Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric HematologyOncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics

Justification: Anemia in children is a significant public health problem in our country. Comprehensive National Nutrition Survey 2016-18 provides evidence that more than 50% of childhood anemia is due to an underlying nutritional deficiency. The National Family Health Survey-5 has reported an increase in the prevalence of anemia in the under-five age group from 59% to 67.1% over the last 5 years. Clearly, the existing public health programs to decrease the prevalence of anemia have not shown the desired results. Hence, there is a need to develop nationally acceptable guidelines for the diagnosis, treatment and prevention of nutritional anemia. Objective: To review the available literature and collate evidence-based observations to formulate guidelines for diagnosis, treatment and prevention of nutritional anemia in children. Process: These guidelines have been developed by the experts from the Pediatric Hematology-Oncology Chapter and the Pediatric and Adolescent Nutrition (PAN) Society of the Indian Academy of Pediatrics (IAP). Key areas were identified as: epidemiology, nomenclature and definitions, etiology and diagnosis of iron deficiency anemia (IDA), treatment of IDA, etiology and diagnosis of vitamin B12 and/or folic acid deficiency, treatment of vitamin B12 and/or folic acid deficiency anemia and prevention of nutritional anemia. Each of these key areas were reviewed by at least 2 to 3 experts. Four virtual meetings were held in November, 2021 and all the key issues were deliberated upon. Based on review and inputs received during meetings, draft recommendations were prepared. After this, a writing group was constituted which prepared the draft guidelines. The draft was circulated and approved by all the expert group members. Recommendations: We recommend use of World Health Organization (WHO) cut-off hemoglobin levels to define anemia in children and adolescents. Most cases suspected to have IDA can be started on treatment based on a compatible history, physical examination and hemogram report. Serum ferritin assay is recommended for the confirmation of the diagnosis of IDA. Most cases of IDA can be managed with oral iron therapy using 2-3 mg/kg elemental iron daily. The presence of macro-ovalocytes and hypersegmented neutrophils, along with an elevated mean corpuscular volume (MCV), should raise the suspicion of underlying vitamin B12 (cobalamin) or folic acid deficiency. Estimation of serum vitamin B12 and folate level are advisable in children with macrocytic anemia prior to starting treatment. When serum vitamin B12 and folate levels are unavailable, patients should be treated using both drugs. Vitamin B12 should preferably be started 10-14 days ahead of oral folic acid to avoid precipitating neurological symptoms. Children with macrocytic anemia in whom a quick response to treatment is required, such as those with pancytopenia, severe anemia, developmental delay and infantile tremor syndrome, should be managed using parenteral vitamin B12. Children with vitamin B12 deficiency having mild or moderate anemia may be managed using oral vitamin B12 preparations. After completing therapy for nutritional anemia, all infants and children should be advised to continue prophylactic iron-folic acid (IFA) supplementation as prescribed under Anemia Mukt Bharat guidelines. For prevention of anemia, in addition to age-appropriate IFA prophylaxis, routine screening of infants for anemia at 9 months during immunization visit is recommended.

What is New in Management of Pediatric Tuberculosis ?

Tuberculosis continues to haunt mankind since its discovery more than a century ago. Although commendable advancements have beenmade in the diagnosis as well as treatment, especially in the last couple of decades, the healthcare burden of this disease worldwide isimmense. Continuously evolving medical science has provided recent changes in national guidelines along with discovery of newer anti-tubercular drugs after many decades. In view of WHO declaring tuberculosis as a global health emergency and strong commitment beingreflected by Government of India whereby National Strategic Plan aims to eliminate tuberculosis by 2025, it is high time that we workcollectively on the goal of tuberculosis elimination. This article sums up the updates on newer anti-tubercular drugs as well as the recentchanges adopted in Revised National Tuberculosis Control Program.

Obstructive Sleep Apnea in Children with Nocturnal Enuresis

There is increasing evidence on the association ofmonosymptomatic nocturnal enuresis (MNE) with obstructivesleep apnea. In this communication, we share our experience offour patients with Primary monosymptomatic nocturnal enuresis(PMNE) with positive Sleep-related breathing disorder (SRBD)score who underwent detailed polysomnography, and were eitherrefractory to desmopressin treatment or relapsed ondiscontinuation of desmopressin.

Normal Values of Liver and Spleen Size by Ultrasonography in Indian Children.

Objectives: To establish normative data for the ultrasonographic measurement of liver and spleen size in healthy Indian children. Setting: Tertiary-care pediatric teaching hospital. Design: Cross-sectional, hospital-based study. Participants: 597 healthy children between the ages of 1 month to 12 years. Measurements: Ultrasonographic evaluation for the assessment of liver and spleen size. These were correlated with the age, sex, height/length and weight of the participants. Results: Normal liver and spleen length and range were obtained sonographically. The liver and spleen length significantly correlated highly with the height/length of the subjects (P=0.0001). Conclusions: The study provides the normal values of liver and spleen size by ultrasonography in healthy Indian children.

OMENS-plus syndrome.

The OMENS syndrome involves craniofacial maldevelopment of the orbit, ear cranial nerve and soft tissue, while OMENS-plus syndrome also includes extracraniofacial anomalies. These may be skeletal, cardiovascular, gastrointestinal, pulmonary, renal and central nervous system malformations. A fourteen-year-old girl presented with hemifacial microsomia, digital abnormalities and pancreatitis. She was diagnosed as O1M2E0N2S1--plus syndrome. Investigations revealed a type Ic choledochal cyst. The latter has not been reported as a gastrointestinal association earlier in literature to the best of the authors' knowledge.