Evaluation of Pertussis Disease in Young Infants in India: A Hospital-Based Multicentric Observational Study.

OBJECTIVES: To evaluate the incidence of laboratory-confirmed pertussis (LCP) among infants hospitalized with acute respiratory infections (ARIs) and meeting the Centers for Disease Control and Prevention (CDC)-recommended clinical case definition. METHODS: An investigator-initiated active surveillance for clinically suspected cases (CSCs) of pertussis screened infants aged ≤6 mo hospitalized with ARIs during January 2020-April 2022 at seven centers across India. Reverse transcription-polymerase chain reaction (RT-PCR) was used to detect Bordetella pertussis in nasopharyngeal swabs. Infants were classified as having 'LCP' or 'probable pertussis' (PP). RESULTS: Among 1102 screened infants, 400 participants met the CDC-2020 clinical case definition for pertussis. Of these, 34/400 (8.5%) had LCP and 46/400 (11.5%) had PP. The proportion of participants with LCP and PP was similar among infants aged 0-3 and 4-6 mo [LCP: 0-3 mo, 21/248 (~9%); 4-6 mo, 13/152 (~9%); PP: 0-3 mo, 30/248 (~12%); 4-6 mo, 16/152 (~11%)]. Cough illness lasted ≥2 wk in 3/34 (~9%) and 34/46 (~74%) participants with LCP and PP, respectively. Notably, 80% CSCs had neither LCP nor PP, and a respiratory pathogen apart from B. pertussis was detected in ~32%. Ventilation was required in 12 participants with LCP/PP. CONCLUSIONS: In this first study from India based on revised CDC guidelines, the incidence of LCP was 8.5%; cough illness was not a predominant feature. Infants below the age appropriate for vaccination are prone to pertussis-related hospital admissions, ICU care, and ventilation. Maternal immunization may be evaluated for neonatal protection, in addition to other strategies, to decrease disease burden in this highly vulnerable group. CLINICAL TRIAL REGISTRATION NUMBER: CTRI/2019/12/022449.

Infant COVID-19 Infection: An Experience from Pediatric Intensive Care Unit of a Tertiary Care Dedicated Pediatric COVID Hospital.

This study aimed to assess different clinical, disease severity, laboratory, treatment, and outcome-related factors of COVID-19 positive infants admitted to a pediatric intensive care unit (PICU) and to compare these parameters with COVID-19 positive noninfants (1-12 years of age) who also required intensive care admission. This retrospective observational study was conducted in a PICU of a tertiary care, dedicated pediatric COVID facility. The clinical, epidemiological, laboratory parameters, and treatment outcomes of COVID-19 infected infants admitted to the PICU were recorded and analyzed. During comparison with the noninfant group, malignancy and coinfection with dengue and scrub typhus were excluded from both groups. A total 313 COVID-19 positive children aged from 1 month to 12 years old were admitted, of which 115 (36.7%) children required PICU admission. Infants constituted 37.4% of total PICU admissions. Most common symptoms were respiratory (83.7%) followed by fever (60.5%). Fifteen (34.9%) infants presented with shock. Ten infants (23.3%) had myocardial dysfunction. C-reactive protein (CRP) and ferritin were high in 60.5 and 16.7% infants, respectively. Fourteen infants needed invasive mechanical ventilation. Nine patients had acute respiratory distress syndrome (ARDS) and five had MIS-C. However, 53.5% infants had different comorbidities. Four infants died and all of them had severe comorbidities. Respiratory distress ( p = 0.009), pediatric sequential organ failure assessment score ( p = 0.032) and number of ARDS cases ( p = 0.044) were significantly higher in infants than noninfants. Infants are one of the most vulnerable groups of children suffering from serious illness from COVID-19 infection requiring PICU admission due to predominantly respiratory involvement. Overall outcome was good among infants without significant comorbidity.

Survival of Persons Living With HIV/AIDS: A Multicentric Study From India.

BACKGROUND: It has been more than 17 years since the introduction of free ART in India. At this point, it would be prudent to look at the factors associated with the survival of persons living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLHA) who are already enrolled in the ART program. METHODS: PLHAs enrolled from antiretroviral therapy (ART) centers located in three different cities in India - Delhi, Pune and Kolkata, and were followed up at six monthly intervals monitoring the WHO stage, CD4 counts, complete blood counts, and liver and kidney function tests, for a duration of three years. RESULTS AND DISCUSSION: The incidence of mortality among HIV/AIDS patients on ART was 5.0 per 1000 patient-years (21/1410, 1.4%). Age at initiation of ART, being above 35 years, was the only significant predictor of mortality (log-rank p = 0.018). Multivariable analysis showed a significant association of an unfavourable outcome (defined as mortality or development of opportunistic infection during follow-up) with male gender (adjusted odds ratio (AOR) = 5.26, p = <0.01) and being unmarried at ART initiation (AOR = 1.39, p = 0.005). CONCLUSION: The survival of PLHA with good adherence to ART is independent of the WHO stage or CD4 counts at the initiation of ART. Initiation of ART after 35 years of age was a significant predictor of mortality.

