Madhuri Kulkarni

Multicenter, Hospital-Based Surveillance of Rotavirus Disease and Strains among Indian Children Aged <5 Years

BACKGROUND Current, nationally representative data on rotavirus disease burden and rotavirus strains in India are needed to understand the potential health benefits of rotavirus vaccination. METHODS The Indian Rotavirus Strain Surveillance Network was established with 4 laboratories and 10 hospitals in 7 different regions of India. At each hospital, children aged <5 years who presented with acute gastroenteritis and required hospitalization with rehydration for at least 6 h were enrolled. A fecal specimen was obtained and was tested for rotavirus with use of a commercial enzyme immunoassay, and strains were characterized using reverse-transcription polymerase chain reaction. RESULTS From December 2005 through November 2007, rotavirus was found in approximately 39% of 4243 enrolled patients. Rotavirus was markedly seasonal in northern temperate locations but was less seasonal in southern locations with a tropical climate. Rotavirus detection rates were greatest among children aged 6-23 months, and 13.3% of rotavirus infections involved children aged <6 months. The most common types of strains were G2P[4] (25.7% of strains), G1P[8] (22.1%), and G9P[8] (8.5%); G12 strains were seen in combination with types P[4], P[6], and P[8] and together comprised 6.5% of strains. CONCLUSIONS These data highlight the need for development and implementation of effective prophylactic measures, such as vaccines, to prevent the large burden of rotavirus disease among Indian children.

Patterns of prescription and drug dispensing

Objective: To analyze the patterns of prescriptions and drug dispensing using World Health Organization core drug use indicators and some additional indices.Methods: Data were collected prospectively by scrutinizing the prescriptions written by pediatric resident doctors and by interviewing parents of 500 outpatient children.Results: The average number of drugs per encounter was 2.9 and 73.4% drugs were prescribed by generic name. Majority of drugs prescribed were in the form of syrups (60.8%). Use of antibiotics (39.6% of encounters) was frequent, but injection use (0.2% of encounters) was very low. A high number of drugs prescribed (90.3%) conformed to a model list of essential drugs and were dispensed (76.9%) by the hospital pharmacy. Certain drugs (5.7%) prescribed as syrups were not dispensed, although they were available in tablet form. Most parents (80.8%) knew the correct dosages, but only 18.5% of drugs were adequately labeled. No copy of an essential drugs list was available. The availability of key drugs was 85%.Conclusion: Interventions to rectify over prescription of antibiotics and syrup formulations, inadequate labeling of drugs and lack of access to an essential drugs list are necessary to further improve rational drug use in our facility.

Poor school performance

Education is one of the most important aspects of human resource development. Poor school performance not only results in the child having a low self-esteem, but also causes significant stress to the parents. There are many reasons for children to under perform at school, such as, medical problems, below average intelligence, specific learning disability, attention deficit hyperactivity disorder, emotional problems, poor socio-cultural home environment, psychiatric disorders and even environmental causes. The information provided by the parents, classroom teacher and school counselor about the child’s academic difficulties guides the pediatrician to form an initial diagnosis. However, a multidisciplinary evaluation by an ophthalmologist, otolaryngologist, counselor, clinical psychologist, special educator, and child psychiatrist is usually necessary before making the final diagnosis. It is important to find the reason(s) for a child’s poor school performance and come up with a treatment plan early so that the child can perform up to full potential.

Leptospirosis in children in Mumbai slums.

Objective : There is limited data available on symptomatic leptospirosis in Indian children. We report an outbreak of leptospirosis that occurred in children living in slums following heavy rainfall and flooding. This hospital — based prospective study was conducted from July to August 2001.Methods : Diagnosis of acute leptospirosis was suspected by following the Indian Leptospirosis Society working definition for leptospirosis. Diagnosis was confirmed by detecting anti —Leptospira antibodies, using either aLeptospira genus — specific latex agglutination assay or a dipstick assay or by a macroscopic slide agglutination test.Result : Thirty (32%) out of 93 children admitted had acute leptospirosis. Fever, bodyache, chills, abdominal pain, headache, vomiting, cough, hepatosplenomegaly, edema and crepitations were the common presenting signs and symptoms. Twenty — two children had anicteric leptospirosis and 8 had Weil disease. Response to penicillin treatment was good in all except in one child with Weil disease who died of renal failure within 3 hours of admission.Conclusion : Leptospirosis has emerged as an infectious disease in Mumbai. During monsoon, parents should ensure that their child does not have contact with the contaminated flood water.

Clinical and psychoeducational profile of children with specific learning disability and co-occurring attention-deficit hyperactivity disorder.

