Diagnosis and Management of Global Development Delay: Consensus Guidelines of Growth, Development and Behavioral Pediatrics Chapter, Neurology Chapter and Neurodevelopment Pediatrics Chapter of the Indian Academy of Pediatrics.

JUSTIFICATION: Global developmental delay (GDD) is a relatively common neurodevelopmental disorder; however, paucity of published literature and absence of uniform guidelines increases the complexity of clinical management of this condition. Hence, there is a need of practical guidelines for the pediatrician on the diagnosis and management of GDD, summarizing the available evidence, and filling in the gaps in existing knowledge and practices. PROCESS: Seven subcommittees of subject experts comprising of writing and expert group from among members of Indian Academy of Pediatrics (IAP) and its chapters of Neurology, Neurodevelopment Pediatrics and Growth Development and Behavioral Pediatrics were constituted, who reviewed literature, developed key questions and prepared the first draft on guidelines after multiple rounds of discussion. The guidelines were then discussed by the whole group in an online meeting. The points of contention were discussed and a general consensus was arrived at, after which final guidelines were drafted by the writing group and approved by all contributors. The guidelines were then approved by the Executive Board of IAP. Guidelines: GDD is defined as significant delay (at least 2 standard deviations below the mean with standardized developmental tests) in at least two developmental domains in children under 5 years of age; however, children whose delay can be explained primarily by motor issues or severe uncorrected visual/hearing impairment are excluded. Severity of GDD can be classified as mild, moderate, severe and profound on adaptive functioning. For all children, in addition to routine surveillance, developmental screening using standardized tools should be done at 9-12 months,18-24 months, and at school entry; whereas, for high risk infants, it should be done 6-monthly till 24 months and yearly till 5 years of age; in addition to once at school entry. All children, especially those diagnosed with GDD, should be screened for ASD at 18-24 months, and if screen negative, again at 3 years of age. It is recommended that investigations should always follow a careful history and examination to plan targeted testing and, vision and hearing screening should be done in all cases prior to standardized tests of development. Neuro-imaging, preferably magnetic resonance imaging of the brain, should be obtained when specific clinical indicators are present. Biochemical and metabolic investigations should be targeted towards identifying treatable conditions and genetic tests are recommended in presence of clinical suspicion of a genetic syndrome and/or in the absence of a clear etiology. Multidisciplinary intervention should be initiated soon after the delay is recognized even before a formal diagnosis is made, and early intervention for high risk infants should start in the nursery with developmentally supportive care. Detailed structured counselling of family regarding the diagnosis, etiology, comorbidities, investigations, management, prognosis and follow-up is recommended. Regular targeted follow-up should be done, preferably in consultation with a team of experts led by a developmental pediatrician/ pediatric neurologist.

Efficacy of Preprocedural Boric Acid Mouthrinse in Reducing Viable Bacteria in Dental Aerosols Produced during Ultrasonic Scaling.

INTRODUCTION: Aerosols and droplets contaminated with bacteria and blood are produced during ultrasonic scaling. Measures to control aerosol contamination in dental clinics are recommended by the Centers for Disease Control and Prevention. This study aimed to evaluate the efficacy of preprocedural boric acid (BA) mouthrinse in reducing bacterial contamination in dental aerosols generated during ultrasonic scaling. MATERIALS AND METHODS: This was a randomised clinical trial in 90 systemically healthy subjects (25-55 yrs) diagnosed with chronic periodontitis who were allocated into three groups of 30 subjects each to receive, Group A - 0.12% chlorhexidine (CHX), Group B - 0.75% BA and Group C-water, as a preprocedural rinse for 1 min. The aerosol generated while performing ultrasonic scaling for 30 min was collected at three locations on blood agar plates. Incubation of the blood agar plates at 37°C for next 48 h for aerobic culture was performed and subsequently colony-forming units (CFUs) were counted. RESULTS: CFUs in Group A were significantly reduced compared with Group B (P < 0.001). When we compare CFUs in all the three groups, CFUs in Groups A and B were statistically significantly reduced compared with Group C (P < 0.001). Furthermore, it was also observed that the assistant's chest area had lowest CFUs whereas patient's chest area had highest. CONCLUSION: This study recommends routine use of preprocedural mouthrinse as a measure to reduce bacterial aerosols generated during ultrasonic scaling and that 0.12% CHX gluconate is more effective than 0.75% BA mouthwash in reducing CFUs count.

Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India.

BACKGROUND: Neurodevelopmental disorders (NDDs) compromise the development and attainment of full social and economic potential at individual, family, community, and country levels. Paucity of data on NDDs slows down policy and programmatic action in most developing countries despite perceived high burden. METHODS AND FINDINGS: We assessed 3,964 children (with almost equal number of boys and girls distributed in 2-<6 and 6-9 year age categories) identified from five geographically diverse populations in India using cluster sampling technique (probability proportionate to population size). These were from the North-Central, i.e., Palwal (N = 998; all rural, 16.4% non-Hindu, 25.3% from scheduled caste/tribe [SC-ST] [these are considered underserved communities who are eligible for affirmative action]); North, i.e., Kangra (N = 997; 91.6% rural, 3.7% non-Hindu, 25.3% SC-ST); East, i.e., Dhenkanal (N = 981; 89.8% rural, 1.2% non-Hindu, 38.0% SC-ST); South, i.e., Hyderabad (N = 495; all urban, 25.7% non-Hindu, 27.3% SC-ST) and West, i.e., North Goa (N = 493; 68.0% rural, 11.4% non-Hindu, 18.5% SC-ST). All children were assessed for vision impairment (VI), epilepsy (Epi), neuromotor impairments including cerebral palsy (NMI-CP), hearing impairment (HI), speech and language disorders, autism spectrum disorders (ASDs), and intellectual disability (ID). Furthermore, 6-9-year-old children were also assessed for attention deficit hyperactivity disorder (ADHD) and learning disorders (LDs). We standardized sample characteristics as per Census of India 2011 to arrive at district level and all-sites-pooled estimates. Site-specific prevalence of any of seven NDDs in 2-<6 year olds ranged from 2.9% (95% CI 1.6-5.5) to 18.7% (95% CI 14.7-23.6), and for any of nine NDDs in the 6-9-year-old children, from 6.5% (95% CI 4.6-9.1) to 18.5% (95% CI 15.3-22.3). Two or more NDDs were present in 0.4% (95% CI 0.1-1.7) to 4.3% (95% CI 2.2-8.2) in the younger age category and 0.7% (95% CI 0.2-2.0) to 5.3% (95% CI 3.3-8.2) in the older age category. All-site-pooled estimates for NDDs were 9.2% (95% CI 7.5-11.2) and 13.6% (95% CI 11.3-16.2) in children of 2-<6 and 6-9 year age categories, respectively, without significant difference according to gender, rural/urban residence, or religion; almost one-fifth of these children had more than one NDD. The pooled estimates for prevalence increased by up to three percentage points when these were adjusted for national rates of stunting or low birth weight (LBW). HI, ID, speech and language disorders, Epi, and LDs were the common NDDs across sites. Upon risk modelling, noninstitutional delivery, history of perinatal asphyxia, neonatal illness, postnatal neurological/brain infections, stunting, LBW/prematurity, and older age category (6-9 year) were significantly associated with NDDs. The study sample was underrepresentative of stunting and LBW and had a 15.6% refusal. These factors could be contributing to underestimation of the true NDD burden in our population. CONCLUSIONS: The study identifies NDDs in children aged 2-9 years as a significant public health burden for India. HI was higher than and ASD prevalence comparable to the published global literature. Most risk factors of NDDs were modifiable and amenable to public health interventions.

A Cross-Sectional Pharmacoepidemiological Study of the Utilization Pattern of Pre-Anesthetic Medications in Major Surgical Procedures in a Tertiary Care Hospital.

