Occurrence and Severity of Deformational Plagiocephaly in Infants: A Single Center Experience.

OBJECTIVE: To estimate the occurrence and severity of deformational plagiocephaly among infants. METHODS: A hospital-based, cross-sectional study was done in the pediatric ward of a tertiary care hospital between April 1, 2022 to October 31, 2022. Cranial Vault Asymmetry Index (CVAI) and Argenta Clinical Classification were applied to consecutive infants aged 1 month to 1 year till the calculated sample size was achieved. RESULTS: 67 infants were recruited and the occurrence of deformational plagiocephaly in the sample was estimated to be 46.3%. Level 2 severity of deformational plagiocephaly was the commonest, while as per the Argenta classification, majority belonged to type I (39.2%). Male gender and developmental delay were the significant risk factors for plagiocephaly with an odds ratio (95% CI) of 3.73 (1.23, 11.26) and 19.25 (2.31, 160.3), respectively. CONCLUSION: A high occurrence of deformational plagiocephaly was found in infants studied. There is a need for more studies to further corroborate these findings and study its associated factors.

Macrolides versus other antibiotics in pediatric scrub typhus: A meta-analysis.

BACKGROUND: While Doxycycline is the recommended drug for treating scrub typhus, there is a growing trend of using Macrolides and Other antibiotics due to their perceived advantages. In this study, we compared the efficacy of Macrolides versus Other antibiotics in the treatment of pediatric scrub typhus. METHODS: Meta-analysis of randomized controlled trials (RCTs) with GRADE (Grading of Recommendations, Assessment, Development and Evaluation) application. Major databases were searched till 30th December 2022. Children of all age groups were included. Primary outcomes included mortality rate and time to defervescence (h). RESULTS: Of the 103 citations retrieved, 5 trials, including 383 children up to 15 years of age with probable and confirmed cases of scrub typhus, were included. None of the trials reported mortality rate. The pooled results from the trials found no significant difference between Azithromycin and Other antibiotics for any of the outcome measures. The certainty of evidence for the primary outcome was deemed to be of "very low certainty", while the certainty of evidence for the secondary outcomes ranged from "low to moderate certainty". CONCLUSIONS: The current meta-analysis revealed that there was no significant difference between Azithromycin and Other antibiotics (such as Doxycycline and Chloramphenicol) in the treatment of scrub typhus in children. However, it's important to note that the evidence generated for the primary outcome was of "very low certainty". PROSPERO REGISTRATION NUMBER: CRD42021276577.

Human Bocavirus infection in childhood acute respiratory infection: Is it an innocent bystander?

PURPOSE: Acute respiratory infection (ARI) is one of the major attributing factors of under-five mortality and morbidity all over the world. Viruses are the most common cause of ARI. Due to the availability of molecular techniques, new viruses are getting isolated from children with ARI. With the above background, the present study was conducted to enlighten on the pathogenic role of human bocavirus (HBoV) in children with ARI. METHODOLOGY: This retrospective study was conducted over a period of >3 years duration. The clinical and laboratory data of the patients with signs and symptoms of ARI were retrieved and analyzed. Clinical profiles and outcome of the patients detected of having HBoV mono or co-infections were further analyzed in details. RESULTS: A total of 237 respiratory samples were subjected to respiratory panel by fast track diagnosis (FTD) multiplex polymerase chain reaction (multiplex PCR), of which 10 samples (mono-infection â€‹= â€‹4) were detected with the presence of HBoV. The clinical details of 8 cases were studied in details (details of rest 2 cases were missing). All the children were less than 3 years of age, with different co-morbid conditions such as low birth weight (n â€‹= â€‹4), cholestatic jaundice (n â€‹= â€‹1), operated case of congenital diaphragmatic hernia (n â€‹= â€‹1), pancytopenia (n â€‹= â€‹1), and primary immune deficiency (n â€‹= â€‹1). Their clinical course did not improve following antibiotic administration, 2 succumbed to death while the rest 6 cases were discharged. CONCLUSION: The present study highlights the fact that HBoV may not be an innocent bystander in the childhood ARI. Larger studies employing appropriate diagnostic modalities are needed to emboss it as a true pathogen and not merely a bystander.

Longitudinally Extensive Transverse Myelitis: One Disease, Variable Outcomes-A Case Series.

