Manish Narang

Oxidative stress in term small for gestational age neonates born to undernourished mothers: a case control study

BackgroundThe objective of this study was to assess the status of oxidative stress in term small for gestational age (SGA) newborn infants born to undernourished mothers by estimating levels of erythrocyte superoxide dismutase (SOD), catalase, reduced glutathione, and serum malondialdehyde (MDA) in cord blood and comparing them to healthy appropriate for gestational age (AGA) controls. This was done in a case control design at a tertiary level teaching hospital.MethodsWe included 20 singleton healthy SGA newborn infants born between 38–40 weeks to undernourished mothers with a) post-pregnancy weight < 50 kg or height < 145 cm AND b) hemoglobin < 8.0 g/dL or serum albumin < 2.5 g/dL. An equal number of age and sex matched AGA newborn infants born to healthy mothers served as Controls. Mothers with other risk factors and newborns with complications during delivery or immediate newborn period were excluded. MDA, SOD, catalase and reduced glutathione were measured in the cord blood of all neonates and compared between the groups (unpaired t test); levels were also correlated to maternal weight, height, hemoglobin, and albumin by both univariate (pearsonian correlation) and multivariate (multiple regression) analysis.ResultsThe activity of MDA was increased (5.33 ± 0.72 vs 2.55 ± 0.22 nmol/mL; P < 0.0001) while levels of superoxide dismutase (493.6 ± 54.9 vs. 786.8 ± 79.1 U/g Hb; P < 0.0001), catalase (1.48 ± 0.24 vs. 2.31 ± 0.20 U/g Hb; P < 0.0001) and reduced glutathione (2.84 ± 0.37 vs 6.42 ± 0.23 Umol/g Hb, P < 0.0001) were decreased in term SGA born to undernourished mothers as compared to term AGA born to healthy mothers. On univariate analysis, all the markers of oxidative stress correlated significantly with maternal parameters (P < 0.005). On multivariate analysis, maternal albumin and hemoglobin accounted for maximum correlation with the markers of oxidative stress.ConclusionsIntrauterine malnutrition is associated with significant oxidative stress in small for gestational age neonates born at term to malnourished mothers.

Predictors of mortality among the neonates transported to referral centre in Delhi, India.

A descriptive study was conducted with an objective to determine the predictors of mortality among referred neonates and to ascertain their transport characteristics. A total of 300 consecutive neonates who were transferred to the centre were enrolled in the study. Following information were recorded: maternal details, birth details, interventions before transportation, details of transportation and neonatal condition at arrival. Detailed clinical assessment and management was done as per standard neonatal protocols. Birth weight <1 kg (OR 0.04; 95% CI: 0.006-0.295, P<0.01) and transportation time >1 hour (OR 5.58; 95% CI: 1.41-22.01, P=0.01) were found to be significant predictors for mortality among the transported neonate. Transport characteristics reflect road transport with limited utility of ambulances and lack of trained health personal. Hence to conclude, extreme low birth weight and prolonged transportation time were found to be significant predictors of neonatal mortality among the transported neonate.

Celiac Disease and H. Pylori Infection in Children: Is there any Association?

Helicobacter pylori (HP) infection can influence the inflammatory and immune responses in the gut and may therefore play a role in the development of gluten‐related enteropathy in genetically susceptible individuals. Our objective was to assess the relationship between celiac disease and HP infection in children.

Efficacy and safety of drotaverine hydrochloride in children with recurrent abdominal pain: A randomized placebo controlled trial

ObjectiveTo evaluate the efficacy and safety of Drotaverine hydrochroride in children with recurrent abdominal pain.DesignDouble blind, randomized placebo-controlled trial.SettingPediatric Gastroenterology clinic of a teaching hospital.Participants132 children (age 4-12 y) with recurrent abdominal pain (Apley Criteria) randomized to receivedrotaverine (n=66) or placebo (n=66) orally.InterventionChildren between 4-6 years of age received 10 mL syrup orally (20 mg drotaverine hydrochloride or placebo) thrice daily for 4 weeks while children >6 years of age received one tablet orally (40 mg drotaverine hydrochloride or placebo) thrice daily for 4 weeks.Outcome MeasuresPrimary: Number of episodes of pain during 4 weeks of use of drug/placebo and number of pain-free days. Secondary: Number of school days missed during the study period, parental satisfaction (on a Likert scale), and occurrence of solicited adverse effects.ResultsReduction in number of episodes of abdominal pain [mean (SD) number of episodes 10.3 (14) vs 21.6 (32.4); P=0.01] and lesser school absence [mean (SD) number of school days missed 0.25 (0.85) vs 0.71 (1.59); P=0.05] was noticed in children receiving drotaverine in comparison to those who received placebo. The number of pain-free days, were comparable in two groups [17.4 (8.2) vs 15.6 (8.7); P=0.23]. Significant improvement in parental satisfaction score was noticed on Likert scale by estimation of mood, activity, alertness, comfort and fluid intake. Frequency of adverse events during follow-up period was comparable between children receiving drotaverine or placebo (46.9% vs 46.7%; P=0.98)ConclusionDrotaverine hydrochloride is an effective and safe pharmaceutical agent in the management of recurrent abdominal pain in children.

