Etiology of Hemoptysis in Children and Adolescents - Multicentric Retrospective Data (2012-2021) From Chennai.

OBJECTIVE: To analyze the etiology of hemoptysis in children and to correlate the severity of bleed with the etiology. METHODS: This retrospective multicentre study reviewed data from inpatient units of four tertiary care public and private sector pediatric hospitals in Tamil Nadu. Methods: Inpatient case records of children (aged 2 month-15 years) treated for hemoptysis at the four institutions between April, 2012 and March, 2021 were identified, after ethical clearance from respective institutions. Data of children with underlying known bleeding disorders like hemophilia or platelet abnormality were excluded from the study. Hemoptysis was categorized as mild, moderate and severe. RESULTS: Of the 73 children who had presented with hemoptysis during the study period, 60 (82.2%) children had mild, 9 (12.3%) had moderate and rest had severe hemoptysis. Idiopathic pulmonary hemorrhage was the most common cause of hemoptysis. The common causes of mild hemoptysis in children were idiopathic pulmonary hemorrhage (n=15, 25%), pulmonary tuberculosis (n=12, 20%) and pneumonia (n=8, 13.3%). Congenital airway anomalies and vascular anomalies were more likely to present with moderate to severe bleed. CONCLUSIONS: Etiology of hemoptysis is broad and categorizing them into mild, moderate and severe may give a clue about the possible etiology, there by restricting to the required investigations.

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.

Indications and outcome of flexible bronchoscopy in neonates.

OBJECTIVE: To analyse the indications, safety and outcome of flexible fiberoptic bronchoscopy (FOB) in neonates. METHODS: This descriptive study was conducted in Level III neonatal unit (ICH, Chennai) and included 84 neonates with various respiratory problems admitted over a 3 y period. RESULTS: The indications included stridor (18%), persistent radiological abnormalities (44%), unexplained wheeze/respiratory distress (21%) and others (17%). The mean age and weight were 25 d and 2.82 kg respectively. Bronchoscopy detected various anomalies like upper airway anomalies (10.7%), lower airway malacia (21%), synchronous airway malacias (19%) and miscellaneous anatomical abnormalities (18%). Bronchoalveolar lavage was done in 62% with microbiological yield in 54% cases.FOB helped in the revision of diagnosis in 57%. Resolution of atelectasis was observed in 13.5% cases. Except for transient hypoxemia in 2 neonates, no other complication was encountered. CONCLUSIONS: Flexible bronchoscopy is safe and useful both as diagnostic and therapeutic tool in neonates with respiratory problems.

Fiberoptic bronchoscopy in unresolved atelectasis in infants.

This retrospective analysis documents the usefulness of fiberoptic bronchoscopy in finding the etiology of 56 cases of unresolved atelectasis in infancy, over a two year period (June 2005 to May 2007). Fiberoptic bronchoscopy identified the etiology leading to a revised diagnosis and change in management strategy in 38 (67.8%) cases, which included congenital airway anomalies (46.4%), inflammatory changes (10.7%), mucus plugs (28.5%), hypoplasia (4%), endobronchial granulation tissue (3.5%) and foreign body (3.5%). Fiberoptic bronchoscopy plays an important role in diagnostic work up of infants with unresolved atelectasis.

Mantoux and contact positivity in tuberculosis.

OBJECTIVE: To study the role of Mantoux and contact history in various forms of Childhood tuberculosis. METHODS: 605 children registered with TB clinic of Institute of Child Health and Hospital for Children, Chennai over a 5 year period from January 2000 to October 2005 with various forms of tuberculosis were recruited in the study. Clinical examination findings, basic investigations, chest skiagrams, computerized tomography (CT) wherever warranted, sputum or gastric aspirates for AFB smear, histopathology wherever possible were analyzed. RESULTS: The study showed that Mantoux positivity in various forms of tuberculosis studied is 34.7%. The positivity of Mantoux was highest in lymph node tuberculosis (53%) and the lowest with CNS tuberculosis (21.2%). Among the other forms, Mantoux positivity was 36.4% in TB abdomen, 44.4% in Skeletal TB, 30.3% in pulmonary tuberculosis. The contact positivity was 30.4% in the sample studied. CONCLUSION: The study also reflects that the extra pulmonary forms of tuberculosis seems to be more common in the pediatric population which constituted 79.8% of the cases included in the study.

Pediatric interstitial lung disease.