OBJECTIVE: A study of the utilization pattern of pre-anesthetic medications in major surgical procedures. MATERIAL AND METHODS: A cross-sectional, pharmacoepidemiological study was conducted among patients undergoing surgical procedures in routine or emergency conditions under general anesthesia. The utilization of pre-anesthetic medicines in all patients was reported. RESULTS: A total of 110 patients (mean age - 42.36 years; 57.27% males) were enrolled. The major (>10%) indications for surgery were carcinoma/tumor - 25 (22.73%), perforation peritonitis - 20 (18.18%), and intestinal obstruction - 11 (10%). All patients received ranitidine plus metoclopramide. Injections of ondansetron, midazolam, pentazocin, anticholinergic agents, and fentanyl were used in 103 (93.64%), 103 (93.64%), 92 (83.64%), 84 (76.36%), and 23 (20.91%) patients, respectively. The dosage of ondansetron was 4 mg in 95 patients (86.36%), while 89.09% patients received 1 mg of midazolam. In 86 patients (78.18%), pentazocine was used in a 15 mg dose. Among the anticholinergic agents, glycopyrrolate was used in 76 patients (69.09%). Glycopyrrolate was used in a 0.2 mg dose in 74 patients (97.37%). The major indications for the use of fentanyl were carcinoma - 8 (34.8%), perforation peritonitis - 4 (17.4%), and surgery for intestinal obstruction - 3 (13%). CONCLUSION: The administration of ondansetron, midazolam, and pentazocin is very common (>80% patients) as pre-anesthetic medication. Glycopyrrolate was the preferred anticholinergic agent. In cancer patients, the use of fentanyl is common.

Evaluation of dietary supplementation of omega-3 polyunsaturated fatty acids as an adjunct to scaling and root planing on salivary interleukin-1ß levels in patients with chronic periodontitis: A clinico-immunological study.

CONTEXT: Host modulation with omega-3 polyunsaturated fatty acids (ω-3 PUFAs) has anti-inflammatory and pro-resolution actions through replacing and inhibiting metabolism of arachidonic acid (AA). AIM: This study was aimed at evaluating clinical parameters and salivary levels of interleukin-1 beta (IL-1ß) after scaling and root planing (SRP) in chronic periodontitis patients, with and without dietary supplementation of ω-3 PUFAs. SETTINGS AND DESIGN: Forty otherwise healthy participants with severe chronic periodontitis were included. Full-mouth periodontal examination and scaling and root planing were done for test and control group (20 participants each). MATERIALS AND METHODS: The control group received SRP alone while test group received daily dose of 700 mg ω-3 PUFA capsules for 3 months. All clinical parameters were checked at baseline, 1 month, and 3 months' duration, whereas levels of IL-1ß were checked in saliva at baseline and 3 months after therapy. STATISTICAL ANALYSIS USED: T-test and repeated measure analysis of variance were used with Statistical Package for the Social Science Windows software. RESULTS: Improvements in all clinical outcomes were similar in both groups over 3 months. Improvements in clinical parameters were not statistically significant on intergroup comparison, except for improvement in Bleeding Index and reduction in levels of IL-1ß, which were statistically significant in test group as compared to control group (P < 0.05). CONCLUSION: Even though adjunct therapy with ω-3 PUFAs can modulate cytokine levels and show proresolution properties, its importance on clinical outcomes may be controversial. Thus, this may be used as an adjunctive management of chronic periodontitis.

The atmospheric electrical index for ENSO modoki: Is ENSO modoki one of the factors responsible for the warming trend slowdown?

Like the southern oscillation index (SOI) based on the pressure difference between Tahiti (17.5°S, 150°W) and Darwin (12.5°S, 130°E), we propose the new atmospheric electrical index (AEI) taking the difference in the model calculated atmospheric electrical columnar resistance (Rc) which involves planetary boundary layer height (PBLH) and aerosol concentration derived from the satellite measurements. This is the first non-oceanic index capable of differentiating between the conventional and modoki La Niña and El Niño both and may be useful in the future air-sea coupling studies and as a complementary to the oceanic indices. As the PBLH variation over Darwin is within 10% of its long term mean, a strong rise in the Rc over Darwin during the modoki period supports modoki's connection with aerosol loading. Our correlation results show that the intensity of El Niño (La Niña) event is almost independent (not independent) of its duration and the possibility of ENSO modoki being one of the factors responsible for the warming trend slowdown (WTS).

Evaluation of terrestrial plants extracts for uranium sorption and characterization of potent phytoconstituents.

