Indian Academy of Pediatrics Consensus Guidelines for Probiotic Use in Childhood Diarrhea

Justification: Several probiotic species and strains, single or combined, have been evaluated in childhood diarrheal disorders, and recommendations have ever been changing as newer trials are published. Therefore, there is a need to develop a guideline for Indian children describing the current role of probiotics in clinical practice. Objectives: To develop a guideline for the use of probiotics in children with diarrhea. Process: A national consultative group (NCG) was constituted by the Indian Academy of Pediatrics (IAP), consisting of subject experts. Sub-topics were allotted to various experts as paired groups for detailed review. Members reviewed the international and Indian literature for existing guidelines, systematic reviews, meta-analyses and trials. Thereafter, two virtual structured meetings of the group were held on 2nd and 22nd August, 2020. The management guidelines were formulated by the group and circulated to the participants for comments. The final guidelines were approved by all experts, and adopted by the IAP executive board. Recommendations: The NCG suggests Lactobacillus GG as a conditional recommendation with low-to-moderate level evidence or Saccharomyces boulardii as a conditional recom-mendation with very low-to-low level evidence as adjuvant therapy in acute diarrhea. The NCG also recommends the use of combination probiotics in neonatal necrotizing enterocolitis (NEC), as these reduce the risk of NEC stage II and above, late-onset sepsis, mortality and also time to achieve full feeds. The NCG does not recommend the use of any kind of probiotics in the therapy of acute dysentery, persistent diarrhea, Clostridium difficile diarrhea and chronic diarrheal conditions such as celiac disease, diarrheapredominant irritable bowel syndrome and inflammatory bowel disease in children. Risk of antibiotic-associated diarrhea (AAD) is high with some antibiotics and most of these cases present as mild diarrhea. The NCG recommends probiotics only in special situations of AAD. L. rhamnoses GG or S. boulardii may be used for the prevention of AAD. VSL#3, a combination probiotic, may be used as an adjuvant in active pouchitis, and for prevention of recurrences and maintenance of remission in pouchitis.

The usefulness of neutrophil to lymphocyte ratio in febrile seizure

Background: Febrile seizure is an event in infancy or childhood, usually occurring between 3 months and 5 years of age associated with fever but without evidence of intracranial infection. The aim of the study was to estimate the usefulness of neutrophil-to-lymphocyte ratio (NLR) in patients with simple and complex febrile seizures.Methods: Retrospective case control'' study was done in a paediatric in patients admitted to tertiary care hospital.' Study period'' was from January 2017 to December 2019. 200 children were analysed in the study. 100 out of 200 were under control group (febrile children without seizure). Remaining 100 were under case group (children with febrile seizure), 54 out of 100 children had'' complex febrile seizure, 46 out of 100 had simple febrile seizure. NLR ratio was done in all children.Results: Total 200 children were analysed in this study.'' High NLR ratio'' was noted among the cases (87 out of 100) compared to control (30 out of 100) p value = <0.001. Among the cases CFS had high NLR ratio compared to SFS, however p value was not significant (0.072).Conclusions: Children with febrile seizure had high NLR ratio compared to those without seizures. However no significant difference was noted between those with simple febrile seizure and complex febrile seizure'' However, larger trials are required'' to assess whether higher NLR can be taken as an independent risk factor for febrile seizure.

Randomized control trial evaluating the effectiveness of ear plugs in hearing loss in NICU preterm babies

Background: The prevalence of hearing loss is higher in neonates admitted to NICU compared to the general population. Preterm babies are more vulnerable to the hearing damage due to their immature inner ear exposing them to various high frequency noises in the NICU to which they were not accustomed. Most NICU in India exceed the recommended sound levels. In order to reduce damage to the ears, foam-based earplugs are used to reduce the sound intensity reaching the ears of these premature babies.Methods: Babies admitted to NICU are allocated alternatively to receive earplugs or not. Cases are preterm babies with earplugs and controls are the ones without earplugs. The incidence of hearing loss is found by OAE testing of the ears at the end of NICU stay.Results: Out of 40 in each group, 6 babies in control group failed the OAE compared the 3 in the earplug group. Babies who did wear earplugs had longer period of NICU stay.Conclusions: Use of earplugs in babies admitted to NICU reduced the incidence of hearing loss and also length of NICU stay.

