Evidence-Based Guidelines for the Management of Allergic Bronchopulmonary Aspergillosis (ABPA) in Children and Adolescents with Asthma.

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) frequently complicates asthma. There is urgent need to develop evidence-based guidelines for the management of ABPA in children. The Evidence Based Guideline Development Group (EBGDG) of the Indian Academy of Pediatrics (IAP) National Respiratory Chapter (NRC) addressed this need. METHODS: The EBGDG shortlisted clinical questions relevant to the management of ABPA in asthma. For each question, the EBGDG undertook a systematic, step-wise evidence search for existing guidelines, followed by systematic reviews, followed by primary research studies. The evidence was collated, critically appraised, and synthesized. The EBGDG worked through the Evidence to Decision (EtD) framework, to formulate recommendations, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Seven clinical questions were prioritized, and the following recommendations formulated. (1) Children with poorly controlled asthma should be investigated for ABPA (conditional recommendation, moderate certainty of evidence). (2) Low dose steroid therapy regimen (0.5 mg/kg/d for the first 2 wk, followed by a progressive tapering) is preferable to higher dose regimens (conditional recommendation, very low certainty of evidence). (3) Oral steroid regimens longer than 16 wk (including tapering), should not be used (conditional recommendation, very low certainty of evidence). (4) Antifungals may or may not be added to steroid therapy as the evidence was neither in favour nor against (conditional recommendation, low certainty of evidence). (5) For clinicians using antifungal agents, the EBGDG recommends against using voriconazole instead of itraconazole (conditional recommendation, very low certainty of evidence). (6) No evidence-based recommendation could be framed for using pulse steroid therapy in preference to conventional steroid therapy. (7) Immunotherapy with biologicals including omalizumab or dupilumab is not recommended (conditional recommendation, very low certainty of evidence). CONCLUSIONS: This evidence-based guideline can be used by healthcare providers in diverse clinical settings.

Multisystem Inflammatory Syndrome in Children (MIS-C) Related to SARS-CoV-2 and 1-Year Follow-up.

OBJECTIVE: To study the demographics, clinical profile, management, outcome and 1-y follow-up of children with multisystem inflammatory syndrome in children (MIS-C). METHODS: This was a retrospective observational study of 54 Children satisfying the WHO MIS-C criteria admitted during the study period. RESULTS: Fifty-four children were included in the study, median age was 5.5 (IQR 8.75), 68.5% were males. PICU admissions were 77%. Most involved organ was gastrointestinal (92%), followed by cardiovascular 85%, central nervous system (CNS) 74%, respiratory 72%, mucocutaneous 59%, and renal 31%, and hypotension was the presenting symptom in 43%. Coronary artery dilatation was seen in 1 (1.8%) child. All patients presented with more than three organs involvement. Raised procalcitonin was seen in 100%, raised BNP in 31.5%, low ejection fraction in 83.3%, and abnormal radiograph in 59%. All children were positive for anti-SARS-CoV-2 antibodies and negative for cultures. Methylprednisolone or intravenous immunoglobulin (IVIg) was used in 77%, mechanical ventilation in 18.5%, and inotropic support in 77%. Aspirin was used in 48% and low molecular weight heparin (LMWH) in 54%. The median stay in hospital was 7 d (IQR 2). There was 1 mortality (1.8%). On 7-d follow-up, 98% children had a normal echocardiography; on 6 mo and 1-y follow-up, all children had normal echocardiography. CONCLUSION: MIS-C is an important complication of COVID-19 infection. Cardiac involvement resolves completely. Coronary artery involvement is not common.

The Development and Validation of a Mobile Application for Guidance for Management of Severe Diabetic Ketoacidosis.

OBJECTIVE: To develop and validate a mobile application-based tool for the management guidance of children and adolescents with diabetic ketoacidosis (DKA). METHODS: The study involved the development of a mobile application-based tool for DKA management in accordance with the International Society of Pediatric and Adolescent Diabetes (ISAPD) guidelines, 2018. The impact of the mobile application in preventing protocol deviation and resultant complications was assessed. Case records of 70 children and adolescents [39 boys, 8.9 (4.1) y of age] with severe DKA managed in the authors' intensive care unit were examined. The application guidance and real-time management were compared to the standard protocol. RESULTS: Protocol deviations were observed in 58 (82.9%), with two or more errors in 28 (40%). These included lack of initial fluid bolus (4, 5.7%), excessive fluid supplementation (8, 11.4%), inadequate initial fluid (25, 35.7%) and potassium supplementation (13, 18.6%), delayed response to fall in potassium (15, 21.4%) and glucose levels (24, 34.3%), and erroneous insulin administration (19, 27.1%). These errors contributed to 42.1% of severe hypokalemia and 56% of significant hypoglycemia episodes. The mobile application guidance was in accordance with the protocol in all the case scenario. CONCLUSION: Deviation from the management protocol is common in DKA and associated with adverse outcomes. Mobile application guidance is expected to reduce the protocol deviation with a potential of improving outcomes.

