Rakesh Lodha

Upper respiratory tract infections.

Acute respiratory infections accounts for 20–40% of outpatient and 12–35% of inpatient attendance in a general hospital. Upper respiratory tract infections including nasopharyngitis, pharyngitis, tonsillitis and otitis media constitute 87.5% of the total episodes of respiratory infections. The vast majority of acute upper respiratory tract infections are caused by viruses. Common cold is caused by viruses in most circumstances and does not require antimicrobial agent unless it is complicated by acute otitis media with effusion, tonsillitis, sinusitis, and lower respiratory tract infection. Sinusitis is commonly associated with common cold. Most instances of rhinosinusitis are viral and therefore, resolve spontaneously without antimicrobial therapy. The most common bacterial agents causing sinusitis areS. pneumoniae, H. influenzae, M. catarrhalis,S. aureus andS. pyogenes. Amoxycillin is antibacterial of choice. The alternative drugs are cefaclor or cephalexin. The latter becomes first line if sinusitis is recurrent or chronic. Acute pharyngitis is commonly caused by viruses and does not need antibiotics. About 15% of the episodes may be due to Group A beta hemolytic streptococcus (GABS). Early initiation of antibiotics in pharyngitis due to GABS can prevent complications such as acute rheumatic fever. The drug of choice is penicillin for 10–14 days. The alternative medications include oral cephalosporins (cefaclor, cephalexin), amoxicillin or macrolides.

Performance of Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality (PIM), and PIM2 in a pediatric intensive care unit in a developing country.

Objective: To determine the discriminative ability and calibration of existing scoring systems in predicting the outcome (mortality) in children admitted to an Indian pediatric intensive care unit (PICU). Design: Prospective cohort study. Setting: Pediatric Intensive Care Unit, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, from July 1, 2002, to July 31, 2003. Patients: A total of 246 patients were admitted. After exclusion of 29 neonates and two patients who stayed in the PICU for ≤2 hrs, 215 patients were enrolled in the study. Of these 215 patients, 139 patients survived at the end of the PICU stay. Interventions: None. Measurements and Main Results: Discrimination between death and survival was assessed by calculating the area under the receiver operating characteristic curve for each model. The areas under the curve (95% confidence intervals) for Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality (PIM), and PIM2 were 0.80 (0.74–0.86), 0.82 (0.76–0.88), and 0.81 (0.75–0.87), respectively. The area under the receiver operating characteristic curves was significantly greater for older children compared with infants. The existing scores underpredicted the mortality; the standardized mortality ratios (SMRs) (95% confidence interval) using PRISM, PIM, and PIM2 models were 1.20 (0.94–1.50), 1.57 (1.24–1.96), and 1.57 (1.24–1.59), respectively. The SMRs were higher in children with severe malnutrition, those with underlying illness, and those with serum albumin ≤2.5 g/dL. Conclusions: The area under the receiver operating characteristic curve for all the models evaluated was >0.8. However, all the models underpredicted mortality. The likely reasons for this could be differences in the patient profile and greater load of severity of illness being managed with lesser resources—both physical and human—and differences in the quality of care.

Recurrent pneumonia in children: clinical profile and underlying causes.

Aim: To study the clinical profile and describe the predisposing causes of recurrent pneumonia in Indian children. Methods: The clinical details and the investigations of children presenting with recurrent pneumonia to the paediatric chest clinic services of a tertiary care centre in northern India were reviewed. Results: Seventy children (44M, 26F) presented with recurrent pneumonia over a period of 5 y. Based on the clinical features and the results of the investigations, underlying illness could be identified in 59 children (84%). The most frequent underlying cause for recurrent pneumonia was recurrent aspiration (24.2%), followed by immunodeficiency (15.7%), asthma (14.2%) and structural anomalies (8.6%).

Zinc as adjunct treatment in infants aged between 7 and 120 days with probable serious bacterial infection: a randomised, double-blind, placebo-controlled trial