Sorption capacity of four plants (Funaria hygrometrica, Musa acuminata, Brassica juncea and Helianthus annuus) extracts/fractions for uranium, a radionuclide was investigated by EDXRF and tracer studies. The maximum sorption capacity, i.e., 100% (complete sorption) was observed in case of Musa acuminata extract and fractions. Carbohydrate, proteins, phenolics and flavonoids contents in the active fraction (having maximum sorption capacity) were also determined. Further purification of the most active fraction provided three pure molecules, mannitol, sorbitol and oxo-linked potassium oxalate. The characterization of isolated molecules was achieved by using FTIR, NMR, GC-MS, MS-MS, and by single crystal-XRD analysis. Of three molecules, oxo-linked potassium oxalate was observed to have 100% sorption activity. Possible binding mechanism of active molecule with the uranyl cation has been purposed.

Use of Infant Feeding Tube for Staged Flexor Tendon Reconstruction.

A two-stage flexor tendon reconstruction using a silicone rod in the first stage and a free tendon graft through the pseudo sheath formed around the silicone in the second stage was described by Hunter and Salisbury for a neglected and failed flexor tendon reconstruction. We are describing a technique where we have used an infant feeding tube as a substitute for silicone rods, which substantially reduces the cost of procedure but delivers the same results.

Attention deficit hyperactivity disorder.

Attention Deficit Hyperactivity Disorder (ADHD) is a common behavioral disorder in children. It is characterized by motor hyperactivity, impulsivity and inattention inappropriate for the age. Approximately 5-10 % of school age children are diagnosed to have ADHD. The affected children show significant impairment in social behavior and academic performance. The DSM-5 criteria are useful in diagnosing three subtypes of ADHD based on presence of symptoms described in 3 domains viz ., inattention, hyperactivity and impulsivity. Co-morbidities like specific learning disability, anxiety disorder, oppositional defiant disorder are commonly associated with ADHD.Education of parents and teachers, behavioral therapy and medication are main components of management. Methylphenidate and Atomoxetine are effective in controlling symptoms of ADHD in most children. Research studies estimated that 30-60 % of children continue to show symptoms of ADHD in adulthood. The general practitioner can play an important role in early diagnosis, appropriate assessment and guiding parents for management of children with ADHD.

Necrotizing soft-tissue infection: laboratory risk indicator for necrotizing soft tissue infections score.

Necrotizing soft tissue infections (NSTI) can be rapidly progressive and polymicrobial in etiology. Establishing the element of necrotizing infection poses a clinical challenge. A 64-year-old diabetic patient presented to our hospital with a gangrenous patch on anterior abdominal wall, which progressed to an extensive necrotizing lesion within 1 week. Successive laboratory risk indicator for necrotizing softtissue infections (LRINEC) scores confirmed the necrotizing element. Cultures yielded Enterococci, Acinetobacter species and Apophysomyces elegans and the latter being considered as an emerging agent of Zygomycosis in immunocompromised hosts. Patient was managed with antibiotics, antifungal treatment and surgical debridement despite which he succumbed to the infection. NSTI's require an early and aggressive management and LRINEC score can be applied to establish the element of necrotizing pathology. Isolation of multiple organisms becomes confusing to establish the etiological role. Apophysomyces elegans, which was isolated in our patient is being increasingly reported in cases of necrotizing infections and may be responsible for high morbidity and mortality. This scoring has been proposed as an adjunct tool to Microbiological diagnosis when NSTI's need to be diagnosed early and managed promptly to decrease mortality and morbidity, which however may not come in handy in an immunocompromised host with polymicrobial aggressive infection.

Paediatric oropharyngeal and cutaneous candidiasis with special reference to Candida dubliniensis.

