The Indian Academy of Pediatrics and Directorate General of Health Services, Government of India White Paper on Transition of Care for Youth with Special Health Care Needs.

Over the years, survival of children with chronic diseases has significantly improved and a large proportion of them now are entering into adulthood. Transition of Care (ToC) of such patients with having childhood onset of chronic diseases to the adult health care system is well organized in developed countries, although it is an emerging concept in India. In situations where the systems for ToC are not in place, such cases are fraught with unsatisfactory health outcomes. With proper ToC in place, these patients are likely to receive uninterrupted care by the adult care physicians and hence reach their full potential. This document highlights the need, rationale and way forward for ToC of youth with special health care needs (YSHCN) across the country. It also describes the standard operating procedures to develop the ToC at a hospital level for clinicians and administrators.

Response assessment by positron emission tomography-computed tomography as compared with contrast-enhanced computed tomography in childhood Hodgkin lymphoma can reduce the need for radiotherapy in low- and middle-income countries.

INTRODUCTION: The InPOG-HL-15-01, a multicentric prospective study, used a risk-stratified and response-based approach with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) backbone to treat children and adolescents with newly diagnosed Hodgkin lymphoma (HL) and reduce the use of radiation therapy (RT). Children/adolescents with bulky disease or inadequate response at early response assessment (ERA) after two cycles of chemotherapy were assigned to receive RT. For ERA, positron emission tomography computed tomography (PET-CT) was recommended but not mandatory in view of limited access. This study aimed to compare the impact of using contrast-enhanced computed tomography (CECT) and PET-CT on treatment decisions and outcomes. METHODOLOGY: 396 patients were enrolled and 382 had an ERA at the assigned time point. Satisfactory response was defined as Deauville score 3 or less for patients undergoing PET-CT and complete response (CR)/very good partial response (VGPR) for patients undergoing CECT. Outcomes of interest incorporate 5 year event-free survival (EFS), EFS including abandonment (EFSa), and overall survival (OS). RESULTS: At ERA, satisfactory response was documented in 277 out of 382 (72.5%) participants and this was significantly higher in PET-CT (151 out of 186, 81.2%) as compared with CECT-based assessments (126 out of 196, 64.3%) respectively (p value < .001). Amongst the 203 patients with nonbulky disease (wherein the indication for RT was entirely dependent on ERA), 96 out of 114 (84.2%) and 61 out of 89 (68.5%) patients achieved a satisfactory response according to the PET-CT and CECT (p value = .008) respectively and hence a lesser proportion of patients in the PET-CT arm received RT. Despite a lower usage of RT the 5 year OS of both groups, ERA based on CECT (91.8%) versus PET-CT (94.1%) was comparable (p value = .391) and so was the 5 year EFS (86.7 vs. 85.5%, p value = .724). CONCLUSION: Use of PET-CT as the modality for ERA is more likely to indicate a satisfactory response as compared with CECT and thereby decreases the need for RT in response-based treatment algorithm for HL-afflicted children. The reduction in the application of RT did not impact the overall outcome and plausibly would lower the risk of delayed toxic effects.

Development assessment of HIV exposed children aged 6-18 months: a cohort study from North India.

HIV exposed children are vulnerable to developmental delay irrespective of their HIV status due to combined effect of risk factors like poverty, prenatal drug exposure, stress and chronic illness in family and malnutrition. This cohort study assessed the development of 50 HIV exposed children aged 6-18 months at a Pediatric Centre of Excellence in HIV care in India. The development was assessed using Development Assessment Scale for Indian Infants (DASII) at enrolment, 3 and 6 months later. The development quotient (DQ) scores and proportion of children with developmental delay (DQ ≤ 70) were compared among two sub-groups, HIV infected (HI) and HIV exposed uninfected (HEU) children. The various social and clinical factors affecting development were studied by univariate and multivariate analysis. Prevalence of developmental delay was 2.4% in the HEU (n = 41), and 33.3% in HI (n = 9). The DQ of HI was significantly lower than that of HEU at all three assessments. The DQ of HI were also significantly lower compared to the HEU at ages 12.1-18 months (83.37 ± 20.73 vs 94.68 ± 5.13, p = 0.005) and 18.1-24 months (84.55 ± 15.35 vs 94.63 ± 5.86, p = 0.006) respectively. The development of HEU was adversely affected by lower socioeconomic status and presence of wasting. In addition, development of HI was also adversely influenced by presence of stunting and opportunistic infections, advanced disease stage and shorter ART duration. We conclude that with optimum care, HEU can have a normal development, while a considerable proportion of HI may continue to have delayed development.

