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.

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.

Total crown replacement technique A biological treatment option for grossly destructed primary molars

Background: Restoration of severely damaged primary molars with very short clinical crowns is a big challenge and often extracted due to the lack of restorative options. Total crown replacement (TCR) is a novel treatment alternative for the restoration of such teeth through bonding of the biological restorations which are the sterile decoronated crowns of the extracted human teeth, obtained from a tooth bank. Case Report: Presented here is a report of two cases restored with the TCR technique. A 9-month follow-up showed satisfactory results in terms of function, esthetics, gingival health, and morphology including occlusal wear. TCR can be a viable and economical alternative for restoration of severely decayed/damaged primary teeth, otherwise indicated for extraction.

Uncommon plasmacytoid myoepithelioma originating from ectopic minor salivary gland in neck: a rare case with rare site presentation

The aim of this case report is to present as case of plasmacytoid at ectopic minor salivary gland in the neck which is a rare neoplasm with uncommon presentation of site. Usually it is a tumor of major salivary gland and more common in parotid gland and less common in the minor salivary gland of the oral cavity predominantly in palate. Here authors are discussing a case of 10-year-old female who presented in our institute with complain of swelling over right mid cervical region which was clinically suspected as reactive cervical lymph node. Patient was evaluated further and cytologically diagnosed as a case of plasmacytoid myoepithelioma. It was also confirmed as a case of plasmacytoid myoepithelioma after histopathology and immunohistochemistry studies. Plasmacytoid myoepithelioma at ectopic minor salivary gland site in the neck is uncommon presentation and only a limited number of cases have been reported in literature.

A comparative evaluation of bone marrow biopsy and bone marrow aspiration in different haematological condition with special reference to leukaemia and lymphoma

Background: For diagnosis of haematological disorders there are three modalities to examine bone marrow, bone marrow aspiration cytology (BMA), bone marrow imprint (BMI) and bone marrow biopsy (BMB). BMA gives cytological picture; BMI also gives cytological picture but cells are less in number and BMB gives cytological as well as architectural picture. BMA alone may not be sufficient to reach diagnosis therefore the present study was undertaken to compare the above modalities. The study was conducted with the aim to perform cytomorphological evaluation of bone marrow in various haematological disorders with special reference to leukaemia and lymphoma and to compare bone marrow aspiration smears with bone marrow trephine biopsy.Methods: The present study was conducted in department of pathology, LLRM Medical College, Meerut inpatients attending the outpatient department and in-patient department of pediatrics and medicine of SVBP Hospital attached to LLRM Medical College, Meerut, over a period of one year i.e. from March 2018 to May 2019. A detailed clinical history, physical examination and laboratory examination of all the cases was done.Results: Out of 50 cases, maximum number of cases were of anemia 26/50 (52%) followed by leukemia 17/50 (34%), lymphoma 5/50 (10%), multiple myeloma 1/50 (2%), myelofibrosis 1/50 (2%), leishmaniasis 1/50 (2%) and idiopathic thrombocytopenic purpura 1/50(2%). BMA smears were compared with biopsy and concordance and discordance was established. The overall diagnostic accuracy of aspiration was 94%.Conclusions: Bone marrow examination is a safe, quick easy and cost-effective procedure with very less patient discomfort. BMA shows better cellular details when compared to BMI and BMB. BMB is diagnostic investigation in dry tap cases like aplastic anemia, myelofibrosis, myelodysplastic syndrome and metastatic tumors. In present study, concordance between BMA and BMB was seen in majority of the cases and diagnostic accuracy was 94% study concludes that bone marrow aspiration cytology and trephine biopsy complement each other and should be performed simultaneously for complete bone marrow work up and evaluation.

Management of Infants with Congenital Adrenal Hyperplasia

Treatment of congenital adrenal hyperplasia (CAH) requires lifelong replacement of glucocorticoids with regular follow up to manageassociated morbidities. The current review focuses on follow-up and management of infants diagnosed with classical CAH pertinent toIndian context. Early initiation of oral hydrocortisone in divided doses is recommended after diagnosis in newborn period, infancy andchildhood. Fludrocortisone is recommended for all infants with classical CAH. All infants should be monitored as per protocol fordisease and treatment related complications. The role of prenatal steroids to pregnant women with previous history of CAH affectedinfant for prevention of virilization of female fetus is controversial.

