SpO2/FiO2 and PaO2/FiO2 for Predicting Intensive Care Admission in Wheezy Children: An Observational Study.

OBJECTIVE: To determine the sensitivity of cut-off of SpO2/FiO2 (SF ratio) < 300 at hospital admission for predicting the need for admission in the pediatric intensive care unit (PICU) in wheezy children. Secondary objectives were to determine the sensitivity of cut-off of SF ratio < 300 for predicting in-hospital mortality and that of PaO2/FiO2 (PF ratio) < 200 for predicting intensive care admission and in-hospital mortality. We also ascertained the correlation between SF ratio and PF ratio in the above population. METHODS: This prospective observational study was conducted on 315 wheezy children aged 6 months to 12 years requiring admission in the pediatric emergency department. Oxygen saturation (SpO2) and fraction of oxygen in inspired air (FiO2) were recorded at admission while the partial pressure of oxygen (PaO2) was measured using arterial blood gas analysis performed within half an hour of admission. All children were managed as per protocol and followed up during hospital stay. Outcome was defined as the need for admission in the pediatric intensive care unit (PICU) or in-hospital mortality. RESULTS: Cut -offs of SF ratio < 300 and PF ratio < 200 were able to determine the need PICU admission with a sensitivity of 97.30% and 62.16% respectively. The best cut-off of SF ratio for predicting PICU admission was < 178.79 [AUC (95% CI) 0.841 (0.767, 0.914)], while that for PF ratio was < 201.81 [AUC (95% CI) of 0.849 (0.775, 0.924)]. Cut-offs of < 300 for SF ratio and < 200 of PF ratio, were able to predict in-hospital mortality with sensitivity of 100%, but specificity of only 3.33% and 46.67%, respectively. There was only a moderate correlation between SF ratio and PF ratio (r = 0.44, P < 0.001). CONCLUSION: SpO2/FiO2 cut-off of < 300 had a good sensitivity in determining need for PICU admission. SF ratio has only a moderate correlation with PF ratio.

Hematological Indices for Identifying Adverse Outcomes in Children Admitted to Pediatric ICUs.

BACKGROUND: The pediatric ICU (PICU) is a specialized area where critically sick children are managed. The mortality rates in PICUs are higher in developing countries as compared to developed nations. Many of these deaths could be prevented if very sick children were identified soon after they arrived at the health facility. Hematological indices like platelet lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) have been frequently used in adults as indicators of mortality. However, their use in the pediatric population is limited due to a lack of validated reference intervals. OBJECTIVE: The objective of the study is to assess the role of hematological indices in identifying adverse outcomes in terms of mortality in children admitted to the PICU. MATERIALS AND METHODS: It is a prospective, observational study done at a tertiary care hospital. All children aged one year to 12 years admitted to the PICU were enrolled in the study. A sample for complete blood count was taken within one hour of admission to the PICU. Children who had received blood products in the last two months, those on chronic medications (>two weeks) that can affect bone marrow cellularity, and known cases of hematological disorders such as megaloblastic anemia, hematological malignancies, immune thrombocytopenia, and aplastic anemia were excluded from the study. PLR, NLR, and platelets to mean platelet volume ratio (PLT/MPV) were determined and compared among the survivors and non-survivors. RESULTS:  Out of 275 enrolled patients, 119 (43.3%) patients expired during the study period. While PLR had high sensitivity and NLR had high specificity (85.71% and 92.31%, respectively) for predicting mortality, none of these parameters had a good area under the curve (AUC) in our study. PLT/MPV of ≥32 had a sensitivity of 39.5% and a specificity of 56.41% for predicting mortality. CONCLUSIONS: Hematological parameters have been used across the world to predict ICU mortality. PLR and NLR are simple hematological biomarkers, easy to calculate, and cost-effective, and ratios are better than individual parameters. More studies and stratified samples are required to evaluate the role of hematological markers in identifying the risk of mortality in children admitted to PICUs.

