ISPAD Clinical Practice Consensus Guideline: Diabetic ketoacidosis in the time of COVID-19 and resource-limited settings-role of subcutaneous insulin.

The International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guideline 2018 for management of diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state provide comprehensive guidance for management of DKA in young people. Intravenous (IV) infusion of insulin remains the treatment of choice for treating DKA; however, the policy of many hospitals around the world requires admission to an intensive care unit (ICU) for IV insulin infusion. During the coronavirus 2019 (COVID-19) pandemic or other settings where intensive care resources are limited, ICU services may need to be prioritized or may not be appropriate due to risk of transmission of infection to young people with type 1 or type 2 diabetes. The aim of this guideline, which should be used in conjunction with the ISPAD 2018 guidelines, is to ensure that young individuals with DKA receive management according to best evidence in the context of limited ICU resources. Specifically, this guideline summarizes evidence for the role of subcutaneous insulin in treatment of uncomplicated mild to moderate DKA in young people and may be implemented if administration of IV insulin is not an option.

'Old Is Gold': How Traditional Indian Dietary Practices Can Support Pediatric Diabetes Management.

Nutrition is crucial for maintaining normal growth, development, and glycemic control in young people with diabetes (PwD). Undue restrictions cause nutrient deficiencies as well as poor adherence to meal plans. Widespread availability of low-cost, ultra-processed, and hyperpalatable food is further damaging. Most families struggle to find ways to provide nutritious, yet attractive, food with a low glycemic index (GI). India is one of the oldest continuous civilizations with a rich and diverse cultural and culinary heritage. Traditional dietary practices, including the centuries-old 'Thali' (meaning plate) concept, emphasize combinations (grains, lentils, vegetables, dairy, spices, prebiotics and probiotics, and fats) of local, seasonal, and predominantly plant-based ingredients. These practices ensure that all of the necessary food groups are provided and fit well with current evidence-based recommendations, including the International Society for Pediatric and Adolescent Diabetes (ISPAD) 2018 Guidelines. Techniques for the preparation, cooking, and preservation of food further impact the GI and nutrient availability. These practices benefit nutrient density, diet diversity, and palatability and thus improve adherence to meal plans and glycemic control. This narrative review describes the ancient wisdom, food composition, and culinary practices from across India which are still valuable today. These may be of benefit worldwide to improve glycemic control as well as quality of life, especially in PwD.

Sirolimus therapy for congenital hyperinsulinism in an infant with a novel homozygous KCNJ11 mutation.

BACKGROUND: Congenital hyperinsulinism results in refractory hypoglycemia. If a therapy with diazoxide has been unresponsive this has been treated by subtotal pancreatectomy in the past. This therapeutic option poses an increased risk of developing diabetes at a later stage. There have been a few case reports on the use of sirolimus in such situations in the recent past. CASE PRESENTATION: Our patient was started on sirolimus very early, on day 29 of life and at the age of 14 months is doing well on sirolimus therapy. His growth and development have been good and he has not had any major complications so far. Genetic testing showed a novel KCNJ11 homozygous mutation on next generation sequencing and the parents were heterozygous carriers. CONCLUSIONS: We report the successful use of sirolimus in the management of diazoxide unresponsive congenital hyperinsulinism with diffuse pancreatic involvement. We believe this is the youngest patient to be initiated on sirolimus so far.

Visceral larva migrans presenting as multiple liver abscesses.

Eosinophilic necrotizing granulomas in the liver, known as visceral larva migrans (VLM), are a rare cause of liver abscesses. The term VLM refers to infections in human tissues caused by the larval stages of ascarid worms of dogs and cats. We report two cases of VLM which presented with high grade fever and abdominal pain for 3-4 months. Marked peripheral eosinophilia, multiple confluent perivenous lesions in the right lobe of liver with characteristic migratory tracts on imaging and biopsy evidence of necrotizing eosinophilic granulomas led to the diagnosis. Complete recovery was achieved with repeated courses of a combination of anthelmintics.

Factors affecting outcome in children with snake envenomation: a prospective observational study.

OBJECTIVES: To evaluate clinical outcome and factors affecting outcome in children with snake envenomation. DESIGN: Prospective observational study. SETTING: Paediatric intensive care unit of a tertiary care teaching hospital in India. PATIENTS: We prospectively enrolled children ≤12 years of age admitted to our hospital with a definitive history of snake bite from August 2007 to June 2010. MEASUREMENTS AND MAIN RESULTS: Demographic characteristics and clinical course of the enrolled children were recorded in a structured proforma and analysed using appropriate statistical methods. Children were treated as per the WHO guidelines (2005) on the management of snake bite in children. Of 110 children studied, 77 (69%) were male. Most (72; 64.2%) had features predominantly of haematotoxic envenomation while 20 (18%) and 18 (16%) children had features of neurotoxic envenomation and local involvement, respectively. 14 children (13%) died and 13 (12%) had major disabilities. On univariable analysis, the following prehospital and admission variables were found to be significantly associated with poor outcome: age, walking for >1 km after the bite, vomiting, haemoglobin ≤10 g/dl at admission and species of snake (cobra). On multivariable analysis, only younger age (adjusted OR 0.85; 95% CI 0.7 to 0.9), walking for >1 km after the bite (adjusted OR 57; 95% CI 4.2 to 782) and haemoglobin ≤10 g/dl at admission (adjusted OR 6; 95% CI 2 to 18.2) remained significant. CONCLUSIONS: Younger age at presentation, anaemia (haemoglobin ≤10 g/dl) and distance walked after the bite may be independent predictors of mortality and morbidity in children with snake bite. These features in victims of snake bite warrant early referral to and management in tertiary care centres.

Primary hypothyroidism, precocious puberty and hypothalamic obesity in Langerhans cell histiocytosis.

A 5 year old girl presented with central diabetes insipidus and primary hypothyroidism. No clinical or radiological evidence of Langerhans cell histiocytosis (LCH) was present. Absent posterior pituitary bright spot was seen in magnetic resonance imaging of the brain. She subsequently developed severe headache, massive obesity, accelerated growth and thelarche. A repeat MRI of the brain revealed hypothalamic tumor. Hormonal investigations revealed, paradoxically, undetectable growth hormone on a clonidine stimulation test. Langerhans cell histiocytosis was proved on electron microscopy of the thyroid tissue. There needs to be a high degree of suspicion for LCH as an etiology of primary hypothyroidism, especially in the presence of diabetes insipidus. Precocious puberty, accelerated growth despite growth hormone deficiency, hypothalamic obesity may occur in pediatric LCH. CNS lesions may have an evolving course, thus repeat neuroimaging is important.