The Indian Academy of Pediatrics and Directorate General of Health Services, Government of India White Paper on Transition of Care for Youth with Special Health Care Needs.

Over the years, survival of children with chronic diseases has significantly improved and a large proportion of them now are entering into adulthood. Transition of Care (ToC) of such patients with having childhood onset of chronic diseases to the adult health care system is well organized in developed countries, although it is an emerging concept in India. In situations where the systems for ToC are not in place, such cases are fraught with unsatisfactory health outcomes. With proper ToC in place, these patients are likely to receive uninterrupted care by the adult care physicians and hence reach their full potential. This document highlights the need, rationale and way forward for ToC of youth with special health care needs (YSHCN) across the country. It also describes the standard operating procedures to develop the ToC at a hospital level for clinicians and administrators.

Spirometry in Children at Six Months After SARS-CoV-2 Infection: A Single-Center Study.

OBJECTIVE: To study the spirometry parameters of children six months after severe acute coronavirus 2 (SARS-CoV-2) infection. METHODS: This single center descriptive study enrolled children aged 7-18 years after 6 months of SARS-CoV-2 infection. A detailed interval history and clinical examination was recorded. Spirometry was performed and best of the three attempts was taken into consideration to measure forced vital capacity (FVC) and forced expiratory volume 1 second (FEV1). RESULTS: A convenience sample of 40 (21 boys) children was enrolled, median (IQR) age 13 (10.75, 17) years. Twelve (30%) children had abnormal spirometry with low FVC (<80%); 10/12 (83.3%) had FEV1<80%. Children who were underweight had higher odds of having abnormal spirometry [OR (95% CI) 5.13 (1.19, 22.11); P=0.028]. There was no significant association of abnormal spirometry with age, sex, severity of initial infection and oxygen requirement during the initial infection (P>0.05). CONCLUSION: Abnormal spirometry results were observed in one-third children post-SARS-CoV-2 infection at six months follow-up.

Comparison of Neurodevelopmental Status in Early Infancy of Infants of Women With and Without Gestational Diabetes Mellitus.

OBJECTIVES: To study the neurodevelopmental status of offsprings of mothers with gestational diabetes (OGDM) aged 3½ mo. METHODS: This cross-sectional study was conducted at a tertiary hospital, New Delhi which included infants aged 3½ mo (+1 wk) who were either offsprings of women with gestational diabetes (cases) or infants of mothers without gestational diabetes mellitus presenting to tertiary care public hospital in India from January, 2018 through March, 2019, with enrollment of infants done between 10 April, 2018 and 30 March, 2019. RESULTS: The development quotient (DQ) using Developmental Assessment Scales for Indian Infants (DASII) was calculated as Motor DQ, Mental DQ and a composite DQ. The mean motor DQ of the enrolled infants was 101.7 (12.02); it was significantly lower for OGDM than controls [101 (1.41) vs. 109.5 (10.6); P <0.001]. The mean mental DQ of the enrolled infants was 88.9 (12.0); it was significantly lower for OGDM than the control group [84 (9.89 vs. 88 (8.48); P = 0.03]. The total development quotient for the enrolled infants was 95.3 (11.3). The total development quotient for study group was significantly lower than the control group [92.5 (5.65) vs. 98.75 (9.54); P = 0.001]. CONCLUSIONS: The mean motor, mental total DQ of offsprings of mothers with GDM were significantly lower than those born to mothers without GDM. Hence follow up, early intervention should be considered for this high risk group.

Factors Affecting Quality of Life in Adolescent Siblings of Children With Autism Spectrum Disorder.

