Etiology of Hemoptysis in Children and Adolescents – Multicentric Retrospective Data (2012-2021) From Chennai

Objective: To analyze the etiology of hemoptysis in children and to correlate the severity of bleed with the etiology. Methods: This retrospective multicentre study reviewed data from inpatient units of four tertiary care public and private sector pediatric hospitals in Tamil Nadu. Methods: Inpatient case records of children (aged 2 month-15 years) treated for hemoptysis at the four institutions between April, 2012 and March, 2021 were identified, after ethical clearance from respective institutions. Data of children with underlying known bleeding disorders like hemophilia or platelet abnormality were excluded from the study. Hemoptysis was categorized as mild, moderate and severe Results: Of the 73 children who had presented with hemoptysis during the study period, 60 (82.2%) children had mild, 9 (12.3%) had moderate and rest had severe hemoptysis. Idiopathic pulmonary hemorrhage was the most common cause of hemoptysis. The common causes of mild hemoptysis in children were idiopathic pulmonary hemorrhage (n=15, 25%), pulmonary tuberculosis (n=12, 20%) and pneumonia (n=8, 13.3%). Congenital airway anomalies and vascular anomalies were more likely to present with moderate to severe bleed. Conclusion: Etiology of hemoptysis is broad and categorizing them into mild, moderate and severe may give a clue about the possible etiology, there by restricting to the required investigations.

Fiberoptic Bronchoscopy in Unresolved Atelectasis in Infants.

This retrospective analysis documents the usefulness of fiberoptic bronchoscopy in finding the etiology of 56 cases of unresolved atelectasis in infancy, over a two year period (June 2005 to May 2007). Fiberoptic bronchoscopy identified the etiology leading to a revised diagnosis and change in management strategy in 38 (67.8%) cases, which included congenital airway anomalies (46.4%), inflammatory changes (10.7%), mucus plugs (28.5%), hypoplasia (4%), endobronchial granulation tissue (3.5%) and foreign body (3.5%). Fiberoptic bronchoscopy plays an important role in diagnostic work up of infants with unresolved atelectasis.

Mantoux and contact positivity in tuberculosis.

OBJECTIVE: To study the role of Mantoux and contact history in various forms of Childhood tuberculosis. METHODS: 605 children registered with TB clinic of Institute of Child Health and Hospital for Children, Chennai over a 5 year period from January 2000 to October 2005 with various forms of tuberculosis were recruited in the study. Clinical examination findings, basic investigations, chest skiagrams, computerized tomography (CT) wherever warranted, sputum or gastric aspirates for AFB smear, histopathology wherever possible were analyzed. RESULTS: The study showed that Mantoux positivity in various forms of tuberculosis studied is 34.7%. The positivity of Mantoux was highest in lymph node tuberculosis (53%) and the lowest with CNS tuberculosis (21.2%). Among the other forms, Mantoux positivity was 36.4% in TB abdomen, 44.4% in Skeletal TB, 30.3% in pulmonary tuberculosis. The contact positivity was 30.4% in the sample studied. CONCLUSION: The study also reflects that the extra pulmonary forms of tuberculosis seems to be more common in the pediatric population which constituted 79.8% of the cases included in the study.

Pediatric interstitial lung disease.

This study was done to ascertain the symptomatology, clinical features and investigations pertaining to interstitial lung diseases (ILD) in children. The medical records of 16 children admitted over a 4-year period from June 2000 to May 2004 with progressive cough, dyspnea, and chest X-ray/High Resolution Computerized Tomography (HRCT) abnormalities suggesting ILD were retrospectively evaluated. Clinical findings, investigations, chest skiagrams, HRCT, bronchoalveolar lavage (BAL) and lung biopsy reports were analyzed. An acute presentation of symptoms was seen in 4 cases (25%). Velcro crackles were the commonest clinical finding, present in 15 cases (93.8%). Serial X-rays revealed findings suggestive of ILD in 12 cases (75%) and HRCT was diagnostic in 13 cases (86.6%). Spirometry done in 5 cases showed a restrictive ventilatory defect, BAL analysis done in 8 cases demonstrated increased neutrophils and lung biopsy done in 5 cases was consistent with idiopathic pulmonary fibrosis. Mean survival duration of 2 years and 7 months after initial diagnosis was observed.

Effectiveness of ampicillin and combination of penicillin and chloramphenicol in the treatment of pneumonias: randomized controlled trial.

