Indrajit Majumdar

The Effect of Iron Therapy on the Growth of Iron‐replete and Iron‐deplete Children

This prospective, double-blind, placebo-controlled trial was designed to study the effect of iron therapy on the growth of iron-replete and iron-deficient children, and to study the change in iron status in iron-deficient children with iron therapy. One hundred and fifty children (aged 6-24 months) were included in the study. After an informed written consent, 100 healthy children, who were iron replete (group I) according to preset criteria, were randomly allocated to receive iron supplements 2 ng/kg/day (group IA) or placebo (group IB). Fifty iron-deficient children (group II) were administered iron syrup 6 mg/kg/day. Growth parameters (weight, length and head-circumference) and hematological parameters were studied for 4 months. Iron therapy, as compared with placebo, produced a significant improvement of mean monthly weight gain (p < 0.001) and linear growth (p < 0.001) in the iron-deficient children. However, it significantly decreased the weight gain (p < 0.001) and linear growth (p < 0.001) of iron-replete children. Caution should therefore be exercised while supplementing iron to children with apparently normal growth and when the iron status of the child is not known.

Lingual Thyroid as a Cause of Primary Hypothyroidism: Congenital Hypothyroidism in the Neonatal Period and Beyond

Congenital hypothyroidism affects 1:2500 to 1:4000 newborns. The majority of cases are related to thyroid dysgenesis, including complete absence of the gland (athyreosis) and abnormal location of the thyroid gland (ectopic). The incidence of lingual thyroid varies from 1:3000 to 1:100 000 and may remain undiagnosed till later in life. Lingual thyroid, characterized by presence of thyroid tissue at the base of the tongue in the region between the circumvallate papillae and the epiglottis, is the most common location for functional ectopic thyroid tissue. It results from failure of normal descent of the embryonic anlage of the thyroid gland from the posterior midline base of tongue to the prelaryngeal location. Lingual thyroid is the only functional thyroid tissue in 70% cases. Females are 8-fold more likely to be affected than males. The most common symptoms in adults include respiratory and swallowing difficulties, foreign body sensation in the throat, hemorrhage, and dysphonia. Hypothyroidism as a presenting sign is seen in 15% to 30% patients. The mean age at presentation in one series was 40.5 years with statistically significant peaks at 12.5 and 50 years. Thyroid carcinoma of lingual thyroid is a rare cause of submandibular masses in adults. The clinical presentation of lingual thyroid in pediatric patients is more variable, with age at presentation ranging from the newborn period to late adolescence. Our case series will highlight clinical manifestations of lingual thyroid in children, which may pose a diagnostic challenge for pediatricians.

Kawasaki Disease Masquerading as Hepatitis A Diagnostic Challenge for Pediatricians

Kawasaki disease (KD) is a systemic vasculitis affecting medium size arteries. It is often included in the differential diagnosis when a young child presents with persistent fever. Diagnosis can be challenging as there are no specific diagnostic tests. Persistent fever for ≥5 days with 4 of the 5 clinical criteria (bilateral bulbar nonexudative conjunctivitis, oral mucosal changes, diffuse rash, changes in extremity, and cervical lymphadenopathy [size > 1.5 cm]) and exclusion of other causes is required for diagnosis. However, the clinical criteria for typical KD may not be fulfilled at presentation and signs may evolve over time. The involvement of coronary arteries and subsequent risk of development of coronary aneurysm, ischemic heart disease, and sudden death in individuals with inadequate or delayed treatment creates a sense of diagnostic urgency. Here we report cases that will help illustrate the difficulties encountered in the diagnosis and management of children presenting as jaundice with fever.

Central Nervous System Herpes Simplex Virus Infection in Afebrile Children With Seizures

Central nervous system herpes simplex virus infection is suspected in patients presenting with acute-onset seizures and lethargy. The potential neurologic sequelae from untreated herpes infection can prompt empirical acyclovir therapy, even in afebrile subjects. The objectives of this study were to determine the frequency of central nervous system herpes simplex virus infection in children presenting with afebrile seizures and to assess the need for empirical acyclovir therapy. Clinical and laboratory data of children with acute-onset afebrile seizures and children with central nervous system herpes simplex virus infection were compared. Polymerase chain reaction and viral cultures of the cerebrospinal fluid for herpes simplex virus infection were negative in all subjects with afebrile seizures; 32.7% of these subjects were empirically treated with acyclovir. In conclusion, central nervous system herpes simplex virus infection is uncommon in children presenting with afebrile seizures, and acyclovir therapy is rarely necessary in subjects with normal neurologic examination and cerebrospinal fluid analysis.

Challenges in Transition of Care for Pediatric Patients after Weight-Reduction Surgery: a Systematic Review and Recommendations for Comprehensive Care

Obesity in pediatric patients is rising with nearly one third of children in the USA classified as overweight and up to 16–18% of the adolescent population obese with at least one comorbid condition. Consequently, bariatric procedures in this population have increased without consistent recommendations for follow-up and transition to adult providers. This review describes the known and potential long-term consequences of bariatric surgery in pediatric patients, reviews the current literature on transitions of care for adolescent patients with chronic illnesses. Additionally, this review summarizes recommendations from the literature for developing a standardized program for transitioning care for post-bariatric surgical patients and offers useful tools and guidelines for doing so.

