Indian Academy of Pediatrics Consensus Statement on Diagnosis and Management of Bone and Joint Infections in Children.

JUSTIFICATION: Osteoarticular infections are fairly common in children but often these are associated with underdiagnosis, delayed diagnosis and improper management. This leads to an increased incidence of complications and poor outcomes. Given the paucity of standard protocols for the management of these children in the Indian context, Indian Academy of Pediatrics (IAP) has taken the initiative to formulate guidelines for the early diagnosis and rational management of bone and joint infections (BJIs). OBJECTIVES: To critically evaluate the current evidence and formulate consensus guidelines for the diagnosis and management of BJIs in children. PROCESS: A committee comprising of eminent national faculty from different parts of the country who are experts in the field of Pediatric Infectious Diseases, Pediatric Orthopedics and Musculoskeletal Radiology was constituted and duly approved by the IAP. On Jan 16, 2021, a virtual meeting was held and a detailed discussions were carried out regarding the need to formulate these guidelines. Subsequently, the expert group defined the key questions in the first stage followed by collection and review of scientific evidences including available national and international recommendations or guidelines. This was followed by detailed deliberation among group members and presentation of their recommendations. The same were finalized in an online meeting on Aug 01, 2021, and a consensus statement was developed and adopted by the group. STATEMENT: BJIs are medical emergencies that need early diagnosis and appropriate therapy to prevent long term sequelae like limb deformities. Bacterial infections like Staphylococcus aureus is the most common etiological agent. Nonspecific and subtle clinical manifestations make the diagnosis of pediatric BJIs more challenging. Diagnosis of BJIs is primarily clinical, supplemented by laboratory and radiological investigations. The choice of antibiotic(s), mode of administration and duration of therapy requires individualization depending upon the severity of infection, causative organism, regional sensitivity patterns, time elapsed between onset of symptoms and the child's presentation, age, risk factors and the clinical and laboratory response to treatment. There is paucity of appropriate guidelines regarding the diagnosis and management of BJIs in children in Indian context. Hence, the need for this expert consensus guidelines in Indian settings.

Indian Academy of Pediatrics Consensus Guidelines for Probiotic Use in Childhood Diarrhea.

JUSTIFICATION: Several probiotic species and strains, single or combined, have been evaluated in childhood diarrheal disorders, and recommendations have ever been changing as newer trials are published. Therefore, there is a need to develop a guideline for Indian children describing the current role of probiotics in clinical practice. OBJECTIVES: To develop a guideline for the use of probiotics in children with diarrhea. PROCESS: A national consultative group (NCG) was constituted by the Indian Academy of Pediatrics (IAP), consisting of subjects experts. Sub-topics were allotted to various experts as paired groups for detailed review. Members reviewed the international and Indian literature for existing guidelines, systematic reviews, meta-analyses and trials. Thereafter, two virtual structured meetings of the group were held on 2nd and 22nd August, 2020. The management guidelines were formulated by the group and circulated to the participants for comments. The final guidelines were approved by all experts, and adopted by the IAP executive board. RECOMMENDATIONS: The NCG suggests Lactobacillus GG as a conditional recommendation with low-to-moderate level evidence or Saccharomyces boulardii as a conditional recommendation with very low-to-low level evidence as adjuvant therapy in acute diarrhea. The NCG also recommends the use of combination probiotics in neonatal necrotizing enterocolitis (NEC), as these reduce the risk of NEC stage II and above, late-onset sepsis, mortality and also time to achieve full feeds. The NCG does not recommend the use of any kind of probiotics in the therapy of acute dysentery, persistent diarrhea, Clostridium difficile diarrhea and chronic diarrheal conditions such as celiac disease, diarrhea-predominant irritable bowel syndrome and inflammatory bowel disease in children. Risk of antibiotic-associated diarrhea (AAD) is high with some antibiotics and most of these cases present as mild diarrhea. The NCG recommends probiotics only in special situations of AAD. L. rhamnoses GG or S. boulardii may be used for the prevention of AAD. VSL#3, a combination probiotic, may be used as an adjuvant in active pouchitis, prevention of recurrences and maintenance of remission in pouchitis.

Indian Academy of Pediatrics Revised (2021) Guidelines on Prevention and Treatment of Vitamin D Deficiency and Rickets.

