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Lung function testing is an essential modality of investigation in children as it provides objective evidence of lung disease/ health. With advances in technology, various tests are available that can aid in the diagnosis of lung disease, assess the progression and response to therapy and document the lung development and evolving lung diseases in infants. This narrative review discusses lung function tests in infants and children. Currently, lung function tests can be performed in every age group, from neonates to the elderly. Spirometry and peak expiratory flow rate (PEFR) are the most employed tests in children more than six years of age. Spirometry helps diagnose and monitoring of both obstructive and restrictive diseases. There is a need for expertise to perform and interpret spirometry correctly. The forced oscillation technique (FOT) or impulse oscillometry (IOS) is done with tidal volume breathing and is feasible even in preschool children. Their utility is mainly restricted to asthma in children at present. Lung function tests can be performed in neonates, infants and children using infant pulmonary function test (PFT) equipment, although their availability is limited. Diffusion capacity for carbon monoxide (DLCO) is a valuable tool in restrictive lung diseases. Lung volumes can be assessed by body plethysmography and multiple washout technique. The latter can also assess lung clearance index. It is essential to perform and interpret the lung function test results correctly and correlate them with the clinical condition for optimum treatment and outcome.
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Coronavirus disease 19 (COVID-19), caused by the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2), has been implicated in having post-COVID-19 sequelae in both adults and children. There is a lack of good data on the prevalence and risk factors for post-COVID-19 sequelae in children. The authors aimed to review the current literature on post-COVID sequelae. The prevalence of post-COVID sequelae in children is highly variable among studies, with an average of 25%. The sequelae may affect many organ systems, though mood symptoms, fatigue, cough, dyspnea, and sleep problems are common. In many studies, it is difficult to establish a causal association due to the lack of a control group. Furthermore, it is difficult to differentiate whether the neuropsychiatric symptoms in children after COVID-19 are due to infection or a result of lockdowns and social restrictions imposed by the pandemic. Children with COVID-19 should be followed by a multidisciplinary team and screened for symptoms, followed by focused laboratory evaluations as needed. There is no specific treatment for the sequelae. Only symptomatic and supportive treatment is required in most cases. More research is necessary to standardize the definitions of sequelae, establish a causal association, assess various treatment options, and the effects of different virus variants, and finally, see the impact of vaccination on the sequelae.
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Background & objectives: Studies assessing the spatial and temporal association of ambient air pollution with emergency room visits of patients having acute respiratory symptoms in Delhi are lacking. Therefore, the present study explored the relationship between spatio-temporal variation of particulate matter (PM)2.5 concentrations and air quality index (AQI) with emergency room (ER) visits of patients having acute respiratory symptoms in Delhi using the geographic information system (GIS) approach. Methods: The daily number of ER visits of patients having acute respiratory symptoms (less than or equal to two weeks) was recorded from the ER of four hospitals of Delhi from March 2018 to February 2019. Daily outdoor PM2.5 concentrations and air quality index (AQI) were obtained from the Delhi Pollution Control Committee. Spatial distribution of patients with acute respiratory symptoms visiting ER, PM2.5 concentrations and AQI were mapped for three seasons of Delhi using ArcGIS software. Results: Of the 70,594 patients screened from ER, 18,063 eligible patients were enrolled in the study. Winter days had poor AQI compared to moderate and satisfactory AQI during summer and monsoon days, respectively. None of the days reported good AQI (<50). During winters, an increase in acute respiratory ER visits of patients was associated with higher PM2.5 concentrations in the highly polluted northwest region of Delhi. In contrast, a lower number of acute respiratory ER visits of patients were seen from the ‘moderately polluted’ south-west region of Delhi with relatively lower PM2.5 concentrations. Interpretation & conclusions: Acute respiratory ER visits of patients were related to regional PM2.5 concentrations and AQI that differed during the three seasons of Delhi. The present study providessupport for identifying the hotspots and implementation of focused, intensive decentralized strategies to control ambient air pollution in worst-affected areas, in addition to the general city-wise strategies.
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Children with cystic fbrosis (CF) constitute a high-risk group for COVID-19 with underlying chronic lung disease. COVID19 severity varying from mild infection to need of intensive care has been described in children with CF. Two children with signifcant underlying pulmonary morbidity are described here, who developed severe disease following SARS-CoV-2 infection. Case 1 (a 9-y-old boy) had pneumonia with respiratory failure requiring noninvasive ventilation support. He had delayed clearance of SARS-CoV-2, with recurrence of symptomatic disease with short asymptomatic period in between. He was also diagnosed with CF-related diabetes and allergic bronchopulmonary aspergillosis during the second episode. Case 2 (an 18-mo-old boy) had two episodes of SARS-CoV-2–related severe lower respiratory infection within a period of 2 mo, requiring high-fow nasal oxygen support. Both children had 3rd pulmonary exacerbation but SARS-CoV-2 was not detected in respiratory secretions. To conclude, children with CF with underlying pulmonary morbidity, can develop severe COVID-19 and prolonged SARS-CoV-2 shedding.