Clinico-immunological profile and outcome of antiretroviral therapy in HIV-positive children

OBJECTIVES To study the clinico-immunological, nutritional and growth characteristics of HIV-infected children and the impact of antiretroviral therapy (ART) on these parameters. DESIGN Retrospective study. SETTING Out-patient department of a paediatric ART centre, Delhi, India. SUBJECTS HIV-positive children registered at the paediatric ART centre of the hospital were enrolled (n 130). Anthropometric measurements were used to classify children into the type of malnutrition according to definitions of the WHO and US Centers for Disease Control and Prevention. Clinical and immunological status of the children was recorded as per WHO guidelines. First-line ART was started based on guidelines of the National AIDS Control Organization. Nutritional status and clinico-immunological characteristics were followed up annually in children receiving ART. RESULTS Of children ≤5 years of age (n 54), stunting was noted in 42·5 % contrary to wasting seen in only 12·9 %. In children >5 years of age (n 76), short stature (40·7 %) and underweight (39·4 %) were seen in almost equal proportions. Asymptomatic presentation was noted in 60·0 %. Following ART, a reduction in wasting was noted in 75·0 % of children ≤5 years of age, whereas only 44·4 % of underweight children >5 years of age showed an improvement after therapy. Stunting and short stature continued to persist in all in children (≤5 years and >5 years, respectively). Clinico-immunologically, 67·5 % improved in clinical status and 62·5 % showed immunological improvement. CONCLUSIONS ART improves the acute parameters of nutritional status like wasting. It also improves the clinical outcome and restores the immune system. At present first-line ART is effective in HIV-positive children.

Comparative efficacy and safety of oral iron chelators and their novel combination in children with thalassemia

ObjectiveTo compare the efficacy and safety of oral iron chelators (Deferiprone and Deferasirox) when used singly and in combination in multi-transfused children with thalassemia.DesignProspective comparative study.SettingThalassemia Center of a medical college affiliated hospitalParticipants and Intervention49 multi-transfused children with thalassemia with a mean (SD) age 11.6 (6.21) y received daily chelation therapy with either deferiprone alone (75 mg/kg/day in 3 divided doses), deferasirox alone (30 mg/kg/day single dose) or their daily combination (same dose as monotherapy) for 12 months.Outcome measuresSerum ferritin levels at the start of study, after 6 months and after 12 months. MRI T2* of liver and heart initially and after 6 months of follow up. 24-hour urinary iron excretion values at the outset and after 12 months of chelation therapy. At every visit for blood transfusion, all patients were clinically assessed for any adverse effects; liver and renal functions were monitored 6-monthly.ResultsAfter 12 months of respective chelation therapy, serum ferritin values decreased from a mean of 3140.5 ng/mL to 2910.0 ng/mL in deferiprone alone group, 3859.2 ng/mL to 3417.4 ng/mL in deferasirox alone group and from 3696.5 ng/mL to 2572.1 ng/ mL in the combination group. The combination therapy was more efficacious in causing fall in serum ferritin levels compared to deferiprone and deferasirox monotherapy (P=0.035 and 0.040, respectively). Results of MRI T2* were equivocal. Combined drug usage produced maximum negative iron balance in the body by maximally increasing the iron excretion in urine from 61.1 μmol/ day to 343.3 μmol/day (P=0.002). No significant adverse reactions were noticed in either the monotherapy or the combination group.ConclusionOral combination therapy of deferiprone and deferasirox appears to be an efficacious and safe modality to reduce serum ferritin in multi-transfused children with thalassemia.

Familial hypercholesterolemia with coarctation of aorta.

A six-year-old female presented with multiple nodular swellings over elbow and wrist which were noticed for last three years [Figures 1, 2]. She had history of frequent episodes of headache and vomiting. Family history was suggestive of sudden death in three siblings [Figure 3]. The exact cause of death was not available but all of them had xanthomas. Parents had an abnormal lipid profile. Father had myocardial infarction at the age of 35 years. On examination, the child had a pulse rate of 98/min. Blood pressure in the lower limbs was less than upper limbs. Examination of cardiovascular system revealed ejection systolic murmur Grade IV over left third intercostal space, which was radiating upwards. Left renal bruit was audible.