Comparison of Emergency Severity Index Version 4 and Modified Pediatric Early Warning Score as Triage Models in the Pediatric Emergency of a Tertiary Care Public Sector Hospital.

OBJECTIVE: To identify the sensitivity of emergency severity index (ESI) version 4 and modified pediatric early warning score (PEWS) in identifying high urgency patients. METHODS: This cross-sectional study was conducted between November, 2019 and October, 2021 in the pediatric emergency department of tertiary hospital in Delhi. 250 patients aged 0-12 years coming to pediatric emergency on pre-decided days for health-related complaints were enrolled. These were assessed with both triage systems within 30 minutes of their arrival by a single researcher. 'High urgency' patients were defined as the ones who either required admission in pediatric ICU or died or had critical value of vital parameters as per institution protocol. RESULTS: ESI version 4 had a sensitivity of 95.5%, specificity of 80.3%, with AUC of 0.879 (95%CI 0.834-0.925) in identifying high urgency patients at levels 1 and 2. Modified PEWS had comparatively lower sensitivity of 79.1%, specificity of 97.8%, with AUC of 0.885 (95%CI 0.825-0.994) in identifying high urgency patients at score of ≥3. The ESI version 4 was found to be a better predictor of admission than the modified PEWS, with a sensitivity of 98.2%. Both the scores were able to identify patients at risk of mortality with a sensitivity of 100%. CONCLUSION: ESI version 4 is a better triage tool than modified PEWS in pediatric population in a tertiary care public hospital setting in this region.

A Quality Improvement Study to Improve Oxygen Prescription in the PICU of a Tertiary Care Centre in Delhi, India.

Introduction Oxygen has been gravely misused since its inception as a therapeutic agent. There is a deficit of audits and baseline data for the Indian population, especially in the pediatric age group, which doesn't allow for standardization of protocols and guidelines. Objective Our study aimed at increasing valid prescription rates to 90% by implementation of quality improvement interventions, and assessing knowledge and perception of healthcare workers towards oxygen therapy. Methodology It followed a before-and-after prospective observational study model where baseline audit data was compared with data observed after the implementation of quality improvement strategies. The data was collected through an audit of the medical records of all pediatric patients receiving oxygen therapy in the PICU. Knowledge and perception of healthcare workers about oxygen therapy were assessed via a self-designed questionnaire. The study was undertaken in three phases, including Quality Improvement (QI) team formation and data collection, root cause analysis, and implementation of Plan-Do-Study-Act (PDSA) cycles. Observations and results In the baseline audit, 1.4% of the prescriptions were complete and valid. Subsequently, over the course of four PDSA cycles, valid prescription rates increased; 62.07% in the first, 79.51% in the second, 81.81% in the third, and 91.42% in the fourth cycle respectively. After applying the chi-square test to compare PDSA4 and baseline data, the p-values for written prescriptions and target saturation were found to be statistically significant. In the healthcare worker survey, we found that 100% of them were aware of indications of oxygen prescription, FiO2, and side effects of excessive usage of oxygen therapy, 95% were aware of conditions affecting pulse-oximetry in the pediatric age group, and 75% knew about target saturation and its significance and the procedure to change alarm settings on the monitor. Conclusion Currently, there exists a lack of effective oxygen prescription audits, especially in India, which can be attributed to a lack of awareness and partly, a lack of initiative. Quality improvement initiatives are effective in improving the valid oxygen prescription rate. However, sustained goals can be achieved through regular audits only.

Genetic Expression of CYP2B6 Gene in Phenobarbitone Responder and Non- responder Neonates.

Quantitative real-time polymerase chain reaction for identifying CYP2B6 gene expression was done on blood samples of 30 phenobarbitone responder and 30 non-responder neonates with seizures. CYP2B6 was observed to be significantly down regulated among phenobarbitone non-responders as compared to phenobarbitone responders (Mean (SD) DCt 17.97 (1.19) vs 15.40 (1.83); P<0.001).

