during hospitalization, along with standard therapy for severe pneumonia. All clinical signs and symptoms of pneumonia were assessed and recorded at 8-h intervals. RESULTS: There were no clinical or statistically significant differences in the duration of tachypnea, hypoxia, chest indrawing, inability to feed, lethargy, severe illness, or hospitalization. Zinc supplementation was associated with a significantly longer duration of pneumonia in the hot season (P = 0.015). CONCLUSIONS: Zinc supplementation had no overall effect on the duration of hospitalization or of clinical signs associated with severe infection in young children hospitalized for severe pneumonia in southern India. This finding differs from the results of 2 previously reported trials wherein zinc supplementation was associated with a shorter period of recovery from severe pneumonia. Given the conflicting results, further research in representative settings is required to help clarify the role of zinc in the treatment of severe pneumonia.

Unusual cause for miliary lung mottling in a child.

A 12-year-old boy presented to us with a diagnosis of disseminated tuberculosis which was made based on a history of prolonged fever, multiple neck swellings and radiological findings of bilateral multiple micronodular opacities. Examination showed a diffuse thyroid gland swelling. He was diagnosed to have papillary thyroid carcinoma with distant metastases to cervical lymphnode on histopathology and to lungs.

Comparison of blood gas values in arterial and venous blood.

OBJECTIVE: To compare pH and PCO2 values of simultaneously obtained arterial, arterialized capillary, and venous blood samples and also to compare oxygen saturation (ASaO2) measured in arterial blood and oxygen saturation by pulse oximetry (PSaO2). METHODS: Prospective study was done in the children admitted in the Pediatric Intensive Care Unit of Christian Medical College Hospital Vellore, requiring critical care. All the three blood gas samples (arterial, capillary and venous) were taken simultaneously and analyzed. Oxygen saturation by pulse oximetry was also recorded. RESULTS: 50 children aged 14 days to 12 years were included in the study. Arterial and capillary pH values were highly correlated (r2=0.9024, p<0.0001). Out of 16 children with arterial acidosis 9(56%) were identified by capillary blood gas. Arterial and venous pH values also showed good correlation (r2=0.8449, p<0.0001). The PCO2 values of arterial and capillary blood gases were found to be highly correlated (r2=0.9534, p<0.0001). The capillary blood gas accurately reflected the arterial PCO2 in 41 (82%) patients. Arterial and venous blood gas PCO2 values had less correlation (r2=0.5917, p=0.011). The arterial oxygen saturation (ASaO2) and oxygen saturation by pulse oximetry (PSaO2) were correlated moderately (r2=0.7241, p<0.0001). CONCLUSION: Even though arterial blood gas analysis is the gold standard, and when an arterial blood gas sample cannot be obtained, a combination of arterialized capillary blood gas and pulse oximetry can be effectively used in acutely ill children of all ages. Venous samples have a good correlation with arterial samples for pH but are not useful for monitoring blood gas status in acutely ill children.

Quantitation of proteinuria by spot urine sampling.

Few studies have shown that calculation of protein/creatinine ratio in a spot urine sample correlates well with the 24-hour urine collection. A study was conducted to compare the accuracy of a spot urinary protein/creatinine ratio (P/C ratio) and urinary dipstick (albustix) with the 24-hour urine protein (24-HUP). Fifty samples from 26 patients were collected. This included a 24-hour urine sample followed by the next voided spot sample. The protein/creatinine ratio was calculated and dipstick (albustix) was performed on the spot sample. This was compared with the 24-hour urine protein excretion. The correlation between the three samples was statistically highly significant (p=<0.001) for all levels of proteinuria. The normal value of protein/creatinine ratio in Indian children was also estimated on 100 normal children attending the OPD and was calculated to be 0.053 (S.E of mean±0.003).

Is this acute lymphoblastic leukaemia or juvenile rheumatoid arthritis.

Arthritis could be a presenting feature of acute lymphoblastic leukaemia (ALL) and could be wrongly diagnosed as juvenile rheumatoid arthritis (JRA). Clinical and laboratory parameters might differentiate ALL and JRA in children who present with arthritis. Out of a total of 250 children of ALL, 10 were referred to the department of child health and paediatric haemato-oncology of Christian Medical College, Vellore during 1990-2002. They were compared with 10 age-matched children who had systematic onset of JRA. The age groups in ALL and JRA were 6.05 +/- 2.45 years and 5.47 +/- 4.4 years respectively. Severe pain as evidenced by inability to walk was found in children but one child with JRA was unable to walk (p < 0.05). Lymphocytosis was noticed in 7 children (70%) with ALL whereas none had in JRA group. ESR was elevated in all cases in both the groups. One case in each group had antinuclear antibody positivity. It can be concluded that ALL can masquerade as systematic onset of JRA. So paediatricians should be careful enough while diagnosing the disease process.

