Comparison of COVID-19 Infection in Children During the First and Second Wave

Concerns have been raised in the media that ‘the third wave’ will severely afect children. Here, an experience of SARSCoV-2 infection in children is reported. Of the 8,626 SARS-CoV-2 RT-PCR tests performed in children (0–17 y) from March 2020 to July 2021 at the authors' institute, 1470 (17%) were positive, [711/4821 (14.7%) during the frst wave (July 2020 to January 2021), and 759/3583 (21.2%) during the second wave (February 2021 to July 2021)]. The children in both waves were similar in presentation (74.1% mildly symptomatic versus 80.2% mildly symptomatic; rest asymptomatic). None of them had COVID pneumonia. Five children died (0.3%), all of a serious primary non-COVID disease. Seventy-three cases of MIS-C during August 2020 to July 2021, with low mortality (2.7%) were also identifed. The similarity in COVID-19 infection in children between the frst and the second waves seems to suggest that the likelihood of the ‘third wave’ hitting children hard is low.

Assessment of Causality in Hospitalized Children With AminoglycosideRelated Nephrotoxicity

Objectives: To evaluate the incidence of aminoglycoside-related nephrotoxicity and ascertain drug causality and its risk factors. Methods: This prospective study was conducted from January, 2019 to January, 2021, and recruited 110 consecutively admitted children aged 1 month to 12 years, receiving aminoglycosides for ?4 days. Drug causality was assessed using Liverpool adverse drug reaction causality assessment tool. Results: 42 (38.2%) children developed acute kidney injury (AKI), with 71 (64.5%) having composite nephrotoxicity (AKI and/or tubular-dysfunction). Only 17 (15.5%) had AKI definitively attributable to aminoglycosides. Hypotension [OR 0.016 (95% CI 0.01-0.71), P=0.03], PRISM-III score 20-29% [OR 55.48 (95% CI 3.66-840.53), P=0.004] and post-surgery patients [OR 3.2 (95% CI 1.01-10.1), P=0.047] were independent predictors of AKI. Conclusions: Only a small proportion of children receiving aminoglycosides had AKI definitively attributable to the drug.

Indian Academy of Pediatrics Revised (2021) Guidelines on Prevention and Treatment of Vitamin D Deficiency and Rickets

Justification: The emerging literature on prevalence of vitamin D deficiency in India, prevention and treatment strategies of rickets, and extra-skeletal benefits of vitamin D suggest the need for revising the existing guidelines for prevention and treatment of vitamin D deficiency in India. Objectives: To review the emerging literature on vitamin D prevalence and need for universal vitamin D supplementation. To suggest optimum vitamin D therapy for treatment of asymptomatic and symptomatic vitamin D deficiency, and rickets. To evaluate the extra-skeletal health benefits of vitamin D in children. Process: A National consultative committee was formed that comprised of clinicians, epidemiologists, endocrinologists, and nutritionists. The Committee conducted deliberations on different aspects of vitamin D deficiency and rickets through ten online meetings between March and September, 2021. A draft guideline was formulated, which was reviewed and approved by all Committee members. Recommendations: The group reiterates the serum 25- hydroxy vitamin D cutoffs proposed for vitamin D deficiency, insufficiency, and sufficiency as <12 ng/mL, 12-20 ng/mL and >20 ng/mL, respectively. Vitamin D toxicity is defined as serum 25OHD >100 ng/mL with hypercalcemia and/or hypercalciuria. Vitamin D supplementation in doses of 400 IU/day is recommended during infancy; however, the estimated average requirement in older children and adolescents (400-600 IU/day) should be met from diet and natural sources like sunlight. Rickets and vitamin D deficiency should be treated with oral cholecalciferol, preferably in a daily dosing schedule (2000 IU below 1 year of age and 3000 IU in older children) for 12 weeks. If compliance to daily dosing cannot be ensured, intermittent regimens may be prescribed for children above 6 months of age. Universal vitamin D supplementation is not recommended in childhood pneumonia, diarrhea, tuberculosis, HIV and non-infectious conditions like asthma, atopic dermatitis, and developmental disorders. Serum 25-hydroxy vitamin D level of >20 ng/mL should be maintained in children with conditions at high-risk for vitamin deficiency, like nephrotic syndrome, chronic liver disease, chronic renal failure, and intake of anticonvulsants or glucocorticoids.

