Oral health status and microbial load of Streptococcus mutans in children with Cerebral palsy in a tertiary care hospital in Delhi

Background: Cerebral palsy (CP) is a childhood debilitating condition which impairs the physical and mental ability of an individual to maintain oral health. Aim: The objective of the present study was assessment of dental neglect and burden of treatment needs of children affected with CP as compared to normal children in a tertiary care hospital in Delhi. Settings and Design: A sample size of 104 children of age group of 6–14 years was selected, in which 52 children of CP (case group) and 52 normal school children (control group) were recruited. Materials and Methods: Children from both groups were examined, and calculation of drug master files (DMFS), defs, oral hygiene index (OHI), and gingival index was done. The presence of trauma and malocclusion was assessed. Present caries activity was assessed by the level of Streptococcus mutans present in saliva in both groups. Treatment needs were then assessed based on intraoral findings. Statistical Analysis: Data were analyzed by SPSS 20.0 software. Student's t-test and nonparametric statistical tests such as Chi-square test and Mann–Whitney test were used as per the nature of variables studied for statistical analysis with the level of significance denoted at P < 0.05. Results: The mean DMFS, gingival index, OHI, and treatment needs were observed to be higher in the CP group. Increased S. mutans levels were observed in saliva of CP patients. Defs score, trauma, and malocclusion were not statistically significantly higher in CP group as compared to the control group. Conclusion: Cerebral palsy group had a poor oral and gingival health, a higher DMFT and burden of treatment needs and an increased risk of further caries progression due to high caries activity indicated by increased level of salivary Streptococcus mutans than the control group.

Pediatric Appropriate Evaluation Protocol for India (PAEP-India): Tool for Assessing Appropriateness of Pediatric Hospitalization

Objectives: To develop and assess Pediatric AppropriatenessEvaluation Protocol for India (PAEP-India) for inter-rater reliabilityand appropriateness of hospitalization.Design: Cross-sectional study.Setting: The available PAEP tools were reviewed and adaptedfor Indian context by ten experienced pediatricians followingsemi-Delphi process. Two PAEP-India tools; newborn (?28 days)and children (>28 days-18 years) were developed. These PAEP-India tools were applied to cases to assess appropriateness ofadmission and inter-rater reliability between assessors.Participants: Two sets of case records were used: (i) 274cases from five medical colleges in Delhi-NCR [?28 days (n=51);>28 days to 18 years (n=223)]; (ii) 622 infants who werehospitalized in 146 health facilities and were part of a cohort (n=30688) from two southern Indian states.Interventions: Each case-record was evaluated by twopediatricians in a blinded manner using the appropriate PAEP-India tools, and ‘admission criteria’ were categorized asappropriate, inappropriate or indeterminate.Main outcome measures: The proportion of appropriatehospitalizations and inter-rater reliability between assessors(using kappa statistic) were estimated for the cases.Results: 97.8% hospitalized cases from medical colleges werelabelled as appropriate by both reviewers with inter-rateragreement of 98.9% (k=0.66). In the southerm Indian set ofinfants, both reviewers labelled 80.5% admissions as appropriatewith inter-rater agreement of 96.1% (k= 0.89).Conclusions: PAEP-India (newborn and child) tools are simple,objective and applicable in diverse settings and highly reliable.These tools can potentially be used for deciding admissionappropriateness and hospital stay and may be evaluated later forusefulness for cost reimbursements for insurance proposes.

Serum Interleukin-6 Levels in Children with Febrile Seizures

Objectives: To compare levels of Interleukin-6 (IL-6) in children with febrile seizures andfebrile controls. Methods: Study conducted in a tertiary-care hospital in Northern India fromNovember 2013 to April 2015, enrolling 160 children (80 each with febrile seizures and febrilecontrols), aged 6 – 60 months. Serum IL-6 estimated by ELISA method. Iron study done asper standard technique. All the cases of febrile seizure were followed up at 1 week, 3 monthsand 6 months for recurrence of seizures. Results: The mean serum IL-6 levels in childrenwith febrile seizures was 62.0 (63.9) pg/mL and febrile controls was 86.9 (70.6) pg/mL(P=0.025). Conclusion: Serum IL-6 levels were significantly lower in children with febrileseizures as compared to febrile controls.

Effect of Carbamazepine Therapy on Homocysteine, Vitamin B12 and Folic Acid Levels in Children with Epilepsy.

