Aarti Kinikar

Predictors of mortality in hospitalized children with pandemic H1N1 influenza 2009 in Pune, India.

ObjectiveTo analyse the factors associated with increased mortality among Indian Children with H1N1.MethodsData were abstracted from available hospital records of children less than 12xa0y of age, who were admitted to Sassoon General Hospital in Pune, India, with confirmed pandemic 2009 H1N1 influenza infection from August 2009 through January 2010. Logistic regression analysis was used to identify clinical characteristics associated with mortality.ResultsOf 775 pediatric cases admitted with Influenza Like Illness (ILI), 92 (11.8%) had confirmed H1N1 influenza infection. The median age of HIN1 cases was 2.5xa0y; 13 (14%) had an associated co-morbid condition. Median duration of symptoms was 4xa0d (interquartile range (IQR), 3–7xa0d). All 92 H1N1 cases received oseltamivir and empiric antimicrobials on admission. Intensive care unit (ICU) admission was required for 88 (96%) children, and 20 (23%) required mechanical ventilation.Fifteen children (16%) died; mortality was associated with presence of diffuse alveolar infiltrate on admission chest radiography (odds ratio (OR) 45, 95%CI :5.4–370; pu2009<u20090.001), use of corticosteroids in ARDS in children who required mechanical ventilation (OR 8.12, 95%CI: 2.44–27.05; pu2009=u20090.001), SpO2 <80% on admission (OR 32.8, 95% CI: 5.8–185.5; pu2009<u20090.001) and presence of ARDS (OR 345.3, 95% CI :33.5–3564.1; pu2009<u20090.001). Necropsy from all children who died showed 9 (60%) had ARDS pattern and necrotizing pneumonitis, diffuse hemorrhage and interstitial pneumonia (nu2009=u20094 each, 27%) with gram positive organisms consistent with severe viral and bacterial co-infection.ConclusionsHypoxia, ARDS and use of corticosteroids in children with ARDS who were mechanically ventilated were the factors associated with increased odds of mortality. Necropsy also suggested bacterial co-infection as a risk factor.

Use of Indigenous Bubble CPAP during Swine Flu Pandemic in Pune, India

ObjectiveTo assess the effectiveness of an indigenously assembled Nasal Bubble CPAP (NB-CPAP) in children during present swine flu pandemic presenting with acute hypoxemic respiratory failure; in improving gas exchange and vital signs; and assess method safety.MethodsThirty Six children with acute hypoxemic respiratory failure admitted to swine flu ICU during the present H1NI pandemic were included (18 confirmed H1N1 positive and 18 confirmed H1N1 negative). After a baseline Arterial Blood Gas, all children received Oxygen via indigenous NB-CPAP Circuit which gave expiratory positive airway pressure of 5xa0cm water and delivered an FiO2 of around 70%. Vital signs, pH, PaO2, PaCO2, PO2/FiO2 and O2 saturation were recorded at start and at 6xa0h into the study.ResultsMedian age of the patients was 18xa0months (58% males, 42% females). Respiratory rate and heart rate improved significantly with indigenous NB-CPAP after 6xa0h of treatment compared with admission (pu2009<u20090.0001 and pu2009<u20090.001), respectively. At the end of 6xa0h on NB-CPAP,PaO2 (pu2009<u20090.0001), PCO2 (pu2009<u20090.0001), PO2/FiO2 (pu2009<u20090.0002) and O2 saturation (pu2009<u20090.001) improved significantly. Median duration of NB-CPAP use was 2xa0days and none required endotracheal intubation. The median hospital stay was 7xa0days.ConclusionsIndigenous NB-CPAP improves hypoxemia and signs and symptoms in hemodynamically stable children with acute respiratory failure due to influenza like illness. It is a cost-effective, safe, well tolerated circuit in highly demanding pandemic situations and may prevent progression to intubation.

Encephalitis in a child with H1N1 infection: First case report from India

Neurological complications have been described with seasonal influenza infection. We report encephalitis manifesting as seizures in a child with confirmed H1N1 infection. Treatment with oseltamivir was started. Child was discharged without any neurological sequelae.

2009H1N1 Infection in a 1-day-old neonate

A full-term female neonate was delivered with meconium stained amniotic fluid by cesarean section by a 2009H1N1 positive 22-year-old second gravida mother, who developed symptoms 8 days prior to delivery. The neonate was completely and immediately isolated from the mother after delivery. Oseltamivir was started at birth to the neonate who had a potential possibility of 2009H1N1 infection. At 5 hours of life, the neonate developed respiratory distress. The neonates throat swab sent for 2009H1N1 by real-time polymerase chain reaction (RT-PCR) assay was positive. The neonate required oxygen by hood for 3 days and made an uneventful recovery. The mother developed acute respiratory distress syndrome after delivery, requiring ventilatory care for 14 days and was discharged after 25 days stay in hospital. 2009H1N1 infection, although rare, needs a high index of suspicion and prompt therapy in neonates. Clinicians should be alert about the possibility of perinatal transmission of 2009H1N1.