BACKGROUND Almost 10% of school-going children have specific learning disability (SpLD) in the form of dyslexia, dysgraphia and/or dyscalculia. Attention-deficit hyperactivity disorder (ADHD) occurs as a comorbidity in about 20% of these children. AIMS To document the clinical profile and academic history of children with SpLD and co-occurring ADHD. SETTINGS AND DESIGN Prospective observational study conducted in our clinic. MATERIALS AND METHODS From August to November 2004, 50 consecutively diagnosed children (34 boys, 16 girls) were included in the study. SpLD was diagnosed on the basis of psychoeducational testing. Diagnosis of ADHD was made by DSM-IV-revised criteria. Detailed clinical and academic history and physical and neurological examination findings were noted. STATISTICAL ANALYSIS Chi-square test or unpaired students t-test was applied wherever applicable. RESULTS The mean age of children was 11.4 years (+/-SD 2.5, range 7-17.1). Fifteen (30%) children had a significant perinatal history, 12 (24%) had delayed walking, 11 (22%) had delayed talking, 5 (10%) had microcephaly, 27 (54%) displayed soft neurological signs and 10 (20%) had primary nocturnal enuresis. There were no differentiating features between the two gender groups. Their academic problems were difficulties in writing (96%), inattentiveness (96%), difficulties in mathematics (74%), hyperactivity (68%) and difficulties in reading (60%). All children had poor school performance, 15 (30%) had already experienced class retention and 20 (40%) had developed aggressive or withdrawn behavior. CONCLUSION Children with SpLD and co-occurring ADHD need to be identified at an early age to prevent poor school performance and behavioral problems.

Clinical and Psychoeducational Profile of Children with Borderline Intellectual Functioning

ObjectiveTo document the clinical profile and academic history of children with borderline intellectual functioning (“slow learners”); and to assess parental knowledge and attitudes regarding this condition.MethodsFrom November 2004 to April 2005, 55 children (35 boys, 20 girls) were diagnosed as slow learners based on current level of academic functioning and global IQ scores (71–84) done by the WISC test. Detailed clinical and academic history; and physical and neurological examination findings were noted. The parents were counseled about the diagnosis and the option of special education.ResultsThe mean age of slow learners was 11.9 years (±SD 2.3, range 8–17). Eighteen (32.7%) children had a significant perinatal history, 15 (27.3%) had delayed walking, 17 (30.9%) had delayed talking, 17 (30.9%) had microcephaly, 34 (61.8%) had presence of soft neurologic signs, and 10 (18.2%) were on complementary and alternative medication therapy. There were no differentiating features between the two gender groups. Their chief academic problems were difficulty in writing (92.7%), overall poor performance in all subjects (89.1%), and difficulty in mathematics (76.4%). Forty-six (83.6%) children had failed in examinations, 34 (61.8%) had experienced grade retention, and 32 (58.2%) had behavior problems. Most parents (83.3%) were reluctant to consider the option of special education.ConclusionSlow learners struggle to cope up with the academic demands of the regular classroom. They need to be identified at an early age and their parents counseled to understand their academic abilities.

Does 3-day course of oral amoxycillin benefit children of non-severe pneumonia with wheeze: a multicentric randomised controlled trial.

Background WHO-defined pneumonias, treated with antibiotics, are responsible for a significant proportion of childhood morbidity and mortality in the developing countries. Since substantial proportion pneumonias have a viral etiology, where children are more likely to present with wheeze, there is a concern that currently antibiotics are being over-prescribed for it. Hence the current trial was conducted with the objective to show the therapeutic equivalence of two treatments (placebo and amoxycillin) for children presenting with non-severe pneumonia with wheeze, who have persistent fast breathing after nebulisation with salbutamol, and have normal chest radiograph. Methodology This multi-centric, randomised placebo controlled double blind clinical trial intended to investigate equivalent efficacy of placebo and amoxicillin and was conducted in ambulatory care settings in eight government hospitals in India. Participants were children aged 2–59 months of age, who received either oral amoxycillin (31–54 mg/Kg/day, in three divided doses for three days) or placebo, and standard bronchodilator therapy. Primary outcome was clinical failure on or before day- 4. Principal Findings We randomized 836 cases in placebo and 835 in amoxycillin group. Clinical failures occurred in 201 (24.0%) on placebo and 166 (19.9%) on amoxycillin (risk difference 4.2% in favour of antibiotic, 95% CI: 0.2 to 8.1). Adherence for both placebo and amoxycillin was >96% and 98.9% subjects were followed up on day- 4. Clinical failure was associated with (i) placebo treatment (adjusted OR = 1.28, 95% CI: 1.01 to1.62), (ii) excess respiratory rate of >10 breaths per minute (adjusted OR = 1.51, 95% CI: 1.19, 1.92), (iii) vomiting at enrolment (adjusted OR = 1.49, 95% CI: 1.13, 1.96), (iv) history of use of broncho-dilators (adjusted OR = 1.71, 95% CI: 1.30, 2.24) and (v) non-adherence (adjusted OR = 8.06, 95% CI: 4.36, 14.92). Conclusions Treating children with non-severe pneumonia and wheeze with a placebo is not equivalent to treatment with oral amoxycillin. Trial Registration ClinicalTrials.gov NCT00407394