Hepatitis B Seroprotection in Pediatric Nephrotic Syndrome

Objectives: To study the prevalence of Hepatitis B seroprotection in children (>1 y) withnephrotic syndrome vaccinated against Hepatitis B vaccine as per the UniversalImmunization Program schedule (0,6,10,14 wk); to compare the Hepatitis B seroprotectionrates and anti-HBs titers among different phenotypes of nephrotic syndrome; to evaluate theassociation between Hepatitis B seroprotection status and the immunosuppressive agents;and to study the correlation between anti-HBs titres and proteinuria. Methods: Hepatitis Bserology and anti-HBs titers were analyzed in 100 children (age-1-18 y) with different clinicalphenotypes of nephrotic syndrome (cases) and 100 healthy controls. Results: Theproportion of seroprotected children among the cases and controls was 37% (n=37) and 61%(n=61), respectively (P<0.04). The median (IQR) anti- HBs antibodies titers among the caseswas 75 (62.5, 81) mIU/mL and 112 (56, 367) mIU/mL among the controls (P=0.001). Theproportion of seroprotected children among the steroid sensitive nephrotic syndrome, steroid-resistant nephrotic syndrome and controls was 40% (n=28), 30% (n=9) and 61% (n=61),respectively (P<0.01). No differences in the anti-HBs titers between children receivingsteroids versus steroids along with other immunosuppressants were found. Weak negativecorrelation was noted between proteinuria and protective titers (r = -0.155; P=0.039).Conclusion: Children with nephrotic syndrome, in general, and steroid-resistant nephroticsyndrome in particular, show poor seroprotection with Hepatitis B vaccination.

Clinical Spectrum of Congenital Anomalies of Kidney and Urinary Tract in Children

Objective: To evaluate the clinical spectrum and patterns of clinical presentation incongenital anomalies of kidney and urinary tract. Methods: We enrolled 307 consecutivelypresenting children with congenital anomalies of kidney and urinary tract at the pediatricnephrology clinic. Patients were evaluated clinically, with serum biochemistry, appropriateimaging and radionuclide scans. Results: The most common anomaly was primaryvesicoureteric reflux (VUR) (87, 27.3%), followed by pelviureteral junction obstruction(PUJO) (62,20.1%), multicystic dysplastic kidney (51 16.6%), non-obstructivehydronephrosis (32, 10.4%) and posterior urethral valves (PUV) (23, 7.4%). 247 (80.4%)anomalies had been identified during the antenatal period. Another 33 (10.7%) werediagnosed during evaluation of urinary tract infection, and 21 (6.8%) during evaluation forhypertension at presentation. Obstructive anomalies presented earlier than non-obstructive(7 (3, 22.5) vs 10 (4, 24) mo: (P=0.01)). The median (IQR) ages of presentation for childrenwith PUV (n=23), VUR (n=87) and PUJO (n=62) were 4 (2, 14) mo, 10 (5, 27) mo, and 7 (3,22.5) mo, respectively. Nine (2.9%) children had extrarenal manifestations. Conclusions:The median age at clinical presentation for various subgroups of anomalies indicatesdelayed referral. We emphasize the need for prompt referral in order to initiate appropriatetherapeutic strategies in children with congenital anomalies of kidney and urinary tract

Effect of Vitamin D and Calcium Supplementation on Bone Mineral Content in Children with Thalassemia

Objective: To evaluate the effect of vitamin D and calcium supplementation forosteoprotection in thalassemia. Methods: 29 children (age 2-12 y) were supplementedwith oral vitamin D (1000 IU/d) and calcium (500 mg/d) for 1 year. The dual energy X-rayabsorptiometry (DXA) was done to assess bone mineral content at baseline and 12 months.Serum 25-hydroxy vitamin D, intact parathyroid hormone, osteocalcin, calcium, phosphate,alkaline phosphatase, and spot urine deoxypyridinoline (DPD)/creatinine were done atbaseline, 6 months and 12 months. Results: The mean (SD) bone mineral content increasedfrom baseline value of 8.4 (2.8) g to 10.8 (3.5) g (P<0.001). The mean (SD) vitamin D levelincreased from baseline value of 16.0 (5.8) ng/mL to 23.4 (6.6) ng/mL (P<0.001). Thechange in serum osteocalcin and spot urine DPD/creatinine ratio were not significant(P=0.062). Conclusions: Oral vitamin D and calcium supplementation increases bonemineral content in children with thalassemia

Russell’s Viper Envenomation-associated Acute Kidney Injury in Children in Southern India.