Mucocutaneous and cutaneous candidiasis, though common in children, is often under-reported. The prevalence of Candida dubliniensis in causing these infections in this age group is also largely unknown. A prospective epidemiological cross-sectional study for candidiasis was performed in paediatric patients clinically suspected of candidiasis with oropharyngeal lesions (75 patients), cutaneous lesions (18 patients) and lesions at both sites (2 patients). Candida species were identified by conventional tests. For C. dubliniensis, chlamydospore production, growth on tobacco agar and growth at 45 °C were performed. Nine isolates were confirmed at a reference centre. The rates of candidiasis were 77.3 % (58 out of 75 patients clinically suspected of candidiasis) and 83.3 % (15/18) in oropharyngeal and cutaneous lesions respectively, and 1 of the 2 children with lesions at both sites was diagnosed as having chronic mucocutaneous candidiasis due to C. dubliniensis. The commonest species isolated was Candida albicans, in 41 (70.7 %) patients with oropharyngeal candidiasis and 11 (73.3 %) with cutaneous lesions; C. dubliniensis was isolated from 11 and 3 children respectively. In the paediatric population, C. albicans predominates in mucocutaneous and cutaneous candidiasis, with C. dubliniensis also contributing substantially.

Posterior scrotal artery flap to cover a groin defect: a new technique.

Commonly, a groin defect is reconstructed with flaps from ipsilateral thigh or lower abdomen. Here we present a case report of use of a pedicled flap from the posterior scrotum based on posterior scrotal artery to cover a groin defect exposing femoral vessels. Posterior scrotal artery, to best of our knowledge, has not been described in the literature to cover a groin defect.

Managing specific learning disability in schools in India.

Specific learning disability (dyslexia, dysgraphia, and dyscalculia) afflicts 5-15% of school-going children. Over the last decade; awareness about this invisible handicap has grown in India. However, much needs to be done to ensure that each afflicted child gets an opportunity to achieve his or her full academic potential in regular mainstream schools. In order to achieve this ideal scenario, all regular classroom teachers should be sensitized to suspect, and trained to screen for this disability when the child is in primary school. School managements should become proactive to set up resource rooms and employ special educators to ensure that these children receive regular and affordable remedial education; and be diligent in ensuring that these children get the mandatory provisions both during school and board examinations. Once specific learning disability is recognized as a disability by the Government of India, these children with the backing of the Right to Education Act, would be able to benefit significantly.

Squamous cell carcinoma of the penis and scrotum in a patient with chronic scrotal and penile lymphedema.

Squamous cell carcinoma arising from tissue affected by chronic lymphedema is rare, though it is recognized that a variety of malignant tumors can arise in chronic congenital or acquired lymphedema. We describe, a case of scrotal and penile squamous cell carcinoma arising in a patient with a history of chronic scrotal and penile lymphedema of filarial origin. We here discuss the management and possible etiology of this unusual case.

Multicenter, hospital-based surveillance of rotavirus disease and strains among indian children aged <5 years.

BACKGROUND: Current, nationally representative data on rotavirus disease burden and rotavirus strains in India are needed to understand the potential health benefits of rotavirus vaccination. METHODS: The Indian Rotavirus Strain Surveillance Network was established with 4 laboratories and 10 hospitals in 7 different regions of India. At each hospital, children aged <5 years who presented with acute gastroenteritis and required hospitalization with rehydration for at least 6 h were enrolled. A fecal specimen was obtained and was tested for rotavirus with use of a commercial enzyme immunoassay, and strains were characterized using reverse-transcription polymerase chain reaction. RESULTS: From December 2005 through November 2007, rotavirus was found in approximately 39% of 4243 enrolled patients. Rotavirus was markedly seasonal in northern temperate locations but was less seasonal in southern locations with a tropical climate. Rotavirus detection rates were greatest among children aged 6-23 months, and 13.3% of rotavirus infections involved children aged <6 months. The most common types of strains were G2P[4] (25.7% of strains), G1P[8] (22.1%), and G9P[8] (8.5%); G12 strains were seen in combination with types P[4], P[6], and P[8] and together comprised 6.5% of strains. CONCLUSIONS: These data highlight the need for development and implementation of effective prophylactic measures, such as vaccines, to prevent the large burden of rotavirus disease among Indian children.

Recollections of learning-disabled adolescents of their schooling experiences: a qualitative study.