Epidemiological trends of tetanus from East Delhi, India: A hospital-based study

OBJECTIVE To study the demographic profile, prognostic indicators, and mortality of tetanus patients and treatment outcomes following intramuscular anti-tetanus immunoglobulin (ATG) alone or combined intrathecal and intramuscular ATG. DESIGN Retrospective study. SETTING Inpatients from a tertiary care hospital. SUBJECTS One hundred children under 12 years of age diagnosed with tetanus and admitted from January 2003 to December 2007 were included in the study. METHODS Case records of patients with neonatal tetanus (n=30) and post-neonatal tetanus (n=70) were evaluated retrospectively. The diagnosis of tetanus was based on World Health Organization (WHO) criteria. The outcomes of patients treated with either intramuscular ATG or both intrathecal and intramuscular ATG were separately compared in the neonatal and post-neonatal groups. RESULTS Our study revealed difficulty in feeding, trismus, spasms, rigidity, and opisthotonus posturing as the predominant clinical manifestations. The survival rate for children receiving tetanus immunoglobulin by the dual route was significantly higher than for children receiving the immunoglobulin via the intramuscular route. Seizures and tremors were poor prognostic factors associated with tetanus.

Safety and immunogenicity of single dose live attenuated varicella vaccine (VR 795 Oka strain) in healthy Indian children: a randomized controlled study.

Varicella, an acute viral systemic infection that may cause lifelong latent infection with the potential for causing clinical reactivation, may be prevented by immunization. The present study was an open label, randomized, controlled, phase III, multicentre trial, conducted to evaluate and compare the safety, tolerability and immunogenicity of a freeze dried live attenuated Oka strain Varicella Vaccine (VR 795 Oka strain) with Varilrix (Oka-RIT strain) in children. A total of 268 healthy Indian children aged 12 months to 12 y with baseline VZV IgG antibody (<100 mIU/ mL) were enrolled, and 256 children completed the study. The extent of rise of VZV IgG antibody titer assessed as 3-fold and 4-fold rise from baseline was found to be significantly higher (89.1% and 85.2%) in the test group as compared to control group (73.4% and 61.7%). The post-vaccination GMT of the test group was significantly higher (112.5 mIU/mL) as compared with the control group (67.8 mIU/mL) (P < 0.001). The seroconversion rate considering the 5 gp ELISA units/ml equivalent to 10mIU/ml were similar in the control (96.5%) and the test (98.3%) groups. The adverse events were not different in the control and test groups (P > 0.05). The test live attenuated vaccine was found to be highly immunogenic, safe and comparable to Varilrix used in control arm.

Effect of quinine and artesunate combination therapy on platelet count of children with severe malaria

Background: There are several case reports of quinine-induced thrombocytopenia but no clinical trials to ascertain its incidence and significance in severe malaria. Objectives: The primary objective was to assess the effect of quinine on the platelet count in children with severe malaria and to compare it with artesunate combination therapy (ACT), and the secondary objective was to assess outcome of treatment with quinine and ACT. Methods: An open-labelled, randomised, controlled trial was undertaken in 100 children aged 6 months to 12 years who were diagnosed with malaria by microscopy and/or rapid diagnostic test kits with at least one WHO clinical or laboratory criterion for severe malaria. All subjects were commenced on either quinine or ACT. Clindamycin was added to artesunate as a combination drug (ACT). It was also given to patients on quinine to avoid its confounding effect on the results. Platelet counts were undertaken every 24 hours for 7 consecutive days, temperature and coma score (Blantyre coma score ≥3 in children <4 years or Glasgow coma score ≥13 in children >4 years) was recorded 6-hourly and peripheral smears were taken 12-hourly until two consecutively negative smears were obtained. The primary outcome was a fall in the platelet count by ≥20% from the time of drug initiation until day 7. The secondary outcome was comparison of the efficacy, parasite clearance time, fever clearance time, coma recovery time and adverse effects of quinine vs ACT. Results: 30.4% patients in the quinine group (n = 48) had ≥20% fall in platelet count and 10.8% of patients in the ACT group (n = 46) (P = 0.02). Despite the fall in platelet count, there was no bleeding. The efficacy of ACT was significantly better than quinine but the other treatment outcomes showed insignificant difference. Conclusion: Quinine should be used with caution in patients with severe malaria because of the potential risk of quinine-induced thrombocytopenia.