Longitudinal extensive transverse myelitis (LETM) is a rare form of widespread inflammation of the spinal cord causing T2 hyperintensity in spinal magnetic resonance imaging (MRI) extending across three or more vertebral segments. It is an acute onset of sensory, motor, and autonomic dysfunction of variable etiology with a likely poor outcome. We present a case series of three cases wherein children between the ages of 4 and 13 years had diverse symptoms from gradual painless loss of vision in both eyes with headache, vomiting and seizure, and a normal central nervous system examination except involvement of the optic nerve to another child with abdominal pain, urinary retention and constipation for 3 days with exaggerated DTR, and patchy sensory loss without any definite sensory level, and to the third child with fever and weakness of lower limbs, hypotonia and grade 1-2/5 power in lower limbs and normal upper limb power. Contrast-enhanced MRI spine of all children showed long segment T2 hyperintensity with variable involvement of the brain. The first two children were treated with pulsed dose methylprednisolone, and the last child received intravenous immunoglobulin followed by methylprednisolone. All were followed with oral prednisolone. LETM has a varied presentation with different etiologies. Antineuromyelitis optica immunoglobulin G (IgG) antibody (Aquaporin-4 IgG) and antimyelin oligodendrocyte glycoprotein antibody are strongly recommended though they may not be locally available or not affordable. Early and aggressive immunomodulatory therapy may help faster recovery, as did with two of our three children.

Eastern India Collaboration on Multisystem Inflammatory Syndrome in Children (EICOMISC): A Multicenter Observational Study of 134 Cases.

Background: Few single center studies from resource-poor settings have reported about the epidemiology, clinical feature and outcome of multisystem inflammatory syndrome in children (MIS-C). However, larger data from multi-center studies on the same is lacking including from Indian setting. Methods: This retrospective collaborative study constituted of data collected on MIS-C from five tertiary care teaching hospitals from Eastern India. Children ≤ 15 years of age with MIS-C as per the WHO criteria were included. Primary outcome was mortality. Results: A total of 134 MIS-C cases were included (median age, 84 months; males constituted 66.7%). Fever was a universal finding. Rash was present in 40%, and conjunctivitis in 71% cases. Gastro-intestinal and respiratory symptoms were observed in 50.7% and 39.6% cases, respectively. Co-morbidity was present in 23.9% cases. Shock at admission was noted in 35%, and 27.38% required mechanical ventilation. Fifteen (11.2%) children died. The coronary abnormalities got normalized during follow-up in all except in one child. Initial choice of immunomodulation had no effect on the outcomes. Presence of underlying co-morbidity, lymphopenia, thrombocytosis, hyponatremia, increased LDH (>300 U/L), and hypoalbuminemia were the factors significantly associated an increased mortality. Conclusions: MIS-C has myriad of manifestations. Underlying co-morbidity, lymphopenia, thrombocytosis, hyponatremia, increased LDH (>300 U/L), and hypoalbuminemia were associated with an increased mortality. No difference in outcome was noted with either steroid or IVIg or both. Coronary artery abnormalities resolved in nearly all cases.

Molecular Characterization and Management of Congenital Hyperinsulinism: A Tertiary Centre Experience.

BACKGROUND: There is limited data from India regarding medical management of congenital hyperinsulinism (CHI). OBJECTIVE: To study the molecular diagnosis, medical management and outcomes of children with CHI. STUDY DESIGN: Ambispective. PARTICIPANTS: Children with CHI admitted in from December, 2011 till March, 2020 at a tertiary care referral hospital. OUTCOMES: Clinical and genetic profile, treatment, and response. RESULTS: 42 children with a median age of 3 days (range 1 day to 6 years) were enrolled, of which 23 (54.7%) were diazoxide-responsive. Mutations were identified in 28 out of 41 (68.2%) patients. The commonest gene affected was ABCC8 in 22 patients. The pathogenic variant c.331G>A in ABCC8 gene was identified in 6 unrelated cases from one community. Good response to daily octreotide was seen in 13 of the 19 (68.4%) diazoxide-unresponsive patients. Monthly long-acting octreotide was initiated and daily octreotide could be stopped or tapered in 9 patients. Sirolimus was tried with variable response in 6 patients but was discontinued in 5 due to adverse effects. Four patients had focal CHI, of which one underwent partial pancreatic resection. The disease severity reduced with age and neurodevelopment was good in the patients with identifiable genetic defects who were optimally managed. CONCLUSIONS: Medical management of CHI is effective, if compliance can be ensured, with good quality of life and neurological outcomes.

Oral Azithromycin Versus Doxycycline in the Treatment of Children With Uncomplicated Scrub Typhus: A Randomized Controlled Trial.