OBJECTIVE: To compare the quality of life (QoL) of adolescent siblings of children with autism spectrum disorder (ASD-Sibs) with siblings of typically developing children (TD-Sibs), and study the factors affecting the QoL. METHODS: Between 1 February, 2021 and 31 September, 2021, 40 children aged 10-18 years, whose sibling was suffering from ASD, were enrolled (Study group). 40 age- and sex-matched siblings of children with no clinically apparent neuro- developmental abnormality or behavioral problem were also enrolled (Control group). Severity of autism was assessed by using the childhood autism rating scale 2 (CARS-2) score. QoL was assessed by a validated version of the World Health Organi-zation Quality of Life questionnaire Brief version (WHO QoL BREF), and compared between cases and controls using Wilcoxon rank sum test. RESULTS: The mean (SD) age of study participants was 13.55 (2.75) years. The mean (SD) CARS-2 score of our sample was 35.78 (5.23). Mild to moderate autism was seen in 23 (57.5%) children, and 13 (32.5%) had severe autism. The median (IQR) QoL in ASD-Sibs was worse than TD-Sibs in physical domain (24 (19,26) vs 32 (29,32); P<0.001), psychological domain (22 (17,23) vs 25 (23,25); P<0.001), social domain (11 (8,12) vs 13 (11,14); P<0.001), and environmental domain (28 (26,31) vs 35 (31,35); P<0.001). Among the ASD-Sibs, severity of the sibling's ASD and the family's socioeconomic status were the only two factors significantly affecting one of the domains of QoL. CONCLUSION: The observed lower QoL score in adolescent siblings of children with ASD, more so in those whose siblings had more severe ASD, suggests the need for targeting the family as a unit while formulating plans for holistic management of children with ASD.

Composition of Common Junk Food Items and Their Contribution to the Dietary Requirement of Children and Adolescents.

OBJECTIVE: To estimate the carbohydrate, energy, fat, protein, and sodium content of commonly consumed junk food items and to compare these to the Recommended Dietary Allowance (RDA) and Estimated Average Requirements (EAR) of children. METHODS: A list of eight common junk food categories was made, and the median nutritional content of carbohydrate, energy, fat, protein and sodium was determined from the commonly consumed brands in these categories. It was compared to the RDA and EAR for two different age groups viz., age 4-6 year, and male adolescents aged 13-15 years. RESULTS: The junk food groups with the highest carbo-hydrate were packaged potato chips and cakes, the group with the highest fat content was packaged potato chips, and the groups with the highest salt content were burgers and packaged potato chips. The %EAR of one packet of some items was 80-90% of daily fat requirement, and more than 60% of daily sodium requirement. CONCLUSIONS: Junk foods contribute substantially to the daily intake of carbohydrates, free sugars, total fats, saturated fats, and sodium of children.

Effect of Daily Vitamin D Supplementation on Serum Vitamin D Levels in Children with Epilepsy Receiving Sodium Valproate Monotherapy: A Randomized, Controlled Trial.

OBJECTIVES: To compare the change in serum vitamin D levels and to compare the changes in serum levels of calcium, phosphate, alkaline phosphatase and parathyroid hormone in vitamin D supplemented and unsupplemented groups after 3 mo. METHODS: In this randomized, parallel group, nonblinded, controlled trial, 40 children, 2-12 y of age with newly diagnosed epilepsy, and vitamin D sufficient status, and started on valproate monotherapy, were randomized into the intervention group (n = 20), which was given daily oral 600 IU vitamin D supplementation, and the control group (n = 20), which was not given any supplementation. Changes in the biochemical parameters was measured in the two groups after 3 mo. RESULTS: There was a significant reduction in the median (IQR) vitamin D levels in the control group as compared to an increase seen in the intervention group [-6.64 (-8.4, -2.65) vs. 5.66 (1.81, 7.12); p < 0.001]. In the control group, 37.5% children developed vitamin D insufficiency and 12.5% developed deficiency whereas only 5% of the intervention group developed vitamin D insufficiency (p = 0.005). There was a significant decrease in ionized calcium (p = 0.02), increase in serum phosphate (p = 0.02), and alkaline phosphatase level (p = 0.003) in the unsupplemented group as compared to the supplemented group. CONCLUSION: Vitamin D supplementation can reduce the valproate-associated decline in vitamin D levels and the negative impact on other markers of bone mineral metabolism. TRIAL REGISTRATION: TCTR20200621002, 19.06.2020, retrospectively registered.

