Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric HematologyOncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics

Justification: Anemia in children is a significant public health problem in our country. Comprehensive National Nutrition Survey 2016-18 provides evidence that more than 50% of childhood anemia is due to an underlying nutritional deficiency. The National Family Health Survey-5 has reported an increase in the prevalence of anemia in the under-five age group from 59% to 67.1% over the last 5 years. Clearly, the existing public health programs to decrease the prevalence of anemia have not shown the desired results. Hence, there is a need to develop nationally acceptable guidelines for the diagnosis, treatment and prevention of nutritional anemia. Objective: To review the available literature and collate evidence-based observations to formulate guidelines for diagnosis, treatment and prevention of nutritional anemia in children. Process: These guidelines have been developed by the experts from the Pediatric Hematology-Oncology Chapter and the Pediatric and Adolescent Nutrition (PAN) Society of the Indian Academy of Pediatrics (IAP). Key areas were identified as: epidemiology, nomenclature and definitions, etiology and diagnosis of iron deficiency anemia (IDA), treatment of IDA, etiology and diagnosis of vitamin B12 and/or folic acid deficiency, treatment of vitamin B12 and/or folic acid deficiency anemia and prevention of nutritional anemia. Each of these key areas were reviewed by at least 2 to 3 experts. Four virtual meetings were held in November, 2021 and all the key issues were deliberated upon. Based on review and inputs received during meetings, draft recommendations were prepared. After this, a writing group was constituted which prepared the draft guidelines. The draft was circulated and approved by all the expert group members. Recommendations: We recommend use of World Health Organization (WHO) cut-off hemoglobin levels to define anemia in children and adolescents. Most cases suspected to have IDA can be started on treatment based on a compatible history, physical examination and hemogram report. Serum ferritin assay is recommended for the confirmation of the diagnosis of IDA. Most cases of IDA can be managed with oral iron therapy using 2-3 mg/kg elemental iron daily. The presence of macro-ovalocytes and hypersegmented neutrophils, along with an elevated mean corpuscular volume (MCV), should raise the suspicion of underlying vitamin B12 (cobalamin) or folic acid deficiency. Estimation of serum vitamin B12 and folate level are advisable in children with macrocytic anemia prior to starting treatment. When serum vitamin B12 and folate levels are unavailable, patients should be treated using both drugs. Vitamin B12 should preferably be started 10-14 days ahead of oral folic acid to avoid precipitating neurological symptoms. Children with macrocytic anemia in whom a quick response to treatment is required, such as those with pancytopenia, severe anemia, developmental delay and infantile tremor syndrome, should be managed using parenteral vitamin B12. Children with vitamin B12 deficiency having mild or moderate anemia may be managed using oral vitamin B12 preparations. After completing therapy for nutritional anemia, all infants and children should be advised to continue prophylactic iron-folic acid (IFA) supplementation as prescribed under Anemia Mukt Bharat guidelines. For prevention of anemia, in addition to age-appropriate IFA prophylaxis, routine screening of infants for anemia at 9 months during immunization visit is recommended.

Immunization of Children with Cancer in India Treated with Chemotherapy – Consensus Guideline from the Pediatric Hematology-Oncology Chapter and the Advisory Committee on Vaccination and Immunization Practices of the Indian Academy of Pediatrics

Justification: Children with cancer need to be immunized against the common vaccine-preventable diseases after completion andsometimes during ongoing treatment of cancer. However, the immunization schedule for these children needs to be altered due todisease and treatment related immune-suppression. Consequently, there are many guidelines/practice statements from around theworld to address this issue, however, there is no such comprehensive guideline from India catering to the need of Indian children withcancer. Process: A guideline was drafted after reviewing the available literature. The draft guideline was discussed and modified in ameeting attended by pediatric oncologists from the PHO chapter and vaccine experts from the ACVIP of the IAP. Subsequently, themodified draft was reviewed and recommendations were finalized.Objective: To review the current evidence and generate a nationallyrelevant guideline for immunization of children receiving chemotherapy for cancer. Recommendations: Live vaccines arecontraindicated during and up to 6 months after end of chemotherapy. Non-live vaccines are also best given after 6 months from the endof treatment for durable immunity. Annual inactivated influenza vaccine is the only vaccine recommended for all children duringchemotherapy whereas hepatitis B vaccine is recommended only for previously unimmunised children with risk of transfusion associatedtransmission of infection. Post-treatment re-immunization/catch-up schedule largely depends on the pre-chemotherapy immunizationstatus. Sibling immunization should continue uninterrupted except for oral polio vaccine which needs to be substituted by the injectablevaccine. Inactivated influenza vaccine is recommended and varicella vaccine is encouraged for all contacts including siblings

Gossypiboma: a surgical menace

Gossypiboma is a rare yet devastating complication. It may be a sequela to any kind of surgical procedure, however intra-abdominal surgeries are commonly implicated as the cause for this entity. In chronic cases, it may even lead to severe morbidity. We report a case of gossypiboma post vaginal hysterectomy, diagnosed and treated successfully by laparoscopy.

Autoamputation of the ovary: a rare consequence of torsion in a mature cystic teratoma

Autoamputation of the ovary may be a result of longstanding infarction resulting from torsion of the ovarian pedicle. This entity may be confused with an ectopic or supernumerary ovary.  A proper detailed history taking is important to provide clues for diagnosis. We report a case of a young female patient diagnosed with autoamputation of unilateral ovary on laparoscopy, with histopathology confirmation of ovary with dermoid cyst.