JUSTIFICATION: The emerging literature on prevalence of vitamin D deficiency in India, prevention and treatment strategies of rickets, and extra-skeletal benefits of vitamin D suggest the need for revising the existing guidelines for prevention and treatment of vitamin D deficiency in India. OBJECTIVES: To review the emerging literature on vitamin D prevalence and need for universal vitamin D supplementation. To suggest optimum vitamin D therapy for treatment of asymptomatic and symptomatic vitamin D deficiency, and rickets. To evaluate the extra-skeletal health benefits of vitamin D in children. PROCESS: A National consultative committee was formed that comprised of clinicians, epidemiologists, endocrinologists, and nutritionists. The Committee conducted deliberations on different aspects of vitamin D deficiency and rickets through ten online meetings between March and September, 2021. A draft guideline was formulated, which was reviewed and approved by all Committee members. RECOMMENDATIONS: The group reiterates the serum 25-hydroxy vitamin D cutoffs proposed for vitamin D deficiency, insufficiency, and sufficiency as <12 ng/mL, 12-20 ng/mL and >20 ng/mL, respectively. Vitamin D toxicity is defined as serum 25OHD >100 ng/mL with hypercalcemia and/or hypercalciuria. Vitamin D supplementation in doses of 400 IU/day is recommended during infancy; however, the estimated average requirement in older children and adolescents (400-600 IU/day, respectively) should be met from diet and natural sources like sunlight. Rickets and vitamin D deficiency should be treated with oral cholecalciferol, preferably in a daily dosing schedule (2000 IU below 1 year of age and 3000 IU in older children) for 12 weeks. If compliance to daily dosing cannot be ensured, intermittent regimens may be prescribed for children above 6 months of age. Universal vitamin D supplementation is not recommended in childhood pneumonia, diarrhea, tuberculosis, HIV and non-infectious conditions like asthma, atopic dermatitis, and developmental disorders. Serum 25-hydroxy vitamin D level of >20 ng/mL should be maintained in children with conditions at high-risk for vitamin deficiency, like nephrotic syndrome, chronic liver disease, chronic renal failure, and intake of anticonvulsants or glucocorticoids.

Indian Academy of Pediatrics Guidelines on Screen Time and Digital Wellness in Infants, Children and Adolescents.

JUSTIFICATION: Screen-based media have become an important part of human lifestyle. In view of their easy availability and increasing use in Indian children, and their excessive use being linked to physical, developmental and emotional problems, there is a need to develop guidelines related to ensure digital wellness and regulate screen time in infants, children, and adolescents. OBJECTIVES: To review the evidence related to effects of screen-based media and excessive screen time on children's health; and to formulate recommendations for limiting screen time and ensuring digital wellness in Indian infants, children and adolescents. PROCESS: An Expert Committee constituted by the Indian Academy of Pediatrics (IAP), consisting of various stakeholders in private and public sector, reviewed the literature and existing guidelines. A detailed review document was circulated to the members, and the National consultative meet was held online on 26th March 2021 for a day-long deliberation on framing the guidelines. The consensus review and recommendations formulated by the Group were circulated to the participants and the guidelines were finalized. CONCLUSIONS: Very early exposure to screen-based media and excessive screen time (>1-2h/d) seems to be widely prevalent in Indian children. The Group recommends that children below 2 years age should not be exposed to any type of screen, whereas exposure should be limited to a maximum of one hour of supervised screen time per day for children 24-59 months age, and less than two hours per day for children 5-10 years age. Screen time must not replace other activities such as outdoor physical activities, sleep, family and peer interaction, studies and skill development, which are necessary for overall health and development of the children and adolescents. Families should ensure a warm, nurturing, supportive, fun filled and secure environment at home, and monitor their children's screen use to ensure that the content being watched is educational, age-appropriate and non-violent. Families, schools and pediatricians should be educated regarding the importance of recording screen exposure and digital wellness as a part of routine child health assessment, and detect any signs of cyberbullying or media addiction; and tackle it timely with expert consultation if needed.

Coronavirus Disease 2019 (COVID-19) Vaccination for Children: Position Statement of Indian Academy of Pediatrics Advisory Committee on Vaccination and Immunization Practices.

JUSTIFICATION: Data generated after the first wave has revealed that some children with coronavirus 19 (COVID-19) can become seriously ill. Multi-inflammatory syndrome in children (MIS-C) and long COVID cause significant morbidity in children. Prolonged school closures and quarantine have played havoc with the psychosocial health of children. Many countries in the world have issued emergency use authorisation (EUA) of selected Covid-19 vaccines for use in children. In India, a Subject Expert Committee (SEC) has recommended the use of Covaxin (Bharat Biotech) for children from the ages of 2-18 years. The recommendation has been given to the Drugs Controller General of India (DCGI) for final approval. OBJECTIVE: To provide an evidence-based document to guide the pediatricians on the recommendation to administer COVID vaccines to children, as and when they are available for use. PROCESS: Formulation of key questions was done by the committee, followed by review of literature on epidemiology and burden of Covid-19 in children, review of the studies on COVID vaccines in children, and the IAP stand on Covid-19 vaccination in children. The available data was discussed in the ACVIP focused WhatsApp group followed by an online meeting on 24 October, 2021, wherein the document was discussed in detail and finalized. RECOMMENDATIONS: The IAP supports the Government of India's decision to extend the COVID-19 vaccination program to children between 2-18 years of age. Children with high-risk conditions may be immunized on a priority basis. The IAP and its members should be a partner with the Government of India, in the implementation of this program and the surveillance that is necessary following the roll-out.