Management of Infants Born with Disorders of Sex Development

The aims of this chapter are the following: (1) provide a concise update on the mechanisms controlling normal and abnormal sexual differentiation, (2) provide a protocol used at our institution for practical management of infants born with DSD, (3) provide information to guide the physician on making a DSD diagnosis and its medical management, (4) provide new behavioral information on DSD, and (5) highlight current differences of opinions about the care of infants born with DSD. A discussion of infants who are born with DSD with normal-appearing genitalia is also included.

Response to Letter to the Editor; Comments on “Challenges in Transition of Care for Pediatric Patients after Weight-Reduction Surgery: a Systematic Review and Recommendations for Comprehensive Care”

We appreciate the comments offered in this letter to the editor and offer the following insight in hopes of clarifying some of the authors’ concerns. While the first half of the article discusses technical aspects of bariatric surgery and the surgical and medical complications one may face, the real focus is on the process of transition. Describing these issues to the intended audience (adult providers) is merely to set the stage for a discussion on why appropriate and long-term care is imperative in our population. As we move into the discussion on transitions in care, we attempt to highlight the benefits for patients including adherence to medical care, improved continuity and attendance of appointments, and increased engagement by young adults who play an active role in the transition process. Through the literature review, we referenced systems that may be modeled where the adult and pediatric providers play an active role in the transition, often beginning with a joint appointment. This is recommended, with success in other chronic diseases, as it helps alleviate some of the stress you alluded to in disrupting the doctor-patient relationship. Additionally, transition programs such as those described function specifically to address the needs of this vulnerable population and allow for collaboration between adult and pediatric providers. While this is not meant to be an all-inclusive handbook on transitional care, we strongly encourage an active conversation between adult and pediatric providers from the onset of patient care to help facilitate this transition. By targeting this article at a largely adult provider population, we hope to stimulate these conversations and raise awareness for the need to adult common discourse and methodology to the transitional population. In order to apply these concepts to the bariatric surgery population, we highlight the medical home and list of stakeholders who are essential to the transition process. While psychiatrists are not specifically mentioned, we have recommended the inclusion of Badolescent behavioral health specialists,^ Bcase worker/social workers,^ and Badult behavioral health specialists.^ All of these providers play an essential role and preparing a patient and family for surgery and should remain engaged throughout the process and well into adulthood. As

Management of Infants Born with Disorders/Differences of Sex Development

Disorders of sex development (DSD) replaced the terms intersex, hermaphroditism, pseudohermaphroditism, sex errors of the body, and ambiguous genitalia in 2006; however, the terminology remains controversial. The current genetic-based classification system of DSD highlights the importance of chromosomal analysis in diagnosis and management of individuals with DSD. Despite advances in the domain of genetics, there has been little change in the endocrine treatment of DSD over the last few decades. On the other hand, there has been an evolving dynamic on many fronts including debates about the efficiency and timing of medically and nonmedically necessary genital surgery on infants and children with a DSD diagnosis; creation of a resolution by the Council of Europe in 2013 on the protection of children’s rights to physical integrity, demanding no one be “subjected to unnecessary medical or surgical treatment that is cosmetic rather than vital for health during infancy or childhood”; more transparency from physicians and other health professionals with families and patients; and an emphasis on the value of shared decision-making on issues such as genital surgery. In essence, there has been an evolving shift to a patient- and family-centered approach with the goal of optimizing quality of life. The aims of this chapter are to (1) provide a concise update on the mechanisms controlling normal and abnormal sexual differentiation, (2) share a protocol used at our institution for the practical management of infants born with DSD, (3) provide information to guide the physician when making a DSD diagnosis and designing medical management, (4) provide new behavioral information on DSD, and (5) highlight current differences of opinion regarding the care of infants born with DSD.

To evaluate the impact of initial chest radiograph on final outcome of ventilated patients

Mechanical ventilation is a life-saving therapy used in children in PICU. These critically ill children are usually extensively investigated in PICU. Chest radiograph is an irreplaceable investigation in these patients prior to ventilation. AIM: We studied the impact of initial chest radiograph on the final outcome of ventilated children. DESIGN: Retrospective. SETTING: Tertiary care teaching hospital. METHOD: One hundred and forty-one children were included in the study. Initial chest radiograph of all the ventilated children was evaluated and outcome of these children was correlated with the initial radiograph at admission. RESULTS: Abnormal initial radiograph was recorded in 60% (n = 84) ventilated children. Overall mortality in ventilated children was 24% (n = 34). Ventilated children with abnormal initial radiograph had significantly greater mortality (28/84) than those with initial normal chest radiograph (6/57) (P CONCLUSION: Initial chest radiograph at the beginning of ventilation may be useful to predict the outcome of these children