Trihexyphenidyl in young children with dystonic cerebral palsy: A single arm study.

PURPOSE: The incidence of dystonic cerebral palsy causing significant morbidity is on the rise. There is a paucity of evidence for the management of dystonia in children. METHODS: Forty-one children aged 6 months-5 years with predominantly dystonic cerebral palsy were started on a predetermined protocol of trihexyphenidyl (0.25-0.52 mg/kg) and followed up at 3, 6 and 12 weeks. Dystonia severity, motor function and developmental age at baseline and 12 weeks were compared using the Global Dystonia Scale (GDS), the Gross Motor Function Measure (GMFM), and Fine Motor/Perceptual Subscale of the Early Developmental Profile-2. Thirty-four children completed the entire 12 weeks of intervention. RESULTS: The mean age of participants was 25±11 months. A significant decrease in median total dystonia scores on the GDS was observed post-intervention (74.5 to 59, p < 0.0001), and 64% of participants gained motor milestones. GMFM scores increased significantly from a median of 19.8% pre-intervention to 26.5% post-intervention (p < 0.0001). There was improvement in the fine motor domain as compared to the baseline (p < 0.0001). The number of children classified at Gross Motor Function Classification System levels 1 and 2 increased to 47.05% from 5.88% in the pre-intervention group. CONCLUSION: Trihexyphenidyl significantly improved dystonia, motor function and development in children with dystonic cerebral palsy in this study. Additional studies are needed to clarify its role in larger numbers of children with this condition.

Effect of Propranolol Prophylaxis on Headache Frequency in Children with Migraine Without Aura: A Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: To compare the efficacy of propranolol prophylaxis with placebo on headache frequency in children with migraine over the 3-mo follow-up. METHODS: In this randomized, double-blind, placebo-controlled trial children aged 6-12 y with newly diagnosed migraine without aura as per the International Classification for Headache Disorders, 3rd edition (ICHD-3) criteria were enroled. They were randomized to the intervention group receiving oral propranolol (1-3 mg/kg/d, BID) and the control group receiving a similar looking, inert, oral placebo for migraine prophylaxis for 3 mo. The number of migraine attacks over the 3-mo follow-up (using a headache diary) was the primary outcome. Pediatric Migraine Disability Assessment Scale (PedMIDAS) was used for assessing disability and Visual analogue scale was used for assessing headache severity. Analysis was done on intention-to-treat basis. RESULTS: Twenty children (10 in each group) completed the study. The two groups were similar at baseline. Both the study drugs produced significant reduction of headache frequency after the study intervention (p = 0.002). However, there was no difference between the two groups with respect to either the median (IQR) number of headache attacks [22 (20, 25) vs. 14 (10, 20); p = 0.05], headache severity [1 (0, 1) vs. 0.5 (0, 1); p = 0.48] or migraine disability [39.5 (28, 44) vs. 35 (22, 38); p = 0.27]. Adverse effects were higher in the intervention group (p = 0.52). CONCLUSIONS: Propranolol was effective for migraine prophylaxis in children but the effect was not higher than placebo. Larger placebo-controlled trials of propranolol need to be conducted to decide its place in migraine prophylaxis in children. TRIAL REGISTRATION: Thailand Clinical Trials Registry; TCTR20200621001.

