Sheila Bhave

Ciprofloxacin in typhoid fever

The study covers 78 children with typhoid fever who were hospitalized in April & May 1990. Serious complications were present in 32% (toxemia 22%, ileus 25% and myocarditis 8%). Blood cultures were positive in 30 of 49 tested. Others were diagnosed by positive Widal test.In vitro cultures ofS. typhi were resistant to chloramphenicol (90%), ampicillin (93%) and co-trimoxazole (97%). However all were highly sensitive to ciprofloxacin and moderately sensitive to cephalexin and gentamycin. Ciprofloxacin alone or in combination was given in 73 of the 78 children and found to be remarkably effective in controlling the disease and preventing relapse. No serious side effects were noted. The cohort is being followed up for possible long term adverse effects.

Wilson's disease.

Wilson’s disease (WD), an inborn error of copper (Cu) metabolism, is now one of the leading liver diseases in children in India The clinical presentation can be extremely varied viz., -all forms of acute and chronic liver disease, minimal to severe neurological disease, psychiatric problems, bony deformities, hemolytic anemia and endocrine manifestations. A high index of suspicion is necessary along with a judicious battery of investigations for diagnosis. Hepatic copper estimation is the most reliable test but is not easily available in India. Liver biopsy may not be possible because of bleeding problems and histological features are often not diagnostic of WD. In the absence of hepatic Cu, a low ceruloplasmin, high 24 hour urinary copper and presence of KF rings aid in making the diagnosis. The mainstay of initial therapy is Cu-chelators like D-Penicillamine, and Trientine for reduction in body copper to sub-toxic levels. Subsequent maintenance therapy is necessarily lifelong with D-Penicillamine, Trientine or Zinc. Children on therapy must be monitored regularly for response, side-effects, compliance and rehabilitation. Response to therapy may be unpredictable, but acute and early presentations like fulminant hepatic failures have a poor outcome. All siblings must be screened for WD as early diagnosis and treatment result in a good outcome. The identification of the WD gene on chromosome 13 has led to the possible use of molecular genetics (haplotype and mutational analyses) in the diagnosis of WD. Parent groups / associations must take active part in holistic management of WD.

Nutrition Management in Chronic Liver Disease

Liver has a central role in nutritional homeostasis and any liver disease leads to abnormalities in nutrient metabolism and subsequent malnutrition. All children with chronic liver disease (CLD) must undergo a periodic nutritional assessment — medical history, anthropometry esp. skinfold thickness and mid-arm circumference, and biochemical estimation of body nutrients. Nutritional rehabilitation is catered to the individual child but generally the caloric intake is increased to 130% of RDA by adding glucose polymers and/or MCT oil (coconut oil) with essential fatty acid supplementation (sunflower oil). The enterai route is preferred and occasionally nasogastric and/or nocturnal feeding are required to ensure an adequate intake. Proteins rich in branched chain amino acids are given in moderation (2–3 gm/kg/day) in compensated cirrhotics unless encephalopathy occurs when protein restriction may be necessary (1 gm/kg/day). Fat-soluble vitamins are supplemented in large quantities esp. in cholestasis along with other vitamins and minerals. Dietary therapy is the mainstay of management of some metabolic liver diseases and may be curative in disorders like galactosemia, fructosemia and glycogen storage disorders. Pre and postoperative nutritional support is an important factor in improving survival after liver transplantation.

Clinical trials of penicillamine in Indian childhood cirrhosis.

The outcome in 15 children with advanced Indian childhood cirrhosis (ICC) treated with penicillamine 20 mg/kg/day was not significantly different from that in untreated children. Among children admitted to a further double blind trial who had ICC but who had not yet developed jaundice or ascites 10 treated with penicillamine and 10 treated with penicillamine plus prednisolone had a significantly improved survival. Fourteen of 29 treated cases made a clinical recovery and were alive 489 to 1460 days from the start of treatment. Biopsy specimens in survivors showed a return to normal liver histology in three, residual fibrosis in six, and inactive micronodular cirrhosis in five. Thus penicillamine, while not shown to be beneficial in advanced ICC, lowered mortality from 93% to 52% in preicteric cases of ICC.

The prevention of Indian childhood cirrhosis

Previous studies have led to the hypothesis that the gross hepatic copper storage characteristic of Indian childhood cirrhosis (ICC) is due to the early introduction of animal milk feeds which have been contaminated with copper from brass household utensils. Amongst the families of 100 cases of ICC, the incidence of ICC in children born after dietary advice had been given (1/86) was significantly lower than in older siblings (12/125). This study attempted to document the incidence of ICC and the usage of brass before and after an intervention programme in Pune District advising against this pattern of infant feeding. The study encountered numerous difficulties in data gathering, but documented a fall in ICC prevalence resulting in its virtual disappearance in Pune District. This contrasted with an unchanged incidence in Chandigarh. Although a fall in brass usage was seen in Pune District, this was actually a spontaneous sociological change rather than a result of health education.

Long term survival in Indian childhood cirrhosis treated with D-penicillamine.

