Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric HematologyOncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics

Justification: Anemia in children is a significant public health problem in our country. Comprehensive National Nutrition Survey 2016-18 provides evidence that more than 50% of childhood anemia is due to an underlying nutritional deficiency. The National Family Health Survey-5 has reported an increase in the prevalence of anemia in the under-five age group from 59% to 67.1% over the last 5 years. Clearly, the existing public health programs to decrease the prevalence of anemia have not shown the desired results. Hence, there is a need to develop nationally acceptable guidelines for the diagnosis, treatment and prevention of nutritional anemia. Objective: To review the available literature and collate evidence-based observations to formulate guidelines for diagnosis, treatment and prevention of nutritional anemia in children. Process: These guidelines have been developed by the experts from the Pediatric Hematology-Oncology Chapter and the Pediatric and Adolescent Nutrition (PAN) Society of the Indian Academy of Pediatrics (IAP). Key areas were identified as: epidemiology, nomenclature and definitions, etiology and diagnosis of iron deficiency anemia (IDA), treatment of IDA, etiology and diagnosis of vitamin B12 and/or folic acid deficiency, treatment of vitamin B12 and/or folic acid deficiency anemia and prevention of nutritional anemia. Each of these key areas were reviewed by at least 2 to 3 experts. Four virtual meetings were held in November, 2021 and all the key issues were deliberated upon. Based on review and inputs received during meetings, draft recommendations were prepared. After this, a writing group was constituted which prepared the draft guidelines. The draft was circulated and approved by all the expert group members. Recommendations: We recommend use of World Health Organization (WHO) cut-off hemoglobin levels to define anemia in children and adolescents. Most cases suspected to have IDA can be started on treatment based on a compatible history, physical examination and hemogram report. Serum ferritin assay is recommended for the confirmation of the diagnosis of IDA. Most cases of IDA can be managed with oral iron therapy using 2-3 mg/kg elemental iron daily. The presence of macro-ovalocytes and hypersegmented neutrophils, along with an elevated mean corpuscular volume (MCV), should raise the suspicion of underlying vitamin B12 (cobalamin) or folic acid deficiency. Estimation of serum vitamin B12 and folate level are advisable in children with macrocytic anemia prior to starting treatment. When serum vitamin B12 and folate levels are unavailable, patients should be treated using both drugs. Vitamin B12 should preferably be started 10-14 days ahead of oral folic acid to avoid precipitating neurological symptoms. Children with macrocytic anemia in whom a quick response to treatment is required, such as those with pancytopenia, severe anemia, developmental delay and infantile tremor syndrome, should be managed using parenteral vitamin B12. Children with vitamin B12 deficiency having mild or moderate anemia may be managed using oral vitamin B12 preparations. After completing therapy for nutritional anemia, all infants and children should be advised to continue prophylactic iron-folic acid (IFA) supplementation as prescribed under Anemia Mukt Bharat guidelines. For prevention of anemia, in addition to age-appropriate IFA prophylaxis, routine screening of infants for anemia at 9 months during immunization visit is recommended.

Indigenously Prepared Ready-to-use Therapeutic Food (RUTF) in Children with Severe Acute Malnutrition

Objective: To compare efficacy of indigenous Ready-to-useTherapeutic Food (Medical Nutrition Therapy) with StandardNutrition Therapy in children with Severe acute malnutrition.Design: Two facility-based and two community-based models:(i) Open prospective randomized controlled trial comparingIndigenous Ready-to-use Therapeutic Food (Medical NutritionTherapy) with Standard Nutrition Therapy; (ii) Only IndigenousReady-to-use Therapeutic Food (Medical Nutrition Therapy); (iii)Doorstep Child Care Centre; and (iv) Community-basedManagement of Acute Malnutrition.Setting: (i) Urban Health Center, Dharavi, Mumbai; (ii) Two daycare centers of Non-governmental Organization SNEHA –Mumbai; (iii) Urban slums, M East and L Ward, MumbaiParticipants: 1105 children aged 6-60 months in community orhospital inpatient/ outpatient department diagnosed as SevereAcute Malnutrition by WHO definition.Intervention: All subjects received either Indigenous Ready-to-use Therapeutic Food (Medical Nutrition Therapy) or StandardNutrition Therapy (protein calorie rich diet) for eight weeks andfollowed up for next four months.Main outcome measures: Mean rate of weight gain (g/kg/day), target weight, change in nutritional status.Results: Rate of weight gain was higher (P<0.05) at 2 weeks onindigenous Ready-to-use Therapeutic Food (Medical NutritionTherapy) (5.63 g/kg/day) as compared to Standard NutritionTherapy (3.43 g/kg/day). 61.2% subjects achieved target weightcompared to 47.7% controls. At 8 weeks, 82.8% subjectsrecovered from Severe Acute Malnutrition compared to 19.3%controls (P<0.005). The results obtained in community werecomparable to facility-based indigenous Ready-to-useTherapeutic Food (Medical Nutrition Therapy). The morbidity wasless in study group at follow-up.Conclusions: Indigenous Ready-to-use Therapeutic Food(Medical Nutrition Therapy) appeared to be superior to StandardNutrition Therapy in promoting weight gain in children with SevereAcute Malnutrition.Keywords:Medical Nutrition Therapy, Micronutrients, Nutritionalrehabilitation, Protein energy malnutrition. Ready-to-use-food