Objectives: To determine the frequency and risk factors of acute kidney injury in children with Russell’s viper envenomation using Acute Kidney Injury Network definition and classification system. Methods: A prospective observational study recruiting 61 subjects managed as per the National Snakebite Protocol. Results: 45.9% of envenomed children had acute kidney injury. The median (IQR) of the maximum serum creatinine level during hospitalization was 2 (1.3-4.8) mg/dL. The distribution of stages 1, 2 and 3 of acute kidney injury was 32.1%, 17.9% and 50% respectively. Dialysis was required in 35.7% of the children with acute kidney injury. Conclusions: Acute kidney injury is common with Russell’s viper envenomation. Native treatments and bleeding manifestations were associated with acute kidney injury in our patient population.

Predictors of Myocardial Dysfunction in Children with Indian Red Scorpion (Mesobuthus tamulus) Sting Envenomation.

Objectives: To identify predictive risk factors for myocardial dysfunction in children with scorpion sting envenomation and to evaluate the effects of Scorpion antivenom and prazosin combination therapy on occurrence of myocardial dysfunction. Design: Observational. Setting: Tertiary care hospital in Southern India. Participants: 85 children aged <13 years with scorpion sting envenomation. Outcome measures: Frequency of myocardial dysfunction; predictors of myocardial dysfunction. Results: 24 children (28.2%) developed myocardial dysfunction. Hypotension at admission (P=0.003) and increased time (>4h) between sting and administration of appropriate therapy (P=0.001) were independent predictors of myocardial dysfunction on logistic regression. Scorpion antivenom plus prazosin combination therapy led to an increase in cumulative proportion of children without myocardial dysfunction. Conclusion: Early (<4 hours) administration of Scorpion antivenom along with prazosin increases the cumulative percentage of children not developing myocardial dysfunction.

Profile of urinary tract infections in paediatric patients.

Background & objectives: this cross-sectional study was conducted at a tertiary care centre in Puducherry, south India, with the aim of finding the profile of the paediatric urinary tract infection (UTI), bacterial pathogens involved, and also to observe vesicoureteric reflux (VUR) and renal scarring in these patients. Methods: A total of 524 paediatric patients ≤13 yr, suspected to have UTI, were included in the study. Urine samples were collected, processed for uropathogen isolation and antibiotic susceptibility test was performed as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Thirty two culture proven children with UTI underwent micturating cysto-urethrography (MCU) and dimercaptosuccinic acid (DMSA) scanning was done for 69 children. Results: of the 524 children, 186 (35.4%) had culture proven UTI with 105 (56.4%) being infants, 50 (27.4%) between 1-5 yr, 30 (16.12%) between 5-13 yr and 129 (69.35%) males. Posterior urethral valve (PUV) was noted in three, hydronephrosis in one, VUR in 18 and renal scarring in 33. VUR as well as renal scarring were more in males >1 yr of age. A significant association (P=0.0054) was noted with a combined sensitivity and specificity of these investigations being 83 and 90 per cent, respectively of the MCU and DMSA scans for detecting VUR. Escherichia coli was the most common pathogen isolated, sensitive to nitrofurantoin, followed by cefoperazone-sulbactam, aminoglycosides and meropenem. Interpretation & conclusions: Our results indicate that UTI varies with age and gender and extensive evaluation is required in boys under one year of age with UTI. This study also highlights the better efficacy of aminoglycosides, cefoperazone-sulbactam and nitrofurantoin in vitro compared with meropenem in gram-negative uropathogens.

Clinical and Microbiological Profiles of Shigellosis in Children.

Shigellosis presents with varied clinical features are dictated by the species involved, virulence factors of the strain, and the host immune status. We studied the species, virulence genes, and antibiotic susceptibility pattern of the Shigella strains isolated from 33 children aged less than 12 years, with clinical features of shigellosis. Identification and antibiotic sensitivity of Shigella species were done using disc diffusion and E-test. Multiplex PCR was done for the detection of virulence genes (ipaH, ial, set1A, set1B, sen, and stx) and ESBL genes. Parents of the children were interviewed using structured questionnaire to assess the severity of the disease; 26 (79%) of the isolates were Shigella flexneri. Ciprofloxacin and ceftriaxone resistance was seen in 23 (69%) and 3 (9%) Shigella isolates respectively. Two ceftriaxone-resistant strains were found to harbour blaCTX gene and the third blaTEM gene. Virulence gene ipaH was detected in 100% of strains while ial, sen, set1A, and set1B were detected in 85%, 61%, 48%, and 48% respectively.

