The Indian Academy of Pediatrics and Directorate General of Health Services, Government of India White Paper on Transition of Care for Youth with Special Health Care Needs.

Over the years, survival of children with chronic diseases has significantly improved and a large proportion of them now are entering into adult hood. Transition of Care (ToC) of such patients with having childhood onset of chronic diseases to the adult health care system is well organized in developed countries, although it is an emerging concept in India. In situations where the systems for ToC are not in place, such cases are fraught with unsatisfactory health outcomes. With proper ToC in place, these patients are likely to receive uninterrupted care by the adult care physicians and hence reach their full potential. This document highlights the need, rationale and way forward for ToC of youth with special health care needs (YSHCN) across the country. It also describes the standard operating procedures to develop the ToC at a hospital level for clinicians and administrators.

Association of Screen Time Usage and Physical Activity With Overweight and Obesity Among School-Going Children in Uttar Pradesh.

Background Being overweight during childhood refers to excess weight for a given height, while obesity denotes excess body fat. These conditions stem from surplus calorie intake and insufficient physical activity. Escalating pediatric obesity is linked to modern sedentary lifestyles, marked by increased screen time, reduced exercise, and poor diets. Once believed to be a concern in affluent nations, obesity now affects developing countries like India due to changing eating habits and urbanization. Despite limitations in measurement tools, such as body mass index (BMI) and waist circumference, recognizing sedentary behaviors such as prolonged screen time is pivotal. The rapidly rising prevalence of pediatric obesity has become a major public health concern; therefore, we conducted this study to determine the prevalence and association of screen time usage with being overweight in school-going children (aged 8-15 years). Methodology This observational, cross-sectional study was conducted in Greater Noida, Uttar Pradesh over 18 months (January 2019 to June 2020) after obtaining institutional ethical committee approval. Participants were 8 to 15-year-old students from three co-educational secondary schools in the region. Children with motor or developmental disabilities were excluded. Written informed parental consent and school permission were secured. Anthropometric measurements included weight (SECA 874 U scale) and height (SECA213 stadiometer), which were used to calculate BMI. Overweight/obesity status followed the Indian Academy of Pediatrics guidelines. A validated questionnaire assessed screen time, and a validated Physical Activity Questionnaire measured physical activity. Both questionnaires were administered twice to validate data. SPSS version 23.0 (IBM Corp., Armonk, NY, USA) was used for data analyses (descriptive, t-test, analysis of variance (ANOVA) test, and chi-square test). P-values <0.05 were considered significant. Results This study involved 604 participants. Among them, 47.7% had a normal BMI, 37.4% were overweight, and 14.9% were obese. Most participants (97.4%) reported screen time of over 60 minutes daily, while 2.6% reported lower screen time. ANOVA revealed significant differences in daily (F = 16.014, p < 0.001) and weekly (F = 16.175, p < 0.001) screen time among BMI categories. Low physical activity was prevalent (97.7%). ANOVA showed significant variations in physical activity scores and durations (p < 0.001), with normal-weight individuals exhibiting higher levels. Conclusions The rising prevalence of overweight among children underscores the need for early intervention strategies, emphasizing the importance of reducing screen time and promoting increased physical activity. These measures are critical in addressing the growing challenge of being overweight during childhood and its potential long-term health implications.

Insulin Resistance in children on Sodium Valproate - A hospital based cross-sectional study in Indian children.

Our objective was to compare the point prevalence of insulin resistance (IR) in children taking sodium valproate (VPA) and phenytoin sodium (PS) monotherapy for >1 year. 150 children, aged 6-18 years, were categorized (50 each) into - group A (VPA), group B (PS) and group C (healthy controls age-sex matched with group A). Groups were compared for metabolic complications and risk factors assessed. The point prevalence of IR and non-alcoholic fatty liver disease was significantly higher in children on VPA (12% and 34% respectively) than on PS and healthy controls, regardless of age, sex, pubertal and nutritional status. The presence of central obesity, acanthosis, hypertension, dyslipidaemia was significantly associated with IR but none showed an independent association on multivariate analysis. Therapy with VPA makes children susceptible to metabolic complications. Close monitoring will facilitate early detection and timely intervention.

Assembling a global database of child pneumonia studies to inform WHO pneumonia management algorithm: Methodology and applications.