Indian Academy of Pediatrics Guidelines on the Fast and Junk Foods, Sugar Sweetened Beverages, Fruit Juices, and Energy Drinks

Justification: In view of easy availability and increasing trend of consumption of fast foods and sugar sweetened beverages (fruit juicesand drinks, carbonated drinks, energy drinks) in Indian children, and their association with increasing obesity and related non-communicable diseases, there is a need to develop guidelines related to consumption of foods and drinks that have the potential toincrease this problem in children and adolescents. Objectives: To review the evidence and formulate consensus statements related toterminology, magnitude of problem and possible ill effects of junk foods, fast foods, sugar-sweetened beverages and carbonated drinks;and to formulate recommendations for limiting consumption of these foods and beverages in Indian children and adolescents. Process:A National Consultative group constituted by the Nutrition Chapter of the Indian Academy of Pediatrics (IAP), consisting of variousstakeholders in private and public sector, reviewed the literature and existing guidelines and policy regulations. Detailed review ofliterature was circulated to the members, and the Group met on 11th March 2019 at New Delhi for a day-long deliberation on framing theguidelines. The consensus statements and recommendations formulated by the Group were circulated to the participants and aconsensus document was finalized. Conclusions: The Group suggests a new acronym ‘JUNCS’ foods, to cover a wide variety ofconcepts related to unhealthy foods (Junk foods, Ultra-processed foods, Nutritionally inappropriate foods, Caffeinated/colored/carbonated foods/beverages, and Sugar-sweetened beverages). The Group concludes that consumption of these foods and beveragesis associated with higher free sugar and energy intake; and is associated with higher body mass index (and possibly with adversecardiometabolic consequences) in children and adolescents. Intake of caffeinated drinks may be associated with cardiac and sleepdisturbances. The Group recommends avoiding consumption of the JUNCS by all children and adolescents as far as possible and limittheir consumption to not more than one serving per week. The Group recommends intake of regional and seasonal whole fruits over fruitjuices in children and adolescents, and advises no fruit juices/drinks to infants and young children (age <2 y), whereas for children aged 2-5 y and >5-18 y, their intake should be limited to 125 mL/day and 250 mL/day, respectively. The Group recommends that caffeinatedenergy drinks should not be consumed by children and adolescents. The Group supports recommendations of ban on sale of JUNCSfoods in school canteens and in near vicinity, and suggests efforts to ensure availability and affordability of healthy snacks and foods. TheGroup supports traffic light coding of food available in school canteens and recommends legal ban of screen/print/digital advertisementsof all the JUNCS foods for channels/magazines/websites/social media catering to children and adolescents. The Group further suggestscommunication, marketing and policy/taxation strategies to promote consumption of healthy foods, and limit availability and consumptionof the JUNCS foods

Prevalence of prediabetes in children and its association with risk factors

Background: Type 2 Diabetes is becoming more common at younger age group. It is important to screen children and adolescents for prediabetes to prevent long-term complications of diabetes. This study was conducted to study the prevalence of prediabetes in children and its association with risk factorsMethods: It is a Prospective hospital-based study. Children aged 6 to 18 years admitted in the Pediatric ward of tertiary care hospital were included. Study was done over a period of 2 years November 2015-October 2017. Participants were screened to find out the prevalence of prediabetes. Prediabetes was defined as fasting glucose concentration (FBS)of 100-125 mg/dl or a HbA1c value of between 5.7% and 6.4%, or a two-hour post-glucose tolerance concentration (OGTT) of 140-199mg/dl.Results: 607 children participated in the study.56.3% were males. Prevalence of Prediabetes was 20.4% with a combination of OGTT, FBS and HbA1c tests. Prevalence by OGTT was 5.9%, HbA1c 4.1% and by FBS was 17.1%. Higher prevalence of prediabetes was associated with male gender, frequent consumption of junk foods, decreased physical activities, overweight, obesity and high waist to hip ratio. Combination of FBS with GTT and FBS with' HbA1c had better sensitivity and specificity when compared to combination of OGTT with HbA1c .Conclusion: Screening of children for prediabetes at younger age especially those with risk factors and intervention with lifestyle modification may help in delaying the progression of the disease.