Development and testing of a game-based digital intervention for working memory training in autism spectrum disorder.

Autism spectrum disorder (ASD) is prevalent globally, yet it lacks cost-effective treatment approaches. Deficits in executive functions occur frequently in autism spectrum disorder and present a target for intervention. Here we report the design and development of five smartphone-based games for training working memory in children with ASD. These open-source games, available free of cost to the community, were designed to match the behavioral preferences and sensorimotor abilities of children with ASD. We then conducted a preliminary trial to test the effectiveness of a month-long intervention using these games. Although we did not see a significant change in the working memory of all children with a month-long training, children who performed better on the games also showed more improvement in their working memory, suggesting that a longer intervention with the games might be useful in improving working memory. Using a Hindi translation of the autism treatment evaluation checklist, we also tested the collateral gains of the training in reducing autistic symptoms. We found no significant change in the autistic symptoms after the intervention. Further, there was no correlation between the change in the working memory and the change in the autistic symptoms.

Impact of Air Pollution on Allergic Rhinitis and Asthma: Consensus Statement by Indian Academy of Pediatrics.

JUSTIFICATION: Rising air pollution is an ever-growing threat to many human diseases. Poor air quality has been directly correlated with respiratory allergies with a disproportionate affection among the pediatric age group. A clear understanding of common air pollutants and their potential contribution in allergic rhinitis and asthma is lacking. OBJECTIVE: To formulate a consensus statement for appropriate understanding among pediatricians and general practitioners about the effects of air pollution on respiratory allergies and their prevention. PROCESS: A group of experts (Pediatric pulmonologists and allergy specialists) from across India were appointed by the Indian Academy of Pediatrics (IAP) to formulate a consensus statement on 'Allergy and Air pollution'. A virtual meeting was conducted on 6th April 2020 to discuss in detail regarding various issues related to the subject and a writing committee was formed with broad consensus. After extensive literature review and multiple virtual sessions, the current document was prepared and circulated via email to the representatives from central IAP and IAP environment chapter. All the experts approved the consensus with minor modifications after a detailed discussion on 29th September 2020 on a virtual platform. RECOMMENDATIONS: Air pollution is the emerging contributor to respiratory allergies due to various mechanisms including oxidative stress and compromised mucociliary clearance. Children are more vulnerable to both outdoor and indoor pollution, due to their unique physiological characteristics. Knowledge about pollutant particle size and air quality index will help in demarcating level and extent of airway involvement. Relevant environmental history in difficult allergic rhinitis and asthma cases, along with conventional pharmacological measures, is warranted. Multipronged approach, targeted at community, physician and individual levels, needs to be emphasized to improve air quality and reduce economic and psychological burden of respiratory allergies.

Flexible Bronchoscopic Removal of Foreign Bodies from Airway of Children: Single Center Experience Over 12 Years.

OBJECTIVE: To report our experience of tracheobronchial foreign body removal in children using flexible bronchoscopy as the primary mode. METHODS: Hospital records of tracheobronchial foreign body extractions between January, 2006 and January, 2018 were reviewed. Clinical presentations, radiological findings, location and types of tracheobronchial foreign bodies, types of bronchoscopes, complications and outcome of the procedures were analyzed. RESULTS: 283 extractions in children with median (range) age of 18 (5-168) months were reviewed. Extraction by flexible bronchoscope, using wire baskets or grasping forceps, was successful in 260 cases. No major complications were encountered. Mean (SD) time for the procedure was 31 (6.3) minutes. CONCLUSION: Airway foreign bodies can safely be removed by flexible bronchoscopy with minimal complications. This procedure can be considered the primary mode for removal of airway foreign bodies by a trained and experienced person.

Predictive Accuracy of Chest Radiographs in Diagnosing Tachypneic Children.

OBJECTIVE: To test the predictive accuracy and reporting reproducibility of digital chest radiographs under low-resource conditions. METHODS: One hundred thirty four tachypneic children who presented to two Indian hospitals were enrolled. Based on review of 16 variables recorded in the Emergency Room (ER) by a senior pediatrician, children were given one of the four clinical diagnoses: pneumonia, wheezy disease, mixed and non-respiratory. Every child also had a digital CXR. It was interpreted by ER physician, pediatrician and two independent radiologists. All used the same standardized interpretation system (one or more of: normal, minor patches, major patches, hyperinflation, lobar change, pleural effusion). RESULTS: The 10 % of CXRs showing pleural effusions reliably predicted pneumonia and disease severity. For all other CXR findings, the correlation between CXR interpretation and clinical diagnosis was moderate to poor. Apart from pleural effusions, inter-observer agreements between interpretations made by ER physician, pediatrician and radiologist were also poor (kappa <0.4). CONCLUSIONS: With the exception of pleural effusions, CXR findings, interpreted by a radiologist, had moderate to poor power to predict respiratory diagnosis or disease severity defined by a pediatrician. Value of CXRs was further reduced by poor inter-observer agreement. When investigating tachypneic children under low-resource conditions, CXRs should be used with a clear understanding of their limitations.