Effect of Concomitant Tuberculosis Infection on COVID-19 Disease in Children: A Matched, Retrospective Cohort Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has had devastating effects on the health of millions globally. Patients with tuberculosis (TB) are a vulnerable population. There is paucity of data to assess association between the 2 diseases in Pediatric population. OBJECTIVE: To elucidate the effect of concomitant TB on clinical course of pediatric COVID-19 disease. METHODS: Retrospective matched cohort study was conducted at dedicated tertiary COVID-19 hospital in India. All consecutive patients aged <18 y admitted with COVID-19 were line listed. Patients with current or recently diagnosed TB were included. Consecutive age and sex matched COVID-19 patients with no history of TB were included as controls. Medical records were retrieved, clinical data entered in pre-determined proforma. RESULTS: During study period, 327 pediatric COVID-19 patients were admitted. Study group included 17 patients with TB. These patients, tended to be referred from other hospitals, be sicker, had lower SpO2 at arrival and higher severity of COVID-19 as compared to controls (All P < 0.05). They required more mechanical ventilation, had longer length of stay and worse outcome. CONCLUSION: COVID-19 may secondarily affect and modify the course of TB in children. Given the high case fatality rate in this association and potentially treatable nature of TB, attention of the policy makers is drawn to this. NAME OF IEC COMMITTEE: Maulana Azad Medical College and Associated Hospital Institutional Ethics Committee. IEC no: F.1/IEC/MAMC/(80/8/2020/No274). Dated 9 November 2020. TRIAL REGISTRATION: CTRI/2021/02/031197 [Registered on: 10 February 2021].

Phytochemical: a treatment option for heavy metal induced neurotoxicity.

Heavy metals are known to be carcinogenic, mutagenic, and teratogenic. Some heavy metals are necessary while present in the growing medium in moderate concentrations known to be essential heavy metals as they required for the body functioning as a nutrient. But there are some unwanted metals and are also toxic to the environment and create a harmful impact on the body, which termed to be non-essential heavy metals. Upon exposure, the heavy metals decrease the major antioxidants of cells and enzymes with the thiol group and affect cell division, proliferation, and apoptosis. It interacts with the DNA repair mechanism and initiates the production of reactive oxygen species (ROS). It subsequently binds to the mitochondria and may inhibit respiratory and oxidative phosphorylation in even low concentrations. This mechanism leads to damage antioxidant repair mechanism of neuronal cells and turns into neurotoxicity. Now, phytochemicals have led to good practices in the health system. Phytochemicals that are present in the fruits and herbs can preserve upon free radical damage. Thus, this review paper summarized various phytochemicals which can be utilized as a treatment option to reverse the effect of the toxicity caused by the ingestion of heavy metals in our body through various environmental or lifestyles ways.

Metabolic Disorders among Children Presenting with Acute Encephalopathy.

OBJECTIVE: To study the clinicoetiological profile of children presenting with acute noninfectious encephalopathy (NIE) and identify the proportion of children having inborn errors of metabolism (IEM). METHOD: This descriptive cross sectional study was conducted in a tertiary care centre in Northern India. Consecutive children, aged more than 28 d and less than 12 y, with acute encephalopathy were enrolled after ruling out CNS infection. All children were evaluated on an internally validated structured proforma. A sequential pre-decided battery of tests was applied to determine the cause of encephalopathy. IEM suspects were subjected to TMS/GCMS followed by mutation analysis for confirmation. RESULTS: Fifty children with noninfectious encephalopathy (NIE) were recruited and metabolic causes were detected in 9 of these children (18%), aged 3 to 42 mo, with female preponderance. The IEMs included lactic acidosis (4), glutaric aciduria (3), isovaleric academia (1), and hyperhomocysteinemia (1). History of previously affected siblings and consanguinity between the parents were important indicators of IEM. MS/MS and mutation analysis were the mainstay of diagnosis in these patients. IEMs contributed to the most common cause amongst cases of NIE. CONCLUSION: IEMs constitute a significant proportion of NIE in India and a high index of suspicion is required to make the diagnosis.

Diagnosis and Management of Global Development Delay: Consensus Guidelines of Growth, Development and Behavioral Pediatrics Chapter, Neurology Chapter and Neurodevelopment Pediatrics Chapter of the Indian Academy of Pediatrics.