Impact of Using Different Growth References on Interpretation of Anthropometric Parameters of Children Aged 8-15 Years

Objective: To compare the effect of the application of threegrowth references (Agarwal, 1992; Indian Academy ofPaediatrics (IAP), 2015; and World Health Organisation (WHO),2007) on interpretation of anthropometric parameters inschoolchildren.Setting: Cross-sectional school-based study.Participants: Children 8-15 years studying in one governmentschool and one private school of Delhi.Procedure: The age- and gender-specific standard deviationscores of height-for-age and BMI-for-age were estimated foreach student enrolled, using the three growth referencesindependently.Main outcome measure: The proportion of children withshort stature, thinness and overweight/ obesity determined byeach growth reference were compared.Results: A total of 1237 students participated in the study. Asignificantly higher proportion of children (both sexes) wereclassified to have short stature using WHO 2007 reference(8.8%) as compared to the Agarwal (3.3%) charts and IAP, 2015references (3.6%). The combined prevalence of overweight andobesity was highest (34.8%) by the IAP, 2015 reference asagainst 32% by Agarwal charts and 29.1% by WHO, 2007reference. Good agreement existed between the IAP, 2015reference and Agarwal charts in classifying subjects intodifferent BMI categories (Kappa=0.82) and short stature(Kappa=0.99).Conclusions: In view of differences noted, use of nationalpopulation derived reference data is suggested to correctlydefine growth trajectories in children.

Newborn Screening and Diagnosis of Infants with Congenital Adrenal Hyperplasia

Congenital adrenal hyperplasia (CAH) is an autosomal recessive endocrine disorder which can manifest after birth with ambiguousgenitalia and salt-wasting crisis. However, genital ambiguity is not seen in male babies and may be mild in female babies, leading to amissed diagnosis of classical CAH at birth. In this review, we provide a standard operating protocol for routine newborn screening forCAH in Indian settings. A standardization of first tier screening tests with a single consistent set of cut-off values stratified by gestationalage is also suggested. The protocol also recommends a two-tier protocol of initial immunoassay/time resolved fluoroimmunoassayfollowed by liquid chromatography tandem mass spectrometry for confirmation of screen positive babies, wherever feasible. Routinemolecular and genetic testing is not essential for establishing the diagnosis in all screen positive babies, but has significant utility inprenatal diagnosis and genetic counseling for future pregnancy.

Comparison of Accuracy and Time Duration Between Direct and Indirect Bonding By Photographic Method: A Short Clinical Study

Introduction: Indirect bonding has been in orthodonticsfor a long time. It has been recognized that accuratebracket positioning is of clinical importance for efficientapplication of biomechanics. Previosly so many methodshave been used for checking accuracy which is verytechnique sensitive, require special equipments, difficultto fabricate and cost effective. Here, to make it moresimplified, photographic method is used for accuracymeasurement. The aim of this study was to compare theaccuracy, and time consuming between direct and indirectbonding by photographic method.Material and methods: Study was performed on 5 patientswith split mouth technique in upper arch where bracketswere bonded on one quadrant of orthodontic modelsfor Indirect bonding one set as predetermined “ideal”bonding. A transfer tray was prepared using biostar sheetand glue gun, then tray is placed into patients mouth andother half quadrant was directly bonded to patients teeth.The accuracy was checked using photographic method inthree parameters Bracket height, Mesiodistal position andAngulation. Time taken for bonding direct and indirectprocedures were calculated.Results Unpaired t test was done which showed statisticalsignificant difference in bracket height and angulation andinsignificant for mesiodistal position. Proving indirectbonding is more accurate and less time consuming than thedirect bonding of braces.Conclusion: There is difference between mean bracketplacement errors for direct and indirect methods, the rangeof errors in the three directions assessed and time takenwere greater for direct than indirect bracket placement.The magnitudes of the findings are of clinically relevantand this method is clinically feasible and cost ineffective.

Signet ring cell cholangiocarcinoma in a patient previously operated for cholecystectomy: is there any connecting link?

