Complementary feeding at 4 versus 6 months of age for preterm infants born at less than 34 weeks of gestation: a randomised, open-label, multicentre trial.

BACKGROUND: Evidence on the optimal time to initiation of complementary feeding in preterm infants is scarce. We examined the effect of initiation of complementary feeding at 4 months versus 6 months of corrected age on weight for age at 12 months corrected age in preterm infants less than 34 weeks of gestation. METHODS: In this open-label, randomised trial, we enrolled infants born at less than 34 weeks of gestation with no major malformation from three public health facilities in India. Eligible infants were tracked from birth and randomly assigned (1:1) at 4 months corrected age to receive complementary feeding at 4 months corrected age (4 month group), or continuation of milk feeding and initiation of complementary feeding at 6 months corrected age (6 month group), using computer generated randomisation schedule of variable block size, stratified by gestation (30 weeks or less, and 31-33 weeks). Iron supplementation was provided as standard. Participants and the implementation team could not be masked to group assignment, but outcome assessors were masked. Primary outcome was weight for age Z-score at 12 months corrected age (WAZ12) based on WHO Multicentre Growth Reference Study growth standards. Analyses were by intention to treat. The trial is registered with Clinical Trials Registry of India, number CTRI/2012/11/003149. FINDINGS: Between March 20, 2013, and April 24, 2015, 403 infants were randomly assigned: 206 to receive complementary feeding from 4 months and 197 to receive complementary feeding from 6 months. 22 infants in the 4 month group (four deaths, two withdrawals, 16 lost to follow-up) and eight infants in the 6 month group (two deaths, six lost to follow-up) were excluded from analysis of primary outcome. There was no difference in WAZ12 between two groups: -1·6 (SD 1·2) in the 4 month group versus -1·6 (SD 1·3) in the 6 month group (mean difference 0·005, 95% CI -0·24 to 0·25; p=0·965). There were more hospital admissions in the 4 month group compared with the 6 month group: 2·5 episodes per 100 infant-months in the 4 month group versus 1·4 episodes per 100 infant-months in the 6 month group (incidence rate ratio 1·8, 95% CI 1·0-3·1, p=0·03). 34 (18%) of 188 infants in the 4 month group required hospital admission, compared with 18 (9%) of 192 infants in the 6 month group. INTERPRETATION: Although there was no evidence of effect for the primary endpoint of WAZ12, the higher rate of hospital admission in the 4 month group suggests a recommendation to initiate complementary feeding at 6 months over 4 months of corrected age in infants less than 34 weeks of gestation. FUNDING: Indian Council of Medical Research supported the study until Nov 14, 2015. Subsequently, Shuchita Gupta's salary was supported for 2 months by an institute fellowship from All India Institute Of Medical Sciences, and a grant by Wellcome Trust thereafter.

Mortality in newborns referred to tertiary hospital: An introspection.

BACKGROUND: India is one of the largest contributors in the pool of neonatal death in the world. However, there are inadequate data on newborns referred to tertiary care centers. The present study aimed to find out predictors of mortality among newborns delivered elsewhere and admitted in a tertiary hospital in New Delhi between February and September 2014. MATERIALS AND METHODS: Hospital data for were retrieved and analyzed for determining predictors for mortality of the newborns. Time of admission, referral and presenting clinical features were considered. RESULTS: Out of 1496 newborns included in the study, there were 300 deaths. About 43% deaths took place in first 24 hours of life. Asphyxia and low birth weight were the main causes of death in early neonatal period, whereas sepsis had maximum contribution in deaths during late neonatal period. Severe hypothermia, severe respiratory distress, admission within first 24 hours of life, absence of health personnel during transport and referral from any hospital had significant correlation with mortality. CONCLUSIONS: There is need for ensure thermoregulation, respiratory sufficiency and presence of health personnel during transport.

Atypical presentation of posterior reversible encephalopathy: in a child with bilateral grade IV vesicoureteric reflux.

Posterior reversible encephalopathy, better known as potential reversible encephalopathy syndrome (PRES), is a clinicoradiological entity mostly described in adult populations manifesting predominantly as bilateral symmetrical diffuse white matter vasogenic oedema in parieto-occipital regions. Rarely it may also present as patchy reversible areas of involvement in the basal ganglia, brainstem and deep white matter. It is reported scarcely in childhood populations. Frequent association with acute hypertension (67-80%) is reported in many studies. Involvement of the brainstem and cervical cord (apart from the typical parieto-occipital lesions) is an extremely rare imaging manifestation of PRES and its recognition is important to avoid misdiagnosis as myelitis or acute disseminated encephalomyelitis by proper clinical correlation. We hereby report a case of PRES in a 7-year-old child showing an uncommon pattern on imaging study involving the brain as well as the brainstem and cervical spinal cord.

Giant cerebral cysticercosis in an infant confused with a thalamic glioma.

Neurocysticercosis is a common parasitic infection of the central nervous system. Intraparenchymal giant cysticercosis has been described in literature, but this is a rare report of a thalamic giant cysticercosis in a young child where the diagnosis could be made on follow-up. A 1½-year-old male child presented with seizures, hemiparesis, and features of raised intracranial pressure. Initial neuroimaging findings of thalamic swelling with minimal edema and contrast enhancement with choline peak on magnetic resonance spectroscopy were attributed to thalamic glioma. Subsequent imaging revealed a ring enhancing lesion with an eccentric nodule suggestive of neurocysticercosis. It later resolved with residual gliosis. The presence of a pathognomic scolex and the resolution of size and symptoms without definitive treatment helped in making the diagnosis. This report reinforces the importance of considering cysticercosis in diagnosis of acute presentations of large cerebral masses in infants, particularly in prevalent regions, and emphasizes the follow-up of these patients.