OBJECTIVE: To assess the effectiveness of ampicillin and a combination of benzyl penicillin and chloramphenicol in the treatment of pneumonias. DESIGN: Randomized controlled trial. SETTING: Tertiary care hospital. SUBJECTS: Patients 5 months to 4 years old with pneumonias of < 2 weeks duration. Exclusion criteria included acute bronchiolitis, allergy to penicillin, postmeasles pneumonia or prior administration of trial antibiotics in full dose for more than 2 days. INTERVENTION: Patients were randomized to receive either ampicillin (100 mg/kg/day) or combination of benzyl penicillin (100,000 units/kg/day) and chloramphenicol (100 mg/kg/day). The outcome measure was cure rate. RESULTS: There were 52 and 49 patients in the ampicillin and the combination groups, respectively. There was no significant difference in the baseline characteristics between groups except, nasal flare and cyanosis which were less in benzyl penicillin plus chloramphenicol group. There was also no difference either in the primary outcome, cure rate or secondary outcomes (days for cure, duration of tachypnea, fever and grunt) in the two. CONCLUSION: Considering the potential toxicity of chloramphenicol and the number of injections and doses to be given for the combination, ampicillin as a single drug could be preferred for the treatment of pneumonias, in this part of the country.

Missed opportunities for immunization in children under 2 years attending an urban teaching hospital.

A cross-sectional survey was done to assess the missed opportunity for immunization (MOI) in children under two years of age attending Medical Outpatient, Newborn Follow-up Service and Immunization Clinic of Institute of Child Health and to evaluate interventions. Baseline survey phase-I was done and two interventions: (i) education and awareness of immunization among health personnel; and (ii) attaching immunization slip to the outpatient form were done. After each intervention phase-II and phase-III surveys were carried out. The data from the different phases were analyzed for the effect of interventions. The total number of children surveyed were 634; 423 from Medical Outpatients, 108 from Newborn Follow-up Service and 103 from immunization Clinic. MOI was 35.5%, 23.1% and 9.7% in the above health facilities, respectively. After intervention I, the MOI was 24.5% and 12.2% in Medical Outpatient and Newborn Follow-up Service and none in Immunization Clinic. After intervention-II there was an improvement in immunization of 18.4%, 30.4% and 16.0% in the three health facilities mentioned above. MOI was avoided because the medical officers advised immunization in the above children. The difference in the MOI among Medical Outpatient and Immunization Clinic between baseline, phase-I and phase-II were significant (p < 0.001). It is concluded that MOI can be brought down by creating awareness periodically and that attaching an immunization schedule to the outpatient forms is an effective method of reducing MOI.

Etiological agents of acute poliomyelitis in south India.

This study was done to identify the specific etiological agents that cause acute poliomyelitis (APM). All the children newly diagnosed clinically as APM at the Institute of Child Health, Madras, during the period May 1988 to May 1989 were recruited. Stool specimen collection, transportation and identification of viruses by culture were done by standard procedures. The total number of children recruited was 312. Specimens were contaminated/insufficient in 10. Analysis was done for 302 cases. Polio virus type II was identified in 25.5% children, type I in 18.5%, type III in 15.9%, multiple polioviruses in 6.3% and non-polio enteroviruses (NPEV) in 20.2% cases. No virus was identified in 13.6%. Among the APM cases clinically diagnosed, the proportion of NPEV has increased considerably from 5% in 1984 to 20.2% in 1988-89. The age distribution was not significantly different between polio viruses and NPEV. The distribution of polio viruses and NPEV did not differ significantly in relation to immunization status, source of water supply, method of excreta disposal and the clinical types. For surveillance and control/eradication program of poliomyelitis, laboratory confirmation is essential.

Bacterial meningitis: diagnosis by latex agglutination test and clinical features.

To know the usefulness of Latex Agglutination Test (LAT) for the diagnosis of bacterial meningitis (BM), it was performed in all the 114 consecutive samples of CSF with polymorphs from 114 prospectively recruited children aged 2 months to 11 years. Definite diagnosis of BM based on culture and/or LAT was evident in 55. Among the 46 LAT positive, culture was positive in 3 only. Major organisms identified by LAT were H. influenzae B (HiB) in 28 and S. pneumoniae (SP) in 15. Ninety per cent of HiB and 67% of SP bacterial meningitis were under one year of age. Fever > 7 days prior to admission was not uncommon (38%) and 26% had received prior antibiotics. Meningeal signs were present in 64%. CSF cells were < 500/mm3 in 24% and sugar was > 50% of blood level in 23%. There was no significant difference in the immediate outcome between HiB and SP meningitis. The case fatality was 22% and was significantly high in cases who had altered level of consciousness on admission (p = 0.02). It is concluded that LAT is very useful for rapid diagnosis of BM.