D-transallethrin: An unusual agent for accidental poisoning

D-trans allethrin, a pyrethroid, is commonly used as a coil mosquito repellant. There are very few reports of human toxicity due to D-trans allethrin. We present the case of an 11-month-old boy who presented to us with excessive salivation, altered sensorium and convulsions following alleged accidental ingestion of a coil containing D-transallethrin. He required mechanical ventilation for a brief period and made a full recovery. Although rare, the possibility of pyrethroid poisoning should be kept in mind in children who present with sudden onset unconsciousness or convulsions.

Seizure susceptibility due to antihistamines in febrile seizures.

To the Editor: We read the article by Tomoyuki Takano [1] with interest. It was a very good attempt to study an important aspect of clinical practice. However, we feel that there are a few issues that have not been clarified by the authors. The exact duration between receipt of last dose of antihistaminic and the onset of febrile seizure has not been described. A child who has received an antihistamine 3-4 days before the seizure would not be appropriate to be included in this study. The inclusion criteria therefore should have been more clearly defined. Second, all the anithistaminics have been grouped together. Antihistamines vary in their potency and duration of action and central nervous system effects, and it would have been better to differentiate those antihistamines which are more likely to precipitate febrile seizures. The study could have been strengthened by including such measures.

Anaemia in HIV infected HAART naïve and HAART exposed children

Background: The 2016 UNAIDS report estimates about 2.1 million people living with HIV in India, of whom about 7 per cent are children under the age of 15 year. The primary objective of this study was to analyze the prevalence of anaemia in HIV Infected HAART naïve and HAART exposed children. The secondary objectives were to analyze the type of anaemia and correlation of anaemia with dietary habits and associated opportunistic infections. Present study was a cross-sectional, observational study carried out in pediatric ART OPD and ward of a tertiary care teaching hospital, from June 2011 to May 2013. Methods: Complete haemogram, peripheral smear and CD4 counts were done on 130 children with confirmed diagnosis of HIV infection. CDC staging was used to stratify children. We used Chi square test to determine the association between CDC staging, HAART therapy, diet and opportunistic infection with anaemia. P-value <0.05 was taken as significant. Results: 80% (n = 27) of the children with no immunosuppression, 86% (n = 58) of the children with moderate immunosuppression and 84% (n = 24) children with severe immunosuppression were anemic. There was no statistically significant relation between worsening immunosuppression and prevalence of anaemia (p = 0.715). 88% of the children with no opportunistic infection (n = 72) were anemic, while 76% (n = 34) children with opportunistic infection were anemic. This difference was statistically significant (p = 0.016). 88% (n = 53) of the children on HAART were anemic while 74% (n = 51) of the children not on HAART were anemic. Children on HAART did not have significantly high prevalence of anaemia when compared to children not on HAART (p = 0.99). Anaemia was significantly more common in children consuming vegetarian diet (88%, n = 46) compared to children consuming mixed diet (74%, n = 58, p <0.01). Conclusions: Prevalence of anaemia is similar in children on HAART compared to HAART naïve children and at all stages of immunosuppression. Anaemia was more common in the presence opportunistic infections and in children consuming vegetarian diet. Microcytic hypochromic anemia was most common type of anaemia followed by normocytic normochromic anaemia.

Tremors Following Blood Transfusion in Children with Megaloblastic Anemia.

To the Editor : Megaloblastic anemia has varied clinical presentation including neurological manifestations. Children with megaloblastic anemia in cardiac failure may require blood transfusion. We observed tremors alike to those seen in infantile tremor syndrome in 8 out of the 10 children who were given blood transfusion for megaloblastic anemia with cardiac failure at our institute. Tremors, as a manifestation of Vitamin B12 deficiency and following treatment with B12 injections have been reported, however, tremors following blood transfusion for megaloblastic anemia have not been reported in the literature, to the best of our knowledge. Ten children who were diagnosed to have megaloblastic anemia (clinical and laboratory diagnosis –serum B12 levels and bone marrow) and who required blood transfusion for cardiac failure due to severe anemia over a 5 y period from 2009 to 2014 were included in this retrospective case series. The youngest child was 4-mo-old while the eldest one was 2y-old in our study (median age 14 mo) and included 6 girls and 4 boys. All children belonged to poor socioeconomic group. History of poor intake or no intake of milk, milk products or animal products and improper complementary feeding was present in all ten children. The cause of B12 deficiency was therefore, most probably nutritional. The clinical findings on history and examination are summarized in Table 1. Figure 1 shows knuckle hyperpigmentation in one of the patients. The laboratory characteristics are shown in Table 2. Folate level could be done in only 4 patients and was in the normal range for age. Serum ferritin and total iron-binding capacity (TIBC) was done in 7 out of ten patients and was in the normal range for age. Serum calcium and magnesium was normal in all children. We could not obtain EEG, neuroimaging, thyroid levels in these patients. Blood transfusion [5 ml/kg of packed red blood cells (PRBC)] was given to all ten children due to presence of congestive cardiac failure as a result of severe megaloblastic anemia. Following blood transfusion, 8 of the 10 children developed coarse tremors in limbs (distal, more prominent in hands), head, face and tongue similar to infantile tremor syndrome. Tremors were absent during sleep. Two of the eight children received anticonvulsants as tremors were misjudged for tremors. The median duration for development of tremors was 38 h after transfusion with a range from 26 to 49 h. The tremors lasted for a median of 17 d with a range from 11 d to 29 d. The tremors resolved in all 8 patients. No drugs were given for