Rationality of Prescriptions by Rational Use of Medicine Consensus Approach in Common Respiratory and Gastrointestinal Infections: An Outpatient Department Based Cross-Sectional Study from India.

BACKGROUND: Drug utilisation studies are relevant for the analysis of prescription rationality and are pertinent in today's context of the increasing burden of antimicrobial resistance. Prescriptions for patients with diarrhoea or Acute Respiratory Infection (ARI) have been analysed in this study to understand the prescription pattern among various categories of prescribers in two tertiary care centers. METHODS: This cross-sectional study was conducted from August 2019 to December 2020 in the medicine and pediatrics outpatient departments of two government teaching hospitals in West Bengal, India. A total of 630 prescriptions were evaluated against WHO standards. Prescriptions were assessed by a 'Rational Use of Medicine Consensus committee' approach. RESULTS: The Fixed Dose Combination (FDC) was used in half of the patients (51%). Both the generic prescription (23.3%) and adherence to hospital formulary rates (36.5%) were low. The antibiotics prescription rate was high (57%), and it was higher for diarrhoea than ARI. Deviations from the standard treatment guidelines were found in 98.9% of prescriptions. Deviations were commonly found with prescriptions written by the junior doctors (99.6%). CONCLUSION: Irrational prescribing patterns prevail in tertiary care centers and indicate the necessity of awareness generation and capacity building among prescribers regarding AMR and its unseen consequences.

Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric Hematology-Oncology 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.

COVID-19 and Co-infection in Children: The Indian Perspectives.

BACKGROUND AND OBJECTIVES: Assessing the co-infections with COVID-19 is crucial to delineate its true clinical impact. Pediatric information in this aspect is limited. Our study aims to analyze the spectrum of co-infections in pediatric COVID-19 patients and determine the clinical as well as laboratory parameters predicting co-infection. METHODOLOGY: In this prospective observational study conducted from June to December 2020 in a single tertiary care institution, data pertaining to demographic, illness and treatment-related variables were analyzed among two subsets of pediatric patients of age 1 month-12 years with RT-PCR-confirmed COVID-19 infection-Group A: those with confirmed co-infection and Group B: moderate to severe disease without co-infection. Among Group A, etiology of co-infection was characterized through relevant microbiological examination within 48 h admission. RESULT: Among our study population, 15.03% and 20.6% had co-infections and moderate to severe disease respectively. Among those with confirmed co-infection, 32.5%, 11.6% and 6.97% recorded blood culture, respiratory secretion and CSF growth, respectively, the picture being dominated by Methicillin resistant and sensitive Staphylococcus aureus. Serum serology demonstrated Scrub typhus infection to be most prevalent. Concurrent respiratory viral infections were seen in 11.6%. Children with co-infection had significantly higher morbidity and need for supportive therapy. Predictors of co-infection were localization of infection, Neutrophil count ≥10×109, age-specific lymphopenia, CRP > 100 mg/dl and hyperferritinemia. CONCLUSION: Co-infections are an important factor prognosticating pediatric COVID infection. Their early detection, prompt and appropriate treatment is of paramount importance.

Scrub Typhus-Associated Hemophagocytic Lymphohistiocytosis: Not a Rare Entity in Pediatric Age Group.

BACKGROUND: Our goal was to study the demographic, clinical and laboratory profile and outcome of scrub typhus-associated hemophagocytic lymphohistiocytosis (HLH) in the pediatric age group. METHODS: We conducted a prospective observational study in a tertiary care teaching hospital over a period of 1 year. Children in the age group of 1 month to 12 years with IgM ELISA positive for scrub typhus were included in the study. HLH was diagnosed using HLH-2004 criteria. Demographic, clinical and laboratory profile, treatment and outcome of HLH patients were noted and also compared with non-HLH scrub typhus patients. RESULTS: Among 58 children with scrub typhus infection, 18 had HLH. The mean age of patients with HLH was 35.3 ± 44.8 months and 61% were male. Anemia, thrombocytopenia and hyperferritinemia were seen in all the patients. Hypertriglyceridemia, hypofibrinogenemia and coagulopathy were noted in 78%, 56% and 44%, respectively. All the patients were treated with intravenous doxycycline for an average duration of 9.5 days. Intravenous immunoglobulin and methylprednisolone were given in 33% and 22% cases, respectively. Complications like acute respiratory distress syndrome (ARDS) (p = 0.001) and MODS (p = 0.004) were significantly high in the HLH group. Younger age (<3 years), fever > 7 days, presence of convulsion, ARDS and MODS were the clinical predictors of scrub typhus-associated HLH. CONCLUSION: HLH in scrub typhus infected children is being increasingly recognized. Younger age, prolonged fever, presence of convulsion, ARDS and MODS should alert clinicians of the risk of HLH. Treating the primary cause usually cures the disease and immunomodulator therapy need not be routinely administered.