BACKGROUND: Little is known about the actual impact of the schooling experience on adolescents with specific learning disability (SpLD). AIMS: To analyze the recollections of adolescents with SpLD who were undergoing education in regular mainstream schools. SETTINGS AND DESIGN: Prospective interview-based study conducted in our clinic. MATERIALS AND METHODS: Adolescents' responses to a semi-structured interview were audio-taped, transcribed verbatim and interpreted by content analysis. The number of participants was determined by 'saturation sampling,' resulting in a total of 30 adolescents. RESULTS: Twelve (40%) adolescents had 'overall' neutral recollections, 9 (30%) had 'overall' positive recollections and 9 (30%) had 'overall' negative recollections about having SpLD during their schooling. Fourteen (46.7%) adolescents stated 'getting provisions' as good features, whereas 7 (23.3%) stated 'feeling different from classmates' and 6 (20%) stated 'being teased by classmates about their disability' as bad features of having SpLD. Nineteen (63.3%) adolescents remembered classroom teachers being supportive, while 7 (23.3%) remembered being insulted by them. Of the 21 adolescents who had undergone remedial education, only 10 (47.6%) acknowledged that it had benefited them. Twenty-one (70%) adolescents stated that availing provisions helped in getting better marks in examinations. Ten (33.3%) adolescents had negative recollections about their parents' behavior in relation to their disability. Twenty (66.7%) adolescents wanted changes in their school to help students with SpLD. CONCLUSION: Improving the knowledge of classroom teachers, classmates and family members about SpLD and about the rationale of provisions will help reduce the unpleasant experiences students with SpLD undergo during their schooling years.

Bone metabolism alteration on antiepileptic drug therapy.

OBJECTIVE: To investigate whether serum total alkaline phosphatase (ALP), bone-specific ALP (bone ALP), calcium, phosphorus, 25-hydroxyvitamin D (25-OHvit D) concentrations are altered early in the course of treatment with carbamazepine or valproic acid monotherapy in ambulatory children with adequate sun exposure; and to determine the effectiveness of simultaneous supplementation with calcium and 25-OHvit D at recommended dietary allowance doses on these biochemical parameters. METHODS: For each drug, children were divided into two groups (Group A: without supplementation; and Group B: with supplementation) and serum biochemical parameters estimated at 0, 30, 60, and 90 days of starting treatment. STATISTICAL ANALYSIS: Serial changes in serum biochemical parameters (mean +/- SD) were compared within each of the four groups using student's paired t test. Also for each drug, serum biochemical parameters were compared between Groups A and B at 0, 30, 60, and 90 days of starting treatment using student's unpaired t test. RESULTS: For both drugs, in Group A, serum total ALP levels were significantly increased above the normal range (P<0.0001) by 90 days of starting treatment; however, serum bone ALP level was significantly increased (P=0.002) only in children on valproic acid. For both drugs when serum biochemical parameters were compared between Groups A and B, supplementation resulted in a significant decrease in serum total ALP (P<0.0001) and bone ALP levels (P<0.001), and a significant increase in serum calcium (P<0.0001) and 25-OHvit D levels (P<0.0001) by 90 days of starting treatment. CONCLUSION: Serum biochemical changes which indicate predisposition to development of rickets or osteomalacia appear within 90 days of starting carbamazepine or valproic acid monotherapy. However simultaneous supplementation with oral calcium and 25-OHvit D is effective in preventing the development of these adverse biochemical changes.

Health-related quality of life of children with newly diagnosed specific learning disability.

The objective of this study was to measure health-related quality of life (HRQL) of children with newly diagnosed specific learning disability (SpLD) using the Child Health Questionnaire-Parent Form 50. We detected clinically significant deficits (effect size > or = -0.5) in 9 out of 12 domains: limitations in family activities, emotional impact on parents, social limitations as a result of emotional-behavioral problems, time impact on parents, general behavior, physical functioning, social limitations as a result of physical health, general health perceptions and mental health; and in both summary scores (psychosocial > physical). Multivariate analysis revealed having > or = 1 non-academic problem(s) (p < 0.0001), attention-deficit hyperactivity disorder (p = 0.005) or first-born status (p = 0.009) predicted a poor psychosocial summary score; and having > or =1 non-academic problem(s) (p = 0.006) or first-born status (p = 0.035) predicted a poor physical summary score. HRQL is significantly compromised in children having newly diagnosed SpLD.