Background: The existing World Health Organization (WHO) pneumonia case management guidelines rely on clinical symptoms and signs for identifying, classifying, and treating pneumonia in children up to 5 years old. We aimed to collate an individual patient-level data set from large, high-quality pre-existing studies on pneumonia in children to identify a set of signs and symptoms with greater validity in the diagnosis, prognosis, and possible treatment of childhood pneumonia for the improvement of current pneumonia case management guidelines. Methods: Using data from a published systematic review and expert knowledge, we identified studies meeting our eligibility criteria and invited investigators to share individual-level patient data. We collected data on demographic information, general medical history, and current illness episode, including history, clinical presentation, chest radiograph findings when available, treatment, and outcome. Data were gathered separately from hospital-based and community-based cases. We performed a narrative synthesis to describe the final data set. Results: Forty-one separate data sets were included in the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) database, 26 of which were hospital-based and 15 were community-based. The PREPARE database includes 285 839 children with pneumonia (244 323 in the hospital and 41 516 in the community), with detailed descriptions of clinical presentation, clinical progression, and outcome. Of 9185 pneumonia-related deaths, 6836 (74%) occurred in children <1 year of age and 1317 (14%) in children aged 1-2 years. Of the 285 839 episodes, 280 998 occurred in children 0-59 months old, of which 129 584 (46%) were 2-11 months of age and 152 730 (54%) were males. Conclusions: This data set could identify an improved specific, sensitive set of criteria for diagnosing clinical pneumonia and help identify sick children in need of referral to a higher level of care or a change of therapy. Field studies could be designed based on insights from PREPARE analyses to validate a potential revised pneumonia algorithm. The PREPARE methodology can also act as a model for disease database assembly.

Treatment of benzodiazepine-resistant status epilepticus: Systematic review and network meta-analyses.

PURPOSE: Multiple interventions have been studied for benzodiazepine-resistant status epilepticus (SE) in children and adults. This review aimed to summarize the available evidence and provide estimates of comparative effectiveness and ranking of treatment effects. METHODS: All randomized controlled trials studying patients (>1 month of age) with benzodiazepine-resistant SE were included. Outcomes including seizure cessation within 60 min, seizure freedom for 24 h, death, respiratory depression warranting intubation and cardiovascular instability were studied. Conventional and network meta-analyses (NMA) were done. RESULTS: Seventeen studies were included (16 in NMA). Phenobarbital and high-dose levetiracetam were significantly superior to phenytoin with respect to seizure cessation within 60 min. Network ranking demonstrated that phenobarbital had the highest probability of being the best among the studied interventions followed by high-dose levetiracetam and high-dose valproate. Network meta-analysis was limited by predominant indirect evidence and high heterogeneity.On pairwise comparisons, phenobarbital was found to be associated with a higher risk of need for intubation and cardiovascular instability. Levetiracetam had a better safety profile than fosphenytoin. CONCLUSIONS: Based on low quality evidence, phenobarbital appears to be the most effective agent for seizure cessation within 60 min of administration in patients with benzodiazepine resistant status epilepticus. High-dose levetiracetam, high-dose valproate and fosphenytoin are probably equally effective. Choice of medication may be guided by effectiveness, safety concerns, availability, cost and systemic co-morbidities.

Thrombosis and thromboembolism: Brighton collaboration case definition and guidelines for data collection, analysis, and presentation of immunization safety data.

This is a Brighton Collaboration case definition of thrombosis and thromboembolism to be used in the evaluation of adverse events following immunization, and for epidemiologic studies for the assessment of background incidence or hypothesis testing. The case definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of SARS-CoV-2 vaccines. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by selected expert reviewers prior to submission.

Derivation and validation of a novel risk assessment tool to identify children aged 2-59 months at risk of hospitalised pneumonia-related mortality in 20 countries.