Varied Hematological Manifestation Of Parvo Virus Infection.

Background & Objective: Human parvovirus B19 infections may cause a widespread benign and self-limiting disease in children known as erythema infectiosum or fifth disease. Infections caused by human parvovirus B19 can result in a wide spectrum of manifestations, which are usually influenced by the patient's immunologic and hematologic status. Patients with underlying hematologic and immunologic disorders who become infected with this virus are at risk for aplastic anemia. We studied different hematological manifestations of Parvovirus infection like anemia, thrombocytopenia , eosinophilia and pancytopenia. Methodology: It was a retrospective study in which we studied 17 patients with parvo B 19 virus positivity their clinical presentation, predisposing diseases , CBC parameters and response to treatment. Parvo virus infection was diagnosed by parvo IgM titer(>11NTU considered as positive) .Also BM histopathology was done whenever possible. Results: Out of 17 patients studied with parvo virus B 19 positivity 12(70.58%) were male and 5(29.42%) were female .The age of presentation was between 2.5 to 14year,with mean of 8.7year.Parvo virus infection was seen amongst patients with HIV n=8(47.05% ), Hemolytic anemia n=4(23.52%),ITP n=2(11.76%) and eosinophilia n=1(5.88%), plasmodium falciparum infection n=1(5.88%) & patient with acute lymphocytic leukemia n=1(5.88%).Commonest hematological manifestations were unexplained anemia n=16(94.11%) , thrombocytopenia n=5(29.41%), eosinophilia n=1(7.7%) , bicytopenia n=6(35.29%) , pancytopenia n=2(11.76%). Out of 17 patients 7(41.17%) were treated with IvIg and rest 10 required only supportive care as infection was transient. Conclusion: Parvo virus infection induced anemia is more severe and persistent in immunocompromised patients. Patients with hemolytic anemias may present with transient aplastic crisis due to parvo virus infection. Parvo virus infection may be considered as a possible etiologic agent for ITP. Coexistent Parvo virus infection in patients with P.falci malaria may be a cause for severe anemia. The hematological manifestations of parvovirus infection results from direct consequences of the ability of parvovirus B19 to target the erythroid cell lineage. However, accumulating evidence suggests that this virus can also affect other cell lineages pathogenesis of which remains to be fully elucidated.[

Guidelines for screening, diagnosis and management of hemoglobinopathies.

The b‑thalassemias and sickle cell disorders are a major health burden in India. Diagnosis and management of these disorders both in adults and in newborns using appropriate approaches and uniform technology are important in different regions of a vast and diverse country as India. In view of a National Thalassemia Control Program to be launched soon, a need was felt for guidelines on whom to screen, cost‑effective technologies that are to be used as well as for establishing prenatal diagnosis programs in regional centers. Newborn screening for sickle cell disorders is in its infancy in India and uniform approaches need to be followed. Also, included are guidelines for monitoring and managing patients who are now growing older and need comprehensive care as well as management of complications of the disease.

Griscelli syndrome - a case report.

Griscelli syndrome is a rare autosomal recessive disorder characterized by partial albinism with variable immunodeficiency. Silvery gray hair with large, clumped melanosomes on microscopy of hair shafts are diagnostic. The commonest complication leading to mortality includes lymphohistiocytic proliferation in various organs, including the brain. We present a child with classic clinical features and confirmatory findings of clumped melanosomes on microscopy of hair shaft.

Diamond-Blackfan anemia: report of 6 cases.

Diamond-Blackfan anemia is a rare congenital hypoplastic anemia. We report 6 children diagnosed as Diamond-Blackfan anemia at our clinic. All had severe pallor at presentation, with mild hepatomegaly and just palpable spleen in one child. Thumb anomaly was present in one of them. All of them had macrocytic or normocytic anemia with reticulocytopenia, and bone marrow examination revealed marked erythroid hypoplasia. All of them were treated with oral steroids with a good response.