JUSTIFICATION: Global developmental delay (GDD) is a relatively common neurodevelopmental disorder; however, paucity of published literature and absence of uniform guidelines increases the complexity of clinical management of this condition. Hence, there is a need of practical guidelines for the pediatrician on the diagnosis and management of GDD, summarizing the available evidence, and filling in the gaps in existing knowledge and practices. PROCESS: Seven subcommittees of subject experts comprising of writing and expert group from among members of Indian Academy of Pediatrics (IAP) and its chapters of Neurology, Neurodevelopment Pediatrics and Growth Development and Behavioral Pediatrics were constituted, who reviewed literature, developed key questions and prepared the first draft on guidelines after multiple rounds of discussion. The guidelines were then discussed by the whole group in an online meeting. The points of contention were discussed and a general consensus was arrived at, after which final guidelines were drafted by the writing group and approved by all contributors. The guidelines were then approved by the Executive Board of IAP. Guidelines: GDD is defined as significant delay (at least 2 standard deviations below the mean with standardized developmental tests) in at least two developmental domains in children under 5 years of age; however, children whose delay can be explained primarily by motor issues or severe uncorrected visual/hearing impairment are excluded. Severity of GDD can be classified as mild, moderate, severe and profound on adaptive functioning. For all children, in addition to routine surveillance, developmental screening using standardized tools should be done at 9-12 months,18-24 months, and at school entry; whereas, for high risk infants, it should be done 6-monthly till 24 months and yearly till 5 years of age; in addition to once at school entry. All children, especially those diagnosed with GDD, should be screened for ASD at 18-24 months, and if screen negative, again at 3 years of age. It is recommended that investigations should always follow a careful history and examination to plan targeted testing and, vision and hearing screening should be done in all cases prior to standardized tests of development. Neuro-imaging, preferably magnetic resonance imaging of the brain, should be obtained when specific clinical indicators are present. Biochemical and metabolic investigations should be targeted towards identifying treatable conditions and genetic tests are recommended in presence of clinical suspicion of a genetic syndrome and/or in the absence of a clear etiology. Multidisciplinary intervention should be initiated soon after the delay is recognized even before a formal diagnosis is made, and early intervention for high risk infants should start in the nursery with developmentally supportive care. Detailed structured counselling of family regarding the diagnosis, etiology, comorbidities, investigations, management, prognosis and follow-up is recommended. Regular targeted follow-up should be done, preferably in consultation with a team of experts led by a developmental pediatrician/ pediatric neurologist.

Evaluation of eruption of deciduous teeth among infants born after low risk pregnancy compared to infants diagnosed with Intra Uterine Growth Restriction.

PURPOSE: The impact of IUGR on holistic growth of an infant is established however, limited evidence has been reported regarding its implication on eruption of deciduous dentition. AIM: Comparative evaluation of eruption of deciduous teeth among infants born after low risk pregnancy and infants diagnosed with Intra Uterine Growth Restriction (IUGR). METHODS: The cross-sectional study included 110 neonates recruited at birth using stratified random sampling based on inclusion and exclusion criteria. Neonates diagnosed without IUGR were allocated to Group I (n = 55) and those diagnosed with IUGR were allocated to Group II (n = 55). Perinatal case history was obtained followed by intraoral examination at birth, 6 months and monthly up to 1 year or till first evidence of teeth eruption. RESULTS: The first evidence of eruption of deciduous teeth was found delayed in Group II (p = 0.0001). The mean gestational age at delivery, estimated fetal weight, frequency of NICU admission, birth weight and infant weight at 6 months was found statistically higher (p = 0.001) in Group I. CONCLUSION: First evidence of deciduous teeth eruption was found delayed among IUGR infants therefore, IUGR along with prematurity, LBW, LSCS delivery, NICU admission can be considered as risk factor for delayed eruption.

Electroencephalogram versus Magnetic Resonance Imaging Brain as the Initial Investigation of Choice in Neurologically Normal Children with First Afebrile Seizure in India.