Hemorrhagic cystitis in two cases of novel influenza A (H1N1) infection

Hemorrhagic cystitis as a complication of influenza A has been described. There is only one case report describing hemorrhagic cystitis in a child with novel pandemic 2009 H1N1 influenza A infection. We report two children with confirmed novel pandemic 2009 H1N1 infection who had hemorrhagic cystitis.

A Study of the Knowledge, Attitude and Practices Regarding Blood Donation in the Relatives of Paediatric Patients in a Tertiary Care Centre

Blood is the most donated tissue in medical practice and a veritable tool in life-saving situations. Despite extensive efforts worldwide, the availability of blood still remains short. In India there is a need of about 8 million units of blood per year and only one third are obtained from voluntary donors. This study was undertaken to check the awareness of blood donation among the relatives of patients attending our wards. It was conducted among 57 participants on the basis of a questionnaire. 74% participants knew about Blood donation but only 21% had donated blood. General awareness about blood donation was high. Participants did not know specific details about the subject. There was a positive attitude to blood donation. Previously prevalent myths are no longer significant. Conclusions: Despite a positive mindset towards blood donation, efforts still need to be undertaken to progress further towards the ultimate goal of eradicating shortage of blood. Introduction: Blood is the most donated tissue in medical practice and a veritable tool in many live-saving situations. Despite the many breakthroughs of medical science today, there is still no ideal substitute. Blood is only manufactured by human beings. Human donation is the only way of acquiring blood to meet emergency requirements in cases of road traffic accidents, complications of pregnancy and childbirth, various anemic disorders and surgical emergencies. Blood donation is the act of giving one’s blood so it can be transfused into another for therapy. Globally, 80 million units of blood are donated each year (1). Despite extensive efforts worldwide, the availability of blood still remains short to meet the increased demand for it. World Health Organization advocates that 3-5% of the population should donate blood every year, which would be the ideal rate for maintaining a country’s stock of blood and blood products at acceptable level (2). The collection of blood should only be from voluntary donors, that is one of the four components of WHO’s integral strategy to promote global safety and minimize risk associated with transfusion (3). Unfortunately, 83% of the global population in developing countries has access to only 40% of voluntary supply of blood (4). In India there is a need of about 8 million units of blood every year, only one third of which are obtained from voluntary donors (5). To prevent transmission of blood-borne infections, the first step is encouraging voluntary, non-remunerated and regular blood donors who will donate blood at least once or three times a year (1, 2). Little wonder many nations across the world are continually evaluating their blood donor strategies in the light of the current demand for blood and its products and the reduction of the available eligible donors due to the stringent criteria in place to ensure blood safety (4). This cross-sectional analytical study was undertaken to check the awareness of blood donation among the relatives of patients attending our wards. We encounter several cases of Thalessemia, Sicke-cell Anemia and other blood disorders in our OPD. Similarly, blood is also required in patients of road-traffic accidents, during deliveries and other surgical emergencies in our hospital. We constantly face a shortage of blood on an emergency basis, despite having a blood bank. A factor playing a role could be the lack of awareness of the people regarding the importance of voluntary blood donation. This study also included counseling of each participant individually and encouragement to voluntarily donate blood. Objectives: 1. To study the depth of knowledge of blood donation in the relatives of Paediatric patients 2. To assess the attitude of the people towards blood donation 3. To study the practices of blood donation followed by the general community. 4. To counsel the participants and improve their understanding of the process of blood donation 5. To correct the myths associated with blood donation in the minds of people in the community. Materials and Methods: The cross-sectional analytical study was conducted among 58 participants. These participants included the relatives of patients in the Paediatric wards. A semi-structured selfadministered questionnaire was used to collect information from each participant on socio-demographic characteristics, knowledge, attitude and factors affecting voluntary blood donation. A written informed consent was taken from each person. Illiterate participants were orally questioned and answers were recorded. Observation and Results: 57 participants (32 females, 25 males) were included in this study. Relatives of children admitted in the general Paediatric wards and our Thalessemia Unit were included.