Antibiotic prescribing pattern in paediatric in patients with first time wheezing.

BACKGROUND: Acute wheezers for the first time in life are an important target group for efforts aimed at reducing unnecessary antibiotic use. OBJECTIVE: To evaluate the effect of clinical, laboratory and radiological data on the decision to prescribe antibiotics to paediatric patients with first time wheezing as well as to seek criteria that would justify antibiotic use. METHODS: A prospective study was made of 47 previous healthy children admitted to our hospital with first time wheezing in life between October 2008- March 2009. All the patients were treated as per the treating unit's protocol with oxygen, bronchodilators with or without antibiotics. The cases were analyzed after discharge and the characteristics of those treated with antibiotics (n = 23) were compared with those who were not (n = 24) and analyzed statistically to find the predictors for antibiotic usage. RESULTS: The mean age of the study groups was 5.8 (+/- 5.1) months. Among the clinical and investigational parameters, presence of predominant crackles and abnormalities on radiograph were the major determinants for antibiotic usage. There were no significant differences in final outcome between these groups. CONCLUSION: Antibiotic usage in first time wheezers is still quite prevalent. Presence of crackles and radiological abnormalities often prompt the usage of antibiotics in such cases.

Evaluation of simple clinical signs of illness in young infants (0-2 months) and its correlation with WHO IMCI algorithm (7 days to 2 months).

OBJECTIVE: To evaluate simple clinical signs of illness in young infants (0 to 2 months) and to correlate with WHO IMCI algorithm (7 days-2 months). DESIGN: Prospective observational. Study conducted in the outpatient department and emergency room of a pediatric tertiary level hospital. METHODS: Four hundred and ninety seven young infants (0 to 2 months) presenting to outpatient department or emergency room were recruited. Detailed history, clinical examination including all signs in IMCI algorithm was recorded in the pre-designed proforma. The study subjects were investigated and managed according to the protocol of treating unit, which served as gold standard. The diagnostic and therapeutic agreement between the gold standard and IMCI was computed. The study subjects were analyzed as one age group (0 to 2 months) and also after de- segregating into early and late neonatal age group (0 to 7 days and 7 days to 2 months age). RESULTS: Mean number of illnesses in 0 to 7 days, 7 days-2 months and 0-2 months groups were 1.97, 2.0 and 2.02 respectively. Those who required referral as per IMCI algorithm had higher proportion of co-morbidities. The referral criteria were fairly sensitive (78 to 85 percent) in predicting hospitalization with moderately high specificity (78 percent). Diagnostic agreement between gold standard and IMCI module was complete in 57 to 68 percent. Amongst diagnostic mismatch, under-diagnosis was found more frequently (72 to 82 percent) than over-diagnosis (17 to 29 percent). The sensitivity of algorithm to identify serious bacterial infections was quite high (96 to 98 percent) with moderately good specificity (80 to 92 percent). Jaundice was single most important complaint accounting for 47 to 62 percent of diagnostic mismatch. CONCLUSION: IMCI algorithm appears to be a promising, feasible and useful intervention strategy to triage and treat young infants in 7 days-2 months age group. This tool remains effective even when extended to 0 to 7 days age group. However a further increase in its sensitivity can be achieved by including yellowness of lower extremities/ palms/ soles as a criterion.