BACKGROUND Serious bacterial infections are a major cause of death in early infancy in developing countries. Inexpensive and accessible interventions that can add to the effect of standard antibiotic treatment could reduce infant mortality. We measured the effect of zinc as an adjunct to antibiotics in infants with probable serious bacterial infection. METHODS In this randomised, double-blind, placebo-controlled trial, we enrolled infants aged 7-120 days with probable serious bacterial infection at three hospitals in New Delhi, India, between July 6, 2005, and Dec 3, 2008. With computer-generated sequences, we randomly assigned infants in permuted blocks of six, stratified by whether patients were underweight or had diarrhoea at enrolment, to receive either 10 mg of zinc or placebo orally every day in addition to standard antibiotic treatment. The primary outcome was treatment failure, which was defined as a need to change antibiotics within 7 days of randomisation, or a need for intensive care, or death at any time within 21 days. Participants and investigators were masked to treatment allocation. All analyses were done by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT00347386. FINDINGS 352 infants were randomly assigned to receive zinc and 348 to placebo. 332 given zinc and 323 given placebo could be assessed for treatment failure. Significantly fewer treatment failures occurred in the zinc group (34 [10%]) than in the placebo group (55 [17%]; relative risk reduction 40%, 95% CI 10-60, p=0·0113; absolute risk reduction 6·8%, 1·5-12·0, p=0·0111). Treatment of 15 (95% CI eight to 67) infants with zinc would prevent one treatment failure. Ten infants receiving zinc died compared with 17 given placebo (relative risk 0·57, 0·27-1·23, p=0·15). INTERPRETATION Zinc could be given as adjunct treatment to reduce the risk of treatment failure in infants aged 7-120 days with probable serious bacterial infection. FUNDING Department of Biotechnology, Government of India; the European Commission; the Meltzer Foundation; and the Research Council of Norway.

Chikungunya Infection in Children

Chikungunya fever is caused by Chikungunya virus (CHIK) and spread by Aedes aegypti and Aedes albopictus. The median incubation period is 2 to 4 days. Vertical transmission of disease from mother to child has also been documented. Clinical manifestations are very variable, from asymptomatic illness to severe debilitating disease. Children are among the group at maximum risk for severe manifestations of the disease and some clinical features in this group are distinct from those seen in adults. Common clinical features include: abrupt onset high grade fever, skin rashes, minor hemorrhagic manifestations, arthralgia/ arthritis, lymphadenopathy, conjunctival injection, swelling of eyelids and pharyngitis. Unusual clinical features include: neurological manifestations including seizures, altered level of consciousness, blindness due to retrobulbar neuritis and acute flaccid paralysis. Watery stools may be seen in infants. Treatment is symptomatic. Generally non- steroidal anti-inflammatory drugs are avoided. Paracetamol may be used for pain and fever. However, NSAIDS may be required for relief of severe arthralgia during convalescent phase.

Newer diagnostic modalities for tuberculosis

The gold standard for diagnosis of tuberculosis is demonstration of mycobacteria from various body fluids. This is often not possible in children due to pauci-bacillary nature of illness. Significant improvement in understanding of molecular biology ofMycobacterium tuberculosis has led to development of newer diagnostic techniques of tuberculosis. Polymerase chain reaction (PCR) is an emerging diagnostic tool for diagnosis of TB in children. However, its role in day-to-day clinical practice needs to be defined. A negative PCR never eliminates possibility of tuberculosis, and a positive result is not always confirmatory. The PCR may be useful in evaluating children with significant pulmonary disease when diagnosis is not readily established by other means, and in evaluating immunocompromised children (HIV infection) with pulmonary disease. In the absence of good diagnostic methods for tuberculosis, a lot of interest has been generated in serodiagnosis. ELISA has been used to detect antibodies to various purified or complex antigens ofM. tuberculosis in children. Despite a large number of studies published over the past several years, serology has found little place in the routine diagnosis of tuberculosis in children, even though it is rapid and does not require specimen from the site of disease. Sensitivity and specificity depend on the antigen used, gold standard for the diagnosis of tuberculosis and the type of tubercular infection. Though most of these tests have high specificity, their sensitivity is poor. In addition, these tests may be influenced by factors such as age, prior BCG vaccination and exposure to environmental mycobacteria. The serological tests, theoretically, may not be able to differentiate between infection and disease. At present, serodiagnosis does not appear to have any role in diagnosis of childhood pulmonary tuberculosis. A new test (QuantiFERON-TB or QFT) that measures the release of interferon-gamma in whole blood in response to stimulation by purified protein derivative is comparable with the tuberculin skin testing to detect latent tubercular infection, and is less affected by BCG vaccination. It can also discriminate responses due to nontuberculous mycobacteria, and avoids variability and subjectivity associated with placing and reading the tuberculin skin test. Polymerase chain reaction based test for identification of katG and rpoB mutation which are associated with isoniazid and rifampicin resistance may help in early identification of drug resistance in mycobacterium.

Disclosure of the HIV infection status in children.