Objectives: To compare the levels of homocysteine, vitamin B12 and folic acid before and after 6 months of carbamazepine therapy and to correlate them with carbamazepine level at 6 months. Design: Prospective comparative study. Setting: Tertiary care centre in North India. Participants: 51 children (2-12 years of age) presenting with motor partial seizures. Intervention: Carbamazepine (10-20 mg/μ/day) for 6 months. Main outcome measure: Change in serum homocysteine, B12, folic acid level. Methods: Fasting venous samples were collected before carbamazepine therapy and after six months. Homocysteine was analyzed using homocysteine enzyme immunoassay. Vitamin B12 and folic acid were estimated using electrochemiluminesence technique. Carbamazepine levels were measured at 6 months. Results: Of the 51 children, 36 (males-21), were followed up and their data analyzed. Mean homocysteine level was 11.51±3.95 μmol/L at recruitment and 11.77±6.65 μmol/L at six months (P=0.785). At recruitment 6(16%) children had homocysteine level above 15 μmol/L which increased to 10(27%) at 6 months. Mean vitamin B12 at recruitment was 292.1±111.2 pg/mL and 297.8±82.9 pg/mL at 6 months (P=0.764). Mean folic acid at recruitment was 9.98±3.45 ng/mL and 10.66±3.97 ng/mL at 6 months (P=0.358). There was no correlation between carbamazepine levels with homocysteine, vitamin B12 and folic acid (P>0.05). There was no effect of age, sex or dietary pattern on homocysteine levels. Conclusion: Hence 6 months of carbamazepine therapy did not cause significant change in serum levels of homocysteine, vitamin B12 and folic acid.

Quality of Life in Children with Epilepsy.

Quality of life was assessed in 108 epileptic children (6-15 years) using a hindi translation of Quality of Life in Children with Epilepsy (QOLCE) questionnaire. The questionnaire consist of 76 items with 16 subscales covering five domains of life: physical function, social function, cognition, emotional and behavioral well being. Overall score was 62.62±21.32. Chronbach’s- for all 13 multi-item subscales was above 0.70, indicating good internal consistency and reliability. Pearson correlation revealed good construct validity. Overall quality of life was affected by age, type of epilepsy, seizure frequency and maternal education (P<0.05). Energy levels, language and attention (P<0.05) were better in older children whereas younger children had better self esteem and lower levels of anxiety. Seizure frequency compromised all fields except stigma, attention, and energy levels (P>0.05).

Efficacy and Safety of Azithromycin for Uncomplicated Typhoid Fever: An Open Label Non-comparative Study.

An open-labelled, non-comparative study was conducted in 117 children aged 2- 12 years to evaluate the efficacy and safety of azithromycin (20mg/ kg/day for 6 days) for the treatment of uncomplicated typhoid fever. Of the patients enrolled based on a clinical definition of typhoid fever, 109 (93.1%) completed the study. Mean (SD) of duration of fever at presentation was 9.1(4.5) days. Clinical cure was seen in 102 (93.5%) subjects, while 7 were withdrawn from the study because of clinical deterioration. Mean day of response was 3.45±1.97. BACTEC blood culture was positive for Salmonella typhi in 17/109 (15.5%) and all achieved bacteriological cure. No serious adverse event was observed. Global well being assessed by the investigator and subjects was good in 95% cases which was done at the end of the treatment. Azithromycin was found to be safe and efficacious for the management of uncomplicated typhoid fever.

Phenytoin Induced Vitamin D Deficiency Presenting as Proximal Muscle Weakness.

A 6-year-old girl presented with proximal muscle weakness of lower limbs. She was receiving phenytoin for epilepsy for 2 years. Serum phenytoin level was within therapeutic range. Serum 25(OH) vitamin D was low (5ng/mL) and serum parathyroid hormone level was high. After administration of oral vitamin D, muscle weakness improved and vitamin D level increased to 39.11ng/mL. Proximal muscle weakness due to vitamin D deficiency following phenytoin intake is rare in children.

Immunization Status of Children Admitted to a Tertiary-care Hospital of North India: Reasons for Partial Immunization or Non-immunization.