INTRODUCTION: Existing risk assessment tools to identify children at risk of hospitalised pneumonia-related mortality have shown suboptimal discriminatory value during external validation. Our objective was to derive and validate a novel risk assessment tool to identify children aged 2-59 months at risk of hospitalised pneumonia-related mortality across various settings. METHODS: We used primary, baseline, patient-level data from 11 studies, including children evaluated for pneumonia in 20 low-income and middle-income countries. Patients with complete data were included in a logistic regression model to assess the association of candidate variables with the outcome hospitalised pneumonia-related mortality. Adjusted log coefficients were calculated for each candidate variable and assigned weighted points to derive the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) risk assessment tool. We used bootstrapped selection with 200 repetitions to internally validate the PREPARE risk assessment tool. RESULTS: A total of 27 388 children were included in the analysis (mean age 14.0 months, pneumonia-related case fatality ratio 3.1%). The PREPARE risk assessment tool included patient age, sex, weight-for-age z-score, body temperature, respiratory rate, unconsciousness or decreased level of consciousness, convulsions, cyanosis and hypoxaemia at baseline. The PREPARE risk assessment tool had good discriminatory value when internally validated (area under the curve 0.83, 95% CI 0.81 to 0.84). CONCLUSIONS: The PREPARE risk assessment tool had good discriminatory ability for identifying children at risk of hospitalised pneumonia-related mortality in a large, geographically diverse dataset. After external validation, this tool may be implemented in various settings to identify children at risk of hospitalised pneumonia-related mortality.

Diagnostic Accuracy of Parents' Evaluation of Developmental Status (PEDS), PEDS Developmental Milestones, and PEDS Combined in Indian Children Aged Less than 2 Years.

OBJECTIVE: To assess the diagnostic accuracy of Parent's Evaluation of Developmental Status (PEDS), PEDS Developmental Milestones (PEDS:DM) and PEDS Combined for developmental screening of Indian children aged less than 2 y. METHOD: A hospital-based study of diagnostic accuracy was conducted over 17 mo. Children under 24 mo (n = 180) were enrolled after exclusion of severe illnesses or known neurodevelopment disorders. The index tools included standardized Hindi translations of PEDS and PEDS:DM. The reference tool was Developmental Assessment Scale for Indian Infants (DASII). Both were administered by blinded researchers. Parameters of diagnostic accuracy were computed. RESULTS: There were 13 (7.2%) failures in PEDS, 119 (66.1%) in PEDS:DM and 119 (66.1%) in PEDS Combined. DASII identified 3 children with developmental delay. Sensitivity (Sn) [95% CI] of PEDS was 33.3 [0.8-90.6] and Specificity (Sp) 93.2 [88.5-96.5]. The Sn and Sp of both PEDS:DM and PEDS Combined were 100 [29.2-100] and 34.5 [27.5-42.0], respectively. CONCLUSIONS: Hindi translations of PEDS, PEDS:DM and PEDS Combined are not suitable for developmental screening of children less than 2 y due to suboptimal diagnostic accuracy.

Point Prevalence of Peripheral Neuropathy in Children and Adolescents with Type 1 Diabetes Mellitus.

OBJECTIVE: To assess the point prevalence of peripheral neuropathy (PN) in children with type 1 diabetes mellitus (T1DM) and to determine their predictors. METHODS: In this cross-sectional study, children aged 8-18 y with T1DM on insulin therapy for > 2 y and free from acute complications were enrolled. All participants were evaluated for symptoms of PN with diabetic neuropathy symptom (DNS) score and underwent a detailed neurological examination. Assessment of nerve dysfunction was done using nerve conduction studies (NCS). The disease-related factors that increase the risk of PN were determined. RESULTS: Fifty children (52% boys) were enrolled with mean age of 12.2 ± 2.8 y and duration of diabetes 5.1 ± 2.1 y. No subject had clinical evidence or DNS score suggestive of PN. Twenty-eight (56%) children demonstrated subclinical neuropathy on NCS. Proportion of children with pure motor, pure sensory, and mixed motor-sensory neuropathy was 40%, 2%, and 14%, respectively. The peroneal nerve was the most common motor nerve affected. Poor glycemic control (HbA1c > 9%) and longer duration of diabetes (> 5 y) were significantly associated with the risk of PN (p value < 0.05). CONCLUSION: A large proportion of children with T1DM have subclinical PN. Poor glycemic control and longer duration of diabetes are risk factors for nerve dysfunction. Neurophysiological studies should be performed in these children to facilitate early detection.

External validation of the RISC, RISC-Malawi, and PERCH clinical prediction rules to identify risk of death in children hospitalized with pneumonia.

