Systematic Identification and Critical Appraisal of Pediatric COVID-19 Guidelines Applicable in India

Objective To systematically identify and critically appraise the methodological quality of pediatric guidelines applicable to management of COVID-19 in India. Methods Pediatric COVID-19 guidelines applicable to India, published until 30 April 2021, were identifed through a systematic search across ten databases. Each was critically appraised for methodological quality using the AGREE-II tool, by at least two appraisers. Median (interquartile range) of the total score and domain-wise scores were calculated, and compared for Indian vs. foreign guidelines, updated vs. original versions of guidelines, and those developed earlier vs. later in the pandemic. Results A total of 62 guidelines was identifed. Only 8 (12.9%) were published in India. The overall AGREE-II score ranged from 4.7% to 72.8%; with median (IQR) 37.9% (29.4, 48.6). This suggested overall low(er) methodological quality. The median (IQR) domain-wise scores were as follows: Scope and Purpose 66.7% (58.3, 83.3), Stakeholder Involvement 41.7% (30.6, 83.3), Rigor of Development 23.4% (14.8, 37.5), Clarity of Presentation 59.7% (50.0, 75.0), Applicability 27.1% (18.8, 33.3), and Editorial Independence 8.3% (0.0, 45.8). This suggested diversity in quality of diferent aspects of the guidelines, with very low quality in the critical domain of methodological rigor. There were no statistically signifcant diferences in the overall scores of Indian vs. foreign guidelines, updated versions vs. original versions, and those developed earlier vs. later in the pandemic. Conclusion The currently available pediatric COVID-19 guidelines have low methodological quality, adversely afecting their credibility, validity, and applicability. Urgent corrective strategies are presented for consideration.

Absence of diarrhea in purge nut ingestion: A case series of eight children.

There are very few case reports in literature of J. curcas poisoning. Previously grown as an ornamental plant; it is presently being cultivated on a large scale for its seed oil, which is used as biodiesel. This has brought this plant in close vicinity to the human population, exposing them to the chance ingestion. We are presenting clinical and biochemical profi le of eight children with J. curcas poisoning. The plant is commonly known to be a purgative and gastrointestinal irritant but the most conspicuous feature in our patients was absence of diarrhea. Lethargy, severe abdominal pain, inability to ingest anything, and intense thirst were the most prominent complaints in all children. The symptoms in all the patients were signifi cant enough to merit admission and intravenous fl uid therapy. Hematological and biochemical workup revealed neutrophilia and raised serum alkaline phosphatase in all patients while leukocytosis was observed in 5 of them. Electrocardiography was normal in all the patients.

Pulmonary diseases and corticosteroids.

Steroids (corticosteroids) are anti-inflammatory drugs. Corticosteroids are used in many pulmonary conditions. Corticosteroids have a proven beneficial role in asthma, croup (Laryngotracheobronchitis), decreasing the risk and severity of respiratory distress syndrome (RDS), allergic bronchopulmonary aspergillosis, interstitial lung disease, hemangioma of trachea, Pulmonary eosinophillic disorders. Role of corticosteroids is controversial in many conditions e.g. idiopathic pulmonary hemosiderosis, bronchiolitis, hypersensitivity pneumonitis, hyperplasia of thymus, bronchiolitis, acute respiratory distress syndrome, aspiration syndromes, atypical pneumonias, laryngeal diphtheria, AIDS, SARS, sarcoidosis, meconium aspiration syndrome (MAS), pulmonary haemorrhage, bronchitis, bronchiolitis obliterans with organizing pneumonia in JRA, histiocytosis, alpha-1 antitrypsin deficiency, bordtella pertusis, pulmonary involvement in histiocytosis. However these are used empirically in many of these conditions despite lack of clear evidence in favour. There is concern about their side effects, especially on growth. Systemic steroids are associated with significant adverse effects. Pulmonary conditions have a strategic advantage that inhaled corticosteroids are useful in many of these. Although inhaled preparations of corticosteroids have been developed to maximise effective treatment of lung diseases characterised by inflammation and reduce the frequency of harmful effects, these have not been eliminated. There are situations where only systemic steroids are useful. Clinicians must weigh the benefits against the potential detrimental effects. It is recommended that standard protocols for use of steroids available in literature should be followed, always keeping a watch on the potential hazards of prolonged use.