Can we distinguish pneumonia from wheezy diseases in tachypnoeic children under low-resource conditions? A prospective observational study in four Indian hospitals.

BACKGROUND: Acute respiratory infections are the commonest cause of mortality and morbidity in children worldwide. A quarter of all deaths occur in India alone. In order to reduce this disease burden, there is a need for better diagnostic criteria, particularly ones allowing early detection of high-risk children. METHODS: We enrolled 516 under 5 year olds, in four Indian hospitals, who met WHO age-dependent tachypnoea criteria for pneumonia at presentation. Patients underwent a protocolised examination assessing 29 items, including history, examination, O2 saturation, plus scores for chest X-ray, auscultation and conscious level. Treatment was determined by the emergency room (ER) physician. All children were reviewed at day 4 by a paediatrician and placed into four diagnostic categories: pneumonia, wheezy disease, mixed and non-respiratory. RESULTS: The majority had wheezy diseases (42.8%). The remainder had pneumonia (35.9%), mixed disease (18.6%) and non-respiratory (2.7%). Best diagnostic predictors for wheezy disease were (auscultation/previous similar episodes) and for pneumonia (auscultation/CXR score). Mortality was 1.6%. Best disease severity predictors were conscious level, weight/age z score and respiratory/pulse rates. INTERPRETATION: Current tachypnoea-based algorithms significantly overdiagnose pneumonia in children and underdiagnose wheezy diseases. Diagnostic accuracy can be improved by various combinations of clinical variables, but the best single diagnostic predictor is auscultation. Simple criteria can also be defined that reliably detect which tachypnoeic children are at high risk of death or deterioration. Management plans based on these protocols could reduce unnecessary antibiotic use, improve the management of wheezy diseases and reduce mortality by earlier identification of high-risk children.

Alliin obtained from leaf extract of garlic grown under in situ conditions possess higher therapeutic potency as analyzed in alloxan-induced diabetic rats.

CONTEXT: Garlic, Allium sativum L. (Liliaceae), possesses high therapeutic and pharmacological properties. Hypoglycemic activity is attributed to alliin (S-allyl cysteine sulfoxide), the main active principle localized in garlic cloves. OBJECTIVE: To compare the production and therapeutic efficiency of alliin extracted from garlic leaves of plants grown under ex situ and in situ conditions. MATERIALS AND METHODS: Alliin content of leaves was quantified and aqueous leaf extracts (from ex situ and in situ grown plants) were given to normal and alloxan-induced diabetic rats for five weeks. RESULTS: Alliin production noted ~50% enhancement in leaves from plants grown under in situ conditions. Serum glucose, triglycerides, total lipids, total cholesterol, low-density lipoprotein (LDL)-, and very low-density lipoprotein (VLDL)-cholesterol in diabetic rats treated with alliin produced from in situ grown plants noted significant reduction of ~54%, 15%, 14%, 20%, 24%, and 15%, while 35%, 14%, 10%, 12%, 17% and 11% reduction was noted in diabetic rats treated with alliin produced from ex situ grown plants in comparison with those administered with distilled water. High-density lipoprotein (HDL)-cholesterol did not show any significant change. Leaf extract of plants lowered serum enzyme levels (alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase) toward the norm better than glibenclamide. The histopathological alteration in pancreas caused by alloxan was also reduced by leaf extract. DISCUSSION AND CONCLUSION: These findings demonstrate leaf extract obtained from plants grown under in situ condition possess higher therapeutic efficiency in comparison with leaf extract obtained from plants grown under ex situ condition. Studies suggest that environmental factors influence production of alliin and its therapeutic potential.

Congenital Tuberculosis.

Congenital tuberculosis is rare in spite of tuberculosis being a common infection worldwide. Due to the nonspecific nature of the presenting signs and symptoms and fatal outcome in absence of early therapy, the importance of early diagnosis is underscored. Young infants with tuberculosis become infected after birth through exposure to family or household members with contagious pulmonary disease. Routes of infection of the fetus before or during birth are dissemination to fetus via the placenta, aspiration of infected amniotic fluid, and direct contact with tuberculous cervicitis or endometritis. We report a case from India of congenital tuberculosis in a 3-month-old male infant who presented with respiratory failure, hepatomegaly, and diffuse infiltrates in the chest radiograph that persisted despite empiric antibacterial therapy. There was no known exposure to tuberculosis by history. Bronchoalveolar lavage culture yielded Mycobacterium tuberculosis. He was successfully treated with quadruple antituberculous medications reinforcing the potential good outcomes with the correct diagnosis.