Cholangiocarcinoma are malefic tumours of bile duct. Signet ring cell carcinoma (SRCC) is rare entity. Several risk factors have been attributed to its ethology, the main overriding link between two being chronic inflammation of the bile system. Cholecystectomy has also been a proposed risk factor. This study was undertaken in Department of Pathology at LLRM Medical College, Meerut. A 49 years old female, operated for cholecystectomy 1.5 year back in same hospital, now presented with chief complains of jaundice and abdominal discomfort. The blood chemistry revealed increased total bilirubin (13.7 mg/dl), Alkaline phosphatase (877.6 IU/L), Carbohydrate Antigen (CA) 199(184 U/ml) and Carcinoembryonic antigen (CEA) (14.5 ng/ml). Computed Tomography (CT) showed a stricture in mid Common bile duct (CBD). Excision of stricture was done using retrocholic hepatico-jejunostomy. Tissue was submitted for histopathology. Histopathological assessment showed SRCC. The patient failed to turn up for further management but returned back after a span of time presenting with gross ascites and pallor ultimately leading to death within 12 weeks of diagnosis. This was the first case of SRCC to arise in a patient who had a previous history of cholecystectomy. Whether there is some connecting link between the two is still not clear. Further studies are warranted in this direction to establish cholecystectomy as an etiological factor for cholangiocarcinoma.

A comparative study for efficacy and safety of low doses of clonidine for hemodynamic stability in patients undergoing laparoscopic cholecystectomy

Background: This randomized prospective double-blind study was designed to evaluate the efficacy and side effects of low doses clonidine for perioperative haemodynamic stability and postoperative recovery.Methods: Patient’s with ASA grade I–II undergoing laparoscopic cholecystectomy were randomized into three groups of 30 patients each. All patients received either normal saline 10 ml (Group I) or 0.8 µg/kg (Group II) or 1 µg/kg (Group III) over duration of 180 seconds, 10 min prior to laryngoscopy and intubation. Anaesthesia was induced with 1% propofol (2 mg/kg) and maintained with nitrous oxide 60% in oxygen and isoflurane. The parameters assessed at various time intervals were heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure and sedation score.Results: Both doses of clonidine proved to be effective in perioperative haemodynamic stability. Clonidine 0.8 mcg/kg was as effectve and safer to Clonidine 1 mcg/kg for attenuatíon of the hemodynamíc responses to laparoscopy. There were no significant differences in the parameters of recovery between groups.Conclusions: Significant hemodynamic derangements can occur during laproscopic cholecystectomy at intubation, pneumoperitoneum and extubation. These were effectively attenuated by premedication with 0.8 mcg/kg and 1 mcg/kg of intravenous clonidine. Dose of 1 mcg/kg though found to be effective but produced adverse effects in form of hypotension and bradycardia.

Comparison of metabolic effects of glimepride and sitagliptin with metformin in patients suffering from type 2 diabetes mellitus in a tertiary care hospital

Background: Diabetes mellitus (DM) is one of the major causes of mortality & morbidity, and patient’s with better control of glycaemic parameters have lesser chronic complications associated with it. Though monotherapy with metformin is first choice for T2DM but is effective in less than 50% of patient and they should be managed with two drug therapy. Both Glimepiride and Sitagliptin are effective with metformin but there has been no study done in this region hence, we planned to study comparison of effects of glimepiride and sitagliptin with metformin in patient of T2DM.Methods: This prospective, open-label, randomized study was done in all patient diagnosed with T2DM, not adequately managed by metformin alone. The patient was divided into two group G (Glimepiride with Metformin) and Group S (Sitagliptin with Metformin) and had a follow up at 3 and 6 months. The biochemical parameters were assessed at 12 weeks and 24 weeks.Results: The result of this study show that both glimepiride and sitagliptin with metformin significantly (p<0.05) lowered both the fasting blood sugar as well as postprandial blood glucose at 3 and 6 months. Glimepiride was more effective in lowering (p<0.05) the plasma glucose at 3 months but both the drugs had comparable result at 6 months. This study also showed that glycosylated haemoglobin was lowered in both groups at three and six months as compared to Day 0 (p<0.05), with glimepiride having better control of glycosylated haemoglobin at 3 months with both groups having comparable result at 6 months.Conclusions: To conclude, this study compared effects of sitagliptin and glimepiride on glycaemic parameters in patients of T2DM and found that both drugs had comparable results.