Intramuscular injection as a provoking factor for paralysis in acute poliomyelitis. A case control study.

In order to identify the role of intramuscular injection (IM) as a provoking factor for poliomyelitis, a case control study as done at the Institute of Child Health, Madras from May 1988 to May 1989. The case was defined as acute poliomyelitis if he had acute asymmetric flaccid paralysis of lower motor neurone type without objective sensory disturbance following a short episode of fever. Controls were taken from children attending outpatient department for fever. Two controls matched for aged and sex were recruited for each case. Recruitment, data collection and clinical examination were done by a single pediatrician. IM injection received within 30 days prior to onset of paralysis or illness was considered to be the risk factor. The total number of cases and controls recruited were 257 and 515, respectively. Among cases, 172 (66.9%) out of 257 and among controls 252 (48.9%) out of 515, received IM injection within one month earlier to onset of paralysis or illness. The overall risk of paralysis, estimated for IM injection, was increased [odds ratio (OR) 2.1 (95% CI, 1.5-3.0)]. The maximum risk for paralysis was observed to be 2 weeks preceding the illness; the ORs for < 7 days was 2.2 (95% CI, 1.6-3.2) and for 7-13 days 3.2 (95% CI, 1.8 to 5.8). The risk of paralysis associated with IM injection was similar for unimmunized and immunized cases (OR 2.4 and 2.2). Multiple injections were not associated with a higher risk of developing paralysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for fatal pneumonia: a case control study.

We conducted a case control study to identify the risk factors for death among hospitalized children with acute pneumonia at the Institute of Child Health, Madras. All the 70 patients who died of pneumonia constituted the case--patients and 140 children recovered from pneumonia, selected by systematic sampling, during the same period served as controls. By univariate analysis, the risk factors for death in pneumonia observed were associated illnesses--Odds Ratio (OR) 22.2. (95% confidence interval [CI] 9.8-51.4; p = < 0.001); congenital anomalies--OR 10.4 (2.9-37.8; p = < 0.001); severe pneumonia--OR 4.2 (1.2-14.4; p = 0.09); marasmic status--OR 2.9 (1.5-5.7; p = 0.001); age under 6 months--OR 2.8 (1.3-5.7; p = 0.004); and severity of the pneumonia (lobar versus segmental)--OR 2.0 (0.9-4.5; p = 0.09). By logistic regression analysis the following risk factors were significant--associated illnesses. (51.6; 18-146.9; p = < 0.001); age under 6 months (6.5; 2-20.6; p = < 0.001), marasmic status (5.8; 2.2-15.6; p = < 0.001); and congenital anomalies (3.8; 2.0-7.1; p = < 0.001). These risk factors should be kept in mind by the clinicians for appropriate intervention at an earlier stage to minimize death.

Reasons for partial/non-immunization with oral polio vaccine/triple antigen among children under five years.

To identify the reasons for non-immunization/postponing immunization, parents of 615 poliomyelitis (APM) children and 908 children attending the Outpatient Department (OPD) for other ailments were interviewed. A total of 165 (26.9%), 185 (30.1%) and 264 (43%) among APM and 645 (71%), 183 (20.2%) and 80 (8.8%) among OPD children were immunized, partially immunized and unimmunized, respectively. Forty two per cent and 21% among parents of APM and OPD children, respectively in the unimmunized group were unaware of the need for immunization. The other reasons are minor illnesses, lack of interest, fear of side reaction, non-availability of vaccine or vaccinator. The decision to withhold immunization was mostly by parents when the child had some minor illnesses, mostly respiratory infections. It is recommended to educate the health personnel-clinicians and para-clinical workers by seminar and training and the public through mass media and group contact on the need for and completion of the immunizations.

Influence of maternal nutritional status on mode of delivery and asphyxia neonatorum.