Anxiety levels in mothers of children with specific learning disability

BACKGROUND Parents of children with specific learning disability (SpLD) undergo stress in coping with their childs condition. AIM To measure the levels of anxiety and find out the cause of anxiety in mothers of children with SpLD at time of diagnosis. SETTINGS AND DESIGN Prospective rating-scale and interview-based study conducted in our clinic. MATERIALS AND METHODS One hundred mothers of children (70 boys, 30 girls) with SpLD were interviewed using the Hamilton anxiety rating scale (HAM-A) and a semi-structured questionnaire. Detailed clinical and demographic data of mothers were noted. STATISTICAL ANALYSIS Chi-square test or unpaired students t-test was applied wherever applicable. RESULTS The mean age of mothers was 40.14 years (+/-SD 4.94, range 25.07-54.0), 73% belonged to upper or upper middle socioeconomic strata of society, 67% were graduates or postgraduates, 58% were full-time home-makers, and 33% lived in joint families. Levels of anxiety were absent in 24%, mild in 75%, and moderate in 1% of mothers. Their mean total anxiety score was 5.65 (+/-SD 4.75, range 0-21), mean psychic anxiety score was 3.92 (+/-SD 3.11, range 0-13), and mean somatic anxiety score was 1.76 (+/-SD 2.05, range 0-10). Their common worries were related to childs poor school performance (95%), childs future (90%), childs behavior (51%), and visits to our clinic (31%). CONCLUSION Most mothers of children with SpLD have already developed mild anxiety levels by the time this hidden disability is diagnosed. These anxieties should be addressed by counseling to ensure optimum rehabilitation of these children.

Prognostic clinical variables in childhood tuberculous meningitis: An experience from Mumbai, India

BACKGROUND In India, tuberculous meningitis (TBM) is still a major cause of neurological disabilities and death. AIM To identify the clinical variables which predict the outcome in childhood TBM. SETTING Tertiary teaching hospital. DESIGN Prospective observational study. MATERIALS AND METHODS Thirty-six clinical variables were analyzed in 123 consecutive children with TBM admitted between May 2000 and August 2003. The outcome was assessed in terms of survival or death. Survival meant that the patient was discharged from hospital having made a complete recovery, or with disability. RESULTS Twenty-five (20%) children recovered completely, 70 (57%) survived with disability, and 28 (23%) died. Employing univariate analysis nine variables correlated with survival with disability outcome: presence of tonic motor posturing, cranial nerve palsy, focal neurological deficit, hypertonia, moderate to severe hydrocephalus, cerebral infarction on cranial CT, and requiring shunt surgery, and absence of extracranial tuberculosis and no antituberculous-related hepatotoxicity; two variables correlated with fatal outcome: presence of deep coma (Glasgow coma scale score P = 0.012, d.f. = 1, OR 0.12, 95% CI 0.02-0.62) correlated with survival with disability outcome, and presence of deep coma (P = 0.030, d.f. = 1, OR 0.35, 95% CI 0.14-0.90) with fatal outcome. CONCLUSION In children with TBM, the presence of hypertonia at admission is an independent predictor of neurological sequelae in survivors, and deep coma is an independent predictor of mortality.

Health-related quality of life of children with newly diagnosed specific learning disability.

The objective of this study was to measure health-related quality of life (HRQL) of children with newly diagnosed specific learning disability (SpLD) using the Child Health Questionnaire-Parent Form 50. We detected clinically significant deficits (effect size > or = -0.5) in 9 out of 12 domains: limitations in family activities, emotional impact on parents, social limitations as a result of emotional-behavioral problems, time impact on parents, general behavior, physical functioning, social limitations as a result of physical health, general health perceptions and mental health; and in both summary scores (psychosocial > physical). Multivariate analysis revealed having > or = 1 non-academic problem(s) (p < 0.0001), attention-deficit hyperactivity disorder (p = 0.005) or first-born status (p = 0.009) predicted a poor psychosocial summary score; and having > or =1 non-academic problem(s) (p = 0.006) or first-born status (p = 0.035) predicted a poor physical summary score. HRQL is significantly compromised in children having newly diagnosed SpLD.