Clinicopathological study of benign and malignant ovarian tumours and the role of HER2/neu and ER expression in these tumours

Background: Ovarian cancers represent the 6th most common cancer among females and are the most common cause of death from gynaecological cancers in the world. The aim is to do clinicopathologic study of ovarian tumours along with evaluation of the expression of estrogen receptor (ER) and human epidermal growth factor receptor (HER2/neu).Methods: A total of 85 cases of ovarian tumors were studied and immunohistochemistry was performed with specific antibodies against ER and HER2/neu as per standard protocol.Results: In present study, surface epithelial tumours were the commonest type comprising 64 cases (75.2%), followed by Germ cell tumours, 17cases (20%) and sex cord stromal tumours, 04 cases (4.8%).Among the surface epithelial tumours , ER‑positive cases were higher in malignant (71.4%) tumours as compared to borderline tumours (33.3%) and benign tumours (7.7%) while Her2/neu positive cases were higher in borderline (66.7%) tumours as compared to malignant tumours (42.9%) and benign tumours (15.3%).Among the germ cell tumours, ER expression was positive in 62.5% cases of mature teratoma while HER2/neu expression was positive in only 12.5% cases of mature teratoma. None of the sex cord stromal tumours showed positive expression of ER and HER2/neu.Conclusions: Positive expression of estrogen receptors is seen predominantly in surface epithelial malignancies and in mature teratoma. It proves the mitogenic role of estrogen in ovarian tumours. Her-2 neu was expressed mainly in malignant tumours. This suggests their carcinogenic role. This also helps in differentiating borderline and malignant tumours.

A Comparison of Audio and Audio-Visual Distraction Techniques in Managing Dental Anxiety in Pediatric Patients: A Clinical Study

Background: Pain and fear of pain makes dental treatmentvery difficult for clinician as well as patients. Minimizing fearand anxiety can help to treat patients more comfortably.Various techniques like audio distraction, audio visualdistraction are used to minimize anxiety.Aim: To compare audio and audio-visual distractiontechniques in managing dental anxiety.Methods: 100 children visiting the Department of Dentistry,UPUMS, Saifai for routine dental care were examined. Theselected 100 children were randomly allocated to 2 groups.Group 1: audio distraction and Group 2: audiovisual group.Results: Venham’s anxiety scale was found to be lower inaudiovisual distraction group, although the difference was notfound to be statistically significant during all the visits.Relatively less increase in pulp rate was also observed in audiovisual distraction group in current study.Conclusion: Audiovisual distraction technique can bepreferred over audio distraction in paediatric patients

A Prospective Study to Analyse the Metabolic Effect of Metformin with Glimepiride on Type 2 Diabetic Patients of North India.

Background: Diabetes Mellitus is a leading disease of developing countries and its incidence is increasing day by day. Among Oral Hypoglycemic agents, Metformin is still the best treatment choice for type 2 diabetes mellitus. Metformin is associated with improvements in lipoprotein metabolism, including decreases in LDL-C, fasting and postprandial TGs, and free fatty acids. Methods: This prospective study was carried out on Type 2 Diabetic patients attending the Diabetic clinic at Teerthanker Mahaveer Medical College & Research Center, Moradabad. Only those patients were included who were not adequately controlled with a stable dose of metformin monotherapy. A total of 125 patients were enrolled in the study taking Glimepiride plus Metformin. The patients received therapy of metformin 500mg three times daily & glimepiride 5mg twice daily. Results: Out of the 125 patients enrolled in the study, only 82 patients completed the study. Out of 82 patients, 49 were males and 33 females. There was a significant reduction (p<0.05) of FPG as compared to baseline. The (PPBS) was reduced from 275.95 ±63.599 (mg/dl) to 167.04±27.084 (mg/dl) at 12 weeks and141.36±31.064(mg/dl) at 24 weeks (mg/dl). There was a significant reduction (p<0.05) of Hb1Ac, TC, TAG, LDL, VLDL, UA, SGOT as compared to baseline but no significant rise in HDL was seen as compared to baseline. Conclusion: Significant improvement in fasting blood sugar (FBS), Postprandial blood sugar (PPBS), Lipid profile and Glycosylated hemoglobin as compared to baseline.