The unusual presentation of a usual organism - the changing spectrum of the clinical manifestations of Plasmodium vivax malaria in children: a retrospective study.

BACKGROUND: Malaria is a major public health problem in the south-east Asian region. Among all countries in the SE Asian region the highest number of cases and deaths are reported from India. Children below 14 years of age contribute to approximately 42% of all the deaths. A majority of the deaths are attributed to severe malaria which is caused by Plasmodium falciparum. It is considered that causes a benign causing febrile illness without significant complications. However, in recent years, the spectrum of is shifting from being the cause of benign fever, to more severe complications. There have been case reports of complications like thrombocytopaenia, cerebral malaria, a disseminated intravascular coagulation, the acute respiratory distress syndrome, hepatic dysfunction and renal involvement. Most of the case reports are from the adult population, with an occasional occurrence of paediatric cases. OBJECTIVE: To highlight the increasing number of severe manifestations in P.vivax malaria in the children who were admitted in the malaria transmission season of 2011, at a tertiary care hospital. DESIGN: A descriptive, cross-sectional study. STUDY SUBJECTS: Children with an acute febrile illness of a duration of < 7 days, which was confirmed as Plasmodium vivax positive malaria by testing the peripheral smears and/or by Rapid Diagnostic Testing, who were admitted in the paediatric ward of a tertiary care hospital in New Delhi (India), during May 2011 to October 2011, Case records of context cases were analysed retrospectively. STATISTICS: The data was summarised by calculating the rates, ratios, proportions, means, standard deviations and the 95% confidence intervals. The Chi square test was applied to assess the significant difference between two qualitative variables. RESULTS: Among the case records of 54 patients, 40.7% were below 5 years. 61% were males and 38.9% were females. Besides hepatomegaly and splenomegaly which were the most common symptoms, which were seen in 81.5% and 72.2% children respectively, the various unusual manifestations seen were severe thrombocytopaenia (37%), jaundice with deranged LFT values (25.9%), abnormal bleeding (18.5%), impaired consciousness with a GCS of < 9 (18.5%), severe anaemia (14.8%), hypotension (11.1%), repeated convulsions (7.6%), pulmonary oedema/ARDS (5.6%) and ascites (5.6%). One case each showed haemoglobinuria, and pleural effusion. CONCLUSION: Plasmodium vivax is emerging as a cause of severe malaria. There is a further need to study the pathophysiology, virulence factors and the molecular mechanisms which are involved in malaria.

Platelet functions and coagulation changes in Indian children with nephrotic syndrome.

INTRODUCTION: Only little is known on the effect of the platelet function in the paediatric nephrotic syndrome. The earlier studies which had been done on hypercoagulability have mainly featured the secondary forms of the nephrotic syndrome and the data on the minimal change type of disease is limited. We therefore, made an effort to study the platelet functions and the coagulation profile in children with the nephrotic syndrome,to find the relationship between the steroid response and the coagulation profile, and to look for the correlation between thromboembolism and the hypercoagulable states. METHODOLOGY: Twenty nine children with the steroid responsive nephrotic syndromewere studied to see the platelet aggregation and the coagulation parameters and their response to the steroid therapy. Doppler studies were done for the renal vein and the inferior vena cava (IVC) thrombus. RESULTS: It was seen that an increased aggregability of the platelets occurred with Adenosine diphosphate (ADP) and collagen (out of the four agonists, ADP, Collagen, Ristocetin and Arachidonic acid) which were used as agonists for the assay. We also observed that the Partial thromboplastin time (PTT) had become prolonged and a significant decline in the high values of the procoagulant proteins (Protein C and Protein S) was seen after the steroid therapy and when the children went into remission. These findings were suggestive of a reversibility of the changes in the steroid responsive nephrotic syndrome with the steroid therapy. One child was found to have thrombosis of the inferior vena cava (IVC) on Doppler studies, which resolved with treatment subsequently. CONCLUSIONS: An increased platelet aggregability contributes to the hypercoagulable states, that may increase the incidence of thrombosis in such patients. Although the incidence of such complications is very low, in a given child with the hypercoagulable states, Doppler may be used to look for any evidence of a latent thrombus and, an early intervention could be instituted. A change in the coagulation parameters points to the reversibility of the changes which are produced in a diseased state.

Stress induced hyperglycemia in a term baby mimicking diabetic ketoacidosis with stroke.

Stress/sepsis induced transient hyperglycemia in the newborn may present with extremely high blood sugar values and may mimic neonatal diabetes mellitus. We present a case of neonatal septicemia with stress induced hyperglycemia mimicking neonatal diabetes mellitus. Extremely high blood sugar values upto 1529 mg/dl with metabolic acidosis were noted in a term good weight baby causing a diagnostic dilemma. It can be seen even in term babies, contrary to the belief that it occurs in preterm and small for gestation babies. Considering the prognostic implications it may cause it is important that hyperglycemia is promptly treated by insulin infusion.