OBJECTIVES: To compare the efficacy of azithromycin versus doxycycline in treatment of children with uncomplicated scrub typhus in terms of percentage of children who attained remission of fever after 72 hours of administration of first dose of the study drug, mean time taken to attain fever defervescence, normalization of laboratory parameters, resolution of hepatosplenomegaly and lymphadenopathy. DESIGN: Interventional, open-labeled randomized controlled trial. STUDY METHODS: Patients admitted with undifferentiated fever in the In-Patient Department (IPD), Department of Paediatrics, All India Institute of Medical Sciences, Bhubaneswar, India, as per the inclusion criteria were randomized and was treated with azithromycin at 10 mg/kg/d in one group and doxycycline at 4.4 mg/kg/d for 5 days in the other group and was assessed based on the primary and secondary objectives. RESULTS: There was no statistically significant difference between the percentage of children who attained remission of fever after 72 hours of administration of azithromycin (98.2%) and doxycycline (96.5%) (P value 0.47) and the average time taken for fever defervescence (azithromycin: 24.53 hours; doxycycline: 25.82 hours; P value 0.36). The odds of attaining fever remission in the doxycycline group as compared with the azithromycin group was 1.01 (95% confidence interval -0.60 to -1.71), which was also statistically not significant. There was less incidence of adverse drug events in the azithromycin group (1.78%) as compared with the doxycycline group (8.6%), which was statistically significant (P value 0.02). CONCLUSION: Azithromycin is equally efficacious in terms of fever defervescence, resolution of clinical signs and laboratory parameters as doxycycline, is safer and better tolerated in children.

Capacity Building of Frontline Workers for Detection of Children (0-6 Years) with Developmental Delays in a Rural Setting: A Cluster-Randomized Trial.

INTRODUCTION: Development during the early stage of life i.e. in the first 1000 d is crucial in determining the psychosocial productivity of a child in the future. Frontline workers (FLWs) are not trained to detect of developmental delays (DDs) in children under the national programme of Rashtriya Bal Swasthya Karyakram (RBSK) in India. OBJECTIVE: To train the FLWs and assess the effectiveness of a training strategy in detection of DDs in children less than 6 y of age using a cluster-randomized trial approach. METHODS: A community-based interventional study was conducted in Khurdha district of Odisha. Training was imparted to FLWs in intervention arm using a training module developed in regional language. Knowledge level of FLWs was assessed before and after the training in both study arms using a structured questionnaire, and data were analyzed in IBM SPSS 22. Outcomes were compared using chi square, Student t (both paired and unpaired) and Man-Whitney U test. After 3 mo of intervention, the investigator examined a sample of children (intervention arm: 870, control arm: 847) for DDs using the Denver Developmental Screening Test II. RESULTS: The mean difference in knowledge scores of FLWs was found to be 7.26 (8.8 to 5.7) and 1.11 (1.38 to 0.84) in intervention and control arm, respectively. Case detection rate by FLWs in intervention and control arm was 61.5% and 9.09%, respectively. CONCLUSION: Capacity building of the FLWs should be considered by the government for integrating them in the Rashtriya Bal Swasthya Karyakram (RBSK) programme for screening children.

Role of Clinical Criteria and Oxygen Saturation Monitoring in Diagnosis of Childhood Pneumonia in Children Aged 2 to 59 Months.

BACKGROUND: Current WHO algorithm has retained the signs and symptoms used in the older version for classifying severity of childhood pneumonia. OBJECTIVE: To study the role of clinical features (including that of current WHO criteria), and oxygen saturation (SpO2) in the diagnosis of childhood pneumonia. STUDY DESIGN: Multicenter prospective cohort study. PARTICIPANTS: Children, 2 to 59 months of age, suffering from acute respiratory infection (ARI). OUTCOME MEASURES: Sensitivity, specificity, and likelihood ratios were calculated for clinical features, and SpO2. RESULTS: Of a total 7026 children with ARI enrolled, 13.4% had pneumonia (37% of them had severe pneumonia), according to WHO criteria. Based on any abnormality on chest x ray (CXR), 46% had pneumonia. The sensitivity and specificity of the existing WHO criteria for diagnosis of pneumonia was 56.5% and 66.2%, respectively, when compared against abnormalities in CXR. Cough and fever, each had sensitivity of >80%. Audible wheeze and breathing difficulty, each had a specificity of >80%. Sensitivity and specificity of tachypnoea were 58.7% and 63.3%, respectively. None of the clinical features alone had a sensitivity and specificity of >80%. Addition of SpO2 of <92% to chest indrawing alone or WHO criteria increased the likelihood of diagnosis of pneumonia. CONCLUSIONS: Current WHO criteria based on rapid respiratory rate and/or chest indrawing has modest sensitivity and specificity, considering CXR abnormalities as gold standard for diagnosis of pneumonia. Addition of SpO2 of <92% to chest indrawing alone or WHO criteria increases the probability of pneumonia diagnosis, and is important in the management of a child with pneumonia.