Re-visiting micro ESR as a screening tool for neonatal sepsis.

Our study evaluated the role of micro-erythrocte sedimentation rate (micro-ESR) in the early detection of neonatal sepsis.Neonates with >34 completed weeks of gestation, appropriate for gestational age, admitted in our Neonatal Intensive Care Unit with clinical suspicion of early onset sepsis were enrolled in the study. A sepsis screen and blood culture was performed on all the babies within 4 h of admission. The sensitivity of micro-ESR for detecting positive blood culture was calculated and the best cut-off was determined using the Area Under Curve.

Early Total Versus Gradually Advanced Enteral Nutrition in Stable Very-Low-Birth-Weight Preterm Neonates: A Randomized, Controlled Trial.

OBJECTIVE: To assess whether early total enteral nutrition (80 mL/kg/d) started on day 1 of life in hemodynamically stable preterm very-low-birth-weight (VLBW) neonates with the rapid advancement of feeds (20 mL/kg/d) help in the earlier achievement of full feeds (180 mL/kg/d). METHODS: Early total enteral nutrition (intervention) group feeding was started with 80 mL/kg/d on the first day in all hemodynamically stable neonates admitted with birth weight of 1000-1499 grams, born at 29-33 wk of gestation as determined by first-trimester ultrasonography (USG) or expanded New Ballard Score (NBS) and was advanced by 20 mL/kg/d until maximum feeds of 180 mL/kg/d were achieved; while in control group feeding was started with 30 mL/kg/d on the first day and was advanced by 20 mL/kg/d until maximum feeds were achieved. Primary outcome measure was time taken to achieve full feeds; secondary outcomes were duration of hospital stay, necrotizing enterocolitis (NEC), time to regain birth weight, duration of antibiotics, and death. RESULTS: Sixty VLBW neonates (1000-1499 g) with comparable baseline demographics were randomized within 24 h of admission to two groups. Early total enteral nutrition intervention group (group I, n = 31) achieved the target of full enteral nutrition at median 6 d; IQR: 0 to 7.8 d, a significantly shorter time compared to the controls (n = 29) (median 10 d; IQR: 9 to 11.0 d; p = < 0.05). CONCLUSION: Early total enteral nutrition started from the first day of life results in significantly less time to achieve full feeds in hemodynamically stable preterm and VLBW infants.

Saving oxygen when it was most needed.

Background: Oxygen is one of the most commonly prescribed drugs across the globe. The ongoing Covid-19 pandemic has put enormous burden on hospital infrastructure and oxygen demand. There is lack of knowledge among healthcare workers regarding optimal utilization of oxygen delivery devices, target oxygen saturations and adequate oxygen prescription. A quality improvement project was designed to optimize the oxygen usage in wards. Methods: A core team comprising one each of consultant, senior resident, junior resident and nursing officer was formed. Fish bone analysis was done to find deficiencies in the existing system and strategy was planned to overcome these deficiencies. The key intervention included education and training of staff, Formulation of Standard Operating Procedures, use of lower target oxygen saturation and use of oxygen concentrators. Results: The project was carried out for a very short period of 5 days, and a total of 180,000 liters of oxygen was saved. The use of oxygen concentrators increased from zero to 9.5% and thus reducing the load on central oxygen supply. Conclusion: The proper training and sensitization of health care workers can help in saving oxygen, which further helps in saving precious human life.

Unusually prolonged neuromuscular weakness caused by krait (Bungarus caeruleus) bite: Two case reports.

