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.

Pediatric Appropriate Evaluation Protocol for India (PAEP-India): Tool for Assessing Appropriateness of Pediatric Hospitalization

Objectives: To develop and assess Pediatric AppropriatenessEvaluation Protocol for India (PAEP-India) for inter-rater reliabilityand appropriateness of hospitalization.Design: Cross-sectional study.Setting: The available PAEP tools were reviewed and adaptedfor Indian context by ten experienced pediatricians followingsemi-Delphi process. Two PAEP-India tools; newborn (?28 days)and children (>28 days-18 years) were developed. These PAEP-India tools were applied to cases to assess appropriateness ofadmission and inter-rater reliability between assessors.Participants: Two sets of case records were used: (i) 274cases from five medical colleges in Delhi-NCR [?28 days (n=51);>28 days to 18 years (n=223)]; (ii) 622 infants who werehospitalized in 146 health facilities and were part of a cohort (n=30688) from two southern Indian states.Interventions: Each case-record was evaluated by twopediatricians in a blinded manner using the appropriate PAEP-India tools, and ‘admission criteria’ were categorized asappropriate, inappropriate or indeterminate.Main outcome measures: The proportion of appropriatehospitalizations and inter-rater reliability between assessors(using kappa statistic) were estimated for the cases.Results: 97.8% hospitalized cases from medical colleges werelabelled as appropriate by both reviewers with inter-rateragreement of 98.9% (k=0.66). In the southerm Indian set ofinfants, both reviewers labelled 80.5% admissions as appropriatewith inter-rater agreement of 96.1% (k= 0.89).Conclusions: PAEP-India (newborn and child) tools are simple,objective and applicable in diverse settings and highly reliable.These tools can potentially be used for deciding admissionappropriateness and hospital stay and may be evaluated later forusefulness for cost reimbursements for insurance proposes.

Lipodystrophy and metabolic complications of highly active antiretroviral therapy.

Objective. To assess the metabolic drug toxicities of first-line, World Health Organization (WHO)-recommended generic highly active antiretroviral therapy (HAART) regimens, to estimate the prevalence of body fat redistribution and to identify associated risk factors. Methods. Cross- sectional observational study. During 3 month period, 52 HIV infected children (25 on HAART; 27 not on HAART) were assessed. Their sociodemographic, clinical, and immunological data was recorded. Children were examined or the signs of fat redistribution (peripheral lipoatrophy and central lipohypertrophy). Liver function tests, fasting blood sugar, lipid profile, serum amylase, serum lactate, blood pH and bicarbonate levels were done in all patients. Results. Twenty-two patients were on stavudine and three on zidovudine based HAART. None of the patients ever received any protease inhibitor. There were no cases of clinical or immunological failure. Children on HAART had significantly lower weight for age and body mass index but the mean height for age was similar between study groups. Only two cases of peripheral lipoatrophy were observed. Hypercholesterolemia was observed in four children on HAART but none without therapy. Hypertriglyceridemia was observed in three children on HAART and seven without therapy. Four cases of asymptomatic mild hyperlactatemia were observed. No case of any hyperglycemia or liver impairment was observed. Conclusion. Metabolic abnormalities and lipodystrophy are emerging complications of HAART in Indian children and needs very close follow up. Future studies with larger sample size and longitudinal model are recommended.

Cystic lymphangiomatous hamartoma masquerading as massive ascites.

We report a 4-year-old boy presenting with a tense massive ascites and large hydrocele. History and physical examination were unremarkable. Routine laboratory studies were normal. Abdominal ultrasonography revealed massive ascites. Contrast CT was suggestive of a large cyst covering the entire peritoneal cavity. At laparotomy, a large cystic tumor was found extending into the scrotum through the left inguinal ring. Histopathologic examination diagnosed the tumor as a cystic lymphangiomatous hemartoma. Although abdominal lymphangiomas are seen in children, but presenting as massive ascites with hydrocele is very rare.

Caspofungin.

Caspofungin is a new antifungal drug meant for intravenous use. It has been shown to be comparable to other antifungal agents such as amphotericin B and fluconazole for empirical therapy in febrile neutropenic patients, oropharyngeal/esophageal candidiasis and invasive aspergillosis. Its efficacy has also been documented in children in small uncontrolled trials. The biggest assets of caspofungin are its excellent tolerability/safety profile and minimal drug interactions.