Indian Academy of Pediatrics Guidelines on Screen Time and Digital Wellness in Infants, Children and Adolescents

Justification: Screen-based media have become an important part of human lifestyle. In view of their easy availability and increasing use in Indian children, and their excessive use being linked to physical, developmental and emotional problems, there is a need to develop guidelines related to ensure digital wellness and regulate screen time in infants, children, and adolescents. Objectives: To review the evidence related to effects of screen-based media and excessive screen time on children’s health; and to formulate recommendations for limiting screen time and ensuring digital wellness in Indian infants, children and adolescents. Process: An Expert Committee constituted by the Indian Academy of Pediatrics (IAP), consisting of various stakeholders in private and public sector, reviewed the literature and existing guidelines. A detailed review document was circulated to the members, and the National consultative meet was held online on 26th March 2021 for a day-long deliberation on framing the guidelines. The consensus review and recommendations formulated by the Group were circulated to the participants and the guidelines were finalized. Conclusions: Very early exposure to screen-based media and excessive screen time (>1-2h/d) seems to be widely prevalent in Indian children. The Group recommends that children below 2 years age should not be exposed to any type of screen, whereas exposure should be limited to a maximum of one hour of supervised screen time per day for children 24-59 months age, and less than two hours per day for children 5-10 years age. Screen time must not replace other activities such as outdoor physical activities, sleep, family and peer interaction, studies, and skill development, which are necessary for overall health and development of the children and adolescents. Families should ensure a warm, nurturing, supportive, fun filled and secure environment at home, and monitor their children’s screen use to ensure that the content being watched is educational, ageappropriate and non-violent. Families, schools and pediatricians should be educated regarding the importance of recording screen exposure and digital wellness as a part of routine child health assessment, and detect any signs of cyberbullying or media addiction; and tackle it timely with expert consultation if needed.

Coronavirus Disease 2019 (COVID-19) Vaccination for Children: Position Statement of Indian Academy of Pediatrics Advisory Committee on Vaccination and Immunization Practices

Justification: Data generated after the first wave has revealed that some children with coronavirus 19 (COVID-19) can become seriously ill. Multi-inflammatory syndrome in children (MIS-C) and long COVID cause significant morbidity in children. Prolonged school closures and quarantine have played havoc with the psychosocial health of children. Many countries in the world have issued emergency use authorisation (EUA) of selected COVID-19 vaccines for use in children. In India, a Subject Expert Committee (SEC) has recommended the use of Covaxin (Bharat Biotech) for children from the ages of 2-18 years. The recommendation has been given to the Drugs Controller General of India (DCGI) for final approval. Objective: To provide an evidence-based document to guide the pediatricians on the recommendation to administer COVID vaccines to children, as and when they are available for use. Process: Formulation of key questions was done by the committee, followed by review of literature on epidemiology and burden of COVID-19 in children, review of the studies on COVID vaccines in children, and the IAP stand on COVID-19 vaccination in children. The available data was discussed in the ACVIP focused WhatsApp group followed by an online meeting on 24 October, 2021, wherein the document was discussed in detail and finalized. Recommendations: The IAP supports the Government of India’s decision to extend the COVID-19 vaccination program to children between 2-18 years of age. Children with high-risk conditions may be immunized on a priority basis. The IAP and its members should be a partner with the Government of India, in the implementation of this program and the surveillance that is necessary following the roll-out.

Clinical Profile of COVID-19 Illness in Children—Experience from a Tertiary Care Hospital

Objective To detail clinical profle and outcome in children infected with SARS-CoV-2. Methods This retrospective study was undertaken at a tertiary care pediatric teaching hospital in Northern India. The data on clinical characteristics and outcome of children (<18 y) with COVID-19 illness from April 2020–October 2020 were reviewed and analyzed. Results A total of 2919 children with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) illness were tested for novel COVID-19 virus in the fu emergency (n=1744), severe acute respiratory infection (SARI) ward (n=825), and non-COVID area (n=350) of the hospital. 8.73% (255/2919) children tested positive for SARS-CoV-2 infection. Of the 255 positive cases, 144 (56.47%) were managed on an outpatient basis and 100 (59 boys) required admission in COVID ward. The mortality rate of patients with SARS-CoV-2 was 11.4% (29/255). Majority of children admitted with COVID-19 had severe to critical illness due to the presence of malnutrition and underlying comorbidities. Conclusions Children of all age groups were susceptible to COVID-19 illness with a slight male preponderance. Amongst infected, two-third were asymptomatic or had mild symptoms that required outpatient management and home isolation. The adverse outcomes were more commonly seen in infants and children>10 y of age with malnutrition and comorbid illness.

Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP) Recommended Immunization Schedule (2018-19) and Update on Immunization for Children Aged 0 Through 18 Years

Justification: There is a need to revise/review recommendations regarding existing vaccines in view of current developments invaccinology. Process: Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics (IAP)reviewed the new evidence, had two meetings, and representatives of few vaccine manufacturers also presented their data. Therecommendations were finalized unanimously. Objectives: To revise and review the IAP recommendations for 2018-19 and issuerecommendations on existing and certain new vaccines. Recommendations. The major changes in the IAP 2018-19 ImmunizationTimetable include administration of hepatitis B vaccine within 24 hours of age, acceptance of four doses of hepatitis B vaccine if acombination pentavalent or hexavalent vaccine is used, administration of DTwP or DTaP in the primary series, and complete replacementof oral polio vaccine (OPV) by injectable polio vaccine (IPV) as early as possible. In case IPV is not available or feasible, the child shouldbe offered three doses of bivalent OPV. In such cases, the child should be advised to receive two fractional doses of IPV at aGovernment facility at 6 and 14 weeks or at least one dose of intramuscular IPV, either standalone or as a combination, at 14 weeks. Thefirst dose of monovalent Rotavirus vaccine (RV1) can be administered at 6 weeks and the second at 10 weeks of age in a two-doseschedule. Any of the available rotavirus vaccine may be administered. Inactivated influenza vaccine (either trivalent or quadrivalent) isrecommended annually to all children between 6 months to 5 years of age. Measles-containing vaccine (MMR/MR) should beadministered after 9 months of age. Additional dose of MR vaccine may be administered during MR campaign for children 9 months to 15years, irrespective of previous vaccination status. Single dose of Typhoid conjugate vaccine (TCV) is recommended from the age of 6months and beyond, and can be administered with MMR vaccine if administered at 9 months. Four-dose schedule of anti-rabies vaccinefor Post Exposure Prophylaxis as recommended by World Health Organization in 2018, is endorsed, and monoclonal rabies antibody canbe administered as an alternative to Rabies immunoglobulin for post-exposure prophylaxis.

Determinants of Nutritional Anemia in Adolescents.

Objectives: To associate the severity of nutritional anaemia with serum levels of ferritin, vitamin B12 and folate; and to determine demographic, socio-economic and nutritional correlates for nutritional anemia in adolescents. Methods: Cross-sectional hospital-based study among 200 adolescents (10-18 y) with anemia. Dietary intake (24-h recall), and serum levels of folate, vitamin B12 and ferritin were estimated. Results: Iron, folate and vitamin B12 deficiency was present in 30.5% 79.5% and 50% of adolescents, respectively. Statistically significant association was observed between severity of anemia and serum vitamin B12 levels, iron intake, folate intake, Vitamin B12 intake, vegetarian diet, attainment of menarche and history of worm infestation. Conclusions: Folate and vitamin B12 deficiencies are more common than iron deficiency in anemic adolescents. Low dietary intake of these nutrients seems to be a significant determinant of their deficiencies.

Antithymocyte globulin and cyclosporin in children with acquired aplastic anemia.

OBJECTIVE: To assess the responses to ATG and cyclosporin combination in patients of aplastic anemia. METHODS: Twenty three (17M: 6F) patients of aplastic anemia (11 very severe aplastic anemia (VSAA) and 12 severe aplastic anemia (SAA), were administered antithymocyte globulin and cyclosporin. RESULTS: The median age of patents was 8 years (range 6-12 years). Three patients died within 2 months of therapy. Twenty children (11 SAA and 9 VSAA) were finally analysed. Six months after the start of treatment, 8/20 (40%) patients responded-2 complete (CR) and 6 partial responses (PR). At the end of 1 year; 2 patients maintained CR and seven patients continued PR (overall responders 45%). The response was better in SAA (54.5%) with 2 CR and 4 PR; than in VSAA (33%) with 3 PR . Eleven (55%) children were alive without response. One patient developed AML 13 months later. CONCLUSION: We conclude that antithymocyte globulin and cyclosporin combination is an effective treatment for aplastic anemia patients who are ineligible for bone marrow transplantation.

Puberty and pubertal disorders.

The authors have focussed in this article on normal physical growth during puberty and events during adolescence with a brief mention of pubertal disorders.