Prevalence of congenital heart disease, Kanpur, India.

Our aim was to study the prevalence, age-wise distribution, and clinical spectrum of congenital heart disease (CHD) at a multi-speciality corporate hospital in North India. A retrospective analysis of records of 10,641 patients over a five-and-a-half year period was done. Clinical examination, echocardiography and color doppler were used as diagnostic tools. A prevalence of 26.4 per 1000 patients was observed. VSD (ventricular septal defect) was the commonest lesion (21.3%), followed by ASD (atrial septal defect) in 18.9% and PDA (patent ductus arteriosus) in 14. 6%. Tetralogy of Fallot was the commonest cyanotic heart disease (4.6%). Maximum number of children with heart disease (82.9%) were diagnosed between 0-3 years of age.

Nutritional quality of leaves of some genotypes of mulberry (Morus alba).

This study was undertaken to determine the proximate composition, vitamins, minerals and the antinutritional factor tannic acid in leaves of six genotypes of mulberry. The results showed that in fresh mulberry leaves the proximate composition values ranged from 71.13 to 76.68% for moisture, from 4.72 to 9.96% for crude protein, from 4.26 to 5.32% for total ash, from 8.15 to 11.32% for Neutral Detergent Fiber (NDF), from 0.64 to 1.51% for crude fat, from 8.01 to 13.42% for carbohydrate and from 69 to 86 kcal/100 g for energy. In dried mulberry leaf powder, moisture ranged from 5.11 to 7.24%, crude protein from 15.31 to 30.91%, total ash from 14.59 to 17.24%, NDF from 27.60 to 36.66%, crude fat from 2.09 to 4.93%, carbohydrate from 9.70 to 29.64% and energy from 113 to 224 kcal/100 g. Among vitamins ascorbic acid and beta-carotene were found to range from 160 to 280 mg/100 g and from 10,000.00 to 14,688.00 microg/100 g, respectively, in fresh mulberry leaves and from 100 to 200 mg/100 g and from 8438.00 to 13,125.00 microg/100 g, respectively, in dried mulberry leaf powder. The minerals iron, zinc and calcium were observed in the ranges of 4.70-10.36 mg/100 g, 0.22-1.12 mg/100 g and 380-786 mg/100 g, respectively, for fresh mulberry leaves, and 19.00-35.72 mg/100 g, 0.72-3.65 mg/100 g and 786.66-2226.66 mg/100 g, respectively, for dried mulberry leaf powder. The tannic acid ranged from 0.04 to 0.08% in fresh leaves and from 0.13 to 0.36% in dried leaf powder.

Mulberry (Morus alba) leaves as human food: a new dimension of sericulture.

Mulberry leaf is commonly used for sericulture in almost every part of the world but its potential to be utilized for human consumption is not well recognized. This paper deals with development of mulberry leaf powder and its use with wheat flour to develop paratha, the most common food item of breakfast and dinner in the Indian diet. The optimum ratio of the mulberry leaf powder and wheat flour (MLP-WF) mix for preparation of paratha on the basis of sensory quality was found to be 1:4. The protein quality of the MLP-WF mix was estimated by measuring the Protein Efficiency Ratio, and was found to be 1.82 against a casein diet for which a value of 2.44 was observed. The in vivo toxic effect of mix was studied and no adverse effect on the growth of internal organs of rats (heart, liver, kidney and testes) was found. The storage stability of the mix was estimated for a period of 2 months in polyethylene bags at room temperature. A non-significant difference was observed between paratha prepared from fresh and stored mix. This indicated that mix can be stored for a period of 2 months at room temperature without loss of quality.

Development of a nutritious low viscosity weaning mix using natural ingredients and microbial amylases.

A nutritious weaning food was developed using natural ingredients; namely, staple cereals and pulses, groundnut, Spirulina and gooseberry. The nutritive value of the developed weaning mix was found to be better than a commercial mix. The viscosity of the mixes was reduced by the addition of bacterial and fungal amylases. Addition of amylases at a concentration of 0.1-0.4% drastically reduced the viscosity in all the formulated mixes. The maximum viscosity reduction effect was evident at 0.2% for bacterial amylase and at 0.4% for fungal amylases.

Neonatal Boerhaave's syndrome with duodenal atresia.

Neonatal Boerhaave's syndrome is a rare condition. Most cases are idiopathic. We report a case of neonatal Boerhaave's syndrome associated with duodenal atresia which could have precipitated the former.