BACKGROUND AND PURPOSE: To compare the rates of clinically relevant information provided by electroencephalogram (EEG) and magnetic resonance imaging (MRI) brain in first afebrile seizure (FAS) in children. METHODS: In this prospective randomized controlled trial, neurologically normal children between the age of 2 and 14 years, presenting with first episode of unprovoked, afebrile generalized or partial seizures, were included. Enrolled patients were randomized into two groups. After stabilization, initial workup and management, group I-patients underwent an EEG followed by MRI, whereas group II-patients underwent an initial MRI brain followed by an EEG. The patients were followed up after results of both the investigations and then every 3 months for seizure recurrence. The primary outcome was the proportion of investigations, providing clinically relevant information. The secondary outcomes were to determine the etiological diagnosis of FAS and record adverse events associated with EEG and MRI. RESULTS: Out of 170 enrolled patients, 52 patients (61.2%) in initial EEG group and 53 patients (70.6%) in initial MRI group had abnormal results on first investigation. An etiological diagnosis could not be made in any patient in initial EEG group. Neuroimaging revealed an etiological diagnosis in 53 patients (70.6%) in initial MRI group. Inflammatory granuloma was found to be the most common cause of FAS, followed by idiopathic epilepsy. CONCLUSIONS: The results of our study done in neurologically normal children with FAS showed a high diagnostic yield with an initial MRI. We recommend MRI brain to be considered as the initial investigation for evaluation of FAS in children.

Indian Academy of Pediatrics Position Paper on Nurturing Care for Early Childhood Development.

Early childhood development (ECD) refers to the physical, motor, socio-emotional, cognitive, and linguistic development of a young child. The 'Countdown to 2030' global distribution of 'children at risk of poor development' indicates the need for urgent action and investment in ECD. Nurturing care enhances ECD, even in the presence of adversities. Strategic actions should exist at multiple levels: the family, community, health care providers and government. Previously, child health related policies and programs of the Government of India functioned in isolation, but have recently started demonstrating multi-sectoral collaboration. Nonetheless, the status of ECD in India is far from optimal. There is strong evidence that parenting programs improve outcomes related to ECD. This is dependent on key programmatic areas (timing, duration, frequency, intensity, modality, content, etc.), in addition to political will, funding, partnership, and plans for scaling up. Each country must implement its unique ECD program that is need-based and customized to their stakeholder community. Barriers like inadequate sensitization of the community and low competency of health care providers need to be overcome. IAP firmly believes that responsive parenting interventions revolving around nurturing care should be incorporated in office practice. This paper outlines IAP's position on ECD, and its recommendations for pediatricians and policy makers. It also presents the roadmap in partnership with other stakeholders in maternal, neonatal, and child health; Federation of Obstetric and Gynaecological Societies of India (FOGSI), National Neonatology Forum (NNF), World Health Organization (WHO), and United Nation Children Fund (UNICEF).

Medical education during COVID-19 associated lockdown: Faculty and students' perspective.

BACKGROUND: The lockdown imposed due to novel coronavirus disease 2019 (COVID-19) has resulted in adopting electronic learning (e-learning) as the means of education in various institutions all over India. This study aimed to collect the experiences of faculty and students regarding e-learning in medical colleges during COVID-19 and to analyse the likely perceived benefits and problems to choose blended learning activities after the COVID crisis. METHODS: A survey-based study was conducted among undergraduate students and faculty members in medical colleges of Delhi-NCR. RESULT: Two hundred forty-eight medical students and 23 faculty members participated in the study. Two hundred twelve (85.4%) students considered medical education to be severely affected during the lockdown and 219 (88.3%) students found the online classes to be useful. Poor connectivity followed by lack of human interface and poor sound or acoustics were the major hindering factors, whereas convenience and access were reported as important facilitating factors. In the postlockdown phase, 135 (54.4%) students want online classes to be continued in addition to classroom teaching for the cognitive domain, 42 (16.9%) students want it for both cognitive and psychomotor domain and 60 (24.1%) do not want online classes. The majority of the faculty members (65.2%) were in favour of including online teaching modules in routine curriculum and 69.6% suggested a 70%:30% distribution of traditional and online classes after the COVID lockdown. CONCLUSION: Implementation of e-learning within the existing curriculum is bound to be challenging; however, it remains the only solution during COVID-19 imposed lockdown for maintaining the chain of learning.