This study was done to ascertain the symptomatology, clinical features and investigations pertaining to interstitial lung diseases (ILD) in children. The medical records of 16 children admitted over a 4-year period from June 2000 to May 2004 with progressive cough, dyspnea, and chest X-ray/High Resolution Computerized Tomography (HRCT) abnormalities suggesting ILD were retrospectively evaluated. Clinical findings, investigations, chest skiagrams, HRCT, bronchoalveolar lavage (BAL) and lung biopsy reports were analyzed. An acute presentation of symptoms was seen in 4 cases (25%). Velcro crackles were the commonest clinical finding, present in 15 cases (93.8%). Serial X-rays revealed findings suggestive of ILD in 12 cases (75%) and HRCT was diagnostic in 13 cases (86.6%). Spirometry done in 5 cases showed a restrictive ventilatory defect, BAL analysis done in 8 cases demonstrated increased neutrophils and lung biopsy done in 5 cases was consistent with idiopathic pulmonary fibrosis. Mean survival duration of 2 years and 7 months after initial diagnosis was observed.

Effectiveness of ampicillin and combination of penicillin and chloramphenicol in the treatment of pneumonias: randomized controlled trial.

OBJECTIVE: To assess the effectiveness of ampicillin and a combination of benzyl penicillin and chloramphenicol in the treatment of pneumonias. DESIGN: Randomized controlled trial. SETTING: Tertiary care hospital. SUBJECTS: Patients 5 months to 4 years old with pneumonias of < 2 weeks duration. Exclusion criteria included acute bronchiolitis, allergy to penicillin, postmeasles pneumonia or prior administration of trial antibiotics in full dose for more than 2 days. INTERVENTION: Patients were randomized to receive either ampicillin (100 mg/kg/day) or combination of benzyl penicillin (100,000 units/kg/day) and chloramphenicol (100 mg/kg/day). The outcome measure was cure rate. RESULTS: There were 52 and 49 patients in the ampicillin and the combination groups, respectively. There was no significant difference in the baseline characteristics between groups except, nasal flare and cyanosis which were less in benzyl penicillin plus chloramphenicol group. There was also no difference either in the primary outcome, cure rate or secondary outcomes (days for cure, duration of tachypnea, fever and grunt) in the two. CONCLUSION: Considering the potential toxicity of chloramphenicol and the number of injections and doses to be given for the combination, ampicillin as a single drug could be preferred for the treatment of pneumonias, in this part of the country.

Missed opportunities for immunization in children under 2 years attending an urban teaching hospital.

A cross-sectional survey was done to assess the missed opportunity for immunization (MOI) in children under two years of age attending Medical Outpatient, Newborn Follow-up Service and Immunization Clinic of Institute of Child Health and to evaluate interventions. Baseline survey phase-I was done and two interventions: (i) education and awareness of immunization among health personnel; and (ii) attaching immunization slip to the outpatient form were done. After each intervention phase-II and phase-III surveys were carried out. The data from the different phases were analyzed for the effect of interventions. The total number of children surveyed were 634; 423 from Medical Outpatients, 108 from Newborn Follow-up Service and 103 from immunization Clinic. MOI was 35.5%, 23.1% and 9.7% in the above health facilities, respectively. After intervention I, the MOI was 24.5% and 12.2% in Medical Outpatient and Newborn Follow-up Service and none in Immunization Clinic. After intervention-II there was an improvement in immunization of 18.4%, 30.4% and 16.0% in the three health facilities mentioned above. MOI was avoided because the medical officers advised immunization in the above children. The difference in the MOI among Medical Outpatient and Immunization Clinic between baseline, phase-I and phase-II were significant (p < 0.001). It is concluded that MOI can be brought down by creating awareness periodically and that attaching an immunization schedule to the outpatient forms is an effective method of reducing MOI.

PIP: In November 1991, a baseline survey was conducted to examine missed opportunities for immunization (MOI) in 634 children aged under 2 years attending the outpatient clinic, newborn follow-up service, and the immunization clinic of the Institute of Child Health in Madras, India. The proportion of MOIs stood at 35.5% in the outpatient clinic, 23.1% in the newborn follow-up service, and 9.7% in the immunization clinic. Shortly after the baseline survey, clinicians received education and increased awareness of immunization. This intervention was evaluated in January 1992. The proportion of MOIs after the first intervention was 24.5% for the outpatient clinic, 12.2% for the newborn follow-up service, and 0 in the immunization clinic. In May 1992, clinicians were instructed to attach an immunization slip to the outpatient form. This intervention was evaluated in June 1992. After the second intervention, the proportion of MOIs was 18.4% in the outpatient clinic, 8% in the newborn follow-up service, and 0 in the immunization clinic. In the outpatient department, MOIs decreased significantly between the baseline and the two interventions (p = 0.003). They did not fall significantly between the two interventions, however. In the immunization clinic, the MOIs also declined significantly between the baseline and the two interventions (p = 0.001). Throughout the study period, the immunization clinic had a lower MOI rate than the outpatient clinic (p 0.001). These findings indicate that periodic sessions creating awareness about immunization (e.g., once every 2-3 months) for health personnel in hospitals and attaching immunization data details to the outpatient forms of the health facility effectively reduces MOIs.