Reasons for the low coverage of immunization vary from logistic ones to those dependent on human behaviour. The study was planned to find out: (a) the immunization status of children admitted to a paediatric ward of tertiary-care hospital in Delhi, India and (b) reasons for partial immunization and nonimmunization. Parents of 325 consecutively-admitted children aged 12-60 months were interviewed using a semi-structured questionnaire. A child who had missed any of the vaccines given under the national immunization programme till one year of age was classified as partially-immunized while those who had not received any vaccine up to 12 months of age or received only pulse polio vaccine were classified as non-immunized. Reasons for partial/non-immunization were recorded using open-ended questions. Of the 325 children (148 males, 177 females), 58 (17.84%) were completely immunized, 156 (48%) were partially immunized, and 111 (34.15%) were non-immunized. Mothers were the primary respondents in 84% of the cases. The immunization card was available with 31.3% of the patients. All 214 partially- or completely-immunized children received BCG, 207 received OPV/DPT1, 182 received OPV/DPT2, 180 received OPV/DPT3, and 115 received measles vaccines. Most (96%) received pulse polio immunization, including 98 of the 111 non-immunized children. The immunization status varied significantly (p<0.05) with sex, education of parents, urban/rural background, route and place of delivery. On logistic regression, place of delivery [odds ratio (OR): 2.3, 95% confidence interval (CI) 1.3-4.1], maternal education (OR=6.94, 95% CI 3.1-15.1), and religion (OR=1.75, 95% CI 1.2-3.1) were significant (p<0.05). The most common reasons for partial or non-immunization were: inadequate knowledge about immunization or subsequent dose (n=140, 52.4%); belief that vaccine has side-effects (n=77, 28.8%); lack of faith in immunization (n=58, 21.7%); or oral polio vaccine is the only vaccine required (n=56, 20.9%. Most (82.5%) children admitted to a tertiary-care hospital were partially immunized or non-immunized. The immunization status needs to be improved by education, increasing awareness, and counselling of parents and caregivers regarding immunizations and associated misconceptions as observed in the study.

Complex regional pain syndrome type 1 and scurvy.

A 5 year old female developed features of complex regional pain syndrome (CRPS) i.e excessive pain to touch, decreased sweating and edema of left ankle 2 years after fracture of left tibia. Gum bleeding, petechiae and pseudoparalysis and suggestive radiograph characterized scurvy. Hyperesthesia improved and child walked with support following administration of vitamin C.

Immunogenicity and safety of live attenuated hepatitis A vaccine: a multicentric study.

OBJECTIVE: To evaluate immunogenicity and tolerability of single dose live attenuated injectable hepatitis A vaccine in four metropolitan cities of India. METHODS: Live attenuated hepatitis A vaccine was administered to 505 children aged 18 to 60 months in four centers across India. Immunogenicity of the vaccine was assessed by estimation of anti-HAV antibody titer at 6 weeks and 6 months following administration of the vaccine. Safety evaluation of the vaccine was also done during the visits. RESULTS: At 6 weeks, 480 subjects (95%) came for the follow-up and 411 (81.4%) subjects reported at the end of 6 months. The geometric mean titer (GMT) of anti-HAV antibody of the subjects who did not have the seroprotective titer at the baseline were assessed at 6 weeks and 6 months which was 81.04 mIU/ml and 150.66 mIU/ml respectively. At 6 weeks, 95.1 % seroconverted and at the end of 6 months, 97.9 % had seroconverted. Both solicited and unsolicited vaccine-induced local and systemic adverse events were insignificant at all the centers, except swelling and induration in a few. CONCLUSION: Live attenuated injectable hepatitis A vaccine was immunogenic and tolerable with minimal reactogenecity, in this study of single dose schedule. Safety profile was also satisfactory in the study population.

Effect of phenytoin and valproic acid therapy on serum lipid levels and liver function tests.

We conducted a case control study to evaluate the effect of phenytoin and valproic acid on serum lipids and liver function tests in epileptic children. Seventy-nine children receiving at least 6 months of antiepileptic monotherapy were categorized into two groups, depending on whether they were receiving phenytoin or valproic acid. Age matched healthy controls were also included. The mean total cholesterol (TC) in children on phenytoin therapy was significantly higher than the control group (P=0.03). Serum triglycerides, low density lipoprotein cholesterol, very low density lipoprotein cholesterol, and high density lipoprotein cholesterol, were not significantly different in the three groups. The proportion of children with TC > 200mg/dL was significantly higher in the phenytoin group. We recommend monitoring of serum lipids of epileptic children receiving phenytoin.

Oral salbutamol for symptomatic relief in mild bronchiolitis a double blind randomized placebo controlled trial.