Indian Academy of Pediatrics Revised Guidelines on School Reopening: First Revision, September 2021.

JUSTIFICATION: The COVID-19 pandemic has affected schooling for more than 24 crores students, since March 2020. Students need a respite from the long standing social isolation so that they regain their chance to develop holistically, but after the devastating effects of the second wave, the administrators as well as parents are skeptical about the decision of school reopening. PROCESS: The Indian Academy of Pediatrics constituted a task force comprising of national and international experts in the field who deliberated on the issue. OBJECTIVES: To bring out scientifically supported guidelines on the prerequisites of opening and attending the schools, in the current context of the COVID-19 pandemic. RECOMMENDATIONS: The task force recommends i) Decentralization of the school reopening decision; ii)Three epidemiological parameters, case positivity rate (<5 or steadily declining number of cases for past two weeks), number of new cases(<20 per lakh population per day for past two weeks) and vaccination coverage (>60% of the vaccine-eligible population) to be met at the local level, before the schools reopen; and iii) Criteria regarding health and vaccination to be met by the schoolattendees.

Breastfeeding and Coronavirus Disease 2019 (COVID-19) Vaccination: Position Statement of Indian Academy of Pediatrics Advisory Committee on Vaccination and Immunization Practices.

JUSTIFICATION: In India, till recently, breastfeeding women have been excluded from the coronavirus disease (COVID-19) vaccination program, rendering a significant population of the country, including frontline workers, ineligible to derive the benefits of the COVID-19 vaccine rollout. OBJECTIVE: The objective of this recommendation is production of an evidence-based document to guide the pediatricians to give advice to breastfeeding mothers regarding the safety of COVID-19 vaccines in lactating women. PROCESS: Formulation of key question was done under the chairmanship of president of the IAP. It was followed by review of literature regarding efficacy and safety of COVID-19 vaccines in breastfeeding women. The recommendations of other international and national professional bodies were also deliberated in detail. The available data was discussed in the ACVIP focused WhatsApp group. Opinion of all members was taken and the final document was prepared after achieving consensus. RECOMMENDATIONS: The IAP/ACVIP recommends the administration of COVID-19 vaccines to all breastfeeding women. The IAP/ACVIP endorses the recent recommendation of the Government of India, to consider all breastfeeding women as eligible for COVID-19 vaccination.

COVID-19-related disruptions to routine vaccination services in India: a survey of paediatric providers.

The COVID-19 pandemic has led to disruptions in essential health services globally. We surveyed Indian paediatric providers on their perceptions of the impact of the pandemic on routine vaccination. Among 424 (survey 1) and 141 (survey 2) respondents representing 26 of 36 Indian states and union territories, complete suspension of vaccination services was reported by 33.4% and 7.8%, respectively. In April-June 2020, 83.1% perceived that vaccination services dropped by half, followed by 32.6% in September 2020, indicating slow resumption of services. Concerns that vaccine coverage gaps can lead to mortality were expressed by 76.6%. Concerted multipronged efforts are needed to sustain gains in vaccination coverage.

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.

IAP Guideline on Practicing Safely During COVID-19 Era: Clinics and Small Establishments.

JUSTIFICATION: The unprecedented COVID-19 pandemic has had a formidable impact on Indian health care. With no sight of its end as yet, various establishments including the smaller clinics and nursing homes are restarting full operations. Hence, there is the need for recommendations to allow safe practice ensuring the safety of both the heath care worker (HCW) and patients. PROCESS: Indian Academy of Pediatrics organized an online meeting of subject experts on 27 July, 2020. A committee was formed comprising of pediatricians, pediatric and neonatal intensivists, and hospital administrators. The committee held deliberations (online and via emails) and a final consensus was reached by November, 2020. OBJECTIVES: To develop recommendations to provide a safe and practical healthcare facility at clinics and small establishments during COVID times. RECOMMENDATIONS: The key recommendation to practise safely in this setting are enumerated. Firstly, organizing the out-patient department (OPD). Secondly, appropriate personal protective equipment (PPE) to provide protection to the individual. Thirdly, decontamination/disinfection of various common surfaces and equipment to prevent transmission of infection from fomites. Next, maintaining the heating ventilation and air conditioning (HVAC) to provide a stress-free, comfortable, and safe environment for patients and HCWs. Finally, steps to effectively manage COVID-19 exposures in a non-COVID-19 facility. All these measures will ensure safe practice during these unprecedent times in clinics and smaller establishments.