An Unusual Etiology of Cerebellar Ataxia.

Cerebellar ataxia, which is the lack of coordination, has a number of causes none of which are as uncommon or unheard of as Scrub typhus. Scrub typhus very rarely presents itself with CNS manifestations. Here, we present the case of a 7-year-old girl from the Hooghly district in West Bengal, who presented to us with the history of fever, cerebellar signs, and sudden onset of visual loss. She was ultimately diagnosed with scrub typhus cerebellitis.

Acute hemorrhagic edema of infancy.

The authors report an 11-mo-old child presenting with acute onset appearance of large, erythematous, palpable purpuric lesions involving face, extremities and trunk. Skin biopsy from the margin of the lesions showed leukocytoclastic vasculitis suggesting a diagnosis of acute hemorrhagic edema of infancy. This rare type of cutaneous vasculitis, despite its grave presentation is a benign condition with self-limiting course.

Ghosal hematodiaphyseal dysplasia with myelofibrosis.

Diaphyseal dysplasia with refractory anemia requiring blood transfusion is a relatively new entity having possible autosomal recessive inheritance. Prednisolone therapy alleviates the need for repeated transfusion. One such case is being reported here.

Rare association of central pontine myelinolysis with infantile tremor syndrome.

Central pontine myelinolysis (CPM) is an acute demyelination within the central basis pontis. Though exact mechanism is not known it is seen commonly with rapid correction of hyponatremia and also with pontine ischemia or infarction, demyelinating diseases, pontine neoplasm and different metabolic diseases. We report a rare association of CPM in a patient of Infantile Tremor Syndrom (ITS). ITS is a syndrome of tremor, mental and physical retardation, pigmentary changes of hair and skin and anemia in malnourished children. Though first reported in Indian subcontinent many identical cases were reported from around the world. Our case is a 15 month old child with generalized tremor, mild hepatosplenomegaly with features of grade II malnutrition including skin and hair changes. All the signs and symtoms of tremor improved after treatment with the World Health Organization (WHO) protocol for protein energy malnutrition (PEM) and administration of propranolol without any side effects.

A randomized controlled trial of oral zinc in acute pneumonia in children aged between 2 months to 5 years.

OBJECTIVE: To evaluate the effectiveness and safety of zinc supplementation as adjuvant in treatment of pneumonia. METHODS: Ninety-eight children with acute bacterial pneumonia, aged between 2 months to 5 years, were studied in a randomized controlled single blind design. They received either zinc supplementation, as zinc acetate syrup, or placebo, as vitamin B-complex syrup, for 14 days, concomitantly with antimicrobial treatment (49 per group). Chest radiograph and blood tests were done for confirmation of diagnosis and severity of pneumonia was assessed by breathing rate, chest in-drawing and body temperature. Potentially immunosuppressed children or those with serious comorbidity were excluded. Follow-up was done daily while subjects were admitted (generally 7 days) and the final assessment made on the 14th day on out-patient basis. RESULTS: Children enrolled in zinc and placebo groups were of comparable age [17 ± 10 and 10 ± 30 months (median ± interquartile range) respectively] and sex distribution [34 (69.4%) vs 31 (63.3%) males respectively]. Duration of illness at diagnosis was also comparable. Patients supplemented with zinc showed no difference in clinical cure rate at 14 days when compared with placebo. Fast breathing was present after 1 wk of treatment in 49% subjects in zinc supplemented vs 43% on placebo (p = 0.685). There was also no difference in breathing rate at study end. Regarding fever, the mean temperature was <99°F in both groups at study end. Hemoglobin, total leukocyte count, standard liver function tests and creatinine showed no difference between groups either at baseline or at study end. There were no treatment emergent adverse events attributable to zinc. CONCLUSIONS: Though well tolerated; the addition of zinc does not improve symptom duration or cure rate in acute bacterial pneumonia in under-five children.