OBJECTIVES: To determine the efficacy of oral salbutamol for providing symptomatic relief in mild bronchiolitis. DESIGN: Randomized double-blind placebo controlled trial. SETTING: Pediatric Outpatient Department of a tertiary care hospital. SUBJECTS: 140 infants (of 310 approached) with a clinical diagnosis of acute bronchiolitis with respiratory rate <or= 70 breath/min, heart rate <or= 200 beats/min, hemoglobin oxygen saturation (SpO2) >or= 95% in room air, no or mild accessory muscle use, and respiratory distress assessment instrument (RDAI) score <or=10. Children were followed up for 14 days. INTERVENTION: Oral salbutamol (0.1 mg/kg/dose) (n=70) or placebo (n=70) three times a day for 7 days or till complete resolution of symptoms,whichever was earlier. OUTCOME VARIABLES: Time for resolution of illness (ROI), duration of fever, cough,coryza, noisy breathing, time to achieve normal feeding and normal sleep, and frequency of hospitalization and adverse effects. RESULTS: Median (SE, 95% CI) duration of resolution of overall illness was similar in the two groups [6 (0, 5 to 7) d in the salbutamol group vs. 5 (1, 4 to 6) days in placebo group; P=0.21]. There was no significant difference in mean duration of fever, cough, coryza, noisy breathing, time to achieve normal feeding and normal sleep; and frequency of hospitalization or adverse effects, between the two groups.However, tremors were observed in 5 infants in the salbutamol group. CONCLUSION: Oral salbutamol is not superior to placebo in reducing the duration of symptoms in mild cases of acute bronchiolitis in children.

Complementary feeding--reasons for inappropriateness in timing, quantity and consistency.

OBJECTIVE: To assess the practice of complementary feeding (CF) in infants 6 month to 2 year, knowledge of mothers regarding CF, and reasons for inappropriate CF practices. METHODS: CF practices were assessed in children aged 6 months to 2 years using semi-structured questionnaire. Demographic profile and mother's knowledge regarding CF was recorded. Cause of inappropriate CF was ascertained by open-ended questions. RESULTS: Among the 200 children studied, 32(16%) were not started on CF at all, and only 35 (17.5%) received CF from 6 months. Of the 168 who were started CF, mean age of starting feeds was 13.37 months. Quantity was adequate in 42(25%) and consistency of food was thick in 64(38%) cases. Only 7(3.5%) mothers started CF at proper time, in adequate quantity and with proper consistency. Knowledge of proper timing was present in 46% of children, adequate quantity in 46.5% and thick consistency in 25.5%. Only 16(8%) mothers had proper knowledge of all three aspects of CF. Knowledge regarding appropriate timing and consistency varied significantly with maternal education and paternal education (Chi-square P< 0.05). On multiple logistic regression only maternal education of graduate level correlated with knowledge of timing of CF (P=0.089. OR-3.5, CI 0.826-15.2). Most common reason for inappropriate practice in 154 mothers who delayed feeds was "tried but did not eat, vomits everything" (52%). CONCLUSION: CF practices were inappropriate and knowledge inadequate in majority of the children studied.

Liver abscess, portal vein thrombosis and cavernoma formation following umbilical vein catherisation in two neonates.

Liver abscess is a rare condition in neonates and its diagnosis requires a high degree of suspicion. CT scan and ultrasound are the most sensitive diagnostic modalities for detecting hepatic abscess. Portal vein thrombosis and cavernoma formation are rare complications following neonatal liver abscess and sepsis. We describe the case of two neonates with hepatic abscess following umblical vein catheterisation, with rare complications of portal vein thrombosis and portal vein cavernoma formation. Therefore, unreserved caution should be exercised in performing umbilical cannulation in neonates due to the inherent risks involved with this procedure.

Hyper-reactive malarial splenomegaly: rare cause of pyrexia of unknown origin.

Hyper-reactive malarial splenomegaly (HMS) or Tropical splenomegaly syndrome(TSS), occurs in areas of high transmission of malaria. These children usually presents with gross splenomegaly and abdominal discomfort, while fever is not the usual manifestation in majority of them. It is a disease of young adults and rarely reported below 8 years of age. Here it is reported a three-year-old child who presented as pyrexia of unknown origin with hepatosplenomegaly, diagnosed as HMS.

Congenital syphilis presenting as swelling of fingers and toes.

Congenital syphilis has varied manifestations in first two years of life. A case of 4-month-old child who was presented with painless swelling of finger and toes is reported. Family history was suggestive of syphilis in parents and one sibling. VDRL test in serum was positive in 1:128 dilution. Treponema pallidum haemagglutination test was positive. The child was treated with crystalline penicillin and responded favourably.

Juvenile amyotrophic lateral sclerosis.

Juvenile amytrophic lateral sclerosis (JALS) is a type of motor neuron disease presenting before 25 years of age. It is characterized by a combination of upper and lower motor signs. It may be familial or sporadic. We are reporting a sporadic case of JALS with onset of symptoms at 4 years of age. Diagnostic criteria and a brief review of literature are presented.

CSF Rhinorrhea and recurrent meningitis caused by transethmoidal meningoencephaloceles.

We report two children presenting with intermittent CSF rhinorrhea and recurrent meningitis. CT scan showed transethmoidal meningoencephalocele.