Indian Academy of Pediatrics Guidelines for Pediatric Skin Care.

OBJECTIVE: To develop standard recommendations for skin care in neonates, infants and children to aid the pediatrician to provide quality skin care to infants and children. JUSTIFICATION: Though skin is the largest organ in the body with vital functions, skin care in children especially in newborns and infants, is not given the due attention that is required. There is a need for evidence-based recommendations for the care of skin of newborn babies and infants in India. PROCESS: A committee was formed under the auspices of Indian Academy of Pediatrics in August, 2018 for preparing guidelines on pediatric skin care. Three meetings were held during which we reviewed the existing guidelines/ recommendations/review articles and held detailed discussions, to arrive at recommendations that will help to fill up the knowledge gaps in current practice in India. The initial draft of the manuscript based on the available evidence and experience, was sent to all members for their inputs, after which it was finalized. RECOMMENDATIONS: Vernix caseosa should not be removed. First bath should be delayed until 24 hours after birth, but not before 6 hours, if it is not practically possible to delay owing to cultural reasons. Duration of bath should not exceed 5-10 minutes. Liquid cleanser with acidic or neutral pH is preferred, as it will not affect the skin barrier function or the acid mantle. Cord stump must be kept clean without any application. Diaper area should be kept clean and dry with frequent change of diapers. Application of emollient in newborns born in families with high risk of atopy tends to reduce the risk of developing atopic dermatitis. Oil massage has multiple benefits and is recommended. Massage with sunflower oil, coconut oil or mineral oil are preferred over vegetable oils such as olive oil and mustard oil, which have been found to be detrimental to barrier function.

Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP): Recommended Immunization Schedule (2020-21) and Update on Immunization for Children Aged 0 Through 18 Years.

JUSTIFICATION: In view of new developments in vaccinology and the availability of new vaccines, there is a need to revise/review the existing immunization recommendations. PROCESS: Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics (IAP) had a physical meeting in March, 2020 followed by online meetings (September-October, 2020), to discuss the updates and new recommendations. Opinion of each member was sought on the various recommendations and updates, following which an evidence-based consensus was reached. OBJECTIVES: To review and revise the IAP recommendations for 2020-21 and issue recommendations on existing and new vaccines. RECOMMENDATIONS: The major changes include recommendation of a booster dose of injectable polio vaccine (IPV) at 4-6 years for children who have received the initial IPV doses as per the ACVIP/IAP schedule, re-emphasis on the importance of IPV in the primary immunization schedule, preferred timing of second dose of varicella vaccine at 3-6 months after the first dose, and uniform dosing recommendation of 0.5 mL (15 µg HA) for inactivated influenza vaccines.

Immunization During the COVID-19 Pandemic: Recommendations From Indian Academy of Pediatrics Advisory Committee on Vaccines and Immunization Practices.

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, immunization practices of all age groups, especially routine childhood vaccines, have been interrupted. Immunization is considered an essential health activity, which needs to be resumed as early as possible. This pandemic has created several unique issues related to routine immunization of individual children at clinics, which needs to be addressed. In this communication, the Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics addresses the common questions and issues related to SARS-CoV-2 and routine immunization services. This also includes the recommendations for routine immunization of SARS-CoV-2 suspect and positive children, and for the logistics to be followed for immunization services.

Indian Academy of Pediatrics Guidelines on School Reopening, Remote Learning and Curriculum in and After the COVID-19 Pandemic.

JUSTIFICATION: With the unprecedented COVID-19 pandemic and the resultant school closure, children all over the country are undergoing a lot of educational, psychosocial, and physical problems. There is an urgent and deep felt need to offer scientific and concrete guidance for these concerns and support children in their educational development during these testing times. OBJECTIVE: To review the guidelines and recommendations given by various international agencies and formulate guidelines in the Indian context on (a) how and when to reopen the schools; (b) ways and means of remote learning; and (c) to identify the contents of curriculum that need restructuring in context of the current situation. PROCESS: Indian Academy of Pediatrics (IAP) formed a task force of pediatricians, educationists and technological experts who connected through various video and social platforms. They gathered and exchanged information and thoughts. The writing committee drafted the guidelines and got approval of all the members of the task force. RECOMMENDATIONS: Schools can be reopened only when the local epidemiological parameters are favorable, the administration is equipped with adequate infrastructure and health care facilities, and the stakeholders (teachers, students, parents, and support staff) are prepared for the new normal. In the meanwhile, remote learning (media-based and /or otherwise) should reach to the last student to maintain uninterrupted education. The curriculum needs to be revised, with focus on revision and core contents. Informal learning of psychosocial empowerment and daily living skills should be encouraged rather than stressful formal learning.