Infantile Colic: An Update

Context: Infantile colic is self-limiting condition but it can be a cause of anxiety for parents and challenge for doctors. The challenge for thedoctors lies in correct identification of the condition and appropriate management. The objective of this review article is to summarize thepathophysiology, treatment options and outcome in infantile colic so that clinicians can have a fair idea about the condition, recentupdates and future prospects.Evidence: A search of the Cochrane Library, PubMed, and Google Scholar was made using the key words “Infant colic”, Infantile colic”,“excessive crying in infants”. All the materials were analyzed and summarized.Results: At present, infantile colic is an area of clinical research both in terms of etiology and treatment. Various etiological theories havebeen proposed but none of them are strong enough to completely describe the condition. Various treatment agents are being tried forcolic like counseling and behavioral modification, dietary modification, lactase and probiotic supplementation, pain relieving agents, andchiropathy. Proper counseling of the parents is the first line of management at present. Simethicone has no role in decreasing thesymptoms of colic and Dicyclomine is not recommended in children younger than six months. No specific recommendations have beenmade on the use of pain relieving agents and manipulative therapies in colic. At present strong evidence is lacking regarding the use ofprobiotics, lactase supplementation and dietary modification.Conclusion: Counseling of parents about the benign nature of the condition is considered first line for now until an effective treatment isestablished. Other treatment options are prescribed on a case-based manner, and based on the parental perception of the condition.

Anti-HBs Titers Following Pentavalent Immunization (DTwP- HBV-Hib) in Term Normal Weight vs Low Birthweight Infants

Objective: To compare anti-HBs titers between term low birthweight (1800-2499 g) infants and normal birthweight infants, 6weeks after last dose of primary immunization with pentavalentvaccine, and to study adverse events following immunization(AEFI) with pentavalent vaccine.Design: Cohort study.Setting: Tertiary-care hospital predominantly catering to urbanpoor population of East Delhi.Participants: 265 low birthweight (1800-2499 g) and 265 normalbirthweight (2500-4000 g) infants. Monovalent Hepatitis B vaccinewas administered within 24 hours of birth followed by three primarydoses of pentavalent vaccine at 6, 10 and 14 weeks. Anti-HBstiters were estimated after 6 weeks of third dose of pentavalentvaccine. Adverse events following immunization (AEFI) monthwere observed for a month after each dose of pentavalent vaccine.Main outcome measures: Anti HBs antibody titers after 6 weeksof primary immunization, and AEFI.Result: 443 (83.5%) infants (225 low birthweight and 218 normalbirthweight infants) completed the follow-up. Seroprotectionagainst hepatitis B virus was achieved in both groups afterpentavalent vaccine administration. Anti HBs GMTs in lowbirthweight infants (194.8 mIU/mL) and normal birthweight infants(204.2 mIU/mL) were comparable (P = 0.17). No serious adverseevents were observed in either group.Conclusion: Three primary doses of pentavalent vaccineadministered along with zero dose of Hepatitis B vaccine at birthprovide good seroprotection. The vaccine appears to be safe inboth low birth weight and normal birthweight infants born at term.

Effect of Gastric Lavage on Meconium?Aspiration Syndrome and Feed Intolerance in Vigorous? Infants Born with Meconium Stained Amniotic Fluid – A?Randomized Control Trial

Objective: To compare the incidence of meconium aspirationsyndrome and feed intolerance in infants born through meconiumstained amniotic fluid with or without gastric lavage performed atbirth.Setting: Neonatal unit of a teaching hospital in New Delhi, India.Design: Parallel group unmasked randomized controlled trial.Participants: 700 vigorous infants of gestational age ?34 weeksfrom through meconium stained amniotic fluid.Intervention: Gastric lavage in the labor room with normal salineat 10 mL per kg body weight (n=350) or no gastric lavage (n=350).Meconiumcrit was measured and expressed as ?30% and >30%.Outcome Measures: Meconium aspiration syndrome, feedintolerance and procedure-related complications during 72 h ofobservation.Results: 5 (1.4%) infants in lavage group and 8 (2.2%) in nolavage group developed meconium aspiration syndrome (RR0.63, 95% CI 0.21, 1.89). Feed intolerance was observed in 37(10.5%) and 53 infants (15.1%) in lavage and no lavage groups,respectively (RR 0.70, 95% CI 0.47, 1.03). None of the infants ineither group developed apnea, bradycardia or cyanosis during theprocedure.Conclusion: Gastric lavage performed in the labor room does notseem to reduce either meconium aspiration syndrome or feedintolerance in vigorous infants born through meconium stainedamniotic fluid.Keywords: Neonate, Prevention, Respiratory distress, Riskfactors, Vomiting.