Clinical features and outcome of systemic lupus erythematosus.

We report the clinical profile, treatment and outcome of systemic lupus erythematosus in 70 patients between the age of 4-15 years. Fever (94.2%), arthritis (65.7%) and malar rash (57.1%) were the chief extra-renal manifestations. The ESR was raised in 98.5% patients, anemia was seen in 60% and direct Coombs test was positive in 58.3%. Antinuclear antibody was positive in all; anti-double stranded DNA antibody and low C3 levels were seen in 77.1% and 80%, respectively. Renal involvement was noted in 77.1% and included proteinuria (53%), hematuria (42.8%), hypertension (18.5% and elevated serum creatinine (8.6%). Renal histology showed class I nephritis in 3.7%, class II in 44.4%, class III in 4.3%, class IV in 44.4% and class V in 1.8%. On follow up 18.8 months later, 70% patients were in remission, 7.5% had active disease and 7.5% died. The characteristics of childhood lupus erythematosus were similar to those previously reported. The outcome was favorable in most cases.

Intermittent clobazam therapy in febrile seizures.

OBJECTIVE: To evaluate the efficacy of intermittent clobazam therapy in preventing the recurrence of febrile seizures and to assess its safety. METHODS: The study was a prospective, randomized, double-blind placebo-controlled trial conducted in the Department of Child Health, Christian Medical College Hospital, Vellore between July 2001 and September 2002. Neurologically normal children between 6 months and 3 years of age with a history of febrile seizures and no evidence of acute CNS infection or EEG abnormality were included into the study. 19 children in a clobazam group and 20 in the placebo group were randomly allocated. Temperature reduction measures with paracetamol and tepid sponging were advised to all children. In addition the dispensed medication was to be administered at the onset of fever and continued for 48 hours irrespective of the duration of fever. The children were then monitored for seizures and adverse effects of clobazam. The children were followed up for a mean period of 9.9 months. The analysis was done on the number of febrile episodes in both the groups. RESULTS: There were a total of 110 episodes of fever during the study period. Mean number of febrile episodes in the clobazam group was 3.1 and in placebo group 2.56. Six (12.5%) of the 48 episodes in placebo group and one (1.7%) of 60 episodes in clobazam group had seizure recurrence. This was statistically significant (p = 0.01). Drowsiness and weakness were present equally in both clobazam and placebo groups whereas ataxia was present only in the clobazam group, the difference being statistically significant (p=0.04). CONCLUSION: Intermittent clobazam therapy is an effective measure in the prevention of recurrence of febrile seizures. The ataxia due to clobazam was much lower than that reported with diazepam.

Clinical profile and outcome of acute renal failure in South Indian children.

This was a retrospective study to assess the clinical profile of children admitted with acute renal failure and to identify factors associated with poor outcome. Fifty-four children (age one month to 12 years) with acute renal failure were studied. Males outnumbered females (38/54; 70%). The leading precipitating causes for renal failure were acute gastro-enteritis (85%), underlying renal pathology (43%), proven sepsis (22%) and suspected sepsis (22%). The main presenting complaints were diarrhoea (86%),oliguria (72%), rapid respiration (37%), oedema (37%), vomiting (19%) and seizures (13%). All patients underwent standard investigations and treatment. Forty-eight per cent of patients required peritoneal dialysis and 15% required ventilation. The overall mortality was 52%. Underlying renal pathology and sepsis both contributed to the high morbidity and mortality. Mortality due to sepsis was 83%; it was 65% in dialysed patients and 100% in those requiring ventilatory support. Biochemical profile of the above patients showed that hyperkalaemia was significantly associated with high mortality (83%) as against 75% in those with hypokalaemia and 33% with normal levels (p<0.001). Patients with hyponatraemia and hypernatraemia similarly had an adverse outcome. Acidosis, seen in 20 patients, had a mortality of 45%. The outcome was poorer in those with high creatinine levels (63%).

Osteopetrorickets.

Rickets is a paradoxical complication of osteopetrosis resulting from the inability of the osteoclasts to maintain a normal calcium-phosphorus balance in the extracellular fluid. Detection of rickets in a child with osteopetrosis is necessary, because treatment of the rickets with vitamin D leads to improvement in activity, decrease in irritability, improvement of appetite, and protects against recurrent respiratory tract infections. If bone marrow transplantation is feasible, then for better results, rickets should be completely treated prior to the transplantation.