Diagnostic Accuracy of the Government of India Mother and Child Protection Card for Developmental Screening of Indian Children Aged 2-36 Months: A Hospital-based Mixed Method Study

Background: Universal developmental screening is recommended at 9, 18, 24 and 36 months. The Government of India Mother and Child Protection (MCP) card is an immunization record that is used to monitor child development, and identify children requiring further evaluation. Objectives: To determine the diagnostic accuracy of the MCP card for developmental screening, and perform its item analysis. Study design: Mixed-method study (prospective study of diagnostic accuracy and qualitative study). Participants: Mother-child dyads of children between 2-36 months of age were recruited from the outpatient department or wards of a tertiary level children’s hospital from November, 2019 to October, 2021. Children with confirmed neurodevelopmental disorders/disability, and mothers with less than 6th standard education were excluded. Intervention: Each mother was given a MCP card, and taught how to mark the items. This was followed by the researcher’s evaluation (index tool). The reference tool was a comprehensive clinical assessment (CCA) by the researcher and an expert. The CCA included clinical examination of hearing, vision, and neurodevelopment; and psychometric assessment of development and adaptive function. Each mother underwent an in-depth interview. Overall and group wise psychometric properties of diagnostic accuracy were computed. The interview transcripts were analyzed thematically. Outcomes: The proportion of children with ‘fail’ and ‘delay’ by the evaluation of the researcher with the MCP card and the expert by the CCA, respectively. Results: The study population included 213 children (40.4% females). Fifty-two (24.4%) children were identified as ‘Fail’ by the MCP card and 43 (20.2%) as ‘delay’ by the expert’s CCA. The overall sensitivity and specificity was 83.7% (95% CI 69.3-93.2) and 90.6% (95% CI 85.2-94.5), respectively. Acceptable diagnostic accuracy was found in the age-group 7-9 months, 13-18 months, and 25-36 months. Conclusions: The MCP card may be used for developmental screening at 9, 18, and 36 months.

Association of Child Neurology (AOCN) Consensus Statement on the Diagnosis and Management of Febrile Seizures

Justification: Febrile seizures are quite common in children but there are controversies in many aspects of their diagnosis and management. Methods: An expert group consisting of pediatric neurologists and pediatricians was constituted. The modified Delphi method was used to develop consensus on the issues of definitions and investigations. The writing group members reviewed the literature and identified the contentious issues under these subheadings. The questions were framed, pruned, and discussed among the writing group members. The final questions were circulated to all experts during the first round of Delphi consensus. The results of the first round were considered to have arrived at a consensus if more than 75% experts agreed. Contentious issues that reached a 50- 75% agreement was discussed further in online meetings and subsequently voting was done over an online platform to arrive at a consensus. Three rounds of Delphi were conducted to arrive at final statements. Results: The expert group arrived at a consensus on 52 statements. These statements pertain to definitions of febrile seizures, role of blood investigations, urine investigations, neuroimaging, electroencephalography (EEG), cerebrospinal fluid analysis and screening for micronutrient deficiency. In addition, role of rescue medications, intermittent anti-seizure medication and continuous prophylaxis, antipyretic medication and micronutrient supplementation have been covered. Conclusion: This consensus statement addresses various contentious issues pertaining to the diagnosis and management of febrile seizures. Adoption of these statements in office practice will improve and standardize the care of children with this disorder.

Clinical Profile and Short-term Outcome of Pediatric Status Epilepticus at a Tertiary-care Center in Northern India

Objective: To assess clinical profile and short term treatmentoutcomes of pediatric status epilepticus (SE) at a tertiary-carecenter in northern India.Methods: Prospective cohort study enrolled children aged 1month to 18 years presenting with SE to the emergencydepartment. Enrolled children (109) were treated as per hospitalprotocols. Clinical features during hospitalization were noted.Pediatric overall performance category (POPC) scale was usedfor classification of outcome at the time of discharge.Results: Acute symptomatic etiology was identified in 66(60.6%) cases (CNS infections were predominant). Previousdiagnosis of epilepsy was found in 32 (29.4%) children; andbenzodiazepine responsive SE were seen in 65 (59.6%)children. Predictors of unfavorable outcome were acutesymptomatic etiology (adjusted OR 4.50; 95% CI 1.49, 13.62) andno treatment administered prior to hospital (adjusted OR 3.97;95% CI 1.06, 14.81).Conclusions: Acute symptomatic etiology, mainly acute CNSinfections, is the leading cause of SE in this region. Early and pre-hospital management with benzodiazepines may improve SEoutcome.