Celiac Disease in Children with Moderate-to-Severe Iron-deficiency Anemia

Objective: To evaluate the proportion of children with moderate to severe iron-deficiencyanemia who have associated celiac disease. Methods: This cross-sectional analytical studywas conducted among children aged 1 to 12 years of age with moderate-to-severe irondeficiency anemia and control children without anemia.Serum IgA-tissue trans-glutaminaselevels were assessed in both cases and controls. All children with positive celiac serologyunderwent upper gastrointestinal endoscopy and duodenal biopsy; biopsy finding of Marshgrade 3 was considered positive for celiac disease. Results: There were 152 anemic childrenand 152 controls with mean (SD) hemoglobinof 7.7 (1.8) and 12.2 (0.74) g/dL, respectively.16 (10.5%) cases and 3 (2%) control patients had positive serology for celiac disease [OR(95% CI) 5.33 (1.52-18.67), P=0.007]. Six (3.9%) children with iron-deficiency anemia andnone of the controls had biopsy features diagnostic of celiac disease. Conclusion:In theNorthern Indian tertiary-care hospital outpatient setting, Celiac disease was associated with4% of children presenting with moderate-to-severe anemia.

Comparative Efficacy and Safety of Oral Iron Chelators and their Novel Combination in Children with Thalassemia.

Objective: To compare the efficacy and safety of oral iron chelators (Deferiprone and Deferasirox) when used singly and in combination in multi-transfused children with thalassemia. Design: Prospective comparative study. Setting: Thalassemia Center of a medical college affiliated hospital Participants and Intervention: 49 multi-transfused children with thalassemia with a mean (SD) age 11.6 (6.21) y received daily chelation therapy with either deferiprone alone (75 mg/kg/day in 3 divided doses), deferasirox alone (30 mg/kg/day single dose) or their daily combination (same dose as monotherapy) for 12 months. Outcome measures: Serum ferritin levels at the start of study, after 6 months and after 12 months. MRI T2* of liver and heart initially and after 6 months of follow up. 24-hour urinary iron excretion values at the outset and after 12 months of chelation therapy. At every visit for blood transfusion, all patients were clinically assessed for any adverse effects; liver and renal functions were monitored 6-monthly. Results: After 12 months of respective chelation therapy, serum ferritin values decreased from a mean of 3140.5 ng/mL to 2910.0 ng/mL in deferiprone alone group, 3859.2 ng/mL to 3417.4 ng/mL in deferasirox alone group and from 3696.5 ng/mL to 2572.1 ng/mL in the combination group. The combination therapy was more efficacious in causing fall in serum ferritin levels compared to deferiprone and deferasirox monotherapy (P=0.035 and 0.040, respectively). Results of MRI T2* were equivocal. Combined drug usage produced maximum negative iron balance in the body by maximally increasing the iron excretion in urine from 61.1 µmol/day to 343.3 µmol/day (P=0.002). No significant adverse reactions were noticed in either the monotherapy or the combination group. Conclusion: Oral combination therapy of deferiprone and deferasirox appears to be an efficacious and safe modality to reduce serum ferritin in multi-transfused children with thalassemia.

Efficacy and Safety of Drotaverine Hydrochloride in Children with Recurrent Abdominal Pain: A Randomized Placebo Controlled Trial.

Objective: To evaluate the efficacy and safety of Drotaverine hydrochroride in children with recurrent abdominal pain. Design: Double blind, randomized placebo-controlled trial. Setting: Pediatric Gastroenterology clinic of a teaching hospital. Participants: 132 children (age 4-12 y) with recurrent abdominal pain (Apley Criteria) randomized to receivedrotaverine (n=66) or placebo (n=66) orally. Intervention: Children between 4-6 years of age received 10 mL syrup orally (20 mg drotaverine hydrochloride or placebo) thrice daily for 4 weeks while children >6 years of age received one tablet orally (40 mg drotaverine hydrochloride or placebo) thrice daily for 4 weeks. Outcome Measures: Primary: Number of episodes of pain during 4 weeks of use of drug/placebo and number of pain-free days. Secondary: Number of school days missed during the study period, parental satisfaction (on a Likert scale), and occurrence of solicited adverse effects. Results: Reduction in number of episodes of abdominal pain [mean (SD) number of episodes 10.3 (14) vs 21.6 (32.4); P=0.01] and lesser school absence [mean (SD) number of school days missed 0.25 (0.85) vs 0.71 (1.59); P=0.05] was noticed in children receiving drotaverine in comparison to those who received placebo. The number of pain-free days, were comparable in two groups [17.4 (8.2) vs 15.6 (8.7); P=0.23]. Significant improvement in parental satisfaction score was noticed on Likert scale by estimation of mood, activity, alertness, comfort and fluid intake. Frequency of adverse events during follow-up period was comparable between children receiving drotaverine or placebo (46.9% vs 46.7%; P=0.98), Conclusion: Drotaverine hydrochloride is an effective and safe pharmaceutical agent in the management of recurrent abdominal pain in children.