Snakebites are common in India and the most common neurotoxic snakebites in India are due to Common krait (Bungarus caeruleus) and cobra (Naja naja). Severe envenomation may mimic brain death or a locked-in state with flaccid paralysis in a descending manner and total ophthalmoplegia. Usually, patients who receive timely antivenom and ventilator support recover completely without any sequalae. We are reporting two cases of krait bite with an unusually long period of flaccid paralysis, which required prolong ventilation. While case 1 required 10 days of mechanical ventilation followed by 5 days of non-invasive ventilation, case 2 required 11 days of mechanical ventilation followed by 5 days of non-invasive ventilation. Both the cases had delayed recovery and residual weakness at 3-month follow up. These case reports suggest that krait bite may cause prolong neuromuscular weakness in children, which has implications for both acute and chronic management.

Identifying Serious Bacterial Infections in Febrile Young Infants.

Fever is one of the most common presenting complaints among infants brought to pediatric emergency. Although most of the infants have benign, self-limiting viral infections, approximately 10% of all may have serious bacterial infection. Clinical examination alone is insufficient to detect serious bacterial infection in well appearing infants, and a standardized approach is always sought for. However, guidelines used in the United States or European countries may not be applicable in a tropical country like India. Deviation from these guidelines leads to challenges of unwarranted hospitalization and antibiotic usage, extra cost of care and risk of antimicrobial resistance. Various prediction rules can detect a low risk infant with negative predictive values ranging from 93.7-100%. While use of biomarkers such as C reactive protein and procalcitonin can be reliable, it is costly and may not be applicable to the local population. Validation studies over varied population are needed in future.

Changing epidemiology of poisoning in children: A retrospective study from a tertiary care center in New Delhi, India.

Poisoning is the fourth leading cause of unintentional injuries in children. With continuously changing environment, the epidemiology of poisoning keeps on changing. The present study was undertaken to describe the clinical and epidemiological profile of childhood poisoning in a tertiary care center of New Delhi, India. All children <12 years of age admitted to pediatric ward with a history of ingestion of poison or envenomation between January 2019 and June 2020 were identified, and their medical records were obtained from medical records department. A total of 203 patients were enrolled in the study. Drugs and medications were the most common agents (19.2% cases), followed by prallethrin (13.7% cases). Majority of the cases were asymptomatic. Vomiting (25%) was the most common symptom. Drugs and medications were the leading cause of poisoning, followed by liquid mosquito repellant. This study highlights the change in characteristics of acute poisoning in Indian children.

Recurrent arthritis: an unusual diagnosis.

Musculoskeletal complaints may be the initial manifestation of childhood leukaemias. When these symptoms predominate at the onset, a diagnosis of one of several rheumatic diseases may be entertained. Where blood tests are normal, no bone marrow examination would normally be indicated. The use of immune-suppressing medication, such as steroids, may lead to diagnostic delay or misdiagnosis.

Predictors of poor outcome in children with steroid sensitive nephrotic syndrome / Factores predisponentes a malos resultados en niños con síndrome nefrótico sensible a esteroides

BACKGROUND AND OBJECTIVE: Nearly 50% of the children with steroid sensitive nephrotic syndrome (SSNS) have a frequently relapsing (FR) or steroid dependent (SD) course, experiencing steroid toxicities and complications of immunosuppression. The study aimed to compare parameters between children with infrequent relapsing (IFR) and FR/SD nephrotic syndrome and to identify the factors associated with a FR/SD course. METHODS: A retrospective analysis of medical records from 2009 to 2014, of children with SSNS attending the pediatric nephrology clinic in a tertiary care medical college and hospital. RESULTS: Out of 325 children (226 males) with SSNS, 213 were IFR and 112 were FRNS/SDNS. The median age of onset was 34 (IQR 24-48) months. The median time to the first relapse was 4 (IQR 3-7) months and 6 (IQR 4-12) months in FR/SD and IFR group respectively. Multivariate logistic regression analysis showed "adequate treatment (≥12 weeks) of the first episode" (odds ratio 0.56, 95% CI 0.34-0.91; p value = 0.02) and "shorter median time to the first relapse" (odds ratio 1.04, 95% CI = 1.01-1.08; p value=0.04) to be independent predictors of FR/SD course. An ROC curve was constructed which showed that time to first relapse < 5.5 months was associated with a sensitivity of 69% and specificity of 60% in predicting a FR/SD course. CONCLUSION: Adequate treatment of the first episode is associated with less chance of an FR/SD course. After treatment of first episode, the first relapse occurring within 5.5 months may predict a frequently relapsing or steroid dependent course