Diagnostic Accuracy of Indian Scale for Assessment of Autism in Indian Children Aged 2-5 Years

Objective: To determine the diagnostic accuracy of Indian Scalefor Assessment of Autism (ISAA) in children aged between 2-5years.Design: Study of diagnostic accuracySetting: Tertiary level hospital, (November 2015 – November2017).Participants: A consecutive sample of 500 children withsuspected Autism (delay or regression of developmentalmilestones, delay or regression in speech, age-inappropriateunderstanding, behaviour, play and/or social interaction) wasrecruited.Procedure: Each child underwent an expert comprehensiveassessment of Autism (reference tool) that included history,observation, examination, diagnostic criteria for Autism SpectrumDisorder (ASD) of the Diagnostic and Statistical Manual of MentalDisorders’, 5th edition, Childhood Autism Rating Scale-2(CARS2), developmental status and adaptive function. This wasfollowed by the administration of ISAA (test tool) in Hindilanguage. Parameters of diagnostic accuracy and ReceiverOperating Characteristic curves were computed.Main Outcome Measures: ASD based on (i) expert assessment,(ii) CARS-2, and (iii) ISAA.Results: In children aged 2-3 years, sensitivity of ISAA was 100%(95% CI 98.2% -100%), specificity 28.9% (95% CI 17.7% to43.4%), positive likelihood ratio 1.4 and negative likelihood ratio 0.In 3-5 year olds, sensitivity was 99.6% (95% CI 97.6% to 99.6%),specificity 33.3% (95% CI 15.1% to 58.3%), positive likelihoodration 1.5 and negative likelihood ratio 0.01. The degrees ofautism based on the existing cut off values were inaccurate.Conclusions: ISAA has sub-optimal performance in diagnosingand assessing severity in 2-5 year old children.

Injuries in Children With Epilepsy: A Hospital-based Study.

Objectives: To study the magnitude and pattern of injuries in children with epilepsy. Methods: This prospective cohort study enrolled children with epilepsy (CWE) aged 2-16 years on treatment with anti-epileptics for a minimum duration of one-month and compared them with their own siblings (controls). A semi-structured questionnaire was used to enquire about epilepsy and type and frequency of injuries sustained at monthly follow-up visits. Participants were followed up for 12-months for occurrence of injuries. Results: 208 cases and 212 controls were analyzed. 21 cases (10.1%) and 10 controls (4.7%) had sustained injuries (P=0.03) (RR 2.1; 95% CI, 1.0 - 4.4). Seizure-related injuries were present in 4.3% of cases. Conclusion: Children with epilepsy are at an increased risk of injuries and hence need supervision.

Consensus Guidelines on Management of Childhood Convulsive Status Epilepticus.

Justification: Status epilepticus has a wide etiological spectrum, and significant morbidity and mortality. Management using a pre-determined uniform protocol leads to better outcomes. Multiple protocols for management of childhood status epilepticus are available, without much consensus. Process: A ‘Multi-disciplinary Consensus Development Workshop on Management of Status Epilepticus in Children in India’ was organized. The invited experts included Pediatricians, Pediatric neurologists, Neurologists, Epileptologists, and Pediatric intensive care specialists from India, with experience in the relevant field. Experts had previously been divided into focus groups and had interacted on telephone and e-mail regarding their group recommendations, and developed consensus on the topic. During the meeting, each group presented their recommendations, which were deliberated upon by the house and a consensus was reached on various issues; the document was finalized after incorporating suggestions of experts on the draft document. Objective: To provide consensus guidelines on evaluation and management of convulsive status epilepticus in children in India (excluding neonatal and super-refractory status epilepticus). Recommendations: Each institution should use a predetermined protocol for management of status epilepticus; prehospital management and early stabilization is the key to a satisfactory outcome of status epilepticus. Pharmacotherapy should not be delayed for any investigations; the initial management should consist of a parenteral benzodiazepine by any route feasible. Subsequent management has been detailed. The group also felt the need for more epidemiological research on status epilepticus from India, and identified certain research areas for the purpose.

Newer Anti-epileptic Drugs.