To assess the influence of maternal malnutrition on the mode of delivery and asphyxia neonatorum, a cross sectional survey of 615 women in the age group of 20-28 yrs at the time of delivery was done. Women with chronic ailments and complicated pregnancies were excluded. The mothers were then classified into three groups based on Weight Height Product Index (WHPI) namely well nourished (WN), moderately malnourished (MMN) and severely malnourished (SMN). The proportion of asphyxiated babies among the three groups did not differ (P greater than 0.05). Abnormal deliveries like caesarean section were more common among SMN group compared to WN group ((P less than 0.01). No such difference was made out between MMN and WN groups (P greater than 0.05).

Epidemiological and clinical features of acute poliomyelitis children admitted in an urban hospital.

Six hundred and fourteen acute poliomyelitis children (57% boys) admitted to the Institute of Child Health, Madras, during January 1988 to September 1989 were studied. Diagnosis was based on clinical grounds. The age ranged from 2 months to 75 months. Residents of Madras city area were 31%, the rest being from neighbouring district (55%) and states (14%). Only 24% got protected water supply and 26% had access to safe disposal of excreta. Only a quarter (26.4%) had been immunized with 3 or more doses of oral polio vaccine. Intramuscular injection was given in 70% within one month of onset of paralysis. The commonest presentation was spinal form (80%) followed by spinobulbar (18%) and bulbar form (2%). Paralysis was severe in 72%, moderate in 6% and mild in 22%. Case fatality was 3.3%. The age at paralysis and clinical features in India have not changed over years. We conclude that the immunization programme should be effectively implemented to the maximum efficiency especially for the poor/illiterate community. Clinicians must be educated to avoid unwarranted intramuscular injections for any febrile illness.

Acute poliomyelitis in children: comparison of epidemiological and clinical features among immunized, partially immunized and unimmunized.

This study was conducted to compare the epidemiological and clinical features of acute poliomyelitis among immunized, partially immunized and unimmunized, as these have been postulated to be different amongst these subgroups. Of 614 children with acute poliomyelitis admitted at the Institute of Child Health, Madras, 162 (26.4%) were immunized, 183 (29.8%) were partially immunized and 269 (43.8%) were unimmunized. Poor environmental sanitation, unprotected water source and parental illiteracy were significantly more common among unimmunized group compared to the immunized group. It is concluded that there is no significant difference in symptoms, signs, clinical types, severity of paralysis and case fatality between the immunized, partially immunized and unimmunized.

Neonatal tetanus: observations on antenatal immunization, natal and immediate post-natal factors.

The objective is to study the present status of the antenatal immunization with tetanus toxoid and the natal and immediate postnatal factors among the cases of neonatal tetanus and the changes over time. Retrospective analysis of 61 case records of Neonatal Tetanus (NNT) during 1987-88 and prospective study of 19 cases of 1989 was done. The number of cases have decreased considerably from 88 in 1984 to 19 in 1989. 80% of cases were from residents outside the city. Antenatal checkup improved from 37.7% in 1987 to 73.7% in 1989. The proportion of mothers of NNT cases who received = greater than 2 doses have increased from 19.7% in 1987-88 to 31.6% in 1989. In the year 1989, 21% and 10.5% have received the I and II doses of TT respectively at the 9th month of pregnancy, the value of which is doubtful. Majority (73.7%) were domiciliary deliveries conducted by dhais and this has not changed over the years. The importance of antenatal booking, immunization at the appropriate time, hygienic obstetric and cord care are stressed.

Age for measles immunization seroconversion after measles vaccination at 6-8 months of age--a randomized controlled trial.

The objective of the study was to compare the effectiveness of measles vaccine by seroconversion in vaccinated children with non-vaccinated children of 6 to 8 months age group in a city slum community so as to study the feasibility of advancing the age of immunization. Live attenuated lyophilized Schwartz strain of measles vaccine was used. Hemagglutination inhibition (HI) antibody was estimated. Seroconversion was defined as either the conversion of negative to positive or a two fold rise in titre. One hundred and thirty two children completed the study. There was no difference in the age, sex and nutritional status between vaccinated and non-vaccinated groups (p greater than 0.7). The seroconversion rate in the vaccinated group was 65% and in the non-vaccinated group was 26%. The age, sex and nutritional status did not significantly affect the seroconversion. Our data suggest that immunization with measles vaccine may be effective as early as 6 months of age. Immunization at 6 months may be needed at least for children in densely populated areas like cities and towns.