Chronic Hypoxemia in a Child: Thinking Outside the Box.

Background: Chronic hypoxemia is generally attributed to primary cardiac or pulmonary entities. Case characteristics: A 9-year-old boy presenting with cyanosis, clubbing and hypoxemia, without icterus or hepatosplenomegaly. Cardiovascular and respiratory system examinations were normal. Outcome: He was diagnosed as type IB Abernethy malformation, a rare cause of hepatopulmonary syndrome. Message: Pediatricians should consider hepatopulmonary syndrome in the differential diagnosis of chronic hypoxemia, even in the absence of jaundice or hepatosplenomegaly.

Clinical Spectrum and Predictive Risk Factors of Major Infections in Hospitalized Children with Nephrotic Syndrome.

This observational study was conducted with the primary objective of studying the incidence of major infections in nephrotic syndrome (NS), while the secondary objectives were to evaluate the risk factors for and the etiological spectrum of major infections. Eighty six children up to 13 years of age fulfilling the International Study of Kidney Disease in Children (ISKDC) criteria for NS, who required 101 hospital admissions were recruited from November 2010 to July 2012. Major infections were defined as those that are disseminated, affecting deep organs, requiring hospitalization or potentially life-threatening. The incidence of major infections was 36.6%. Among the major infections, peritonitis and pneumonia together accounted for 72.9%, while urinary tract infections and cellulitis accounted for 16.2%. On logistic regression, severe ascites and more severe clinical types of NS independently predicted major infections, while serum cholesterol >400 mg/dL was the sole predictor of peritonitis.

The Renal Cysts and Diabetes (RCAD) Syndrome in a Child with Deletion of the Hepatocyte Nuclear Factor-1β Gene.

The authors describe a 14-yr-old boy who presented with non-ketotic hyperglycemia, elevated serum creatinine levels and deranged liver function. There was no microalbuminuria or proteinuria. He also had mild mental retardation with learning difficulties. Ultrasonography of the abdomen revealed multiple renal cysts of varying sizes in both the kidneys. Dosage analysis of the hepatocyte nuclear factor (HNF)-1β gene by multiplex ligation-dependent probe amplification (MLPA) detected a heterozygous whole gene deletion (p.Met1_Trp557del). This finding is consistent with the diagnosis of renal cysts and diabetes (RCAD) syndrome. This is the first case of the RCAD syndrome reported in an Indian patient. Pediatricians need to be aware of this entity whenever renal disease is seen in a diabetic child in the absence of microalbuminuria or proteinuria.

Congenital langerhans cell histiocytosis with skin and lung involvement: Spontaneous regression.

Congenital self-healing Langerhans cell histiocytosis (CSHLCH) is a rare type of Langerhans Cell Histiocytosis, presenting at birth or during the neonatal period with eruption of multiple, discrete red-brown papules or nodules that undergo spontaneous regression. Systemic signs are generally absent. We describe a 4-month-old infant presenting with reddish brown nodular cutaneous lesions since birth with a past history suggestive of pulmonary involvement. Skin biopsy showed a dermal infiltrate of pleomorphic histiocytes; which were CD1a and S-100 positive, consistent with the diagnosis of CSHLCH. Both pulmonary and cutaneous lesions showed spontaneous resolution.

Ovarian tumors with elevated ca-125 levels and severe juvenile hypothyroidism: A need for increased awareness.

A 15-yr-old girl presented with bilateral gross ovarian tumors, clinical features of long-standing unrecognized hypothyroidism and markedly elevated CA-125 levels. Ovarian resection was avoided, as the presentation was consistent with the Van Wyk and Grumbach syndrome; and the patient was treated with replacement of thyroid hormone. Regression of the ovarian tumors occurred 6 months after initiation of the treatment. The authors emphasise the need for increased awareness and screening for hypothyroidism in patients with ovarian tumors, in order to prevent inadvertent operative interventions.