ObjectiveTo determine the perception of caregivers about the disclosure of the diagnosis of HIV infection in children.MethodsCaregivers of fifty HIV-infected children were enrolled in the study after taking written informed consent. They were interviewed using a structured questionnaire. The questionnaire included information on the demographic details, questions about the disclosure status of HIV infection in children and perceptions about the disclosure of status to child.ResultsOnly 7 out of the 50 children (14%) were aware of their HIV status while 43/50 (86%) were unaware; as reported by their guardians/ parents. Only 6 percent children (3/50) were given factual information about the disease while 68% (34/50) were given no information. Majority of caregivers felt mid-teenage as the appropriate age for disclosing the HIV infection status and that the parents were the appropriate persons to reveal the infection status (21/50, 42%).ConclusionThere is need to develop and implement guidelines for disclosure of HIV infection status to HIV-infected children in resource limited settings.

Profile of Childhood Poisoning at a Tertiary Care Centre in North India

ObjectivesTo determine the profile and outcome (discharge from emergency room after observation, admission or death) of pediatric patients presenting with acute poisoning to a tertiary care centre in north India.MethodsWe retrospectively reviewed the last 2 year (July, 2004 to July, 2006) hospital records of pediatric emergency room to profile all cases of pediatric poisoning during that period and noted their outcome. All cases age ≤ 12 years with definite history of poisoning were included.Results111 patients presented to the pediatric emergency during the study period. Mean age of our patients was 3.12 ± 2.04 yrs (SD). Majority of our patients (63.9%) was in the 1–3 yr age group. Males outnumbered females by a factor of two; majority of our patients resided in urban areas. Kerosene (27.9%), drugs (19.8%) and insecticides (11.7%) were the agents most frequently implicated. Almost all (96.9%) ingestions were accidental in nature. Thirty six patients (32.4%) were asymptomatic after 6 hr of observation in the emergency ward; 75 patients (67.6%) developed symptoms related to toxic ingestion. The common serious symptoms included altered sensorium, respiratory distress, seizures, ataxia, hypotension, cyanosis and burns; three patients required intubation and mechanical ventilation. Almost one third of our patients underwent gastric lavage; no patient with kerosene poisoning or any other inappropriate indication underwent the same.ConclusionThe trends for pediatric poisoning noted at our centre are not very different from those observed in hospital-based studies conducted more than a decade ago, despite the rapid socioeconomic development in our country. In sharp contrast to developing countries, where majority of poisonings are due to common non-toxic household products, most of our patients require hospitalization because of severe symptoms related to dangerous nature of toxins ingested. Consultation with the poison cell results in improved patient management.

Is axillary temperature an appropriate surrogate for core temperature

The ideal technique for measuring temperature should be rapid, painless, reproducible and accurately reflect the core temperature. While axillary temperature is commonly used because of convenience and safety, there are conflicting reports abouts its accuracy. To determine whether axillary temperature can act as a surrogate for oral/rectal temperatures, a prospective comparative study was conducted. The axillary and rectal temperatures (Group 1: infants < 1 year age) and axillary and oral temperatures (Group 2: children 6–14 years age) were compared using mercury-in-glass, thermometers. Various tests of agreement were applied to the data obtained. Rectal and axillary temperatures for infants agreed well; the mean difference (95% limits of agreement) between the two being 0.6°C (−0.3°C, 1.4°C). Similarly, the mean difference (95% limits of agreement) between oral and axillary measurements for children aged 6–14 years was observed to be 0.6°C (−0.4°C, 1.4°C). Axillary temperature appears to be an acceptable alternative to rectal/oral temperature measurements in children.

Portal hypertension in north Indian children

Etiological factors associated with portal hypertension in children influence the decision about therapy and the prognosis. This cross-sectional observational study was performed at a tertiary care centre in northern India from January, 1990 to December, 1994. Children below the age of 14 years with suspected portal hypertension were prospectively assembled into a cohort to determine the etiology and clinical profile of portal hypertension. Of the 115 patients with portal hypertension, 76.5% had extrahepatic portal hypertension (EHPH). Remaining 23.5% of the cases had intrahepatic and post-hepatic causes of portal hypertension. Children with EHPH had a significantly earlier onset of symptoms as compared to those with intrahepatic portal hypertension (p = 0.002) and bled significantly more frequently (p = 0.00). Forty per cent of patients with chronic liver disease (CLD) never had jaundice. History suggestive of potential etiological factors could be elicited in only 7% of EHPH patients. The commonest site of block in splenoportal axis was at the formation of the portal vein. An inverse relation of bleeding rates with duration of illness was seen in EHPH. Of the 10 CLD patients in whom liver biopsy could be done, cirrhosis was present in 6 patients.Understanding the natural history of EHPH and portal hypertension due to other etiologies may have significant implications in choosing the appropriate intervention and predicting the outcome.