Predictors of mortality among the neonates transported to referral centre in Delhi, India.

A descriptive study was conducted with an objective to determine the predictors of mortality among referred neonates and to ascertain their transport characteristics. A total of 300 consecutive neonates who were transferred to the centre were enrolled in the study. Following information were recorded: maternal details, birth details, interventions before transportation, details of transportation and neonatal condition at arrival. Detailed clinical assessment and management was done as per standard neonatal protocols. Birth weight <1 kg (OR 0.04; 95% CI: 0.006-0.295, P<0.01) and transportation time >1 hour (OR 5.58; 95% CI: 1.41-22.01, P=0.01) were found to be significant predictors for mortality among the transported neonate. Transport characteristics reflect road transport with limited utility of ambulances and lack of trained health personal. Hence to conclude, extreme low birth weight and prolonged transportation time were found to be significant predictors of neonatal mortality among the transported neonate.

Informed Consent in Pediatric Practice.

Informed consent is a communication process of providing the patient/parents/guardians with relevant information regarding the treatment and the diagnosis, so that they can make informed decisions. The process of informed consent in pediatric patients is not well understood. The amount of information to be disclosed in an informed consent is a matter of debate. There are four basic elements to the content of informed consent form: nature of procedure, risks, benefits and alternatives. The article delineates the essential elements and legal implications of informed consent in pediatric practice.

Fraser-cryptophthalmos syndrome with colonic atresia.

Fraser cryptophthalmos syndrome is a severe genetic disorder comprising of cryptophthalmos, syndactyly and genitourinary abnormalities. Gastrointestinal malformations are also increasingly being described. We describe a neonate with this syndrome having colonic atresia leading to cecal rupture and pneumoperitoneum.

Efficacy of permethrin cream and oral ivermectin in treatment of scabies.

OBJECTIVE: To compare the efficacy of mass treatment of scabies with permethrin cream and oral ivermectin in a closed urban pediatric population. METHODS: A comparative trial of topical permethrin and oral ivermectin was conducted in a closed population of 84 children living in a urban hostel of Delhi. RESULTS: After mass treatment with 2 doses of oral ivermectin, one case was recorded in following 6 months, as compared to 22 cases in preceding 6 months when children were treated with a single application of 5% permethrin. CONCLUSION: Mass treatment of scabies with ivermectin in an endemic population is more efficacious as compared to topical permethrin application in reducing the baseline prevalence, decreasing the chain of transmission and chances of reinfection.

Intracranial arteriovenous malformation with maternal carbamazepine use.

1 1/2 month old child born to primigravida mother on prolonged carbamazepine therapy presented with recurrent seizures. The child had abnormal facies and was diagnosed to be having arteriovenous malformation with intracranial hemorrhage on neuroimaging. This case suggests that development of arteriovenous malformation in a child with maternal carbamazepine therapy may occur as a part of clinical profile of 'fetal anticonvulsant syndrome'.

Neonatal pseudohypoparathyroidism.

The case of a neonate is presented who had early onset seizure associated with hypocalcemia, hyperphosphatemia, and raised parathyroid hormone. The infant did not have any stigmata of pseudohypoparathyroidism. The hypocalcemia was initially resistant to calcium therapy, but responded to vitamin D analog therapy. The diagnosis of 'neonatal pseudohypoparathyroidism' was entertained; the infant remained stable and seizure-free with normal serum biochemistry during 3 months of follow-up.

Meropenem.

Meropenem is a new carbapenem antibacterial agent with wide spectrum of activity against gram-negative, gram-positive and anaerobic organisms. It is stable against most beta-lactamases produced by gram-negative bacteria and has greatest utility in treating severe infections in hospitalized children. It has good CSF penetrability and useful in treatment of childhood meningitis and infections in neutropenic children. Due to concern relating to emergence of resistance, it should be used as a reserve drug in difficult-to-treat infections caused by resistant organisms or when conventional treatment fails.

Linezolid.

Linezolid is an oxazolidinone antibacterial agent that acts by inhibiting the initiation of bacterial protein synthesis. Linezolid has a wide spectrum of activity against gram-positive organisms including methicillin resistant staphylococci, penicillin resistant pneumococci and vancomycin resistant enterococcus faecalis and E. faecium. Linezolid has a good bio-availability orally and could be switched from parenteral to oral therapy while treating serious infections. Linezolid is well tolerated in children.