BACKGROUND: Existing scores to identify children at risk of hospitalized pneumonia-related mortality lack broad external validation. Our objective was to externally validate three such risk scores. METHODS: We applied the Respiratory Index of Severity in Children (RISC) for HIV-negative children, the RISC-Malawi, and the Pneumonia Etiology Research for Child Health (PERCH) scores to hospitalized children in the Pneumonia REsearch Partnerships to Assess WHO REcommendations (PREPARE) data set. The PREPARE data set includes pooled data from 41 studies on pediatric pneumonia from across the world. We calculated test characteristics and the area under the curve (AUC) for each of these clinical prediction rules. RESULTS: The RISC score for HIV-negative children was applied to 3574 children 0-24 months and demonstrated poor discriminatory ability (AUC = 0.66, 95% confidence interval (CI) = 0.58-0.73) in the identification of children at risk of hospitalized pneumonia-related mortality. The RISC-Malawi score had fair discriminatory value (AUC = 0.75, 95% CI = 0.74-0.77) among 17 864 children 2-59 months. The PERCH score was applied to 732 children 1-59 months and also demonstrated poor discriminatory value (AUC = 0.55, 95% CI = 0.37-0.73). CONCLUSIONS: In a large external application of the RISC, RISC-Malawi, and PERCH scores, a substantial number of children were misclassified for their risk of hospitalized pneumonia-related mortality. Although pneumonia risk scores have performed well among the cohorts in which they were derived, their performance diminished when externally applied. A generalizable risk assessment tool with higher sensitivity and specificity to identify children at risk of hospitalized pneumonia-related mortality may be needed. Such a generalizable risk assessment tool would need context-specific validation prior to implementation in that setting.

The Status of Early Childhood Development in India: Will We Reach the Countdown to 2030 Targets?

Early childhood development (ECD) provides building blocks for future educational achievement, emotional and moral development; the early years of life provide a critical window of opportunity for intervention. Experts across the world are emphasizing on promotion of ECD through the 5-pronged Nurturing Care Framework (NCF). The Sustainable Development Goals have focussed on optimum development for all children by 2030. For India, with 164.5 million population of children between 0-6 years, the magnitude of the problem is huge. We have been focusing on ECD since the launching of the Integrated Child Development Scheme (ICDS) in 1976. Many national policies and programs have evolved since then to promote ECD. Inspite of all efforts, the overall picture of early childhood development in India is still not optimal, due to multiple factors. All five components of nurturing care framework have not been included comprehensively in the services offered. If India focuses on these areas and comes up with a convergent ECD delivery system through a single portal that can be provided with equity at the grassroot level, coupled with proper documentation, we may proceed towards our goals at a better pace. Multiple stakeholders (the government, public and private health care providers, non-government organizations, professional bodies) need to work in synergy to enable us to reach the 2030 goals.

Early Childhood Development: A Paradigm Shift From Developmental Screening and Surveillance to Parent Intervention Programs.

A large proportion of children under the age of five years who do not attain their expected developmental potential belong to low- and middle-income countries (LMICs). The strategies used for identifying children with high risk for developmental delay/disorders include developmental screening, surveillance, and monitoring. Suitability criteria for developmental screening tools in LMICs have been established, but few tools meet all the benchmarks. Based on these, the authors identified two tools that may be considered suitable in the Indian context; the International guide for monitoring child development and the Monitoring child development in the integrated management of childhood illnesses context. However, implementing and sustaining a universal developmental screening program using these is not feasible in the present circumstances. There is emerging evidence that parent intervention programs have significant impact on outcomes related to early childhood development (ECD). The nurturing care framework encompasses five strategies known to enhance ECD in young children even in the presence of adversities; good health, adequate nutrition, responsive caregiving, opportunities for early learning and safety and security. This article discusses the paradigm shift to incorporation of nurturing care-based preventive, supportive and promotive health care services in office practice with active parental involvement. This may prove to be a better option with a more positive, long lasting and quicker impact on ECD.

Growth faltering in early infancy: highlights from a two-day scientific consultation.

Faltering of growth in early life has been recognized as a public health challenge among Indian babies. A two-day consultation on growth faltering in early infancy was organized to examine the data and evidence on identification and management of early growth failure and to identify knowledge gaps and future areas of research. The consultation was supported by the Biotechnology Industry Research Assistance Council (BIRAC), the Indian Academy of Pediatrics (Nutrition Chapter), Vardhman Mahavir Medical College and Safdarjung Hospital, and the Society for Applied Studies. It brought together researchers, clinicians, policy makers and program managers.

Use of the International League Against Epilepsy (ILAE) 1989, 2010, and 2017 Classification of Epilepsy in children in a low-resource setting: A hospital-based cross-sectional study.