Etiological agents of acute poliomyelitis in south India.

This study was done to identify the specific etiological agents that cause acute poliomyelitis (APM). All the children newly diagnosed clinically as APM at the Institute of Child Health, Madras, during the period May 1988 to May 1989 were recruited. Stool specimen collection, transportation and identification of viruses by culture were done by standard procedures. The total number of children recruited was 312. Specimens were contaminated/insufficient in 10. Analysis was done for 302 cases. Polio virus type II was identified in 25.5% children, type I in 18.5%, type III in 15.9%, multiple polioviruses in 6.3% and non-polio enteroviruses (NPEV) in 20.2% cases. No virus was identified in 13.6%. Among the APM cases clinically diagnosed, the proportion of NPEV has increased considerably from 5% in 1984 to 20.2% in 1988-89. The age distribution was not significantly different between polio viruses and NPEV. The distribution of polio viruses and NPEV did not differ significantly in relation to immunization status, source of water supply, method of excreta disposal and the clinical types. For surveillance and control/eradication program of poliomyelitis, laboratory confirmation is essential.

Evaluation of CSF variables as a diagnostic test for bacterial meningitis.

Specific aetiological diagnosis of bacterial meningitis (BM) in developing countries is often difficult. Frequently, differentiating BM from viral and TB meningitis is not easy. A study was carried out with the easily and quickly performed CSF morphological and biochemical changes as a diagnostic test against the gold standard of CSF culture and/or the latex agglutination test (LAT). Children between 2 months and 11 years of age, suspected to have acute meningitis, were prospectively recruited. CSF cell count and morphology, Gram stain, culture, and protein and sugar estimations were carried out as per standard procedures. The laboratory personnel were blind to the clinical details and the findings of each other. Diagnosis based on gold standard was possible in 55 out of 114 cases. With CSF polymorphs > 60 per cent and sugar < 50 per cent of blood level as constants, various levels of total cells and protein were considered for their diagnostic properties. The protein level was not useful. We found the best cut-off level of cell count for diagnosis of BM to be 300/mm3, based on the receiver operating characteristics curve, the point of maximum accuracy. These findings were validated by comparing the clinical features, CSF changes and outcome characteristics of non-confirmed cases with the above criteria with the confirmed cases; these were found to be the same except for age.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial meningitis: diagnosis by latex agglutination test and clinical features.

To know the usefulness of Latex Agglutination Test (LAT) for the diagnosis of bacterial meningitis (BM), it was performed in all the 114 consecutive samples of CSF with polymorphs from 114 prospectively recruited children aged 2 months to 11 years. Definite diagnosis of BM based on culture and/or LAT was evident in 55. Among the 46 LAT positive, culture was positive in 3 only. Major organisms identified by LAT were H. influenzae B (HiB) in 28 and S. pneumoniae (SP) in 15. Ninety per cent of HiB and 67% of SP bacterial meningitis were under one year of age. Fever > 7 days prior to admission was not uncommon (38%) and 26% had received prior antibiotics. Meningeal signs were present in 64%. CSF cells were < 500/mm3 in 24% and sugar was > 50% of blood level in 23%. There was no significant difference in the immediate outcome between HiB and SP meningitis. The case fatality was 22% and was significantly high in cases who had altered level of consciousness on admission (p = 0.02). It is concluded that LAT is very useful for rapid diagnosis of BM.

Intramuscular injection as a provoking factor for paralysis in acute poliomyelitis. A case control study.

In order to identify the role of intramuscular injection (IM) as a provoking factor for poliomyelitis, a case control study as done at the Institute of Child Health, Madras from May 1988 to May 1989. The case was defined as acute poliomyelitis if he had acute asymmetric flaccid paralysis of lower motor neurone type without objective sensory disturbance following a short episode of fever. Controls were taken from children attending outpatient department for fever. Two controls matched for aged and sex were recruited for each case. Recruitment, data collection and clinical examination were done by a single pediatrician. IM injection received within 30 days prior to onset of paralysis or illness was considered to be the risk factor. The total number of cases and controls recruited were 257 and 515, respectively. Among cases, 172 (66.9%) out of 257 and among controls 252 (48.9%) out of 515, received IM injection within one month earlier to onset of paralysis or illness. The overall risk of paralysis, estimated for IM injection, was increased [odds ratio (OR) 2.1 (95% CI, 1.5-3.0)]. The maximum risk for paralysis was observed to be 2 weeks preceding the illness; the ORs for < 7 days was 2.2 (95% CI, 1.6-3.2) and for 7-13 days 3.2 (95% CI, 1.8 to 5.8). The risk of paralysis associated with IM injection was similar for unimmunized and immunized cases (OR 2.4 and 2.2). Multiple injections were not associated with a higher risk of developing paralysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical efficacy of trivalent oral poliomyelitis vaccine: a case-control study.