Profile of Scrub Typhus Meningitis/Meningoencephalitis in Children with and without Scrub Typhus IgM Antibody in CSF.

The aim of this article was to study the spectrum of scrub typhus meningitis/meningoencephalitis (STM) cases in children. Children ≤14 years of age with acute undifferentiated febrile illness were included. Immunoglobulin M (IgM) enzyme-linked immunosorbent assay was done in blood and cerebrospinal fluid (CSF) of children with suspected STM. Demographic, clinical, and laboratory details were expressed as descriptive statistics. Factors associated with neurological involvement were identified on univariate analysis. A total of 76 children had ST during the study period (meningitis/meningoencephalitis = 8 [10.5%], of which 5 [62.5%] had detectable ST IgM antibodies in CSF). The included children were 4 to 12 years of age with boys > girls. Headache and vomiting were common in those with STM, whereas hyponatremia and thrombocytopenia were common in those without STM. All children with STM recovered with sequelae in one child (right lateral rectus palsy). There was no mortality. STM has an incidence of 10.5% in children with ST from Eastern India. Headache and vomiting were significant predictors of STM, whereas hyponatremia and thrombocytopenia were significant predictor of non-STM.

Dyke-Davidoff-Masson Syndrome: A Rare Cause of Acquired Cerebral Hemiatrophy.

Dyke-Davidoff-Masson syndrome is a rare disease of childhood which is clinically characterized by hemiparesis, refractory seizures, facial asymmetry, and mental retardation. The classical radiological findings are cerebral hemiatrophy, calvarial thickening, and hyperpneumatization of the frontal sinuses. Seizure refractory to medical management warrants surgical intervention with excellent outcome. Here, we are reporting two such cases who presented late and diagnosis was made on the basis of magnetic resonance imaging brain features. Both of our children responded to oral anticonvulsant and are on regular follow-up.

Clinical Profile and Risk Factors for Severe Disease in 402 Children Hospitalized with SARS-CoV-2 from India: Collaborative Indian Pediatric COVID Study Group.

INTRODUCTION: There is a lack of large multicentric studies in children with COVID-19 from developing countries. We aimed to describe the clinical profile and risk factors for severe disease in children hospitalized with COVID-19 from India. METHODS: In this multicentric retrospective study, we retrieved data related to demographic details, clinical features, including the severity of disease, laboratory investigations and outcome. RESULTS: We included 402 children with a median (IQR) age of 7 (2-11) years. Fever was the most common symptom, present in 38.2% of children. About 44% had underlying comorbidity. The majority were asymptomatic (144, 35.8%) or mildly symptomatic (219, 54.5%). There were 39 (9.7%) moderate-severe cases and 13 (3.2%) deaths. The laboratory abnormalities included lymphopenia 25.4%, thrombocytopenia 22.1%, transaminitis 26.4%, low total serum protein 34.7%, low serum albumin 37.9% and low alkaline phosphatase 40%. Out of those who were tested, raised inflammatory markers were ferritin 58.9% (56/95), c-reactive protein 33.3% (41/123), procalcitonin 53.5% (46/86) and interleukin-6 (IL-6) 76%. The presence of fever, rash, vomiting, underlying comorbidity, increased total leucocyte count, thrombocytopenia, high urea, low total serum protein and raised c-reactive protein was factors associated with moderate to severe disease. CONCLUSION: Fever was the commonest symptom. We identified additional laboratory abnormalities, namely lymphopenia, low total serum protein and albumin and low alkaline phosphatase. The majority of the children were asymptomatic or mildly symptomatic. We found high urea and low total serum protein as risk factors for moderate to severe disease for the first time.

COVID-19 related multi-inflammatory syndrome presenting with uveitis - A case report.

Multi Inflammatory Syndrome (MIS-C) associated with Corona Virus Disease (COVID) in children and young adults presents with a varied clinical spectrum; from that mimicking Kawasaki disease (KD), Incomplete Kawasaki disease to even Hemophagocytic Lymphohistiocytosis. A 14-year-old girl, presented to us, with headache, fever, bilateral uveitis, unilateral cervical lymphadenopathy, oral mucosal changes and abdominal pain. A disproportionate increase in inflammatory markers and Interleukin - 6, in the setting of a negative COVID real-time reverse transcription polymerase chain reaction (RTPCR) and significantly elevated COVID antibody titre confirmed our diagnosis. She was treated with intravenous Immunoglobulin and oral steroids with which she recovered. We want to highlight considering the possibility of MIS-C in children presenting with uveitis at a time when COVID-19 has been conquering the world with community spread.