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Objective: To document morbidities in adolescents with cystic fibrosis (CF) from India. Methods: Details of children with cystic fibrosis surviving beyond 15 years of age were extracted from hospital records, and analyzed. Results: 43 children [Median (IQR) age 18.7 (17, 20.6) years, were enrolled. Median (IQR) body mass index was 15.82 (13.5, 19.05) kg/m2. Pseudomonas species were isolated from respiratory specimens of 34 (79%) adolescents. Allergic bronchopulmonary aspergillosis (ABPA) and Cystic fibrosis-related diabetes (CFRD) were seen in 12 (28%) and 11 (26%) patients, respectively. Conjugated hyperbilirubinemia and distal intestinal obstruction syndrome (DIOS) were diagnosed in 15 (35%) and 6 (14%) children, respectively. Pseudomonas species colonization (P=0.04) and multiple pulmonary exacerbations in last one year (P<0.001) were significant predictors of FEV1% predicted. Conclusion: Malnutrition, chronic airway colonization, ABPA, CFRD, conjugated hyperbilirubinemia and DIOS are morbidities observed in adolescents with CF in India. The data support the need for early screening of CF-associated morbidities.
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Objectives: To evaluate association between total IgE levels and wheezing in preschoolchildren from India. Methods: Datawere collected in a prospective birth cohort study relatedto wheezing till three years of age. Total IgE was measured at enrolment, at one year and twoyears of age and correlated with wheezing episodes. Results: A total of310 (167 boys)children were enrolled. Total IgE levels increased with age (P<0.001). Overall, 101 (32.6%)children had 182 episodes of wheezing. The median (IQR) total IgE levels in children withwheezing and without wheezing were similar at one year [42.1 (12.7, 93.5) vs 41.9 (17.1,96.7) kU/L; P=0.39] and two years of age [62.8 (32.4, 212.0) vs 75 (25.8, 173.0) kU/L,P=0.92). Conclusion: Total IgE levels increased with age and were not different in preschoolchildren with and without wheezing.
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Objective: To develop a normal reference range of Infantpulmonary function test (IPFT) indices for Indian children.Design: Prospective birth cohort study.Setting: Division of Pediatric Pulmonology of a tertiary-careinstitute in India from August 2012 to March 2017.Participants: All neonates born at the institute during the studyperiod were screened for eligibility.Measurement: IPFT at baseline and every 6-month until 36-months of age.Main Outcome Measure(s): Tidal breathing flow-volume loop(TBFVL), Rapid thoracoabdominal compression (RTC), andRaised volume RTC (RVRTC) indices at baseline and follow-up.Results: 310 newborns were enrolled in the cohort; 281 of them(169 male) had completed 36-months of follow-up at the end ofthe study period. There was no influence of gender on thebaseline IPFT indices. Tidal volume per unit body weight (VT/kg)significantly increased from baseline to 36 months of age(P<0.001) while the peak ratio (tPTEF/tE) initially decreased in first18-months of age (P<0.001), after that returned to the baselinevalue by 36 months of age. RTC indices did not changesignificantly from baseline values. In RVRTC, the ratio of forcedexpiratory volume in 0.5s to forced vital capacity (FEV0.5/FVC)was significantly decreased from baseline to 36 months of age(P=0.002).Conclusions: Normal values for various IPFT indices for TBFVL,RTC, and RVRTC from neonates to the age of 36-month areprovided. These data may be used as normative data for healthyneonates and children of Indian origin
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Objectives: To compare propofol and fentanyl to induceconscious sedation in children undergoing flexiblebronchoscopy.Study design: Randomized controlled trial.Setting: Pediatric Pulmonology division at a tertiary care centerin Delhi, India.Participants: Children aged 3-15 years who underwentflexible bronchoscopy.Intervention: Children received either intravenous propofol 1mg/kg administered as a slow bolus over 1 minute followed by 2mg/kg/hour infusion, or intravenous Fentanyl 2 μg/kgadministered as a slow bolus over one minute.Outcomes: Primary outcome was time to achieve conscioussedation (Ramsay score 3). Secondary outcomes were need foradjuvant midazolam, physician satisfaction, level of cough,recovery features, and side-effects in the groups.Results: 53 children (propofol 27, fentanyl 26) were enrolled inthe study. The mean (SD) time taken to achieve Ramsay score 03was lower in propofol than fentanyl [15.7 (4.4) s vs 206 (55) s,P<0.001]. Propofol arm had significantly higher physiciansatisfaction, less requirement of adjuvant midazolam, lesscoughing and faster regain of full consciousness. There was nodifference in drug side-effects between the groups.Conclusion: Propofol has a shorter sedation induction time, lesscoughing during procedure, less recovery time, and betterphysician satisfaction compared to fentanyl for flexiblebronchoscopy in children.