Clinical and imaging correlation of cerebral palsy: a retrospective study in a tertiary care centre

Background: Cerebral Palsy is the most common chronic motor disorder of childhood. Clinical spectrum is different in developing and developed countries. Aim of the study was to evaluate the clinical profile, co-morbidities and the imaging correlate of children with CP.Methods: Data was collected retrospectively from individual case records from March 2016 to October 2018. All children aged 2 years and above with clinical signs of cerebral palsy were included in the study.Results: A total of 78 children had the diagnosis of cerebral palsy, out of which 63 cases were included which satisfied the inclusion criteria. Most of the children were born out of singleton pregnancy (90.4%). The mean gestational age was 36.94'1.48 weeks. Most common type of cerebral palsy noted in present study was spastic quadriplegic type (n=34) followed by diplegic type (n=14). Epilepsy was associated in 36.5% (n=23) of children, and most commonly associated with spastic quadriplegic type of cerebral palsy(n=16). Other associated abnormalities included mental retardation, speech, hearing, cognitive, and behavioral abnormalities. Magnetic resonance imaging was normal in 60.3% (n=38) of children and abnormal in 39.68% (n=25) of children. Diffuse cerebral atrophy was the most common abnormal finding (n=9). Other abnormal findings included periventricular leucomalacia, basal ganglia lesions, cortical/subcortical lesion, focal infarcts and miscellaneous lesions.Conclusions: MRI helps in knowing the pathological basis of the disease, but clinical findings carry utmost importance. MRI positivity was seen in only 39.68% of cases. Hearing abnormalities being the most common association, proper screening tests and regular follow up is very essential.

Universal hearing screening in newborns: experience in a tertiary care hospital of Mangalore, Karnataka, India

Background: The aim of the study was to do universal hearing screening of all newborns using otoacoustic emission (OAE), to know the incidence and risk factors of hearing loss in neonates.Methods: This was a prospective observational study done in a tertiary care hospital in Mangalore city in Karnataka. 950 neonates were screened with distortion product otoacoustic emission (DPOAE) during the study period of one year from 2017 to 2018. A repeat test was done at one and a half months of age if the first test failed. Auditory brain stem evoked response (ABER) was performed at 3 months of age if both the tests failed. Babies with hearing loss were referred to ENT specialist for further management. Comparison of the variables was done by student's t test and Chi-square test. P-value <0.05 was considered statistically significant.Results: Out of the 950 newborns screened with DPOAE test, 204 (21.4 %) babies had abnormal screen either in single or both ears. 7 out of 204 (3.43%) babies had abnormal OAE on repeat testing at one and half months. 2 out of 7 babies (0.96 %) had significant hearing loss ABER was performed at 3 months of age.Conclusions: Early identification by screening of hearing loss prevents a significant public health concern. Early recognition and intervention prior to 6 months have a significant positive impact on development.

Prognostic value of rise in neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) in predicting the mortality in paediatric intensive care

Background: When the body is stressed in diverse pathological conditions, it responds by mounting an inflammatory response. Predictive biomarkers reflecting the response may serve as guide to management. Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio has been frequently used in adult patients as an indicator for mortality. However, no study has looked into their use within pediatric population. The objective of the study is to assess the prognostic value of rise in NLR and PLR in pediatric intensive care as markers of mortality.Methods: A retrospective study based on 3 year data from HIMS and G-HEALTH data systems of AJ Institute of Medical Science, of all patients admitted to PICU after excluding those in whom all the study parameters were not retrievable, were postoperative patients and/or stay was less than 5 days. NLR and PLR ratios were determined and compared to PELOD 2 using SPSS version 17.0.Results: The demographic data was matched. PELOD 2 (>20) predicted mortality in 72.2% of the patients, while NLR increase predicted in 61.1% and PLR increase in 77.8%. A decreasing trend in NLR and PLR were both closely related to better survival. Among the 3, Rise in PLR had higher sensitivity, specificity, PPV, NPV, and overall accuracy of 72.73% (p <0.001) to predict mortality.Conclusions: The study gives an insight into the fact that simple and inexpensive markers such as rise in NLR and PLR helps in predicting the mortality in the pediatric intensive care which is comparable to PELOD 2 score.

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.

Defining the Best Interest of a Child: Who Comes First – The Child or the Fetus?

In 2017, a 10-year-old girl, who was allegedly raped and impregnated, was denied an abortion on the basis of the Medical Termination ofPregnancy Act 1971. This perspective re-examines this issue while prioritizing the best interest of the child. We recommend that boardsshould be constituted at district-level hospitals, headed by senior pediatricians, and supported by obstetricians, psychologists,neonatologists, medical social workers, and others to decide the course of action – in particular, the outcome, irrespective of the weeksof pregnancy. If not compatible with the child’s life, earlier termination of pregnancy should be considered ensuring the availability ofstate-of-the-art care to the newborn and the young mother