ANTECEDENTES Y OBJETIVO: Casi el 50% de los niños con síndrome nefrótico sensible a esteroides (SNSE) presentan un curso frecuentemente recurrente (FR) o dependiente de esteroides (DE) y padecen toxicidades por esteroides y complicaciones por la inmunodepresión. El estudio tuvo como objetivo comparar los parámetros entre los niños con recurrencias infrecuentes (RI) y el síndrome nefrótico FR/DE, e identificar los factores asociados con un curso FR/DE. MÉTODOS: Un análisis retrospectivo de las historias clínicas de 2009-2014 de los niños con SNSE que asisten a la clínica de nefrología pediátrica en una facultad de medicina y un hospital de atención especializada. RESULTADOS: De 325 niños (226 varones) con SNSE, 213 fueron RI y 112 fueron SNFR/SNDE. La mediana de edad de inicio fue 34 (RIC: 24-48) meses. El tiempo medio hasta la primera recaída fue 4 (RIC: 3-7) meses y 6 (RIC: 4-12) meses en los grupos FR/DE e RI, respectivamente. El análisis de regresión logística multivariante mostró "tratamiento adecuado (≥ 12 semanas) del primer episodio" (razón de posibilidades: 0,56; IC del 95%: 0,34-0,91; valor p = 0,02) y "tiempo medio más corto hasta la primera recaída» (razón de posibilidades: 1,04; IC del 95%: 1,01-1,08; valor p = 0,04) para ser factores predisponentes independientes del curso FR/DE. Se construyó una curva ROC que mostró que el tiempo hasta la primera recaída < 5,5 meses se asoció con una sensibilidad del 69% y una especificidad del 60% en la predicción de un curso FR/DE. CONCLUSIÓN: El tratamiento adecuado del primer episodio se asocia con menos posibilidades de un curso FR/DE. Después del tratamiento del primer episodio, la primera recaída que ocurre dentro de los 5,5 meses puede pronosticar un curso frecuentemente recurrente o dependiente de esteroides

Predictors of poor outcome in children with steroid sensitive nephrotic syndrome.

BACKGROUND AND OBJECTIVE: Nearly 50% of the children with steroid sensitive nephrotic syndrome (SSNS) have a frequently relapsing (FR) or steroid dependent (SD) course, experiencing steroid toxicities and complications of immunosuppression. The study aimed to compare parameters between children with infrequent relapsing (IFR) and FR/SD nephrotic syndrome and to identify the factors associated with a FR/SD course. METHODS: A retrospective analysis of medical records from 2009 to 2014, of children with SSNS attending the pediatric nephrology clinic in a tertiary care medical college and hospital. RESULTS: Out of 325 children (226 males) with SSNS, 213 were IFR and 112 were FRNS/SDNS. The median age of onset was 34 (IQR 24-48) months. The median time to the first relapse was 4 (IQR 3-7) months and 6 (IQR 4-12) months in FR/SD and IFR group respectively. Multivariate logistic regression analysis showed "adequate treatment (≥12 weeks) of the first episode" (odds ratio 0.56, 95% CI 0.34-0.91; p value=0.02) and "shorter median time to the first relapse" (odds ratio 1.04, 95% CI=1.01-1.08; p value=0.04) to be independent predictors of FR/SD course. An ROC curve was constructed which showed that time to first relapse <5.5 months was associated with a sensitivity of 69% and specificity of 60% in predicting a FR/SD course. CONCLUSION: Adequate treatment of the first episode is associated with less chance of an FR/SD course. After treatment of first episode, the first relapse occurring within 5.5 months may predict a frequently relapsing or steroid dependent course.