Need and Purpose of review: A number of newer anti-epileptic drugs have been developed in the last few years to improve the treatment outcomes in epilepsy. In this review, we discuss the use of newer anti-epileptic drugs in children. Methods used for locating, selecting, extracting and synthesizing data: MEDLINE search (1966-2013) was performed using terms “newer anti-epileptic drugs”, “Oxcarbazepine”, vigabatrin”, topiramate”, “zonisamide”, “levetiracetam”, “lacosamide”, “rufinamide”, “stiripentol”, “retigabine”, “eslicarbazepine”, “brivaracetam”, “ganaxolone” and “perampanel” for reports on use in children. Review articles, practice parameters, guidelines, systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case series were included. The main data extracted included indications, efficacy and adverse effects in children. Main conclusions: Oxcarbazepine is established as effective initial monotherapy for children with partial-onset seizures. Vigabatrin is the drug of choice for infantile spasms associated with tuberous sclerosis. Lamotrigine , levetiracetam and lacosamide are good add-on drugs for patients with partial seizures. Lamotrigine may be considered as monotherapy in adolescent females with idiopathic generalized epilepsy. Levetiracetam is a good option as monotherapy for females with juvenile myoclonic epilepsy. Topiramate is a good add-on drug in patients with epileptic encephalopathies such as Lennox-Gastaut syndrome and myoclonic astatic epilepsy.

Consensus Guidelines on Evaluation and Management of Suspected Acute Viral Encephalitis in Children in India.

Justification: Viral encephalitis is an important cause of mortality and morbidity in children. The etiological agents are varied, and physicians treating such children often feel limited by the lack of uniform guidelines on evaluation and management of these critically ill children in resource-constrained settings. Process: An ‘Expert Group Meeting on Viral Encephalitis in Children’ was held on 19th January, 2012 in Gurgaon, Haryana (under the aegis of PEDICON 2012, the National Conference of Indian Academy of Pediatrics). The invited experts included pediatricians and microbiologists with expertise in the relevant field. Various issues related to the subject were discussed and it was decided to bring out recommendations on the topic. The final recommendations were produced after circulating the draft document, and incorporating/discussing all changes, by e-mail. Objectives: To aid the pediatrician in the evaluation and management of children with suspected viral encephalitis and to assist the public health authorities in acute encephalitis surveillance. These guidelines do not cover viral encephalitis in the neonatal period and in immunocompromised children, Rabies encephalitis, and chronic viral encephalitis such as Subacute sclerosing panencephalitis (SSPE). Recommendations: Recommendation for evaluation and management of suspected viral encephalitis in children are presented. In any acute encephalitis outbreak, pediatricians should be aware of the common viral causes of encephalitis in their area, what information and samples they should collect, and the contact details of the District Surveillance Unit. Pending specific diagnosis and therapy (which may or may not be possible), prompt empirical therapy and meticulous supportive care are important to prevent ongoing brain damage, and improve outcome.

Management of Raised Intracranial Pressure.

Appropriate management of raised intracranial pressure begins with stabilization of the patient and simultaneous assessment of the level of sensorium and the cause of raised intracranial pressure. Stabilization is initiated with securing the airway, ventilation and circulatory function. The identification of surgically remediable conditions is a priority. Emergent use of external ventricular drain or ventriculo-peritoneal shunt may be lifesaving in selected patients. In children with severe coma, signs of herniation or acutely elevated intracranial pressure, treatment should be started prior to imaging or invasive monitoring. Emergent use of hyperventilation and mannitol are life saving in such situations. Medical management involves careful use of head elevation, osmotic agents, and avoiding hypotonic fluids. Appropriate care also includes avoidance of aggravating factors. For refractory intracranial hypertension, barbiturate coma, hypothermia, or decompressive craniectomy should be considered.

Approach to the Child with Coma.

Coma and other states of impaired consciousness represent a medical emergency. The potential causes are numerous, and the critical window for diagnosis and effective intervention is often short. The common causes of non-traumatic coma include central nervous system infections, metabolic encephalopathy (hepatic, uremic, diabetic ketoacidosis etc.), intracranial bleed, stroke and status epilepticus. The basic principles of management include 1) Rapid assessment and stabilization, 2) Focussed clinical evaluation to assess depth of coma, localization of lesion in the central nervous system and possible clues to etiology, and 3) Treatment including general and specific measures. Commonly associated problems such as raised intracranial pressure and seizures must be recognized and managed to prevent secondary neurologic injury.

Normal Values of Liver and Spleen Size by Ultrasonography in Indian Children.

Objectives: To establish normative data for the ultrasonographic measurement of liver and spleen size in healthy Indian children. Setting: Tertiary-care pediatric teaching hospital. Design: Cross-sectional, hospital-based study. Participants: 597 healthy children between the ages of 1 month to 12 years. Measurements: Ultrasonographic evaluation for the assessment of liver and spleen size. These were correlated with the age, sex, height/length and weight of the participants. Results: Normal liver and spleen length and range were obtained sonographically. The liver and spleen length significantly correlated highly with the height/length of the subjects (P=0.0001). Conclusions: The study provides the normal values of liver and spleen size by ultrasonography in healthy Indian children.