Pelvic tuberculosis: from millets to masses

An adnexal mass is a common entity in the reproductive age group. Ovarian masses form a majority of this condition. Tuberculosis is a disease commonly encountered in the Tropics and is endemic to India. Abdominopelvic affliction of this disease is common in women especially in the reproductive age groups. It may present with variety of non-specific clinical features and often poses an enormous diagnostic dilemma Author report one such case, presenting with a clinical impression of ovarian malignancy, however, was diagnosed to be a case of extensive pelvic tuberculosis on laparoscopy. Tissue biopsy was consistent with the finding of tuberculosis.

Footprint lesion: a mirror image of an endometrial polyp

Endometrial polyps may present with a variety of symptomatology. They are mostly benign and commonly encountered in the reproductive age group. Hysteroscopy is an emerging tool for diagnostic as well as a therapeutic purposes. We report a case of endometrial polyp diagnosed on hysteroscopy, with a “footprint”, that is contact lesion visible. This is a relatively rare phenomenon, and there is sparse information and literature regarding this entity. Hence the true nature of its effects is yet unknown.

Cesarean scar pregnancy: scope for hysteroscopy

Scar ectopic pregnancy also known as cesarean scar pregnancy is a rare form of an extrauterine pregnancy. The blastocyst is implanted at the site of the previous cesarean scar. Most patients remain asymptomatic and are detected on routine ultrasonography imaging. The diagnosis and management of this condition is hence challenging and difficult. A timely ultrasonography in the early weeks of gestation is the key to preventing catastrophic events like uterine perforation and excessive hemorrhage. There is a wide armamentarium of treatment modalities to choose from, however each case must be individualised. Medical management has its own limitations and often patients are required to have a long-term follow-up. We present a case of a cesarean scar pregnancy managed conservatively with systemic methotrexate but subsequently requiring surgical intervention done successfully via hysteroscopy. A repeat ultrasonography done a fortnight later revealed no retained products of conception.

Hotdog in bun: a recent technique for oophoropexy

Ovarian torsion is an acute gynaecological emergency. It may present at any age group, however it is more common in the reproductive years. The patient may present with a myriad of clinical features which are often non-specific posing a diagnostic dilemma. Ultrasonography is the best initial modality of imaging. Once diagnosed a surgical approach is the mainstay of treatment. Preservation of ovaries and preventing recurrence in young patients is crucial. We present a case of a young adolescent girl diagnosed with an ovarian torsion who was managed laparoscopically. Oophoropexy was done to avoid future recurrence by an emerging method called the “Hotdog in bun” technique.

Endoscopy in the management of a rudimentary non-communicating functional horn

Mullerian anomalies are developmental malformations of the female reproductive tract, often diagnosed late. They are classified into numerous types like a septate uterus, bicornuate or unicornuate uterus etc. A rudimentary non-communicating functional horn is a rare variant of a unicornuate uterus. It may present with a wide spectrum of symptoms like severe dysmenorrhea, infertility, lump in abdomen or rarely maybe diagnosed with a ruptured ectopic in the horn. The diagnosis of this entity is a difficult and challenging. Authors present a case of a young adolescent diagnosed with this Mullerian anomaly, the role of hysteroscopy in confirmation of diagnosis and the management of the patient by laparoscopy successfully. The patient was completely relieved of her symptoms post-surgery.

A novel approach for laparoscopic retrieval of dermoid cyst

A dermoid cyst is a germ cell tumour, benign in nature and common in young women under the age of 30. They are usually asymptomatic and often detected incidentally on imaging. Resection of the cyst is important owing to complications like torsion or malignancy. Laparoscopic surgery is the modality of choice in today’s era. However, rupture of the cyst during laparoscopic retrieval is any surgeon’s nightmare. Hence, good surgical skill and a reliable method of retrieval are of prime importance here. Authors present a novel method of dermoid extraction done laparoscopically with a sterile urine collection (urobag) bag. This is an easy and simple method which decreases the rate of spillage owing to the strength of the bag.

Immunogenicity and safety of live attenuated hepatitis A vaccine: a multicentric study.

OBJECTIVE: To evaluate immunogenicity and tolerability of single dose live attenuated injectable hepatitis A vaccine in four metropolitan cities of India. METHODS: Live attenuated hepatitis A vaccine was administered to 505 children aged 18 to 60 months in four centers across India. Immunogenicity of the vaccine was assessed by estimation of anti-HAV antibody titer at 6 weeks and 6 months following administration of the vaccine. Safety evaluation of the vaccine was also done during the visits. RESULTS: At 6 weeks, 480 subjects (95%) came for the follow-up and 411 (81.4%) subjects reported at the end of 6 months. The geometric mean titer (GMT) of anti-HAV antibody of the subjects who did not have the seroprotective titer at the baseline were assessed at 6 weeks and 6 months which was 81.04 mIU/ml and 150.66 mIU/ml respectively. At 6 weeks, 95.1 % seroconverted and at the end of 6 months, 97.9 % had seroconverted. Both solicited and unsolicited vaccine-induced local and systemic adverse events were insignificant at all the centers, except swelling and induration in a few. CONCLUSION: Live attenuated injectable hepatitis A vaccine was immunogenic and tolerable with minimal reactogenecity, in this study of single dose schedule. Safety profile was also satisfactory in the study population.