A case-control study was carried out between May 1988 and May 1989 to assess the effectiveness of three doses of trivalent oral poliomyelitis vaccine (TOPV3) in children aged 6-35 months in Madras city. All the cases were patients with acute paralytic poliomyelitis who were residing in Madras city and were hospitalized in the Institute of Child Health; they represented 95% of such cases in the city. The diagnosis was based on clinical grounds and confirmed by stool culture which was positive in 60%. Age- and sex-matched controls, all residing in the city of Madras, were recruited concurrently from the Institute's outpatient department. There were 78 cases and 315 controls. Vaccine efficacy observed for TOPV3 was 81% (95% CI, 58-91%) for the 6-35-month age group and 86% (95% CI, 67-94%) for the 6-23-month age group. Vaccine efficacy, after controlling for age using the Mantel-Haenszel method, was 83% (95% CI, 67-91%). An unimmunized child was at 5 times greater risk of developing acute paralytic poliomyelitis than a fully immunized child.

PIP: Between May 1988 and May 1989 in the city of Madras, India, epidemiologists compared data on 78 children, 6-35 months old, with acute paralytic poliomyelitis (APM) with data on 315 age-matched controls to evaluate the efficacy of trivalent oral poliomyelitis vaccine (TOPV3) in the field. The cases and controls lived in Madras. The cases were hospitalized in the Institute of Child Health. They comprised 95% of the APM cases in Madras, TOPV3's vaccine efficacy stood at 81% for 6-35 year olds and 86% for 6-23 month olds. The epidemiologists used the Mantel-Haenszel method to control for age and found TOPV3's vaccine efficacy to be 83%. Vaccine efficacy increased significantly with the number of TOPV3 doses in both the 6-35 and 6-23 month age groups (p .001). Children who had received no doses of TOPV3 were at a 5 times greater risk of developing paralysis than children receiving all 3 doses of TOPV3, at 4.2 times greater risk than those receiving 1 dose, and at 2.8 times greater risk than those receiving 2 doses.

Risk factors for fatal pneumonia: a case control study.

We conducted a case control study to identify the risk factors for death among hospitalized children with acute pneumonia at the Institute of Child Health, Madras. All the 70 patients who died of pneumonia constituted the case--patients and 140 children recovered from pneumonia, selected by systematic sampling, during the same period served as controls. By univariate analysis, the risk factors for death in pneumonia observed were associated illnesses--Odds Ratio (OR) 22.2. (95% confidence interval [CI] 9.8-51.4; p = < 0.001); congenital anomalies--OR 10.4 (2.9-37.8; p = < 0.001); severe pneumonia--OR 4.2 (1.2-14.4; p = 0.09); marasmic status--OR 2.9 (1.5-5.7; p = 0.001); age under 6 months--OR 2.8 (1.3-5.7; p = 0.004); and severity of the pneumonia (lobar versus segmental)--OR 2.0 (0.9-4.5; p = 0.09). By logistic regression analysis the following risk factors were significant--associated illnesses. (51.6; 18-146.9; p = < 0.001); age under 6 months (6.5; 2-20.6; p = < 0.001), marasmic status (5.8; 2.2-15.6; p = < 0.001); and congenital anomalies (3.8; 2.0-7.1; p = < 0.001). These risk factors should be kept in mind by the clinicians for appropriate intervention at an earlier stage to minimize death.

Reasons for partial/non-immunization with oral polio vaccine/triple antigen among children under five years.

To identify the reasons for non-immunization/postponing immunization, parents of 615 poliomyelitis (APM) children and 908 children attending the Outpatient Department (OPD) for other ailments were interviewed. A total of 165 (26.9%), 185 (30.1%) and 264 (43%) among APM and 645 (71%), 183 (20.2%) and 80 (8.8%) among OPD children were immunized, partially immunized and unimmunized, respectively. Forty two per cent and 21% among parents of APM and OPD children, respectively in the unimmunized group were unaware of the need for immunization. The other reasons are minor illnesses, lack of interest, fear of side reaction, non-availability of vaccine or vaccinator. The decision to withhold immunization was mostly by parents when the child had some minor illnesses, mostly respiratory infections. It is recommended to educate the health personnel-clinicians and para-clinical workers by seminar and training and the public through mass media and group contact on the need for and completion of the immunizations.