Indian childhood cirrhosis (ICC) is an almost uniformly fatal disease whose outcome may be modified with penicillamine if given at a sufficiently early stage. Twenty nine children with ICC seen in Pune, India, in 1980-7, who had survived at least five years from onset of penicillamine treatment, were reviewed aged 6.3 to 13 years. They were assessed clinically, biochemically, histologically, and by duplex Doppler ultrasound examination. None had symptoms suggestive of liver disease. There were no toxic effects of penicillamine other than asymptomatic proteinuria. Hepatosplenomegaly reduced significantly and liver function tests returned to normal in all. In four children, significant hepatosplenomegaly was associated with an abnormal duplex Doppler hepatic vein flow pattern and micronodular cirrhosis on biopsy. Clinical findings, growth and development, and ultrasound examination were normal in the remainder. Review of serial liver biopsy specimens showed a sequence of recovery from ICC through inactive micronodular cirrhosis to virtually normal histological appearances. The four children who still have micronodular cirrhosis beyond four years from onset remain on penicillamine treatment. In the others penicillamine was stopped after 1-7 (mean 3.5) years without relapse, strong evidence that ICC is not due to an inborn error of copper metabolism.

Changing pattern of chronic liver disease (CLD) in India

SummaryIn Summary, a common killer disease of yesteryears-ICC, has become rare and treatable in early 1990s. The most plausible reason for this is the change in feeding vessels associated with changing life styles. Increased awareness and improved diagnostic facilities have led to identification of other chronic liver disorders such as Biliary Atresia, chronic Hepatitis and Wilsons Disease. The prognosis in these diseases depends on early detection and regular therapy. Substantial differences exist in features of some of these diseases in India as compared to Western descriptions. And finally, though 50% of the original CLD (ICC) can be considered to be almost eradicated, the fight in the understanding and management of the other 50% will have to continue unabated.

Clinical predictors of outcome in hypoxic ischaemic encephalopathy in term neonates

Thirty-eight full-term infants with hypoxic ischaemic encephalopathy were followed up prospectively to determine simple predictors of outcome at 1 year. Three predictors of outcome, based on clinical examination alone, were evaluated. These were presence of seizures, grading of encephalopathy and neurobehavioural assessment at discharge from the hospital. Development was assessed using the Bayley scales of infant development, and a mental and motor quotient below 85 was considered to be delayed development. At 1 year, 15 infants showed delayed development; five of them had cerebral palsy. Predictive values were determined for each indicator. Seizures per se did not affect the outcome. All infants with mild encephalopathy were normal. The predictive value of moderate-to-severe encephalopathy was 50%. Abnormal neurobehaviour at the age of 7 days or at discharge, if earlier, was found to be the best predictor of outcome with a predictive value of 91.6%.

Effectiveness of a 5-year school-based intervention programme to reduce adiposity and improve fitness and lifestyle in Indian children; the SYM-KEM study

Design Non-randomised non-blinded school-based intervention study. Setting Two schools in the cities of Pune and Nasik, India. Participants The intervention group comprised children attending a Pune school from 7–10 years until 12–15 years of age. Two control groups comprised children of the same age attending a similar school in Nasik, and children in the Pune intervention school but aged 12–15 years at the start of the study. Intervention A 5-year multi-intervention programme, covering three domains: physical activity, diet and general health, and including increased extracurricular and intracurricular physical activity sessions; daily yoga-based breathing exercises; making physical activity a ‘scoring’ subject; nutrition education; healthier school meals; removal of fast-food hawkers from the school environs; and health and nutrition education for teachers, pupils and families. Main outcome measures Body mass index (BMI), waist circumference, physical fitness according to simple tests of strength, flexibility and endurance; diet; and lifestyle indicators (time watching TV, studying and actively playing). Results After 5 years the intervention children were fitter than controls in running, long jump, sit-up and push-up tests (p<0.05 for all). They reported spending less time sedentary (watching TV and studying), more time actively playing and eating fruit more often (p<0.05). The intervention did not reduce BMI or the prevalence of overweight/obesity, but waist circumference was lower than in the Pune controls (p=0.004). Conclusions It was possible to achieve multiple health-promoting changes in an academically competitive Indian school. These changes resulted in improved physical fitness, but had no impact on the childrens BMI or on the prevalence of overweight/obesity.

Long-term immunogenicity of single dose of live attenuated hepatitis A vaccine in Indian children

ObjectivesTo assess immunogenicity of a single dose of live attenuated hepatitis A vaccine in Indian children, ten years after immunization.MethodsOf 143 children vaccinated in 2004, 121 children were evaluated in 2014, clinically and for anti-HAV antibodies.Results13 children were early vaccine failures who received two doses of HAV vaccine subsequently. 106 (98%) of 108 remaining children had seroprotective levels with a geometric mean titer of 100.5 mIU/mL. On analysis of all 121 children, the immunogenicity was 87.6%.ConclusionSingle dose of live attenuated hepatitis A vaccine provides long-term immunity in Indian children.