OBJECTIVES: This cross-sectional study was designed to test the applicability of the 1989, 2010, and 2017 International League Against Epilepsy (ILAE) classification of epilepsy in children from a resource-limited setting in India. METHODS: Classification of seizure types and syndromes was done through parental interviews and review of medical records in children with epilepsy aged one month to 18 years. Available investigations including EEG, MRI, and metabolic/genetic tests were used in classifying patients as per the 1989, 2010, and 2017 ILAE (level II-epilepsy type) classification. We compared the proportion of children remaining unclassified by each scheme. RESULTS: Seven hundred and twenty-six children (436 males, mean age 6.4 ± 4.6 years) were enrolled. Using the 1989 ILAE classification, we were able to classify 95.7%, and 82.6% children by the 2010 scheme. The 2017 ILAE classification could classify all 726 children at level I (seizure type), 664 (91.0%) children at level II (epilepsy type), and an electroclinical syndrome could be identified in 409 (56.1%) of the children. An etiology could be identified in 75%, perinatal brain injury being the most frequent. West syndrome was the most common electroclinical syndrome, identified in 22.7% patients. The 1989 ILAE classification system was superior to the 2010 system (P = .01) in epilepsy classification. There was no difference between the 1989 and 2017 schemes (P = .31) or the 2010 and 2017 schemes (P = .10). SIGNIFICANCE: The 2017 ILAE classification, being multidimensional, allowed classification of children who could not undergo extensive evaluation due to economic constraints and also provided room for overlapping etiologies.

Sensorineural hearing loss (SNHL) as an adverse event following immunization (AEFI): Case definition & guidelines for data collection, analysis, and presentation of immunization safety data.

This is a Brighton Collaboration case definition of the term "Sensorineural Hearing Loss" to be utilized in the evaluation of adverse events following immunization. The case definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of vaccines for Lassa Fever and other emerging pathogens. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and define levels of diagnostic certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network.

Neuro-Developmental and Epilepsy Outcomes of Children with West Syndrome: A Cross-Sectional Study from North India.

OBJECTIVES: To assess the neurodevelopmental outcome of West syndrome (WS) in Indian children, who differ in their clinical profile from the western population. MATERIALS AND METHODS: This cross-sectional study enrolled children aged 2--5 years with prior diagnosis of WS between November 2013 and March 2015. They were assessed for epilepsy outcome and developmental outcome using developmental profile 3 (DP3) and vineland adaptive behavioral scale II (VABS II). RESULTS: Sixty-one children were enrolled. Perinatal asphyxia (40.9%), neonatal hypoglycemia (14.8%), and neonatal meningitis (9.8%) were predominant causes among the children with known etiology. Favorable epilepsy outcome (seizure freedom for >6 months) was observed in 29/61 patients (47.5%). Moderate to severe developmental delay was observed in 55/61 children (91.8%). Favorable developmental outcome (GDS by DP3 >70) was observed in just 5/61 (8%) patients. CONCLUSIONS: This study highlights the high prevalence of developmental delay in this population of children with WS, with adverse perinatal events being the most common etiology.

Clinical Profile and Short-term Outcome of Pediatric Status Epilepticus at a Tertiary-care Center in Northern India.

OBJECTIVE: To assess clinical profile and short term treatment outcomes of pediatric status epilepticus (SE) at a tertiary-care center in northern India. METHODS: Prospective cohort study enrolled children aged 1 month to 18 years presenting with SE to the emergency department. Enrolled children (109) were treated as per hospital protocols. Clinical features during hospitalization were noted. Pediatric overall performance category (POPC) scale was used for classification of outcome at the time of discharge. RESULTS: Acute symptomatic etiology was identified in 66 (60.6%) cases (CNS infections were predominant). Previous diagnosis of epilepsy was found in 32 (29.4%) children; and benzodiazepine responsive SE were seen in 65 (59.6%) children. Predictors of unfavorable outcome were acute symptomatic etiology (adjusted OR 4.50; 95% CI 1.49, 13.62) and no treatment administered prior to hospital (adjusted OR 3.97; 95% CI 1.06, 14.81). CONCLUSIONS: Acute symptomatic etiology, mainly acute CNS infections, is the leading cause of SE in this region. Early and pre-hospital management with benzodiazepines may improve SE outcome.