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Objective: To determine occurrence of malnutrition in childrenwith cystic fibrosis and identify predictors of malnutrition at time ofenrolment and after 2 years of follow up.Design: Retrospective chart review.Setting: Pediatric chest clinic at a tertiary-care center in northernIndia.Patients: Cystic fibrosis patients enrolled between 2009-2015with at least 3 years follow-up.Procedure: Weight and height were noted at enrolment, and after1 year and 2 years of follow-up. Clinical details, medications, andpulmonary exacerbations during second year were recorded.Main outcome measure: Occurrence of malnutrition i.e. weightfor age Z-score < -2.Results: 61 medical records were reviewed. Occurrence ofmalnutrition at baseline, and 1- and 2-year follow-up was 65.5%,54.1% and 57.3%, respectively. Weight for age Z-score atenrolment significantly correlated with time to diagnosis fromonset r=0.015, P=0.029). Weight for age Z-score at 2-year follow-up was significantly associated with steatorrhea (P=0.03),increased frequency of stools (P<0.01) and pulmonaryexacerbation (P=0.03) during second year. Linear regressionshowed significant association between weight for age Z-score at2 years with steatorrhea and pulmonary exacerbations [r=-0.795(-1.527, -0.062)] and [r=-0.261 (-0.493, -0.028)]. Pulmonaryexacerbations during second and third year had significantcorrelation with weight for age Z-score at the beginning ofrespective years (r = -0.219, P=0.015).Conclusion: Occurrence of malnutrition is high in children withcystic fibrosis in this region, with uncontrolled fat malabsorptionand recurrent respiratory infections being significant risk factors.
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Objectives: To document clinical features and outcome of children with sarcoidosis.Methods: Case records of 18 children (mean (SD) age 9 (2.2) years) diagnosed withsarcoidosis between 2006 and 2016 were reviewed. All children were followed up every 2-3months and monitored for clinical and laboratory parameters. Their treatment and outcomewere recorded. Results: Clinical features at the time of diagnosis were fever (83%), uveitis(50%), difficulty in breathing (44%), hepatosplenomegaly, weight loss, arthritis and peripheraladenopathy. Imaging findings included: hilar adenopathy (94%), abdominal nodes (50%) andpulmonary infiltrates (44%). All children were treated with steroids (range 6-12 months) andweekly low dose oral methotrexate. All patients showed significant improvement over a mean(SD) duration of follow-up of 3.1 (0.9) years, as assessed by resolution of clinical symptoms,and improvement in spirometry parameters, erythrocyte sedimentation rate, and serumangiotensin converting enzyme levels. Conclusions: Children with sarcoidosis seem torespond well to systemic steroids and low dose methotrexate. Delayed diagnosis and ocularinvolvement are probably associated with poor outcome.
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Background: Plastic bronchitis is characterized by formation of extensive obstructiveendobronchial casts and high recurrence rates. Case characteristics: Two children (1-year-old girl, 7-year-old boy) who had recurrent episodes of respiratory distress with acuteworsening. Bronchoscopy revealed membrane-like casts. Both children were managed withnebulized N-acetylcysteine in addition to management for asthma. Outcome: Symptom-free without recurrence for more than 9 months of follow-up. Message: Nebulized N-acetylcysteine may be helpful in prevention of recurrence of plastic bronchitis due to asthma.
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Snake bite is a common condition in tropical countries. Neurotoxic features of snake bite vary from early morning neuroparalytic syndrome to various cranial nerve palsies. Locked in syndrome (LIS) is a rare presentation. We present four children that had LIS; three patients had total and one had incomplete LIS. All patients made successful recovery with polyvalent anti-snake venom and supportive management. This case series highlights the importance of early diagnosis of LIS in snake bite.
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Ketamine has bronchodilator properties and is used for severe bronchospasm in adults and children with asthma. Here, we report successful use of ketamine in a young infant with bronchospasm.
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Radio, television (TV), movies, video games, cell phones, and computer networks have assumed central roles in our children’s daily lives. The media has demonstrated potentially profound effects, both positive and negative, on children’s cognitive, social, and behavioral development. Considering the increasing exposure of children to newer forms of media, we decided to review the current literature on the effects of media on child health both in the Western countries and India. It is widely accepted that media has profound influence on child health, including violence, obesity, tobacco and alcohol use, and risky sexual behaviors. Simultaneously, media may have some positive effects on child health. We need to find ways to optimize the role of media in our society, taking advantage of their positive attributes and minimizing their negative ones. We need to understand better how to reverse the negative impact of media and make it more positive.
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Acrodermatitis Enteropathica (AE) is an important nutritional disorder of children affecting both innate and cell mediated immunity. It predisposes to secondary bacterial and candida superinfections. We describe an infant with typical features of AE who had candida infection with a fulminant course. Need of early recognition and prompt initiation of therapy for fungal infection in AE is emphasized.