Nonsevere Acute Respiratory Syndrome Human Coronaviruses in Children Hospitalized with Acute Lower Respiratory Infection.

BACKGROUND: The nonzoonotic (nonsevere acute respiratory syndrome (SARS)/Middle East respiratory syndrome) human coronaviruses (HCoVs) are usually considered as the causative agent for acute respiratory infection. We studied the characteristics and outcome of children with non-SARS HCoV acute lower respiratory infection (ALRI). METHODS: This was a cross-sectional study from a tertiary care teaching hospital in eastern India. RESULTS: Of 137 samples tested positive for respiratory viruses, 13 were due to HCoV (7 boys, median age: 2 years). Cough was the most common symptom, followed by breathing difficulty and fever. An underlying comorbid condition present in 38.4%. Co-infection with other viruses was seen in 69% of cases. Chest radiograph was abnormal in 69.3% of children. Antibiotics were administered in 53.8%. The median length of hospitalization was 5 d, irrespective of underlying disease. There was no mortality. CONCLUSIONS: HCoV is an uncommon but increasingly recognized cause of ALRI in hospitalized children. No severe illness was found in children with underlying comorbidities. This study underscores the importance of HCoV in causation of childhood ALRI, necessitating a surveillance system in India.

Prevalence of Insulin Resistance in Urban Indian School Children Who Are Overweight/Obese: A Cross-Sectional Study.

Background: Limited data are available for insulin resistance (IR) in over-weight/obese children from the Indian subcontinent. Identifying predictors of IR in this population is important, as they may be used as a screening tool for future metabolic complications. Materials and Methods: This school-based cross-sectional study was conducted in an Eastern Indian city. Anthropometry and blood pressure measurements were carried out as per the published guidelines. Venous blood samples were taken in a fasting state to measure plasma glucose, insulin, and lipid profile. IR was measured quantitatively by a homeostatic model of assessment (HOMA-IR). Results: A total of 545 (28.2%) children who were overweight or obese were included. The male:female ratio was 1:1.27. The overall prevalence of metabolic syndrome (MS) in these children was 21.8%. Around 32.3% of children had HOMA-IR of ≥2.5, and 22.2% had HOMA-IR of ≥3.16. The mean HOMA-IR in children with MS was 5.46 compared to 2.18 in those without MS. An increased risk of IR with low HDL, high triglyceride, increased waist circumference, and increased BP (both systolic and diastolic) was found. This means that insulin resistance was more common in children who were overweight or obesity and had underlying MS. Conclusions: The present school-based study found a high prevalence of insulin resistance among children who were overweight or obese. This could predict an increased risk of future adverse cardio-vascular events in the studied children. The findings of this study would help in planning and implementing primary prevention programs targeting weight management and lifestyle change in schoolchildren.

Prevalence of Musculoskeletal Pain and Its Relation With Weight of Backpacks in School-Going Children in Eastern India.

Background: Recently, heavy school backpacks have become a significant concern among parents and health professionals, as well as the media, but evidence for the same is limited in the Indian context. Aim: To find the prevalence of musculoskeletal pain among school-going children and its relationship with backpack weight. Design: Cross-sectional study. Method: This study was carried out among school-going children from grade 6 to 10 with age of 10 to 16 years from an urban and rural location. Schools were selected randomly from all enlisted schools in the district of Khurdha, Odisha state of India. A structured questionnaire was administered to assess symptoms of musculoskeletal pain. Anthropometric measurements along with backpack weight were taken. Statistical Analysis: Chi-square test was performed for categorical variables and Student's t-test for continuous variables. Multivariate regression analysis was performed to identify factors with maximum effect on musculoskeletal pain. Results: The prevalence of musculoskeletal pain was 18.8% in the preceding year. Backpacks weights were higher among children of urban schools as compared with rural areas. Children from urban schools were more likely to have pain than those from rural schools (OR 1.88, 95% CI 1.41-2.49). Those children with a backpack weight more than 10% of body weight had almost twice the risk of musculoskeletal pain compared to backpack weight less than 10% (OR 1.91, 95% CI 1.4-2.6) in univariate analysis where as no significant association was found on multivariate analysis. Conclusion: The prevalence of musculoskeletal pain was high in school-going children. In children, carrying higher backpack weight, and a higher percentage of the backpack to bodyweight had a significant association with musculoskeletal pain. Gender, height, body mass index, and backpack weight to body weight > 10% had no association with musculoskeletal pain.