Acute bilateral vision loss as the presenting feature of subacute sclerosing panencephalitis.

A 12-yr-old boy with an atypical presentation of subacute sclerosing panencephalitis (SSPE) is described. Bilateral macular chorioretinitis preceded the neurological symptoms by 3 weeks. Both visual and neurological features had an acute onset. Clinicians need to be aware that macular chorioretinitis in a child may be the heralding feature of SSPE.

Outcome in childhood guillain-barré syndrome.

To assess the outcome of children diagnosed with Guillain-Barré syndrome (GBS), followed up for a median duration of 25 months. Methods. Tertiary center, prospective follow up of children with GBS enrolled from Dec 2003 through Sep 2006. Functional recovery was determined at 12 months and later using Hughes scale (0-6). Clinical, electrophysiological variables were compared between the good outcome (grade 0/1) and bad outcome groups (died or functional grade >1). Results. Among 52 children with a median age of five yr there was male preponderance (75.4%). Mortality during acute phase was 11.5% (6/52). Among the survivors long term data was obtainable in 40 of the 46 children. At one year follow up 87.5% children had fully recovered or had minimal symptoms, beyond one year this rose to 95%. Only 2 among 40 had significant symptoms at last follow up (1 grade-2 and 1 grade-3). Factors significantly associated with poor outcome were: need for artificial ventilation, inexitable nerves on nerve conduction testing and delayed independent walking. Conclusion. Children needing ventilation have the worst short-term prognosis. However, irrespective of severity during acute phase, good long-term recovery can be expected in most children.

Gliomatosis cerebri.

A 6-year-old boy who presented with worsening hemiplegia, behaviour problems and seizures after an episode of encephalitis-like illness is reported. MRI revealed diffuse signal change and swelling of the left cerebral hemisphere. The diagnosis of gliomatosis cerebri was confirmed by brain biopsy. Parents refused radiotherapy and the child worsened and died 6 months after diagnosis.

ACTH therapy in refractory generalized epilepsy.

Adrenocorticotropic hormone (ACTH) has a long track record for the treatment of infantile spasms. However, there is paucity of data on the use of ACTH in the treatment of epilepsy beyond infantile spasms. We report the use of ACTH in two children with refractory generalized epilepsy. Both patients responded well. ACTH may be considered as a useful adjunctive therapy in patients with intractable generalized seizures. Side effects and cost however, remain important concerns.

Rhombencephalosynapsis: association with single umbilical artery.

A 6-year-old girl who presented with developmental delay and non-progressive ataxia is described. MRI of brain showed agenesis of cerebellar vermis with fusion of cerebellar hemispheres and dentate nuclei. MRI findings were characteristic of rhombencephalosynapsis. Partial agenesis of corpus callosum and absent septum pellucidum were also seen. The child had also been noted to have a single umbilical artery at birth: a hitherto undescribed association.

Approach to inborn errors of metabolism presenting in the neonate.

Inborn errors of metabolism (IEM) are an important cause of acute illness in newborns. Presentation may mimic common neonatal conditions such as sepsis. Prompt detection requires a high index of suspicion and the early measurement of biochemical markers such as blood ammonia. Diagnosis is important not only for treatment but also for genetic counselling. Guidelines for diagnosis and early management of IEM presenting in the neonatal period are described.

Acute cysticercal meningitis--missed diagnosis.

Neurocysticercosis is the commonest CNS parasitic disease worldwide but cysticercal meningoencephalitis is relatively rare, especially in Indian patients. We herein report a girl with cysticercal meningitis that was initially not suspected and later diagnosed on the basis of cerebrospinal fluid (CSF) eosinophilia. The need for CSF examination with wright-giemsa staining to avoid missing CSF eosinophilia is discussed.

Bilateral ocular scrofuloderma with orbital tuberculosis.

Ocular scrofuloderma with orbital tuberculosis is a rarely described presentation of childhood tuberculosis. Bilateral involvement has not been reported earlier in the medical literature. Here is reported a 3-year-old boy who presented with bilateral infraorbital swellings of tubercular etiology. Computed tomography (CT) scan of the upper face revealed enhancing soft tissue lesions in both the lower lids of the eyes, with extraconal extension into the orbits and with erosion of the right zygomatic bone. Tubercular etiology was confirmed by the Ziehl Neelsen staining of the aspirate from the lesion, which was positive for acid-fast bacilli and growth of Mycobacterium tuberculosis in the aspirate culture. The patient showed marked improvement of his lesions on anti-tubercular treatment.